Module 5 Skill Station: Management of Prevalent Infections in Children Following a Disaster

Transcription

1 Module 5 Skill Station: Management of Prevalent Infections in Children Following a Disaster Objectives of the module Section I- Influenza Understand the difference between antigenic drift and shift with regards to influenza viruses. Describe the rationale for influenza testing during an epidemic. Describe the rationale for treating with anti-viral therapy during and influenza epidemic. Describe surge planning for an H1N1 pandemic. Section II - Integrated management of childhood illness (IMCI) Describe the rationale for the WHO evidence-based syndromic approach to case management as described in the IMCI. Assess and classify the condition of a child to determine its severity and establish the relationship between this classification and the subsequent management. Section III- Acute respiratory infections Mention the three key clinical signs used to assess a child with cough or difficult breathing, and based on these signs classify acute respiratory clinical illness into three categories. Diagnose and develop a treatment plan (medications, supportive care and monitoring) using available resources for patients with: -Severe pneumonia -Pneumonia -Upper respiratory infection -Ear problems without pneumonia Section IV- Measles Explain why measles infection can be so devastating in displaced populations. Design a measles immunization campaign in an affected area and establish priority target populations for the provision of measles vaccine based on the availability of vaccine supplies and prior levels of measles vaccine coverage among the pediatric population. 1

2 Recognize Koplik spots and the classical measles rash; describe variations of the classical measles rash and the circumstances in which they are seen. Describe the evolution of the clinical manifestation of classic measles over time and name the three complications of measles that contribute most to mortality. Section V- Febrile illnesses: Malaria, dengue Acknowledge the public health importance of febrile illnesses such as malaria and dengue in the context of acute emergency settings. Understand the role of the clinician in malaria identification, prevention and treatment using the IMCI approach. Enumerate the factors that lead to malaria illness, and differentiate the species of malaria that cause benign (uncomplicated) and malignant (complicated) malaria. Describe which individuals are more likely to suffer morbidity and mortality from malaria infection, and the causes that determine the higher risk. Describe the features of severe/complicated malaria, and distinguish these features from those associated with typical uncomplicated malaria. Diagnose and develop a treatment plan (medications, supportive care, and monitoring) using available resources for patients with: - Severe/complicated malaria - Typical uncomplicated malaria - Severe dengue fever - Dengue fever Section VI- Other cases that require attention at the scene of the disaster Bear in mind other clinical entities, such as tuberculosis, at the scene of the disaster. Consider meningitis in emergency settings and assess clinical findings. Section VII- Immunization in disaster situations Acknowledge the importance of measles immunization in a disaster situation. Recognize the characteristics of tetanus-prone injuries and wounds. Discuss specific situations that require the use of other vaccines. Section VIII- Infections in infants 0 to 2 months of age Identify and understand the treatment for sick infants 0 to 2 months of age. 2

3 . Presentation format Clinical case discussion in classroom, slide presentation Duration 90 minutes Materials 4 Classrooms or lecture rooms with enough chairs for the audience in a semicircular arrangement. Blackboard or flip chart. Enough white sheets and pencils or pens for all participants. Scenario/clinical case(s) for the facilitator. Printed clinical scenario(s) for participants. If clinical cases are to be projected (images, data, etc.), the following equipment is required: - Slides/audiovisual material on clinical cases - Projection equipment (projector, computer, etc.) - Screen Cases Case 1 You are working in the Emergency Department (ED) during the beginning of an outbreak of H1N1 influenza. The H1N1 strain circulating at this time appears to be more severe than in the past few years. There are concerns that antigenic shift has resulted in a strain that is causing more severe pneumonia and a much higher case fatality rate, especially among children and young adults. A 5 year old boy comes to the hospital ED with his mother, who says that he has had a fever for 4 days. While he first complained about a sore throat, he now has a bad cough and often vomits with his coughing. He also complains that he hurts all over. He is sleeping poorly and doesn t have an appetite. On your physical examination you note that his temperature is 39, HR 120, RR 60 and BP 100/60. He has moderate to severe subcostal retractions. 3

4 1A. How would you classify and manage this patient according to IMCI? Response: No danger signs, a respiratory rate greater than 40 indicates pneumonia and moderate to severe subcostal retractions suggests hypoxia and severe pneumonia needing hospitalization 1B. What study if available would be a part of your initial additional assessment and subsequent management? Response: oxygen saturation 83% and place on nasal cannula oxygen to maintain an oxygen saturation of at least 92% 1C. Which additional studies would you order if available? Response: CBC and differential Basic Metabolic panel Blood culture Chest x-ray Nasal wash or tracheal aspirate for Viral RDT (such as respiratory viral DFA or PCR) Response: The results of his work up are: Hgb 10 and HCT 35%, WBC with 14,900 76% segmented neutrophils (10% bands) and low platelets of 75,000. Serum sodium 128 Blood culture pending Chest x-ray reveals extensive consolidation of his left lower lobe and infiltrate in right lower lobe. Influenza testing positive for H1 N1 1D. How would you manage this child now? Response: Admit IV antibiotics (what antibiotics) vancomycin or cefuroxime Oxygen Antiviral therapy 4

5 The patient was admitted to the Pediatric ICU. He deteriorated rapidly requiring intubation and pressor support to maintain his blood pressure. His hyponatremia related to SIADH resulted in pulmonary edema. Within 24 hours of admission to the Pediatric ICU despite treatment with vancomycin and hypertonic saline he died in respiratory failure. His initial blood culture grew MRSA. This new H1N1 strain seems to be more severe than in the past few years. There are concerns that antigenic shift has resulted in a strain that is causing more severe pneumonia and a much higher case fatality rate especially among children and young adults. 1E. Can more than one type of influenza be circulating at the same time? If so what are the main possible types of circulating influenza? Response: There may be 3 types of influenza viruses circulating: Type A an H1N1 and H3N2 and Type B 1F. What is the difference between antigenic drift and shift with regards to influenza viruses? Response: Antigenic drift: Occurs among influenza A viruses resulting in emergence of new variants of prevailing strains every year New variants result in seasonal flu each winter Some years are worse than others partly related to degree of drift Antigenic Shift: Major changes occur in the surface antigens of influenza A viruses Occurs by mutation or by re-assortment between viruses Changes are more significant than those associated with antigenic drift Changes lead to emergence of potentially pandemic strains by creating a virus that is markedly different from recently circulating strains. During the next week the ED and hospital is overwhelmed with patients seeking care. The majority are worried well or patients with relatively mild URI symptoms. The hospital laboratory is overwhelmed with specimens for influenza testing and requests that ED physicians do something to reduce the number of requested tests. 5

6 At a meeting of the ED staff physicians, it is clear that there needs to be a policy on influenza diagnostic tests. You volunteer to help write the first draft of a clinical algorithm for testing. You know that specimens for viral culture, immunofluorescent, or rapid diagnostic tests should be obtained if possible during the first 72 hours of illness, because the quantity of virus shed decreases rapidly as illness progresses beyond that point. Rapid enzyme immunoassay diagnostic tests for identification of influenza A and B antigens in respiratory tract specimens are available commercially, although their reported sensitivity (44% 97%) and specificity (76% 100%) compared with viral culture are variable and differ by test and specimen type. Additionally positive and negative predictive values of these influenza screening tests is influenced by the prevalence of circulating influenza viruses resulting in an increased likelihood of false-positive results during periods of low influenza activity. Direct fluorescent antibody (DFA) and indirect immunofluorescent antibody (IFA) staining for detection of influenza A and B antigens in nasopharyngeal or nasal specimens are available in your laboratory and can yield results in 3 to 4 hours. Reverse transcriptase-polymerase chain reaction (RT-PCR) testing of respiratory tract specimens is also available and has a high sensitivity and specificity in particular with the current 2012 H1N1 pandemic strain. 1G. In designing an algorithm for Influenza testing and treatment what are the key clinical questions that should be addressed in the algorithm? Response: Is the clinical presentation compatible with an influenza infection? How many strains of influenza are currently circulating? Will a direct clinical change result from viral testing? If not do not test..are there high risk patients regardless of their illness severity that should receive antiviral therapy? If so who are they? Will the child be hospitalized? When should low risk patients receive antiviral therapy? Should all negative rapid flu tests have a PCR back up test if available? What anti-virals should be used to treat AH1 swine and AH1 seasonal infection? 1G. Does the algorithm in the handout from TCH address all these questions adequately? 6

7 Your hospital does not have an adequate H1N1 pandemic surge plan. You have been asked to rapidly help design this plan for outpatient and inpatient settings. 1 H. What are the critical components of a comprehensive H1N1 pandemic surge plan? Response: Critical components of comprehensive plans must address the following: 1)Screening, surveillance, and tracking of exposed individuals; 2) controlled acc ess to the healthcare facility; 3) prevention strategies (isolation and cohorting, personal protective equipment use, vaccination, antiviral prophylaxis, modification of environmental controls (i.e. separate areas for ill and non ill patients), visitation policies, ill- staff protocols; 4) disease-specific admission criteria, treatment, and triage algorithms; and 5) enabling the continuity of limited clinical operations 6) plans to handle a sustained surge of patients in terms of both staffing needs and physical space/ treatment areas 7) provisions for additional triage areas as well as the potential for additional critical care needs beyond hospitals capacity 8) expanded ventilator needs and just in time training of additional respiratory therapist equivalents 1I. What are the critical components of a surge plan for the ICU? Response: Determine number of expected critical patients. Inventory critical care supplies, medications and equipment. If needs exist, work with the hospital incident command structure to address these needs. Establish a critical care expanded staffing plan for multiple days of assignments. Determine ability to expand critical care spaces into other critical care sites (NICU, CICU) as well as non-traditional sites (PACU, converting OR space or medical floor space). 1 J. Your county health department will receive an initial shipment of 10,000 vaccine doses against the new strain. Which population groups should have the highest priority to receive the vaccine? 7

8 Response: First responders (EMTs, police, firemen), health care workers, pregnant women, high risk conditions, the young and elderly. Case 2 A mother and her two 9-month-old twins (a boy and a girl) are sent by a nurse in sector 2. The mother says both have had cough and nasal congestion for several days, but one of them now has fever, refuses to eat but drinks tea, has had difficulty breathing and coughs frequently. You examine the children and notice that the boy seems well fed and hydrated and in a general good condition, except for a nasal congestion. Both his tympanic membranes (TM) are opacified, erythematous and immobile. The rest of the physical examination is normal. The girl is much smaller. Her weight/height is 78% and mid upper arm circumference (MUAC) is 13 cm. Her axillary temperature is 39.4 ºC and her RR 55, both TM are opacified and immobile, she has a greenish thick nasal discharge and has no oral injuries. She has moderate difficulty breathing, with serious subcostal retractions. Her mucous membranes are pink and not cyanotic. She has diminished air entry on the right lung base, with some wheezing and crackles in the same place. The skin examination is unremarkable. 1) What is the diagnosis for the boy? No complications (afebrile) or, at the most, upper airway infection and otitis media. 2) Which is the diagnosis for the girl? Malnourishment Acute lower airway infection 3) How would you treat these patients? Boy: amoxicillin or penicillin (IM) Girl: - Antibiotics: Ceftriaxone (IM) or Penicillin (IM) or Amoxicillin (PO). Be more cautious when treating infections if there is malnourishment: deterioration can be quicker. - Give oxygen if available. - Refer to a hospital. 8

9 - Nutrition: enroll in complementary feeding program. - Fluid maintenance with ORS to prevent dehydration. Case 3 In the last 5 days of October there have been heavy rains in a region affected by the eruption of a volcano. Floods and mud slides are reported in several villages and communities close to the town. As a consequence, around 2,300 people have been evacuated and are now living in shelters. In the morning, an 8-year-old boy is brought to the medical care center. The child has had fever, rhinorrhea, cough and joint pain for 3-4 days. The mother thought it was a common cold and gave him antipyretic drugs. The boy improved, but the fever restarted yesterday, and now there is a maculopapular rash on his trunk and abdomen. He also complains of bloody stool. At the physical examination, he looks weak, a little dehydrated, with petechiae in arms and legs. 1) Which is the likely diagnosis? Dengue fever 2) A positive tourniquet test confirms your suspicion. How would you manage him at this moment? Clinical control and support therapy. Maintain good hydration with oral rehydration salts (ORS). If possible, platelet count and hematocrit control. 3) Which are the possible complications? The most serious complication is the dengue shock syndrome. It presents as severe hemodynamic compromise, with or without lung involvement. Metabolic disorders can occur: hypoglycemia, metabolic acidosis and hepatic or renal failure. Mortality rates vary from 1% to 5%, although higher rates have been reported. 4) How are the severe forms of this disease treated? Volume expansion to control shock (normal saline or Ringer lactate). Parenteral hydration, avoiding fluid overload. Glycemia control. Hemoglobin and hematocrit control. Whole blood transfusion or packed red blood cells. 9

10 Antipyretic drugs as needed. 5) Are corticosteroids useful for this disease? Corticosteroids do not affect the progression of the disease; thus, they are not indicated. 10

11 Case 4 The nurse from sector 14 sends you a 5-year-old child. He tells you on the radio that, as reported by his mother, the child has had fever for 2-3 days (tactile), does not eat and is irritable. The mother comes to your tent with the patient and 3 other siblings: 1 infant of 4 months of age, a 4-year-old girl and a 6-year-old boy. At the examination you notice he seems ill and irritable, but can be consoled by his mother. Axillary temperature is 39ºC and RR is 35. His mucous membranes are wet; in fact, he has profuse watery nasal secretions. You note lesions on the buccal mucosa. The conjunctiva is injected, but there are no eye secretions. Both tympanic membranes are quite reddened, bulging, and immobile. He has metallic cough with disseminated dry rales but without spasmodic cough or crackles and air entry is symmetrical on both hemi thorax. He has an erythematous rash on his face and neck, which blanches on pressure. 1) Which is the likely diagnosis? Measles 2) What are the lesions seen in the patient s mouth called? Köplik spots 3) How long do they last? They are transient; they last a few days. 4) If no oral lesions are seen, what else can be included in the differential diagnosis of this patient? Viral syndrome/otitis media Rubella Scarlet fever Staphylococcal toxin disease Mononucleosis by Epstein-Barr virus 5) When no oral lesions can be found, is the presumptive diagnosis ruled out? No, it can be measles even if no Köplik spots are found. 6) Describe how the rash may evolve. 11

12 It starts on the forehead and spreads, in a cephalocaudal manner, on the trunk and towards the limbs in 3-5 days. It disappears over time in the same pattern. After disappearing, there may be fine desquamation. 7) How would you treat this patient? A. With vitamin A - Dose: 200,000 IU (VO), particularly if the child is malnourished. B. Nutrition assessment - Weight/height 95%, MUAC 14 cm. - Ophthalmologic examination: unremarkable. C. Treat complications - Oral antibiotic: amoxicillin for 5 days. D. Public Health - Notify Public Health authorities! 8) Is it necessary to isolate the child? No, it is not necessary. 9) Which of the siblings is at the highest risk of catching the disease? The 4 year-old girl. The 6-year-old boy is probably immune already, and even if he is not, statistically the risk is lower because he is older than 5. The infant is likely to be protected by his mother s antibodies. From now on, make the questions consecutively. Your camp has priority to receive the measles vaccine due to the abovementioned case. At least hours will elapse before the supplies to keep the cold chain, the vaccines and other items arrive. 10) What should you do while you wait for the vaccines? Obtain information about the number of children at risk among those younger than 5 years old. Ask nurses in your sector to identify all the families with children in the target age range (6 months-5 years). Divide them in age groups (6-12/12-23/24-59 months), measure the MUAC and examine the eyes of those that seem malnourished or ill. 12

13 Count them and register them somehow, in order to give vitamin A to the main target group (from 6 months to 5 years old) >Will you do it now or at the time of immunization? Dose: 6 months-12 months 100,000 IU by mouth >12 months 200,000 IU bymouth Program how to organize vaccine distribution Will you distribute them in the central treatment tent or within each sector? How many refrigerators will there be? What are the requirements for vaccine storage? Who will be removed from other tasks? Your list indicates the following: 456 children of 6-12 months (~180 with ill or weak appearance) 523 children >12-23 months (~155 with ill or weak appearance) 1010 children months (~50 with ill or weak appearance) You receive a call on the radio from the headquarters of the Joint Emergency Command. They inform you that vaccines will arrive first time tomorrow, provided the climate allows for the arrival of the plane. You are told that at this time there are only 1500 doses of the vaccine for your camp. 11) How will you assign priorities to administer the vaccines in your camp? All infants from 6 to 12 months old. All children from 12 to 23 months old. The 50 ill children from 24 to 59 months old = (subtotal) 929 doses. Possible options for the remaining 471 doses: Immunize all children younger than 5 years old in the sector where the first case appeared, close to the tent with the initial case or: Immunize all children from 24 to 36 months old, then those from 36 to 48 months... until the stock of vaccines is depleted There is no ideal answer, but students should weigh pros and cons of the different plans, in order to use all vaccines in the best possible way. 13

14 12) How will you identify those that have been immunized if, at a later date, they receive more vaccines? Giving each family/child an immunization card (the WHO team has guidelines for immunization cards). Writing an X with a pen on the back of immunized children and telling them not to wash. Always ask natives of reference or interpreters what is the culturally most appropriate behavior. Case 5 The nurse in sector 8 calls you again to tell you there is a very sick child he is going to take to your treatment tent. He says the boy has had a seizure that lasted around 5 minutes. When he arrives, the 4-year-old boy only responds to deeply painful stimulation, but breathes spontaneously with a RR of 30 breaths/minute, and a HR 130 beats/minute. Axillary temperature is 40.5 ºC. When interviewing the mother, you find out the boy has had fever for several days; however, they had arrived at the camping site the day before. The child has refused to eat or drink since yesterday, and has been sleepy all the morning and difficult to arouse. The nurse was attempting to register new arrivals at the camp, when he saw this boy with seizures on the floor in front of the tent. The mother says this is the first time her son has had a seizure. On physical examination, you notice he is more active, but moans in an incoherent way and is disoriented when he opens his eyes briefly. His mucous membranes are very dry and pale. His eyes, ears, nose and throat seem normal. He has no neck stiffness; he does not cooperate with the examination and pushes you. The thoracic exam is unremarkable. His limbs have reduced skin turgidity, pale nail beds and multiple insect bites. 1) Which is the differential diagnosis for the main disease? Severe malaria (complicated). Sepsis/meningitis. Typhoid fever. Febrile seizure complicating another febrile disease. Shigella with seizure. 2) Which other medical conditions are there? 14

15 Possible hypoglycemia. Moderate to serious dehydration (5-10 %). 15

16 3) Which are the most compelling problems? What would be your first step? A. The most compelling problems are hemodynamic stability and possible hypoglycemia. Fluid therapy and maintenance with additional glucose (consider glucose bolus). Normal saline or Ringer lactate (IV) followed by dextrose (5%, 1/2-1/3). ORS (by NG tube or VO) would be an alternative. NG tube: nasogastric tube. B. Urgent empiric therapy for malaria and bacterial pathogens within 1 hour. Quinine PO/NG tube. If not tolerated within 45 minutes, give a loading dose IM or IV 20 mg/kg, and then 10 mg/kg every 8-12 hours > PO not tolerated, and thus administer IM. Ceftriaxone (IV or IM) and vancomicin IV (if available). 4) You could give him the first doses of medication and rehydration is imminent. Is there anything else you should or could do? Transport the patient. You report the case by long-range radio to determine if established treatment centers can care for the patient. You are told that the hospital that can be reached by air is not in full service yet. The last time you asked, the hospital in the closest city was not accepting refugees, but they will check again and call you. It will get dark in an hour and you can not stay in the camping site. 5) What arrangement will you do for the patient? Repeat the quinine and antibiotic doses in the morning. Infuse IV fluids (if you have not done it yet). Give ORS and more glucose to the mother so that she can give it to him with a spoon in the mouth during the night. In the morning, the boy is still feverish, but rests peacefully. The mother says he said a few words, but is still difficult to stimulate. He has been urinating and had no more seizures. 16

17 6) How would you give him his medication this morning? Check if he can swallow it > no, he rejects liquids. Quinine NG tube/im, 10 mg/kg. Ceftriaxone IM. Fluids with glucose NG tube/iv. 7) By the end of the day the boy is taking his liquids by mouth, although he is still apathic and confused. Would you try to give him an oral dose of quinine before leaving the camp tonight? You can try to give him both quinine and cloranphenicol orally for at least 30 minutes before leaving, so that he can receive an IM dose if he vomits the oral dose. If he tolerates the oral dose, give him SP and another dose of ceftriaxone (IM). Provide more ORS and glucose for the mother. 8) You come back the following morning and the patient still is apathic but awake, and can answer questions. How do you complete the treatment? The patient must complete a total 7 days dose of quinine and a dose of sulphadoxine pirimetamine. Consider ceftriaxone for 10 days. 17

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