INFECTIOUS AND COMMUNICABLE DISEASES PYRAMID POINTS Clinical manifestations

INFECTIOUS AND COMMUNICABLE DISEASES

PYRAMID POINTS • Clinical manifestations of the various infectious and communicable diseases • Infectious periods of the various infectious and communicable diseases • Methods of transmission of the various infectious and communicable diseases • Teaching related to measures to prevent transmission of infectious and communicable diseases • Immunization schedules • Contraindications to immunizations

RUBEOLA (MEASLES) • AGENT – Virus • INCUBATION PERIOD – 10 to 20 days • COMMUNICABLE PERIOD – From 4 days before to 5 days after the rash appears; mainly during prodromal (catarrhal) stage

RUBEOLA (MEASLES) • SOURCE – Respiratory tract secretions, blood, and urine of infected person • TRANSMISSION – Airborne or direct contact with infectious droplets

RUBEOLA (MEASLES) • ASSESSMENT – Fever – Malaise – Coryza and cough – Rash appears as red, discrete maculopapules that blanch easily with pressure and gradually turn a brownish color (lasts 6 to 7 days); rash begins behind the ears and spreads downward to the feet – Koplik’s spots: small, red spots with a bluishwhite center and a red base located on the mucosa that last 3 days

RUBEOLA (MEASLES) From Seidel HM et al (1995): Mosby’s guide to physical examination, (3 rd ed. ), St. Louis: Mosby.

RUBEOLA (MEASLES) From Wong, D. (1999). Whaley and Wong’s nursing care of infants and children, ed 6, St Louis: Mosby.

KOPLIK SPOTS From Wong, D. (1999). Whaley and Wong’s nursing care of infants and children, ed 6, St Louis: Mosby.

RUBEOLA (MEASLES) • IMPLEMENTATION – Respiratory precautions if hospitalized – Restrict to quiet activities and bed rest – Use a cool mist vaporizer for cough and coryza – Dim lights if photophobia is present – Administer antipyretics for fever

ROSEOLA (EXANTHEMA SUBITUM) • AGENT – Human herpesvirus type 6 (HHV-6) • INCUBATION PERIOD – 5 to 15 days • COMMUNICABLE PERIOD – Unknown but thought to extend from the febrile stage to the time the rash first appears • SOURCE – Unknown • TRANSMISSION – Unknown

ROSEOLA (EXANTHEMA SUBITUM) From Habif TP: Clinical dermatology: a color guide to diagnosis and therapy, ed. 3, St. Louis, 1996, Mosby.

ROSEOLA (EXANTHEMA SUBITUM) • ASSESSMENT – Fever for 3 to 5 days followed by a rash (rosepink macules that blanch with pressure) – The rash appears 2 to 3 days after the onset of fever and lasts 1 to 2 days • IMPLEMENTATION – Supportive

RUBELLA (GERMAN MEASLES) • AGENT – Rubella virus • INCUBATION PERIOD – 14 to 21 days • COMMUNICABLE PERIOD – 7 days before to approximately 5 days after the rash appears • SOURCE – Nasopharyngeal secretions; virus is also present in blood, stool, and urine

RUBELLA (GERMAN MEASLES) • TRANSMISSION – Airborne or direct contact with infectious droplets – Indirectly via articles freshly contaminated with nasopharyngeal secretions, feces, or urine – Transplacental

RUBELLA (GERMAN MEASLES) From Habif TP: Clinical dermatology: a color guide to diagnosis and therapy, ed. 3, St. Louis, 1996, Mosby.

RUBELLA (GERMAN MEASLES) RASH From Wong, D. (1999). Whaley and Wong’s nursing care of infants and children, ed 6, St Louis: Mosby.

RUBELLA (GERMAN MEASLES) • ASSESSMENT – Low-grade fever – Malaise – Pinkish-red maculopapular rash that begins on the face and spreads to the entire body – Petechiae may occur on the soft palate • IMPLEMENTATION – Supportive treatment – Isolate the infected child from pregnant women

MUMPS • AGENT – Paramyxovirus • INCUBATION PERIOD – 14 to 21 days • COMMUNICABLE PERIOD – Immediately before and after the swelling begins • SOURCE – Saliva of infected person and possibly urine

MUMPS • TRANSMISSION – Direct contact with infected person – Droplet spread from infected person • ASSESSMENT – Fever – Headache and malaise – Anorexia – Earache aggravated by chewing, followed by parotid glandular swelling

MUMPS • IMPLEMENTATION – Respiratory precautions – Bed rest until the parotid glandular swelling subsides – Avoid foods that require chewing – Apply hot or cold compresses as prescribed to the neck – To relieve orchitis, apply warmth and local support with tight-fitting underpants

CHICKENPOX (VARICELLA) • AGENT – Varicella zoster virus (VZV) • INCUBATION PERIOD – 13 to 17 days • COMMUNICABLE PERIOD – 1 day before eruption of lesions (prodromal) to 6 days after the first crop of vesicles, when crusts have formed

CHICKENPOX (VARICELLA) • SOURCE – Respiratory tract secretions of infected person; skin lesions • TRANSMISSION – Direct contact, droplet (airborne) spread, and contaminated objects

CHICKENPOX (VARICELLA) • ASSESSMENT – Slight fever, malaise, and anorexia followed by a macular rash that first appears on the trunk and scalp and moves to the extremities – Lesions become pustules, begin to dry, and develop a crust – Lesions may appear on the mucous membranes of the mouth, the genital area, and the rectal area

STAGES OF LESIONS IN CHICKENPOX From Wong, D. (1999). Whaley and Wong’s nursing care of infants and children, ed 6, St Louis: Mosby.

CHICKENPOX (VARICELLA) RASH From Wong, D. (1999). Whaley and Wong’s nursing care of infants and children, ed 6, St Louis: Mosby.

CHICKENPOX (VARICELLA) From Habif TP: Clinical dermatology: a color guide to diagnosis and therapy, ed. 3, St. Louis, 1996, Mosby.

CHICKENPOX (VARICELLA) • IMPLEMENTATION – In the hospital setting, strict isolation – In the home setting, isolate the infected child until the vesicles have dried – Isolate high-risk children from the infected child

PERTUSSIS (WHOOPING COUGH) • AGENT – Bordetella pertussis • INCUBATION PERIOD – 5 to 21 days (usually 10 days) • COMMUNICABLE PERIOD – Greatest during the catarrhal stage • SOURCE – Discharge from the respiratory tract of the infected person

PERTUSSIS (WHOOPING COUGH) • TRANSMISSION – Direct contact or droplet spread from infected person; indirect contact with freshly contaminated articles • ASSESSMENT – Symptoms of respiratory infection followed by increased severity of cough

PERTUSSIS (WHOOPING COUGH) • IMPLEMENTATION – Isolation during the catarrhal stage; if hospitalized, institute respiratory precautions – Administer antimicrobial therapy as prescribed – Administer pertussis-immune globulin as prescribed

PERTUSSIS (WHOOPING COUGH) • IMPLEMENTATION – Reduce environmental factors that promote paroxysms of cough such as dust, smoke, and sudden changes in temperature – Encourage fluid intake – Provide high humidity with the use of a humidifier or tent

DIPHTHERIA • AGENT – Corynebacterium diphtheriae • INCUBATION PERIOD – 2 to 5 days • COMMUNICABLE PERIOD – Variable; until virulent bacilli are no longer present (three negative cultures), usually 2 weeks but as long as 4 weeks

DIPHTHERIA • SOURCE – Discharge from the mucous membrane of the nose and nasopharynx, skin, and other lesions of the infected person • TRANSMISSION – Direct contact with infected person, carrier, or contaminated articles

DIPHTHERIA • ASSESSMENT – Low-grade fever, malaise, sore throat – Foul-smelling, mucopurulent nasal discharge – Gray membrane on the tonsils and pharynx – Lymphadenitis (neck edema)

DIPHTHERIA • IMPLEMENTATION – Strict isolation of the hospitalized child – Administer antitoxin as prescribed (preceded by a skin or conjunctival test to rule out sensitivity to horse serum) – Bed rest – Administer antibiotics as prescribed

POLIOMYELITIS • AGENT – Enteroviruses • INCUBATION PERIOD – 7 to 14 days • COMMUNICABLE PERIOD – Not exactly known; the virus is present in the throat and feces shortly after infection and persists for approximately 1 week in the throat and 4 to 6 weeks in the feces

POLIOMYELITIS • SOURCE – Oropharyngeal secretions and feces of the infected person • TRANSMISSION – Direct contact with infected person; fecal-oral and oropharyngeal routes

POLIOMYELITIS • ASSESSMENT – Fever, malaise, anorexia, nausea, headache, sore throat – Abdominal pain followed by soreness and stiffness of the trunk, neck, and limbs that progresses to flaccid paralysis

POLIOMYELITIS • IMPLEMENTATION – Enteric precautions – Supportive treatment – Bed rest – Monitor for respiratory paralysis – Physical therapy

SCARLET FEVER • AGENT – Group A, beta-hemolytic streptococci • INCUBATION PERIOD – 1 to 7 days • COMMUNICABLE PERIOD – During the incubation period and clinical illness, approximately 10 days; during the first 2 weeks of the carrier stage, although may persist for months

SCARLET FEVER • SOURCE – Nasopharyngeal secretions of infected person and carriers • TRANSMISSION – Direct contact with infected person or droplet spread; indirectly by contact with contaminated articles, ingestion of contaminated milk, or other foods

SCARLET FEVER • ASSESSMENT – Abrupt high fever, vomiting, headache, malaise, abdominal pain – A red, fine papular rash in the axilla, groin, and neck that spreads to cover the entire body – The rash blanches with pressure except in areas of deep creases and folds of the joints (Pastia’s sign)

SCARLET FEVER RASH From Wong, D. (1999). Whaley and Wong’s nursing care of infants and children, ed 6, St Louis: Mosby.

SCARLET FEVER • ASSESSMENT – The tongue is coated and papillae become red and swollen (white strawberry tongue); by the fourth to fifth day the white coat sloughs off leaving prominent papillae (red strawberry tongue) – Tonsils are edematous and covered with a gray -white exudate – Pharynx is edematous and beefy-red in color

WHITE STRAWBERRY TONGUE AND RED STRAWBERRY TONGUE From Wong, D. (1999). Whaley and Wong’s nursing care of infants and children, ed 6, St Louis: Mosby.

SCARLET FEVER • IMPLEMENTATION – Respiratory precautions until 24 hours after the initiation of treatment – Supportive therapy – Bed rest – Encourage fluid intake – Administer antibiotics as prescribed

ERYTHEMA INFECTIOSUM (FIFTH DISEASE) • AGENT – Human parvovirus B 19 (HPV) • INCUBATION PERIOD – 4 to 14 days, may be as long as 20 days • COMMUNICABLE PERIOD – Uncertain but before the onset of symptoms in most children

ERYTHEMA INFECTIOSUM (FIFTH DISEASE) • SOURCE – Infected person • TRANSMISSION – Unknown; possibly respiratory secretions and blood

ERYTHEMA INFECTIOSUM (FIFTH DISEASE) • ASSESSMENT – Fever – Myalgia – Lethargy – Nausea – Vomiting – Abdominal pain

ERYTHEMA INFECTIOSUM (FIFTH DISEASE) • STAGES OF THE RASH – Erythema of the face (slapped face appearance) chiefly on the cheeks; disappears by 1 to 4 days – Approximately 1 day after the rash appears on the face, maculopapular red spots appear, symmetrically distributed in the extremities; rash progresses from proximal to distal surfaces and may last a week or more – Rash subsides but may reappear if the skin becomes irritated or traumatized by such factors as the sun, heat, cold, or friction

ERYTHEMA INFECTIOSUM (FIFTH DISEASE) From Habif TP: Clinical dermatology: a color guide to diagnosis and therapy, ed. 3, St. Louis, 1996, Mosby.

ERYTHEMA INFECTIOSUM (FIFTH DISEASE) • IMPLEMENTATION – Respiratory isolation in the hospitalized child – Pregnant women should not be in contact with or care for the infected person – Supportive – Administer antipyretics, analgesics, and antiinflammatory medications as prescribed

INFECTIOUS MONONUCLEOSIS • AGENT – Epstein Barr (EB) virus • INCUBATION PERIOD – 4 to 6 weeks • COMMUNICABLE PERIOD – Unknown, the virus is shed before the onset of the disease until 6 months or longer after recovery

INFECTIOUS MONONUCLEOSIS • SOURCE – Oral secretions • TRANSMISSION – Direct intimate contact, infected blood

INFECTIOUS MONONUCLEOSIS • ASSESSMENT – Fever, sore throat, malaise, headache, fatigue, nausea, abdominal pain – Lymphadenopathy and hepatosplenomegaly

INFECTIOUS MONONUCLEOSIS • IMPLEMENTATION – Supportive – Monitor for signs of splenic rupture, which includes abdominal pain, left upper quadrant pain, or left shoulder pain

ROCKY MOUNTAIN SPOTTED FEVER • AGENT – Rickettsia rickettsii • INCUBATION PERIOD – 2 to 14 days • SOURCE – Tick; mammal source: wild rodents, dogs • TRANSMISSION – Bite of infected tick

HARD TICK: SOURCE OF ROCKY MOUNTAIN SPOTTED FEVER From Leahy, J. & Kizilay, P. (1998). Foundations of nursing practice, Philadelphia: W. B. Saunders. Courtesy of the Centers for Disease Control and Prevention.

ROCKY MOUNTAIN SPOTTED FEVER • ASSESSMENT – Fever, malaise, anorexia, vomiting, headache, myalgia – Maculopapular or petechial rash primarily on the extremities (ankles and wrists) but may spread to other areas, characteristically on the palms and soles

ROCKY MOUNTAIN SPOTTED FEVER • IMPLEMENTATION – Vigorous supportive care – Administer antibiotics as prescribed – Teaching regarding protection from tick bites

ENTEROBIASIS (PINWORM) • AGENT – Enterobius vermicularis • SOURCE – Universally present in temperate climatic zones – Eggs are ingested or inhaled (eggs float in the air), hatch in the upper intestine, mature in 2 to 8 weeks, and migrate to the cecal area; females then mate, migrate out the anus, and lay eggs

ENTEROBIASIS (PINWORM) • TRANSMISSION – Favored in crowded conditions – Ingestion or inhalation of eggs – Hand-to-mouth or fecal-oral route – Contaminated items (pinworm eggs persist in the environment for 2 to 3 weeks)

ENTEROBIASIS (PINWORM) • ASSESSMENT – Intense perianal itching, irritability, restlessness, poor sleep, bed-wetting, distractibility, short attention span – In females, the worm may migrate to the vagina and urethra and cause infection

ENTEROBIASIS (PINWORM) • IMPLEMENTATION – Identify the worms – Use of a flashlight to inspect the anal area 2 to 3 hours after the child is asleep – Tape test: Transparent, sticky tape is used to obtain a specimen from the child’s perianal area; specimen is collected in the morning as soon as the child awakens and before a bowel movement or a bath

ENTEROBIASIS (PINWORM) • IMPLEMENTATION – Enteric precautions – Anthelmintic medications (all household members are treated); course of medication is repeated in 2 weeks following the first course to prevent reinfection – Teach home care measures to prevent reinfection

IMMUNIZATIONS • GENERAL CONTRAINDICATIONS – Severe febrile illness – Live virus vaccines are generally not administered to anyone with an altered immune system – Allergic reaction to a previously administered vaccine or a substance in the vaccine

HEPATITIS B VACCINE (Hep B) • Protects against hepatitis B • All infants should receive the first dose of hepatitis B vaccine soon after birth and before hospital discharge • The first dose of hepatitis B vaccine may also be given by age 2 months if the infant’s mother is HBs. Ag-negative • Only monovalent hepatitis B vaccine can be used for the birth dose

HEPATITIS B VACCINE (Hep B) • Monovalent or combination vaccine containing Hep B may be used to complete the series; four doses of the vaccine may be given if combination vaccine is used • The second dose should be given at least 4 weeks after the first dose, except for Hibcontaining vaccine which cannot be administered before age 6 weeks • The third dose should be given at least 16 weeks after the first dose and at least 8 weeks after the second dose

HEPATITIS B VACCINE (Hep B) • The last dose in the series (third or fourth dose) should not be administered before age 6 months • Infants born to HBs. Ag-positive mothers should receive hepatitis B vaccine and 0. 5 ml hepatitis B immune globulin (HBIG) within 12 hours of birth at separate sites; the second dose is recommended at age 1 to 2 months and the vaccination series should be completed (third or fourth dose) at age 6 months

HEPATITIS B VACCINE (Hep B) • Infants born to mothers whose HBs. Ag status is unknown should receive the first dose of the hepatitis B vaccine series within 12 hours of birth; maternal blood should be drawn at the time of delivery to determine the mother’s HBs. Ag status and if the test is positive, the infant should receive HBIG as soon as possible (no later than age 1 week) • Contraindication: Anaphylactic reaction to common baker’s yeast

DTa. P (DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS) • Protects against diphtheria, tetanus, and pertussis • DTa. P is administered at 2 months, 4 months, 6 months, between 15 to 18 months of age, and between 4 to 6 years of age • The fourth dose of DTa. P can be given as early as 12 months of age, provided 6 months have elapsed since third dose and the child is unlikely to return at age 15 to 18 months of age

DTa. P (DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS) • Tetanus and diphtheria toxoids (Td) is recommended at 11 to 12 years of age if at least 5 years have passed since the last dose of tetanus and diphtheria toxoid-containing vaccine • Subsequent routine Td boosters are recommended every 10 years • Contraindication: Encephalopathy within 7 days of administration of previous dose

HAEMOPHILUS INFLUENZAE TYPE b CONJUGATE (Hib) VACCINE • Protects against Haemophilus influenzae type b • Hib is administered at 2 months, 4 months, 6 months, and between 12 to 15 months of age • Depending on the brand of Hib vaccine used for the first and second doses, a dose at 6 months of age may not be needed • DTa. P/Hib combination products should not be used for primary immunization in infants at age 2, 4, or 6 months, but can be used as boosters following any Hib vaccine

INACTIVATED POLIOVIRUS VACCINE (IPV) • Protects against polio • An all-IPV schedule is recommended for routine childhood poliovirus vaccination in the United States • IPV is administered at 2 months, 4 months, between 6 and 18 months, and between 4 to 6 years of age • Cautions: Anaphylactic reaction to neomycin or streptomycin

MEASLES, MUMPS, RUBELLA (MMR) • Protects against measles, mumps, and rubella (German measles) • The first dose of MMR is administered between 12 to 15 months of age; the second dose is administered at 4 to 6 years of age • The second dose may be administered during any health care visit, provided at least 4 weeks have elapsed since the first dose and that both doses are administered beginning at or after age 12 months

MEASLES, MUMPS, RUBELLA (MMR) • Those who have not previously received the second dose should complete the schedule by the visit at 11 to 12 years • MMR contains minute amounts of neomycin; measles and mumps vaccine, which are grown on chick embryo tissue cultures, are not believed to contain significant amounts of egg cross-reacting proteins

MEASLES, MUMPS, RUBELLA (MMR) • CONTRAINDICATIONS – Pregnancy – Known altered immunodeficiency – Allergic to contents of immunization (prior to the administration of MMR vaccine, assess for a known history of allergy to neomycin or related antibiotics)

MEASLES, MUMPS, RUBELLA (MMR) • CONTRAINDICATIONS – Presence of recently acquired passive immunity through blood transfusions, immunoglobulin, or maternal antibodies (MMR should be postponed for a minimum of 3 months after passive immunization with immunoglobulins and blood transfusions, except washed blood cells, which do not interfere with the immune response)

VARICELLA VACCINE • Protects against chickenpox • Varicella zoster vaccine is administered between 12 and 18 months of age • Susceptible children 13 years of age and older (who have not had chickenpox or have not been previously vaccinated) need 2 doses, given at least 4 weeks apart

VARICELLA VACCINE • CONTRAINDICATIONS – Pregnancy – Immunocompromised individuals – Children receiving corticosteroids

PNEUMOCOCCAL VACCINE (PCV) • The heptavalent pneumococcal conjugate vaccine (PCV) is recommended for all children aged 2 to 23 months and for certain children aged 24 to 59 months • Pneumococcal polysaccharide vaccine (PPV) is recommended in addition to PCV for certain highrisk groups

HEPATITIS A VACCINE • Recommended for use in selected geographical areas and for certain high-risk groups

INFLUENZA VACCINE • Recommended annually for children who are at least 6 months of age with certain risk factors (including, but not limited to, asthma, cardiac disease, sickle cell disease, HIV, and diabetes mellitus) and can be administered to all others wishing to obtain immunity