COMMUNITY HEALTH NSC 322 by MRS AGU CHEKWUBE

 Management, prevention and control of communicable diseases.

 Community participation in community based health care
 Mobilization and organization of group for specific program
 Promotion of self determination and self reliance
Communicable diseases are a major cause of suffering, disability and death in the world.
Communicable diseases refer to diseases that can be transmitted and make people ill.
They are caused by infective agents (pathogens), e.g. bacteria, viruses, fungi and parasite
which invade the body and multiply or release toxins to cause damages to normal body
cells and their functions. In severe cases, they may lead to death. These infective agents
can spread from a source of infection (e.g. patients, sick animals) to a person through
various routes of transmission. A communicable disease is one that is spread from one
person to another through a variety of ways that include: contact with blood and bodily
fluids; breathing in an airborne virus; or by being bitten by an insect.
1. Physical contact with an infected person, through touch (staphylococcus), sexual
intercourse (gonorrhea, HIV), fecal/oral transmission (hepatitis A), or droplets
(influenza, TB)
2. Contact with a contaminated surface or object (Norwalk virus), food (salmonella, E.
coli), blood (HIV, hepatitis B), or water (cholera);
3. Bites from insects or animals capable of transmitting the disease (mosquito: malaria
and yellow fever; flea: plague); and
4. Travel through the air, such as tuberculosis or measles.
LIST OF COMMUNICABLE DISEASES
i. 2019-nCoV
ii. Ebola
iii. Flu
iv. Hantavirus
v. Hepatitis A
vi. Hepatitis B
vii. HIV/AIDS
viii. Measles
ix. Monkeypox
x. MRSA
xi. Pertussis
xii. Rabies
xiii. Sexually Transmitted Disease

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 xiv. Shigellosis
xv. Tuberculosis
xvi. West Nile Virus
xvii. Zika
xviii. Dengue and severe dengue
xix. Trachoma
xx. Lymphatic filariasis
xxi. Onchocerciasis
xxii. Trypanosomiasis, human African (sleeping sickness)
xxiii. Cholera
xxiv. Leishmaniasis
xxv. Crimean-Congo haemorrhagic fever
xxvi. Marburg haemorrhagic fever
xxvii. Rift Valley fever
xxviii. Smallpox
CORONAVIRUS DISEASE (COVID-19)
Coronavirus disease (COVID-19) is an infectious disease caused by the SARS-CoV-2
virus. COVID-19 affects different people in different ways. Most infected people will
develop mild to moderate illness and recover without hospitalization.
Most common symptoms: Fever, cough, tiredness, loss of taste or smell,
Less common symptoms: Sore throat, headache, aches and pains, diarrhea, a rash on skin,
or discolouration of fingers or toes, red or irritated eyes,
The virus can spread from an infected person’s mouth or nose in small liquid particles
when they cough, sneeze, speak, sing or breathe. These particles range from larger
respiratory droplets to smaller aerosols.
It is important to practice respiratory etiquette, for example by Covering your nose and
mouth with your bent elbow or a tissue when you cough or sneeze, coughing into a flexed
elbow, and to stay home and self-isolate until you recover if you feel unwell. Maintain a
safe distance from others (at least 1 metre), even if they don’t appear to be sick, wear a
mask in public, especially indoors or when physical distancing is not possible, stay open,
well-ventilated spaces over closed ones, open a window if indoors, use soap and water, or
an alcohol-based hand rub. Get vaccinated
EBOLA VIRUS DISEASE
Ebola virus disease (EVD), formerly known as Ebola haemorrhagic fever, is a severe,
often fatal illness affecting humans and other primates.
The virus is transmitted to people from wild animals (such as fruit bats, porcupines and
non-human primates) and then spreads in the human population through direct contact

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with the blood, secretions, organs or other bodily fluids of infected people, and with
surfaces and materials (e.g. bedding, clothing) contaminated with these fluids.
The incubation period, that is, the time interval from infection with the virus to onset of
symptoms, is from 2 to 21 days. A person infected with Ebola cannot spread the disease
until they develop symptoms.
Symptoms of EVD can be sudden and include: fever, fatigue, muscle, pain, headache,
and sore throat. This is followed by vomiting, diarrhea, rash, symptoms of impaired
kidney and liver function, and in some cases internal and external bleeding (e.g. oozing
from the gums, blood in the stools). Laboratory findings include low white blood cell and
platelet counts and elevated liver enzymes.
It can be difficult to clinically distinguish EVD from other infectious diseases such as
malaria, typhoid fever and meningitis. 
Supportive care - rehydration with oral or intravenous fluids - and treatment of specific
symptoms improves survival. A range of potential treatments including blood products,
immune therapies and drug therapies are currently being evaluated. 
FLU
Influenza (flu) is a common viral infection, contagious respiratory illness caused
by influenza viruses that infect the nose, throat, and lungs. Some people, such as older
people, young children, and people with certain health conditions, are at higher risk of
serious flu complications.  There are two main types of influenza (flu) viruses: Types A
and B. The influenza A and B viruses that routinely spread in people (human influenza
viruses) are responsible for seasonal flu epidemics each year..
Symptoms include fever, chills, muscle aches, cough, congestion, runny nose, headaches
and fatigue.
The best way to reduce the risk of flu and its potentially serious complications is by
getting vaccinated each year. The flu is treated primarily with rest and fluid to let the
body fight the infection on its own. Over-the-counter anti-inflammatory pain relievers
may help with symptoms.
HANTAVIRUS
Hantavirus (HV) is an emerging zoonotic disease transmitted by rodents such as mice and
rats. It is characterized by symptoms of fever, myalgia, and gastrointestinal complaints,
including nausea, vomiting, abdominal pains, and diarrhoea, followed by sudden onset of
respiratory distress and hypotension.

The most common clinical form of the disease is Hantavirus Pulmonary Syndrome (HPS)
which can lead to death. Symptoms of HPS may develop up to 42 days -and in some

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cases up to 56 days- after exposure, the incubation period varies from a few days to six
weeks after exposure. making it difficult to identify the exact source of infection.
Transmission
Cases of human hantavirus infection usually occur in rural areas (forests, fields, farms,
etc.), where rodents hosting the virus may be found. However, transmission may also
occur in urban areas. The virus is contracted through the inhalation of rodent droppings
(urine and feces) and saliva. Only some types of rat and mouse can transmit the virus that
causes HPS to people. Simplified hantavirus infection cycle.

The chance of exposure to hantaviruses is greatest when individuals work, play, or live in
enclosed spaces where there is an active rodent infestation. Human infection does not
appear to be limited to a particular age, race, ethnic group, or gender.
Small skin breaks and rodent bites are probably effective but uncommon routes of human
infection. Cats and dogs are not known to host hantaviruses, these domestic animals may
bring infected rodents into contact with humans
Diagnosis and treatment
Early identification and timely medical care improves clinical outcome. Care during the
initial stages of the illness should include antipyretics and analgesics as needed. In some
situations, patients should receive broad-spectrum antibiotics while confirming the
etiologic agent.
Given the rapid progression of HPS, clinical management should focus on the patient's
haemodynamic monitoring, fluid management, and ventilation support. Severe cases
should be immediately transferred to intensive care units (ICUs).
Hantavirus infections may resemble other diseases such as leptospirosis, dengue fever,
chikungunya and even influenza in the early stage. Including this disease in the
differential diagnosis concerning febrile syndromes may result in a timelier recognition
and improved case management.
Fatality rates may significantly decrease through early recognition.

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Prevention
HPS occurrence can be prevented by reducing people’s contact with rodents and their
excrement, as well as well as through hygienic practices prevent rodent infestations in the
home, workplace and recreation areas. There is currently no vaccine against hantavirus in
the Americas.
HEPATITIS A
Hepatitis A is an inflammation of the liver caused by the hepatitis A virus (HAV). The
virus is primarily spread when an uninfected (and unvaccinated) person ingests food or
water that is contaminated with the faeces of an infected person. The disease is closely
associated with unsafe water or food, inadequate sanitation, poor personal hygiene and
oral-anal sex.
Unlike hepatitis B and C, hepatitis A does not cause chronic liver disease but it can cause
debilitating symptoms and rarely fulminant hepatitis (acute liver failure), which is often
fatal.
Hepatitis A occurs sporadically and in epidemics worldwide, with a tendency for cyclic
recurrences, they can also be prolonged, affecting communities for months through
person-to-person transmission. Hepatitis A viruses persist in the environment and can
withstand food production processes routinely used to inactivate or control bacterial
pathogens.
The virus can also be transmitted through close physical contact (such as oral-anal sex)
with an infectious person, although casual contact among people does not spread the
virus.
Symptoms
The incubation period of hepatitis A is usually 14–28 days.
Symptoms of hepatitis A range from mild to severe and can include fever, malaise, loss
of appetite, diarrhoea, nausea, abdominal discomfort, dark-coloured urine and jaundice (a
yellowing of the eyes and skin). Not everyone who is infected will have all the
symptoms.
Adults have signs and symptoms of illness more often than children. The severity of
disease and fatal outcomes are higher in older age groups. Infected children under 6 years
of age do not usually experience noticeable symptoms, and only 10% develop jaundice.
Hepatitis A sometimes relapses, meaning the person who just recovered falls sick again
with another acute episode. This is normally followed by recovery.
Who is at risk?
Anyone who has not been vaccinated or previously infected can get infected with the
hepatitis A virus. In areas where the virus is widespread (high endemicity), most hepatitis
A infections occur during early childhood. Risk factors include:

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  poor sanitation;
 lack of safe water;
 living in a household with an infected person;
 being a sexual partner of someone with acute hepatitis A infection;
 use of recreational drugs;
 sex between men; and
 travelling to areas of high endemicity without being immunized.
Diagnosis
Cases of hepatitis A are not clinically distinguishable from other types of acute viral
hepatitis. Specific diagnosis is made by the detection of HAV-specific immunoglobulin G
(IgM) antibodies in the blood. Additional tests include reverse transcriptase polymerase
chain reaction (RT-PCR) to detect the hepatitis A virus RNA and may require specialized
laboratory facilities.
Treatment
There is no specific treatment for hepatitis A. Recovery from symptoms following
infection may be slow and can take several weeks or months. It is important to avoid
unnecessary medications. Acetaminophen, paracetamol and medication against vomiting
should be avoided.
Hospitalization is unnecessary in the absence of acute liver failure. Therapy is aimed at
maintaining comfort and adequate nutritional balance, including replacement of fluids
that are lost from vomiting and diarrhoea.
Prevention
Improved sanitation, food safety and immunization are the most effective ways to combat
hepatitis A.
The spread of hepatitis A can be reduced by:
 Adequate supplies of safe drinking water;
 Proper disposal of sewage within communities; and
 Personal hygiene practices such as regular hand washing before meals and after
going to the bathroom.
Several injectable inactivated hepatitis A vaccines are available internationally. All
provide similar protection from the virus and have comparable side effects. No vaccine is
licensed for children younger than 1 year of age.
HEPATITIS B
Hepatitis B is a potentially life-threatening liver infection caused by the hepatitis B virus
(HBV). It is a major global health problem. It can cause chronic infection and puts people
at high risk of death from cirrhosis and liver cancer.

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A safe and effective vaccine that offers 98% to 100% protection against hepatitis B is
available. Preventing hepatitis B infection averts the development of complications
including chronic disease and liver cancer.
In highly endemic areas, hepatitis B is most commonly spread from mother to child at
birth (perinatal transmission) or through horizontal transmission (exposure to infected
blood), especially from an infected child to an uninfected child during the first 5 years of
life. The development of chronic infection is common in infants infected from their
mothers or before the age of 5 years.
Hepatitis B is also spread by needle stick injury, tattooing, piercing and exposure to
infected blood and body fluids, such as saliva and menstrual, vaginal and seminal fluids.
Transmission of the virus may also occur through the reuse of contaminated needles and
syringes or sharp objects either in health care settings, in the community or among
persons who inject drugs. Sexual transmission is more prevalent in unvaccinated persons
with multiple sexual partners.
Hepatitis B infection acquired in adulthood leads to chronic hepatitis in less than 5% of
cases, whereas infection in infancy and early childhood leads to chronic hepatitis in about
95% of cases. This is the basis for strengthening and prioritizing infant and childhood
vaccination.
The hepatitis B virus can survive outside the body for at least 7 days. During this time,
the virus can still cause infection if it enters the body of a person who is not protected by
the vaccine. The incubation period of the hepatitis B virus ranges from 30 to 180 days.
The virus may be detected within 30 to 60 days after infection and can persist and
develop into chronic hepatitis B, especially when transmitted in infancy or childhood.
Symptoms
Most people do not experience any symptoms when newly infected. However, some
people have acute illness with symptoms that last several weeks, including yellowing of
the skin and eyes (jaundice), dark urine, extreme fatigue, nausea, vomiting and abdominal
pain. People with acute hepatitis can develop acute liver failure, which can lead to death.
Among the long-term complications of HBV infections, a subset of persons develops
advanced liver diseases such as cirrhosis and hepatocellular carcinoma, which cause high
morbidity and mortality.
Diagnosis
It is not possible on clinical grounds to differentiate hepatitis B from hepatitis caused by
other viral agents, hence laboratory confirmation of the diagnosis is essential. Several
blood tests are available to diagnose and monitor people with hepatitis B. They can be
used to distinguish acute and chronic infections. WHO recommends that all blood

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donations be tested for hepatitis B to ensure blood safety and avoid accidental
transmission.
Treatment
There is no specific treatment for acute hepatitis B. Therefore, care is aimed at
maintaining comfort and adequate nutritional balance, including replacement of fluids
lost from vomiting and diarrhoea. Most important is the avoidance of unnecessary
medications. Acetaminophen, paracetamol and medication against vomiting should be
avoided.
Chronic hepatitis B infection can be treated with medicines, including oral antiviral
agents. Treatment can slow the progression of cirrhosis, reduce incidence of liver cancer
and improve long term survival. In 2021 WHO estimated that 12% to 25% of people with
chronic hepatitis B infection will require treatment, depending on setting and eligibility
criteria.
WHO recommends the use of oral treatments (tenofovir or entecavir) as the most potent
drugs to suppress hepatitis B virus. Most people who start hepatitis B treatment must
continue it for life.
HIV/AIDS
Human immunodeficiency virus (HIV) is an infection that attacks the body’s immune
system, specifically the white blood cells called CD4 cells. HIV destroys these CD4 cells,
weakening a person’s immunity against opportunistic infections, such as tuberculosis and
fungal infections, severe bacterial infections and some cancers.
People diagnosed with HIV should be offered and linked to antiretroviral treatment
(ART) as soon as possible following diagnosis and periodically monitored using clinical
and laboratory parameters, including the test to measure virus in the blood (viral load). If
ART is taken consistently, this treatment also prevents HIV transmission to others.
At diagnosis or soon after starting ART, a CD4 cell count should be checked to assess a
person’s immune status. The CD4 cell count is a blood test used to assess progression of
HIV disease, including risk for developing opportunistic infections and guides the use of
preventive treatment. The normal range of CD4 count is from 500 to 1500 cells/mm3 of
blood, and it progressively decreases over time in persons who are not receiving or not
responding well to ART. If the person’s CD4 cell count falls below 200, their immunity
is severely compromised, leaving them susceptible to infections and death. Someone with
a CD4 count below 200 is described as having an advanced HIV disease (AHD).
MEASLES
Measles is a highly contagious, serious disease caused by a virus. Measles is caused by a
virus in the paramyxovirus family and it is normally passed through direct contact and

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through the air. The virus infects the respiratory tract, then spreads throughout the body.
Measles is a human disease and is not known to occur in animals.
Signs and symptoms
The first sign of measles is usually a high fever, which begins about 10 to 12 days after
exposure to the virus, and lasts 4 to 7 days. A runny nose, a cough, red and watery eyes,
and small white spots inside the cheeks can develop in the initial stage. After several
days, a rash erupts, usually on the face and upper neck. Over about 3 days, the rash
spreads, eventually reaching the hands and feet. The rash lasts for 5 to 6 days, and then
fades. On average, the rash occurs 14 days after exposure to the virus (within a range of 7
to 18 days).
Who is at risk?
Unvaccinated young children are at highest risk of measles and its complications,
including death. Unvaccinated pregnant women are also at risk. Any non-immune person
(who has not been vaccinated or was vaccinated but did not develop immunity) can
become infected. Measles outbreaks can be particularly deadly in countries experiencing
or recovering from a natural disaster or conflict. Damage to health infrastructure and
health services interrupts routine immunization, and overcrowding in residential camps
greatly increases the risk of infection.
Transmission
Measles is one of the world’s most contagious diseases. It is spread by coughing and
sneezing, close personal contact or direct contact with infected nasal or throat secretions.
The virus remains active and contagious in the air or on infected surfaces for up to 2
hours. It can be transmitted by an infected person from 4 days prior to the onset of the
rash to 4 days after the rash erupts.
Measles outbreaks can result in epidemics that cause many deaths, especially among
young, malnourished children. In countries where measles has been largely eliminated,
cases imported from other countries remain an important source of infection.
Treatment
No specific antiviral treatment exists for measles virus.
Severe complications from measles can be reduced through supportive care that ensures
good nutrition, adequate fluid intake and treatment of dehydration with WHO-
recommended oral rehydration solution. This solution replaces fluids and other essential
elements that are lost through diarrhoea or vomiting. Antibiotics should be prescribed to
treat eye and ear infections, and pneumonia.
All children diagnosed with measles should receive two doses of vitamin A supplements,
given 24 hours apart. This treatment restores low vitamin A levels during measles that

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occur even in well-nourished children and can help prevent eye damage and blindness.
Vitamin A supplements have also been shown to reduce the number of measles deaths.
Prevention
Routine measles vaccination for children, combined with mass immunization campaigns
in countries with high case and death rates, are key public health strategies to reduce
global measles deaths.
MONKEYPOX
Monkeypox is a viral zoonosis (a virus transmitted to humans from animals) with
symptoms similar to those seen in the past in smallpox patients, although it is clinically
less severe. Animal hosts include a range of rodents and non-human primates.
The pathogen
Monkeypox virus is an enveloped double-stranded DNA virus that belongs to
the Orthopoxvirus genus of the Poxviridae family. There are two distinct genetic clades
of the monkeypox virus: the central African (Congo Basin) clade and the west African
clade. The Congo Basin clade has historically caused more severe disease and was
thought to be more transmissible. The geographical division between the two clades has
so far been in Cameroon, the only country where both virus clades have been found.
Natural host of monkeypox virus
Various animal species have been identified as susceptible to monkeypox virus. This
includes rope squirrels, tree squirrels, Gambian pouched rats, dormice, non-human
primates and other species. Uncertainty remains on the natural history of monkeypox
virus and further studies are needed to identify the exact reservoir(s) and how virus
circulation is maintained in nature.
Transmission
Animal-to-human (zoonotic) transmission can occur from direct contact with the blood,
bodily fluids, or cutaneous or mucosal lesions of infected animals. In Africa, evidence of
monkeypox virus infection has been found in many animals including rope squirrels, tree
squirrels, Gambian pouched rats, dormice, different species of monkeys and others. The
natural reservoir of monkeypox has not yet been identified, though rodents are the most
likely. Eating inadequately cooked meat and other animal products of infected animals is
a possible risk factor. People living in or near forested areas may have indirect or low-
level exposure to infected animals.
Human-to-human transmission can result from close contact with respiratory secretions,
skin lesions of an infected person or recently contaminated objects. Transmission via
droplet respiratory particles usually requires prolonged face-to-face contact, which puts
health workers, household members and other close contacts of active cases at greater
risk. However, the longest documented chain of transmission in a community has risen in

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recent years from 6 to 9 successive person-to-person infections. This may reflect
declining immunity in all communities due to cessation of smallpox vaccination.
Transmission can also occur via the placenta from mother to fetus (which can lead to
congenital monkeypox) or during close contact during and after birth. While close
physical contact is a well-known risk factor for transmission, it is unclear at this time if
monkeypox can be transmitted specifically through sexual transmission routes. Studies
are needed to better understand this risk.
Signs and symptoms
The incubation period (interval from infection to onset of symptoms) of monkeypox is
usually from 6 to 13 days but can range from 5 to 21 days.
The infection can be divided into two periods:
Monkeypox is usually a self-limited disease with the symptoms lasting from 2 to 4
weeks. Severe cases occur more commonly among children and are related to the extent
of virus exposure, patient health status and nature of complications. Underlying immune
deficiencies may lead to worse outcomes. Although vaccination against smallpox was
protective in the past, today persons younger than 40 to 50 years of age (depending on the
country) may be more susceptible to monkeypox due to cessation of smallpox
vaccination campaigns globally after eradication of the disease.  Complications of
monkeypox can include secondary infections, bronchopneumonia, sepsis, encephalitis,
and infection of the cornea with ensuing loss of vision. The extent to which
asymptomatic infection may occur is unknown. 
Diagnosis
The clinical differential diagnosis that must be considered includes other rash illnesses,
such as chickenpox, measles, bacterial skin infections, scabies, syphilis, and medication-
associated allergies. Lymphadenopathy during the prodromal stage of illness can be a
clinical feature to distinguish monkeypox from chickenpox or smallpox.
If monkeypox is suspected, health workers should collect an appropriate sample and have
it transported safely to a laboratory with appropriate capability. Confirmation of
monkeypox depends on the type and quality of the specimen and the type of laboratory
test. Thus, specimens should be packaged and shipped in accordance with national and
international requirements. Polymerase chain reaction (PCR) is the preferred laboratory
test given its accuracy and sensitivity. For this, optimal diagnostic samples for
monkeypox are from skin lesions – the roof or fluid from vesicles and pustules, and dry
crusts. Where feasible, biopsy is an option. Lesion samples must be stored in a dry, sterile
tube (no viral transport media) and kept cold. PCR blood tests are usually inconclusive
because of the short duration of viremia relative to the timing of specimen collection after
symptoms begin and should not be routinely collected from patients.

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As orthopoxviruses are serologically cross-reactive, antigen and antibody detection
methods do not provide monkeypox-specific confirmation. Serology and antigen
detection methods are therefore not recommended for diagnosis or case investigation
where resources are limited. Additionally, recent or remote vaccination with a vaccinia-
based vaccine (e.g. anyone vaccinated before smallpox eradication, or more recently
vaccinated due to higher risk such as orthopoxvirus laboratory personnel) might lead to
false positive results.
In order to interpret test results, it is critical that patient information be provided with the
specimens including: a) date of onset of fever, b) date of onset of rash, c) date of
specimen collection, d) current status of the individual (stage of rash), and e) age.

METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA)

INFECTION
Methicillin-resistant Staphylococcus aureus (MRSA) infection is caused by a type of
staph bacteria that's become resistant to many of the antibiotics used to treat ordinary
staph infections.
Most MRSA infections occur in people who've been in hospitals or other health care
settings, such as nursing homes and dialysis centers. When it occurs in these settings, it's
known as health care-associated MRSA (HA-MRSA). HA-MRSA infections usually are
associated with invasive procedures or devices, such as surgeries, intravenous tubing or
artificial joints. HA-MRSA can spread by health care workers touching people with
unclean hands or people touching unclean surfaces.

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Another type of MRSA infection has occurred in the wider community — among healthy
people. This form, community-associated MRSA (CA-MRSA), often begins as a painful
skin boil. It's usually spread by skin-to-skin contact. At-risk populations include groups
such as high school wrestlers, child care workers and people who live in crowded
conditions.
Risk factors for HA-MRSA
 Being hospitalized. MRSA remains a concern in hospitals, where it can attack
those most vulnerable — older adults and people with weakened immune systems.
 Having an invasive medical device. Medical tubing — such as intravenous lines
or urinary catheters — can provide a pathway for MRSA to travel into your body.
 Residing in a long-term care facility. MRSA is prevalent in nursing homes.
Carriers of MRSA have the ability to spread it, even if they're not sick themselves.
Complications
MRSA infections can resist the effects of many common antibiotics, so they're more
difficult to treat. This can allow the infections to spread and sometimes become life-
threatening.
MRSA infections may affect your:
 Bloodstream
 Lungs
 Heart
 Bones
 Joints
Prevention
Preventing HA-MRSA
In the hospital, people who are infected or colonized with MRSA often are placed in
isolation as a measure to prevent the spread of MRSA. Visitors and health care workers
caring for people in isolation may need to wear protective garments.
They also must follow strict hand hygiene procedures. For example, health care workers
can help prevent HA-MRSA by washing their hands with soap and water or using hand
sanitizer before and after each clinical appointment.
Hospital rooms, surfaces and equipment, as well as laundry items, need to be properly
disinfected and cleaned regularly.
PERTUSSIS
Pertussis, also known as whooping cough, is a highly contagious respiratory infection
caused by the bacterium Bordetella pertussis. 

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Pertussis spreads easily from person to person mainly through droplets produced by
coughing or sneezing. The disease is most dangerous in infants, and is a significant cause
of disease and death in this age group.
The first symptoms generally appear 7 to 10 days after infection. They include a mild
fever, runny nose and cough, which in typical cases gradually develops into a hacking
cough followed by whooping (hence the common name of whooping cough). Pneumonia
is a relatively common complication, and seizures and brain disease occur rarely.
People with pertussis are most contagious up to about 3 weeks after the cough begins,
and many children who contract the infection have coughing spells that last 4 to 8 weeks.
Antibiotics are used to treat the infection.
Rabies
Rabies is a vaccine-preventable, zoonotic, viral disease. Once clinical symptoms appear,
rabies is virtually 100% fatal. In up to 99% of cases, domestic dogs are responsible for
rabies virus transmission to humans. Yet, rabies can affect both domestic and wild
animals. It is spread to people and animals through bites or scratches, usually via saliva.
Rabies is present on all continents, except Antarctica, with over 95% of human deaths
occurring in the Asia and Africa regions. Rabies is one of the Neglected Tropical
Diseases (NTD) that predominantly affects poor and vulnerable populations who live in
remote rural locations. Approximately 80% of human cases occur in rural areas.
Although effective human vaccines and immunoglobulins exist for rabies, they are not
readily available or accessible to those in need. Globally, rabies deaths are rarely reported
and children between the ages of 5–14 years are frequent victims.
Prevention
Eliminating rabies in dogs
Rabies is a vaccine-preventable disease. Vaccinating dogs is the most cost-effective
strategy for preventing rabies in people. Dog vaccination reduces deaths attributable to
dog-mediated rabies and the need for PEP as a part of dog bite patient care.
Awareness on rabies and preventing dog bites
Education on dog behaviour and bite prevention for both children and adults is an
essential extension of a rabies vaccination programme and can decrease both the
incidence of human rabies and the financial burden of treating dog bites. Increasing
awareness of rabies prevention and control in communities includes education and
information on responsible pet ownership, how to prevent dog bites, and immediate care
measures after a bite. Engagement and ownership of the programme at the community
level increases reach and uptake of key messages.
Immunization of people

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The same vaccine is used to immunize people after an exposure (see PEP) or before
exposure to rabies (less common). Pre-exposure immunization is recommended for
people in certain high-risk occupations such as laboratory workers handling live rabies
and rabies-related (lyssavirus) viruses; and people (such as animal disease control staff
and wildlife rangers) whose professional or personal activities might bring them into
direct contact with bats, carnivores, or other mammals that may be infected.
Pre-exposure immunization might be indicated also for outdoor travellers to and
expatriates living in remote areas with a high rabies exposure risk and limited local
access to rabies biologics. Finally, immunization should also be considered for children
living in, or visiting such areas. As they play with animals, they may receive more severe
bites, or may not report bites.
Symptoms
The incubation period for rabies is typically 2–3 months but may vary from 1 week to 1
year, dependent upon factors such as the location of virus entry and viral load. Initial
symptoms of rabies include a fever with pain and unusual or unexplained tingling,
pricking, or burning sensation (paraesthesia) at the wound site. As the virus spreads to the
central nervous system, progressive and fatal inflammation of the brain and spinal cord
develops.
There are two forms of the disease:
 Furious rabies results in signs of hyperactivity, excitable behaviour, hydrophobia
(fear of water) and sometimes aerophobia (fear of drafts or of fresh air). Death
occurs after a few days due to cardio-respiratory arrest.
 Paralytic rabies accounts for about 20% of the total number of human cases. This
form of rabies runs a less dramatic and usually longer course than the furious
form. Muscles gradually become paralysed, starting at the site of the bite or
scratch. A coma slowly develops, and eventually death occurs. The paralytic form
of rabies is often misdiagnosed, contributing to the under-reporting of the disease.
Diagnosis
Current diagnostic tools are not suitable for detecting rabies infection before the onset of
clinical disease, and unless the rabies-specific signs of hydrophobia or aerophobia are
present, clinical diagnosis may be difficult. Human rabies can be confirmed intra-vitam
and post mortem by various diagnostic techniques that detect whole viruses, viral
antigens, or nucleic acids in infected tissues (brain, skin or saliva)2
Transmission
People are usually infected following a deep bite or scratch from an animal with rabies.

15
Transmission can also occur if saliva of infected animals comes into direct contact with
human mucosa or fresh skin wounds. Contraction of rabies through inhalation of virus-
containing aerosols or through transplantation of infected organs is described, but
extremely rare. Human-to-human transmission through bites or saliva is theoretically
possible but has never been confirmed. The same applies for transmission to humans via
consumption of raw meat or milk of infected animals.
Post-exposure prophylaxis (PEP)
Post-exposure prophylaxis (PEP) is the immediate treatment of a bite victim after rabies
exposure. This prevents virus entry into the central nervous system, which results in
imminent death. PEP consists of:
 Extensive washing and local treatment of the bite wound or scratch as soon as
possible after a suspected exposure;
 a course of potent and effective rabies vaccine that meets WHO standards; and
 the administration of rabies immunoglobulin (RIG), if indicated.
Starting the treatment soon after an exposure to rabies virus can effectively prevent the
onset of symptoms and death.
Extensive wound washing
This first-aid measure includes immediate and thorough flushing and washing of the
wound for a minimum of 15 minutes with soap and water, detergent, povidone iodine or
other substances that remove and kill the rabies virus.
Exposure risk and indications for PEP
Depending on the severity of the contact with the suspected rabid animal, administration
of a full PEP course is recommended as follows:
All category II and III exposures assessed as carrying a risk of developing rabies require
PEP.
This risk is increased if:
 the biting mammal is a known rabies reservoir or vector species
 the exposure occurs in a geographical area where rabies is still present
 the animal looks sick or displays abnormal behaviour
 a wound or mucous membrane was contaminated by the animal’s saliva
 the bite was unprovoked
 the animal has not been vaccinated.
The vaccination status of the suspect animal should not be the deciding factor when
considering to initiate PEP or not when the vaccination status of the animal is
questionable. This can be the case if dog vaccination programmes are not being
sufficiently regulated or followed out of lack of resources or low priority.

16
 SEXUALLY TRANSMITTED INFECTIONS (STIS) (CHLAMYDIA,
GONORRHOEA, SYPHILIS AND TRICHOMONIASIS)
More than 30 different bacteria, viruses and parasites are known to be transmitted
through sexual contact. Eight of these pathogens are linked to the greatest incidence of
sexually transmitted disease. Of these, 4 are currently curable: syphilis, gonorrhoea,
chlamydia and trichomoniasis. The other 4 are viral infections which are incurable:
hepatitis B, herpes simplex virus (HSV or herpes), HIV and human papillomavirus
(HPV).
STIs are spread predominantly by sexual contact, including vaginal, anal and oral sex.
Some STIs can also be transmitted from mother-to-child during pregnancy, childbirth and
breastfeeding.
A person can have an STI without showing symptoms of disease. Common symptoms of
STIs include vaginal discharge, urethral discharge or burning in men, genital ulcers and
abdominal pain.
Prevention of STIs
When used correctly and consistently, condoms offer one of the most effective methods
of protection against STIs, including HIV. Condoms also protect against unintended
pregnancy in mutually consented sexual relationships. Although highly effective,
condoms do not offer protection for STIs that cause extra-genital ulcers (i.e., syphilis or
genital herpes). When possible, condoms should be used in all vaginal and anal sex.
Safe and highly effective vaccines are available for 2 viral STIs: hepatitis B and HPV.
These vaccines have represented major advances in STI prevention. By the end of 2020,
the HPV vaccine was introduced as part of routine immunization programmes in 111
countries, most of them high- and middle-income. HPV vaccination could prevent the
deaths of millions of women over the next decade in low- and middle-income countries,
where most cases of cervical cancer occur, if high (>80%) vaccination coverage of young
women (ages 11–15) can be achieved.
Research to develop vaccines against herpes and HIV is advanced, with several vaccine
candidates in early clinical development. There is mounting evidence suggesting that the
vaccine to prevent meningitis (MemB) has cross-protection against gonorrhoea. More
research into vaccines for chlamydia, gonorrhoea, syphilis and trichomoniasis are needed.
Other biomedical interventions to prevent some STIs include adult male circumcision and
microbicides.
Diagnosis of STIs
Accurate diagnostic tests for STIs are widely used in high-income countries. These are
especially useful for the diagnosis of asymptomatic infections. However, diagnostic tests
are largely unavailable in low- and middle-income countries. Where testing is available,

17
it is often expensive and geographically inaccessible, and patients often need to wait a
long time (or need to return) to receive results. As a result, follow-up can be impeded and
care or treatment can be incomplete.
The only inexpensive, rapid tests currently available for STIs are for syphilis, hepatitis B
and HIV. The rapid syphilis test is already in use in some resource-limited settings. A
rapid dual HIV/syphilis test is now available whereby a person can be tested for HIV and
syphilis from a single finger-stick and using a single testing cartridge. These tests are
accurate, can provide results in 15 to 20 minutes, and are easy to use with minimal
training. Rapid syphilis tests have been shown to increase the number of pregnant women
tested for syphilis. However, increased efforts are still needed in most low- and middle-
income countries to ensure that all pregnant women receive a syphilis test at the first
antenatal care visit.
Several rapid tests for other STIs are under development and have the potential to
improve STI diagnosis and treatment, especially in resource-limited settings.
Treatment of STIs
Effective treatment is currently available for several STIs.
 Three bacterial STIs (chlamydia, gonorrhoea and syphilis) and one parasitic STI
(trichomoniasis) are generally curable with existing single-dose regimens of
antibiotics.
 For herpes and HIV, the most effective medications available are antivirals that
can modulate the course of the disease, though they cannot cure the disease.
 For hepatitis B, antiviral medications can help to fight the virus and slow damage
to the liver.
Antimicrobial resistance (AMR) of STIs – in particular gonorrhoea – to antibiotics has
increased rapidly in recent years and has reduced treatment options. The Gonococcal
AMR Surveillance Programme (GASP) has shown high rates of resistance to many
antibiotics including quinolone resistance, increasing azithromycin resistance and
emerging resistance of extended-spectrum cephalosporins, a last-line treatment,
increasing the risk that gonorrhoea will be untreatable.
AMR for other STIs, though less common, also exists, making prevention and prompt
treatment critical.
STI case management
Low- and middle-income countries rely on identifying consistent, easily recognizable
signs and symptoms to guide treatment, without the use of laboratory tests. This is called
syndromic management. This approach, which often relies on clinical algorithms, allows
health workers to diagnose a specific infection on the basis of observed syndromes (e.g.,
vaginal discharge, urethral discharge, genital ulcers, abdominal pain).

18
Syndromic management is simple, assures rapid, same-day treatment, and avoids
expensive or unavailable diagnostic tests for patients that present with symptoms. This
approach results in overtreatment and missed treatment as the majority of STIs are
asymptomatic. Thus, WHO recommends countries enhance syndromic management by
gradually incorporating laboratory testing to support diagnosis. In settings where quality
assured molecular assays are available, it is recommended to treat STIs based on
laboratory tests. Moreover, STI screening strategies are essential for those at higher risk,
such sex workers, men who have sex with men, adolescents in some settings and
pregnant women due to potential severe consequences to the babies.
To interrupt transmission of infection and prevent re-infection, treating sexual partners is
an important component of STI case management.
Controlling the spread
Behaviour change is complex
Despite considerable efforts to identify simple interventions that can reduce risky sexual
behaviour, behaviour change remains a complex challenge. Research has demonstrated
the need to focus on carefully defined populations, consult extensively with the identified
target populations, and involve them in design, implementation and evaluation.
Education and counselling can improve people’s ability to recognize the symptoms of
STIs and increase the likelihood that they will seek care and encourage a sexual partner
to do so. Unfortunately, lack of public awareness, lack of training among health workers,
and long-standing, widespread stigma around STIs remain barriers to greater and more
effective use of these interventions.
Health services for screening and treatment of STIs remain weak
People seeking screening and treatment for STIs face numerous problems. These include
limited resources, stigmatization, poor quality of services and often out-of-pocket
expenses.   
Marginalized populations with the highest rates of STIs – such as sex workers, men who
have sex with men, people who inject drugs, prison inmates, mobile populations and
adolescents – often do not have access to adequate and friendly health services.
In many settings, STI services in low- and middle-income countries are often neglected
and underfunded. These problems lead to difficulties in providing screening for
asymptomatic infections, insufficient number of trained personnel, limited laboratory
capacity and inadequate supplies of appropriate medicines.
SHIGELLOSIS
Shigellosis is a bacterial infection that affects the digestive system. It’s caused by a group
of bacteria called Shigella.

19
The Shigella bacterium is spread through contaminated water and food or through contact
with contaminated feces. The bacteria release toxins that irritate the intestines, causing
the primary symptom of diarrhea.
Young children are more likely than older children and adults to get shigellosis. This may
be because young children put their fingers in their mouths often and are more likely to
ingest the bacteria. The large number of diaper changes in childcare centers may also
increase the concentration of infection in this age group.
Recognizing the symptoms of shigellosis
Frequent bouts of watery diarrhea are the main symptom of shigellosis. Abdominal
cramping, nausea, and vomiting may also occur. Many people who have shigellosis also
have either blood or mucus in their stool, and they may run a fever.
Symptoms usually begin within 1–2 days of coming in contact with Shigella. In some
cases, symptoms of infection may appear in as little as 12 hours after contact.
Diarrhea and other signs of shigellosis usually last between 5–7 days. Mild infection
lasting a couple of days may not require treatment.
It’s still possible for Shigella bacteria to be present in your stool for weeks after your
symptoms have gone away. This means that you can potentially spread the infection to
others for several weeks, even though you feel better.
It’s critical to stay hydrated in between bouts of diarrhea. Call your doctor if you have
diarrhea for longer than 3 days. This is very important, especially if you can’t keep down
food or water. Dehydration is a real danger associated with shigellosis.
Treatment for shigellosis
Combating dehydration is the main goal of treatment for most cases of shigellosis.
It’s important to drink plenty of fluids, especially electrolyte solutions, many of which
are available over the counter.
It’s usually not advisable to take any type of medication to relieve your diarrhea, as this
will keep the bacteria in your system longer and may make the infection worse.
Moderate or severe infections may require medical treatment. Treatment will usually
include antibiotics to eliminate the bacteria from your digestive tract.
Your doctor may test your stool to confirm that Shigella is the source of the infection.
Confirmation of Shigella helps your doctor to choose the right medication to fight
shigellosis. Drug options include powerful antibiotic medications, such as
azithromycin (Zithromax)
 ciprofloxacin (Cipro)
 sulfamethoxazole/trimethoprim (Bactrim)

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Hospitalization for shigellosis is rare. However, in some severe situations, hospitalization
is required. If you have extreme nausea and vomiting, you may need intravenous
fluids and medication.
Complications associated with shigellosis
Most people have no lasting ill effects from shigellosis.
The CDC reports that approximately 2 percent of people who contract Shigella
flexneri (one of several types of Shigella) develop a condition called post-infection
arthritis. Symptoms of post-infection arthritis include joint pain, painful urination, and
eye irritation.
Post-infection arthritis can become a chronic condition that lasts several months, years, or
the rest of your life. It’s caused by a reaction to the Shigella infection and happens only in
people who are genetically predisposed to it.
Other potential but rare complications of shigellosis include bloodstream infections,
seizures in young children, and hemolytic-uremic syndrome.
Can you get shigellosis twice?
Shigella is a group of several different bacteria. Once you’ve contracted one type
of Shigella, you’re unlikely to develop an infection from the same bacteria again.
However, you may contract a different bacterium from the same family.
Preventing shigellosis
You can prevent shigellosis by practicing good personal hygiene:
 Wash your hands before and after you use the bathroom or change a diaper
 Discard dirty diapers in a closed bag or trashcan to prevent the spread of the
bacteria
 Use soap and warm water every time you wash your hands
 Wipe down changing tables and kitchen counters with antibacterial wipes before
and after use.
Avoid close personal contact with someone who has shigellosis until at least several days
after the diarrhea has ended. People who have shigellosis shouldn’t prepare food for
others until they feel better and stop having diarrhea.
TUBERCULOSIS
TB is caused by bacteria (Mycobacterium tuberculosis) and it most often affects the
lungs. TB is spread through the air when people with lung TB cough, sneeze or spit. A
person needs to inhale only a few germs to become infected.
Every year, 10 million people fall ill with tuberculosis (TB). Despite being a preventable
and curable disease, 1.5 million people die from TB each year – making it the world’s top
infectious killer.

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TB is the leading cause of death of people with HIV and also a major contributor to
antimicrobial resistance.
TB infection and disease are curable using antibiotics.
DENGUE AND SEVERE DENGUE
Dengue is a mosquito-borne viral disease that has rapidly spread to all regions of WHO
in recent years. Dengue virus is transmitted by female mosquitoes mainly of the
species Aedes aegypti and, to a lesser extent, Ae. albopictus. These mosquitoes are also
vectors of chikungunya, yellow fever and Zika viruses. Dengue is widespread throughout
the tropics, with local variations in risk influenced by climate parameters as well as social
and environmental factors.
Dengue causes a wide spectrum of disease. This can range from subclinical disease
(people may not know they are even infected) to severe flu-like symptoms in those
infected. Although less common, some people develop severe dengue, which can be any
number of complications associated with severe bleeding, organ impairment and/or
plasma leakage. Severe dengue has a higher risk of death when not managed
appropriately. Severe dengue was first recognized in the 1950s during dengue epidemics
in the Philippines and Thailand. Today, severe dengue affects most Asian and Latin
American countries and has become a leading cause of hospitalization and death among
children and adults in these regions.
Dengue is caused by a virus of the Flaviviridae family and there are four distinct, but
closely related, serotypes of the virus that cause dengue (DENV-1, DENV-2, DENV-3
and DENV-4). Recovery from infection is believed to provide lifelong immunity against
that serotype. However, cross-immunity to the other serotypes after recovery is only
partial, and temporary. Subsequent infections (secondary infection) by other serotypes
increase the risk of developing severe dengue.
Dengue has distinct epidemiological patterns, associated with the four serotypes of the
virus. These can co-circulate within a region, and indeed many countries are hyper-
endemic for all four serotypes. Dengue has an alarming impact on both human health and
the global and national economies. DENV is frequently transported from one place to
another by infected travellers; when susceptible vectors are present in these new areas,
there is the potential for local transmission to be established.
Transmission through mosquito bite
The virus is transmitted to humans through the bites of infected female mosquitoes,
primarily the Aedes aegypti mosquito. Other species within the Aedes genus can also act
as vectors, but their contribution is secondary to Aedes aegypti.
After feeding on an DENV-infected person, the virus replicates in the mosquito midgut,
before it disseminates to secondary tissues, including the salivary glands. The time it

22
takes from ingesting the virus to actual transmission to a new host is termed the extrinsic
incubation period (EIP). The EIP takes about 8-12 days when the ambient temperature is
between 25-28°C. Variations in the extrinsic incubation period are not only influenced by
ambient temperature; a number of factors such as the magnitude of daily temperature
fluctuations, virus genotype , and initial viral concentration can also alter the time it takes
for a mosquito to transmit virus. Once infectious, the mosquito is capable of transmitting
virus for the rest of its life.
Human-to-mosquito transmission
Mosquitoes can become infected from people who are viremic with DENV. This can be
someone who has a symptomatic dengue infection, someone who is yet to have a
symptomatic infection (they are pre-symptomatic), but also people who show no signs of
illness as well (they are asymptomatic).
Human-to-mosquito transmission can occur up to 2 days before someone shows
symptoms of the illness up to 2 days after the fever has resolved.
Risk of mosquito infection is positively associated with high viremia and high fever in
the patient; conversely, high levels of DENV-specific antibodies are associated with a
decreased risk of mosquito infection (Nguyen et al. 2013 PNAS). Most people are
viremic for about 4-5 days, but viremia can last as long as 12 days .
Maternal transmission
The primary mode of transmission of DENV between humans involves mosquito vectors.
There is evidence however, of the possibility of maternal transmission (from a pregnant
mother to her baby). While vertical transmission rates appear low, with the risk of
vertical transmission seemingly linked to the timing of the dengue infection during the
pregnancy. When a mother does have a DENV infection when she is pregnant, babies
may suffer from pre-term birth, low birthweight, and fetal distress.
Other transmission modes
Rare cases of transmission via blood products, organ donation and transfusions have been
recorded. Similarly, transovarial transmission of the virus within mosquitoes have also
been recorded. 
Dengue should be suspected when a high fever (40°C/104°F) is accompanied by 2 of the
following symptoms during the febrile phase (2-7 days):
 severe headache
 pain behind the eyes
 muscle and joint pains
 nausea
 vomiting
 swollen glands

23
  rash. 
Warning signs that doctors should look for include:
 severe abdominal pain
 persistent vomiting
 rapid breathing
 bleeding gums or nose 
 fatigue
 restlessness
 liver enlargement
 blood in vomit or stool. 
If patients manifest these symptoms during the critical phase, close observation for the
next 24–48 hours is essential so that proper medical care can be provided, to avoid
complications and risk of death. Close monitoring should also continue during the
convalescent phase. 
TRACHOMA
Trachoma is the leading infectious cause of blindness worldwide. It is caused by an
obligate intracellular bacterium called Chlamydia trachomatis. The infection is
transmitted by direct or indirect transfer of eye and nose discharges of infected people,
particularly young children who harbour the principal reservoir of infection. These
discharges can be spread by particular species of flies.
Environmental factors associated with more intense transmission of C.
trachomatis include:
 inadequate hygiene
 crowded households
 inadequate access to water
 inadequate access to and use of sanitation.
Prevention and control
Elimination programmes in endemic countries are being implemented using the WHO-
recommended SAFE strategy. This consists of:
 Surgery to treat the blinding stage (trachomatous trichiasis);
 Antibiotics to clear infection, particularly mass drug administration of the
antibiotic azithromycin, which is donated by the manufacturer to elimination
programmes, through the International Trachoma Initiative;
 Facial cleanliness; and
 Environmental improvement, particularly improving access to water and
sanitation.

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 ONCHOCERCIASIS
Onchocerciasis – or “river blindness” – is a parasitic disease caused by the filarial
worm Onchocerca volvulus transmitted by repeated bites of infected blackflies
(Simulium spp.). These blackflies breed along fast-flowing rivers and streams, close to
remote villages located near fertile land where people rely on agriculture.
In the human body, the adult worms produce embryonic larvae (microfilariae) that
migrate to the skin, eyes and other organs. When a female blackfly bites an infected
person during a blood meal, it also ingests microfilariae which develop further in the
blackfly and are then transmitted to the next human host during subsequent bites.
 It is transmitted to humans through exposure to repeated bites of infected blackflies of the
genus Simulium
 Symptoms include severe itching, disfiguring skin conditions, and visual impairment,
including permanent blindness.
Clinical signs and symptoms
Onchocerciasis is an eye and skin disease. Symptoms are caused by the microfilariae,
which move around the human body in the subcutaneous tissue and induce intense
inflammatory responses when they die. Infected people may show symptoms such as
severe itching and various skin changes. Infected people may also develop eye lesions
which can lead to visual impairment and permanent blindness. In most cases, nodules
under the skin form around the adult worms.
WHO recommends treating onchocerciasis with ivermectin at least once yearly for 10 to
15 years. 
TRYPANOSOMIASIS, HUMAN AFRICAN (SLEEPING SICKNESS)
Human African trypanosomiasis, also known as sleeping sickness, is a vector-borne
parasitic disease. It is caused by infection with protozoan parasites belonging to the
genus Trypanosoma. They are transmitted to humans by tsetse fly ( Glossina genus) bites
which have acquired their infection from human beings or from animals harbouring
human pathogenic parasites.
Tsetse flies are found just in sub-Saharan Africa though only certain species transmit the
disease. For reasons that are so far unexplained, in many regions where tsetse flies are
found, sleeping sickness is not. Rural populations living in regions where transmission
occurs and which depend on agriculture, fishing, animal husbandry or hunting are the
most exposed to the tsetse fly and therefore to the disease. The disease develops in areas
ranging from a single village to an entire region. Within an infected area, the intensity of
the disease can vary from one village to the next.
 

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Forms of human African trypanosomiasis
Human African trypanosomiasis takes 2 forms, depending on the subspecies of the
parasite involved:
 Trypanosoma brucei gambiense is found in 24 countries in west and central Africa.
This form currently accounts for 97% of reported cases of sleeping sickness and
causes a chronic infection. A person can be infected for months or even years without
major signs or symptoms of the disease. When more evident symptoms emerge, the
patient is often already in an advanced disease stage where the central nervous system
is affected.
 Trypanosoma brucei rhodesiense is found in 13 countries in eastern and southern
Africa. Nowadays, this form represents under 3% of reported cases and causes an
acute infection. First signs and symptoms are observed a few months or weeks after
infection. The disease develops rapidly and invades the central nervous system. Only
Uganda presents both forms of the disease, but in separate zones.
Another form of trypanosomiasis occurs mainly in Latin America. It is known as
American trypanosomiasis or Chagas disease. The causal organism belongs to a
different Trypanosoma subgenus, is transmitted by a different vector and the disease
characteristics are different than HAT.
Animal trypanosomiasis
Other parasite species and sub-species of the Trypanosoma genus are pathogenic to
animals and cause animal trypanosomiasis in wild and domestic animals. In cattle, the
disease is called Nagana. Trypanosomiasis in domestic animals, particularly in cattle, is a
major obstacle to the economic development of affected rural areas.
Animals can host the human pathogen parasites, especially T. b. rhodesiense, of which
domestic and wild animals are an important reservoir. Animals can also be infected
with T. b. gambiense and probably act as a reservoir to a lesser extent. However the
precise epidemiological role of the animal reservoir in the gambiense form of the disease
is not yet well known.
The disease is mostly transmitted through the bite of an infected tsetse fly but there are
other ways in which people are infected:
 Mother-to-child infection: the trypanosome can cross the placenta and infect the fetus.
 Mechanical transmission through other blood-sucking insects is possible, however, it
is difficult to assess its epidemiological impact.
 Accidental infections have occurred in laboratories due to pricks with contaminated
needles.
 Transmission of the parasite through sexual contact has been reported.

26
In the first stage, the trypanosomes multiply in subcutaneous tissues, blood and lymph.
This is also called haemo-lymphatic stage, which entails bouts of fever, headaches,
enlarged lymph nodes, joint pains and itching
In the second stage the parasites cross the blood-brain barrier to infect the central nervous
system. This is known as the neurological or meningo-encephalic stage. In general this is
when more obvious signs and symptoms of the disease appear: changes of behaviour,
confusion, sensory disturbances and poor coordination. Disturbance of the sleep cycle,
which gives the disease its name, is an important feature. Without treatment, sleeping
sickness is considered fatal although cases of healthy carriers have been reported.
Disease management: diagnosis
Disease management is made in 3 steps:
 Screening for potential infection. This involves using serological tests (only
available for T. b.gambiense) and checking for clinical signs - especially swollen
cervical lymph nodes.
 Diagnosing by establishing whether the parasite is present in body fluids.
 Staging to determine the state of disease progression. This entails clinical
examination and in some cases analysis of the cerebrospinal fluid obtained by
lumbar puncture.
Diagnosis must be made as early as possible to avoid progressing to the neurological
stage in order to elude complicated and risky treatment procedures
The long, relatively asymptomatic first stage of T. b. gambiense sleeping sickness is one
of the reasons why an exhaustive, active screening of the population at risk is
recommended, to identify patients at an early stage and reduce transmission by removing
their status of reservoir. Exhaustive screening requires a major investment in human and
material resources. In Africa such resources are often scarce, particularly in remote areas
where the disease is mostly found. As a result, some infected individuals may die before
they can ever be diagnosed and treated.
Treatment
The type of treatment depends on the form of the disease and the disease stage. The
earlier the disease is identified, the better the prospect of a cure. The assessment of
treatment outcome requires follow up of the patient up to 24 months and entails clinical
assessment and laboratory exams of body fluids including in some cases, cerebrospinal
fluid obtained by lumbar puncture, as parasites may remain viable for long periods and
reproduce the disease months after treatment.
Treatment success in the second stage depends on drugs that cross the blood-brain barrier
to reach the parasite.

27
New treatment guidelines for gambiense human African trypanosmiasis were issued by
WHO in 2019. In total six different drugs are used for the treatment of sleeping sickness.
These drugs are donated to WHO by manufacturers and distributed free of charge to
disease endemic countries.
Drugs used in the treatment of first stage:
 Pentamidine: discovered in 1940, used for the treatment of the first stage of T. b.
gambiense sleeping sickness. Despite non-negligible undesirable effects, it is in
general well tolerated by patients.
 Suramin: discovered in 1920, used for the treatment of the first stage of T. b.
rhodesiense. It provokes certain undesirable effects, including nephrotoxicity and
allergic reactions.
Drugs used in the treatment of second stage:
 Melarsoprol: discovered in 1949, it is used for the treatment of
both gambiense and rhodesiense infections. It is derived from arsenic and has
many undesirable side effects, the most dramatic of which is reactive
encephalopathy (encephalopathic syndrome) which can be fatal (3% to 10%). It is
currently recommended as first-line treatment for the rhodesiense form, but rarely
used in the gambiense form.
 Eflornithine: much less toxic than melarsoprol, registered in 1990 is only
effective against T.b. gambiense. It is generally used in combination with
nifurtimox (as part of the Nifurtimox-eflornithine combination therapy, NECT)
but can be used also as monotherapy. The regimen is complex and cumbersome to
apply.
 Nifurtimox: The Nifurtimox-eflornithine combination therapy, NECT, was
introduced in 2009. It simplifies the use of eflornithine by reducing the duration of
treatment and the number of IV perfusions, but unfortunately it has not been
studied for T.b. rhodesiense. Nifurtimox is registered for the treatment of
American trypanosomiasis but not for human African trypanosomiasis. Both drugs
are provided free of charge by WHO to endemic countries with a kit containing all
the material needed for its administration.
Drugs used in the treatment of both stages:
Fexinidazole is an oral treatment for gambiense human African trypanosomiasis It was
included in 2019 in the WHO Essential medicines list and WHO human African
Trypanosomiasis treatment guidelines. This molecule is indicated as first line for first
stage and non-severe second stage. It should be administered for 10 days within 30
minutes after a solid meal and under supervision of trained medical staff. Currently a
clinical trial for its use in rhodesiense HAT is ongoing.

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 CHOLERA
Cholera is an acute diarrhoeal infection caused by eating or drinking food or water that is
contaminated with the bacterium Vibrio cholerae. Cholera remains a global threat to
public health and is an indicator of inequity and lack of social development. Researchers
have estimated that every year, there are 1.3 to 4.0 million cases of cholera, and 21 000 to
143 000 deaths worldwide due to the infection.
Cholera is an extremely serious disease that can cause severe acute watery diarrhoea with
severe dehydration. It takes between 12 hours and 5 days for a person to show symptoms
after consuming contaminated food or water. Cholera affects both children and adults and
can kill within hours if untreated.
Most people infected with Vibrio cholerae do not develop any symptoms, although the
bacteria are present in their faeces for 1-10 days after infection. This means the bacteria
are shed back into the environment, potentially infecting other people.
Cholera is often predictable and preventable. It can ultimately be eliminated where access
to clean water and sanitation facilities, as well as good hygiene practices, are ensured and
sustained for the whole population.
LYMPHATIC FILARIASIS
Lymphatic filariasis, commonly known as elephantiasis, is a neglected tropical disease.
Infection occurs when filarial parasites are transmitted to humans through mosquitoes.
Infection is usually acquired in childhood causing hidden damage to the lymphatic
system.
The painful and profoundly disfiguring visible manifestations of the disease,
lymphoedema, elephantiasis and scrotal swelling occur later in life and can lead to
permanent disability. These patients are not only physically disabled, but suffer mental,
social and financial losses contributing to stigma and poverty.
In 2020, 863 million people in 50 countries were living in areas that require preventive
chemotherapy to stop the spread of infection.
The global baseline estimate of people affected by lymphatic filariasis was 25 million
men with hydrocele and over 15 million people with lymphoedema.  At least 36 million
people remain with these chronic disease manifestations. Eliminating lymphatic filariasis
can prevent unnecessary suffering and contribute to the reduction of poverty.
Cause and transmission
Lymphatic filariasis is caused by infection with parasites classified as nematodes
(roundworms) of the family Filariodidea. There are 3 types of these thread-like filarial
worms:
 Wuchereria bancrofti, which is responsible for 90% of the cases
 Brugia malayi, which causes most of the remainder of the cases

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  Brugia timori, which also causes the disease.
Adult worms nest in the lymphatic vessels and disrupt the normal function of the
lymphatic system. The worms can live for approximately 6–8 years and, during their
lifetime, produce millions of microfilariae (immature larvae) that circulate in the blood.
Mosquitoes are infected with microfilariae by ingesting blood when biting an infected
host. Microfilariae mature into infective larvae within the mosquito. When infected
mosquitoes bite people, mature parasite larvae are deposited on the skin from where they
can enter the body. The larvae then migrate to the lymphatic vessels where they develop
into adult worms, thus continuing a cycle of transmission.
Lymphatic filariasis is transmitted by different types of mosquitoes for example by
the Culex mosquito, widespread across urban and semi-urban areas, Anopheles, mainly
found in rural areas, and Aedes, mainly in endemic islands in the Pacific.
Symptoms
Lymphatic filariasis infection involves asymptomatic, acute, and chronic conditions. The
majority of infections are asymptomatic, showing no external signs of infection while
contributing to transmission of the parasite. These asymptomatic infections still cause
damage to the lymphatic system and the kidneys and alter the body's immune system.
When lymphatic filariasis develops into chronic conditions it leads to lymphoedema
(tissue swelling) or elephantiasis (skin/tissue thickening) of limbs and hydrocele (scrotal
swelling). Involvement of breasts and genital organs is common. Such body deformities
often lead to social stigma and sub-optimal mental health, loss of income-earning
opportunities and increased medical expenses for patients and their caretakers. The
socioeconomic burdens of isolation and poverty are immense.
Acute episodes of local inflammation involving skin, lymph nodes and lymphatic vessels
often accompany chronic lymphoedema or elephantiasis. Some of these episodes are
caused by the body's immune response to the parasite. Most are the result of secondary
bacterial skin infection where normal defenses have been partially lost due to underlying
lymphatic damage. These acute attacks are debilitating, may last for weeks and are the
primary cause of lost wages among people suffering with lymphatic filariasis.
Vector control
Mosquito control is a supplemental strategy supported by WHO. It is used to reduce
transmission of lymphatic filariasis and other mosquito-borne infections. Depending on
the parasite-vector species, measures such as insecticide-treated nets, indoor residual
spraying or personal protection measures may help protect people from infection. The use
of insecticide-treated nets in areas where Anopheles is the primary vector for filariasis
enhances the impact on transmission during and after MDA. Historically, vector control

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has in select settings contributed to the elimination of lymphatic filariasis in the absence
of large-scale preventive chemotherapy.
LEISHMANIASIS
Leishmaniasis is caused by a protozoa parasite from over 20 Leishmania species. Over 90
sandfly species are known to transmit Leishmania parasites. There are 3 main forms of
the disease:
 Visceral leishmaniasis (VL), also known as kala-azar is fatal if left untreated in over
95% of cases. It is characterized by irregular bouts of fever, weight loss, enlargement
of the spleen and liver, and anaemia. Most cases occur in Brazil, East Africa and in
India. An estimated 50 000 to 90 000 new cases of VL occur worldwide annually,
with only between 25 to 45% reported to WHO. It remains one of the top parasitic
diseases with outbreak and mortality potential. In 2020, more than 90% of new cases
reported to WHO occurred in 10 countries: Brazil, China, Ethiopia, Eritrea, India,
Kenya, Somalia, South Sudan, Sudan and Yemen. 
 Cutaneous leishmaniasis (CL) is the most common form of leishmaniasis and causes
skin lesions, mainly ulcers, on exposed parts of the body, leaving life-long scars and
serious disability or stigma. About 95% of CL cases occur in the Americas, the
Mediterranean basin, the Middle East and Central Asia. In 2020 over 85% of new CL
cases occurred in 10 countries: Afghanistan, Algeria, Brazil, Colombia, Iraq, Libya,
Pakistan, Peru, the Syrian Arab Republic and Tunisia. It is estimated that between 600
000 to 1 million new cases occur worldwide annually.
 Mucocutaneous leishmaniasis leads to partial or total destruction of mucous
membranes of the nose, mouth and throat. Over 90% of mucocutaneous leishmaniasis
cases occur in Bolivia (the Plurinational State of), Brazil, Ethiopia and Peru.
Transmission
Leishmania parasites are transmitted through the bites of infected female phlebotomine
sandflies, which feed on blood to produce eggs. The epidemiology of leishmaniasis
depends on the characteristics of the parasite and sandfly species, the local ecological
characteristics of the transmission sites, current and past exposure of the human
population to the parasite, and human behaviour. Some 70 animal species, including
humans, have been found as natural reservoir hosts of Leishmania parasites.
Leishmania-HIV co-infection
Leishmania-HIV coinfected people have high chance of developing the full-blown
clinical disease, and high relapse and mortality rates. Antiretroviral treatment reduces the
development of the disease, delays relapses and increases the survival of the coinfected
patients. As of 2021, leishmania-HIV coinfection have been reported from 45 countries.

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High Leishmania-HIV coinfection rates are reported from Brazil, Ethiopia and the state
of Bihar in India.
Major risk factors
Socioeconomic conditions
Poverty increases the risk for leishmaniasis. Poor housing and domestic sanitary
conditions (such as a lack of waste management or open sewerage) may increase sandfly
breeding and resting sites, as well as their access to humans. Sandflies are attracted to
crowded housing as these provide a good source of blood-meals. Human behaviour, such
as sleeping outside or on the ground, may increase risk.
Malnutrition
Diets lacking protein-energy, iron, vitamin A and zinc increase the risk that an infection
will progress to a full-blown disease.
Population mobility
Epidemics of both cutaneous and visceral leishmaniasis are often associated with
migration and the movement of non-immune people into areas with existing transmission
cycles. Occupational exposure as well as widespread deforestation remain important
factors.
Environmental changes
The incidence of leishmaniasis can be affected by changes in urbanization, and the
human incursion into forested areas.
Climate change
Leishmaniasis is climate-sensitive as it affects the epidemiology in several ways:
 changes in temperature, rainfall and humidity can have strong effects on vectors
and reservoir hosts by altering their distribution and influencing their survival and
population sizes;
 small fluctuations in temperature can have a profound effect on the developmental
cycle of Leishmania promastigotes in sandflies, allowing transmission of the
parasite in areas not previously endemic for the disease;
 drought, famine and flood can lead to massive displacement and migration of
people to areas with transmission of Leishmania, and poor nutrition could
compromise their immunity.
Diagnosis and treatment
In visceral leishmaniasis, diagnosis is made by combining clinical signs with
parasitological, or serological tests (such as rapid diagnostic tests). In cutaneous and
mucocutaneous leishmaniasis serological tests have limited value and clinical
manifestation with parasitological tests confirms the diagnosis.

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The treatment of leishmaniasis depends on several factors including type of disease,
concomitant pathologies, parasite species and geographic location. Leishmaniasis is a
treatable and curable disease, which requires an immunocompetent system because
medicines will not get rid of the parasite from the body, thus the risk of relapse if
immunosuppression occurs. All patients diagnosed as with visceral leishmaniasis require
prompt and complete treatment. Detailed information on treatment of the various forms
of the disease by geographic location is available in the WHO technical report series 949,
"Control of leishmaniasis".
Prevention and control
Prevention and control of leishmaniasis requires a combination of intervention strategies
because transmission occurs in a complex biological system involving the human or
animal reservoir host, parasite and sandfly vector. Key strategies for prevention are listed
below:
 Early diagnosis and effective prompt treatment reduces the prevalence of the
disease and prevents disabilities and death. It helps to reduce transmission and to
monitor the spread and burden of disease. Currently there are highly effective and
safe anti-leishmanial medicines particularly for visceral leishmaniasis, although
they can be difficult to use. Access to medicines has significantly improved thanks
to a WHO-negotiated price scheme and a medicine donation programme through
WHO.
 Vector control helps to reduce or interrupt transmission of disease by decreasing
the number of sandflies. Control methods include insecticide spray, use of
insecticide–treated nets, environmental management and personal protection.
 Effective disease surveillance is important to promptly monitor and act during
epidemics and situations with high case fatality rates under treatment.
 Control of animal reservoir hosts is complex and should be tailored to the local
situation.
 Social mobilization and strengthening partnerships – mobilization and education
of the community with effective behavioural change interventions must always be
locally adapted. Partnership and collaboration with various stakeholders and other
vector-borne disease control programmes is critical.
CRIMEAN-CONGO HAEMORRHAGIC FEVER
Crimean-Congo haemorrhagic fever is a viral haemorrhagic fever usually transmitted by
ticks. It can also be contracted through contact with viraemic animal tissues (animal
tissue where the virus has entered the bloodstream) during and immediately post-
slaughter of animals. CCHF outbreaks constitute a threat to public health services as the
virus can lead to epidemics, has a high case fatality ratio (10-40%), potentially results in

33
hospital and health facility outbreaks, and is difficult to prevent and treat. CCHF is
endemic in all of Africa, the Balkans, the Middle East and in Asia. 
MARBURG VIRUS DISEASE
Marburg virus disease is a highly virulent disease that causes haemorrhagic fever, with a
fatality ratio of up to 88%. It is in the same family as the virus that causes Ebola virus
disease. Two large outbreaks that occurred simultaneously in Marburg and Frankfurt in
Germany, and in Belgrade, Serbia, in 1967, led to the initial recognition of the disease.
The outbreak was associated with laboratory work using African green monkeys
(Cercopithecus aethiops) imported from Uganda. Subsequently, outbreaks and sporadic
cases have been reported in Angola, Democratic Republic of the Congo, Kenya, South
Africa (in a person with recent travel history to Zimbabwe) and Uganda. In 2008, two
independent cases were reported in travellers who visited a cave inhabited by Rousettus
bat colonies in Uganda. 
Human infection with Marburg virus disease initially results from prolonged exposure to
mines or caves inhabited by Rousettus bat colonies. Once an individual is infected with
the virus, Marburg can spread through human-to-human transmission via direct contact
(through broken skin or mucous membranes) with the blood, secretions, organs or other
bodily fluids of infected people, and with surfaces and materials (e.g. bedding, clothing)
contaminated with these fluids. 
RIFT VALLEY FEVER
Rift Valley fever (RVF) is a viral zoonosis that primarily affects animals but also has the
capacity to infect humans. Infection can cause severe disease in both animals and
humans. The disease also results in significant economic losses due to death and abortion
among RVF-infected livestock. RVF virus is a member of the Phlebovirus genus.
Transmission in humans
The majority of human infections result from direct or indirect contact with the blood or
organs of infected animals. The virus can be transmitted to humans through the handling
of animal tissue during slaughtering or butchering, assisting with animal births,
conducting veterinary procedures, or from the disposal of carcasses or fetuses. Certain
occupational groups such as herders, farmers, slaughterhouse workers, and veterinarians
are therefore at higher risk of infection.
The virus infects humans through inoculation, for example via a wound from an infected
knife or through contact with broken skin, or through inhalation of aerosols produced
during the slaughter of infected animals.
There is some evidence that humans may become infected with RVF by ingesting the
unpasteurized or uncooked milk of infected animals.

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  Human infections have also resulted from the bites of infected mosquitoes, most
commonly the Aedes and Culex mosquitoes and the transmission of RVF virus by
hematophagous (blood-feeding) flies is also possible.
 To date, no human-to-human transmission of RVF has been documented, and no
transmission of RVF to health care workers has been reported when standard
infection control precautions have been put in place.
 There has been no evidence of outbreaks of RVF in urban areas.
Clinical features in humans
Mild form of RVF in humans
The following are clinical features of the mild form of RVF in humans:
 The incubation period (the interval from infection to onset of symptoms) for RVF
varies from 2 to 6 days.
 Those infected either experience no detectable symptoms or develop a mild form
of the disease characterized by a feverish syndrome with sudden onset of flu-like
fever, muscle pain, joint pain and headache. Some patients develop neck stiffness,
sensitivity to light, loss of appetite and vomiting; in these patients the disease, in
its early stages, may be mistaken for meningitis.
 The symptoms of RVF usually last from 4 to 7 days, after which time the immune
response becomes detectable with the appearance of antibodies and the virus
disappears from the blood.
Severe form of RVF in humans
While most human cases are relatively mild, a small percentage of patients develop a
much more severe form of the disease. This usually appears as 1 or more of 3 distinct
syndromes: ocular (eye) disease (0.5–2% of patients), meningoencephalitis (less than 1%
of patients) or haemorrhagic fever (less than 1% of patients).
The following are clinical features of the severe form of RVF in humans:
 Ocular form: In this form of the disease, the usual symptoms associated with the
mild form of the disease are accompanied by retinal lesions. The onset of the
lesions in the eyes is usually 1 to 3 weeks after appearance of the first symptoms.
Patients usually report blurred or decreased vision. The disease may resolve itself
with no lasting effects within 10 to 12 weeks. However, when the lesions occur in
the macula, 50% of patients will experience a permanent loss of vision. Death in
patients with only the ocular form of the disease is uncommon.
 Meningoencephalitis form: The onset of the meningoencephalitis form of the
disease usually occurs 1 to 4 weeks after the first symptoms of RVF appear.
Clinical features include intense headache, loss of memory, hallucinations,
confusion, disorientation, vertigo, convulsions, lethargy and coma. Neurological

35
 complications can appear later (after more than 60 days). The death rate in patients
who experience only this form of the disease is low, although residual
neurological deficit, which may be severe, is common.
 Haemorrhagic fever form: The symptoms of this form of the disease appear 2–4
days after the onset of illness, and begin with evidence of severe liver impairment,
such as jaundice. Subsequently signs of haemorrhage then appear such as vomiting
blood, passing blood in the faeces, a purpuric rash or ecchymoses (caused by
bleeding in the skin), bleeding from the nose or gums, menorrhagia and bleeding
from venepuncture sites. The case-fatality ratio for patients developing the
haemorrhagic form of the disease is high at approximately 50%. Death usually
occurs 3 to 6 days after the onset of symptoms. The virus may be detectable in the
blood for up to 10 days, in patients with the hemorrhagic icterus form of RVF.
Diagnosis
Because the symptoms of Rift Valley fever are varied and non-specific, clinical diagnosis
is often difficult, especially early in the course of the disease. Rift Valley fever is difficult
to distinguish from other viral haemorrhagic fevers as well as many other diseases that
cause fever, including malaria, shigellosis, typhoid fever, and yellow fever.
Definitive diagnosis requires testing that is available only in reference laboratories.
Laboratory specimens may be hazardous and must be handled with extreme care. Rift
Valley fever virus infections can only be diagnosed definitively in the laboratory using
the following tests:
 reverse transcriptase polymerase chain reaction (RT-PCR) assay
 IgG and IgM antibody enzyme-linked immunosorbent assay (ELISA)
 virus isolation by cell culture.
Treatment and vaccines
As most human cases of RVF are relatively mild and of short duration, no specific
treatment is required for these patients. For the more severe cases, the predominant
treatment is general supportive therapy.
An inactivated vaccine has been developed for human use. However, this vaccine is not
licensed and is not commercially available. It has been used experimentally to protect
veterinary and laboratory personnel at high risk of exposure to RVF. Other candidate
vaccines are under investigation.
RVF virus in host animals
RVF is able to infect many species of animals causing severe disease in domesticated
animals including cattle, sheep, camels and goats. Sheep and goats appear to be more
susceptible than cattle or camels.

36
Age has also been shown to be a significant factor in the animal's susceptibility to the
severe form of the disease: over 90% of lambs infected with RVF die, whereas mortality
among adult sheep can be as low as 10%.
The rate of abortion among pregnant infected ewes is almost 100%. An outbreak of RVF
in animals frequently manifests itself as a wave of unexplained abortions among livestock
and may signal the start of an epidemic.
Ecology and mosquito vectors
Several different species of mosquito are able to act as vectors for transmission of the
RVF virus. The dominant vector species varies between different regions and different
species can play different roles in sustaining the transmission of the virus.
Among animals, the RVF virus is spread primarily by the bite of infected mosquitoes,
mainly the Aedes species, which can acquire the virus from feeding on infected animals.
The female mosquito is also capable of transmitting the virus directly to her offspring via
eggs leading to new generations of infected mosquitoes hatching from eggs.
However, when analysing RVF major outbreaks, 2 ecologically distinct situations should
be considered. At primary foci areas, RVF virus persists through transmission between
vectors and hosts and maintains through vertical transmission in Aedes mosquitoes.
During major outbreak in primary foci, the disease can spread to secondary foci through
livestock movement or passive mosquitoes dispersal and amplifies in naïve ruminants via
local competent mosquitoes like Culex, Mansonia and Anopheles that act as mechanical
vectors. Irrigation schemes, where populations of mosquitoes are abundant during long
periods of the year, are highly favourable places for secondary disease transmission.
Prevention and control
Controlling RVF in animals
Outbreaks of RVF in animals can be prevented by a sustained programme of animal
vaccination. Both modified live attenuated virus and inactivated virus vaccines have been
developed for veterinary use. Only 1 dose of the live vaccine is required to provide long-
term immunity but this vaccine may result in spontaneous abortion if given to pregnant
animals. The inactivated virus vaccine does not have this side effect, but multiple doses
are required in order to provide protection which may prove problematic in endemic
areas.
Animal immunization must be implemented prior to an outbreak if an epizootic is to be
prevented. Once an outbreak has occurred animal vaccination should NOT be
implemented because there is a high risk of intensifying the outbreak. During mass
animal vaccination campaigns, animal health workers may, inadvertently, transmit the
virus through the use of multi-dose vials and the re-use of needles and syringes. If some
of the animals in the herd are already infected and viraemic (although not yet displaying

37
obvious signs of illness), the virus will be transmitted among the herd, and the outbreak
will be amplified.
Restricting or banning the movement of livestock may be effective in slowing the
expansion of the virus from infected to uninfected areas.
As outbreaks of RVF in animals precede human cases, the establishment of an active
animal health surveillance system to detect new cases is essential in providing early
warning for veterinary and human public health authorities.
Public health education and risk reduction
During an outbreak of RVF, close contact with animals, particularly with their body
fluids, either directly or via aerosols, has been identified as the most significant risk
factor for RVF virus infection. Raising awareness of the risk factors of RVF infection as
well as the protective measures individuals can take to prevent mosquito bites is the only
way to reduce human infection and deaths.
Public health messages for risk reduction should focus on:
 reducing the risk of animal-to-human transmission as a result of unsafe animal
husbandry and slaughtering practices. Practicing hand hygiene, wearing gloves
and other appropriate individual protective equipment when handling sick animals
or their tissues or when slaughtering animals.
 reducing the risk of animal-to-human transmission arising from the unsafe
consumption of fresh blood, raw milk or animal tissue. In the epizootic regions, all
animal products (blood, meat, and milk) should be thoroughly cooked before
eating.
 the importance of personal and community protection against mosquito bites
through the use of impregnated mosquito nets, personal insect repellent if
available, light coloured clothing (long-sleeved shirts and trousers) and by
avoiding outdoor activity at peak biting times of the vector species.

As noted above, laboratory workers are also at risk. Samples taken from suspected human
and animal cases of RVF for diagnosis should be handled by trained staff and processed
in suitably equipped laboratories.
Vector control
Other ways in which to control the spread of RVF involve control of the vector and
protection against their bites.
Larviciding measures at mosquito breeding sites are the most effective form of vector
control if breeding sites can be clearly identified and are limited in size and extent.
During periods of flooding, however, the number and extent of breeding sites is usually
too high for larviciding measures to be feasible.

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RVF forecasting and climatic models
Forecasting can predict climatic conditions that are frequently associated with an
increased risk of outbreaks, and may improve disease control. In Africa, Saudi Arabia
and Yemen RVF outbreaks are closely associated with periods of above-average rainfall.
The response of vegetation to increased levels of rainfall can be easily measured and
monitored by Remote Sensing Satellite Imagery. In addition RVF outbreaks in East
Africa are closely associated with the heavy rainfall that occurs during the warm phase of
the El Niño–Southern Oscillation (ENSO) phenomenon.
These findings have enabled the successful development of forecasting models and early
warning systems for RVF using satellite images and weather/climate forecasting data.
Early warning systems, such as these, could be used to trigger detection of animal cases
at an early stage of an outbreak, enabling authorities to implement measures to avert
impending epidemics.
Within the framework of the new International Health Regulations (2005), the forecasting
and early detection of RVF outbreaks, together with a comprehensive assessment of the
risk of diffusion to new areas, are essential to enabling the implementation of effective
and timely control measures.
SMALLPOX
Smallpox is an acute contagious disease caused by the variola virus, a member of the
orthopoxvirus family. It was one of the most devastating diseases known to humanity and
caused millions of deaths before it was eradicated. It is believed to have existed for at
least 3000 years. Early symptoms of smallpox include high fever, fatigue and severe back
pain, and less often, abdominal pain and vomiting. Two to 3 days later the virus
produces a characteristic rash with bumps full of a clear liquid, which later fill with pus
and finally develop a crust that dries and falls off. The rash begins on the face and
hands, then spreads to the rest of the body. Lesions develop in the mucous membranes
of the nose and mouth and ulcerate soon after formation.
Smallpox is transmitted from person to person via infective droplets during close contact
with infected people who have symptoms of the disease, or in some cases through
contaminated clothing and bedding. It has an incubation period of 7–17 days after
exposure and only becomes infectious once a fever develops. People remain infectious
until the last scabs fall off.
Healthy habits prevent germs and infectious diseases from spreading
1 Handle & prepare food safely
2 Wash hands often
3 Clean & disinfect commonly used surfaces
4 Cough and sneeze into a tissue or your sleeve

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5 Do not share personal items
6 Get vaccinated
7 Avoid touching wild animals
8 Stay home when sick
MODULE 2 - MOBILIZATION AND ORGANIZATION OF GROUP FOR
SPECIFIC PROGRAM
Community mobilization is an attempt to bring both human and non-human resources
together to undertake developmental activities in order to achieve sustainable
development. In community mobilization, it involves is the process of bringing together
as many stakeholders as possible to raise people's awareness of and demand for a
particular programme, to assist in the delivery of resources and services, and to
strengthen community participation for sustainability and self-reliance.
A lot can be achieved when people from different parts of the community share a
common goal and actively participate in both identifying needs and being part of the
solution. Community mobilization helps to empower communities and enable them to
initiate and control their own development, action is stimulated by a community itself, or
by others, that is planned, carried out, and evaluated by a community's individuals,
groups, and organizations on a participatory and sustained basis to improve the health,
hygiene and education levels so as to enhance the overall standard of living in the
community. In other words, it can be viewed as a process which begins a dialogue among
members of the community to determine who, what, and how issues are decided, and also
to provide an avenue for everyone to participate in decisions that affect their lives.

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 LIST OF COMMUNITY MOBILIZATION ACTIVITIES
Community mobilization aims to mobilize and engage community members to address a
particular cause. Engagement of community mobilizers needs to happen early and
individuals need to be involved from the definition of the problem through to the
generation of adequate solutions. The level of engagement of individuals may vary
depending on their interest and capabilities. They may just listen to some messages on the
radio, participate in meetings and events, or they can proactively design, organize and
implement activities. Below is a list of activities that can be used to mobilize
communities into action. The list below provides some of the many ways to mobilize
community members however use your creativity to think of other ways to mobilize
community members.
Community meetings to discuss an issue with community leaders, which may include
traditional, religious and local political leaders, among others.
Public debates in which community members question leaders on a specific,
predetermined topic. These debates can be recorded on the radio and then broadcast.
Puppet shows and participatory theatre where audiences are encouraged to participate
by developing alternative scenarios that would lead to better outcomes.
Village literacy fairs where information about a predetermined topic is shared.
Dance and concerts conveying key messages. The events can be recorded and screened
through cinema units or made to go viral on the Internet.
Mobile cinema units screening short films addressing a specific topic and followed by
discussions and questions/answer sessions. Sporting events and competitions where
messages are conveyed before and after the games and at halftime.
Listening groups to listen to and discuss a particular radio program.
Quiz competitions between teams addressing knowledge of a specific topic.
Print media such as leaflets and cartoon strips for distribution in the community.
Community coalitions made up of people who practice desired behaviors, or who have
survived the outbreak and can act as positive role models and decrease stigma.
Door-to-door sessions where mobilizers enter household to discuss the outbreak and
protective practices in privacy.
Storytelling in which a narrator recounts a pertinent story which may be real or fictional,
to highlight key messages and the importance of protective behaviors.

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 ORGANIZATION OF GROUPS
Groups are prevalent in our social lives and provide a significant way to understand and
define ourselves—both through groups we feel a connection to and those we do not.
Group refers to any collection of at least two people who interact with some frequency
and who share a sense that their identity is somehow aligned with the group.
Groups also play an important role in society. As enduring social units, they help foster
shared value systems and are key to the structure of society as we know it.
The concept of a group is central to much of how we think about society and human
interaction. Society exists in groups. 
In a group, individuals behave differently than they would if they were alone. They
conform, they resist, they forge alliances, they cooperate, they betray, they organize, they
defer gratification, they show respect, they expect obedience, they share, they manipulate,
etc. Being in a group changes their behaviour and their abilities. 
Community Mobilization: Strategies Guided by Best Practice
1. Secure Strong Leadership
 Engage strong leadership with community member support to drive the community-
wide efforts. Strong leaders can include both individuals who take on the work and
the organization(s) that spearhead collaborative efforts. Lead organizations should
possess a number of key characteristics including: the will to serve as the leader of the
community mobilization effort over a significant period of time; the capacity to
provide both infrastructure and human resources; financial stability; the ability to
garner and manage financial resources, and the respect and support of the community.
 Ensure that individuals and organizations in leadership positions have adequate
support and resources.
2. Establish a Formal Structure
 Develop a formal structure that can effectively lead community change efforts. This
structure serves six essential functions: providing overall strategic direction,
facilitating dialogue between partners, managing data collection and analysis,
handling communication, coordinating community outreach, and mobilizing funding.
 Establish key structures and develop guiding documents to help facilitate the
coordination of community-wide efforts. These may include specific committees
(such as steering committees and subcommittees dedicated to a certain issue or
strategy), organizational charts, codified rules of operation (such as bylaws), policy
statements adopted by the partnership, and formal letters of agreement for those who
lead, organize, and participate in the community-wide effort.

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 3. Engage Diverse Organizations, Community Leaders, and Residents
 Engage stakeholders who are most likely to support evidence-based teen pregnancy
prevention efforts. Engage young people, parents, educators, health care providers,
and community-based organizations. Reach out to organizations and key players that
are outside of the “usual suspects” (such as sexuality educators or family planning
centers). This includes religious leaders, businesses, policy makers, media
personalities, and others who have significant influence in the community.
4. Ensure Authentic Participation and Shared Decision Making
 Support a sense of commitment and ownership of the vision and plan for the
community-wide effort by establishing clear roles and responsibilities for all group
members, developing shared decision making processes, and ensuring that community
members are in key decision-making roles.
5. Ensure Authentic and Productive Roles for Young People
 Engage young people in all aspects of program planning, development,
implementation, and evaluation. Provide training on how to effectively develop
youth-adult partnerships. Create opportunities for both youth and adults to share
decision making. Be sure to carve out specific roles for both groups based in part on
their age and prior experiences.
 Remember to consider the practical challenges of involving young people such as
scheduling meetings after school and on weekends, providing transportation, and
offering meals as incentives for attendance.
6. Develop a Shared Vision
 Create a shared understanding of the goals of the community partnership by drafting a
written mission statement specific to the collaboration. Though this statement may
share aspects with the mission guiding the lead organization and/or its partners,
making it distinct and different can help unify a vision. Once the mission statement
has been agreed upon, be sure to make all partners aware of it so that everyone is
working toward the same goal.
7. Conduct a Needs Assessment
 Build a solid understanding of the current state of teen pregnancy and sexual health in
the community by conducting an environmental scan and community mapping
process. Use a variety of techniques such as surveys, focus groups, and interviews
with residents and key stakeholders. Compile data on adolescent sexual behavior
rates, teen birth rates, health factors, school data, and information on out-of-school or
youth at high risk as well as knowledge, attitudes, perceptions and behaviors. Assess
what is already available to young people by gathering information on community-

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 based, school system, youth development, and family planning / health center
resources.
 The needs assessment research will inform the direction of the mobilization effort by
serving as the basis for creating a strategic plan, program activities, internal
communication plans, and public education campaigns. Be sure to clearly define the
community that the partnership is designed to serve whether it is by geographic
location or other population characteristics.
8. Create a Strategic Plan
 Draft a strategic plan that lays out the partnership’s goals (the explicit ways that
community partners are going to address the problems identified in the needs
assessment) and objectives (the activities that will be carried out in pursuit of the
goal). The strategic plan should identify the social, structural, and individual changes
that will lead to reductions in teen pregnancy and birth rates.
 Social changes include increased public will; greater community leadership capacity;
increased and high quality community participation, and supportive community
norms.
 Structural changes include changes made by institutions such as schools, health
departments, and family planning centers and/or changes in policies and practices that
support individual behavior change.
 Individual changes include shifts in knowledge, skills, and behaviors among both
youth and adults.
 Ensure that goals and objectives are SMART (specific, measurable, achievable,
realistic, and time-framed).
9. Implement Mutually Reinforcing Strategies
 Decide on the activities that participants—whether individuals or organizations—will
undertake to support the goals and objectives enumerated in the strategic plan.
Identify a range of key strategies aimed toward youth – such as implementing
evidence-based sexuality education programs in schools or improving access to youth
friendly family planning services – as well as key strategies that support the overall
mobilization effort. For example, develop strategies that will improve stakeholder
participation, develop local leadership, and improve resource mobilization.
 Remember to reevaluate these activities as conditions in the community change or
new funding becomes available.
10. Create a Fundraising Strategy
 Explore a wide range of funding opportunities to ensure that the strategies and
activities can continue beyond the life of the original funding cycle. Consider diverse
funding sources including foundation grants, gifts from individual donors, and in-kind

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 donations from organizations and business in the area. Focus on local resources
whenever possible.
 Consider drafting standard fundraising language that can be used for a variety of
“asks.” Make sure to include the best argument for why the community partnership is
important as well as your mission, goals, objectives, strategies, and plans for
evaluation. Don’t forget to add specific information about the community from the
needs assessment.
11. Establish Effective Channels for Internal Communication
 Ensure a constant flow of information by adopting formal communication strategies
that allow for frequent, deliberate, and productive exchanges between partners.
 Consider appointing a skilled communicator to the role of “relationship manager” and
putting this person in charge of continually informing members about what the
partnership, the committees, the subcommittees, and even individual members are
doing to advance the mission and strategic plan.
12. Educate the Community
 Educate and inspire the community by holding forums, engaging local media,
designing public service announcements, creating billboard campaigns, drafting
letters to the editor, launching web-based and social media campaigns, or holding
home health parties, parent meetings, roundtables, and conferences. The goal of
public education campaigns is to generate awareness, motivate action, encourage
funding, and keep the community focused on the issue at hand.
 Remember to tailor the messages to the community, incorporate data from the needs
assessment, and chose spokespeople who resonate with the intended audience.
13. Conduct Process and Outcome Evaluations
 Decide in advance how the partnerships are going to define success and remember
that there is often a long delay between when a partnership begins its activities and
when there is a measurable impact on youth in the community (such as a reduction in
teen birth rates). Set key benchmarks and progress points along the way.
 Design both process and outcome evaluations and decide on the intervals at which
each will be conducted. Process evaluations will help determine, for example, how
many community members have participated in each activity and whether the activity
was carried out as originally planned. Outcome evaluations will assess whether the
partnership resulted in expected changes in the community.
14. Evaluate the Community Mobilization Effort Separately
 Conduct an evaluation to help determine the impact of the mobilization effort – that
is, whether the partnership was successful in building leadership, shifting norms in the
community, harnessing community buy-in, and mobilizing financial resources.

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 Evaluate the partnership by looking at the quality of the strategic plan, level of
member participation, total number of actions implemented, satisfaction of members
and staff, collaboration of members and member agencies, members’ knowledge of
the problem at hand, perceived ownership and empowerment of members, partner
mobilization and maintenance, and team functioning.

MODULE 3 - COMMUNITY PARTICIPATION IN COMMUNITY BASED

HEALTH CARE
Community participation is defined as the involvement of people in a community in
projects to solve their own problems. People cannot be forced to 'participate' in projects
which affect their lives but should be given the opportunity where possible.
Community participation is a foundational principle of primary health care, with widely
reputed benefits including improved health outcomes, equity, service access, relevance,
acceptability, quality and responsiveness..
Community participation is widely believed to be beneficial to the development,
implementation and evaluation of health services.
The importance of community participation by health professionals was formally
recognised by the 1986 Ottawa Charter in which health promotion was defined as
"the process of enabling people to increase control over and to improve their
health" (WHO, 1986). It further specified that to achieve health for all and to
reduce health inequalities, health promotion should "work through concrete and
effective community action in setting priorities, making decisions, planning
strategies, and implementing them to achieve better health"
A community consists of people living together in some form of social organization and
cohesion. Although it may vary significantly in size and socioeconomic profile, its
members usually share social, cultural, economic characteristics as well as common
interests, including health.
The term “community involvement” is generally preferred to “participation” and points
to the idea of partnership and shared responsibility with health services rather than to the
notion of using the community to reduce the burden on the health services. 
Promoting involvement is much more than simply proposing participation in services
planned and designed from the outside.
Building an operational partnership with the community, with the goal of improving the
health status of the population, is a step beyond participation and involvement. In a
partnership, the institution that has the mandate to provide health and social services to
address the essential needs of the population intervenes through its normative role and

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professional expertise to support the community in its own endeavour to achieve better
health status.
People can undertake health promotion, preventive measures and action to support care in
their own homes and communities. Communities, by sharing responsibilities with the
health system, may often suggest an approach to these interventions that is more adequate
for the local context.
A fundamental principle of primary health care states that everyone in the community
should have access to it and everyone should be involved in it. Having access indicates
the potential to use a service if it is needed. The proof of access is the use of the service
rather than a simple existence of a facility.
Community or citizen participation is well recognized as an essential means to a healthier
and sustainable planet by both the environment and the health fields.

Community participation in health means that community members take part in a range
of health related activities which allow them to have input and control over decisions
about health care. There are varying degrees of participation depending on the nature of
the community and the degree of control over agenda setting, or the degree of ownership
of the process by the community. Community participation in health offers various
advantages in health care and development, among which are helping communities to
develop problem-solving skills, encouraging them take responsibility for their health and
welfare, ensuring that the needs and problems of the community are adequately
addressed, ensuring that the strategies and methods used are culturally and socially
appropriate or acceptable and finally it enhances sustainability. It is the responsibility of
the government at various level, non-governmental organizations, international health
agencies and health care programme planners and providers to help the community to
organize themselves and be involved in their health care and development. Plans must not
be imposed or policies formulated without involving the community in all matters
concerning health and development.
The participatory collaboration method helps development in local communities through
capacity-building as an empowering process. This leads participants to increase control
over their lives by nurturing community strengths and problem-solving abilities.
Community involvement examples include engaging with, volunteering for or donating
to local schools, neighborhood associations, government, and/or nonprofit organizations.

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A community participation approach is a cost effective way to extend a health care
system to the geographical and social periphery of a country; communities that begin to
understand their health status objectively rather than fatalistically may be moved to take a
series of preventive measures; communities that invest labor, time, money, and materials
in health promoting activities are more committed to the use and maintenance of the
things they produce, such as water supplies; health education is most effective in the
context of village activities; and community health workers, if they are well chosen, have
the confidence of the people. An error made in early efforts at community participation
was to assume that villages were uniformly free from internal exploitation. Some are
cohesive moral communities, but in other there is grievous exploitation of landless
laborers by landowners and shopkeepers. Villages may be divided by caste or ethnic
origin. Political organization of villages may be democratic or they may be governed in
an authoritarian manner. In politically unstable countries where the central government
has a rather tenuous control over the rural periphery, genuine community initiatives may

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be viewed as threatening and may not receive official encouragement. Social groups
within communities may be tremendous assets. In planning the community participation
aspects of primary health care, the collaboration of an anthropologist or rural sociologist
with field experience is recommended. Promoting community participation is a skill
which must be taught to community health workers, and backed up with support services.
The genuine commitment of medical staff to community self help is crucial to the
motivation process. Motivation within the community quickly breaks down if materials,
expertise, and salaries fail to arrive when promised. Community activities are most
successfully promoted with reference to the people's own ideas of purity/pollution,
cleanliness/dirtiness, and health/illness. Guidelines for successful community
participation include: projects undertaken should be ones that the community has
identified as a priority; demonstrations and activities to promote health might be linked
with agricultural initiatives, adult literacy campaigns, or programs from other sectors; and
it is necessary to make sure the community fully understands all the costs in labor, time,
money, and materials. If projects or long term community health programs fail, a quick,
simple analysis should be made of constraints that may be operating. 

WHO BENEFITS FROM A COMMUNITY PARTICIPATION APPROACH?

Community participation has many direct beneficiaries when carried out with a high
degree of community input and responsibility. Everyone benefits when participating in
the activities. For example, adults and youth might participate in village committees to
improve services. Everyone might watch a play or video and learn from presentations
about local programs. Youth benefit from improved knowledge about contraception and
HIV/AIDS or from increased skill in negotiating condom use, and other community
members’ benefit too. A truly participatory program involves and benefits the entire
community, including youth, young children, parents, teachers and schools, community
leaders, health care providers, local government officials, and agency administrators.
Programs also benefit because trends in many nations towards decentralization and
democratization also require increased decision making at the community level.
Community participation is considered important in primary health care development and
there is some evidence to suggest it results in positive health outcomes.
PROMOTION OF SELF DETERMINATION AND SELF RELIANCE
Self-determination and control over one’s own life is critical for all individuals, including
individuals with developmental disabilities (Kennedy, 1996). Self-determination provides
the conceptual foundation for policy, vision, and social systems in the field of
developmental disabilities. As the field has evolved from early assumptions about
“handicap” and “disability” the central role of the individual has been captured by the

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construct of “self-determination.” Promoting self-determination has become best practice
in the education of students with intellectual and developmental disabilities. Self-
determination is really not about control. It is about taking action in your life to get the
things you want and need. For example, if someone says: "If you do this I will give you
coke" even if you decide to do it you are not the person who took the action in the
first place.
Self-determination offers a broad vision with personal implications. It is a construct with
multiple facets and as such there will be no single practice or package of practices for
achieving self-determination that applies to all people or all contexts. f self-determination
has its origins in the field of special education with the writings of Nirje (1972), who
discussed individuals’ rights to have control over decisions regarding their personal lives
and access to information to make those decisions.
Activities to promote self-determination might focus on building a person’s capacity to
perform actions leading to greater self-determination (problem solving, decision, making,
goal setting, self-advocacy, etc.), focus on modifying the context or the environment in
some way to better enable someone to make things happen in their own lives, or to
provide supports (e.g., technology) that enhance self determination.

PRINCIPLES OF SELF DETERMINATION

The principles of Self-Determination are; 
Freedom, 
Authority,
Support,
Responsibility, &
Confirmation.
TYPES OF SELF-DETERMINATION - Self-determination has two aspects, internal and
external. Internal self-determination is the right of the people of a state to govern
themselves without outside interference and external self-determination is the pursuit of
full legal secession for a given people from a larger political entity
SKILLS OF SELF DETERMINATION - Self-determination involves many attitudes and
abilities including: self-awareness, assertiveness, creativity, and pride, and problem
solving and self-advocacy skills. To take charge of your own life, you must be able to set
goals, evaluate options, make choices and then work to achieve your goals.

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THE USE OF SELF DETERMINATION IN NURSING PRACTICE
Self-determination theory (SDT) - Self-determination theory (SDT) is a broad theory of
human personality and motivation concerned with how the individual interacts with and
depends on the social environment. SDT defines intrinsic and several types of extrinsic
motivation and outlines how these motivations influence situational responses in different
domains, as well as social and cognitive development and personality. SDT is centered
on the basic psychological needs of autonomy, competence, and relatedness and their
necessary role in self-determined motivation, well-being, and growth. Finally, SDT
describes the critical impact of the social and cultural context in either facilitating or
thwarting people's basic psychological needs, perceived sense of self-direction,
performance, and well-being.

Code of Ethics: The Right to Self Determination

A patient’s right to self-determination is part of their inherent human dignity. Provision
of the Code of Ethics for Nurses calls us to practice with compassion and respect for the
inherent dignity, worth, and unique attributes of every person. Autonomy, etc

Topic not fully handled - To be continued when you return from posting.

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