Communicable and Infectious Disease Risks

Communicable and Infectious Disease Risks
Chapter 14 Communicable and Infectious Disease Risks This chapter describes selected communicable diseases and their nursing management. It concludes with implications for population-focused nursing care in primary, secondary, and tertiary prevention. Copyright © 2016 by Elsevier Inc.

Copyright © 2016 by Elsevier Inc.
Objectives Describe the natural history of human immunodeficiency virus (HIV) infection and appropriate client education at each stage. Explain the clinical signs of selected communicable diseases. Evaluate the trends in incidence of HIV, STDs, hepatitis, and tuberculosis, and identify groups that are at greatest risk. Copyright © 2016 by Elsevier Inc.

Objectives (Cont.) Analyze behaviors that place people at risk of contracting selected communicable diseases. Evaluate nursing activities to prevent and control selected communicable diseases. Explain the various roles of nurses in providing care for those with selected communicable diseases. Copyright © 2016 by Elsevier Inc.

Human Immunodeficiency Virus Infection
Natural history of HIV Transmission Epidemiology of HIV/AIDS HIV surveillance HIV testing Perinatal and pediatric HIV infection AIDS in the community Resources Copyright © 2016 by Elsevier Inc.

Natural History of HIV Three stages: Primary infection (within about 1 month of contracting virus) Clinical latency (when body shows no symptoms) Use of highly active antiretroviral therapy (HAART) has greatly increased survival time of persons with HIV/AIDS Symptomatic disease (AIDS) CD4 T-lymphocyte count less than 200/mL with documented HIV infection AIDS-related opportunistic infections Primary infection state may go unrecognized; person may experience mononucleosis-like syndrome. AIDS-related opportunistic infections Pneumocystis jiroveci carinii pneumonia Oral candidiasis Pulmonary tuberculosis Invasive cervical cancer Recurrent pneumonia Copyright © 2016 by Elsevier Inc.

Transmission Transmitted through exposure to blood, semen, transplanted organs, vaginal secretions, and breast milk Those who have had blood, sexual, or needle-sharing exposure with an HIV-infected person are at risk for contracting the virus. NOT transmitted through casual contact (touching or hugging someone) or through mosquitoes or other insects Copyright © 2016 by Elsevier Inc.

Epidemiology of HIV/AIDS
First cases of AIDS identified in 1981 Worldwide 35.3 million people live with HIV infection Sub-Saharan Africa accounts for more than 70% of all HIV infections Epidemic also growing in central Asia, the Middle East, and Eastern Europe Treatment for HIV infection has been given higher priority Prevalence of AIDS has increased Copyright © 2016 by Elsevier Inc.

HIV Testing HIV antibody test Indicates the presence of the antibody to HIV Enzyme-linked immunosorbent assay (EIA) Screens blood and other donor products Does not reveal whether individual has symptomatic AIDS, nor does it isolate the virus Western blot Confirmatory test minimizes false-positive results Routine testing and voluntary screening Routine testing is recommended for all clients attending health department STD clinics, family planning clinics, community health centers, and primary care offices. Voluntary screening programs for HIV may be either confidential or anonymous: the process for each is unique. Copyright © 2016 by Elsevier Inc.

Perinatal and Pediatric HIV Infection
Perinatal transmission Accounts for nearly all HIV infection in children and can occur during pregnancy, labor and delivery, or breastfeeding Recommendation Make HIV testing routine part of prenatal care. Pediatric infection Despite having an HIV-infected mother, many children do not acquire HIV/AIDS. However, one or both parents may die, thus indirectly affecting the health of the child. The effectiveness of antiretroviral therapy in pregnant women and newborns in preventing transmission from mother to fetus or infant has made pediatric HIV rates decline sharply. Copyright © 2016 by Elsevier Inc.

HIV Stage 3 (AIDS) in the Community
Chronic disease Much care is provided in the home. Nurses provide teaching to clients and families. Adherence to HAART: critical Americans with Disabilities Act of 1990 Mental health issues HIV-infected children Should attend school Impaired immunity to childhood diseases The Americans with Disabilities Act of 1990 and other laws protect persons with asymptomatic HIV infection and AIDS against discrimination in housing, at work, and in other public situations. Mental health issues, such as depression, substance abuse, and bipolar disorder, are often present in someone newly diagnosed with HIV. These conditions must be addressed prior to or simultaneously with HIV treatment to be effective. HIV-infected children should attend school because the benefit of attendance outweighs the risk of transmitting or acquiring infections. Copyright © 2016 by Elsevier Inc.

Quick Recall What is the greatest challenge raised by allowing children infected with HIV to attend school? A. These children are at higher risk for sports injuries. B. Other children are put at risk of acquiring HIV infection. C. These children are more likely to develop complications from childhood diseases. D. Other children can tell they are different, which may lead to social isolation. Answer is C. Copyright © 2016 by Elsevier Inc.

How’d You Do? HIV-infected children should attend school; no case of HIV infection in the United States has been transmitted in a school setting. Instead, because of impaired immunity, children with HIV infection are more likely to get childhood diseases and suffer serious sequelae. Copyright © 2016 by Elsevier Inc.

Sexually Transmitted Diseases
Gonorrhea Syphilis Chlamydia Genital herpes Human papillomavirus infection Sexually transmitted diseases The number of new cases (the incidence) of STDs, such as gonorrhea, herpes simplex virus, human papillomavirus (HPV), and chlamydia continues to increase. Chlamydia is the most commonly reported infectious disease. Gonorrhea is the second most common. Because of the impact of STDs on long-term health and the emergence of eight new STDs since 1980, continued attention to their prevention and treatment is vital. Copyright © 2016 by Elsevier Inc.

Gonorrhea Bacterium Infects mucous membranes of the genitourinary tract, rectum, and pharynx Transmission Genital-genital contact, oral-genital contact, and anal-genital contact Uncomplicated versus complicated Highest incidence in United States African Americans, persons in the South, and women 15 to 24 years of age Number of antibiotic-resistant cases rising Uncomplicated gonorrhea refers to limited cervical or urethral infection. Complicated gonorrhea includes salpingitis, epididymitis, systemic gonococcal infection, and gonococcal meningitis. Increase of antibiotic-resistant gonorrhea in the United States Penicillin-resistant gonorrhea first identified in 1976 By 1990, 64,972 resistant cases reported Antibiotic-resistance N. gonorrhoeae has continued to develop exponentially, with gonorrhea becoming resistant to every antibiotic used for treatment. In 2012, the CDC revised its treatment guidelines and no longer recommended oral cephalosporins as a recommended first-line treatment for gonorrhea, in an effort to preserve the last remaining treatment option (CDC, 2013a). At this time, combination therapy of ceftriaxone IM along with either oral doxycycline or azithromycin is the most reliably effective treatment for uncomplicated gonorrhea (CDC, 2012g). The injection route versus the previously recommended oral cefixime may make treatment more challenging due to patient fear of injection and health care facilities having to stock injectable medication (CDC, 2013a). Increase in cases attributed in part to indiscriminate or illicit use of antibiotics as prophylactic by persons with multiple sexual partners Copyright © 2016 by Elsevier Inc.

Syphilis Treponemal spirochetes Infect moist mucous/cutaneous membranes Direct contact Sexual contact or mother-to-fetus Blood transfusion (early-stage donor) Highest rates Men having sex with men (MSM); recently, number of infected women has increased Clinical signs Primary, secondary, tertiary Congenital syphilis Congenital syphilis is transmitted transplacentally and, if untreated, can cause premature stillbirth, blindness, deafness, facial abnormalities, crippling, or death. Copyright © 2016 by Elsevier Inc.

Chlamydia Bacterium Infects genitourinary tract and rectum of adults Causes conjunctivitis and pneumonia in neonates Transmission Mucous membrane contact with mucopurulent discharge from infected site Most common reportable infectious disease If left untreated, chlamydia can result in pelvic inflammatory disease (PID). Copyright © 2016 by Elsevier Inc.

Genital Herpes Herpes simplex viruses 1 and 2 Majority of cases caused by HSV-2 Increasing number of cases caused by HSV-1 No cure Transmission Direct exposure; infects genitalia and skin HSV-2 occurrence 16.2% of American adolescents Of particular concern to women and children Linked with development of cervical cancer Increased risk of fatal newborn infection Copyright © 2016 by Elsevier Inc.

Human Papillomavirus Infection
HPV genital warts Mouth, genitals, and anus Transmission Direct contact with HPV-associated warts FDA-licensed vaccines Bivalent Quadrivalent Complications Link to cervical cancer Other cancers: vaginal, anal, and oropharyngeal Copyright © 2016 by Elsevier Inc.

Hepatitis Hepatitis A virus Hepatitis B virus Hepatitis C virus Non-ABC hepatitis Viral hepatitis refers to a group of infections that primarily affect the liver. These infections have similar clinical presentations but different causes and characteristics. Copyright © 2016 by Elsevier Inc.

Hepatitis A Virus (HAV)
Most common transmission Fecal-oral route Sources: water, food, feces, or sexual contact Found worldwide Vaccine available since 1995 Incidence has declined 92% Makes HAV completely preventable High-risk groups High-risk groups: Travelers to countries with high rates of the disease Children living in areas with high rates of HAV infection Injection drug users MSM Persons with clotting disorders or chronic liver disease Copyright © 2016 by Elsevier Inc.

Hepatitis B Virus (HBV)
Spread through blood and body fluids Remains alive outside body For at least 1 week High-risk groups Acute or chronic infections Vaccine available Occupational Safety and Health Administration (OSHA) regulations High-risk groups: Users of injection drugs; persons with STDs or multiple sex partners; immigrants/refugees and their descendants who came from areas with a high endemic rate of HBV; health care workers; clients on hemodialysis; inmates of long-term correctional institutions. The acute infection is self-limited: individuals develop an antibody to the virus and successfully eliminate the virus from the body. They subsequently have lifelong immunity against the virus. Chronically infected individuals are unable to rid their bodies of the virus and remain lifelong carriers of the hepatitis B surface antigen (HBsAg). As carriers, they can transmit HBV to others. They may develop hepatic carcinoma or chronic active hepatitis. OSHA regulations Mandates specific activities to protect workers from HBV and other bloodborne pathogens Requires employers to identify the risk of blood exposure to various employees If employees perform work that involves a potential exposure to others’ body fluids, employers are mandated to offer the HBV vaccine to employee at the employer’s expense and to offer annual educational programs on preventing HBV and HIV exposure in the workplace. Employees have the right to refuse the vaccine. Copyright © 2016 by Elsevier Inc.

Hepatitis C Virus (HCV)
Most common chronic bloodborne infection in United States Transmission Blood or body fluids of an infected person enter an uninfected person High-risk groups Spread rapidly during 1980s Chronic liver disease from HCV 12th leading cause of death in adults in United States Most common reason for liver transplant High-risk groups: Health care workers and emergency personnel who are accidentally exposed Infants who are born to infected mothers Injection drug users, particularly those who share needles or other drug use equipment Those born between 1945 and 1965 Copyright © 2016 by Elsevier Inc.

Non-ABC Hepatitis Very uncommon in the United States Hepatitis D (HDV): chronic or acute, only occurs in those already infected with HBV; no vaccine Hepatitis E (HEV): acute infection transmitted by fecal-oral route; no chronic carriers; no vaccine Hepatitis G (GB virus C): does not cause acute or chronic hepatitis; virus has been isolated in patients with posttransfusion hepatitis Copyright © 2016 by Elsevier Inc.

Tuberculosis (TB) Transmission Airborne droplets Common symptoms Cough, fever, fatigue, hemoptysis, chest pains, weight loss Epidemiology WHO reports 12 million cases in 2012 and 1.3 million deaths due to TB (WHO, 2013) Drug-resistant TB Multidrug-resistant TB (MDRTB) Extremely drug-resistant TB (XDRTB) Transmission Usually occurs through exposure to the tubercle bacilli in airborne droplets from persons with pulmonary tuberculosis who talk, cough, or sneeze Epidemiology (2012) Southeast Asia and Western Pacific region account for 58%. Africa accounts for 25% of cases. In United States, half of new cases are in New York, Florida, Texas, and California. Drug-resistant TB Multidrug-resistant TB (MDRTB): resistant to rifampin and isoniazid Extremely drug-resistant TB (XDRTB): MDRTB plus added resistance to fluoroquinolones and at least three injectable second-line drugs (e.g. amikacin, kanamycin, and capreomycin) Copyright © 2016 by Elsevier Inc.

TB: Diagnosis and Treatment
Tuberculin skin test (TST) Previously, purified protein derivative (PPD) test Used for initial screening Followed by chest x-ray for persons with positive skin reaction and pulmonary symptoms Prompt treatment with multiple antimicrobial drugs Treatment failure may be due to lack of client adherence, which can result in drug resistance. U.S. drug regimens include isoniazid and sometimes rifampin. Copyright © 2016 by Elsevier Inc.

Nurse’s Role in Providing Preventive Care for Communicable Diseases
Primary prevention Education on how to avoid infection Secondary prevention Testing and counseling for HIV Posttest counseling Partner notification and contact tracing Tertiary prevention Directly observed therapy Standard precautions Primary prevention Assessment: client’s risk level, sexual history, partner notification Interventions: client education and other actions aimed at prevention Sexual behavior: abstinence, condom use, female condoms (Fig. 14-4) Drug use: IV drug use, danger of using shared needles and syringes Community outreach: to reach those who do not seek care on their own Community education: spreading information about modes of transmission, testing, vaccine availability, early symptoms Evaluation: to determine whether adequate vaccination occurs, whether risky behavior changes to safe behavior, whether illness is prevented Secondary prevention—screening for disease to ensure early identification, treatment, and follow-up with contacts Tertiary prevention—managing symptoms, maintaining psychosocial support Directly observed therapy (DOT) programs for TB medication—nurses observe and document individual clients taking their TB drugs Standard precautions Client and family education about infection control in the home Dispelling myths and fears about transmission of HIV Copyright © 2016 by Elsevier Inc.

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