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M O D U L E 5

Management of Prevalent Infectionsin Children Following a Disaster

Stephen Berman | Christine Nyquist | Julia A. Lynch | Ángela Gentile

5

INTRODUCTION

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. According to the World Health Organization (WHO), children

living in low-income countries are 10 times more likely to die before reaching age

5 than children in the industrialized world (Black, 2003;WHO, 1999; Murray, 1996), the

main causes of death being pneumonia, diarrhea, measles, malaria, and malnutrition.

During acute humanitarian emergencies, mortality related to those common

childhood infections increases due to crowded living conditions; displacement to

areas with higher disease prevalence; and compromised personal hygiene resulting

from inadequate water supplies, contaminated water, and poor sanitation. The pre-

existing nutritional status (particularly micronutrient and vitamin A deficiencies) and

immunization rates of children, as well as the pre-existing primary care infrastructure

and the degree of damage caused by the disaster, also affect childhood morbidity and

mortality after a disaster. Figure 1 summarizes the causes of death in two refugee

camps and illustrates the significance of various illnesses following a disaster.

These stark statistics emphasize the importance of using strategies based on the

Integrated Management of Childhood Illness (IMCI) Program, developed to prevent

and treat infections during an acute humanitarian emergency.

Management of PrevalentInfections in Children Following a Disaster

Stephen Berman, MD, FAAPChristine Nyquist, MD

Col. Julia A. Lynch, MD, FAAPDr. Ángela Gentile

5

Figure 1 summarizes the causes of

death in two refugee camps and illus-

trates the significance of various ill-

nesses following a disaster.

These stark statistics emphasize

the importance of using strategies

based on the Integrated Management

of Childhood Illness (IMCI) Program,

developed to prevent and treat infec-

tions during an acute humanitarian

emergency.

FIGURE 1. Mortality in two refugee camps

ARI: acute respiratory infectionFrom Famine-affected, refugee, and displaced populations: Recommendations forPublic Health issues. MMWR 1992(RR-13); 1-76.

Malawi, 1990

Malaria25% Malnutrition

23%

Diarrhea11%

Measles10%

Other22%

ARI 9%

Sudan,Wad KowliCamp, 1985

Malaria7%

ARI 9%

Measles53%

Other 1%

Diarrhea30%

SECTION I / IMC I

OBJECTIVES

� Describe the rationale for the WHOevidence-based syndromic approach tocase management as described in theIMCI.

� List the clinical illnesses included in theIMCI program and their relevance insituations associated with disasters.

� Assess and classify the condition of achild to determine its severity andestablish the relationship between thisclassification and the subsequentmanagement.

� List the danger signs that should beroutinely checked in all children.

What is IMCI?The strategy for the IMCI was designedby PAHO and WHO to enhance chil-dren’s health and reduce the mortalityand morbidity due to the most prevalentdiseases in developing countries.

This strategy includes the early diagno-sis, treatment and timely referral of chil-dren under 5 years of age with the mostcommon diseases. It also contributes toimproving parental skills and practicesassociated with the home care of chil-dren. A community-based approach isessential for childhood health, because itpromotes healthy habits in the family, ade-

INTEGRATED MANAGEMENTOF CHILDHOOD ILLNESS (IMCI)

CASE 1A 15-month-old boy presents at the emergency department with a fever. He hadbeen healthy until 3 days ago, when he developed symptoms of upper respiratoryairway infection. His mother reports giving ibuprofen to her son the day before,because of the fever. The child continues to be febrile with reduced food and fluidintake, urine output, and activity level. There is no history of vomiting, diarrhea,cough, or rash. He is not receiving any medication. You note fatigue and irritabilitywhen the child is stimulated during the physical examination. Respiratory rate is50 breaths/min, pulse rate 162 beats/min, blood pressure 92/70 mm Hg, andaxillary temperature 38.9ºC. He has dry lips but wet oral mucosa without lesions.His neck is flexible. Lung and heart examination are unremarkable with nosignificant findings. A few isolated petechiae are noted over the abdomen andlower limbs. Peripheral pulse is normal and capillary refill time is 3 seconds.

What is your global clinical impression for this boy?What is the most probable diagnosis?What treatment strategies you should adopt initially?

week to 2 months: bacterial infectionand diarrhea). They must also beassessed for nutritional and immuniza-tion status, feeding disorders, and otherpotential problems.

� Only a limited number of carefullyselected clinical signs are used, basedon evidence of their sensitivity andspecificity to detect diseases. Thesesigns were selected also consideringthe available resources in first-levelhealth care facilities.

� The combination of individual signs leadsto a child’s classification rather than adiagnosis. This classification indicates theseverity of the condition and calls forspecific actions based on whether thechild (a) should be urgently referred to ahigher level of care, (b) requires specifictreatments, or (c) can be safely managedat home. The classification is colorcoded:red requires hospital referral or admis-sion; yellow indicates the need to initiatetreatment; and green indicates homemanagement.

� The IMCI strategy addresses most, butnot all, of the major reasons why a sickchild is brought to a clinic. A child witha chronic condition or a less commonillness may require special care. Theguidelines do not describe the manage-ment of trauma or other acute emer-gencies due to accidents or injuries.

� IMCI management strategy uses a limit-ed number of essential drugs andencourages the active participation ofcaregivers in the treatment of children.

� A basic component of the IMCI strate-gy is the counselling of caretakersabout home management issues, suchas feeding, fluids, and when to return toa health facility (Box 1).

6 SECTION I / IMCI

quate care of children (feeding, clothing,stimulation, etc.), disease prevention, andprompt seeking of medical care whenalarming signs and symptoms are noted.

The IMCI strategy also helps healthcareprofessionals take advantage of opportuni-ties for prevention, promote childhooddevelopment, and encourage the rationaluse of drugs and medications. This strategyis not meant for chronic or less frequentdiseases or acute emergencies. As a com-plement to ambulatory care, this strategyincludes procedures and practices at differ-ent referral levels and types of hospitals.

The IMCI strategy is based on theimportance of simple clinical signs andsymptoms, the proper classification of thedisease, timely treatment, and interven-tions for prevention and follow-up. It isparticularly useful in the first level of care,i.e., camps, medical offices, health care cen-ters or hospital primary care departments.It includes a series of procedural algo-rithms and standardized forms to recordthe patients’ care. Figure 2 shows thealgorithm describing the care processes.

IMCI guidelinesThe practical IMCI guidelines are basedon the following principles:� All sick children must be assessed forgeneral danger signs, which indicate theneed for immediate referral or admis-sion to a hospital.

� All sick children must be routinelyassessed for major symptoms (for chil-dren from 2 months to 5 years old:cough or difficult breathing, diarrhea,fever, ear problems; for infants age 1

IMCI strategy is alsouseful to integrateaspects of nutrition,immunization, healthpromotion, and diseaseprevention.

7SECTION I / IMCI

Assessment of sick childrenThe assessment procedure for this agegroup includes a number of importantsteps that must be taken by the healthcare provider: (1) Take a history and talkwith the caregiver about the child’s prob-lem; (2) check for general danger signs; (3)assess major symptoms; (4) evaluatenutritional status; (5) assess the child’sfeeding; (6) check immunization status;and (7) look for other problems.

Danger signs that should be routinely checked in allchildrenSeizures during the current illness. Seizuresmay result from fever. Febrile seizures dolittle harm beyond frightening the parents.But seizures may also be associated withmeningitis, cerebral malaria, or other lifethreatening conditions. All children withseizures during the current illness shouldbe considered seriously ill.

Unconsciousness or lethargy. An uncon-scious child is likely to be seriously ill. Alethargic child who is awake but does nottake any notice of his/her surroundings ordoes not respond normally to sounds ormovement may also be very sick. Thesesigns can be associated with many condi-tions, including severe dehydration, severehypoxia, sepsis, or meningitis.

Inability to drink or breastfeed. An infantmay be unable to drink if he/she is tooweak or cannot swallow. Observe the childwhile the mother breastfeeds or giveshim/her something to drink.

Persistent vomiting.Vomiting itself may bea sign of serious illness. This symptom mayalso prevent the child from taking medica-tions or fluids for rehydration.

A child with one or more of these signsmust be considered seriously ill and willrequire hospital referral. To start treatmentfor severe illnesses without delay, quicklyassess the child for the most importantcauses of serious illness and death, includingacute respiratory infection (ARI), diarrheaand dehydration, sepsis, malaria, and measles.

BOX 1. Key aspects of the IMCI strategy

� Evaluates general danger signs� Assesses major symptoms � Assesses nutritional status, immunization

status, feeding disorders, and otherpotential problems

� Includes a limited number of carefullyselected clinical signs

� Combines clinical signs to define theclassification for the evaluated child

� Addresses most, but not all, of the majorreasons why a sick child is brought to aclinic

� Uses a limited number of essential drugs� Encourages active involvement of adult

caretakers in the children’s management� Offers counselling to caretakers

FIGURE 2. Summary of the process of integrated care of children

ASSESS the child: Check for danger signs (or possible bacterial infection). Ask about mainsymptoms. If a main symptom is reported, assess further. Check nutrition and immunization

status. Check for other problems.

CLASSIFY the child’s illnesses: Use a color-coded triage system to classify the child’s main symptoms, and his or her nutrition or feeding status.

For all sick children age 1 week up to 5 years who are brought to a first-level health facility

IF URGENT REFERRALis needed and possible

IDENTIFY URGENT PRE-REFERRALTREATMENT(S)

needed for the child’s classifications

TREAT THE CHILD: Give urgent pre-referraltreatment(s) needed

REFER THE CHILD:- Explain to the child’s caretaker the need

for referral.- Calm the caregiver’s fears and help solve

any problems.- Write a referral note addressed to the

hospital.- Give instructions and supplies needed to

care for the child on the way to the hospital.

IF NO URGENT REFERRALis needed or possible

IDENTIFY TREATMENT needed for thechild’s classifications: Identify specific medical

treatments and/or advise

TREAT THE CHILD: Give the first dose oforal drugs in the clinic and/or advise the child’scaregiver. Teach the caretaker how to give oraldrugs and how to treat local infections at home.If needed, give immunizations.

COUNSEL THE MOTHER:- Assess the child’s feeding, including breast-

feeding practices, and solve feedingproblems, if present.

- Advise about feeding and fluids duringillness and when to return to a healthfacility.

- Counsel the mother about her own health.

FOLLOW-UP CARE: Give follow-up care when the child returns to the clinic and, if necessary,reassess the child for new problems.

SECTION I / IMCI8

FIGURE 3. IMCI strategy for case management in the outpatient health carefacility, first-level referral service, and at home for the sick child from age 2months to 5 years

THE INTEGRATED CASE MANAGEMENT PROCESS

OUTPATIENT HEALTH CARE FACILITY

Check for DANGER SIGNS• Seizures

• Lethargy/unconsciousness• Inability to drink/breast-feed

• Vomiting

Assess MAIN SYMPTOMS• Cough/difficult breathing

• Diarrhea • Fever

• Ear problems

Assess NUTRITION, IMMUNIZATIONSand POTENTIAL FEEDING PROBLEMS

Check for OTHER PROBLEMS

CLASSIFY CONDITIONS and IDENTIFY TREATMENT ACTIONS

According to color-coded treatment

REDUrgent referral

OUTPATIENT HEALTHCARE FACILITY

• Pre-referral treatments• Counsel parents

• Refer child

GREENHome management

HOMECaregiver is

counselled on:• Home treatment(s)• Feeding and fluids• When to return

immediately• Follow-up

REFERRAL FACILITY• Emergency Triage and

Treatment (ETAT)• Diagnosis• Treatment

• Monitoring and follow-up

YELLOWTreatment at

outpatient health care facility

OUTPATIENT HEALTHCARE FACILITY

• Treat local infection• Give oral drugs

• Counsel and teach caretaker• Follow-up

SECTION I / IMCI 9

What is Influenza?Influenza is a segmented, single-strandedenveloped RNA virus classified into influen-za A, B and C based on antigenic differ-ences. Influenza A is a potentially severe ill-ness, causes epidemics and pandemics, israpidly changing, and infects birds, swine,horses, seals, and humans. Influenza B ismore uniform, causes epidemics and onlyinfects humans. Influenza C is of minimalpublic health impact and infects humansand swine. Further subtyping of influenza Avirus is based on the neuraminidase andhemagglutinin proteins on the viral surface.There are 16 different hemagglutinins and 9different neuraminidase subtypes.Hemagglutinin proteins allow the virus tostick to cells by binding to a specific recep-tor. The neuraminidase protein helps newlyformed viral particles get released from thecell surface so that they have the potentialto infect other cells. Only H1N1, H2N2,H3N2 subtypes are associated with wide-spread epidemics in human. Since 1997,rare but severe infections in humans with

SECTION II / INFLUENZA INFECTIONS

INFLUENZA INFECTIONS

OBJECTIVES� Understand the influenza virus pathogenesis

and epidemiology.� Describe clinical symptoms of influenza and

diagnostic and treatment options.� Evaluate treatment and prevention

methodologies for influenza and incorporatethem into preparedness plans.

influenza A subtype H5N1 viruses havebeen identified in Asia, Africa, Europe, andthe Middle East where these viruses arepresent in domestic or wild birds.

Repeated seasonal influenza epidemicspersist because the type A and type Bviruses undergo constant and rapid changedue to antigenic drift. Antigenic drift refersto a gradual change in the virus that occursthrough a slow series of amino acidschanges in the hemagglutinin or neu-raminidase surface antigens. Occurringonly after a particular viral strain hasbecome established in humans, antigenicdrift represents an adaptation to the devel-opment of host antibodies. Newly devel-oped antigenic strains of influenza thenprevail for a period of 2 to 5 years, only tobe replaced by the next emerging strain.This new strain can then trigger a new epi-demic, since it is now unfamiliar to theantibody repertoire of the population. Thedevelopment of yet another set of hostantibodies eventually protects the popula-tion–at the same time it puts pressure onthe virus to drift yet again. Ongoing changecaused by antigenic drift requires ongoingreformulation of influenza vaccines usuallyon an annual basis. The World HealthOrganization and the Centers for DiseaseControl and Prevention continually trackthese changes to better recommendstrains to be contained in the next season-al influenza vaccine.

In contrast to the gradual evolution ofstrains subject to antigenic drift, antigenic

SECTION II / INFLUENZA INFECTIONS 11

shift occurs as soon as a type A influenzavirus with a completely novel hemagglutininor neuraminidase moves into humans fromanother host species. The primary source isbirds, certain species of which carry a reser-voir of 15 influenza A subtypes. These sub-types either genetically reassort themselveswith circulating human influenza virus orare transmitted directly into humans, typi-cally via intermediate hosts such as swine.Antigenic shift of type A influenza virusesoccurs less frequently than antigenic drift,but with more dramatic impact that canlead to a pandemic. A pandemic is definedby the emergence and global spread of anew influenza A virus subtype to which thepopulation has little or no immunity andthat spreads rapidly from human to human.Pandemics, therefore, can cause increasedmorbidity and mortality rates comparedwith seasonal influenza. During the 20thcentury, there have been four influenza pan-demics, in 1918 (H1N1), 1957 (H2N2),1968 (H3N2), and 2009-10 (H1N1). Therecent influenza pandemics of 2009 H1N1(“swine flu”) was caused by genetic reas-sortment between human, two avian andone swine influenza viruses. Avian influenza(H5N1) continues to cause outbreaksamong poultry and wild birds worldwidebut has caused relatively few cases ofhuman H5N1 infection although case fatali-ty rates are greater than 50 percent.

EpidemiologyInfluenza is spread from person to personprimarily by respiratory droplets createdby coughing or sneezing. Contact with

respiratory droplet-contaminated sur-faces or fomites is another possible modeof transmission. During community out-breaks of influenza, the highest attackrates occur among school-aged children.Secondary spread to adults and otherchildren within a family is common.Incidence and disease severity depend, inpart, on immunity developed as a result ofprevious experience (by natural disease)or recent influenza immunization with thecirculating strain or a related strain. Intemperate climates, seasonal epidemicsusually occur during winter months. Peakinfluenza activity in the United States canoccur anytime from November to Maybut most commonly occurs in Januaryand February. Community outbreaks canlast 4 to 8 weeks or longer. Circulation of2 or 3 influenza virus strains in a commu-nity may be associated with a prolongedinfluenza season of 3 months or more andbimodal peaks in activity. Influenza is high-ly contagious, especially among semienclosed institutionalized populations.

Attack rates in healthy children gener-ally have been found to be 10% to 40%each year, but illness rates as low as 3%also have been reported. Childrenyounger than 5 years of age visit clinics oremergency departments for influenza ill-ness at the rate of 1 to 2 children per 100annually. Influenza and its complicationshave been reported to result in a 10% to30% increase in the number of courses ofantimicrobial agents prescribed to chil-dren during the influenza season. Thesemedical care encounters for children withinfluenza result in considerable costs and

ness and correlates with the presence offever.

Complications of InfluenzaPost influenza complications are common.Influenza is an important cause of otitismedia. Acute myositis characterized by calftenderness and refusal to walk has beendescribed especially with influenza type B. Ininfants, influenza can produce a sepsis-likepicture and occasionally can cause croup,bronchiolitis, or pneumonia. Although thelarge majority of children with influenzarecover fully after 3 to 7 days, previouslyhealthy children can have severe symptomsand complications. Neurologic complica-tions associated with influenza range fromfebrile seizures to severe encephalopathyand encephalitis with status epilepticus, withresulting neurologic sequelae or death. Reyesyndrome has been associated with influen-za infection and salicylate exposure. Deathfrom influenza-associated myocarditis hasbeen reported. Invasive secondary infec-tions or coinfections with group A strepto-coccus, Staphylococcus aureus (includingmethicillin-resistant S. aureus [MRSA]),Streptococcus pneumoniae, or other bacterialpathogens can result in severe disease anddeath.

Hospitalization rates among childrenyounger than 2 years of age are similar tohospitalization rates among people 65years of age and older. Children youngerthan 24 months of age consistently are atsubstantially higher risk of hospitalizationthan are older children, and the risk ofhospitalization attributable to influenzainfection is highest in the youngest chil-

likely are an important cause of inappro-priate antimicrobial use.

Influenza Pathogenesis and Symptoms Influenza in adults typically begins withthe sudden onset of fever, often accompa-nied by chills or rigors, headache, malaise,diffuse myalgia, and nonproductive cough.Subsequently, respiratory tract signsincluding sore throat, nasal congestion,rhinitis, and cough become more promi-nent. Conjunctival injection, abdominalpain, nausea, vomiting, and diarrhea areless commonly associated with influenzaillness. Influenza symptoms may be differ-ent among different age populations witholder children and adolescents havingmore classic adult influenza like symp-toms. Neonates may present with feverand a sepsis like picture and toddlers mayhave few respiratory signs but have vom-iting and diarrhea as their predominantsymptom. The usual incubation periodbetween the time someone is exposedand infected with influenza virus to thetime that they experience symptoms ofillness ranges from 18 hours to 5 or moredays with an average of 2-3 days. Onceinfected with influenza the principal siteof replication is the columnar epitheliumin the back of the throat. Viral shedding inrespiratory secretions occurs for 1 daybefore illness and 5-10 days after illnessonset. Viral titers are generally higher inyoung children with shedding lasting 10days or longer. Peak shedding of virus gen-erally occurs during the first 3 days of ill-

SECTION II / INFLUENZA INFECTIONS12

increased likelihood of false-positiveresults during periods of low influenzaactivity. Direct fluorescent antibody (DFA)and indirect immunofluorescent antibody(IFA) staining for detection of influenza Aand B antigens in nasopharyngeal or nasalspecimens are available at most hospital-based laboratories and can yield results in3 to 4 hours. Reverse transcriptase-poly-merase chain reaction (RT-PCR) testing ofrespiratory tract specimens may be avail-able at some institutions and offers poten-tial for high sensitivity and specificity inparticular with the 2009-2010 H1N1 pan-demic strain.

Treatment of InfluenzaTreatment is mostly supportive with rest,fluids, and antipyretics such as acetamino-phen or ibuprofen. Aspirin and other salicy-late-containing products should be avoidedas it is associated with a rare severe com-plication called Reye Syndrome. Antiviralsadministered within 2 days of illness onsetmay have the greatest benefit to reducethe duration of uncomplicated influenza ill-ness and should be considered for thosewho are at increased risk of severe orcomplicated influenza infection. Other can-didates for antiviral therapy include healthychildren with moderate to severe illnessand people with special environmental,family, or social situations where ongoinginfluenza illness would be detrimental.Antiviral treatment should be continuedfor 5 days and be discontinued approxi-mately 24 to 48 hours after symptomsresolve. Children with severe influenza

dren. Rates of hospitalization and morbid-ity attributable to complications, such asbronchitis and pneumonia, are evengreater in children with high-risk condi-tions, including hemoglobinopathies, bron-chopulmonary dysplasia, asthma, cysticfibrosis, malignancy, diabetes mellitus,chronic renal disease, and congenitalheart disease. Influenza virus infection inneonates also has been associated withconsiderable morbidity, including a sepsis-like syndrome, apnea, and lower respira-tory tract disease. Fatal outcomes, includ-ing sudden death, have been reported inboth chronically ill and previously healthychildren. All influenza-associated pediatricdeaths are nationally notifiable and shouldbe reported to the CDC through statehealth departments.

Diagnostic TestsSpecimens for viral culture, immunofluo-rescent, or rapid diagnostic tests should beobtained if possible during the first 72hours of illness, because the quantity ofvirus shed decreases rapidly as illness pro-gresses beyond that point. Rapid enzymeimmunoassay diagnostic tests for identifi-cation of influenza A and B antigens in res-piratory tract specimens are available com-mercially, although their reported sensitivi-ty (44%–97%) and specificity (76%–100%)compared with viral culture are variableand differ by test and specimen type.Additionally positive and negative predic-tive values of these influenza screeningtests is influenced by the prevalence of cir-culating influenza viruses resulting in an


season. Specific drug recommendationsfor treatment and chemoprophylaxis mayvary by season, geographic location, andlevel of circulating viral resistance. TheCDC website provides current recom-mendations for treatment and chemopro-phylaxis of influenza: www.cdc.gov/flu/professionals/antivirals/index.htm.

Zanamivir (Relenza®) is available as a drypowder administered via oral inhalationwith a plastic device. The dose is twobreath-activated inhalations (one 5 mg blis-ter per inhalation = 10 mg) bid for 5 days.Zanamivir is not recommended for use inpatients with underlying airway diseaseincluding asthma or COPD, because of alack of safety and efficacy data in thesepatients. Oseltamivir (Tamiflu®) is availableas pills or liquid and is given twice daily for5 days, with dose adjustments required inrenal impairment. Pediatric dosing ofoseltamivir for 1 – 12 years is 2 mg/Kg/dose bid x 5 days (max. dose = 75 mg) andfor 13 years and older: 75 mg bid x 5 days.

ChemoprophylaxisChemoprophylaxis or prolonged adminis-tration of antiviral medications during theperiods of highest risk for transmission isan adjunct for control and prevention ofinfluenza in specific situations and is not asubstitute for immunization. Chemopro-phylaxis should be considered for protec-tion of children at increased risk of severeinfection or complications who are unableto receive influenza vaccine due to con-traindications and for immunocompro-mised children who may not respond to

should be evaluated carefully for possiblecoinfection with bacterial pathogens, suchas Staphylococcus aureus, that might requireantimicrobial therapy.

In the United States, two classes ofantiviral medications are available for treat-ment or prophylaxis of influenza infections:neuraminidase inhibitors (oseltamivir andzanamivir) and adamantanes (amantadineand rimantadine). Treatment has beenshown to decrease the duration of flu-related symptoms by 1 to 1.5 days.Oseltamivir has been approved for chemo-prophylaxis and treatment of patients olderthan one year old. Zanamivir has beenapproved for treatment in patients 7 yearsand older and chemoprophylaxis ofpatients age 5 years and older.

Influenza B viruses intrinsically areresistant to adamantanes and since 2005all H3N2 strains in the United States havebeen resistant to adamantanes. Duringthe 2008–2009 influenza season, virtuallyall H1N1 influenza strains were resistantto oseltamivir but remained susceptibleto zanamivir, amantadine, and rimanta-dine. The most recent pandemic 2009-2010 H1N1 strain was once again suscep-tible to oseltamivir.

These resistance patterns among circu-lating influenza A virus strains presentchallenges in selecting antiviral medica-tions for treatment and chemoprophylax-is of influenza and provide additional rea-sons for clinicians to test patients forinfluenza virus infection and to consultsurveillance data in their communitywhen evaluating people with acute respi-ratory tract illnesses during the influenza


care workers who are ill should be restrict-ed from working until they are healthy.

The primary measure to prevent influen-za is vaccination of both patients and fami-lies, and healthcare workers. The rapid evo-lution of new strains of influenza necessi-tates annual reformulation of the vaccinestrains and annual vaccination of vaccinerecipients to maintain immunity to currentinfluenza strains. All currently available inac-tivated and live attenuated influenza vac-cines are trivalent, meaning they contain 3strains that represent the most recent cir-culating wild-type strains in a given year: A(H3N2), A (H1N1), and B. Initiation ofinfluenza vaccination programs should startas soon as influenza vaccine is availablefrom manufacturers and should be contin-ued throughout the influenza season.

Surveillance and SurgePlanningDuring the pre-pandemic intervals,healthcare providers and healthcare facili-ties play an essential role in surveillancefor suspected cases of infection withnovel strains of influenza and should beon the alert for such cases. Novel strainsmay include avian or animal influenzastrains that can infect humans such asavian influenza A H5N1 or novel influenzaA H1N1 and new or re-emergent humanviruses that cause cases or clusters ofhuman disease. For detection of casesduring the Pre-Pandemic and PandemicIntervals, hospitals should have predeter-mined thresholds for activating pandemicinfluenza surveillance plans.

vaccine. Other considerations include theprotection of unimmunized high-risk chil-dren or children who were immunizedless than two weeks before influenza cir-culation and who may not have developedan adequate immune response, protectionof unimmunized close contacts of high-risk children, protection of immunizedhigh-risk children if the circulating influen-za strain is a poor match to the strain inthe vaccine and for the control of influen-za outbreaks in some institutional closedsettings.

Prevention of InfluenzaGood infection control maintenance is awell known cornerstone of disease man-agement and needs to be the focus ofgeneral practice management of all respi-ratory outbreaks including seasonal andpandemic influenza. Infection controlrefers to all policies, procedures andactivities that aim to prevent or minimizethe risk of transmission of infectious dis-eases. This includes simple measures suchas adequate hand hygiene by hand wash-ing or hand rubs, and cough etiquette tomore involved measures such as personalprotective equipment (PPE).

Hospitalized patients with influenzashould be placed on droplet precautions(mask, gown and glove). Respiratoryhygiene/cough etiquette (placing masks onpatients with a cough when outside of theirroom) should be incorporated into infec-tion control practices. Visitors who haveany respiratory illness symptoms should bediscouraged from visiting patients. Health


Screening, surveillance, and tracking ofexposed individuals; 2) controlled accessto the healthcare facility; 3) preventionstrategies (isolation and cohorting, PPEuse, vaccination, antiviral prophylaxis,modification of environmental controls(i.e., separate areas for ill and non illpatients); 4) disease-specific admissioncriteria, treatment, and triage algorithms;and 5) enabling the continuity of limitedclinical operations.

In all healthcare settings, patients withsymptoms of influenza or influenza like ill-ness (ILI) should be segregated from non-influenza patients as rapidly as possible,especially in a triage setting. When possi-ble, consider having different teams of staffshould care for influenza and non-influenzapatients. In acute care settings, triage nonILI patients promptly to specific non ILIwaiting and examining areas, physically sep-arate from the ILI assessment area to pre-vent their exposure to ILI if possible.Additionally separate entrances and exitsshould be established for those whobelieve they may have been exposed to ILIor those that are in need of other types ofmedical attention if feasible.

Admission policies and testing andtreatment algorithms should also be cre-ated for determining if a patient needs tobe admitted to the hospital or if an alter-nate care facility may be more appropri-ate if altered standards of care are beingused. If possible, hospitals triage protocolsfor phone triage may help to educatepatients and families and provide helpwith illness management without access-ing the clinic, emergency department or

Influenza pandemics are different frommany of the threats for which publichealth and the healthcare system are cur-rently planning. The pandemic will lastmuch longer than most other emergencyevents and may include “waves” of influen-za activity separated by months (in 20thcentury pandemics, a second wave ofinfluenza activity occurred 3 to 12months after the first wave). The numbersof healthcare workers and first respon-ders available to work can be expected tobe reduced; they will be at high risk of ill-ness through exposure in the communityand in healthcare settings, and some mayhave to miss work to care for ill familymembers. It is reasonable to assume thatabsenteeism may exceed 25%. Resourcesin many locations could be limitedbecause of how widespread an influenzapandemic would be.

The goal of a pandemic surge plan foran emergency department or other out-patient setting is to provide safe and effec-tive care in the event of an influenza pan-demic or similar event, and to optimizeresources and mitigate throughput issuesin order to provide for maximum surgecapacity for pediatric patients presentingto the emergency department for care.Utilizing the all-hazards approach todevelop plans for epidemic and pandemicrespiratory illness is based on the con-cept that most disaster-response func-tions are common to all disaster types,and unified planning provides thestrongest basis for effective response.

Critical components of comprehensiveplans must address the following: 1)


stages of a pandemic, and most of themwould likely be supplied to industrializedcountries, developing countries will needto focus initially on nonpharmaceuticalinterventions. Maintaining a balancebetween pharmaceutical and nonpharma-ceutical interventions is necessary toachieve the best use of limited resources.

During an influenza pandemic, additionalessential medical supplies such as gloves,masks, syringes, antipyretics, and antimicro-bial agents will also be required. These sup-plies are insufficient in healthcare facilitiesin developing countries, even in nonemer-gency situations. Lack of these supplies mayhamper provision of adequate medical carefor patients with pandemic influenza. BasicPPE such as disposable gloves and surgicalmasks are needed for protecting health-care workers. Anti-microbial agents areexpected to be effective for secondarybacterial pneumonia, which can be a majorcause of death for patients with pandemicinfluenza.

Providing better medical care during apandemic is essential to reduce the healthconsequences of the pandemic includingdeath. Since the availability of pharmaceu-tical interventions in developing countriesis less likely, nonpharmaceutical interven-tions such as social distancing and person-al hygiene may be the only available inter-ventions. Essential medical supplies suchas masks, gloves, and antimicrobial agentsshould be available in hospitals and clinics.The stockpiles of these basic supplies canbe more cost-effective in developingcountries than stockpiles of more expen-sive antiviral agents. Healthcare personnel

hospital setting. The diagnosis and treat-ment algorithms used at the Children’sHospital Colorado can be found in thismodule appendix.

Special Issues in DevelopingCountriesSeveral factors may be involved in thehigh mortality rates pandemics cause indeveloping countries. These include lackof access to adequate medical care, weakpublic health infrastructures, social factorssuch as housing conditions and popula-tion density, and host factors such asnutritional status and co-existing medicalconditions. Core interventions to controlor mitigate the effects of an influenza pan-demic include pharmaceutical interven-tions such as vaccines and antiviral agents,and nonpharmaceutical interventionssuch as quarantine, isolation, social dis-tancing, and personal hygiene.

Antiviral agents are particularly usefulin the early stages of a pandemic whenthere is shortage of vaccines. Stockpilingof neuraminidase inhibitors is part ofmany industrialized countries pandemicpreparedness plans however stockpiles ofantiviral agents available in developingcountries is small and limited. The mostcritical limiting factor for stockpiling neu-raminidase inhibitors in developing coun-tries is their high cost and allocatingscarce resources to stockpile sufficientquantities of oseltamivir for an unpre-dictable influenza pandemic. Because onlya limited number of vaccines will be ini-tially available, particularly in the early


tance of building human surge capacityallows the allocation of health resourcesincluding the provision of essential healthservices and determination of the roleseach institution plays in the response.Infection prevention and control activitieshave been critical to protect healthcareworkers and to prevent the nosocomialspread of influenza infections.

Additionally, there is an urgent need tohave better detection methods forinfluenza viruses, including the creation orstrengthening and scaling-up of laborato-ry capacity for influenza diagnosis in mostsettings (low-, middle-, and high-incomecountries), through international net-works of collaboration, technology trans-fer, and capacity-building efforts.Pharmacologic interventions including theuse of antiviral drugs and medical inter-ventions such as antimicrobials to treatsecondary bacterial pneumonias, alongwith the use of supportive medical caresuch as oxygen, anti-inflammatory drugs,and antipyretics, have also shown to be acritical component of the overallresponse activities during the currentinfluenza pandemic. Finally, all countriesshould develop pandemic influenza vac-cine deployment or antiviral deploymentplans, regardless of the current absence ofavailability of pandemic influenza vaccineor adequate supplies of antiviral medica-tions.

should be trained for infection controlmeasures, especially hand hygiene and useof personal protective equipment. Theoverarching goal is to maintain the cur-rent healthcare and public health systemsneed to minimize the impact of a pandem-ic. The link to PAHO’s Pandemic InfluenzaA (H1N1) 2009 manuals that describepreparedness planning, infection preven-tion and control, nonpharmaceuticalstrategies and IMCI diagnosis, treatmentand management protocols in Spanish,English, Portuguese and French ishttp://new.paho.org/hq/index.php?option=com_content&task=view&id=2914&Itemid=1084&lang=en.

Lessons Learned from 2009-2010 H1N1 PandemicThe WHO plans to continue to strengtheninfluenza surveillance and the early warn-ing system, build capacity to cope with apandemic, and further coordinate globalscientific research and development activi-ties. The current novel influenza A (H1N1)pandemic confirms the need for prepared-ness plans that focus on both nonpharma-ceutical strategies (social distancing, infec-tion control and quarantine), and pharma-ceutical strategies (antiviral drugs use forthe treatment and prophylaxis of influenza,and the use of influenza vaccines) to miti-gate the effect of the pandemic. The impor-


measles infections are less than 0.1% indeveloped countries, in developing coun-tries the rates exceed 1% to 2%. CFRsfor hospitalized cases have been reducedby the use of vitamin A treatment.

In developing countries, mortalityfrom measles is related to the intensityof the exposure and host’s nutritionaland immunologic status. Secondary caseswithin a household are at greater riskthan index cases. Knowing the level ofmeasles vaccination coverage in theaffected community and the frequency ofmeasles cases diagnosed within the pastfew years is helpful. If measles cases havebeen diagnosed in the community withinthe past several years, plan a measlesimmunization campaign, regardless ofthe immunization coverage level.

Give measles vaccination high priorityin a large displaced or refugee populationbecause there may be enough susceptiblechildren to cause an epidemic.Malnourished children living in crowdedshelters following a disaster are especiallyvulnerable and at high risk for severe dis-ease. Implement a surveillance system toidentify possible measles cases in thecamp or area. Educate medical staff aboutthe clinical signs that suggest measles,such as fever, cough, conjunctivitis, andrash. Respiratory syndromes are oftennonspecific; measles cases can be easilyoverlooked and other respiratory infec-tions can be mistaken for measles.

What is the impact of measles?A measles outbreak is potentially devas-tating in displaced populations. In manyparts of the developing world measles isone of the leading causes of childhoodmorbidity and mortality: it is highly con-tagious and spreads through aerosolizedparticles from respiratory secretionscontaining the virus. Measles fatalitiesvary from 200,000 to 800,000 per yearin developing countries (Black 2003;WHO 1999 and 2001; Murray 1996).While case fatality rates (CFR) for all

SECTION II I / MEASLES

MEASLES

OBJECTIVES� Explain why measles infection can be so

devastating in displaced populations.� Design a measles immunization campaign

in an affected area and establish prioritytarget populations for the provision ofmeasles vaccine based on the availabilityof vaccine supplies and prior levels ofmeasles vaccine coverage among thepediatric population.

� Recognize Koplik spots and the classicalmeasles rash; describe variations of theclassical measles rash and thecircumstances in which they are seen.

� Describe the evolution of the clinicalmanifestation of classic measles overtime and name the three complicationsof measles that contribute most tomortality.

Measles is one of theleading causes ofchildhood morbidityand mortality: it ishighly contagious andspreads throughaerosolized particlesfrom respiratorysecretions containingthe virus.

In developingcountries, mortalityfrom measles is relatedto the intensity of theexposure and host’snutritional andimmunologic status.

20 SECTION III / MEASLES

recommendations is 100,000 IU for infantsand 200,000 IU for children older than 12months. Pregnant women should receiveonly 30,000 IU of vitamin A.

Measles diagnosisFollowing an incubation period of 10 to12 days from exposure, measles pro-drome is characterized by 2 to 4 days offever, cough, coryza, and conjunctivitis.During this period, Koplik spots can beseen as tiny blue-white spots on anintensely reddened oral mucosa. Theselesions disappear within 3 days. The mac-

Importance of vaccinationUnfortunately, isolation of patients is notan effective preventive measure since indi-viduals are most contagious in the pro-dromal period, before a diagnosis can bemade. The only effective approach is tovaccinate the population as soon as possi-ble. Give measles vaccination the highestpriority early in disaster situations. Donot delay until cases of measles have beenreported (Box 2) (CDC, 1992).

Consider vaccinating children present-ing with acute illness, such as fever, diar-rhea, and ARI, as well as malnourishedchildren and those with tuberculosis orHIV infection.

Vitamin A and measlesVitamin A deficiency increases measles-associated morbidity and mortality.

Moreover, measles infection increasesthe severity of the complications resultingfrom vitamin A deficiency. Vitamin A isimportant in maintaining epithelization ofthe respiratory tract and in the recover-ing process after infection. It also plays akey role in the body’s immune defenses.

Children deficient in vitamin A whobecome infected with measles have highercorneal ulceration and fatality rates.Develop a plan to administer prophylacticvitamin A in conjunction with a measlesimmunization program. However, whenmeasles vaccine is not yet available and adelay is anticipated, administer vitamin A.This vitamin by itself reduces morbidityand mortality during measles outbreaks.The prophylactic dose of vitamin A accord-ing to World Health Organization current

Give measlesvaccination the highestpriority early indisaster situations. Donot delay until cases ofmeasles have beenreported.

Vitamin A deficiencyincreases measles-associated morbidityand mortality.

BOX 2. Guidelines fordeveloping and implementing anearly vaccination plan fordisplaced populations

If there are enough vaccines available,proceed to the immunization of allchildren from 6 months to 5 years of ageand give a second dose at 9 months tochildren who received the first dosebetween 6 and 9 months

Immunize older children and adults whenmeasles cases have been diagnosed inthese age groups and supplies aresufficient for all children 6 months to 5years of age

If resources are insufficient, immunizechildren on the following priority orderaccording to risk : (1) malnourished orsick children from 6 months to 12 yearsof age who are enrolled in a feedingprogram; (2) children 6 to 23 months ofage; (3) children 24 to 59 months of age

Give measlesvaccination the highestpriority early indisaster situations. Donot delay until cases ofmeasles have beenreported.

Vitamin A deficiencyincreases measles-associated morbidityand mortality.

BOX 2. Guidelines fordeveloping and implementing anearly vaccination plan fordisplaced populations

If there are enough vaccines available,proceed to the immunization of allchildren from 6 months to 5 years of ageand give a second dose at 9 months tochildren who received the first dosebetween 6 and 9 months

Immunize older children and adults whenmeasles cases have been diagnosed inthese age groups and supplies aresufficient for all children 6 months to 5years of age

If resources are insufficient, immunizechildren on the following priority orderaccording to risk : (1) malnourished orsick children from 6 months to 12 yearsof age who are enrolled in a feedingprogram; (2) children 6 to 23 months ofage; (3) children 24 to 59 months of age

rhea is present, is crucial. If the child refus-es feeding, consider using a nasogastrictube. Give additional fluids to prevent ortreat dehydration. When acute infectionhas resolved, enroll malnourished childrenin a feeding program, if available.

Most measles-related deaths are associ-ated with pneumonia, croup, and diarrhea.Rare acute complications includeencephalitis and endocarditis. Majorlongterm sequelae in developing countriesinclude measles-related blindness, malnu-trition, and chronic lung disease. Theimmunosuppressive effect of measles maydelay recovery for many months and causerecurrent infections and later death.

ClassificationMeasles is classified according to the

severity of the illness. Refer severe orvery severe cases to a hospital (Husseyand Berman, 2003).

Mild: Fever resolves within 4 days andrash within 8 days with no sign of compli-cations.

Moderate: There are signs of secondarybacterial upper respiratory infection:acute otitis media, sinusitis, or cervicaladenitis.

Severe: Signs of respiratory distressemerge with tachypnea, indrawing,reduced oxygen saturation, or stridor.

Other possible signs are heart mur-murs or electrocardiographic changes,ophthalmologic signs of vitamin A defi-ciency or corneal ulcerations, deep or

ulopapular erythema or morbilliform rashof measles first appears on the hairlineand forehead, then moves downward toinvolve the face, neck, and the rest of thebody. Initially the lesions are discrete andthen become confluent. If no complica-tions occur, fever disappears within 2 to 3days after the onset of rash.

The rash persists for 4 to 6 days. Itbecomes brownish in color for a few daysbefore desquamating. Many children haveanorexia, and some have mild stomatitis.Generalized lymphadenopathy can occur,but it is uncommon.

Measles complicationsMeasles is a highly catabolic disease, asso-ciated with reduced food intake,increased gastrointestinal losses, andrapid weight loss. Complications occur inapproximately 30% of cases; complicationrates are even higher in developing coun-tries. The most frequent acute complica-tions are pneumonia, croup, otitis media,and diarrhea. Measles virus is immunosup-pressive and predisposes to secondaryviral and bacterial infections, as well as tothe reactivation of tuberculosis.

Malnourished children often have atyp-ical presentations that may vary fromhemorrhagic lesions associated withmucosal bleeding and disseminatedintravascular coagulation (called blackmeasles), to a less intense rash because ofcompromised cell mediated immunity.These children may also have a deeperdesquamation resulting in extensive areasof depigmentation. Providing nutritionalsupport continued feeding, even if diar-

Complications occur inapproximately 30% ofcases; complication ratesare even higher indeveloping countries.

Most measles-relateddeaths are associatedwith pneumonia,croup, and diarrhea.

SECTION III / MEASLES 21

SECTION III / MEASLES

than 12 months. Repeat the dose in 24hours. For patients with ophthalmologicsigns of vitamin A deficiency (xerosis,Bitot’s spots, keratomalacia, corneal ulcer-ation, or clouding) repeat the dose in 4-6weeks to prevent corneal ulceration.

Severe mouth ulceration can be a con-sequence of herpes infection and maycontribute to reduced fluid and foodintake. Promote oral hygiene with regularmouth washes using clean water and theapplication of local antiseptic solutions.Consider gentian violet to treat mouthulcers.

Prevent secondary eye infectionsthrough regular cleansing of the eyes withwater and topical antibiotics, such astetracycline. Consider a protective eyepad to prevent secondary infection.

If dysentery is present, treat with anappropriate antibiotic therapy for Shigella.

extensive mouth ulcers, bloody diarrhea,jaundice, abdominal pain, moderate tosevere dehydration, or purpura (hemor-rhagic measles). Patients with severe mal-nutrition, immunodeficiency disorders,cardiopulmonary disorders, or pre-exist-ing tuberculosis are most at risk.

Very severe: Patient exhibits any of thefollowing symptoms: altered mental statuswith coma, seizures, or focal neurologicsigns; shock with poor peripheral perfu-sion; upper airway obstruction or signs ofrespiratory failure; signs of congestiveheart failure; or acute abdominal pain withperitoneal signs.

How can complications ofmeasles be prevented?Administer vitamin A 100,000 IU toinfants and 200,000 IU to children older

22

Acute Respiratory Infections: The Patient withCough or Difficult BreathingAll types of respiratory infections aremore common among people living inovercrowded conditions in developingcountries. Most cases of acute respirato-ry infections (ARI) are viral upper respira-tory tract infections that should not bemanaged with antibiotics. The IMCI strat-egy uses 3 key clinical signs to assess chil-dren with cough or difficult breathing:

—Respiratory rate (RR) distinguishes thepresence or absence of pneumonia.

—Lower chest wall indrawing indicatessevere pneumonia.

—Stridor in a calm child indicatessevere upper airway obstruction and theneed for hospital admission.

ACUTE RESPIRATORY INFECTIONS

OBJECTIVES� Know the 3 key clinical signs used to

assess a child with cough or difficultbreathing and based on these signs classifyacute respiratory clinical illness into 3categories.

� Diagnose and develop a treatment plan(medications, supportive care andmonitoring) using available resources forpatients with:— Severe pneumonia— Pneumonia— Upper respiratory infection— Ear problem without pneumonia

CASE 2A 3-month-old infant presents with fever, restlessness, and poor food intake. He is irritable and it is difficult to soothe him. He is breathing normally. His vital signs include respiratory rate 36 beats/min, heart rate 120 beats/min,blood pressure 90/58 mm Hg, temperature 102ºF (39.2ºC), and oxygen saturation98%. The fontanelle looks full and the neck is flexible. Capillary refill time is 2 seconds.

Which of these findings are consistent with the diagnosis of meningitis?Which is the most important therapeutic measure to be implemented?Which complications could possibly occur?

SECTION IV / ACUTE RESPIRATORY INFECTIONS

24 SECTION IV / ACUTE RESPIRATORY INFECTIONS

ture of the chest wall. Chest indrawingshould only be considered present if itpersists in a calm child. Agitation, ablocked nose, or breastfeeding can allcause temporary chest indrawing.

StridorStridor is a harsh noise made when thechild inhales. Children who present withstridor when calm are at substantial riskof upper airway obstruction and shouldbe referred. Some children with mildcroup manifest stridor only when they arecrying or agitated.

WheezingSometimes a wheezing noise is heard atexhalation. Wheezing is usually associatedwith asthma or viral bronchiolitis. Withfast breathing, no distinction is madebetween children with bronchiolitis andthose with pneumonia.

In some cases, especially when a childhas wheezing at exhalation, the final deci-sion on presence or absence of fastbreathing can be made after a test with arapid-acting bronchodilator (if available).Experience suggests that even whereasthma rates are high, mortality fromasthma is relatively uncommon.

Respiratory rateNo single clinical sign has a better combi-nation of sensitivity and specificity todetect pneumonia in children under 5years than RR. Even auscultation by anexpert is less sensitive as single sign.Cutoff rates for fast breathing (tachypnea)depend on the child’s age. Normal RR ishigher in children aged 2 to 12 monthsthan in children from 12 months to 5years (Table 1).

The specificity of RR for detectingpneumonia depends on the prevalence ofbacterial pneumonia among the popula-tion. In areas with high levels of viralpneumonia, RR has relatively modestspecificity. Nevertheless, even if the use ofRR leads to some over-treatment, this willstill be small compared with the use ofantibiotics among all children with an ARI,as frequently occurs.

Lower chest wall indrawingLower chest indrawing is defined as theinward movement of the bony structureof the chest wall with inspiration. It is auseful marker of severe pneumonia. It ismore specific than “intercostal indrawing,”which includes the soft tissue betweenthe ribs without affecting the bony struc-

Child’s age Cutoff rate for fast breathing (tachypnea)

2 months to 12 months 50 breaths per minute or more

12 months to 5 years 40 breaths per minute or more

TABLE 1. Respiratory rate

Give outpatient antibiotics to childrenwith a fast RR for their age to treat bac-terial pneumonia when they do not haveadditional danger or severe signs. Fastbreathing, as defined by WHO, detectsabout 80% of children with pneumoniawho need antibiotic treatment. Treatmentbased on this classification has beenshown to reduce mortality.

Patients with cough and no signs sug-gesting pneumonia or severe disease donot require antibiotics. Such children mayrequire a safe agent to relieve cough. Achild with cough will normally improve in1 to 2 weeks. However, a child withchronic cough (more than 30 days) needsto be further assessed (and, if needed,referred) to rule out tuberculosis, asthma,whooping cough, or another respiratoryproblem (Mulholland et al., 1992).

AntibioticsFirst-line oral antibiotics for suspectedpneumonia will typically be amoxicillin orcotrimoxazole (trimethoprim-sulfame-thoxazole). Intramuscular (IM) antibioticsused to treat severe pneumonia or verysevere disease include chloramphenicol,benzylpenicillin, and ceftriaxone. IM chlo-ramphenicol (40 mg/kg every 12 hours) iscommonly used for serious infectionswhen oral agents cannot be administered.Bear in mind that there is no pharmaco-logic value to giving IM or intravenous (IV)chloramphenicol instead of the oral agentin terms of achievable blood levels(Sazawal and Black, 1992).

Classification of children withcough or difficult breathingBased on a combination of the aforemen-tioned clinical signs, children presentingwith cough or difficult breathing can beclassified into 3 categories: those whorequire referral for possible severe pneu-monia or very severe disease, those whorequire antibiotics as outpatients, andthose who do not require antibiotic treat-ment (Box 3).

The group requiring referral for possiblevery severe disease includes children withany general danger sign, lower chestindrawing, or stridor when calm. Childrenwith severe pneumonia or very severe dis-ease are more likely to have life-threaten-ing invasive bacterial infections. This indi-cates the need to use injectable antibiotics.

BOX 3. Classification of childrenwith cough or difficult breathingaccording to clinical signs

Very severe respiratory diseaseor pneumonia (RED)– Any general danger sign – Chest indrawing – Stridor in a calm child

Pneumonia (YELLOW)– Fast breathing

Cough without pneumonia (GREEN)– No signs of pneumonia or – other severe disease

SECTION IV / ACUTE RESPIRATORY INFECTIONS 25

26 SECTION IV / ACUTE RESPIRATORY INFECTIONS

toiditis and should be referred to a hospi-tal for treatment. Before referral, thesechildren should receive a dose of antibi-otics and a single dose of paracetamol forpain. Children with ear pain or ear dis-charge for less than 14 days are classifiedas having acute otitis. Treat them for 5 dayswith the same first-line antibiotic as forpneumonia. If there is ear discharge formore than 14 days, the child’s classificationis chronic otitis. Attempt to wick or dry upthe ear. In this case antibiotics are not rec-ommended because they are expensiveand their efficacy is not proven.

If no signs of ear infection are found,children are classified as having no earinfection and do not require any specifictreatment.

Ear problemsEar problems are the next condition thatshould be checked in all children broughtto the outpatient health care facility. Achild presenting with an ear problemshould first be assessed for general dan-ger signs, cough or difficult breathing, diar-rhea, and fever. Although otitis is rarely acause of death, it is the main cause ofdeafness in lowincome areas, which inturn leads to learning problems.

Clinical assessmentWhen otoscopy is not available, examinethe child for the following clinical signs:

Tender swelling behind the ear. The mostserious complication of an ear infection isan infection in the mastoid bone (mas-toiditis). It usually manifests with swellingbehind one of the ears. In infants, thisswelling may also be above the ear. Whenpresent, this sign is considered positiveand should not be mistaken for swollenlymph nodes.

Ear pain. In the early stages of acute oti-tis, a child may suffer ear pain, which usu-ally causes the child to cry and becomeirritable.

Ear discharge. This is another sign of anear infection.

Classification of ear problemsBased on the presence and duration of

clinical signs (swelling behind the ear, earpain or ear discharge), the child’s condi-tion can be classified as mastoiditis, acuteotitis, or chronic otitis (Box 4).

Children presenting with swelling of themastoid bone are classified as having mas-

BOX 4. Classification of earproblems

Mastoiditis– Tender swelling behind the ear

Acute otitis– Ear discharge for less than 14 days

– Ear pain

Chronic otitis– Ear discharge for more than14 days

No ear infection– No ear pain or discharge

FEBRILE ILLNESSES (MALARIA, DENGUE)

OBJECTIVES� Recognize the public health importance

of febrile illnesses, such as malaria anddengue, in the context of acuteemergency settings.

� Understand the role of the clinician inmalaria identification, prevention, andtreatment using the IMCI strategy.

� List the factors that lead to malaria anddifferentiate the species that cause benign(uncomplicated) and malignant(complicated) malaria.

� Describe which individuals are moreprone to suffer morbidity and mortalityfrom malaria infection and the causes thatdetermine the higher risk.

� Describe the features ofsevere/complicated malaria anddistinguish these features from thoseassociated with typical uncomplicatedmalaria.

� Diagnose and develop a treatment plan(medications, supportive care, andmonitoring) using available resources forpatients with:— Severe/complicated malaria— Typical uncomplicated malaria— Severe dengue fever— Dengue fever

infection produces a clinical syndromethat ranges in severity depending on thespecies of the parasite and the immunestatus of the individual. Malaria caused byPlasmodium vivax, P. malariae, and P. ovaleusually results in mild or moderate dis-ease. P. falciparum often results in a life-threatening disease and severe anemia.The emergence of multidrug-resistant P.falciparum is a global problem.

Worldwide there are 300 million newcases of malaria each year and 1 to 2 mil-lion deaths. Most deaths occur in childrenunder 5 years of age. Most susceptibleindividuals to severe, fatal malaria includeinfants and young children, malnourishedchildren, and pregnant women.

Children who have been recently treat-ed for malaria can contract malaria again.Malaria immunity following an infection isat best partial, and protects only againstthe species causing the initial infection.Children can therefore be infected with adifferent malaria species in regions havingmore than one prevalent species or theycan be reinfected with the same species. Arelapse or recrudescence of an existinginfection can be related to a failure toeradicate a parasite that has becomedrug-resistant or to a patient’s failure toadhere to a therapeutic regimen.

Malaria occurs in areas of SoutheastAsia and Latin America where transmis-sion is seasonal or limited to specific focal

Characteristics and incidenceof malariaMalaria is caused by a protozoan bloodparasite (Plasmodium) transmitted by theAnopheline mosquito as a vector. The

SECTION V / FEBRILE ILLNESSES

Most susceptibleindividuals to severe,fatal malaria includeinfants and youngchildren, malnourishedchildren, and pregnantwomen.

28 SECTION V / FEBRILE ILLNESSES

areas, so the general population does nothave a high level of acquired immunity.Both children and adults in these areasare at high risk for severe disease. Malariaalso occurs in areas of Africa where thedisease is widespread and endemic. It gen-erates high levels of acquired immunity inadults, but young children are at higherrisk for severe disease. Most Anophelinemosquitoes are not well adapted to urbanenvironments or places about 3,900 ft(1,200 m) above sea level. Consequently,individuals living within a malaria endemiccountry may be nonimmune if they livewithin one of these malaria-free “pock-ets.” When these nonimmune people aredisplaced from their communities toareas with high malaria transmission, theconsequences can be devastating.

Malaria diagnostic testsMalaria infection is diagnosed by identify-ing the parasite in stained (Giemsa orWright) blood smears. A blood sample iseasily obtained from a finger prick. After adrop is placed on a clean labeled glassslide, spread it with another glass slideinto a thin blood smear. Thick smears areobtained by placing some drops of bloodon a glass slide and spreading the dropswith the corner of another glass slide.Dry the resulting smear without fixation.Since thick smears allow the examinationof more blood than thin smears, theyfacilitate the detection of the parasite incases of low-grade parasitemia. Newrapid diagnostic tests for malaria havebeen developed and will become morewidely available in the future.

Children suspected of having malariashould have thick and thin smears ofperipheral blood done whenever possi-ble. Serial samples at 6- to 12-hour inter-vals for 48 hours may be necessary toidentify the parasite. Species identifica-tion in the field setting is important only for discriminating between P. falci-parum and other species because thetreatment can be different. P. vivax, P. ovale, and malariae are all sensitive tochloroquine and produce less severe dis-ease than P. falciparum.

The quantitative level of parasitemia isa prognostic marker; >5% of parasitizedred blood cells is associated with highmortality. Low-grade parasitemia relatedto partial immunity or treatment canresult in a negative smear. Even patientswith cerebral malaria can be smear-nega-tive at presentation.

Therefore, when the clinical history andpresentation suggest malaria, begin treat-ment regardless of the presence of para-sites on the smears. If experienced labo-ratory technicians and equipment are notavailable, then the diagnosis and treat-ment of malaria must be based on thepresence of clinical signs and symptomsconsistent with malaria and the knowl-edge of local malaria prevalence.

However, it is also important toacknowledge that malaria can coexistwith other conditions that cause fever. Inthe absence of specific diagnostic tests,empiric treatment of any serious febrileillness should include coverage for malar-ia, as well as other pathogens. Remember:fever in a malaria endemic area should be

When the clinicalhistory andpresentation suggestmalaria, begintreatment regardless ofthe presence ofparasites on thesmears.

29SECTION V / FEBRILE ILLNESSES

considered caused by malaria unlessanother cause is identified.

SurveillanceIn areas with endemic malaria, determinethe proportion of febrile illness in a campor settlement attributable to malaria bycomparing thick (and thin, if possible)blood smears from a sample of patientsunder 5 years of age who have a historyof recent fever with an equal number ofpatients without fever. Comparing theprevalence of malaria parasites in theblood of these two groups gives an indica-tion of how much malaria is contributingto acute febrile illness in the general pop-ulation. This will be useful for the empiricmanagement of other patients.

ChemoprophylaxisChemoprophylaxis for malaria is rarelyfeasible in the acute emergency setting. Ithas been used to limit epidemics ingroups without immunity that are relocat-ed to a high malaria transmission area andto reduce mortality among targeted pop-ulations, such as malnourished childrenunder 5 years of age.

Adequate infrastructure and resourcesmust be available to implement a preven-tive chemoprophylaxis program for a tar-geted population. Efforts must be coordi-nated with local and national public healthauthorities.

Clinical presentationThere are two distinct clinical malariapresentations: typical uncomplicatedmalaria and severe, complicated malaria.

Typical uncomplicated malaria presentswith fever, chills, headaches, myalgias, diar-rhea, and anemia. Classic malaria fever hasbeen described as paroxysms of feversand shaking chills lasting 8 to 12 hours,every 2 to 3 days. During the afebrile peri-od, fever disappears and the subject feelsrelatively well (depending on the species).The febrile paroxysms coincide with thecyclical release of parasites from rupturedred blood cells; the afebrile period coin-cides with the quiet growth of the para-site in a new population of red bloodcells. Partially immune individuals mayhave a non-specific fever pattern.

Malaria is considered to be very severeif parasitemia is >5% or any of the follow-ing complications is present: severe ane-mia associated with hemoglobinemia,bleeding diathesis, hypotension and shock,renal failure, hypoglycemia, acidosis, orencephalopathic signs (cerebral malaria).Cerebral malaria is associated with signsof acute encephalopathy (coma andseizures), normal cerebrospinal fluid(CSF), and no other identifiable cause(meningitis, viral encephalitis, metabolicabnormalities). Cerebral malaria mortalityvaries from 15% to 50% (Table 2).

Treatment of typical uncomplicated malariaThe treatment of malaria depends on thelikelihood of a malaria infection and therisk of chloroquine-resistant P. falciparumor P. vivax, the severity of the infection, thesetting, and the availability of drugs. Inhigh-risk areas, treat all forms of typicaluncomplicated malaria not caused by

Remember: fever in amalaria endemic areashould be consideredcaused by malariaunless another cause isidentified.

There are two distinctclinical malariapresentations: typicaluncomplicated malariaand severe,complicated malaria.


Moderate Severe Very Severe

Headache, malaise, irritable(can be soothed)

or

Parasitemia <2%

WITHOUT SIGNS OF• Dehydration

• Respiratory distress orpulmonary edema

• Severe anemia

• Bleeding or a metabolicdisorder

TABLE 2. Degree of illness in malaria

Irritable and not easilysoothed, poor eye contact(lethargic), feeds poorly

or

Signs of mild or moderatedehydration but goodperipheral perfusion

or

Pallor but no signs of severeanemia or bleeding

or

Parasitemia >2% and <5%

But

No signs of respiratorydistress, pulmonary edema,severe anemia, or a metabolicdisorder

Unresponsive, too weak tofeed, or extreme weaknessor seizures

or

Signs of severe dehydrationwith shock, poor peripheralperfusion with cold, mottledextremities, capillary refill >2seconds, low blood pressure

or

Signs of respiratory distress orpulmonary edema withrespiratory rate >60, cyanosis,or respiratory failure

or

Severe normocytic anemia,hemoglobinuria, or bleedingassociated with disseminatedintravascular coagulation

or

Metabolic disorder,hypoglycemia, metabolicacidosis, or renal failure

or

Parasitemia ≥5%

Berman S. Pediatric Decision Making. 4ª ed. Philadelphia: Mosby, 2003.


Plasmodium falciparum with oral or naso-gastric chloroquine phosphate (except forchloroquine-resistant parasites). Prima-quine is effective at preventing relapsesbecause it eradicates the liver stages of P.vivax and P. ovale that persist in patientswho have experienced the acute illness.This drug is not normally used in disastersituations.

In low-risk areas or areas with season-al malaria, only treat children presentingwith fever with no other identified cause(acute respiratory infection, ear infection,pharyngitis, measles, etc.). However, thepersistence of fever longer than 5 daysrequires reassessment and, if possible, lab-oratory testing for malaria.

The management of all forms ofPlasmodium falciparum now recommendedby the WHO since 2008, given theincreasing resistance to chloroquineshown by these organisms, is a new firstline therapy that replaces classical chloro-quine phosphate: artemisininbased agents.There are combination therapies andnon-combination therapies, but the firstare recommended. They are given orallyfor 3 days.

1. Combination therapies (2 drugs in one tablet)� artemether-lumefantrine (Coartem®)(Table 3)

� artesunate + mefloquine� artesunate + amodiaquine

2. Non-combination therapies(Table 4)� artesunate (4 mg/kg once a day for 3

days) + mefloquine (25 mg/kg basedivided in 2 doses on the second andthird days)

� artesunate (4 mg/kg once a day for 3days) + SP (sulfadoxine 25 mg/kg +pirimetamine 1,25 mg/kg as a singledose on day 1) in areas where cure ratewith SP is higher than 80%

� artesunate (4 mg/kg once a day for 3days) + amodiaquine (10 mg bse/kg/dayfor 3 days) in areas where cure rateswith amodiaquine as single therapy arehigher than 80% If the abovementioneddrugs are not available, recommendedtherapy continues to be chloroquinephosphate. For children, a total dose of25 mg/kg of chloroquine over a 3-day

TABLE 3. Dosage schedules for artemether-lumefantrine

Weight (approx. age)Number of tablets at approximate timing (hours) of dosing

0 h 8 h 24 h 36 h 48 h 60 h

5-14 kg (<3 years) 1 1 1 1 1 1

15-24 kg (>3-8 years) 2 2 2 2 2 2

25-34 kg (>9-13 years) 3 3 3 3 3 3

>34 kg (>14 years) 4 4 4 4 4 4

Adapted from: World Health Organization. Manual for the health care of children in humanitarian emergencies, 2008.

The treatment ofmalaria depends onthe likelihood of amalaria infection andthe risk ofchloroquine-resistant P.falciparum or P. vivax,the severity of theinfection, the setting,and availability ofdrugs.

In low-risk areas orareas with seasonalmalaria, only treatchildren presentingwith fever with noother identified cause(acute respiratoryinfection, ear infection,pharyngitis, measles,etc.).


period; 10 mg base/kg (maximum 1 g =600 mg base), then 5 mg base/kg 6 hours later; 5 mg base/kg/dose at 24 and 48 hours. For adults, 1 g (600 mgbse), 500 mg (300 mg base) 6 hourslater; then 500 mg (300 mg base) at 24 and 48 hours.Chloroquine-resistant strains of P. falci-

parum are common throughout many

regions of the world. When the propor-tion of chloroquine-resistant P. falciparumis less than 25%, it may be reasonable touse chloroquine as first-line treatment inless severe patients and assess theresponse. Failure to respond in 48 to 72hours indicates infection with a resistantstrain. Treat children with chloroquine-resistant P. falciparum uncomplicated

TABLE 4.

Dosage schedules for artesunate + mefloquine

Dosage schedules for artesunate + SP

Age Number of artesunate tablets(50 mg) per day

Number of mefloquine tablets(250 mg base) per day

Day 1 Day 2 Day 3 Day 1 Day 2 Day 3

5-11 months 1/2 1/2 1/2 – 1/2 –

>1-6 years 1 1 1 – 1 –

>7-12 years 2 2 2 – 2 1

>13 years 4 4 4 – 4 2

Age Number of artesunate tablets(50 mg) per day

Number of SP tablets(25 mg S + 500 mg P base) per day


5-11 months 1/2 1/2 1/2 1/2 – –

>1-6 years 1 1 1 1 – –

>7-12 years 2 2 2 2 – –

>13 years 4 4 4 3 – –

Dosage schedules for artesunate + amodiaquine

Age Artesunate tablet (50 mg)

Amodiaquine tablet (153 mg base)


5-11 months 1/2 1/2 1/2 1/2 1/2 1/2

>1-6 years 1 1 1 1 1 1

>7-12 years 2 2 2 2 2 2

>13 years 4 4 4 4 4 4

Adapted from: World Health Organization. Manual for the health care of children in humanitarian emergencies, 2008.


malaria with quinine sulfate 25 mg/kg/daytid for 3 to 7 days (depending on resist-ance patterns to quinine) plus one of thefollowing:

� Doxycycline 2,2 mg/kg/day for 7 days (adult dose 100 mg bid for 7 days)

� Tetracycline 25 mg/kg/day qid for 7 days (adult dose 250 mg qid for 7days)

� Clindamycin 20 mg/kg/day tid for 7days (adult dose same as for children)

Treat children who may have acquiredmalaria in Southeast Asia (Thailand) andEast Africa with quinine for 7 days,because of the presence of multipleresistant strains in these areas. Additionalalternative therapies for resistant P. falci-parum include atovaquone-proguanil,mefloquine, halofantrine (associated withheart-related side effects), and artesunate.See appendix for Centers for DiseaseControl and Prevention (CDC) actualrecommended treatment options.

Chloroquine is effective and safe fortreating pregnant women. This is impor-tant because malaria during pregnancy ismore severe and can be fatal. Ideally, usesupervised therapy. Observe administra-tion of at least the first dose to be surethat it is not vomited.

If chloroquine phosphate is not avail-able, hydroxychloroquine sulfate is alsoeffective, but in this case 400 mg ofhydroxychloroquine are equivalent to 500mg of chloroquine phosphate.

In several regions mixed infection withspecies of P. falciparum and P. vivax com-

monly occurs. If diagnosis of infection isbased solely on clinical data, therapy mustcover both types of parasites. In the acutephase of an emergency, the detection of aP. falciparum infection is a priority andartemisininbased agents (except arte-sunate SP) are effective against bothorganisms.

Supportive management of uncompli-cated malaria includes antipyretics, oralrehydration solution (ORS), assessment,and possible referral to a feeding programfor malnutrition. Successfully treatedpatients should improve by 48 hours andbe symptom-free by 72 hours. If symp-toms persist after 3 days, obtain a newblood smear and consider the possibilityof chloroquine-resistant malaria or analternative cause for the fever.

Treatment of severe and complicated malariaAssume that all severe, complicatedmalaria infections are caused by resistantP. falciparum strains unless proven other-wise. Children with severe, complicatedmalaria can deteriorate rapidly, so initiatetreatment with the best available drugand, if possible, arrange a transfer to ahospital for intravenous (IV) therapy (seeappendix).

As from 2008, given the increasingchloroquine resistance mentioned above,the first line treatment for severe malariarecommended by the WHO is based onartemisinin derivatives, such as:� IM artemether

Intramuscular (IM) loading dose (3.2mg/kg) as a single dose on day 1


Maintenance dose (1.6 mg/kg) IM untilthe child tolerates oral therapy� Intravenous (IV) or IM artesunateIV loading dose (2.4 mg/kg) over 3 min-

utes as a single dose on day 1, at 0, 12 and24 hours

Maintenance dose (2.4 mg/kg) over 3minutes, starting on day 2, once a day, untilthe child tolerates oral therapy� Rectal artesunate, only if IV or IMroutes are not feasibleAdminister rectal artesunate 10 mg/kg

in a suppository. Repeat the dose if thedrug is eliminated within the first hour.Repeat the dose in 24 hours if the patientcan not be transferred to the hospital.Artesunate suppositories remain stable attemperatures of up to 40 degrees and,therefore, require warm, not cold, tem-peratures for transportation and storage.

After IM or IV therapy, the patientshould be switched to oral therapy; therecommended agent in this case isartemetherlumenfratine (Coartem®) dur-ing three days.

If first-line drugs were unavailable, anoption is quinine dihydrochloride. A load-ing dose of 20 mg/kg in 10 mL/kg of 5%dextrose should be administered IV over4 hours, followed by 10 mg/kg over 4hours (maximum 1,800 mg/kg) until oraltherapy can be started (see Appendix).Blood glucose monitoring for hypo-glycemia is recommended every 4 hoursafter each loading and maintenance infu-sion. If IV quinine is required for morethan 48 hours, maintenance dose shouldbe reduced to 7 mg/base/kg. It is extreme-ly important to bear the infusion volume

into account. In order to avoid volumeoverload due to the IV administration ofliquid, the quinine infusion volume shouldbe included in the estimation of daily liq-uid requirements.

Quinine can be diluted in 5% glucosesolution, 10% glucose, 4% glucose, 0.18%saline or 0.9% normal saline. It should bediluted to a total volume of 10 mL/kg (thesame volume should be used both for theloading dose and the maintenance dose)and infused over 4 hours. After a mini-mum of three IV doses of quinine, thepatient should be switched to oral thera-py. Therapy options by this route include:artemetherlumefantrine (Coartem®) over3 days, or oral quinine 10 mg base/kg,every 8 hours, until a 7-day course iscompleted. In areas of multiple resistantmalaria, quinine should be combined withoral clindamycin, 5 mg/kg 3 times a day,during 7 days. Mefloquine should beavoided in children that have been incoma, since it increases the risk of neu-ropsychiatric complications.

A third choice is administering an initialdose of quinine sulfate by oral route ornasogastric tube until IV therapy is avail-able. If the patient vomits, repeat the dosewithin 30 minutes. If vomits persist, startIM quinidine 10 mg/kg every 4 hourseuntil the patient is transferred to a hospi-tal for IV therapy. At the hospital, treatvery severely ill patients with an IV load-ing dose of quinine gluconate 10 mg/kgadministered over 1 to 2 hours, then witha 0.02 mg/kg/min continuous infusionuntil oral therapy can be given. If possible,measure hemoglobin, blood sugar, and


perform blood and cerebrospinal fluid(CSF) cultures.

Treat children with severe complicatedmalaria with antibiotics for potential bac-teremia or meningitis pending the resultsof blood and CSF cultures. If possible, mon-itor the patient for electrocardiographicchanges (QT interval, arrhythmias), cin-chonism (tinnitus, nausea, headache, andvisual changes), and hypoglycemia.Discontinue IV quinidine as soon as thechild has improved and switch to oral ornasogastric quinine to complete a 3 or 7day course (varies by region).

Indications for exchange transfusionvary according to the quality of intensivecare facilities and availability and safety ofblood products. The theoretical benefitsof an exchange transfusion are para-sitemia reduction, correction of anemia,improved oxygenation, and enhanced cap-illary blood flow. It is recommended whenchildren have signs of very severe illnesswith parasitemia >10%.

Supportive treatment of severe, com-plicated malaria includes antipyretics andoral rehydration solution (ORS). Monitorsigns that suggest fluid overload causingpulmonary or cerebral edema. Additionalsugar may be added to the ORS becauseof the risk for hypoglycemia.

Initial treatment of seizures with 50%dextrose is recommended, followed byphe-nobarbital (10 mg/kg IM) if seizures persist.

DengueDengue infections occur worldwide butare most prevalent in Southeast Asia,although an important outbreak has

occurred in Central and South America. InSoutheast Asia, outbreaks of hemorrhagicfever occur cyclically every 4 to 5 years. Itis caused by an arbovirus, usually acquiredby the bite of Aedes mosquitoes. There are4 closely related serotypes of denguevirus, all of which can cause severe disease.

Dengue fever is a mild, self-limitedfebrile episode that is associated withrash. It begins with fever, respiratorysymptoms (sore throat, coryza, cough),anorexia, nausea, vomiting, and headache.Back pain, myalgias, arthralgias, and con-junctivitis are less frequent symptoms.The initial fever resolves within approxi-mately 1 week, and a generalized morbil-liform or maculopapular rash develops afew days later. Fever often returns withthe rash (Table 5).

Dengue hemorrhagic fever (DHFgrades I and II) is characterized byhemoconcentration, thrombocytopenia,and coagulation abnormalities.

Dengue shock syndrome (DHFgrades III and IV) is the most severeform of the disease (approximately 25%of cases) and is characterized by severehypovolemia and shock. Fatality ratesrange from 1% to 5%, although much high-er rates have been reported.Complications include severe bleeding,pleural effusions, shock, pneumonia, liverdysfunction or failure, encephalopathy,and pulmonary hemorrhage.

The underlying immunopathology ofsevere dengue infection involves host andviral factors, and possibly sequential infec-tions with different virus serotypes.Cardinal features are a marked increase in

The underlyingimmunopathology ofsevere dengueinfection involves hostand viral factors andpossibly sequentialinfections withdifferent virusserotypes.


Mild/Moderate(Dengue fever)

Severe (DHF grades I and II)

Mental status:headache, malaise,irritable (can besoothed)

No signs ofdehydration

Good peripheralperfusion

Normal bloodpressure

No signs ofrespiratory distress orpulmonary edema

Tourniquet test:negative No signs of severeanemia or bleeding

No signs of metabolicor end-organ failure

TABLE 5. Degree of illness in dengue infection

Mental status: headache,malaise, irritable (can besoothed)

Signs of dehydration


Normal blood pressure

No signs of respiratorydistress or pulmonaryedema

Tourniquet test: positiveLow platelet count<100,000 Raised hematocrit>20% No signs of severeanemia or bleeding


Severe(Dengue shock

syndrome, DHF grade III)

Very Severe (DHF grade IV)

Mental status: irritable(easily soothed), pooreye contact (lethargic),feeds poorly

Signs of moderatedehydration withhemoconcentration


Pulse pressure <20 mm Hg

Signs of respiratorydistress (pneumonia or pulmonary edema)

Tourniquet test: positiveLow platelet count<100,000 Raised hematocrit >20%Signs of severe anemiaor bleeding


Mental status:unresponsive, tooweak to feed, extremeweakness, or seizures

Signs of severedehydration withshock

Poor peripheralperfusion

Pulse pressure <10 mm Hg,Capillary refill >2 seconds

Signs of severerespiratory distress(pneumonia,pulmonary edema orCHF) with RR >60

Tourniquet test:positive; Low plateletcount <100,000;Raised hematocrit>20%; Life threateninganemia, bleedingassociated with DIC

Metabolic disorder,including hypoglycemia,metabolic acidosis, orliver or renal failure

Berman S. Pediatric Decision Making. 4th ed. Philadelphia. Mosby, 2003.DIC: Disseminated Intravascular Coagulation. DHF: Dengue Hemorrhagic Fever. RR: Respiratory Rate. CHF: Congestive Heart Failure.


capillary permeability and a bleeding dis-order. Increased capillary permeabilitypredisposes to pulmonary edema, pleuraleffusion, and ascites, as well as intravascu-lar involvement and hemoconcentration.Bleeding (epistaxis, purpura, petechiae,gastrointestinal

hemorrhage, menorrhagia) is related todisseminated intravascular coagulation(DIC), with thrombocytopenia and liverdamage.

Leukopenia and neutropenia are char-acteristic findings. In dengue hemorrhagicfever and dengue shock syndrome, mostcommon laboratory findings includehemoconcentration, thrombocytopenia,increased prothrombin time, and abnor-malities in fibrinogen and other coagula-tion factors. Liver function may beimpaired (in particular with elevatedtransaminases). Virus isolation and sero-logic tests confirm the diagnosis.

Treatment of dengueFor patients with grades III and IV DHF,administer an isotonic fluid (Ringer’s lac-

tate or normal saline solution) at 10 to 20mL/kg/hour for hemodynamic stabiliza-tion. To prevent fluid overload, reduce therate of infusion to 1 to 5 mL/kg/hour assoon as the hemodynamic condition sta-bilizes. If there is no improvement (perfu-sion, pulse pressure, or hematocrit) with-in 1 hour, consider changing to a colloidsolution.

Hospitalize grade IV DHF patients in anintensive care unit whenever possible. Inthese cases monitor fluid replacement. Ifpulse pressure on admission is <10 mmHg, consider initial resuscitation with acolloid solution starting at 10 mL/kg/hour.Also consider transfusion with wholeblood or packed red cells and fresh frozenplasma to correct severe anemia and toreplace clotting factors. Heparin shouldbe used with caution only when DIC per-sists despite hemodynamic stabilization,correction of acidosis, and good oxygena-tion. Systemic steroids do not appear tobe effective. Diuretics may be required inthe recovery phase to prevent sustainedfluid overload.

SECTION VI / OTHER CASES THATREQUIRE ATTENTION

OTHER CASES THAT REQUIREATTENTION AT THE SCENE OF THE DISASTER

OBJECTIVES� Distinguish other clinical entities that can

present at the scene of the disaster, suchas tuberculosis.

� Consider meningitis in emergency settingsand assess the clinical findings.

TuberculosisEven though tuberculosis (TB) is the lead-ing infectious cause of death in someparts of the developing world, TB treat-ment and control programs are not partof an emergency relief response. TB is achronic infection and effective treatmentis very resource-intensive. Treatment pro-grams need to include resources to iden-tify and monitor true cases by sputumsmears exam, a stable population for atleast 6 months (to complete shortcoursetherapy), enough available drugs to treatall cases, and enough personnel to super-vise all therapy in the first 2 to 3 months.Administration of anti-TB drugs to per-sons who will not adhere to or completetreatment is likely to contribute to drugresistance in the community.

MeningitisMeningitis is the inflammation of themembranes (meninges) that surround thebrain and spinal cord. Encephalitis is theinflammation of the cerebral cortex.Meningoencephalitis involves both themeninges and the cerebral cortex.

Meningitis may be due to viral, bacteri-al, or fungal infections. Approximately twothirds of diagnosed cases are viral andone third are bacterial. The most commonviral infections are caused by enterovirus-es and herpes simplex virus.

The most common bacterial pathogensthat cause meningitis during the first 3months of life include group BStreptococcus (GBS), Escherichia coli, Listeriamonocytogenes, enterococci, Staphylococcusaureus, and gram-negative enteric organ-isms. The viral pathogens in this age groupare herpes simplex virus, enterovirus, andcytomegalovirus.

Pathogens infecting infants older than 3months of age and children are mostoften S. pneumoniae, Haemophilus influen-zae type b (Hib) and Neisseria meningi-tidis. Other organisms such as M. tubercu-losis, Salmonella, and Mycoplasma pneumo-niae are rare.

The frequency of Haemophilus infectionhas dramatically decreased with immuniza-tion. However, in areas of the world where

Even thoughtuberculosis (TB) isthe leading infectiouscause of death in someparts of the developingworld, TB treatmentand control programsare not part of anemergency reliefresponse.

39SECTION VI / OTHER CASES THAT REQUIRE ATTENTION

cases to health authorities and makeattempts to obtain appropriate samplesfor identification of the causative agent.

Identification of Neisseria meningitidis isparticularly important because of its epi-demic potential and the fact that a rea-sonably effective vaccine is available.

During confirmed N. meningitidis out-breaks, implement vaccination andchemoprophylaxis of household contacts.

N. meningitidis remains susceptible topenicillin all over the world. A long-actingsuspension of chloramphenicol in oil,called tifomycin, could be an alternative topenicillin. When other antibiotics areavailable, the initial antibiotic therapydepends on the age of the patient. Treatnewborn infants with ampicillin and anaminoglycoside (gentamicin) or cefo-taxime. Ampicillin is needed to coverListeria and enterococci. Treat infants 1 to3 months of age with ampicillin and ceftri-axone, or cefotaxime to cover enterococ-cus, Listeria, and H. influenzae. Treat olderchildren with vancomycin and ceftriaxoneif the rate of penicillin-resistant S. pneumo-niae in the area is high.

When non susceptible organisms areidentified, consider the recommendedhigh doses of cefotaxime and ceftriaxone,and add rifampin when the minimuminhibitory concentration (MIC) of thenonsusceptible pneumococci is >2.0 µg/mL.If possible, obtain serum creatinine levelsbefore giving vancomycin and repeatweekly during treatment, because van-comycin excretion depends on glomeru-lar filtration.

Use penicillin G, ampicillin, cefotaxime,

conjugate Hib vaccine is not administered,this organism remains a common cause ofmeningitis. Viral pathogens most prevalentin this age group include enterovirus,arbovirus, herpes simplex virus, herpesvirus, influenza, and Epstein-Barr virus.

Clinical findings of meningitisLook for changes in mental status andlevel of activity, including irritability,changes in feeding and sleeping patterns,unresponsiveness, and seizures.

Check for signs of meningeal irritation:nuchal rigidity, bulging fontanelle, paradox-ical irritability, and Brudzinski and Kernigsigns.

Evaluate hydration status and signs ofshock, such as mottled skin, slow capillaryrefill, increased pulse, and decreasedblood pressure. Perform a neurologicexamination and document focal neuro-logic signs, paresis, or ataxia. Measure thehead circumference and look for exan-them, purpura or petechiae, or soft-tis-sue, bone, or joint infections.

Signs associated central nervous sys-tem complications include focal neurolog-ic findings, prolonged seizures, persistentchanges in mental status, enlarging headcircumferences, or ataxia. Complicationsinclude subdural effusion or empyema,cerebral edema, cerebral abscess, cerebralinfarction, or hydrocephalus.

Treatment of meningitisSuspected cases of severe sepsis ormeningitis need to be treated promptlywith the best available drugs. Report such

When the clinicalhistory andpresentation suggestmalaria, begintreatment regardless ofthe presence ofparasites on thesmears.

40

or ceftriaxone for N. meningitidis. Theduration of intravenous therapy varieswith the pathogen. Treat gram-negativeenteric organisms for 21 days; S. pneumo-niae for 10 to 14 days; H. influenzae for 7to 10 days, and N. meningitidis for 4 to 7days.

When using aminoglycosides or chlo-ramphenicol, monitor blood levels if pos-

sible (therapeutic levels for gentamicin ortobramycin are 4 to 8 µg/mL; forkanamycin or amikacin, 15 to 25 µg/mL).Adequate blood chloramphenicol levelscan be achieved with oral administration.Whenever possible, avoid administeringaminoglycosides in patients with renal dis-ease and chloramphenicol in patients withhepatic dysfunction.

SECTION VI / OTHER CASES THAT REQUIRE ATTENTION

The only vaccine that must be routinelyadministered during immediate emer-gency relief efforts is measles. A routineimmunization program for other vaccinesshould only be considered if the popula-tion is expected to stay in the area forlonger than 3 months, if it is possible tokeep appropriate records, and if otherassistance efforts are not disrupted orcompromised by the activities needed forvaccination.

TetanusTetanus immunization is not routinelyrecommended in disaster situations, but ifthe vaccine is available, it is reasonable toapply it prophylactically to individuals whohave tetanus-prone wounds if the time ofthe last tetanus immunization is unknownor greater than 5 years, or when the childhas not received the primary 3-dose vac-

cination series. The characteristics oftetanus-prone wounds are a wound thatwas first cleaned more than 6 hours afterits occurrence; irregular wounds; woundsfrom bullets, crushing, burns, or frostbite;and presence of devitalized tissue orwound contaminants.

Specific situations requiringprophylaxisPertussisThe vaccine. It is well established that per-tussis vaccine provides clinical protectionafter exposure to the disease in most peo-ple. The effectiveness of the vaccine with aregimen of 3 or more doses is around 80%to 90%. Appropriately immunized childrenwho acquire the disease have milder symp-toms and fewer complications.

Management of outbreaks. When anincrease in the number of cases is sus-pected, mass immunization is a priority inchildren under 7 years old. If disease ratesare higher among children over 7 yearsold and adolescents, use of acellular vac-cines may be considered.

Household contacts—vaccination. House-hold contacts and other close contacts ofpatients under 7 years old who have had atleast 4 previous doses of diphtheria-tetanus-pertussis vaccine (DTP or DTaP)must receive a booster injection of DTP orDTaP, unless they have received a dose

SECTION VII / VACCINATION IN DISASTER SITUATIONS

VACCINATION IN DISASTER SITUATIONS

OBJECTIVES� Acknowledge the importance of measles

immunization in a disaster situation.� Recognize the characteristics of

tetanusprone injuries and wounds.� Describe specific situations that require

the use of other vaccines.

Management of outbreaks. When casesof diphtheria are suspected, mass vaccina-tion is indicated, taking into account therates of incidence by age groups.

Household contacts—vaccination. Asym-ptomatic contacts whose immunizationregimen is complete and who havereceived their last dose more than 5 yearsago must receive a DTP or dT boosteraccording to their age. Close asympto-matic contacts whose immunization regi-men is incomplete (<3 doses of diphther-ic toxoid) or whose immunization statusis unknown must receive a dose and com-plete the schedule.

Chemoprophylaxis. Whatever theirimmunization status, close contacts mustbe kept under surveillance for 7 days todetect any evidence of the disease, havecultures taken for Corynebacterium diph-theriae, and receive antimicrobial prophy-laxis with oral erythromycin (40-50mg/kg/day for 7 days, with a maximum of2 g/day) or a single intramuscular (IM)dose of penicillin G benzathine (600,000IU for those <30 kg and 1.2 million unitsfor older children and adults). Obtain newthroat cultures in contacts identified ascarriers within 2 weeks after completionof treatment.

Meningococcal diseaseFew infectious diseases cause as much con-cern among the general population andhealth workers as meningococcal infection.The estimated attack rate for householdcontacts is 4 cases per 1,000 exposed per-sons. This is 500 to 800 times higher thanrates in the general population.

42 SECTION VII / VACCINATION IN DISASTER SITUATIONS

within the past 3 years. Children under 7years old who have not been immunizedor who have previously received less than4 doses must start or continue their vacci-nation regimen according to the nationalprogram. A fourth dose must be adminis-tered to children who received their thirddose 6 or more months before exposure.

Chemoprophylaxis. All household con-tacts and other close contacts, regardlessof their age or immune status, shouldreceive erythromycin (40-50 mg/kg/dayorally, divided in 4 doses), for 14 daysbecause immunity after vaccination is nottotal and infection may not be prevented.It has been proven that erythromycineliminates the carrier state and is effectivein limiting secondary spread. For patientswho are intolerant to erythromycin, clar-ithromycin (15 mg/kg/day orally divided in2 doses, for 1 week) may be administered;other options are azithromycin andtrimethoprim-sulfamethoxazole.

DiphtheriaThe vaccine. In diphtheria, as in tetanus,immunity relies only on the presence inblood and interstitial fluids of antitoxinIgG antibodies with titers ≥0.01 IU/mL.These antibodies work locally, where thetoxin is released by the bacteria, and inblood against the toxin that reaches thecirculation. After primary immunizationwith 3 doses of toxoid, antitoxin titersabove 0.01 IU/mL can be found for 5 ormore years, and after one or more boost-er injections they persist for 10 years. Inclinical practice, vaccination has shown anefficacy rate above 99%.

43SECTION VII / VACCINATION IN DISASTER SITUATIONS

Chemoprophylaxis is indicated forthose individuals who meet the criteriafor close contacts. The goal is to eradicateN. meningitidis carriers and prevent theoccurrence of secondary cases.� Close contacts: household members,attendees at child care centers, nurseryschools, schools, universities, and mem-bers of closed communities that are incontact with any individual withmeningococcal disease for more than 4hours daily, 5 days a week; any other per-son directly exposed to oral secretionsof the patient (e.g., sharing tableware,drinks, kisses; sneezing or coughing).

� Secondary case: any case occurring in aclose contact 24 hours or more afteronset of the disease in the primarycase. Because there is a high rate ofsecondary disease during the 5 days fol-lowing contact, give chemoprophylaxiswithin the first 24 hours. It is not indi-cated beyond 14 days. A nasopharyn-geal culture to determine the need forchemoprophylaxis is not warranted. If

the patient was treated with third gen-eration cephalosporins, chemoprophy-laxis before discharge is not needed.Rifampin is the first choice agent forchemoprophylaxis in children, but thereare alternatives for adults (Table 4).Chemoprophylaxis is indicated forhousehold members and contacts(Box 5). Monitor exposed individualsand assess if they have a febrile disease.

The vaccine: immunogenicity and effective-ness. With unconjugated polysaccharidevaccines, protection is achieved 7 to 10days after immunization. Bivalent A + Cvaccine is safe and effective (85% to 90%)in children older than 2 years old and inadults. The A component induces animmune response from 3 months of ageon, with a seroconversion rate of 88%after the second dose, applied in childrenbetween 7 and 12 months old.

Management of outbreaks. An outbreakof meningococcal disease is defined whenthe attack rate is higher than 10 cases in

Agent Age Group Dose Duration

Rifampin Newborns 5 mg/kg/dose Every 12 h for 2 daysChildren 10 mg/kg/doseAdults 600 mg/dose

Ceftriaxone ≤12 years 125 mg IM Single dose>12 years 250 mg IMPregnant women 250 mg IM

Ciprofloxacin ≥18 years 500 mg orally Single dose

TABLE 4. Recommended agents for chemoprophylaxis

IM: Intramuscular.


100,000 persons, in a specific area, with anepidemiologic relation among cases, andwith a predominating serogroup. Withactive epidemiologic surveillance, an out-break is also considered when the inci-dence rate by age is doubled.

Where can outbreaks occur? Outbreakscan occur in an institution or an organiza-tion. In this case, an outbreak is defined by3 or more confirmed, presumptive, orprobable cases occurring in a period of 3

months or less within the same institutionor organization, but without close con-tacts (e.g., schools, universities, militaryorganizations, jails).

Community outbreaks are defined by 3or more confirmed, presumptive, or prob-able cases that occur in 3 months or lessamong people who live in the same areaand are not close contacts (e.g., smalltowns, cities, countries).

Guidelines for evaluation and management of a meningococcal disease outbreak1. Reinforcement of active surveillanceIn areas where surveillance for meningo-coccal disease is passive, case reports maybe incomplete or delayed. When an out-break is suspected, alert public healthauthorities and request immediate reportof new cases.

2. Case detection and bacteriologic confirmationEstablish the diagnosis of meningococcaldisease considering confirmed, presump-tive, or probable cases.a. Confirmed case: isolation of N. menin-

gitides from a usually sterile site(blood, CSF) in an individual withclinically consistent findings.

b. Presumptive case: observation ofGram-negative diplococci in any usu-ally sterile site, with negative culturesand symptoms of disease.

c. Probable case: positive antigen testfor N. meningitidis (latex agglutination

BOX 5. Indications for chemoprophylaxis

Contacts who should receivechemoprophylaxis

Household members Individuals who often sleep or eat with the

patient, and meet the definition of contact Contacts in child care centers and nursery

schools (including staff members) for morethan 4 hours during 5 days of the previousweek

Individuals who have been directlyexposed to the patient’s secretionsthrough kissing or sharing food, drinks,toothbrushes, etc.

Individuals administering mouth-to-mouthresuscitation

Individuals who experience unprotectedcontact during endotracheal intubation inthe 7 days prior to the onset of thedisease

Situations where chemoprophylaxis isNOT indicated:

Casual contact: no direct exposure to thepatient’s oral secretions (classmates orcoworkers)

Indirect contact: no contact with thepatient, only with his/her contact

Health care workers with no directexposure to the patient’s oral secretions

45SECTION VII / VACCINATION IN DISASTER SITUATIONS

test, immunoelectrophoresis), withnegative cultures and consistentsymptoms.

Information about serogroup is essen-tial. Laboratories not performing this testroutinely should forward the sample toreferral laboratories of higher complexityto identify the serogroup. If possible,investigate N. meningitidis subtype bypulsed-field gel electrophoresis or multi-locus enzyme electrophoresis to deter-mine if the strains of a group of cases areinterrelated and whether they representan outbreak.

3. Appropriate treatment ofpatients, according to management guidelines

4. Chemoprophylaxis and carefulobservation of contactsChemoprophylaxis and careful observa-tion are recommended for close contacts.Chemoprophylaxis for individuals whoare not close contacts is ineffective in

preventing community outbreaks; there-fore, it is not recommended. Exposedindividuals must be carefully monitoredand evaluated in case of any febrile illness.

5. Investigation of relationships bet-ween casesIn addition to demographics, obtain thefollowing information for each affectedindividual: history of close contact withanother primary case; participation insocial activities or sports; attendance atchild care centers, kindergartens, schools,universities, or clubs. This information willhelp identify cases as co-primary or sec-ondary, reveal relationships betweencases, and define the population at risk.

6. Assessment of the relationship ofthe suspected outbreak with thecommunity or with an institution ororganization

7. Definition of at-risk populationIn outbreaks related to an institution ororganization, cases are linked with ashared affiliation, such as attending thesame day care center, kindergarten,school, or university or belonging to thesame sports team. In such cases, thepopulation at risk is everyone in thoseplaces. On the other hand, in communi-ty outbreaks patients do not share anaffiliation, only a geographically definedlocation, such as a neighborhood, smalltown, city, or country. The risk groupincludes every individual living in thoseplaces.

Co-primary case:

Case occurring in a close

contact within 24 hours of

the onset of the disease in

the primary case

x 100,000

Attack rate =

Number ofprobable and

confirmed cases(over a 3-month

period)

Population at risk


8. Estimation of attack rateAttack rate can be estimated by the fol-lowing formula:

With a global attack rate higher than 10cases in 100,000, consider vaccination of

at-risk population. Consider the incidencerates by age groups. If the incidence ratedoubles in a population with adequateepidemiological surveillance, immuniza-tion may be considered.

9. Selection of the target group forvaccinationConsider the guidelines from publichealth authorities regarding theserogroup involved and the age groupaffected. In that case, it is necessary tohave adequate vaccine supplies.

Co-primary case:

Case occurring in a close

contact within 24 hours of

the onset of the disease in

the primary case

x 100,000

Attack rate =

Number ofprobable and

confirmed cases(over a 3-month

period)

Population at risk

SECTION VIII / INFECTIONS IN INFANTS 0 TO 2 MONTHS OF AGE

INFECTIONS IN INFANTS 0 TO 2 MONTHS OF AGE

OBJECTIVES� Identify and establish the treatment for

sick infants 0 to 2 months of age.

Assessment of the sick infant0 to 2 months of ageAs mentioned previously, newborn andinfants under 2 months of age are veryvulnerable to infections, with high mor-bidity and mortality rates associated withvery severe clinical conditions includingsepsis, meningitis, and pneumonia. Thus, ifan infant under 2 months is suspected ofhaving a severe neonatal illness or a pos-sible severe bacterial infection, there is notime to lose in laboratory studies. It isextremely important to start antibiotictherapy immediately and to refer thepatient to a hospital if needed resourcesare not available.

Infants weighing less than 2,000 g whoare brought to the primary health carefacility with a possible infection should bereferred to a hospital for specializedtreatment, regardless of the severity ofthe condition, because they are more vul-nerable due to their immaturity. Theassessment of the infant 0 to 2 monthsold should include the following ques-tions:

� What is your baby doing?� Is he/she feeding well or poorly?� Has he/she vomited / Is he vomiting all

he eats?� Has he/she had diarrhea?� Has he/she difficulty breathing?� Has he/she had fever or hypothermia?� Has he/she had seizures or shivering?

In addition, look for clinical signs thatindicate the severity of the illness, from

subtle signs such as “he doesn’t lookgood” to neurologic signs (e.g., seizures) ordifficult breathing. Assessment of body tem-perature, hydration status, capillary refill,and fontanelle characteristics are alsoimportant, as well as looking for otherproblems (congenital anomalies, surgicaldisorders). Figure 3 shows the algorithmused by the Integrated Management ofChilhood Illness (IMCI) for assessment ofsick infants 0 to 2 months of age.

Classification of the infant 0 to 2 months of age with severe illness or possible severe bacterial infectionBased on general danger signs, infants canbe classified into four different categoriesas shown in Table 5.

Children presenting with any sign in theupper row of Table 5 are classified as hav-ing a severe illness or possible severe bacter-ial infection. In infants younger than 2

If an infant less than2 months is suspectedof having a severeneonatal illness or apossible severebacterial infection,there is no time tolose in laboratorystudies.

It is extremelyimportant to startantibiotic therapyimmediately and torefer the patient to ahospital if neededresources are notavailable.

48 SECTION VI / VACCINATION IN DISASTER SITUATIONS

TABLE 5. Classification of the infant 0 to 2 months with severe illness orpossible severe bacterial infection

SIGNS CLASSIFY AS TREATMENT

(RED)One out of the following signs:

“Doesn’t look good”Cannot be breastfedLethargic/unconscious or flaccidVomitingSeizuresIntense pallorWeight <2,000 gRR > 60 or <30 per minTemperature <36.5ºC or>37.5ºCBulging fontanelleApneaNasal flaringGruntingSevere lower chest wall indrawingCentral jaundiceJaundice bellow the umbilicusPetechiae, pustules or vesicles inthe skin (many or extended)Pus drainage from earUmbilicus redness extending toskinPoor capillary refill (>2 sec)

• Abdominal distension

(RED)

SEVEREILLNESS

OR

POSSIBLESEVERE

BACTERIALINFECTION

(RED)URGENTLY refer to hospital,according to the guidelines forstabilization and transportationGive the first IM dose ofrecommended antibioticsPrevent hypoglycemiaKeep the child warmAdvise the mother/ caregivernot to stop breastfeedingClarify any doubt and givesupport to the mother/caregiverAdvise mother to accompanythe child and show how to keepthe infant warm on the way tothe hospital

(YELLOW)Ocular pus dischargeRed umbilicus or draining pus Skin pustules (few or localized)

(YELLOW)

LOCALBACTERIALINFECTION

(YELLOW)Give an appropriate oral antibioticfor 7 daysTeach the mother/caregiver how totreat local infections at homeApply local treatment (topicalantibiotic)Teach the mother/caregiver torecognize signs of dangerClarify doubts and give support tothe mother/ caregiverFollow up 2 days later

(GREEN)Normal activityFeeding wellNormal physical examinationresultsWhite plaques in the mouth

(GREEN)

NOBACTERIALINFECTION

(GREEN)Counsel the mother to continuebreastfeeding No additional treatmentTeach the mother to recognize signsof danger and to implement hygienicmeasuresTell the mother when to come backto the clinic Check immunization statusClarify doubts and give support tothe mother/caregiverConsider applying Nistatin locally100,000 units in the mouth, 4 timesa day

Look for clinical signsthat assess the severityof the presentation,from very subtle signssuch as “he doesn’tlook good” toneurologic signs orsevere difficultybreathing.

SECTION VI / INFECTIONS IN INFANTS 0 TO 2 MONTHS OF AGE

months old, it is difficult to distinguishbetween a very severe illness and a severeinfection, such as sepsis or meningitis,since clinical findings are usually similar.For this reason, the classification givesboth possibilities.

If the infant is suffering from a local butextensive bacterial infection, he or sheshould also be classified as having a possiblesevere bacterial infection because the localinfection can disseminate and result in sep-sis, due to the immaturity of the immunesystem. He or she needs to be referredurgently to a specialized hospital to receivedifferent kinds of treatments, such as oxy-gen or parenteral antibiotics. Before trans-fer, administer the first dose of the ade-quate antibiotic. Transfer according to theguidelines for stabilization and transport.Counsel the mother or caregiver in orderto clarify possible doubts and provide sup-port. Infants with no general danger signsbut who have purulent discharge from theumbilicus or eyes, pustules in the skin (lim-ited in number or localized), are classifiedas having a local bacterial infection. Childrenwho exhibit no danger signs are classifiedas having no bacterial infection.

Treatment of infants 0 to2 months of age with infectionInfants 0 to 2 months old who need to betransferred to a hospital more than 5hours away should receive an intramuscu-lar (IM) dose of an adequate antibiotic.

Possible antibiotic combinationsinclude:

� gentamicin + ampicillin� gentamicin + G penicillin procaine

Avoid oral feeding if the infant presentswith altered consciousness or difficultbreathing, and administer a 5% dextrosesolution through nasogastric tube to pre-vent hypoglycemia.

If there is no incubator available for thetransfer, the “mother kangaroo” tech-nique is advisable in order to preventhypothermia. If available, also administersupplemental oxygen during the transferto prevent hypoxemia.

Infants 0 to 2 months of age with a localbacterial infection should receive an ade-quate oral antibiotic as well as topicalantibiotic therapy according to the site ofinfection.

Infants 0 to 2 monthsold who need to betransferred to ahospital more than 5 hours away shouldreceive anintramuscular dose ofan adequate antibiotic.

49

SUMMARY / SUGGESTED READING50

Black RE. Persistent diarrhea in children in developing countries.Pediatr Infect Dis J 1993;12:751-761.

Black RE, Morris SS, Bryce J. Where and why are 10 millionchildren dying every year? Lancet 2003;361:2226-2234.

Centers for Disease Control. Health Issues. MMWR 1992;41:RR-I3.

Fontaine O. Acute Diarrhea Pediatric Decision Making. 4th ed.Philadelphia, Pa: Mosby; 2003.

Hussey G, Berman S. Measles Pediatric Decision Making. 4th ed.Philadelphia, Pa: Mosby; 2003.

Management of uncomplicated malaria and the use of antimalarialdrugs for the protection of travellers. Report of an informalconsultation, Geneva, September18-21, 1995. Geneva: World HealthOrganization; 1997 (unpublished document WHO/MAL/96.1075 Rev1 1997; available on request from Division of Control of TropicalDiseases [CTD]).

Mandell, Douglas and Bennett, eds. Principles and Practice ofInfectious Diseases. Churchill Livingstone; 2000.

Mulholland EK, et al. Standardized diagnosis of pneumonia in developing countries. Pediatr Infect Dis J 1992;1:77-81.

Murray CJL, Lopez AD. The global burden of disease: acomprehensive assessment of mortality and disability fromdiseases, injuries and risk factors in 1999 and projected to2020. Geneva: World Health Organization; 1996.

Sazawal S, Black RE. Meta-analysis of intervention trials on casemanagement of pneumonia in community settings. Lancet1992;340(8818):528-533.

Technical basis for the case management of measles. DocumentWHO/EPI/95. Geneva: World Health Organization; 1995.

The management of bloody diarrhea in young children. DocumentWHO/CDD/94.9 Geneva: World Health Organization; 1994.

World Health Organization.http://www.who.int/vaccines/en/vitamina.shtml

World Health Organization. Manual for Health Care of Children inHumanitarian Emergencies 2008.

World Health Organization, Department of Child and AdolescentHealth and Development. Model chapter for Textbooks IMCIIntegrated Management of Childhood Illness, 2001.

World Health Organization. World Health Report 1999: Making aDifference. Geneva: World Health Organization; 1999.

SUGGESTED READING

SUMMARYThe morbility and mortality associated with infectious diseases are very high indeveloping countries. During acute humanitarian emergencies, morbility and mor-tality increase significantly. Deterioration of the nutritional status associated withsuch situations increases the risk of infectious diseases among the affected children.The IMCI strategy, designed for primary care management of children and based

on a number of clinical signs at presentation, is an ideal tool for the effective man-agement of people affected by disasters, particularly in situations with limitedresources, both material and human. This tool allows a quick and simple distinctionbetween children who require referral to the hospital and those with less severeillness that can be managed in a less complex setting.Measles, acute respiratory infections, malaria, dengue, and acute diarrhea are the

infections that cause more concern in an emergency setting. Take also into consid-eration sepsis and meningitis. It is important to recognize these diseases as early aspossible in order to give appropriate therapy and prevent a possible outbreakamong people displaced by a disaster.

51CASE RESOLUTION

Case resolution

Case 1. The child is ill-appearing, febrile, tachycardic, and tachypneic with a physical examremarkable for scattered petechiae on the abdomen and lower extremities. The primaryconcern is whether this child is in shock. Tachycardia and decreased capillary refill areconsistent with compensated shock.Since the child is febrile and has a history of an upper respiratory disease, the most like-

ly etiology of the shock is sepsis. The fever and the presence of petechiae suggest a severebacterial infection, most likely meningococcemia. While many other conditions such asviral infection—influenza, enterovirus, adenovirus, infectious mononucleosis, or group AStreptococcus infection—can present with fever and petechiae, meningococcal infection israpidly progressive and life-threatening.Initial management begins with 100% oxygen. An IV line was placed and a blood sample

was sent for complete blood count, serum electrolytes, coagulation studies, and culture.Rapid blood glucose determination was 120 mg/dL. As the child was tachypneic and hadsigns of shock, the lumbar puncture was deferred and IV antibiotics were administeredimmediately. An IV bolus of normal saline was given because of poor oral intake anddecreased urine output, with no signs of cardiac or pulmonary disease.His initial laboratory tests showed a white blood cell count of 21,000. Serum bicarbonate

was 11, prothrombin time 15 seconds, and partial thromboplastin time 28 seconds.Over the next several hours the child developed purpura, had increasing respiratory dis-

tress, and labile blood pressure. He was intubated and ventilated. His blood culture grewN. meningitidis.

Case 2. The infant is manifesting many of the classic features of an acute presentation of bacterialmeningitis. The patient is irritable, febrile, and has a bulging fontanelle. The fact that thepatient has a supple neck should not dissuade the examiner from the overall impressionof meningitis. Children younger than 18 months frequently lack sufficient neckmusculature to manifest nuchal rigidity.Because the patient is well oxygenated and has stable vital signs, the most pressing inter-

vention is the rapid delivery of IV antibiotics. Antibiotics should cover all possible organ-isms, especially S. pneumoniae. Treatment should begin with cefotaxime or ceftriaxone andvancomycin (if resistant S. pneumoniae is in the community). Possible complications ofmeningitis include seizures, syndrome of inappropriate antidiuretic hormone (SIADH),and intracranial hypertension.

(Adapted from: ACEP/AAP. The APLS: The Pediatric Emergency Medicine Resource. 4a ed, 2004.)

52 MODULE REVIEW

MODULE REVIEW

SECTION I - INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI)

1.What is IMCI?

2.What are the IMCI steps for the assessment of sick children?

3. What are the general danger signs that must be routinely checked in allchildren?

SECTION II - INFLUENZA

1.What are the risk factors for having a more severe Influenza infection?

2.What methods can be used to prevent the spread of H1 N1 Influenza infectionsin the hospital and community?

SECTION III - MEASLES

1. How should measles immunization be implemented?

2.What is the relationship between vitamin A and measles?

3. How is a measles diagnosis made?

4.Which are the most common complications of measles?

SECTION IV - ACUTE RESPIRATORY INFECTIONS

1. What are the clinical signs that should be assessed in children with cough orrespiratory problems?

2.What are the antibiotics used for lower respiratory infections?

3. How should ear problems be assessed?

SECTION V - FEBRILE ILLNESSES: MALARIA, DENGUE

1. How is a malaria diagnosis made?

2.What is the clinical presentation of malaria?

3.What is the treatment for classic malaria and for complicated malaria?

4. How is dengue infection classified?

53

SECTION VI - OTHER CASES THAT REQUIRE ATTENTION AT THESCENE OF THE DISASTER

1.What clinical signs raise the suspicion of meningitis?

2.What must be taken into consideration for the treatment of meningitis?

SECTION VII - VACCINATION IN DISASTER SITUATIONS

1.What interventions are recommended when tetanus is suspected?

2.What are the situations that require prophylaxis?

3. How should a meningitis outbreak be evaluated and managed?

SECTION VIII - INFECTIONS IN INFANTS 0 TO 2 MONTHS OF AGE

1. What are the clinical signs that suggest a severe illness in infants 0 to 2 monthsof age?

2. What immediate action should be taken with an infant 0 to 2 months of agewith severe illness?

MODULE REVIEW

APPENDIX54

INTeRIm INFlueNzA TesTINg AlgoRIThm

Currently Influenza A-H1 (Swine), susceptible to oseltamivir (Tamiflu), is the only strain circulating in Colorado. Recommendations will change as strains change inthe community – for most current information go to “Planettch/Quicklinks/Influenza info”

Patient presenting to ED/NOC/outpatient clinic

Patients presenting with symptoms consistent with Influenza

Patient requiring hospitalization

Rapid Flu IA*

with backup PCR

Respiratory

Flu IA* with

backup PCR

Treat presumptively (even if symptoms>48 hrs) until both tests are influenza

negative. Use Oseltamivir or Zanamivir while prevalence of

seasonal influenza is low. (See tables)No treatment recommended

Patient NOT requiring hospitalization

High-Risk Childα

No Test

Recommended

Low-Risk Child

1. Place immediately in and rigorously enforce DROPLET PRECAUTIONS

2. Give information sheet that recommends notification of high-risk contacts

αHigh Risk Child per CDC suggestion = Children < 2 yrs (CDC includes those 2-5 yrs but many experts feel that isexcessive); children with any of the following medical conditions: chronic pulmonary (including asthma), cardiovascular(except hypertension), renal, hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, or metabolicdisorder (including diabetes mellitus); immunosuppression including that caused by medications or by HIV; pregnantwomen; persons who are receiving long-term aspirin therapy; residents of chronic-care facilities; or children who presentwith a severe illness.

*Nasopharyngeal Aspirate – Observe droplet precautions + N95 mask and eye protection. Get a good specimen – thequality of the result is directly proportional to the quality of the specimen! Immunoassay (IA) sensitivity alone = 70%.

Note to ordering physicians – Due to the increased number of samples being tested, the microbiology lab will only callphysicians for respiratory virus results if positive for Influenza. It is the ordering physician’s responsibility to follow up for allother testing results.

Recommendations will change when seasonal influenza and/or RSV become more widespread in the community.

APPENDIX 55

Adults 75-mg capsule twice per day 75-mg capsule once per dayfor 5 days

Children 15 kg 60 mg per day divided into 2 doses 30 mg once per day(age, 12 months or lessor older), weight:

16-23 kg 90 mg per day divided into 2 doses 45 mg once per day

24-40 kg 120 mg per day divided into 2 doses 60 mg once per day

>40 kg 150 mg per day divided into 2 doses 75 mg once per day

Table 1. Influenza A-h1 (swine) oseltamivir dosing recommendations

Agent, group Treatment Chemoprophylaxis

Amantadine Resistant Susceptible Resistant No activityRimantadine

Oseltamivir Susceptible Resistant Susceptible Susceptible(Tamiflu)

Zanamivir Susceptible Susceptible Susceptible Susceptible(Relenza)

Table 3. summary of Antiviral Resistance, u.s. 2008-09

AntiviralInfluenza viruses

A-h1 (swine) A-h1 (seasonal) A-h3 (seasonal) B (seasonal)

<3 months 12 mg twice daily

3-5 months 20 mg twice daily

6-11 months 25 mg twice daily

Table 2. Dosing recommendations for antiviral treatment of children youngerthan 1 year using oseltamivir

Age Recommended treatment dose for 5 days

INFlueNzA ANTIVIRAls

management of prevalent infections in children following a ......imci management strategy uses a...

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