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Pneumonia in Developing Countries: Still Unresolved Problem. Dr. Pushpa Raj Sharma Professor, Department of Child Health Institute of Medicine Kathmandu, Nepal. This Presentation. Epidemiology Risk factors Aetiological agents Clinical syndromes Investigations Treatment

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pneumonia in developing countries still unresolved problem

Pneumonia in Developing Countries: Still Unresolved Problem

Dr. Pushpa Raj Sharma

Professor, Department of Child Health

Institute of Medicine

Kathmandu, Nepal

this presentation
This Presentation
  • Epidemiology
  • Risk factors
  • Aetiological agents
  • Clinical syndromes
  • Investigations
  • Treatment
  • Future implications
slide3

A case:

  • 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.
case contd
Case (contd)
  • Second day:
    • Mother felt child is better but continues to be tachypnoeic, chest indrawing, fever persisting.
    • Vancomycin added with oxygen
case contd5
Case (contd)
  • Third day
    • Severe respiratory distress
    • Pus drained through water seal drainage
    • Antibiotics contd.
    • Discharged after 2 wk.

Strepto.pneumoniae isolated

total live births and surviving infants in south east asia
Total live births and surviving infants in South East Asia

Worlds population prospects. 2004 Revision. New York, United Nations, 2005

burden of pneumonia
Burden of Pneumonia

South Asia

  • Population of approximately 667 million
  • Approximately 170 million infants and children, (about one-third of all the children in developing countries).

60240

18240

135600

82320

576480

,1000

Unicef (www.childinfo.org) and Hyder et al ;

Extrapolated from Black et al

burden of disease
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)
slide13
Acute respiratory infection prevalence in under 5 children by socioeconomic status in selected countries

Based on World Bank data 2000.

risk factors
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.

risk factors contd
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.

slide16

Risk Factors: Too many …………..

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.

slide17

Risk Factors contd

Indoor Air Pollution

Emissions Along The Household Fuel Ladder Smith et al.98

aetiology
N. America and Europle(nine studies /range: 43-80%)

Aetiology of pneumonia established in 62%:

S. pneumoniae 22%

RSV 20%

H. influenzae 7%

M. pneumoniae 15%

Africa and S. America(eight studies/ range: 32-68%)

Aetiology of pneumonia established in 56%:

S. pneumoniae 33%

H. influenzae 21%

RSV

M. pneumoniae

Aetiology:
slide21
Aetiology: Yield from cultures of lung puncture on 755 neonates who were stillborn or died in the first 72 hours of life

Naeye RL, Dellinger WS, Blanc WA. Fetal and maternal features of antenatal bacterial

infections. J Pediatr 1971;79:733–9.

aetiology burden of hib disease in nepal based on hib rapid assessment tool of who
Aetiology: Burden of Hib disease in Nepal(Based on Hib Rapid Assessment Tool of WHO)

*per 100,000 U5s

Paper presented at the WHO dissemination seminar by Dr. Fiona Russeli et al

bacterial or viral
Fever > 38.50C

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< 38.50C

Marked recession

Hyperinflation

Respiratory rate normal or raised

Hyperinflation and patchy collapse in 25%

Lobar collapse when severe

Bacterial or Viral?

LOOKS SICK

atypical pneumonia
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

comparison of methods for the detection of pneumonia in children
Comparison of Methods for the Detection of Pneumonia in Children

Method Sensitivity Specificity

Stethoscope 53% 59%

(crepetations)

Simple clinical signs 77% 58%

(fast breathing or

chest indrawing)

Note: Pneumonia diagnosis confirmed by Chest X-ray

slide30
Diagnostic value of total leucocyte count in radiologically positive cases:sensitivity: 33.7% and specificity: 71.8%
indications for cxr in either primary care or hospital
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
laboratory studies
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.

clinical diagnosis
Clinical Diagnosis
  • Tachypnoea according to the usual

WHO criteria:

<2 months: 60

2-12 months: 50

!-5 years: 40

antibiotics for opd treatment in 4months to 5 year old children
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/ disp.tab or three tea spoon per dose of 125mg/5ml concentration.

N Engl J Med 2002;346:429-37.

three days versus five days treatment with amoxicillin for nonsevere community acquired pneumonia
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)

slide37

Time for temperature to settle in the oral and IV groups

=IV treatment

--------- = oral treatment

Wellek logrank

test for equivalence

P=0.0013

ITT

P=0.0001

Probability that the child meets the primary

outcome measure after time t

Time for temperature to be less than 380C for 24 continuous hours (days)

Arch Dis Child Edu Pract 2004; 29-34

slide38

Time to resolution of symptoms

IV group

Time to resolution of symptoms

oral group

Number of children

Number of children

Time to resolution of symptoms in days

Time to resolution of symptoms in days

Median of 9 days to full recovery in both arms of the study

Arch Dis Child Edu Pract 2004; 29-34

slide39

Length of stay in hospital in the

IV group

Length of stay in hospital in the

oral group

Length of hospital stay in days

Number of children

IV Group - median 2.1 days (1.8-2.9) Oral Group - median 1.77 days (1-2.2) P=<0.001

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

indications for admission to hospital
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

swt therapy
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

previous studies comparing macrolides with other groups of antibiotics
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

indication of macrolide in infant
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
slide44

Vitamin A and pneumonia

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.

zinc and pneumonia
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: 1Bhutta 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. 2Bhandari 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.

slide46

Pneumonia with associated diseases

  • 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

hib vaccination schedule
HibVaccination schedule

Recommended vaccination schedule

from 2 months old: same schedule as DTP

Act-HIB™

6, 10, 14 weeks

booster at 18 months

of age

2- 4- 6 months

12-15 months

ACIP

Recommendation

Plotkin S, Vacccine, 3rd ed. 1999

pneumococcal vaccination schedule
PneumococcalVaccination schedule??

Recommended vaccination schedule

from 2 months old: same schedule as DTP

PCV

2- 4- 6 months

12-15 months

PPV

Recommended in addition to the PCV for certain high risk group after two years.

immunization for common serotypes pneumococcus
Immunization for common serotypes (pneumococcus)

PCV7 (Wyeth) *

PCV12 (Wyeth) * * *

PCV10 (GSK) * * * *

areas of continuing uncertainty
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
areas of continuing uncertainty51
Areas of continuing uncertainty
  • • All children under 2 years should be given the new conjugate pneumococcal vaccine routinely or not
  • • Variation in individual host response to the disease: the reason.
  • The aetiology of pneumonia.
  • Long term follow-up and effects of pneumonia
saars and now the avian flue
SAARS and now The Avian Flue!!!!!
  • 2  Mar  06 – Medical News TodayAuthorities 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.