Epidemiology of Mononucleosis Sample Paper
Epstein-Barr virus is the pathogen that causes mononucleosis. Mononucleosis is also referred to as “the kissing disease” or mono and the virus is transmitted via contact with bodily fluids of an infected person, particularly saliva. The spread through saliva is responsible for the name “kissing disease”, as the virus is spread via kissing, sharing silverware such as cups, spoons or forks, drinks, or food with the infected individual. It is also spread when an infected person sneezes or coughs near a healthy person. The symptoms of infection include fatigue, fever, sore throat, sore muscles, swollen lymph nodes, vomiting and loss of appetite (Naughton et al., 2021).
Additional symptoms include palatal petechiae, rash and periorbital and eyelid edema. Some infected individuals may present with no symptoms or extremely mild symptoms that they go unnoticed. The majority of persons with mono recover within 2 to 4 weeks, but fatigue may last for several weeks more. Other individuals take as much as 6 months or longer to clear the symptoms. The diagnosis of mononucleosis is based on a high index of suspicion by the doctor, focusing on the symptoms. The doctor may assess the patient for swollen lymph nodes, tonsils or enlarged liver or spleen (Naughton et al., 2021). A complete blood count determines whether white blood cells are elevated and presence of atypical leukocytes. Antibody tests check for presence of specific antibodies within the circulation produced by the body’s immune system in response to Epstein Barr Virus, which is the gold standard test.
Complications of mononucleosis include swollen tonsils, enlarged spleen, enlarged liver, blood disorders, heart disease and nervous system pathology. Swollen tonsils result from increased immune response to the infection, causing enlargement of lymph nodes due to hyper-active reticulo-endothelial system (Naughton et al., 2021). Swollen tonsils result in difficulty in swallowing or breathing through the oral cavity. An enlarged spleen results from a hyper-active reticulo-endothelial system in response to active infection. Also, since the body destroys infected red blood cells at an alarming rate, the spleen engages in hematopoiesis to replace lysed red blood cells, in a process referred to as extramedullary hematopoiesis. An enlarged spleen presents as a sharp pain of sudden onset on the left hypochondriac region of the abdomen.
Since damaged red blood cells pass through the liver to conjugate and metabolize the hemoglobin, the patient may present with jaundice or hepatitis following infection of liver cells. The body’s immune system may actively destroy large numbers of erythrocytes, resulting in a hemolytic anemia. Platelet destruction results in thrombocytopenia (Naughton et al., 2021). The infection may also result in inflammation of the heart. i.e. myocarditis, presenting with an irregular heart beat and murmur. Infection of the nervous system may present with symptoms such as seizures, inflammation of the brain (encephalitis) or inflammation of the meninges covering the brain (meningitis). More severe complications from mononucleosis ensue in a host with a weakened immune system, for instance, in HIV/AIDS patients and persons taking immunosuppressive medications such as corticosteroids and cancer chemotherapy.
No definitive treatment exists to cure mononucleosis. As such, the disease is managed by placing the patient on bed rest, administering intravenous fluids for rehydration and managing the pain and fever using pain relievers such as acetaminophen or NSAIDS. The enlarged tonsils are managed by corticosteroids (Naughton et al., 2021). Also, there is no vaccine to prevent infection and the virus may stay in the host’s saliva for several months without physical symptoms of disease. Thus the best way of prevention includes washing hands often and avoiding sharing drinks, foods, toothbrushes and silverware.
Studies reveal that 75 % of adults of ages 18 to 22 years develop infectious mononucleosis following EBV infection. Among infected persons, 10 % are asymptomatic while 15 % exhibit atypical symptoms (Dunmire, Hogquist & Balfour, 2015). The incidence within the United States is 500 cases per 100 000 per year, with an annual incidence rate of 200 to 800 cases per 100 000 for young adults between 15 and 19 years. The prevalence of EBV worldwide is 95 %. The mortality rate is 17 % globally and morbidity is undetermined.
Social Determinants of Health
Infectious mononucleosis has higher incidence among individuals from upper socioeconomic groups compared to lower socioeconomic groups, as revealed by a study conducted in London (Dunmire, Hogquist & Balfour, 2015). This observation is attributable to the fact that individuals from high socioeconomic groups escape subclinical infection with Epstein Bar Virus during childhood to later develop the infection in adulthood. Moreover, individuals from lower socioeconomic groups may have under-diagnosis of the infection owing to inability to access medical care. This proposition is further supported by the presence of antibodies to Epstein-Barr virus among persons of lower socioeconomic groups, such as military recruits and pediatric patients in poor neighborhoods (Dunmire, Hogquist & Balfour, 2015). The higher prevalence of the antibody is also observed among students in universities and colleges. These findings are attributable to overcrowded living conditions since the disease is spread mainly via salivary contact. In overcrowding, an infectious person coughs salivary droplets containing the infectious virus, which are inhaled by healthy occupants of the room who acquire the infection. The prevalence of antibodies to EBV is lower in persons from middle-class environments, owing to adequate spacing and less risks for overcrowding. Among occupations, the incidence of mononucleosis is higher among nurses, doctors and other medical personnel and lower among manual workers. In addition to higher exposure risk to infected patients, medical workers may access diagnostic facilities with ease, resulting to high rates of detected illnesses.
A study by Cambridge University assessed the social determinants of mononucleosis as household socioeconomic position using mother’s educational level (Higher, degree, A, As, S level, GCSE), equivalised income rank with the partner’s joint income and the employment status (managerial, intermediate, small employers, own account workers, lower supervisory/technical occupations and semi-routine/routine occupations) (Black & Black, 2018). The area environment was determined as Large urban, Town or rural while the home environment was described by variables assessing for overcrowding (less than 1.5 rooms per person), collective child care (using nannies) and temperature in the child’s room. The housing tenure was described as owner, rent privately, social housing and other. The likelihood for EBV infection was significantly lower in children from higher social class, higher equivalised income and with mother having higher educational level (Black & Black, 2018). The likelihood for infection was higher among children sleeping in cold rooms, overcrowded homes, rented accommodation, and larger towns/cities. Urban dwelling exposes individuals to higher risks of contacting the virus via reduced personal space such as in public transport and living within small shared spaces. The low socioeconomic status (education, income and occupation) leads to inadequate living conditions within households, especially overcrowding and social renting, that increases the chances of spreading or acquiring the virus.
Host factors favoring infection with Epstein-Barr virus include genetic susceptibility, immunodeficiency, immunosuppression, intimate salivary contact with a carrier and airborne virus. Genetic susceptibility was identified in a study investigating individuals with inborn immune system errors, who exhibited higher susceptibility to and increased frequency of disease induced by the virus infection (Barros et al.,2019). Infants also have higher risks of developing EBV infection as maternal antibody (IgG) disappears from their bloodstream.
The children infected with Epstein Barr virus are often asymptomatic, and the infection could be confused for other differential diagnoses of common pediatric illnesses. But infection in adolescence and young adulthood results in characteristic features of infectious mononucleosis. Adolescents and young adults have increased risk of acquiring the infection, particularly in crowded living conditions such as in hostels, and intimate salivary contact involved in sexually active individuals. Sharing of silverware including cups, knives, forks and spoons is also common within this population, further increasing the likelihood of acquiring an infection (Bar-Or et al.,2020).
The epithelial linings of the oropharynx and uterine cervix are composed of squamous cells that the virus easily infects by bypassing the physiological barriers such as salivary and mucoid secretions. The role of a weakened immune system in developing the disease cannot be ignored. EBV has higher likelihood of developing into infectious mononucleosis in individuals who have immunosuppression secondary to organ transplant, chemotherapy, diabetes mellitus or human immunodeficiency virus.
Factors contributing to the virulence of EBV include increased antigen variation, selective infection of B lymphocytes, presence of a glycoprotein for attachment to cells and a latent phase. During the latent phase, the virus resides within the host without detection by the host’s immune system, enabling sustained viral replication and infection of more cells and tissues (Bar-Or et al.,2020). The replication cycle is also enhanced by the promoter of the viral gene ZEBRA that halts the latent phase and initiates the replication. Infecting B lymphocytes of hosts enables the virus to go undetected by the immune system, since B lymphocytes are involved in processing pathogen antigens, regulating immune responses and producing antibodies against infection. As a result, autoreactive infected B cells circulate, reaching specific target organs and initiate tissue damage, B cell damage, and release of the virus to infect new cells (Barros et al.,2019). The viral glycoprotein present on the lipid envelope enables the virus to attach to uninfected cells and commence the infection process.
Environmental factors contributing to spread of the virus include cold temperatures, poorly ventilated accommodations, humid environments and overcrowding. Exposure to cold triggers the human body to release cortisol into the circulation, which leads to reduced numbers of circulatory lymphocytes (Dunmire, Hogquist & Balfour, 2015). Since lymphocytes are the immune cells involved in combating virus infection, their reduced numbers makes it easier for the virus to cause infection in the host. Poorly ventilated rooms translate to air being stationary within confined spaces. In such cases, the airborne virus stays in the room air for longer periods, increasing the chances of its inhalation by an occupant. Likewise, overcrowding translates to less personal space between individuals, leading to higher chances of transmitting the virus via aerosol droplets incase an infected person coughs.
Role of a Community Health Nurse
The role of a community health nurse in dealing with infectious mononucleosis cannot be ignored. Since the disease is airborne, the community health nurse works with other health professionals to formulate appropriate strategies regarding sanitation, public practices, business interactions and personal interactions that would prevent the spread of the Epstein-Barr Virus (Naughton et al., 2021). For instance, the community health nurse may discourage kissing a person presenting with fever, malaise and other symptoms of infection.
The nurse may also encourage construction of buildings with adequate ventilation to prevent virion aerosols from being confined to rooms with stationary air that would favor transmission. The nurse also educates the caregivers interacting with the infected on the best practices to avoid acquiring the infection. Additional roles of a community health nurse involve holding educational campaigns to increase awareness of mononucleosis among the population, especially in crowded places like churches and schools.
In case finding, the nurse should have a high index of suspicion. A patient presenting with fever, muscle pain, lymphadenopathy and a sore throat should be highly suspected of Epstein-Barr virus infection (Naughton et al., 2021). In assessment, the nurse should check the temperature, respiratory rate, blood pressure and pulse rate to rule out life-threatening complications from the illness. Also, the health worker should order for laboratory workups to confirm the presence of antibodies to the virus within the circulation to provide a definitive diagnosis.
Every case should be documented in the facility’s medical records. The nurse then calculates the incidence of the disease and compares with other reported incidences from the records. A figure that is higher than expected is characteristic of an outbreak, which the nurse ought to report to the Centers for Disease Control and Prevention (Naughton et al., 2021). The department of health may then formulate strategic preventive measures to curb the outbreak before transformation into a pandemic. The nurse is directly involved in providing care to persons infected with Epstein Barr Virus, including administering the appropriate medication for symptoms relief and educating the individual on how to prevent spreading the pathogen to other persons.
The Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention keeps track of infectious mononucleosis. The CDC is the national agency that develops and applies disease control and prevention, promotes environmental health and holds health education activities for improved health of U.S. citizens (Black & Black, 2018). To achieve its objectives, the CDC carries out epidemiologic studies and laboratory analyses to keep relevant surveillance of diseases, enabling the body to identify, define and prevent health problems. The organization actively engages in collection, analysis and distribution of data pertaining to disease and acts as the leading agency in formulating and implementing solutions to environmental health challenges.
The agency also operates series of studies focused on developing and testing effective disease prevention, control and health promotion programs (Black & Black, 2018). At the national level, CDC formulates and assesses the occupational health and safety standards recommended by professionals, and provides training, research and technical aid to provide healthy and safe working environments for professionals across various disciplines. An additional responsibility involves conducting a nationwide program to improve hospital laboratories’ performance.
Worth-noting, the CDC controls both introduction and spread of an infectious disease, besides providing consultation and aid to international agencies and other nations seeking to promote health, preserve environmental health or improve disease prevention and control (Levinson, 2017). An intriguing finding is that the organization provides the Preventive Health and Health Services Block Grant to applicants, in addition to program expertise and assistance to State, Federal, local or private organizations dealing with disease control and prevention.
In the case of infectious mononucleosis, since no vaccine for EBV has completed successful clinical trial to date, the appropriate prevention strategy taken by CDC is to enhance awareness of the spread of the virus among U.S. citizens. CDC educates the community on the importance of proper hygiene practices, appropriate ventilation of buildings and avoiding overcrowding in public and private places (Levinson, 2017). Also, members of the population are cautioned against engaging in close salivary contact with suspected infected persons, including acts of kissing or sharing silverware such as forks, spoons and cups.
Global Implication of Infectious Mononucleosis
While the global incidence of infectious mononucleosis remains undetermined, an incidence of 90% is noted among children in developing nations (Dunmire, Hogquist & Balfour, 2015). The children experience asymptomatic EBV infection before they attain five years and are insusceptible to mononucleosis at later stages in their lives. Also, infectious mononucleosis has no specific racial or ethnic predilections, but its incidence is higher among persons of high socioeconomic class in developed countries.
Whereas the disease shows no preference for either sex, splenic rupture as a complication is more common in males, with only 10 % of splenic ruptures being among women(Dunmire, Hogquist & Balfour, 2015). In Central Africa, Epstein Barr-virus is associated with an increased risk of developing Burkitt Lymphoma, particularly in children. The virus is closely linked to nasopharyngeal carcinoma among Alaskan Eskimos and Cantonese Chinese.
Curtly, infectious mononucleosis is an infectious disease that poses a significant public health problem, primarily owing to ignorance of the public on existence of the Epstein-Barr virus and its mode of transmission. The role of the community nurse in identifying the cases, diagnosing, providing appropriate relief of symptoms and educating the public on prevention measures cannot be overemphasized. The mentioned facts have been adequately discussed in this paper.
- Bar-Or, A., Pender, M. P., Khanna, R., Steinman, L., Hartung, H. P., Maniar, T., … & Joshi, M. A. (2020). Epstein–Barr virus in multiple sclerosis: theory and emerging immunotherapies. Trends in molecular medicine, 26(3), 296-310. https://www.sciencedirect.com/science/article/pii/S1471491419302941
- Barros, M. H. M., Vera-Lozada, G., Segges, P., Hassan, R., & Niedobitek, G. (2019). Revisiting the tissue microenvironment of infectious mononucleosis: identification of EBV infection in T cells and deep characterization of immune profiles. Frontiers in immunology, 10, 146. https://www.frontiersin.org/articles/10.3389/fimmu.2019.00146/full
- Black, J. G., & Black, L. J. (2018). Microbiology: principles and explorations. John Wiley & Sons.
- Dunmire, S. K., Hogquist, K. A., & Balfour, H. H. (2015). Infectious Mononucleosis. Current topics in microbiology and immunology, 390(Pt 1), 211–240. https://doi.org/10.1007/978-3-319-22822-8_9
- Levinson, W. (2017). Review of medical microbiology and immunology.
- Naughton, P., Healy, M., Enright, F., & Lucey, B. (2021). Infectious Mononucleosis: diagnosis and clinical interpretation. British Journal of Biomedical Science, 1-10. https://www.tandfonline.com/doi/abs/10.1080/09674845.2021.1903683