ACUTE RESPIRATORY INFECTIONS

Dr. Surya Rao

Assistant Professor
Department of Community Medicine
AMC
 Learning Objectives
• Introduction

• Epidemiological determinants

• Mode of Transmission

• Clinical Assessment

• Classification of Illness

• Treatment

• Prevention of Acute respiratory infections

 INTRODUCTION

It causes inflammation of the respiratory tract anywhere from nose to alveoli with
combination of signs and symptoms.

It is classified depending upon the site:

Acute Upper Respiratory Infections (AURI)

Acute Lower Respiratory Infections (ALRI)

AURI includes:
common cold,
pharyngitis and otitis media

ALRI includes namaste

epiglottitis,
laryngitis,
laryngotracheitis,
bronchitis,
bronchiolitis and
pneumonia.
 Epidemiological Determinants
AGENT FACTORS:

The microbial agents that cause ARI are numerous and include bacteria and viruses.

Even within species they show wide diversity of antigenic type.

Severity of illness is determined by whether secondary bacterial infection occurs or not.

 Host factors:

• Case fatality rates are higher in young infants and malnourished children.

• In developing countries like India, malnutrition and low birth weight is often a major
problem, the rates are highest in those children.

• The rates of pharyngitis and otitis media increase from infancy to peak at the age of 5 years.
 Risk factors:
• Climatic conditions
• Housing
• Level of industrialization
• Socio economic development
• Overcrowded dwellings
• Poor nutrition
• Low birth weight
• Intense indoor smoke pollution

Mode of transmission:
• Air borne route
• Chain of transmission is maintained by direct person- person contact
 Clinical assessment:

History to be elicited:
Age of the child
Since how long the child is coughing
Young infant stopped feeding well (less than 2 months)
The child is able to drink (2 months to 5 years)
H/O fever
Child is excessively drowsy/difficult to wake
Irregular breathing
Convulsions
The child turning blue
 Physical examination:

Count the breaths in one minute.

Fast breathing depend upon the age of the child.

It should be seen for 1 full minute looking at the abdominal movement or lower chest when
the child is calm.
 Fast Breathing:
Age: Less than 2months
Fast breathing: 60 breaths /more

Age:2months to 1 year
Fast breathing: 50 breaths/more

Age:1 to 5 years
Fast breathing: 40 breaths/more
 Look for chest indrawing:

The child has chest indrawing if the lower chest wall goes in when the child breathes in.
It occurs when the effort required to breathe in is much greater than normal.
 Look and listen for stridor:

Stridor makes a harsh noise when the child breaths IN.

It occurs when there is narrowing of the larynx, trachea or epiglottis which interferes with
air entering the lungs.

This condition is called croup.

 Look for wheeze:
Wheezing is soft whistling noise when the child breathes OUT.

It is caused by narrowing of air passage in lung.

Breathing out phase takes longer than normal and effort.

Elicit H/O previous history of wheezing.

If so, the child is classified as having recurrent wheeze.

 Other Signs:

See if the child is abnormally sleepy or difficult to wake.

Feel for fever or lower body temperature.

Cyanosis is a sign of hypoxia, must be checked in good light.

 Check for severe malnutrition

• High risk factor.

• Case fatality rates are higher in these children.

• In a severely malnourished children with pneumonia, fast breathing and chest indrawing
may not be as evident.

• Impaired/absent response to hypoxia and a weak/absent cough reflex.

• These children need careful evaluation and management for pneumonia

 Classification of illness
Child aged 2 months – 5 years:
• Very severe disease
• Severe pneumonia
• Pneumonia
• No pneumonia

Infants less than 2 months:

• Very severe pneumonia
• Severe pneumonia
• No pneumonia.
 Child aged 2 months to 5 years Very severe disease:

Signs: not able to drink, convulsions, abnormally sleepy or difficult to wake, Stridor in
calm child and Severe malnutrition

Treatment:
• Refer urgently to hospital
• Give first dose of antibiotic
• Treat fever, if present
• Treat wheezing ,if present
• If cerebral malaria is present, give an antimalarial
Severe pneumonia
Signs : chest indrawing, recurrent wheezing

Treatment:
• Refer urgently to hospital

• Give first dose of antibiotic

• Treat fever, wheezing if present

• If referral is not feasible treat with an antibiotic and follow closely

 Pneumonia

Signs : fast breathing and no chest indrawing

Treatment:

• Advice mother to give home care

• Give an antibiotic •

Treat wheezing / fever if present •

Advice mother to return with child after 2 days for reassessment/ earlier if the
child is getting worst
 Infants less than 2 years
Very severe pneumonia:

Signs : stopped feeding well, convulsions, abnormally sleepy, stridor, wheezing, fever or
hypothermia

Treatment :
• Refer URGENTLY to hospital
• Keep young infant warm
• Give first dose of an antibiotic
 No pneumonia: cough or cold

Signs : no chest indrawing and no fast breathing

Treatment :
• Advice mother to give the following home care – keep young infant warm, breast
feed frequently, clear nose if it interferes with feeding

• Return if any danger signs- breathing becomes difficult/fast, not feeding, and
infant becomes sicker
 Management of AURI:

DO NOT require treatment with antibiotics.

Causative agents are viruses.

Increase resistant strains and cause side effects.

Symptomatic treatment and care at home.

 Prevention of ARI:

ARI control programme is the part of RCH programme.

Improved living conditions.

Better nutrition.

Reduction of smoke pollution indoors.

Better Maternal Child Health care.

Immunization.
 Also know as ‘’SEASONAL FLU’’
Influenza is an ‘acute Respiratory tract infection’ caused by influenza virus characterized by
sudden onset of chills, malaise, fever, muscular pain and cough.

Can occur as:

Sporadic case / seasonal case.

Epidemic case.

Pandemic case.
 CASUATIVE AGENT

‘’INFLUENZA VIRUS’’ 3 types –

Type A
Type B

Type C

Pandemic were caused by ‘’TYPE A”

 PROBLEM STATEMENT

Its an international disease.

Occur in all countries and affect millions of people.

May occur pandemic every 10-40 years due to major antigenic changes as occurred in
- 1918 … SPANISH INFLUENZA

-1957… ASIAN INFLUENZA

-1968….. HONG KONG INFLUENZA

 AT PRESENT

• A(H1NI)

• A(H3N2)

• INFLUENZA B

WHO identify human infection with a new strain A(H5NI) In HONG KONG in mid 1997.
 EPIDEMIOLOGICAL DETERMINANTS

AGENT FACTOR:
• Influenza virus are classified under ‘’ORTOMYXOVIRS’’ .
• Out of A,B and C types A and B are responsible for epidemics throughout the world.
• Influenza A virus have 2 distinct surface antigen - Heamagglutinin (H)…. Attachment of
virus to susceptible cell - Neuraminidase (N)….. Release of virus from infected cell.
• No antigenic shifts of type B virus.

What is antigenic shift and drift:

• Antigenic shift results from genetic recombination of human and animal or avian virus.
• Antigenic Drift involve point mutation in the gene.
• Type B show lessor degree changes and Type C is antigenically stable.
 RESERVOIR OF INFECTION:
• Major reservoir of influenza are animals and birds.
• Virus isolate from many animals and birds like swine, horses , dogs, domestic poultry, and
wild birds etc. New stains form due to recombination between man, animals and birds.

SOURCE OF INFECTION:
• Cases or subclinical cases.
• During epidemic asymptomatic infection occur, play important role in spread of infection.
• Respiratory tract secretions are also infective.

Period of infectivity:
• Virus is present in nasopharynx from 1-2 DAY BEFORE AND 1-2 DAY After onset of
symptoms.
 HOST FACTOR:

AGE and SEX:

• All age groups and both sexes are affected.
• Attack rate is lower among adults.
• Children constitute an important link in transmission chain.

Mortality rate:
• Highest mortality rate during epidemic among - Old People (generally over 85).

- Children under 18 months.

- Or person with systemic diseases such as: - chronic heart disease CHD - respiratory diseases
- renal disease - also seen among diabetics person.
 IMMUNITY
Specific antibodies against HA and NA.

Resistance to initiation of infection is related to antibody against HA.

Decrease severity of disease and decrease transmission related to NA

ENVIONMENTAL FACTIOR

SEASON
- Epidemic usually occur in winter month in northern hemisphere.
- In southern hemisphere outbreaks occur in winter or rainy season.
OVERCROWDING
- Enhance transmission.
 MODE OF TRANSMISSION

• Person to person by droplet infection or droplet nuclei.

• Use of fomites.

PORTAL OF ENTERY: is respiratory tract

INCUBATION PERIOD: 18-72 hours

 PATHOGENSIS:

Virus

Superficial EPI of respiratory tract

Inflammation

Necrosis.
 CLINICAL FEATURES
• Fever

• Chills

• Generalized ache and pain

• Headache and myalgia

• Coughing

• Generalized weakness
- Fever last for 1-5 days and average 3 days in adults.
 COMPLICATIONS

• Sinusitis

• Otitis media

• Purulent bronchitis

• Pneumonia

• Ray syndrome (type B)

 PANDEMIC INFLUENZA

• H1NI 2009.

• Diff in pathogenesis from seasonal influenza in aspects.

• Little or no pre-existing immunity against virus wider impact of infection among children
and young adults.

• Virus can infect the Lower respiratory tract infection rapidly progress to pneumonia
especially in children and young to middle age group.

• Incubation period approx. 2-3 DAYS up to 7 days.

 CLINICAL FEATURES

Uncomplicated influenza Complicated influenza

• Fever • Shortness of breath and dyspnea
• Cough • Lower RTI ( pneumonia )
• Sore throat • CNS involvement
• Muscle pain • Sever dehydration
• Malaise • Secondary complications
• No dyspnea and shortness of breath • COPD asthma renal failure
• GIT symptom may also present.
 RISK FACTORS
• Infant and young children under 2 year of age
• Pregnant females
• Person of COPD or asthma
• Chronic cardiac disease
• Metabolic disorder, like diabetes
• Chronic renal failure
• Hepatic failure
• Immunocompromised patient
• Aspirin therapy
• Old age
 LAB DIAGNOSIS:

VIRUS ISOLATION - virus can be detected by indirect fluorescent antibody technique.

SERIOLOGY - Heamagglutination inhibition (HI) and ELISA

- 4 folds r greater increase in titer indicate the influenza infection
 PREVENTION

• Good ventilation of public buildings.

• Avoid overcrowding specially during epidemics.

• Cover your mouth while sneezing and coughing.

• Immunization vaccine must administrate at least 2 weeks before the onset of epidemic.

• Due to antigenic changes new vaccinations are always required

 VACCINE FOR SELECTED POPULATION

• In industries to reduce absenteeism.

• In public servants to prevent critical public services.

• Certain age groups like elders and children under 18 month to prevent from sever
complications.

• Also the people with chronic illness like systemic diseased to prevent death.
 Killed vaccine:
• Required strains of vaccine are grown in allantonic cavity of chick embryo

• Harvested purified and killed by beta- propiolactone

• Formulation: aqueous or saline

• Administration: - 0.5ml for adults and children over 3 years - 0.25ml for children from 6 to
36 month of age (3 years ).
 ROUT:

• Site of injection - Intramuscular – Subcutaneous

 LIVE ATTANUATED VACCINE

• A trivalent live attenuated vaccine administered as a single dose intranasal spray.

• For healthy individual avoid in Immunocompromised patient.

CONTRAINDICATION OF VACCINE
• People with h/o anaphylactic shock
• People with h/o sever reaction to influenza vaccine.
• Who develop Guillain-Barre syndrome.
• Children less then 6 month of age (inactivated influenza vaccine is not approved).
• People with moderate to sever fever.
 DRUG TREATMENT
• Symptomatic treatment.
• Prophylaxis - Neuraminidase inhibiters - Zanamivir and oseltamivir.
• Influenza A is treated with zanamivir or combination of oseltamivir and rimantadine.
• Influenza B is treated with oseltamivir.

Factors contribute to rapid spread

• Short incubation period
• Large number of subclinical cases
• High proportion of susceptible population
• Short duration of immunity
• Absence of cross immunity
 AVAIN INFLUENZA H5NI:

• Also called Bird Flu…Primarily infect birds.

• H5N1 strain first infect humans in Hong Kong causes 18 cases and 6 deaths.

• Poultry Outbreak in Pakistan in 2006.

• Worldwide spread of disease since 2007m

SEVERE ACUTE RESPIRATORY SYNDROME (SARS)
 Learning objectives..

• Background situations
• Problem statement
• Epidemiological concerns: IP & MOT
• Case definition
• Diagnostic confirmations
• Complications of SARS
• Treatment, Prevention & Prognostic factors of SARS.
 Introduction..

• Caused by Coronavirus

• The most common symptoms: fever, malaise, chills, headache myalgia,

dizziness, cough, sore throat and running nose.

• In some cases there is rapid deterioration with low oxygen saturation and acute
respiratory distress requiring ventilatory support.

• CFR 10%

• Chest X-ray findings typically begin with a small, unilateral patchy shadowing,
and progress over 1-2 days to become bilateral and generalized, with interstitial infiltration.
 Problem statement..

• The earliest case was traced to a health care worker in China, in late 2002, with
rapid spread to Hong Kong, Singapore, Vietnam, Taiwan and Toranto.

• As of early August 2003, about 8,422 cases were reported to the WHO from 30
countries with 916 fatalities.
 Incubation period & Mode of transmission
• IP: 2 to 7 days, commonly 3 to 5 days

• The primary mode of transmission appears to be through direct or indirect contact with
respiratory droplets or fomites.

• The use of aerosol-generating procedures (endotracheal intubation, bronchoscopy,

nebulization treatments) in hospitals may amplify the transmission of the SARS coronavirus.

• The natural reservoir appears is bat. It is the disease of Civet.

• The SARS virus can survive for hours on common surfaces outside the human body, and
up to four days in human waste.

• The virus can survive at least for 24 hours on a plastic surface at room temperature, and
 Case definition..

• Case definition for notification of SARS under the International Health Regulation
(2005) – In the period following an outbreak of SARS, a notifiable case of SARS is defined as

• an individual with laboratory confirmation of infection with SARS coronavirus

(SARSCoV) who either fulfils the clinical case definition of SARS or has worked in a laboratory
handling live SARS-CoV or storing clinical specimens infected with SARS-CoV.
 Clinical case definition of SARS..
1. A history of fever, or documented fever AND

2. One or more symptoms of lower respiratory tract illness (cough, difficulty in breathing,
shortness of breath) AND

3. Radiographic evidence of lung infiltrates consistent with pneumonia or acute

respiratory distress syndrome (ARDS) or autopsy findings consistent with the pathology of
pneumonia or ARDS without an identifiable cause AND

4. No alternative diagnosis fully explaining the illness.

 Clinical case definition of SARS..
1. A history of fever, or documented fever AND

2. One or more symptoms of lower respiratory tract illness (cough, difficulty in breathing,
shortness of breath) AND

3. Radiographic evidence of lung infiltrates consistent with pneumonia or acute respiratory

distress syndrome (ARDS) or autopsy findings consistent with the pathology of pneumonia or
ARDS without an identifiable cause AND

4. No alternative diagnosis fully explaining the illness

 Diagnostic tests required for laboratory confirmation of SARS .

(a) Conventional reverse transcriptase PCR (RT-PCR) and real- time reverse transcriptase PCR
(real-time RT-PCR) assay detecting viral RNA present in:
1. At least 2 different clinical specimens (e.g. nasopharyngeal and stool specimens)

OR

2. The same clinical specimen collected on 2 or more occasions during the course of the
illness (e.g. sequential nasopharyngeal aspirates)

OR

3. Virus culture from any clinical specimen.

(b) Enzyme-linked immunosorbent assay (ELISA) and immunofluorescent assay (IFA)

1. Negative antibody test on serum collected during the acute phase of illness, followed by
positive antibody test on convalescent-phase serum, tested simultaneously

OR

2. A 4-fold or greater rise in antibody titre against SARS-CoV between an acute-phase serum
specimen and a convalescent- phase serum specimen (paired sera), tested simultaneously.

The positive predictive value of a SARS-CoV diagnostic test is extremely low; So,
In the absence of known SARS-CoV transmission to humans, the diagnosis should be
independently verified in one or more WHO international SARS reference and verification
network laboratories. Every single case of SARS must be reported to WHO
 Epidemiological aspect
• Health care workers, especially those involved in procedures generating aerosols, accounted for
21 per cent of all cases.

• Maximum virus excretion from the respiratory tract occurs on about day 10 of illness and then
declines.

• The efficiency of transmission appears to be greatest following exposure to severely ill patients
or those experiencing rapid clinical deterioration, usually during the second week of illness.

• There was no evidence that patient transmits infection 10 days after fever has resolved.

• Children are rarely affected by SARS. To date, there have been two reported cases of
transmission from children to adults and no report of transmission from child to child.

• Furthermore, no evidence of SARS has been found in infants of mothers who were infected
 Epidemiological aspect.. Cont..

• International flights have been associated with the transmission of SARS from
symptomatic probable cases to passengers or crew.

• WHO recommends exit screening and other measures to reduce opportunities for further
international spread associated with air travel during the epidemic period.
 Complications

• As with any viral pneumonia, pulmonary decompensation is the most feared problem.

• ARDS occurs in about 16% patients, and about 20-30% of patients require intubation
and mechanical ventilation.

• Squeal of intensive care include infection with nosocomial pathogens, tension

pneumothorax from ventilation at high peak pressures, and non-cardiogenic pulmonary edema.
 Treatment

• Severe cases require intensive support.

• Although a number of different agents including ribavirin (400-600 mg/d and4 g/d),
lopinavir/ritonavir (400 mg/100 mg), interferon type 1, intravenous immunoglobulin, and
systemic corticosteroids were used to treat SARS patients during the 2003 epidemic.

• The treatment efficacy of these therapeutic agents remains inconclusive and further
research is needed.
 Prognosis

• The overall mortality rate of identified cases is about 10% to 14%.

• Mortality is age-related, ranging from less than 1 % in persons under 24 years of age to
greater than 50% in persons over 65 years of age.

• Poor prognostic factors include advanced age, chronic hepatitis B infection treated with
lamivudine, high initial or high peak lactate dehydrogenase concentration, high neutrophil count
on presentation, diabetes mellitus, acute kidney disease, and low counts of CD4 and CD8 on
presentation.
 Prevention
As there is no vaccine against SARS, the preventive measures for SARS control are appropriate
detection and protective measures which include :
1. Prompt identification of persons with SARS, their movements and contacts;

2. Effective isolation of SARS patients in hospitals;

3. Appropriate protection of medical staff treating these patients;

4. Comprehensive identification and isolation of suspected SARS cases;

5. Simple hygienic measures such as hand-washing after touching patients, use of appropriate and well-fitted
masks, and introduction of infection control measures;

6. Exit screening of international travellers;

Thank you