Student Guide Module 5: Management of Prevalent Infections in Children Following a Disaster Objectives for this session Section I - Integrated Management of Childhood Illness (IMCI) Understand the IMCI strategy of classification and management for children 2-6 months of age and 6 months to 5 years. Section II - 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 an influenza epidemic. Describe surge planning for an H1N1 pandemic. Section III - Acute respiratory infections Know the 4 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: -Pneumonia -Upper respiratory infection -Ear problems without pneumonia Section IV - Measles Recognize the clinical presentation and evolution of 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.
Section V - Febrile Illness: Malaria, Dengue, Chikungunya Understand the public health importance of febrile illness such as malaria and dengue in the context of acute emergency settings. Understand the IMCI strategy for malaria identification, prevention and treatment. Understand the cause, risk factors, and presentation of benign (uncomplicated) and malignant (complicated) malaria. Diagnose and develop a treatment plan (medications, supportive care, and monitoring) using available resources for patients with: - Severe/complicated malaria - Uncomplicated malaria - Severe dengue fever - Dengue fever Section VI - Other infectious diseases that require attention in disaster scenarios Understand the importance of clinical entities such as meningitis, tuberculosis and HIV in displaced populations. 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. Initial Scenario You are staffing a clinic in a camp for a large displaced population fleeing their homes because of a war. The situation in the camp with respect to shelter, clean water and food is marginal and many of the children have moderate or severe acute malnutrition. Over 100 children come to clinic daily so you must see the patients quickly to be sure that everyone is seen and receive needed care. You have trained nurses to triage the children according to IMCI protocols so that the sickest will be seen first so they can be stabilized to the extent possible, and if necessary urgently transferred to the hospital.
Case 1 A 2 year old girl (name) is brought to your clinic by her mother. She appears lethargic and her mother says she has not been able to eat or drink anything today. Yesterday she vomited everything she tried to eat. She has had a high fever (to mother s touch) for 3 days. Her temperature today is 40 o C. Her MUAC is 114 mm. Her heart rate is 120 and her respiratory rate is 36. As you start to exam her, she begins to seize. 1) What are the 5 IMCI general danger signs and which of these does she have? 2) According to IMCI how would you classify and manage this girl? Case 2 A mother and her 7 month old daughter are triaged by the nurse to be seen quickly. She has fever, cough and difficult breathing. The mother says she has been coughing for several days and last night felt hot to her touch. She has not been able to sleep and does not seem interested or able to breast feed. Her axillary temperature is 39.4 ºC and her RR is 55, with severe subcostal retractions. She has diminished air entry on the right lung base, with rales in the same place. She appears lethargic to you and has capillary refill of 3-4 seconds. She has poor skin turgor. Her MUAC is 113 mm so she has severe acute malnutrition. 1) How should you classify this child according to IMCI and why? 2) How should she be managed? Case 3 You now see a 2 year old boy with a 1 week history of coughing that has gotten worse during the past day. He felt hot for 2 days after he started coughing but his fever seemed to then get better. Last night he felt hot again and mother noticed that he was breathing fast. He has been eating although his appetite is decreased. He has not been vomiting and has not had convulsions. On examination his temperature is 39 o C, RR is 50 and he has severe subcostal retractions. He has rales over his left lower lung but no wheezing or stridor. He is alert but appears irritable. There is no history of an HIV exposure. You have pulse oxymetry and his oxygen saturation is 90%. 1) How should you classify this child according to IMCI and why? 2) How should he be managed?
Case 4 There is an influenza outbreak in the crowded camp and you suspect it is caused by 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 4 year old boy comes to the clinic with his mother, who says that he has felt very hot for the past 2 days. While he complained about a headache and sore throat when he felt hot he is now is coughing all the time. He now vomits when his coughing is bad. He couldn t sleep last night and refuses to eat. He will drink. On your physical examination you note that his temperature is 39 o C, HR 120, RR 60 and BP 100/60. He has moderate to severe subcostal retractions. He appears lethargic but is not unconscious. He has not had convulsions. 1) How should you classify this child according to IMCI and why? 2) How should he be managed? Scenario Continued: Your shift in the clinic is finished so you accompany the family to the local hospital. When you arrive the pulse oxygen study shows his oxygen saturation to be 79% so you administer oxygen with a nasal cannula and try to get his saturation over 90%. 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 H1N1 3) How would you manage this child now?
Scenario continued: 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. 4) What is the difference between antigenic drift and shift with regards to influenza viruses? Scenario continued: During the next week your clinic and the local hospital are overwhelmed with patients seeking care. The majority are worried patients with URI symptoms and uncomplicated pneumonia without danger signs. The hospital laboratory only has a limited number of influenza rapid diagnostic test kits and will soon run out. The hospital also only has a limited amount of 2 types of antiviral medication. You need to develop a policy about who should be tested and who should be treated with oseltamivir (Tamiflu). You know that specimens for viral rapid diagnostic tests should be obtained during the first 72 hours of illness, because the quantity of virus shed decreases rapidly as illness progresses beyond that point. 5) In designing your policy for Influenza testing and treatment what are the key clinical questions that should be addressed? Scenario continued: You now need to develop an influenza H1N1 pandemic surge plan for the clinic and hospital. 6) What are the critical components of a comprehensive H1N1 pandemic surge plan? 7) What are the critical components of a surge plan for the ICU? 8) You hope to receive an initial shipment of 1,000 vaccine doses against the new influenza strain. Which population groups should have the priority to receive the vaccine?
Case 5 A 10-year-old boy is brought to the medical care center. His mother says he is complaining of headache, muscle aches, and joint pain. He has felt hot to her for several days. He has vomited a few times. He seemed to get better but the fever restarted yesterday, and now he has a rash all over his body. Today his mother saw that his stool looked like it was bloody. On examining him, he looks weak, dehydrated, and has petechiae on his arms and legs. 1) Which are the 2 most likely diagnoses for his initial symptoms? 2) Is there a way to determine if the petechiae are due to a low platelet count without doing a CBC? 3) How would you manage him at this moment? 4) What complications can be associated with Dengue? 5) How are the severe forms of this disease treated? 6) Are corticosteroids useful for this disease? Case 6 The nurse triages a 5-year-old child as having a cough or cold because there were no danger signs, fast breathing or chest indrawing, or diarrhea. He has felt hot to the mother for 2-3 days. On examination he seems ill and irritable but is not lethargic and can be consoled by his mother. On examination his temperature is 39ºC and RR is 35. He has no chest indrawing. You are impressed with his rash mostly on his face and neck and become very anxious when you see whitish lesions on an erythematous base on his buccal mucosa. He also has conjunctivitis and copious nasal discharge. Both tympanic membranes are reddish yellow, bulging, and immobile. He has metallic sounding cough. 1) Why are you so worried? 2) If this is measles how will the rash usually evolve? 3) How would you treat this patient? 4) Is it necessary or even possible to isolate the child?
Scenario continued: You receive word that the refugee camp has priority to receive the measles vaccine which can be delivered in 48 hours once they receive the necessary information from you about your needs and resources for maintaining the cold chain. 5) What information to you need to obtain ASAP? 6) What is the dose of vitamin A for 6-12 months and older than 12 months? 7) You need to put together a vaccination plan. What are some of the issues that you need to consider in organizing how you will vaccinate the population? Scenario continued: You receive a call on the radio that vaccines will arrive first thing tomorrow, provided the weather 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. Your list of children from the census indicates the following: 456 children of 6-12 months (~180 ill or malnourished) 523 children >12-23 months (~155 ill or malnourished) 1010 children 24-59 months (~50 with ill or malnourished 8) How will you assign priorities to administer the vaccines in your camp? 9) How will you identify those that have been immunized if, at a later date, they receive more vaccines?