BA

Infectious Diseases and Immunizations

Muscle Capacitation

  • Host: A living animal (including birds and arthropods) that provides sustenance or shelter to an infectious agent under natural conditions.
  • Incubation Period: The time between initial contact with an infectious organism and the first appearance of symptoms.
  • Infection: The entry and development/multiplication of an infectious agent in a body.
  • Infectious Agent: An organism (virus, bacteria, etc.) capable of producing infection.
  • Mantoux Tuberculin Skin Test (TST): Standard method for detecting latent TB since the 1930s.
  • Nosocomial Infection: An infection acquired in a hospital or healthcare facility that was not present or incubating at the time of admission.
  • Portal of Entry: The means by which an infectious agent enters a host.
  • Susceptible Person or Animal: Lacking sufficient resistance to prevent infection/disease when exposed to an infectious agent.
  • Sexually Transmitted Infection (STI): A contagious disease transmitted by sexual contact.
  • Mode of Transmission: Mechanisms by which an infectious agent spreads to humans.

Communicable Diseases

Influenza

  • Severe disease; can be fatal in the elderly and debilitated.
    • Signs and Symptoms:
      • Fever or feeling feverish/chills
      • Cough
      • Sore throat
      • Runny or stuffy nose
      • Muscle or body aches
      • Headaches
      • Fatigue
      • Possible vomiting and diarrhea (more common in children).
    • Mode of Transmission:
      • Airborne
      • Droplet spread

Hepatitis

  • Inflammation of the liver; five types (A, B, C, D, and E) have been identified.

Hepatitis A (HAV)

  • Liver infection caused by the Hepatitis A virus; highly contagious.
    • Signs and Symptoms:
      • Fever
      • Fatigue
      • Loss of appetite
      • Nausea
      • Vomiting
      • Abdominal pain

Hepatitis B (HBV)

  • Liver infection caused by the Hepatitis B virus; transmitted via blood, semen, or other body fluids from an infected person.
    • Medical personnel receive a three-part immunization for protection.
    • Incubation Period: Symptoms begin approximately 90 days after exposure (range: 60-150 days).
    • Signs and Symptoms:
      • Fever
      • Fatigue
      • Loss of appetite
      • Nausea
      • Vomiting
      • Abdominal pain
      • Dark urine
      • Clay-colored bowel movements
      • Joint pain
      • Jaundice
    • Mode of Transmission:
      • Percutaneous or mucosal contact with infectious blood or body fluids (semen, saliva).
        1. Birth to an infected mother
        2. Contact with blood or open sores of an infected person
        3. Needle sticks or sharp instrument exposures
        4. Sharing items like razors or toothbrushes
    • HBV is NOT spread through: food, water, sharing utensils, breastfeeding, hugging, kissing, hand-holding, coughing, or sneezing.

Hepatitis C (HCV)

  • Liver infection caused by the Hepatitis C virus; a bloodborne virus.
    • Most commonly spread through sharing needles or other equipment for injecting drugs.
    • Can be short-term, but becomes chronic in 70-85% of cases; chronic HCV can lead to serious health problems and death.
    • Many infected people are unaware of their infection; there is no vaccine.
    • The best way to prevent Hepatitis C is by avoiding behaviors that can spread the disease, especially injecting drugs.
    • Signs and Symptoms:
      • Fatigue
      • Fever
      • Abdominal pain
      • Loss of appetite
      • Nausea
      • Vomiting
      • Joint pain
      • Jaundice (eyes)
    • Mode of Transmission:
      • Primarily through large or repeated percutaneous exposures to infectious blood.
        1. Injection drug use (most common in the US)
        2. Receipt of donated blood/organs (rare since blood screening in 1992)
        3. Needle stick injuries in healthcare
        4. Birth to infected mother
      • Infrequently through:
        1. Sex with an HCV-infected person (inefficient)
        2. Sharing personal items contaminated with infectious blood (razors, toothbrushes; inefficient)
        3. Invasive healthcare procedures (outbreaks)

Strep Throat

  • Signs and Symptoms:
    • Sore throat
    • Pain when swallowing
    • Red and swollen tonsils; possibly with white patches or pus
    • Tiny, red spots (petechiae) on the roof of the mouth
    • Swollen lymph nodes in the front of the neck
    • Other symptoms: headache, stomach pain, nausea, or vomiting. Possible rash (scarlet fever).
    • Cough, runny nose, hoarseness, and conjunctivitis are not symptoms of strep throat (suggest a virus).
  • Mode of Transmission:
    • Airborne droplet spread
    • Direct contact with skin lesion

Tuberculosis (TB)

  • Caused by Mycobacterium tuberculosis; usually attacks the lungs, but can affect other body parts.
    • Signs and Symptoms:
      • Bad cough lasting 3+ weeks
      • Chest pain
      • Coughing up blood or sputum
      • Weakness or fatigue
      • Weight loss
      • No appetite
      • Chills
      • Fever
      • Night sweats
    • Mode of Transmission: Respiratory or droplet spread; bacteria discharged in sputum.
    • TB is NOT spread by: Shaking hands, sharing food/drink/toothbrushes, touching bed linens/toilet seats, or kissing.

Bacterial Meningitis

  • Signs and Symptoms:
    • Nausea
    • Vomiting
    • Photophobia (sensitivity to light)
  • Incubation: Symptoms appear quickly or over several days (typically 3-7 days after exposure).
  • Mode of Transmission:
    • Airborne or droplet spread
    • Direct contact with nasopharyngeal secretions of infected host

Sexually Transmitted Infections/Diseases

Gonorrhea

  • STD caused by Neisseria gonorrhea; infects mucous membranes (reproductive tract, mouth, throat, eyes, rectum).
    • Signs and Symptoms:
      • Men: Many asymptomatic; urethral infection may cause dysuria or white/yellow/green discharge (1-14 days after infection). Epididymitis may cause testicular/scrotal pain.
      • Women: Mostly asymptomatic; mild symptoms (dysuria, increased vaginal discharge, vaginal bleeding between periods) mistaken for bladder/vaginal infections. Risk of serious complications regardless of symptoms.
      • Rectal infection: Discharge, anal itching/soreness/bleeding, painful bowel movements; may be asymptomatic.
      • Pharyngeal infection: Sore throat; usually asymptomatic.
    • Transmission:
      • Sexual contact (penis, vagina, mouth, anus) with infected partner; ejaculation not required.
      • Perinatally (mother to baby during childbirth).
    • Re-infection possible after treatment with subsequent sexual contact with infected individual
    • Diagnosis: Microscopic examination of discharge
    • Treatment: Penicillin or Cephalosporin medications.

Chlamydia

  • Common STD caused by Chlamydia trachomatis; causes cervicitis in women, urethritis/proctitis in both sexes. Can lead to serious complications in women (PID, infertility, ectopic pregnancy, chronic pelvic pain).
    • Signs and Symptoms:
      • Most people are asymptomatic
      • Women: Abnormal vaginal discharge, burning sensation during urination.
      • Men: Discharge from penis, burning sensation during urination, pain/swelling in one or both testicles (less common).
      • Rectal infection: Pain, discharge, and bleeding.
    • Transmission:
      • Sexual contact (penis, vagina, mouth, anus) with infected partner; ejaculation not required.
      • Perinatally (untreated mother to baby during childbirth): ophthalmia neonatorum (conjunctivitis) or pneumonia in infants.
      • Re-infection possible after treatment with subsequent sexual contact with infected individual
    • Diagnosis:
      • Women: urine test or swab specimens from the endocervix or vagina
      • Men: Urine test or urethral swab
      • Rectal swab specimen for infections in persons that engage in repetitive anal intercourse
    • Treatment:
      • Azithromycin OR Doxycycline
      • Treating infected patients prevents transmission to sex partners
      • Treating pregnant women usually prevents transmission to the infant during birth
    • Alternative Regiments - Erythromycin Base, Erythromycin ethylsuccinate, Ofloxacin, Levofaloxacin

Syphilis

  • STD caused by Treponema pallidum; can cause long-term complications if untreated.
    • Signs and Symptoms:
      • "The Great Pretender"; symptoms mimic other diseases. Progression of stages (weeks, months, years).
      • Primary syphilis: Chancre (firm, painless, infectious ulcer at bacteria entry).
      • Secondary syphilis: Skin lesions mimicking other dermatological disorders.
      • Tertiary syphilis: Follows a latent period of 2+ years.
    • Transmission:
      • Direct contact with a syphilitic sore (chancre) on genitals, vagina, anus, rectum, lips, or mouth during vaginal, anal, or oral sex.
      • Pregnant women can transmit to unborn child.
    • Diagnosis:
      • Blood test: Rapid Plasma Reagent (RPR)
      • Microscopic exam: Dark field microscopy of skin scraping from chancre.
    • Treatment:
      • Benzathine Penicillin G 2.4 million units
      • Without treatment, patient is infectious in primary/secondary stages and anytime skin lesions are present.
      • Doxycycline, Tetracycline, and Erythromycin (for penicillin allergies).
    • Follow-up:
      • Exam by Provider
      • Blood test
      • Treatment of contacts

Genital Herpes

  • STD caused by herpes simplex viruses (HSV-1 or HSV-2); common in the US.
    • Approximately 776,000 new cases annually; 15.5% of persons aged 14-49 have HSV-2 infection.
    • Prevalence likely higher due to increasing genital herpes infections caused by HSV-1.
    • HSV-1 typically acquired in childhood from mother; declining HSV-1 prevalence may increase susceptibility to genital herpes from HSV-1.
    • Transmission:
      • Contact with lesions, mucosal surfaces, genital secretions, or oral secretions.
      • Can be shed from skin that looks normal.
      • HSV-2 usually during sexual contact with someone with genital HSV-2 infection.
      • Most commonly transmitted from infected partner without visible sores.
      • Asymptomatic HSV-2 infections: genital HSV shedding occurs on 10% of days.
    • Signs and Symptoms:
      • Most individuals are asymptomatic or have mild symptoms.
      • Symptoms: vesicles (blisters) on/around genitals, rectum, or mouth.
      • Incubation period: average of 4 days (range: 2-12 days).
      • Vesicles break and leave painful ulcers (2-4 weeks to heal).
      • First outbreak: longer duration of herpetic lesions, increased viral shedding, and systemic symptoms (fever, body aches, swollen lymph nodes, headache).
      • Recurrent outbreaks: common in the first year; prodromal symptoms (tingling/shooting pains in legs/hips/buttocks) before eruption. Shorter and less severe than first outbreak.
      • Outbreaks decrease over time. Recurrences/subclinical shedding less frequent for genital HSV-1 than HSV-2.
    • Diagnosis: Smear from lesions or viral culture.
    • Treatment:
      • No cure; lesions recur throughout life.
        • Symptoms relieved by warm baths.
        • First episode treated with Acyclovir for relief.
        • Promising medications being tested.

Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS)

  • Signs and Symptoms: * Nonspecific symptoms until opportunistic disease occurs * Opportunistic disease takes advantage of decreased helper cells 1. Lymphadenopathy 2. Anorexia 3. Chronic diarrhea 4. Weight loss 5. Fever
    • Transmission
      • HIV transmitted through specific activities: sexual behaviors and needle or syringe use.
      • Only certain body fluids (blood, semen, pre-seminal fluid, rectal fluids, vaginal fluids, breast milk) from HIV-infected person can transmit HIV if they contact mucous membrane or damaged tissue or injected into the bloodstream
      • Sharing needles or syringes, rinse water, or other equipment used to prepare drugs for injection
      • HIV can live in a used needle up to 42 days depending on temperature and other factors.
    • Diagnosis:
      • HIV infection is the most often diagnosed by using HIV-1 antibody test
      • A positive blood test for the HTLV antibody does not automatically mean that the patient has the disease, only that he/she is at risk
      • ELISA- Enzyme Linked Immunosorbent Assay Test
      • Western Blot Test
    • Treatment:
      • No known treatment
      • Treatment limited to systemic relief. More data being gathered but obsolete quickly.

Genitourinary Examination

  • Provider performs examination of male/female genitals with HM assistance.
  • HM assists provider during examination and provides standby coverage.
  • HM should understand procedures for thorough exam.
  • HM WILL NOT perform exam without provider supervision.
  • Elements: history, lab results, inspection.

Immunizations

  • Vaccines led to global smallpox eradication, polio elimination (US and most countries), and reduced incidence of other diseases.
  • Modern vaccines: safe and generally effective.
    • Adverse effects: usually mild, rarely life-threatening.
  • No vaccine is 100% effective; some vaccinated people may still acquire disease.
  • Effectiveness for children: well-defined; most vaccines protect 80%+ after primary series.
  • Decision to vaccinate: assess disease risks, vaccination benefits, and vaccination risks. Relative balance of risks/benefits changes over time.
  • Adults: increasing attention due to vaccine-preventable diseases. Adult immunization schedules published yearly (since 2002) based on age group and medical/other indications.

Special Circumstances

  • Travel

  • Occupational Exposure

  • Pregnancy

    Storage and Handling of Vaccines

  • Inattention to handling/storage contributes to vaccine failure.

  • Live-virus vaccines (MMR, varicella, yellow fever, etc.) are heat sensitive.

  • Inactivated vaccines tolerate limited heat exposure but are damaged by freezing (cold sensitive). Freezing is the most common storage error. Temp: 0 \degree C (32 \degree F) or colder.

Immunization Administration

  • Proper administration ensures safety and effectiveness.

Foundation: "Rights of Medication Administration" applied to each encounter:
1. Right patient
2. Right vaccine and diluent (if applicable)
3. Right time (age, interval, expiration date)
4. Right dosage
5. Right route (needle gauge/length, technique)
6. Right site
7. Right documentation
* Patient's immunization history should be reviewed at every healthcare visit before administering vaccine.

  • Assess drug contradictions
    • Contraindications and precautions prevent adverse events.
    • All patients should be screened for contraindications and precautions prior to administering any vaccine, even if the patient has previously received that vaccine. The patient's status may change from one visit to the next or recommendations regarding contraindications and precautions may have changed
    • Comprehensive training needed for personnel administering vaccines.
    • Obtain complete immunization history and compare to medical record and immunization information system.
    • Screening patients electronically is a way to save time. NAVMED 6230/4 is the form used to screen patients

Patient care during vaccine administration

  • Use simple strategies to ease the vaccination process:
    • Positive attitude
    • Soft, calm voice
    • Eye contact
    • Explain why the vaccine is needed
    • Be Honest about what to expect
  • Positioning & Comforting Restraint: Consider comfort, safety, age, activity level, and site of administration.
  • Awareness of syncope (fainting) after vaccination (older children, adolescents, adults) and related fall risk.
    *Observe the patient to make sure there are no symptoms (e.g. weakness, dizziness, pallor) for 15 minutes in a seated or lying position.
    *Aspiration is no longer required before administering a vaccine.
    *Order of injections may affect pain response. Inject most painful last (MMR, HPV).

Route of Administration

P.

  • Route determines immune response; most vaccines given IM or SC. Immunogenicity reduced if not given by recommended route.
  • Example: subcutaneous hepatitis B vaccine in buttock = lower seroconversion than intramuscular in deltoid.

Most vaccines coadministered simultaneously at separate sites. Administer in separate limbs.

Injection preparation

  • Verify the correct patient using two identifiers
  • Assess the patient for specific contraindications
  • Assess the patient's history of allergies, including any drug allergies, type of allergens, and normal allergic reaction
  • Verify the practitioner's order
  • Review medication reference information
  • Verify the medication's expiration date
  • Visually inspect the medication for particulates, discoloration, or other loss of integrity. Do not use any medication that is cloudy or precipitated unless its manufacturer indicates that this is safe because it may lead to harmful side effects
  • Assemble prescribed medication, appropriate-size needles, syringes, and other administration supplies
Needle and Syringe Sizes
  1. Subcutaneous:
    • Needle size: 25-27 gauge needle
    • Syringe size: 3.5 mL or less
  2. Intradermal:
    *Needle size: 25-27-gauge needle
    *Syringe size: 3.5 mL or less
  3. Intramuscular:
    • Needle size: 22-25 gauge needle
    • Syringe size: 3.5 mL or less
  • Ensure the SEVEN RIGHTS OF MEDICATION safety
  • Explain the procedure and tell the patient that the injection causes a slight burning or stinging. Ensure the patient's understanding and role in the procedure
  • Perform hand hygiene and don clean gloves

Select appropriate site for injection based on patient age, muscle tissue mass, and medication volume and viscosity
Preliminary preparation:

  • Inspect skin surface over sites for bruises, inflammation, or edema.
  • Assist the patient to a comfortable position appropriate for the chosen injection site
  • Locate injection site again using anatomic landmarks
  • Cleanse site with alcohol or an antiseptic swab, between third and found
  • Remove needle cap by pulling it straight off Subcutaneous Injection (SC)
    • Support the skin at the site by gently bunching up the tissue between your thumb and index finger of your non-dominant hand
    • Hold the barrel of the syringe in your dominant hand between the thumb and index finger, bracing with the remaining three fingers
    • Insert the needle bevel up into the skin at a 45-degree angle with a firm. quick forward thrust
    • Release pinched up skin from the non-dominant hand
    • Inject the medication by pushing the plunger into the barrel with a slow continuous motion

Intradermal (ID)- PPD test

  • Hold syringe between thumb and forefinger of dominant hand with bevel of needle pointing up
  • With non-dominant hand, stretch skin over site with forefinger or thumb
  • Select an injection site on the palm side of the forearm about 2 to 4 inches below the elbow
  • With needle almost against patient's skin, insert it slowly at a 5 to 15 degree angle until resistance is felt
  • Advance needle through epidermis to approximately 1/8 inch below skin surface
  • Inject medication slowly. Normally resistance is felt. If not, needle is too deep; remove and begin again
  • While injecting medication, a small 1/4 inch bleb resembling a mosquito bite will appear on skin surface
    • Gently cleanse area with alcohol pad, working outward 2 inches
    • Removed needle cap by pulling it straight off

Intramuscular (IM)

  • Hold syringe between thumb and forefinger of dominant hand as if holding a dart, palm down
  • Locate the deltoid
  • Spread the skin taught between thumb and forefinger over the selected muscle
  • Inject the vaccine into the tissue
  • Apply gentle pressure to the site; do not massage. Assess the site and applied a bandage if needed
  • Discard uncapped needle (or needle enclosed in safety shield) and attached syringe into a sharps container
  • Assess, treat, and reassess pain
  • Discard supplies, remove gloves, and perform hand hygiene
  • Document the procedure in the patient's record

Anaphylaxis Management

  • For medical management of anaphylaxis, the following must be immediately accessible:
    • Stethoscope
      *Blood pressure cuff (sphygmomanometer)
      *Minimum of three adult doses of epinephrine (1:1000)
      *Oral airway, bag valve mask or equipment to administer oxygen by positive pressure
      *Equipment and ability to activate an emergency medical system
  • ACIP recommends observing persons for 15-20 minutes after immunization.

Document Immunizations

Electronic documentation (DOD approved) preferred.
Printed report from electronic ITS, SF 601, or DD Form 2766C, accompanied by clinic stamp and authorized signature, qualifies as official paper record.
Vaccine administration date: day, month (spelled out or abbreviated), year.
Transcribed records: include "Transcribed from official records" and transcriber's initials.

Forms

SF 601: Health Record-Immunization Record:
Record prophylactic immunizations, sensitivity tests, reactions to transfusions/drugs/foods/allergies, and blood typing.
Record information until space is exhausted.
Verify previous entries and bring current immunizations forward.
Retain old SF 601 beneath new SF 601.
Prepare NAVMED 6230/4 - Adult Immunization Record
Complete all patient demographics
Identify type of immunization to be administered
Complete each block identified by the corresponding header

Documenting Intradermal Skin Test

TST is standard method for detecting Mycobacterium tuberculosis infection. Requires standardized procedures, training, supervision, and practice.
Skin test reaction read 48-72 hours after administration. Reschedule if patient doesn't return within 72 hours.
*Skin test interpretation depends on:
Measurement (mm) of induration
Person's risk of TB infection and progression to disease if infected

Classification of Tuberculin Skin Test Reaction (TST):

An induration of 5 or more millimeters is considered positive in:
HIV-infected persons
Recent contact of a person with TB disease
Persons with fibrotic changes on chest radiograph consistent with prior TB
Patients with organ transplants
An induration of 10 or more millimeters is considered positive in
Recent immigrants (<5 years) from high-prevalence countries
Injection drug users
Residents and employees of high-risk congregate settings
Mycobacteriology laboratory personnel
Persons with clinical conditions that place them at high risk
Children <4 years of age
Infants, children, and adolescents exposed to adults in high-risk categories

Place the results on the NAVMED 6230/4 in the section Tuberculosis Sensitivity Test.
Place the date, type, dose, route, site, and results in each block followed by the date read, and person reading the result and their signature.