Malaria Case Report Case Report:    An 18 years old male university student visited the Health Unit complaining of unexplained high fever for 2 – 3 days. On physical examination, he had flu-like symptoms. His body temperature is about 38.2º. However, after a complete history taking, he revealed a history of visiting to Nigeria for a camping a week before.   

He was anxious about malaria infection and this agreed with the comments of the physician-in-charge. A complete blood count on this patient was performed. \ The result show normal appearance accepted for presentation of malarial parasite in red blood cell.  He was diagnosed for vivax malarial infection and referred to the nearby hospital for proper treatment. If you were an epidemiologist, How to investigate this problem?

Malaria survey

Definition: field study in endemic areas to find out the magnitude of malaria problems and ecological factors related to endemicity (host-agent-environment)

Steps: Planning Preparation Implementation &interpretation: Vector study: types of mosquito, density, species, life span, choices to host resting habits, breeding habits, resistance to insecticides.

Malaroimetric indices A-Human: 1-splenic index (non specific): the percentage of children between 2-9 years showing enlargement of spleen, excluding other causes of spleenomegaly (Bilharisiasis and Leshmania). 2-gametocyte index (specific): the percentage of the host having gametocytes in their blood.

3-infant parasitic index (specific): the percentage of the infants below the age of one year showing malaria parasites in their blood. It is the most sensitive index for recent infection.

B-Vector Indices: 1.Oocyte index: percentage of oocyte in the stomach wall of female anopheles. 2.Sporosoite index: percentage of female anopheles having sporozoite index in their salivary glands.

In a village in Upper Egypt, an increasing number of cases of high fever with rigors, severe headache and body aches. By specific investigations, these cases were confirmed to be malaria What are the most important preventive measures that should be done in this situation?

Prevention

General prevention: 1- Sanitary environment such as filling small collection of water to eliminate breeding places. 2- Eradication of breeding spaces biologically by ducks and frogs and chemically by spraying of crude oil and larvicides on water surface.

3-Destruction of adult mosquitoes by spraying of screened living and sleeping quarters with a liquid aerosol . 4- in endemic area use screen ,bed nets, animal barrier between breeding places and habitation.

5- personal protection against mosquito bites (the first line): avoid outdoor exposure between dusk and dawn. Wearing long loose clothing after dusk with light color. Avoid perfumes and colognes. Use effective insect repellents. Using knock- down sprays or plug in vaporizing devices indoor. Using mosquito net and insecticides treated bed nets.

6- Health education of the public for the mode of transmutation, protection from exposure and importance of treatment. 7- Blood donors with positive history should be avoided

Control

A-Cases: 1-Early case finding by laboratory examination of clinically suspected persons and by periodic survey. 2-Notifiction to local health office. 3- Isolation is not required.

appropriate therapy should be started immediately: Delay it can have serious or fatal consequences. It is complex and should be infectious disease physician. Most strains of p. falciparum are resistant to chloroquine. If the species cannot be identified with confidence the patient should be treated as the most serious type.

B-Contacts: 1- Enlistment of age and sex B-Contacts: 1- Enlistment of age and sex. 2- investigation of contact and source of infection search for people at high risk. C-Epidemic measures: . A single case of malaria of endogenous origin constitutes an outbreak and should be considered as a public health emergency . Aggressive outbreak control.

D- International measures for travelers : Checklist for travelers to malarious areas: 1.Risk for malaria : Higher in sub-Saharan Africa than other part in the world. No vaccine is currently available (vaccine under trial). Appropriate chemoprophylaxis and anti-mosquito measures will help prevention.

2.Personal protective measures 3.chemoprophylaxis: a) Primary prophylaxis Drug Usage Before travel During travel After travel chloroquine weekly 1-2 weeks continue 4 week mefloquine doxycycline Daily 1-2 days Atovaquone\ proguanil 7 days

Travel to areas with out chloroquine resistant strain: 1-Chloroquine once –a-week. 2-Hydroxychloroquine 3- Mefloquine, doxycycline,Atovaquone\ proguanil Travel to areas with chloroquine resistant p.falciparum: Mefloquine,Doxycycline,Atovaquone\ proguanil 21

Travel to areas with mefloquine resistant p.falciparum: Atovaquone\ proguanil, doxycycline, B) Terminal prophylaxis: To prevent relapse that may occur 4years or more after chemoprophylaxis. Primaquine to prevent relapse with p.vivax and p.ovale For 14 days after the travelers has left the malaria endemic areas. 4.In case of illness: the traveler should be informed about mild symptoms warned that delay in treatment is fatal.

Tetanus

What is the causative organism? What are the modes of transmission ? At 4 o`clock in the after noon of April 20, 2009 a young married women 25 years old had an accident by her car . She was left bleeding in the road for 2 hours until the ambulance came and took her to the hospital. The doctor examined her and the wound in the back of her head was dressed then she was dismissed from the hospital. After a week she exhibited all the symptoms of tetanus ; had rigid neck and muscle spasm especially in her face . She asked the doctor and was referred to the fever hospital. What is the causative organism? What are the modes of transmission ? What is the prevention of tetanus? What is the steps of control of the case ?

Causative agent: Clostridium tetani, a gram positive anaerobic spore forming organisms. Reservoir: The natural habitat of the organisms are in the soil contaminated by excreta of herbivorous animals e.g. horses, cattle, sheep and goats and sometimes man. Incubation period: 3- 21 days although it may range from one day to several months depending on the character, extent and location of the wound. Most cases occur within 14 days.

Mode of transmission: 1. Infection of wounds: By spores introduced to the punctured wounds contaminated with soil, street dust or animal faeces through laceration, burns, or trivial unnoticed wounds. The presences of necrotic tissues and or foreign bodies favor anaerobic organisms to produce toxins. Intravenous drug use is an independent risk factor for tetanus in the absence of acute injuries

2. Post operative surgical tetanus: - Contaminated instruments or defectively sterilized catgut - contaminated wounds by dust containing spores. 3. Puerperal sepsis: Using contaminated instruments in labor or abortion. 4. Tetanus neonatorum: -by contaminated hands with soil - Contaminated instruments for cutting the cord (scissor or knife) -Using contaminated dressing or fomites to cover the stump.  

Prophylaxis in wound management Tetanus prophylaxis in wounded person is based on: Careful assessment of the wound weather clean or contaminated, The immunization status of the person. Management of wound Cleaning of wound, surgical debridement if required and proper dose of antibiotics (penicillin).

Those who have been completely immunized Minor and uncontaminated wounds require a booster dose of toxoid if more than 10 years have passed since last dose was given. For major and contaminated wounds a single booster injection of tetanus toxoid should be given in the day of injury for those who not received tetanus toxoid since 5 years.

Persons who are non immunized or those who have not completed their primary immunization Require a dose of toxoid as soon as possible and require TIG or ATS in case of contaminated major wound, separate syringes and separate sites must be used. If ATS of animal origin is used, it is essential to do sensitivity l.D test.

Specific treatment TIG 1M in dose of 3000 - 6000 IU. Control: Case Early case finding Notification to local health office Isolation: No need for isolation but the patient should be hospitalized for management. Release after cure. Treatment: Specific treatment TIG 1M in dose of 3000 - 6000 IU. If TIG is not available, ATS (equine) in a single large dose given IM preceded by hypersensitivity test

Metronidazole I.V in large doses should be given 7-14 days. The wound should be debrided widely and excised if possible. careful attention to provide an adequate airway and to control muscle spasm Contacts Investigation of contacts and source of infection to determine the circumstances of injury Outbreak measures Not applicable except for rare cases as clusters of Intravenous drug users.

Case of tetanus neonatorum On Tuesday 2005, a boy was born in a country in rural area. His umbilical cord was cut with a knife and the stump was dressed with olive oil. After a week the baby could not feed and suckle. There was episodes of convulsion and stiffness. His mother took him to the doctor and the doctor referred him to the fever hospital. What is the features of the confirmed case? What is the mode of transmition in this case? How could we prevent it and protect the mother?

Case Definition: Suspected case: Any death of unknown cause between 3 to 28 days of life. Confirmed Case: Neonatal tetanus is diagnosed on clinical findings and does not depend upon laboratory confirmation. A confirmed case is any infant with: A normal ability to suck and cry during the first 2 days of life History of poor feeding or inability to such between the ages of 3 and 28 days Episodes of convulsions or stiffness (i.e. jerking of the muscles).

Mode of transmission: The disease occurs through introduction of tetanus spores via the umbilical cord during delivery.

Prevention of tetanus neonatorum Vaccination of mothers by TT during pregnancy Health education of mother about the importance of vaccination during pregnancy. Sanitation of the place of deliveries, sterilization of all instrument used in deliveries and all articles, scissors, scalpel used in cutting the cord, Using sterilized catgut in ligation of the cord. Using sterile dressing in covering the stump.

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