community medicine topic covered

1. MANAGEMENT OF
ACUTE RESPIRATORY
INFECTIONS AND
INFLUENZA IN
CHILDREN OF 2
MONTHS TO 5
YEARS OLD.
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2. Acute respiratory infections (ARI’S) are classified
as:
• Upper respiratory infections (URI)
• Lower respiratory infections (LRI)
It is a common cause of illness in children
under 5yr and is a major cause of morbidity
and mortality in them.
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The causative agents depend on:
1.Age
2.Immune status
3.Seasonal variations
4.Setting in which the infection is acquired i.e.
community or hospital acquired.
 Some of the agents causing infection and its
clinical features are :-

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AGENT CLINICAL FEATURES
A. BACTERIA
• BORDETELLA PERTUSSIS
• CORYNEBACTERIUM DIPTHERIAE
• HEMOPHILUS INFLUENZAE
• STAPHYLOCOCCUS PYOGENES
• STREPTOCOCCUS PNEUMONIAE
• STREPTOCOCCUS PYOGENES
Paroxysmal cough
Nasal/ tonsillar/pharyngeal
membranous exudate with or without
severe toxaemia
Acute epiglottitis (type B)
Lobar or bronchopneumonia
Acute exacerbations of chronic
bronchitis
Acute pharyngitis and tonsillitis
B. VIRUS
• ADENOVIRUS(endemic types 1,2,5)
• ENTEROVIRUS (ECHO & Coxsackie)
• INFLUENZA A
• CORONAVIRUSES AND
RHINOVIRUSES
• PARAINFLUENZA VIRUSES
Lower respiratory infection
Variable respiratory infection
Fever , aching, malaise, occasional
primary pneumonia
Common cold
Croup and severe bronchiolitis and
pneumonia
C. OTHER AGENTS

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CONTROL TREATMEN
T
PREVENTIO
N

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CONTROL OF ARIs
 Improving the primary medical care services and developing
better methods for early detection, treatment and where
possible, prevention of acute respiratory infections is the best
strategy to control ARI.
 Effective reduction of mortality due to pneumonia is possible
if children suffering from it are treated correctly.
 Education of mother is also necessary since compliance with
treatment and seeking care promptly when signs of
pneumonia are observed.
 The WHO guidelines include :
1. Clinical assessment
2. Physical examination

7. 1. CLINICAL ASSESSMENT
• History taking and clinical assessment is very important in
management of ARI.
• Points to be noted are following:
a. Age of child
b. For how long child is coughing
c. Whether child is able to drink water or not
d. History of any antecedent illness like measles, etc
e. Fever is present or absent
f. Child is drowsy or not or if he finds difficulty in waking up (if yes,
then for how long )
g. Presence of convulsions?
h. History of irregular breathing
i. H/O short periods of not breathing or child turning blue
j. H/O treatment during the illness
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8. 2. PHYSICAL EXAMINATION
• Look and listen for the following :
1) COUNT THE BREATHS IN ONE MINUTE : As the children
get older, their breathing rate slows down. The chest and
abdomen must be exposed for counting. Count the
respiratory rate for full one minute. Fast breathing is
present when the respiratory rate is :
• 60 breaths per minute or more in a child less than 2 months
of age
• 50 breaths per minute or more in a child aged 2 months upto
12 months
• 40 breaths per minute or more in a child aged 12 months
upto 5 years
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2) LOOK FOR CHEST INDRAWING : Look for chest
indrawing when the child breaths IN. The child has indrawing
if the lower chest wall goes in when the child breaths in. Chest
indrawing occurs when the effort required to breath in, is
much greater than normal.
3) LOOK AND LISTEN FOR STRIDOR : A child with stridor
makes a harsh noise when breathing IN. Stridor occurs when
there is narrowing of the larynx, trachea or epiglottis which
interferes with air entering the lungs. These conditions are
called croup.
4) LOOK FOR WHEEZE : Presence of soft wheezing noise
maybe present or the child might show signs that breathing
OUT is difficult. Wheezing is caused by narrowing of air
passages in the lungs. H/O of previous episodes of wheezing
is asked.

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5) See if the child is abnormally sleepy or difficult to wake. An abnormally
sleepy child is drowsy most of the time when he or she should be awake
or alert.
6) Feel for fever or low body temperature.
7) CHECK FOR SEVERE MALNUTRITION : Malnutrition is a high risk
factor and case fatality rates are higher in such children. In severly
malnourished chidren with pneumonia, fast breathing and chest indrawing
may not be as evident as in other children. These children need careful
evaluation for pneumonia as well as careful management.
8) Cyanosis is a sign of hypoxia. Cyanosis must br checked in good light.
9) Nasal mucosa might show signs of eythema or edema maybe
present.
10) Nasal discharge is present in case of viral infections
11) Foul breath maybe present due to processing of inflammatory
products by the resident flora.
12) ORAL MUCOSA: Pharyngeal erythema, sputum production, palate
vesicles or ulcers, ulcerative stomatitis, tonsillar hypertrophy
13) Conjunctivitis in case of adenovirus infection.
14) PERCUSSION: resonant, hyper-resonant, dull, stony dull
15) AUSCULTATION: breath sounds, added sounds

11. TREATMENT ACCORDING TO THE
CLINICAL ILLNESS
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1. VERY SEVERE DISEASE 2. SEVERE PNEUMONIA
3. PNEUMONIA (NOT
SEVERE)
4. NO PNEUMONIA : COUGH
OR COLD
TYPES OF
CLINICAL
ILLNESSES

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14. PHARMACOTHERAPY
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In children of less than 2 months, cotrimoxazole is not routinely
recommended. These children are treated as for severe pneumonia.
The condition of the child is to be assessed after 48 hrs.
(2.5 ml)
(5 ml)
(7.5 ml)

16. FOR VERY SEVERE DISEASE
• Children with signs of very severe disease are in
imminent danger of death, and should be treated in a
health facility with provision for oxygen therapy and
intensive monitoring, as these cases require
supportive therapy in addition to specific treatment of
pneumonia.
• Chloramphenicol IM is the D.O.C. in such cases.
• Treat for 48 hrs – if condition improves switch over to
oral dose and if the condition worsens or does not
improve then switch to IM injections of Cloxacillin
and Gentamycin.
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17. PREVENTION OF ARI’S
• In developing countries, improved living conditions,
better nutrition and reduction of smoke pollution
indoors will reduce the burden of mortality and
morbidity associated with ARI.
• Better MCH care.
• Immunisation is also an important measure to reduce
cases of pneumonia which occur as a complication f
vaccine preventable disease, especially measles.
• Health promotional activities are specially important
in vulnerable areas.
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18. IMMUNIZATION
MEASLES VACCINE
Pneumonia is a serious
complication of measles and the
most common cause of death
associated with measles
worldwide.
Thus, reducing the incidence of
measles in children by
vaccination would also help to
reduce deaths from pneumonia.
HIB VACCINE
Haemophilus influenzae type B
is an important cause of
pneumonia and meningitis
among the children in
developing countries. The
vaccine is often given in
combination with DPT and
polio vaccine. The vaccine
schedule is at 6,10,and 14
weeks of age. A booster doses is
given between 12-18 months
which provides additional
benefit to limit burden of Hib
disease among children
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19. INFLUENZA
 Influenza is an acute respiratory tract infection
caused by influenza virus, of which there are
4 types – A,B,C and D.
 Type A and B are the strains causing the
epidemics.
 The disease is characterised by sudden onset
of chills, malaise, fever, muscular pains and
cough.
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20. INVESTIGATIONS
 Routine baseline investigations.
 Confirmation of H1N1
 Real time (RT PCR)
 Isolation of virus in culture.
 Four fold rise in virus specific neutralizing antibodies.
 Clinical specimens :
a. nasopharyngeal swab
b. throat swab
c. nasal swab
d. tracheal aspirate (for intubated patients)
 Collect before administration of anti viral drugs
 Keep the specimens at 4 degree celsius in the viral transport media until
transported.
 Should be transported within 24 hrs. if not then should be stored at -70
degree celsius.
 Paired blood samples at an interval of 14 days for serological testing
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21. PHARMACOLOGICAL
TREATMENT
OSELTAMIVIR
 NA inhibitor
 Can be given as young as 2 weeks of life
 Used for both prophylaxis and treatment.
 In age >1 year :
a) <15kg – 30 mg BD for 5 days
b) 15 – 23kg – 45mg BD for 5 days.
c) 24-<40kg – 60mg BD for 5 days
d) >40kg – 75mg BD for 5 days
 Transient nausea and vomitting are the common side effects.
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ZANAMIVIR
 NA inhibitors
 Used in oseltamivir resistant
cases
 Available in inhalational and IV
preparations
 Recommended in age 7 years
and older
 Treatment :
10mg BD for 5 days
 Prophylaxis
10mg OD for 5 days

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24. CHEMOPROPHYLAXIS
 Oseltamivir is the drug of choice.
 But in case of influenza-B Zanamivir is used. If
this is contraindicated then Rimantadine is used.
 For 10 days after the last exposure
 Maximum period of 6 weeks
 Age >1 year :
a) <15kg – 30 mg BD for 5 days
b) 15 – 23kg – 45mg BD for 5 days.
c) 24-<40kg – 60mg BD for 5 days
d) >40kg – 75mg BD for 5 days
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25. VACCINES
A. KILLED VACCINES
• Inactivated influenza vaccine (IIP) (Trivalent)
• Three strains are used
• Antibodies will develop 2 weeks after vaccination
• IM route
• Protective efficacy is 50 to 60 %
• Excellent safety profile/ costs around 650 rupees
• Recommended after 6 completed months
• 6 months to8 years 0.25ml / 2 doses / 4 weeks apart / per year.
• Soreness, redness and tenderness over injection site are
common SE.
• Contra indicated in people who are at higher risk of
developing complications.
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B. LIVE ATTENUATED VACCINES
• Trivalent
• administered as a single dose intranasal spray.
• It is effective in preventing the disease.
• Approved for use in healthy individuals between 2 years
and 49 years of age.
• Because the risk of transmission of live attenuated
vaccine virus to immunocompromised individuals is
unknown, it should not be used in household members of
immunocompromised individuals, health care workers
or others with close contact with immunosuppressed
persons.

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