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Pneumonia in Developing Countries: Still Unresolved Problem Dr. Pushpa Raj Sharma Professor, Department of Child Health Institute of Medicine Kathmandu,

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Presentation on theme: "Pneumonia in Developing Countries: Still Unresolved Problem Dr. Pushpa Raj Sharma Professor, Department of Child Health Institute of Medicine Kathmandu,"— Presentation transcript:

1 Pneumonia in Developing Countries: Still Unresolved Problem Dr. Pushpa Raj Sharma Professor, Department of Child Health Institute of Medicine Kathmandu, Nepal

2 This Presentation Epidemiology Risk factors Aetiological agents Clinical syndromes Investigations Treatment Future implications

3 4 months old One day history of excessive crying Sent home with the diagnosis of windy colic with anti- spasmodics Next day: –Grunting, respiratory distress, fever. –Admitted, IV ceftriaxone. A case:

4 Case (contd) Second day: –Mother felt child is better but continues to be tachypnoeic, chest indrawing, fever persisting. –Vancomycin added with oxygen

5 Case (contd) Third day –Severe respiratory distress –Pus drained through water seal drainage –Antibiotics contd. –Discharged after 2 wk. Strepto.pneumoniae isolated

6 Total live births and surviving infants in South East Asia Worlds population prospects. 2004 Revision. New York, United Nations, 2005

7 Leading infectious causes of mortality, 2000 estimates

8 Burden of Pneumonia Population of approximately 667 million Approximately 170 million infants and children, (about one-third of all the children in developing countries). South Asia 60240 135600 576480 82320 18240,1000 Unicef ( and Hyder et al ;www.childinfo.orgExtrapolated from Black et al

9 MONTH OF Feb. 2006

10 Hospital Admissions Then and Now NEPAS J 1988; 7; 1-8

11 Age distribution of pneumonia in hospital

12 Burden of Disease ARI episodes/child/year in U5: 5-9 Pneumonia in ARI: 1:30-50 (2-3% of all ARI). Most of these pneumonia are bacterial in developing countries. Deaths in ARI are mostly due to pneumonia Duration of illness who died from pneumonia: 3.5 days (Jumla Nepal)

13 Acute respiratory infection prevalence in under 5 children by socioeconomic status in selected countries Based on World Bank data 2000.

14 Risk Factors In a multivariate analysis, the variables found to be most closely associated with mortality were breastfeeding, education of the father, the number of under-fives, family income and birth weight. Having a low weight-for-age was also strongly associated with mortality but the retrospective nature of the study makes this finding difficult to interpret. Int J Epidemiol. 1989 Dec;18(4):918-25.

15 Risk Factors contd. Current and past malnutrition were associated with acute lower respiratory infection (ALRI), even after adjusting for potential confounders (odds ratio: 2.03; 95% confidence interval: 1.202.43). Decreasing malnutrition along with timely and proper treatment of ARI may improve children's health in developing countries. Acta Paediatr. 2000 May;89(5):608-9.

16 A study conducted by the World Bank found that the share of brick kilns in the valley's air pollution was 28 per cent while that of domestic fuel burning was 25 per cent, cement factory 17 per cent, vehicle emission 12 per cent and road dust 9 per cent. The study estimated that dust particles in the air cause 18,863 cases of asthma and 4,847 cases of bronchitis in Kathmandu every year. Risk Factors: Too many …………..

17 Emissions Along The Household Fuel Ladder Smith et al.98 Indoor Air Pollution Risk Factors contd

18 Aetiology: N. America and Europle (nine studies /range: 43- 80%) Aetiology of pneumonia established in 62%: –S. pneumoniae 22% –RSV 20% –H. influenzae7% –M. pneumoniae15% Africa and S. America (eight studies/ range: 32- 68%) Aetiology of pneumonia established in 56%: –S. pneumoniae 33% –H. influenzae21% –RSV –M. pneumoniae

19 Aetiology: Viruses isolated from children with ARI (n=287) Unpublished report: CHRP; IOM

20 Aetiology based on lung aspirates StudyCountryAge:yrsTotal CS.PneuH.InflS.Aurother Schuster, 1966 Chile<1067/125 (54%) 26/125 (21%) 19/125 (15%) 15/125 (12%) 13/125 (10%) Rozov 1974 Brazil<720/37 (54%) 15/37 (41%) 3/37 (8%) 1/37 (3%0 1/37 (3%) Silverma n 1977 Nigeria<854/88 (61%) 31/88 (35%) 9/88 (10%) 8/88 (9%) 20/88 (23%) Shan 1984 Papua NG <548/71 (68%) 27/71 (38%) 41/71 (58%) 1/71 (1%) 23/71 (32%) Wall 1986 Gambia<929/51 (57%) 26/51 (51%) 12/51 (24%) 1/51 (2%) 2/51 (4%) Ikeogu 1988 Zimbabe<1113/40 (32% 7/40 (18%) 3/40 (8%) 4/40 (10%) 1/40 (2%) Total231/412 (56%) 132/312 (42%) 96/312 (31%) 29/312 (9%) 60/312 (19%)

21 Aetiology: Yield from cultures of lung puncture on 755 neonates who were stillborn or died in the first 72 hours of life BacteriaNumber Escherichia coli71 Aerobacter aerogenes45 Streptococcus beta haemolytic29 Pseudomonas aeruginosa27 Streptococcus viridans21 Staphylococcus aureus17 Proteus vulgaris11 Streptococcus non haemolytic (Group D)8 Naeye RL, Dellinger WS, Blanc WA. Fetal and maternal features of antenatal bacterial infections. J Pediatr 1971;79:733–9.

22 Aetiology : Burden of Hib disease in Nepal (Based on Hib Rapid Assessment Tool of WHO) Eastern regionWestern regionUnder 5 mortality rate Annual Hib meningitis incidence* 5.413.784 Annual number of Hib meningitis cases 1964973,048 Annual number of Hib Meningitis death 5950914 Annual number of Hib pneumonia cases 9802,48615,241 Annual number of Hib pneumonia deaths 1473732,286 *per 100,000 U5s Paper presented at the WHO dissemination seminar by Dr. Fiona Russeli et al


24 Bacterial or Viral? Fever > 38.5 0 C Respiratory rate >50/min Chest recession Wheeze is not a sign of primary bacterial LRTI (except in mycoplasma) Other viruses may be concurrent Clinical and radiological signs of consolidation rather than collapse. Infants and young children Wheeze Fever< 38.5 0 C Marked recession Hyperinflation Respiratory rate normal or raised Hyperinflation and patchy collapse in 25% Lobar collapse when severe LOOKS SICK

25 Atypical Pneumonia Clark J, Archives Disease Childhood 2003 Mean age of children with M pneumoniae 3.5 yrs Block S, Paediatric Infectious Disease Journal 1995 23% of 3-4 year old children had M pneumoniae

26 Signs of Pneumonia

27 Symptoms and Signs in Pneumonia

28 Comparison of Methods for the Detection of Pneumonia in Children MethodSensitivitySpecificity Stethoscope53%59% (crepetations) Simple clinical signs77%58% (fast breathing or chest indrawing) Note: Pneumonia diagnosis confirmed by Chest X-ray

29 Comparison of total leucocyte counts in different age group with clinically diagnosed as pneumonia

30 Diagnostic value of total leucocyte count in radiologically positive cases: sensitivity: 33.7% and specificity: 71.8%

31 Indications for CXR in either primary care or hospital For diagnosis of child <5 years with fever of 39°C of unknown origin If complication (for example, pleural effusion) suspected Atypical symptoms or unresponsive to treatment For follow up of children with lobar collapse or ongoing symptoms

32 Laboratory studies* Complete blood count Not helpful in distinguishing etiology Erythrocyte sedimentation rate Not helpful in distinguishing etiology C-reactive protein level Not helpful in distinguishing etiology Gram stain and culture Helpful if specimen is adequate Polymerase chain reaction Helpful with Mycoplasma and Chlamydia infections Rapid viral antigen testing Useful if available Serologies Not helpful in acute settings Imaging Chest radiograph*Not helpful in distinguishing etiology*-Not routinely recommended. *Pediatr Infect Dis J 2002;21:592-8, 613-4.

33 Clinical Diagnosis Tachypnoea according to the usual WHO criteria: <2 months: 60 2-12 months: 50 !-5 years: 40

34 Is Co-trimoxazole still the first line of drug for IMCI

35 Antibiotics for OPD treatment in 4months to 5 year old children Amoxicillin, 90 mg per kg per day orally in divided doses every 8 hours for 7 to 10 days A 10 Kg child will need one and half tablet per dose of 250mg/ or three tea spoon per dose of 125mg/5ml concentration. N Engl J Med 2002;346:429-37.

36 Three days versus five days treatment with amoxicillin for nonsevere community acquired pneumonia Three day courses of amoxicillin are as effective as five days without increasing risk of relapse or worsened disease. 15 mg/kg amoxicillin every 8 hourly. Lancet, July 23, 2002 (MASCOT Group) BMJ 2004;328:791 (3 April), (ISCAP Group)

37 Time for temperature to settle in the oral and IV groups =IV treatment --------- = oral treatment Probability that the child meets the primary outcome measure after time t Time for temperature to be less than 38 0 C for 24 continuous hours (days) Wellek logrank test for equivalence P=0.0013 ITT P=0.0001 Arch Dis Child Edu Pract 2004; 29-34

38 Time to resolution of symptoms IV group Time to resolution of symptoms oral group Time to resolution of symptoms in days Number of children Median of 9 days to full recovery in both arms of the study Arch Dis Child Edu Pract 2004; 29-34

39 Length of stay in hospital in the IV group IV Group - median 2.1 days (1.8-2.9) Oral Group - median 1.77 days (1-2.2)P=<0.001 Number of children Length of hospital stay in days Length of stay in hospital in the oral group Length of hospital stay in days IV Group - median 2.1 days (1.8-2.9) Oral Group - median 1.77 days (1-2.2) P=<0.001 Arch Dis Child Edu Pract 2004; 29-34

40 Indications for admission to hospital Older children Oxygen saturation <92% Respiratory rate > 50 Difficulty breathing Grunting Signs of dehydration Family not able to support at home > 1 year 120/182 (66%) met 1 or more criteria Thorax. 2002;57;1-24

41 SWT Therapy No RCT’s in children 2 prospective observational studies Both demonstrate that IV therapy for CAP can be successfully be decreased to 2-4 days Al-Eidan F, Journal Antimicrobial Chemotherapy 1999 Ciommo V, Journal of evaluation in clinical practice 2002

42 Previous studies comparing macrolides with other groups of antibiotics Only 1 study in children comparing beta- lactams with macrolides Divided children clinically into “atypical” (randomised to azithromycin or erythromycin) or “classic” pneumonia (randomised to amoxicillin or azithromycin) Results – no difference between the 2 groups Kogan et al Pediatric Pulmonology 2003

43 Indication of macrolide in infant 3 weeks to 3 months If patient is afebrile: Azithromycin, 10 mg per kg orally on day 1, then 5 mg per kg per day on days 2 through 5or Erythromycin, 30 to 40 mg per kg per day orally in divided doses every 6 hours for 10 days Admit if patient is febrile or hypoxic

44 The evidence did not suggest a significant reduction with vitamin A adjunctive treatment in mortality, measures of morbidity, nor an effect on the clinical course of pneumonia in children with non-measles pneumonia. However, not all studies measured all outcomes, limiting the number of studies that could be incorporate into the meta- analyses, so that there may have been a lack of statistical power to detect statistically significant differences. Cochrane Database Syst Rev. 2005 Jul 20;(3): CD003700. Vitamin A and pneumonia

45 ZINC AND PNEUMONIA FINDINGS: In a pooled analysis of trials, zinc supplementation reduced the incidence of pneumonia infection by 41% and daily zinc supplementation reduced the incidence of pneumonia in Delhi children ages 6 to 30 months given vitamin A IMPLICATION: Zinc reduces the incidence of pneumonia but zinc in combination with vitamin A may be more effective than the administration of either micronutrient alone. Sources: 1 Bhutta ZA, et al. Prevention of diarrhea and pneumonia by zinc supplementation in children in developing countries: pooled analysis of randomized controlled trials. J Pediatr. 1999 Dec;135(6):689-97. 2 Bhandari N, et al. Effect of routine zinc supplementation on pneumonia in children aged 6 months to 3 years: randomised controlled trial in an urban slum. BMJ. 2002 Jun 8;324(7350):1358.

46 Most children in developing countries with recurrent pneumonia diagnosed by WHO criteria do not have evidence of tuberculosis, HIV infection or pulmonary anomalies, but they may be more likely to have asthma, and this should be considered as an alternative diagnosis. Pediatr Infect Dis J. 2002 Feb;21(2):108-12 Pneumonia with associated diseases

47 Hib Hib Vaccination schedule Recommended vaccination schedule Recommended vaccination schedule from 2 months old: same schedule as DTP 6, 10, 14 weeks 2- 4- 6 months booster at 18 months of age 12-15 months Plotkin S, Vacccine, 3rd ed. 1999 ACIP Recommendation Act-HIB™

48 Pneumococcal Pneumococcal Vaccination schedule?? Recommended vaccination schedule Recommended vaccination schedule from 2 months old: same schedule as DTP 2- 4- 6 months 12-15 months PCV PPV Recommended in addition to the PCV for certain high risk group after two years.

49 Immunization for common serotypes (pneumococcus) PCV7 (Wyeth) * PCV12 (Wyeth) * * * PCV10 (GSK) * * * *

50 Areas of continuing uncertainty The most useful clinical signs and symptoms that help to predict a diagnosis of pneumonia Which children require a chest x ray before treatment Which test to detect the causative organism will be sensitive, specific, affordable, and quick and easy to use Which antibiotic should be prescribed Which route should be used for administering the antibiotic prescribed If the intravenous route is used when should a switch to oral antibiotics occur

51 All children under 2 years should be given the new conjugate pneumococcal vaccineroutinely or not Variation in individual host response to the disease: the reason. The aetiology of pneumonia. Long term follow-up and effects of pneumonia Areas of continuing uncertainty

52 SAARS and now The Avian Flue!!!!! 2 Mar 06 – Medical News Today 2 Mar 06 – Medical News Today Authorities in Germany have today announced detection of H5N1 avian influenza in a domestic cat. The cat was found dead over the weekend on the northern island of Ruegen. Since mid- February, more than 100 wild birds have died on the island, and tests have confirmed H5N1 infection in several. Formation of bulla in the lung parenchyma: difficult to ventilate.

53 The Avian Flu


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