Community Health

Laws that protect the environment

-Clean Air Act -Occupational Health and Safety Act (OSHA) -National Institute of Occupational Safety and Health (NIOSH) -Clean Water Act -Comprehensive Environmental Response, Compensation, and Liability Act

Environmental Health-Natural Disasters

-Referred to as all-hazard preparedness= --Individual level --Family level --Community level -Knowing what industries are near will give good indication of substances to plan for and how they will be carried

Emerging disease:

"one that has appeared in a population for the first time, or that may have existed previously but is rapidly increasing in incidence or geographic range"* Eradicated diseases: Smallpox no longer exists Polio and Dracunculiasis (Guinea Worm) are nearly eradicated Newly emerging diseases: Covid 19 SARS (severe acute respiratory syndrome) Mers Reemerging diseases: Malaria TB Bacterial pneumonia All due to drug resistance

There is a relationship between childhood trauma and adult social and health outcomes

- In the original ACE Study conducted between 1995 and 1997 in San Diego, CA , Doctors Vincent Felitti and Robert Anda found a positive relationship between the number of ACEs, and negative adult social and health outcomes, including an increased risk for smoking, drinking to excess, increased drug use, and compromised mental health. These relationships were also found in subsequent studies conducted by the Centers for Disease Control and Prevention.

ANA Principles of Environmental Health for Nursing Practice with Implementation Strategies

-10 Principles( Box 6-1 p. 131) for healthy safe environments that are applicable across settings -The Precautionary Principle- guides nurses to use products and practices that do not harm human health or the environment and to take preventive action in the face of uncertainty. Issues from the ANA report: -Knowledge of the role environmental health plays in the health of individuals, families, and populations. -Ability to assess for environmental hazards and make appropriate referrals. -Advocacy. -Utilization of appropriate risk communication strategies. -Understanding of policies and legislation related to environmental health.

Human Reservoir

-A person who is acutely ill -A person who is a carrier: Incubating carrier - someone who has been infected but has not yet shown signs of the disease Inapparent carrier - someone who is infected but does not develop the disease, yet continues to shed the agent Convalescent carrier - a person who is infected but no longer shows signs of acute disease Chronic carrier - infected with the agent with no sign of disease for a long period of time

The Environmental Health History

-An individual environmental exposure assessment begins with time and place. -An assessment includes: 1.an exposure survey 2.a work history 3.an environmental history*

Environmental Health Risk Reduction

-Apply basic principles of disease prevention. -Prevention is a core goal in PHN. -Every nurse's role in risk reduction -Shift to e-records to avoid paper -Recycle -Promote minimal packaging and green wrappers -Go fragrance free -Turn off equipment not used -Report dysfunctional plumbing -Promote local sustainable foods (organic) -Start a Green Team -Education -Create community

Nursing practice

-Care to patients -Preventative measures -Personal protective equipment (PPE) -Proper cleaning of equipment -Preventing transmission to coworkers, self, and other patients -Understanding communicable diseases --Individual level --Population level

Communicable Disease Investigations

-Case Fatality Rate (CFR) Determines severity of the outbreak Number of fatal cases divided by the number of cases -Epidemic Curve Plotted on graph Shows number of cases Y axis X axis placed by date This shows time elapsed from exposure to clinical symptoms

Infectious respiratory disease continues to be a major public health issue

-Chicken pox -Diphtheria -Rubella -Influenza -Vaccinations = decline in these diseases

Roles for Nurses in Environmental Health

-Community involvement/public participation -Individual and population risk assessment -Risk communication -Epidemiologic investigations -Policy development -Nurses need to know how to assess for environmental health risks and develop educational and other preventive interventions to help individuals, families, and communities understand and, where possible, decrease the risks

Role of the Nurse

-Create a trusting environment. -Show respect, compassion, and concern. -Do not make assumptions. -Coordinate a network of services and providers. -Advocate for accessible health care services. -Focus on prevention. -Know when to walk beside the patient and when to encourage the patient to walk ahead. -Develop a network of support for yourself. Nursing Care of the Homeless: -Be committed -Use leadership skills -Use available resources uBe an advocate -Foster communication and trust -Assess the problem -Plan and give care Levels of Prevention: Interventions for the homeless can be assigned to more than one level of prevention. Primary prevention services include affordable housing, effective job training programs, employer incentives, preventive health care services, multisystem case management, birth control services, safe sex education, needle exchange programs, and counseling programs. Secondary prevention services target persons on the verge of homelessness as well as those who are newly homeless, using supportive and emergency housing, targeted case management, housing subsidies, soup kitchens and meal sites, and comprehensive physical and mental health services. Tertiary prevention for the homeless includes comprehensive case management, physical and mental health services, emergency shelter housing, needle exchange programs, and drug and alcohol treatment. At all these levels, nurses can educate and influence policy makers and legislators to impact public policy and funding for interventions that are effective in assisting the homeless.

Nursing Actions to Promote Access to Care for Vulnerable Populations

-Create a trusting environment. -Show respect, compassion, and concern. -Do not make assumptions. uCoordinate services and providers. -Advocate for accessible health care services. -Focus on prevention. -Know when to "walk beside" the client and when to encourage the client to "walk ahead." -Know what resources are available. -Develop your own support network.

Culture of Health

-Culture of health: a concept introduced by the Robert Wood Johnson Foundation in 2013. --Definition: "Where good health flourishes across geographic, demographic, and social sectors; where being healthy and staying healthy is an esteemed social value; and everyone has access to affordable, quality health care"

Foodborne Diseases

-Food infection Salmonellosis Gastroenteritis -Food intoxication Botulism Food infection Food intoxication results from toxins produced by bacterial growth, chemical contaminants (heavy metals), and a variety of disease-producing substances found naturally in certain foods, such as mushrooms and some seafood. Food intoxication occurs when there is production of toxins as a byproduct of normal bacterial life-cycle, such as staphylococcus aureus or clostridium perfringens. *****Foodborne botulism occurs when a person ingests pre-formed toxin that leads to illness within a few hours to days. Foodborne botulism is a public health emergency emergency because the contaminated food may still be available to other persons besides the patient. With foodborne botulism, symptoms begin most commonly between 12 and 36 hours after eating toxin-containing food. Symptoms of botulism include double vision, blurred vision, drooping eyelids, slurred speech, difficulty swallowing, dry mouth, muscle weakness that always descends through the body Because the botulism toxin is destroyed by high temperatures, persons who eat home-canned foods should consider boiling ( heat above 160 degrees) the food for 10 minutes before eating it to ensure safety. Instructions on safe home canning can be obtained from county extension services or from the US Department of Agriculture. Because honey can contain spores of Clostridium botulinum and this has been a source of infection for infants, children less than 12 months old should not be fed honey. Honey is safe for persons 1 year of age and older.

Host Factors

-Four factors influence risk or susceptibility of contracting a disease... host resistance, immunity (natural or acquired), herd immunity, and infectiousness. -Host factors can include biologic behavioral and sociodemographic things such as: genetic susceptibility, immunity, age, SES, and eating habits -Two types, humoral and cellular -Humoral immunity means that the host carries antibodies to the agent in the blood. -Cellular immunity is specific to each type of cell. --Passive immunity: transferred from one individual to another --Artificial passive immunity: involves the transfer of antibodies and can be done in various forms --Active immunity: acquired through exposure to the agent -Resistance is the host's ability to withstand infection, and it may involve natural or acquired immunity. Natural immunity refers to species-determined, innate resistance to infectious disease. Herd immunity refers to the immunity of a group or community and is based on the resistance of a high proportion of individual members of a group to an infection. This is the basis for increasing immunization coverage for vaccine-preventable diseases. Infectiousness is the measure of the potential ability of an infected host to transmit the infection to other hosts.

Communicable Disease: Epidemic Curve

-Graph also helps determine if you have: Point source. Exposure at one point in time Intermittent source. Exposure comes and goes Continuous source. Exposure is ongoing

Actions to Reduce Health Disparities

-Increase cultural awareness and sensitivity -Initiate cultural assessment of the individual, community, or population -Promote training to develop culturally sensitive and empathetic communication skills -Increase the diversity of the health-care staff -Make sure patients receive equitable health-care services -Be a patient advocate -Always use a translator, as needed -Recognize that nurses and other care providers can be discriminatory

Host Characteristics: Resistance and Colonization

-Inherent resistance: -resists disease without antibodies -inherited or acquired -Colonization: -infected with agent but no sign of disease -can spread disease -example: methicillin-resistant staphylococcus aureus (M R S A)

Measures of Protection

-Keep clean -Separate raw food -Cook thoroughly -Keep food at safe temperatures -Use safe water and raw materials.

Environmental Health-Issues specific to nursing practice

-Knowledge of the role environment plays in health of individuals, families, and populations. -Ability to assess health hazards and make referrals. -Use of appropriate risk communication strategies. -Understand policies and legislation related to environmental health.

Environmental Exposure

-Land and soil -Contaminated land designations -Superfund site -Highly contaminated -Threat designated by the Environmental Protection Agency (EPA) -Brownfield site -Previously used -Now slated for redevelopment -Food -Pathogenic causes: E. coli, Salmonella; pesticides; genetically modified organisms (GMOs) -Environmental causes: pesticides, antibiotics in animals

Culture of Health Action Framework

-Making Health a Shared Value -Fostering Cross-Sector Collaboration -Creating Healthier, More Equitable Communities -Strengthening Integration of Health Services and Systems -Improved Population Health, Well-being, and Equity

Diseases of Travelers

-Malaria -Foodborne and waterborne disease -Diarrheal disease

Communicable Disease: Outbreak Investigation*****

-Management of epidemic Identify source Isolate source How best to break the cycle -Incubation period Exposure to onset of symptoms -Herd immunity Greater population protected (vaccine) Protects those who are not or choose not to be vaccinated.

Information Sources

-National Library of Medicine (NLM) -ToxTown -Household Products page -Environmental pages -Safe Cosmetics database -"Right to Know" is an American Nurses Association (ANA) environmental health principle that recommends access to all information necessary to make informed decisions to protect our health.***

Lesbian, Gay, Bisexual, Transgender, Queer

-Persons who do not conform to established gender norms often face stigma, discriminatory practices, and/or social exclusion. -Can adversely affect health through: -increased susceptibility to diseases and poor mental and physical health -decreased access to health services* -Gender identification and sexual orientation occur across a continuum rather than in the more traditional binary model of female and male. -This continuum includes persons who identify as straight (cisgender), gay, lesbian, bisexual, transgender, agender, or other gender-based terms (L G B T Q+).* L G B T Q+ persons are at greater risk for poor health than their heterosexual counterparts. This is attributable to: -differences in sexual behavior -social and structural inequities, such as the stigma and discrimination that L G B T Q+ populations experience* -increased risk for communicable diseases, suicide, mental health issues and substance use disorders often linked to discrimination and social isolation* -increased risk for violence, especially hate crimes

Environmental Health- Water

-Potable Water- Water quality is a health determinate of populations -Consumer Confidence Reports (CCRs) -Sources of pollution -Waste from industry, pharmaceuticals -Storm runoff, erosion, especially due to loss of 80% of the world's forests leading to massive erosion -Water globally -Diarrheal disease -1.1 billion do not have safe drinking water -Barriers -Not meeting this millennium goal

Homelessness

-Poverty can lead to homelessness The Stewart B. McKinney Homeless Assistance Act of 1987 (PL 100-77) defines homelessness as "lacking a fixed, regular, and adequate nighttime residence and ... has a primary nighttime residency that is: (A) a supervised publicly or privately operated shelter designed to provide temporary living accommodations; (B) an institution that provides a temporary residence for individuals intended to be institutionalized; or (C) a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings" (cited in National Coalition for the Homeless, 2009a, p 1). This definition generally refers to persons who are homeless on the streets, are in shelters, or face eviction within 1 week. Definition of homelessness: primary night residency that is as follows: -A supervised, temporary public or private shelter -A temporary residence for individuals intended to be institutionalized -A public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings -Two ways of acquiring homeless numbers -Point-in-time counts -Number of persons who are homeless on a given day or during a given week -Period prevalence counts -Number of people who are homeless over a given period of time -Both methods typically undercount those who are homeless. -Many homeless people are hard to find. Most likely to be homeless? -Single homeless adults are more likely to be males -The number of homeless families has increased -42% African American -38% White -20% Hispanic -4% Native American -2% Asian -Victims of domestic violence -Veterans -1.5 million children, 42% under age 6

Children and Poverty

-Poverty rate for children is 21.8% higher than for any other age group -Poverty among African-American and Hispanic children is three times greater than that of white, non-Hispanic children. -Children in poverty are at risk for the following: -Lack of adequate nutrition and brain development -Maternal substance abuse or depression -Exposure to environmental toxins -Trauma and abuse -Lower-quality daily care Some of the effects of poverty on children can be seen in Box 33-1. Poverty increases the likelihood of chronic disease, injuries, traumatic death, developmental delays, poor nutrition, inadequate immunization levels, iron deficiency anemia, and elevated blood lead levels. Furthermore, children of poverty are more likely than nonpoor children to be hungry and suffer from fatigue, dizziness, irritability, headaches, ear infections, frequent colds, weight loss, inability to concentrate, and increased school absenteeism.

Exposure Risk Assessment

-Process to determine the probability of a health threat associated with an exposure -Extent to which a population may suffer effects -Four steps= Four phases 1.Hazard identification, the first step of an exposure risk assessment, seeks details to input from government information portals about the exposure. This is determining whether a chemical is known to be associated with negative health effects (in animals or humans) 2.A dose-response assessment, the second step, is based on experiments and looks for the correlation between an increase in harmful effects and the increase in the quantity of a substance. 3.An exposure assessment, the third step, is the consideration of the level, timing, and extent of the exposure.--Estimating how much and by which route of entry the chemical might enter the human body 4.A risk characterization, the last step, pulls together the information gathered in the previous steps to determine the health risk of those affected. -Subject to interpretation

Foundational Practices to Advance Health Equity

-Purposefully expand the understanding and conversation of what creates health to include the "opportunity for health" -Strengthen the capacity of communities to create their own healthy futures. Use public health tools: partnerships, engagement, convening ability, data, reports, education, policy, resources, legislation. -Implement a "health in all policies" approach with health equity as the goal in program and policymaking (organize resources-and how systems work)

Diarrheal Disease

-Rotavirus accounts for 40% of all infant diarrhea -500,000 child deaths under age of 5 years old -Vaccine introduced in 2006 -Seen a big decline in hospitalizations and deaths of young infants Caused by: Bacteria Virus Protozoa Mode of transmission: Waterborne (for example, cholera) Foodborne/person to person (for example, E. coli) Most common route for transmission is the fecal-oral route. Good hand hygiene, especially hand washing, and soap alone can reduce the incidence of diarrheal disease by as much as 48%.*** Efficient sanitary systems and safe drinking water also play a huge role in preventing diarrheal diseases.

Health Disparities- Nurses are Part of the Solution

-Speak out about health inequities in communities -Be advocates for: Individuals, Communities, Neighborhoods, Populations, Systems. -Initiate/support healthier school programs -Collect accurate data for policy makers -Assist in developing health programs for the vulnerable -Culturally design programs of health promotion, intervention, and prevention -Educate communities on disparities they have and engage them to help find solutions -Educate coworkers on health as well as social disparities uInvest in social justice for all

Environmental Health Sciences----Toxicology

-The basic science applied to understanding the health effects associated with chemical exposures -Similar to pharmacology but only negative effects of chemical exposures are studied -Pollutants have multiple routes into the body Individuals have unique responses The probability that harm will be done depends on: 1.ability to cause harm in humans 2.does it enter body and reach susceptible organs 3. the amount present -Pollutants can enter body from a variety of routes --Lungs, GI tract, Skin, Mucous membranes Routes of entry: -Ingestion -Inhalation -Dermal absorption Toxicology: Toxicology is the basic science that studies. 1. Pollution can enter our bodies via the lungs (inhalation), gastrointestinal tract (ingestion), skin, and even mucous membranes (dermal absorption). 2. Most chemicals can cross the placental barrier as well as the blood-brain barrier. 3. Age, weight, other drugs taken, and underlying health status can also affect environmental exposure response. 4. Most chemicals cross the placental barrier and can affect the fetus, just as most chemicals cross the blood-brain barrier. In addition to direct damage to cells, tissues, organs and organ systems, there can be changes to the DNA from chemical exposures that can change gene expression which, in turn, can predict disease. This latter effect is the focus of a relatively new biological study, epigenetics.

**Key to the control of communicable diseases is understanding

-The infectious agent. -Who is at risk. -Mode of transmission. -Prevention. -Treatment.

Social determinants of health are more important than or equal to individual behavioral choices such as:

-Tobacco, high-fat and high-calorie diets, and a sedentary lifestyle. -Socioeconomic circumstances during early childhood are a better predictor of cardiovascular disease Role of Race -Race is a social construct with no biological foundation -Complicated causation between race and poor health outcomes -Segregation in jobs, environment, education impact, health and outcomes Within the same racial group, social class determines the rate of health disparity. Middle- and upper-class minority groups generally have better health and outcomes than those living in poverty. The more years of education the better the health.

Communicable Diseases: Agents

-Two other groups included in pathogens that do not cause but carry disease are: -Arthropods. -Parasitic insects. Examples are: Ticks. Fleas. Lice.

Ten Golden Rules for Safe Food Preparation

1. Choose foods processed for safety 2. Cook food thoroughly 3. Eat Cooked foods immediately 4. Store cooked foods carefully 5. Reheat cooked foods thoroughly 6. Avoid contact between raw foods and cooked foods 7. Wash hands repeatedly 8. Keep all kitchen surfaces meticulously clean 9. Protect foods from insects, rodents, and other animals 10. Use safe water

10 Principles for Healthy, Safe Environments

1.Knowledge of environmental health concepts is essential to nursing practice. 2.The Precautionary Principle guides nurses in their practice to use products and practices that do not harm human health or the environment, and to take preventive action in the face of uncertainty. 3.Nurses have a right to work in an environment that is safe and healthy. 4.Healthy environments are sustained through multidisciplinary collaboration. 5.Choices of materials, products, technology, and practices in the environment that impact nursing practice are based on the best evidence available. 6. Approaches to promoting a healthy environment respect the diverse values, beliefs, cultures, and circumstances of patients and their families. Nurses participate in assessing the quality of the environment in which they practice and live. 7.Nurses, other health care workers, patients, and communities have the right to know relevant and timely information about the potentially harmful products, chemicals, pollutants, and hazards to which they are exposed. 9.Nurses participate in research of best practices that promote a safe and healthy environment. 10.Nurses must be supported in advocating for and implementing environmental health principles in nursing practice

Environmental Health- Air

Ambient air and quality= -Air surrounding a place -Pollutant levels not harmful to humans -Travel with the winds Mobile or nonpoint source -Cars and trucks on the road Criteria air pollutants (set of major air pollutants). Ground-level ozone and particulate matter -Most hazardous to human health -Sources of pollution ---Point sources (identifiable—e.g., smokestacks) ---Non-point sources (mobile—e.g., cars and trucks) -Clean Air Act -Indoor air quality (IAQ)

Outbreak Investigation Steps

A systematic epidemiological investigation can: -Determine if there is a sudden increase in the incidence of a C D -Define what constitutes a case -Determine the severity of the outbreak - Case Fatality Rate (C F R) -Map out the epidemic curve -Generate a hypothesis -Conduct case finding -Determine common source of exposure -Identify source of transmission on take action

Perinatal and Pediatric HIV Infection

Accounts for nearly all HIV infection in children and can occur during pregnancy, labor and delivery, or breastfeeding HAART in pregnant women Recommended that HIV testing be routine part of prenatal care; all pregnant women should be tested for HIV Despite having an HIV-infected mother, many children do not acquire HIV/AIDS. However one or both parents may die. The effectiveness of antiretroviral therapy in pregnant women and newborns in preventing transmission from mother to fetus or infant has made pediatric HIV rates decline sharply.

Nurse's Role in Providing Preventive Care for Communicable Diseases

At all levels of prevention, the nurse functions as: -Counselor -Educator -Advocate -Case manager - Primary care provider Assessment and counseling individuals and family members Interventions at the community level -Media campaigns -High-risk population education and screening -Peer counseling -Partnerships with community-based organizations -Policy development Currently: TB seen in immune-suppressed patients Seen in community through MDRTB Shows the importance of following trends of communicable diseases Surveillance of disease should include: Geographic area. Age. Race. Location. Birth place (foreign or U.S. citizen).

Chlamydia

Bacterium -Infects genitourinary tract and rectum of adults -Causes conjunctivitis and pneumonia in neonates Transmission -Mucous membrane contact with mucopurulent discharge from infected site Most common reportable infectious disease If left untreated, chlamydia can result in pelvic inflammatory disease (PID). Most people who have chlamydia don't know it since the disease often has no symptoms Under-reporting is substantial because most people with chlamydia are not aware of their infections and do not seek testing. Also, testing is not often done if patients are treated for their symptoms.

Gonorrhea

Bacterium -Infects mucous membranes of the genitourinary tract, rectum, and pharynx Transmission -Genital-genital contact, oral-genital contact, and anal-genital contact Uncomplicated gonorrhea refers to limited cervical or urethral infection. Complicated gonorrhea includes salpingitis, epididymitis, systemic gonococcal infection, and gonococcal meningitis. Highest incidence in United States -African Americans, persons in the South, and women 15 to 24 years of age Number of antibiotic-resistant cases rising

AIDS in the Community

Chronic disease -Much care is provided in the home. -Nurses provide teaching to clients and families. Adherence to HAART: critical The Americans with Disabilities Act of 1990 and other laws protect persons with asymptomatic HIV infection and AIDS against discrimination in housing, at work, and in other public situations. Mental health issues, such as depression, substance abuse, and bipolar disorder, are often present in someone newly diagnosed with HIV. These conditions must be addressed prior to or simultaneously with HIV treatment to be effective. HIV-infected children should attend school because the benefit of attendance outweighs the risk of transmitting or acquiring infections. Although a cure for HIV does not yet exist, antiretroviral therapy (ART) can keep you healthy for many years, and greatly reduces your chance of transmitting HIV to your partner(s) if taken consistently and correctly. ART reduces the amount of virus (or viral load) in your blood and body fluids. ART is recommended for all people living with HIV, regardless of how long they've had the virus or how healthy they are.

Assessment Issues

Because members of vulnerable populations often experience multiple stressors, nursing assessment must balance the need to be comprehensive with the ability to focus only on information that the nurse needs and the client is willing to provide. Socioeconomic Considerations: Because socioeconomic variables are important factors that predispose people to vulnerability, assessment should include evaluation of the adequacy of the individual's or family's social supports and economic self-sufficiency. This includes the client's perceived adequacy of socioeconomic resources and formal and informal support networks. C. Physical Health Issues: Nurses should explain to clients the value of preventive assessments. If the client agrees, the nursing assessment should include evaluation of the client's preventive health needs, including age-appropriate screening tests. Referrals may be necessary for some screenings. Assessment should also include preventive screenings for physical health problems for which certain vulnerable groups are at a particularly high risk. D. Biological Issues: Vulnerable populations should be screened for congenital and genetic predisposition to illness and either receive education and counseling as appropriate or be referred to other health professionals as necessary. Health fairs are an effective means of conducting screenings. E. Psychological Issues: Vulnerable family groups should be assessed for stress, healthy or dysfunctional family dynamics, effective communication patterns, caregiving capabilities, and the extent to which family developmental tasks are being met. Individuals should be assessed for the presence of stressors, usual coping skills, levels of self-efficacy, overall sense of well-being, level of self-esteem, and depression and anxiety. Depression is a prevalent problem for members of vulnerable groups and is a critical predictor of risky behaviors, such as abuse or violence. Vulnerable individuals and groups should be assessed for risks of or exposure to abuse or violence. F. Lifestyle Issues: Vulnerable individuals, families, and groups face challenges in maintaining healthy lifestyles Therefore it is critical to assess their lifestyle factors, including diet, exercise, rest, and the use of drugs, alcohol, and caffeine. G. Environmental Issues: Vulnerable groups are more likely to be exposed to environmental hazards, such as pollutants or carcinogens, than other groups. The nurse should assess the living environment for asbestos, lead-based paint, noise, water and air quality, industrial wastes, and the incidence of crime.

Environmental Health-Key issues

Built Environment -Study how human made environments impede or facilitate health -Example: Obesity and the built environment ---EBP obesity is related to built environments ---Influence on diet and exercise That obesity is based on the environment around them. Ex. Walking trails, sidewalks etc.

Environmental Justice and Environmental Health Disparities

Certain environmental health risks disproportionately affect poor people and people of color in the United States. -More likely to live near a hazardous waste site or an incinerator -More likely to have children who are lead poisoned -More likely to have children with asthma Justice- its not okay to do whatever that are doing for that environment.

Transmission of Communicable Diseases

Chain of Infection: Agent Reservoir Portal of exit Mode of transmission Portal of entry Susceptible host Communicable diseases occur as a result of interaction between a host (person), infectious agent (bacteria), and environment (contaminated food, water)—epidemiological triangle

Environmental Health-Exposure types

Chemical= -Carbon monoxide -Metals -Pesticides -80,000+ world wide -Agency for Toxic Substance and Disease Registry -Provides information -Affects on health Biological agents= -Bacteria -Viruses -Rickettsia -Molds -Plant and animal contact -Fungi -Allergens= -Dust mites -Cockroaches Physical agents= -Injurious exchange of energy -Heat -Cold -Radiation -Noise -Vibration -Falls -Vehicle crashes -Crush injuries -Violence

Children's Environmental Health

Children's bodies operate differently than adults, putting them at potentially increased risk for toxic exposure. -Increased respiratory rate translates to a proportionately greater exposure to air pollutants. -Immature blood-brain barrier -Kidneys less effective at filtering undesirable chemicals -Susceptible populations Children= Soil contaminated with heavy metals Toys' lead paint Cigarette smoke Carbon monoxide Alcohol Have faster rates of absorption Faulty play equipment Violence Chemicals Safe places to play

CH.8 Communicable Disease

Communicable diseases in top 10 causes of death Lower respiratory infections- influenza and pneumonia -Most common C D cause of death Diarrheal diseases Tuberculosis

CH.6 Environmental Health

Defined by WHO as: "Environmental health addresses all the physical, chemical, and biological factors external to a person, and all the related factors impacting behaviors. It encompasses the assessment and control of those environmental factors that can potentially affect health. It is targeted towards preventing disease and creating health-supportive environments. This definition excludes behavior not related to environment, as well as behavior related to the social and cultural environment, and genetics."

Healthy People 2020

Goal: HIV: Prevent human immunodeficiency virus (HIV) infection and its related illness and death. Goal: STD: Promote responsible sexual behaviors, strengthen community capacity, and increase access to quality services to prevent STDs and their complications

Test for HIV

ELISA test (also called EIA) -Is a screening test- only tells you presence or absence of antibody to HIV -False negatives can happen during the "window period" which is between 6 weeks and 3 months after exposure -ELISA antibody test is the most commonly used test. Only screens for infection- doesn't tell if the person has symptomatic HIV or isolate the virus.. Just tell presence of antibody. Use this screening test to screen blood and donor products Western Blot -Confirmatory test, most diagnostic, confirms HIV Oral fluid rapid HIV screening tests -99% accurate -Gives results in 20 minutes

Governmental Environmental Protection

EPA -Regulatory body -Performs environmental assessments, Performs research, Educates -Sets and enforces national environmental standards Important steps and concepts -Permitting=Limits the amount of pollutants that you can put in the air. -Environmental standards=maximum level that's allowed -Compliance=process that ensure that permit is met -Monitoring=making sure that you are doing it.

Poverty

Economic factors are, perhaps, the most important ones influencing the health status of an individual or group. -Socioeconomic status (S E S): a composite measure of income, education, and occupation -Poverty threshold: the standard of living below which a family lacks the goods and services commonly taken for granted by mainstream society -Poverty guidelines: determining who is eligible for federal programs aimed at aiding those living in poverty* Effects of Poverty: Poverty directly affects health and well-being. Persons living in poverty and near-poverty have higher rates of chronic illness, higher infant mortality and morbidity rates, shorter life expectancy, more complex health problems, and more complications and physical limitations caused by chronic disease. Hospitalization rates for poor persons are three times those for persons with higher incomes. Poor health outcomes are related to decreased access to care. Access issues can be related to inability to pay for health care, lack of insurance or being underinsured, geographical location, language, maldistribution of providers, transportation challenges, inconvenient hours of service, and negativity or discrimination by health care providers to the poor clients. Access is especially difficult for the working poor.

Environmental Factors

Environment: conditions external to the host and agent associated with the transmission of the agent Reservoir: where the agent resides Human Animal Water, food, air, or soil Environmental Factors: The environment refers to all that is external to the human host, including physical, biological, social, and cultural factors that facilitate the transmission of an infectious agent from an infected host to other susceptible hosts. Think of the enviro factors listed in EPI lecture,,, Physical- geology, climate, habitat Biological - human population, Flora, Fauna ( things like mosquitos, sources of food, vectors) Socioeconomic- occupation, urbanization ( crowding, tension) Disasters also facilitate the spread of diseases.

Environmental Health: Older Adults

Environmental= -Vision loss -Hearing loss -Respiratory disease -Skin fragility -Decreased metabolic rate -Osteoporosis -Longevity=higher burden of absorbed chemicals in their system=Bioaccumulation Weather= -Heat waves -Cold conditions -Space heaters run on kerosene=fire hazard -Fires -Housing codes enforced

Environmental Risks

Examples of environmental toxins can include: -Toxins: lead, pesticides, mercury, air pollution, solvents, asbestos, radon -Air pollution: carbon monoxide, particulate matter, ozone, lead, aerosols, nitrogen dioxide, sulfur dioxide, tobacco smoke -Water pollution: waste, erosion after mining or timbering, run-off from chemicals added to the soil

Testing for HIV

HIV Test Counseling: -Assess risk -Discuss risk behaviors and how to avoid engaging in them -Develop with the client a risk-reduction plan -Establish the follow-up appointment and posttest counseling Posttest Counseling: -Negative: counsel on risk-reduction activities; make sure client understands test may not be truly negative (6-12 weeks before evidence of HIV antibody) -Positive: counsel about the need for reducing his or her risks and notifying past partners HIV is a blood borne pathogen.

Human Papillomavirus Infection

HPV genital warts -Mouth, genitals, and anus Transmission -Direct contact with HPV-associated warts FDA-licensed vaccines -Bivalent -Quadrivalent Complications -Link to cervical cancer -Other cancers: vaginal, anal, and oropharyngeal There are more than 40 HPV types that can infect the genital areas of males and females. These HPV types can also infect the mouth and throat. Most people who become infected with HPV do not even know they have it.

Chapter 7: Health Disparities and Vulnerable Populations

Health and health care disparities refer to differences in health and health care between population groups. Disparities occur across many dimensions, including race/ethnicity, socioeconomic status, age, location, gender, disability status, and sexual orientation. Health disparity exists when "...a health outcome is seen to a greater or lesser extent between populations."** from HP 2020 Health care in the United States --The most costly --Poorer outcomes than other industrialized countries Health Outcomes are worse for: --Lower income individuals/families. --Racial and ethnic minorities. --Those lacking health insurance. --Health disparities are inequality in some aspect of health. Lack of access to health care -Results in negative impact on health outcomes -Insurance too expensive -Even with insurance care, it remains too expensive - Limitation in primary care -Large deductibles Results -Episodic visits -Use of ED for health care

Health and Social Gradients

Health gradient: -A series of progressively increasing or decreasing differences between populations -Reflects the relationship between health and income at the population level with health gradually improving as income improves Social gradient: -"...a gradient in health that runs from top to bottom of the socioeconomic spectrum....The social gradient in health means that health inequities affect everyone."*

Waterborne disease outbreaks and pathogens

Hepatitis A Bacillary dysentery Cholera Typhoid fever Water-borne pathogens usually enter water supplies through animal or human fecal contamination and frequently cause enteric disease. They include viruses, bacteria and protozoans. Hepatitis A is the most widely publicized water-borne agent. The most important water-borne bacterial diseases are cholera, typhoid fever, and bacillary dysentery. Protozoa are especially problematic for municipal water because they do not respond to traditional chlorine treatment as do enteric and coliform bacteria.

Genital Herpes

Herpes simplex viruses 1 and 2 -Majority of cases caused by HSV-2 -Increasing number of cases caused by HSV-1 No cure Transmission -Direct exposure; infects genitalia and skin HSV-2 occurrence -16.2% of American adolescents -Of particular concern to women and children -Linked with development of cervical cancer -Increased risk of fatal newborn infection

Healthy People 2020 Objectives for Environmental Health

Humans interact with the environment -This affects the quality of health Healthy People focuses on six environmental objectives -Outdoor air -Surface and groundwater -Toxins and hazardous wastes -Homes and communities -Infrastructure and surveillance -Global environment

Migrant workers, immigrants, refugees, and asylees

Immigrants-Legally immigrated from one country to another Refugee-Outside home country and unable or unwilling to return due to persecution Asylee-Unable or unwilling to return to country of nationality because of persecution Migrant-Move from place to place following seasonal agricultural jobs Risk factors for poorer health outcomes: -Substandard housing -Crowded living quarters -Poor nutrition -Exposure to pesticides -Lack of access to health care Interventions and Policy for Migrant Workers: -The U.S. Immigration and Nationality Act (I N A) protects immigrant and migrant workers from discrimination. Refugees and Impact on Health: -Globally, refugees experience: -food insecurity, poor sanitation, exposure to multiple communicable diseases, violence, and mental health issues with limited medical care. -Many live in refugee camps, some for several years, with a major impact on their health.* -Those living in refugee camps are at greater risk for a number of health issues.* -Children in refugee camps are at increased risk for stunted growth due to chronic malnutrition.

Agent Factors

Infectivity of the agent: capacity of an agent to enter and multiply in the host Pathogenicity: capacity of the agent to cause disease in the human host Toxigenicity: ability to release toxins that contribute to disease within the human host Virulence: ability to cause disease Antigenicity: ability to produce antibodies in the human host

LTBI vs. Pulmonary TB Disease

Latent TB Infection TST positive Negative chest radiograph No symptoms or physical findings suggestive of TB disease Pulmonary TB Disease TST usually positive Chest radiograph may be abnormal Symptoms may include one or more of the following: fever, cough, night sweats, weight loss, fatigue, hemoptysis, decreased appetite Respiratory specimens may be smear or culture positive

Lead

Lead-based paint and lead contaminated dust are the most hazardous sources of lead for U.S. children. Lead-based paints were banned for use in housing in 1978. All houses built before 1978 are likely to contain some lead-based paint. However, it is the deterioration of this paint that causes a problem. Approximately 24 million housing units have deteriorated leaded paint and elevated levels of lead-contaminated house dust. More than 4 million of these dwellings are homes to one or more young children. Children under the age of 6 years old are at risk because they are growing so rapidly and because they tend to put their hands or other objects, which may be contaminated with lead dust, into their mouths. Children living at or below the poverty line who live in older housing are at greatest risk. Additionally, children of some racial and ethnic groups and those living in older housing are disproportionately affected by lead. It is important to determine the construction year of the house or the dwelling where your child spends a large amount of time (e.g., grandparents or daycare). In housing built before 1978, assume that the paint has lead unless tests show otherwise. Talk to your state or local health department about testing paint and dust from your home for lead. Make sure your child does not have access to peeling paint or chewable surfaces painted with lead-based paint. Children and pregnant women should not be present in housing built before 1978 that is undergoing renovation. They should not participate in activities that disturb old paint or in cleaning up paint debris after work is completed. Create barriers between living/play areas and lead sources. Until environmental clean-up is completed, you should clean and isolate all sources of lead. Close and lock doors to keep children away from chipping or peeling paint on walls. You can also apply temporary barriers such as contact paper or duct tape, to cover holes in walls or to block children's access to other sources of lead. Regularly wash children's hands and toys. Hands and toys can become contaminated from household dust or exterior soil. Both are known lead sources. Regularly wet-mop floors and wet-wipe window components. Because household dust is a major source of lead, you should wet-mop floors and wet-wipe horizontal surfaces every 2-3 weeks. Windowsills and wells can contain high levels of leaded dust. They should be kept clean. If feasible, windows should be shut to prevent abrasion of painted surfaces or opened from the top sash. Take off shoes when entering the house to prevent bringing lead-contaminated soil in from outside. Prevent children from playing in bare soil; if possible, provide them with sandboxes. Plant grass on areas of bare soil or cover the soil with grass seed, mulch, or wood chips, if possible. Until the bare soil is covered, move play areas away from bare soil and away from the sides of the house. If you have a sandbox, cover the box when not in use to prevent cats from using it as a litter box. That will help protect children from exposure to animal waste.

Communicable Disease at the Global Level

Malaria is a global health problem -Spread by the bite of an infected mosquito -Subtropical areas -Affects greater than one half of world's population HIV/AIDS -Can go 15 years after exposure before developing AIDS -20% are unaware they are infected

Hepatitis C Virus

Most common chronic bloodborne infection in United States Transmission ---Blood or body fluids of an infected person enter an uninfected person High-risk groups: • Health care workers and emergency personnel who are accidentally exposed • Infants who are born to infected mothers • Injection drug users, particularly those who share needles or other drug use equipment • Those born between 1945 and 1965 The treatment for hepatitis C virus (HCV) infection has evolved substantially since the introduction of highly effective HCV protease inhibitor therapies in 2011. Since that time new drugs with different mechanisms of action have become and continue to become available. Currently available therapies can achieve sustained virologic response (SVR) defined as the absence of detectable virus 12 weeks after completion of treatment; an SVR is indicative of a cure of HCV infection. Over 90% of HCV infected persons can be cured of HCV infection regardless of HCV genotype, with 8-12 weeks of oral therapy (20). For a complete list of currently approved FDA therapies to treat hepatitis C

Hepatitis A

Most common transmission -Fecal-oral, Shellfish from contaminated water, poor sanitation, contaminated food handlers, oral-anal sexual activity -Found worldwide Vaccine available since 1995 -Incidence has declined 92% -Makes HAV completely preventable High-risk groups: • Travelers to countries with high rates of the disease • Children living in areas with high rates of HAV infection • Injection drug users • MSM • Persons with clotting disorders or chronic liver disease Can survive on hands. Prevention- improved sanitation, immunization, early treatment with gamma globulin

Applying the Nursing Process to Environmental Health

Note the environmental aspects of the problem in every step of the proces= Assessment: Use your observational skills (e.g., windshield surveys); interview community members; ask your individual clients; and ask the families of your clients. Review Web-based data on existing exposures, such as air and water pollution monitoring data, drinking water testing, and contaminated soil. Relate the disease and the environmental factors in the diagnosis. Planning: Look at community policy and laws as methods to facilitate the care needs for the client; include environmental health personnel in planning. Intervention: Coordinate medical, nursing, and public health actions to meet the client's needs. Ensure that the affected person or family is referred for appropriate clinical care. Evaluation: Examine criteria that include the immediate and long-term responses of the client as well as the recidivism of the problem for the client

Policy and Advocacy

Nurses can guide and drive policy. -1 in every 100 Americans is a registered nurse! -Nurses have a responsibility to be informed and take action in the best interest of public. -Nurses can serve as resources for state and federal legislators and staff. -Nurses also work as advocates for environmental justice and rights of others. 2008—Alliance of Nurses for Healthy Environments -Created to coalesce nurses and nursing organizations around relevant issues

Groups That Should Be Tested for LTBI

Persons at higher risk for exposure to or infection with TB •Close contacts of a person known or suspected to have TB •Foreign-born persons from areas where TB is common •Residents and employees of high-risk congregate settings •Health care workers (HCWs) who serve high-risk clients •Medically underserved, low-income populations •High-risk racial or ethnic minority populations •Children exposed to adults in high-risk categories •Persons who inject illicit drugs Persons at higher risk for TB disease once infected •Persons with HIV infection •Persons recently infected with M. tuberculosis •Persons with certain medical conditions •Persons who inject illicit drugs Persons with a history of inadequately treated TB

PrEP

Pre-exposure prophylaxis (or PrEP) is when people at very high risk for HIV take HIV medicines daily to lower their chances of getting infected. A combination of two HIV medicines (tenofovir and emtricitabine), sold under the name Truvada® is approved for daily use as PrEP to help prevent an HIV-negative person from getting HIV from a sexual or injection-drug-using partner who's positive. Studies have shown that PrEP reduces the risk of getting HIV from sex by more than 90% when used consistently. Among people who inject drugs, PrEP reduces the risk of getting HIV by more than 70% when used consistently. No. PrEP does not work the same way as a vaccine. A vaccine teaches your body to fight off infection for several years. For PrEP, you take a pill every day by mouth. The pill that was shown to be safe and to help block HIV infection is called "Truvada" (pronounced tru vá duh). Truvada is a combination of two drugs (tenofovir and emtricitabine). If you take PrEP daily, the presence of the medicine in your bloodstream can often stop HIV from taking hold and spreading in your body. If you do not take PrEP every day, there may not be enough medicine in your bloodstream to block the virus

Environmental Health Assessments

Risks can be categorized as follows: -Medium: air, water, soil, or food -Type: chemical, biological, or radiological -Setting: urban, rural, or suburban Point source- fixed thing putting out population ex. Factory, business Non-point source- truck. Moves and doesn't stay in one place.

Nurse's Role in Providing Preventive Care for Communicable Diseases cont.

Primary prevention •Assessment: client's risk level, sexual history, partner notification •Interventions: client education and other actions aimed at prevention •Sexual behavior: abstinence, condom use, female condoms •Drug use: IV drug use, danger of using shared needles and syringes •Community outreach: to reach those who do not seek care on their own •Community education: spreading information about modes of transmission, testing, vaccine availability, early symptoms •Evaluation: to determine whether adequate vaccination occurs, whether risky behavior changes to safe behavior, whether illness is prevented Secondary prevention—screening for disease to ensure early identification, treatment, and follow-up with contacts Tertiary prevention—managing symptoms, maintaining psychosocial support •Directly observed therapy (DOT) programs for TB medication—nurses observe and document individual clients taking their TB drugs Standard precautions •Client and family education about infection control in the home •Dispelling myths and fears about transmission of HIV

Community Environmental Health Assessment

Protocol for Assessing Community Excellence in Environmental Health (PACE EH) -Collaborative, Community-based approach -Expands capacity of health agencies -Engages the community -Generates an action plan based on priorities -Outlines tasks -Identify local environmental health issues -Set priorities for action -Target populations most at risk -Address identified issues

Environmental Health-Psychosocial Factors

Real or perceived threats -Live in fear -Experience stress, panic, and anxiety -Affect health, safety, and well-being Mixed exposure -Usually more than one threat -Interaction and a subsequent increase in hazard can occur when different agents are combined. -Example: noise in the presence of some chemicals may result in what is called ototoxicity, or damage to the inner ear, that results from exposure to pharmaceuticals, chemicals, and/or ionizing radiation*

Healthy People 2020/2030 goals for HIV/AIDS

Reduce the number of people who become infected with HIV Increase access to care and improve health outcomes for people living with HIV Reduce HIV-related health disparities

Planning and Implementing Care for Vulnerable Populations

Roles of the Nurse: Nursing roles when working with vulnerable populations include case finder, health teacher, counselor, direct care provider, monitor and evaluator of care, case manager, advocate, health program planner, and participant in developing health policies. Specific principles of intervening apply in working with vulnerable populations. Nurses empower clients by helping them acquire the skills needed for healthy living and for being an effective health care consumer. Health education is one key to working with vulnerable populations. Empowerment is fostered by providing culturally and linguistically appropriate health-promoting strategies. In general, more agencies are needed that provide comprehensive services with non-restrictive eligibility requirements. Agencies are frequently specialized, forcing vulnerable populations to go to many agencies to find the services they need. Resources: Nurses should know about community agencies that offer health and social services for vulnerable populations. Nurses should also follow up with the client after a referral to such agencies to ensure that the desired outcome was achieved. Evaluation of therapeutic nursing interventions begins with client goals and objectives and focuses on the extent to which client outcomes are achieved. Evaluation takes place while providing care and gives the nurse a basis for revising therapeutic interventions to make them more effective. Evaluation also takes place when a case is closed or when a program is completed, and then it gives the nurse data to use in providing care to similar clients or programs in the future.

Right to Know

Several environmental statutes give the public the right to know about the hazardous chemicals in the environment. -Health professionals and community members can easily access key information by zip code regarding major sources of pollution that are being emitted into the air or water in their community. Consumer Confidence Reports=When a water supplier provides drinking water to a community, the supplier, in contrast to individual wells, must test the water and report the results to its customers in the form. Nurses should review the consumer confidence reports, sometimes referred to as right to know reports, to determine what pollutants have been found in the drinking water. Hazard Communication Standard: this standard requires employers (including hospitals) to maintain a list of all of the hazardous chemicals that are used on-site. -Material safety data sheet (MSDS).

Vulnerable Populations

Social determinants contribute to risk levels. -Economic factors: lower-income clients are at increased risk for health problems -Live in substandard housing -Live in close proximity to pollution sources -Employed in more dangerous occupations -Have less access to healthy food options -Life cycle factors -Very young and very old are more vulnerable -EPA report: "Growing Smarter/Living Healthier: A Guide to Smart Growth and Active Aging"

Solutions to Health Disparities should focus on:

Social determinants. Collaboration and promotion of community engagement. Promoting sustainable and effective partnerships. Media outreach and communication of research findings.

Hepatitis B Virus

Spread through blood and body fluids Remains alive outside body -For at least 1 week High-risk groups: •Users of injection drugs; persons with STDs or multiple sex partners; immigrants/refugees and their descendants who came from areas with a high endemic rate of HBV; health care workers; clients on hemodialysis; inmates of long-term correctional institutions. The acute infection is self-limited: individuals develop an antibody to the virus and successfully eliminate the virus from the body. They subsequently have lifelong immunity against the virus. Chronically infected individuals are unable to rid their bodies of the virus and remain lifelong carriers of the hepatitis B surface antigen (HBsAg). As carriers, they can transmit HBV to others. They may develop hepatic carcinoma or chronic active hepatitis. OSHA regulations •Mandates specific activities to protect workers from HBV and other bloodborne pathogens •Requires employers to identify the risk of blood exposure to various employees •If employees perform work that involves a potential exposure to others' body fluids, employers are mandated to offer the HBV vaccine to employee at the employer's expense and to offer annual educational programs on preventing HBV and HIV exposure in the workplace. Employees have the right to refuse the vaccine.

Stages of Homelessness

The concept of homelessness has two broad categories: crisis poverty and persistent poverty. Persons in crisis poverty often have lives marked by hardship and struggle, resulting in transient or episodic homelessness. Persons in persistent poverty are chronically homeless men and women, many of whom have mental or physical disabilities and lack money and family support. These persons may have other severe co-morbidities, such as alcohol or drug abuse and chronic health and family problems. Today's homeless population includes people of every age, sex, ethnic group, and family type. Common Health Conditions of the Homeless: -Upper respiratory disorders -TB -Skin disorders and infestations -Alcoholism / drug abuse -HIV/AIDS -Mental Illness -Dental caries -Hypothermia and heat related illnesses -Malnutrition

Examples of Primary Prevention for Infectious Diseases

To prevent the occurrence of disease: •Responsible sexual behavior •Malaria chemoprophylaxis •Tetanus boosters, flu shots •Rabies preexposure immunization •Safe food-handling practices in the home •Repellants for preventing vector-borne disease •Following childhood immunizations recommendations, and "no shots, no school" laws •Regulated and inspected municipal water supplies •Bloodborne pathogen regulations •Restaurant inspections •Federal regulations protecting American cattle from exposure to bovine spongiform encephalopathy (BSE)

Prevention and Control

The cycle of transmission for a specific pathogen provides needed information on the type of intervention that could break the chain of infection. Interventions can be aimed at any point in the cycle of transmission. The goal of prevention and control programs is to reduce the prevalence of a disease to a level at which it no longer poses a major public health problem. In some cases, diseases may even be eliminated or eradicated. Role of nurses: •Caring for patients •Preventing transmission to coworkers, self, others • Immunizations • Communicable disease surveillance and control • Teach and monitor bloodborne pathogen control. • Advise on prevention of vectorborne diseases. • Teach methods for responsible sexual behavior and screen for STIs. • Screen for TB, identify TB contacts, and deliver directly observed TB treatment. •Personal Protective equipment, proper cleaning of equipment Improve host resistance to infectious agents and other environmental hazards Improved hygiene, nutrition, and physical fitness; increased immunization cover-age; provision of chemoprophylaxis and chemotherapy; stress control and improved mental health Improve safety of the environment Improved sanitation, provision of safe water and clean air; proper cooking and storage of food; control of vectors and animal reservoir hosts Improve public health systems Increased access to health care; adequate health education; improved surveillance systems Facilitate social and political changes to ensure better health for all people Individual, organizational, and community action; legislation

Vulnerability at the Population Level

The degree of vulnerability experienced by different populations is influenced by: -Social determinants of health including economic and environmental factors -Social capital -Health system determinants -Individual risk factors and population-level factors influence the vulnerability of at-risk groups

Mode of Transmission

The method through which the agent leaves its reservoir and enters its host Water, food, air, vectors, fomites, unprotected sexual contact, or penetrating trauma Vectors are usually insects that carry the disease from the reservoir to humans Fomite is an inanimate object Modes of transportation • Vertical transmission is the passing of the infection from parent to offspring via sperm, placenta, milk, or contact in the vaginal canal at birth. Mother to child ( transplacental, perinatal, post-partum ) • Horizontal transmission is the person-to-person spread of infection through one or more of the following four routes: direct/indirect contact, common vehicle, airborne, or vectorborne. Direct Contact- Skin, sexual, person to person Indirect Contact- Fomites, waterborne, airborne, aerosol, transfusions/injections Common vehicle/indirect refers to transportation of the infectious agent from an infected host to a susceptible host via food, water, milk, blood, serum, saliva or plasma. Vectors are arthropods, such as ticks and mosquitoes, or other invertebrates, such as snails, fleas, that transmit the infectious agent by biting or depositing the infective material near the host.

Examples of Secondary Prevention for Infectious Diseases

To prevent the spread of disease: ••Immunoglobulin after hepatitis A exposure ••Immunization and chemoprophylaxis as appropriate in meningococcal outbreak ••Rabies postexposure immunization ••Tuberculosis screening for health care workers ••Sexually transmitted disease (STD) partner notification ••Human immunodeficiency virus (HIV) testing and treatment ••Quarantine

Natural History of HIV

Three stages: -Primary infection (within about 1 month of contracting virus) -Incubation period/ clinical latency (when body shows no symptoms) --Use of highly active antiretroviral therapy (HAART) has greatly increased survival time of persons with HIV/AIDS -Symptomatic disease (CD4 counts 200-499 cells/mm3) AIDS -CD4 T-lymphocyte count less than 200 cells/mm3 with documented HIV infection -AIDS-related opportunistic infections Primary Infection: Flu like symptoms, mono like illness , fever malaise, rash, symptoms usually occur within 3 weeks of initial exposure, after which the person becomes asymptomatic Asymptomatic- can last years ( up to 10 years or longer)

Examples of Tertiary Prevention for Infectious Diseases

To reduce complications and disabilities through treatment and rehabilitation: ••Pneumocystis jiroveci (previously known as Pneumocystis carinii) pneumonia (PCP) chemoprophylaxis for people with AIDS ••Regular inspection of hands and feet as well as protective footwear and gloves to avoid trauma and infection for leprosy clients who have lost sensation in those areas

Tuberculosis (TB)

Transmission -Airborne droplets-Usually occurs through exposure to the tubercle bacilli in airborne droplets from persons with pulmonary tuberculosis who talk, cough, or sneeze Common symptoms -Cough, fever, fatigue, hemoptysis, chest pains, weight loss Epidemiology -WHO reports 12 million cases in 2012 and 1.3 million deaths due to TB (WHO, 2013) Drug-resistant TB -Multidrug-resistant TB (MDRTB) -Extremely drug-resistant TB (XDRTB) •Multidrug-resistant TB (MDRTB): resistant to rifampin and isoniazid •Extremely drug-resistant TB (XDRTB): MDRTB plus added resistance to fluoroquinolones and at least three injectable second-line drugs (e.g. amikacin, kanamycin, and capreomycin)

Transmission

Transmitted through exposure to blood, semen, transplanted organs, vaginal secretions, and breast milk -Those who have had blood, sexual, or needle-sharing exposure with an HIV-infected person are at risk for contracting the virus. IS NOT transmitted through casual contact (touching or hugging someone), or through mosquitoes or other insects

Nursing Approaches to Care in the Community

Trends Related to Caring for Vulnerable Populations: In the twenty-first century there is a renewed emphasis on caring for vulnerable population groups in the community through partnerships between groups such as public health, managed care, and community groups. •Wrap-around services: comprehensive health services are available and social and economic services are "wrapped around" these services •Comprehensive services: focus on more than one health problem or concern •Advocacy: actions taken on behalf of another •Social justice: includes egalitarianism and equality Comprehensive health services are health services that focus on more than one health problem or concern; are typically provided in community health centers and nurse-managed clinics and are thought of as safety net providers, increasing access to health and social services for vulnerable populations. A related trend is to develop culturally and linguistically appropriate forms of outreach and care delivery to more effectively promote the health of specific populations. Linguistically appropriate health care means communicating health-related assessment and information in the recipient's primary language when possible and always in a language the recipient can understand. There is a trend toward providing more comprehensive, family-centered services when treating vulnerable populations using concepts such as one-stop services, wrap-around services, mobile outreach clinics, and safety net providers. Nurses in the community focus on advocacy (set of actions one takes on behalf of another) and social justice (providing equitable care and social supports for the most disadvantaged members of society) concerns.

Syphilis

Treponemal spirochetes -Infect moist mucous/cutaneous membranes Direct contact -Sexual contact or mother-to-fetus -Blood transfusion (early-stage donor) Highest rates -Men having sex with men (MSM); recently, number of infected women has increased Clinical signs -Primary, secondary, tertiary Congenital syphilis is transmitted trans placentally and, if untreated, can cause premature stillbirth, blindness, deafness, facial abnormalities, crippling, or death. Syphilis is caused by the spirochete Treponema pallidum. The incidence of syphilis has been declining. 1. The clinical signs of syphilis are divided into early and late stages. Latency, a period when there are no clinical signs of infection, may occur during the early and late stages, but the client has historical or serological evidence of infection.

TB: Diagnosis and Treatment

Tuberculin skin test (TST) Previously, purified protein derivative (PPD) test Used for initial screening Followed by chest x-ray for persons with positive skin reaction and pulmonary symptoms Prompt treatment with multiple antimicrobial drugs Treatment failure may be due to lack of client adherence, which can result in drug resistance. U.S. drug regimens include isoniazid and sometimes rifampin.

Individual Environmental Exposure History

Use of the "I PREPARE" mnemonic device I—Investigate Potential Exposures Have you ever felt sick after coming in contact with a chemical, such as a pesticide or other substances? Do you have any symptoms that improve when you are away from your home or work? P—Present Work Are you exposed to solvents, dusts, fumes, radiation, loud noise, pesticides, other chemicals? Do you know where to find material safety data sheets for chemicals with which you work? Do you wear PPE? Are work clothes worn home? Do coworkers have similar health problems? R—Residence When was your residence built? What type of heating do you have? Have you recently remodeled your home? What chemicals are stored on your property? Where is the source of your drinking water? E—Environmental Concerns Are there environmental concerns in your neighborhood (e.g., air, water, soil)? What types of industries or farms are near your home? Do you live near a hazardous waste site or landfill? P—Past Work What are your past work experiences? What job did you have for the longest period of time? Have you ever been in the military, worked on a farm, or done volunteer or seasonal work? A—Activities What activities and hobbies do you and your family pursue? Do you burn, solder, or melt any products? Do you garden, fish, or hunt? Do you eat what you catch or grow? Do you use pesticides? Do you engage in any alternative healing or cultural practices? R—Referrals and Resources Environmental Protection Agency (www.epa.gov), National Library of Medicine—Toxnet Programs (www.nlm.nih.gov), Agency for Toxic Substances and Disease Registry (www.atsdr.cdc.gov), Association of Occupational and Environmental Clinics (www.aoec.org). Occupational Safety and Health Administration (www.osha.gov), EnviRN website (www.enviRN.umaryland.edu), Local Health Department, Environmental Agency, Poison Control Center E—Educate (a checklist) Are materials available to educate the client? Are alternatives available to minimize the risk of exposure? Have prevention strategies been discussed? What is the plan for follow-up?

Vulnerability and Vulnerable Populations

Vulnerability: -the degree to which an individual, population or organization is unable to anticipate, cope with, resist and recover from the impact of disease and disasters* Vulnerable populations: -based on race, ethnicity, age, gender, sexual orientation, history of incarceration, socioeconomic status, exposure to violence and war, and lack of a permanent residence*

Climate Change

WHO: "Climate change is a significant and emerging threat to public health, and changes the way we must look at protecting vulnerable populations." Nurses' main roles -Mitigation: working at individual, community, institutional, and governmental level to ensure energy-conserving policies and practices -Response: public health nurses must be prepared for increased fire- and storm-related disasters

Factors Associated with Risk for STDs

Younger than 25 years Member of minority group Residing in an urban setting Being impoverished Using crack cocaine Common STDs: Gonorrhea Syphilis Chlamydia Hepatitis B Genital herpes HPV Bacterial: usually treatable with antibiotic; however antibiotic-resistant strains of gonorrhea are emerging (e.g., gonorrhea, syphilis, Chlamydia) Viral: cannot be cured (e.g., herpes simplex virus 2; human papillomavirus infection [genital herpes]) ***especially know which ones are viral.

Health Equity

attainment of the highest level of health for all people -Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities. (Healthy People 2020) Health Equity Versus Equality-When all people have "the opportunity to 'attain their full health potential' and no one is 'disadvantaged from achieving this potential because of their social position or other socially determined circumstance'".

U.S. Incarcerated Population

persons living under the jurisdiction of state or federal prisons, and in the custody of local jails -Correctional population: includes the incarcerated population as well as persons living in the community while supervised on probation or parole -The United States has 5% of the world's population and 25% of its prisoners.* uA history of incarceration leads to limited opportunities for: -employment -education -housing -a stable family life -This, in turn, has significant impact on health.** The health needs of the incarcerated reflect a vulnerable population: -Poverty -Limited access to health care, low education levels, substance use, mental health issues, and communicable diseases such as hepatitis and H I V -The stresses of prison life, poor diet, and frequently less-than-adequate medical care exacerbate noncommunicable conditions such as diabetes and hypertension

How do we reduce or prevent ACES?

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Adverse Childhood Experiences (ACES)

stressful or traumatic events, including abuse and neglect.

Disease development

• Exposure to an infectious agent does not always lead to an infection and vice-versa. • Infection refers to the entry, development, and multiplication of the infectious agent in the susceptible host. • Disease is one of the possible outcomes of infection and it may indicate a physiological dysfunction or pathological reaction. • Incubation period is the time interval between invasion by an infectious agent and the first appearance of signs and symptoms of the disease. • Communicable period is the interval during which an infectious agent may be transferred directly or indirectly from an infected person to another person.

Transmission of Communicable Diseases Disease Spectrum-

•Endemic refers to the constant presence of a disease within a geographic area or a population. • Epidemic refers to the occurrence of disease in a community or region in excess of normal expectancy. • Pandemic refers to an epidemic occurring worldwide and affecting large populations.

Basic Principles of Treatment for TB disease

•Provide safest, most effective therapy in shortest time •Multiple drugs to which the organisms are susceptible •Never add single drug to failing regimen •Ensure adherence to therapy Adherence •Nonadherence is a major problem in TB control •Use case management and directly observed therapy (DOT) to ensure patients complete treatment