MODULE V

Management of Prevalent

Infections in Children

Following a Disaster

• Acute respiratory infections

• Diarrhea and dehydration

• Measles

• Malaria

• Malnutrition

MAIN CAUSES OF DEATH

The IMCI strategy

2 components based on the child’s age:

• sick young infant aged up to 2 months

• sick child aged 2 months up to 5 years

The IMCI strategy

• The clinical decision making approach

involves using a limited number of

symptoms and signs to classify the

severity of illness, which determines the

management with guidelines for follow-up,

counseling for the parents, and

instructions regarding when to return

additional care is needed.

Management

• Pink: needs to be urgently referred to a

higher level of care

• Yellow: requires specific treatments

• Green: can be safely managed at home

with supportive care

Sick young infant aged up to 2 months

• Classification and management of severe

disease (pneumonia, meningitis, and sepsis),

local bacterial infection, jaundice, diarrhea, HIV

infection, poor weight gain, breast feeding and

other feeding problems, immunization status,

and mother’s health.

Severe disease (PINK)

• Not feeding, convulsions, fast breathing

(more than 60 breaths per minute) severe chest

indrawing, fever or low temperature, and lack of

movement.

• Refer urgently to the hospital with a first

antibiotic dose and treatment to prevent

low blood sugar

Local bacterial infection (YELLOW)

• Signs of umbilical infection (redness and

or purulent discharge) or skin pustules

• Treat with an appropriate antibiotic.

Sick child aged 2 months up to 5 years

• Classification and management of

respiratory disease, diarrhea, febrile

illness (malaria), measles, ear infections,

malnutrition, anemia, HIV, and

immunization status.

IMCI STRATEGY DANGER SIGNS

• Unable to drink or breast feed (too

weak)

• Vomits everything

• Had convulsions

• Lethargic or unconscious

• Convulsing now

Very severe respiratory disease

Any general danger sign

Stridor in a calm child

Pneumonia

Fast breathing

Chest indrawing

Cough without pneumonia

No signs of pneumonia or severe disease

IMCI: COUGH OR DIFFICULT BREATHING

ANTIBIOTIC ARSENAL

• Oral antibiotics

– Amoxicillin

– Cotrimoxazole (TMPSMX)

• Intramuscular (IM) antibiotics

– Benzylpenicillin

– Cefuroxime or Ceftriaxone

INFLUENZA VIRUS

• Family Orthomyxoviridae– “myxo” mucus

– segmented, single-stranded

RNA

• Influenza A first isolated

1933; Influenza B 1940

• 15 hemagglutinin (HA) and

9 neuraminidase (NA)

subtypes– Only H1N1, H2N2, H3N2

subtypes associated with

widespread epidemics in

humans

CLINICALLY RELEVANT INFLUENZA

VIRUSES

Type A Potentially severe illness

Epidemics and pandemics

Rapidly changing

Birds, swine, horses, seals, humans

Type B Usually less severe illness

Epidemics

More uniform

Humans

Type C Usually mild or asymptomatic illness

Minimal public health impact

Humans, swine

INFLUENZA: A CONTINUOUSLY CHANGING

VIRUS

Polymerase Proteins (PP)

Hemagglutinin (HA) *cell entry

Neuraminidase (NA)

*cell escape

M1, M2

Nucleoprotein (NP)

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

RNA

Hemagglutinin

Neuraminidase

Antibodies

Sialic acid

ANTIGENIC DRIFT (A & B)

ANTIGENIC SHIFT (A ONLY)

TRANSMISSION OF INFLUENZA

• Person to person

• Droplet spread

– small particle aerosols

• Fomite contamination

– Steel and plastic 24-48 hrs

– Cloth, paper, tissues 8-12 hrs

– Hands 5 min (high viral titer)

• Principal site of replication- columnar epithelium

• Incubation period- 18 hrs to 5 or more days (average 2-3 days)

• Virus shedding 3-7 days

• Viral titers are generally higher in young children with shedding

lasting 10 days or longer

RECOGNIZING PEDIATRIC INFLUENZA

Neonates Infants/Toddlers Children/Teens

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

HeadacheSore throat

INFLUENZA VIRUS INFECTION COMPLICATIONS

• Acute otitis media

(children)

• Sinusitis

• Pneumonia

• Exacerbation of

underlying illness

• Dehydration (infants)

• Encephalopathy

• Reye syndrome

(children)

• Myositis

• Myocarditis

• Febrile seizures

Common Complications Uncommon Complications

MEASLES

• Highly contagious infection (98-100% in susceptible

contacts)

• Transmission through respiratory secretions

(contact and aerosolized particles)

• Incubation period: 10-14 days

• Mortality rate Nutrition / crowding / inoculum

Overcrowded living conditions are an important

triggering factor for epidemics

NATURAL HISTORY OF MEASLES

Identification of one case in a camp should speed up

immunization process

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7Incubation

10-14 days

Fever ------------- FEVER--------------------]

Cough ---------------------------------------------------- - - -

Conjunctivitis ----------------------------------------- - - -

Coryza ------------------------------------------------- - - -

Köplik spots---]

Exposure

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

RASH – DAY 1

RASH – DAY 2

MEASLES: CLINICAL MANIFESTATIONS

KÖPLIK SPOTS

MEASLES AND VITAMIN A DEFICIENCY

MEASLES

unmasks an

underlying

Vitamin A

deficiency

SYNERGIC EFFECT

VITAMIN A DEFICIENCY

(even subclinical)

increases measles-

associated morbidity

and mortality

Measles-associated morbidity and mortality may be

reduced by administering Vitamin A to high risk

populations

Measles Managment

• Evaluate for associated infections

• Classify any child having a general danger

sign, clouding of the cornea, or deep or

extensive mouth ulcers as severe

complicated measles and refer urgently to

the hospital with vitamin A, the first dose of

an appropriate antibiotic, and if there is

eye discharge or corneal clouding an dose

of tetracycline eye ointment.

Measles Managment

• The presence of eye drainage and or

mouth ulcers without other signs is

classified as yellow. Treatment includes

Vitamin A, tetracycline eye ointment for

eye discharge, and gentian violet for

mouth ulcers. These children need a

follow up visit in 3 days.

• A child without complications is green and

needs only vitamin A.

ALGORITHM FOR

A SUSPECTED CASE OF MEASLES

Child with fever

and rash consistent

with measles

Report case to

Alert System

Search for other

cases and

Quarantine

Start response

and

prevention

Measles vaccine

Priority groups

Resources and logistics

Case Confirmation

• Laboratory tests

Local response

• Guarantee vaccines

• Vitamin A

• National Response

Team

Incubation

Headache

Myalgia

Rash

Bone pain

Vomiting

Abdominal Pain

Cyanosis

Shock

Hemorrhages

Hepatitis

Plasma leakage

DENGUE

CLINICAL MANIFESTATIONS

OF DENGUE

Grade Hemorrhage Platelets CapillaryPermeability

I Positive <100,000 Plasma leakage*

tourniquet test

II Spontaneous <100,000 Plasma leakage*bleeding

III (DSS) Spontaneous <100,000 Plasma leakage+

bleeding PP <20 mmHgHypotension

IV (DSS) Spontaneous <100,000 Profound shock

bleeding Absent pulse or BP

*Hct admission >20%/age or reduction Hct >20% post-resuscitation fluids

PP: pulse pressure

WHO GUIDELINES FOR THE DIAGNOSIS OF DENGUE HEMORRHAGIC FEVER (DHF)

• 80% asymptomatic infections

• Unusual manifestations

– Hepatitis

– Encephalopathy

– Pancreatitis

– Pleural effusion

DENGUE MANIFESTATIONS

IN CHILDREN

• Rest

• Acetaminophen/Paracetamol

• No aspirin or NSAIDs

• No antibiotics

• Oral rehydration (WHO solution)

50 mL/kg over 4-6 hours

Maintenance 80-100 mL/kg/day

• Monitor CNS signs

MANAGEMENT OF THE CHILD

WITH DENGUE

• Hospitalization in case of grade II HDF

Platelets <100,000

Hematocrit > 20% over normal

• Colloid solutions at 6 mL/kg/hr

MANAGEMENT OF THE CHILD

WITH HEMORRHAGIC DENGUE

Improvement Worsening

3 mL/kg/hr 10 mL/kg/hr

MALARIA

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

Plasmodium vivax

Plasmodium ovale

Plasmodium malariae

• Geographical distribution: Tropic / Subtropics

• Transmission: Anopheles mosquito

Plasmodium falciparum

MALARIA SUSCEPTIBILITY

In endemic areas, there is partial immunity in older children

and adults due to previous infection

Most susceptible individuals to severe and fatal malaria:

• Non-immune and immunocompromised people

• Infants and young children, pregnant women and malnourished

•Plasmodium falciparum-infected people

Infection

Identification of parasitemia

Asymptomatic

Disease

Presence of signs and symptoms

Acute, subacute, chronic

FEVER

37

38

39

Non-specific Pattern

39

38

37

Classical Pattern

Partially immune patients may develop moderate

fever with a non-specific pattern

Patients will feel and look sick due to fever, but they

will feel relatively well between paroxysms of fever

Associated chills, headache, myalgia

MALARIA

CLINICAL MANIFESTATIONS

Severe Malaria

• Parasitemia is >5%

• Any of the following complications:

-prostration (patient unable to sit or walk)

-multiple convulsions

-impaired consciousness not attributable

to another cause

-abnormal bleeding

-meningeal signs

-jaundice ( hemolysis)

Malaria Diagnosis

• Rapid diagnostic tests

– Bedside testing

• Thick and thin blood smears

– Difficult in a disaster situation

Malaria Management

• The clinical diagnosis of malaria based on

non specific signs and symptoms tends to

be highly inaccurate.

• When a patient presents with febrile illness

who lives in an area with malaria, in the

absence of available diagnostic testing

begin treatment when the clinical history

and presentation are consistent with

malaria.

Types of Malaria

P. falciparum – Most severe type of MALARIA (MALIGNANT)

High lethality rate in infected individuals

Highly drug-resistant

Plasmodium vivax “BENIGN” MALARIA

Plasmodium ovale Most are sensitive

Plasmodium malariae to chloroquine

• These infections cause morbidity and contribute to multifactorial mortality

Treatment of Uncomplicated Malaria: P. Falciparum or Unknown Species

Preferred Therapies (check your country policy):

Atovaquone-Proguanil (Malarone)

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

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

4 tablets BID for 4 more doses

Second-Line Therapies:

Quinine sulfate plus: Doxycycline, Tetracycline, or Clindamycin

Mefloquine

Uncomplicated Malaria: Chloroquine-

Sensitive Species/Areas

• Children: a total dose of 25 mg/kg of CHLOROQUINE

over a 3-day period

t = 0 10 mg/kg po

t = 6 h 5 mg/kg po or 10mg/kg

t = 24 h 5 mg/kg po at t = 24 h

t = 48 h 5 mg/kg po

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

• Pregnant women: Malaria is SEVERE. Chloroquine

treatment is safe

Malaria Supportive Treatment

• Fever control

– Antipyretics, no more than a few doses

– Cool compresses

• Dehydration

– Oral rehydration solution, increased need for fluids

• Malnutrition

– Assess and treat

Anticipate symptom resolution at 48-72 hours

Severe complicated malaria treatment

• First line (preferred treatment) is

Artesunate parentral (IV/IM).

• In the absence of parenteral form of Artesunate,

Artemether IM is acceptable.

• Quinine is acceptable option but requires

attention to the proper dosage and

administration with IV fluids. There is a loading

dose and maintenance dose and care needs to

be taken to prevent hypoglycemia

Thank you