NURSING MANAGEMENT OF PATIENT’S WITH IMMUNOLOGICAL

DISORDERS

REVIEW OF IMMUNE SYSTEM

Immune system is the body's major defense mechanism against infectious organisms and
abnormal or damaged cells.
Immune system comprises Leukocytes, Granulocytes, Monocytes, Macrophages, Lymph
nodes, Spleen, Thymus gland and Lymphoid tissues. Tonsils and Adenoids

FUNCTIONS OF IMMUNE SYSTEM

1.Immune system defends and protect human body from infection caused by bacteria, virus,
fungi and para sites.
2. Immune system removes and destroyed damaged or dead cells. Immune system identifies
and destroy malignant cells and prevent the development of tumors.
Minor injuries like lacerations or bruises and major injuries like surgery, burns and
systematic diseases activate immune system of our body.
COMPONENTS OF IMMUNE SYSTEM
LEUKOCYTES (WBC)
These are primary cells of immune system. In the bone marrow, they develop from stem
cells, the hemocytoblasts. Leukocytes migrate themselves to the site of invasion (by bacteria,
virus, fungi and para site) detect it, attack it and destroy anything that is recognised as foreign
material.
The normal number of circulatory leukocytes is 4500 10,000 cell per cubic millimeter of
blood. During infection bone marrow release additional WBC which is called leukocytosis. If
bone marrow does not produce sufficient number of WBC or destruction of WBC is more
than it lead to leukopenia. Granulocytes, monocytes and lymphocytes are three sub types of
leukocytes.

GRANULOCYTES
Granulocytes comprise 60-80% of total number of blood leukocytes. Their cytoplasm have
conscious granules with destinctive coloration. Granulocytes live for few hours to few days.
When foreign material enter into the body, they protect the body from them. Neutrophils,
eosinophils and baso phils are three subtypes of granulocytes.
Neutrophils (polymorphonuclear leukocytes) → They have 10-12μm diameter and nucleus
has 2-5 lobes. Neutrophils are produced in the bone marrow and released into the circulation
when they get matured. These cells perform phagocytosis. They destruct the bacteria with
lysosomes.
Eosinophils : Eosinophils have 10-12 um diameter. They comprise 1-4% of total number of
the circulating leukocytes. They get mature in bone marrow within 3-6 days and released in
circulation. They have 30 minutes circulating half life and 12 days tissue half life. They
found in large number in GI tract and respiratory tract. They destroy certain parasitic worms
by releasing toxic enzymes. They also involve in hyper sensitivity response and phagocytize
antigen-antibody complexes during inflammatory response.
Basophils: Their diamter is 8-10 um and they comprise 0.5-1% of all WBCs. Their nucleus
has 2 lobes and their granules applear deep blue purple. Basophils release heparin, histamine
and serotonin during allergic reactions/hypersensitivity or stress response.

AGRANULOCYTES
Agranulocyte leukocytes possess cytoplasmic granules and they are not visible under light
microscope due to poor staining qualities. Manocytes, macrophages and lymphocytes T cells
& B cells are types of agranulocytes and are mediators of immunity.
Monocytes: It comprises 3-8% of all WBCs. After release from bone marrow, they circulate
for 1-2 days in serum. Nucleus of monocytes is kidney shaped or horse shoe shaped and
cytoplasm is blue gray and have foamy apperance. Blood transports monocytes into tissue
and get mature into macrophages. Some becomes fixed macrophages (reside in particular
tissue) e.g. alveolar macrophages in lungs, microglia in brain, macrophages in spleen, lymph
node, bone marrow & tonsils, kuffer cells in liver. Other becomes wandering macrophages
which roam in tissues & gather at site of infection. These cells do phagocytosis.
Lymphocytes: It comprise 20-25% of all WBCs. Its diameter is 6-9 µm and some has 10-14
um diameter. Lymphocytes dervie from stel cells in bone marrow. They have homing pattern
as they circulate and then return to concentrate lymphoid tissue (lymph nodes, spleen, thymus
gland, tonsils, peyer's patches of ileum and appendix). They mediate immune response.
B cells develop into plasma cells which secrete anti bodies.
T-cells invade virus, cancer cells and transplanted tissue cells. Natural killer cells wide
variety of infectious microbes and certain spontaneously arising tumor cells. Function of
these three cells is inter-related.
NK cells are found in spleen, lymph nodes, bone marow and blood. They provide imune
surveillance & resistance to infection.

LYMPHOID SYSTEM
It consists of the lymph nodes, spleen, thymus tonsils and lymphoid tissue.
Thymus gland: It is bilobed organ located in mediastium between sternum and aorta. The
thymus have deeply staining outer cortex & light staining central. medulla. The cortex
composed of large number of T-cells and epithelial cells & macrophages. Immature T-cells
migrate from red bone marrow to cortex of thymus, where they get mature. Medulla consist
of mature T-cells, epithelial cells, dendritic cells & macrophages. Thymosin, immuno
regulatory hormone of thyumus, stimulate lymphopoiesis, formation of lymphocytes or
lymphoid tissue.
Spleen: It is largest lymphoid organ in the body. It is located in the left hypochondriac region
between the stomach and diaphragm. Spleen filter the blood. Spleen has two kind of tissue.
White pulp & red pulp. White pulp serve a site for lymphocyte proliferation and immune
surveillance. Blood filtration takes place in red pulp. In venous sinus of red pulp phagocystic
cells dispose of damaged or aged RBCs & platelets. Bacteria, virus, toxins are also removed
from blood. It also stores blood and breakdown products of RBCs.
Lymph nodes: Body has about 600 bean shaped lymph nodes. They are 1-25 mm long and
covered by capsule of dense connective tissue and extend into lymph node capsular exten
sions that are called trabeculae and divide the node into compartments and provide support
and passage to blood vessels into interior of node. Lymph nodes filter foreign products or
antigens from lymph and provide place and space for proliferation of lymphocytes & mac
rophages.
Bone marrow: Hollow cavity of long bones have soft tissue called bone marrow. It is present
in mainly femur, humerus as well as flat bones of pelvis, ribs & sternum. It produce & store
hematopoietic stem cells. All components of blood produced in bone marrow.
Antigen :
Antigens are substances that are recognised as foreign. When they enter into body they
initiatve specific immune response. Antigens are large protein molecules. It have two
characteristics.
Immunogenicity is the ability to stimulate a specific immune response. Specific reactivity -
ability to stimulate specific immune system component.

IMMUNE RESPONSE
Small parts of large antigen molecule act as the triggers for immune responses and they are
called epitons or antigen determinants. Most antigen have many epitons and they activate T
cells for production of a specific antibodies.
Immune response involve two types of cells - lymphocytes and antigen presenting cells
(APCs) when antigen encounter the body. All APCs are dendritic cells (DC) and develop
from stem cells in bone marrow, DC arise from monocytes, myeloid type immune cells.
Dendrite cells derive from lymphocyte precursors. DC activate T cells against cancer cells.
DC, help the B lymphocytes to produce antibodies and regulate immune system to prevent
autoimmune disease.
B cells produces antibodies (immunoglobulins) that eliminate bacteria, bacterial toxins and
free viruses called antibody mediated response. T cells form cell mediated cellular immune
response when they are activated by viral infected cells. Cancer cells and foreign tissue
transplants. Cell mediated response always involve all attacking cells. Depending upon the
location given pathogen initiate both types of immune response.
DEFENCE OF BODY
Skin and mucous membranes of body act as first line of defense against pathogens. Pathogen
very rarely can enter the intact skin but if skin is broken virus, bacteria can pen etrate the
epidermis and invade adjacent tissues or circulate in blood & other parts of body.
Mucus membranes have mucus and it trap the foreign material with help of cilia e.g. swal
lowing mucus send the bacteria to stomach and gastric juices destroy them.
INTERNAL DEFENCES
Pathogens cross the physical & chemical barrier of the skin and mucous membrane, then
encounter a second line of defense: antibodies, phagocytes, natural killer cells, inflamma tion
and fever.
1. Anti microbial proteins: Virus infect the lymphocytes macrophages and fibroblasts and
they produce protein called interferons. Interferons diffuse unaffected cells and synthesize
antiviral proteins with prevent replication of virus. Transfeurins (iron bind proteins) inhibit
the growth of certain bacteria by supplying less iron to them.
Natural killer cells & phagocytes: Natural killer cells bind to infected human cell and
release granules that contain toxic substances or protein (perfoxin) and create channel in
membrane and cytolysis occur. They destroy cells but microbes does not die. They are de
stroyed by phagocytosis.
Phagocytes: Phagocytes engulf microbes and other cell derbis. This process is known as
phagocytosis. Phagocytosis occur in five phases: chemotaxis, adherence, ingestion, digestion
and killing.
Chemotaxis - Invading microbes, WBCs, damaged tissue cell or activated complement pro
teins secrete chemicals that attract phagocytes.
Adherence Adherence means attachment of phagocyte to microbe. Ingestion - Phagocytes
extends projections called pseudopods and engulf microbe. This process is called ingestion.
Pseudopods meet and form sac called phagosome that surround microorganism.
Digestion - Phagosome merge with lysosome in the cytoplasm and form phagolysosome.
They break the wall and secrete lethal oxidants.
Killing - Microbes are killed by oxidants & digestive enzymes secreted by lysosome. They
kill microbe within phagolysosome.
INFLAMMATION
It is a nonspecific, defensive response of body to tissue damage. Pathogens, abrasions,
chemical irritants, disturbance of cells and extreme temperatures may produce inflammation.
Redness, pain, heal & swelling are the four main characteristics of inflammation.
Inflammation is an attempt to prevent their spread to other tissues, dispose off microbes,
foreign material & toxins and prepare site for repair.
STAGES OF INFLAMMATION
Vasodilation: Vasodilation (increase in diameter) & increased permeability is a immediate
reaction of inflammation. Increased permeability permits the antibodies and clotting factors
from blood to enter in the injured area.
Histamine: Neutrophils and macrophages go to the site of injury and stimulate the release of
histamine which cause vasodilation.
Kinins: Polypeptides Kininogens formed in blood and cause vasodilation & increase
permeability and serve as chemotactic agents for phagocytosis.
Prostaglandins (PGs): These lipids are released by damaged cells and intensify effect of
histamine and kinins. It also stimulates the emigration of phagocytes through capillary walls.
Leukotrienes (LTs): Basophils and most cells produce leukotrienes - They cause permeabil
ity and help in adherance of phagocytes to antigens.
Complement: This promotes phagocytosis.
IMMUNITY
Immunity refers to the protection of the body from disease. Immunity can be natural or
acquired, active or passive. Immunity is produced by activation of Body's immune response.
Immunocompetent clients have immunity to in activate and remove the antigen.
Active immunity: When body produces antibodies or develops immune lymphocytes against
specific antigens is called active immunity.
Active immunity result from disease producing agents and after development of disease for
example chicken pox. After chicken pox, person got life long immunity. This type of immu
nity also called natural immunity.
For some diseases, if you want to prevent spread of disease in community mainly for highly
infectious diseases that cause epidemics. For that, immunization or vaccination is used to
provide artificially acquired immunity. Vaccination provide adequate level of antibodies and
memory cells also provide effective immunity e.g. MMR, typhoid vaccine.
Passive immunity : Passive immunity provide temporary protection against disease pro
ducing antigens. It is provided by antibodies produced by animals or other people. Mother
transfer antibodies via placenta and breast feeding to infant and it is called naturally ac quired
passive immunity. Rabies human immunoglobulin and hepatitis B immune globulin are
examples of artificially acquired passive immunity.

ASSESSMENT OF IMMUNE SYSTEM

Health history and physical examination used to assess immune function.
HISTORY
1. Biographical and demographic data
Gender: Age, sex and living environment has to be asked. Some auto immune diseases are
more common in females as compared to males
GERANTOLOGIC CONSIDERATIONS
Frequency and severity of infections are increased in old age people due to decreased ability
to respond to antigens. Production of B & T lymphocytes also decreased in bone marrow.
Various systems of body also have decreased functional ability e.g. enlargement of prostate
gland cause statis of urine which impair bacterial clearance in renal system and predispose
the person to UTIs.
Nutrition: Nurse should assess the nutritional pattern of patient. Inadequate intake of
proteins, lipids impair immune function. Lipid deficiency also lead to deficiency of fat solu
tion vitamins. Vitamins help in maturation of immune cells. Present Illness: Allergic
reactions, altered immune system or disorders of lympathetic disorder produced clinical
manifestations. Ask these manifestations: Quality and quantity of symptoms like rhinitis,
sneezing, nasal stuffiness, wheezing, coughing, fatigue, vomiting, diarrhoea, pruritis has to be
asked from patient. Patient may report lymph node swelling and edema of extremity.
Ask about severity and location of symptoms like severity of skin rash, location of swol len
lymph nodes.Enquire from patient regarding precipating factors or allergens include inhalants
(e.g. pollens, spores, dirt) contact agents (soap, fibers, cosmetics & topical drugs & lotions).
Ingested agents (e.g, food, drugs liquid) and injectables e.g. drugs vaccines. Ask the client
about events that predispose the person for occurance of these symptoms.

Ask about the treatment that decrease or stop the symptoms/disease e.g, drugs, home
remedies etc.

PAST HEALTH HISTORY

Childhood disease: Ask about childhood disease or allergic manifestations e.g. sneezing,
coughing and wheezing and treatment that relieved those illnesses. Also take history
regarding suffering from any infectious disease and recent exposure to any infection &
allergen e.g. Tuberculosis.
Immunizations - Ask about previous immunizations, any immunization taken against al
Allergies Ask the client about previous history of allergy and factors that relieve that allergy.
particular allergy (food, drugs).
Ask about any history of anaphylactive reaction and any hospitalization due to allergic reac
Major illnesses and hospitalization: Ask the client about major illness like Cancer, Sexually
transmitted diseases (STDs) (Gonorrhea, Syphilis, HPV infection), Hepatitis A, B, C, D, E,
HIV, Autoimmune diseases (e.g. rhematoid arthritis SLE), Tuberculosis, Surgery (e.g. mas
tectomy with axillary clearance), Renal disease, congestive heart failure. Hypertension and
Peripheral vascular disease psoriasis. History of previous blood transfusions also be taken.
Family health history: Ask about any allergy and sensitivity (eg. Hay fever) as it runs in
families.
Psychosocial history: Ask about occupation (occupation like working in cotton industries,
dust exposure) and area of working (like in open field or near roadside), as it predispose the
person for allergic reactions.
Environment: Ask about home and outside environment like presence of pets, vegetation
near house.
Habits: Ask about habits of person like smoking poor nutrition and alcohol intake and
exercise.
All the body systems should be reviewed regarding following associative
REVIEW OF SYSTEMS
General manifestations: Malaise, fatigue, unusual reaction to insect cluding over the counter
(OTCs), fever. problems. bite or medicines, in
Integumentary system: Rashes, dermatitis, ulticaria, pruritis, scratching, dryness & scaling.
Respiratory: Rhinitis, change in rate of respiration, dyspnea, frequent cough (dry or pro
ductive) bronchospasm, respiratory distress and hyperventilation. Cardiovascular:
Hypotension, tachycardia, vasculitis, anaemia dysrhythmia.
Gastro intestinal: Diarrhoea, vomiting, cramping, food intolerances, colitis. Genitourinary
system: Hematuria, any discharge and increased frequency of urination burning micturation.
Musculoskeletal system: Joint mobility, edema & pain. Neuro sensory system: Hearing loss,
visual changes, headache & migraine, ataxia, tetany and cognitive dysfunction.
Apart from body systems, also assess organs to rule out presence of these symptoms: Eyes-
excessive lacrimation, rubbing or blinking, conjunctivitis, dark circles around eyes. Ears-
pain in ear, feeling of fullness in ears, rupthered tympanic membranes. Nose sneezing,
rhinitis, nasal polyps, nasal voice quality, nose rubbing, epistaxis. Throat-swollen lips or
tongue,
PHYSICAL EXAMINATION
Disorders of lympathetic system includes inflammation & lymphadenopathy & enlargement
of lymph nodes. Superficial lymph nodes, liver & spleen are accessible during palpation.
Techniques used for assessment are inspec tion & palpation. Inspect the patient's skin and
mucus mem brane for lesions, dermatitis, purpura, ulticaria, inflamma tion. Also inspect for
chills & sweating.
Inspection: metry.
Palpation- Axillary lymph nodes, anterior and posterior cervical nodes and inguinal lymph
nodes are palpated for swelling, tenderness & warmth. Normally lymph nodes are small (1cm
diameter or less than 1cm), round, soft, single, non tender particularly in cervical & inguinal
areas.
Abnormal lymph nodes are larger than 1cm diameter, hard, fixed to underlying tissues &
tender. Identify these characteristics thoroughly and note down the location of lymph node.

DIAGNOSTIC TEST
TEST OF IMMUNOLOGIC STATUS
1) Complete blood counts.
2) CD, cell count in HIV patients depict depletion of T helper cells.
3) T and B lymphocyte assays e.g. increased levels are present in chronic lymphocytic
leukemia, multiple myeloma, diGeorge syndrome and reduced levels are in acute
lymphocytic leu kemia and severe combined immunodeficiency disease...
4) Bone marrow biopsy done to rule out blood disorders.
5) Immunoglobulin assay: Test for humoral immunity
B cells quantification with monoclonal antibody. Specific antibody response.
Total serum globulins and individual immunoglobulins by electrophoresis.

TEST FOR CELLULAR IMMUNITY

Total lymphocyte count.
Delayed hypersensitivity skin test.
Cytokine production.
Helper and suppressor T cell functions.
6) Phagocyte cell function test.
7) Acquired Immuno Deficiency Syndrome Test (AIDS).
1. Enzyme linked immunosorbent assay (ELISA) - done in HIV suspected patient. It has high
sensitivity.
2. Western blot - More specific test for presence of HIV antibody.
3. Radio immuno precipitation assay (RIPA) - Done in HIV patients.
It is more time consuming than western blot.
4. Polymerase chain reaction.
8) Hypersensitivity Test: Scratch test, patch test, intradermal test and radio allergosorbent test
(RAST) done to check hypersensitivity.
9) Lymphangiography: Lymphangiography allows direct visualization of the lympathetic
system to assess the presence of primary malignancy.
10) Specific antigen antibody test: Complement fixation test, agglutination and
imunofluorescence done to rule out specific antigen antibody reaction.
11) Food allergy testing: Food allergy are tested by skin testing.
testing.

IMMUNODEFICIENCY DISORDERS

When immune system of body does not adequately protect the body, immuno deficiency
exists. Immuno deficiency disorder are primary & secondary. Immuno deficiency disorder
exist due to impairment of one or more immune mechanisms dysfunction which include
phagocytosis, humoral response, cell mediated response, complement and a combined hu
moral and cell mediated deficiency.

PRIMARY IMMUNO DEFICIENCY DISORDERS

Primary immuno deficiency disorders occur when immune cells are improperly developed
and immune cells are absent. Phagocytic defects, B-cell deficiency, T-cell deficiency, a com
bined B-cell and T-cell deficiency. Mostly these disorders are genetic in origin. They occur
more in infants as compared to adults. Patient are more susceptible to infections.

Ten warning signs of primary immuno deficiency diseases

1.Eight or more new infections per year.

2. Two or more serious sinus infections/year.
3.Two months use of antibiotics without any effect.
4. Two or more episodes of pneumonia within a year.

5. Failure to thrive.
6. Recurrent, deep abscesses.
7. Persistent thrush after 1 year of age.
8. Need for intravenous antibiotics,
9. Two or more deep seated infections (sepsis, meningitis, cellulitis).
10. Family history of primary immunodeficiency diseases.
PHAGOCYTIC DYSFUNCTION
All phagocytic defects are genetic in origin and mainly innate immune system of body af
fected. In some types of phagocytic disorders, the neutrophils are impaired, due to this they
cannot exit the circulation and travel to site of infection. As a result patient can not start
inflammatory response against pathogenic organisms.
CHRONIC GRANULOMATOUS DISEASE
This disease is caused by defects in the phagocyte nicotinamide dinuclatide phosphate
(NADPH) oxidase. Patient represents with recurrent or persistent infections of soft tissue,
lungs & other organs and resistant to aggressive treatment with antibiotics. Phagocytic dis
orders include quantitative phagocytic cell deficiency e.g. neutropenia or qualitative func
tional defects of these cells.
Clinical manifestations:
In phagocytic cell disorders, incidence of bacterial (Staphylococcus aureus, E-coli, Klebsiella
species, Salmonella etc.) & fungal (Mycobacterium species, Candida glabrate, Candida
albicans, Aspercillus fumigatus) infections increased. These disorders are caused by non
pathogenic organisms which normally does not cause disease. People develop fungal
infections from candida organisms and viral infections from herpes simplex or herpes zoster
and bacterial infections. Patient have recurrent cutaneous abscesses, gingivitis, chronic
eczema, bronchitis, pneumonia, chronic otitis media and sinusitis, frequent & recurrent pneu
monia.
Hyper immuno globulinemia E syndrome (Job syndrome). White blood cells can not ini tiate
an inflammatory response to infectious organisms - Patient represents with recurrent skin and
pulmonary abscesses, abnormalities of connective tissue, skeleton and dentition and patient
have extremetely high levels of immunoglobulin (IgE). Phagocytic cell disorders may be
symptomatic, but severe neuropenia exists and patient have deep and painful mouth ulcers,
gingivitis, stomatitis and cellulitis. Death may occur in 10% of patient with neutropenia due
to excessive infection.
Diagnosis: Complete history should be taken to assess signs/symptoms of recurrent infec tion
with fever in child. Rarely present in adults. This provide key to diagnosis. Laboratory
analysis by the nitroblue tetrazolium reductase test (NBT). It indicate the cytocidal (causing
death of cells) activities of phagocytic cells (expressed as percent reducing neutrophils).
Medical management: Neutropenic patients have more risk for infections despite advances
in supportive care. Antibiotic (Trimethoprim Sulfamethoxazole), anti-viral & anti-fungal
(Itraconazole-adult dose 200mg; not to exceed 400mg/day) treatment given for the treatment
of infections. Granulocyte transfusions are used sometimes but rarely helpful as it have short
half life. Granulocyte colony stimulating factor (G-CSF) or Granulocyte-macrophage colony
stimulating factor (GM-CSF) are proved successful because these proteins draw non
lymphoid stem cells from bone marrow and increase their maturation.
Bone marrow transplantation rarely performed as it is controversial because of high risk of
serious complications which can cause death. Hematopoietic stem cell transplantation can
also be used and it is very helpful as it help in regeneration of all deficient cells.
NURSING MANAGEMENT
Standard infection control measures should be taken e.g. wearing lap, mask, gown. Hand
washing is very important. All these measures prevent infection.

B CELL DEFICIENCIES
B cell deficiencies are inherited. It has two types - (1) Lack of differentiation of B cells
precursors into mature B cells. Due to this plasma cells are absent, and germinal centers from
all lympathetic tissue disappear which lead to complete absence of antibody production
against invading infectious material e.g. bacteria, virus, fungi & parasite. (ii) B cell
deficiency due to lack of differentiate of B cells into plasma cells. Sex linked
agammaglobulinemia (Bruton's disease). X linked a gamma globulinemia is more common in
males if they have affected male relative. In this disease, all antibodies disappear from plasma
of the patient. Immunoglobulins IgG, IgM, IgA, IgD, IgE and B cells are low or absent in
peripheral blood. Due to this infants suffer from severe infections soon after birth at less than
6 months of age.
CLINICAL MANIFESTATIONS
Sex-linked a gamma globulinemia: Mother transfer some antibodies to baby which present
upto 5-6 months of age of baby. As these antibodies decline- infant become sympomatic with
severe pyogenic infections and may need hospatilization.
II. Hypogammaglobulinemia: It is also called common variable immuno deficiency disease
(CVID). This B cells deficiency result for lack of differentiation of B cell into plasma cells.
Diminished antibody production present in this disorder. Patient have normal lymph fol licles
and many B lymphocytes that produce some antibodies. CVID- incorporate variety of defects
ranging from immunoglobulin A deficiency. In some patients only the plasma cells that
produce IgA are absent. At other extreme patient have severe panhypoglobulinemia (IgG,
IgA and IgM) (general lack of immunoglobulins in blood). This disease occur in adults and
gender does not affect the disease occurance.
CVID: Pernicious anemia present in more than half of the patients. Lymphoid hyperplasia of
small intestine, spleen and gastric atropy present when we do the biopsy. Patient may develop
rheumatoid arthritis and hypothyroidism. Patient have increase risk of chronic lung disease,
hepatitis, gastric cancer and malab sorption (which cause chronic diarrhea). Patient with
CVID are more susceptible to infections with haemophilus influenzae, strep tococcus
penumoniae and staphylococcus aureus. Patient have chronic progressive bron chiectasis and
pulmonary failure due to frequent respiratory tract infections. Patient with bronchiectasis
have regular cough in morning with yellow or green sputum. Patient may have Giardia
lamblia infection (Giardia lamblia protozoa cause inflammation of intestine & diarrhea).
Pneumocystis pneumonia (PCP) also seen in patients as opportunistic infection.
DIAGNOSIS
1. Serum immunoglobulins (IgG, IgM and IgA) checked which shows deficiency and ab
sence of all serum immunoglobulins.
History of patient taken regarding recurrent bacterial infections (respiratory, GI tract). B cells
count along with specific immunoglobulins, levels are measured.
Serology test done to monitor the titer level of antibodies of childhood vaccinations.
Childhood immunizations indicate the functioning of B cells during infancy & child hood.
Hemoglobulin & hematocrit levels are checked to rule out pernicious anemia.
Biopsy of spleen, stomach & small intestine may be done to assess lymphoid hyperplasia.

MEDICAL MANAGEMENT
1. Intravenous immunoglobulin given in case of primary B cell deficiency disorders.
2. Interleukin 2 therapy may be given, but this is still under trial.
3. Antimicrobial treatment given for respiratory infections.
4. Metronidazol given for 7-10 days to treat G. lamblia infestation of intestine. Atabrine
(Quinacrine HCI) also be given.
Vitamine B, injections given as monthy basis for the treatment of pernicious anemia (vitamin
B,, deficiency). Postural drainage & physiotherapy given to patient with chronic lung disease
or bronchiectasis.
INTRAVENOUS IMMUNOGLOBULIN IVIG INFUSION
Intravenous immunoglobulin (IVIG) given to patient having primary immunodeficiency dis
order. Dosage 100-400mg/kg body weight administered monthly or more frequently to ensure
adequate serum levels of immunoglobulin G.
Adverse effects: Flank pain, chills, tightness in chest which terminating with slight rise in
body temperature. - Hypotension
- Anaphylactic reactions
Available preparation; It supplied in 5% solution or a lyophilized powder with a reconsti
tuting diluent prepared from cohn fraction II obtained from pools of 1000 to 10,000 donors.

NURSING RESPONSIBILITIES
1. Check the weight of patient prior to treatment.
2. Check vital signs before, during and after IV infusion of IVIG.
3. Administer prescribed pre treatment prophylactic aspirin or IV antihistamine such as
Benadryl.
4. Check long term tolerance of persons receiving IVIG if you have to change the preparation
as all preparations are not biological equivalent.
5. Administer IV infusion at slow rate not to exceed 3ml/min.

6. Be aware that corticosteroids may be used to prevent possible severe reactions.

7. Be careful about reactions as patients have low gamma globulin levels and may have more
severe reactions than those with normal levels (eg, patients who receive gamma globulin for
thrombocytopenia or kawasaki disease.
8. Always keep in mind that patients who have imunoglobulin A (IgA) deficiency, they have
IgE antibodies to IgA, which requires administration of plasma or immunoglobulin
replacement from IgA deficient patients as All IV immunoglobulin preparations contain some
IgA that may cause anaphylactic reaction in patients with IgE anti IgA antibodies.
9. Risk for transmission of hepatitis, HIV or other virus is extremely low with this admin ister
of IVIG
T-CELL DEFICIENCIES
T-cell deficiencies are genetic disorders, T-cells play a regulatory role in immune system
function. T cells loss of function occur along with loss of B cell function. T cell deficiency
persons have more susceptibility to in fections.
Thymic hypoplasia (DiGeorge syndrome): It is a primary T cell immuno deficiency
disease. This is caused by genetic abnormality in which several genes are ab sent on
chromosome 22. Symptoms of disease vary according to differences in the amount of genetic
mate rial affected. Thymus gland fails to develop normally during embryogenesis which lead
to T-cell deficiency. Immediately after birth infant manifest symptoms like cardiac anomaly.
Clinical manifestations: In this syndrome infants born with hypo parathyroidism with
resultant hypocalcemia (resistance to standard therapy of calcium), congenital heart failure,
cleft lip & palate, dysmorphic facial features and possibly renal abnormalities. Infants with
Di George syndrome are susceptible to yeast, fungal, protozoan and viral infections mainly
more susceptible to childhood diseases (chickenpox, measles, rubella). Usually these infec
tions are severe & fatal. Infants who born with congenital heart defects can have heart failure.
In this syndrome most frequently presenting sign is hypocalcemia which is resistant to
standard therapy and this occur within 24 hours of life.
Chronic mucocutaneous candidiasis: This T-cells disorder associated with selective defect
in T-cell immunity. It is caused by an autosomal recessive inheritance. It occur equally in
male & females. This disease occur with or without endocrinopathy. This auto immune dis
order involve thymus and other endocrine glands.
Clinic manifestations of chronic mucocutaneous candidiasis : Initial presentation of this
disease may result of either chronic candidiasis infection of mucous membrane, skin & nails
or idiopathic endocrinopathy. Patient manifestation include hypocalcemia and tetany sec
ondary to hypofunction of parathyroid gland. Addison's disease (hypofunction of adrenal
cortex) is a major cause of death in these patients. This occur suddenly and without any
history of previous symptoms.
Diagnosis: T-cell count evaluated Comprehensive immunologic analysis also done. FISH
analysis (For fluorescent In Situ Hybridization)- Identify microdelection of chro mosome no.
22 at position 22q 11.2. It helps in diagnosis of DiGeorge syndrome.
MEDIAL MANAGEMENT & DI GEORGE SYNDROME
Oral calcium supplements along with vitamin D or tients to treat hypocalcemia. parathyroid
hormone given to pa Surgical intervention required for congenital heart disease, Thymus
graft-Fetal thymus, postnatal thymus or human leukocyte antigen (HLA) matched bone
marrow used for permanent reconstitution of T-cell immunity. DiGeorge Syndrome: T-cell
function improves with age and become normal by 5 years of age.
IVIG therapy used for antibody deficiency.
Chronic mucocutaneous candidiasis antifungal agents-Miconazole (topical), clotrimazole &
ketoconazole orally and IV amphotericin B given.
COMBINED B CELL AND T CELL DEFICIENCIES
Combined B cell and T cell deficiencies affect the immune system. They comprise a heterog
enous group of disorders and characterised by profound impairment in development or
function of cellular, the humoral or both parts of immune system. Autosomal recessive and X
linked conditions present in these disorders. These conditions appear early in life. It
comprises three disorders.
1. Ataxia telangiectasia: It is an autosomal recessive neuro degenerative disorder. It is
caused by defect on chromsome 11. Ataxia telangiectasia mutation affects both T cell & B
cell immunity. Selection IgA deficiency exist in 40% of patients. IgA and IgG subclass
deficien cies along with IgE deficiencies has been identified. T cell deficiency with variable
degree observed and it become severe as age advances. This disease is associated with
neurologic, vascular, endocrine, hepatic and cutaneous abnormalities. It is accompanied by
progressive cerebellar ataxia, telangiectasias, recurrent bacterial infection of the sinuses and
lungs and an increased incidence of cancer. Ataxia telangiectasia: Ataxia and telangiectasia
(vascular lesion caused by dilated blood vessels) of eyes and skin occur in first 4 hours of
life. Chronic lung disease, cognitive impairment, neurologic symptoms (unsteady gait-ataxia)
and physical disability become severe after 10 years of age.
In case of long term life survivors person develop progressive deterioration of immunologic
and neurologic functions. Some patient has life up to 50 years of life. Death in patients occur
due to infection or lymphoreticular or epithelial cancer. 2. Severe combined immuno
deficiency disease: SCID is a term used for wide variety of congenital and hereditary
immunologic defects. These defects are characterised by early onset of infection and defect in
B cell & T cell systems, lymphoid aplasia and thymic dyspla sia. This is X linked, autosomal
recessive or sporadic inheritance disorders
Clinical manifestations of SCID: Symptoms appear within first 3 months of life. Respira
tory infections and pneumonia, oral thrush, diarrhoea and failure to thrive are main symp
toms. Some infections have resistant to treatment. Shedding of viruses such as cytom virus
from the respiratory and gastrointestinal tract and respiratory syncytial persistant.
Maculopapular and erythematous skin rashes may occur. Other common manifestations are
vomiting, fever and persistent rash.
Wiskott- Aldrish Syndrome (WAS): It is an inherited immunodeficiency caused by a
variety of mutations in gene encording the WAS protein. WAS protein gene is located on the
short arm of the X chromosome. Characteristics of this disease are frequent infections,
thrombocytopenia with small platelets, eczema and increased risk for auto immune disor ders
& malignancies. Patient also have bleeding due to thrombocytopenia. Blood vessel
inflammation (Vasculitis) is a most common autoimmune manifestation. Anaemia may occur
as antibodies destroy. Patient's red blood cells (hemolytic ane mia). Some patients have high
fever in absence of infection, associated with swollen joints, tender lymph gland, kidney
inflammation and gastrointestinal symptom such as diarrhoea.
Nozelof's Syndrome: Characterised by severe infections & malignancies.
TREATMENT
Ataxia-telangiectasia
Antimicrobial therapy.
Postural drainage and physical therapy for the treatment of chronic lung disease. Fetal thymus
tissue transplantation and IVIG administration done. Vaccination with influenza and
pneumococcal may be helpful.
SCID:
Stem cell & bone marrow transplantation done.
Human leukocyte antigen-identical sibling can donate stem cells for patient which can be
transplanted.
IVIG administration can be given.
Thymus gland transplantation can be done.
Wiskott-Aldrish Syndrome: Antimicrobial treatment given.
Splenectomy with continuous antibiotic therapy prophylaxis done.
IVIG administration given.
Bone marrow transplantation can be given.
For prophylaxis - continuous antibiotic therapy given. For autoimmune diseases- High dose
of immunosuppressive & steroids can be given.
Nezelof's syndrome: Antimicrobiology therapy, IV immuno globulins can be administered.
Bone marrow & thymus transplantations can be done.
NURSING MANAGEMENT
Nursing diagnosis: Risk for infection due to disease condition.
Nursing interventions :
1. Hand washing should be done prior to entering in the room & touching the patient and
prior to any procedure.
2. Use standard infection control practices like wearing gown, gloves, mask.
3. Always monitor the patient in clinical setting for infection e.g. presence of fever & other
symptoms.
4. Identify all the complications in advance.
5. Monitor all haemodynamic functions of patient to assess risk for secondary infections
which can be fatal.
SECONDARY IMMUNODEFICIENCIES
Secondary immunodeficiencies are acquired deficiency. Secondary immunodeficiencies oc
cur due to underlying disease or treatment of underlying disease. Causes of secondary
immunodeficiencies include:
Malnutrition, chronic stress, burn, uremia, diabetes mellitus, exposure to immuno toxic drugs
(corticosteroids and chemotherapeutic). Certain autoimmune disorders SLE, certain virus
(Epstein Barr virus) infection, exposure to immunotoxic chemicals, self administration of
recreational drugs and alcohol. AIDS is a most common secondary immunodeficiency disor
der.
CLINICAL MANIFESTATIONS
Secondary immunodeficiencies cause immuno suppression and patients are called immuno
compromised hosts.
Atrophy of the thymus gland & lymphoid tissue occurs.
Increased susceptibility to infections.
NURSING MANAGEMENT OF PATIENTS WITH IMMUNO DEFICIENCIES
Complete assessment has to be done and history has to be taken regarding all the infections,
their predisposing factors and frequency of occurance of infections and methods & response
to past treatments.
Assessment has to be done regarding identification of sign & symptoms of present ill ness-
skin, respiratory, oral, gastro intestinal or genito urinary infections and measures taken to
relieve these symptoms.
Nutritional status, stress level and coping skills of patient assessed. Use of alcohol, drugs,
tobacco nutrition and general hygiene practices assessed.
Nursing diagnosis: Risk for infection due to immunodeficiency. Nursing interventions: Hand
hygiene must be assessed and proper hand washing should be taught to patient.
- Good dental and personal hygiene should be taught to patient.
- Standard infection control measures should be taught to patient eg. doning of gown, gloves
& mask. Strict asepsis should be maintained during invasive procedures such as dressing ch
venipuncture and bladder catheterization.
Teach the patient to avoid contact with person who has infection. Continuously monitor the
lab valves e.g. bloodculture, urine culture stool culture, if wound present- wound culture.
2. Deficient knowledge
Nursing interventions: All the treating options should be explained to patient e.g. Gene
therapy, bone marrow & stem cell transplantation, thymus transplantation and use of intra
venous immunoglobulins (IVID).
Advice the patient to practice good hand washing technique & maintenance of hygiene.
Potential risk and benefits of the treatment should be explained to patient.
Teach the patient regarding signs & symptoms that has to identified such as fever, chills, wet
or dry cough, breathing problems, swollen glands, nausea/vomiting. Report these
manifestations to physicians. Teach the patient to take good nutrition.

Educate the person that he should avoid eating raw fruits & vegetables. Teach the patient that
he should stop consumption of alcohol, tobacco and use of unprescribed medicines.
Advice the patient to take proper rest and regular exercise. Advice the patient regarding
cleaning of kitchen, bathroom to prevent infection.

ACQUIRED IMMUNO DEFICIENCY SYNDROME

French scientists in 1983 isolated etiologic agent associated with AIDS and named
lymphodenopathy associated virus (LAV). After one year American scientist claimed the
discovery of etiological agent & named it human T-cell lymphotropic virus type III (HTLV
III). Infact both scientist discovered same virus in 1986. International society on the tax
onomy of viruses renamed the virus are called it Human immunodeficiency virus.
Since 1986, two scientific names are used to distinguish between two virus are HIV 1 & HIV
2. After that it was discovered that this virus can mutate rapidly and also change its shape/
appearance.
EPIDEMIOLOGY
Worldwide AIDS kills more than 8000 people every day, 1 person every 10 sec onds
(UNAIDS, 2006). AIDS has claimed almost 39 million lives; namely affected HIV patients
includes 50% males & 50% females and unsafe sex practices was predominant most of
transmission. Estimated number of HIV infections in In dia has declined as from 5.5 million
in 2005 to below 2.5 million in 2007. According to "UNAIDS reports 2011 there has been
50% decline in cases.
Agent:
HIV virus is a RNA virus. It has 1/10,000th of a millimeter in diameter. It has protein capsule
containing two strands of genetic maternal (RNA and enzymes). Virus replicate in T
lymphocytes and remain in lymphoid tissue in latent state. HIV virus is easily killed by heat.
Source of infection: Virus found in greatest concentration in blood, semen & CSF. Lower
concentration has been detected in tears, saliva, breast milk, urine, cervical and vaginal
secretions. HIV virus also been isolated in brain tissue, lymph nodes, bone marrow cells &
skin.
Most cases have occured between age group of 20-40 years (sexually active persons) and
this. Children under 15 years of age contribute 3% of cases.
High risk groups: Male homosexuals and bisexuals, heterosexual partners (including
prostitutes), intravenous drug abusers, transfusion recipients of blood & blood products,
haemophilias & patients suffering from STDs.
Incubation period: It ranges from 6 weeks-10 years. Antibodies are produced against virus
and detectable in blood between 6 weeks to 6 months. It is also called window period.
MODE OF TRANSMISSION
1. Sexual transmission:
Unprotected sexual contact with HIV infected partner. Homosexuals, hetero sexual & any
form of anal, vaginal, oral intercourse. The risk of infection is more in person who receives
semen & having skin abrasions. Anal inter course carries a higher risk of transmission than
vaginal intercourse as it causes tissue injury in receiving partner.

2. Contact with blood & blood products:

AIDS is transmitted by contamination of blood & blood products (with HIV virus),
equipment/articles contaminated with blood e.g. sharing shaving blades, sharing needles by
IV drug users, rajors, skin piercing needles, tattooing needles, blades and needle stick injuries
from contamined needles. If any equipment used for HIV infected person & has not been
sterilized, it can be a source of HIV infection. Needle stick exposure to HIV infected blood is
0.3-0.4%. Risk is higher if blood from patient have high viral load.

3. Perinatal transmission:
HIV can be transmitted from mother to child through placenta during delivery or by breast
feeding after birth on average. Twenty five percent of infants have risk of HIV that born from
untreated mothers having HIV infection.
GERONTALOGIC CONSIDERATIONS REGARDING AIDS

HIV infection in middle aged & older population sometimes misunderstood and
misdiagnosed. HIV related dementia in older patients may mimic Alzheimer's disease and
misdiag nosed. Several factors put older population at risk for HIV.
a) Older adults does not wear condoms as they feel condoms can be used only for un wanted
birth prevention.
b) Older adults think they will not get HIV.
c) Older gay adults begin new relationship along with younger person (who may carries HIV
infection).
 Older adults may be IV drug users,
 Older adults may have received HIV infected blood transfusions and exposed to
unsterilized syringes/articles infected with HIV.
 As age advances immune system of body has decline in function that put the person at
increased risk for infectious - cancer, autoimmune disorders.
PATHOPHYSIOLOGY

 HIV virus is a RNA virus and it replicate inside a living cell. It replicate in a
backward manner going from RNA to DNA.
 Virus enter into body through any route.
 HIV attaches to target cells membrane that have receptor molecule, CD4
  Virus sheds its protein coat and covert RNA to DNA in presence of enzyme reverse
transcriptase
 Viral DNA integrate to host DNA and duplicate it during normal division.
 Virus remain latent and became activated to produce new RNA and to form virions
(pro virus).
 Disrupt cell membrane and cells of host person
 Virus budding occurs and new virus proceeds to infect other cells.
 HIV virus primarily infects Helper T and CD, cells. It can also infect macrophages,
lympho cytes, monocytes and astrocytes.
CLINICAL MANIFESTATIONS
Acute infection:
HIV specific antibodies present & accompanied by flu like syndrome fever, swollen lymph
nodes, sore throat, headache, malaise, nausea, muscle and joint pain, diarrhoea and diffuse
rash. These symptoms are called acute HIV infection and they last for 1-2 weeks although
some persist for several months. Viral load increases and CD, cell count fall temporarily but
quickly return to baseline levels.
CHRONIC HIV INFECTION
Asymptomatic phase or early chronic phase:
CD, counts remain above 500 cells/ ul and viral load will be low. Fatigue, head- ache, low
grade fever, night sweats, persistant generalized lymphadenopathy may occur.

Intermediate chronic infection:

Viral load cells/ul. Patient may have unexplained se vere weight loss (10% of measured body
weight) persistant fever, night sweats, chronic diarrhea, recurrent headache and fatigue and
localzied infections. Lymphodenopathy, can didiasis, oral or genital herpes, oral hairy
lackoplakia & kaposi sarcoma is present.

Late chronic infection:

Viral load increases and CD, count drops below 200 cells/ul. HIV wast ing syndrome occur
i.e. 10% weight loss, unex plained diarrhoea for more than 1 month and un explained fever
for more than 1 month. Patient have risk of developing one or more opportunis tic diseases. It
can be of following types :
Fungal:
Candidiasis of bronchi, trachea, lungs or oesophagus, pneumocystic carinii pneumonia etc.
cryptococcus neoformans.
Viral:
Cytomagovirus (CMV) disease other than liver, spleen or lymh nodes, CMW retinitis, bron
chitis, pneumonitis or esophagitis, enter pulmo nary cryptococcosis.
Protozoal:
Toxoplasmosis of the brain, chronic intestinal isosporiasis. Bacterial: M cobacterium
tuberculosis of an site.
Secondary cancers:
Invasive cervical cancer, kaposi's sarcoma, immunoblastic lymphoma or primary lymphoma
of brain.
Neurologic manifestations: HIV encephalopathy.

DIAGNOSTIC STUDIES :
1. Rapid HIV antibody test provide result in 20 minute and it is also reliable test. TO confirm
HIV, further are required tests.
 Enzyme linked immunosorbent assay (ELISA). This identify the antibodies not virus.
It is highly sensitive test.
 Western blot antibody testing is more reliable but takes more time and expensive than
ELISA.
 HIV viral load test measures amount of actively replicating HIV.
 CBC (complete blood count) done to detect anaemia, leukopenia and
thrombocytopenia. CD, cell counts: This test done to monitor the progress of disease
and treatment of disease (ART) also depend upon this test.
 B-Microglobulin- cell surface protein indicative of macrophage levels > 3.5 mg/dl
asso ciated with rapid progression of disease. Not useful in intravenous drug users.
 P 24 antigen-indicates active HIV replication. Tends to be positive prior to
seroconversion and with advanced disease.

DIAGNOSIS OF AIDS
For purpose of AIDS surveillance an adult or adolescent (>12 years of age) considered to
have AIDS if at least 2 of the following major signs are present in combination with at least 1
of the minor signs listed below.

Major Signs
 Weight loss > 10% of body weight
 Chronic diarrhoea for more than 1 months
 Prolonged fever for more than 1 month (constant or intermittent)
Minor Signs
 Persistent cough for more than 1 month
 Generalised pruritic dermatitis
 History of herpes zoster
 Oropharyngeal candidiasis
 herpes simplex infection
 Chronic progressive or disseminated Generalized lymphadenopathy
 Presence of either generalized Kaposi sarcoma or cryptococcal meningitis will be
suffi cient for the diagnosis of AIDS.
  For patients with tuberculosis, persistent caugh for more than 1 months should not be
considered as minor case.
Treatment:
 Medical management for patient done with following aims.
 To decrease viral load.
 To maintain or raise CD, count.
 To delay the occurance of opportunistic infections.

Antiretroviral Treatment
Treatment is recommended when CD, count decrease 200 cell/μl or person may have severe
disease regardless of CD, levels. Four groups of drugs are given. NRTIS: Insert a piece of
DNA into developing DNA chain, blocking further development of chain and leaving the
production of the new strand of HIV DNA incomplete.

1. Nucleoside reverse transcriptase inhibitors (NRTIS):

Zidovudine is first choice of drug 500-600 mg orally daily.
Lamivudine (3TC) 150 mg orally twice daily. Stavudine Zerit (d4T)- 40mg orally twice
daily.
2. Protease inhibitors (PIs)
Prevent the protease enzyme from cutting HIV proteins into proper lengths neded to allow
variable virions to assemble and bud out from the cell membrane.
Saquinavir (SQV) - 600 mg orally three times daily..
Indinarvir Crixivan (IDV) - 800 mg orally three times daily.
Nelfinavir (verecept) 750 mg orally three times daily. Atazanavir/Ritonavir (ATV/r) 300mg+
100mg once daily.

3. Non nucleoside reverse transcriptase inhibitors (NNRTIs)

NNRTIS: Combine with reverse transcriptase enzyme to block the process needed to con vert
HIV RNA into HIV DN A. Nevirapine NVP (viramune) 200 mg orally daily for 2 weeks.
Then 200 mg orally twice daily.
Dela Virdine (DLV) Rescriptor-400 mg orally three times daily.
4. Nuclectide reverse Transcriptase inhibitors (Nt RTIs)
Inhibit the action of reverse transcriptase e.g. Tenofovir 300mg orally once daily.

5. Bactrim, septra-antibacterial drug used for other infections

Antidiarrheal therapy for treatment of diarrhea. Chemotherapy for the treatment of kaposi's
sarcoma.
6. Anti depressant therapy also given to uplift mood of patient
7. Nutrition therapy
Oral diet, NG feeding & parenteral feeding should be given to prevent malnutrition.
Appetite simulants should be used.
High calorie, low fat and easily digestible protein diet given. Digestible and palatable diet
should be given to patient.

PREVENTION OF HIV INFECTION

Nurse should educate the patient regarding following points
 Advice the patient to practice safe sexual practices. Advice patients to abstain from
sharing sexual fluids.
 Advice patient to reduce number of sexual partners to one. You should be faithful to
your partner. Patient should always use latex condoms during sexual activity.
 Advice patient to avoid anal intercourse because it cause injury to tissues and chances
to get infection is more.
 Advice patient to avoid manual-anal inter course (fisting).
 Educate the patient about non penetrative sexual activity such as body massage, social
kissing, mutual masturbation etc.
 Advice the patient to avoid sharing needles, razors, tooth brushes, sex toys or blood
contamined articles.
 Advise HIV patient to avoid unprotected sex with an other HIV positive patient as
cross infection can occur..
 Educate HIV positive pa tient to avoid donating blood, plasma, body organs or sperm.
 Advice the patient to avoid ear piercing and tattooing as it can transmit infection to
health persons.
 Advice patients to use fe male condoms and avoid using cervical caps or dia phragms
without using a condom as well.
 IV injection drug users should be instructed the methods to clean their sy ringes and
avoid sharing cotton and other drug use equipment.
 Discuss family planning issues with patient and risk of transmission to babies.
 Discuss role of antiretrovial therapy for the prevention of perinatal HIV transmission.
HIV positive patient should be instructed not to breast feed their infants as HIV also
transmitted via milk.
 Contraceptive methods also should be discussed with patient. If HIV positive female
use estrogen oral contraceptive, it shown increased shedding of HIV in vaginal &
cervical secretions.
 IUD also increase the risk of transmission of HIV as IUD string serve as a mean to
transmite the infection.

STANDARD SAFETY PRECAUTIONS

Standard safety precautions is used to prevent the transmission of nosromial infection.
A. Use of protective barriers
1. Wear gloves, gowns, masks and aprons when you handle blood or body fluids.
 2. Change gloves after use and remove promptly after use mainly before touching
uncontamined items.
3. Face shield, mask, eye protection should be worn during carrying out procedures that
likely to generate blood.
B. Environmental control:
 Clean bathroom and kitchen surfaces with 1:10 bleach & water solution when they
contamined with blood or body fluids.
 Maintain adequate lighting & ventilation to reduce growth of bacteria.
 Disinfect beds, bed rails, bed side equipments.
 Discard all waste from HIV patient separately & should not mix with household
waste.
4. Patient care equipment
 Wash utensils as usual.
 Wash contaminated laundry separately with 1:10 bleach & water solution.
 All contamined articles should be sterilized prior to reuse for another patient.
resuscitation
 Use mouth piece, resuscitation bag as an alternative to mouth to mouth method.
5. Wash hands:
 Use antiseptic antimicrobial agent for washing hands.
 Wash hands prior to procedure and immediately after procedure.
6. Avoid accidental injuries
Teach all the health care workers that never recap the used needles or manipulate
them by using both hands or any technique that direct the needle toward your body.
 Do not remove, bend, break the needle attached with disposable syringes by hand.
 Use puncture proof containers for disposing needles, rajors, scalpal & blades.
 Place reusable syringes & needles (glass syringes) in puncture
POST EXPOSURE PROPHYLAXIS
If any health personnel sustain a puncture injury or needle stick injury. Take these actions
immediately:

1. Wash the area with soap & water.

2. Immediately inform sister in charge, concern physician or in charge of injury reporting

3. Identify the source- patient & its HIV status, hepatitis B & hepatitis C status. If HIV status
of patient is unknown immediately check HIV status with Ora quick rapid testing as result will
come within 20 minutes.
4. Give baseline testing samples for HIV, hepatitis B, & hepatitis C as soon as possible.
5. Start the prophylaxis medicines within 2 hours after exposure. Continue medication up to 4
weeks and practice safer sex practices.

6. Follow post exposure testing at 1 month, 3 months and 6 months and perhaps 1 year.

7. Document the exposure in detail for your own records as well for employer.

COMPLEMENTARY & ALTERNATIVES MODALITIES

These therapies are used to improve the overall well being of patient.
1 Psychological or spiritual therapies may include humor hypnosis, guided imaginary should
be used.
2. Nutritional therapy may include vegetarian, vitamin B or Beta carotene supplements and
turmeric, chinease herbs can also be used.
3. Acupressure, acupuncture, massage therapy, reflexology therapeutic touch, yoga used to
relieve stress of patient.

REHABILITATION OF AIDS PATIENTS

Rehabilitation centres in country dedicated to hospitalizing and rehabilitating patients with

severe AIDS and palliatively supporting terminal AIDS patients. They provide medical, so cial
and psychological services. Patients are treated with sympathetic attitude and advices to take
adequate rest and diet rich in proteins and vitamins. In these homes patients learn new
strategies for an improved quality of life.

NATIONAL AIDS CONTROL PROGRAMME

The Government of Indian in 1985 constituted a task force to look into the matter of spread of
AIDS from one country to another. National AIDS control programme was launched in 1987.
In the year 1992, the Ministry of Health and Family Welfare set up a National AIDS Control
Organisation as a separate wing to monitor and implement the various components of the
programme. The Government of India launched a 5 year HIV/AIDS control project from
september 1992 to september 1997 as 100 percent centrally sponsored project for all
states/UTS. The project was later on extended upto March 1999, The phase II (1999-2004) of
National AIDS Control Programme has become effective from in 32 status/UTs and 3
Municipal corporations namley Ahmedabad, Chennai and Mumbai through AIDS Control
Society. India has developed third National Programme Implementation Plan (NACP III, 2007
2012)

The National AIDS Control Programme phase II has two key objectives:
1. To reduce the spread of HIV infection in India; and
2. To strengthen India's capacity to respond to HIV/AIDS on a long term basis.
During 2003-2004; the programme on the prevention and control of HIV/AIDS has been
given to more balanced combination of initiative to cope up with the emerging profile of the
epidemics. The initiatives are as follows

A. Prevention :

1. High risk populations

(a) Targeted interventions
(b) STD treatment
(c) Condom programming
(d) Multisectoral collobration
(e) Public private partnership

2. Low risk populations

(a) Holistic IEC and social mobilisation
(b) Safe blood.
(c) Voluntary counselling and testing.
(d) AIDS vaccine initiative.
(e) Sensitive youth and adolescents.
(f) Work place interventions.
B. Care:
Low cost care and support:
(a) Prevention of parent to child transmission.
(b) Management of HIV-TB co-infection.

(c) Treatment of opportunistic infections.

(d) Piloting ART.
(e) Post exposure prophylaxis.
C. Surveillance
Evidence based planning:
(a) Annual sentinel surveillance.
(b) AIDS case detections.
(c) Mapping of high risk groups.
(d) Behaviourial surveillance.

NATIONAL AIDS PREVENTION AND CONTROL POLICY

In April 2002, the Government of India approved the National AIDS Prevention and Control
Policy. The basic framework of the policy remains the same. The objectives include reduc tion
of the impact of the epidemic and to bring about a zero transmission rate of AIDS by year
2007.

Blood Safety Programme :

Blood transfusion services have been considered as an integral part of the health care system.
Blood transfusion councils have been set up at national and state level. Only licensed blood
banks are permitted to operate in the country and voluntary blood donation is encouraged.
Zonal blood testing centres have been established to provide linkage with other blood banks
affiliated to public, private and voluntary sectors. The function of these zonal centres is to test
the blood sample from the blood banks attached to them and to report the results of HIV tests
same day.

Counselling and HIV Testing:

HIV testing is carried out on a voluntary basis with appro priate pre-test and post-test
counselling.
Voluntary Counselling and Testing (VCT) is a key entry point for a range of interventions in
HIV prevention and care, like preventing HIV transmission from mother to child during child
birth, referrels for STD treatment, condom promotion, care and support for treatment for
oppurtunistic infections, management of HIV-TB co-infection and referrals to desig nated
medical centres for Anti-Retroviral Therapy (ART). NACO has supported the estab lishment
of VCT centres in all states..

STD Control Programme :

STD control is linked to HIV/AIDS control as behaviour resulting the transmission of STD and
HIV are same. HIV is transmitted more easily in the pres ence of another STD. Hence, early
diagnosis and treatment of STD is now recognised as one of the major strategies to control the
spread of HIV infection.
Condom Promotion : Among the probable source of HIV infection in India, heterosexual
intercourse constitute the major route, as almost 85 percent HIV infectious occur due to
unprotected and multipartner sexual contacts. This type of transmission can be prevented by
consistent use of good quality condoms.

The three major areas in which NACO has made significant progress in relation to condom
programming are (a) quality control of condoms, (b) social marketing of condoms, and (c)
involvement of NGOs and private voluntary organisations in the programme.

HIV Surveillance :
During 1993 a Sentinel surveillance system was introduces with a objec tive to identify trends
of seropositivity in specific high risk groups as well as low risk groups.
Different types of surveillance activities are being carried out in the country to detect the
spread of the disease and to make appropriate strategy for prevention and control. The types of
surveillance are: (a) HIV sentinel surveillance, (b) HIV sero-surveillance, (c)AIDS case
surveillance, (d) STD surveillance, (e) Behavioural surveillance, (f) Integration with
surveillance of other diseases like tuberculosis etc.

Targetted Surveillance :
The basic purpose of the targetted intervention programme is to ers. IUDs, truckers,
homosexual men, migrant labourers and street children, as sex work

School AIDS Education Programme

The school AIDS education is one of the important activities of NALP that focuses towards
student youth to raise awareness level and develop a safe and responsible life style. A training
module called "learning for life" has been pre pared and distributed to all the states.

INFORMATION, EDUCATION, COMMUNICATION (IEC) AND SOCIAL

MOBILIZATION
The objective of the IEC strategy in the National AIDS control Programme are: to raise
awareness, improve knowledge and understanding among the general public about the AIDS
infection and STD, routes of transmission, method of prevention; to promote desirable prac
tice such as avoiding multiple sex partner, use of condom, sterilization of needles/ syringes and
voluntary blood donation, to mobilize all sectors of society to integrates messages and
programme on AIDS into their existing activities; to create a supportive environment for the
care and rehabilitation of persons with HIV/AIDS.

RED RIBBON EXPRESS PROJECT

NACO launched the second phase of the red ribbon express project on 1 Dec., 2009 to
commemorate the World AIDS day. This eight coach exhibition train has to travel 22 states
covering 152 halt stations during its year long journey. The journey of train will be continu ing
every year in Dec.

Family Health Awareness Compaign (FHAC)

The importance of reproductive tract infection (RTI), including sexually transmitted disease
(STD) has increased with the introduction of HIV/AIDS epidemic in the country. The
objectives of this compaign are:

(i) To raise awareness levels regarding HIV/AIDS in rural and slum areas and other
vulnerable groups of the population.

(ii)To make people aware about the services available under the public sector for
management of RTI/STD.

(iii) To facilitate the early detection and prompt treatment of RTI/STD cases by utilising the
infrastructure available under primary health care system, including provisioin of drugs;
(iv) To strengthen the capacity of medical and paramedical professionals working der health
care system to respond to HIV/AIDS epidemic adequately.
(iv) To use safe blood from licensed blood banks and blood storage centres.
(v) To use safe blood from licensed blood banks and blood storage centres.
(vi) To be aware that HIV can be transmitted from the infected mother to her baby during
pregnancy, delivery and breast feeding.

Anti-Retroviral Treatment:
The Government has decided to provide anti-retroviral treat ment at government hospitals, free
of cost, for HIV cases in six high prevalence states i.e. Tamilnadu, Andhra Pradesh,
Maharashtra, Karnatka, Manipur, Nagaland and Delhi. Prior ity category will be pregnant HIV
women and children upto 15 years of age and full blown AIDS cases.
National AIDS Telephone Helpline:
A toll free national AIDS telephone help line has been set up to provide access to information
and counselling HIV/AIDS related issues. This is a computerized 4-digit number 1097, with a
voice response system linked with a telephone help line.

GOALS OF NACP III

To reverse and halt the AIDS epidemic in India over the next five years by incorporating
programmes for prevention, support, care and treatment. It will be achieved by four stages:
1. Prevention of new infection in high risk groups and population by way of
Saturation of coverage of high risk group with targeted interventions.
Intervention for prevention of AIDS in the general population.
2. Provide optimal care, support and treatment to a large number of people living with
HIV/AIDS.
3. Strengthening of human resources in prevention, cell, support and treatment programmes,
infrastructre and system at district, state and national level.
4. Strengthening of national wide strategic information management system, for this same
strategies are laid down to reduce new ifnection in high first year of programme.
Sixty percent in high prevalence states to reverse the epidemic.
forty percent in vulnerable states to stabilize epidemic.

PRIORITIES OF NACP III

1. Main emphasis is on prevnetion while integrating care, support and treatmentt
2. Population having highest risk of exposure to HIV will receive the highest priority for
intervention. It will include sex workers, homosexuals men and intravenous drug users. After
that groups which have high level of exposure to HI infection such as long distance truck
drivers, prisoners, migrants and street children.
3. Population having greater need of assessment and prevention services like treatment of STIs
valuntary counselling and testing and condoms provisoin will be further in the line of priority.
4. There should have access to prophylaxis and management of opportunistic infections to all
needy persons. All person who need anti-retroviral treatment should receive first line of ARV
drugs.
5. Prevention of mother to child transmission of disease and HIV positive children should have
access to ART. 6. Welfare agencies should mitigate the impact of HIV by providing nutritional
support and provision of income generated resources.
7. Community care centres should provide psychosocial support outreach services, refferals
and palliative care. 8. NACP III should work with women's groups, youth groups and trade
unions to integrate HIV prevention.

TENTH FIVE YEAR PLAN GOALS:

a) 80 percent coverage of high risk groups through targetted intervention.

b) 90 percent coverage of schools and colleges through education programmes.
c) 80 percent awareness among the general population in rural areas,
d) Reducing transmission through blood to less than 1 percent.
e) Establishing at least one voluntary testing and counselling centre in every district.
f) Scaling up of prevention of mother to child transmission activities upto the district level and;
g) Achieving zero level inrease of HIV/AIDS prevalance by 2007.

INTERNATIONAL AGENCIES FOR AIDS

UN agencies: WHO, UNAIDS, UNICEF, UNDP, UNFPA, UNESCO and World Bank along
with FAO, ICO, UNHCR, WFP and NGOs all these agencies work for AIDS patients WHO,
UNICEF keep budget for health policies. These agneices raise public awareness through mass
media, help the developing countries by providing access to medicines required for AIDS
patients.

INFECTION CONTROL PROGRAM

WHO and centres for Disease Control and Prevention (CDC) are principal agencies which set
guidelines about infection control strategies. This includes:

Standard precautions: Include hand hygiene, use of gloves and other barriers (mask, eye
protection face shield, gown) proper handling of patient care equipment and linen, environ
mental control, prevention of injury from sharps devices and patient's rooms.