SARS ARI (social preventive pharmacy)

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monovalent Men C conjugate vaccine, one single low as 3-4 per cent, its incidence in developing countries intramuscular dose is recommended for children aged � 12 range between 20 to 30 per cent. This difference is due to months, teenagers and adults. Children 2 - 1 1 months of age high prevalence of malnutrition, low birth weight and require 2 dose administration at an interval of at least 2 indoor air pollution in developing countries ( 1 ) .

months and a booster about 1 year thereafter. Quadrivalent
ARI is an important cause of morbidity in the children.
vaccines are administered as a single dose to individuals
On an average, children below 5 years of age suffer about
aged � 2 years.
5 episodes of ARI per child per year, thus accounting for

Meningococcal vaccines should be stored at 2-8°C. about 238 million attacks. Consequently, although most of

Conjugate vaccines are preferred over polysaccharide the attacks are mild and self limiting episodes, ARI is

vaccines due to their potential for herd protection and their responsible for about 30-50 per cent of visits to health

increased immunogenicity, particularly in children < 2 years facilities and for about 20-40 per cent of admissions to

of age. Both vaccines are safe when used during pregnancy hospitals (1). It is also a leading cause of disabilities

( 1 ) . WHO recommends that countries with high or medium including deafness as a sequelae of otitis media (2).

endemic rates of invasive meningococcal disease and
Pneumonia kills more children than any other disease
countries with frequent epidemics should introduce
(more than AIDS, malaria and measles combined). More
appropriate large-scale meningococcal vaccination
than 1.1 million under 5 years of age children die from
programmes ( 1 ) . ·
pneumonia each year, accounting for almost 17 per cent

under-five deaths worldwide. Yet, little attention is paid to
this disease (3). Streptococcus pneumoniae is a major cause
1. WHO (2011), Weekly Epidemiological Record, No, 47, 18th Nov.
of illness and death in children, as well as in adults.
According to a WHO estimate, about 1.6 million cases of
2. Govt. oflndia (2014),National Health Profile 2013, DGHS, Ministry of
fatal . pneumococcal disease occur worldwide, mostly in
Health and Family Welfare, New Delhi.
infants and elderly. In addition, immunocompromised
3. Cvjetanovic, B. et al ( 1 9 7 8 ) . Bu// WHO, 56 {SupplementNo.l): 8 1 .

4. WHO ( 2 0 1 2 ) , International travel and Health, 2 0 1 2 . individuals of all ages are at increased risk (4). Disease rates

5. Jawetz, et al, (2007), Medical Microbiology, 24th e d . , A Lange Medical and mortality are higher in developing than industrialized

Book. countries, with majority of deaths occurring in Sub-Saharan

Africa and South Asia. Children who are poor,

ACUTE RESPIRATORY INFECTIONS undernourished in remote areas are more likely to suffer

from pneumonia. Moreover, only 34 per cent of children with

suspected pneumonia received antibiotics during 2 0 1 2 (4).
Infections of the respiratory tract are perhaps the most

common human ailment. While they are a source of Likewise, haemophi/us inf/uenzae type B (Hib) bacteria is

estimated to cause 3 million cases of severe pneumonia and
discomfort, disability and loss of time for most adults, they
meningitis, and approximately 386,000 deaths per year in
are a substantial cause of morbidity and mortality in young
children under 5 years of age (5).
children and the elderly. Many of these infections run their

natural course in older children and in adults without The key pneumonia indicators developed for prevention
specific treatment and without complications. However, in and treatment of pneumonia are as shown in Table 1 . It also
young infants, small children and in the elderly, or in shows the data pertaining to pneumonia from South-East
persons with impaired respiratory tract reserves, it increases Asia countries for the year 2008-2012.
the morbidity and mortality rates.
In India, in the states and districts with high infant and
Acute respiratory infections (ARI) may cause child mortality rates, ARI is one of the major causes of
inflammation of the respiratory tract anywhere from nose to death. ARI is also one of the major reasons for which
alveoli, with a wide range of combination of symptoms and children are brought to the hospitals and health facilities.
signs. ARI is often classified by clinical syndromes Hospital records from states with high infant mortality rates
depending on the site of infection and is referred to as ARI show that upto 1 3 % of inpatient deaths in paediatric wards
of upper (AURI) or lower (ALRI) respiratory tract. The upper are due to ARI. The proportion of death due to ARI in the
respiratory tract infections include common cold, pharyngitis community is much higher as many children die at home.
and otitis media. The lower respiratory tract infections The reason for high case fatality may be that children are
include epiglottitis, laryngitis, laryngotracheitis, bronchitis, either not brought to the hospitals or brought too late.
bronchiolitis and pneumonia.
In India, during the year 2 0 1 3 , about 3 1 . 7 million cases
The clinical features include running nose, cough, sore of ARI were reported. During 2 0 1 3 about 3 , 2 7 8 people died
throat, difficult breathing and ear problem. Fever is also of ARI and 2,597 died of pneumonia. Pneumonia was
common in acute respiratory infections. Most children with responsible for about 18 per cent of all 'under 5 year' deaths
these infections have only mild infection, such as cold or in India (8).
cough. However, some children may have pneumonia which

is a major cause of death. In less developed countries, E p i d e m i o l o g i c a l determinants
measles and whooping cough are important causes of severe

respiratory tract infection. Agent factors

The microbial agents that cause acute respiratory
Problem statement
infections are numerous and include bacterias and viruses.

Every year ARI in young children is responsible for an Even within species they can show a wide diversity of

estimated 3 . 9 million deaths worldwide. About 90 per cent antigenic type. The agents are those most frequently

of the ARI deaths are due to pneumonia which is usually encountered in a normal population. The bacteria involved

bacterial in origin. The incidence of ARI is similar in can all be isolated with varying frequency from carriers, and

developed and developing countries. However, while the cause illness in only minority of infected persons. The

incidence of pneumonia in developed countries may be as viruses that have been found in association with acute


Key p n e u m o n i a indicators : mortality, prevention and treatment in South-East Asia countries (2008-2012)

Pneumonia deaths Prevention Treatment

% of u n d e r 5 % of children who are % of infants who % of one year % of under 5 with

Countries deaths under weight, 0-59 months are exclusively old immunized pneumonia taken to

due to Moderate to Severe breast-fed against appropriate health

pneumonia severe (< 6 months) Measles Hib care provider

(2012) (2008-2012) (2008-2012) (2008-2012) 2012 2012 (2008-2012)

India 14 43 16 46 74 69

Bangladesh 13 36 10 64 96 96 35

Bhutan 17 13 3 49 95 74

Indonesia 17 18 5 42 80 75

Myanmar 17 23 6 24 84 69

Maldives 8 17 3 48 98 22

Nepal· 13 29 8 70 86 90 50

Sri Lanka 6 21 4 76 99 99 58

Thailand 8 7 1 15 98 84

[ World 15 15 9 38 84 45 59

Source : (6, 7)

respiratory disease are numerous. They are the, primary case of lower respiratory tract infections. The agents

cause of the great majority of respiratory illnesses. However, considered to be capable of acute respiratory diseases, the

the severity of the illness is often determined by whether or age group most frequently affected, and the characteristic

not secondary bacterial infection occurs, particularly in the clinical features are as shown in Table 2.


The agents causing ARI, age group affected and clinical features

Agent Age group (s) most frequently affected Characteristic clinical features


Bordetella pertussis Infants and young children Paroxysmal cough

Corynebacterium diphtheriae Children Nasal/tonsillar/pharyngeal membranous exudate ±

severe toxaemia

Haemophilus influenzae Adults Acute exacerbations of chronic bronchitis pneumonia

Children Acute epiglottitis (H.influenzae type B)

Klebsiel/a pneumoniae Adults Lobar pneumonia ± lung abscess

Legionella pneumophi/a Adults Pneumonia

Staphylococcus pyogenes All ages Lobar and broncho-pneumonia (esp. secondary to

influenza) ± lung abscess

Streptococcus pneumoniae All ages Pneumonia (lobar or multilobular) Acute exacerbations

of chronic bronchitis

Streptococcus pyogenes All ages Acute pharyngitis and tonsillitis


Adenoviruses - endemic types ( 1 , 2 , 5 ) Young children Lower respiratory .

- epidemic types (3,4, 7 ) Older children and young adults Febrile pharyngitis and influenza-like illness

Enteroviruses (ECHO and Coxsackie) All ages Variable respiratory

Influenza A · All ages J Fever, aching, malaise, variable respiratory

B School children Occasional primary pneumonia
Secondary bacterial pneumonia in elderly

c Rare Mild upper respiratory

Measles Young children Variable respiratory with characteristic rash

Parainfluenza 1 re-infection in later life :

J Young children
J Croup J mild upper respiratory

3 Infants Bronchiolitis and pneumonia

Respiratory syncytial virus Infants and young children Severe bronchiolitis and pneumonia

Rhinoviruses (multiple serotypes)]
All ages Common cold
Corona virus

Other agents

Chlamydia type B (Psittacosis) Adults exposed to infected birds Influenza-like illness and atypical pneumonia

Coxiel/a burnetti (Q fever) Adults exposed to sheep and cattle Atypical pneumonia

Mycoplasma pneumoniae School children and young adults Febrile bronchitis and atypical pneumonia

S o u r c e : (9)

Host factors C l i n i c a l assessment

Small children can succumb to the disease within a matter History taking and clinical assessment is very important

of days. Case fatality rates are higher in young infants and in the management of the acute respiratory infections. Note

malnourished children. Age-specific mortality rates show the age of the child, for how long the 'child is coughing,

wide differences between countries. In general, rates tend to whether the child is able to drink (if the child is aged

be high in infants and young children, and in the elderly in all 2 months upto 5 years), has the young infant stopped

countries, although the age group with the highest rates can feeding well (child less than 2 months), has there been any

differ. In developing countries where malnutrition and low antecedent illness such as measles, does the child have

birth weight is often a major problem, the rates in children fever, is the child excessively drowsy or difficult to wake (if

tend to be the highest. By contrast, in developed countries yes, for how l o n g ) , did the child have convulsions, is there

respiratory infections are only exceptionally fatal in infants irregular breathing, short periods of not breathing or the

but are commonly terminal in the elderly. child turning blue, any history of treatment during the

Upper respiratory tract infections, e . g . , common cold and

pharyngitis are several times higher in children than in Physical examination
adults. Rates for pharyngitis and otitis media increase from

infancy to a peak at the age of 5 years. Illness rates are Look and listen for the following :

highest in young children and decrease with the increasing
age, except in the third decade of life when young adults are children get -older, their breathing rate slows down.
exposed to infection by their own young children. Adult Therefore, the cut-off point used to determine if a child has
women experience more illness than men. The greater fast breathing will depend on the age of the child. Count the
exposure of women to small children may be responsible for respiratory rate for full one minute using the second's hand
this. Under 3 years of age boys are affected more often and of the watch looking at the abdominal movement or lower
more severely. chest when the child is calm. The chest and abdomen must

be exposed for counting. Increased respiratory rate is of
Risk factors
significance only if it persists.

Many risk factors for respiratory tract infections have Fast breathing is present when the respiratory rate is :
been identified. They include not only the climatic
60 breaths per minute or more in a child less than
conditions but also the housing, level of industrialization and
2 months of age
socio-economic development. In developing countries,
50 breaths per minute or more in a child aged
overcrowded dwellings, poor nutrition, low birth weight and
2 months upto 12 months
intense indoor smoke pollution underline the high rates.
40 breaths per minute or more in a child aged
Local mortality rates are particularly affected by the extent
12 months upto 5 years.
of influenza epidemics. Studies in developed countries have

shown that higher rate of infection is common in younger However, repeat the count for a young infant (age less

sibling of school going children who introduce infection into than 2 months) if the count is 60 breaths per minute or

the household. Maternal cigarette smoking has also been more. This is important because the breathing rate of young

linked to increased occurrence of respiratory tract infections infant is often erratic. Occasionally young infants stop

during the first year of life. Children from· low socio­ breathing for a few seconds, and then breath very rapidly for

economic status tend to have more respiratory infections. a short period.

The infection is more common in preschool children
(2) LOOK FOR CHEST INDRAWlNG : Look for chest
attending day-care centres. The infections tend to be more
indrawing when the child breaths IN. The child has
common in urban communities than in rural communities.
indrawing if the lower chest wall goes in when the child

breaths in. Chest indrawing occurs when the effort required
Mode of transmission
to breath in, is much greater than normal.

All the causative organisms are normally transmitted by
the airborne route. As most viruses do not survive for long
stridor makes a harsh noise when breathing IN. Stridor
outside the respiratory tract, the chain of transmission is
occurs when there is narrowing of the larynx, trachea or
maintained by direct person-to-person contact.
epiglottis which interferes with air entering the lungs. These

conditions are often called croup.
(4) LOOK FOR W H E E Z E : A child with wheezing makes a

Improving the primary medical care services and soft whistling noise or shows signs that breathing OUT is

developing better methods for early detection, treatment difficult, wheezing is caused by narrowing of the air passage

and where possible, prevention of acute respiratory in the lungs. The breathing-out phase takes longer than

infections is the best strategy to control ARI. Effective normal and requires effort.

reduction of mortality due to pneumonia is possible if If the child is wheezing, ask the mother if her child has
children suffering from pneumonia are treated correctly. had a previous episode of wheezing within the past year. If
Education of mother is also crucial since compliance with so, the child should be classified as having recurrent wheeze.
treatment and seeking care promptly when signs of
(5) See if the child is abnormally sleepy or difficult to
pneumonia are observed, are among the key factors which
wake. An abnormally sleepy child is drowsy most of the time
determine the outcome of the disease. The
when he or she should be awake and alert.
recommendations by WHO for the management of acute
(6) Feel for fever or low body temperature.
respiratory infections in children and the practical guidelines

for out-patient care are discussed below (10). The same ( 7 ) CHECK FOR SEVERE MALNUTRITION: Malnutrition

guidelines are followed in India ( 1 1 ) . when present is a high risk factor and case fatality rates are

higher in such children. In severely malnourished children II. Severe p n e u m o n i a
with pneumonia, fast breathing and chest indrawing may not
The most important signs to consider when deciding if
be as evident as in other children. A severely malnourished
the child has pneumonia are the c h i l d ' s respiratory rate, and
child may have an impaired or absent response to hypoxia
whether or not there is chest indrawing. A child with chest
and a weak or absent cough reflex. These children need
indrawing may not have fast breathing if the child becomes
careful evaluation for pneumonia as well as careful
exhausted, and if the effort needed to expand the lungs is
too great. Then the breathing slows down. In such cases,

(8) Cyanosis is a sign of hypoxia. Cyanosis must be chest indrawing may be the only sign in a child with severe

checked in good light. p n e u m o n i a . A child with chest indrawing is at higher risk of

death from pneumonia than a child with fast breathing

CLASSIFICATION OF ILLNESS alone. A child classified as having severe pneumonia also

has other signs such as :
A. C h i l d aged 2 months upto 5 years
- nasal flaring, when the nose widens as the child
Classifying the illness means making decisions about the breaths in;
type and severity of disease. The sick child should be put
- grunting, the short sounds made with the voice when
into one of the four classifications :
the child has difficulty in breathing; and

I. Very severe disease - cyanosis, a dark bluish or purplish coloration of the

II. Severe pneumonia skin caused by hypoxia.

III. Pneumonia (not severe) Some children with chest indrawing also have wheezing.
IV. No pneumonia : cough or cold Children who have chest indrawing and a first episode of

Each disease classification has a corresponding treatment wheezing often have severe p n e u m o n i a . However, children

plan which should be followed. The following guidelines are with chest indrawing and recurrent wheezing most often do

used to manage a child who is 2 months upto 5 years of age. not have severe pneumonia. Chest indrawing in these

children is caused by the asthmatic condition. Therefore,

I. Very severe d i s e a s e they must be assessed before deciding the line of treatment.

The danger signs and possible causes are : Management of the child classified as having severe

pneumonia is summarized in Table 4.
a. Not able to drink : A child who is not able to drink

could have severe pneumonia or bronchiolitis,
III. P n e u m o n i a ( n o t severe)
septicaemia, throat abscess, meningitis or cerebral
A child who has fast breathing and no chest indrawing is
classified as having pneumonia (not severe). Most children
b. Convulsions, abnormally sleepy or difficult to wake :
are classified in this category if they are brought early for
A child with these signs may have severe pneumonia
treatment. Management of the child with pneumonia (not
resulting in hypoxia, sepsis, cerebral malaria or
severe) is summarized in the Table 4.
meningitis. Meningitis can develop as a complication

of pneumonia or it can occur on its own.
IV. No p n e u m o n i a : cough or c o l d
c. Stridor in calm child : If a child has stridor when calm,
Most children with a cough or difficult breathing do not
the child may be in danger of life-threatening
have any danger signs or signs of pneumonia ( chest in drawing
obstruction of the air-way from swelling of larynx,
or fast breathing). These children have a simple cough or cold.
trachea or epiglottis.
They are classified as having "no pneumonia : cough or cold".
d. Severe malnutrition : A severely malnourished child is
They do not need any antibiotic. Majority of such cases are
at high risk of developing and dying from p n e u m o n i a .
viral infections where antibiotics are not effective. Normally a
In addition, the child may not show typical signs of the
c h i l d with cold will get better within 1-2 weeks. However, a
child with chronic cough (lasting more than 30 days) may have
A child who is classified as having severe disease is very tuberculosis, asthma, whooping cough or some other
ill and should be referred urgently to a hospital. problem. Refer the child with chronic cough for further
Management of a child having very severe disease is investigations. Management of a child classified as no
summarized in Table 3. p n e u m o n i a : cough or cold is summarized in Table 4.

TABLE 3 B. C l a s s i f y i n g i l l n e s s of young infant
Management of very severe disease
Infants less than 2 months of age are referred to as young

Not able to drink, infants. Young infants have special characteristics that must

SIGNS Convulsions
be considered when their illness is classified. They can

become sick and die very quickly from bacterial infections,
Abnormally sleepy or difficult to wake
are much less likely to cough with pneumonia, and
Stridor in calm child, or
frequently have only non-specific signs such as poor feeding,
Severe malnutrition
fever or low body temperature. Further, mild chest
CLASSIFY AS VERY SEVERE DISEASE indrawing is normal in young infants because their chest

wall bones are soft. The presence of these characteristics
Refer URGENTLY to hospital
means that they will be classified and treated differently from
TREATMENT Give first dose of an antibiotic
older children. Many of the cases may have added risk factor
Treat fever, if present
of low birth weight. Such children are very susceptible to
Treat wheezing, if present
temperature changes and even in tropical climates, death
If cerebral malaria if possible, give an antimalarial
due to cold stress or hypothermia are common. In young

Source : (10 ) infants the cut-off point for fast breathing is 60 breaths per


Management of p n e u m o n i a in a child aged 2 months upto 5 years

SIGNS Chest indrawing No chest indrawing and No chest indrawing and
(if also recurrent wheezing, fast breathing (50 per minute No fast breathing (Less

go directly to treat wheezing) or more if child 2 months than 50 per minute if
upto 12 months; 40 per minute child 2 months up to 12 months;
or more if child Less than 40 per minute if child
12 months upto 5 years). is 12 months up to 5 years).


Refer URGENTLY to hospital Advise mother to give If coughing more than 30
Give first dose of an antibiotic home care. days, refer for assessment.

Give an antibiotic.

TREATMENT Treat fever, if present, Treat fever, if present. Assess and treat ear
Treat wheezing, if present Treat wheezing, if present. problem or sore throat, if present.
(if referral is not feasible, Advise mother to return Assess and treat other problems.
treat with an antibiotic with child in 2 days for Advise mother to give home care.
and follow closely) reassessment, or earlier if the Treat fever, if present.

child is getting worse. Treat wheezing, if present.


Re-assess in 2 days a child who is taking an antibiotic for pneumonia

SIGNS Not able to drink Breathing slower
Has chest indrawing Less fever
Has other danger signs Eating better

TREATMENT Refer URGENTLY to hospital Change antibiotic or Refer Finish 5 days of antibiotic.

S o u r c e : (10)

minute. Any pneumonia in young infant is considered to be Some of the danger signs of very severe disease are :

severe. They should be referred immediately to a hospital.
(a) Convulsions, abnormally sleepy or difficult to wake :
Table 5 is used to classify the illness of a young infant.
A young infant with these signs may have hypoxia from

TABLE 5 pneumonia, sepsis or meningitis. Malaria infection is

Classification and management of illness in young infants unusual in children of this age, so antimalarial treatment is

not advised.

Stopped feeding well,
(b) Strider when calm : Infections causing strider (e.g.

SIGNS Abnormally sleepy or dlfficultto wake,
diphtheria, bacterial tracheitis, measles or epiglottitis) are

Stridor in calm child, rare in young infants. A young infant who has strider when

Wheezing, or calm should be classified as having very severe disease.
Fever or low body temperature
(c) Stopped feeding well : A young infant who stops

feeding well ( i . e . , takes less than half of the usual amount of
milk) may have a serious infection and should be classified

as having very severe disease.
TREATMENT Refer URGENTLY to hospital

Keep young infant warm
(d) Wheezing : Wheezing is uncommon in young infants
Give first dose of an antibiotic
and is often associated with hypoxia.

Severe chest indrawing, No severe chest indrawing
( e ) Fever or low body t e m p e r a t u r e : Fever (38°C or more)
SIGNS or Fast breathirig and No fast breathing
is uncommon in young infants and more often means a
(60 per minute or more) (less than 60 per minute)
serious bacterial infection. In addition, fever may be the only

CLASSIFY AS SEVERE PNEUMONIA NO PNEUMONIA : sign of a serious bacterial infection. In young infants an

COUGH OR COLD infection may sometimes cause the body temperature to

drop ( h y p o t h e r m i a ) .
Refer URGENTLY to Advise mother to give the
A young infant who is classified as having very severe
TREATMENT hospital. Keep young following home care :

infant warm. - Keep young infant warm. disease should be referred urgently to a hospital for

Give first dose of an - Breast-feed frequently. treatment. The management is summarized in Table 5.
antibiotic(If referral - Clear nose if it interferes

is not feasible.treat with feeding.

with an antibiotic and Return quickly i f : ­ TREATMENT
followclosely). Breathing becomes difficult,

Breathing becomes fast,

Feeding becomes a problem

The young infantbecomes UPTO 5 YEARS
The standard treatment for childhood acute respiratory

Source: (10) infections in India is as follows (10) :


BREATHING) Treatment of severe p n e u m o n i a (2 months - 5 years)

Cotrimoxazole is the drug of choice for the treatment of
Antibiotics Dose* Interval Mode
pneumonia. Studies carried out in India have confirmed the

efficacy of cotrimoxazole to be similar to ampicillin and A. First 48 hours 50,000 JU 6 hourly IM

procaine penicillin and cure rates of upto 95% have been Benzyl penicillin per kg/dose
recorded. Cotrimoxazole is less expensive with few side
Ampicillin 50 mg/kg/dose 6 hourly IM
effects and can be used safely by health workers at the
peripheral health facilities and at home by the mothers. Chloramphenicol 25 mg/kg/dose 6 hourly IM

Recommended dose schedule is as shown in Table 6.
B. 1 . If condition IMPROVES, then for the next 3 days give :

Procaine penicillin 50,000 JU/kg Once IM
(maximum 4 lac JU)
Treatment of pneumonia
Daily dose schedule of cotrimoxazole Ampicillin 50 mg/kg/dose 6 hourly Oral
Paediatric tablet : ·. Paediatric syrup : Chloramphenicol 25 mg/kg/dose 6 hourly Oral

Sulphamethoxazole 100 mg Each spoon (5. ml) :
B. 2 . If NO IMPROVEMENT, then for the next 48 hours :
AGE/WEIGHT and Trimethoprim 20 mg Sulphamethoxazole
200 mg and

-Trimethoprim 40 mg If ampicillin is used change to chloramphenicol IM;

If chloramphenicol is used, change to cloxacillin 25 mg/kg/dose, every 6
< 2 months One tablet twice a day Half spoon (2.5 ml) hours along with gentamycin 2 . 5 mg/kg/dose, every eight hours.
(Wt. 3-5 kg) twice a day If condition improves continue treatment orally.

2-12 months Two tablets twice a day One spoon (5 ml) C. Provide symptomatic treatment for fever and wheezing, if
(Wt. 6-9 kg) twice a day

D.Monitor fluid and food intake
1-5 years Three tablets twice a day One. and half spoon
(Wt. 1 0 - 1 9 kg) (7.5 ml) twice a day. E. Advise mother on home management on discharge

* The doses can be rounded off to nearest administrable doses

In children less than two months, cotrimoxazole is not

routinely recommended. These children are to be treated as

for severe pneumonia. However, in case of delay in referral,
cotrimoxazole may be initiated. Cotrimoxazole should not
The treatment in these conditions is, basically the s a m e .
be given to premature babies and cases of neonatal
The child must be hospitalized. Treatment with
j a u n d i c e . Such children when seen by a health worker must
cotrimoxazole may be started by the health worker before
be referred to a health facility.
referring the child. If pneumonia is suspected the child
The condition of the child should be assessed after 48
should be treated with intramuscular injections of b en z yl
hours. Cotrimoxazole should be continued for another 3
penicillin or injection ampicillin, along with injection
days in children who show improvement in clinical
gentamycin. Chloramphenicol is not recommended as the
c o ndition . If there is no significant change in condition
first line of treatment in young infants. The treatment plan is
(neither improvement nor worsening), cotrimoxazole should
as shown in Table 8 .
be continued for another 48 hours and condition reassessed.

If at 48 hours or earlier the condition worsens, the child TABLE 8

should be hospitalized immediately. Treatment of pneumonia in children aged less than 2 months

Children with severe pneumonia should be treated as
< 7 days to 2 months
inpatients with intramuscular injections of benzyl penicillin

(after test dose), ampicillin or chloramphenicol. The In]. Benzyl Penicillin 50,000 JU/kg/dose 12 hourly 6 hourly

condition of the child must be monitored every day and OR

reviewed after 48 hours for antibiotic therapy as detailed in Inj Ampicillin . 50 mg/kg/dose 12 hourly 8 hourly

Table 7 . Antibiotic therapy must be given for a minimum of 5
In]. Gentamycin 2.5 mg/kg/dose 12 hourly 8 hourly
days and continued for at least 3 days after the child gets well.

Besides antibiotics, therapy for the associated conditions,
if any, must be instituted immediately. The child should be

Children with signs of very severe disease are in kept warm and dry. Breast-feeding must be promoted

imminent danger of death, and should be treated in a health strongly as the child who is not breast-fed is at a much

facility, with provision for oxygen therapy and intensive higher risk of diarrhoea.

monitoring, as these cases require supportive therapy in
addition to specific treatment of pneu m o n ia.

Chloramphenicol IM is the drug of choice in all such cases. Many children with presenting symptoms of cough, cold

and fever do not have pneumonia (no fast breathing or chest
Treat for 48 hours - if condition improves switch over to
indrawing) and DO NOT require treatment with antibiotics.
oral c h l o r a m p h e n i c o l . Chloramphenicol should be given for

a total of 10 days. If condition worsens or does not improve Antibiotics are not recommended for coughs and colds

after 48 hours, switch to IM injections of cloxacillin and because majority of cases are caused by viruses and

gentamycin. antibiotics are not effective, they increase resistant strains

and cause side-effects while providing no clinical benefit, vaccine containing capsular antigens of 23 serotypes against

and are wasteful expenditure. Symptomatic treatment and this infection have been available for adults and children

care at home is generally enough for such cases. The over 2 years of age. Children under 2 years of age and

mothers must be advised on how to take care of the child at immunocompromised individuals do not respond well to the

home. vaccine. It is recommended for selected groups, e . g . , those

who have undergone splenectomy or have sickle-cell

Prevention of Acute Respiratory Infections disease, chronic diseases of heart, lung, liver or kidney;

diabetes mellitus, alcoholism, generalized malignancies,
Present understanding of risk factors of respiratory tract
organ transplants etc. In some industrialized countries like
infection in childhood indicates several approaches for
USA it is routinely advised for everyone aged above 65
primary prevention. In developing countries, improved living
years ( 1 3 ) .
conditions, better nutrition and reduction of smoke pollution

indoors will reduce the burden of mortality and morbidity A dose of 0 . 5 ml of PPV23 contains 25 micrograms of

associated with ARI. Other preventive measures include purified capsular polysaccharide from each 23 serotypes.

better MCH care. Immunization is an important measure to For primary immunization, PPV23 is administered as a

reduce cases of pneumonia which occur as a complication of single intra-muscular dose. preferably in the deltoid muscle

vaccine preventable disease, especially measles. It is obvious or as subcutaneous dose. The vaccine should not be mixed
that community support is essential to reduce the disease in the same syringe with other vaccines, for e.g. with
burden. Families with young children must be helped to influenza vaccine, but may be administered at the same time
recognize pneumonia. Health promotional activities are by separate injection in the other arm. Simultaneous
specially important in vulnerable areas ( 1 1 ) . administration does not increase adverse events or decrease

the antibody response to either vaccine. Protective capsular
type-specific antibody levels generally develop by the third
Vaccines hold promise of saving millions of children from week following vaccination (4).
dying of pneumonia. Three vaccines have potential of
Minor adverse reactions, such as transient redness and
reducing deaths from pneumonia. These vaccines work to
pain at the site of injection occur in 30-50 per cent of those
reduce the incidence of bacterial pneumonia.
who have been vaccinated, more commonly following

1 . MEASLES VACCINE subcutaneous administration. Local reactions are more

frequent in recipients of the 2nd dose of the vaccine (4).
Pneumonia is a serious complication of measles and the

most common cause of death associated with measles b. PCV : Two conjugate vaccines are available since

worldwide. Thus, reducing the incidence of measles in young 2009 PCV and PCV • The PCV conjugate vaccine is
10 13 7

children through vaccination would also help to reduce deaths gradually being removed from the market ( 1 4 ) . Both PCV

from pneumonia. A safe and effective vaccine against measles and PCV are preservative free and their recommended

is available for past 40 years. Please refer to page 148 for storage temperature is 2-8°C. The vaccine must not be

details. frozen.

For PCV administration to infants, WHO recommends
3 primary doses (the 3 p + O schedule) or, as an alternative,
Haemophilus influenzae type B (Hib, is an important cause 2 primary doses plus one booster (the 2 p + 1 schedule). In
of pneumonia and meningitis among children in developing 3p+O schedule, vaccination can be initiated as early as
countries. Hib vaccine has been available for more than a 6 weeks of age with an interval betweeen doses of 4-8
decade. It reduces dramatically the incidence of Hib weeks, with doses given at 6, 1 0 and 14 weeks or 2, 4, and
meningitis and pneumonia in infants and nasopharyngeal 6 months, depending on programme convenience ( 1 4 ) .
colonization by Hib bacteria. It's high cost has posed obstacle
If 2p+ 1 schedule is selected, the 2 primary doses are
to its introduction in developing countries.
given during infancy as early as 6 weeks of age at an interval
The vaccine is often given as a combined preparation with
preferably of 8 weeks or more for young infant, and 4-8
DPT and poliomyelitis vaccine. Three or four doses are given
weeks or more between primary doses for infants '?:.7 months
depending on the manufacturers and type of vaccine used,
of age. One booster dose should be given between 9-15
and is given intramuscularly. The vaccine schedule is at 6, 1 0 ,
months of age ( 1 4 ) .
and 14 weeks of age or according to national immunization
Mild reactions like erythema and tenderness to PCV- 7
schedule. In many industrialized countries a booster dose is
occur in upto 50 per cent of recipients, but systemic
given between 12-18 months which provides additional
reactions are unknown. Revaccination is not recommended
benefit to limit burden of Hib disease among children ( 1 2 ) .
for those who had a anaphylactic reaction to initial dose.
For children more than 12 months of age, who have not

received their primary immunization series a single dose is HIV positive and preterm babies who have received their

sufficient for protection. The vaccine is not generally offered 3 primary doses of vaccine before reaching 12 months of
to children aged more than 24 months ( 1 2 ) . age may benefit from a booster dose in the second year of

No serious side-effects have been recorded, and no life. Interrupted schedules should be resumed without

contraindications are known, except for hyper-sensitivity to repeating the previous doses ( 1 4 ) .

previous dose of vaccine. All conjugate vaccine have an When primary immunization is initiated with one of these
excellent safety record, and where tested, do not interfere vaccines, it is recommended that remaining doses are
substantially with immunogenecity of other vaccines given administered with the same product. Interchangeability
simultaneously ( 1 3 ) . between PCV and PCV has yet not been documented.
10 13

WHO recommends inclusion of PCVs in childhood
immunization programme worldwide, particularly in

a. PPV23 : For years, the polysaccharide non-conjugate countries with high under-five mortalities ( 1 4 ) .

9. Epidemiology of Diseases, Edited by Miller, D.L. and Farmer, R . D . ,
The Integrated Global Action Plan for the
Blackwel Scientific Publications.
Prevention and Control of Pneumonia and
10. WHO (1995), The management of acute respiratory infections in
Diarrhoea (15) children, Practical guidelines for outpatient care, World Health

Organization, Geneva.
The Integrated Global Action Plan for the Prevention and
11. Govt of India ( 1 9 9 4 ) , National Child S u r v i v a l and Safe Motherhood
Control of Pneumonia and Diarrhoea (GAPPD) proposes a
Programme, Programme Interventions, MCH Division, Ministry of
cohesive approach to ending preventable pneumonia and
Health and Family Welfare, New Delhi.
diarrhoea deaths. It brings together critical services and
12. WHO (2006), Weekly Epidemiological Record, No. 47, 24th Nov.
interventions to create healthy environments, promotes 2006.

practices known to protect children from disease, and 13. WHO (2006, International Travel and Health.

ensures that every child has access to proven and 14. WHO (2012), Weekly Epidemiological Record, No. 14, 6th April,

appropriate preventive and treatment measures. 2012.

15. WHO, UNICEF (2013), Ending Preventable Child Deaths from
The specific goals for 2025 are to:
Pneumonia and Diarrhoea by 2025. The Integrated Global Action Plan

for Pneumonia and Diarrhoea.
reduce mortality from pneumonia in children less than

5 years of age to fewer than 3 per 1000 live births;
reduce mortality from diarrhoea in children less than 5
· • (SARS) ·. . , .
years of age to fewer than 1 per 1000 live births;

reduce the incidence of severe pneumonia by 75% in
Severe acute respiratory syndrome (SARS) is a
children less than 5 years of age compared to 2 0 1 0
communicable viral disease, caused by a new strain of
coronavirus, which differs considerably in genetic structure
reduce the incidence of severe diarrhoea by 75% in
from previously recognized coronavirus.
children less than 5 years of age compared to 2010

levels; The most common symptoms in patient progressing to

SARS include fever, malaise, chills, headache myalgia,
reduce by 40% the global number of children less than 5
dizziness, cough, sore throat and running nose. In some
years of age who are stunted compared to 2 0 1 0 levels.
cases there is rapid deterioration with low oxygen saturation
Theses goals are ambitious and will require significant
and acute respiratory distress requiring ventilatory support.
political will and mobilization of additional resources if they
It is capable of causing death. in as many as 10 per cent
are to be reached.
cases ( 1 ) .

Coverage targets to be maintained or reached have also
Chest X-ray findings typically begin with a small,
been set to define efforts needed to attain the above goals.
unilateral patchy shadowing, and progress over 1-2 days to
These are:
become bilateral and generalized, with interstitial/confluent

By the end of 2025: infiltration. Adult respiratory distress syndrome has been

observed in a number of patients in the end stages.
90% full-dose coverage of each relevant vaccine

(with 80% coverage in every district);
Problem statement
90% access to appropriate pneumonia and
The earliest case was traced to a health care worker in
diarrhoea case management (with 80% coverage
China, in late 2002, with rapid spread to Hong Kong,
in every district);
Singapore, Vietnam, Taiwan and Taranto. As of early August
at least 50% coverage of exclusive breast-feeding
2003, about 8,422 cases were reported to the WHO from 30
during the first 6 months of life;
countries with 9 1 6 fatalities (2).

- virtual elimination of paediatric HIV.
Incubation period
By the end of 2030:
The incubation period has been estimated to be 2 to 7
universal access to basic drinking-water in health
days, commonly 3 to 5 days ( 1 ) .
care facilities and homes;

universal access to adequate sanitation in health Mode of transmission

care facilities by 2030 and in homes by 2040;
The primary mode of transmission appears to be through
universal access to handwashing facilities (water direct or indirect contact of mucous membranes of eyes,
and soap) in health care facilities and homes; nose, or mouth with respiratory droplets or fomites. The use

universal access to clean and safe energy of aerosol-generating procedures (endotracheal intubation,

technologies in health care facilities and h o m e s . bronchoscopy, nebulization treatments) in hospitals may

amplify the transmission of the SARS coronavirus. The virus

References is shed in stools but the role of faecal-oral transmission is

unknown. The natural reservoir appears to be the horseshoe
1. WHO ( 1 9 9 9 ) , Health Situation in the South-East Asia Region 1994-

1997, Regional Office for SEAR, New Delhi.
bat (which eats and drops fruits ingested by civets, the

2. WHO (1995), The World Health Report 1995, Bridging the gaps, earlier presumed reservoir and a likely amplifying host).

Report of the Director-General. ·
The SARS virus can survive for hours on common
3. UNICEF, WHO (2006), Pneumonia theforgotton killer of children.
surfaces outside the human body, and up to four days in
4. WHO (2008), Weekly Epidemiological Record, No. 42, 17th Oct,
human waste. The virus can survive at least for 24 hours on
a plastic surface at irqom temperature, and can live for
5. WHO (2008), Weekly Epidemiological Record, No. 7, 15th Feb, 2008.
extended periods in the cold.
6. WHO ( 2 0 1 4 ) , World Health Statistics 2014.

7. UNICEF ( 2 0 1 4 ) , The State of Worlds Children, 2 0 1 4 .
C a s e definition (4)
8. Govt. of India ( 2 0 1 4 ) , National Health Profile 2013, DGHS, Ministry of ,::-;:>,

Health and Family Welfare, New Delhi. The case definition is based on current understanding of
the clinical features of SARS, and available epidemiological E p i d e m i o l o g i c a l aspect
data. It may be revised as new information accumulates.
Health care workers, especially those involved in

procedures generating aerosols, accounted for 2 1 per cent of
Case definition for notification of SARS under the
all cases. Maximum virus excretion from the respiratory tract
International Health Regulation (2005)
occurs on about day 10 of illness and then declines. The
In the period following an outbreak of SARS, a notifiable
efficiency of transmission appears to be greatest following
case of SARS is defined as an individual with laboratory
exposure to severely ill patients or those experiencing rapid
confirmation of infection with SARS coronavirus (SARS­
clinical deterioration, usually during the second week of
CoV) who either fulfils the clinical case definition of SARS or
illness. When symptomatic cases were isolated within 5 days
has worked in a laboratory handling live SARS-CoV or
of the onset of illness, few cases of secondary transmission
storing clinical specimens infected with SARS-CoV.
occurred. There was no evidence that patient transmits

infection 1 0 days after fever has resolved.
Clinical case definition of SARS
Children are rarely affected by SARS. To date, there have
1. A history of fever, or documented fever
been two reported cases of transmission from children to
AND adults and no report of transmission from child to child.

2. One or more symptoms of lower respiratory tract illness Three separate epidemiological investigations have not

(cough, difficulty in breathing, shortness ?f breath) found any evidence of SARS transmission in schools.

Furthermore, no evidence of SARS has been found in
infants of mothers who were infected during pregnancy.
3. Radiographic evidence of lung infiltrates consistent with

pneumonia or acute respiratory distress syndrome International flights have been associated with the

transmission of SARS from symptomatic probable cases to
(ARDS) or autopsy findings consistent with the
passengers or crew. WHO recommends exit screening and
pathology of pneumonia or ARDS without an identifiable
other measures to reduce opportunities for further
international spread associated with air travel during the
epidemic period.
4. No alternative diagnosis fully explaining the illness.

Diagnostic tests required for laboratory confirmation of
As with any viral pneumonia, pulmonary
decompensation is the most feared problem. ARDS occurs in
{a) Conventional reverse transcriptase PCR (RT-PCR) and about 1 6 % patients, and about 20-30% of patients require
real-time reverse transcriptase PCR (real-time RT-PCR) . intubation and mechanical ventilation. Sequelae of intensive
assay detecting viral RNA present i n : care include infection with nosocomial pathogens, tension

pneumothorax from. ventilation at high peak pressures, and
1. At least 2 different clinical specimens (e.g.

nasopharyngeal and stool specimens) non-cardiogenic pulmonary edema.


2. The same clinical specimen collected on 2 or more
Severe cases require intensive support. Although a number
occasions during the course of the illness (e.g.
of different agents including ribavirin (400-600 mg/d and
sequential nasopharyngeal aspirates)
4 g/d), lopinavir/ritonavir ( 400 mg/100 m g ) , interferon type 1 ,

OR intravenous immunoglobulin, and systemic cortiocosteroids

3. A new extract from the original clinical sample tested were used to treat SARS patients during the 2003 epidemic,

positive by 2 different assays or repeat RT-PCR or the treatment efficacy of these therapeutic agents

real-time RT-PCR on each occasion of testing remains inconclusive and further research is needed.

Subsequent studies with ribavirin show no activity against the
virus in vitro, and a retrospective analysis of the epidemic in
4. Virus culture from any clinical specimen.
Toronto suggests worse outcomes in patients who receive the

(b) Enzyme-linked immunosorbent assay (ELISA) and drug (5).

immunofluorescent assay (!FA)
1. Negative antibody test on serum collected during the
The overall mortality rate of identified cases is about
acute phase of illness, followed by positive antibody
1 4 % . Mortality is age-related, ranging from less than 1 % in
test on convalescent-phase serum, tested
persons under 24 years of age to greater than 50% in
persons over 65 years of age. Poor prognostic factors
include advanced age, chronic hepatitis B infection treated
2. A 4-fold or greater rise in antibody titre against with lamivudine, high initial or high peak lactate
SARS-CoV between an acute-phase serum specimen dehydrogenase concentration, high neutrophil count on
and a convalescent-phase serum specimen (paired presentation, diabetes mellitus, acute kidney disease, and
sera), tested simultaneously. low counts of CD4 and CD8 on presentation. Many

In the absence of known SARS-CoV transmission to subclinical cases probably go undiagnosed. Seasonality, as

humans, the positive predictive value of a SARS-CoV with influenza, is not established ( 5 ) .

diagnostic test is extremely low; therefore, the diagnosis
should be independently verified in one or more WHO

international SARS reference and verification network As there is no vaccine against SARS, the preventive

laboratories. Every single case of SARS must be reported to measures for SARS control are appropriate detection and

WHO. . protective measures which include :

1. Prompt identification of persons with SARS, their were HIV positives, and 3 . 5 per cent of the new and 2 0 . 5 per

movements and contacts; cent of previously treated cases were of MDR-TB. It is

2. Effective isolation of SARS patients in hospitals; estimated that about 1 . 5 million people died of TB, of these

3. Appropriate protection of medical staff treating these 360,000 were HIV positive and 2 1 0 , 0 0 0 MDR-TB cases.

patients; About 60 per cent of TB cases and deaths occur among
4. Comprehensive identification and isolation of suspected men, but burden of disease ( 3 . 3 million) among women is
SARS cases; high. In 2 0 1 3 , an estimated 5 1 0 , 0 0 0 women died as a result

5. Simple hygienic measures such as hand-washing after of TB, more than one-third of whom were H l v p o s i t i v e . An

touching patients, use of appropriate and well-fitted estimated 550,000 (6 per cent of total cases) children under

masks, and introduction of infection control measures; 15 years of age had TB of whom 80,000 died.

6. Exit screening of international travellers;
TB detection and treatment outcome : During 2 0 1 3 , of
7. Timely and accurate reporting and sharing of the estimated 9 million cases, only 6 . 1 million cases were
information with other authorities and/or governments.
reported to WHO. Of these 5 . 7 million were people newly

diagnosed and 0.4 million were already on treatment. The
notification rate was about 64 per cent. About 3 million
1. WHO ( 2 0 0 3 ) , Weekly Epidemiological Record No. 12, 2 1 March 2003.
missed cases were either not diagnosed or diagnosed but not
2. WHO (2003), World Health Report 2003, Shaping the future.
3. W H O (2003), Weekly Epidemiological Record No. 43, 24th Oct. 2003.
In 2 0 1 3 , the treatment success rate continued to be high
4. WHO (2009), Weekly Epidemiological Record No. 7, 13th Feb. 2009.

5. Stephen J. Mcphee et al, (2010), Current Medical Diagnosis and at 86 per cent among all new TB cases.

Treatment, 49th Ed. A Lange Medical Publication.
The South East Asia Region accounts for 39 per cent of

the global burden of TB in terms of incidence and India

alone accounts for 24 per cent of the world's TB cases. It is

estimated that about 3 . 4 million new cases of TB continue to

Tuberculosis is a specific infectious disease caused by occur each year in this Region, most of them in India,

M. tuberculosis. The disease primarily affects lungs and Bangladesh, Indonesia, Myanmar and Thailand. 6.2 per

causes pulmonary tuberculosis. It can also affect intestine, cent of the cases with HIV known status (39 per cent of total

meninges, bones and joints, lymph glands, skin and other SEAR cases) were HIV-positive. 89 per cent of HIV-positive

tissues of the body. The disease is usually chronic with TB cases were on co-trimoxazole preventive therapy and

varying clinical manifestations. The disease also affects 61 per cent of these cases were put on antiretroviral therapy.

animals like cattle; this is known as "bovine tuberculosis", Level of MDR-TB is still low in the Region (less than 2 . 2 per

which may sometimes be communicated to man. Pulmonary · cent), however, this translates into nearly 9 0 , 0 0 0 estimated

tuberculosis, the most important form of tuberculosis which MDR-TB cases among all the notified TB cases in 2 0 1 2 (3).

affects m a n , will be considered here. Each year, more than 2 million TB cases are registered for

treatment with more than 85 per cent success rate of new
Problem statement sputum smear positive cases. TB mortality rate has

WORLD decreased more than 40 per cent since 1990 (3).

Tuberculosis remains a worldwide public health problem The actual burden of paediatric TB is not known due to

despite the fact that the causative organism was discovered diagnostic difficulties. It is assumed that about 1 0 per cent of

more than 100 years ago and highly effective drugs and total TB load is found in children. Globally, about 1 million

vaccine are available making tuberculosis a preventable and cases of paediatric TB are estimated to occur every year, with

curable disease. Technologically advanced countries have more than 100,000 deaths (4). Childhood deaths from TB

achieved spectacular results in the control of tuberculosis. are usually caused by meningitis or disseminated disease ( 1 ) .

This decline started long before the advent of BCG or Though MDR-TB and XDR-TB is documented among

chemotherapy and has been attributed to changes in the paediatric age groups, there are no estimates of overall

"non-specific" determinants of the disease such as burden because of diagnostic difficulties and exclusion of

improvements in the standard of living and the quality of life children in most of the drug resistant surveys (4).

of the people coupled with the application of available In many developing countries, acquired drug resistance
technical knowledge and health resources. remains high, because national tuberculosis control

It is estimated that about one-third of the current global programmes in these countries have not been able to

population is infected asymptomatically with tuberculosis, of achieve a high cure rate over a very long period of time,

whom 5-10 per cent will develop clinical disease during even after the introduction of short-course chemotherapy.

their lifetime. Most new cases and deaths occur in Poverty, economic recession, malnutrition, overcrowding,

developing countries where infection is often acquired in indoor air pollution, tobacco, alcohol abuse and diabetes

childhood. The annual risk of tuberculosis infection in high make populations more vulnerable to tuberculosis. Increase

burden countries is estimated to be 0.5-2 per cent (1). in human migration has rapidly mixed infected with

Patients with infectious pulmonary tuberculosis disease can uninfected communities. To make global situation worse,

infect 1 0 - 1 5 persons in a year. tuberculosis has formed a lethal combination with HIV.

Tuberculosis remains a major global health problem. The DOTS remains central to the public health approach to

current global picture of TB shows continued progress but not tuberculosis control, which is now presented as Stop TB

fast enough. During the year 2013, an estimated Strategy. To be classified as DOTS, a country must have

9 million people developed TB, which is equivalent to officially accepted and adopted the strategy by 2004, and

126 cases per 100,000 population. Most of the cases must have implemented the four technical components of

occurred in Asia (56 per cent) and the African regions DOTS in at least part of the country. DOTS coverage is

(29 per cent). Of these incident cases 1 . 1 million ( 1 3 per cent) defined as the percentage of the national population living