2. Amoebiasis
• Entamoeba Hystolitica –protozoan
(parasite)
• MOT = 5 F’s, fecal oral route
• IP = 2-4 weeks
• IMMUNITY = xxx

3. • Dx microscopic stool exam or rectal
secretions
• (tetra nucleated cyst and trophozoites)
• Diarrhea and constipation (non
dysenteric)
• Blood streaked, diarrhea and watery
mucoid, abd’l cramps (dysenteric)
• Extra amoebiasispenile, vagina, spleen, liver, anal, lungs
and meninges
• Metronidazole (Flagyl)

4. Typhoid Fever
•
•
•
•
Salmonella typhosa (bacteria)
MOT = same with amoebiasis (5 F’s)
IP = 1-3 weeks
IMMUNITY
• Active = vaccine
• Passive = xxx
• Natural = lifetime immunity

5. Pathophysiology
• Oral ingestion
• Bloodstream
• Reticuloendothelial system (lymph
node, spleen, liver)
• Bloodstream
• Gallbladder
• Peyer’s patches of SI
• necrosis and ulceration

6. • 1st week step ladder (BLOOD)
• 2nd week rose spot and fastidial
• typhoid pyschosis (URINE &
STOOL)
• 3rd week (complications) intestinal
bleeding,
• perforation, peritonitis, encephalitis,
• 4th week (lysis) decreasing S?SX
• 5th week (convalescent)

7. • Blood (typhi dot) 1st week after
• Stool and urine 2nd week after
• Chloramphenicol

8. • Rose spot (abdominal rashes)
• Step ladder fever to fastidial (peak of
fever) typhoid psychosis
• Peyer’s patches of small intestine
• May stay in the gallbladder (hiding
area)

9. BACKGROUND
Cholera, is a Greek word, which means the
gutter of the roof. It is caused by bacteria:
Vibrio cholerae, which was discovered in 1883
by Robert Koch during a diarrheal outbreak in
Egypt.
V. cholerae has 2 major biotypes: classical
and El Tor, which was first isolated in Egypt in
1905. Currently, El Tor is the predominant
cholera pathogen worldwide.

10. EPIDEMIOLOGY/3
• Crowding & gathering of people during
religious rituals (e.g. Muslims pilgrimage
to Mecca or Hindu swimming festivals in
holy rivers) enhance the spread of
infection.
• Index cases when travelled back to their
homes may pass the organism to at risk
individuals leading to secondary epidemic
or small scale infection.

11. PATHOGENESIS
V cholerae cause clinical disease by producing
an enterotoxin that promotes the secretion of
fluid and electrolytes into the lumen of the gut.
The result is watery diarrhea with electrolyte
concentrations isotonic to those of plasma.
The enterotoxin acts locally & does not invade
the intestinal wall. As a result few WBC & no
RBC are found in the stool.

12. PATHOGENESIS/2
Fluid loss originates in the duodenum and
upper jejunum; the ileum is less affected.
The colon is usually in a state of absorption
because it is relatively insensitive to the toxin.
The large volume of fluid produced in the
upper intestine, however, overwhelms the
absorptive capacity of the lower bowel, which
results in severe diarrhea.

13. TRANSMISSION
Cholera is transmitted by the fecal-oral route
through contaminated water & food.
Person to person infection is rare.
The infectious dose of bacteria required to
cause clinical disease varies with the source. If
ingested with water the dose is in the order of
103-106 organisms. When ingested with
food, fewer organisms are required to produce
disease, namely 102-104.

14. TRANSMISSION/2
V. cholerae is a saltwater organism & it is
primary habitat is the marine ecosystem.
Cholera has 2 main reservoirs, man & water.
Animals do not play a role in transmission of
disease.
V. cholerae is unable to survive in an acid
medium. Therefore, any condition that reduces
gastric acid production increases the risk of
acquisition.

15. HOST SUSCEPTIBILITY
The use of antacids, histamine-receptor
blockers, and proton-pump inhibitors increases
the risk of cholera infection and predisposes
patients to more severe disease as a result of
reduced gastric acidity.
The same applies to patients with chronic
gastritis secondary to Helicobacter pylori
infection or those who have had a gastrectomy.

16. AT RISK GROUPS
All ages but children & elderly are more
severely affected.
Subjects with blood group “O” are more
susceptible; the cause is unknown.
Subjects with reduced gastric acid.

17. CLINICAL PICTURE
Incubation period is 24-48 hours.
Symptoms begin with sudden onset of
watery diarrhea, which may be followed by
vomiting. Fever is typically absent.
The diarrhea has fishy odor in the
beginning, but became less smelly & more
watery over time.

18. CLINICAL PICTURE/2
The classical textbook “rice water”
diarrhea, which describes fluid stool with
very little fecal material, appears within
24h from the start of the illness.
In severe cases stool volume exceeds 250
ml /kg leading to severe dehydration, shock
& death if untreated.

19. CHOLERA IN CHILDREN
Breast-fed infants are protected.
Symptoms are severe & fever is frequent.
Shock, drowsiness & coma are common.
Hypoglycemia is a recognized
complication, which may lead to convulsions.
Rotavirus infection may give similar picture
& need to be excluded.

20. TREATMENT
The primary goal of therapy is to replenish
fluid losses caused by diarrhea & vomiting.
Fluid therapy is accomplished in 2 phases:
rehydration and maintenance.
Rehydration should be completed in 4
hours & maintenance fluids should replace
ongoing losses & provide daily requirement.

21. PUBLIC HEALTH ASPECTS
Isolation & barrier nursing is indicated
Notification of the case to local authorities &
WHO.
Trace source of infection.
Resume feeding with normal diet when vomiting
has stopped & continue breastfeeding infants &
young children.

22. PREVENTION
Education on hygiene practices.
Provision of safe, uncontaminated, drinking
water to the people.
Antibiotic prophylaxis to house-hold
contacts of index cases.
Vaccination against cholera to travellers to
endemic countries & during public gatherings.

23. CHOLERA VACCINES
The old killed injectable vaccine is obsolete
now because it is not effective.
Two new oral vaccines became available in
1997. A Killed & a live attenuated types.
Both provoke a local immune response in
the gut & a blood immune response.
Cholera vaccination is no more required for
international travellers because risk is small.

24. BLOOD
BORNE DISEASES

25. What Is Hepatitis?
• Hepatitis means inflammation of the liver
• Hepat (liver) + itis (inflammation)= Hepatitis
• Viral hepatitis means there is a specific virus that
is causing your liver to inflame (swell or become
larger than normal)

26. Inflammation
Walls of
scar
tissue
begin to
form
Healthy liver cells
become trapped
by a wall of scar
tissue

27. Viral Hepatitis
5 types:
A: fecal-oral transmission
B: sexual fluids & blood to blood
C: blood to blood
D: travels with B
E: fecal–oral transmission
Adapted from Corneil, 2003
Vaccine
Preventable

28. Hepatitis C
• Affects each person differently
• No vaccine available
• Many people have the virus and do not
even know it
• Approximately 1 out of 100 Canadians
infected
Overall cure rate with new treatment is
55% Service 2003
*BC Hepatitis
*

29. Factors Affecting Progression
• 30yrs or longer if:
• Young at time of infection
• Healthy liver at time of infection
• Female
• 20yrs or less if:
• Drinking alcohol
• Co-infection (HIV, Hep B)
• Damaged liver before infection
Adapted from Bigham, BC Hepatitis Services 2002

30. Signs and Symptoms
•
Individuals may have one or more of the following
symptoms, while others experience no symptoms:
–Tiredness
–Nausea
–Muscle or joint pain
–Trouble sleeping
–Loss of appetite
–Weight loss
–Abdominal pain
–Itchiness
–Depression
–Dark urine (pee)

31. Signs and Symptoms
• A few may have specific liver related symptoms
initially:
• Pale stool (poo)
• Jaundice (yellowing of the skin or eyes)

32. Prevention
• Never share drug equipment
•
Straws, bills, needles, syringes, water, filter, cooker,
pipes etc…
• Never share tooth brushes/razors or any personal
hygiene articles that have blood on them (even tiny
amounts).
• Practice safer sex

33. Prevention
• Always make sure new & sterilized equipment is being
used for tattooing & piercing
• Make sure ink for tattooing is not being shared
• Do not touch dirty needles without proper equipment or
following proper procedures

34. Dirty Needle Precautions
1. Handle only if you have proper equipment
•
Sturdy pair of gloves, tongs or pliers and a puncture proof
container (heavy plastic or metal)
2. Place needle in puncture proof container
•
Do not touch needle with bare hands and do not try to recap
needle if cap present
3. Can dispose container in garbage but better if it is
taken to health clinic or needle exchange
4. At school, notify custodian, teacher, nurse or
police liaison officer

35. Needle Prick
1.
Do not “milk” prick site
2.
Wash the area with soap and water
3.
Go to nearest emergency department for assessment and
treatment

36. HEPATITIS A

37. PREVENTION
•
If already infected with HAV
1. Wash your hands thoroughly every
time you use the bathroom, before
touching or preparing food, and
before touching others. Wash
carefully with soap and warm water
and dry thoroughly.
2. Contaminated surfaces should be
cleaned with household bleach to kill
the virus.
3. Heat food or water to 185°F or 85°C
to kill the virus.
NOTE: Strict personal hygiene and hand
washing help prevent transmission of
HAV to others.

38. PREVENTION…
•
If NOT yet Infected with HAV
1. Wash your hands carefully with soap
and warm water several times a
day, including every time you use the
bathroom, every time you change a
diaper, and before preparing food.
2. Do not eat raw or undercooked
seafood or shellfish such as oysters
from areas of questionable sanitation
(just about everywhere).
3. Travelers to developing countries
should not drink untreated water or
beverages with ice in them. Fruits and
vegetables should not be eaten
unless cooked or peeled.

39. Vaccines that Work against HAV
• Havrix and VAQTA
• contain no live virus and are very safe
• given in a series of 2 shots. The second
is given 6-18 months after the first.
• protection starts about 2-4 weeks after
the first shot. The second dose is
necessary to ensure long-term
protection.
• thought to protect from infection for at
least 20 years
• must be given before exposure to the
virus

40. Groups Recommended to
have the HAV Vaccine
• All children older than 2 years who live in
communities where the number of HAV
infections is unusually high or where there
are periodic outbreaks of hepatitis A
• People who are likely to be exposed to
HAV at work
• . Travelers to developing countries (it must
be given at least 4 weeks before travel)
• Men who have sex with men
• People who use illegal drugs
• people with impaired immune systems or
chronic liver disease
• People with blood-clotting disorders who
receive clotting factors

41. MEDICAL TREATMENT
• No specific medicines to cure infection
with hepatitis A
• immune globulin- given to people who are
likely to be exposed to someone who is
infected with HAV

42. MEDICAL TREATMENT …
1. Bed rest during the acute stage and a
diet that is both acceptable to the
patient and nutritious are part of the
treatment and nursing care.
2. During the period of anorexia, the
patient should receive frequent small
feedings, supplemented, if
necessary, by IV fluids with glucose.
3. If dehydration occurs, IV fluids are
being prescribed to help the patient
feel better.

43. MEDICAL TREATMENT…
4. Medicines are being prescribed by
the physician to control nausea and
vomiting.
5. People whose symptoms are wellcontrolled can be cared for at home. If
dehydration or other symptoms are
severe, then the patient is managed
at the hospital.
6. Gradual but progressive ambulation
seems to hasten recovery, provided
the patient rests after activity and
does not participate in activities to the
point of fatigue.

44. Dietary Management
1.
2.
3.
4.
Recommend small, frequent meals.
Provide intake of 2,000 to 3,000 kcal/day
during acute illness.
Although early studies indicate that a
high-protein, high-calorie, diet may be
beneficial, advise patient not to force
food and to restrict fat intake.
Carefully monitor fluid balance.

45. Dietary Management
5.
6.
7.
If anorexia, nausea and vomiting
persist, enteral feedings may be
necessary.
Instruct patient to abstain from alcohol
during the acute illness and for 6 months
after recovery.
Advise patient to avoid substances
(medication, herbs, illicit drugs and
toxins) that may affect liver function.

46. NURSING MANAGEMENT
•
The patient is usually managed at home
unless symptoms are severe.
• The nurse assists the patient and family in
coping with temporary disability and
fatigue that are common in hepatitis and
instructs them to seek additional health
care if the symptoms persist or worsen

47. Self-Care at Home
1. Take it easy; curtail your normal
activities and spend time resting at
home.
2. Drink plenty of clear fluids to
prevent dehydration.
3. Avoid medicines and substances
that can cause harm to the liver
such as acetaminophen (Tylenol)
and preparations that contain
acetaminophen.

48. Self-Care at Home…
4. Avoid alcoholic beverages, as
these can worsen the effects of
HAV on the liver.
5. Avoid prolonged, vigorous
exercise until symptoms start to
improve.
6. Call your health care provider if
symptoms worsen or a new
symptom appears.
7. Be very careful about personal
hygiene to avoid fecal-oral
transmission to other members
of the household.

49. HEPATITIS B

50. PREVENTION
• immune globulin (BayHep B, NabiHB)
• given along with the hepatitis B vaccine
to unvaccinated people who have been
exposed to hepatitis B
• Engerix-B, Recombivax HB
• safe and works well to prevent the
disease
• a total of 3 doses of the vaccine are
given over several months
• recommended for all children younger
than 19 years

51. Groups Recommended to
have the HBV Vaccine
1. All children younger than 18
years, including newborns-especially those born to mothers
who are infected with HBV.
2. All health care and public safety
workers who may be exposed to
blood
3. People who have hemophilia or
other blood clotting disorders and
receive transfusions of human
clotting factors
4. People who require hemodialysis for
kidney disease

52. Groups Recommended to
have the HBV Vaccine…
5. Travelers to countries where HBV
infection is common - This includes
most areas of Africa, Southeast
Asia, China and central
Asia, Eastern Europe, the Middle
East, the Pacific Islands, and the
Amazon River basin of South
America.
6. People who are in prison
7. People who live in residential
facilities for developmentally
disabled persons

53. Groups Recommended to
have the HBV Vaccine…
8. People who inject illegal drugs
9. People with chronic liver disease such
as hepatitis C
10. People who have multiple sex partners or
have ever had a sexually transmitted
disease
11. Men who have sex with men

54. Other ways to protect
yourself from HBV
infection
• Safe Sex
• Don't share needles or other sharp
equipments such as razors
• Health care workers should follow
standard precautions and handle needles
and sharps safely
• Think about the health risks if you are
planning to get a tattoo or body piercing

55. MEDICAL TREATMENT
•
Acute hepatitis B infection
•
•
•
If dehydration occurs, IV fluids are being
prescribed to help the patient feel better.
Medicines are being prescribed by the
physician to control nausea and vomiting.
People whose symptoms are wellcontrolled can be cared for at home. If
dehydration or other symptoms are
severe, then the patient is managed at the
hospital
NOTE: No treatment can prevent acute HBV
infection from becoming chronic

56. MEDICAL TREATMENT…
• Chronic hepatitis B infection
• Regularly measuring the amount of
HBV DNA in the blood gives a good
idea of how fast the virus is multiplying
• Treatment: antiviral drugs
• not appropriate for everyone with
chronic HBV infection. It is reserved
for people whose infection is most
likely to progress to chronic hepatitis
B.

57. Medications
• Interferon alfa-2b (Intron A) - was
the standard treatment of chronic
hepatitis B for several years
• Lamivudine (Epivir) - an alternative
for people who cannot or do not
want to take interferon
• Adefovir dipivoxil (Hepsera) works well even in people whose
disease is resistant to lamivudine
• Entecavir (Baraclude) - newest
medication approved for chronic
hepatitis B

58. Surgery and Other Therapy
• No herbs, supplements, or other
alternative therapy is known to work as
well as antiviral medication in slowing HBV
replication and promoting liver healing in
hepatitis B.
• no surgical therapy for hepatitis B
• If liver damage is severe enough, the
only treatment that will help is liver
transplant

59. NURSING MANAGEMENT
• nurse identifies psychosocial issues
and concerns, particularly the effects
of separation from family and friends
if the patient is hospitalized during
acute and infective stage.
• Follow-up visits by a home care
nurse may be needed to assess the
patient’s progress and answer the
family members’ questions about
disease transmission
• reinforces previous instructions

60. Self-Care at Home
1. Drink plenty of fluids to prevent
dehydration. Water is fine;
broth, sports drinks, Jello, frozen
ice treats (such as Popsicles), and
fruit juices are even better
because they provide calories.
2. Avoid medicines and substances
that can cause harm to the
liver, such as acetaminophen
(Tylenol).
3. Avoid drinking alcohol until your
health care provider OKs it. If your
infection becomes chronic, you
should avoid alcohol for the rest of
your life.

61. Self-Care at Home…
4.
5.
Avoid using drugs, even legal drugs,
without consulting your doctor. Hepatitis
can change the way drugs affect you. If
you take prescription medications,
continue taking them unless your health
care provider has told you to stop. Do
not start any new medication
(prescription or nonprescription), herbs,
or supplements without first talking to
your health care provider.
Try to eat enough for adequate nutrition.
Eat foods that appeal to you, but try to
maintain a balanced diet. Many people
with hepatitis have the greatest urge to
eat early in the day.

62. Self-Care at Home…
6. Take it easy. Your activity level
should match your energy level.
7. Avoid prolonged, vigorous
exercise until symptoms start to
improve.
8. Call your health care provider for
advice if your condition worsens or
new symptoms appear.
9. Avoid any activity that may spread
the infection to other people

63. HEPATITIS C

64. PREVENTION
• no vaccine for the prevention of
HCV transmission
• best means of preventing
transmission of HCV is to
prevent contact with infected blood
and organs and to avoid high-risk
sexual behavior such as multiple
partners and anal contact.
• Avoiding alcohol and drugs that can
damage the liver may help slow the
rate of progression of the disease.

65. MEDICAL TREATMENT
• pegylated interferon alpha
(Pegasys, PEG-Intron) - often combined
with an antiviral drug called ribavirin
(Virazole)

66. Certain medical conditions
preclude the use of
interferon
•
•
•
•
•
Depression and certain other mental and
neurologic disorders
Active alcohol or drug abuse
Autoimmune diseases such as
rheumatoid arthritis, systemic lupus
erythematosus, or psoriasis
Low blood hemoglobin level (anemia) or
blood cell counts
Cirrhosis that is severe enough to cause
symptoms such as
jaundice, wasting, fluid retention that
causes swelling, or mental disturbances

67. Medication
• Interferon alpha (Intron A) pegylated type (Pegasys, PEGIntron)
• Interferon is a protein that the body
makes naturally in response to viral
infections in order to fight the infection.
Pegylation describes a chemical
process that makes the interferon last
longer in the body.
• Ribavirin (Virazole)
• has little effect on HCV, but interferon
increases its potency

68. Surgery and Other Therapy
• For end-stage liver disease, the only
treatment is liver transplantation
• Alternative therapies has not been
proven to work in any scientific study
• most promising complementary therapy
is milk thistle
• licorice and ginseng
• ginger (to reduce nausea) and St.
John's wort (to relieve depression) may
be taken as complementary therapy to
help relieve the side effects of
interferon

69. NURSING MANAGEMENT
• Same as Hepatitis B

70. Patient Instruction
•
•
•
•
•
Eat a varied, healthy diet, take part in
some physical activity daily, and get
plenty of rest.
Drink plenty of water and other
noncaffeinated fluids to stay well
hydrated.
Avoid alcoholic beverages and
medicines such as nonsteroidal antiinflammatory drugs (like
Brufen, Aleve, Advil) that can be
harmful in people with liver disease.
If you have symptoms, avoid prolonged
or vigorous physical exercise until your
symptoms improve.
If symptoms worsen at any time, contact

71. Self-Care at Home
1. Take it easy; get plenty of rest.
2. Drink plenty of fluids to prevent
dehydration.
3. Do not drink alcohol of any
kind, including beer, wine, and
hard liquor.
4. Avoid medicines and substances
that can cause harm to the liver
such as acetaminophen (Tylenol)
and other preparations that contain
acetaminophen.
5. Avoid prolonged, vigorous
exercise until symptoms start to
improve

72. RABIES

73. CONTENTS:

74. What is rabies? (DEFINITION & ETIOLOGY)
•
•
Is an acute infectious disease of warmblooded animals and humans
characterized by an involvement of the
nervous system resulting in death.
It is caused by the RABIES VIRUS, a
rhabdovirus of the genus lyssavirus.

75. The Rabies Virus
RV – a neurotropic filterable virus present in the
saliva of rabid animals. It has a preferrence for
nerve tissues.
Rod-shaped
rabies viruses
colored for
effect
RHABDOVIRUS: any group of rod-shaped
RNA viruses with 1 important
member, rabies virus, pathogenic to man.
The virus has a predilection for tissue of
mucus-secreting glands and the Central
Nervous System. All warm-blooded
animals are susceptible to infection with
these viruses.
Parts of the rabies
virus
A rhabdovirus of the genus lyssavirus.
RHABDO: from Greek
rhabdos, "rod"
LYSSA: Greek –
frenzy, rage, fury, canine
madness
This is a
photograph of
the virus under
electron
microscope

76. How do you get rabies? (MODE & MEDIA
OF TRANSMISSION, IMMUNITY)
•All warm-blooded mammals are susceptible.
Natural immunity in man is unknown.
•You get rabies through the saliva of an
infected animal by an exposure to an open
break in the skin such as bites, open wound or
scratch and inhalation of infectious aerosols
such as from bats.
•In some cases, it is transmitted through
organ transplants (corneal transplant), from an
infected person.
•The virus gets transmitted through
saliva, tears, semen, some liquor (amniotic
fluid, CST) but not blood, urine or stool.

77. How do you know if an animal has rabies?
• Animals with rabies may act differently from
healthy animals.
• Some signs of rabies in animals are:





•
•
changes in an animal’s behavior
general sickness (fever, restlessness)
problems swallowing
increased drooling
aggression (biting at inanimate objects, aimless running)
Wild animals may move slowly or may act as if they are tame. Some wild animals
(foxes, raccoons, skunks) that normally avoid porcupines, may even try to bite
these prickly rodents.
A pet that is usually friendly may snap at you or may try to bite.

78. How do you know if one has rabies?
(DIAGNOSIS)
•There is yet no way of immediately knowing who had acquired
rabies virus. No tests are available to diagnose rabies in humans
before the onset of clinical disease.
•The most reliable test for rabies in patients who have clinical signs
of the disease is a DIRECT IMMUNOFLUORESCENT STUDY of a
full thickness biopsy of the skin taken from the back of the neck
above the hair line.
•The RAPID FLUORESCENT FOCUS INHIBITION TEST
is used to measure rabies-neutralizing antibodies in
serum. This test has the advantage of providing results
within 24 hours. Other tests of antibodies may take as
long as 14
•days.

79. EPIDEMIOLOGY
RABIES INCIDENCE:
WORLDWIDE:35, 00050, 000 cases/ year
(WHO)

80. EPIDEMIOLOGY
PHILIPPINES: 350-450 cases/ year
5-7 per million population
DOG BITE INCIDENCE: 140, 000- 560, 000/ year
200-800 per 100, 000 population/ year
AGE MOST AFFECTED: 5-14 year age group
(53% of cases)
BITING ANIMALS: (SLH STUDY 1982- 2002)
DOGS: 98%
PET:
88%
STRAY:
10%
CATS:
2%

81. • Based on the report from NCDPC (2004), the
six regions with the most number of rabies
cases are Western Visayas, Central
Luzon, Bicol, Central Visayas, Ilocos and
Cagayan Valley
• Data shows that 53.7 percent of animal bite
patients are children
• Dogs remain the principal animal source of
rabies

82. STAGES OF RABIES INFECTION
Rabies virus
Entry into the body
INCUBATI0N PERIOD
(20 – 90 days)
INVASION
(0 – 10 days)
EXCITEMENT
(2 – 7 days)
PARALYTIC
COMA
(5 – 14 days)
DEATH

83. RABIES CLASSIFICATION
ANIMAL RABIES
• There are two common types of rabies. One type is "furious" rabies.
Animals with this type are hostile, may bite at objects, and have an
increase in saliva. In the movies and in books, rabid animals foam at the
mouth. In real life, rabid animals look like they have foam in their mouth
because they have more saliva.
The second and more common form is known as paralytic or "dumb" rabies.
The dog pictured below has this type. An animal with "dumb" rabies is timid
and shy. It often rejects food and has paralysis of the lower jaw and
muscles.
• Another two types of rabies. One type is “urban” rabies. The type of
rabies in domestic dogs and cats.
The other type is called “ sylvatic” rabies. These type came from wild
animals such as bats, weasels, skunks and moles & voles.

84. HUMAN RABIES
• Humans also have a “furious” type, the
classic foaming of the
mouth, aggression, apprehension &
hydrophobia, and the “dumb”
type, progressive paralysis of the body
until they couldn’t breathe anymore.

85. DIFFERENT STAGES OF RABIES
INFECTION
C
A
T
S
D
O
G
S
B
A
T
S
VIRUS IN SALIVA
INHALED AEROSOLS
VIRUS IN SALIVA
INVASION PHASE
INVASION PHASE
PARALY
SIS
EXCITEMENT
PARALY
SIS
DEATH
DEATH

86. INVASION STAGE
• Also called PRODOME PERIOD;
•
•
Prodrome – symptom indicative of an
approaching disease
2-10 DAYS
Sensory changes on the site of entry.
Pain: dull, constant pain referable to the nervous pathways proximal to
the location of the wound or itching, intermittent, stabbing pains
radiating distally to the region of inoculation. In general, sensitivity is
the early symptom which may be ascribed to the stimulative action of
the virus affecting groups of neurons, esp. sensory system. Though
there is apt to be decreased sensitivity to local pain e.g. needle
introduction, patient may complain bitterly of drafts & bed clothes
which produce a general stimulation
Tick me!

87. • Fever,headache malaise sore throat
anorexia increased sensitivity (bright
lights, loud noises) increased muscle
reflex irritability, tics and muscle tone
• Overactive facial expression

88. EXCITATION STAGE
•
•
•
•
•
•
•
•
•
Also called ACUTE NEUROLOGICAL PHASE;
hyperactivity
2 – 10 DAYS
Imminent thoraco-lumbar involvement (SNS):
pupillary dilation, lacrimation increased thick
saliva production / foaming of mouth, excessive
perspiration, increased HR
Anxiety: increased
nervousness, insomnia, apprehension; a strong
desire to be up, wandering aimlessly about, and
Fear: a sense of impending doom
Hydrophobia (perhaps, SNS stimulation:
depresses GI activity > inhibits
esophageal, gastric & intestinal function) >
violent expulsion of fluids, drooling (in attempt
not to swallow) > dehydration and parched mouth
& tongue
Pronounced muscular stimulation & general
tremor
Mania (tearing of clothes & bedding, cases of
biting & fighting rare but may occur) and
Hallucinations with lucid intervals (normal mental
function in which patient is well-oriented &
answers questions intelligently)
Convulsions( besides r/t pronounced muscular
stimulation, further precipitated by sensory
stimuli – sight, sound, name of water > throat
spasms > choking > apnea, cyanois, gasping
> death, but if patient survive excitement phase…
Tick me
Tick me 1st!
next!
Sympathetic nervous system
Parasympathetic nervous
system

89. Tick me!

90. PARALYTIC STAGE
-also called DEPRESSION PHASE
• Gradual weakness of muscle groups
• muscle spasms cease
• OCULAR PALSY – strabismus, ocular
incoordination, nystagmus, diplopia, central
type partial blindness > responds poorly to
light, @ times pupil is constricted or unequal
(parasympathetic involvement)
• Oro-facial: FACIAL & MASSETER PALSY >
difficulty closing eyes & mouth, face
expressionless
• Oral: Weakness of muscles of phonation >
hoarsness & loss of voice
• Loss of tendon reflexes, always precedes
weakness of extremity
• Corneal reflex decreased or absent, dry

91. • Ears: VERTIGO . Middle ear disease . Early
symptom, but may develop @ any period
• Neck stiffness
• (+) Babinski [lesions of pyramidal tract], ( - )
Kernig’s ( - ) Brudzinski’s
• Cardiac: shifts from tachycardia (100 –
120bpm) @ bed rest to bradycardia (40 -60
bpm)
• Respi: Cheyne-Stokes > breathing pattern
characterized by a periodic 10 – 6- sec of
apnea followed by gradual increasing depth
and frequency of respiration
• Local sensation (pin prick, heat, cold)
diminished
• Incoordination

92. • Hydrophobia and aerophobia gone, but still
has some difficulty swallowing
• General arousal (PNS stimulation)
• Bladder & intestinal retention and
obstipation (damage to to innervation of the
musculature of intestine & bladder)(SNS
damage)
in some cases, patient shows period of
recovery, this apparent remission is followed
by progressive
• Ascending, flaccid paralysis of extremities
until it reaches the respiratory muscle
• Apathy, stupor
• Complications:
Pneumothorax, thrombosis, secondary
infections

93. MANAGEMENT
NURSING INTERVENTIONS
• HIGH RISK FOR INFECTION
TRANSMISSION
• provide patient isolation
• handwashing. Wash hands
before and after each
patient contact and
following procedures that
offer contamination risk
while caring for an individual
patient. Handwashing
technique is important in
reducing transient flora on
outer epidermal layers of
skin.
• Wear gloves when handling
fluids and other potential

94. • KNOWLEDGE DEFICIT (about
the disease, cause of infection and
preventive measures)
• assess patient’s and
family’s level of
knowledge on the
disease including
concepts, beliefs and
known treatment.
• Provide pertinent data
about the disease:
• organism and route of
transmission
• treatment goals and

95. • ALTERED BODY TEMPERATURE: FEVER RELATED
TO THE PRESENCE OF INFECTION. Since fever is
continuous, provide other modes to reduce
discomfort.
• If patient is still well
oriented, Inform the relation
of fever to the disease
process. The presence of virus
in the body …
• Monitor temperature at
regular intervals
• Provide a well ventilated
environment free from drafts
and wind.

96. • DEHYDRATION related to refusal
to take in fluids secondary to throat
spasms and fear of spasmodic
attacks.
• Assess level of
dehydration of patient.
• Maintain other routes of
fluid introduction as
prescribed by the
physician e.g. parenteral
routes
• Moisten parched mouth
with cotton or gauze
dipped in water but not
dripping.

97. IMMUNIZATION
ACTIVE IMMUNIZATION
- induce antibody and T-cell production in order to
neutralize the rabies virus in the body. It induces an
active immune response in 7-10 days after
vaccination, which may persist for one year or more
provided primary immunization is completed.
TYPES:
a. PVRV (Purified Vero Cell Rabies Vaccine)
b. PCEVC (Purified Chick Embryo Cell Vaccine)

98. PASSIVE IMMUNIZATION
- RIG (Rabies Immune Globulins)
- provide the immediate availability of antibodies at the
site of exposure before it is physiologically possible for
the pt.to begin producing his own antibodies after
vaccination.
- Important for pts. w/ Cat III exposures
Types:
a. HRIG (Human Rabies Immune Globulins)
b. Highly Purified Antibody Antigen Binding fragments
c. ERIG (Equine Rabies Immune Globulins)

99. VACCINATION
(Intradermal Schedule)
Day of
Immunization
PVRV/PCECV
Site
DAY 0
0.1 ml
L & R deltoids/
anterolateral thighs of
infants
DAY 3
0.1 ml
L & R deltoids/
anterolateral thighs of
infants
DAY 7
0.1 ml
L & R deltoids /
anterolateral thighs of
infants
DAY 28/30
0.1 ml
L & R deltoids/
anterolateral thighs of
infants

100. Intramuscular Schedule
Day of
Immunization
PVRV
PCECV
Site
Day 0
0.5 ml
1.0 ml
One deltoid/
anterolateral
thigh of infants
Day 3
0.5 ml
1.0 ml
Same
Day 7
0.5 ml
1.0 ml
Same
Day 14
0.5 ml
1.0 ml
Same
Day 28
0.5 ml
1.0 ml
same

101. MANAGEMENT OF RABIES
PATIENT
• Once symptoms start, treatment should
center on comfort care, using sedation &
avoidance of intubation & life support
measures once diagnosis is certain
1.
a.
b.
c.
MEDICATIONS
Diazepam
Midazolam
Haloperidol + Dipenhydramine

102. 2. SUPPORTIVE CARE
- Pts w/ confirmed rabies should receive adequate
sedation & comfort care in an appropriate medical
facility.
a. Once rabies diagnosis has been confirmed, invasive
procedures must be avoided
b. Provide suitable emotional and physical support
c. Discuss & provide important info. to relatives
concerning transmission of dse. & indication for PET
of contacts
d. Honest gentle communication concerning prognosis
should be provided to relatives of pt

103. 3. INFECTION CONTROL
a. Patient should be admitted in a quiet, draftfree, isolation room
b. HLCR workers & relatives in contact w/ pt should wear
proper personal protective equipment
(gown, gloves, mask, goggles)
4. DISPOSAL OF DEAD BODIES

104. Tetanus

105. • Tetanus
• Clostridium tetani
• MOT = wound setting
• IP = 3 -21 days
• IMMUNITY
• Active = TT
• Passive = TAT and TIG
• Natural = active none, passive (+)

106. • Wound Infection
• FATAL INFECTION OF THE CNS
• TOXIN-NEUROTOXIN

107. • PATHOPHYSIOLOGY:
• SETTING OF WOUND ---- ENTRANCE
OF C.T. ---- RELEASES TETANUS
TOXIN ---- TETANOSPASMIN
(CNS), TETANOLYSIN (BLOOD) ---ABSORBED BY MOTOR NERVE
ENDINGS ---- SYNAPSE
(CONNECTION BETWEEN
NEURONS) ---- MYONEURAL
JUNCTION ---- ACETYLCHOLINE
DISTURBANCE IN THE
TRANSMISSION OF NERVE IMPULSE

108. •
•
•
•
Trismus – lock jaw
Risus sardonicus - maskface
Risorius - grinsmile
Dx wound and blood extraction (non
specific)

109. • Immunization
• DPT (0.5 ml IM) 1 – 1 ½ months old 2 after 4 weeks 3 – after 4 weeks
• 1 st booster – 18 mos
• 2 nd booster – 4-6 yo
• subsequent booster – every 10 yrs
thereafter
• TT (0.5 ml IM) TT1 - 6 months within
preg TT2 - one month after TT1 TT3 to
TT5 - every succeeding preg or every
year
• TAT (horse) and TIG (human)

110. • Management
• 1. Anticonvulsant, muscle relaxants,
• antibiotics, wound cleansing and
debridement, hyperbaric chamber
• 2. Active-DPT and tetanus toxoid
• 3. Passive-TIG and TAT, placental
immunity