MODULE V. Management of Prevalent Infections in Children Following a Disaster

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1 MODULE V Management of Prevalent Infections in Children Following a Disaster

2 MAIN CAUSES OF DEATH Acute respiratory infections Diarrhea and dehydration Measles Malaria Malnutrition

3 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

4 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.

5 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

6 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.

7 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

8 Local bacterial infection (YELLOW) Signs of umbilical infection (redness and or purulent discharge) or skin pustules Treat with an appropriate antibiotic.

9 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.

10 IMCI STRATEGY DANGER SIGNS Unable to drink or breast feed (too weak) Vomits everything Had convulsions Lethargic or unconscious Convulsing now

11 IMCI: COUGH OR DIFFICULT BREATHING 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

12 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

13 INFLUENZA VIRUS Family Orthomyxoviridae myxo mucus segmented, single-stranded RNA Influenza A first isolated 1933; Influenza B hemagglutinin (HA) and 9 neuraminidase (NA) subtypes Only H1N1, H2N2, H3N2 subtypes associated with widespread epidemics in humans

14 CLINICALLY RELEVANT INFLUENZA VIRUSES Type A Type B Type C Potentially severe illness Epidemics and pandemics Rapidly changing Birds, swine, horses, seals, humans Usually less severe illness Epidemics More uniform Humans Usually mild or asymptomatic illness Minimal public health impact Humans, swine

15 INFLUENZA: A CONTINUOUSLY CHANGING VIRUS Hemagglutinin (HA) *cell entry Neuraminidase (NA) *cell escape M1, M2 Nucleoprotein (NP) Polymerase Proteins (PP) Adapted from: Hayden FG et al. Clin Virol. 1997:

16 ANTIGENIC DRIFT (A & B) RNA Hemagglutinin Neuraminidase Antibodies Sialic acid

17 ANTIGENIC SHIFT (A ONLY)

18 TRANSMISSION OF INFLUENZA Person to person Droplet spread small particle aerosols Fomite contamination Steel and plastic 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

19 RECOGNIZING PEDIATRIC INFLUENZA Neonates Infants/Toddlers Children/Teens High fever GI symptoms Rapid onset Lethargy Fever >103 F (>39.5 C) High fever Decreased eating Anorexia Cough Mottling Respiratory syndromes Chills Apnea Malaise Headache Sore throat

20 INFLUENZA VIRUS INFECTION COMPLICATIONS Common Complications Acute otitis media (children) Sinusitis Pneumonia Exacerbation of underlying illness Dehydration (infants) Uncommon Complications Encephalopathy Reye syndrome (children) Myositis Myocarditis Febrile seizures

21 MEASLES Highly contagious infection (98-100% in susceptible contacts) Transmission through respiratory secretions (contact and aerosolized particles) Incubation period: days Mortality rate Nutrition / crowding / inoculum Overcrowded living conditions are an important triggering factor for epidemics

22 NATURAL HISTORY OF MEASLES Identification of one case in a camp should speed up immunization process Incubation days Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Exposure Fever FEVER ] Cough Conjunctivitis Coryza Köplik spots---] Rash

23 RASH DAY 1

24 RASH DAY 2

25 MEASLES: CLINICAL MANIFESTATIONS KÖPLIK SPOTS

26 MEASLES AND VITAMIN A DEFICIENCY SYNERGIC EFFECT MEASLES unmasks an underlying Vitamin A deficiency VITAMIN A DEFICIENCY (even subclinical) increases measlesassociated morbidity and mortality Measles-associated morbidity and mortality may be reduced by administering Vitamin A to high risk populations

27 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.

28 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.

29 ALGORITHM FOR A SUSPECTED CASE OF MEASLES Child with fever and rash consistent with measles Start response and prevention Report case to Alert System Search for other cases and Quarantine Case Confirmation Laboratory tests Local response Guarantee vaccines Vitamin A National Response Team Measles vaccine Priority groups Resources and logistics

30 DENGUE Incubation Headache Myalgia Rash Bone pain Vomiting Abdominal Pain Cyanosis Shock Hemorrhages Hepatitis Plasma leakage

32 CLINICAL MANIFESTATIONS OF DENGUE

33 WHO GUIDELINES FOR THE DIAGNOSIS OF DENGUE HEMORRHAGIC FEVER (DHF) Grade Hemorrhage Platelets Capillary Permeability 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 mmhg Hypotension 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

34 DENGUE MANIFESTATIONS IN CHILDREN 80% asymptomatic infections Unusual manifestations Hepatitis Encephalopathy Pancreatitis Pleural effusion

35 MANAGEMENT OF THE CHILD WITH DENGUE Rest Acetaminophen/Paracetamol No aspirin or NSAIDs No antibiotics Oral rehydration (WHO solution) 50 ml/kg over 4-6 hours Maintenance ml/kg/day Monitor CNS signs

36 MANAGEMENT OF THE CHILD WITH HEMORRHAGIC DENGUE Hospitalization in case of grade II HDF Platelets <100,000 Hematocrit > 20% over normal Colloid solutions at 6 ml/kg/hr Improvement Worsening 3 ml/kg/hr 10 ml/kg/hr

37 MALARIA Caused by a protozoal blood parasite capable of causing a wide spectrum of diseases Plasmodium vivax Plasmodium ovale Plasmodium malariae Plasmodium falciparum Geographical distribution: Tropic / Subtropics Transmission: Anopheles mosquito

38 MALARIA SUSCEPTIBILITY In endemic areas, there is partial immunity in older children and adults due to previous infection Infection Identification of parasitemia Asymptomatic Disease Presence of signs and symptoms Acute, subacute, chronic 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

39 MALARIA CLINICAL MANIFESTATIONS FEVER Non-specific Pattern 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

40 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)

41 Malaria Diagnosis Rapid diagnostic tests Bedside testing Thick and thin blood smears Difficult in a disaster situation

42 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.

43 Types of Malaria P. falciparum Most severe type of MALARIA (MALIGNANT) High lethality rate in infected individuals Highly drug-resistant Plasmodium vivax Plasmodium ovale Plasmodium malariae BENIGN MALARIA Most are sensitive to chloroquine These infections cause morbidity and contribute to multifactorial mortality

44 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

45 GJ1 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

46 Slide 45 GJ1 May want to de-emphasize this slide and the next ones on chloroquine sensitive malaria, given the limited geographical ares areas where it is still relevent Gaensbauer, James, 9/22/2014

47 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 hours

48 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

49 Thank you

MODULE V. Management of Prevalent Infections in Children Following a Disaster

MODULE V. Management of Prevalent Infections in Children Following a Disaster MODULE V Management of Prevalent Infections in Children Following a Disaster MODULE V Management of Common Childhood Illness Following a Disaster Infections FACTORS IMPACTING INFECTIONS IN DISASTER SITUATIONS