FAECO-ORAL DISEASES

Faecal-oral diseases are those diseases that are transmitted by faecal

material passing into the mouth, principally via contaminated water,
hands and food, and are prevented by improvements in water supply,
sanitation and hygiene. The most important of these diseases in most
emergencies are various diarrhoeal diseases. Diseases with outbreak risk
are those that may spread rapidly and require a rapid response to protect
public health.

They include; cholera, typhoid, shigellosis, helminths (ascariasis,

hookworm,tape worm)

CHOLERA

Cholera is an acute diarrheal illness caused by infection of the

intestine with the bacteria Vibrio cholerae.

Cholera is an infectious disease that causes severe watery diarrhea,

which can lead to dehydration and even death if untreated.
Definition

 Cholera is an acute, diarrheal illness caused by infection of the

intestine with the bacterium Vibrio cholerae. It is spread by
ingestion of contaminated food or water. The infection is often
mild or without symptoms, but sometimes it can be severe and life
threatening

RISK FACTORS

 Age: Children: more susceptible than adults, And Elderly

also higher susceptible.
 Immunity: Less immune higher risk.
 People with low gastric acid levels
 Blood types  O>> B > A >AB.
 Highest in the lower socioeconomic groups.
 Movement of population(pilgrimages, marriages, fairs and
festivals) results in increased risk of exposure to infection.
 Contaminated water and food.
 Certain human habit favoring water and soil pollution.
 Low standard of personal hygiene.
 Lack of education and poor quality of life.
Incubation period

From a few hours up to 5 days, but commonly 1-2 days.

Mode of transmission

 Feacally contaminated water.

 Contaminated food and drinks

 Direct contact.

CLINICAL MENIFESTATIONS

Cholera is an extremely virulent disease that can cause severe

acute watery diarrhea.

It takes between 12 hours and 5 days for a person to show

symptoms after ingesting contaminated food or water .

Vomiting

Cramps – profuse, painless diarrhea and vomiting of clear fluid.

"rice water" (1L/hour) >20 mL/kg during a 4-hour
observationperiod

Without treatment, death in 18 hours-several days

Typical rice water diarrhoea

Consequences of severe dehydration

DIAGNOSIS EVALUATION

• Stool specimen.

• Confirm presence of cholera toxin by

Dehydration leads to high blood urea & serum creatinine.

Hematocrit & WBC will also be high due to hemoconcentration.

TREATMENT

REHYDRATION:

i. Rehydration phase
 The goal of the rehydration phase is to restore normal
hydration status, which should take no more than 4 hours.
 Set the rate of intravenous infusion in severely dehydrated
patients at 50-100 mL/kg/hr. • Lactated Ringer solution is
preferred over isotonic sodium chloride solution because
saline does not correct metabolic acidosis
ii. Maintainence phase
 The goal of maintenance phase is maintain normal hydration
status by replacing ongoing losses.
 The oral route is preferred , the use of ORS at a rate of 500-
1000 ml/hr
 . Fluids should never be restricted.
Antibiotic treatment

• Antimicrobial therapy is useful for

 prompt eradication of the Vibrio

 diminish the duration of diarrhea
 decrease the fluid loss.

Antibiotics should be administered to moderate or severe cases

 Tetracycline is the drug of choice .  3 day period in BD of 500

mg for adults, 125 mg for children aged 4-13 years, 50 mg for
age0-3 years.

Administer zinc

PREVENTION & CONTROL

 Drink and use safe water.

 Wash hands often with soap and safe water.
 Use latrines ;do not defecate in any body of water.
 Cook food well (especially seafood), keep it covered, eat it
hot, and peel fruits and vegetables.
 Clean up safely—in the kitchen and in places where the
family bathes and washes clothes.
 Remove and wash any bedding or clothing that may have had
contact with diarrheal stool, preferably in a washing machine,
in warm or hot water. Usual machine detergents are
sufficient; bleach is not necessary.
 Patients with cholera should not swim while ill with diarrhea
or for 2 weeks after resolution of symptoms.
 If a household member develops acute, watery diarrhea,
administer oral rehydration solution (ORS) and seek
healthcare immediately
 Healthcare providers should take precautions to prevent the
spread of cholera in clinical setting
 Vaccination(oral vaccine)
 Chomeoprophylaxis  It is advised only for household
contacts or of a closed community in which cholera has
occurred.
TYPHOID FEVER
Definition
Typhoid fever is an acute bacterial infection mainly caused by
Salmonella Typhi
Causative Organism - Salmonella Typhi.
Mode of transmission - By water and food contaminated by faeces and
urine of patients and carriers. Flies may infect Food which will turn in to
source of infection.
Incubation period -10 days to 14 days
 
Clinical manifestations
  Fever (High grade 103 - 104F)
  Cough and sore throat
  Severe mental confusion
  Fatigue
  Weakness
  Vomiting
  Weight Loss
  Headache
  Abdominal pain
  Severe Diarrhea
  Severe Constipation
  Skin rash ( pink spots)
If the typhoid fever continues untreated for more than two or three
weeks, the affected individual may be delirious or unable to stand or
move and which will lead to fatal complication.

Diagnosis
Widal Test
 
Control measures
  Control of reservoir
  Sanitation and hygiene.
  Immunization
1. Control of reservoir - The usual methods of control are their
identification
a.  Early Diagnosis : Culture of blood and stools are the important
investigation for the confirmation of the diagnosis of cases.
b.  Notification : Notification to the health authority to prevent the
spread and control the infection.
c. Isolation  :  Infected  cases  should  be isolated till     three 
bacteriologically negative stools and urine.
d. Treatment - Appropriate    treatment to control the infection and
prevent complications.
e. Disinfection : Stools and urine should be received in closed
containers and disinfected with 5% cresol for at least 2 hours.
  All soiled clothes and linen should be soaked in 2% chlorine solution
and steam sterilized.
  All health care providers should disinfect their hand(hand washing)
  Follow-up examination of stools and urine should be done for
typhoid 3 to 4 months.
  Carriers should be identified by cultured and serological examination.
  The carriers should be kept under surveillance. They should be
prevented from handling food, milk or water for others.
  Health education regarding washing of hands with soap, after
defaecation or urination and before preparing food is an essential.
2. Sanitation and Hygiene
  Protection and purification of drinking water supply.
  Improvement of basic sanitation and promotion of food hygiene.
3. Immunization - There are two vaccines to prevent typhoid.
  One is an inactivated (killed) Typhoid vaccine given in injection
form.
  The other is a live, attenuated (weakened) vaccine which is taken
orally (by mouth).
 
Treatment
Appropriate Antibiotics
Nursing care
  Maintain body temperature to normal.
  Provide comfort measures.
  Follow side effects of drugs.
  Monitor vital signs.
  Follow strict precautions such as hands washing, wearing gloves and
health education to all persons about personal hygiene
  Observe the patient closely for sign and symptoms of complications
such as bowel perforation.
  Accurately record intake and output.
  Provide proper skin and mouth care.
Complications
  Intestinal bleeding
  Fresh blood in the motion
  Intestinal perforation (occur in the third week).

DYSENTERY

Dysentery is inflammation and infection of the intestines, which results

in diarrhea containing blood or mucus.

Dysentery can occur as a result of a bacterial or parasitic infection.

These infections typically spread as a result of poor hygiene or
sanitation.
Dysentery refers to bloody diarrhea, which can sometimes also contain
mucus. It can occur due to infectious germs, parasites, and irritation of
the gut from chemicals.
Types of dysentery
i. Bacillary (shigellosis)
The most common type of infection is bacillary dysentery, or
shigellosis. This type is due to infection with the Shigella bacteria.
– Shigellosis is a highly contagious bacterial infection resulting in
bloody diarrhoea.
There are 4 serogroups of shigella: S. dysenteriae, S. sonnei, S.
flexneri, S. boydii.
– S. dysenteriae type 1 (Sd1) is the only strain that causes large scale
outbreaks. It has the highest case fatality rate (up to 10%).
– Patients at risk of death are children under 5 years, malnourished
patients, children after measles, adults over 50 years.
Clinical features
– Diarrhoea with bright red blood visible in stool , with or without fever
– Abdominal and rectal pain frequent
– Signs of serious illness: fever above 39 °C; severe dehydration;
seizures, altered mental status
Complications
 febrile seizures (5 to 30% of children)
 rectal prolapse (3%),
 septicaemia
 intestinal obstruction or perforation
 moderate to severe haemolytic uraemic syndrome
Laboratory investigations
Shigellosis in an epidemic context:
– Confirm the causal agent (stool culture) and perform antibiotic
sensitivity tests.
– Perform monthly culture and sensitivity tests (antibiotic resistance can
develop rapidly, sometimes during the course of an outbreak).
Treatment
– Patients with signs of serious illness or with life-threatening risk
factors must be admitted as inpatients.
– Treat patients with neither signs of serious illness nor risk factors as
outpatients.
– Antibiotherapy:
1. Ciprofloxacin PO for 3 days
Children: 15 mg/kg 2 times daily (max. 1 g daily)
Adults: 500 mg 2 times daily
• if the strain is sensitive
• if there is no antibiotic sensitivity test
• if oral administration is possible
2. Ceftriaxone IM for 3 days
Children: 50 to 100 mg/kg once daily (max. 1 g daily)
Adults: 1 to 2 g once daily
• in patients with severe infection and/or oral administration is not
possible
• in pregnant women
If resistance or contra-indication to ciprofloxacin or if no improvement
within 48 hours of starting firstline treatment:
3. Azithromycin PO for 5 days
Children: one dose of 12 mg/kg on D1 then 6 mg/kg once daily from D2
to D5
Adults: one dose of 500 mg on D1 then 250 mg once daily from D2 to
D5 or
4. Cefixime PO for 5 days
Children: 8 mg/kg once daily (max. 400 mg daily)
Adults: 400 mg once daily
If there is no improvement 48 hours after starting second-line treatment,
treat for amoebiasis
5. For pain and/or fever:
Paracetamol PO.All opioid analgesics are contra-indicated as they slow
peristalsis.
– Supportive therapy:
• nutrition: nutritional supplement with frequent meals
• rehydration: administration of ORS according to WHO protocols (see
Dehydration(see page 34), Chapter 1).
• zinc supplement in children under 5 years
– Never give loperamide or any other antidiarrhoeal.
– Management of complications: rectal prolapse reduction, septicaemia
– Isolation of hospitalised patients; school exclusion of children treated
as outpatients.
– Hygiene (handwashing, hygienic preparation and storage of food,
home hygiene, etc.).
– Management if signs worsen or bloody diarrhoea in entourage (seek
medical attention).
 ii. AMOEBIC DYSENTERY
Amoebiasis is a parasitic infection due to the intestinal protozoa
Entamoeba histolytica. Transmission is faecal-oral, by ingestion of
amoebic cysts from food or water contaminated with faeces.
Usually, ingested cysts release non-pathogenic amoebae and 90% of
carriers are asymptomatic.
In 10% of infected patients, pathogenic amoebae penetrate the mucous
of the colon: this is the intestinal amoebiasis (amoebic dysentery). The
clinical picture is similar to that of shigellosis, which is the principal
cause of dysentery.
Occasionally, the pathogenic amoebae migrate via the blood stream and
form peripheral abscesses.
Amoebic liver abscess is the most common form of extra-intestinal
amoebiasis.
Clinical features
• diarrhoea containing red blood and mucus
• abdominal pain, tenesmus
• no fever or moderate fever
• possibly signs of dehydration
– Amoebic liver abscess presents with;
• painful hepatomegaly; mild jaundice may be present
• anorexia, weight loss, nausea, vomiting
• intermittent fever, sweating, chills; change in overall condition
Investigations
Amoebic dysentery: identification of mobile trophozoites (E. histolytica
histolytica) in fresh stool samples
– Amoebic liver abscess: indirect haemoagglutination and ELISA
Treatment
– Amoebic dysentery
• The presence of cysts alone should not lead to the treatment of
amoebiasis.
• Amoebiasis confirmed with a parasitological stool examination:
Tinidazole P.O
Children: 50 mg/kg once daily for 3 days (max. 2 g daily)
Adults: 2 g once daily for 3 days
or
Metronidazole PO
Children: 15 mg/kg 3 times daily for 5 days
Adults: 500 mg 3 times daily for 5 days
• Oral rehydration salts (ORS) if there is risk of, or if there are signs of
dehydration
– For Amoebic liver abscess
• Tinidazole PO: same treatment for 5 days
• Metronidazole PO: same treatment for 5 to 10 days

Helminthes(intestinal worms)
ASCARIASIS
Definition
Ascariasis is an infection by the nematode Ascaris lumbricoides. It is the
most
common helminthic parasite of humans.
Etiology
Ascariasis is the largest intestinal nematode. The females are between 20
– 35 cm
in length, while the males vary between 15 and 30cm. The female lays
about
200,000 eggs per day.

Clinical features
Most infections are asymptomatic. However, in heavier infections there
is;
 abdominal pain or discomfort
 nausea
 vomiting
 anorexia and passage of adult worms via anus or mouth may occur.
During the lung phase, about 9 - 12 days after ingestion of the eggs, the
individual
may occasionally present with;
dry cough
chest pain
fever
wheezing
shortness of
breath and blood streaked sputum associated.
Diagnosis
Depends on the microscopic demonstration of eggs in the stool or
recovery of an
adult worm in the stool or after passing through the mouth or nose
Treatment
Mebendazole
Adults and children >10 kg = 100 mg po bid for 3 days
Children < 10 kg = 50 mg po bid for 3 days
Albendazole
Adult and children >10 kg = 400 mg po single dose or for 3 days in
heavy infections
Children < 10 kg = 200 mg po single dose or for 3 days in heavy
infections
Pyrantel pamoate 10 mg/kg up to a maximum of 1gm po once
Piperazine citrate 75mg/kg po once to a maximum of 3.5 gm for adults
and children
over 12 years; and a maximum of 2.5 gm for children between 2 – 12
years.
Levamisole 120 – 150 mg po once

TRICHURIASIS (WHIP WORM INFECTION)

Definition
Trichuriasis is an infection of the human intestinal tract, caused by the
nematode
Trichuris trichuira (whip worm).
Clinical features
Trichuriasis is asymptomatic in most persons. However, children tend to
acquire
heavier infection and some may experience;
anorexia
nausea and abdominal pain.
Occasionally it causes bloody or mucoid diarrhea in young infants.
Heavy and
chronic infections may cause rectal prolapse.
Moderately heavy whip worm burdens also contribute to growth
retardation.
Diagnosis
Depends on microscopic detection of the characteristic lemon shaped
egg of the
parasite in the stool
Treatment
• Mebendazole
Adults and children >10 kg = 100 mg po bid for 3days
Children < 10 kg = 50 mg po bid for 3 days
• Albendazole
Adults and children >10 kg = 400 mg po daily for 3 days
Children <10 kg = 200 mg po daily for 3 days
HOOK WORM INFECTION
Etiology
Hook worm infection is caused by one of the two hook worm species;
namely
Ancylostoma duodenale and Necator americanus.
Adult hook worms, which are about 1cm long, use buccal teeth or
cutting plates to attach to the small bowel mucosa and ingest blood and
intestinal fluid (0.2 ml /day per Ancylostoma adult) and cause large
volume blood loss from intestinal bleeding.
Clinical Features
Most hookworm infections are asymptomatic.
However, infective larvae may provoke itching rash at the site of skin
penetration. Moreover, larvae migrating through the lungs occasionally
cause mild transient pneumonitis in the early intestinal phase.
Infected persons may develop epigastric pain, diarrhea and other
abdominal symptoms.
However, the major consequence of chronic hookworm infection is
blood loss resulting in iron deficiency, which in marginally nourished
individuals may manifest with anemia and hypoproteinemia.
Diagnosis
• Microscopic recovery of the typical eggs
• Concentration techniques may be required to detect light infections
Treatment-
Mebendazole, albendazole or Pyrantel pamoate: similar to ascariasis
Dietary therapy: supplementation of oral iron preparations for iron
deficiency anemia, plus proteins & vitamins.

ENTEROBIASIS
Definition
Enterobiasis is an infection of the human intestinal tract by Enterobius
vermicularis
(the pinworm)
Etiology and Life Cycle
Enterobius vermicularis is a spindle shaped parasite of man and attaches
to the
mucosa of the lower ileum, ceacum and ascending colon. Pinworm eggs
are
infective shortly after being excreted. After ingestion, the eggs hatch in
the upper
intestine and liberate larvae which migrate to the region of the ileum.
Copulation
(mating) of the worms takes place in the lower small intestine, and then
the migrate to the ceacum or lower bowel and pass through the anus
where upon contact with the air they shower their sticky eggs on the
perianal skin.
Clinical features
Most pinworm infections are asymptomatic.
The most common symptom when
present is intense perianal itching. It is worse at night and may lead to
excoriation
and bacterial superinfection. Heavy infections may manifest with
abdominal pain,
anorexia and weight loss.
Diagnosis
Eggs are not typically found in the stool because they are released on the
perineum.
Therefore, eggs deposited in the perianal region are detected from
perianal swab or
by the application of clear cellulose tape to the perianal region in the
morning. The
tape is then transferred to slide to be seen under a microscope.
Treatment
• Mebendazole
Adult and children >10 kg = 100 mg po once then repeat same dose in 2
weeks
Children < 10 kg = 50 mg po once then repeat same dose in 2 weeks OR
• Albendazole
Adult and children >10 kg = 400 mg po single dose then repeat same
dose in 2
weeks
Children < 10 kg = 200 mg po single dose then repeat same dose in 2
weeks
2. Alternatives:
Pyrantel pamoate 11mg/kg po maximum 1.0 gram single dose then
repeat same
dose in 2 weeks
- Warm tap water enema may help
- Family members should be treated to decrease potential source of
reinfection
Prevention of intestinal worms
Ways to prevent faecal contamination of hands
A Wash hands with soap and clean water:
After defaecation, or cleaning the bottom of a child, or changing an
   
infant’s nappy (diaper).
After working with soil, or after children have been playing on soil,
   
where there has been open defaecation by people or animals.
    Before preparing food or eating.
B Cut fingernails and avoid putting fingers into the mouth.
Ways to prevent contamination from unsafe food
C Prepare and eat food safely:
Observe thorough hand hygiene before and during any contact with
   
food
Ensure that all utensils are completely clean; allow them to ‘air dry’
   
after washing (don’t wipe with a cloth)
    Wash raw vegetables and fruits thoroughly in clean water
    Cook other food items thoroughly, particularly meat and fish
    Eat cooked food while it is hot and reheat food thoroughly if it has
 cooled
    Cover food so it cannot be exposed to flies.
D Promote exclusive breastfeeding of infants under six months old:
If babies or young children are fed animal milk or formula, the bottle
   and teat, or cup and spoon, should be thoroughly washed with clean
water and soap before every feed
    Animal milk should be boiled and cooled before drinking
    Formula milk should be mixed with boiled cooled water.
E Control flies:
    Cover food to prevent contamination by flies
Dispose of faeces and other wastes safely, so flies cannot land on
   
sewage.
Ways to prevent contamination from unsafe water
F Protect water sources from contamination with faeces:
    Use a properly constructed latrine and safe disposal of faeces
    Avoid open defaecation in the fields (Figure 32.4)
    Avoid direct contact of hands with drinking water
Install protected water sources, such as covered wells with
   
pumps
Boil water before drinking, or using in preparation of food or
G
fluids
Use clean drinking cups and clean covered containers for
H
storing water.
VECTOR BORNE DISEASES

Vector-borne diseases are infections transmitted by the bite of infected

arthropod species, such as mosquitoes, ticks, sandflies, and blackflies
Vectors are organisms that transmit pathogens and parasites from one
infected person (or animal) to another, causing serious diseases in
human populations

Malaria

Definition

Malaria is a parasitic infection due to protozoa of the

genus Plasmodium, transmitted to humans by the bite
of Anopheles mosquitoes.
Transmission by transfusion of parasite infected blood and
transplacental transmission are also possible.
Aetiology
Five species of Plasmodium cause malaria in humans: 
 P. falciparum
 P. vivax
 P. ovale
 P. malariae 
 P. knowlesi.
All species may cause uncomplicated malaria.
Severe malaria (defined by the presence of complications) is
almost always due to P. falciparum. and, less frequently, P.
vivax and P. knowlesi.
–  Uncomplicated malaria can rapidly progress to severe malaria,
 and severe malaria may cause death within a few hours if left
untreated.

Malaria lifecycle

life cycle of the malaria parasites is divided between two hosts: the
mosquito
and the human.
1. The malaria parasites (in the form of SPOROZOITES) which are
injected from the salivary glands of the mosquito into the blood when an
infective mosquito bites a human rapidly enter liver cells.
2. Within the liver cells the sporozoites proliferate into another form of
the malaria parasites called MEROZOITES.
For P. vivax and P. ovale some malaria parasites remain dormant for
some time and are called HYPNOZOITES.
The collection of merozoites within the liver cell is called a LIVER
SCHIZONT.
3. Rupture of the liver schizonts releases merozoites into the blood
where they enter red blood cells (erythrocytes) to begin a phase of
asexual reproduction.
4. Within the erythrocytes the malaria parasites first assume a form
called
TROPHOZOITES and then multiply by binary fission to become many
merozoites. The collection of merozoites within the erythrocyte is called
an
ERYTHROCYTIC SCHIZONT. Rupture of erythrocytic schizonts
releases many
merozoites which then infect other red blood cells. This cycle is repeated
indefinitely.
5. Eventually some merozoites differentiate into sexual forms called
GAMETOCYTES.
6. The gametocytes within their erythrocytes may be ingested by a
mosquito.
7. In the mosquito gut, lysis of the erythrocytes frees gametocytes to
develop into
GAMETES. Each male gamete develops into eight sperm-like
MICROGAMETES which fertilize the female MACROGAMETES to
form
ZYGOTES.
8. The resulting zygotes become OOKINETES which penetrate the
mosquito’s
mid-gut wall and multiply to form another form of malaria parasites
called
sporozoites. The bags of sporozoites on the mosquito gut wall are called
OOCYSTS
9. Rupture of the oocyst releases sporozoites that infect the mosquito’s
salivary glands.

Clinical features
Malaria should always be considered in patients living in or coming
from, an endemic area, who presents with fever (or history of fever in
the previous 48 hours). 
a. Uncomplicated malaria
Children under 5 years
• fever (raised temperature detected by thermometer or touch) or a
history
of fever
• loss of appetite
• weakness
• lethargy
• vomiting
Older children and adults
 • fever (raised temperature detected by thermometer or touch) or a
history
of fever
• loss of appetite
• nausea
• vomiting
• headache
• joint pains
• muscle aches
• weakness
• lethargy
b. Severe malaria
 In addition to the above, patients presenting with one or more of
the following complications should be hospitalised immediately:
 Impaired consciousness, including coma.
 Seizures: more than 2 episodes of generalised or focal (e.g.
abnormal eye movements) seizures within 24 hours.
 Prostration: extreme weakness; in children: inability to sit or
drink/suck
 Respiratory distress: rapid, laboured breathing or slow, deep
breathing
 Shock: cold extremities, weak or absent pulse, capillary refill time
≥ 3 seconds, cyanosis. 
 Jaundice: yellow discolouration of mucosal surfaces of the mouth,
conjunctivae and palms.
 Haemoglobinuria: dark red urine.
 Abnormal bleeding: skin (petechiae), conjunctivae, nose, gums;
blood in stools.
 Acute renal failure: oliguria (urine output < 12 ml/kg/day in
children and < 400 ml/day in adults) despite adequate hydration.
Laboratory
Parasitological diagnosis
Diagnosis of malaria should be confirmed, whenever possible. If testing
is not available, treatment of suspected malaria should not be delayed. 
i. Rapid diagnostic tests (RDTs) 
Rapid tests detect parasite antigens. They give only a qualitative
result (positive or negative) and may remain positive several
days or weeks following elimination of parasites.
ii. Microscopy
Thin and thick blood films enable parasite detection, species
identification, quantification and monitoring of parasitaemia.
Blood films may be negative due to sequestration of the
parasitized erythrocytes in peripheral capillaries in severe
malaria, as well as in placental vessels in pregnant women.
Note: even with positive diagnostic results, rule out other causes of
fever.
Additional examinations
iii. Haemoglobin (Hb) level
To be measured routinely in all patients with clinical anaemia,
and in all patients with severe malaria.
iv. Blood glucose level
To be measured routinely to detect hypoglycaemia in patients
with severe malaria and those with malnutrition

Management of malaria

Treatment of uncomplicated falciparum malaria

When treating a patient with uncomplicated malaria you should

always keep the following points in mind:
 * Always give a full course of treatment: the right number of
tablets over the right number of days.

* Give the medicine orally unless the patient vomits repeatedly.

* If symptoms persist but there are no danger signs wait at least 48

hours before you change the treatment.

a. First line treatment

Artemether/Lumefantrine is the recommended first line

medicine for the treatment of uncomplicated malaria.

The first dose should be given under supervision of the health

worker. It should preferably be taken with food or fluids. Fatty
meals or milk improve absorption of this medicine.

If vomiting occurs within half (1/2) an hour of swallowing the

medicine, the dose shouldbe repeated and the attendant should
receive a replacement dose from the health worker.

Pregnant women in the first trimester of pregnancy should not take

Artemether/ Lumefantrine.

Artemether/Lumefantrine is contraindicated for children below

5Kg body weight.

Alternative first line treatment of uncomplicated malaria with Artesunate

+ Amodiaquine

Artesunate + Amodiaquine combination treatment can be used as first

line treatment for uncomplicated malaria in situations when
Artemether/Lumefantrine is not available.

Separate scored tablets contain 50mg of Artesunate and 153mg base of

Amodiaquine, respectively.

b. Second lineTreatment
Quinine tablets are the second line medicine for the treatment of
uncomplicated

malaria. This means it should only be given when the first line medicine
(Artemether/ Lumefantrine) has failed or when it is contra-indicated.

Quinine tablets (300 mg salt) are given as a dose of 10 mg/kg (up to a

maximum of

600mg) every 8 hours for 7 days.

c. Supportive treatment and counseling for uncomplicated malaria.

Good management of uncomplicated malaria does not consist of

antimalarial treatment

alone. It also should include the following supportive treatment:

• antipyretic treatment

• fluids and food

• counseling

ii. Antipyretic treatment

If the fever is high (axillary temperature 38.5 C and above) an

antipyretic should given. Children below 8 years of age should only
receive Paracetamol while older children and adults can be given either
Paracetamol or Aspirin. The dosage of Paracetamol is 10mg per Kg
body weight up to maximum of 1000mg eight hourly.

iii. Fluid and food

Patients with fever lose a lot of fluid through sweating and respiration.
They should be encouraged to drink plenty of fluids to avoid
dehydration.

Although a sick person should not be forced to eat, care must be taken
that the energysupply is sufficient. Light foods or fruit juices should be
offered frequently. Babies should continue to be breast-fed

iv. Counseling

A patient can comply with the treatment a lot better if he/she fully
understands why and how to take the treatment and what to expect
during its course. Therefore, you should explain to the patient or the
caretaker the following:

• That the cause of the illness is malaria. The disease is characterized by

fever and is transmitted by mosquitoes.

• The correct way to take the medicines

• In order to be totally cured, the patient must take the full course of
treatment.

• Symptoms may not disappear immediately after taking the first dose.
Improvement may take up to two days.

• The patient should consult a health worker immediately if symptoms

worsen or if they persist beyond two days.

• The patient should take another dose if he/she vomits the medicine
within 30 minutes.

• The patient should not change treatment by himself/herself.

• Before you give any medication, always ask about a history of

reactions and avoid medicines which caused serious reactions in the
same patient
c. Treatment of uncomplicated malaria during pregnancy

Any pregnant woman presenting with fever should be treated for

malaria. Throughout pregnancy, quinine should be used as the first line
treatment. During the first trimester (first 12 weeks of pregnancy) it is
not recommended to take ACTs at all.

However after the first trimester, if there are no suitable alternatives,

ACTs may be used as first line treatment. The doses of quinine and
ACTs during pregnancy are the same as those for adults who are not
pregnant.

To prevent the ill effects of malaria during pregnancy, all pregnant

women should

receive two (2) doses of SP as preventive treatment.

* The first dose of SP (3 tablets) is given as directly observed treatment

during the 4th to 6th months of pregnancy.

* To prevent new malaria infections, pregnant women should be advised

to sleep under insecticide treated nets.

MANAGEMENT OF COMPLICATED MALARIA

1. Antimalarial treatment

Pre-referral treatment

If the patient needs to be transferred, administer before

transfer:artesunate (10 mg/kg)

Inpatient treatment

The drug of choice is artesunate, preferably IV, or if not possible IM.

For patients in shock: IM route is not appropriate, use artesunate IV
only.wary

Artesunate slow IV injection or, if

waaawrhWrrwrrrrwrrrrwrrrrwhraehrrh possible, slow IM injection, into
the anterior thigh:

Children under 20 kg: 3 mg/kg/dose

Children 20 kg and over and adults: 2.4 mg/kg/dose

– One dose on admission (H0)

– One dose 12 hours after admission (H12)

– One dose 24 hours after admission (H24)

– Then one dose once daily

Treat parenterally for at least 24 hours (3 doses), then, if the patient can
tolerate the oral route, change to a complete 3-day course of an ACT.

If not, continue parenteral treatment once daily until the patient can
change to oral route (without exceeding 7 days of parenteral treatment).

If artesunate is not unavailable, artemether may be an alternative:

Artemether IM into the anterior thigh (never administer by IV route)

Children and adults: 3.2 mg/kg on admission (D1) then 1.6 mg/kg once
daily

Treat parenterally for at least 24 hours (2 doses), then, if the patient can
tolerate the oral route, change to a complete 3-day course of an ACT. If
not, continue parenteral treatment once daily until the patient can change
to oral route (without exceeding 7 days of parenteral treatment).
Quinine IV is still recommended in some national protocols. It may be
used in treatment of malaria with shock if artesunate IV is not available.
The dose is expressed in quinine salt:

– Loading dose: 20 mg/kg to be administered over 4 hours, then, keep

the vein open with an infusion of 5% glucose over 4 hours; then

– Maintenance dose: 8 hours after the start of the loading dose, 10 mg/kg
every 8 hours (alternate quinine over 4 hours and 5% glucose over 4
hours).

For adults, administer each dose of quinine in 250 ml of glucose. For

children under 20 kg, administer each dose of quinine in a volume of 10
ml/kg of glucose.

Treat parenterally for at least 24 hours, then, if the patient can tolerate
the oral route, change to a complete 3-day course of an ACT (or if not
available, oral quinine to complet your heart is we 7 days of quinine
treatment). If not, continue parenteral treatment until the patient can
change to oral route (without exceeding 7 days of parenteral treatment).

2. Symptomatic treatment and management of complications

Hydration

Maintain adequate hydration. The fluid of choice in children is Ringer

lactate-Glucose 5% (RL-G5%). Use a premixed solution if available.

If not, add 50 ml of G50% to 500 ml of RL or 100 ml of G50% to 1000

ml of RL. If RL is not available, use

0.9% sodium chloride instead

Adjust the volume according to clinical condition in order to avoid

dehydration or fluid overload (risk of pulmonary oedema).

Fever
Paracetamol in the event of high fever only.

Severe anaemia

Treatment by transfusion

Hypoglycaemia

Children: 2 ml/kg of 10% glucose by slow IV (2 to 3 minutes)

Adults: 1 ml/kg of 50% glucose by slow IV (3 to 5 minutes)

– The risk of hypoglycaemia is higher in patients receiving IV quinine.

Coma

Check/ensure the airway is clear, measure blood glucose level and assess
level of consciousness.

In the event of hypoglycaemia or if blood glucose level cannot be

measured, administer glucose.

If the patient does not respond to administration of glucose, or if

hypoglycaemia is not detected:

– Insert a urinary catheter; place the patient in the recovery position.

– Monitor vital signs, blood glucose level, level of consciousness, fluid

balance (urine output and fluid

input) hourly until stable, then every 4 hours.

– Rule out meningitis (lumbar puncture) or proceed directly to

administration of an antibiotic (see

Meningitis

– Reposition the patient every 2 hours; ensure eyes and mouth are kept
clean and moist, etc.
Respiratory distress

– Rapid laboured breathing:

Check for pulmonary oedema (crepitations on auscultation), which may

occur with or without fluid overload: reduce IV infusion rate if the
patient is receiving IV therapy, nurse semi-sitting, oxygen, furosemide
IV: 1 mg/kg in children, 40 mg in adults. Repeat after 1 to 2 hours if
necessary.

Oliguria and acute renal failure

Look first for dehydration ,especially due to inadequate fluid intake or

excessive fluid losses (high fever, vomiting, diarrhoea). Treat
dehydration if present. Be aware of the risk of fluid overload and acute
pulmonary oedema. Monitor for the return of urine output.

Acute renal failure (ARF) is found almost exclusively in adults and is

more common in Asia than Africa.

Insert a urinary catheter, measure output. Restrict fluids to 1 litre/day (30

ml/kg/day in children), plus additional volume equal to urine output.
Renal dialysis is often necessary.

Prevention and control of malaria

Malaria can be controlled by preventing mosquitoes from reaching and

biting humans,reducing the population of mosquitoes and reducing the
malaria parasite load in the human population.

a. Prevention of contact between mosquitoes and humans

This can be achieved through use of insecticide treated mosquito
nets, screening of houses, site selection and other feasible
interventions.
i. Use of insecticide treated mosquito nets.
 The best way to prevent bites is to sleep under insecticide
treated mosquito nets. Such nets create a physical barrier which
prevents man-m
ii. Screening of houses
Screening of houses by putting mesh in windows, doors, and
ventilators reduces the
entry of mosquitoes into the houses. Doors and windows should
also be closed early
in the evening.
iii. Site selection
Residential houses should be built far away from marshes and
other collections of stagnant water where mosquitoes breed.
b. Reduction of the mosquito population
Reduction of the mosquito population can be achieved by
destruction of adult mosquitoes and larvae and reduction of
breeding sites.
i. Destruction of adult mosquitoes
- Spraying of the internal walls of human dwellings with
residual insecticides
- Use of insecticide treated mosquito nets (ITN)
ii. Destruction of mosquito larvae
- Intermittent cleaning and drying of water containers and
intermittent crop irrigation at least once every 7 days ensures
that mosquitoes do not have sufficient time to complete their
breeding cycle.
- Putting chemicals (e.g. temephos, pirimiphos-methyl), fish
(e.g. Gambusia affinis) or bacteria (Bacillus thuringiesis
israelensis) that kill larvae into stagnant water bodies
(larviciding) interrupts the mosquito breeding cycle.
iii. Reduction of mosquito breeding sites
 - Peridomestic sanitation e. g. reducing breeding places around
the home by proper disposal of broken utensils and plastic bags,
old tyres and filling in holes in the ground.
- Environmental management e. g. constructing drainage
channels for storm water and rivers and drainage of stagnant
water bodies.
- Water management e. g. protection of sources of water for
domestic, agricultural or industrial use
c. Destruction of malaria parasites
Reduction of malaria parasites can be achieved through case
management and preventive treatment.
1. Early diagnosis and prompt treatment of malaria cases (Case
management)
- Effective treatment reduces the length of morbidity and the
risk of mortality. Those who are successfully treated also cease
to serve as sources of malaria parasites.
2. Preventive treatment.
- Intermittent preventive treatment of pregnant women reduces
the risk of poor pregnancy outcomes e. g. maternal anaemia,
maternal death, abortion and low birth weight babies
- Chemoprophylaxis for special risk groups (e.g. sicklers, non-
immune visitors, children prone to very frequent febrile
convulsions) reduces the risk of morbidity and mortality.
d. Advocacy, health education, and social mobilisation
Provision of malaria control interventions requires aggressive
advocacy among decision makers at all levels and the public at
large. Uptake of these interventions calls for a continuous and
concerted effort by health workers in mobilizing and educating
the public.
ONCHOCERCIASIS (RIVER BLINDNESS)

The distribution of onchocerciasis is linked to that of its vector

(Simulium), which reproduces near rapidly flowing rivers in intertropical
Africa (99% of cases), Latin America (Guatemala, Mexico, Ecuador,
Colombia, Venezuela, Brazil) and Yemen.
Clinical features
In endemic areas, the following signs, alone or in combination, are
suggestive of onchocerciasis:
– Onchocercomas: painless subcutaneous nodules containing adult
worms, usually found over a bony prominence (iliac crest, trochanters,
sacrum, rib cage, skull, etc.), measuring several mm or cm in size, firm,
smooth, round or oval, mobile or adherent to underlying tissue; single,
or multiple and clustered.
– Acute papular onchodermatitis: papular rash, sometimes diffuse but
often confined to the buttocks or lower extremities, intensely itchy,
associated with scratch marks, often superinfected (“filarial scabies”) 1 .
This arises from dermal invasion by microfilariae.
– Late chronic skin lesions: patchy depigmentation on the shins
(“leopard skin”), skin atrophy or areas of dry, thickened, peeling skin
(lichenification; “lizard skin”).
– Visual disturbances and ocular lesions:

Laboratory
– Detection of the microfilariae in the skin (skin snip biopsy, iliac crest).
– If the skin biopsy is positive, look for loiasis in regions where loiasis is
co-endemic (mainly in Central Africa).
Treatment
Antiparasitic treatment
– Diethylcarbamazine is contra-indicated (risk of severe ocular lesions).
– Doxycycline PO (200 mg once daily for 4 weeks; if possible 6 weeks)
kills a significant percentage of adult worms and progressively reduces
the number of O. volvulus microfilariae2 . It is contraindicated in
children < 8 years and pregnant or breast-feeding women.
– Ivermectin PO is the drug of choice: 150 micrograms/kg single dose;
a 2nd dose should be administered after 3 months if clinical signs persist.
Repeat the treatment every 6 or 12 months to maintain the parasite load
below the threshold at which clinical signs appear3 . Ivermectin is not
recommended in children < 5 years or < 15 kg and pregnant women.
Nodulectomy (surgical removal of onchocercomas)
Nodules are benign, often deep, and their ablation does not treat
onchocerciasis. Thus, nodulectomy is reserved for cranial nodules (their
proximity to the eye is a risk factor for visual compromise) or nodules
which are cosmetically unacceptable. In other cases, refrain from
nodulectomy. Nodulectomy is performed under local anaesthesia, in an
appropriately equipped facility.

SCHISTOSOMIASIS
Schistosomiases are acute or chronic visceral parasitic diseases
due to 5 species of trematodes (schistosomes). The three main
species infecting humans are Schistosoma haematobium,
Schistosoma mansoni and Schistosoma japonicum. Schistosoma
mekongi and Schistosoma intercalatum have a more limited
distribution.
– Humans are infected while wading/bathing in fresh water
infested with schistosome larvae. Symptoms occurring during
 the phases of parasite invasion (transient localized itching as
larvae penetrate the skin) and migration (allergic manifestations
and gastrointestinal symptoms during migration of
schistosomules) are frequently overlooked. In general,
schistosomiasis is suspected when symptoms of established
infection become evident. Each species gives rise to a specific
clinical form: genito-urinary schistosomiasis due to S.
haematobium, intestinal schistosomiasis due S. mansoni, S.
japonicum, S. mekongi and S. intercalatum.
– The severity of the disease depends on the parasite load.
Heavily infected patients are prone to visceral lesions with
potentially irreversible sequelae. Children aged 5 to 15 years are
particularly at risk: prevalence and parasite load are highest in
this age group.
– An antiparasitic treatment should be administered to reduce
the risk of severe lesions, even if there is a likelihood of re-
infection.

Clinical features
Parasite/ Clinical features/Diagnosis
Epidemiology1 (established infection)
Genito- S. haematobium  Urinary manifestations:
urinary Distribution: Africa, o In endemic areas,
schistosomias Madagascar and the urinary
is Arabian peninsula schistosomiasis
should be suspected
in any patients who
complain of
macroscopic
haematuria (red
coloured urine
 throughout, or at the
end of, micturition).
Haematuria is
frequently associated
with polyuria/dysuria
(frequent and painful
micturition).
o In patients, especially
children and
adolescents, with
urinary symptoms,
visual inspection of
the urine (and
dipstick test for
microscopic
haematuria if the
urine appears grossly
normal) is
indispensible.
o Presumptive
treatment is
recommended in the
presence of macro- or
microscopic
haematuria, when
parasitological
confirmation
(parasite eggs
detected in urine)
cannot be obtained.
 Genital manifestations:
 In women, symptoms of
genital infection (white-
yellow or bloody vaginal
discharge, itching, lower
abdominal pain,
dyspareunia) or vaginal
lesions resembling genital
warts or ulcerative lesions
on the cervix; in men,
haematospermia (blood in
the semen).
 If left untreated: risk of
recurrent urinary tract
infections,
fibrosis/calcification of the
bladder and ureters,
bladder cancer; increased
susceptibility to sexually
transmitted infections and
risk of infertility.
 In endemic areas, genito-
urinary schistosomiasis
may be a differential
diagnosis to the genito-
urinary tuberculosis, and in
women, to the sexually
transmitted infections
(especially in women with
an history of haematuria).

Treatment
praziquantel PO
Children 4 years and over and adults :
• S. haematobium, S. mansoni, S. intercalatum: 40 mg/kg single
dose or 2 doses of 20 mg/kg administered 4 hours apart
• S. japonicum, S. mekongi: 2 doses of 30 mg/kg or 3 doses of
20 mg/kg administered 4 hours apart