CDI Module 17: Community Management of Pneumonia

©Jhpiego Corporation

The Johns Hopkins UniversityA Training Program on Community-Directed Intervention (CDI) to Improve Access to Essential Health Services

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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

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Why We Cannot Ignore Pneumoniain 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

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Pneumonia Is Common in Africa

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Relation Between Pneumoniaand 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

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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

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Two Most Important Signs of Pneumonia

Difficult Breathing

Fast Breathing

Photo by WHO/M. Weber athttp://whqlibdoc.who.int/hq/2009/WHO_FCH_CAH_NCH_09.04_eng.pdf

Framework for Pneumonia Control

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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 forHIV-infected and exposed children

Zinc supplementation forchildren with diarrhea

*Streptococcus pneumoniae**Hemophilis influenzae b

REDUCE PNEUMONIA MORTALITY

AND MORBIDITY

TREAT

children who become ill with pneumonia

Case management in community, health center and hospital

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Protecting Children from Pneumonia

Protect children by providing a healthy environment

Reduce indoor air pollution Encourage handwashing Promote exclusive breastfeeding for six months

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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

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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

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Preventive Measures: Breastfeeding and Handwashing with Soap

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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

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Status of Global Pneumococcal Conjugate Vaccine Introduction (2008)

Here we see slow progress with a vaccine to prevent another form of pneumonia

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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

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Chart for Classifying and TreatingRespiratory 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

• Fast breathing (see below) 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 old12 months to 5 years old

The child has fast breathing if you count…50 breaths or more per minute40 breaths or more per minute

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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

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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

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Cough, Fast Breathing, FeverGive Appropriate Dosage by Age or Weight

Age or Weight

Co-TrimoxozoleGive two times daily

for five days

AmoxicillinGive three times daily

for five daysAdult Tablet

80 mg trimethoprim + 400 mg

sulfamethoxazole

Pediatric Tablet20 mg trimethoprim +

100 mg sulfamethoxazole

Syrup/per 5 ml40 mg trimethoprim

+ 200 mg sulfamethoxazole

Tablet250 mg

Syrup125 mg per 5 ml

Two months up to 12 months (4kg to <10kg)

1/2 2 5 ml 1/2 5 ml

12 months up to five years(10kg‒19kg)

1 3 7.5 ml 1 10 ml

This is a sample schedule and dose table for oral antibioticsUsers will need to confirm and comply with specific country treatment guidelines

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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