Management of Prevalent Infections in Children Following a Disaster

Transcription

1 5 M O D U L E 5 Management of Prevaent Infections in Chidren Foowing a Disaster Stephen Berman Ribka Amsau Nee-Kofi Moud-Miman Lisa Abuogi Christine Nyquist Juia A. Lynch Ángea Gentie

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3 Management of Prevaent Infections in Chidren Foowing a Disaster Stephen Berman, MD, FAAP Ribka Amsau, MD Nee-Kofi Moud-Miman, MD Lisa Abuogi, MD Christine Nyquist, MD Co. Juia A. Lynch, MD, FAAP Dr. Ángea Gentie, MD INTRODUCTION Morbidity and mortaity resuting from an acute humanitarian emergency in deveoping countries are reated to the excessive chidhood mortaity that existed prior to the disaster. The main causes of mortaity are neonata causes, pneumonia, diarrhea foowed by maaria, meases, injury, and meningitis. Manutrition is an underying condition that increases the risk of dying from a of the above causes. During acute humanitarian emergencies, mortaity reated to those common chidhood infections increases due to crowded iving conditions; dispacement to areas with higher disease prevaence; and compromised persona hygiene resuting from inadequate water suppies, contaminated water, and poor sanitation. The preexisting nutritiona status (particuary micronutrient and vitamin A deficiencies) and immunization rates of chidren, as we as the pre-existing primary care infrastructure and the degree of damage caused by the disaster, aso affect chidhood morbidity and mortaity after a disaster. Figure 1 summarizes the causes of death in two refugee camps and iustrates the significance of various inesses foowing a disaster. These stark statistics emphasize the importance of using strategies based on the Integrated Management of Chidhood Iness (IMCI) Program, deveoped to prevent and treat infections during an acute humanitarian emergency. 5

4 FIGURE 1. Mortaity in two refugee camps Figure 1. Cause-specific m orbidity and mortaity in chidren younger than five years of age for r efugee camps in the UNHCR HIS d atabase, January 2006 to February A. Mortaity for a recorded causes. Cases of watery and boody diarrhea were combined. B. Out-patient visits for major causes of morbidity within refugee camps. Suspected and confirmed cases of maaria were combined, as were cases of watery and boody diarrhea. Ony causes accounting for 5% or more of mortaity or morbidity are shown, with the remaining causes isted as Other.

5 SECTION I / IMCI INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI) OBJECTIVES Describe the rationae for the WHO evidence-based syndromic approach to case management as described in the IMCI. List the cinica inesses incuded in the IMCI program and their reevance in situations associated with disasters. Assess and cassify the condition of a chid to determine its severity and estabish the reationship between this cassification and the subsequent management. List the danger signs that shoud be routiney checked in a chidren. What is Integrated Management of Chidhood Iness (IMCI)? The strategy for the IMCI was designed by WHO to enhance chidren s heath and reduce mortaity and morbidity caused by the most prevaent chidhood diseases throughout the word, but especiay in countries having the highest under 5 mortaity rates. The IMCI strategy addresses most, but not a, of the major reasons why a sick chid needs medica attention. A chid with a chronic condition or a ess common iness may require additiona specia care and IMCI guideines do not CASE 1 A 15-month-od boy presents at the emergency department with a fever. He had been heathy unti 3 days ago, when he deveoped symptoms of upper respiratory airway infection. His mother reports giving ibuprofen to her son the day before, because of the fever. The chid continues to be febrie with reduced food and fuid intake, urine output, and activity eve. There is no history of vomiting, diarrhea, cough, or rash. He is not receiving any medication. You note fatigue and irritabiity when the chid is stimuated during the physica examination. Respiratory rate is 50 breaths/min, puse rate 162 beats/min, bood pressure 92/70 mm Hg, and axiary temperature 38.9ºC. He has dry ips but wet ora mucosa without esions. His neck is fexibe. Lung and heart examination are unremarkabe with no significant findings. A few isoated petechiae are noted over the abdomen and ower imbs. Periphera puse is norma and capiary refi time is 3 seconds. What is your goba cinica impression for this boy? What is the most probabe diagnosis? What treatment strategies you shoud adopt initiay?

6 6 SECTION I / IMCI describe the management of trauma or other acute emergencies due to accidents or injuries. This IMCI strategy seeks to integrate the acute care for chidren under 5 years of age across the continuum of cinica services; from community heath worker encounters through first eve referra heath care faciities (camps, medica offices, heath care centers and hospita primary care departments) and then in hospitas. The cinica decision making approach invoves using a imited number of symptoms and signs to cassify the seve- rity of iness, which determines the chid s treatment/management. See Figure 2. IMCI management aso incudes guideines for foow-up, counseing the parents, and instructions regarding when to return when additiona care is needed. The IMCI approach focuses training and materias on the need to improve parenta skis and practices reated to care seeking behaviors, the vaue of preventive services such as immunization and nutrition, and home care of chidren. The basic principes of IMCI are presented in Box 1. BOX 1. Principes of the Integrated Cinica Case Management IMCI cinica guideines are based on the foowing principes: 1. Examining a sick chidren aged up to five years of age for genera danger signs and a young infants for signs of very severe disease. These signs indicate severe iness and the need for immediate referra or admission to hospita. 2. The chidren and infants are then assessed for main symptoms: In oder chidren the main symptoms incude: Cough or difficuty breathing, Diarrhoea. Fever, and Ear infection. In young infants, the main symptoms incude: Loca bacteria infection, Diarrhoea, and Jaundice, 3. Then in addition, a sick chidren are routiney checked for: Nutritiona and immunization status, HIV status in high HIV settings, and Other potentia probems. 4. Ony a imited number of cinica signs are used, seected on the basis of their sensitivity and specificity to detect disease through cassification. A combination of individua signs eads to a chid s cassification within one or more symptom groups rather than a diagnosis. The cassification of iness is based on a coourcoded triage system: PINK indicates urgent hospita referra or admission, YELLOW indicates initiation of specific outpatient treatment. GREEN indicates supportive home care. 5. IMCI management procedures use a imited number of essentia drugs and encourage active participation of caregivers in the treatment of their chidren. 6. An essentia component of IMCI is the counseing of caregivers regarding home care: Appropriate feeding and fuids, When to return to the cinic immediatey, and When to return for foow-up

7 SECTION I / IMCI 7 FIGURE 2. Summary of the process of integrated care of chidren For a sick chidren age 1 week up to 5 years who are brought to a first-eve heath faciity ASSESS the chid: Check for danger signs (or possibe bacteria infection). Ask about main symptoms. If a main symptom is reported, assess further. Check nutrition and immunization status. Check for other probems. CLASSIFY the chid s inesses: Use a coor-coded triage system to cassify the chid s main symptoms, and his or her nutrition or feeding status. IF URGENT REFERRAL is needed and possibe IF NO URGENT REFERRAL is needed or possibe IDENTIFY URGENT PRE-REFERRAL TREATMENT(S) needed for the chid s cassifications IDENTIFY TREATMENT needed for the chid s cassifications: Identify specific medica treatments and/or advise TREAT THE CHILD: Give urgent pre-referra treatment(s) needed TREAT THE CHILD: Give the first dose of ora drugs in the cinic and/or advise the chid s caregiver. Teach the caretaker how to give ora drugs and how to treat oca infections at home. If needed, give immunizations. REFER THE CHILD: - Expain to the chid s caretaker the need for referra. - Cam the caregiver s fears and hep sove any probems. - Write a referra note addressed to the hospita. - Give instructions and suppies needed to care for the chid on the way to the hospita. COUNSEL THE MOTHER: - Assess the chid s feeding, incuding breastfeeding practices, and sove feeding probems, if present. - Advise about feeding and fuids during iness and when to return to a heath faciity. - Counse the mother about her own heath. FOLLOW-UP CARE: Give foow-up care when the chid returns to the cinic and, if necessary, reassess the chid for new probems.

8 8 SECTION I / IMCI IMCI guideines The IMCI charts can be found in the appendix of this modue. The IMCI strategy is divided into 2 components based on the chid s age; management of the sick chid aged 2 months up to 5 years and management of the sick young infant aged up to 2 months. The sick chid management incudes respiratory disease, diarrhea, febrie iness (maaria), meases, ear infections, manutrition, anemia, HIV, and immunization status. See Figure 3. The sick young infant management incudes severe disease (respiratory and sepsis), oca bacteria infection, jaundice, diarrhea, HIV infection, weight gain, breast feeding and other feeding probems, immunization status and mother s heath. See Figure 4. IMCI reated research has identified from the traditiona cinica history and physica examination a imited number of cinica symptoms and signs, based on evidence of their sensitivity and specificity to detect diseases and predict mortaity. These were seected aso considering the avaiabe resources in first-eve heath care faciities. Obtaining the necessary information uses a ask, ook and isten training approach. The presence of these more imited symptoms and signs eads to a chid s cassification rather than a diagnosis. This cassification indicates the severity of the condition, which cas for specific actions based on whether the chid (a) needs to be urgenty referred to a higher eve of care, (b) requires specific treatments, or (c) can be safey managed at home. The cassification is coor coded: pink requires hospita referra or admission; yeow indicates the need to initiate treatment at home; and green indicates home supportive care management Assessment of sick chidren 2 months to 5 years The assessment procedure for this age group incudes a number of important steps that must be taken by the heath care provider: (1) Take a history and tak with the caregiver about the chid s probem; (2) check for genera danger signs; (3) assess major symptoms; (4) evauate nutritiona status; (5) assess the chid s feeding; (6) check immunization status; and (7) ook for other probems. Danger signs that shoud be routiney checked in a chidren In the sick chid management there are 5 genera danger signs: 1. not abe to drink or breast feed, 2. vomits everything, 3. convusions, 4. ethargic or unconscious, and 5. now convusing. These genera danger signs indicate the need for immediate referra to a hospita because they predict serious infections and conditions such as bacteria meningitis, cerebra maaria, and septic shock, which untreated often ead to death. Seizures are associated with meningitis, cerebra maaria, or other ife threatening conditions. However, not a seizures may be ife threatening, as some seizures may resut from fever. Febrie seizures do itte harm beyond frightening the parents.

9 SECTION I / IMCI 9 FIGURE 3. Management of the Sick Chid Aged 2 Months Up to 5 Years Name: Age: Weight (kg): Height/Length (cm): Temperature ( C) Ask: What are the chid s probems? Initia Visit? Foow-up Visit? ASSESS (Circe a signs present) CHECK FOR GENERAL DANGER SIGN NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING CONVULSIONS LETHARGIC OR UNCONSCIOUS CONVULSING NOW DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? For how ong? Days Count the breaths in one minute: breaths per minute. Fast breathing? Look for chest indrawing Look and isten for stridor Look and isten for wheezing DOES THE CHILD HAVE DIARRHOEA? For how ong? Days Is there bood in the stoo? Look at the chids genera condition. Is the chid: Lethargic or unconscious? Restess and irritabe? Look for sunken eyes. Offer the chid fuid. Is the chid: Not abe to drink or drinking poory? Drinking eagery, thirsty? Pinch the skin of the abdomen. Does it go back: Very sowy (onger then 2 seconds)? Sowy? DOES THE CHILD HAVE FEVER? (by history/fees hot/ temperature 37.5 C or above) Decide maaria risk: High Low No For how ong? Days If more than 7 days, has fever been present every day? Has chid had meases within the ast 3 months? Do a maaria test, if NO genera danger sign in a cases in high maaria risk or NO obvious cause of fever in ow maaria risk: Test POSITIVE? P. faciparum P. vivax NEGATIVE? Look or fee for stiff neck Look for runny nose Look for signs of MEASLES: Generaized rash and One of these: cough, runny nose, or red eyes Look for any other cause of fever. CLASSIFY Genera danger sign present? Yes No Remember to use Danger sign when seecting cassifications Yes No Yes No Yes No If the chid has meases now or within the ast 3 months: Look for mouth ucers. If yes, are they deep and extensive? Look for pus draining from the eye. Look for couding of the cornea.

10 10 SECTION I / IMCI FIGURE 3. Management of the Sick Chid Aged 2 Months Up to 5 Years, continued ASSESS (Circe a signs present) DOES THE CHILD HAVE AN EAR PROBLEM? Is there ear pain? Is there ear discharge? If Yes, for how ong? Days Look for pus draining from the ear Fee for tender sweing behind the ear THEN CHECK FOR ACUTE MALNUTRITION AND ANAEMIA Look for oedema of both feet. Determine WFH/L z-score: Less than -3? Between -3 and -2? -2 or more? Chid 6 months or oder measure MUAC mm. Look for pamar paor. Severe pamar paor? Some pamar paor? If chid has MUAC ess than 115 mm or WFH/L ess than -3 Z scores: Is there any medica compication: Genera danger sign? Any severe cassification? Pneumonia with chest indrawing? Chid 6 months or oder: Offer RUTF to eat. Is the chid: Not abe to finish? Abe to finish? Chid ess than 6 months: Is there a breastfeeding probem? CHECK FOR HIV INFECTION Note mother s and/or chid s HIV status Mother s HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Chid s viroogica test: NEGATIVE POSITIVE NOT DONE Chid s seroogica test: NEGATIVE POSITIVE NOT DONE If mother is HIV-positive and NO positive viroogica test in chid: Is the chid breastfeeding now? Was the chid breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and chid on ARV prophyaxis? CLASSIFY Yes No CHECK THE CHILD S IMMUNIZATION STATUS (Circe immunizations needed today) BCG DPT+HIB-1 DPT+HIB-2 DPT+HIB-3 Meases 1 Meases 2 Vitamin A OPV-0 OPV-1 OPV-2 OPV-3 Mebendazoe Hep B0 Hep B1 Hep B2 Hep B3 RTV-1 RTV-2 RTV-3 PCV-1 PCV-2 PCV-3 ASSESS FEEDING if the chid is ess than 2 years od, has MODERATE ACUTE MALNUTRITION, ANAEMIA, or is HIV exposed or infected Do you breastfeed your chid? Yes No If yes, how many times in 24 hours? times. Do you breastfeed during the night? Yes No Does the chid take any other foods or fuids? Yes No If Yes, what food or fuids? How many times per day? times. What do you use to feed the chid? If MODERATE ACUTE MALNUTRITION: How arge are servings? Does the chid receive his own serving? Who feeds the chid and how? During this iness, has the chid s feeding changed? Yes No If Yes, how? ASSESS OTHER PROBLEMS: Ask about mother s own heath Return for next immunization on: (Date) FEEDING PROBLEMS

11 SECTION I / IMCI 11 FIGURE 4. Management of the Sick Young Infant Aged Up to 2 Months Name: Age: Weight (kg): Temperature ( C) Ask: What are the infant s probems?: Initia Visit? Foow-up Visit? ASSESS (Circe a signs present) CHECK FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTION Is the infant having difficuty in feeding? Has the infant had convusions? Count the breaths in one minute. breaths per minute Repeat if eevated: Fast breathing? Look for severe chest indrawing. Look and isten for grunting. Look at the umbicuus. Is it red or draining pus? Fever (temperature 38 C or above fees hot) or ow body temperature (beow 35.5 C or fees coo) Look for skin pustues. Are there many or severe pustues? Movement ony when stimuated or no movement even when stimuated? THEN CHECK FOR JAUNDICE When did the jaundice appear first? Look for jaundice (yeow eyes or skin) Look at the young infant s pams and soes. Are they yeow? DOES THE YOUNG INFANT HAVE DIARRHOEA? Look at the young infant s genera condition. Does the infant: move ony when stimuated? not move even when stimuated? Is the infant restess and irritabe? Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: Very sowy? Sowy? THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT If the infant has no indication to refer urgenty to hospita Is there any difficuty feeding? Yes No Is the infant breastfed? Yes No If yes, how many times in 24 hours? times Does the infant usuay receive any other foods or drinks? Yes No If yes, how often? What do you use to feed the chid? Determine weight for age. Low Not ow Look for ucers or white patches in the mouth (thrush). CHECK FOR HIV INFECTION Note mother s and/or chid s HIV status: Mother s HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN Chid s viroogica test: NEGATIVE POSITIVE NOT DONE Chid s seroogica test: NEGATIVE POSITIVE NOT DONE If mother is HIV positive and and NO positive viroogica test in young infant: Is the infant breastfeeding now? Was the infant breastfeeding at the time of test or 6 weeks before it? If breastfeeding: Is the mother and infant on ARV prophyaxis? CLASSIFY Yes No

12 12 SECTION I / IMCI FIGURE 4. Management of the Sick Young Infant Aged Up to 2 Months, continued ASSESS (Circe a signs present) ASSESS BREASTFEEDING Has the infant breastfed in the previous hour? If the infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. Is the infant abe to attach? To check attachment, ook for: Chin touching breast: Yes No Mouth wide open: Yes No Lower ip turned outward: Yes No More areoa above than beow the mouth: Yes No not we attached good attachment Is the infant sucking effectivey (that is, sow deep sucks, sometimes pausing)? not sucking effectivey sucking effectivey CHECK THE CHILD S IMMUNIZATION STATUS (Circe immunizations needed today) BCG DPT+HIB-1 DPT+HIB-2 Hep B 1 Hep B 2 200,000 I.U OPV-0 OPV-1 OPV-2 vitamin A to mother ASSESS OTHER PROBLEMS: Ask about mother s own heath CLASSIFY Return for next immunization on: (Date) An unconscious chid is ikey to be seriousy i. A ethargic chid who is awake but does not take any notice of his/her surroundings or does not respond normay to sounds or movement may aso be very sick. These signs can be associated with many conditions, incuding severe dehydration, severe hypoxia, sepsis, or meningitis. Inabiity to drink or breastfeed. An infant may be unabe to drink if he/she is too weak or cannot swaow. Observe the chid whie the mother breastfeeds or gives him/her something to drink. Persistent vomiting. Vomiting itsef may be a sign of serious iness. This symptom may aso prevent the chid from taking medications or fuids for rehydration. A chid with one or more of these signs must be considered seriousy i and wi require hospita referra. To start treatment for severe inesses without deay, quicky assess the chid for the most important causes of serious iness and death, incuding acute respiratory infection (ARI), diarrhea and dehydration, sepsis, maaria, and meases. Cough and Difficut Breathing When a chid presents with cough, the parent is asked about the presence of fast breathing. Fast breathing resuts when ung compiance is reduced by infitrate or consoidation associated with pneumonia or bronchioitis. Research has estabished respiratory rate (breaths per minute) threshods for fast breathing: 60 in an infant up to 2 months, 50 in chid 2 months to 12 months, and 40 in a chid 12 months to 5 years. When the chid is cam, respirations shoud be counted for 1 minute. One minute timers are avaiabe to faciitate the accurate counting of breaths/minute. Subcosta chest indrawing (retractions) is associated with decreased oxygen saturation that affects the centra

13 SECTION I / IMCI 13 nervous system respiratory drive center, which contros the force of the diaphragm. In addition to checking for fast breathing and chest indrawing, it is important to isten for stridor and wheezing. The chid is cassified having severe pneumonia or another very severe disease (PINK) if there is any genera danger sign or stridor in a cam chid. This chid needs to be referred urgenty to the hospita and receive a first dose of an antibiotic. If the chid has fast breathing and or chest indrawing, the chid is cassified as having pneumonia (YELLOW) and is given ora amoxiciin (or an appropriate aternative) for 5 days. Wheezing chidren are given a tria with a rapid acting bronchodiator for up to 3 times. Chidren without any signs of pneumonia or danger signs are cassified as having an upper respiratory infection or cod (GREEN) and receive home care with a safe cough remedy. If their wheezing responded to a therapeutic rapid acting bronchodiator tria they are given a rapid acting bronchodiator for 5 days. (See IMCI chart for cough or difficut breathing in the appendix.) Diarrhea When a chid presents with diarrhea, the cassification of severity is based on whether there is bood in the stoo, how ong the chid has had diarrhea, and the presence of the foowing cinica signs: unconscious, ethargy, restess, irritabe, sunken eyes, abiity and way of drinking, skin turgor. These signs are used to cassify the severity of dehydration. IMCI management of diarrhea is reviewed in modue 6. Fever and Meases When a chid presents with fever by history or a temperature higher than 37.5 C., the severity cassification is based on the duration of the fever, whether the chid had meases within the past 3 months, and the foowing signs: a stiff neck, runny nose, any bacteria cause of the fever, signs of meases. The cassification takes into account whether the chid ives in an area with maaria and if the chid now has meases or had within the ast 3 months. The management of maaria and meases is reviewed ater in this modue. (See IMCI chart for fever in the appendix) Ear infection When a chid presents with ear pain or ear discharge the cassification considers if there is tender sweing behind the ear suggesting mastoiditis. A chid with mastoiditis is cassified as PINK and referred urgenty to a hospita with the first dose of an appropriate antibiotic. Acute ear pain or ear discharge is considered yeow and the ear infection is treated with an antibiotic for 5 days. When the ear drainage has asted more than 14 days the ear infection has become chronic and is managed by ear wicking and topica quinoone eardrops for 14 days. (The IMCI chart on ear infection is found in the appendix) Manutrition and Anemia The chid is assessed for acute manutrition based on finding edema of both feet, the weight for ength percentie ( Z score) using WHO growth standards and the mid upper arm circumference for chidren oder than

14 14 SECTION I / IMCI 6 months. Anemia is recognized by pamar paor. The severity cassification is made on the basis of these findings pus the presence of any medica probem/compication identified earier in the IMCI decision making process. The IMCI management of manutrition and anemia is reviewed in modue 8. HIV infection In areas of the word with a high prevaence of HIV infection, IMCI checks for a possibe HIV infection noting the mother and chid s HIV status ( viroogy test and seroogy test). The IMCI approach to HIV infection is reviewed ater in this modue. Immunization Status, Feeding and Mother s Heath IMCI then checks the chid s immunization status and assesses feeding if the chid is ess than 2 years od. Other Probems Asking about other parenta concerns and probems is hepfu. Mother s heath is aways vauabe as this has a direct impact on the chid s heath. Management of the Sick Young Infant up to 2 Months (see chart in the appendix) Severe Disease and Loca Bacteria Infection Young chidren having any of the foowing danger signs have very severe disease and shoud be urgenty referred to the hospita with a first antibiotic dose and treatment to prevent ow bood sugar: 1. not feeding, 2. convusions, 3. fast breathing ( more than 60 breaths per minute) 4. severe chest indrawing, 5. fever or ow temperature, 6. ack of movement. A young infant with signs of umbiica infection (redness and or puruent discharge) is cassified as yeow having a oca bacteria infection and treated with an appropriate antibiotic). Jaundice An infant is assessed for jaundice by asking when the infant first ooked yeow and noting what areas of the body appear yeow especiay the soes and pams. The infant is cassified as severe if the jaundice was noticeabe before 24 hours of age or invoves the soes and pams at any age. Jaundice is reviewed in modue 7. Diarrhea When the infant presents with diarrhea the infant s genera condition and movements are noted as we as the presence of sunken eyes and skin turgor in order to cassify the severity of dehydration. This is reviewed in modue 6. Poor weight gain, ow weight, feeding probem The infant s cassification is based on a feeding history reated to breast feeds, additiona foods or drinks, weight for age, and the presence of ucers or white patches in the mouth suggesting thrush. Poor weight gain and breast feeding probems are reviewed in modue 8.

15 SECTION I / IMCI 15 HIV infection In areas of the word with a high prevaence of HIV infection, IMCI checks for a possibe HIV infection noting the mother and chid s HIV status ( viroogy test and seroogy test). The IMCI approach to HIV infection is reviewed ater in this modue. Assess Breastfeeding Observe the mother breastfeeding if the infant has not fed in the previous hour and check attachment and suck. Breastfeeding is reviewed in modue 8. Immunization Status and Mother s Heath It is aways necessary to ask about immunization status and assess for other probems such as mother s heath especiay possibe mastitis or severe postpartum depression. Summary IMCI is famiy and community centered. This approach is essentia for chidhood heath, because it promotes heathy habits in the famiy, adequate care of chidren (feeding, cothing, stimuation, etc.), disease prevention, and prompt seeking of medica care when aarming signs and symptoms are noted. The IMCI strategy aso heps heathcare professionas take advantage of opportunities for prevention, promote chidhood deveopment, and encourage the rationa use of drugs and medications.

16 16 SECTION I / IMCI FIGURE 5. IMCI strategy for case management in the outpatient heath care faciity, first-eve referra service, and at home for the sick chid from age 2 months to 5 years THE INTEGRATED CASE MANAGEMENT PROCESS OUTPATIENT HEALTH CARE FACILITY Check for DANGER SIGNS Seizures Lethargy/unconsciousness Inabiity to drink/breast-feed Vomiting Assess MAIN SYMPTOMS Cough/difficut breathing Diarrhea Fever Ear probems Assess NUTRITION, IMMUNIZATIONS and POTENTIAL FEEDING PROBLEMS Check for OTHER PROBLEMS CLASSIFY CONDITIONS and IDENTIFY TREATMENT ACTIONS According to coor-coded treatment PINK Urgent referra OUTPATIENT HEALTH CARE FACILITY Pre-referra treatments Counse parents Refer chid YELLOW Treatment at outpatient heath care faciity OUTPATIENT HEALTH CARE FACILITY Treat oca infection Give ora drugs Counse and teach caretaker Foow-up GREEN Home management HOME Caregiver is counseed on: Home treatment(s) Feeding and fuids When to return immediatey Foow-up REFERRAL FACILITY Emergency Triage and Treatment (ETAT) Diagnosis Treatment Monitoring and foow-up

17 SECCIÓN X / X SECTION II / INFLUENZA INFECTIONS 17 INFLUENZA INFECTIONS OBJECTIVES Understand the infuenza virus pathogenesis and epidemioogy. Describe cinica symptoms of infuenza and diagnostic and treatment options. Evauate treatment and prevention methodoogies for infuenza and incorporate them into preparedness pans. What is Infuenza? Infuenza is a segmented, singe-stranded enveoped RNA virus cassified into infuenza A, B and C based on antigenic differences. Infuenza A is a potentiay severe i ness, causes epidemics and pandemics, is rapidy changing, and infects birds, swine, horses, seas, and humans. Infuenza B is more uniform, causes epidemics and ony infects humans. Infuenza C is of minima pubic heath impact and infects humans and swine. Further subtyping of infuenza A virus is based on the neuraminidase and hemaggutinin proteins on the vira surface. There are 16 different hemaggutinins and 9 different neuraminidase subtypes. Hemaggutinin proteins aow the virus to stick to ces by binding to a specific receptor. The neuraminidase protein heps newy formed vira partices get reeased from the ce surface so that they have the potentia to infect other ces. Ony H1N1, H2N2, H3N2 subtypes are associated with widespread epidemics in human. Since 1997, rare but severe infections in humans with infuenza A subtype H5N1 viruses have been identified in Asia, Africa, Europe, and the Midde East where these viruses are present in domestic or wid birds. Repeated seasona infuenza epidemics persist because the type A and type B viruses undergo constant and rapid change due to antigenic drift. Antigenic drift refers to a gradua change in the virus that occurs through a sow series of amino acids changes in the hemaggutinin or neuraminidase surface antigens. Occurring ony after a particuar vira strain has become estabished in humans, antigenic drift represents an adaptation to the deveopment of host antibodies. Newy deveoped antigenic strains of infuenza then prevai for a period of 2 to 5 years, ony to be repaced by the next emerging strain. This new strain can then trigger a new epidemic, since it is now unfamiiar to the antibody repertoire of the popuation. The deveopment of yet another set of host antibodies eventuay protects the popuation at the same time it puts pressure on the virus to drift yet again. Ongoing change caused by antigenic drift requires ongoing reformuation of infuenza vaccines usuay on an annua basis. The Word Heath Organization and the Centers for Disease Contro and Prevention continuay track these changes to better recommend strains to be contained in the next seasona infuenza vaccine. In contrast to the gradua evoution of strains subject to antigenic drift, antigenic

18 18 SECTION II / INFLUENZA INFECTIONS shift occurs as soon as a type A infuenza virus with a competey nove hemaggutinin or neuraminidase moves into humans from another host species. The primary source is birds, certain species of which carry a reservoir of 15 infuenza A subtypes. These subtypes either geneticay reassort themseves with circuating human infuenza virus or are transmitted directy into humans, typicay via intermediate hosts such as swine. Antigenic shift of type A infuenza viruses occurs ess frequenty than antigenic drift, but with more dramatic impact that can ead to a pandemic. A pandemic is defined by the emergence and goba spread of a new infuenza A virus subtype to which the popuation has itte or no immunity and that spreads rapidy from human to human. Pandemics, therefore, can cause increased morbidity and mortaity rates compared with seasona infuenza. During the 20th century, there have been four infuenza pandemics, in 1918 (H1N1), 1957 (H2N2), 1968 (H3N2), and (H1N1). The recent infuenza pandemics of 2009 H1N1 ( swine fu ) was caused by genetic reassortment between human, two avian and one swine infuenza viruses. Avian infuenza (H5N1) continues to cause outbreaks among poutry and wid birds wordwide but has caused reativey few cases of human H5N1 infection athough case fataity rates are greater than 50 percent. Epidemioogy Infuenza is spread from person to person primariy by respiratory dropets created by coughing or sneezing. Contact with respiratory dropet-contaminated surfaces or fomites is another possibe mode of transmission. During community outbreaks of infuenza, the highest attack rates occur among schoo-aged chidren. Secondary spread to aduts and other chidren within a famiy is common. Incidence and disease severity depend, in part, on immunity deveoped as a resut of previous experience (by natura disease) or recent infuenza immunization with the circuating strain or a reated strain. In temperate cimates, seasona epidemics usuay occur during winter months. Peak infuenza activity in the United States can occur anytime from November to May but most commony occurs in January and February. Com mun ity outbreaks can ast 4 to 8 weeks or onger. Circuation of 2 or 3 infuenza virus strains in a community may be associated with a proonged infuenza season of 3 months or more and bimoda peaks in activity. Infuenza is high y contagious, especiay among semi encosed institutionaized popuations. Attack rates in heathy chidren generay have been found to be 10% to 40% each year, but iness rates as ow as 3% aso have been reported. Chidren younger than 5 years of age visit cinics or emergency departments for infuenza iness at the rate of 1 to 2 chidren per 100 annuay. Infuenza and its compications have been reported to resut in a 10% to 30% increase in the number of courses of antimicrobia agents prescribed to chidren during the infuenza season. These medica care encoun ters for chidren with infuenza resut in considerabe costs and ikey are an important cause of inappropriate antimicrobia use.

19 SECTION II / INFLUENZA INFECTIONS 19 Infuenza Pathogenesis and Symptoms Infuenza in aduts typicay begins with the sudden onset of fever, often accompanied by chis or rigors, headache, maaise, diffuse myagia, and nonproductive cough. Subsequenty, respiratory tract signs incuding sore throat, nasa congestion, rhinitis, and cough become more prominent. Conjunctiva injection, abdomina pain, nausea, vomiting, and diarrhea are ess commony associated with infuenza iness. Infuenza symptoms may be different among different age popuations with oder chidren and adoescents having more cassic adut infuenza ike symptoms. Neonates may present with fever and a sepsis ike picture and todders may have few respiratory signs but have vomiting and diarrhea as their predominant symptom. The usua incubation period between the time someone is exposed and infected with infuenza virus to the time that they experience symptoms of iness ranges from 18 hours to 5 or more days with an average of 2-3 days. Once infected with infuenza the principa site of repication is the coumnar epitheium in the back of the throat. Vira shedding in respiratory secretions occurs for 1 day before iness and 5-10 days after iness onset. Vira titers are generay higher in young chidren with shedding asting 10 days or onger. Peak shedding of virus generay occurs during the first 3 days of i - ness and correates with the presence of fever. Compications of Infuenza Post infuenza compications are common. Infuenza is an important cause of otitis media. Acute myositis characterized by caf tenderness and refusa to wak has been described especiay with infuenza type B. In infants, infuenza can produce a sepsis-ike picture and occasionay can cause croup, bronchioitis, or pneumonia. Athough the arge majority of chidren with infuenza recover fuy after 3 to 7 days, previousy heathy chidren can have severe symptoms and compications. Neuroogic compications associated with infuenza range from febrie seizures to severe encephaopathy and encephaitis with status epiepticus, with resuting neuroogic sequeae or death. Reye syndrome has been associated with infuenza infection and saicyate exposure. Death from infuenza-associated myocarditis has been reported. Invasive secondary infections or coinfections with group A strepto coccus, Staphyococcus aureus (incuding methiciinresistant S. aureus [MRSA]), Streptococcus pneumoniae, or other bacteria pathogens can resut in severe disease and death. Hospitaization rates among chidren younger than 2 years of age are simiar to hospitaization rates among peope 65 years of age and oder. Chidren younger than 24 months of age consistenty are at substantiay higher risk of hospitaization than are oder chidren, and the risk of hospitaization attributabe to infuenza infection is highest in the youngest chidren. Rates of hospitaization and morbidity attributabe to compications, such as bronchitis and pneumonia, are even greater in chidren with high-risk condi-

20 20 SECTION II / INFLUENZA INFECTIONS Treatment of Infuenza Treatment is mosty supportive with rest, fuids, and antipyretics such as acetaminophen or ibuprofen. Aspirin and other saicyate-containing products shoud be avoided as it is associated with a rare severe compication caed Reye Syndrome. Antiviras administered within 2 days of iness onset may have the greatest benefit to reduce the duration of uncompicated infuenza i ness and shoud be considered for those who are at increased risk of severe or compicated infuenza infection. Other candidates for antivira therapy incude heathy chidren with moderate to severe iness and peope with specia environmenta, famiy, or socia situations where ongoing infuenza iness woud be detrimenta. Antivira treatment shoud be continued for 5 days and be discontinued approximatey 24 to 48 hours after symptoms resove. Chidren with severe infuenza shoud be evauated carefuy for possibe coinfection with bacteria pathogens, such as Staphyococcus aureus, that might require antimicrobia therapy. In the United States, two casses of antivira medications are avaiabe for treattions, incuding hemogobinopathies, bronchopumonary dyspasia, asthma, cystic fibrosis, maignancy, diabetes meitus, chronic rena disease, and congenita heart disease. Infuenza virus infection in neonates aso has been associated with considerabe morbidity, incuding a sepsisike syndrome, apnea, and ower respiratory tract disease. Fata outcomes, incuding sudden death, have been reported in both chronicay i and previousy heathy chidren. A infuenza-associated pediatric deaths are nationay notifiabe and shoud be reported to the CDC through state heath departments. Diagnostic Tests Specimens for vira cuture, immunofuorescent, or rapid diagnostic tests shoud be obtained if possibe during the first 72 hours of iness, because the quantity of virus shed decreases rapidy as iness progresses beyond that point. Rapid enzyme immunoassay diagnostic tests for identification of infuenza A and B antigens in respiratory tract specimens are avaiabe commerciay, athough their reported sensitivity (44% 97%) and specificity (76% 100%) compared with vira cuture are variabe and differ by test and specimen type. Additionay positive and negative predictive vaues of these infuenza screening tests is infuenced by the prevaence of cir cuating infuenza viruses resuting in an increased ikeihood of fase-positive resuts during periods of ow infuenza activity. Direct fuorescent antibody (DFA) and indirect immunofuorescent antibody (IFA) staining for detection of infuenza A and B antigens in nasopharyngea or nasa specimens are avaiabe at most hospitabased aboratories and can yied resuts in 3 to 4 hours. Reverse transcriptase-poymerase chain reaction (RT-PCR) testing of respiratory tract specimens may be avaiabe at some institutions and offers potentia for high sensitivity and specificity in particuar with the H1N1 pandemic strain.

21 SECTION II / INFLUENZA INFECTIONS 21 ment or prophyaxis of infuenza infections: neuraminidase inhibitors (osetamivir and zanamivir) and adamantanes ( amantadine and rimantadine). Treatment has been shown to decrease the duration of fu-reated symptoms by 1 to 1.5 days. Osetamivir has been approved for chemoprophyaxis and treatment of patients oder than one year od. Zanamivir has been approved for treatment in patients 7 years and oder and chemoprophyaxis of patients age 5 years and oder. Infuenza B viruses intrinsicay are resistant to adamantanes and since 2005 a H3N2 strains in the United States have been resistant to adamantanes. During the infuenza season, virtuay a H1N1 infuenza strains were resistant to osetamivir but remained susceptibe to zanamivir, amantadine, and rimantadine. The most recent pandemic H1N1 strain was once again susceptibe to osetamivir. These resistance patterns among circuating infuenza A virus strains present chaenges in seecting antivira medications for treatment and chemoprophyaxis of infuenza and provide additiona rea sons for cinicians to test patients for infuenza virus infection and to consut surveiance data in their community when evauating peope with acute respiratory tract inesses during the infuenza season. Specific drug recommendations for treatment and chemoprophyaxis may vary by season, geographic ocation, and eve of circuating vira resistance. The CDC website provides current recommendations for treatment and chemo- prophyaxis of infuenza: professionas/antiviras/index.htm. Zanamivir (Reenza ) is avaiabe as a dry powder administered via ora inhaation with a pastic device. The dose is two breath-activated inhaations (one 5 mg bister per inhaation = 10 mg) bid for 5 days. Zanamivir is not recommended for use in patients with underying airway disease incuding asthma or COPD, because of a ack of safety and efficacy data in these patients. Osetamivir (Tamifu ) is avaiabe as pis or iquid and is given twice daiy for 5 days, with dose adjustments required in rena impairment. Pediatric dosing of osetamivir for 1 12 years is 2 mg/kg/ dose bid x 5 days (max. dose = 75 mg) and for 13 years and oder: 75 mg bid x 5 days. Chemoprophyaxis Chemoprophyaxis or proonged administration of antivira medications during the periods of highest risk for transmission is an adjunct for contro and prevention of infuenza in specific situations and is not a substitute for immunization. Chemoprophyaxis shoud be considered for protection of chidren at increased risk of severe infection or compications who are unabe to receive infuenza vaccine due to contraindications and for immunocompromised chidren who may not respond to vaccine. Other considerations incude the protection of unimmunized high-risk chidren or chidren who were immunized ess than two weeks before infuenza circuation and who may not have deveoped an adequate immune response, protection of unimmunized cose contacts of

22 22 SECTION II / INFLUENZA INFECTIONS high-risk chidren, protection of immunized high-risk chidren if the circuating infuenza strain is a poor match to the strain in the vaccine and for the contro of infuenza outbreaks in some institutiona cosed settings. Prevention of Infuenza Good infection contro maintenance is a we known cornerstone of disease management and needs to be the focus of genera practice management of a respiratory outbreaks incuding seasona and pandemic infuenza. Infection contro refers to a poicies, procedures and activities that aim to prevent or minimize the risk of transmission of infectious diseases. This incudes simpe measures such as adequate hand hygiene by hand washing or hand rubs, and cough etiquette to more invoved measures such as persona protective equipment (PPE). Hospitaized patients with infuenza shoud be paced on dropet precautions (mask, gown and gove). Respiratory hygiene/cough etiquette (pacing masks on patients with a cough when outside of their room) shoud be incorporated into infection contro practices. Visitors who have any respiratory iness symptoms shoud be discouraged from visiting patients. Heath care workers who are i shoud be restricted from working unti they are heathy. The primary measure to prevent infuen za is vaccination of both patients and fami ies, and heathcare workers. The rapid evo ution of new strains of infuenza necessitates annua reformuation of the vaccine strains and annua vaccination of vaccine recipients to maintain immunity to current infuenza strains. A currenty avaiabe inactivated and ive attenuated infuenza vaccines are trivaent, meaning they contain 3 strains that represent the most recent cir cuating wid-type strains in a given year: A (H3N2), A (H1N1), and B. Initiation of infuenza vaccination programs shoud start as soon as infuenza vaccine is avaiabe from manufacturers and shoud be continued throughout the infuenza season. Surveiance and Surge Panning During the pre-pandemic intervas, heathcare providers and heathcare faciities pay an essentia roe in surveiance for suspected cases of infection with nove strains of infuenza and shoud be on the aert for such cases. Nove strains may incude avian or anima infuenza strains that can infect humans such as avian infuenza A H5N1 or nove infuenza A H1N1 and new or re-emergent human viruses that cause cases or custers of human disease. For detection of cases during the Pre-Pandemic and Pandemic Intervas, hospitas shoud have predetermined threshods for activating pandemic infuenza surveiance pans. Infuenza pandemics are different from many of the threats for which pubic heath and the heathcare system are currenty panning. The pandemic wi ast much onger than most other emergency events and may incude waves of infuenza activity separated by months (in 20th century pandemics, a second wave of infuenza activity occurred 3 to 12

23 SECTION II / INFLUENZA INFECTIONS 23 months after the first wave). The numbers of heathcare workers and first responders avaiabe to work can be expected to be reduced; they wi be at high risk of iness through exposure in the community and in heathcare settings, and some may have to miss work to care for i famiy members. It is reasonabe to assume that absenteeism may exceed 25%. Resources in many ocations coud be imited because of how widespread an infuenza pandemic woud be. The goa of a pandemic surge pan for an emergency department or other outpatient setting is to provide safe and effective care in the event of an infuenza pandemic or simiar event, and to optimize resources and mitigate throughput issues in order to provide for maximum surge capacity for pediatric patients presenting to the emergency department for care. Utiizing the a-hazards approach to deveop pans for epidemic and pandemic respiratory iness is based on the concept that most disaster-response functions are common to a disaster types, and unified panning provides the strongest basis for effective response. Critica components of comprehensive pans must address the foowing: 1) Screening, surveiance, and tracking of exposed individuas; 2) controed access to the heathcare faciity; 3) prevention strategies (isoation and cohorting, PPE use, vaccination, antivira prophyaxis, modification of environmenta contros (i.e., separate areas for i and non i patients); 4) disease-specific admission criteria, treatment, and triage agorithms; and 5) enabing the continuity of imited cinica operations. In a heathcare settings, patients with symptoms of infuenza or infuenza ike iness (ILI) shoud be segregated from noninfuenza patients as rapidy as possibe, especiay in a triage setting. When possi be, consider having different teams of staff shoud care for infuenza and non- infuenza patients. In acute care settings, triage non ILI patients prompty to specific non ILI waiting and examining areas, physicay separate from the ILI assessment area to pre vent their exposure to ILI if possibe. Additionay separate entrances and exits shoud be estabished for those who beieve they may have been exposed to ILI or those that are in need of other types of medica attention if feasibe. Admission poicies and testing and treatment agorithms shoud aso be created for determining if a patient needs to be admitted to the hospita or if an aternate care faciity may be more appropriate if atered standards of care are being used. If possibe, hospitas triage protocos for phone triage may hep to educate patients and famiies and provide hep with iness management without accessing the cinic, emergency department or hospita setting. The diagnosis and treatment agorithms used at the Chidren s Hospita Coorado can be found in this modue appendix. Specia Issues in Deveoping Countries Severa factors may be invoved in the high mortaity rates pandemics cause in deveoping countries. These incude ack

24 24 SECTION II / INFLUENZA INFECTIONS of access to adequate medica care, weak pubic heath infrastructures, socia factors such as housing conditions and popuation density, and host factors such as nutritiona status and co-existing medica conditions. Core interventions to contro or mitigate the effects of an infuenza pandemic incude pharmaceutica interventions such as vaccines and antivira agents, and nonpharmaceutica interventions such as quarantine, isoation, socia distancing, and persona hygiene. Antivira agents are particuary usefu in the eary stages of a pandemic when there is shortage of vaccines. Stockpiing of neuraminidase inhibitors is part of many industriaized countries pandemic preparedness pans however stockpies of antivira agents avaiabe in deveoping countries is sma and imited. The most critica imiting factor for stockpiing neuraminidase inhibitors in deveoping countries is their high cost and aocating scarce resources to stockpie sufficient quantities of osetamivir for an unpredictabe infuenza pandemic. Because ony a imited number of vaccines wi be initiay avaiabe, particuary in the eary stages of a pandemic, and most of them woud ikey be suppied to industriaized countries, deveoping countries wi need to focus initiay on nonpharmaceutica interventions. Maintaining a baance between pharmaceutica and nonpharmaceutica interventions is necessary to achieve the best use of imited resources. During an infuenza pandemic, additiona essentia medica suppies such as goves, masks, syringes, antipyretics, and antimicro- bia agents wi aso be required. These suppies are insufficient in heathcare faciities in deveoping countries, even in nonemergency situations. Lack of these suppies may hamper provision of adequate medica care for patients with pandemic infuenza. Basic PPE such as disposabe goves and surgica masks are needed for protecting heathcare workers. Anti-microbia agents are expected to be effective for secondary bacteria pneumonia, which can be a major cause of death for patients with pandemic infuenza. Providing better medica care during a pandemic is essentia to reduce the heath consequences of the pandemic incuding death. Since the avaiabiity of pharmaceutica interventions in deveoping countries is ess ikey, nonpharmaceutica interventions such as socia distancing and persona hygiene may be the ony avaiabe interventions. Essentia medica suppies such as masks, goves, and antimicrobia agents shoud be avaiabe in hospitas and cinics. The stockpies of these basic suppies can be more cost-effective in deveoping countries than stockpies of more expensive antivira agents. Heathcare personne shoud be trained for infection contro measures, especiay hand hygiene and use of persona protective equipment. The overarching goa is to maintain the current heathcare and pubic heath systems need to minimize the impact of a pandem ic. The ink to PAHO s Pandemic Infuenza A (H1N1) 2009 manuas that describe preparedness panning, infection prevention and contro, nonpharmaceutica strategies and IMCI diagnosis, treatment and management protocos in Spanish,