RAJIV GANDHI UNIVERSITY OF HEALTHSCIENCES,BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OFSUBJECTS FOR DISSERTATION

1 NAME OF THE CANDIDATE AND ADDRESS

MS.T. SIVAKUMARI1st YEAR M.Sc NURSING,INDIAN COLLEGE OF NURSING,TILAKNAGAR, BYPASS ROAD,CONTONMENT,BELLARY – 583104

2 NAME OF THEINSTITUTION

INDIAN COLLEGE OF NURSING,TILAKNAGAR, BYPASS ROAD, CONTONMENT,BELLARY – 583104

3 COURSE OF STUDY AND SUBJECT

DEGREE OF MASTER OF NURSING.PAEDIATRIC NURSING

4 DATE OF ADMISSION TOCOURSE

10-06-2009

5 TITLE OF THE TOPIC ANALYTICAL STUDYTO ASSES THE EFFECTIVENESS OF PLANNED TEACHING PROGRAMME ON MANAGEMENT AND PREVENTION OF TYPHOID FEVER AMONG THE MOTHERS OF SCHOOL AGE CHILDREN ADMITTED IN THE SELECTED HOSPITAL, AT BELLARY, KARNATAKA

6. BRIEF RESUME OF THE INTENDED WORK

1

INTRODUCTION:

“ Enteric fever ” is a global major public health problem . “ Typhoid fever

” , an acute systemic infectious disease seen only in humans. Enteric fever caused

by “salmonella typhi” . Almost 80% of the cases and deaths are in Asia and the rest

occur mostly in Africa and Latin America. Enteric fever is endemic in many

developing Countries , including India.1

The incidence of typhoid fever estimated 16-33 million cases of annually

resulting in 5,00,000 to 6,00,000deaths in endemic areas the world health

organization identifies typhoid as a serious public health problem. Its incidence is

highest in children and young adults between 5 and 19 years old. Typhoid fever is a

disorder of school age children and of adults. Typhoid is a common significant

cause of morbidity between 1 and 5 years of age.2

The name salmonella typhi is derived from the ancient Greek typhos. An

ethereal smoke or cloud that was believed to cause disease and madness. Primary

source of infection are stool and urine. Secondary sources of infection are

contaminated water, food, fingers or hands. Mode of transmission is mainly feco

oral route or urine oral route. Typhoid fever is characterized by a slowly

progressive fever ,( 104 degree f), profuse sweating, gastroenteritis, and diarrhoea,

rashes ,rose – colored spots may appear.3

2

The diagnosis of typhoid fever may be included blood culture , widal test ,

bone marrow culture , stool and urine culture and ELISA Specific treatment of

enteric fever used to be fluoroquinolones such as ciprofloxacin chloramphenicol,

cephalosporin including ceftriaxone. prompt treatment of the disease with

antibiotics reduces the case-fatality rate to approximately 1%. Death occurs in

between 10%, the case fatality rate in the united states in the pre-antibiotic era was

– 9 to 13%.4

The complications of typhoid fever mainly, encephalopathy, intestinal

hemorrhage, toxic myocarditis, bronchitis sanitation and hygiene are the critical

measures that can be taken to prevent typhoid. Care ful food preparation and

washing of hands are there fore crucial to preventing typhoid. 5

6.1 NEED FOR THE STUDY:

Typhoid fever occurs worldwide, primarily in developing nations whose

sanitary conditions are poor. Typhoid fever is endemic in Asia, Africa, Latin

America, the Caribbean, and oceania. typhoid fever infects roughly 21.6 million

people and kills an estimated 2,00,000 people every year.6 With prompt and

appropriate antibiotic therapy, typhoid fever is typically a short term febrile illness

with a negligible risk of mortality. Un treated typhoid fever is a life – threatening

In 1920, 35 ,994 cases of typhoid fever were reported. Currently 200-400 cases of

typhoid fever are reported per year in the united states. 75% of which occur in

international travelers with in 30 days of entry. 7

3

A base line census was under taken in 1995. Between Nov 1,1995, and oct

31,1996, we visited 8172 residents of 1820 households in Kalkaji, Delhi, twice

weekly to detect febrile cases. 63 culture – positive typhoid fever cases were

detected. Of these 28 (44%) were in children aged under 5 years.The incidence rate

of typhoid per 1000 person – years was 27.3 at age under 5 years, 11.7 at 5 – 19

years and 1.1 between 19 and 40 years. The difference in the incidence of typhoid

fever between those under 5 years and those age 5 – 19 years (15.6 per 1000 person

years ) 95% and those aged 19-40 years 26.2 was significant. Morbidity in those

under 5 and in older people was similar in terms of duration of fever, signs and

symptoms, and need for the hospital admission.8

When untreated, typhoid fever persists of three weeks to a month. Death

occurs in between 10% and 30% of untreated cases. Though in some communities

case fatality rates may be as high as 47%.9 Typhoid fever is a particularly difficult

problem in parts of the world with poor sanitation practices. In the United States,

most patients who contract typhoid fever have recently returned from travel to

another country where typhoid is much more common, including Mexico, Peru,

Chile, India and Pakistan.10

The timing of symptoms and host response may vary based on geographic

region, race factors, and the infected bacterial strain. The stepladder fever pattern

that was once the hallmark of typhoid fever now occurs in a few as 12% cases. In

appropriate treatment is initiated with in a few days of full blown illness, the

4

patients condition markedly improves with in 4 to 5 days. Any delay in treatment

increases the likelihood of complications.11

In Karnataka, Mysore city account for the highest number of typhoid fever

cases according to district health officer in Tumkur district merely 40 people in the

village. Our findings challenge the, common view that typhoid fever is a disorder

of school age children and of adults. Typhoid is a common and significant cause of

morbidity between 1 – 5 years of age. The optimum age of typhoid immunization

and the choice of vaccines needs to be reassessed.12

A prospective study was conducted on enhancing knowledge and awareness

of typhoid fever among mothers. The data was collected from the mothers, the

result revealed that only 0.3% the participants scored. The participants scored very

poor. The current medical nursing literature reflects the prevalence of typhoid fever

in high among school children. Based on the literature and investigator experiences

the investigator feels that it is the important to create awareness among mothers of

school age children to prevent the child mortality and morbidity. So the knowledge

of the mothers may be applied in early recognition of typhoid fever help in

selecting for early medical validation. Hence the investigator planned to impart the

knowledge by conducting planned teaching programme to mothers of school age

children.

5

6.2 REVIEW OF LITERATURE:

Review of literature is a key step in research process. Review of literature

refers to an extensive, exhaustive and systemative examination of publications

relevant to the research project.13

A prospective follow up study of residence of a low income urban area of

Delhi, India with active surveillance for case detection. Calculation of the incidence

of typhoid fever during pre school years is important to defined the optimum age of

immunization and the choice of vaccines for public health programmes in

developing countries. Hospital based studies have suggested that children younger

than 5 years do not need vaccination. Against typhoid fever, but this view needs to

be re examined in community based longitudinal studies. 63 culture positive

typhoid fever cases were detected. Of these, 28 were in children aged under 5

years. The optimum age of typhoid immunization and the choice of vaccines need

to be re assessed.14

The IVI-NICED study, which was supported by the gates foundation and the

governments of korea, Sweden, and Kuwait, also revealed that delivering the low-

cost vi typhoid vaccine is logistically and programmatically possible. The fact that

the level of overall protection was similar dr. Clemens, a co-author of the study. “ It

6

also suggest the need for consideration of herd protective effects in future

deliberations about the use of this vaccine in developing countries. The production

of technology for the high yield vi polysaccharide is being transferred to

high – quality produces in developing countries. The International vaccine institute

( IVI ) is the world’s only International organization devoted exclusively to

developing and introducing new and improved vaccines to protect the world’s

poorest people , especially children in developing countries. Established as an

initiative of the united Nations development programme in 1997, the IVI operates

under research in 28 countries of Asia, Africa and Latin America, on vaccine

against diarrheal infections.15

A US – based study of imported strain noted an increase in the number or

MDR and nalidixic acid resistant S. typhi globally, although all isolates remained

sensitive to ciprofloxacin and ceftriaxone. In Bangladesh there has been a reported

decrease in MDR isolates with no corresponding increase in sensitive strains. The

exact mechanism of resistance is not fully understood but various studies have

found that a single mutation in the gyrA gene is sufficient to confer resistance to

nalidixic acid and reduced susceptibility to fluoroquinolones.16

A study on salmonella enterica serovar paratyphi A revealed that high-level

resistance to ciprofloxacin is also associated. The variation in the susceptibility

patterns reported for S-typhi, it is important to constantly monitor it to provide

suitable guidelines for treatment. S-para typhi A resistant to ciprofloxacin with a

MIC value of 8µg/ml and 32µg/ml has been reported from our centre. Here we

7

report the isolation of a strain of S-typhi showing high level resistance to

ciprofloxacin.17

In this study the strain was isolated from the blood sample of a 19 year old

male presenting with enteric fever at government general hospital, Pondicherry,

India, in September 2007. The antimicrobial susceptibility was determined, by the

disc of diffusion method. The MIC of ciprofloxacin as determined by the E-test

method was found to be > 32µg/ml. In this study was found to be sensitive to most

antibiotics except quinolones and intermediately susceptible to ampicillin.

Explained by the fact that resistance to other antibiotic is plasmid mediated. Cases

reported in India where S-typhi strains are resistant to first line antibiotics. 2008

there are reports of high level ciprofloxacin resistant salmonella enterica from

many centers in india. In developing countries such as India, ciprofloxacin

continues to be the main stay in the treatment of enteric fever as it is orally

effective and economical.18

Van state hospital study and 18 years old female patient admitted with the

complaints of fever and fatigue beginning 15 days, accompanied by headache,

weakness, palpitations. The patient was transferred to the infectious disease

department of the medical faculty of “ yuzuncu ” university on the physical

examination, temperature, pulse rate, B·P, respirations increased. In laboratory

examinations, leukocytes 2.500/mm³, erythrocytes, 3.360.000/mm³, Hb 9.9gr/dl,

platelets, 31.000/mm³, deficiency was determine. After sample were taken for

8

microbiological analyses, oral treatment of ciprofloxacin and electrolyte

replacement was maintained.19

In Gruber widal test study, to antibody was 1:200 and TH antibody 1:100.

After two days of admission, S.typhi was grown in blood culture. Repeated gruber-

widal test revealed that to antibodies increased to 1:800 and TH antibodies to 1:200

one week later.Her platelets came to 199.000 and also her leucopenia improved.

After two weeks of antibiotic therapy, the patient was discharged with full

recovery.20

WHO study for uses of vi vaccines in developing countries, its use has been

limited. The IVI in collaboration with NICED conducted a phase four cluster.

Randomized effectiveness trial, which randomized 80 geographic clusters of an

urban Kolkata slum. Over two years of follow up, the vi group was shown to have

61 % fewer episode of typhoid than the control group. Protection of vaccinated

children under 5 years of age by vi was even higher, 80%, interestingly, un

vaccinated neighbors of vi vaccinated persons had a 44% lower risk of typhoid,

indicating that vi vaccine conferred substantial herd protection.The over all level of

protection among all residents of the vi clusters, regardless of whether they were

vaccinated was 57%. Since the coverage of residents of the vi clusters, was about

60% this observation indicates that vi vaccine prevented as many cases of typhoid

in the total population as a vaccine that was nearly 100% protective in vaccinated

persons.21

9

A study was conducted in laboratory testing the current recommendation are

that isolates should be tested simultaneously against ciprofloxacin and against

nalidixic acid (NAL) and that isolates that are sensitive to both CIP and NAL

should be reported as “ sensitive to ciprofloxacin ”, but that isolates testing

sensitive to CIP. An analysis of 271 isolates showed that around 18% of isolates

with a reduced susceptibility to ciprofloxacin would not be picked up by this

method.22

A study by WHO according to statistics from the united states center for disease

control, the chlorination of drinking water has led to dramatic decreases in the

transmission of typhoid fever in the U·S. currently the W·H·O is recommended by

the two vaccines for typhoid fever. These are the live, oral Ty 21a vaccine (sold as

vivotif Berna) and the injectable typhoid polysaccharide vaccine both are between

50 to 80 % protective and are recommended for travelers to areas where typhoid is

endemic. W·H·O estimated 16 – 33 million cases of annually resulting in 5,00,000

to 6,00,000 deaths in endemic areas. Older killed whole cell – vaccine that is still

used in countries where the newer preparations are not available, but this vaccine is

no longer recommended for use. Because it has a higher rate of side effects.23

Astudy conducted by american clinician as members of this cohort often

come to the United States for higher degrees. The risk factors often also predispose

to other intra cellular pathogens, the case fatality rate in the United States in the pre

10

– antibiotic era was 9 – 13% since 1900, improved sanitation and successful

antibiotic treatment have steadily decreased the incidence of typhoid fever in the

united states. In 1920, 35,994 cases of typhoid fever were reported. Currently 200-

400 cases of typhoid fever are reported per year in the united states, 75% of which

occur in International travelers with in 30 days of entry. In most contemporary

presentations of typhoid fever, the fever has a steady insidious onset.24

6.3 STATEMENT OF THE PROBLEM:

Analytical study to assess the effectiveness of planned teaching programme

on management and prevention of typhoid fever among the mothers of school age

children admitted in the selected hospitals at Bellary, Karnataka.

6.4 OBJECTIVE OF THE STUDY:

1. To assess the knowledge among mothers of school age children regarding

typhoid fever.

2. To develop and conduct the planned teaching programme.

3. To evaluate the effectiveness of planned teaching programme by post test

knowledge score.

4. To find the association between the knowledge scores and selected

demographic variables.

11

6.5RESEARCH HYPOTHESIS:

H1: There will be significant difference between pre-test and post-test of

knowledge score on typhoid fever among mothers of school age children at 0.05

level.

H2: There will be a significant association between knowledge scores among

mothers of school age children with selected demographic variables.

6.5 VARIABLES UNDER STUDY:

INDEPENDENT VARIABLES

Planned teaching programme on typhoid fever management and its prevention.

DEPENDENT VARIABLES

knowledge among mothers of school age children regarding typhoid fever and

management and its prevention

ATTRIBUTE VARIABLE

Age, education, occupation, religion, family size, income etc

12

6.6 OPERATIONAL DEFINITIONS:

1. Analytical study: Using analytical method, detailed examination and analysis of

mothers knowledge regarding management and prevention of typhoid fever.

2. Assess: In this study assessment refers to an systematic collection of data.

3. Effectiveness: refresh to extent to which the planned teaching program has

achieved the desired effect in improving the knowledge of mothers of school age

children on typhoid fever management and its prevention.

4. Planned teaching programme : refers to drawing to systematically organized

teaching strategies for a group of mothers that enhances she knowledge regarding

typhoid fever management and its prevention.

5. Knowledge: refers to correct responses from the mothers of school age

children during interviews schedule regarding typhoid fever management and its

prevention.

6 Mothers: the female parents of school age children.

7 Typhoid fever: an a acute bacteria infection caused by salmonella typhi. The

illness is characterized by prolonged typical continuous fever for 3 to 4 weeks with

prostration relative bradycardia and involvement of spleen and lymph nodes.

13

6.8 ASSUMPTIONS :

The mothers school age children may not have adequate knowledge

regarding typhoid fever.

Teaching strategy regarding typhoid fever management and its prevention may

have to improve the knowledge among mothers

6.9 DELIMITATIONS:

Study is delimited to mothers of school age children only.

Mothers of school age children who are available at the time data collection

7. MATERIALS AND METHODS:

7.1 SOURCE OF DATA:

The data will be collected from mothers accompanying with school age

children selected hospital at Bellary.

7.2 METHOD OF COLLECTION OF DATA:

7.2.1 RESEARCH DESIGN:

The research design chosen for the study is pre-experimental “one group

pretest and post test design”.

14

7.2.2 RESEARCH APPROACH:

An evaluative research approach.

7.2.3 RESEARCH SETTING:

Study will be conducted in selected hospital at Bellary.

7.2.4 POPULATION:

The population included in the present study is the mothers of school age

children.

7.2.5 SAMPLE SIZE:

The total sample size consists of 60 mothers of school age children in

selected hospitals, at Bellary.

7.2.6 SAMPLING TECHNIQUE:

Non-probability, purposive sampling technique will be used.

7.2.7 SAMPLING CRITERIA:

Inclusion criteria:

Mothers accompanying with school age children in selected hospitals at

bellary.

Mothers of school age children who are willing to participate in the study.

15

Mothers of school age children who can understand and speak Kannada and

English or Hindi.

Exclusion criteria

Mothers who are not available at the time of data collection.

7.2.8 DATA COLLECTION TOOLS:

Structural interview schedule will be conducted into two parts.

Part 1: Demographic data such as age, sex, education, occupation, religion,

family size etc.

Part 2: Knowledge questionnaire regarding typhoid fever management and its

prevention.

7.2.9 COLLECTION OF DATA:

The investigator herself collection the data from the mother of school age

children who are accompanying to selected hospitals, at bellary

Structural interview schedule is used to assess the knowledge by taking

pretest on typhoid fever management and its prevention.

Conducted planned teaching programme for who are accompanying to

selected hospitals, at bellary.

Same structured interview schedule for the pre-test will be used for post- test

7.2.10 DATA ANALYSIS METHODS:

16

The investigation will be use descriptive and inferential statistics.

Paired “ t ” test will be used to test the significant difference in the

knowledge scores between pre-test and post test scores

Chi-Square test is used to determine the knowledge scores with demographic

variables

It is presented in the form of table, diagrams and graphs, pie charts based

findings.

7.3 DOES THE SUDY REQUIRE ANY INVESTGATION OR

INTERVENTION TO BE CONDUCTED ON PATIENTS OR

OTHER HUMANS OR ANIMALS ? IF SO, PLASES DESCRIBE,

BRIEFLY.

No

7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR

INSTITUION IN CASE OF?

Yes,

8. LIST OF REFERENCES:

1. The World Health Report, Report of the Director General WHO (1996)

world health Organization: Geneva.

2. The world health report, Report of the Director General WHO (1996) world

health Organization: Geneva.

17

3. Christie AB. Infectious Diseases: Epidemiology and Clinical Practice. 4th

Ed. Edinburgh, Scotland: Churchill Livingstone; 1987.

4. Jesudason MV, John TJ (1992) Plasmid mediated multidrug resistance in

Salmonella Typhi. Indian J Med Res 95:66-67.

5. Chambers HF, Infectious Diseases: Bacterial and Chlamydial. In: Tierney

LM, McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis and Treatment.

37th ed. London: Prentice Hall International Inc, 1998:1267-303.

6. Crump JA, Ludy SP, Mintz ED. The global burden of typhoid fever. Bull

World Heatlth Organ. May 2004;82(5) :346-53. [Medline].

7. Crump JA, Ram PK, Gupta SK, Miller MA, Mintz ED. Part I. Analysis of

data gaps pertaining to Salmonella enterica serotype Typhi infections in low and

medium human development index countries, 1984-2005. Epidemiol infect. Apr

2008;136(4):436-48. [Medline].

8. Steinberg EG, Bishop R, Haber P, Dempsey AF, Hoekstra RM, Nelson JM,

et al. Typhoid fever in travelers: who should be targeted for prevention?. Clin infect

Dis. Jul 15 2004;39(2):186-91. [Medline]

9. Crump JA, Ram PK, Gupta SK, Miller MA, Mintz ED. Part I. Analysis of

data gaps pertaining to Salmonella enterica serotype Typhi infections in low and

medium human development index countries, 1984-2005. Epidemiol infect. Apr

2008;136(4):436-48. [Medline].

18

10. According to Rosalyn Carson-DeWitt, MD

11. Butler T, Islam A, Kabir I, et al. Patterns of morbidity and mortality in

typhoid fever dependent on age and gender: review of 52 hospitalized patients with

diarrhea. Rev infect Dis.Jan-Feb 1991;13(1):85-0. [Medline]

12. Anju Sinha MD a, Sunil Sazawal MD a d, Ramesh Kumar Md a, Seema

Sood MD b, Vankadara P Reddaiah et al undertook a prospective follow-up study

of residents of a low-income urban area of Delhi, India.

13. BT Basavanthappa. “Nursing Research”. New Delhi : Jaypee Publication :

2005. P 49.

14. Anju Sinha MD a, Sunil Sazawal MD a d, Ramesh Kumar Md a, Seema

Sood MD b, Vankadara P Reddaiah et al undertook a prospective follow-up study

of residents of a low-income urban area of Delhi, India.

15. National Institute of Cholera and Enteric Diseases (NICED) in kolkata,

India, was published in the July 23 issue of the New England Journal of Medicine

(NEJM)

16. Rahman M, Ahamad A, Shoma S (2002) Decline in epidemic of multidrug

resistant Salmonella Typhi is not associated with increased incidence of

antibiotiscusceptible strain in Bangladesh. Epidemiol infect.

19

17. Harish BN, MAdhulika U, Parija SC (2004) Isolated highlevel ciprofloxacin

resistance in Salmonella enterica subsp. Enterica serotype Paratyphi A. J Med

Microbiol 53:819.

18. Raveeendran R, Wattal C, Sharma A, Oberoi J K, Prasad K J, Datta S (2008)

High level ciprofloxacin resistance in Salmonell enterica isolated from blood.

Indian J Med Microbiol 26:50-53.

19. Turan Buzoan, Omer Evirgen, Hasan Irmak, HAsan Karsen, Hayrettin

Akdeniz Yuzuncu Yyl University, Faculty of Medicine, Department of Infectious

Diseases and Clinical. Microbiology, Van, Turkey.

20. Eur J Gen Med 2007; 4(2):83-86: Dr. Omer Evirgen Yuzuncu Yyl

Universitesi Typ Fakultesi ARabtyma Hastanesi, Enfeksiyon Hastalyklary Servisi

65200 Van, Turkey.E-mail: omerevirgen@yahoo.com.

21. National Institute of Cholera and Enteric Diseases (NICED) in kolkata,

India, was published in the July 23 issue of the New England Journal of Medicine

(NEJM)

22. WHO Report, According to statistics from the united States Centre for

disease control. WHO World Health Report, Report of the Director General WHO

(1996) World Health Organisation : Geneva.

23. WHO Report, According to statistics from the united States Centre for

disease control. WHO World Health Report, Report of the Director General WHO

(1996) World Health Organisation : Geneva.

20

24. Christie AB. Infectious Diseases: Epidemiology and Clinical Practice. 4th

Ed. Edinburgh, Scotland: Churchill Livingstone; 1987.

9 Signature of the student

1

0Remarks of guide

The research topic selected for the study

is relevant and forwarded for the needful

action.

1

1Name and designation of the

guide

Mrs. SUMITHRA DEVI

H.O.D. Department of Child Health

Nursing, Indian College Of Nursing,

Bellary.

1

2

Guide

Mrs. SUMITHRA DEVI

Department of Child Health Nursing,

Indian College Of Nursing,

Bellary.

1

3

Signature

1

4

Co-Guide ( If any ) Mrs. PATEL NIRUPAMA

1

5

Signature

1

6Head of the Department

Mrs. SUMITHRA DEVI

HOD. Dept. of Child Health Nursing,

Indian College Of Nursing, Bellary.

21

1

7

Signature

1

8

Remarks of the chairman &

principal

I discussed with the research committee.

I felt that research problem is good &

feasible

1

9

Signature

22