POST GRADUATE DIPLOMA IN

WATER, HYGIENE

AND SANITATION

MODULE 2

COMMUNICABLE DISEASES
 Table of Contents

Introduction to Communicable Diseases……………………………………………………...Pg. 3

Prevention and Control of Communicable Diseases and Community Diagnosis……………Pg.21

Bacterial Vaccine-Preventable Diseases……………………………………..........................Pg. 39

Viral Vaccine-Preventable Diseases………………………………………………………….Pg.55

Malaria Epidemiology and Transmission………………………………………….…………Pg.70

Assignments ………………………………………………………………………………….Pg.86
 Executive Summary

Access to water and sanitation is one of the major challenges for the 21st century. According to
WHO (2004), 1.1 billion people across the world do not have access to safe water and 2.4 billion
people do not have access to basic sanitation facilities. As a consequence every year around 4
million people, the majority of who are children, die from water and sanitation related diseases.
Water is not only important for public health, but also for general livelihoods: crop production
(70 to 80% of all water used is for crop production), livestock production, industry, commerce
and daily life depend on access to water. Water-supply conditions therefore affect health, hunger,
and poverty and community development.

This disastrous access to water and sanitation is due partly to a lack of infrastructure but also to
poor management that creates waste, contamination and degradation of the environment. Water
shortages may lead to tensions between individuals, communities or countries, which can evolve
into conflicts. At the same time, the demand for water is increasing due to population growth,
urbanization (rural exodus) and industrialization. Urbanization has also created extremely poor
sanitary conditions.

Most of these problems can be solved through comprehensive management of water resources
and demand. Water is a finite resource that must be managed with a global vision that works at
three levels: international to define rules to protect water resources and to avoid international
conflicts; national to apply defined rules and to define national water-access policies; and local

to develop local initiatives to ensure communities’ water access.

The Post graduate Diploma in WASH which is a eight module course which starts with
introduction of the basic concepts in WASH, Then taking the students to other topics like Water
Supply, Communicable Diseases, Sanitation and Waste Management and finally embarking the
final two modules on urban Wash since currently more than half of world population live in
urban area, and it’s in urban areas where the problem of poor sanitation and waste management
is severely felt.
 Chapter 1

Communicable Diseases

Introduction

Diseases may be classified as communicable or non-communicable. Communicable diseases are

caused by infectious agents that can be transmitted to other people from an infected person,

animal or a source in the environment. Communicable diseases constitute the leading cause of

health problems in Developing countries.

Before we describe each communicable disease relevant to Africa in detail in later chapters, it is

important that you first learn about the basic concepts underlying communicable diseases.

Understanding these basic concepts will help you a lot, as they form the basis for this Module.

In this module, we introduce you to definitions of important terms used in communicable

diseases, the types of infectious agents that cause these diseases, the main factors involved in

their transmission, and the stages in their natural development. This will help you to understand

how measures for the prevention and control of communicable diseases are put into place at

several levels of the health system, including in homes and at your community.

What are communicable diseases?

As described in the introduction, the organisms that cause communicable diseases are called

infectious agents, and their transmission to new uninfected people is what causes communicable

diseases; (note that infectious diseases is an interchangeable term). Familiar examples of

communicable diseases are malaria and tuberculosis. Diseases such as heart disease, cancer and
diabetes mellitus, which are not caused by infectious agents and are not transmitted between

people, are called non-communicable diseases.

The burden of communicable diseases in a case of Ethiopia

Communicable diseases are the main cause of health problems in Ethiopia. According to the

Ethiopian Federal Ministry of Health, communicable diseases accounted for most of the top ten

causes of illness and death in 2008.

Nb. Please not the following:

Outpatient refers to someone who comes to a health facility seeking treatment, but does not stay

overnight. An inpatient is someone admitted to a health facility, who has at least one overnight

stay; and A clinical diagnosis is based on the typical signs and symptoms of the disease, without

confirmation from diagnostic tests, e.g. in a laboratory

Endemic and epidemic diseases

Not all communicable diseases affect a particular group of people, such as a local community, a

region, a country or indeed the whole world, in the same way over a period of time. Some

communicable diseases persist in a community at a relatively constant level for a very long time

and the number of individuals affected remains approximately the same. These communicable

diseases are known as endemic to that particular group of people; for example, tuberculosis is

endemic in the population of Ethiopia and many other African countries.

By contrast, the numbers affected by some communicable diseases can undergo a sudden

increase over a few days or weeks, or the rise may continue for months or years. When a

communicable disease affects a community in this way, it is referred to as an epidemic. Malaria

is endemic in some areas of Ethiopia, and it also occurs as epidemics due to an increase in the

number of cases suddenly at the beginning or end of the wet season.

Prevention and control measures

The health problems due to communicable diseases can be tackled by the application of

relatively easy measures at different levels of the health system. Here, we will use some

examples at the individual and community levels, which are relevant to your work as a Health

Extension Practitioner.

Some measures can be applied before the occurrence of a communicable disease to protect a

community from getting it, and to reduce the number of cases locally in the future. These are

called prevention measures. For example, vaccination of children with the measles vaccine is a

prevention measure, because the vaccine will protect children from getting measles. Vaccination

refers to administration of vaccines to increase resistance of a person against infectious diseases.

Once a communicable disease occurs and is identified in an individual, measures can be applied

to reduce the severity of the disease in that person, and to prevent transmission of the infectious

agent to other members of the community. These are called control measures. For example, once

a child becomes infected with measles, treatment helps reduce the severity of the disease, and

possibly prevents the child’s death, but at the same time it decreases the risk of transmission to
other children in the community. In this context, treatment of measles is considered a control

measure

Factors involved in the transmission of communicable diseases

Transmission is a process in which several events happen one after the other in the form of a

chain. Hence, this process is known as a chain of transmission (Figure 1.1). Six major factors can

be identified: the infectious agent, the reservoir, the route of exit, the mode of transmission, the

route of entry and the susceptible host. We will now consider each of these factors in turn.

Infectious agents

Scientific names
Tables 1.1 and 1.2 referred to Plasmodium falciparum as an infectious agent causing malaria.

This is an example of how infectious agents are named scientifically, using a combination of two

words, the ‘genus’ and the ‘species’ names. The genus name is written with its initial letter

capitalised, followed by the species name which is not capitalised. In the example above,

Plasmodium is the genus name and falciparum refers to one of the species of this genus found in

Ethiopia. There are other species in this genus, which also cause malaria, e.g. Plasmodium vivax.

Sizes and types of infectious agents

Infectious agents can have varying sizes. Some, such as Plasmodium falciparum and all bacteria

and viruses, are tiny and are called micro-organisms, because they can only be seen with the aid

of microscopes. Others, such as the ascaris worm (Ascaris lumbricoides), can be easily seen with

the naked eye. The different types of infectious agents are illustrated in Table 1.3 according to

their size, starting with the largest and ending with the smallest, and are then discussed below
Table 1.3 Different types of infectious agents: their number of cells, visibility and examples

Helminths are worms made up of many cells; for example, Ascaris lumbricoides.

Protozoa are micro-organisms made up of one cell; for example, Plasmodium falciparum.

Bacteria are also micro-organisms made up of one cell, but they are much smaller than protozoa

and have a different structure; for example Vibrio cholerae, which causes cholera.

Viruses are infectious agents that do not have the structure of a cell. They are more like tiny

boxes or particles and are much smaller than bacteria; for example, HIV (the Human

Immunodeficiency Virus), which can lead to AIDS.

Though not as common as causes of communicable disease in humans, other types of infectious

agents include fungi (e.g. ringworm is caused by a fungus infection), and mites (similar to

insects), which cause scabies.

Reservoirs of infectious agents

Many infectious agents can survive in different organisms, or on non-living objects, or in the

environment. Some can only persist and multiply inside human beings, whereas others can

survive in other animals, or for example in soil or water. The place where the infectious agent is

normally present before infecting a new human is called a reservoir. Without reservoirs,

infectious agents could not survive and hence could not be transmitted to other people. Humans

and animals which serve as reservoirs for infectious agents are known as infected hosts. Two

examples are people infected with HIV and with the bacteria that cause tuberculosis; these

infectious agents persist and multiply in the infected hosts and can be directly transmitted to new

hosts.

Animals can also be reservoirs for the infectious agents of some communicable diseases. For

example, dogs are a reservoir for the virus that causes rabies (Figure 1.3). Diseases such as

rabies, where the infectious agents can be transmitted from animal hosts to susceptible humans,

are called zoonoses (singular, zoonosis).

Non-living things like water, food and soil can also be reservoirs for infectious agents, but they

are called vehicles (not infected hosts) because they are not alive. You will learn more about

them later in this study session.

Bacteria called Mycobacterium bovis can be transmitted from cattle to humans in raw milk and

cause a type of tuberculosis. In this example, what is the infectious agent and the infected host or

hosts?

The infectious agent is Mycobacterium bovis and the infected hosts are cattle and humans.

Route of exit

Before an infectious agent can be transmitted to other people, it must first get out of the infected

host. The site on the infected host through which the infectious agent gets out is called the route

of exit. Some common examples are described below.

Respiratory tract
The routes of exit from the respiratory tract are the nose and the mouth. Some infectious agents

get out of the infected host in droplets expelled during coughing, sneezing, spitting or talking,

and then get transmitted to others (Figure 1.4). For example, people with tuberculosis in their

lungs usually have a persistent cough; Mycobacterium tuberculosis uses this as its route of exit

Gastrointestinal tract

The anus is the route of exit from the gastrointestinal tract (or gut). Some infectious agents leave

the human body in the stool or faeces (Figure 1.5). For example, the infectious agents of

shigellosis, a disease which can cause bloody diarrhoea, use this route of exit.
Skin

Some types of infectious agents can exit the body through breaks in the skin. For example, this

route of exit is used by Plasmodium protozoa, which are present in the blood and get out of the

human body when a mosquito bites through the skin to suck blood.

Modes of transmission

Once an infectious agent leaves a reservoir, it must get transmitted to a new host if it is to

multiply and cause disease. The route by which an infectious agent is transmitted from a

reservoir to another host is called the mode of transmission. It is important for you to identify

different modes of transmission, because prevention and control measures differ depending on

the type. Various direct and indirect modes of transmission are summarised in Table 1.3 and

discussed below it
Direct modes of transmission

Direct transmission refers to the transfer of an infectious agent from an infected host to a new

host, without the need for intermediates such as air, food, water or other animals. Direct modes

of transmission can occur in two main ways:

Person to person: The infectious agent is spread by direct contact between people through

touching, biting, kissing, sexual intercourse or direct projection of respiratory droplets into

another person’s nose or mouth during coughing, sneezing or talking. A familiar example is the

transmission of HIV from an infected person to others through sexual intercourse.

Transplacental transmission: This refers to the transmission of an infectious agent from a

pregnant woman to her fetus through the placenta. An example is mother-to-child transmission

(MTCT) of HIV.

Indirect modes of transmission

Indirect transmission is when infectious agents are transmitted to new hosts through

intermediates such as air, food, water, objects or substances in the environment, or other animals.

Indirect transmission has three subtypes:

. Airborne transmission: The infectious agent may be transmitted in dried secretions from

the respiratory tract, which can remain suspended in the air for some time. For example, the

infectious agent causing tuberculosis can enter a new host through airborne transmission.

. Vehicle-borne transmission: A vehicle is any non-living substance or object that can be

contaminated by an infectious agent, which then transmits it to a new host. Contamination refers

to the presence of an infectious agent in or on the vehicle.

. Vector-borne transmission: A vector is an organism, usually an arthropod, which

transmits an infectious agent to a new host. Arthropods which act as vectors include houseflies,

mosquitoes, lice and ticks.

Route of entry

Successful transmission of the infectious agent requires it to enter the host through a specific part

of the body before it can cause disease. The site through which an infectious agent enters the host

is called the route of entry.

We have already mentioned all the routes of entry in previous sections. Can you summarise what

they are, and give an example of an infectious agent for each of them?

The routes of entry are:

. The respiratory tract: some infectious agents enter the body in air breathed into the lungs.

Example: Mycobacterium tuberculosis.

. The gastrointestinal tract: some infectious agents enter through the mouth. Example: the

infectious agents causing diarrhoeal diseases enter through the mouth in contaminated food,

water or on unclean hands (Figure 1.6).

. The skin provides a natural barrier against entry of many infectious agents, but some can
enter through breaks in the skin. Example: malaria parasites (Plasmoduim species) get into the
body when an infected mosquito bites through the skin to suck blood.
Susceptible hosts and risk factors

After an infectious agent gets inside the body it has to multiply in order to cause the disease. In

some hosts, infection leads to the disease developing, but in others it does not. Individuals who

are likely to develop a communicable disease after exposure to the infectious agents are called

susceptible hosts. Different individuals are not equally susceptible to infection, for a variety of

reasons.

Factors that increase the susceptibility of a host to the development of a communicable disease

are called risk factors. Some risk factors arise from outside the individual – for example, poor

personal hygiene, or poor control of reservoirs of infection in the environment. Factors such as

these increase the exposure of susceptible hosts to infectious agents, which makes the disease

more likely to develop.

Additionally, some people in a community are more likely to develop the disease than others,

even though they all have the same exposure to infectious agents. This is due to a low level of
immunity within the more susceptible individuals. Immunity refers to the resistance of an

individual to communicable diseases, because their white blood cells and antibodies (defensive

proteins) are able to fight the infectious agents successfully. Low levels of immunity could be

due to:

 diseases like HIV/AIDS which suppress immunity

 poorly developed or immature immunity, as in very young children

 not being vaccinated

 poor nutritional status (e.g. malnourished children)

 pregnancy.

Natural history of a communicable disease

The natural history of a communicable disease refers to the sequence of events that happen one

after another, over a period of time, in a person who is not receiving treatment. Recognizing

these events helps you understand how particular interventions at different stages could prevent

or control the disease. (You will learn about this in detail in Study Session 2.)

Events that occur in the natural history of a communicable disease are grouped into four stages:

exposure, infection, infectious disease, and outcome (see Figure 1.6). We will briefly discuss

each of them in turn

Stage of exposure

In the stage of exposure, the susceptible host has come into close contact with the infectious

agent, but it has not yet entered the host’s body cells. Examples of an exposed host include:

 a person who shakes hands with someone suffering from a common cold

 a child living in the same room as an adult with tuberculosis

 a person eating contaminated food or drinking contaminated water.

Stage of infection

At this stage the infectious agent has entered the host’s body and has begun multiplying. The

entry and multiplication of an infectious agent inside the host is known as the stage of infection.

For instance, a person who has eaten food contaminated with Salmonella typhii (the bacteria that

cause typhoid fever) is said to be exposed; if the bacteria enter the cells lining the intestines and

start multiplying, the person is said to be infected.

At this stage there are no clinical manifestations of the disease, a term referring to the typical

symptoms and signs of that illness. Symptoms are the complaints the patient can tell you about

(e.g. headache, vomiting, dizziness).

Signs are the features that would only be detected by a trained health worker (e.g. high

temperature, fast pulse rate, enlargement of organs in the abdomen).

Stage of infectious disease

At this stage the clinical manifestations of the disease are present in the infected host. For

example, a person infected with Plasmodium falciparum, who has fever, vomiting and headache,

is in the stage of infectious disease – in this case, malaria. The time interval between the onset

(start) of infection and the first appearance of clinical manifestations of a disease is called the

incubation period. For malaria caused by Plasmodium falciparum the incubation period ranges

from 7 to 14 days.

Remember that not all infected hosts may develop the disease, and among those who do, the

severity of the illness may differ, depending on the level of immunity of the host and the type of

infectious agent. Infected hosts who have clinical manifestations of the disease are called active

cases. Individuals who are infected, but who do not have clinical manifestations, are called

carriers. Carriers and active cases can both transmit the infection to others.
 Chapter 2

Prevention and Control of Communicable Diseases and Community Diagnosis

Introduction

In the first chapter, you learned about the basic concepts in the transmission of communicable

diseases. The knowledge you gained will help you to understand this study session because they

are interlinked. In the first section, you will learn about the different ways of classifying

communicable diseases. Following classification you will learn the approaches in prevention and

control of communicable disease. This will help you in identifying appropriate measures for the

prevention and control of communicable diseases that you, as a Health Extension Practitioner,

and other health workers will put into place in your community. This study session forms the

basis for study sessions later in this Module on specific diseases such as malaria, tuberculosis

and HIV/AIDS. Finally, you will learn how to apply the methods of community diagnosis to

assess and prioritise actions to prevent and control the main communicable diseases in your

community

Classification of communicable diseases

Communicable diseases can be classified in different ways into groups with similar

characteristics. Classification will help you to select and apply appropriate prevention and

control measures that are common to a class of communicable diseases. In this section you will

learn the basis for each way of classifying communicable diseases and its relevance to your

practice. This will be clarified using examples of communicable diseases that you may already

be familiar with.
In chapter 1 you have learned the types of infectious agents which can be used for classification

of communicable diseases. Apart from this, there are two main ways of classifying

communicable diseases, which are important for you to know. The classification can be clinical

or epidemiologic, as described in Box 2.1

Box 2.1 Two ways of classifying communicable diseases

Clinical classification is based on the main clinical manifestations (symptoms and signs)

of the disease.

Epidemiologic classification is based on the main mode of transmission of the disease.

Now, we will discuss the details of each type of classification with specific examples.

2.1.1 Clinical classification of communicable diseases

As stated in Box 2.1, this classification is based on the main clinical manifestations of the

disease. This way of classification is important in helping you to treat the symptoms and signs

that are common to (shared by) individuals who suffer from different diseases. Clinical

classification is illustrated by the example given below.

Diarrhoeal diseases

Some diseases are classified as diarrhoeal diseases. The main clinical symptom is diarrhoea,

which means passage of loose stool (liquid faeces) three or more times per day. Two examples of

diarrhoeal diseases are shigellosis and cholera. People with watery diarrhoeal disease suffer from

loss of fluid from their bodies. Therefore, even though the infectious agent might be different, as

in the examples of shigellosis and cholera, the common management of patients with diarrhoeal

disease includes fluid replacement (Figure 2.1).

Other clinical classifications

Another clinical classification refers to diseases characterised as febrile illnesses, because they

all have the main symptom of fever, for example, malaria. Respiratory diseases are another

clinical classification; their main symptoms include cough and shortness of breath, as in

pneumonia.
Diseases have many symptoms and signs. As a Health Extension Practitioner, you will need to

decide which symptom is the main one for classification. Using the method of clinical

classification will help you decide to treat the main symptom. You will be able to identify the

main symptoms more easily when you learn about specific diseases later on in this Module. Bear

in mind that for most diseases, treatment of the main symptom is only supportive (that is it will

not cure the disease). Therefore, you have to give treatment specific to the infectious agent. This

will be discussed later in this Module under the specific diseases.

Epidemiologic classification

This classification is based on the main mode of transmission of the infectious agent. The

importance of this classification for you is that it enables you to select prevention and control

measures which are common to (shared by) communicable diseases in the same class, so as to

interrupt the mode of transmission. To clarify the importance of epidemiologic classification,

consider the following examples.

Cholera and typhoid fever are two different diseases which can be transmitted by drinking

contaminated water. Therefore, they are classified as waterborne diseases, using the

epidemiologic classification. The common prevention measures for the two diseases, despite

having different infectious agents, include protecting water sources from contamination and

treatment of unsafe water before drinking, for example by boiling (Figure 2.2) or adding

chlorine.
The main types of epidemiologic classification are described in Box 2.2

Box 2.2 Epidemiologic classification of communicable diseases

Based on the mode of transmission of the infectious agent, communicable diseases can

be classified as:

 Waterborne diseases: transmitted by ingestion of contaminated water.

 Foodborne diseases: transmitted by the ingestion of contaminated food.

 Airborne diseases: transmitted through the air.

 Vector-borne diseases: transmitted by vectors, such as mosquitoes and flies.

General approaches in the prevention and control of communicable diseases

You now have a working knowledge of factors involved in the chain of disease transmission and

how to classify communicable diseases. This knowledge will help you to identify prevention and

control measures that can be applied at each link in the chain. When we say prevention it refers

to measures that are applied to prevent the occurrence of a disease. When we say control it refers

to measures that are applied to prevent transmission after the disease has occurred. Most of the

measures for prevention and control of communicable diseases are relatively easy and can be

applied using the community’s own resources. You have an important role in educating the

public to apply these measures effectively.

Measures targeting the reservoir of infection

During your community practice, the prevention and control measures you will undertake

depend on the type of reservoir. In this section we will discuss measures for tackling human and

animal reservoirs. When you encounter an infected person, you should undertake the measures

described below.

Diagnosis and treatment

First, you should be able to diagnose and treat cases of the disease, or refer the patient for

treatment at a higher health facility. There are two ways to identify an infected individual: when

a patient comes to you (Box 2.3, on the next page, describes how you should approach a patient

in order to identify a case), and by screening (discussed below). Identifying and treating cases as
early as possible, reduces the severity of the disease for the patient, avoiding progression to

complications, disability and death; and it also reduces the risk of transmission to others.

Box 2.3 Approaches to the diagnosis of a case

The first step is to ask about the main complaints of the patient.

Then ask about the presence of other related symptoms and risk factors.

Examine the patient physically to detect signs of any diseases you suspect.

Finally, refer the patient for laboratory examinations if available (e.g. blood

examination for malaria).

Screening

Screening refers to the detection of an infection in an individual who does not show any signs or

symptoms of the disease. It is carried out using specific tests called screening tests. Screening

will help you to detect an infection early and organise appropriate treatment so as to reduce

complications and prevent transmission to others. An example of screening that may be familiar

to you is screening the blood of pregnant women for HIV infection

Isolation

Following detection of an infectious disease, you may need to separate patients from others to

prevent transmission to healthy people. This is called isolation. It is not indicated for every

infection, but it is important to isolate people with highly severe and easily transmitted diseases.

For example, an adult case of active pulmonary tuberculosis (‘pulmonary’ means in the lungs)
should be kept in isolation in the first two weeks of the intensive phase of treatment. The

isolation period lasts until the risk of transmission from the infected person has reduced or

stopped. The period and degree of isolation differs between different diseases, as you will learn

in later in the chapter.

Reporting

Cases of communicable diseases should be reported to a nearby health centre or woreda Health

Office periodically, using the national surveillance guidelines.

Animal reservoirs

When infected animals are the reservoir involved in the transmission of communicable diseases,

different measures can be undertaken against them. The type of action depends on the animal

reservoir, and ranges from treatment to destroying the infected animal, depending on the

usefulness of the animal and the availability of treatment. For example to prevent and control a

rabies outbreak, the measures to be taken are usually to destroy all stray dogs in the area, and

vaccinate pet dogs if the owner can afford this protection and the vaccine is available.

Measures targeting the mode of transmission

The measures that can be applied to interrupt transmission of infectious agents in water, food,

other vehicles and by vectors, are described below.

Water

Measures to prevent transmission of infection due to contaminated water include boiling the

water, or adding chemicals like chlorine. Disinfection is the procedure of killing most, but not

all, infectious agents outside the body by direct exposure to chemicals. Adding chlorine is one

method of disinfecting water. Physical agents can also be used, for example filtering water

through a box of sand, or pouring it through several layers of fine cloth. Faecal contamination of

water should also be prevented by protecting water sources and through proper use of latrines

(Figure 2.3).

Food
Measures to prevent transmission in contaminated food include washing raw vegetables and

fruits, boiling milk, and cooking meat and other food items thoroughly before eating.

Contamination with faeces can be prevented by hand washing and proper use of latrines.

Other vehicles

Measures to tackle transmission in or on vehicles other than water and food include:

 Contaminated objects like household utensils for cooking, eating and drinking should be

washed with soap and water.

 Contaminated medical instruments and clothing can be sterilized, disinfected or properly

disposed of.

Sterilisation involves destruction of all forms of micro-organisms by physical heat, irradiation,

gas or chemical treatment. The difference between disinfection and sterilisation is that

disinfection kills most, but not all, micro-organisms. Disinfection can be done using alcohol,

chlorine, iodine or heating at the domestic level; whereas sterilisation has to use extreme heating,

irradiation or strong chemicals like a high concentration of chlorine.

Vectors

Measures against vectors include preventing breeding of vectors, through proper disposal of

faeces and other wastes, eradication of breeding sites, and disinfestation. Disinfestation is the
procedure of destroying or removing small animal pests, particularly arthropods and rodents,

present upon the person, the clothing, or in the environment of an individual, or on domestic

animals. Disinfestation is usually achieved by using chemical or physical agents, e.g. spraying

insecticides to destroy mosquitoes, and removing lice from the body and clothing.

Measures targeting the susceptible host

The measures described below help to protect the susceptible host either from becoming

infected, or from developing the stage of infectious disease if they are exposed to the infectious

agents.

Vaccination

As you already know from Study Session 1, vaccination refers to administration of vaccines to

increase the resistance of the susceptible host against specific vaccine-preventable infections. For

example, measles vaccination helps to protect the child from measles infection, and BCG

vaccination gives some protection from tuberculosis (Figure 2.4).

Chemoprophylaxis

Chemoprophylaxis refers to the drugs given to exposed and susceptible hosts to prevent them

from developing an infection. For example, individuals from non-malarial areas who are going to

a malaria endemic area can take a prophylactic drug to prevent them from developing the disease

if they become infected with malaria parasites from a mosquito bite.

Maintaining a healthy lifestyle

Proper nutrition and exercise improves a person’s health status, supports the effective

functioning of their immune system, and increases resistance to infection.

Limiting exposure to reservoirs of infection

Measures taken to decrease contact with reservoirs of infection include:

 Condom use to prevent transmission of HIV and other sexually transmitted infections

(STIs).

 Use of insecticide treated nets (ITNs) over the bed at night, insect repellants and wearing

protective clothing to prevent diseases transmitted by insect vectors.

 Wearing surgical or very clean gloves and clean protective clothing while examining

patients, particularly if they have wounds, or the examination involves the genital area.

 Keeping personal hygiene, like taking a daily bath and washing your hands frequently.

Hand washing with soap and water is the simplest and one of the most effective ways to

prevent transmission of many communicable diseases (Figure 2.5). The times when

hands must be washed are indicated in Box 2.4.

 Box 2.4 When to wash hands with soap and clean water?

 After using the toilet

 After handling animals or animal waste

 After changing a diaper (nappy) or cleaning a child’s

bottom

 Before and after preparing food

 Before eating

 After blowing the nose, coughing, or sneezing

 Before and after caring for a sick person

 After handling waste material.

Now you have many good ideas on what measures can be undertaken to prevent and control

communicable diseases. However, you have to apply these methods effectively in order to

prevent and control the most important communicable diseases in your community. But how do

you identify these diseases? In the next section we will answer this question.

Community diagnosis

In order to select and apply effective prevention and control measures, you first have to

determine which type of diseases are common in the community you are working with. How do

you do that? The method is called community diagnosis and it involves the following four steps:
  Data collection

 Data analysis

 Prioritising problems

 Developing an action plan.

Let’s start with data collection and proceed to the others step by step.

Data collection

Data collection refers to gathering data about the health problems present in the community. This

is important as it will help you to have good ideas about the type of problems present in the area

where you work. Where do you get useful data concerning the health problems in your

community? The following sources of data can be used:

 Discussion with community members about their main health problems

 Reviewing records of the health services utilized by the community

 Undertaking a community survey or a small-scale project

 Observing the risks to health present in the community.

 After collecting data it should be analysed to make meaning out of it.

Data analysis

Data analysis refers to categorising the whole of the data you collected into groups so as to make

meaning out of it. For instance you can assess the magnitude of a disease by calculating its

prevalence and its incidence from the numbers of cases you recorded and the number of people

in the population in your community.

Prevalence refers to the total number of cases existing in the population at a point in time, or

during a given period (e.g. a particular month or year). The number of cases can be more usefully

analysed by calculating the prevalence rate in the community: to do this you divide the total

number of cases you recorded in a given period into the total number of people in the population.

The result is expressed ‘per 1,000 population’ in a community as small as a kebele. For example,

suppose that in one year you record 100 cases of malaria in a kebele of 5,000 people: for every

1,000 people in the kebele, there were 20 malaria cases in that year. So the prevalence rate of

malaria in that kebele is expressed as 20 cases per 1,000 people in that year.

Calculating the prevalence rate is more useful than just counting the number of cases, because

the population size in your kebele can change over time. The prevalence rate takes account of

changes in the number of people, so you can compare the prevalence rates from different years,

or compare the rate in your kebele with the rate in another one.

Prevalence rates and incidence rates can also be expressed as ‘per 10,000’ or ‘per 100,000’ in

much larger populations, e.g. of a region or a whole country

Incidence refers only to the number of new cases of a disease occurring in a given period. The

incidence rate is calculated by dividing the total number of new cases of the disease in a certain

period of time into the total number of people in the population, and is expressed as ‘per 1,000

population’.
■ If there were 10 new cases of cholera in a kebele of 5,000 people in one month, what is

the incidence rate of cholera per 1,000 population in that period?

□ The incidence rate in this example is two new cholera cases per 1,000 population.

As a health professional working in a community affected by several health problems at the same

time it is difficult to address all the problems at once. Therefore, you should give priority to the

most important ones first. But how do you prioritise? You are going to see how to do that next.

Prioritising health problems

Prioritising refers to putting health problems in order of their importance. The factors that you

should consider in prioritising are:

 the magnitude of the problem: e.g. how many cases are occurring over what period of

time?

 the severity of the problem: how high is the risk of serious illness, disability or death?

 the feasibility of addressing the problem: are the prevention and control measures

effective, available and affordable by the community?

 the level of concern of the community and the government about the problem.

 Health problems which have a high magnitude and severity, which can be easily solved,

and are major concerns of the community and the government, are given the highest

priority. After prioritising which disease (or diseases) you will give most urgent attention

to, the next step is to develop an action plan.

Action plan
An action plan sets out the ways in which you will implement the interventions required to

prevent and control the disease. It contains a list of the objectives and corresponding

interventions to be carried out, and specifies the responsible bodies who will be involved. It also

identifies the time and any equipment needed to implement the interventions. Once you have

prepared an action plan you should submit it for discussion with your supervisor and other

officials in the woreda Health Office to get their approval. Then implement the work according

to your plan.

Now that you have learned the basic concepts and methods relating to communicable diseases in

general, it is time for you to move on to consider the diagnosis, treatment, prevention and control

of specific diseases. In the next two study sessions, you will learn about the bacterial and viral

diseases that can be prevented by vaccination.

 Chapter 3

Bacterial Vaccine-Preventable Diseases

Introduction

This chapter and the next one focus on the communicable diseases that can be prevented by

immunization with vaccines. Together they are known as vaccine-preventable diseases. In this

study session you will learn about vaccine-preventable diseases caused by bacteria. In chapter 4

we will describe those that are caused by viruses. Greater understanding of these diseases will

help you to identify the ones that are common in your community, so that you can provide

effective vaccination programmes, and identify and refer infected people for specialised

treatment at a higher health facility.

In this chapter, you will learn some basic facts about bacterial vaccine-preventable diseases,

particularly how these diseases are transmitted, and how they can be treated and prevented. Our

focus will be on tetanus and meningitis, because tuberculosis (TB), which is a bacterial vaccine-

preventable disease, will be discussed in much more detail in later in the Module. Bacterial

pneumonia (infection of the lungs), caused by bacteria called Streptococcus pneumoniae and

Haemophilus influenzae,

Vaccines, immunity and vaccination

Before we can tell you about the vaccine-preventable diseases, you need to understand what is

meant by a vaccine. Vaccines are medical products prepared from whole or parts of bacteria,

viruses, or the toxins (poisonous substances) that some bacteria produce. The contents of the
vaccine have first been treated, weakened or killed to make them safe. If a vaccine is injected

into a person, or given orally by drops into the mouth, it should not cause the disease it is meant

to prevent, even though it contains material from the infectious agent. Vaccines are given to

susceptible persons, particularly children, so that they can develop immunity against the

infectious agent (Figure 3.1).

As you will recall from chapter 1, immunity refers to the ability of an

 individual to resist a communicable disease. When a dead or weakened micro-

 organism is given in the form of a vaccine, this process is called vaccination

 or immunization. For simplicity, in this Module we will refer to

 ‘vaccination’, but you should be aware that these two terms are used

 interchangeably.
The vaccine circulates in the body and stimulates white blood cells called lymphocytes to begin

producing special defensive proteins known as antibodies. Antibodies are also normally

produced whenever a person is infected with active bacteria or viruses transmitted from a

reservoir in the community. Antibodies and white blood cells are very important natural defences

against the spread of infection in our bodies, because they can destroy infectious agents before

the disease develops. What vaccination does is to stimulate this normal response, by introducing

a weakened or killed form of infection, which the white blood cells and antibodies attack.

This defensive response against the harmless vaccine increases the person’s level of immunity

against the active infectious agents, if the same type that was in the vaccine gets into the body.

The protective effect of vaccination lasts for months or years afterwards, and if several

vaccinations are given with the same vaccine, the person may be protected from that infection for

their lifetime. The Module on Immunization will teach you all about the vaccines available in

Ethiopia in the Expanded Programme on Immunisation (EPI), and how they are stored and

administered in vaccination programmes.

Overview of bacterial vaccine-preventable diseases

Vaccine-preventable diseases are important causes of death in children. The causes, infectious

agents, modes of transmission, symptoms, and methods of prevention, treatment and control of
the most important bacterial vaccine-preventable diseases are summarized in Table 3.1. Note that

some of the diseases shown in Table 3.1, such as diphtheria and pertussis, are no longer common

in Ethiopia, or in other countries where vaccination in childhood against their infectious agents is

widespread. Tuberculosis and bacterial pneumonia are discussed in detail in later study sessions.

In this chapter, we will describe tetanus and bacterial meningitis, so that you will be able to

identify and refer cases of these diseases, and also know how you might help to prevent them in

your community
Tetanus
In this section, you will learn about what tetanus is, how it is transmitted, what its clinical

symptoms are, and how it can be treated and prevented. Having this information will help you to

identify cases of tetanus and refer them to the nearby hospital or health centre for further

treatment. All cases should be reported to the District Health Office. After reading this section,

you should also be able to educate your community about the causes of tetanus, and how to

prevent it. You will learn how to give the tetanus toxoid vaccine to children, and to women of

reproductive age, in the Module on Immunization.

Definition, cause and occurrence of tetanus

Tetanus is a neurological disorder, that is, a disorder of the nervous system. Symptoms of tetanus

are tight muscles that are difficult to relax, and muscle spasms (muscle contractions that occur

without the person wanting them to). These problems with the muscles are caused by a toxin

(poison) produced by the bacteria called Clostridium tetani.

Tetanus is among the top ten causes of illness and death in newborns in Ethiopia. Tetanus in

newborns is called neonatal tetanus. Nine out of every 1,000 newborns in Ethiopia have neonatal

tetanus. More than 72% of the newborns who have tetanus will die.

Tetanus is also common among older children and adults who are susceptible to the infection.

Unvaccinated persons are at risk of the disease, and people who have a dirty wound which

favours the growth of the bacteria that cause tetanus are especially vulnerable.

Mode of transmission of tetanus

People can get tetanus through exposure to tetanus bacteria (Clostridium tetani) which are

always present in the soil. The bacteria can be transmitted directly from the soil, or through dirty

nails, dirty knives and tools, which contaminate wounds or cuts. A newborn baby can become

infected if the knife, razor, or other instrument used to cut its umbilical cord is dirty, if dirty

material is used to dress the cord, or if the hands of the person delivering the baby are not clean.

Unclean delivery is common when mothers give birth at home in poor communities, but it can be

prevented by skilled birth attendants (Figure 3.2).

The disease is caused by the action of a toxin produced by the bacteria, which damages the

nerves of the infected host. This toxin is produced during the growth of the tetanus bacteria in

dead tissues, in dirty wounds, or in the umbilicus following unclean delivery of the newborn.

Clinical manifestations of tetanus

The time between becoming infected with Clostridium tetani bacteria and the person showing

symptoms of tetanus disease is usually between three and 10 days, but it may be as long as three

weeks.

In cases of tetanus, the shorter the incubation period, the higher the risk of death. In children and

adults, muscular stiffness in the jaw, which makes it difficult or impossible to open the mouth

(called ‘locked jaw’) is a common first sign of tetanus. This symptom is followed by neck

stiffness (so the neck cannot be bent), difficulty in swallowing, sweating, fever, stiffness in the

stomach muscles, and muscular spasms (involuntary contraction of the muscles).

Babies infected with tetanus during delivery appear normal at birth, but they become unable to

feed by suckling from the breast at between three and 28 days of age. Their bodies become stiff,

while severe muscle contractions and spasms occur (Figure 3.3). Death follows in most cases

■ A newborn baby (10 days old) who was born in a village with the assistance of traditional

birth attendants, is brought to you with fever, stiffness in the stomach muscles and difficulty in

opening his mouth, so he is unable to breastfeed. What is the possible cause of this baby’s

symptoms, and why do you make this diagnosis? What action will you take?
□ The newborn may have tetanus since he was born at home without the care of a skilled

birth attendant. The umbilical cord could be infected by tetanus. You should refer this child

urgently to the nearest health centre or hospital

Treatment, prevention and control of tetanus

Once a person has tetanus, he or she will be treated by an antibiotic drug. Antibiotics are

medicines that destroy bacteria, or stop them from multiplying in the body. However, many

people who have tetanus die despite the treatment. Hence, prevention is the best strategy, and

vaccination is the best way to prevent tetanus.

Tetanus toxoid (TT) vaccination

The tetanus vaccine contains inactivated tetanus toxoid (poison), which is why it is often called

TT vaccine. Tetanus toxoid vaccination is given routinely to newborns and infants as part of the

threefold DPT vaccine (with diphtheria and pertussis vaccines), or the pentavalent (fivefold)

vaccine, which includes vaccines for diphtheria, tetanus, pertussis, Hepatitis B (a virus), and a

bacterium called Haemophilus influenzae type B (Hib). Neonatal tetanus can also be prevented

by vaccinating women of childbearing age with tetanus toxoid vaccine, either during pregnancy

or before pregnancy. This protects the mother and enables anti-tetanus antibodies to be

transferred to the growing fetus in her uterus.

■ What is the name given to this mode of transmission

□ The transmission from mother to fetus is called transplacental transmission because the

mother’s antibodies pass across the placenta and into the baby.

Cleanliness is also very important, especially when a mother is delivering a baby, even if she has

been vaccinated with TT vaccine.

People who recover from tetanus do not have increased natural immunity and so they can be

infected again. Therefore they will need to be vaccinated.

The World Health Organization (WHO) and UNICEF set a goal to eliminate neonatal tetanus by

2005. Elimination in this case would mean that the number of neonatal tetanus cases would have

to be reduced to below one case per 1,000 live births per year in every district. Notice that

elimination of a communicable disease does not mean there are no cases — just very few right

across a country or region. Eradication means the total and sustained disappearance of the

disease from the population.

■ Do you think that tetanus can ever be eradicated? Explain why, or why not.

□ Because tetanus bacteria survive in soil in the environment, eradication of the disease is

not possible.

To achieve the elimination goal, countries like Ethiopia, with a high number of tetanus cases

every year, need to implement a series of prevention strategies, which include those listed in Box

3.1.
 Box 3.1 Strategies to prevent and control tetanus

 Vaccinating a higher percentage of pregnant women against tetanus with vaccines

containing tetanus toxoid (TT).

 Vaccinating all females of childbearing age (approximately 15–45 years) with TT vaccine

in high-risk areas where vaccination coverage is currently low.

 Outreach vaccination campaigns where health workers go to rural villages and give TT

vaccine, usually three times at intervals (known as a ‘three-round’ vaccination campaign).

 Promoting clean delivery and childcare practices, through better hygiene and care of the

newborn’s umbilicus.

 Improving surveillance and reporting of cases of neonatal tetanus. The case finding and

reporting will help us to give appropriate treatment and vaccination to children.

Meningococcal meningitis

In this section, we will describe what meningococcal meningitis is, how it is transmitted, what its

clinical symptoms are, and also how it can be treated and prevented. With this information, we

hope you will be able to identify a person with meningitis and refer him or her urgently to the

nearest health centre or hospital for further diagnosis and treatment. You should also be able to

detect meningococcal meningitis epidemics in the community.

Definition and cause of meningococcal meningitis

Meningococcal meningitis is an infection of the brain and spinal cord by the bacterium Neisseria

meningitidis (also known as the meningococcus bacterium). The disease is caused by several

groups of meningococcus bacteria, which are given distinguishing codes such as type A, B, C, Y

and W135.

The disease occurs globally, but in sub-Saharan Africa, meningitis epidemics occur every two to

three years. An epidemic is a sudden and significant increase in the number of cases of a

communicable disease, which may go on rising for weeks, months or years. Meningitis

epidemics are common in many countries of Sub-Saharan Africa, including Ethiopia. In

Ethiopia, these epidemics are usually caused by group A and C type meningococcus bacteria,

and are more common in western Ethiopia. The disease is most common in young children, but it

also can affect young adults living in crowded conditions, in institutions, schools and refugee

camps.

In populations over 30,000 people, a meningitis epidemic is defined as 15 cases per 100,000

inhabitants per week; or in smaller populations, five cases in one week or an increase in the

number compared to the same period in previous years.

Mode of transmission and clinical symptoms

Meningococcal meningitis is transmitted to a healthy person by airborne droplets from the nose

and throat of infected people when they sneeze or cough. The disease is marked by the sudden

onset of intense headache, fever, nausea, vomiting, sensitivity to light and stiffness of the neck.

Other signs include lethargy (extreme lack of energy), coma (loss of consciousness), and

convulsions (uncontrollable shaking, seizures). Box 3.2 summarises the general signs of
meningitis, which may also be caused by some other serious conditions, and the more specific

signs which are characteristic of meningitis.

Box 3.2 General and more specific signs of meningitis in infants

General signs of meningitis:

 Drowsy, lethargic or unconscious

 Reduced feeding

 Irritable

 High pitched cry.

More specific signs of meningitis:

 Convulsion (fits)

 Bulging fontanelle in infants.

During examination of a baby with meningitis, you will notice stiffness of the neck, or bulging of

the fontanelle – the soft spot on top of the head of infants (see Figure 3.4). The fontanelle bulges

because the infection causes fluid to build up around the brain, raising the pressure inside the

skull. A bulging fontanelle due to meningitis is observed in infants since the bones of the skull

are not yet fused together

Children may also show rigid posture due to irritation of the covering part of the brain or spinal

cord. To check the presence of neck stiffness, ask the parents to lay the child in his/her back in

the bed and try to flex the neck of the child (Figure 3.5).

If meningitis is not treated, mortality is 50% in children. This means that half of all cases end in

death. However, with early treatment, mortality is reduced to between 5 to 10%. But about 10 to

15% of those surviving meningococcal meningitis will suffer from serious complications

afterwards, including mental disorders, deafness and seizures.

Diagnosis and treatment of meningitis

Meningitis is diagnosed by physical examination of the person, and by laboratory testing of the

fluid from their spinal cord, where the meningococcal bacteria can be found. In the hospital or

health centre, the meningitis is treated using antibiotics given intravenously (IV), that is, liquid

antibiotics given directly into the bloodstream through a vein.

■ Tetanus and meningitis are both diseases in which fever and stiffness of the neck are

important symptoms. How could you tell these diseases apart in babies by examining them

yourself?

□ Tetanus and meningitis can both be manifested by fever and neck stiffness, but there are

other specific signs of each disease which help in differentiation. For instance, people with

tetanus may have tightness of the abdominal muscles and may be unable to open their mouths.

By contrast, the bulging fontanelle is a typical sign of meningitis in young babies, which would

not be found in cases of tetanus. However, these diseases are very difficult to distinguish on the

basis of clinical examination alone.

Prevention and control of meningococcal meningitis

Next we describe how to prevent meningococcal meningitis from spreading in a community. The

most important preventive and control methods are summarized in Box 3.3.
 Box 3.3 Strategies to prevent and control meningitis

 Early identification and prompt treatment of cases in the health facility and in the

community.

 Education of people in the community on the symptoms of meningitis, the mode of

transmission and the treatment of the disease.

 Reporting any cases of meningitis to the District Health Office; and avoiding close

contact with the sick persons. Your health education messages should tell everyone about

this.

 Vaccination against meningococcus bacteria of types A, C, Y and W135, as described in

the Immunization Module.

A mass immunization campaign that reaches at least 80% of the entire population with

meningococcus vaccines can prevent an epidemic. However, these vaccines are not effective in

young children and infants, and they only provide protection for a limited time, especially in

children younger than two years old. A single case of meningitis could be a warning sign for the

start of an epidemic. As a community Health Extension Practitioner, you will need to educate

your community about the symptoms of meningitis and how it is transmitted. All cases should be

reported to the District Health Office.

The next study session is also about vaccine-preventable diseases, but we turn your attention to

those common diseases of this type that are caused by viruses.

 Chapter 4

Viral Vaccine-Preventable Diseases

Introduction

In chapter 3 we gave an overview of vaccine-preventable diseases, and then focused on two of

the main diseases in this category that are caused by bacteria. In this study session, you will learn

about the major vaccine-preventable diseases that are caused by viruses, how they are

transmitted, and how they can be prevented and controlled. Knowing the signs and symptoms of

these viral diseases will help you to identify them in your community, so that you can refer

infected people quickly for treatment at a nearby health centre. Greater understanding of viral

vaccine-preventable diseases will also enable you to explain to parents why they should have

their children vaccinated to prevent them from susceptibility to these viruses. How to give

vaccines to children is described in the Immunization Module.

Overview of viral vaccine-preventable diseases

As you know from Study Session 1 of this Module, viruses are microscopic infectious agents that

do not have the structure of a cell; they are more like tiny boxes or particles. They are much

smaller than bacteria and can only be seen with the most powerful microscopes. Some of the

diseases caused by viruses can be prevented by vaccination, as you will learn in this study

session.

■ Do you know of any human communicable diseases caused by a virus?

□ HIV disease and AIDS are caused by the human immunodeficiency virus (HIV). You

may also have thought of measles, polio or hepatitis.

HIV cannot be prevented by vaccination at the present time, but the other three viral diseases

mentioned above are part of the Expanded Programme of Immunization (EPI) in Ethiopia and

many other countries around the world (see Table 4.1, on the next page). The composition of the

vaccines, which contain dead or weakened viruses or fragments of their structure, and the routes

of administration, are described in detail in the Immunization Module. In the following sections,

we will look at each of these diseases in turn

Note that (unlike bacteria, which have two-part species names) the names of most viruses are

simply the disease it causes followed by the word ‘virus’, as in ‘measles virus’

Measles
In this section, you will learn about what measles is, how it is transmitted, what its signs and

symptoms are, and how it can be treated and prevented. Having this information will help you to

identify a child with measles and give necessary treatment. After reading this section, you should

also be able to identify an epidemic of measles in the community if it occurs, so you will be able

to report it to the District Health Office.

Definition, cause and occurrence of measles

Measles is a highly transmissible infectious disease caused by the measles virus. Globally,

measles kills more children than any other vaccine-preventable disease. In 2008, there were

around 165,000 deaths from measles worldwide – most of them in young children and almost all

of them in low-income countries. Because the virus is so easily transmitted, you should be aware

that it usually causes an epidemic and may cause many deaths, especially among malnourished

children. In Ethiopia, measles occasionally causes epidemics. Almost 5,000 children suffered

from measles in 2009 and 2,726 cases had already been confirmed in 2010 by early July of that

year. However, it is estimated that deaths from measles can be reduced by more than 60%

through effective vaccination programmes.

Figure 4.1 Transmission of measles by airborne droplets occurs easily in schools. (Photo: Ali

Wyllie)

Mode of transmission of measles

Measles is spread through contact with the nose and throat secretions of infected people, and in

airborne droplets released when an infected person sneezes or coughs. A person with measles

can infect others for several days before and after he or she develops symptoms. The disease

spreads easily in areas where infants and children gather, for example in health centres, homes

and schools (Figure 4.1).

Clinical manifestations of measles

The first sign of infection with measles is a high fever, which begins approximately 10–12 days

after exposure to the virus and lasts for several days. During this period, the child may develop a
runny nose, a cough, red and watery eyes (Figure 4.2), and small white spots inside his or her

cheeks.

After several days, a slightly raised rash (appearance of small pigmentations or red spots on the

skin, or ‘shifta’ in Amharic), develops, usually on the face and upper neck. Over a period of

about three days, the rash spreads to the body (Figure 4.3) and then to the hands and feet. It lasts

for five or six days and then gradually fades. The incubation period from exposure to the onset of

the rash averages 14 days.

To identify cases of measles, you need to confirm the presence of fever and rash, with cough or

running nose, or conjunctivitis (red eyes).

Measles may be severe, causing several complications that can lead to permanent disability or

death, including pneumonia (infection of the lower respiratory tract), encephalitis (infection in

the brain), otitis media (infection of the middle ear), corneal clouding and blindness (Figure 4.4),

and diarrhoea with dehydration.

Severe measles, manifested by complications such as pneumonia, and clouding of the eyes or

blindness, is particularly likely in poorly nourished children, especially those who do not receive

sufficient vitamin A in their diet. Vitamin A, which is found in yellow vegetables like carrots and

yellow fruits like mangoes, is essential for good eyesight and it also strengthens the immune

system of children. If measles develops in a child with a shortage of vitamin A, this makes the

disease more severe and damage to eyesight is more likely. Measles and vitamin A deficiency

together are a major cause of blindness among children in Africa and in other areas of the world

where measles is common. Children who live in crowded conditions and whose immune systems

have been weakened by HIV/AIDS, or other diseases, are also more likely to develop severe

measles.
■ Give a reason why malnourished children are more likely to develop severe measles.

□ Children with malnutrition, particularly those who lack vitamin A, have weak immunity

and cannot fight the measles virus, which causes severe clinical symptoms and may even kill

them.

Treatment, prevention and control of measles

It is very important to encourage children with measles to eat and drink. Advise the parents to

help their child as much as possible with nutrition and intake of fluids; treat any dehydration with

oral rehydration salts (ORS) as necessary. Antibiotics should only be prescribed for ear

infections and pneumonia caused by bacteria, which are able to develop in the person weakened

by measles. Remember that antibiotics only attack bacteria – they have no activity against any

viruses, including the measles virus.

IU stands for International Unit; this is the internationally agreed measurement of vitamin

dosages

Vitamin A supplementation

As lack of vitamin A is such a problem associated with measles, all children in developing

countries who are diagnosed with measles should receive two doses of vitamin A supplements

given 24 hours apart, at a dosage appropriate to their age (see Table 4.2). For instance, a 7

month-old infant with measles should receive one dose of vitamin A, which contains 100,000

International Units (IU) on the day of diagnosis (day 1) and also on the next day (day 2). Giving

Vitamin A can help prevent eye damage and blindness and reduce the number of deaths from

measles by 50%, so this is a very important and effective part of the treatment.
Measles vaccination

Measles is prevented by vaccination with measles vaccine. By the year 2008, successful

vaccination campaigns all over the world had succeeded in reducing measles deaths by around

75% — a huge drop from the 750,000 deaths in the year 2000. The World Health Organization

(WHO) estimated that in 2008 around 83% of the world’s children were receiving one dose of

measles vaccine by their first birthday.

All infants at nine months of age or shortly thereafter should be vaccinated through routine

immunization services. This is the foundation of the sustainable measles death-reduction

strategy. It is also possible to reduce infections with measles by giving vaccination to vulnerable

children. For example, to reduce the risk of measles infection in hospitals, all children between

the ages of six and nine months, who have not received measles vaccine and who are admitted to

a hospital, should be vaccinated against measles. If the children’s parents do not remember or

know whether they have received measles vaccine, the child should still be vaccinated. If a

hospitalised child has received measles vaccine before nine months of age, a second dose should

be administered at nine months, or as soon as possible after nine months.

All children should be provided with a second opportunity for measles vaccination. This is to

make sure that children who did not receive a previous dose of measles vaccine, or children who

were vaccinated earlier but did not develop immunity, have another chance to develop immunity.

The second opportunity may be delivered either through routine immunization services or

through periodic mass campaigns of vaccination.

Measles surveillance

Measles surveillance (looking for cases of measles in the community) should be strengthened at

community level, so that there is early warning of any possible epidemics. Try to persuade

parents that a child with measles should be kept isolated from other children who have not

previously had measles or been vaccinated, to avoid the disease from spreading. As a health

worker, you should report any cases of measles in your community to the District Health Office.

As well as this, of course, you have the important task of vaccinating all children who are around

nine months old against measles.

Poliomyelitis (polio)

In this section, we will describe what polio is and how it is transmitted, its clinical symptoms,

how it is treated and how it can be prevented and controlled. This will help you to identify cases

of polio and refer them for further diagnosis and treatment. It will also help you to give health

education in your community about how to prevent polio in children through the administration

of oral polio vaccine in drops into the mouth.

Definition, cause and occurrence of polio

Poliomyelitis (usually called polio) is a viral disease that causes paralysis (weakness or inability

to use the muscles) of the legs, arms or hands. Polio is caused by three types of viruses, namely,

poliovirus types 1, 2 or 3; (note that ‘poliovirus’ is all one word). Many countries agreed in 1988

to try to eradicate polio completely from the world. The Ethiopian government has a plan to

eradicate the disease in the near future. As a result of a continuing vaccination programme, polio

is fortunately becoming a rare disease in Ethiopia. However, there are sometimes cases among

people who come to Ethiopia from neighbouring countries such as Sudan.

Mode of transmission and clinical manifestation of polio

Polioviruses are transmitted when people drink water or eat food contaminated by faeces (or

stools) which carry the virus (faeco-oral transmission). However, most children infected by

polioviruses never feel ill. Less than 5% of those infected may have general flu-like symptoms

such as fever, loose stools, sore throat, headache, or stomach ache. Most children who get a

poliovirus infection without symptoms develop immunity and have lifelong protection against

polio. A few children may develop a kind of paralysis called acute flaccid paralysis (AFP),

which is characterized by acute (rapidly developing, severe) loss of movement or weakness of

the legs, arms or hands.

Paralytic polio begins with mild symptoms and fever, followed by severe muscle pain and

paralysis, which usually develops during the first week of illness. Patients may lose the use of

one or both arms or legs. Some patients may not be able to breathe because of the paralysis of

respiratory muscles in the chest, which can lead to death. Some patients who develop paralysis

due to polio recover the ability to move the affected limbs to some degree over time, but the
degree of recovery varies greatly from person to person. A diagnosis of polio is confirmed by

laboratory testing of stool samples

Treatment and prevention of polio

While the initial symptoms of acute polio such as muscle pain and fever can be relieved, there is

no treatment that can cure the weakness and paralysis if AFP develops. Regular physical exercise

can help paralysed children to resume some activity. Prevention of polio by vaccination is the

best method to eradicate the disease. Three doses of oral polio vaccine (OPV) are given during

routine vaccinations for other communicable diseases, and/or during campaigns for polio

eradication. A detailed description of the vaccination procedure is given in the Immunization

Module.

An initial dose of OPV can also be given at birth or before 2 weeks of age.

Polio surveillance and reporting

You should immediately report a case of AFP to the District Health Office and take stool

samples from the patient. The stool sample should be sent to Addis Ababa to identify the virus.

Stool specimens must be collected within 14 days of paralysis onset in order to have the greatest

chance of isolating the virus.

Try to collect the first specimen at the time of the case investigation. If the patient is not able to

produce a stool, leave a cup, cold box and frozen ice packs with the family so that they can

collect it from the patient later.

To collect faeces from the child, ask him or her to defaecate onto clean paper. Use a spatula or

very clean spoon to put the stool specimen in a clean container and label it and write the date.
After collection, the specimens must be placed immediately in a refrigerator for shipment, or in a

cold box between frozen ice packs at 4–8°C. The specimens must reach the laboratory in Addis

Ababa within 72 hours of collection.

■ Gemechis is a two-year-old boy who has had weakness in his legs for the last two days.

His mother has told you that he has mild fever and diarrhoea. What should you do?

□ The boy may have AFP due to poliovirus infection. You should collect a stool sample

from Gemechis and immediately report to the District Health Office and have the sample sent to

Addis Ababa for laboratory analysis.

For further evaluation and treatment, refer the child to the nearest health centre.

As a Health Extension Practitioner, if you identify a case of AFP you must report it immediately.

You will also routinely need to give the oral polio vaccine (OPV) to all eligible children in your

community.

Hepatitis B

In this section, we describe what hepatitis B is and how it is transmitted, its clinical symptoms,

and how it can be treated and prevented. This will help you to identify cases of hepatitis and

refer them for further investigation and treatment, and also to educate your community about

what causes hepatitis B and how it can be prevented by vaccination and safer sexual practices.

Definition, cause and occurrence of hepatitis B

Hepatitis is a term referring to a serious inflammation of the liver. Several viruses can cause

hepatitis, but the hepatitis B virus (or HBV) is the most important one. Hepatitis B disease is a

major global health problem and the most serious type of viral hepatitis. The WHO estimates that
an estimated two billion people have been infected with HBV worldwide, and more than 350

million have chronic (long-term) liver infections. About 600,000 people die every year as a result

either of acute liver infection, or of chronic liver damage or liver cancer, which develops slowly

over decades and eventually leads to their death.

Mode of transmission and clinical manifestation of HBV

HBV is carried in the blood and other body fluids of people who are infected. It is usually spread

by contact with infected blood or body fluids in the following ways:

Injury or injection: with contaminated sharp unsterile objects or instruments.

From a pregnant mother to her baby: During birth, the virus which exists in the blood or body

fluid of the mother may be transmitted to the baby.

Unprotected sexual intercourse: During sexual intercourse without a condom, the virus which

exists in the blood of the infected person may be transmitted to the other partner through

scratches or wounds, or through small breaks in the delicate membranes covering the sexual

organs.

The incubation period of hepatitis B averages six weeks, but may be as long as six months.

Young children who are infected (usually at birth) often show no symptoms. Also, a larger

proportion of children become chronic carriers of HBV, compared with infected adults.

■ Do you remember what a ‘chronic carrier’ means?

□ It is a person who carries the infection for a long period of time and can transmit the

infectious agent to others, but without showing any symptoms of the disease themselves.
People who show symptoms of hepatitis B disease may feel weak and experience stomach upsets

and other flu-like symptoms, which may last several weeks or months. They may also have very

dark urine or very pale stools. Jaundice, which presents with yellowing of the skin or a yellow

colour in the whites of the eyes (Figure 4.5), is common. Jaundice results when the liver is

unable to deal with a yellow substance called bilirubin, which is formed when old red blood cells

are broken up and their constituents are recycled to make new red blood cells. If the liver is

damaged, it can’t deal with the bilirubin, which builds up in the body causing the yellow

discoloration.

A laboratory blood test is required for confirmation of hepatitis B infection. Most HBV

infections in adults are followed by complete recovery and 90% of adults will be completely rid

of the virus within six months. Recovery also means that they are naturally protected from

further infection with HBV for the rest of their lives. However, 30–90% of infants and children

who become infected with HBV become chronic carriers of the virus, and they have a much

increased risk of developing chronic, life-threatening liver damage or liver cancer much later in

life.
Treatment, prevention and control of hepatitis B

You should be aware that there is no curative treatment for acute hepatitis B disease. Advise

patients or the parents of affected children to try to keep eating and drinking; replacement of

fluids lost through vomiting or diarrhoea is essential, and giving ORS is recommended if

dehydration is a concern. In chronic hepatitis B infection, the disease can sometimes be halted

with medication, but the drugs cost thousands of dollars and are rarely available in developing

countries.

Prevention of hepatitis B disease is by vaccination, which is 95% effective. All infants should get

three or four doses of hepatitis B vaccine during the first year of life, as part of routine

vaccination schedules. In Ethiopia, it is usually given in the pentavalent vaccine, which protects

against HBV and four bacterial diseases. Your role is to educate your community about how

hepatitis B is transmitted and how transmission can be avoided, and you will need to give the

pentavalent vaccine to infants.

■ Do you know another viral disease which has the same modes of transmission as hepatitis

B? What health education messages can you give to people to protect themselves from both

diseases?

□ HIV has the same modes of transmission as HBV. The advice on protection from

acquiring both these viruses is to avoid contact with another person’s blood or body fluids,

particularly during sexual intercourse.

 Chapter 5

Malaria Epidemiology and Transmission

Introduction

In this chapter you will learn about the burden of malaria worldwide, in Africa and in Ethiopia.

As malaria is a vector-borne disease you will learn about the vectors, which in the case of

malaria are the mosquitoes that carry the malaria parasite from person to person. You will learn

where mosquitoes lay their eggs and the stages of development leading up to a new flying adult.

Information about the breeding habitats (water collections where mosquitoes lay eggs and

develop), and the life cycle of mosquitoes, is essential for you to target anti-vector interventions

in the right way.

A clear understanding of the life cycle of the malaria parasite and of the mosquito, the vector

which transmits it from person to person, will help you carry out your responsibility of protecting

people in your community from getting malaria and of treating people who do get malaria.

The burden of malaria

Malaria is one of the most serious diseases to affect people in developing countries with tropical

and subtropical climates. It is particularly dangerous for young children and for pregnant women

and their unborn babies, although others may also be seriously affected in some circumstances.

Malaria is endemic in 109 countries and more than three billion of the world’s population lives in

malaria risk regions. Globally, 300–500 million episodes of malaria illness occur each year,

resulting in over one million deaths. As Figure 5.1 (on the next page) shows, changes in socio-

economic conditions and anti-malaria interventions have gradually reduced the areas of the
world where malaria is endemic, but it is still widespread as a major global disease. A

communicable disease is said to be endemic in a region or country if it is always present there. In

areas where many cases occur throughout the year, the disease is said to be highly endemic, or

(to say it another way) it has high endemicity.

Figure 5.1 Changing geographical range of malaria. In 1946, the high risk range was all three

coloured areas; by 1966, it was down to the yellow and brown areas; and by 1994 it was only the

brown areas. (Source: The Open University, 2003, Infectious Disease, Book 5: Evolving

Infections, Figure 3.1)

More than 90% of the worldwide deaths from malaria occur in sub-Saharan Africa and most of

these deaths are in children. Malaria risk is highest in tropical Africa where conditions (which

will be considered further below) are very favourable for malaria transmission (Figure 5.2).
■ Look at Figure 5.2 and describe what it shows about the incidence of malaria in Africa.

□ Figure 5.2 shows that the highest incidence of malaria (as shown in red) is around the

equator and in the tropics. Malaria is much less common in the northern and southern part of the

continent.

The intricate interactions between host, parasite, vector and the environment are the major

factors in the distribution of malaria. Different areas can experience different levels of incidence

rates.

Malaria can be viewed in terms of being stable or unstable. Malaria is said to be stable (and

therefore endemic) when malaria infections occur for many months in a year, over many years.

People living in highly endemic areas usually exhibit a high level of immunity and tolerate the

infection well.
Immunity against malaria is the ability to fight the infection, which is developed by people with

repeated episodes of malaria. Under endemic conditions, children under the age of five years,

and pregnant mothers, are most likely to be infected as they have weaker immunity.

Unstable (epidemic) malaria refers to a seasonal type of transmission seen in areas of low

endemicity, or to outbreaks in areas previously without malaria, or among non-immune persons.

Epidemics can be due to changes in human behaviour, environmental and climate factors. For

example, human migration and resettlement can introduce malaria into an area that did not have

it previously, and this can expose a population to the disease that was not immune to malaria.

Malaria epidemics generally occur when the population in an area has weak immunity to the

disease, because so many people in the population will be vulnerable to malaria, not just children

under five years of age and pregnant women.

However, it is important to remember that children and mothers are always more at risk, so they

will need particular attention.

Malaria parasites

Malaria is caused by Plasmodium parasites. Plasmodium parasites infect people and attack the

red blood cells, which often leads to severe illness and death. The parasites are spread to people

through the bites of infected Anopheles mosquitoes, which are the malaria vectors and which

bite mainly between dusk and dawn.

There are four types of human malaria, each due to one of the parasites with the following

specific names:

 Plasmodium falciparum

 Plasmodium vivax

 Plasmodium malariae

 Plasmodium ovale.

Plasmodium falciparum and Plasmodium vivax are the most common malaria parasites in

Ethiopia. 60% of malaria infections in Ethiopia are due to

P. falciparum and 40% are due to P. vivax. P. falciparum is the most deadly and requires special

attention.

Although both parasites are widely distributed, some communities will have more falciparum

malaria while others will have more vivax malaria. Do you know which type of infection is more

common in your community?

Life cycle of the malaria parasite

Human malaria (Plasmodium parasite) is transmitted from an infected person to another person

by Anopheles mosquitoes, as shown in Figure 5.4. The parasite spreads by infecting two types of

hosts: humans and female Anopheles mosquitoes. The mosquitoes then act as the vector for the

parasite. Malaria is a human parasite that is transmitted only between people; malaria is not

transmitted from animals to humans, or from humans to animals.

Now you are going to learn about the life cycle of the parasite. Please study Figure 5.5 very

carefully as it is going to help you understand about the pathology, signs, symptoms and

treatment of malaria in the subsequent study sessions.

Malaria in humans develops via two stages: a liver and red blood cell stage. When an infected

mosquito pierces a person's skin to take a blood meal, malaria parasites in the mosquito's saliva

enter the bloodstream and migrate to the person’s liver. Within 30 minutes of being introduced

into the human body, they infect liver cells, multiplying in the liver cells for a period of 6–15

days. In the process they become thousands of parasites which, following rupture of the liver
cells, escape into the blood and infect red blood cells, thus beginning the red blood cell stage of

its life cycle.

Within the red blood cells, the parasites multiply further, periodically breaking out of their host

cells to invade fresh red blood cells. Several replication cycles occur. The pathology and clinical

manifestations associated with malaria are almost exclusively due to the red blood cell stage

parasites (Figure 5.5). The blood stage parasites are those that cause the symptoms of malaria.
When certain forms of blood stage parasites, called gametocytes, are picked up by a female

Anopheles mosquito during a blood meal, they start another, different cycle of growth and

multiplication in the mosquito. After 10-18 days, the parasites are found in the mosquito's

salivary glands. When the Anopheles mosquito takes a blood meal from another human, the

parasites are injected with the mosquito's saliva and start another human infection when they

enter the new person’s liver cells. Thus the mosquito carries the disease from one human to

another, acting as a vector. Unlike the infected human, the mosquito vector does not suffer from

the presence of the parasites.

The most common way to be infected with malaria is through the natural transmission by

mosquitoes, as already described. However, malaria can also be transmitted via blood

transfusions or sharing syringes. Mother to child transmission during pregnancy has also been

documented, but all the modes of transmission other than via the mosquito are believed to be

very rare and unimportant.

Incubation period of malaria

When a person becomes infected with one of the Plasmodium parasites that cause malaria, he or

she will not feel sick immediately. The period between infection with the parasites that cause the

disease and the beginning of malaria symptoms is called the malaria incubation period. The

infected person may feel normal from 7 to 21 days when infected with Plasmodium parasites. P.

falciparum has a shorter incubation period (7 to 14 days) than P. vivax (12 to 18 days).

Plasmodium malariae tends to have a much longer incubation period, as you can see from Table

5.1
Partial immunity to malaria

The severity of the attack depends on the Plasmodium species, as well as other circumstances,

such as the state of immunity and the general health and nutritional status of the infected

individual.

Following several attacks of malaria, people living in highly endemic regions can develop partial

immunity that can protect them from severe attacks and death. But no-one develops complete

immunity against malaria that can fully protect the person from infection. Pregnant women and

children under five years of age are more susceptible to severe forms of the disease and death

due to their weak immune system.

Life cycle of the mosquito vector

Now you will learn about the life cycle of the vector of the malaria parasite, the mosquito.

Mosquitoes have four different stages in their life cycle: the egg, larva, pupa and adult (see

Figure 5.6 on the next page). The first three stages are immature and are found in water
collections. The adult is a flying insect. The time taken for the different stages to develop

depends on temperature and nutritional factors in their environment. Development takes a shorter

time at higher temperatures.

Eggs

A female Anopheles mosquito normally mates only once in her lifetime. It usually requires a

blood meal after mating before her eggs can develop. While the blood meal is not essential for

the survival of female mosquitoes, it is crucial for successful egg production and egg laying.

Blood meals are generally taken every two to three days, before the next batch of eggs is laid.

About 100 to 150 eggs are laid on the water surface during oviposition (egg laying). Oviposition

sites vary from small hoof prints and rain pools to streams, swamps, canals, river beds, ponds,

lakes and crop fields. Each species of mosquito prefers different types of habitats to lay eggs.

Under the best conditions in the tropics, the average lifespan of female Anopheles mosquitoes is

about three to four weeks.

Larvae

A larva hatches from the egg after one or two days and generally floats parallel under the water

surface, since it needs to breathe air. It feeds by taking up food from the water. When disturbed,

the larva quickly swims towards the bottom, but it soon needs to return to the surface to breathe.

There are four larval stages or instars. The small larva emerging from the egg is called the first

instar. After one or two days it sheds its skin and becomes the second instar, followed by the

third and fourth instars at further intervals of about two days each. The larva remains in the

fourth instar stage for three or four more days before changing into a pupa. The total time spent

in the larval stage is generally eight to ten days at normal tropical water temperatures. At lower

temperatures, the larval stages take longer to develop.

Pupae

The pupa is the stage during which a major transformation takes place, from living in water to

becoming a flying adult mosquito. The pupa is shaped like a comma. It stays under the surface

and swims down when disturbed, but it does not feed. The pupal stage lasts for two to three days,

after which the skin of the pupa splits. Then the adult mosquito emerges and rests temporarily on

the water's surface until it is able to fly.

Adult mosquitoes
Mating takes place soon after the adult emerges from the pupa. The female usually mates only

once because it receives sufficient sperm from a single mating for all subsequent egg batches.

Normally the female takes her first blood meal only after mating, but sometimes the first blood

meal can be taken by young virgin females. The first batch of eggs develops after one or two

blood meals (depending on the species); while successive batches usually require only one blood

meal. The process of blood-feeding, egg maturation and egg laying is repeated several times

throughout the life of the mosquito. The length of time between two feeding cycles depends on

the external temperature. In Anopheles arabiensis, for example, the cycle takes 48 hours when

the average day-night temperature is 23°C.

Malaria transmitting vectors in Ethiopia

You have now learned that malaria is transmitted from an infected person to another person by

mosquitoes. However, not all mosquitoes carry malaria. There might be mosquitoes biting

people in your village, but they may not be the ones that transmit the infection. The mosquitoes

that transmit malaria belong to a group of mosquitoes called Anopheles. However, not all

Anopheles mosquitoes are vectors of malaria. For example there are more than 40 species of

Anopheles mosquitoes in Ethiopia, but only four species of Anopheles mosquitoes carry malaria.

The scientific names of these mosquitoes are:

 Anopheles arabiensis

 Anopheles pharoensis

 Anopheles funestus

 Anopheles nili.
An. arabiensis is the most important transmitter of malaria in Ethiopia and is responsible for

more than 95% of transmissions. It is found everywhere in Ethiopia. The other three are

secondary vectors of very minor importance.

Distinguishing the above four species of Anopheles from other Anopheles mosquitoes is not

your responsibility and will not be part of this training. However, it is important for you to

distinguish Anopheles mosquitoes in general from other mosquitoes at their larval stage.

Distinguishing Anopheles mosquitoes from other types

There are two common types of mosquitoes that lay their eggs in water: anophelines, which can

be vectors of malaria, and culicines, which do not carry malaria. It is very important that you

know the difference in the morphology (structure and shape) of these mosquitoes to identify the

exact breeding habitats that support the development of the potential vectors Now study the

differences in the body structure and resting position in water collections of the anopheline and

culicine larvae, as illustrated in Figure 5.7. You don’t need magnifying or other equipment to

distinguish anopheline and culicine larvae. You can tell the difference by looking at the larvae in

the vector breeding waters. Your mentor will show you the difference between the two during

your practical training. This will be a very important part of your task as a Health Extension

Practitioner: identifying water collections that shelter anopheline larvae and taking action to

eliminate such breeding grounds or kill the larvae.

There are four stages in the mosquito life cycle, and three of them — eggs, larvae and pupae —

are to be found in water.

Eggs

Mosquito eggs either clump together in a ‘raft’ (Culex) or float separately (Aedes); anopheline

eggs float separately and each of them has ‘floats’.

Larvae

The culicine larva has a breathing tube (siphon) which it also uses to hang down from the water

surface, whereas the anopheline larva has no siphon and rests parallel to and immediately below

the surface.

Pupae
Pupae of both anophelines and culicines are comma-shaped and hang just below the water

surface. They swim when disturbed. The breathing trumpet of the anopheline pupa is short and

has a wide opening, whereas that of the culicine pupa is long and slender with a narrow opening.

However, it is difficult to distinguish anopheline from culicine pupae in the field.

Adults

With live mosquitoes, you can distinguish between adult anopheline and culicine mosquitoes by

observing their resting postures. Anophelines rest at an angle between 50o and 90o to the

surface, whereas culicines rest more or less parallel to the surface.

Behaviour of mosquitoes that transmit malaria

To help you work effectively to prevent malaria transmission, you need to learn about the most

important behaviours of a malaria-transmitting mosquito.

Female mosquitoes can feed on animals and humans. Most species show a preference for certain

animals or for humans. They are attracted by the body odours, carbon dioxide and heat emitted

from the animal or person. Species of mosquitoes that prefer to feed on animals are usually not

very effective in transmitting diseases from person to person. Those who prefer to take human

blood are the most dangerous as they are more likely to transmit diseases between people. One of

the reasons why An. arabiensis mosquitoes are better vectors of malaria than other mosquitoes is

that they feed mostly on humans and very little on cattle.

Most anopheline mosquitoes bite at night. Some species bite just after sunset while others bite

later, around midnight or in the early morning. Those that bite in the early evening may be more

difficult to avoid than species that feed at night.

Some species prefer to feed in forests, some outside houses and others indoors. Mosquitoes that

enter a house usually rest on a wall, under furniture or on clothes hanging in the house.

Mosquitoes that bite outside usually rest on plants, in holes, in trees, or on the ground, or in other

cool dark places.

Because digestion of the blood-meal and development of the eggs takes 2-3 days, a blood-fed

mosquito looks for a safe resting place that is shaded and offers protection from drying out.

Some species prefer to rest in houses or cattle sheds, while others prefer to rest outdoors, on

vegetation or at other natural sites. After the mosquito takes a blood meal indoors, it usually rests

inside the house, some for a short period and some for days. Mosquitoes do not usually bite

while eggs are developing.

Adult females can normally live between 20 days and one month. The average survival is much

shorter at 6-9 days. The average life-span of the female has direct relevance to its efficiency as a

malaria vector, because it has to live long enough to transmit malaria (i.e. long enough for the

parasite to complete its life cycle in the mosquito host, approximately 10 days).

On average, the flight range of adult Anopheles is between a few hundred metres and 2

kilometres. Therefore water collections very close to houses are more important sources of

vectors than those located far away from houses.

 Assignment

1. Consider a disease known as diabetes mellitus, which is characterized by an increase in

the blood sugar level. Infectious agents may contribute to the development of the disease

in early childhood, but are not the main cause of the disease. Can it be classified as

communicable? Explain your reasons

2. How would you classify pulmonary tuberculosis using the epidemiologic method? What

is the main importance of such classification?

3. Describe four or more bacterial vaccine-preventable diseases that have the same modes of

transmission.

4. What are the causes and methods for preventing bacterial meningitis?

5. Explain two characteristics that illustrate how the Anopheles larvae are different from

other mosquito larvae. Using illustration is advised