MODULE V

Management of Prevalent Infections in Children Following a Disaster

• Acute respiratory infections

• Diarrhea and dehydration

• Measles

• Malaria

• Malnutrition

MAIN CAUSES OF DEATH

Leading Causes of Death (under age 5)

Prevalent Infections in Children

• Morbidity and mortality resulting from an acute humanitarian emergency in developing countries are related to the excessive childhood mortality that existed prior to the disaster.

• Conditions are made worse during the disaster (crowding, compromised hygiene, contaminated water, poor sanitation), increasing mortality from common childhood infections.

• Pre-existing health conditions, nutritional status, and immunization rates are important to know!

Integrated Management of Childhood Illness (IMCI)

• Designed by WHO and UNICEF in 1990s• Strategy to reduce morbidity and mortality from the most

prevalent diseases in developing countries based on simple clinical signs and procedural algorithms

• Early diagnosis Early treatment Timely referral• Community-based approach• Improves parenting skills and practices associated with

home care• Integrates aspects of nutrition, immunization, health

promotion, and disease prevention

The IMCI strategy

2 components based on the child’s age:(1) Sick young infant aged up to 2 months (2) Sick child aged 2 months up to 5 years

The IMCI strategy

• The clinical decision making approach involves using a limited number of symptoms and signs to classify the severity of illness, which determines the management with guidelines for follow-up, counseling for the parents, and instructions regarding when to return and if additional care is needed.

IMCI Management: Assessment

• All sick children are assessed for “general danger signs”– Seizures, unconsciousness/lethargy, inability to drink or

breastfeed, persistent vomiting– Indication for immediate referral or admission to a hospital

• All sick children are routinely assessed for: – Major symptoms1 week – 2 months: bacterial infection and diarrhea2 months – 5 years: cough or difficulty breathing,

diarrhea, fever, ear problems– Nutritional and immunization status– Feeding and other potential problems

IMCI Management: Classification

• Uses a few carefully-selected clinical signs – Based on their sensitivity and specificity to detect

disease• A combination of individual signs leads to a

child’s classification rather than a diagnosis– Classifications are color coded– Red/Pink = urgently refer to a higher level of care – Yellow = requires specific treatment– Green = can be safely managed at home

IMCI Management: Treatment and Counseling

• Guidelines address most illnesses (but certain chronic or less common illnesses may require special care)

• Management procedures – Uses a limited number of essential drugs– Encourages active participation of caretakers

• An essential component of the IMCI guidelines is the counseling of caretakers (feeding, fluids, return precautions)

IMCI Case Management at First Level, Referral Level and at Home

FIRST-LEVEL OUTPATIENT HEALTH FACILITY

Give FOLLOW-UP care when the child returns, and if necessary, reassess for new problems

Ask about CHILD’S PROBLEMSCheck for

GENERAL DANGER SIGNS

ASSESS for MAIN SYMPTOMS:COUGH OR DIFFICULT

BREATHINGDIARRHOEA

FEVER

ASSESS forMALNUTRITION AND ANAEMIA

Check for OTHER PROBLEMS

CLASSIFY CHLID’S

CONDITIONSAND

IDENTIFYTREATMENT

“YELLOW” -SPECIFIC

TREATMENT AT FIRST

LEVEL FACILITY

“GREEN” -HOME

MANAGEMENT

“RED” - PRE-REFERRAL

TREATMENT AND

REFERRAL

ADVISEparents about

REFERRAL

FIRST-LEVEL REFERRAL HEALTH FACILITY

EMERGENCY TRIAGE

ASSESSMENT AND

TREATMENT(ETAT)

DIAGNOSE AND TREAT COMMON SERIOUS

CONDITIONS

MONITOR PATIENT PROGRESS

TEACHparents about

treatment

COUNSELthem about

feeding and when

toreturn

HOME

GIVE ORAL DRUGSAND/OR

TREAT LOCAL INFECTION

GIVE FOOD AND FLUIDS(follow feeding recommendations)

RETURN TO HEALTH FACILITYWHEN NEDED

Essential IMCI drugs

• ORT• Sugar water• Paracetamol• Mebendazole• Salbutamol• Iron• Vitamin A• Gentian Violet• Diazepam

• Oral antibiotics– Amoxicillin & bactrim– Ciprofloxacin– Tetracylcine & erythromycin

• Oral antimalarials• Tetracycline eye ointment

• IM Quinine• IM Ampicillin• IM Gentamicin

Sick young infant aged up to 2 months

• Classification and management Severe disease (pneumonia, meningitis, and sepsis) Local bacterial infection Jaundice Diarrhea HIV infection Poor weight gain Breast feeding and other feeding problems Immunization status Mother’s health

Severe disease (RED/PINK)

• Not feeding, convulsions, fast breathing (more than 60 breaths per minute), severe chest in-drawing, fever or low temperature, and lack of movement

• Refer urgently to the hospital with a first antibiotic dose and treatment to prevent low blood sugar

Local bacterial infection (YELLOW)

• Signs of umbilical infection (redness and or purulent discharge) or skin pustules

• Treat with an appropriate antibiotic

Sick child aged 2 months up to 5 years

• Classification and management Respiratory disease Diarrhea Febrile illness (malaria) Measles Ear infections Malnutrition Anemia HIV Immunization status

IMCI Strategy: Danger Signs

• Unable to drink or breast feed • Vomits everything• Had convulsions• Lethargic or unconscious• Convulsing now

Very severe respiratory disease• Any general danger sign• Stridor in a calm child

Pneumonia• Fast breathing• Chest indrawing

Cough without pneumonia• No signs of pneumonia or severe disease

IMCI: Cough or Difficulty Breathing

INFLUENZA VIRUS

• Family Orthomyxoviridae– “myxo” mucus– segmented, single-stranded

RNA

• Influenza A first isolated 1933; Influenza B 1940

• 15 hemagglutinin (HA) and 9 neuraminidase (NA) subtypes– Only H1N1, H2N2, H3N2

subtypes associated with widespread epidemics in humans

Clinically Relevant Influenza Viruses

Type A Potentially severe illnessEpidemics and pandemicsRapidly changingBirds, swine, horses, seals, humans

Type B Usually less severe illnessEpidemicsMore uniformHumans

Type C Usually mild or asymptomatic illness Minimal public health impactHumans, swine

Influenza: A Continually Changing Virus

Polymerase Proteins (PP)

Hemagglutinin (HA) *cell entry

Neuraminidase (NA)*cell escape

M1, M2

Nucleoprotein (NP)

Adapted from: Hayden FG et al. Clin Virol. 1997:911-942.

RNA

Hemagglutinin

NeuraminidaseAntibodiesSialic acid

Antigenic Drift (A & B)

Antigenic Shift (A only)

Transmission of Influenza

• Person to person• Droplet spread

– small particle aerosols• Fomite contamination

– Steel and plastic 24-48 hrs– Cloth, paper, tissues 8-12 hrs– Hands 5 min (high viral titer)

• Principal site of replication- columnar epithelium• Incubation period- 18 hrs to 5 or more days (average 2-3 days)• Virus shedding 3-7 days• Viral titers are generally higher in young children with shedding

lasting 10 days or longer

Recognizing Pediatric Influenza

Neonates Infants/Toddlers Children/Teens

High fever GI symptoms Rapid onsetLethargy Fever >103°F (>39.5°C) High feverDecreased eating Anorexia CoughMottling Respiratory syndromes ChillsApnea Malaise

HeadacheSore throat

Influenza Virus Complications

• Acute otitis media (children)

• Sinusitis• Pneumonia• Exacerbation of

underlying illness• Dehydration (infants)

• Encephalopathy• Reye syndrome

(children)• Myositis• Myocarditis• Febrile seizures

Common Complications Uncommon Complications

MEASLES

• Highly contagious infection (98-100% in susceptible contacts)

• Transmission through respiratory secretions(contact and aerosolized particles)

• Incubation period: 10-14 days

• Mortality rate ⇒ Nutrition / crowding / inoculum

Overcrowded living conditions are an important triggering factor for epidemics

Natural History of Measles

Identification of one case in a camp should speed up immunization process

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7Incubation 10-14 days

Fever ------------- FEVER--------------------]Cough ---------------------------------------------------- - - -Conjunctivitis ----------------------------------------- - - -Coryza ------------------------------------------------- - - -

Köplik spots---]

Exposure

Rash ---------------- - - -

Measles Rash – DAY 1

Measles Rash – DAY 2

Measles Clinical Manifestations

Measles and Vitamin A Deficiency

MEASLES unmasks an underlying Vitamin A deficiency

SYNERGIC EFFECT

VITAMIN A DEFICIENCY (even subclinical) increases measles-associated morbidity and mortality

Measles-associated morbidity and mortality may be reduced by administering Vitamin A to high risk

populations

Measles Management

• Evaluate for associated infections • Classify any child having a general danger

sign, clouding of the cornea, or deep or extensive mouth ulcers as severe complicated measles and refer urgently to the hospital with vitamin A, the first dose of an appropriate antibiotic, and if there is eye discharge or corneal clouding a dose of tetracycline eye ointment.

Measles Management

• The presence of eye drainage and or mouth ulcers without other signs is classified as yellow. Treatment includes Vitamin A, tetracycline eye ointment for eye discharge, and gentian violet for mouth ulcers. These children need a follow up visit in 3 days.

• A child without complications is green and needs only vitamin A.

Algorithm for a Suspected Case of Measles

Child with fever and rash consistent

with measles

Report case toAlert System

Search for othercases andQuarantine

Start response and

prevention

Measles vaccinePriority groups

Resources and logistics

Case Confirmation• Laboratory tests

Local response• Guarantee vaccines• Vitamin A• National Response

Team

Incubation

HeadacheMyalgiaRashBone painVomiting

Abdominal PainCyanosisShockHemorrhagesHepatitisPlasma leakage

DENGUE

Clinical Manifestations of Dengue

Grade Hemorrhage Platelets CapillaryPermeability

I Positive <100,000 Plasma leakage*tourniquet test

II Spontaneous <100,000 Plasma leakage*bleeding

III (DSS) Spontaneous <100,000 Plasma leakage+bleeding PP <20 mmHg

Hypotension

IV (DSS) Spontaneous <100,000 Profound shockbleeding Absent pulse or BP

*Hct admission >20%/age or reduction Hct >20% post-resuscitation fluidsPP: pulse pressure

WHO Guidelines for the Diagnosis of Dengue Hemorrhagic Fever (DHF)

• 80% asymptomatic infections

• Unusual manifestations– Hepatitis– Encephalopathy– Pancreatitis – Pleural effusion

Dengue Manifestations in Children

• Rest

• Acetaminophen/Paracetamol

• No aspirin or NSAIDs

• No antibiotics

• Oral rehydration (WHO solution)50 mL/kg over 4-6 hoursMaintenance 80-100 mL/kg/day

• Monitor CNS signs

Management of the Child with Dengue

• Hospitalization in case of grade II HDFPlatelets <100,000 Hematocrit > 20% over normal

• Colloid solutions at 6 mL/kg/hr

Management of the Child with Hemorrhagic Dengue

Improvement Worsening

↓ 3 mL/kg/hr ↑ 10 mL/kg/hr

MALARIA

Caused by a protozoal blood parasite capable of causing a wide spectrum of diseases

Plasmodium vivaxPlasmodium ovalePlasmodium malariae

• Geographical distribution: Tropic / Subtropics

• Transmission: Anopheles mosquito

Plasmodium falciparum

Malaria Susceptibility

In endemic areas, there is partial immunity in older children and adults due to previous infection

Most susceptible individuals to severe and fatal malaria: • Non-immune and immunocompromised people • Infants and young children, pregnant women and

malnourished •Plasmodium falciparum-infected people

InfectionIdentification of parasitemia

Asymptomatic

DiseasePresence of signs and

symptomsAcute, subacute, chronic

FEVER

37

38

39

Non-specific Pattern

393837

Classical Pattern

Partially immune patients may develop moderate fever with a non-specific pattern

Patients will feel and look sick due to fever, but they will feel relatively well between paroxysms of fever

Associated chills, headache, myalgia

Malaria Clinical Manifestations

Severe Malaria

• Parasitemia is >5%• Any of the following complications:

-prostration (patient unable to sit or walk)-multiple convulsions-impaired consciousness not attributable

to another cause-abnormal bleeding-meningeal signs-jaundice ( hemolysis)

Malaria Diagnosis

• Rapid diagnostic tests– Bedside testing

• Thick and thin blood smears– Difficult in a disaster situation

Malaria Management

• The clinical diagnosis of malaria based on non specific signs and symptoms tends to be highly inaccurate.

• When a patient presents with febrile illness who lives in an area with malaria, in the absence of available diagnostic testing, begin treatment when the clinical history and presentation are consistent with malaria.

Types of Malaria

P. falciparum – Most severe type of MALARIA (MALIGNANT)High lethality rate in infected individualsHighly drug-resistant

Plasmodium vivax “BENIGN” MALARIAPlasmodium ovale Most are sensitive Plasmodium malariae to chloroquine

• These infections cause morbidity and contribute to multifactorial mortality

Treatment of Uncomplicated Malaria: P. Falciparum or Unknown Species

Preferred Therapies (check your country policy):

Atovaquone-Proguanil (Malarone)– 4 adult tabs (1000mg Atovaquone) po qd x 3 days

Artemether-lumefantrine (Coartem)– 4 tablets immediately, 4 tablets 8 hours later, then

4 tablets BID for 4 more doses

Second-Line Therapies: Quinine sulfate plus: Doxycycline, Tetracycline, or Clindamycin

Mefloquine

Uncomplicated Malaria: Chloroquine-Sensitive Species/Areas

• Children: a total dose of 25 mg/kg of CHLOROQUINE over a 3-day period

t = 0 10 mg/kg pot = 6 h 5 mg/kg po or 10mg/kgt = 24 h 5 mg/kg po at t = 24 ht = 48 h 5 mg/kg po

• Adults: similar schedule. 1 gr followed by 500 mg x 3

• Pregnant women: Malaria is SEVERE. Chloroquine treatment is safe

Malaria Supportive Treatment

• Fever control– Antipyretics, no more than a few doses– Cool compresses

• Dehydration– Oral rehydration solution, increased need for fluids

• Malnutrition– Assess and treat

Anticipate symptom resolution at 48-72 hours

Severe Complicated Malaria Treatment

• First line (preferred treatment) is Artesunate parentral (IV/IM).

• In the absence of parenteral form of Artesunate, Artemether IM is acceptable.

• Quinine is acceptable option but requires attention to the proper dosage and administration with IV fluids. There is a loading dose and maintenance dose and care needs to be taken to prevent hypoglycemia.

Summary

• Pre-existing health conditions, nutritional status, and immunization rates are important to know!

• IMCI is a strategy developed by WHO to reduce morbidity and mortality from the most prevalent diseases in developing countries based on simple clinical signs and procedural algorithms

• IMCI focuses on a community-based approach to promote home care and timely referrals and integrates aspects of nutrition, immunization, health promotion, and disease prevention

• Examples: Influenza, Measles, Dengue, Malaria

Thank you