Prevention and control of Pneumonia.pptx

Pneumonia is a form of acute respiratory infection that affects the lungs due to inflammation and consolidation of the lung tissue resulting in pus and fluid filled alveolar cavities which may be bacterial, viral, fungal or parasitic. It can cause mild to severe life-threatening illness in people of all ages; however, it is the single largest infectious cause of death in children worldwide with the most common organism being Streptococcus pneumoniae and Haemophilus influenza.
The lungs are made up of small sacs called alveoli, which fill with air when a healthy person breathes. When an individual has pneumonia, the alveoli are filled with pus and fluid, which makes breathing difficult and limits oxygen intake.
Most children with these infections have a mild infection like cold and cough, but some children may have pneumonia which is a major cause of death.
In less developed countries, measles and whooping cough are important causes of severe respiratory tract infection.
Childhood pneumonia continues to be the topmost infectious killer among under-five children, contributing to 17.51 percent of under-five deaths in India.
More than 80% of deaths associated with pneumonia occur in children during the first 2 years of life.
Pneumonia affects children and families everywhere, but deaths are highest in southern Asia and sub-Saharan Africa. Children can be protected from pneumonia, it can be prevented with simple interventions, and it can be treated with low-cost, low-tech medication and care.
Streptococcus pneumoniae is responsible for 78% of lobar pneumonia cases and 13% of bronchopneumonia cases.
Haemophilus influenza is the 2nd most common cause of pneumonia
RSV is the most common viral cause of pneumonia
Chlamydia type B- adults exposed to infected birds- influenza like illness and atypical pneumonia
Coxiella burnetti- adults exposed to sheep and cattle- atypical pneumonia
Mycoplasma pneumoniae- school children and young adults- febrile bronchitis and atypical pneumonia
RISK FACTORS -Climatic conditions
Household overcrowding
Small household size
Low socio-economic status
Low parental education level
Poor nutrition
Low birth weight
Intense indoor smoke pollution, Air pollution
Chronic diseses, HIV infection, chemotherapy
All the causative organisms are transmitted person to person by the airborne route.
As most virus do not survive for long outside the respiratory tract, the chain of transmission is maintained by person-to-person contact.
All the causative organisms are transmitted person to person by the airborne route.
As most virus do not survive for long outside the respiratory tract, the chain of transmission is maintained by person-to-person contact.
Revised classification includes the changing of recommendations for first line antibiotics and re-defining the classification of pneumonia severity.
Oral amoxicillin > oral cotrimoxazole
Oral amoxicillin = injectable penicillin/ampicillin
World health organization developed pneumonia control

1. PREVENTION AND CONTROL OF PNEUMONIA Presenter: Dr Shivani Bandekar Guide: Dr T V Sangrulkar 1

2. PNEUMONIA: INTRODUCTION Pneumonia is a form of acute respiratory infection that affects the lungs due to inflammation and consolidation of the lung tissue resulting in pus and fluid filled alveolar cavities which may be bacterial, viral, fungal or parasitic . It can cause mild to severe life-threatening illness in people of all ages; however, it is the single largest infectious cause of death in children worldwide with the most common organism being Streptococcus pneumoniae and Haemophilus influenza. The lungs are made up of small sacs called alveoli, which fill with air when a healthy person breathes. When an individual has pneumonia, the alveoli are filled with pus and fluid, which makes breathing difficult and limits oxygen intake. 2

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4. PNEUMONIA: INTRODUCTION Acute respiratory infections are a source of discomfort, disability and loss of time for most adults, but they are also a substantial cause of morbidity and mortality in young children and the elderly. 4

5. PNEUMONIA: INTRODUCTION 5

6. PNEUMONIA: INTRODUCTION ARI is often classified clinically depending on the site of infection, and is referred to as: AURI (Acute Upper Respiratory Infection)- common cold, pharyngitis and otitis media ALRI (Acute Lower Respiratory Infection)- epiglottitis, laryngitis, laryngotracheitis, bronchitis, bronchiolitis and pneumonia . 6

7. PNEUMONIA: INTRODUCTION Most children with these infections have a mild infection like cold and cough, but some children may have pneumonia which is a major cause of death. In less developed countries, measles and whooping cough are important causes of severe respiratory tract infection. 7

8. PNEUMONIA: PROBLEM STATEMENT Childhood pneumonia continues to be the topmost infectious killer among under-five children, contributing to 17.51 percent of under-five deaths in India. More than 80% of deaths associated with pneumonia occur in children during the first 2 years of life. Pneumonia affects children and families everywhere, but deaths are highest in southern Asia and sub-Saharan Africa. Children can be protected from pneumonia, it can be prevented with simple interventions, and it can be treated with low-cost, low-tech medication and care. 8

9. PNEUMONIA : PROBLEM STATEMENT 9

10. PNEUMONIA : PROBLEM STATEMENT According to Statistical report 2020, the under-5 mortality is 32 per 1000 live births and the goal of National Health Policy 2017 is to reduce U5MR to 23 per 1000 live births by 2025. In order to achieve the National Health Policy goals, the Pneumonia mortality in children needs to reduce to less than 3 per 1000 live births. 10

11. BACTERIAL AGENTS AGENT AGE GROUP AFFECTED CLINICAL FEATURES S. Pneumoniae All ages Pneumonia , acute exacerbation of chronic bronchitis H. influenzae Adults, Children Acute exacerbation of chronic bronchitis Acute epiglottitis K. Pneumoniae Adults Lobar pneumonia, lung abscess C. diphtheriae Children Nasal/tonsillar/pharyngeal membranous exudate , severe toxaemia L. pneumophilia Adults Pneumonia S. Pyogenes All ages Lobar and broncho pneumonia B. pertussis Infants and young children Paroxysmal cough Streptococcus pyogenes All ages Acute pharyngitis and tonsillitis 11

12. BACTERIAL AGENTS Streptococcus pneumoniae is responsible for 78% of lobar pneumonia cases and 13% of bronchopneumonia cases. Haemophilus influenza is the 2 nd most common cause of pneumonia 12

13. VIRAL AGENTS AGENT AGE GROUP AFFECTED CLINICAL FEATURES Respiratory syncytial virus Infants and young children Severe bronchiolitis and pneumonia Adenovirus – endemic types Epidemic types Young children Older children and young adults Lower respiratory Febrile pharyngitis, influenza like illness Influenza A B C All ages School children Rare Fever, malaise, aching, bacterial pneumonia in elderly Mild upper respiratory Measles Young children Variable respiratory with characteristic rash Parainfluenza 1 2 3 Young children Young children Infants Croup Bronchiolitis and pneumonia 13

14. VIRAL AGENTS cont.. AGENT AGE GROUP AFFECTED CLINICAL FEATURES Rhinovirus All ages Common cold Coronavirus All ages Common cold Enterovirus(ECHO, coxsackie) All ages Variable respiratory 14

15. VIRAL AGENTS RSV is the most common viral cause of pneumonia 15

16. OTHER AGENTS Chlamydia type B- adults exposed to infected birds- influenza like illness and atypical pneumonia Coxiella burnetti - adults exposed to sheep and cattle- atypical pneumonia Mycoplasma pneumoniae- school children and young adults- febrile bronchitis and atypical pneumonia 16

17. HOST FACTORS Young infants & malnourished children Low birth weight Failure of breast-feeding Lack of primary immunization Vitamin A deficiency Antecedent viral infections 17

18. RISK FACTORS Climatic conditions Household overcrowding Small household size Low socio-economic status Low parental education level Poor nutrition Low birth weight Intense indoor smoke pollution, Air pollution Chronic diseses , HIV infection, chemotherapy 18

19. MODE OF TRANSMISSION All the causative organisms are transmitted person to person by the airborne route. As most virus do not survive for long outside the respiratory tract, the chain of transmission is maintained by person-to-person contact. 19

20. CLASSIFICATION OF CHILDHOOD PNEUMONIA 20

21. OTHER CLASSIFICATIONS OF PNEUMONIA PRIMARY AND SECONDARY PNEUMONIA Primary pneumonia is the lung infection that occurs directly after an acute illness, usually caused by a virus. Secondary pneumonia could be due to Aspiration, ineffective coughing or partial bronchial obstruction. 21

22. CLASSIFICATION BY MODE OF AQUIRING NOSOCOMIAL PNEUMONIA It is acquired by the patient in a hospital after being admitted for > 48hours or < 7 days after a patient is discharged from hospital. COMMUNITY AQUIRED PNEUMONIA Pneumonia that develops outside the hospital is considered as CAP. 22

23. CLASSIFICATION BASED ON CAUSATIVE AGENT VIRAL PNEUMONIA BACTERIAL PNEUMONIA FUNGAL PNEUMONIA RICKETTSIAL PNEUMONIA PROTOZOAL PNEUMONIA CHEMICAL PNEUMONIA 23

24. CLASSIFICATION BASED ON SITE OF LUNG INVOLVED LOBAR PNEUMONIA Consolidation of whole lobe of lung BRONCHOPNEUMONIA Characterized by inflammation of bronchioles and alveoli, thereby resulting in patchy bilateral consolidation of lungs. INTERSTITIAL / ATYPICAL PNEUMONIA it involves the inflammation and infection of the areas between the alveoli, leading to the scarring of the lung tissue 24

25. CONTROL OF ARI Proper classification of disease and treatment Improving the primary medical care services Developing better methods for early detection, treatment Prevention of ARI Education of mother is also crucial 25

26. CLASSIFICATION OF CHILDHOOD PNEUMONIA 26

27. CLASSIFICATION OF CHILDHOOD PNEUMONIA Revised classification includes the changing of recommendations for first line antibiotics and re-defining the classification of pneumonia severity. Oral amoxicillin > oral cotrimoxazole Oral amoxicillin = injectable penicillin/ampicillin 27

28. CONTROL OF ARI World health organization developed pneumonia control strategy in the early 1980s and management of the pneumonia cases was the cornerstone of this strategy. The classification determined the appropriate case management actions and these guidelines were incorporated into the original version of Integrated Management of Childhood Illness (IMCI) . 28

29. PROPER CLINICAL ASSESSMENT History taking & clinical assessment is very important in management of ARI Making note of age of the child, for how long the child is coughing, whether the child is able to drink, not feeding well, vomits everything, any antecedent illness such as measles, does the child have fever, is the child excessively drowsy or lethargic, difficult to wake, did the child have convulsions, is there irregular breathing, the child turning blue and any history of treatment during the illness etc. 29

30. PHYSICAL EXAMINATION LOOK AND LISTEN Count the breaths in one minute Breaths in one minute Age of child 60 or more < 2 months 50 or more 2 months to 12 months 40 or more 12 months to 5 years 30

31. PHYSICAL EXAMINATION 2. Look for chest indrawing The child has indrawing if the lower chest wall goes in when the child breaths IN and it occurs when the effort required to breathe in is much greater than normal. 31

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33. PHYSICAL EXAMINATION 3. Look and listen for stridor. Stridor is a harsh noise when breathing IN It occurs when there is narrowing of the larynx, trachea or epiglottis 4. Look for wheeze Wheeze is a soft whistling noise while breathing OUT It occurs when there is narrowing of air passage in the lungs 33

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36. PHYSICAL EXAMINATION 5. See if child is abnormally sleepy or difficult to wake 6. Feel for fever or low body temperature 7. Check for severe malnutrition Fast breathing and chest indrawing may not be as evident as in normal children Impaired response to hypoxia and weak or absent cough reflex 8. Look for cyanosis 36

37. TREATMENT OF NO PNEUMONIA HOME BASED CARE Increase breast feeding Keep Hydration Keep the baby warm home made decoctions like ginger tea, lime juice, etc Look for danger signs Educating the mother and family on hygiene 37

38. TREATMENT OF PNEUMONIA CHILD AGED 2 MONTHS UPTO 5 YEARS Fast breathing and Chest indrawing pneumonia – oral amoxicillin, 40mg/kg/dose twice daily for 5 days Severe pneumonia – 1 st line treatment Ampicillin- 50mg/kg or benzyl penicillin- 50,000 IU/kg IM/IV every 6 hourly for 5 days Gentamicin- 7.5mg/kg IM/IV OD for 5 days -2 nd line Treatment- Ceftriaxone 38

39. TREATMENT OF PNEUMONIA 3. HIV infected and HIV exposed – 1 st line- Ampicillin + Gentamicin or Ceftriaxone 2 nd line- Ceftriaxone alone 4. Empiric cotrimoxazole- Pneumocystis jirovecii pneumonia <1 year age. 39

40. TREATMENT OF PNEUMONIA Dosage of amoxicillin for pneumonia treatment according to revised guidelines reflect three age bands 2months – 12months (4-<10kgs) – 1 tab (250mg) twice a day x 5 days (10 tabs) 12months – 3 years (10-<14kgs)- 2 tabs (250mg) twice a day x 5 days (20 tabs) 3years – 5 years (14-19kgs)- 3 tabs (250mg) twice a day x 5 days (30 tabs) 40

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42. TREATMENT OF PNEUMONIA Pneumonia treatment under 2 months of age Child must be hospitalized and treated with IM benzyl penicillin or injection ampicillin, along with injection gentamicin ANTIBIOTIC DOSE AGE < 7 DAYS AGE > 7DAYS UPTO 2 MONTHS BENZYL PENICILLIN OR AMPICILLIN 50,000 IU/KG/DOSE 50MG/KG/DOSE 12 HOURLY 12 HOURLY 6 HOURLY 8 HOURLY GENTAMICIN 2.5MG/KG/DOSE 12 HOURLY 8 HOURLY 42

43. ADVANTAGES OF THE REVISED RECOMMENDATIONS Oral amoxicillin – fast breathing and chest indrawing pneumonia Classification simplified – 2 categories of pneumonia Better access to treatment closer to home increased Need for referrals – decreased Hospitalization and risk of nosocomial and injection borne infections- reduced AMR – diminished Training of health workers - simplified 43

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45. PREVENTION OF ARI HEALTH PROMOTION Efficient antenatal care to reduce the incidence of LBW. Essential care of the newborn and special care of LBW newborn. Promotion of exclusive breastfeeding up to the first six months of life. Promotion of adequate nutrition of the growing children. Improvement in the living conditions (Housing and sanitation). Reduction of parental smoking and smoke pollution indoors. Limiting the size of the family to prevent overcrowding. 45

46. HEALTH PROMOTION Health education of mothers about correct ARI case management at home with the following points. To increase feeding and to keep the child warm. To clear the nose by instillation of breastmilk, if runny nose interferes with feeding. To relieve the cough with home made decoctions like tea, ginger, lime juice, etc. To recognize danger signs such as fast breathing (increased respiratory rate) and difficult breathing. (Chest in drawing). 46

47. SPECIFIC PROTECTION Strengthening the existing routine primary immunization. Oral vitamin A Other vaccines which can be given are pneumococcal vaccine and Haemophilus influenzae B vaccine. 47

48. IMMUNIZATION 3 vaccines have potential of reducing deaths from pneumonia Measles vaccine HiB Vaccine Pneumococcal pneumonia vaccine 48

49. MEASLES VACCINE Pneumonia is a serious complication of measles and the most common cause of death associated with measles worldwide. This vaccine is live attenuated vaccine 0.5ml is given subcutaneously in the left arm 2 doses – 9months and 15-18months Stored in the dark at 2-8 degree Celsius and used within 4 hours 49

50. HAEMOPHILUS INFLUENZA B VACCINE Haemophilus influenza is an important cause of pneumonia and meningitis among children in developing countries. Pentavalent vaccine- gives protection from 5 life threatening diseases – diphtheria, pertussis, tetanus, hepatitis B, HiB Given at 6, 10, 14 weeks, and booster dose at 12-18months, each dose of 0.5 ml each given by IM injection, in anterolateral aspect of the mid-thigh. Stored and transported at 2–8-degree Celsius. 50

51. PNEUMOCOCCAL PNEUMONIA VACCINE PPV23 It is a non-conjugate vaccine containing capsular antigens of 23 serotypes against this infection It is available for adults and children over 2 years of age. It is recommended for selected groups, example- splenectomy patients, sickle-cell disease, chronic disease of heart, lung, kidney, liver, DM, alcoholism, generalized malignancies, organ transplants etc. Dose 0.5ml administered as a single intramuscular dose preferably in deltoid muscle or as subcutaneous dose. 0.5 ml of this vaccine contains 25 micrograms of purified capsular polysaccharide from the 23 serotypes 51

52. PNEUMOCOCCAL PNEUMONIA VACCINE PCV Two conjugate vaccines PCV 10 and PCV 13 are available since 2009 WHO recommends 3p+0 or 2p+1 schedule. The National Immunization schedule of India recommends PCV for infants up to 1 year of age in 3 doses (2 primary and 1 booster) at 6 weeks, 14 weeks and 9 months. 0.5ml is given as IM injection in the anterolateral aspect of right mid-thigh 52

53. INTEGRATED GLOBAL ACTION PLAN FOR THE PREVENTION AND CONTROL OF PNEUMONIA AND DIARRHOEA (GAPPD) It proposes a cohesive approach to ending preventable pneumonia and diarrhoea deaths. It brings together critical services and interventions to create healthy environment, promote practices known to protect children from disease and ensures every child has access to proven and appropriate preventive and treatment measures. 53

54. GOALS OF GAPPD FOR 2025 : Reduce mortality from pneumonia in under 5 age to <3 per 1000 live births. Reduce mortality from diarrhoea in under 5age to <1 per 1000 live births. Reduce the incidence of severe pneumonia by 75% in under 5 age Reduce the incidence of severe diarrhoea by 75% in under 5 age Reduce by 40% the global number of under 5 children who are stunted 54

55. COVERAGE TARGETS BY THE END OF 2025: 90% full dose coverage of each relevant vaccine (with 80% coverage in every district) 90% access to appropriate pneumonia and diarrhoea case management (with 80% coverage in every district) At least 50% coverage of exclusive breastfeeding during the first 6 months of life Virtual elimination of paediatric HIV 55

56. COVERAGE TARGETS BY THE END OF 2030: Universal access to basic drinking water in health care facilities and homes Universal access to adequate sanitation in health care facilities by 2030 and in homes by 2040 Universal access to handwashing facilities in health care facilities and homes Universal access to clean and safe energy technologies in health care facilities and homes 56

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58. SOCIAL AWARENESS AND ACTION PLAN TO NEUTRALIZE PNEUMONIA SUCCESSFULLY 12th November 2024 on the World Pneumonia Day 58

59. SAANS: KEY OBJECTIVES Adoption and adherence to Pneumonia Management guidelines 2019 Create awareness & mobilize community towards increased adoption of health promotive behaviors and practices for Pneumonia Protection, Prevention and Treatment Early identification and management of under-five children to detect suspected pneumonia cases Strengthen facility-level management for cases of severe-pneumonia 59

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61. SAANS CAMPAIGN Early preparedness, roll out and monitoring of the SAANS campaign by States/UTs and districts would be key to the success of control of childhood pneumonia. Emphasis and focus for early identification and appropriate management of childhood pneumonia cases through home visits by ASHAs and other front-line workers (ANMs/ CHOs) during the campaign period SAANS campaign also focus on strengthening of health facilities for pediatric care. Ensure that all eligible children receive 3 doses of Pneumococcal Conjugate Vaccine (two primary doses at 6 weeks and 14 weeks and a booster dose at 9 months) as per the national immunization schedule under the Universal Immunization Programme (UIP). Create Awareness about Indoor and Outdoor Air Pollution and its effects on under-5 Children. 61

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66. THEME OF WORLD PNEUMONIA DAY 2024 “EVERY BREATH COUNTS: STOP PNEUMONIA IN ITS TRACK” The theme highlights the significance of every breath, and stopping pneumonia through early detection, treatment and prevention 66

67. REFERENCES WORLD HEALTH ORGANIZATION MINISTRY OF HEALTH AND FAMILY WELFARE- GOI PARK’S TEXTBOOK OF PSM 27 TH EDITION A H SURYAKANTA TEXTBOOK OF PSM 3 RD EDITION 67

68. THANK YOU 68