MODULE V Management of Prevalent Infections in Children Following a Disaster.
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Transcript of MODULE V Management of Prevalent Infections in Children Following a Disaster.
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MODULE V
Management of Prevalent Infections in Children Following a Disaster
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• Acute respiratory infections
• Diarrhea and dehydration
• Measles
• Malaria
• Malnutrition
MAIN CAUSES OF DEATH
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The IMCI strategy
2 components based on the child’s age:
•sick young infant aged up to 2 months
•sick child aged 2 months up to 5 years
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The IMCI strategy
• The clinical decision making approach involves using a limited number of symptoms and signs to classify the severity of illness, which determines the management with guidelines for follow-up, counseling for the parents, and instructions regarding when to return additional care is needed.
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Management
• Pink: needs to be urgently referred to a
higher level of care
• Yellow: requires specific treatments
• Green: can be safely managed at home with supportive care
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Sick young infant aged up to 2 months
• Classification and management of severe disease (pneumonia, meningitis, and sepsis), local bacterial infection, jaundice, diarrhea, HIV infection, poor weight gain, breast feeding and other feeding problems, immunization status, and mother’s health.
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Severe disease (PINK)
• Not feeding, convulsions, fast breathing (more than 60 breaths per minute) severe chest indrawing, fever or low temperature, and lack of movement.
• Refer urgently to the hospital with a first antibiotic dose and treatment to prevent low blood sugar
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Local bacterial infection (YELLOW)
• Signs of umbilical infection (redness and or purulent discharge) or skin pustules
• Treat with an appropriate antibiotic.
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Sick child aged 2 months up to 5 years
• Classification and management of respiratory disease, diarrhea, febrile illness (malaria), measles, ear infections, malnutrition, anemia, HIV, and immunization status.
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IMCI STRATEGY DANGER SIGNS
• Unable to drink or breast feed (too weak)
• Vomits everything
• Had convulsions
• Lethargic or unconscious
• Convulsing now
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Very severe respiratory disease
Any general danger sign
Stridor in a calm child
PneumoniaFast breathing
Chest indrawing
Cough without pneumonia
No signs of pneumonia or severe disease
IMCI: COUGH OR DIFFICULT BREATHING
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ANTIBIOTIC ARSENAL
• Oral antibiotics
– Amoxicillin
– Cotrimoxazole (TMPSMX)
• Intramuscular (IM) antibiotics
– Benzylpenicillin
– Cefuroxime or Ceftriaxone
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INFLUENZA VIRUS
• Family Orthomyxoviridae– “myxo” mucus
– segmented, single-stranded RNA
• Influenza A first isolated 1933; Influenza B 1940
• 15 hemagglutinin (HA) and 9 neuraminidase (NA) subtypes– Only H1N1, H2N2, H3N2
subtypes associated with widespread epidemics in humans
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CLINICALLY RELEVANT INFLUENZA VIRUSES
Type A Potentially severe illnessEpidemics and pandemicsRapidly changingBirds, swine, horses, seals, humans
Type B Usually less severe illnessEpidemicsMore uniformHumans
Type C Usually mild or asymptomatic illness Minimal public health impactHumans, swine
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INFLUENZA: A CONTINUOUSLY CHANGING VIRUS
Polymerase Proteins (PP)
Hemagglutinin (HA) *cell entry
Neuraminidase (NA)*cell escape
M1, M2
Nucleoprotein (NP)
Adapted from: Hayden FG et al. Clin Virol. 1997:911-942.
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RNA
Hemagglutinin
NeuraminidaseAntibodies
Sialic acid
ANTIGENIC DRIFT (A & B)
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ANTIGENIC SHIFT (A ONLY)
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TRANSMISSION OF INFLUENZA
• Person to person
• Droplet spread
– small particle aerosols
• Fomite contamination
– Steel and plastic 24-48 hrs
– Cloth, paper, tissues 8-12 hrs
– Hands 5 min (high viral titer)
• Principal site of replication- columnar epithelium
• Incubation period- 18 hrs to 5 or more days (average 2-3 days)
• Virus shedding 3-7 days
• Viral titers are generally higher in young children with shedding lasting 10 days or longer
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RECOGNIZING PEDIATRIC INFLUENZARECOGNIZING PEDIATRIC INFLUENZA
Neonates Infants/Toddlers Children/Teens
High fever GI symptoms Rapid onsetLethargy Fever >103°F (>39.5°C) High feverDecreased eating Anorexia CoughMottling Respiratory syndromes ChillsApnea Malaise
HeadacheSore throat
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INFLUENZA VIRUS INFECTION COMPLICATIONS
• Acute otitis media (children)
• Sinusitis• Pneumonia• Exacerbation of
underlying illness• Dehydration (infants)
• Encephalopathy• Reye syndrome
(children)• Myositis• Myocarditis• Febrile seizures
Common ComplicationsCommon Complications Uncommon ComplicationsUncommon Complications
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MEASLES
• Highly contagious infection (98-100% in susceptible contacts)
• Transmission through respiratory secretions (contact and aerosolized particles)
• Incubation period: 10-14 days
• Mortality rate Nutrition / crowding / inoculum
Overcrowded living conditions are an important
triggering factor for epidemics
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NATURAL HISTORY OF MEASLES
Identification of one case in a camp should speed up
immunization process
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7Incubation 10-14 days
Fever ------------- FEVER--------------------] Cough ---------------------------------------------------- - - - Conjunctivitis ----------------------------------------- - - - Coryza ------------------------------------------------- - - -
Köplik spots---]
Exposure
Rash ---------------- - - -
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RASH – DAY 1
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RASH – DAY 2
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MEASLES: CLINICAL MANIFESTATIONSKÖPLIK SPOTS
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MEASLES AND VITAMIN A DEFICIENCY
MEASLES unmasks an underlying Vitamin A deficiency
SYNERGIC EFFECT
VITAMIN A DEFICIENCY (even subclinical) increases measles-associated morbidity
and mortality
Measles-associated morbidity and mortality may be reduced by administering Vitamin A to high risk
populations
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Measles Managment
• Evaluate for associated infections
• Classify any child having a general danger sign, clouding of the cornea, or deep or extensive mouth ulcers as severe complicated measles and refer urgently to the hospital with vitamin A, the first dose of an appropriate antibiotic, and if there is eye discharge or corneal clouding an dose of tetracycline eye ointment.
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Measles Managment
• The presence of eye drainage and or mouth ulcers without other signs is classified as yellow. Treatment includes Vitamin A, tetracycline eye ointment for eye discharge, and gentian violet for mouth ulcers. These children need a follow up visit in 3 days.
• A child without complications is green and needs only vitamin A.
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ALGORITHM FOR A SUSPECTED CASE OF MEASLESChild with fever
and rash consistent with measles
Report case toAlert System
Search for othercases andQuarantine
Start response and
prevention
Measles vaccinePriority groups
Resources and logistics
Case Confirmation• Laboratory tests
Local response• Guarantee vaccines• Vitamin A• National Response Team
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Incubation
HeadacheMyalgiaRashBone painVomiting
Abdominal PainCyanosisShockHemorrhagesHepatitisPlasma leakage
DENGUE
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CLINICAL MANIFESTATIONS OF DENGUE
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Grade Hemorrhage Platelets CapillaryPermeability
I Positive <100,000 Plasma leakage*tourniquet test
II Spontaneous <100,000 Plasma leakage*bleeding
III (DSS) Spontaneous <100,000 Plasma leakage+bleeding PP <20 mmHg
Hypotension
IV (DSS) Spontaneous <100,000 Profound shockbleeding Absent pulse or BP
*Hct admission >20%/age or reduction Hct >20% post-resuscitation fluidsPP: pulse pressure
WHO GUIDELINES FOR THE DIAGNOSIS OF DENGUE HEMORRHAGIC FEVER (DHF)
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• 80% asymptomatic infections
• Unusual manifestations
– Hepatitis
– Encephalopathy
– Pancreatitis
– Pleural effusion
DENGUE MANIFESTATIONS IN CHILDREN
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• Rest
• Acetaminophen/Paracetamol
• No aspirin or NSAIDs
• No antibiotics
• Oral rehydration (WHO solution)
50 mL/kg over 4-6 hours
Maintenance 80-100 mL/kg/day
• Monitor CNS signs
MANAGEMENT OF THE CHILD WITH DENGUE
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• Hospitalization in case of grade II HDF
Platelets <100,000
Hematocrit > 20% over normal
• Colloid solutions at 6 mL/kg/hr
MANAGEMENT OF THE CHILD WITH HEMORRHAGIC DENGUE
Improvement Worsening
3 mL/kg/hr 10 mL/kg/hr
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MALARIA
Caused by a protozoal blood parasite capable of causing a wide spectrum of diseases
Plasmodium vivaxPlasmodium ovalePlasmodium malariae
• Geographical distribution: Tropic / Subtropics
• Transmission: Anopheles mosquito
Plasmodium falciparum
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MALARIA SUSCEPTIBILITY
In endemic areas, there is partial immunity in older children and adults due to previous infection
Most susceptible individuals to severe and fatal malaria: • Non-immune and immunocompromised people • Infants and young children, pregnant women and malnourished •Plasmodium falciparum-infected people
Infection
Identification of parasitemia
Asymptomatic
DiseasePresence of signs and
symptoms
Acute, subacute, chronic
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FEVER
37
38
39
Non-specific Pattern
39
38
37
Classical Pattern
Partially immune patients may develop moderate fever with a non-specific pattern
Patients will feel and look sick due to fever, but they will feel relatively well between paroxysms of fever
Associated chills, headache, myalgia
MALARIACLINICAL MANIFESTATIONS
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Severe Malaria
• Parasitemia is >5%• Any of the following complications:
-prostration (patient unable to sit or walk)
-multiple convulsions
-impaired consciousness not attributable
to another cause
-abnormal bleeding
-meningeal signs
-jaundice ( hemolysis)
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Malaria Diagnosis
• Rapid diagnostic tests– Bedside testing
• Thick and thin blood smears– Difficult in a disaster situation
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Malaria Management
• The clinical diagnosis of malaria based on non specific signs and symptoms tends to be highly inaccurate.
• When a patient presents with febrile illness who lives in an area with malaria, in the absence of available diagnostic testing begin treatment when the clinical history and presentation are consistent with malaria.
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Types of Malaria
P. falciparum – Most severe type of MALARIA (MALIGNANT)
High lethality rate in infected individuals
Highly drug-resistant
Plasmodium vivax “BENIGN” MALARIA Plasmodium ovale Most are sensitive Plasmodium malariae to chloroquine
• These infections cause morbidity and contribute to multifactorial mortality
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Treatment of Uncomplicated Malaria: P. Falciparum or Unknown Species
Preferred Therapies (check your country policy):
Atovaquone-Proguanil (Malarone)
– 4 adult tabs (1000mg Atovaquone) po qd x 3 days
Artemether-lumefantrine (Coartem)– 4 tablets immediately, 4 tablets 8 hours later, then
4 tablets BID for 4 more doses
Second-Line Therapies:
Quinine sulfate plus: Doxycycline, Tetracycline, or Clindamycin
Mefloquine
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Uncomplicated Malaria: Chloroquine-Sensitive Species/Areas
• Children: a total dose of 25 mg/kg of CHLOROQUINE over a 3-day period
t = 0 10 mg/kg po
t = 6 h 5 mg/kg po or 10mg/kg
t = 24 h 5 mg/kg po at t = 24 h
t = 48 h 5 mg/kg po
• Adults: similar schedule. 1 gr followed by 500 mg x 3
• Pregnant women: Malaria is SEVERE. Chloroquine treatment is safe
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Malaria Supportive Treatment
• Fever control– Antipyretics, no more than a few doses– Cool compresses
• Dehydration– Oral rehydration solution, increased need for fluids
• Malnutrition– Assess and treat
Anticipate symptom resolution at 48-72 hours
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Severe complicated malaria treatment
• First line (preferred treatment) is
Artesunate parentral (IV/IM). • In the absence of parenteral form of Artesunate,
Artemether IM is acceptable. • Quinine is acceptable option but requires
attention to the proper dosage and administration with IV fluids. There is a loading dose and maintenance dose and care needs to be taken to prevent hypoglycemia
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Thank you