ACUTE RESPIRATORY

INFECTIONS

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ARI is the infection of respiratory tract anywhere from
nose to alveoli.
It is often classified depending on site of infection as:
1. ARI of Upper Respiratory Tract (AURI)
2. ARI of Lower Respiratory Tract ( ALRI)

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AURI
3.Otitis Media
1.Common Cold
2.Pharyngitis

1.Epiglottitis

2.Laryngitis

3.Bronchitis
4.Bronchiolitis

5.Pneumonia

ALRI
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PROBLEM STATEMENT

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1.WORLD

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Incidence : Similar in Developed and Developing
Country. However,
In developed countries: As low as 3-4%
In developing countries: between 20-30%

Morbidity: On an average, children below 5 year of

age suffer about 5 episodes of ARI per child per year;
accounting for:
30-50%- visit to health facilities
20-40%- of admission to hospitals
It is also leading cause of disabilities including
deafness as a sequel of otitis media.
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Mortality :
ARI in young children-Every year 3.9 Million
death worldwide.
90% deaths – Pneumonia usually bacterial

Pneumonia kills more children than any other

disease(AIDS, Malaria and Measles combined).
More than 2 million children die from pneumonia
each year.
Accounting for almost 18% under five deaths
worldwide.

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2.NEPAL

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In FY 2071/72 a total of 2,208,221 ARI cases were
reported among children of < 5 yr old age.
Reported ARI cases per 1,000 under‐five population
was 783
The reported total ARI related deaths was 337 in the FY
2071/72.
ARI case fatality rate among under‐five children was
0.15 in FY 2071/72

Source: Annual Report, Department of Health Services:2072/073,Ministry of health, Government of Nepal

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 Proportion of different ARIs:FY 2071/72

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Source: Annual Report, Department of Health Services:2072/073,Ministry of health, Government of Nepal
 Reported Cases : Comparison

Source: Annual Report, Department of Health Services:2072/073,Ministry of health, Government of Nepal

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 ARI New cases/1000 : Comparison

Source: Annual Report, Department of Health Services:2072/073,Ministry of health, Government of Nepal

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 ARI Reported Deaths

Source: Annual Report, Department of Health Services:2072/073,Ministry of health, Government of Nepal

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EPIDEMIOLOGICAL DETERMINANTS

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 ENVIRONMENT

HOST AGENT

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 1.Agent Factors
Are numerous – Include 1. Bacterias
2. Viruses
1. Bacterias
Bacterias Age Group Frequently Involved
1. Bordetella pertussis Infant and young children
2. Corneybacterium diphtheriae Children
3. Haemophilus influenzae Adults
4. Klebsiella pneumoniae Adults
5. Legionella pneumophila Adults
6. Staphylococcus pyogenes All ages
7. Streptococcus pneumoniae All ages
8. Streptococcus pyogenes All ages

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2. Viruses
Viruses Age Group Frequently
Involved
1.Adenovirus- Endemic- type 1,2,5 Young children
Epidemic-type 3,4,7 Older children and young adults
2. Enterovirus (ECHO and Coxsackie) All ages
3. Influenza – A All ages
B All ages, School children
C Rare

4. Measles Young children

5. Parainfluenza - 1,2,3 Young children
6. Respiratory syncytial virus Infants and young children
7. Rhinoviruses ( Multiple Serotypes) All ages
8. Coronavirus All ages
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2. Other agents
Agents
1. Chlamydia type B ( Pssittacosis)
2. Coxiella bruntti ( Q fever)
3. Mycoplasma pneumoniae
Age Group Frequently
Involved
Adult exposed to infected birds
Adults exposed to sheep and cattle
School children and immune
compromised
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 2.Host Factors
All age group are affected by ARI.
Small children are more often affected by ARI other
than any age group.
Case fatality rates higher in young infants and
malnourished children.
In general rates tend to be high in infants and young
children, and in the elderly in all countries, however the
age group with highest rates can differ.
In developing countries where malnutrition and low
birth weight is often a major problem, rates in children
tend to be highest.
By contrast in developed countries respiratory
infections are only exceptionally fatal in infants but are
commonly terminal in the elderly. 20
Upper Respiratory Tract infections, e.g. Common cold
and Pharyngitis are several times higher in children than
in adults.
Rate of pharyngitis increase from infancy to a peak at
the age of 5 years.
Illness rates are highest in young children and decrease
with increasing age, except third decade of life when
young adults are exposed to infection by their own
young children.
Adult woman experience more illness than men: More
exposed to children
Under 3 years of age : Boys more affected and more
severely.
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 3.Environmental Factors
Climatic conditions
Overcrowding dwellings : Urban>Rural communities
Low birth weight
Indoor air pollution
Maternal cigarette smoking
Poor nutrition
Socio economic status: More common in children from
low socioeconomic status family

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 Mode of Transmission
All causative organism : Transmitted by airborne route.
As most viruses do not survive for long outside the
respiratory tract : chain of transmission is maintained by
direct person to person contact.

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 Control of ARIs

Improving the primary medical care services and

developing better methods for:
-Early detection, treatment and whenever possible
prevention
Is the best strategy to control ARI.
 Education to mother: Seeking care when signs of
pneumonia observed, compliance with treatment

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 The management of
acute respiratory
infections in children:
Practical guideline for outpatient care
1. Clinical Assessment
2. Physical Examination
3. Classification and management of illness
4. Treatment

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 1.Clinical Assessment

 History taking and clinical assessment is very important

in management of acute respiratory infections.
 Ask:
1. How old is the child ?
2. Is the child coughing ? For how long ?
3. Age 2 month up to 5 yr : Is the child able to
drink?
Age less than 2 months: Has the young infant
stopped feeding well?
4. Has the child had fever? For how long?
5. Has the child had convulsions?
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 2.Physical Examination
Look and Listen for the following:
1. Count the breaths in one minute:
- Cut off point for tachypnea depend the age of
child
- Expose the chest and abdomen: count for full one
minutes using second’s hand of the watch looking
at abdominal movement
-Fast breathing is present when the respiratory
rate is:
Aged Significant BPM
Less than 2 months 60 breaths per minute or more
2 months up to 12 months 50 breaths per minute or more
12 months up to 5 years 40 breaths per minute or more
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2.Chest Indrawing : during inspiration
3. Stridor : harsh noise when child breaths in
4. Wheeze: soft whistling noise when breathing out
5. Sleepy/ difficult to wake
6.Body temperature: feel for fever or low body
temperature
7. Severe malnutrition
8. Cyanosis: sign of hypoxia

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 3.Classification of Illness
 Classifying the illness means making decisions about
the type and severity of disease.
 Each disease classification has a corresponding
treatment plan which should be followed.

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 A.Child aged 2 months up to 5 years
The sick child should be put into one of the four
classifications:
1. Very severe disease
2. Severe pneumonia
3. Pneumonia(not severe)
4. No pneumonia: cough or cold

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 1. Very Severe Disease

Extracted from WHO: The management of Acute respiratory infection in children Practical guideline for OPD care
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2. Severe Pneumonia 3.Pneumonia 4. No pneumonia: Cough or Cold

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Extracted from WHO: The management of Acute respiratory infection in children Practical guideline for OPD care
 B. Classifying illness of young infant

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Extracted from WHO: The management of Acute respiratory infection in children Practical guideline for OPD care
 4.TREATMENT

A. For children aged 2 months up to 5

years

 The standard treatment for childhood acute

respiratory infections is as follows

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 1.Pneumonia(Child with cough and Fast
Breathing)
Cotrimoxazole is the drug of choice
The pediatric tablet of 120 mg consist of:
100 mg-Trimethoprim
20 mg- Sulphamethoxazole
The pediatric syrup of 5 ml consists:
40 mg-Trimethoprim
200 mg- Sulphamethoxazole
The recommended dose is:
Aged/Weight Tablet Syrup
< 2 months(3-5 kg) 1 tablet twice a day ½ spoon twice a day
2-12 months(6-9 kg) 2 tablet twice a day 1 spoon twice a day
1-5 years(10-19 kg) 3 tablets twice a day 1 and ½ spoon twice a
day
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 1.Pneumonia(Child with cough and Fast
Breathing):CONTINUE
The condition of child should be assessed after 48
hours.
Improvement in clinical condition : Cotrimoxazole
should be continued for another 3 days
No significant change i.e neither improvement nor
worsening: Cotrimoxazole continued for another 48
hours and condition reassessed.
If at 48 hours or earlier condition worsens: child
should be hospitalized immediately

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 2.Severe Pneumonia(Chest in-drawing)
Treated as inpatients with intramuscular injections of
benzyl penicillin (after test dose), ampicillin or
chloramphenicol.
Condition of child must be monitored everyday and
reviewed after 48 hours for antibiotic therapy
Antibiotic therapy must be given for a minimum of 5 days
and continued for at least 3 days after the child gets well.

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Antibiotics Dose Interval Modes
A.First 48 hours
Benzyl penicillin 50,000IU/Kg/dose 6 hourly IM
or 50 mg/kg/dose 6 hourly IM
Ampicillin 25 mg/kg/dose 6 hourly IM
or
Chloramphenicol
B. 1. If condition IMPROVES, then for the next 3 days give:
Procaine Penicillin 50,000IU/Kg/dose Once IM
Or
Ampicillin 50 mg/kg/dose 6 hourly Oral
Or
Chloramphenicol 25 mg/kg/dose 6 hourly Oral

B. 2. If no IMPROVEMENT, then for the next 48 hour change

antibiotic
If ampicillin used change to chloramphenicol IM.
If chloramphenicol used change to Cloxacillin.
If condition improves continue treatment orally.
C. Provide symptomatic treatment for fever and wheezing, if required.
D. Monitor fluid and food intake.
E. Advise mother on home management on discharge.
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 3.Very Severe Disease

Oxygen therapy with intense monitoring

Chloramphenicol IM is drug of choice in all case
Treat for 48 hours:
If condition improves: switch over to oral chloramphenicol
Should be taken total for 10 days
If condition worsens or does not improve: Switch to IM
injections of cloxacillin and gentamycin.

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 B. Pneumonia in young infants under 2
months of age
Treatment basically same.
Child must be hospitalized.
Treatment with cotrimoxazole started by health worker before referring the
child.
If pneumonia suspected child should be treated with IM injections of benzyl
penicillin or injection of ampicillin, along with injection gentamycin.
Chloramphenicol not recommended as the first line of treatment in young
infants.
Treatment plan is as shown:
Syrup
Drugs Dose Age <7 days Age 7 days to 2
months
Inj. Benzyl penicillin 50,000 IU/kg/dose 12 hourly 6 hourly
OR
Inj. Ampicillin 50 mg/kg/dose 12 hourly 8 hourly
And
Inj. Gentamycin 2.5 mg/kg/dose 12 hourly 8 hourly
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Management of AURI ( No pneumonia)
Many children with presenting symptoms of cough,
cold and fever do not have pneumonia ( no fast
breathing or chest in drawing) and DO NOT require
treatment with antibiotics.
Antibiotics are not recommended in cough and colds
because majority of cases are caused by viruses and
antibiotics are not effective, they increase resistant
strains and cause side effects while providing no clinical
benefit
Symptomatic treatment and case at home generally
enough for such cases.

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 Prevention and Control

 Improved living condition

 Better nutrition
 Reduction of indoor air pollution
 Better maternal and child health care
 Immunization
 Immunization
1. Measles Vaccine
2. HIB Vaccine
3. Pneumococcal Pneumonia Vaccine
Measles Vaccine
• Pneumonia is a serious complication of Measles
and most common cause of death associated with
Measles worldwide.
• Reduction of incidence of Measles in young
children thru vaccination also reduces the
incidence of Pneumonia.
• EPI : MR vaccine at 9 and 15 month

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HIB Vaccine
• Haemophilous influnzae type B is an important
cause of Pneumonia and Meningitis among
children in developing countries.
• Hib vaccine effectively reduces the incidence of Hib
Meningitis and Pneumonia.
• EPI : 6 , 10 and 14wk

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Pneumococcal Pneumonia
Vaccine
• Two types
i. PPV 23 : given to children above 2 years of age
and adults as single IM dose in deltoid
ii. PCV : EPI – 6 wk, 10 wk and 9 month

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PREVENTION AND CONTROL:GLOBAL
STRATEGY
Ending Preventable Child Deaths from
Pneumonia and Diarrhea by 2025
The integrated Global Action Plan for Pneumonia and
Diarrhea(GAPPD)
 Specific Goals for 2025: Reduction in
< 5 year children
 Mortality from pneumonia to < 3 per 1000 live
births.
 Incidence of severe pneumonia by 75% compared to
2010 levels ()
 Incidence of severe diarrhea by 75% compared to
2010 levels ()
 Global number of children stunted by 40%
compared to 2010 levels ()
 Coverage Targets: By the end of
2025
 90% full-dose coverage of each relevant vaccine
(with 80% coverage in each district)
 90% access to appropriate pneumonia and
diarrhea case management (with 80% coverage in
each district)
 At least 50% coverage of exclusive breast-feeding
during the first 6 months of life
 Virtual elimination of pediatric HIV
Coverage Targets: By the end of 2030

Universal Access in health care

facilities and home to-
 Basic drinking water
 Adequate sanitation (2030/2040)
 Hand washing facilities
 Clean and safe energy technologies
 Prevention and Control:
National Strategies
Community Based Integrated Management of
Neonatal and Childhood Illness (CB-IMNCI)
 CB-IMCI + CB-NCP = CB-IMNCI (2071 BS)
 ARI control program since 1987
 Core Objectives
 To reduce the morbidity, mortality and disability
among newborns, infants and children aged <5
yrs.
 To improve the nutritional status of children
Strategic Interventions
 Newborn Specific Interventions
 Promotion of birth preparedness plan, newborn
care practices and postnatal care
 Identification and management of non-
breathing babies at birth, pre-term and low birth
weight babies
 Management of sepsis and diarrhea
 Child Specific Interventions
 Case management of children ( 2-59 months)
from:
1. Pneumonia
2. Diarrhea
3. Malaria
4. Measles
5. Malnutrition
 Cross Cutting Interventions
 Behavior change communication for
1. Healthy pregnancy
2. Safe delivery
3. Healthy newborn
4. Healthy U5 children

 Timely referral of sick children

 Cross Cutting Interventions
(contd..)
 Improved interpersonal communication skills of
HWs and FCHVs
 Achieve high effective coverage of interventions
 Improved knowledge related to
1. Essential Newborn Care
2. Nutrition
3. Care of sick children
ARI Cases Treated at different Level: FY 2071/72

Source: Annual Report, Department of Health Services:2072/073,Ministry of health, Government of Nepal

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