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Communicable

Diseases

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Communicable and Infectious Diseases:


Historical View
In

1900, communicable diseases


were the leading cause of death in
Canada

By

2000, improved nutrition and


sanitation, vaccines, and antibiotics
had put an end to the epidemics that
once ravaged entire populations

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However: infectious diseases have not


vanished

Organisms once susceptible to antibiotics


are becoming increasingly drug resistant

New killers are emerging, and old familiar


diseases are taking on different, more
virulent characteristics

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Emerging infectious diseases:

Those diseases with an increased


incidence in the past two decades or with
the potential to increase in the near future

They can include newer or known


infectious disease

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Can you suggest what some of these


diseases
are?

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Recent examples are:

Ebola
HIV / AIDS
Hantavirus pulmonary syndrome
West Nile virus
Legionnaires disease
Flesh-eating disease
Lyme disease
Mad cow disease
SARS

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How do the determinants of health relate to


health, illness, health promotion,
communicable diseases and disease
prevention?

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Determinants of Health
There are associations between the
determinants of health and communicable
and infectious diseases, e.g.:
Low income is linked to increased rates of
sexually transmitted infection
Low literacy levels are a barrier to receiving
effective care for sexually transmitted infections

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Prevention and Control


of
Communicable Diseases

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Prevention and control programs:


seek to reduce the prevalence of a disease
to a level at which it no longer poses a
major community health problem

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Elimination: The removal of the disease


from a large geographical area, such as a
country or region of the world

Eradication: The irreversible termination


of all transmission of infection by
extermination of the infectious agents
worldwide

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Agent , Host, Environment

Transmission of communicable diseases


depends on the successful interaction of
three factors together known as the
epidemiological triangle:
The host
The infectious agent
The environment

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Changes in any of these three factors may


result in disease transmission

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Name the four categories of Agents

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. Agent

Four main categories of infectious agents that


can cause infection or disease are:

Bacteria
Fungi
Parasites
Viruses

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What is a host and name examples?

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Host

A human or animal host may harbour an


infectious agent

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Four host factors influence the spread of


disease:
1. Resistance: The ability of the host to
withstand infection
2. Immunity: A resistance to an infectious agent

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Herd immunity: The resistance of a group of


people to invasion and spread of an
infectious agent
4. Infectiousness: A measure of the potential
ability of an infected host to transmit the
infection to other hosts

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Environment

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Environment

Environment: All that is external to the human


host: physical, biological, social, and cultural
factors

Environmental factors aid the transmission of an


infectious agent from an infected host to other
susceptible hosts

Changing environmental factors can reduce


communicable disease risk

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What are the modes of transmission of


infectious diseases?

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. Vertical transmission:

Passing an infection from parent to


offspring through sperm, placenta, milk,
or contact in the vaginal canal at birth

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. Horizontal transmission:

Person-to-person spread of infection


Can happen in four ways:

Direct / indirect contact


Common vehicle
Airborne
Vector-borne

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Common Vehicle:
Transport of infectious agent
From: infected host
To: susceptible host
Via: food, water, milk, blood, serum, salvia
or plasma

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1. Infection vs. disease

Infection: The entry, development, and


multiplication of the infectious agent in
the susceptible host

Disease: One of the possible outcomes of


infection; may indicate a physiological
dysfunction or pathological reaction

Infection does not always cause disease


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Vector
A nonhuman organism:
Insect- tick, mosquito, snails, flies
They bite or deposit infected material near
host

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Incubation period:

The time interval between invasion by an


infectious agent and the first appearance
of signs and symptoms of the disease
Communicable period:

The time interval during which an


infectious agent may be transferred
directly or indirectly from an infected
person to another person
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People with infectious diseases may exhibit


a broad spectrum of disease that ranges
from subclinical infection to severe and fatal
disease

At the community level, the disease may


occur in endemic, epidemic, or pandemic
proportion

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1. Endemic: Constantly present in a given


geographical area or population
2. Epidemic: An occurrence of disease in a
community or region that is greater than
normally expected
3. Pandemic: A worldwide epidemic
affecting large populations (e.g., SARS)

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Surveillance

Surveillance: Systematically collecting,


organizing, and analyzing current,
accurate, and complete data for a defined
disease condition

This information is promptly provided to


those who need it

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All provinces and territories in Canada are


required to report communicable diseases

The Public Health Agency of Canada


maintains a list of Nationally Notifiable
Infectious Diseases which must be reported
P. 535-538 textbook

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Primary prevention seeks to reduce the


incidence of disease through health
promotion and education

Secondary prevention seeks to reduce the


prevalence of disease or to diminish
morbidity through early diagnosis and
treatment

Tertiary prevention seeks to reduce complications


and disabilities related to disease through treatment
and through mental and physical rehabilitation

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What actions do CHNs take as prevention?

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Prevention is at the centre of public and


community health

Examples of CHN roles:

Education
Immunization
Screening

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A multisystem approach to the control of


communicable diseases involves:
1. Improving host resistance
2. Improving safety of the environment
3. Improving public health systems
4. Facilitating social and political changes to
ensure better health for all people

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Vaccines are one of the most effective


methods of preventing and controlling
communicable diseases

Many diseases such as polio, diphtheria,


pertussis, and measles are controlled by
vaccines, but have not been eradicated

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In Canada, most children are immunized by


the time they enter school

Although immunization is strongly


recommended, it is not compulsory

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It is important to be alert for


communicable disease cases in regions
where:

Groups obtain exemption from immunization


on religious or health belief grounds
Immunization is incomplete
International visitors are frequent

Prompt outbreak control is essential among


susceptible populations

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. Influenza

Influenza (flu): A viral respiratory infection


often indistinguishable from the common
cold or other respiratory diseases
The most important factors to note about
influenza are:

Its epidemic nature

The mortality due to pulmonary complications,


especially in the elderly
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There are three types of influenza viruses: A,


B, and C

Types B and C are fairly stable, but type A is


constantly changing
Flu vaccines are prepared each year based on
the best possible prediction of what type and
variant of virus will be most prevalent that
year

Immunization is necessary annually and is


given in the fall before the flu season begins
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. Smallpox

Smallpox has been considered eradicated


since 1979

The last known natural death from


smallpox occurred in 1977

The only documented existing virus


sources are located in freezers at the CDC
in Atlanta and a research institute in
Russia
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It is important to be familiar with the


clinical and epidemiological features of
smallpox because:

There is a potential for bioterrorism


Many health care providers have never seen
this disease

It is important to know how it is


differentiated from chickenpox

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Nonvaccine-preventable diseases:

Diseases that cannot be prevented by


vaccination, e.g., tuberculosis

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Groups in Canada at risk for TB are:


Those who travel to and from countries where TB is
endemic
First Nations peoples living in communities with a
high prevalence of TB
People living on the streets
Residents of some long-term care facilities or
persons in correctional facilities

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Healthcare workers
Persons with weakened immune systems (e.g.,
alcoholics, diabetics, those infected with HIV, older
adults)

CHNs may:
Administer and interpret TB skin tests
Collect specimens
Monitor medications
Provide education and support when necessary
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In Canada, since 1997, the number of


reported cases of STIs have increased:
Chlamydia is the most common
Gonorrhea is the second most common
Syphilis is the least common

STIs have long-term health effects, so CHNs


should be knowledgeable about them

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Chlamydia:

Caused by the organism Chlamydia


trachomatis, which causes infection of the
urethra and cervix

Infections may be asymptomatic and, if


untreated, result in severe morbidity

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Gonorrhea:
.

Caused by the bacterium Neisseria


gonorrhoeae

Can result in inflammation of the urethra


and cervix and dysuria, or it may result in
no symptoms

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HIV infection:

HIV infection and AIDS continue to have a


significant political and social effect on
society

It is estimated that more than 42 million


people are infected with HIV, most in
developing countries

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Public fears and an attitude of blame have


led to discrimination toward the two most
commonly afflicted groups: homosexuals
and intravenous drug users

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When HIV enters the body, it can cause a


flu-like syndrome that may go undetected

The symptoms are:

Lymphadenopathy
Myalgias
Sore throat
Lethargy
Rash
Fever

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If left untreated, about 80% to 90% of HIVinfected persons live for about 10 years

During this prolonged incubation period,


clients have gradual deterioration of the
immune system and can transmit the virus
to others

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AIDS: A disabling or life-threatening illness


caused by HIV, or a CD4 T-lymphocyte count
of less than 200/mL with documented HIV
infection

AIDS is the last stage on the long continuum


of HIV infection

It may result from damage caused by HIV,


secondary cancers, or opportunistic
organisms
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Transmission:

HIV is transmitted through exposure to blood,


semen, vaginal secretions, and breast milk

It is not spread through casual contact, such


as coughing or sneezing

Screening has significantly reduced the risk


of transmission of HIV by blood products and
organ donations

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What is a nosocomial infection?

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Nosocomial infections:

Infections that are acquired during


hospitalization or develop within a hospital
setting

They may involve clients, health care


workers, visitors, or anyone who has
contact with a hospital

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Hepatitis
Persons most at risk are:
Travellers to countries with high rates of HAV
infection
Children in areas of high rates
Injection drug users
Men having sex with men
Persons with clotting disease or chronic liver
disease
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2. Hepatitis B virus (HBV)


HBV is found mostly in:

Users of injection drugs

Persons with STIs or multiple sex partners

Immigrants and refugees (and their


descendants) from areas with high endemic
rates of HBV

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Health care workers

Hemodialysis clients

Inmates of long-term correctional institutions

Young adults, especially homeless adolescents

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The number of new cases of HBV has


decreased with the use of the HBV vaccine

HBV infection can be prevented by:

Immunization

Prevention of nosocomial occupational


exposure

Prevention of exposure via sex or injection drug


use

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Hepatitis C virus (HCV)

Transmitted when blood or body fluids of


the infected person enter an uninfected
person

The silent stalker up to 70% of newly


infected people experience no symptoms
and it may take up to 30 years for
symptoms to appear

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Primary prevention includes:

Screening of blood products and donor


organs and tissue

Risk reduction counselling and services


(including a sexual and injection drug use
history)

Infection control practices

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Secondary prevention strategies include:

Testing of high-risk individuals, including


those who seek HIV testing and
counselling

Appropriate medical follow-up of infected


clients

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HCV testing should be offered to:

Those who received blood or an organ


transplant before 1992

Healthcare workers who have been exposed


to blood or body fluids

Children born to HCV-positive women

Those who have ever injected drugs or been


on dialysis
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Routine testing for HCV is NOT recommended


for:

Healthcare workers

Pregnant women

Household contacts of HCV-positive persons

The general population

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How are water borne diseases transmitted?

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. Water-borne Diseases

Pathogens usually enter water supplies


through animal or human fecal
contamination and frequently cause
enteric disease

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Hepatitis A is the most widely publicized


water-borne viral agent

The most important water-borne bacterial


diseases are:

Cholera
Typhoid fever
Bacillary dysentery

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Protozoa do not respond to traditional


chlorine treatment as do enteric and
coliform bacteria

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Food-borne illness (food poisoning)

Often categorized as food infection or


food intoxication

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Food infection:

Results from bacterial, viral, or parasitic


infection of food
Includes salmonellosis, hepatitis A, and
trichinosis

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Food intoxication:

Results from

Toxins produced by bacterial growth

Chemical contaminants (e.g., heavy metals)

A variety of disease-producing substances


found naturally in certain foods (e.g.,
mushrooms, seafood)

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Examples of food intoxications are:

Botulism
Mercury poisoning

Food infections are usually associated with incubation


periods of 12 hours to several days after ingestion of the
infected food

Food intoxications become obvious within minutes to


hours after ingestion

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Much food-borne illness can be prevented


through effective food preparation,
handling, and storage
Salmonellosis:

A bacterial food-borne illness

Although morbidity can be significant,


death is uncommon except among infants,
older adults, and the debilitated

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What group has the highest rate of infection


in our population?

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The rate of infection is highest among


infants and small children

It is estimated that only a small proportion


of cases are recognized clinically and that
only 1% of clinical cases are reported

The number of Salmonella infections yearly


may be in the millions

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Transmission route: Eating inadequately


cooked food that:

Comes from an infected animal


Is contaminated by feces of an infected animal
or person

Meat, poultry, and eggs are the foods most


often associated with salmonellosis
outbreaks

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Where do outbreaks commonly occur?

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Outbreaks occur commonly in restaurants,


hospitals, nursing homes, and childrens
institutions

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Escherichia coli 0157:H7

First described in humans in 1992 after


two outbreaks of illness were associated
with eating undercooked hamburgers
from a fast-food restaurant chain

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Vector-borne diseases encountered in some


parts of Canada are those associated with
ticks, such as Lyme disease and Rocky
Mountain spotted fever (less common)

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Infection causes bloody diarrhea,


abdominal cramps, and, infrequently, fever

Hamburger appears to be involved in


outbreaks

The best protection is to cook food


thoroughly

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Vectors: Non-human organisms, often


insects, that either mechanically or
biologically play a role in the transmission
of an infectious agent from source to host

Biological transmission: The vector is necessary for the developmental


stage of the infectious agent

Mechanical transmission: Occurs when an insect simply contacts the


infectious agent with its legs or mouth and carries it to the host

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Measures for preventing exposure to ticks


include:
Reducing tick populations
Avoiding tick-infested areas
Wearing protective clothing when outdoors
Using repellents
Immediately inspecting for and removing ticks
when returning indoors

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CHNs who work with large immigrant


populations or with international travelers
may encounter malaria and dengue fever,
carried by mosquitoes

West Nile virus is an example of an endemic


mosquito-borne virus

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Diseases of Travellers
Malaria:

A potentially fatal disease characterized


by regular cycles of fever and chills

Caused by the blood-borne parasite


Plasmodium, transmitted through the bite
of an infected mosquito

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Worldwide, the most prevalent vector-borne


disease

No vaccine is available

Prevention depends on protection against


mosquitoes and appropriate
chemoprophylaxis

Gaining drug resistance, so decisions about


anti-malarial drugs must be tailored to the
individual
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Diarrheal diseases:

Much food-borne disease can be avoided


in other countries if the traveller eats
thoroughly cooked foods prepared with
reasonable hygiene

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Water in many areas is not potable

Drinking unsafe water can lead to a variety


of infections

Only boiled water, bottled water, or water


purified with iodine or chlorine compounds
should be consumed

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Zoonosis:

An infection transmitted under natural


conditions from a vertebrate animal to a
human
Means of transmission include:

Animal bites
Inhalation
Ingestion
Direct contact
Arthropod intermediates
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Rabies:

A well-known zoonosis

A significant public health problem


worldwide

Causes as many as 55,000 human deaths


a year, mostly in developing regions such
as Asia and Africa

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Even if there is no suspicion of rabies, a


physician should be contacted because tetanus
or antibiotic prophylaxis may be indicated
If an individual is bitten:

Clean the wound thoroughly with soap and water


Consult a physician immediately

Suspect rabies if the bite is from a wild animal


or an unprovoked attack from a domestic
animal

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Parasitic diseases are more common in


developing countries than in Canada because
of:
The tropical climate in many of the countries
Their often inadequate prevention and control
measures

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Several factors are leading to an increase in


parasitic infections in Canada:
International travel
Immigration from developing countries
An increased number of refugees

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Some common parasites that cause infections


a CHN might encounter are:
Enterobius (pinworm)
Giardia lamblia
Trichuris trichiura (whipworm)
Ascaris lumbricoides (roundworm)
Taenia solium (pork tapeworm)

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Diagnosis of parasitic diseases is based on


history of travel, characteristic clinical signs
and symptoms, and use of laboratory tests

Effective drug treatment is available for


most parasitic diseases

CHNs play a key role in the prevention,


diagnosis, and control of parasitic infections

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Community Health Nurses Role


in Providing Preventive Care
for Communicable Diseases

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Consists mainly of activities to keep people


healthy before the onset of disease, e.g.:
Assessing for risky behaviours
Providing relevant intervention through
education on how to avoid infection, mostly
through healthy behaviours

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The CHN should:

Obtain a sexual and injection drug use


history for clients and their partners

Identify the total number partners AND the


number of contacts with these partners

Be clear that this information is


confidential

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1

Based on the sexual history and risk


assessment, the CHN can identify specific
education and counselling needs

Nursing action focuses on education and


contracting with clients to change behaviour

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2

Primary Prevention

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3

Client education for preventing STIs includes


education about:
Safer sex
Drug use

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4

Community outreach:

Because of the illegal nature of injectable


drugs and the poverty associated with HIV,
many people at risk do not seek health
care

CHNs go into communities where those at


risk live to provide risk-reduction
education, counselling, and referral

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5

Community education:

CHNs may provide educational sessions


about STIs to community groups

These sessions are most effective when


delivered in settings where groups
regularly meet, such as churches, schools,
or businesses

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6

Topics covered include:


Symptoms of HIV and other STIs
Modes of transmission
Ways to prevent infection
Available community resources

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7

Evaluation:

Based on behaviour change toward safer


behaviour

The best indicator of success is measuring


the incidence and prevalence of the
diseases

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8

Includes:
Screening for diseases to ensure early
identification and treatment
Follow-up with contacts to prevent further spread

CHN should recommend that persons who


have engaged in high-risk behaviour be
tested for HIV

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9

Topics covered include:


Symptoms of HIV and other STIs
Modes of transmission
Ways to prevent infection
Available community resources

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0

Evaluation:

Based on behaviour change toward safer


behaviour

The best indicator of success is measuring


the incidence and prevalence of the
diseases

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1

Secondary Prevention

Includes:
Screening for diseases to ensure early
identification and treatment
Follow-up with contacts to prevent further spread

CHN should recommend that persons who


have engaged in high-risk behaviour be
tested for HIV

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2

The Canadian Guidelines on Sexually


Transmitted Infections identify at-risk
persons who should be offered HIV testing

The STI guidelines outline the pre- and postcounselling needed for persons with
negative and positive antibody test results

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3

Partner notification (contact tracing):

Confidentially identifying and notifying


exposed sexual and injection drug-use
partners of clients who have a reportable STI

Plans are made for the partner to seek followup care

An example of a population-level intervention


aimed at controlling communicable diseases

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4

Partner notification programs usually occur


in conjunction with reportable disease
requirements and are carried out by most
health departments

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5

Tertiary Prevention

Can apply to many of the chronic STIs and


to TB

For viral STIs, the focus is on managing


symptoms and psychosocial support
regarding future interpersonal relations

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6

Directly observed therapy (DOT) programs


for TB medications:
If clients prematurely stop taking medication, the
TB may become resistant
This can affect an entire community of susceptible
people
The CHN observes and documents individual
clients taking their TB drugs

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AIDS
Management in the home may include:
Monitoring physical status
Referring the family to additional care services for
maintaining the client in the home

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8

Infection control education

Teaching caregivers about infection control


in the home is vital

Standard/routine precaution procedures


must be taught to caregivers in the home
setting

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9

All blood and articles soiled with body fluids


must be handled as if they were infectious
or contaminated by blood-borne pathogens

This should include the use of gloves, mask,


goggles, and gown when necessary

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QUIZ

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Q-1
Of the following statements about Salmonella
made by a class member, which one indicates that
additional teaching is needed?
a."Certain pets and farm animals may be
Salmonella carriers."
b."It is possible to transmit Salmonella through
person-to-person contact."
c."Salmonella may be spread through blood once
the infected blood is exposed to air."
d."Salmonella outbreaks are usually due to
contaminated meat, poultry, and eggs."

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ANS: C
Meat, poultry, and eggs are the foods
most often associated with
salmonellosis outbreaks. Animals are
common reservoirs for the various
Salmonella serotypes. Although
infected humans may also be
carriers, animals are more likely to be
chronic carriers. Reptiles, such as
iguanas, have been implicated as
Salmonella carriers, as well as turtles,
poultry, cattle, swine, rodents, dogs,
and cats. Person-to-person
transmission is an important
consideration in day care and
institutional settings. Anthrax (not
Salmonella) forms spores when
infected blood is exposed to air.

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3

Q-2
Of the following interventions for infectious
diseases, which one is most representative of
primary prevention?
a.A tetanus booster every 10 years
b.A tetanus booster after stepping on a nail
c.Tetanus immunoglobulin after stepping on a
nail
d.Giving antibiotics to a client who has tetanus
and placing the client on seizure precautions

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ANS: A
Giving tetanus boosters before any
exposure has occurred is a primary
prevention measure.

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Q-3
What group is most at risk today for an outbreak of
pneumococcal pneumonia?

a.Adolescents who have not yet received their


booster shots
b.Elderly over age 65 who live in nursing homes
and other extended care facilities
c.Elementary school children who have not been
immunized
d.Young adults who have never been exposed to
the agent before

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ANS: B
The outbreaks in chronic care facilities were
determined to be the result of failure to
vaccinate at-risk populations, particularly the
elderly over age 65 who live in or visit
community settings with many older adults. As
the majority of deaths caused by pneumococcal
and influenza disease occur in those over 65,
nurses should make an effort to ensure that such
vaccinations are routinely administered in
institutions that serve the older adult population.

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Q-4
Who might be most at risk for an infectious
disease?

a.The woman who has been taking


antituberculosis (TB) medication for 3 months
b.The 85-year-old woman who recently emigrated
with her much younger family from Asia and
currently spends her days in an unlicensed senior
day care center
c.A full-time nurse at the local public health clinic
d.A volunteer nurse aide at the STD clinic

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ANS: B
Crowded living arrangements in institutional
settings lead to higher risk for residents.
Immigrants from countries where TB is
indigenous are also at risk. The 85-year-old
emigrant, having two risk factors, would
therefore be the most vulnerable.

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Q-5
People are fearful of the West Nile virus. What
could a nurse truthfully say to them?
a."As long as you stay out of forested areas, you'll
be safe."
b."Don't touch any dead birds or other small
animals and you'll be fine."
c."It is spread by infected mosquitoes, so wear
insect repellent."
d."The disease only occurs in isolated sections of
the United States, so you're probably safe."

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ANS: C
West Nile virus is spread over a wide
geographic area and is considered an
epidemic. Because it is spread by infected
mosquitoes, people should consider using
insect repellent.

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Q-6
A CHN asks a class to describe the ways in which
HIV can be transmitted. Which of the following
responses by students indicates a need for
additional teaching?
a."Droplet spread from sneezing or coughing"
b."Having unprotected sex with someone who is
infected"
c."Sharing needles when shooting up drugs"
d."Transfusions of blood products that are
contaminated with HIV"

Reference Elsevier(2008)

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ANS: A
HIV is transmitted through sexual contact
involving exchange of body fluids with an
infected person; sharing needles, syringes and
other equipment used to inject IV drugs;
perinatal transmission from mother to child
during delivery or breastfeeding; and through
transfusions of contaminated blood (though
less common than previously). HIV is not
transmitted through coughing or sneezing.

Reference Elsevier(2008)

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