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monovalent Men C conjugate vaccine, one single low as 3-4 per cent, its incidence in developing countries
intramuscular dose is recommended for children aged � 12 range between 20 to 30 per cent. This difference is due to
months, teenagers and adults. Children 2 - 1 1 months of age high prevalence of malnutrition, low birth weight and
require 2 dose administration at an interval of at least 2 indoor air pollution in developing countries ( 1 ) .
Meningococcal vaccines should be stored at 2-8°C. about 238 million attacks. Consequently, although most of
Conjugate vaccines are preferred over polysaccharide the attacks are mild and self limiting episodes, ARI is
vaccines due to their potential for herd protection and their responsible for about 30-50 per cent of visits to health
increased immunogenicity, particularly in children < 2 years facilities and for about 20-40 per cent of admissions to
of age. Both vaccines are safe when used during pregnancy hospitals (1). It is also a leading cause of disabilities
( 1 ) . WHO recommends that countries with high or medium including deafness as a sequelae of otitis media (2).
4. WHO ( 2 0 1 2 ) , International travel and Health, 2 0 1 2 . individuals of all ages are at increased risk (4). Disease rates
5. Jawetz, et al, (2007), Medical Microbiology, 24th e d . , A Lange Medical and mortality are higher in developing than industrialized
ACUTE RESPIRATORY INFECTIONS undernourished in remote areas are more likely to suffer
common human ailment. While they are a source of Likewise, haemophi/us inf/uenzae type B (Hib) bacteria is
natural course in older children and in adults without The key pneumonia indicators developed for prevention
specific treatment and without complications. However, in and treatment of pneumonia are as shown in Table 1 . It also
young infants, small children and in the elderly, or in shows the data pertaining to pneumonia from South-East
persons with impaired respiratory tract reserves, it increases Asia countries for the year 2008-2012.
the morbidity and mortality rates.
In India, in the states and districts with high infant and
Acute respiratory infections (ARI) may cause child mortality rates, ARI is one of the major causes of
inflammation of the respiratory tract anywhere from nose to death. ARI is also one of the major reasons for which
alveoli, with a wide range of combination of symptoms and children are brought to the hospitals and health facilities.
signs. ARI is often classified by clinical syndromes Hospital records from states with high infant mortality rates
depending on the site of infection and is referred to as ARI show that upto 1 3 % of inpatient deaths in paediatric wards
of upper (AURI) or lower (ALRI) respiratory tract. The upper are due to ARI. The proportion of death due to ARI in the
respiratory tract infections include common cold, pharyngitis community is much higher as many children die at home.
and otitis media. The lower respiratory tract infections The reason for high case fatality may be that children are
include epiglottitis, laryngitis, laryngotracheitis, bronchitis, either not brought to the hospitals or brought too late.
bronchiolitis and pneumonia.
In India, during the year 2 0 1 3 , about 3 1 . 7 million cases
The clinical features include running nose, cough, sore of ARI were reported. During 2 0 1 3 about 3 , 2 7 8 people died
throat, difficult breathing and ear problem. Fever is also of ARI and 2,597 died of pneumonia. Pneumonia was
common in acute respiratory infections. Most children with responsible for about 18 per cent of all 'under 5 year' deaths
these infections have only mild infection, such as cold or in India (8).
cough. However, some children may have pneumonia which
Every year ARI in young children is responsible for an Even within species they can show a wide diversity of
estimated 3 . 9 million deaths worldwide. About 90 per cent antigenic type. The agents are those most frequently
of the ARI deaths are due to pneumonia which is usually encountered in a normal population. The bacteria involved
bacterial in origin. The incidence of ARI is similar in can all be isolated with varying frequency from carriers, and
developed and developing countries. However, while the cause illness in only minority of infected persons. The
incidence of pneumonia in developed countries may be as viruses that have been found in association with acute
EPIDEMIOLOGY OF COMMUNICABLE DISEASES
TABLE 1
Key p n e u m o n i a indicators : mortality, prevention and treatment in South-East Asia countries (2008-2012)
Countries deaths under weight, 0-59 months are exclusively old immunized pneumonia taken to
India 14 43 16 46 74 69
Bangladesh 13 36 10 64 96 96 35
Bhutan 17 13 3 49 95 74
Indonesia 17 18 5 42 80 75
Myanmar 17 23 6 24 84 69
Maldives 8 17 3 48 98 22
Nepal· 13 29 8 70 86 90 50
Sri Lanka 6 21 4 76 99 99 58
Thailand 8 7 1 15 98 84
[ World 15 15 9 38 84 45 59
Source : (6, 7)
respiratory disease are numerous. They are the, primary case of lower respiratory tract infections. The agents
cause of the great majority of respiratory illnesses. However, considered to be capable of acute respiratory diseases, the
the severity of the illness is often determined by whether or age group most frequently affected, and the characteristic
not secondary bacterial infection occurs, particularly in the clinical features are as shown in Table 2.
TABLE 2
The agents causing ARI, age group affected and clinical features
Agent Age group (s) most frequently affected Characteristic clinical features
Bacteria
severe toxaemia
of chronic bronchitis
Virus
- epidemic types (3,4, 7 ) Older children and young adults Febrile pharyngitis and influenza-like illness
2
J Young children
J Croup J mild upper respiratory
Respiratory syncytial virus Infants and young children Severe bronchiolitis and pneumonia
Other agents
Chlamydia type B (Psittacosis) Adults exposed to infected birds Influenza-like illness and atypical pneumonia
Coxiel/a burnetti (Q fever) Adults exposed to sheep and cattle Atypical pneumonia
Mycoplasma pneumoniae School children and young adults Febrile bronchitis and atypical pneumonia
S o u r c e : (9)
ACUTE RESPIRATORY INFECTIONS
Small children can succumb to the disease within a matter History taking and clinical assessment is very important
of days. Case fatality rates are higher in young infants and in the management of the acute respiratory infections. Note
malnourished children. Age-specific mortality rates show the age of the child, for how long the 'child is coughing,
wide differences between countries. In general, rates tend to whether the child is able to drink (if the child is aged
be high in infants and young children, and in the elderly in all 2 months upto 5 years), has the young infant stopped
countries, although the age group with the highest rates can feeding well (child less than 2 months), has there been any
differ. In developing countries where malnutrition and low antecedent illness such as measles, does the child have
birth weight is often a major problem, the rates in children fever, is the child excessively drowsy or difficult to wake (if
tend to be the highest. By contrast, in developed countries yes, for how l o n g ) , did the child have convulsions, is there
respiratory infections are only exceptionally fatal in infants irregular breathing, short periods of not breathing or the
but are commonly terminal in the elderly. child turning blue, any history of treatment during the
illness.
Upper respiratory tract infections, e . g . , common cold and
infancy to a peak at the age of 5 years. Illness rates are Look and listen for the following :
Many risk factors for respiratory tract infections have Fast breathing is present when the respiratory rate is :
been identified. They include not only the climatic
60 breaths per minute or more in a child less than
conditions but also the housing, level of industrialization and
2 months of age
socio-economic development. In developing countries,
50 breaths per minute or more in a child aged
overcrowded dwellings, poor nutrition, low birth weight and
2 months upto 12 months
intense indoor smoke pollution underline the high rates.
40 breaths per minute or more in a child aged
Local mortality rates are particularly affected by the extent
12 months upto 5 years.
of influenza epidemics. Studies in developed countries have
shown that higher rate of infection is common in younger However, repeat the count for a young infant (age less
sibling of school going children who introduce infection into than 2 months) if the count is 60 breaths per minute or
the household. Maternal cigarette smoking has also been more. This is important because the breathing rate of young
linked to increased occurrence of respiratory tract infections infant is often erratic. Occasionally young infants stop
during the first year of life. Children from· low socio breathing for a few seconds, and then breath very rapidly for
Improving the primary medical care services and soft whistling noise or shows signs that breathing OUT is
developing better methods for early detection, treatment difficult, wheezing is caused by narrowing of the air passage
and where possible, prevention of acute respiratory in the lungs. The breathing-out phase takes longer than
infections is the best strategy to control ARI. Effective normal and requires effort.
reduction of mortality due to pneumonia is possible if If the child is wheezing, ask the mother if her child has
children suffering from pneumonia are treated correctly. had a previous episode of wheezing within the past year. If
Education of mother is also crucial since compliance with so, the child should be classified as having recurrent wheeze.
treatment and seeking care promptly when signs of
(5) See if the child is abnormally sleepy or difficult to
pneumonia are observed, are among the key factors which
wake. An abnormally sleepy child is drowsy most of the time
determine the outcome of the disease. The
when he or she should be awake and alert.
recommendations by WHO for the management of acute
(6) Feel for fever or low body temperature.
respiratory infections in children and the practical guidelines
for out-patient care are discussed below (10). The same ( 7 ) CHECK FOR SEVERE MALNUTRITION: Malnutrition
guidelines are followed in India ( 1 1 ) . when present is a high risk factor and case fatality rates are
EPIDEMIOLOGY OF COMMUNICABLE DISEASES
(8) Cyanosis is a sign of hypoxia. Cyanosis must be chest indrawing may be the only sign in a child with severe
III. Pneumonia (not severe) Some children with chest indrawing also have wheezing.
IV. No pneumonia : cough or cold Children who have chest indrawing and a first episode of
Each disease classification has a corresponding treatment wheezing often have severe p n e u m o n i a . However, children
plan which should be followed. The following guidelines are with chest indrawing and recurrent wheezing most often do
used to manage a child who is 2 months upto 5 years of age. not have severe pneumonia. Chest indrawing in these
I. Very severe d i s e a s e they must be assessed before deciding the line of treatment.
The danger signs and possible causes are : Management of the child classified as having severe
Not able to drink, infants. Young infants have special characteristics that must
SIGNS Convulsions
be considered when their illness is classified. They can
Source : (10 ) infants the cut-off point for fast breathing is 60 breaths per
ACUTE RESPIRATORY INFECTIONS
TABLE 4
Give an antibiotic.
TREATMENT Treat fever, if present, Treat fever, if present. Assess and treat ear
Treat wheezing, if present Treat wheezing, if present. problem or sore throat, if present.
(if referral is not feasible, Advise mother to return Assess and treat other problems.
treat with an antibiotic with child in 2 days for Advise mother to give home care.
and follow closely) reassessment, or earlier if the Treat fever, if present.
I I
TREATMENT Refer URGENTLY to hospital Change antibiotic or Refer Finish 5 days of antibiotic.
S o u r c e : (10)
minute. Any pneumonia in young infant is considered to be Some of the danger signs of very severe disease are :
Classification and management of illness in young infants unusual in children of this age, so antimalarial treatment is
not advised.
Stridor in calm child, rare in young infants. A young infant who has strider when
CLASSIFY AS SEVERE PNEUMONIA NO PNEUMONIA : sign of a serious bacterial infection. In young infants an
drop ( h y p o t h e r m i a ) .
Refer URGENTLY to Advise mother to give the
A young infant who is classified as having very severe
TREATMENT hospital. Keep young following home care :
infant warm. - Keep young infant warm. disease should be referred urgently to a hospital for
Give first dose of an - Breast-feed frequently. treatment. The management is summarized in Table 5.
antibiotic(If referral - Clear nose if it interferes
procaine penicillin and cure rates of upto 95% have been Benzyl penicillin per kg/dose
OR
recorded. Cotrimoxazole is less expensive with few side
Ampicillin 50 mg/kg/dose 6 hourly IM
effects and can be used safely by health workers at the
OR
peripheral health facilities and at home by the mothers. Chloramphenicol 25 mg/kg/dose 6 hourly IM
2-12 months Two tablets twice a day One spoon (5 ml) C. Provide symptomatic treatment for fever and wheezing, if
required·
(Wt. 6-9 kg) twice a day
should be hospitalized immediately. Treatment of pneumonia in children aged less than 2 months
FREQUENCY
SEVERE PNEUMONIA (CHEST IN-DRAWING)
ANTIBIOTIC DOSE Age Age 7 days
Children with severe pneumonia should be treated as
< 7 days to 2 months
inpatients with intramuscular injections of benzyl penicillin
(after test dose), ampicillin or chloramphenicol. The In]. Benzyl Penicillin 50,000 JU/kg/dose 12 hourly 6 hourly
reviewed after 48 hours for antibiotic therapy as detailed in Inj Ampicillin . 50 mg/kg/dose 12 hourly 8 hourly
AND
Table 7 . Antibiotic therapy must be given for a minimum of 5
In]. Gentamycin 2.5 mg/kg/dose 12 hourly 8 hourly
days and continued for at least 3 days after the child gets well.
Children with signs of very severe disease are in kept warm and dry. Breast-feeding must be promoted
imminent danger of death, and should be treated in a health strongly as the child who is not breast-fed is at a much
facility, with provision for oxygen therapy and intensive higher risk of diarrhoea.
Chloramphenicol IM is the drug of choice in all such cases. Many children with presenting symptoms of cough, cold
a total of 10 days. If condition worsens or does not improve Antibiotics are not recommended for coughs and colds
after 48 hours, switch to IM injections of cloxacillin and because majority of cases are caused by viruses and
and cause side-effects while providing no clinical benefit, vaccine containing capsular antigens of 23 serotypes against
and are wasteful expenditure. Symptomatic treatment and this infection have been available for adults and children
care at home is generally enough for such cases. The over 2 years of age. Children under 2 years of age and
mothers must be advised on how to take care of the child at immunocompromised individuals do not respond well to the
Prevention of Acute Respiratory Infections disease, chronic diseases of heart, lung, liver or kidney;
indoors will reduce the burden of mortality and morbidity A dose of 0 . 5 ml of PPV23 contains 25 micrograms of
associated with ARI. Other preventive measures include purified capsular polysaccharide from each 23 serotypes.
better MCH care. Immunization is an important measure to For primary immunization, PPV23 is administered as a
reduce cases of pneumonia which occur as a complication of single intra-muscular dose. preferably in the deltoid muscle
vaccine preventable disease, especially measles. It is obvious or as subcutaneous dose. The vaccine should not be mixed
that community support is essential to reduce the disease in the same syringe with other vaccines, for e.g. with
burden. Families with young children must be helped to influenza vaccine, but may be administered at the same time
recognize pneumonia. Health promotional activities are by separate injection in the other arm. Simultaneous
specially important in vulnerable areas ( 1 1 ) . administration does not increase adverse events or decrease
most common cause of death associated with measles b. PCV : Two conjugate vaccines are available since
worldwide. Thus, reducing the incidence of measles in young 2009 PCV and PCV • The PCV conjugate vaccine is
10 13 7
children through vaccination would also help to reduce deaths gradually being removed from the market ( 1 4 ) . Both PCV
10
from pneumonia. A safe and effective vaccine against measles and PCV are preservative free and their recommended
13
is available for past 40 years. Please refer to page 148 for storage temperature is 2-8°C. The vaccine must not be
details. frozen.
received their primary immunization series a single dose is HIV positive and preterm babies who have received their
sufficient for protection. The vaccine is not generally offered 3 primary doses of vaccine before reaching 12 months of
to children aged more than 24 months ( 1 2 ) . age may benefit from a booster dose in the second year of
No serious side-effects have been recorded, and no life. Interrupted schedules should be resumed without
contraindications are known, except for hyper-sensitivity to repeating the previous doses ( 1 4 ) .
previous dose of vaccine. All conjugate vaccine have an When primary immunization is initiated with one of these
excellent safety record, and where tested, do not interfere vaccines, it is recommended that remaining doses are
substantially with immunogenecity of other vaccines given administered with the same product. Interchangeability
simultaneously ( 1 3 ) . between PCV and PCV has yet not been documented.
10 13
a. PPV23 : For years, the polysaccharide non-conjugate countries with high under-five mortalities ( 1 4 ) .
EPIDEMIOLOGY OF COMMUNICABLE DISEASES
Organization, Geneva.
The Integrated Global Action Plan for the Prevention and
11. Govt of India ( 1 9 9 4 ) , National Child S u r v i v a l and Safe Motherhood
Control of Pneumonia and Diarrhoea (GAPPD) proposes a
Programme, Programme Interventions, MCH Division, Ministry of
cohesive approach to ending preventable pneumonia and
Health and Family Welfare, New Delhi.
diarrhoea deaths. It brings together critical services and
12. WHO (2006), Weekly Epidemiological Record, No. 47, 24th Nov.
interventions to create healthy environments, promotes 2006.
practices known to protect children from disease, and 13. WHO (2006, International Travel and Health.
ensures that every child has access to proven and 14. WHO (2012), Weekly Epidemiological Record, No. 14, 6th April,
By the end of 2025: infiltration. Adult respiratory distress syndrome has been
universal access to clean and safe energy of aerosol-generating procedures (endotracheal intubation,
technologies in health care facilities and h o m e s . bronchoscopy, nebulization treatments) in hospitals may
2. WHO (1995), The World Health Report 1995, Bridging the gaps, earlier presumed reservoir and a likely amplifying host).
Health and Family Welfare, New Delhi. The case definition is based on current understanding of
the clinical features of SARS, and available epidemiological E p i d e m i o l o g i c a l aspect
data. It may be revised as new information accumulates.
Health care workers, especially those involved in
2. One or more symptoms of lower respiratory tract illness Three separate epidemiological investigations have not
(cough, difficulty in breathing, shortness ?f breath) found any evidence of SARS transmission in schools.
pneumonia or acute respiratory distress syndrome International flights have been associated with the
Complications
Diagnostic tests required for laboratory confirmation of
As with any viral pneumonia, pulmonary
SARS .
decompensation is the most feared problem. ARDS occurs in
{a) Conventional reverse transcriptase PCR (RT-PCR) and about 1 6 % patients, and about 20-30% of patients require
real-time reverse transcriptase PCR (real-time RT-PCR) . intubation and mechanical ventilation. Sequelae of intensive
assay detecting viral RNA present i n : care include infection with nosocomial pathogens, tension
OR
Treatment
3. A new extract from the original clinical sample tested were used to treat SARS patients during the 2003 epidemic,
positive by 2 different assays or repeat RT-PCR or the treatment efficacy of these therapeutic agents
real-time RT-PCR on each occasion of testing remains inconclusive and further research is needed.
In the absence of known SARS-CoV transmission to subclinical cases probably go undiagnosed. Seasonality, as
humans, the positive predictive value of a SARS-CoV with influenza, is not established ( 5 ) .
international SARS reference and verification network As there is no vaccine against SARS, the preventive
laboratories. Every single case of SARS must be reported to measures for SARS control are appropriate detection and
1. Prompt identification of persons with SARS, their were HIV positives, and 3 . 5 per cent of the new and 2 0 . 5 per
2. Effective isolation of SARS patients in hospitals; estimated that about 1 . 5 million people died of TB, of these
3. Appropriate protection of medical staff treating these 360,000 were HIV positive and 2 1 0 , 0 0 0 MDR-TB cases.
5. Simple hygienic measures such as hand-washing after of TB, more than one-third of whom were H l v p o s i t i v e . An
touching patients, use of appropriate and well-fitted estimated 550,000 (6 per cent of total cases) children under
masks, and introduction of infection control measures; 15 years of age had TB of whom 80,000 died.
5. Stephen J. Mcphee et al, (2010), Current Medical Diagnosis and at 86 per cent among all new TB cases.
Tuberculosis is a specific infectious disease caused by occur each year in this Region, most of them in India,
M. tuberculosis. The disease primarily affects lungs and Bangladesh, Indonesia, Myanmar and Thailand. 6.2 per
causes pulmonary tuberculosis. It can also affect intestine, cent of the cases with HIV known status (39 per cent of total
meninges, bones and joints, lymph glands, skin and other SEAR cases) were HIV-positive. 89 per cent of HIV-positive
tissues of the body. The disease is usually chronic with TB cases were on co-trimoxazole preventive therapy and
varying clinical manifestations. The disease also affects 61 per cent of these cases were put on antiretroviral therapy.
animals like cattle; this is known as "bovine tuberculosis", Level of MDR-TB is still low in the Region (less than 2 . 2 per
which may sometimes be communicated to man. Pulmonary · cent), however, this translates into nearly 9 0 , 0 0 0 estimated
tuberculosis, the most important form of tuberculosis which MDR-TB cases among all the notified TB cases in 2 0 1 2 (3).
affects m a n , will be considered here. Each year, more than 2 million TB cases are registered for
Tuberculosis remains a worldwide public health problem The actual burden of paediatric TB is not known due to
despite the fact that the causative organism was discovered diagnostic difficulties. It is assumed that about 1 0 per cent of
more than 100 years ago and highly effective drugs and total TB load is found in children. Globally, about 1 million
vaccine are available making tuberculosis a preventable and cases of paediatric TB are estimated to occur every year, with
curable disease. Technologically advanced countries have more than 100,000 deaths (4). Childhood deaths from TB
achieved spectacular results in the control of tuberculosis. are usually caused by meningitis or disseminated disease ( 1 ) .
This decline started long before the advent of BCG or Though MDR-TB and XDR-TB is documented among
chemotherapy and has been attributed to changes in the paediatric age groups, there are no estimates of overall
"non-specific" determinants of the disease such as burden because of diagnostic difficulties and exclusion of
improvements in the standard of living and the quality of life children in most of the drug resistant surveys (4).
of the people coupled with the application of available In many developing countries, acquired drug resistance
technical knowledge and health resources. remains high, because national tuberculosis control
It is estimated that about one-third of the current global programmes in these countries have not been able to
population is infected asymptomatically with tuberculosis, of achieve a high cure rate over a very long period of time,
whom 5-10 per cent will develop clinical disease during even after the introduction of short-course chemotherapy.
their lifetime. Most new cases and deaths occur in Poverty, economic recession, malnutrition, overcrowding,
developing countries where infection is often acquired in indoor air pollution, tobacco, alcohol abuse and diabetes
childhood. The annual risk of tuberculosis infection in high make populations more vulnerable to tuberculosis. Increase
burden countries is estimated to be 0.5-2 per cent (1). in human migration has rapidly mixed infected with
Patients with infectious pulmonary tuberculosis disease can uninfected communities. To make global situation worse,
infect 1 0 - 1 5 persons in a year. tuberculosis has formed a lethal combination with HIV.
Tuberculosis remains a major global health problem. The DOTS remains central to the public health approach to
current global picture of TB shows continued progress but not tuberculosis control, which is now presented as Stop TB
fast enough. During the year 2013, an estimated Strategy. To be classified as DOTS, a country must have
9 million people developed TB, which is equivalent to officially accepted and adopted the strategy by 2004, and
126 cases per 100,000 population. Most of the cases must have implemented the four technical components of
occurred in Asia (56 per cent) and the African regions DOTS in at least part of the country. DOTS coverage is
(29 per cent). Of these incident cases 1 . 1 million ( 1 3 per cent) defined as the percentage of the national population living