Chronic HBV inf:

Interferon alpha
Lamivudine (antiviral)
Adefovir
(nucleotide nucleoside
analog)

Vaccine Preventable Communicable Diseases

Dr. Sy and Dr. Bernal 2011-2012
Communicable Diseases Chain of Infection
1. Pathogen of Causation
2. A reservoir or place where the pathogen lives
3. Method of transmission
4. Susceptible host
Toxoids
Inactivated bacterial toxins
Toxin is modified in vaccine production and is
often combined with agents that prolong its
absorption, enhancing its antigenicity
Toxoid retains the ability to stimulate antitoxin
formation in the recipient
Do not induce lifelong immunity and must be
boosted periodically
VACCINE PREVENTABLE COMMUNICALBLE
DISEASES (except rubella, rubeola, varicella,
meningococcal infections)
Differences Between Viral Hepatitis A and B
Transmi
ssion

Clinical
presenta
tion

Diagnos
tic Test

Treatme
nt

LBC 3B

Viral Hepa A
Person to person:
Fecal contamination
and oral ingestion

Starts with fever

(usually lasting
not>5 days),
malaise, anorexia,
as fever subsides,
urine becomes dark
colored and then
jaundice develops,
appetite improves in
infants and young
children, older
persons become
more anorexic with
jaundice lasting for
weeks
Serum IgM, present
at onset and lasts for
4 months or longer
IgG anti-HAV
detected shortly
after the appearance
of IgM
Presence of total
antiHAV w/o IgM
anti HAV indicates
previous infection
of immunity
Supportive

Viral Hepa B
Through blood, body
fluids, wound exudates,
semen, cervical
secretions, saliva
Perinatal occurring from
blood exposure during
labor
variety of symptoms
and signs; non-specific
Clinical hepatitis with
jaundice or fulminant
hepatitis
Complications
-Chronic hepatitis
-Cirrhosis
-Liver cancer

See next table

Acute HBV inf: no

specific therapy

Diagnostic test for hepa B virus antigens and ab

Factors
to be
tested

HBV
antigen
or Ab

Use

Detection of acutetly or
chronically ill people: 1st
serologic marker of infection
to appear
Identification of people who
have resolved HBV infection;
determination of immunity
after immunization
Identification of infected
people at risk of transmitting
HBV-marker of infectivity
Marker of improvement-goal
of therapy of chronically
infected patients
Identification of people with
acute, resolved, or chronic
HBV infection: not present
after immunization
Identification of people with
acute or recent HBV infections
including HBsAG negative
people during the window
phase of infection

Mycobacterium tuberculosis
Non motile, non spore forming, pleiomorphic,
weakly gram positive rods typically slender and
slightly bent
More acid fast and exacting nutritional
requirements grow more slowly, and form less
pigment than non-pathogenic Mycobacteria
Clinical Presentation
Variable: depends on:
o Age of patient
o Organ or organs involved
o Stage of infection e.g. primary or
reinfection
o Host immune response
o Reproduction and spread of the
organism
Diagnosis
Determine presence of tuberculosis
o Clinical manifestations: fever, anorexia,
weight loss, night sweats
o Tuberculin test (mantoux test)
o Microbiology

AFB smears
BACTEC radiometric system
with early morning sputum or 3
gastric aspirates
o PCR when diagnosis cannot be readily
establish
Determine type and extent
o Chest radiograph
o Other procedures depending on s and sx
o Determine clinical activity
o Find out source of infection

Diptheria: Corynebacterium diphtheria

Irregularly staining gram positive non motile
non sporulating pleomorphic bacilli
Both toxigenic and non toxigenic strains may
cause disease but only the former causes
myocarditis or neutritis
Epidemiology
Incubation period: 1-6 days
Period of communicability: 2-6 weeks after
infection (<4 days for patients properly treated
with antibiotics)
Chronic carriage can occur in spite of
antimicrobial therapy
Can occur in immunized or partially immunized
persons
Clinical Classification
Based on anatomic location of initial infection
and membrane (more than 1 site may be
affected)
o Nasal
o Tonsillar
o Pharyngeal
o Laryngeal (laryngotracheal)
o Cnjunctival
o Cutaneous
o Genital
Nasal Diphtheria
Initially resembles a common cold
Gradually discharge becomes serosanguinous,
then mucopurulent with a foul odor; and
excoriates nares and upper lip
Systemic symptoms, usually absent
White membrane on nasal septum
Occurs most often in infants
Tonsillar and Pharyngeal Diphtheria
Severity of symptoms depends on degree of
toxin production and extent of membrane
Onset insidious but is a more severe form
LBC 3B

Initial symptoms low grade fever, anorexia,

malaise, soreness of throat
Within 1-2 days, pearly white or gray membrane
appears sloughs off in 7-10 days in mild cases
(picture) Gray brown leather-like adherent
membrane
Soft tissue edema and elnlarged cervical lymph
nodes
bull neck appearance

Laryngeal Diphtheria
Reflects a downward extension of the
membrane from the pharynx, but occasionally
only the larynx is involved
Clinical findings indistinguishable from those
of other types of infectious croup
o Cough brassy or metallic
Diagnosis
Clinical
Examination of direct smears from the
diphtheritic membrane or lesions
Culture of the material (using a special medium)
beneath the membrane or part of the membrane
Complications
Myocarditis- toxic cardiomyopathy (cause
of mortality in 50-60% of patients)
Toxic neuropathy
In severe cases
o Respiratory and circulatory collapse
o Palate may be paralyzed with
difficulty of swallowing or
regurgitation
o Stupor coma and death may occur
w/in a week
Treatment
Diptheria equine antitoxin (neutralize only the
free toxin)
o A single dose (IV) must be administered
even before culture results are available
o If patient is sensitive, desensitization is
necessary
Dosage of Diphtheria Antitoxin
Clinical type
Dose (units)
Nasopharyngeal
40,000-60,000
Pharyngeal or laryngeal 48 20,000-40,000
hr
Extensive >/= 3 days
80,000-120,000
Diffuse swelling of neck
Cutaneous
20,000-40,000

Antimicrobial therapy not a substitute for

antitoxin (halt toxin production treat localized
infections, prevent transmission of organisms)
o Erythromycin: 40-50 mg/kg/d orally for
14 days or
o Penicillin G 100,000-150,000
units/kg/day in 4 doses IV for 14 days

Pertussis
Etiology
Bordetella pertussis (95%)
Less frequently Bordetella parapertussis
Epidemiology
Worldwide
Occurs endemically with 3 to 5 year cycles of
increase disease
All ages affected
Transmission: close contact via respiratory tract
secretions
Incubation period 6-21 days (usually 7-10 days)
Contagiousness-attack rate 100%
Most contagious during catarrhal stage and the
first 2 weeks after onset
Length of communicability depends on
o Age
o Immunization status
o Previous episodes of pertussis
o Prev antibiotic tx

Clinical Manifestations
Catarrhal
Paroxysmal
8(?) weeks
About 4 weeks
Catarrhal sx,
Repetitive series
midcough, slight of 5-10 forceful
fever
coughs followed
by sudden
massive
inpiratoy effort,
a terminal
whoop and
suffusion and
vomiting

Convalescent
About 2 weeks
Decreasing
frequency and
severity of the
cough

Diagnosis
Usually clinical
Culture of nasopharyngeal mucus: gold std
PCR
Direct fluorescent Ab testing
Periph bld exam
o Leukocytosis or a leukemoid rxn with
lymphocytosis
LBC 3B

Complications
Secondary infections (pneumonia, otitis media)
Seizures
Encephalopathy
Conjunctival/scleral/retinal/CNS hemorrhages
Petecchiae on the upper body
Epistaxis
Pneumothorax, subcutaneous emphysema
Umbilical/inguinal hernia
Rectal prolapse
Treatment
Age
<1mo

Azithromycin
10mg/kg/day
once daily for
5 days

1-5mo

10mg/kg/day
once daily for
5 days

6mo child

Day 1:
10mg/kg (not
to exceed
500mg)
Day 2-5
5mg.kg once a
day not to
exceed
250mg/day
Day 1 500mg
Days 2-5 250
mg

Adolescents

Erythromycin
4050mg/kg/day
in 4 divided
doses for 14
days
4050mg/kg/day
in 4 divided
doses for 14
days
Same as above
but not exceed
2 g/day

Clarithromycin
Not
recommended

2g/day in 4
doses for 14
days

1g/day in 2
doses for 7
days

15mg/kg/day
in 2 doses for
7 days

Same as above
but not exceed
1 g/day

Tetanus Clostridium tetani

G + spore forming motile anaerobic bacilli
usually present in soil and animal feces
Vegetative form produces a potent plasmid
encoded exotoxin (tetanospamin) which binds to
gangliosides at the myoneural junction of the
skeletal muscle and on neural membranes in the
spinal cord blocking inhibitory impulses to
motor neurons
Affected muscles sustain maximal contaction
and cannot relax
Portal of entry
Wounds recognized or unrecognized
o Greatest risk with devitalized tissue and
deep-puncture trauma
Umbilical cord stump
Circumcision wound
Not transmissible from person to person
Incubation period
Older infants and children: 2dys-months but usu
w/in 14 days

Clinical types
Localized
o Cephalic
Generalized
o Neonatal
Localized Tetanus
Unyielding, persistent, painful rigidity of the grp
of muscles that lies in close proximity to the site
of entry
o May persist for several weeks of months
o No residua
May precede generalized tetanus
Cephalic tetanus (rare form of localized tetanus
involving the bulbar musculature)
Portal of entry
Wounds foreign bodies in the head nostrils and
neck
Chronic otitis media
Following tonsillectomy
Incubation period 2 days
Clinical features: palsies of CN III, IV,VII,IX,
X, and XII singly or in any combination
Duration: days to months
Prognosis poor
Generalized Tetanus
Trismus (masseter muscle spasm: lockjaw) most
common presenting manifestation
Headache, restless irritability
Difficulty chewing dysphagia, neck stiffness
Risus sardonicus (sardonic smile of tetanus)intractable spasms of facial and buccal muscles
Rigidity of abdominal or thoracic musclesopisthotonus
Gen seizures (tetanospasms) sudden outburst of
tonic contraction of all grps of muscles--opisthotonus
o Pain in spastic muscles severe
o Face becomes florid and later cyanotic
neck veins distended
o Triggered by slightest stimuli
o Body temperature increases by 2-5
degrees F
Neonatal Tetanus
Infantile form of gen tetanus
Onset
o Age 3-12 days
o Poor suck
o Excessive crying
LBC 3B

Trismus: difficult swallowing other tetanic

spasms and frequently opisthotonus
Usual cause of death bronchopneumonia or
pulmo hemorrhage

Diagnosis
Clinical
Cultures from offending wound (but diagnosis
infrequently confirmed) isolated in only 1/3 of
cases
Treatment
Tetanus immune globulin single dose
o Neonates 500 units
o Older infants and other children 3,0006,000 units
If not available equine tetanus antitoxin 50,000100,000 units (20,000 units IV)
Antimicrobials 30 mg/kg/day in 4 divided doses
for 10-14 days
Penicillin G 100,000 units/kg/day in 4 doses for
10-14 days
Proper cleansing and debridement of all wounds
Supportive care
Control of spasms diazepam: 0.1-0.2 mg/kg IV
4-6 hr
Place in dark and quiet room
Poliomyelitis
Polio virus + enterovirus w/ serotypes 1,2,3
Occur only in humans
Transmission
o Fecal oral
o Thru the respi tract
Risk factors
o More commone in infants and young
children
o Poor hygiene conditions
Incubation period
o Asymptomatic or mild poliomyelitis: 36 days
o Paralytic poliomyelitis: 7-21 days
Clinical Manifestations
Type
Inapparent
Abortive

Non paralytic

Incidence
Manifestation
90-95%
Asymptomatic
5%
Fever malaise headache anorexia
sore throat abdominal or muscular
pain lasting for 2-3 dyas
1%
Headache nausea and vomiting
(more intense)
Soreness and stiffness of posterior
muscles of neck trunk and limbs
Fleeting paralysis of the bladder
and constipation

Prognosis
No sequela
Recovery
complete

Recovery
complete

Paralytic
Spinal

Paralytic
Bulbar

Paralytic
Polio
encephalitis

Nuchal and spinal rigidity

First phase corresponds to abortive
Feels beeter for 2-5 days
Second phase prev sx exacerbated
and now assoc w/ severe headache
and muscle pain presthesia
fasciculations and spasm followed
w/in 1-2 dyas by asymmetric
flaccid paralysis with lower motor
neuron signs
May occur w/o SC involvement
(dysfxn of the CN and medullary
centers)
-Nasal twang
-inability to swallow
-pooling of pharyngeal secretions
-absence of effective coughing
-Nasal regurgitation of saliva and
fluids
-Deviation of palate uvula tongue
-involvement of vital centers in
medulla(cardiac and respi sx)
-Paralysis of 2 or both vocal cords
-Weakness of the hyoid muscles
(_____ sign)
Rare
Similar to other forms of enceph
and can only be attributed to
polioviruses if accompanied by
flaccid paralysis and by viral
studies

o
Variable

Guarded

Guarded

Preparation of the child and family for

prolonged treatment required and for
permanent disability if this seems likely

Haemophilus influenza
A pleomorphic G(-) coccobacillus
Epidemiology: Age at risk children less tha 4yo
Incubation period: unknown
Mode of transmission
o In neonates
Aspiration of Amniotic fluid
Contact w/ genital secretions
o In older children: person to person
Inhalation of respi droplets
Direct contact w/ respi sec
Clinical Spectrum
Pneumonia
Epiglottitis
Otittis media
Bacteremia
Meningitis
Pericarditis
Cellulitis
Septic arthritis

CSF Findings
Week
1st

nd

Leukocytes
With CNS
involvement 20-300
cells/mm3 initially
with PMNs
predominant but
shift to
mononuclears soon
Fails to near normal

Protein
Normal or slightly
elevated

Rises to 50-100
mg/dL

In polioencephalitis CSF may remain normal or show

minor changes
Diagnosis
WHO recommendations
Isolation and identification of poliovirus in the
stool with specific indentification of wild type
and vaccine type strains
2 stool specimens collected 24-48 hr apart
(poliovirus conc in stools high during the 1st
week of illness)
Treatment
Supportive
Objectives
o Limit progression of the disease
o Prevention of ensuing skeletal
deformities
LBC 3B

Diagnostic tests
Culture
For meningitis latex particulate agglutination
test
Treatment
Antimicrobials
o Meningitis meropenem or ampicillin
and chloramphenicol
o Respiratory infections: amoxicillin,
chloramphenicol, cefuroxime
Other therapeutic measures depend on type of
infection
Mumps
Etiology: A RNA virus in the Paramyxoviridae family
Epidemiology:
MOT: contact w/ infected respiratory tract sec
Incubation period usu 16-18 days but may occur
12 to 25 days after exposure
Clinical Manifestation
A systemic disease characterized by swelling of
one or more of the salivary glands usu the
parotid gland
Approx. 1/3 of the cases present only w/ respi
tract infection

Complications
_______
Pancreatitis
Meningoencephalitis tranverse myelitis
ascending ____radiculitis
Arthritis
Thyroiditis
Vasculitis
Glomerulonephritis
Myocarditis
Diagnostic Test
Isolation of the virus from throat washing,
saliva, urine or spinal fluid
Detection of mumps specific IgM antibody
Treatment: Supportive
Influenza
Classification of Influenza Viruses
A
B
Types A and B causes of epidemic influenza
C
Epidemiology
Transmission
o Droplet spread, with inhalation of
airborne particles produced by coughing
and sneezing; most common mode of
transmission
o Direct contact with articles recently
contaminated by nasopharyngeal
secretions
Incubation period is 1-3 days
Age prevalence:
o Precise morbidity and mortality rates
difficult to determine bec other respi
tract viruses including RSV and
parainfluenze viruses can present
symptoms similar of influenze
o Attack rates in healthy children in US
estimated at 10-40% each year
Clinical Presentation of Upper Respiratory Illness
Caused by Influenza
Cough: dry, hacking, peaks after 3-4 days and
persists for more than a week after other
symptoms have resolved
Sore throat but w/o an exudate
Rhinorrhea
Eye discomfort: tearing, photophobia, or burning
LBC 3B

Common manifestation of Influenza in Children >/= 5yo

Flu like syndrome
o Fever
o Cough
o Headache
o Myalgia
o Malaise
Diagnostic Tests
Specimens must be obtained during the first 72
hours of illness for :
o Virus culture
o Immunofluorescent studies
o Rapid diagnostic tests
RT-PCR
Complications
Bacterial superinfection: the most common
complication
o Otitis media
o Pneumonia
S. pnemoniae
S. aureus: may be assoc w/
tracheitis and TSS
H. influenza
Grp. A strep
Cardiac
o Myocarditis
CNS
o Encephalitis
o Encephalopathy
o Transverse myelitis
o Reye syndrome
o Guillain Barre syndrome
Myositis
o Occurs as respiratory sx wane during
influenza B inf
o Acute pain and tenderness in the
gastrocnemius and soleus muscles that is
severe enough to limit walking
o Serum creatine kinase, transient
o Recovery usually occurs in 3-4 days
Treatment: Antiviral Drugs
Virus
Route
Treatment
indications
Prophylaxis
indications
Adverse
effects

Amantadine
A
Oral
>/=1 yr

Rimantadine
A
Oral
>/=13 yr

Zanamivir
A,B
Inhalation
>/=7 yr

Oseltamivir
A,B
Oral
>/=1 yr

>/=1 yr

>/=1 yr

Not lic

>/=1 yr

CNS
anxiety

CNS anxiety

Bronchospasm

Nausea
vomiting

Pneumococcal Infections
Etiology
S. pneumonia

Serotypes usu causing invasive disease in

children
4, 6B, 9V, 14, 18C, 19F, 23F

Epidemiology
Transmission: person to person, presumably
respi droplet contact
Incubation period varies according to the
serotype: can be as short as 1-3 days
Clinical Spectrum
Community acquired pneumonia
Meningitis
Sinusitis
Conjunctivitis
Less freq: periorbital cellulitis, endocarditis,
pericarditis, osteomyelitis, septic arthritis,
neonatal septicemia
Diagnostic Test
Gram stained smears and cultures of material
obtained from a supurative focus
Blood culture in patients suspected to have an
invasive disease
Antibiotic Therapy
Penicillin
o If resistant to penicillin, vancomycin
o Other antibiotics: ceftriaxone,
cefotaxime
Rotavirus
Etiology
Segmented double stranded RNA viruses
belonging to the Reoviridae family with 7
distinct antigenic groups
Epidemiology
MOT
o Direct or indirect contact with infected
people
o Fecal-oral route
Incubation period: 2-4 days
Clinical Presentation
Toxigenic (luminal) diarrhea: watery stools
vomiting and fever usu lasting 3-5 days
Diagnostic Tests
For groups A
o Enzyme immunoassay
o Latex agglutination test
Treatment
No specific antiviral tx
Treatment of dehydration
LBC 3B

Human Papillomavirus
Epidemiology
MOT
o Person-person by direct contact
o Thru minor trauma to the skin
o Sexual contact
o In the neonate: aspiration of the infected
secretions in the birth canal
Incubation period: not known but estimated to
be from 3 months to several years
Clinical Spectrum
Skin warts
Flat warts
Anogenital warts (condylomata acuminate)
Respi tract papillomatosis: usu involviong the
larynx or other areas of the upper respi tract
Cervical cancer: vulvar and penile cancer less
frequent
Diagnostic Tests
Culture
Cervical dysplasias: Pap smear or liquid based
cytology and biopsy
Treatment
Directed toward elimination of the lesions that
results from the infection rather than the virus
itself
Denouncement
Vaccination is a powerful and dynamic tool.
Programs and schedules are individualized in
countries based on local epidemiologic data and
have undergone constant evaluation and
changes.