CDI Module 17: Community Management of Pneumonia ©Jhpiego Corporation The Johns Hopkins University A Training Program on Community-Directed Intervention (CDI) to Improve Access to Essential Health Services

Module 17 Objectives By the end of this module, learners will: Describe the global burden of pneumonia and reasons it cannot be neglected Describe the signs and symptoms of pneumonia and its relationship to other acute respiratory infections (ARIs) Define pneumonia Describe methods for prevention and treatment of pneumonia

Why We Cannot Ignore Pneumonia in Efforts to Control Malaria Pneumonia kills more children than any other illness Any effort to improve overall child survival must make the reduction of pneumonia’s death toll a priority More than 35 million childhood pneumonia episodes occur in African children each year More than one million of these children die

Pneumonia Is Common in Africa

Relation Between Pneumonia and Other ARIs Pneumonia and other ARIs share similar clinical features such as presence of: Fever Cough Vomiting (sometimes) Chest pain/indrawing Rapid breathing Zinc and vitamin A are useful in managing both pneumonia and ARI, especially lower ARI Co-trimoxazole and amoxicillin are effective drugs against pneumonias caused by some bacterial pathogens, but these do not cure ARI caused by viruses

Recognizing Pneumonia Bacterial pneumonia usually causes children to become severely ill, with high fever and rapid breathing Viral infections, however, often come on gradually and may worsen over time Some common symptoms of pneumonia in children and infants include rapid or difficult breathing, cough, fever, chills, headaches, loss of appetite and wheezing Children under five with severe cases of pneumonia may struggle to breathe, with their chests moving in or retracting during inhalation (known as “lower chest wall indrawing”) Young infants may suffer convulsions, unconsciousness, hypothermia, lethargy and feeding problems

Two Most Important Signs of Pneumonia Difficult Breathing Fast Breathing Photo by WHO/M. Weber at http://whqlibdoc.who.int/hq/2009/WHO_FCH_CAH_NCH_09.04_eng.pdf

Framework for Pneumonia Control PROTECT PREVENT children by providing a healthy environment children from becoming ill with pneumonia Exclusive breastfeeding for six months Adequate nutrition Prevent low birth weight Reduce indoor air pollution Handwashing Vaccination against measles, pertussis, Spn* and Hib** Prevention of HIV in children Co-trimoxazole prophylaxis for HIV-infected and exposed children Zinc supplementation for children with diarrhea REDUCE PNEUMONIA MORTALITY AND MORBIDITY *Streptococcus pneumoniae **Hemophilis influenzae b TREAT children who become ill with pneumonia Case management in community, health center and hospital

Protecting Children from Pneumonia Protect children by providing a healthy environment Reduce indoor air pollution Encourage handwashing Promote exclusive breastfeeding for six months

Protecting Children from Pneumonia (continued) Reduce low birth weight (LBW)—defined as weight at birth <2.5kg—by: Preventing malaria in pregnancy Provide long-lasting insecticide-treated nets (LLINs) and intermittent preventive treatment in pregnancy (IPTp) Ensuring good maternal nutrition Provide food that contains zinc (e.g., vegetables, eggs, meat and fish) and iodine (e.g., fish, iodized salt and okra). Using a hematinic (to prevent anemia) Optimizing maternal health

Preventing Pneumonia in Children Preventing children from developing pneumonia in the first place is essential for reducing child deaths Key prevention measures include: Promoting adequate nutrition (including breastfeeding and zinc intake) Raising immunization rates Reducing indoor air pollution Recent research also suggests that handwashing may play a role in reducing the incidence of pneumonia

Preventive Measures: Breastfeeding and Handwashing with Soap

Countries That Have Introduced Hib Vaccine against Pneumonia Vaccines can prevent some forms of pneumonia Only around half of 193 countries worldwide have adopted Hib3 vaccine and implemented it up to 80% coverage We still have a long way to go with this strategy

Status of Global Pneumococcal Conjugate Vaccine Introduction (2008) Here we see slow progress with a vaccine to prevent another form of pneumonia On the slide above, GAVI refers to the GAVI Alliance (formerly known as the Global Alliance for Vaccines and Immunization.

Preventing HIV in Children Routine assessment for signs/symptoms of HIV (persistent diarrhea, failure to thrive) HIV testing Pneumocystis carinii pneumonia (PCP) prophylaxis (starting at six months) Prevention and treatment of TB or malaria Specific interventions to reduce mother-to-child transmission (MTCT) of HIV include antiretroviral (ARV) treatment and prophylaxis, safe delivery procedures, counseling and support for safe infant feeding

Treatment

Chart for Classifying and Treating Respiratory Illness Signs Classify As Treatment Fast breathing (see below) Lower chest wall indrawing Stridor in calm child Severe pneumonia Refer urgently to hospital for injectable antibiotics and oxygen, if needed Give first dose of appropriate antibiotic Non-severe pneumonia Prescribe appropriate antibiotic Advise mother about other supportive measures and when to return for a follow-up visit No fast breathing Other respiratory illness Advise mother about other supportive measures and when to return if symptoms persist or get worse What is fast breathing? If the child is… 2 months to 12 months old 12 months to 5 years old The child has fast breathing if you count… 50 breaths or more per minute 40 breaths or more per minute

Treatment Co-trimoxazole and amoxicillin are effective drugs against bacterial pathogens and are often used to treat children with pneumonia in developing countries Infants under two months of age, with signs of pneumonia/sepsis: Are at risk of suffering severe illness and death more quickly than older children, and Should be immediately referred to a hospital or clinic for treatment

Medicine for Cough, Fast Breathing, Fever Give an appropriate oral antibiotic For pneumonia, acute ear infection, severe classifications requiring first dose of antibiotics: First-line antibiotic co-trimoxazole Adult tablet = trimethoprim (80 mg) + sulfamethoxazole (400 mg) Pediatric tablet = trimethoprim (20 mg) + sulfamethoxazole (100 mg) Syrup/per 5 ml = 40 mg trimethoprim + 200 mg sulfamethoxazole Second-line antibiotic amoxicillin Tablet 250 mg; syrup 125 mg per 5 ml In all the children on co-trimoxazole prophylaxis, give amoxicillin

Cough, Fast Breathing, Fever Give Appropriate Dosage by Age or Weight Co-Trimoxozole Give two times daily for five days Amoxicillin Give three times daily Adult Tablet 80 mg trimethoprim + 400 mg sulfamethoxazole Pediatric Tablet 20 mg trimethoprim + 100 mg sulfamethoxazole Syrup/per 5 ml 40 mg trimethoprim + 200 mg sulfamethoxazole Tablet 250 mg Syrup 125 mg per 5 ml Two months up to 12 months (4kg to <10kg) 1/2 2 5 ml 12 months up to five years (10kg‒19kg) 1 3 7.5 ml 10 ml This is a sample schedule and dose table for oral antibiotics Users will need to confirm and comply with specific country treatment guidelines

Summary Points Infants under two months of age with signs of pneumonia/sepsis: Are at risk of suffering severe illness and death more quickly than older children, and Should be immediately referred to a hospital or clinic for treatment Research evidence has shown that handwashing and breastfeeding may prevent pneumonia Use an appropriate oral antibiotic for treatment