Acute Respiratory Infection and SARS with IMNCI management

Acute Respiratory Infection and SARS with IMNCI management
ACUTE RESPIRATORY INFECTIONS(ARI) May cause the inflammation of respiratory tract anywhere from nose to alveoli.
May be classified as
AURI – Acute Upper Respiratory Infection (common cold, pharyngitis & otitis media) or
ALRI – Acute Lower Respiratory Infection ( epiglottitis , laryngitis, layngotracheitis , bronchitis, bronchiolitis & pneumonia)�

1. Acute Respiratory infections Dr. R Sharma Assistant professor Community Medicine

2. LEARNING OBJECTIVES CM 8.1 Describe and discuss the epidemiological and control measures including the use of essential laboratory tests at the primary care level for communicable diseases CM 8.3 numerate and describe disease specific National Health Programs including their prevention and treatment of a case.

3. CM 8.4 Describe the principles and enumerate the measures to control a disease epidemic CM 8.5 Describe and discuss the principles of planning, implementing and evaluating control measures for disease at community level bearing in mind the public health importance of the disease CM 8.6 Educate and train health workers in disease surveillance, control & treatment and health education

4. ACUTE RESPIRATORY INFECTIONS(ARI): ACUTE RESPIRATORY INFECTIONS(ARI) May cause the inflammation of respiratory tract anywhere from nose to alveoli. May be classified as AURI – Acute Upper Respiratory Infection (common cold, pharyngitis & otitis media) or ALRI – Acute Lower Respiratory Infection ( epiglottitis , laryngitis, layngotracheitis , bronchitis, bronchiolitis & pneumonia)

5. Clinical features: Most of infections are mild and self limiting. Running nose Cough Sore throat Difficult breathing Ear problem Fever Most of children – mild infection such as cold or cough Some children – severe infection such as pneumonia which is a major cause of death (Bacterial pneumonia)

6. Problem statement: Most common ailment of humans. Each year, acute respiratory infections cause approximately 3.9 million deaths worldwide Bangladesh, India, Indonesia & Nepal – 40% of the deaths d/t ARI. 90% of ARI deaths d/t pneumonia. High incidence is due to malnutrition, low birth weight, indoor air pollution Incidence of pneumonia in developed countries is low as 3-4% and higher in developing as 30-40%

7. ARI is an important cause of morbidity in the children below 5 year About 5 episode of ARI / child/year. Pneumonia kills more children than any other disease Strept . Pneumoniae is a major cause of illness and 1.6 million death in children. Hib causes 3 million cases of severe pneumonia and meningitis with 3,86,000 deaths in under 5 per year.

8. Epidemiology: Agents – Bacteria and viruses Clinical picture may vary with etiological agent May be present in normal people but may cause disease in only few. Severity of illness often determined by whether or not secondary bacterial infection occur particularly in LRI

9. AGENT FACTORS: Agent : BACTERIA AGE GROUP AFFECTED CHRACTERISTIC CLINICAL FEATURES Bordetella pertussis Infants & young children Poroxysmal cough Corynebacterium diphtheriae Children Nasal/ tonsillar /pharyngeal membranous exudates, toxemia Hemophilus influenzae Adults Children Acute ex of ch bronchitis, Pneumonia, Acute epiglottitis Klebsiella pneumoniae Adults Lobar pneumonia, lung abscess Legionella pneumophila Adults Pneumonia Staph. pyogenes All ages Lobar and bronchopneumonia lung abscess Strep. pneumoniae All ages Pneumonia, Acute ex of ch bronchitis Strep. pyogenes All ages Acute pharyngitis & tonsillitis

10. Viruses Agent Age group affected Clinical feature Adenovirus Young children Older children & adults Lower respiratory Febrile pharyngitis Enterovirus All ages Febrile pharyngitis Influenza A, B, C All ages variable Measles Young children variable Parainfluenza 1, 2, 3 Young children Croup, bronchiolitis and pneumonia Respiratory Syncytial Virus Infants and young children Severe bronchiolitis and pneumonia Rhinovirus All ages Common cold Coronavirus All ages Common cold

11. Other agents Chlamydia type B (Psittacosis) Adults exposed to infected birds Influenza like illness & Atypical pneumonia Coxiella burntii (Q fever) Adults exposed to sheep and cattle Atypical pneumonia Mycoplasma pneumoniae School children and young adults Febrile bronchitis & atypical pneumonia

12. Host factors Morbidity and mortality are high in young infants and malnourished children along with elderly population. URTI several times higher in children than adults Rates for pharyngitis and otitis media increases from infancy to peak at age of 5 year Adult women experience more illness than men

13. Risk Factors: Significant risk factors are Low SE status, low parental education, Maternal smoking, preschool children attending day care centres Overcrowded dwelling, intense indoor smoke pollution, low birth weight , prematurity Poor nutrition, anaemia , malnutrition weaning from breast milk at < 6 months, a negative history of vaccination, Infection rate higher in siblings of school children who introduce infection in the household. More common in urban communities then in rural communities

14. Mode of transmission: Airborne route Since viruses do not survive outside for long duration, transmission maintained by person to person contact.

15. PREVENTION AND CONTROL OF ARIs: Improving the medical care services and developing better methods for detection. Early diagnosis of pneumonia and prompt management (Antibiotics) Education of mother for danger signs and compliance of treatment Vaccination- measles, mumps, HiB , Pneumococcal Recent changes – Management as per the IMNCI protocol

16. What is IMNCI ? 17 IMNCI is an integrated approach to child health that focuses on the well-being of the whole child. IMNCI aims to reduce death, illness and disability, and to promote improved growth and development among children under five years of age. IMNCI includes both preventive and curative elements that are implemented by families and communities as well as by health facilities.

17. Guidelines for IMNCI 18 Evidence-based, syndromic approach to case management includes rational, effective and affordable use of drugs and diagnostic tools. An evidence-based syndromic approach can be used to determine the: Health problem(s) the child may have. Severity of the child’s condition, and Actions that can be taken to care for the child (e.g. refer the child immediately, manage with available resources, or manage at home).

18. In addition, IMNCI promotes: Adjustment of interventions to the capacity of the health system, and Active involvement of family members and the community in the health care process. The strategy includes three main components: Improving case management skills of health-care staff Improving overall health systems Improving family and community health practices.

19. Elements of case management process 20 Assess - C h i l d b y c hec k ing f or dange r s i g ns b y his t o r y and examination. Classify - Child's illness by color coded triage system. Identify - Specific treatments. Treatments - Instructions of oral drugs, feeding & fluids.

20. Counsel - Mother about breast feeding & about her own health as well as to follow further instructions on further child care. Follow up care - Reassess the child for new problems .

21. Clinical Assessment: History taking and clinical assessment very important . Note the following Age of the child, for how long the child has been coughing, whether the child is able to drink, has the young infant stopped feeding well, does the child have fever, is the child drowsy or difficult to wake, did the child have convulsions, is there irregular breathing, any history of treatment.

22. Physical examination: Look and listen the following: 1. COUNTING THE NUMBER OF BREATHS IN ONE MINUTE To assess fast breathing Respiratory rate cut offs : >/= 60 breaths per minute in a child less than 2 months >/=50 breaths per minute in child aged 2month upto 12 months >/=40 breaths per minute in child aged 12 months upto 5 years Repeat count if count is 60 in young infant

23. 2. LOOK FOR CHEST INDRAWING : when the child breathes IN 3. LOOK AND LISTEN FOR STRIDOR: harsh noise when the child breathes IN (=croup d/t narrowing of larynx, trachea/epiglottis) (diphtheria, tracheitis, measles, epiglotitis ) 4. LOOK FOR WHEEZE : when the child breathes out (soft whistling noise) d/t narrowing of air passage in lungs Recurrent wheeze : if child had previous attack within one year

24. 5. See if child is abnormally sleepy or difficult to wake(drowsy) 6. FEEL FEVER OR LOW BODY TEMPERATURE : 7. CHECK FOR SEVERE MALNUTRITION : high risk factor and high case fatality rate with malnutrition 8. CHECK FOR CYANOSIS: (sign of hypoxia must be checked in good light)

25. CLASSIFICATION OF DISEASE: A. CHILD AGED 2 MONTHS UPTO 59 MONTHS: Put the child into one of 3 revised classification- I. Cough and cold: No pneumonia II. Fast breathing and/or chest indrawing: Pneumonia III. Severe pneumonia or very severe disease

26. NO PNEUMONIA: SIGNS - Cough and cold CLASSIFY AS - No pneumonia TREATMENT - Home care advised

27. Antibiotics are not recommended for coughs and colds because majority of cases are caused by viruses and antibiotics are not effective, they increase resistant strains and cause side-effects while providing no clinical benefit, and are wasteful expenditure. Symptomatic treatment and care at home is generally enough for such cases. The mothers must be advised on how to take care of the child at home. Breast Feeding should be continued.

28. PNEUMONIA: SIGNS -Fast Breathing and/or -Chest Indrawing CLASSIFY AS - Pneumonia TREATMENT -Oral Antibiotics -Home care is advised

29. Children with fast breathing pneumonia with no chest indrawing or general danger sign should be treated with oral amoxicillin : at least 40 mg/kg/dose twice daily (80 mg/kg/day) for five days. Children with fast-breathing pneumonia who fail on first line treatment with amoxicillin should have the option of referral to a facility where there is appropriate second line treatment. Children age 2-59 months with chest indrawing pneumonia should be treated with oral amoxicillin : at least 40 mg/kg/dose twice daily for five days.

30. VERY SEVERE DISEASE: SIGNS -Not able to drink -Convulsions -Abnormally sleepy or difficult to wake - Stridor in a calm child -Severe malnutrition CLASSIFY AS - VERY SEVERE DISEASE

31. TREATMENT -Refer URGENTLY -Give first dose of antibiotic -Treat fever, if present -Treat wheeze, if present -If cerebral malaria is possible, give antimalarial Children aged 2-59 months with severe pneumonia should be treated with parenteral ampicillin (or penicillin) and gentamicin as a first-line treatment.

32. - Ampicillin : 50 mg/kg, or benzyl penicillin: 50,000 units per kg IM/IV every 6 hours for at least five days - Gentamicin : 7.5 mg/kg IM/IV once a day for at least five days Ceftriaxone should be used as a second-line treatment in children with severe pneumonia having failed on the first-line treatment.

33. The revised recommendations present a number of advantages such as Oral amoxicillin can be used to treat both fast breathing pneumonia and chest indrawing pneumonia; Pneumonia classification and management are simplified to two categories instead of three; Access to antibiotic treatment closer to home is increased;

34. The need for referrals to higher level facilities is decreased; The probability of hospitalization and thus the risk of nosocomial and injection borne diseases is reduced; The probability of antimicrobial resistance is diminished, due to better adherence to the simplified treatment; and Training of health workers is simplified.

35. CLASSIFICATION OF DISEASE B. Young Infants Aged less than 2 Months : Special characters: They become sick & die quickly from bacterial infection They Less likely to cough Frequently have only non specific signs like poor feeding , fever/low body temp. Mild chest indrawing is normal because their cheat wall bone are soft Some have low birth weight as a risk factor Fast breathing 60/min is considered as severe pneumonia Any pneumonia in young infant consider to be severe

36. Danger signs in young infants Danger signs of very severe disease: A. Convulsion, abnormally sleepy or difficult to wake B. Stridor when calm: C. Stopped feeding well D. Weezing : E. Fever or low body temp.

37. The treatment in these conditions is, basically the same. The child must be hospitalized. Treatment may be started by the health worker before referring the child. If pneumonia is suspected the child should be treated with intramuscular injections of benzyl penicillin or injection ampicillin, along with injection gentamycin.

38. Treatment: Young infant having having severe disease or pneumonia should be hospitalized and treated. Antibiotics recommended Parenteral Benzyl Penicillin or Ampicillin & Gentamycin Oral – Cotrimoxazole tablets / suspension Antibiotics Dose Frequency Age < 7days Frequency Age > 7 days to 2 months Inj. Benzyl penicillin OR Inj. Ampicillin AND Inj. Gentamycin 50000 IU/kg/dose 50mg/kg/dose 2.5mg/kg/dose 12 hourly 12 hourly 12 hourly 6 hourly 8hourly 8 hourly

39. VACCINATION: MEASLES HIB VACCINE PNEUMOCOCCAL PNEUMONIA PPV23 ( polysaccharide non-conjugate vaccine ) PCV ( Two conjugate vaccines PCV10 and PCV13 )

40. SEVERE ACUTE RESPIRATORY SYNDROME (SARS) Severe acute respiratory syndrome (SARS) is a communicable viral disease , caused by a new strain of coronavirus, which differs considerably in genetic structure from previously recognized coronavirus.

41. SYMPTOMS Fever, malaise, chills, headache myalgia, dizziness, cough, sore throat and running nose. In some cases there is rapid deterioration with low oxygen saturation and acute respiratory distress requiring ventilatory support. It is capable of causing death in as many as 10 per cent cases

42. Incubation period 2 to 7 days commonly 3 to 5 days Direct or indirect contact of mucous membranes of eyes, nose, or mouth with respiratory droplets or fomites. Mode of transmission

43. Clinical case definition of SARS 1. A history of fever, or documented fever AND 2. One or more symptoms of lower respiratory tract illness (cough, difficulty in breathing, shortness of breath) AND

44. 3. Radiographic evidence of lung infiltrates consistent with pneumonia or acute respiratory distress syndrome (ARDS) or autopsy findings consistent with the pathology of pneumonia or ARDS without an identifiable cause AND 4. No alternative diagnosis fully explaining the illness.

45. DIAGNOSTIC TESTS Reverse transcriptase PCR (RT-PCR) Enzyme-linked immunosorbent assay (ELISA) and immunofluorescent assay (IFA)

46. TREATMENT Severe cases require intensive support. Although a number of different agents including ribavirin (400-600 mg/d and 4 g/d), lopinavir/ritonavir (400 mg/100 mg), interferon type 1, intravenous immunoglobulin, and systemic corticosteroids are used.

47. PREVENTION As there is no vaccine against SARS, the preventive measures for SARS control are appropriate detection and protective measures which include : 1. Prompt identification of persons with SARS, their movements and contacts; 2. Effective isolation of SARS patients in hospitals;

48. 3. Appropriate protection of medical staff treating these patients; 4. Comprehensive identification and isolation of suspected SARS cases; 5. Simple hygienic measures such as hand-washing after touching patients, use of appropriate and well-fitted masks, and introduction of infection control measures; 6. Exit screening of international travellers; 7. Timely and accurate reporting and sharing of information with other authorities and/or governments.

49. REVISION/ FEEDBACK

50. Risk Factors: Significant risk factors are Low ………….. status, low parental education, Maternal smoking, preschool children attending day care centres ………………… dwelling, intense indoor smoke pollution, low birth weight , prematurity Poor nutrition, anaemia , malnutrition weaning from breast milk at < ………… months, a negative history of ………………, Infection rate higher in siblings of school children who introduce infection in the household. More common in ………….. communities then in …………… communities.

51. Risk Factors: Significant risk factors are Low SE status, low parental education, Maternal smoking, preschool children attending day care centres Overcrowded dwelling, intense indoor smoke pollution, low birth weight , prematurity Poor nutrition, anaemia , malnutrition weaning from breast milk at < 6 months, a negative history of vaccination, Infection rate higher in siblings of school children who introduce infection in the household. More common in urban communities then in rural communities

52. Physical examination: Look and listen the following: 1. COUNTING THE NUMBER OF BREATHS IN ONE MINUTE To assess fast breathing Respiratory rate cut offs : >/= ………… breaths per minute in a child less than 2 months >/=…………. breaths per minute in child aged 2month upto 12 months >/=………….. breaths per minute in child aged 12 months upto 5 years Repeat count if count is 60 in young infant

53. Physical examination: Look and listen the following: 1. COUNTING THE NUMBER OF BREATHS IN ONE MINUTE To assess fast breathing Respiratory rate cut offs : >/= 60 breaths per minute in a child less than 2 months >/=50 breaths per minute in child aged 2month upto 12 months >/=40 breaths per minute in child aged 12 months upto 5 years Repeat count if count is 60 in young infant