COMMUNICABLE AND NCDs
COMMUNICABLE AND NCDs
COMMUNICABLE AND NCDs
Communicable disease: a disease that can be spread to a person from another person, an
animal or object. Ex: common cold, influenza, tuberculosis, etc.
Non-communicable disease: a disease that can NOT be spread from person to person. Eg:
cancer, heart disease, cirrhosis, etc.
Common Pathogens:
Virus: smallest simplest life form. It causes upper respiratory infections and many
other type of diseases.
Bacteria: simple one-celled organisms. They are everywhere. Not all bacteria is bad.
Fungi: more complex than bacteria, but cannot make their own food. Thrive in warm,
moist environments.
Page 1 of 147
The poor hygiene behaviors promote the transmission of infectious diseases. The fecal-oral
and respiratory routes are the most common sources of transmission.Young children and
adults may not wash their hands after using toilets and before eating/preparing food.
COMMUNICABLE DISEASES
Definition of terms
Infection
Infection is the entry and development or multiplication of an infectious agent in the body
of man or animals. An infection does not always cause illness. There are several levels of
infection also known as Gradients of infection:
a. Colonization (S. aureus in skin and normal nasopharynx)Germs can also be in or on the
body, but not make you sick. This is called colonization
b. Subclinical or inapparent infection (polio): presence of infection in a host without the
occurrence of recognizable symptoms or signs.
c. Latent infection (virus of herpes simplex) - Virus latency (or viral latency) is the ability
of a pathogenic virus to lie dormant (latent) within a cell. A latent viral infection is a
type of persistent viral infection which is distinguished from a chronic viral infection.
d. Manifest or clinical infection. A clinical infection means one that presents with some
clinical symptoms. It's an infection where the patient has some complaints like fever,
cough etc. A 'subclinical' infection is where the patient is infected with organisms but
doesn't have any symptoms yet.
Contagious disease: A contagious disease is the one that is transmitted through contact.
Examples include scabies, trachoma, STD and leprosy.
Page 2 of 147
Vector of infection: An insect or any living carrier that transports an infectious agent from
an infected individual or its wastes to a susceptible individual or its food or immediate
surroundings. Both biological and mechanical transmissions are encountered.
Prevalence of an infectious disease: Number of cases (old and new) at a given time
Endemic: It refers to the constant presence of a disease or infectious agent within a given
geographic area or population group. It is the usual or expected frequency of disease within
a population.(En = in; demos = people)
Pandemic and Exotic:An epidemic usually affecting a large proportion of the population,
occuring over a wide geographic area such as a section of a nation, the entire nation, a
continent or the world, e.g. Influenza pandemics.
Exotic diseases are those which are imported into a country in which they do not otherwise
occur, as for example, rabies in the UK.
Sporadic: The word sporadic means “scattered about”. The cases occur irregularly,
haphazardly from time to time, and generally infrequently. The cases are few and
separated widely in time and place that they show no or little connection with each other,
nor a recognizable common source of infection.
However, a sporadic disease could be the starting point of an epidemic when the conditions
are favorable for its spread.
Latent period:This is the period between exposure and the onset of infectiousness (this
may be shorter or longer than the incubation period).
A case
A case is defined as “a person in the population or study group identified as having the
particular disease, health disorder, or condition under investigation”
Page 4 of 147
Chain of Disease Transmission
Page 5 of 147
The six factors involved in the chain of disease transmission are:
B. Reservoir of infection:
Any person, animal, arthropod, plant, soil or substance (or combination of these) in which
an infectious agent normally lives and multiplies, on which it depends primarily for
survival and where it reproduces itself in
Types of reservoirs
1) Man:There are a number of important pathogens that are specifically adapted to man,
such as: measles, smallpox, typhoid, meningococcal meningitis, gonorrhea and syphilis.
The cycle of transmission is from human to human.
2) Animals: Some infective agents that affect man have their reservoir in animals. The
term “zoonosis” is applied to disease transmission from animals to man under natural
conditions.
For example:
Page 6 of 147
o Man is not an essential part (usual reservoir) of the life cycle of the agent.
Many of the agents are basically saprophytes living in soil and fully adapted to live freely in
nature. Biologically, they are usually equipped to withstand marked environmental
changes in temperature and humidity. A saprophyte is an organism which gets its energy
from dead and decaying organic matter. This may be decaying pieces of plants or animals.
This means that saprophytes are heterotrophs. They are consumers in the food chain.
Page 8 of 147
E. Portal of entry:
The site in which the infectious agent enters to the susceptible host. For example:
Carriers
A carrier is “an infected person or animal that harbors a specific infectious agent in the
absence of (visible) clinical disease and serves as a potential source of infection to others.
This phenomenon occurs either due to inadequate treatment or immune response, the
disease agent is not completely eliminated, leading to a carrier state.
Types of carriers
Page 9 of 147
Incubatory or precocious carriers: These are individuals or persons who excrete the
pathogen during the incubation period (i.e. before the onset of symptoms or before the
characteristic features of the disease are manifested). E.g. Measles, mumps, chickenpox
and hepatitis
Convalescent Carriers: These are those who continue to harbor the infective agent after
recovering from the illness. E.g. Diphtheria, Hepatitis B virus.
Chronic Carriers: The carrier state persists for a long period of time. E.g. Typhoid fever,
Hepatitis B virus infection
Page 10 of 147
Concepts of Prevention and Control of communicable diseases: Concept of Prevention
Prevention
The goals of medicine are to promote health, to preserve health, to restore health when it is
impaired, and to minimize suffering and distress. These goals are embodied in the word
"prevention"
The concept of prevention is best defined in the context of levels, traditionally called
primary, secondary and tertiary prevention. A fourth level, called primordial prevention,
was later added.
Determinants of Prevention
1. Primordial prevention
Primordial prevention consists of actions and measures that inhibit the emergence of risk
factors in the form of environmental, economic, social, and behavioral conditions and
cultural patterns of living etc.
In primordial prevention, efforts are directed towards discouraging children from adopting
harmful lifestyles
The main intervention in primordial prevention is through individual and mass education
2. Primary prevention
Primary prevention can be defined as the action taken prior to the onset of disease, which
removes the possibility that the disease will ever occur.It signifies intervention in the pre-
pathogenesis phase of a disease or health problem.
It includes the concept of "positive health", a concept that encourages achievement and
maintenance of "an acceptable level of health that will enable every individual to lead a
socially and economically productive life".
Page 12 of 147
Primary prevention
Achieved
by
Specific
Health promotion
protection
Immunization and
Health chemoprophylaxi
seroprophylaxis
education Use
s of specific nutrients or supplementations
Environmental modifications
Protection against occupational hazards
Nutritional
interventions Safety of drugs and
Life style and behavioral changes Control
foods of environmental
hazards,
e.g. air pollution
Health promotion is “the process of enabling people to increase control over the
determinants of health and thereby improve their health”.
The WHO has recommended the following approaches for the primary prevention of
chronic diseases where the risk factors are established: A.
Population (mass) strategy B. High –risk strategy
Page 13 of 147
A. Population (mass) strategy: “Population strategy" is directed at the whole population
irrespective of individual risk levels. For example, studies have shown that even a small
reduction in the average blood pressure or serum cholesterol of a population would
produce a large reduction in the incidence of cardiovascular disease. The population
approach is directed towards socio-economic, behavioral and lifestyle changes
B. High -risk strategy: The high -risk strategy aims to bring preventive care to individuals
at special risk. This requires detection of individuals at high risk by the optimum use of
clinical methods.
1. Health promotion: This consists of general non-specific interventions that enhance health
and the body’s ability to resist disease, such as measures aimed at the improvement of
socio-economic status through the provision of adequately-paid jobs, education and
vocational training, affordable and adequate housing, clothing, and food, old-age pension
benefits; emotional and social support, relief of stress, etc. In short it is any intervention
that promotes a healthier and happier life.
2.Prevention of exposure:This includes actions such as the provision of safe and adequate
water, proper excreta disposal, vector control, safe environment at home (e.g., proper
storage of insecticides and medicines, out of children’s reach), at school and at work (e.g.,
proper ventilation, monitoring of harmful substances in factories), and on the streets (e.g.,
driver licensing laws).
3. Prevention of disease:-This occurs during the latency period between exposure and the
biological onset of disease. An example for this is immunization. Immunization against an
infectious organism does not prevent it from invading the immunized host, but prevents it
from establishing an infection.
Active immunization means exposing the host to a specific antigen against which it will
manufacture its own protective antibodies after an interval of about three weeks (during
which the immunized person remains susceptible to the disease). For active immunization
to be protective, the timing of its administration must be at least three weeks prior to
exposure.
Page 14 of 147
Passive immunization means providing the host with the antibodies necessary to fight
against disease.Passive immunization, on the other hand, is commonly given after exposure
has occurred (as in the case of exposure to rabies or tetanus), or shortly before an exposure
is expected, as in the administration of immune globulin to prevent viral hepatitis A).
Both forms of immunization act after exposure.
Breastfeeding is an example of an intervention that acts at all three levels of primary
prevention:
Health promotion: by providing optimal nutrition for a young child, either as the sole
diet up to four months of age, or as a supplement in later months.
Prevention of exposure: by reducing exposure of the child to contaminated milk.
Prevention of disease after exposure: by the provision of anti-infective factors,
including antibodies, white blood cells, and others
Page 15 of 147
3. Secondary prevention
It is defined as “action which halts the progress of a disease at its incipient stage and
prevents complications.” The specific interventions are: early diagnosis (e.g. screening
tests, and case finding programs….) and adequate treatment.
Secondary prevention attempts to arrest the disease process, restore health by seeking out
unrecognized disease and treating it before irreversible pathological changes take place,
and reverse communicability of infectious diseases.
It thus protects others from in the community from acquiring the infection and thus
provide at once secondary prevention for the infected ones and primary prevention for
their potential contacts.
Secondary prevention attempts to arrest the disease process, restore health by seeking out
unrecognized disease and treating it before irreversible pathological changes take place,
and reverse communicability of infectious diseases.
It thus protects others from in the community from acquiring the infection and thus
provide at once secondary prevention for the infected ones and primary prevention for
their potential contacts.
The objective here is to stop or slow the progression of disease so as to prevent or limit
permanent damage, through the early detection and treatment of disease. (e.g. breast
cancer (prevention of the invasive stage of the disease), trachoma (prevention of
blindness), and syphilis (prevention of tertiary or congenital syphilis
WHO Expert Committee in 1973 defined early detection of health disorders as “ the
detection of disturbances of homoeostatic and compensatory mechanism while
biochemical, morphological and functional changes are still reversible.”
The earlier the disease is diagnosed, and treated the better it is for prognosis of the case
and in the prevention of the occurrence of other secondary cases.
16
4. Tertiary prevention
It is used when the disease process has advanced beyond its early stages.After permanent
damage has set in, the objective of tertiary prevention is to limit the impact of that damage.
The impact can be physical, psychological, social (social stigma or avoidance by others),
and financial.
It is defined as “all the measures available to reduce or limit impairments and disabilities,
and to promote the patients’ adjustment to irremediable conditions.”
Intervention that should be accomplished in the stage of tertiary prevention are disability
limitation, and rehabilitation.
Rehabilitatio
n
Psychologica
Medical Vocational Social
l
rehabilitation rehabilitation rehabilitation
rehabilitation
17
18
Concepts of Communicable Disease Control
The term disease control describes ongoing operations aimed at reducing:
The incidence of disease
The duration of disease and consequently the risk of transmission
The effects of infection, including both the physical and psychosocial complications
The financial burden to the community.
Control>>>>>>Elimination>>>>>>> Eradication
Control refers to the reduction of the incidence and prevalence of communicable disease to
a level where it cannot be a major public health problem. Control activities focus on
primary prevention or secondary prevention, but most programs combine both.
Between control and eradication, an intermediate goal has been described, called "regional
elimination" The term "elimination" is used to describe interruption of transmission of
disease, as for example, elimination of measles, polio and diphtheria from large geographic
regions or areas. Regional elimination is now seen as an important precursor of eradication
a) Man as reservoir:
When man is the reservoir, eradication of an infected host is not a viable option.
Instead, the following options are considered:
Detection and adequate treatment of cases: arrests the communicability of the
disease (e.g.Treatment of active pulmonary tuberculosis).
Isolation: separation of infected persons for a period of communicability of the
disease.Isolation is indicated for infectious disease with the following features:
-High morbidity and mortality
-High infectivity
19
Quarantine: limitation of the movement of apparently well person or animal who
has been exposed to the infectious disease for duration of the maximum incubation
period of the disease.
b) Animals as reservoir:
Action will be determined by the usefulness of the animals, how intimately they are
associated to man and the feasibility of protecting susceptible animals.
For example:
- Plague: The rat is regarded as a pest and the objective would be to destroy the
rat and exclude it from human habitation.
- Rabies: Pet dogs can be protected by vaccination but stray dogs are destroyed.
- Infected animals used for food are examined and destroyed.
c) Reservoir in non-living things: Possible to limit man’s exposure to the affected area
(e.g.Soil, water, forest, etc.).
2. Interruption of transmission :
This involves the control of the modes of transmission from the reservoir to the potential
new host through:
- Improvement of environmental sanitation and personal hygiene
- Control of vectors
- Disinfections and sterilization
3. Protection of susceptible host:
This can be achieved through:
- Immunization: Active or Passive
- Chemo-prophylaxis- (e.g Malaria, meningococcal meningitis, etc.)
- Better nutrition
- Personal protection. (e.g.wearing of shoes, use of mosquito bed net, insect
repellents, etc.)
4. Disease Eradication:
Eradication literally means to "tear out by roots". It is the process of “Termination of all
transmission of infection by extermination of the infectious agent through surveillance and
20
containment”.Eradication is an absolute process, an "all or none" phenomenon, restricted
to termination of an infection from the whole world. It implies that disease will no longer
occur in a population.To-date, only one disease has been eradicated, that is smallpox.
Key points
The goals of medicine are to promote health, to preserve health, to restore health when
it is impaired, and to minimize suffering and distress. These goals are embodied in the
word "prevention"
The objective of preventive medicine is to intercept or oppose the "cause" and thereby
the disease process. This epidemiological concept permits the inclusion of treatment as
one of the modes of interventions to diseases.
Nutrition plays an important role in preventing illness and reducing morbidity and
mortality in people living with other infectious diseases
Quiz
1. State the six important factors that involve the chain of communicable diseases
transmission.
2. Describe the three levels of disease prevention.
3. Explain the methods used to control communicable diseases
The four factors crucial to the spread of communicable diseases include (A) The infective
agent, (B) The source of infection, (C) The mode of transmission and (D) The host.
The control of the spread of communicable diseases should focus on controlling all these
four factors so as to break the chain of infection.
22
23
Natural History of disease
The natural history of disease refer to the process of disease/condition progression from
the time it affect an individual to the time the individual recovers or dies if appropriate
measures are not instituted. The process has two distinct periods;
Pre-pathogenesis period: this is the period before the disease infects an individual. The
agent and host are interacting in the environment. At this level the host defense system is
well capable of handling the agent (causative organisms) hence there is no disease.
Pathogenesis period is the period that starts when the body defense mechanism has been
overcome by the agent (disease causing organisms). This result to the host cells dying this
takes various stages;
Sub clinical horizon; the host cells have started dying but to major effects are felt yet and
the host has no signs or symptoms of the disease. At this level only laboratory tests would
reveal the extent of damage.
Clinical horizon; at this time the damage on the cells is so much that some of the hosts
body functions are starting to fail. This manifests in signs and symptoms of a disease that
the host is feeling uncomfortable or sick. If the host does not receive appropriate medical
intervention then thy get in to the next stage.
Early disease stage; at this time the disease effects are real as a result of massive cell
damages that are affecting tissues functions. The host need appropriate intervention to
correct the damage. If they fail to receive correct interventions then the disease gets in to
the next level.
Advanced disease; at this level the damage to the host systems is massive and may be
irreversible leading to disability, or permanent damage. The host has three outcomes at
this stage i.e. recover, permanent disability, convalescence or in worst cases death.
##Communicable diseases are diseases that are as a result of the causative organism
spreading from one person to another or from animals to people. They are among the
major causes of illnesses in Kenya and the entire Africa. These diseases affect people of all
ages but more so children due to their exposure to environmental conditions that support
24
the spread. Communicable diseases are preventable base on interventions placed on
various levels of transmission of the disease.
New and emerging diseases are challenging public health as never before. Unfortunately,
many of these diseases affect the poor and marginalized sections of society, and contribute
not only to ill health and poverty at micro-level but also have serious socio-economic
implications at the macro-level.
Health workers have an important role to play in the control of these diseases by applying
effective and efficient management, prevention and control measures. Health workers need
to be equipped with capacity to target communicable diseases for eradication.
25
BASIC EPIDEMIOLOGY
Epidemiology is the study of distribution and determinants of disease and conditions among
populations. In the past, epidemiology was concerned exclusively with studying the nature
of infectious diseases, the causes and conditions of their origin, their spread in human
populations as well as the methods of preventing, controlling and eliminating them.
Epidemiological methods are increasingly playing an important role in the study of the
incidence and distribution of non-infectious (non-communicable disease) diseases, the
health status on population factors related to the origin and spread of those diseases and
factors that can help to maintain and restore health.
Disease distribution is considered in terms of Persons, time and place (Who, when and
where). Persons who are affected by disease in terms of age, sex, race, occupation etc. The
common characteristics relating to those persons affected by disease.
Time relates to when the diseases is most likely to strike e.g. an epidemic, endemic,
seasonal, cyclic etc
Place refer to the geographical distribution of a diseases and the common characteristics
that are favourable for that diseases in the given locality. Some diseases are localized,
regional, pandemic etc
The causative factors of disease are agent, host, and environment. These three factors are
referred as epidemiological triad. The mere presence of these factors is not sufficient to
initiate a disease. An interaction of all these three factors is necessary for individuals to be
affected. In pre-pathogenesis phase, the disease agent is already present but it has not
entered man. The next phase is the Pathogenesis: this phase begins with the entry of
disease agent into man. There are certain interval of time before the onset of clinical signs
and symptoms of the disease.
Epidemiological triad
26
27
Agent refers to the disease causing organism characteristics e.g. habitation, breeding
migration, infectivity, climatic and environmental factors favouring its existence.
Host refers to the biological makeup of the individuals that make the vulnerable to the
specified illness e.g. physical condition, genetic makeup, habits etc.
Environment refers to the ecological conditions that favour the interaction of host and
agent e.g. swampy areas, bushes within households, sanitation etc.
Control and prevention measures can be implemented at the various levels of the chains
shown above.
For example:
To break the chain between host and environment for malaria disease you need to clear
swampy areas, bushes and proper disposal of waste.
To break the chain between host and agent in malaria disease one can take prophylactic
anti-malaria drugs.
To break the chain between the environment and the agent one can spray the breeding
sites for mosquitoes and for the vector and host chain one can sleep under mosquito
net.
Vector is a vehicle that some of the agents or disease causing organism require to be move
from one point to the other, some require it to complete their developmental cycle e.g. a
mosquito in transmission of malaria. Not all communicable diseases require a vector for
transmission.
29
Epidemiological methods
Epidemiologic methods are the various approaches in which data is gathered analyzed and
reports written with regard to various diseases distribution and determinants. They enable
us to plan and evaluate disease management in communities.
They are several classified as:
A. Descriptive methods e.g. Individual based (case study and case series)
B. Population based (correlation studies, cross sectionals studies and surveys)
C. Analytical studies e.g. prospective (cohort studies) and retrospective (case control)
D. Experimental studies
E. Community based studies e.g. community trials
A. Descriptive studies
These are basic studies that seek to describe the situation as it is. These methods utilize
simple descriptive statistics such as percentages tables and graphs to describe the disease
situation. These studies generate hypothesis.
a. Individual based studies; they reflect on single individuals as the unit of study
Case report – a single unique case is reported as it is identified by the health worker.
Case series- several case reports that have similar characteristics are analyzed so as to
draw conclusions in relation to the particular disease of interest.
30
C. Analytical studies
These studies are more advanced in methodology and analysis and their findings are more
generalisable as compared to descriptive studies. While descriptive studies generate
hypothesis these ones test hypothesis.
a). Prospective studies (Cohort studies): These studies start with individuals with an
exposure of interest (cohorts) and are followed up over time as they are compared with
individuals who do not have the exposure of interest. Analysis is then done to find out if
those who had exposure will develop the outcome of interest more that those without
exposure.
Example: People working in farms (exposed to zoonotic disease) are followed up over time
to establish if they will manifest the zonnotic diseases. Simultaneously a similar group of
individuals who do not work in the farms are followed up to establish if they develop
zoonotic disease.
b). Retrospective (case control studies) These studies are easier to conduct consume less
time and are cheaper than the cohort studies. Two groups are selected from a population
one group with the disease of interest (case) and another without (control). Then they are
asked about their past in order to establish if they had a common exposure that might have
caused the disease. These studies are however prone to recall biases.
Example: In a community people who have amoebiasis may be asked about their food
(sources, preparation, storage and consumption) they have been consuming. Another
group from same community who do not suffer from amebiasis is also asked the same
questions then the data is analyzed.
D. Experimental studies
These are studies conducted in a controlled environment where the researcher has control
over all variables. It is a laboratory set up kind of study. They are very useful in isolation of
the actual disease causative agent. They are very strict and also very expensive. They
require highly specialized personnel and equipment.
Example: In one community water may be fluoridate while in the other it may not. The two
are followed up and with time if those taking water that is not fluoridated start
31
complaining of teeth problem then the effects of fluoride are confirmed.
Disease surveillance
Health Surveillance may be defined as the tracking and forecasting of any health event or
healthdeterminant through the; Continuous collection of high-quality data, Integration,
analysis and interpretation of those data into surveillance products (for example reports,
advisories, alerts, and warnings), Dissemination of those surveillance products to those
who need to know.
Surveillance products are produced for a specific public health purpose or policy objective.
Surveillance should be purposeful, economical, and action oriented. It should not only
detect emerging health risks, but include systems that allow public health officials to
monitor and evaluate progress in health protection and disease prevention.
New health risks such as bioterrorism and zoonoses, re-emergence of some diseases (e.g.,
multiresistant bacteria), and globalization have fundamentally altered the scope and
response time expected of surveillance programs at every level. Surveillance uses whatever
data sources will provide the necessary information.
Surveillance systems may share data with personal health services information systems,
but the end-products are different. Most of the data currently available from health
facilities are originally generated for administrative purposes. They can serve as raw
material for health services management and research, as well as for disease and health
surveillance if procedures for capturing and handling administrative data are appropriately
adapted.
32
Sources of surveillance data
In general, surveillance data can originate from any of four classes of source:
Special purpose: i.e., data collected specifically for a particular surveillance need. Special
purpose data sources select the most relevant data and facilitate detection and response,
but are costly to operate and may be difficult to maintain over the long term.
Surveys: Usually collected for more general health surveillance purposes, survey data
differ from other special purpose data sets in that they are usually cross-sectional or 'one-
off' and may be useful for multiple surveillance functions.
Clinical: For many surveillance purposes, this is the ideal source. Indeed, new diseases and
emerging clusters of known diseases are often first suspected by intelligent clinicians who
observe unusual patterns of illness, and work with others to initiate more systematic
surveillance. Optimum efficiency in clinical surveillance can only be achieved if the clinical
data are accessible electronically. This is rarely the case at present. The Electronic Health
Record has the potential to be a rich source of surveillance data in future. Moreover, as
submissions to the Committee have pointed out, clinical data for surveillance need to be
assembled from a range of providers and facilities, including family physicians and other
primary care providers, emergency departments, pharmacists, and veterinarians.
In 1998 WHO/AFRO, following the resolution of the 48th assembly started promoting
Integrated Disease Surveillance and Response (IDSR) for all member state to adopt as the
main strategy to strengthen national disease surveillance system.
33
Integrated disease surveillance and response (IDSR)
The specific goals of IDSR are to:
Strengthen district level surveillance and response for priority diseases,
Integrate laboratory with laboratory support,
Reduce duplication in reporting,
Share resources among disease control programs,
Basic ingredients:
A good network of motivated people,
Clear case definition and reporting mechanism,
Efficient communication system,
Basic but sound epidemiology,
Laboratory support,
Good feedback and rapid response:
Translate surveillance and laboratory data into specific and timely public health
actions
With the global momentum to scale up response to communicable diseases, public health
practitioners need to review constantly their performance in detecting and responding to
communicable diseases.
Notifiable diseases
In Kenya according to the public health act cap 254 ; 17(1) there are diseases that should
be notified to the higher authorities above your office as a health worker once you come
across them. They include;
14. Erysipelas, puerperal fever (including septicaemia, pyasmia, septic pelvic cellulitis or
other serious septic condition occurring during the puerperal state),
15. Enteric or typhoid fever (including para-typhoid fever),
16. Epidemic cerebro-spinal meningitis or cerebro-spinal fever,
17. Sleeping sickness or human trypanosomiasis,
18. Diphtheria or membranous croup measles,
19. Yaws and all forms of tuberculosis which are clinically recognizable apart from reaction
to the tuberculin test.
Some of the diseases are notifiable locally to the Medical Office of Health and others to both
the medical officer of health and the world Health Organization.
Diseases notifiable to the MOH on a weekly basis are Amoebiasis, schistomiasis (bilharzia),
ancylostoma (hookworms), brucellosis, dysentery, encephalitis and filariasis.
35
Importance of epidemiology in communicable diseases control
Page 36 of 147
the community to determine the probable number of cases and identify the population
at risk. Prevalence and incidence rates are also calculated using the data obtained.
5) Confirming or ruling out the diagnosis of actual cases and suspected cases to make
sure that all the cases and contacts are identified to organize activities aimed at
identifying the causative agent and determine whether any success is achieved to
established to ensure that serological methods and proper diagnostic tests are being
utilized and to establish criteria for defining a case and make sure known and suspected
cases are analysed.
6) Determining whether there is a true epidemic situation or not by calculating the
rates and comparing these rates with those which would correspond to an epidemic.
7) Determining the necessary data that characterize an epidemic using
epidemiological methods-descriptive, analytical and experimental. It is also used in
selecting and in obtaining the necessary specimens for laboratory tests in interviewing
cases and in acquiring other necessary data e.g. climate, demography, types of soil,
sanitation, routes of communication among others.
8) Data processing: This entails the preparation of tables, graphs, diagrams, maps, and
calculation of rates, ratios, proportions and maps showing distribution of cases to
construct an epidemic curve.
9) Data analysis: These interpret the epidemic curve, mode of transmission, determining
groups at risk in terms of time, person, place and incubation periods for those cases
detected and exposed for a short time.
10)Formulation of hypothesis on original source, duration of exposure and mode of
transmission: This shows the most likely reservoir, causative agent, mode of
transmission, vector agent, route of exit from the reservoir and port of entry into the
susceptible host. An explanatory report is also prepared on the facts which in addition
indicate the most probable source and mechanism of transmission.
11)Testing the hypotheses: In this process additional data is obtained to confirm the
exposure of the cases to the indicated sources and to verify the mode of transmission.
The specimens of the indicated source confirm its identity by isolating the agent from
the case.
Page 37 of 147
12)Identification of the recommendations to control the problem by laying down
procedures to eliminate or control the source, to prevent exposure of the susceptible
subjects to the source, to convert susceptible subjects into immune subjects and
indicate the appropriate treatment for cases, contact and carriers.
13)Evaluation of the effectiveness of the control measures by getting specimens for
laboratory tests, carrying out inspections, evaluating the procedure for handling cases
controlling the source and continuing with intensive surveillance operations.
14)Writing a report on the epidemic: The report summarizes all relevant data obtained
and enumerates the various interpretations made. The report describes the measures
taken, indicates the degree of the effectiveness of control measures, and explains the
results obtained and the measurers necessary to improve the control and surveillance
operations.
15)Evaluation: This involves collecting the relevant data through routine reports, using
direct or indirect health problem indicators e.g. incidence and prevalence of a disease
for which control activities have been organized.
There may be organized ad hoc surveys of population to measure absence/ presence of
indicators of programme efficiency.
Enables us to know the disease distribution patterns
Enables us to know the disease causation factors
It equips us with data that we can apply for effective prevention and control of diseases
It enable us to understand the disease progression and what measures need to be take
to halt or reduces disease effects
It enables us to evaluate intervention programs
It enables us to conduct research with regard to communicable diseases and how they
affect populations.
Incidence rates help us to know how fast the disease is spreading, infecting or affecting
people
Prevalence rates help us to know how many people are having a disease in the
population
Prevalence can also give an indication of how fast people are recovering, dying from the
disease and how many are in chronic stage of the disease.
Page 38 of 147
With this knowledge you can be able to interpreter and predict disease epidemiologic
patterns and hence plan for interventions. You can determine if a disease is an epidemic or
endemic.
There are various ways of classifying communicable diseases; the classification below is
the one that is considered to be best for ease of understanding.
Prevention
The goals of medicine are to promote health, to preserve health, to restore health when it is
impaired, and to minimize suffering and distress. These goals are embodied in the word
"prevention"
Page 39 of 147
Prevention; Definition and Concept
The concept of prevention is best defined in the context of levels, traditionally called
primary, secondary and tertiary prevention. A fourth level, called primordial prevention,
was later added.
Determinants of Prevention
g. a knowledge of causation,
h. dynamics of transmission,
Environmental factors
Immunologic factors
Nutritional factors
Genetic factors
Page 40 of 147
Services, Social factors, and Spiritual factors
Page 41 of 147
Leavell’s Levels of Prevention
Levels of prevention
Primordial prevention
Primary prevention
Secondary prevention
Tertiary prevention
Primordial prevention
Primordial prevention consists of actions and measures that inhibit the emergence of
risk factors in the form of environmental, economic, social, and behavioral conditions
and cultural patterns of living etc.
For example, many adult health problems (e.g., obesity, hypertension) have their early
origins in childhood, because this is the time when lifestyles are formed (for example,
smoking, eating patterns, physical exercise).
Page 42 of 147
The main intervention in primordial prevention is through individual and mass
education
Primary prevention
Primary prevention can be defined as the action taken prior to the onset of disease,
which removes the possibility that the disease will ever occur.
It includes the concept of "positive health", a concept that encourages achievement and
maintenance of "an acceptable level of health that will enable every individual to lead a
socially and economically productive life".
Page 43 of 147
Primary prevention
Achieved by
Specific
Health promotion
protection
Health promotion
Health promotion is “the process of enabling people to increase control over the
determinants of health and thereby improve their health”.
The WHO has recommended the following approaches for the primary prevention of
chronic diseases where the risk factors are established:
Page 44 of 147
Population (mass) strategy
The high -risk strategy aims to bring preventive care to individuals at special risk. This
requires detection of individuals at high risk by the optimum use of clinical methods.
Secondary prevention
It is defined as “action which halts the progress of a disease at its incipient stage and
prevents complications.” The specific interventions are: early diagnosis (e.g. screening
tests, and case finding programs….) and adequate treatment.
Secondary prevention attempts to arrest the disease process, restore health by seeking out
unrecognized disease and treating it before irreversible pathological changes take place,
and reverse communicability of infectious diseases.
It thus protects others from in the community from acquiring the infection and thus
provide at once secondary prevention for the infected ones and primary prevention for
their potential contacts.
Secondary prevention attempts to arrest the disease process, restore health by seeking out
unrecognized disease and treating it before irreversible pathological changes take place,
and reverse communicability of infectious diseases.
Page 45 of 147
It thus protects others from in the community from acquiring the infection and thus
provide at once secondary prevention for the infected ones and primary prevention for
their potential contacts.
WHO Expert Committee in 1973 defined early detection of health disorders as “ the
detection of disturbances of homoeostatic and compensatory mechanism while
biochemical, morphological and functional changes are still reversible.”
The earlier the disease is diagnosed, and treated the better it is for prognosis of the case
and in the prevention of the occurrence of other secondary cases.
Tertiary prevention
It is used when the disease process has advanced beyond its early stages. It is defined as
“all the measures available to reduce or limit impairments and disabilities, and to promote
the patients’ adjustment to irremediable conditions.”
Intervention that should be accomplished in the stage of tertiary prevention are disability
limitation, and rehabilitation.
Disability limitation
disease
impairment
disability
handica
p
Page 46 of 147
Impairment: Impairment is “any loss or abnormality of psychological, physiological or
anatomical structure or function.”
Rehabilitatio
n
Psychologica
Medical Vocational Social
l
rehabilitation rehabilitation rehabilitation
rehabilitation
(II) Control
Concept of control:
Page 47 of 147
Control activities focus on primary prevention or secondary prevention, but most
programs combine both.
control
elimination
eradication
Disease Elimination
Between control and eradication, an intermediate goal has been described, called
"regional elimination"
Disease Eradication
Page 48 of 147
Eradication is an absolute process, an "all or none" phenomenon, restricted to
termination of an infection from the whole world. It implies that disease will no
longer occur in a population.
Monitoring
Objectives of Surveillance
to provide information about new and changing trends in the health status of a
population, e.g., morbidity, mortality, nutritional status or other indicators and
environmental hazards, health practices and other factors that may affect health
(b) to provide feed-back which may be expected to modify the policy and the
system itself and lead to redefinition of objectives, and
Page 49 of 147
Control of infectious diseases (the 4 “C”s
Contro
l
Diagnosis
notification
isolation observation detection Epidemiological
Investigation &
disinfection
treatment containment
follow up
release
Evaluation of control
Evaluation is the process by which results are compared with the intended
objectives, or more simply the assessment of how well a program is performing.
Page 50 of 147
Evaluation may be crucial in identifying the health benefits derived (impact on
morbidity, mortality, sequelae, patient satisfaction).
Evaluation studies may also be carried out to generate information for other
purposes, e.g., to attract attention to a problem, extension of control activities,
training and patient management, etc.
To summarize
The goals of medicine are to promote health, to preserve health, to restore health
when it is impaired, and to minimize suffering and distress.
Quiz
Match the following statements. Each option may be selected once, more than
once, or not at all:
Page 51 of 147
(b) recommending regular physical activity to a patient with no known
medical problem
Page 52 of 147
A. Faeco-Orally Transmitted Diseases
Introduction
Faeco-orally transmitted diseases are diseases in which the infectious agents are found
in faeces (stool) and enter the body through the mouth (oral route). The mode of
transmission may be in contaminated food or water, on the hands, or on objects such as
bowls, spoons and cups. These diseases are also referred to as faeco-oral diseases.
Faeco-oral diseases can be caused by a wide range of infectious agents, including bacteria,
viruses, protozoa (single-celled parasites) and helminths (parasitic worms). All human
parasites, whether they are single-celled or many-celled, live inside the human body: some
are harmless, but others cause disease. Poliomyelitis (polio) is a viral faeco-orally
transmitted disease.
Page 53 of 147
duodenalis
Taeniasis (taeniasis is ‘tee-nya-sis’) Taenia saginata (most cases)
m(tapeworm)
Page 54 of 147
Direct and indirect faeco-oral transmission
Faeco-oral transmission means ‘from faeces to mouth’. The route can either be:
1. Direct transmission from contaminated hands touching the mouth and transferring
the infectious agents directly; A person’s hands become contaminated with faeces in
several ways, including:
Page 55 of 147
Sources of water (streams, wells, etc.) can be contaminated with faeces washed out
of the soil by heavy rain if people defaecate in open fields, or in poorly constructed
latrines
Hands or utensils for eating or drinking may be washed in contaminated water
Contaminated containers may be used to fetch or store water.
The figure (f-diagram) below illustrates the different ways that faeco-oral transmission can
occur via the six Fs:
For example; microbes in faeces on the ground by a well can get into the water system and
be drunk by a child, hands that have not been washed after going to the toilet can carry
microbes onto foods, which are then eaten, infecting another child, who gets diarrhoea and
Page 56 of 147
spreads more microbes.
Water That Has Come Into Contact With Faeces And Is Then Inadequately Treated
Before Drinking;
Food That Has Been Handled With Faeces Present;
Poor Sewage Treatment Along With Disease Vectors Like Houseflies;
Poor or absent cleaning after handling faeces or anything that has been in contact with
it
Page 57 of 147
Key practices designed to prevent diarrhoeal infection and break the transmission
route:
Faeces in the public and domestic environment are the primary source of diarrhoeal
pathogens. Safe disposal of stools is the best way to prevent infection. Ideally adult and
child stools should be disposed of in toilets or latrines. In places where this is not possible,
stools should be buried
Hand washing
Hands readily become contaminated with faecal material after going to the toilet or
cleaning children’s bottoms. Rinsing fingers with water alone is not enough. Hands need to
be well washed after contact with faeces; either rubbed with an abrasive such as ash or
mud, or with a detergent such as soap.
A plentiful and accessible water supply makes hand washing and cleaning easier, which
helps to keep the environment free of pathogens. Ensuring that faecal material does not get
into water supplies at the source is probably far more effective than boiling, filtering, and
covering water jars.
Fly control
Though flies can carry microbes from faeces to food, fly control is difficult to achieve. If
stools are disposed of in toilets or latrines and these latrines have covers, then fly-based
disease transmission will be minimised.
Food hygiene
Page 58 of 147
Poor food handling practices contribute to diarrhoeal infection largely because they offer
bacterial pathogens the opportunity to multiply. This way people can consume much
greater doses of microbes. Diarrhoeas often peak in warm, humid seasons in the tropics,
when conditions are favourable to the multiplication of bacteria on food.
Feeding bottles are especially dangerous because they are hard to sterilise and bacteria
grow quickly in warm milk.
Page 59 of 147
Ways to prevent faecal contamination of hands
Page 60 of 147
Ways to prevent contamination from unsafe water
QUIZ: Use the letters assigned to each measure to indicate your answers
Which of the measures described above will help to prevent the transmission of infectious
agents by flies?
Measures C6, E1, E2, F1 and F2 will all reduce the risk of faeco-oral diseases
transmitted by flies.
Which of the measures described above are most important when preparing milk for
feeding to young children?
Measures A1, A2, A3, B, C1, C2, D1, D2, D3, G and H.
In simple terms, the average faeces can contain 10,000,000 viruses and 1,000,000 bacteria
Cholera
Poliomyelitis
Page 61 of 147
Typhoid Fever
Hepatitis A and E
Shigellosis
1) Diarrhoea
Diarrhoea occurs when stools contain more water than normal, and are loose or watery. In
many regions diarrhoea is defined as three or more loose or watery stools in a 24-hour
period. Children between the ages of 6 months and 2 years often have diarrhoea. It is more
common in settings of poor sanitation and hygiene, including a lack of safe drinking water.
Causative Agents
Viruses such as retro viruses, myxoviruses; bacteria such as salmonella; fungi; parasites
such as Gardia, stronglyloides and other infections like otitis media, measles, broncho-
pneumonia.
Incubation Period
This can take a few hours to three days.
Occurrence
It is universal in distribution. 2,195 Children die daily of diarrhea more than AIDS, malaria
and measles combined – that’s like losing nearly 32 school buses full of children each day.
Diarrhea diseases accounts for 1 in 9 child deaths worldwide, making diarrhea the second
leading cause of death among children under the age of 5 years. For children with HIV,
diearrhoea is even more deadly; the death rate for these children is 11 times higher than
the rate for children without HIV. About 45% of the children in the world die from
diarrhea-associated diseases. Anybody can get diarrhea.
Susceptibility
All people are susceptible although babies and children are at a much higher risk.
Mode of transmission
Infection is acquired through man, animal, flies, faeces and refuse. All unhygienic practices
encourage infection. The organisms are ingested through food, water and milk.
Contamination occurs due to poor hand washing habits when feeding, eating, preparing
and serving food. Contamination also occurs due to poor water and refuses disposal
methods. Raw and improperly cooked foods may also be a source of infection as they can
Page 62 of 147
cause indigestion, leading to diarrhea. Diarrhea may be associated with other diseases like
cholera, shigella dysentery, typhoid and amoebiasis. Bottle feeding of babies can also lead
to diarrhea.
Travellers' Diarrhea
Travelers' diarrhea, is the most common illness affecting travelers. Each year between
20%-50% of international travelers, an estimated 10 million persons, develop diarrhea.
The onset of Travellers’ Diarrhea usually occurs within the first week of travel but may
occur at any time during travel, and even after returning home.
The most important determinant of risk is the traveler's destination. High-risk
destinations are the developing countries of Latin America, Africa, the Middle East, and
Asia. Attack rates are similar for men and women. The primary source of infection is
ingestion of fecally contaminated food or water.
Bacterial enteropathogens cause approximately 80% of Travellers’ Diahrrea. The most
common causative agent isolated in countries surveyed has been enterotoxigenic
Escherichia coli (e.Coli).
Besides e.Coli and other bacterial pathogens, a variety of viral and parasitic enteric
pathogens also are potential causative agents.
The good news is that Travellers’ Diarrhea is rarely life-threatening. The natural history is
that 90% of cases resolve within 1 week, and 98% resolve within 1 month
Clinical features
A person suffering from diarrhea typically passes abnormally loose stool 4-5 times or more
a day and may show signs of dehydration such as;
Thirst
Page 63 of 147
Dry mucous membranes and lips
Dry furred tougue
Sunken eyes
Lack of tears
Rapid weight loss
Rapid and weak pulse
Inelastic skin
Less urine (oliguria)
General weakness
Sunken fontanelle
Laboratory Diagnosis
A stool sample is taken for ova and cysts and for culture and sensitivity
Types Of Diarrhoea
Most diarrhoea that causes dehydration is loose or watery. Cholera is one example, though
only a small proportion of all loose or watery diarrhoeas are due to cholera.
i. Acute Diarrhoea
Acute Diarrhoea is an episode of diarrhoea that lasts less than 14 days. Acute watery
diarrhoea causes dehydration and contributes to malnutrition. The death of a child with
acute diarrhoea is usually due to dehydration.
ii. Persistent Diarrhoea
Persistent Diarrhoea is an episode that lasts 14 days or more. Up to 20% of episodes of
diarrhoea become persistent, and this often causes nutritional problems and contributes to
death in children.
iii. Dysentery
Dysentery is diarrhoea with blood in the stool, with or without mucus. The most common
cause of dysentery is Shigella bacteria. Amoebic dysentery is not common in young
children. A child may have both watery diarrhoea and dysentery.
Acute Diarrhea
• Increased number of bowel movements
• Loose and watery stools
Page 64 of 147
•↑ Fluid and electrolyte loss
Diarrhea Etiology
• Watery
Rotavirus, Norwalk like viruses, enterotoxigenic E coli (ETEC), Vibrio cholerae,
Staphylococcus aureus, Clostridium difficile, Giardia, and cryptosporidia
•Bloody
Shigella and Entamoeba histolytica. Campylobacter organisms, invasive E coli, Salmonella,
Aeromonasorganisms, C difficile, and Yersinia
Diarrhoea Management
• Maintain appropriate hydration
• Continued feeding
• Drug therapy: limited cases (Integrated Management Childhood Illness)
– Dysentery /cholera
– Antiparasitic (amebiasis/giardiasis)
Persistent Diarrhoea
•>14 days (IMCI > 7 days)
•Causes
•Inadequate diet
•Malabsorption
•Parasitosis
•Management
•Adjust diet
•Consider antiparasitic agents
Page 65 of 147
Management of Diarrhoea Diseases
Rehydration and electrolytes is the first priority. Give fluids immediately using whatever is
readily available through appropriate route. Appropriate drugs are given after isolating the
causative agent.
a) Oral rehydration solution
In preparing oral rehydration solution (ORS), measure 1 litre of drinking water into a
container and add one sachet of ORS. Taste the solution. It should not be more salty than
tears. Give the patient small sips every few minutes.
Even when the person is vomiting, the vomit is normally less than the solution taken and
some absorption still takes place in the gut. Twenty different campanies make ORS and
have clear instruction of how to make the solution.
One litre of solution of oral rehydration salts contains 2.9 grams of sodium citrate
dehydrate (best recommended), or 2.9 grams of sodium citrate or 2.5 grams sodium
bicarbonate (also recommended), 1.5 grams of potassium chloride and 20 grams of
glucose (carrier molecule for the solution) or 20 grams sucrose or 40 grams of
common sugar. UNICEF packets are available and contain WHO recommendations.
Page 66 of 147
Anti-diarrhoea drugs like mist kaolin and lomotil are not recommended although
some doctors do prescribe them depending on the individual case.
Page 67 of 147
severe under-nutrition. If patient has diarrohea for longer than 14 days with or without
blood, continue feeding and refer for treatment. If the patient has fever 38.5 o C (101oF) or
greater, show the mother how to cool the child with a wet cloth and fanning and look for
and treat other causes fro instance pneumonia and malaria
Infectious agent
It is caused by shigella group of bacilli – which are non-motile and gram-negative. Shigella
is comprised of four species or serotypes.
Group A= Shigella dysentraie (most common cause)
Group B= Shigella flexneri
Group C= Shigella boydii
Group D= Shigella sonnei
Epidemiology
Occurrence- It occurs worldwide, and is endemic in both tropical and temperate climates.
Outbreaks commonly occur under conditions of crowding and where personal hygiene is
poor, such as in jails, institutions for children, day care centers, mental hospitals and
refugee camps. It is estimated that the disease causes 600,000 deaths per year in the world.
Two-thirds of the cases, and most of the deaths, are in children under 10 years of age.
Reservoir-Humans and domestic animals may harbor and disseminate the organisms
Mode of transmission-
Mainly by direct or indirect fecal-oral transmission from a patient or carrier. Transmission
through water and milk may occur as a result of direct fecal contamination. Flies can
Page 68 of 147
transfer organisms from latrines to a non-refrigerated food item in which organisms can
survive and multiply.
Incubation period-
12 hours-4 days (usually 1-7 days)
Period of communicability
During acute infection and until the infectious agent is no longer present in feces, usually
within four weeks after illness. The carrier state may persist for one to two years
Mode of Transmission
The disease may be transmitted through contaminated food, milk, water, hands and the
faecal-oral route. It can also be transmitted indirectly via soiled articles and by flies
Clinical Manifestation/features
The onset is sudden and characterized by
Fever, rapid pulse, vomiting and abdominal cramp are prominent.
Anorexia
Diarrhea usually appears after 48 hours with dysentery supervening two days later.
Headache
Malaise
Generalized abdominal tenderness.
Tenesmus is present and feces are bloody, mucoid and of small quantity. ( there is
an urge to open the bowel (tetesmus) but it is painful and difficult and if anything
comes out, it is purulent, and contains mucus and blood
Dehydration is common and dangerous - it may cause muscular cramp, oliguria,
toxemia and shock.
Diagnosis
Page 69 of 147
The disease is diagnosed on the based on clinical features
Stool microscopy (presence of pus cells)
Stool and rectum swabs of culture and sensitivity
Management
The disease is managed by isolating suspected and confirmed cases until the stool is free
from organism. Rehydration is done orally in mild cases and intravenous fluids given in
severe cases. Strict intake and output charts should be maintained while the patient is put
on bed rest and a light, balanced low residue diet. Concurrently and terminal disinfection
are carried out and the patient’s vital signs, TPR and BP and the general condition i.e pain,
muscle cramps, types of stool, anxiety and signs of dehydration are observed.
The anus which tends to get sores, should be kept dry. The sores can be soothed by
applying petroleum jelly. A daily bath to prevent pressure sores is necessary
Page 70 of 147
DIARRHEA
0-2 months old infants
Dehydration
Dehydration Evaluation
Assess Degree
Identify Type
Page 71 of 147
MILD Up to 5% 3%
3) Cholera
Modes of Transmission: Faecal Oral Route. Robert Koch (1843-1910) discovered cholera.
John Snow (1913) was the first to demonstrate that cholera is transmitted by contaminated
water.
The patient starts passing stools frequently, which are white like rice water, and gets
repeated vomiting. The disease can be diagnosed by the microscopic examination of the
stool or the vomit when the typical comma-shaped cholera vibrio’s can be seen.
Treatment:
Rapid replacement of fluid and electrolytes is needed by oral rehydration- therapy. You can
make your own oral rehydration solution (ORS) at home by adding one teaspoon of sugar
and a pinch of salt to one quarter of water. Drugs tetracycline and chloramphenicol are
used.
Page 72 of 147
Modes of Transmission: Polio virus usually enters the body via alimentary canal (faecal
oral route) where it multiplies and reaches the nervous system through the blood stream.
It produces inflammation of the nervous system. Stiffness of the neck is an important sign.
Paralysis starts following the weakness of particular skeletal muscles. The attack of
paralysis begins with high fever, headache, chilliness, pain all over the body.
There must be provided an adequate arrangement for proper disposal of urine and faeces
of the patient, because they contain polio virus. Overcrowding of children in schools,
playgrounds and cinema halls should be avoided. Polio is preventive. Polio vaccine is safe
and effective. The first polio vaccine was prepared by Jonas Salk (1953). The killed virus is
called “Salk Vaccine” and injected to develop immunity. Jonas Salk is called “father of polio
vaccine”.
B. Airborne Diseases
The average person has two or three colds a year. Colds are caused by many viruses, which
cause similar symptoms. The same virus can cause another cold after re-exposure.
Page 73 of 147
However, the second illness is usually milder and lasts for a shorter period of time.
Seasonal patterns may be seen for some of the viruses.
Transmission:
Common cold viruses can be spread by three mechanisms:
O Direct contact –colds are primarily spread from person-to-person via hands.
The virus can stay alive on the skin for at least two hours. Thus, if a sick person
shakes someone’s hand and that individual then touches his eye, nose, or mouth, the
virus can be transmitted and later infect that person.
O Indirect contact –viruses may survive on surfaces such as countertops for several
hours thus can be transmitted from touching that surface and then touching the
mouth, nose, or eyes.
O Inhaling viral particles –droplets containing viral particles can be breathed,
coughed, or sneezed into the air and transmitted to others if another person is
standing close (within a few feet) and the droplet touches that person’s eye, nose, or
mouth. Covering the mouth while coughing or sneezing reduces this risk.
Persons with colds shed viruses the most on the second day of illness, however, low levels
of viral shedding may persist for up to two weeks.
Saliva generally does not spread the common cold virus as most people with a cold have
no detectable virus in their saliva.
Studies of using recirculated air in commercial airliners versus fresh air ventilation show
no difference in the number of colds reported by persons after the flight.
Risk factors:
There are some factors that can increase the risk and severity of illness with a cold. There is
no scientific basis for the belief that a cold climate increases susceptibility to getting a
respiratory illness. Increased risks of developing cold symptoms occur with:
1. Psychological stress
2. Lack of sleep or sleep disturbances
Page 74 of 147
3. Exposure to children in daycare settings
Clinical features:
Symptoms of the common cold are mostly due to the response of the individual to the
infection, rather than to direct damage to the respiratory tract from the virus. Symptoms
vary from person to person and include:
Rhinitis (runny nose) and congestion are the most common symptoms.
Sore throat, sneezing, cough, malaise (feeling ill)
Fever is uncommon in adults but may be present in children
Purulent (colored, thick drainage containing pus) drainage may be seen with the
common cold. The presence of purulence does not distinguish between a cold or
sinus infection.
Diagnosis:
The diagnosis is based on symptoms and observed signs.
Swelling and congestion of nasal passages
Redness of the throat
Enlarged lymph nodes in the neck
Page 75 of 147
Normal lung exam
Chest x-rays not needed unless chest exam is abnormal
Complications:
Acute sinus infections are a rare complication in adults with colds. Viral sinusitis occurs
more frequently than secondary bacterial sinusitis. Viral sinusitis will resolve within 3
weeks without antibiotic treatment.
Lower respiratory tract disease:
O RSV (respiratory syncytial virus) can cause an infection in the lungs especially in
children, older adults, and immune compromised patients.
O Acute asthma attacks occur with colds thought to be due to changes in airway
reactivity which can last up to four weeks following an infection.
Ear infections:
O Because colds cause problems with drainage and pressure regulation of the
middle ear, an acute ear infection (otitis media) can occur.
Treatment:
Symptomatic therapy is the only thing necessary for treating the common cold as it is a
self-limited infection (meaning it will go away with time). Antibiotics are not effective and
Page 76 of 147
should not be prescribed unless there is convincing evidence of the presence of a bacterial
infection.
Page 77 of 147
O Topical glucocorticoids such as Flonase®, Nasonex®, etc. are of no proven benefit
for patients with the common cold though are of benefit in treating patients with
allergic rhinitis.
Zinc
O Zinc intake has been shown to be associated with a reduction in the duration and
severity of cold symptoms.
O However, zinc containing products, especially intranasal ones, have been
associated with the permanent loss of smell.
Vitamins and herbal remedies
O Vitamin C –if started after the onset of cold symptoms does not reduce symptom
severity or duration.
O Echinacea –studies have failed to demonstrate any benefit when used to treat the
common cold.
Antiviral therapy
O There are studies using intranasal interferon for the treatment of the common
cold. There may be some benefit to the use of interferon but the safety and
practicality of use has yet to be determined and this product is not currently
available.
Antibiotic therapy
O Treatment with antibiotics for the common cold causes more harm than benefit.
Antibiotics do not kill viruses and should not be prescribed for a cold. Adults treated
with antibiotics have a risk for developing allergic reactions such as rashes; GI
symptoms such as diarrhea, nausea, vomiting; swelling of the face; seizures;
dizziness; etc.
Analgesics
O Acetaminophen and non steroidal anti-inflammatory drugs (NSAIDs) reduce
headaches, achiness, and fevers. They do not improve cough or nasal discharge and
do not reduce the duration of symptoms.
Prevention:
Page 78 of 147
Studies have not proven that the use of alcohol gels prevent developing symptoms of a
respiratory illness as the virus can be spread by inhaling droplet particles. However
general hygienic measures such as hand washing have been shown to prevent the spread of
respiratory viruses especially from younger children.
Decontamination of environmental surfaces with disinfectants that kill viruses may help
decrease the rate of transmission. However a study of the effectiveness of antibacterial
cleaning products failed to show a difference when compared to standard cleaning
products in the incidence of colds.
Vitamins -regular supplementation with vitamins C, D, and E have not been shown to
decrease the incidence of colds.
Zinc –there have been studies that show that children taking zinc sulfate decreased the
rate of development of colds, however studies have not shown this to work for adults. Zinc,
especially when found in intranasal products, can lead to the loss of smell.
Pathogen:
Mycobacterium tuberculosis.
Modes of Transmission:
The bacteria damage the tissues and release a toxin named tuberculin which produces the
disease. It affects the lungs, lymph nodes, bones and joints.
Incubation period:
Page 79 of 147
Symptoms of pulmonary (lungs) tuberculosis are fever, cough, blood containing sputum,
pain in the chest and loss of weight, excessive fatigue, failure of appetite, slight rise of
temperature in the evening, hoarseness of throat, night sweating and rapid pulse. Diagnosis
of ТВ is done by Mantoux Test.
BCG vaccine gives protection against tuberculosis. When coughing, he/she should keep the
handkerchief before his/her mouth. Tuberculosis is curable.
3) Pneumonia
Lymph and mucus collect in the alveoli and bronchioles of the lungs so that the lungs do not
get sufficient air. Therefore, proper exchange of gases does not take place in the alveoli. No
vaccine is available
Treatment:
4) Measles
History of Measles
Page 80 of 147
Measles is an acute viral infectious disease. References to measles can be found from as
early as the 7th century. The disease was described by the Persian physician Rhazes in the
10th century as “more to be dreaded than smallpox.”
In 1846, Peter Panum described the incubation period of measles and lifelong immunity
after recovery from the disease. Enders and Peebles isolated the virus in human and
monkey kidney tissue culture in 1954. The first live attenuated vaccine was licensed for use
in the United States in 1963 (Edmonston B strain).
Before a vaccine was available, infection with measles virus was nearly universal during
childhood, and more than 90% of persons were immune by age 15 years. Measles is still a
common and often fatal disease in developing countries. The World Health Organization
estimates there were 145,700 deaths globally from measles in 2013.
Measles infection was distinguished from smallpox as early as the 9th century by an Arab
physician by the nameof AbuBecr Razi (the Doctor of Baghdad).
• However, there is no record of repeated epidemics identified as measles until the 11th
and 12th centuries.
• Measles was first mentioned as a childhood disease in 1224.
• The Danish physician Peter Panum is generally given credit for illuminating the basic
principles of measles infection and epidemiology during his trip to the Faroe Islands in
1846 during a measles epidemic.
• Estimated to have killed about 200 million worldwide in the last 150 years
Page 81 of 147
• There is only one antigenic type of measles virus. Although studies have documented
changes in the Hglycoprotein, these changes do not appear to beepidemiologically
important (i.e., no change in vaccine efficacy has been observed).
• Measles virus is rapidly inactivated by heat, light, acidic pH, ether, and trypsin. It has a
short survival time (<2 hours) in the air, or on objects and surfaces.
In 2000, countries represented by the World Health Organization (WHO) Regional Office
for Africa established a goal to reduce, by the end of 2005, measles mortality to 50% of the
506,000 deaths from measles estimated in 1999.
In Kenya, an east African country with a population estimated at 33.4 million in 2005, the
Kenya Expanded Programme on Immunization (KEPI) in the Ministry of Health began
implementing these strategies in 2002 with a wide age range catch-up SIA* and reduced
the number of reported measles cases by >99%, from 11,304 in 2001 to 20 in 2004. A
follow-up SIA, initially scheduled for July 2005, was postponed to 2006 to include
concurrent distribution of long-lasting insecticide-treated bed nets (LLINs).
This report documents progress made in reducing measles morbidity and mortality in
Kenya and describes the consequences of a large measles outbreak, beginning in
September 2005, on the integrated measles follow-up SIA
Immunization Activities
KEPI was established within the Kenya Ministry of Health in 1980, with the goal of
immunizing all children in the country against six vaccine-preventable diseases. § National
Page 82 of 147
coverage with 1 dose of measles vaccine (provided at age 9 months) increased in the early
1990s to 84% of children aged 12 months but decreased to 72% in 2002.
To accelerate measles control, goals were established in 2002 to achieve and maintain
national average measles vaccination coverage at 90%, with every district expected to
attain a coverage of >85%. Since then, reported national measles vaccination coverage
increased to 77% in 2006, and the proportion of districts with coverage >85% increased
from 10% in 2002 (eight of 77 districts) to 35% in 2006 (27 of 78 districts).
Measles Surveillance
After the 2002 measles catch-up SIA, Kenya implemented a system of case-based
surveillance for measles within the existing surveillance network for acute flaccid paralysis.
In this system, for each suspected measles patient who visits a health facility, a measles
case report form is completed, and a blood specimen is taken for measles immunoglobulin
M testing at the national measles laboratory.
In an outbreak, defined as five or more cases reported from the same health area in a
month, specimens are collected from five cases. If three or more test positive, the outbreak
is confirmed as measles, untested cases are confirmed by epidemiologic linkage, and
specimen collection stops after throat swabs are collected for viral genotyping.
In 2003, a total of 1,791 suspected measles cases were reported through this case-based
surveillance system, including 59 cases that were confirmed by laboratory or
epidemiologic linkage. In 2004, a total of 1,968 suspected cases were reported, including 20
Page 83 of 147
that were confirmed; in 2005, a total of 1,061 suspected cases were reported, including 151
that were confirmed.
During 2003--2005, more than 99% of suspected cases were reported with a blood
specimen, and the proportion of districts reporting at least one suspected measles case
increased from 69% in 2004 to 99% in 2005.
Measles Virus
The measles virus is a paramyxovirus, genus Morbillivirus.
It is 120–250 nm in diameter, with a core of single-stranded RNA, and is closely related to
the rinderpest and canine distemper viruses. Two membrane envelope proteins are
important in pathogenesis.
They are the F (fusion) protein, which is responsible for fusion of virus and host cell
membranes, viral penetration, and hemolysis, and the H (hemagglutinin) protein, which is
responsible for adsorption of virus to cells.
There is only one antigenic type of measles virus. Although studies have documented
changes in the H glycoprotein, these changes do not appear to be epidemiologically
important (i.e., no change in vaccine efficacy has been observed).
Measles virus is rapidly inactivated by heat, sunlight, acidic pH, ether, and trypsin. It has a
short survival time (less than 2 hours) in the air or on objects and surfaces
Pathogenesis
Measles is a systemic infection. The primary site of infection is the respiratory epithelium
of the nasopharynx. Two to three days after invasion and replication in the respiratory
epithelium and regional lymph nodes, a primary viremia occurs with subsequent infection
of the reticuloendothelial system.
Page 84 of 147
Following further viral replication in regional and distal reticuloendothelial sites, a second
viremia occurs 5–7 days after initial infection. During this viremia, there may be infection
of the respiratory tract and other organs. Measles virus is shed from the nasopharynx
beginning with the prodrome until 3–4 days after rash onset.
Clinical Features
The incubation period of measles, from exposure to prodrome, averages 10–12 days. From
exposure to rash onset averages 14 days (range, 7–21 days).
The prodrome lasts 2–4 days (range 1–7 days).
It occurs 1–2 days before the rash to 1–2 days after the rash, and appears as punctate blue-
white spots on the bright red background of the buccal mucosa.
The measles rash is a maculopapular eruption that usually lasts 5–6 days. It begins at the
hairline, then involves the face and upper neck. During the next 3 days, the rash gradually
proceeds downward and outward, reaching the hands and feet.
The maculopapular lesions are generally discrete, but may become confluent, particularly
on the upper body. Initially, lesions blanch with fingertip pressure. By 3–4 days, most do
not blanch with pressure. Fine desquamation occurs over more severely involved areas.
The rash fades in the same order that it appears, from head to extremities.
Other symptoms of measles include anorexia; diarrhea, especially in infants; and
generalized lymphadenopathy.
Page 85 of 147
Measle Systoms
• Disease caused by the measles virus is typically marked by a prodrome of fever,
conjunctivitis, coryza, and cough which is followed by the development of a rash of flat
macules which first appear on the head and then move to the chest, trunk, and limbs. These
macules typically fuse resulting in large blotches that can be slow to fade.
• Children get complications like diarrhea
• According to the WHO, the yearly global incidence of measles is estimated to be 50 million
cases, of which 1.5 million are fatal.
– Healthy populations 1 death per thousand cases
– Developing nations around 10% mortality
– In immunocompromised people upto 30% mortality
• Two serious complications of measles infection are acute postinfectious encephalitis,
which occurs in about 1 in every 1,00
0 cases (15% mortality), and subacute sclerosing panencephalitis (SSPE), which occurs in
about 1 in every 300,000 cases (fatal).
Measles Treatment
Complications
Page 86 of 147
Approximately 30% of reported measles cases have one or more complications.
Complications of measles are most common among children younger than 5 years of age
and adults 20 years of age and older.
From 1985 through 1992, diarrhea was reported in 8% of measles cases, making this the
most commonly reported complication of measles. Otitis media was reported in 7% of
cases and occurs almost exclusively in children. Pneumonia (in 6% of reported cases) may
be viral or superimposed bacterial, and is the most common cause of measles-related
death.
Acute encephalitis occurs in approximately 0.1% of reported cases. Onset generally occurs
6 days after rash onset (range 1–15 days) and is characterized by fever, headache,
vomiting, stiff neck, meningeal irritation, drowsiness, convulsions, and coma. Cerebrospinal
fluid shows pleocytosis and elevated protein.
The case-fatality rate is approximately 15%. Some form of residual neurologic damage
occurs in as many as 25% of cases. Seizures (with or without fever) are reported in 0.6%–
0.7% of cases.
Death from measles was reported in approximately 0.2% of the cases in the United States
from 1985 through 1992. As with other complications of measles, the risk of death is
highest among young children and adults. Pneumonia accounts for about 60% of deaths.
The most common causes of death are pneumonia in children and acute encephalitis in
adults.
C. Zoonotic Diseases
1) Rabies (Hydrophobia):
Pathogen:
Page 87 of 147
Rabies virus.
The virus is introduced in the body by the bite of rabid (mad) dogs usually. It can be
injected by the bite of jackals, wolves, cats etc.,
Incubation period:
Fear of water is the most important characteristic symptom of this disease. Other
symptoms are saliva from the mouth, severe headache, high fever, alternating periods of
excitement and depression, inability to swallow even fluids due to choked throat. The virus
destroys the brain and spinal cord. Rabies is 100% fatal.
There should be compulsory immunisation of dogs and cat population. All ownerless and
stray dogs should be destroyed. Wound of the bitten person should be immediately washed
with soap and water. After this give anti rabies vaccine to the patient. The pet should be
watched for 10 days after it has bitten someone to make sure that it does not have rabies
virus.
1) Malaria
Page 88 of 147
As the sexual phase of the malarial parasite occurs in the mosquito it is considered the
definitive (= primary) host of malarial parasite.
As the asexual phase of the malarial parasite occurs in man, it is considered the
intermediate (= secondary) host. As the female Anopheles mosquitoes feed on blood, only
they can serve as vector hosts (= carrier) of malarial parasites. The parasite does not harm
the mosquito.
Historical Aspects:
Lancisi (1717) first suspected a relationship between swamp, malaria and mosquito.
Laveran (1880) discovered that malaria is caused by protozoan parasite. In fact he
discovered Plasmodium. He got Nobel Prize in 1907. His topic of discovery was “Role of
Protozoans in Causing Disease”.
Life cycle of Plasmodium requires two hosts for completion, such a two host life cycle is
called digenetic.
1. Infective stage of Plasmodium is sporozoite. When the mosquito bites another human,
sporozoites are injected with bite.
Page 89 of 147
3. The parasite reproduces asexually in liver cells, bursting the cell and releasing into the
blood.
4. Parasites enter the red blood cells and reproduce asexually there bursting the red blood
cells and causing cycles of fever and other symptoms. Released parasites infect new red
blood cells.
Page 90 of 147
Human Species of Plasmodium and Types of Malaria:
1. Plasmodium vivax:
It is most common in India. It is less common in Africa. Its incubation period is about 14
days. It causes Benign Tertian Malaria. Recurrence of fever is after every 48 hours (every
third day). Recurrent attacks of fever are called paroxysms.
2. Plasmodium falciparum:
Page 91 of 147
It is common in certain parts of India. It is the greatest killer of human beings over most
parts of Africa and else where in tropics. Its incubation period is about 12 days. Recurrence
of fever is after every 48 hours (every third day). It causes Malignant (=Aestivo-autumnal
or Pernicious or Cerebral or Tropical) Tertian Malaria.
3. Plasmodium malariae:
It is common in tropical Africa, Burma, Sri Lanka and parts of India. It is less common in
India. This was the species of malarial parasite discovered by Laveran. This is the only
species which can also infect other primates. Its incubation period is 28 days. Recurrence of
fever is after 72 hours (every 4th day). It causes Quartan Malaria.
4. Plasmodium ovale:
This is the rarest of the four species which infect man. It is mostly found in tropical Africa.
It is usually not seen in India. Its incubation period is about 14 days. It causes Mild Tertian
Malaria.
Symptoms of Malaria:
The patient displays symptoms of malaria fever after a period of 14 days from infectious
bite. Early restlessness, less appetite and slight sleeplessness are followed by muscular
pains, headache and a feeling of chilliness. In response to chills the body temperature starts
rising and may reach 106°F at the height of fever. The patient sweats a lot and the
temperature steadily goes down to normal, till the next attack takes place after 48 hours.
Page 92 of 147
Control of Malaria:
Malaria is widely spread disease in India. There is separate antimalaria department of the
government which controls malaria through National Malaria Eradication Programme
(NMEP).
Quinine, the oldest drug for malaria, and other drugs are also used for this purpose.
Quinine is extracted from the bark of the cinchona tree which is mostly growing in West
Indies, India, Sri Lanka, Java and Peru. Other anti-malarial drugs are paludrine and
Primaquin, Chloroquinine, Camoquin and Comoprima. Now malaria is also being treated
with sulpha drugs such as sulphadoxin, dapsone, etc.
Ducks, larvivorous fish like Gambusia, some adult insects like dragon flies, insectivorous
plants such as Utricularia, are the natural enemies of mosquito larvae and pupae as they
feed upon them. These may be introduced in the water containing the larvae and pupae.
2) Chikungunya:
Pathogen:
It is caused by Chikungunya virus. This virus was first isolated from human patients and
Aedes aegypti mosquitoes from Tanzania in 1952. The name ‘Chikungunya’ is derived from
the native word for the disease in which patient lies “doubled up” due to severe joint pains.
Epidemics of chikungunya have occurred in many African countries.
Mode of Transmission:
Page 93 of 147
Its symptoms include sudden onset of fever, crippling joint pains, lymphadenopathy and
conjunctivitis. Some show haemorrhagic manifestations. The fever is typically biphasic.
Chikungunya has been reported from India.
Incubation Period:
Mode of Transmission: The virus of dengue fever is transmitted by the bite of Aedes
aegypti (mosquito).
Two types of dengue fever are common: classical dengue fever and dengue haemorrhagic.
(iii) Pain behind the eyes which worsens with eye movement,
Page 94 of 147
(v) Loss of sense of taste and appetite,
(i) Bleeding from the nose, mouth, gums and skin bruising,
No specific therapy is available. Symptomatic care including bed rest, adequate fluid intake
and analgesic medicine is recommended. Do not take aspirin and dispirin.
Page 95 of 147
NON COMMUNICABLE DISEASES
RA often affects pairs of joints (both hands, both feet, etc) and can affect more than one
joint, including the small joints in the wrists and hands. Over time, other joints can be
affected such as shoulders, elbows, knees, feet, and ankles.
Over time, the inflammation of RA can cause damage to the joints. In some patients, this
may lead to permanent joint damage. As this joint damage progresses, in severe cases, it
can cause deformity of the joints and loss of function. It may begin to interfere with daily
activities, making them more difficult and painful to do.For these reasons, it’s important to
get an accurate diagnosis as early as possible.
About 1.3 million Americans suffer from RA. It affects people worldwide at a similar rate.
RA often begins in middle age, but can start at any age. RA affects 2 to 3 times as many
women than men.
Causes of RA
The exact cause of RA is not known. Research has found that there are many possible
causes, including:
Genetics. People with family members who have RA may be more likely to get it
Page 96 of 147
Some of the most common symptoms a person with RA may experience are stiffness in the
morning and pain and swelling of joints—often in the same joint on both sides of the body.
As RA progresses, joint damage may worsen. This can also cause the surrounding muscles,
ligaments, and tendons to become weak and unable to work normally.
Symptoms of the disease may appear, go away for some time, and then return, making
diagnosis even more difficult. But remember, RA is a disease that progresses over time.
That is why it is so important to get an accurate diagnosis as early as possible.
Up to 40% of people with RA may develop other conditions during the course of their
disease. While RA affects the joints, people with RA may also be more likely to have the
following conditions:
Heart disease
Bone loss
Sjö gren’s syndrome (dry mouth and dry eyes) and other eye problems
Anemia
Infections
Lung disease
Some of these conditions may be a result of having RA. Medications used to treat RA could
increase some of these risks as well.
Page 97 of 147
Signs and Symptoms of RA
RA affects different people in different ways. Symptoms may slowly develop over several
years, or the disease may progress quickly. Symptoms may be mild or very severe. You may
go through phases called “flares” or “flare-ups” when symptoms are severe. At other times,
it may seem as if the disease and its symptoms have gone away. This is called “remission.”
Joint pain and swelling may happen slowly and may occur over weeks or months. The small
joints in the wrists and hands are often inflamed first. Over time, other joints may be
painful and swollen due to RA. The common signs and symptoms of RA include:
Painful joints
Swollen joints
Low fever
Fatigue
Loss of appetite
Feeling weak
Weight loss
Page 98 of 147
Page 99 of 147
Page 100 of 147
Diagnosing and Managing RA
There is no one test that can show that you have RA. But your doctor can use a combination
of tools to help diagnose RA:
Physical exam
Symptoms
Lab tests
Other tests include white blood-cell count, anemia test, erythrocyte sedimentation rate
(ESR), and C-reactive protein
X-rays
Treatment of RA
Once one has diagnosed with RA, it is very important to start treatment as soon as possible.
i. Reduce pain
The details of your treatment plan will depend on the progress of the disease. Your
rheumatologist can suggest various treatment options, such as lifestyle changes,
medications, and sometimes surgery.
Joint care
Pain relievers
Corticosteroids
All medications have side effects. It is important to discuss the risks and benefits of your
treatment options with your doctor in order to find the proper treatment plan for you.
Stress reduction
Healthy diet
Seeing a rheumatologist
2) Osteoarthritis
Osteoarthritis is a joint disease that mostly affects cartilage. Cartilage is theslippery tissue
that covers the ends of bones in a joint. Healthy cartilage allowsbones to glide over each
other. It also helps absorb the shock of movement. Inosteoarthritis, the top layer of
cartilage breaks down and wears away. This allowsbones under the cartilage to rub
together. The rubbing causes pain, swelling, andloss of motion of the joint. Over time, the
joint may lose its normal shape. Also,
bone spurs may grow on the edges of the joint. Bits of bone or cartilage can breakoff and
float inside the joint space, which causes more pain and damage.People with osteoarthritis
often have joint pain and reduced motion. Unlike someother forms of arthritis,
osteoarthritis affects only joints and not internal organs.Osteoarthritis occurs most often in
older people. Younger people sometimes getosteoarthritis, primarily from joint injuries.
Causesof Osteoarthritis
Osteoarthritis usually happens gradually over time. Some risk factors that might
lead to it include:
Being overweight.
Diagnosis
Osteoarthritis can occur in any joint. It occurs most often in the hands, knees, hips,
and spine. Warning signs of osteoarthritis are:
Stiffness in a joint after getting out of bed or sitting for a long time.
Swelling or tenderness in one or more joints.
A crunching feeling or the sound of bone rubbing on bone.
2
No single test can diagnose osteoarthritis. Most doctors use several methods to diagnose
the
disease and rule out other problems:
Medical history.
Physical exam.
X rays.
Other tests such as blood tests or exams of the fluid in the joints.
Doctors often combine treatments to fit a patient's needs, lifestyle, and health.
Osteoarthritis
treatment has four main goals:
Improve joint function.
Keep a healthy body weight.
Control pain.
Achieve a healthy lifestyle.
3) Cancer
Facts
In the most basic terms, cancer refers to cells that grow out-of-control and invade other
tissues. Cells become cancerous due to the accumulation of defects, or mutations, in their
DNA. Certain factors lead to cancer and they include:
Most of the time, cells are able to detect and repair DNA damage. If a cell is severely
damaged and cannot repair itself it undergoes the so-called programmed cell death or
apoptosis. Cancer occurs when damaged cells grow, divide, and spread abnormally instead
of self-destructing as they should.
Cancer: This is the uncontrolled growth of abnormal cells anywhere in a body. These
abnormal cells are termed cancer cells, malignant cells, or tumor cells. These cells can
infiltrate normal body tissues.
The following table (National Cancer Institute 2016) gives the estimated numbers of new
cases and deaths for each common cancer type:
The three most common cancers in men, women, and children in the U.S. are as follows:
The incidence of cancer and cancer types are influenced by many factors such as age,
gender, race, local environmental factors, diet, and genetics. Consequently, the incidence of
cancer and cancer types vary depending on these variable factors. For example, the World
Health Organization (WHO) provides the following general information about cancer
worldwide:
Cancer is a leading cause of death worldwide. It accounted for 8.2 million deaths
(around 22% of all deaths not related to communicable diseases; most recent data
from WHO).
Lung, stomach, liver, colon, and breast cancer cause the most cancer deaths each
year.
Deaths from cancer worldwide are projected to continue rising, with an estimated
13.1 million deaths in 2030 (about a 70% increase).
Different areas of the world may have cancers that are either more or less predominant
than those found in the U.S. One example is that stomach cancer is often found in Japan,
while it is rarely found in the U.S. This usually represents a combination of environmental
and genetic factors.
Anything that may cause a normal body cell to develop abnormally potentially can cause
cancer. Many things can cause cell abnormalities and have been linked to cancer
development. Some cancer causes remain unknown while other cancers have
environmental or lifestyle triggers or may develop from more than one known cause. Some
may be developmentally influenced by a person's genetic makeup. Many patients develop
cancer due to a combination of these factors. Although it is often difficult or impossible to
determine the initiating event(s) that cause a cancer to develop in a specific person,
research has provided clinicians with a number of likely causes that alone or in concert
with other causes, are the likely candidates for initiating cancer. The following is a listing of
major causes and is not all-inclusive as specific causes are routinely added as research
advances:
It is important to point out that almost everyone has risk factors for cancer and is exposed
to cancer-causing substances (for example, sunlight, secondary cigarette smoke, and X-
rays) during their lifetime, but many individuals do not develop cancer. In addition, many
people have the genes that are linked to cancer but do not develop it. Why? Although
Recently, other risk factors have been added to the list of items that may increase cancer
risk. Specifically, red meat (such as beef, lamb, and pork) was classified by the
International Agency for Research on Cancer as a high-risk agent for potentially causing
cancers; in addition processed meats (salted, smoked, preserved, and/or cured meats)
were placed on the carcinogenic list. Individuals that eat a lot of barbecued meat may also
increase risk due to compounds formed at high temperatures. Other less defined situations
that may increase the risk of certain cancers include obesity, lack of exercise, chronic
inflammation, and hormones, especially those hormones used for replacement therapy.
Other items such as cell phones have been heavily studied. In 2011, the World Health
Organization classified cell phone low energy radiation as "possibly carcinogenic," but
this is a very low risk level that puts cell phones at the same risk as caffeine and pickled
vegetables.
Proving that a substance does not cause or is not related to increased cancer risk is
difficult. For example, antiperspirants are considered to possibly be related to breast
cancer by some investigators and not by others. The official stance by the NCI is "additional
research is needed to investigate this relationship and other factors that may be involved."
This unsatisfying conclusion is presented because the data collected so far is contradictory.
Other claims that are similar require intense and expensive research that may never be
done. Reasonable advice might be to avoid large amounts of any compounds even remotely
Symptoms and signs of cancer depend on the type of cancer, where it is located, and/or
where the cancer cells have spread. For example, breast cancer may present as a lump in
the breast or as nipple discharge while metastatic breast cancer may present with
symptoms of pain (if spread to bones), extreme fatigue (lungs), or seizures (brain). A few
patients show no signs or symptoms until the cancer is far advanced.
The American Cancer Society describes seven warning signs and/or symptoms that a
cancer may be present, and which should prompt a person to seek medical attention. The
word CAUTION can help you remember these.
Other signs or symptoms may also alert you or your doctor to the possibility of your having
some form of cancer. These include the following:
Types of Cancer
There are over 200 types of cancer. However, the NCI lists several general categories (see
list in first section of this article). This list is expanded below to list more specific types of
cancers found in each general category; it is not all inclusive and the cancers listed in
quotes are the general names of some cancers:
Carcinoma: Cancer that begins in the skin or in tissues that line or cover internal
organs -- "skin, lung, colon, pancreatic, ovarian cancers," epithelial, squamous and
basal cell carcinomas, melanomas, papillomas, and adenomas
Sarcoma: Cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other
connective or supportive tissue -- "bone, soft tissue cancers," osteosarcoma,
synovial sarcoma, liposarcoma, angiosarcoma, rhabdosarcoma, and fibrosarcoma
Leukemia: Cancer that starts in blood-forming tissue such as the bone marrow and
causes large numbers of abnormal blood cells to be produced and enter the blood --
"leukemia," lymphoblastic leukemias (ALL and CLL), myelogenous leukemias (AML
and CML), T-cell leukemia, and hairy-cell leukemia
Lymphoma and myeloma: Cancers that begin in the cells of the immune system --
"lymphoma," T-cell lymphomas, B-cell lymphomas, Hodgkin lymphomas, non-
Hodgkin lymphoma, and lymphoproliferative lymphomas
Central nervous system cancers: Cancers that begin in the tissues of the brain and
spinal cord -- "brain and spinal cord tumors," gliomas, meningiomas, pituitary
adenomas, vestibular schwannomas, primary CNS lymphomas, and primitive
neuroectodermal tumors
Cancer Specialists
A doctor who specializes in the treatment of cancer is called an oncologist. He or she may
be a surgeon, a specialist in radiation therapy, or a medical oncologist. The first uses
surgery to treat the cancer; the second, radiation therapy; the third, chemotherapy and
related treatments. Each may consult with the others to develop a treatment plan for the
particular patient.
In addition, other specialists may be involved depending upon where the cancer is located.
For example, ob-gyn specialists may be involved with uterine cancer while an
immunologist maybe involved in treatment of cancers that occur in the immune system.
Your primary care physician and main oncologist will help you to determine what
specialists are best to be members of your treatment team.
Diagnosis
Some cancers are diagnosed during routine screening examinations. These are usually tests
that are routinely done at a certain age. Many cancers are discovered when you present to
your health care professional with specific symptoms. A physical exam and medical history,
especially the history of symptoms, are the first steps in diagnosing cancer. In many
Imaging studies are commonly used to help physicians detect abnormalities in the body
that may be cancer. X-rays, CT and MRI scans, and ultrasound are common tools used to
examine the body. Other tests such as endoscopy, which with variations in the equipment
used, can allow visualization of tissues in the intestinal tract, throat, and bronchi that may
be cancerous. In areas that cannot be well visualized (inside bones or some lymph nodes,
for example), radionuclide scanning is often used. The test involves ingestion or IV
injection of a weakly radioactive substance that can be concentrated and detected in
abnormal tissue.
The preceding tests can be very good at localizing abnormalities in the body; many
clinicians consider that some of the tests provide presumptive evidence for the diagnosis of
cancer. However, in virtually all patients, the definitive diagnosis of cancer is based on the
examination of a tissue sample taken in a procedure called a biopsy from the tissue that
may be cancerous, and then analyzed by a pathologist. Some biopsy samples are relatively
simple to procure (for example, skin biopsy or intestinal tissue biopsy done with a device
called an endoscope equipped with a biopsy attachment). Other biopsies may require as
little as a carefully guided needle, or as much as a surgery (for example, brain tissue or
lymph node biopsy). In some instances, the surgery to diagnose the cancer may result in a
cure if all of the cancerous tissue is removed at the time of biopsy.
The biopsy can provide more than the definitive diagnosis of cancer; it can identify the
cancer type (for example, the type of tissue found may indicate that the sample is from a
primary [started there] or metastatic type of brain cancer [spread from another primary
tumor arising elsewhere in the body]) and thereby help to stage the cancer. The stage, or
cancer staging, is a way for clinicians and researchers to estimate how extensive the cancer
is in the patient's body.
Cancer Staging
There are a number of different staging methods used for cancers and the specific staging
criteria varies among cancer types. According to the NCI, the common elements considered
in most staging systems are as follows:
However, there are two main methods that form the basis for the more specific or
individual cancer type staging. The TMN staging is used for most solid tumors while the
Roman numeral or stage grouping method is used by some clinicians and researchers on
almost all cancer types.
The TNM system is based on the extent of the tumor (T), the extent of spread to the lymph
nodes (N), and the presence of distant metastasis (M). A number is added to each letter to
indicate the size or extent of the primary tumor and the extent of cancer spread (higher
number means bigger tumor or more spread).
The following is how the NCI describes the TNM staging system:
The Roman numeral or stage grouping method is described by the NCI as follows:
Stage Definition
In situ: Abnormal cells are present only in the layer of cells in which they
developed.
Localized: Cancer is limited to the organ in which it began, without evidence of
spread.
Regional: Cancer has spread beyond the primary site to nearby lymph nodes or
organs and tissues.
Distant: Cancer has spread from the primary site to distant organs or distant lymph
nodes.
Unknown: There is not enough information to determine the stage.
Staging of cancer is important; it helps the physician to decide on the most effective
therapeutic protocols, provides a basis for estimating the prognosis (outcome) for the
patient, and provides a system to communicate the patient's condition to other health
professionals that become involved with the patients' care.
Cancer Treatment
The cancer treatment is based on the type of cancer and the stage of the cancer. In some
people, diagnosis and treatment may occur at the same time if the cancer is entirely
surgically removed when the surgeon removes the tissue for biopsy. Although patients may
receive a unique sequenced treatment, or protocol, for their cancer, most treatments have
one or more of the following components: surgery, chemotherapy, radiation therapy, or
combination treatments (a combination of two or all three treatments).
Individuals obtain variations of these treatments for cancer. Patients with cancers that
cannot be cured (completely removed) by surgery usually will get combination therapy, the
composition determined by the cancer type and stage. Palliative therapy (medical care or
treatment used to reduce disease symptoms but unable to cure the patient) utilizes the
Cancer Prognosis
The prognosis (outcome) for cancer patients may range from excellent to poor. The
prognosis is directly related to both the type and stage of the cancer. For example, many
skin cancers can be completely cured by removing the skin cancer tissue; similarly, even a
patient with a large tumor may be cured after surgery and other treatments like
chemotherapy (note that a cure is often defined by many clinicians as a five-year period
with no reoccurrence of the cancer). However, as the cancer type either is or becomes
aggressive, with spread to lymph nodes or is metastatic to other organs, the prognosis
decreases. For example, cancers that have higher numbers in their staging (for example,
stage III or T3N2M1; see staging section above) have a worse prognosis than those with
low (or 0) numbers. As the staging numbers increase, the prognosis worsens and the
survival rate decreases.
However, cancers in general have a decreasing life expectancy as the stage of the cancer
increases. Depending on the type of the cancer, as the prognosis decreases, so does life
expectancy. On the positive side, cancers that are treated and do not recur (no remissions)
within a five-year period in general suggest that the patient will have a normal life
expectancy. Some patients will be cured, and a few others may get recurrent cancer.
Unfortunately, there are no guarantees.
There are many complications that may occur with cancer; many are specific to the cancer
type and stage and are too numerous to list here. However, some general complications
that may occur with both cancer and its treatment protocols are listed below:
Cancer Prevention
Cancer Screening
Screening tests and studies for cancer are meant to help detect a cancer at an early stage
when the cancer is more likely to be potentially cured with treatment. Such screening
studies are breast exams, testicular exams, colon-rectal exams (colonoscopy),
mammography, certain blood tests, prostate exams, urine tests and others. People who
have any suspicion that they may have cancer should discuss their concerns with their
doctor as soon as possible. Screening recommendations have been the subject of numerous
conflicting reports in recent years. Screening may not be cost effective for many groups of
patients or lead to unnecessary further invasive tests, but individual patients' unique
circumstances should always be considered by doctors in making recommendations about
ordering or not ordering screening tests.
Cancer Treatment
Cancer treatment is the use of surgery, radiation, medications and other therapies to cure a
cancer, shrink a cancer or stop the progression of a cancer. Many cancer treatments exist.
Depending on the particular situation, one may receive one treatment or they may receive
a combination of treatments.
Neo-adjuvant therapy is similar, but treatments are used before the primary
treatment in order to make the primary treatment easier or more effective.
Palliative treatment. Palliative treatments may help relieve side effects of treatment
or signs and symptoms caused by cancer itself. Surgery, radiation, chemotherapy and
hormone therapy can all be used to relieve symptoms. Other medications may relieve
symptoms such as pain and shortness of breath. Palliative treatment can be used at
the same time as other treatments intended to cure your cancer.
Expectations
Many cancer treatments are available. The treatment options will depend on several
factors, such as the type and stage of the cancer, the general health, and one’s preferences.
Bone marrow transplant. Your bone marrow is the material inside your bones that
makes blood cells from blood stem cells. A bone marrow transplant, also knowns as a
stem cell transplant, can use your own bone marrow stem cells or those from a donor.
A bone marrow transplant allows your doctor to use higher doses of chemotherapy to
treat your cancer. It may also be used to replace diseased bone marrow.
Hormone therapy. Some types of cancer are fueled by the body's hormones.
Examples include breast cancer and prostate cancer. Removing those hormones from
the body or blocking their effects may cause the cancer cells to stop growing.
4) Type2 diabetes
Overview
Type 2 diabetes is a chronic condition that affects the way the body metabolizes sugar
(glucose) — an important source of fuel for the body. With type 2 diabetes, the body either
Type 2 diabetes used to be known as adult-onset diabetes, but today more children are
being diagnosed with the disorder, probably due to the rise in childhood obesity. There's
no cure for type 2 diabetes, but losing weight, eating well and exercising can help manage
the disease. If diet and exercise aren't enough to manage your blood sugar well, you may
also need diabetes medications or insulin therapy.
Symptoms
Signs and symptoms of type 2 diabetes often develop slowly. In fact, one can have type 2
diabetes for years and not know it. Look for:
Increased thirst
Frequent urination
Increased hunger
Fatigue
Blurred vision
Slow-healing sores
Frequent infections
Causes
Type 2 diabetes develops when the body becomes resistant to insulin or when the pancreas
is unable to produce enough insulin. Exactly why this happens is unknown, although
genetics and environmental factors, such as being overweight and inactive, seem to be
contributing factors.
Insulin is a hormone that comes from the gland situated behind and below the stomach
(pancreas).
As your blood sugar level drops, so does the secretion of insulin from your pancreas.
Glucose — a sugar — is a main source of energy for the cells that make up muscles and
other tissues.
Glucose comes from two major sources: food and your liver.
Sugar is absorbed into the bloodstream, where it enters cells with the help of insulin.
When your glucose levels are low, such as when you haven't eaten in a while, the liver
breaks down stored glycogen into glucose to keep your glucose level within a normal
range.
In type 2 diabetes, this process doesn't work well. Instead of moving into the cells, sugar
builds up in your bloodstream. As blood sugar levels increase, the insulin-producing beta
cells in the pancreas release more insulin, but eventually these cells become impaired and
can't make enough insulin to meet the body's demands. In the much less common type 1
diabetes, the immune system mistakenly destroys the beta cells, leaving the body with little
to no insulin.
Weight. Being overweight is a main risk factor for type 2 diabetes. However, one does
not have to be overweight to develop type 2 diabetes.
Fat distribution. If one stores fat mainly in the abdomen, they have a greater risk of
type 2 diabetes than if they store fat elsewhere, such as in the hips and thighs. The
risk of type 2 diabetes rises if one is a man with a waist circumference above 40
inches (101.6 centimeters) or a woman with a waist that's greater than 35 inches
(88.9 centimeters).
Inactivity. The less active one is, the greater their risk of type 2 diabetes. Physical
activity helps in controlling one’s weight, uses up glucose as energy and makes the
cells more sensitive to insulin.
Family history. The risk of type 2 diabetes increases if the parent or sibling has type
2 diabetes.
Race. Although it's unclear why, people of certain races — including black, Hispanic,
American Indian and Asian-American people — are more likely to develop type 2
diabetes than white people are.
Age. The risk of type 2 diabetes increases as one gets older, especially after age 45.
That's probably because people tend to exercise less, lose muscle mass and gain
weight as they age. But type 2 diabetes is also increasing dramatically among children,
adolescents and younger adults.
Areas of darkened skin, usually in the armpits and neck. This condition often
indicates insulin resistance.
Complications
Type 2 diabetes can be easy to ignore, especially in the early stages when one is feeling fine.
But diabetes affects many major organs, including the heart, blood vessels, nerves, eyes and
kidneys. Controlling the blood sugar levels can help prevent these complications.
Heart and blood vessel disease. Diabetes dramatically increases the risk of heart
disease, stroke, high blood pressure and narrowing of blood vessels (atherosclerosis).
Eye damage. Diabetes increases the risk of serious eye diseases, such as cataracts and
glaucoma, and may damage the blood vessels of the retina, potentially leading to
blindness.
Prevention
Healthy lifestyle choices can help prevent type 2 diabetes, and that's true even when one
has diabetes in the family. If they have already received a diagnosis of diabetes, one can use
healthy lifestyle choices to help prevent complications. If one has prediabetes, lifestyle
changes can slow or stop the progression to diabetes.
Eating healthy foods. Choose foods lower in fat and calories and higher in fiber.
Focus on fruits, vegetables and whole grains.
Avoiding being sedentary for long periods. Sitting still for long periods can
increase your risk of type 2 diabetes. Try to get up every 30 minutes and move around
for at least a few minutes.
5) Gout
Overview
Gout is a common and complex form of arthritis that can affect anyone. It's characterized
by sudden, severe attacks of pain, swelling, redness and tenderness in the joints, often the
joint at the base of the big toe. An attack of gout can occur suddenly, often waking one up in
the middle of the night with the sensation that their big toe is on fire. The affected joint is
hot, swollen and so tender that even the weight of the sheet on it may seem intolerable.
Gout symptoms may come and go, but there are ways to manage symptoms and prevent
flares.
Symptoms
The signs and symptoms of gout almost always occur suddenly, and often at night. They
include:
Intense joint pain. Gout usually affects the large joint of the big toe, but it can occur
in any joint. Other commonly affected joints include the ankles, knees, elbows, wrists
and fingers. The pain is likely to be most severe within the first four to 12 hours after
it begins.
Limited range of motion. As gout progresses, you may not be able to move your
joints normally.
Causes
Gout occurs when urate crystals accumulate in the joint, causing the inflammation and
intense pain of a gout attack. Urate crystals can form when one has high levels of uric acid
in their blood.
The body produces uric acid when it breaks down purines — substances that are found
naturally in the body. Purines are also found in certain foods, such as steak, organ meats
and seafood. Other foods also promote higher levels of uric acid, such as alcoholic
beverages, especially beer, and drinks sweetened with fruit sugar (fructose).
Normally, uric acid dissolves in the blood and passes through the kidneys into urine. But
sometimes either the body produces too much uric acid or the kidneys excrete too little
uric acid. When this happens, uric acid can build up, forming sharp, needlelike urate
crystals in a joint or surrounding tissue that cause pain, inflammation and swelling.
Risk factors
One is more likely to develop gout if they have high levels of uric acid in their body. Factors
that increase the uric acid level in the body include:
Diet. Eating a diet rich in meat and seafood and drinking beverages sweetened with
fruit sugar (fructose) increase levels of uric acid, which increase one’s risk of gout.
Alcohol consumption, especially of beer, also increases the risk of gout.
Family history of gout. If other members of one’s family have had gout, then they
more likely to develop the disease.
Age and sex. Gout occurs more often in men, primarily because women tend to have
lower uric acid levels. After menopause, however, women's uric acid levels approach
those of men. Men are also more likely to develop gout earlier — usually between the
ages of 30 and 50 — whereas women generally develop signs and symptoms after
menopause.
Complications
People with gout can develop more-severe conditions, such as:
Recurrent gout. Some people may never experience gout signs and symptoms again.
Others may experience gout several times each year. Medications may help prevent
gout attacks in people with recurrent gout. If left untreated, gout can cause erosion
and destruction of a joint.
Advanced gout. Untreated gout may cause deposits of urate crystals to form under
the skin in nodules called tophi (TOE-fie). Tophi can develop in several areas such as
your fingers, hands, feet, elbows or Achilles tendons along the backs of your ankles.
Kidney stones. Urate crystals may collect in the urinary tract of people with gout,
causing kidney stones. Medications can help reduce the risk of kidney stones.
Prevention
During symptom-free periods, these dietary guidelines may help protect against future
gout attacks:
Limit or avoid alcohol. Recent evidence suggests that beer may be particularly likely
to increase the risk of gout symptoms, especially in men.
Get your protein from low-fat dairy products. Low-fat dairy products may actually
have a protective effect against gout, so these are the best-bet protein sources.
Limit your intake of meat, fish and poultry. A small amount may be tolerable, but
one should pay close attention to what types — and how much — seem to cause
problems for them.
Diagnosis
Tests to help diagnose gout may include:
Joint fluid test where the doctor may use a needle to draw fluid from the affected
joint. Urate crystals may be visible when the fluid is examined under a microscope.
X-ray imaging. Joint X-rays can be helpful to rule out other causes of joint
inflammation.
Dual energy CT scan. This type of imaging can detect the presence of urate crystals
in a joint, even when it is not acutely inflamed. This test is not used routinely in
clinical practice due to the expense and is not widely available.
Treatment
Treatment for gout usually involves medications. Gout medications can be used to treat
acute attacks and prevent future attacks. Medications can also reduce the risk of
complications from gout, such as the development of tophi from urate crystal deposits.
Drugs used to treat acute attacks and prevent future attacks include:
Corticosteroids are generally used only in people with gout who can't take either
NSAIDs or colchicine. Side effects of corticosteroids may include mood changes,
increased blood sugar levels and elevated blood pressure.
Options include:
Side effects of allopurinol include a rash and low blood counts. Febuxostat side effects
include rash, nausea and reduced liver function.
Causes
Irritating effect of acidic gastric reflux on the oesophageal mucosa
Stress
Ingestion of an irritating agent
Viral inflammation
Fungal infection
Intubation
Aging
Radiation such as for lung cancer treatment
Medication that gets stuck in oesophagus e.g. tetracycline
Chronic or reflux esophagitis is a result of recurrent gastroesophageal reflux owing
to a hiatal hernia, reduced Lower Oesophageal Sphincter (LES) pressure, increased
abdominal pressure and recurrent vomiting.
Symptoms
Heartburn
Regurgitation
Dysphagia
Bleeding
Nutrition implication
Indigestion
Anaemia
Aims of nutritional management
Prevent irritation of the oesophageal mucosa in the acute phase
Prevent oesophageal reflux
Peptic Ulcer
An ulcer is an erosion of the mucous membrane
Peptic ulcer disease includes esophageal, gastric and duodenual ulcers. It normally involves
the gastric and duodenal regions of the gastrointestinal tract.
peptic ulcers – ulcers of the stomach or duodenum
gastric ulcer – ulcer in the stomach
duodenal ulcer – ulcer occurring in the duodenum
Research identifies the Helicobacter (H.) pylori bacteria as the primary cause in 95% of
gastric and duodenal ulcers. The remaining 5% is caused by non-steroidal anti-
inflammatory medication usage (e.g. aspirin and ibuprofen) and excessive production of
stomach acid.
Because the primary cause of peptic ulcers is Helicobacter pylori infection, the focus of
treatment is the elimination of the bacteria with antibiotic and proton pump inhibitor
therapy; and cimetidine.
The antibiotics kill the bacteria, and cimetidine inhibits acid secretion in the stomach and
thus helps to heal the ulcer.
Antacids containing calcium carbonate can also be prescribed to neutralize any excess acid.
NB: Alcohol and aspirin irritate the mucous membrane of the stomach, and cigarette
smoking decreases the secretion of the pancreas that buffers gastric acid in the duodenum
Bland diet
Moderate in fibre and connective tissues
Little or no condiments or spices except salt in small amounts
Avoid or eliminate highly acid foods
Foods simply prepared
Foods to avoid
Fatty and tough meat
Fried foods
Sour foods
Unripe citrus fruits like oranges and sweet lime
Garlic
Ginger strongly flavoured vegetables
Strong spices and condiments
Chillies, pickles
Strong tea and coffee
Both ulcerative colitis and Crohn's disease usually involve severe diarrhea, abdominal pain,
fatigue and weight loss.IBD can be debilitating and sometimes leads to life-threatening
complications.
Symptoms
Inflammatory bowel disease symptoms vary, depending on the severity of inflammation
and where it occurs. Symptoms may range from mild to severe. One is likely to have
periods of active illness followed by periods of remission.Signs and symptoms that are
common to both Crohn's disease and ulcerative colitis include:
Diarrhea
Blood in stool
Reduced appetite
Causes
The exact cause of inflammatory bowel disease remains unknown. Previously, diet and
stress were suspected, but now doctors know that these factors may aggravate but don't
cause IBD.One possible cause is an immune system malfunction. When the immune system
tries to fight off an invading virus or bacterium, an abnormal immune response causes the
immune system to attack the cells in the digestive tract, too. Heredity also seems to play a
Risk factors
Age. Most people who develop IBD are diagnosed before they're 30 years old. But
some people don't develop the disease until their 50s or 60s.
Race or ethnicity. Although whites have the highest risk of the disease, it can occur in
any race. If you're of Ashkenazi Jewish descent, your risk is even higher.
Family history. You're at higher risk if you have a close relative — such as a parent,
sibling or child — with the disease.
Where you live. If you live in an industrialized country, you're more likely to develop
IBD. Therefore, it may be that environmental factors, including a diet high in fat or
refined foods, play a role. People living in northern climates also seem to be at greater
risk.
Complications
Ulcerative colitis and Crohn's disease have some complications in common and others that
are specific to each condition. Complications found in both conditions may include:
Colon cancer. Having IBD increases the risk of colon cancer. General colon cancer
screening guidelines for people without IBD call for a colonoscopy every 10 years
Skin, eye and joint inflammation. Certain disorders, including arthritis, skin lesions
and eye inflammation (uveitis), may occur during IBD flare-ups.
Medication side effects. Certain medications for IBD are associated with a small risk
of developing certain cancers. Corticosteroids can be associated with a risk of
osteoporosis, high blood pressure and other conditions.
Blood clots. IBD increases the risk of blood clots in veins and arteries.
Bowel obstruction. Crohn's disease affects the full thickness of the intestinal wall.
Over time, parts of the bowel can thicken and narrow, which may block the flow of
digestive contents. One may require surgery to remove the diseased portion of their
bowel.
Anal fissure. This is a small tear in the tissue that lines the anus or in the skin around
the anus where infections can occur. It's often associated with painful bowel
movements and may lead to a perianal fistula.
Toxic megacolon. Ulcerative colitis may cause the colon to rapidly widen and swell, a
serious condition known as toxic megacolon.
Diagnosis
A doctor will likely diagnose inflammatory bowel disease only after ruling out other
possible causes for the signs and symptoms. To help confirm a diagnosis of IBD, one may
have one or more of the following tests and procedures:
Blood tests
Tests for anemia or infection. A doctor may suggest blood tests to check for anemia
— a condition in which there aren't enough red blood cells to carry adequate oxygen
to the tissues — or to check for signs of infection from bacteria or viruses.
Fecal occult blood test. One may need to provide a stool sample so that a doctor can
test for hidden blood in the stool.
Sigmoidoscopy exam
Colonoscopy. This exam allows the doctor to view the entire colon using a thin,
flexible, lighted tube with an attached camera. During the procedure, the doctor can
also take small samples of tissue (biopsy) for laboratory analysis. Sometimes a tissue
sample can help confirm a diagnosis.
Flexible sigmoidoscopy. A doctor uses a slender, flexible, lighted tube to examine the
rectum and sigmoid, the last portion of one’s colon. If the colon is severely inflamed, a
doctor may perform this test instead of a full colonoscopy.
Imaging procedures
X-ray: of the abdominal area to rule out serious complications, such as a perforated
colon.
Computerized tomography (CT) scan. A CT scan looks at the entire bowel as well as
at tissues outside the bowel. CT enterography is a special CT scan that provides better
images of the small bowel. This test has replaced barium X-rays in many medical
centers.
Magnetic resonance imaging (MRI). An MRI scanner uses a magnetic field and radio
waves to create detailed images of organs and tissues. An MRI is particularly useful
for evaluating a fistula around the anal area (pelvic MRI) or the small intestine (MR
enterography). Unlike a CT, there is no radiation exposure with an MRI.
Treatment
The goal of inflammatory bowel disease treatment is to reduce the inflammation that
triggers the signs and symptoms. In the best cases, this may lead not only to symptom relief
Anti-inflammatory drugs
Anti-inflammatory drugs are often the first step in the treatment of inflammatory bowel
disease. Anti-inflammatories include corticosteroids and aminosalicylates, such as
mesalamine (Asacol HD, Delzicol, others), balsalazide (Colazal) and olsalazine (Dipentum).
These drugs work in a variety of ways to suppress the immune response that releases
inflammation-inducing chemicals in the intestinal lining. For some people, a combination of
these drugs works better than one drug alone.
One class of drugs called tumor necrosis factor (TNF)-alpha inhibitors, or biologics, works
by neutralizing a protein produced by your immune system. Examples include infliximab
(Remicade), adalimumab (Humira) and golimumab (Simponi). Other biologic therapies that
may be used are natalizumab (Tysabri), vedolizumab (Entyvio) and ustekinumab (Stelara).
Antibiotics
In addition to controlling inflammation, some medications may help relieve the signs and
symptoms, but a patient should always talk to their doctor before taking any over-the-
counter medications. Depending on the severity of the IBD, the doctor may recommend one
or more of the following:
Iron supplements. Forpeople with chronic intestinal bleeding there is a risk that
they may develop iron deficiency anemia and need to take iron supplements.
Surgery
If diet and lifestyle changes, drug therapy, or other treatments don't relieve your IBD signs
and symptoms, your doctor may recommend surgery.
Surgery for ulcerative colitis. Surgery can often eliminate ulcerative colitis. But that
usually means removing one’s entire colon and rectum (proctocolectomy).
In most cases, this involves a procedure called an ileal pouch anal anastomosis. This
procedure eliminates the need to wear a bag to collect stool. A surgeon constructs a
In some cases a pouch is not possible. Instead, surgeons create a permanent opening
in the abdomen (ileal stoma) through which stool is passed for collection in an
attached bag.
Surgery for Crohn's disease. Up to one-half of people with Crohn's disease will
require at least one surgery. However, surgery does not cure Crohn's disease.
During surgery, the surgeon removes a damaged portion of the digestive tract and
then reconnects the healthy sections. Surgery may also be used to close fistulas and
drain abscesses.
The benefits of surgery for Crohn's disease are usually temporary. The disease often
recurs, frequently near the reconnected tissue. The best approach is to follow surgery
with medication to minimize the risk of recurrence.