epi diseases handouts

Lecture Notes on EPI Diseases / National TB Control Program (DOTS)

Prepared By: Mark Fredderick R Abejo RR, MAN

Clinical Instructor

1

EPI TARGET DISEASES

Disease Causative

Agent

Mode of

Transmission

Clinical

Manifestation

Reservoir Diagnostic

Exam

Treatment Nursing

Implication

Tuberculosis

“Primary

Complex” is less

than 3 years old

- any child who

does not return to

normal health after

measles or

whooping cough.

Most hazardous

period: first 6-12

months after

infection

Highest in risk

of developing:

under 3 years old

Mycobacterium

Tuberculosis

Droplet Infection

( inhalation of

bacilli from

patient who

coughs and

sneeze)

Degree of

Communicability

Depends upon:

- num.of bacilli

- virulence of

bacilli

- environmental

conditions

General weakness

Loss of weight,

cough and wheeze

which does not

respond to antibiotic

therapy.

Fever and night

sweat

Abdominal swelling

with a hard painless

mass and free fluid

Hemoptysis and

chest pain

Painful firm or soft

swelling in a group of

superficial lymph

nodes.

Note:

In young children the

only sign of pulmonary

TB may be stunted

growth or failure to

thrive

Man

And

Diseased

Cattle

(Bovine TB)

Sputum

Exam

3 sample are

taken with 24

hrs:

- spot sample

(1st visit)

- early

morning

specimen

- spot sample

(2nd

visit)

Note: at least 2

sample are

positive

Chest Xray

Mantoux

Test

- .1 cc

injection of

PDD and 48-

72 hours

reading

* 10 mm +

5 mm + (HIV

pt.)

DOTS

- patient is

required to take

the Ant-Tb

drugs in the

presence of a

health care

provider to

ensure

compliance to

treatment

regimen

Anti-TB drugs:

(RIPES)

Rifampicin

Isoniazid

Pyrazinamide

Ethambutol

Streptomycin

Pointers for

teaching on Anti-

TB drugs:

Rifampicin: taken

befor meals,

causes red urine

urine

Isoniazide: causes

peripheral neuritis,

given with Vit.B6

Pyrazinamide:

cause

hyperurucemia

Ethambutol: causes optic

neuritis/ blurring

of vision

Streptomycin: cause tinnitus, loss

of hearing balance,

damage to 8th

cranial nerve

Note: After 2-4

weeks of

treatment, patient

is no longer

contagious



Clinical Instructor

2

The National Tuberculosis Control Program

Vision: A country where Tb is no longer a public health problem

Mission: Ensure that TB DOTS services are available, accessible and

affordable to the communities in collaboration with the LGU’s

and other partners

Goal: To reduce prevalence and mortality from TB by half the year

2015 ( Millennium Development Goal )

Targets:

1. Cure at least 85% of the sputum smear- positive TB patient discovered.

2. Detect at least 70% of the estimated new sputum smear-positive TB cases.

NTP Objectives and Strategies

Objective A:

Improve access to and quality of services provided to TB patients, TB

symptomatics and communities by health care institutions and providers

Strategies:

Enhance quality of TB diagnosis.

Ensure TN patient’s treatment compliance.

Ensure public and private health care providers adherence to the

implementation of national standards of care for TB patients.

Improve access to services through innovative service delivery mechanisms for

patients living in challenging areas.

Objective B:

Enhance the health-seeking behavior on TB by communities, especially

the TB symptomatics

Strategies:

Develop effective, appropriate and culturally-responsive IEC/communication

materials.

Organize barangay advocacy groups

Objective C:

Increase and sustain support and financing for TB

control activities

Strategies:

Facilitate implementation of TB-DOTS Center certification and

accreditation

Build TB coalitions among different sectors

Advocate for counterpart input from local government units

Mobilize/extend other resources to address program limitations

Objective D:

Strengthen management (technical and operational) of TB

control services at all levels

Strategies:

Enhance managerial capability of all NTP program managers at all

levels

Establish an efficient data management system for both public and

private sectors.

Implement a standardized recording and reporting system.

Conduct regular monitoring and evaluation at all levels.

Advocate for political support through effective local governance

KEY POLICIES

Case Finding

1. DSSM ( Direct Sputum Smear Microscopy ) shall be the

primary diagnostic tool in NTP case finding.

Note: No TB diagnosis shall be made based on Xray result alone

likewise

result of PDD skin test (Mantoux Test)

2. All TB symptomatic identified shall undergo DSSM for diagnosis

before start of treatment

Note: Only contraindication for sputum collection is hemoptysis



Clinical Instructor

3

3. After three sputum specimen yielding negative result X-ray and culture

are necessary

Note: Diagnosis based on Xray shall be made by the TB Diagnostic

Committee.

4. Only trained medical technologist or microscopist shall perform DSSM.

Patients with the following conditions shall be recommended for

hospitalization:

massive hemoptysis

pleural effusion

military TB ( TB of the Spine “Pot’s Disease”)

TB meningitis

TB pneumonia

and those requiring surgical intervention

Anti-TB drugs:

(RIPES)

Rifampicin

Isoniazid

Pyrazinamide

Ethambutol

Streptomycin

Two Formulation of Anti-TB Drugs

1. Fixed-Dose Combination ( FDCs) – two or more first line anti-TB drugs

are combined in one tablet. There are 2,3, or 4 drug fixed dose

combinations.

2. Single Drug Formulation (SDF) – each drug is prepared individually.

Isoniazid, Pyrazinamide and Ethambuto are in tablet form while

Rifampicin is in capsule form and streptomycin is injectable.

RECOMMENDED CATEGORY OF TREATMENT REGIMEN

Category Type of TB

Patient

Treatment Regimen

Intensive

Phase

Continuation

Phase

Total

Period

I

New smear

positive PTB

New smear

positive PTB

with extensive

parenchymal

lesion

EPTB and

Severe

concomitant

HIV disease

2 RIPE

4 RI

6

mos.

II

Treatment

Failure

Relapse

Return after

default

2 RIPES

/1 RIPE

5 RIE

8

mos.

III

New smear-

negative PTB

With minimal

parenchymal

lession

2 RIP

4 RI

6

mos.

IV

Chronic ( still

smear-positive

after supervised

re-treatment )

Refer to

or DOTS

to City

Specialized

Plus Center

Provincial

Coordinator

facility

refer

NTP



Clinical Instructor

4

DOSAGE PER CATEGORY OF TRATMENT REGIMEN

A. Fixed-Dose Combination Formulation

The number of tablets of FDCs per patient will depend on the body

weight.

Categories I and III : 2 RIPE / 4 RI ( FDC)

Body Weight

(kg)

No.of tablets per day

Intensive Phase

( 2 months )

FDC-A ( RIPE)

No. of tablets per day

Continuation Phase

( 4 months )

FDC-B (RI)

30 - 37 2 2

38 – 54 3 3

55 – 70 4 4

More than 70 5 5

Categories II : 2 RIPES / RIPE / 4RIE (FDC)

Body

Weight

Intensive

Phase

Continuation Phase

First

Two (2)

Months 3rd

Month

FDC-B

( RI )

E

400

mg

FDC-A

(RIPE)

Streptomycin FDC-A

(RIPE)

30 – 37 2 0.75 g 2 2 1

38 – 54 3 0.75 g 3 3 2

55 – 70 4 0.75 g 4 4 3

More

than 70

5 0.75 g 5 5 3

B. Single Dose Formulation ( SDF )

Simply add 1 tablet of Isoniazid ( 100mg) , Pyrazinamide

(500mg) and Ethambutol ( 400mg) each for the patient weighing more

than 50kg before treatment initiation. Modify drug dosage within

acceptable limits according to patient’s body weight, particularly those

weighing less than 30 kg at the time of diagnosis.

Categories I and III: 2 RIPE / 4 RI (SDF)

Anti-TB Drugs No. of tablets per day

Intensive Phase

( 2 months )

No. of tablets per day

Continuation Phase

( 4 months )

Rifampicin 1 1

Isoniazid 1 1

Pyrazinamide 2

Ethambutol 2

Categories II: 2 RIPES / 1 RIPE / 5 RIE

Anti-TB

Drugs

No. of Tablets /

Intensive

(3months )

Vial per day

Phase

No.of Tablets per

day

Continuation Phase

( 5 months )

First 2 months 3rd

months

Rifampicin 1 1 1

Isoniazid 1 1 1

Pyrazinamide 2 2

Ethambutol 2 2 2

Streptomycin 1 vial per day

Note: 56 vials of Streptomycin for two months



Clinical Instructor

5

Drug Dosage per Kg. Body Weight

Anti-TB Drugs

Dose per Kg Body Weight and Maximum Dose

Rifampicin 5 ( 4 – 6 ) mg/kg and not to exceed 400 mg daily

Isoniazid 10 ( 8 – 12 ) mg/kg and not to exceed 600 mg daily

Pyrazinamide 25 ( 20 – 30 ) mg/kg and not to exceed 2 mg daily

Ethambutol 15 ( 15 – 20 ) mg/kg and not to exceed 1.2 g daily

Streptomycin 15 ( 12 – 18 ) mg/kg and not to exceed 1 g daily

D.O.T.S ( Directly-Observed Treatment Shortcourse ) “TuTok Gamutan”

5 Elements of D.O.T.S

Sustained political commitment

Access to quality-assured sputum microscopy

Standardized short-course chemotherapy for all cases of TB

Uninterrupted supply of essential drugs

Recording and reporting system enabling outcome assessment of all patients

and assessment of overall program performance.

MANAGEMENT OF CHILDREN WITH TB

Prevention

BCG vaccination shall be given to all infants.

BCG vaccine is moderately effective. It has a protective efficacy of:

50 % against any TB disease

64 % against TB meningitis

74 % against death from TB

Case Finding

Cases of TB in children are reported and identified in two instances:

- The patient sought consultation.

- The patient was reported to have been exposed to an adult with TB

All TB symptomatic children 0-9 years old, except sputum positive

child shall subject to PDD testing

- Only trained nurse and midwife shall do the PDD test and recording

- Testing and reading shall be conducted once a week either on Monday

or

Tuesday.

Note: 10 children shall be gathered for testing to avoid wastage.

A child shall be suspected as having TB and considered symptomatic

if with any three (3) of the following sign and symptoms:

cough and wheezing for 2 weeks or more

unexplained fever for 2 weeks or more

loss of appetite, loss of weight, failure to gain weight

failure to respond to a 2 weeks of appropriate antibiotic therapy

failure to regain state of health 2 weeks after a viral infection or after

having measles.

A child shall be clinically diagnosed or confirmed of having TB if he

has any three (3) of the following condition:

positive history of exposure to an adult/ adolescent TB case

presence of sign and symptoms suggestive of TB

positive Mantoux Test

abnormal chest radiograph suggestive of TB

Management

For children with exposure to TB

Should undergo physical examination and PDD testing (Mantoux Test)

A child with productive cough shall be referred for DSSM, if found

positive, treatment shall be started immediately. PDD testing shall no

longer needed.

Children without sign/symptoms of TB but with positive Mantoux Test

and those with symptoms of TB but negative Mantoux Test shall

referred for chest x-ray examination.



Clinical Instructor

6

For children with signs and symptoms of TB

A child to have signs and symptoms of TB with either known or unknown

exposure shall be referred for Mantoux test.

For children with known contact but with negative Mantoux and those

unknown contact but with positive Mantoux shall be referred for chest x-ray

examination.

For a negative x-ray report, Mantoux test shall be repeated after 3 months.

Chemoprophylaxis of Isoniazid for 3 months shall be given to children less

than 5 years old with negative chest x-ray after which Mantoux test shall be

repeated

Treatment

D.O.T.S will still be followed just like in adult

Short course regimen:

- at least 3 anti-TB drugs for 2 months ( intensive phase )

- 2 anti-TB drugs for 4 months ( continuation phase )

* For Extra Pulmonary TB Cases:

- 4 anti-TB drugs for 2 months ( intensive phase )

- 2 anti-TB drugs for 10 months ( continuation phase )

Domiciliary treatment shall be the preferred mode of care

No treatment shall be initiated unless the patient and health worker has agreed

upon a caseholding mechanism for treatment compliance.

Treatment Regimen

A. Pulmonary TB

Drugs Daily Dose (mg/kg per body

weight )

Duration

Intensive Phase

Rifampicin

Isoniazid

Pyrazinamide

10-15 mg/kg body weight



2 months

Continuation

Phase

Rifampicin

Isoniazid



4 months

B. Extra Pulmonary TB

Drugs Daily Dose (mg/kg per body weight ) Duration

Intensive Phase

Rifampicin

Isoniazid

Pyrazinamide

Plus

Ethambutol

OR

Streptomycin






2

months

Continuation

Phase

Rifampicin

Isoniazid



10

months

Public Health Nurse Responsibilities ( Childhood TB )

1. Interview and open treatment cards for identified TB children.

2. Perform Mantoux testing and reading to eligible children

3. Maintain NTP records

4. Manage requisition and distribution of drugs

5. Assist the physician in supervising the other health workers of the

RHU in the proper implementation of the policies and guidelines

on TB in children.

6. Assist in the training of other health workers on Mantoux testing

and reading.



Clinical Instructor

7

EPI TARGET DISEASES

Disease Causative

Agent

Mode of

Transmission

Clinical

Manifestation

Reservoir Diagnostic

Exam

Treatment Nursing

Implication

Diphteria it is an

acute pharyngitis,

acute

nasopharyngitis

or acute laryngitis

with Pseudo

membrane –

grayish white in

color with leathery

consistency in the

throat and on the

tonsil

Corynebacterium

diphtheriae

Respiratory

Droplets

Nasal

dryness of the

upper lip

serosanguinous

secretion in the

nose

Pharyngeal

“Bullneck” appearance

because of the

enlarge cervical

lymph nodes.

Laryngeal

sore throat

hoarseness

brassy metallic

cough

Man

Schick’s Test

- test for the

susceptibility to

Diptheria

Moloney Test

- for hyper-

sensitivity to

Diptheria toxin

Antibiotics

Pen G

Potassium

Erythromycin

Isolate patient

until 2-3 cultures

taken at least

24hrs apart are

negative

Small frequent

feeding

Promote

absolute rest

Use ice collar to

relieve pain of

sore throat

May put on soft

diet

Pertussis

- 100 days cough

- Whooping cough

- “tuspirina”

Bordetella

Pertussis

Airborne –

droplet

Primarily by

direct contact

with he

discharge from

respiratory

mucous

membranes of

infected person

At first, the

infected child may

have a common

cold with runny

nose, sneezing

and mild cough

Intermittent

episode of

paroxysmal

cough followed

by a whoop

ending vomiting

Man

Bordet-

Gengou Agar

Plate

- used for

culture medium

Erythromycin

Ampicillin

- is given 5-7 days

Place the patient

on NPO during

paroxysmal stage

to prevent

aspiration

Position prone

for infants and

upright for older



Clinical Instructor

8

Neonatal Tetanus

Clostridium

Tetani

- which produces

the exotoxins:

Tetanolysin

Tetanospasmin

Unhygienic

cutting of

umbilical cord

Improper

handling of cord

stump esp. when

treated with

contaminated

substance

Assess the

NEWBORN for a

history of all 3 of the

following:

Normal suck and

cry for the first 2

days of life

Onset of illness

between 3 and 28

days

Inability to suck

followed by

stiffness of the

body and

convulsion

In OLDER

CHILDREN, the

following may be

observed:

Trismus –

lockjaw

Opisthotonus –

arching of the

neck and back

Ridus

Sardonicus –

sardonic smile

Soil

Intestinal

canal of

animal

Man

Blood Culture

CSF analysis

Penicillin

Erythromycin

Tetracycline

- administered

within 4 hours of

injury

Prevention

Aseptic

handling of the

neonatal

umbilical cord

Tetanus Toxiod

immunization for

mothers

Active

immunization of

DPT



Clinical Instructor

9

Poliomyelitis

“Infantile

Paralysis”

3 Types of Polio

Virus

Type I

Brunhilde

Type II

Lansing

Type III Leon

Fecal-oral route

Oral route

through

pharyngeal

secretion

Contact with

infected person

Abortive - did not

progress to systemic

infection

Non-paralytic –

slight involvement

of the CNS

Poker spine or

stiffness of the

spinal column

Spasms of the

hamstring

With paresis

Paralytic – severe

involvement of CNS

Hoyne’s Sign –

head falls back

when he is in

supine with

shoulder elevated

Paralysis

Head log/drop

Tripod position

– extend his arm

behind for support

when he sits up

Kernig’s sign

Brudzinski sign

Man

Throat swab

Stool exam

Lumbar exam

Pandy’s test

- for CSF

analysis

Strict Isolation

Hot moist

compress to

relieve spasm

Use protective

devices:

- handroll to

prevent claw hand

- trochanter roll, to

prevent outer

rotation of femur

- footboard



Clinical Instructor

10

Hepatitis B

- it is liver

infection caused by

the B type of

hep.virus.

It attacks livers the

liver often

resulting in

inflammation

Hepa B Virus

3 P’s

Person to person

Parenteral

Placental

Prodromal/pre-

icteric

Symptoms of

URTI

Weight loss

Anorexia

RUQ pain

Malaise

Icteric

Jaundice

Acholic stool

bile-colored

urine

Man

Liver

Function Test

Increase CHO

Moderate fat

Low CHON

Observed universal

precaution

Measles

Paramyxo Virus

Droplet 3 C’s

Conjunctivitis

Coryza

Cough

Koplik’s spot –

bluish gray spot on

the buccal mucosa.

Generalized blotch

rash

Man

Observe

respiratory

isolation

Should kept out

of school for at

least 4 days after

rash appear

For

Photophobic,

darkened room,

sunglasses

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