PTA 120 Pathophysiology Day 16

1. PTA 120 PathophysiologyDay 16 Infectious Diseases

2. Objectives • Describe the reasons why infections can occur both at the cellular level and the organism level. • Define infectious diseases including signs and symptoms of each: • Hepatitis • HIV / AIDS • Cytomegalovirus • Syphilis • Nosocomial Infections

3. Objectives • West Nile Virus • Diseases which require immunity in health care workers • Botulism • Influenza • Meningitis • Discuss how infectious pathologies can adversely affect function requiring the modification of treatment intervention to protect the patient from worsening the condition and optimize treatment outcomes.

4. Objectives Discuss the modifications and precautions that may be required for the treatment of patients with infectious disorders. Demonstrate understanding of the PTA’s role in the disease process and infection control.

5. Textbooks Pathology for Physical Therapist Assistants, Ch 10 Physical Therapy Clinical Handbook for PTAs, Section 1-6

6. Physiology of Infection Quick review

7. Why Do Infections Occur? • Factors involved in infection • Portal of entry • Virulence of organism • Aggressiveness • Toxin production • Dose (number) of pathogens • Individual condition (predisposition) to infection

8. Modes of Transmission • Direct physical contact • Mucous membranes • Intact skin • Broken skin • Indirect physical contact • Inhalation • Ingestion From Christensen BL, Kockrow ED: Foundations of nursing, ed 5, 2006, St. Louis, Mosby.

9. When infection occurs • Phagocytosis • White blood cells take in and destroy waste and foreign material • Neutrophils • Macrophages • Natural Killer Cells • Type of lymphocyte • Can recognize body cells with abnormal membranes • Found in lymph nodes, spleen, bone marrow, blood • Secrete protein that breaks down cell membrane

10. Why does the PTA need to know about Hepatitis? The PTA must make informed decisions about vaccinations and infection control, as hepatitis B is a blood-borne pathogen more likely to be contracted by health care workers.

11. Hepatitis • Group of liver infections and diseases caused by various viruses • Several types • Hepatitis A (HAV) • Hepatitis B (HBV) • Hepatitis C (HCV) • Hepatitis D (HDV) • Hepatitis E (HEV) • Hepatitis G (GEV) • Alcoholic Hepatitis

12. Hepatitis • Hepatitis A (HAV) • Transmitted through contact with body fluids, feces, and ingestion of contaminated food and drinking water • Hepatitis D (HDV), E (HEV) and G (HGV) • Alcoholic hepatitis • A chronic and serious condition of the liver caused by extreme alcohol intake

13. Hepatitis B • Description • CDC estimates 800,000 to 1.4 million people in U.S. have chronic hepatitis • 350,000,000 affected, 620,000 deaths worldwide annually • Males between 25 and 44 most affected • Risk for infection greatest in people with immunosuppressive disorders and health care workers • Vaccinations recommended for children and health care workers • Virus lives on equipment up to 7 days • OSHA and CDC recommendations for clean-up

14. Hepatitis B • Etiology • DNA virus, blood – borne pathogen • Transmitted through contact with contaminated blood, blood products, or through sexual contact • Incubation period from 6 weeks to 6 months • Symptoms • Loss of appetite, nausea and vomiting • Weakness, fatigue, joint and muscle pains, aching • Fever, skin rash • Jaundice, dark-colored urine

15. Hepatitis B • Treatment • Prevention, vaccinations • Medications

16. Treatment is not directly indicated for patients with Hepatitis B • Standard Precautions • Immunizations Physical Therapy Interventions For Hepatitis B

17. Hepatitis C • Description • > 85% develop chronic form • > 4 million in U.S. and 180 million worldwide affected • Etiology • RNA virus, transmitted through blood • Transmitted via infected blood • Most common in those persons who use IV illicit drugs or have multiple sexual partners

18. Hepatitis C • Signs and Symptoms • Usually mild • Reduction in appetite, abdominal pain, tenderness over liver region • Muscle and joint pain • Jaundice, cirrhosis • Treatment • Prevention • Medications for progressive forms • Possible liver transplant if severe

19. Treatment is indicated for associated arthritis and fibromyalgia, which result in functional deficits, and is focused on improving function, increasing joint mobility, strengthening, endurance, and education on energy conservation techniques. Physical Therapy Interventions For Hepatitis C

20. Why does the PTA need to know about HIV / AIDS? The PTA may Work with people with HIV or aids in various settings, with some patients in the end stages of the disease. A clear knowledge of the disease is necessary to understand appropriate precautions and myths about the disorder.

21. HIV/AIDS • Description • HIV = human immunodeficiency virus • Sexually transmitted viral disease • AIDS = acquired immune deficiency syndrome • Failure of body to develop antibodies to infecting organisms • Worldwide deaths = 25 million • Worldwide people living with the disease = 33.4 million • Most affected in Africa and Asia; 2/3 of all people with AIDS live in sub-Saharan Africa • Homosexual and bisexual men; African American men and women

22. AIDS • Etiology • Blood-borne pathogen; several viruses exist, including HIV 1 and 2 • May remain undetectable in the blood and person may / may not show symptoms for prolonged time • Body fails to develop antibodies (vs. attacking its own cells) -> susceptible to opportunistic infections -> body does not recognize or defend itself -> infections become life threatening • RNA retrovirus, attaches to CD4 receptor of T-lymphocytes; requires reverse transcriptase to multiply

23. AIDS • Rate of disease progression = rate that the virus attacks more T-lymphocytes • Transmitted through blood and bodily fluids • Sexually • Shared hypodermic needles • Blood transfusions in early 1980s

24. AIDS • Signs and Symptoms • Flu-like initially • Long-term • Weight loss, chronic diarrhea • Chronic fatigue, generalized progressive weakness • Joint arthritis • AIDS dementia complex • Neurological symptoms • Secondary / opportunistic infections

25. AIDS • Treatment • Pharmacology • “soup” or “cocktail” • HAART – highly active antiretroviral therapy to improve T-cell count, suppress HIV replication, reduces incidence of opportunistic infections

26. Treatment is indicated for muscle weakness and atrophy, fatigue, peripheral neuropathy, coordination problems, and AIDS dementia complex. Education of the patient and care providers includes transfer and ambulation training, as well as any assistance required for daily living activities. • Patients often benefit from physical touch, as they are often isolated. • Diagnosis of HIV / AIDS must be kept confidential for privacy reasons. Physical Therapy Interventions For HIV / AIDS

27. Why does the PTA need to know about sexually transmitted diseases? These diseases are seen frequently in the general population, and may be seen in physical therapy for associated joint, muscle, and mobility problems. It is important to understand the transmission of these diseases through blood and body fluid contact, and the importance of Standard precautions to prevent the spread of disease.

28. Cytomegalovirus • Description • CMV • Most common congenital virus in U.S.; 1 in 150 infants affected, 1 in 5 develop permanent disability • Related to herpes viruses • Etiology • Present in all body fluids, transmission through close contact with infected fluids • May be passed to fetus through pregnancy or breast milk

29. Cytomegalovirus • Signs and Symptoms • May or may not be present; may mimic influenza • Newborn symptoms: low birth weight, microcephaly, respiratory problems mental and motor delays, seizures, • In immunocompromised: colitis, pulmonary infections, encephalitis, neuropathy, retinitis • Organ transplant patients • Treatment • Infants treated with antiviral medication to prevent hearing loss • Antiviral medications for complications

30. Physical therapy is not directly indicated for CMV, but it is extremely important to follow Standard Precautions, with particular attention paid to hand washing and glove wearing. • It is often highly recommended that PTs, PTAs, and all other health care workers who are or might be pregnant do not work with patients with CMV, as the virus could possibly be spread to the fetus. Physical Therapy Interventions For Cytomegalovirus

31. Syphilis • Description • Sexually transmitted bacterial disease • 36,000 diagnosed in U.S. in 2006 • Congenital syphilis; women 20 – 24 years of age; men = 35 – 39 years of age • Etiology • Bacteria Treponemapallidum • Spread through sexual contact with chancre (open sore) • Indirect contact with contaminated surfaces • Incubation period of 3 weeks; transmitted to fetus after 10th week of pregnancy

32. Syphilis • Signs and Symptoms • Primary stage: infectious, small, painless chancres on genitalia, anus, lips, mouth; heals without treatment • Secondary stage: infectious, red-brown rash on soles of feet and palms; fever, sore throat, headaches and muscle aches, weight and hair loss, fatigue • Tertiary or late-stage: affects internal organs • Tabesdorsalis (progressive locomotorataxia), syphilitic spinal sclerosis – infection of spinal cord • Sensory nerve axons destroyed • Dementia, incoordination (ataxic gait); paralysis, weakness, numbness, blindness, deafness, severe pain, death • Syphilitic arthritis

33. Syphilis • Treatment • Penicillin by intramuscular injection • Regular screening • Education on avoiding at risk behaviors and condom use to avoid spreading the disease

34. Physical therapy is not directly indicated for the primary and secondary stages, but may be needed in the late stage for neurological or musculoskeletal manifestations of the disease. Physical Therapy Interventions For Syphilis

35. Why does the PTA need to know about nosocomial infections? Nosocomial infections are commonly found in hospitals as well as extended care facilities. Knowledge of these infections is critical to understanding the precautions necessary in order to prevent the spread of the infection to other patients or to himself.

36. Nosocomial Infections • Description • Hospital – acquired, health care-associated • 5 infections / 1,000 patient days in the hospital • Result in 26,250 deaths per year; focus on decreasing length of hospital stays

37. Nosocomial Infections • Etiology • Caused by viruses, bacteria, and fungi • Most common agents are Streptococci, Staphylococcus aureus, Enterococci, Pseudomonas, Escherichia coli, and Enterobacter species • Intensive care units • Risk increases with invasive procedures ( IV lines, catheters, intubation)

38. Nosocomial Infections • Etiology • Risk factors in 3 groups: • Patient-related: seriousness of illness, whether the immune system is compromised, and length of stay needed • Organizational: contamination of air-conditioning or water systems, how close together patient beds are placed, and nurse-to-patient ratio • Iatrogenic: associated with pathogens on hands of health care team

39. Nosocomial Infections • Signs and Symptoms • Develop a fever while in hospital • Related to invasive procedure performed • Fever, skin rash, fatigue, tachycardia • Treatment • Broad spectrum antibiotic until exact cause is known • Antibacterial, antiviral, antifungal medications • Removal of catheters or lines thought to be the source • Prevention; handwashing

40. Physical therapist assistants are responsible for preventing the spread of infections through following standard precautions and meticulous hand-washing after patient contact and / or handling any lines. Physical Therapy Interventions For Nosocomial Infections

41. Why does the PTA need to know about vector- and animal-borne infectious diseases? A PTA may encounter these diseases both in the U.S. and when traveling around the world. Is important to know how to prevent the diseases in themselves, as well as recognizing signs and symptoms in patients they treat that may have these infections.

42. West Nile Virus • Description • Also West Nile Encephalitis • Affects humans, mammals, birds • First noted in Uganda, has spread to several parts of the world • In 2007 = 3630 cases, 124 fatalities • Etiology • Birds are reservoirs for the virus -> bitten by mosquito -> mosquito picks up live virus -> transmitted to humans and other animals via mosquito bite

43. West Nile Virus • Signs and Symptoms • Only seen in 20% of infected people, usually mild • Fever, headache, swollen lymph nodes, skin rash, eye pain • Can be neurological involvement, developing encephalitis or meningitis • Treatment • Prevention of mosquito bites • Gloves when handling dead animals and birds • No vaccination available

44. Physical therapy may be indicated during more advanced stages of the disease as problems arise with mental and physical abilities. The patient’s physical functioning may be impacted. Physical Therapy Interventions For West Nile Virus

45. Why does the PTA need to know about infectious disease immunity? working in health care, the PTA will be exposed to many of these diseases. Immunity to these diseases will protect the pta.

46. Preventable Infectious Diseases for Which Health Care Workers are Required to Have Immunity • Diphtheria • Corynebacteriumdiphtheriae bacteria • Mumps • Paramyxovirus • Pertussis (whooping cough) • Bacteria Bordetellapertussis or Bordetellaparapertussis

47. Preventable Infectious Diseases for Which Health Care Workers are Required to Have Immunity • Poliomyelitis and post-polio syndrome • Virus • Rubella (German measles) • Virus • Rubeola (measles) • Single-strand RNA Morbillivirus

48. Preventable Infectious Diseases for Which Health Care Workers are Required to Have Immunity • Tetanus • Bacteria Clostridium tetani • Varicella (chicken pox – children, shingles - adults) • Herpes zoster virus

49. Why does the PTA need to know about other infectious diseases? Other infections are commonly seen in health care, and the PTA will need to understand the precautions related to the diseases. In addition, the pta needs to be aware of the diseases that may be involved in a terrorist attack.

50. Botulism • Description • Food poisoning • In U.S, 145 people / year diagnosed; infants • Etiology • Clostridium botulinumin bottled or canned foods • Bacterial spores produce toxins which prevent acetylcholine release -> paralysis