Download Module 5 Skill Station: Infections

Module 5 Skill Station: Management of Prevalent Infections in Children Following
a Disaster
Objectives of the module
Section I - Integrated Management of Childhood Illness (IMCI)
• Understand the IMCI strategy of classification and management for children 2-6
months of age and 6 months to 5 years.
Section II - Influenza
• Understand the difference between antigenic drift and shift with regards to influenza
viruses.
• Describe the rationale for influenza testing during an epidemic.
• Describe the rationale for treating with anti-viral therapy during an influenza epidemic.
• Describe surge planning for an H1N1 pandemic.
Section III - Acute respiratory infections
• Know the 4 key clinical signs used to assess a child with cough or difficult breathing,
and based on these signs classify acute respiratory clinical illness into three categories.
• Diagnose and develop a treatment plan (medications, supportive care and monitoring)
using available resources for patients with:
-Severe pneumonia
-Pneumonia
-Upper respiratory infection
-Ear problems without pneumonia
Section IV - Measles
• Explain why measles infection can be so devastating in displaced populations.
• Design a measles immunization campaign in an affected area and establish priority
target populations for the provision of measles vaccine based on the availability of
vaccine supplies.
• Recognize the clinical presentation and evolution of measles.
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Section V - Febrile Illness: Malaria, Dengue, Chikungunya
• Understand the public health importance of febrile illness such as malaria and dengue
in the context of acute emergency settings.
• Understand the IMCI strategy for malaria identification, prevention and treatment.
• Understand the cause, risk factors, and presentation of benign (uncomplicated) and
malignant (complicated) malaria.
• Diagnose and develop a treatment plan (medications, supportive care, and
monitoring) using available resources for patients with:
- Severe/complicated malaria
- Typical uncomplicated malaria
- Severe dengue fever
- Dengue fever
Section VI - Other cases that require attention at the scene of the disaster
• Understand the importance of clinical entities such as meningitis, tuberculosis and
HIV in displaced populations.
Section VII - Immunization in disaster situations
• Acknowledge the importance of measles immunization in a disaster situation.
• Recognize the characteristics of tetanus-prone injuries and wounds.
• Discuss specific situations that require the use of other vaccines.
Section VIII - Infections in infants 0 to 2 months of age
• Identify and understand the treatment for sick infants 0 to 2 months of age.
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Presentation format
Clinical case discussion in classroom, slide presentation
Duration
90 minutes
Materials
• 4 Classrooms or lecture rooms with enough chairs for the audience in a semicircular
arrangement.
• Blackboard or flip chart.
• Enough white sheets and pencils or pens for all participants.
• Scenario/clinical case(s) for the facilitator.
• Printed clinical scenario(s) for participants.
• If clinical cases are to be projected (images, data, etc.), the following equipment is
required:
- Slides/audiovisual material on clinical cases
- Projection equipment (projector, computer, etc.)
- Screen
Initial Scenario
You are staffing a clinic in a camp for a large displaced population fleeing their
homes because of a war. The situation in the camp with respect to shelter, clean
water and food is marginal and many of the children have moderate or severe
acute malnutrition. Over 100 children come to clinic daily so you must see the
patients quickly to be sure that everyone is seen and receive needed care. You
have trained nurses to triage the children according to IMCI protocols so that the
sickest will be seen first so they can be stabilized to the extent possible, and if
necessary urgently transferred to the hospital.
Case 1
A 2 year old girl (name) is brought to your clinic by her mother. She appears lethargic
and her mother says she has not been able to eat or drink anything today. Yesterday
she vomited everything she tried to eat. She has had a high fever (to mother’s touch)
for 3 days. Her temperature today is 40
o
C. Her MUAC is 114 mm. Her heart rate is
120 and her respiratory rate is 36. As you start to exam her, she begins to seize.
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1) What are the 5 IMCI general danger signs and which of these does she have?
Response:
• Unable to drink or breast feed (too weak)-yes
• Vomits everything-yes
• Had convulsions-no
• Lethargic or unconscious-yes
• Convulsing now-yes
2) According to IMCI how would you classify and manage this girl?
Response: Pink- very severe disease
• Give diazepam (or available alternative medication) to stop the seizure
• Complete the assessment and treat with an available antibiotic for possible
meningitis or sepsis (Antibiotics: Ceftriaxone (IM) or Penicillin (IM) or Amoxicillin
(PO)
• Treat to prevent low blood sugar
• Keep the child warm
• Consider a malaria rapid diagnostic test if available and if available consider
treatment for cerebral malaria
• Refer urgently to a hospital
Case 2
A mother and her 7 month old daughter are triaged by the nurse to be seen quickly.
She has fever, cough and difficult breathing. The mother says she has been coughing
for several days and last night felt hot to her touch. She has not been able to sleep and
does not seem interested or able to breast feed. Her axillary temperature is 39.4 ºC
and her RR is 55, with severe subcostal retractions. She has diminished air entry on
the right lung base, with rales in the same place. She appears lethargic to you and has
capillary refill of 3-4 seconds. She has poor skin turgor. Her MUAC is 113 mm so she
has severe acute malnutrition.
1) How should you classify this child according to IMCI and why?
Response:
• Very severe disease and severe pneumonia because she has 2 danger signs
(unable to feed, and lethargy) and pneumonia (chest indrawing and fast
breathing)
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3) How should she be managed?
Response:
• Give first dose of an appropriate antibiotic (Antibiotics: Ceftriaxone (IM) or
Penicillin (IM) or Amoxicillin (PO).
• Give oxygen if available
• Treat to prevent low blood sugar (ORS if possible)
• Keep warm
• Refer urgently to the hospital
Case 3
You now see a 2 year old boy with a 1 week history of coughing that has gotten worse
during the past day. He felt hot for 2 days after he started coughing but his fever
seemed to then get better. Last night he felt hot again and mother noticed that he was
breathing fast. He has been eating although his appetite is decreased. He has not been
vomiting and has not had convulsions. On examination his temperature is 30oC, RR is
50 and he has severe subcostal retractions. He has rales over his left lower lung but no
wheezing or stridor. He is alert but appears irritable. There is no history of an HIV
exposure. You have pulse oxymetry and his oxygen saturation is 90%.
1) How should you classify this child according to IMCI and why?
Response:
• Yellow, pneumonia because he has no danger signs, chest indrawing and fast
breathing
2) How should she be managed?
Response:
• Give 5 days of Amoxicillin (PO)
• Give a safe cough remedy
• Revisit in 3 days
• Review danger signs with mother
Case 4
There is an influenza outbreak in the crowded camp and you suspect it is caused by an
outbreak of H1N1 influenza. The H1N1 strain circulating at this time appears to be
more severe than in the past few years. There are concerns that antigenic shift has
resulted in a strain that is causing more severe pneumonia and a much higher case
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fatality rate, especially among children and young adults. A 4 year old boy comes to the
clinic with his mother, who says that he has felt very hot for the past 2 days. While he
complained about a headache and sore throat when he felt hot and now is coughing all
the time. He even now vomits when his coughing is bad. He couldn’t sleep last night
and refuses to eat. He will drink. On your physical examination you note that his
temperature is 39 o C, HR 120, RR 60 and BP 100/60. He has moderate to severe
subcostal retractions. He appears lethargic but is not unconscious. He has not had
convulsions.
1) How should you classify this child according to IMCI and why?
Response:
• Very severe disease and severe pneumonia because she has 1 danger signs
(lethargy) and pneumonia (chest indrawing and fast breathing)
2) How should she be managed?
Response:
• Give first dose of an appropriate antibiotic (Antibiotics: Ceftriaxone (IM) or
Penicillin (IM) or Amoxicillin (PO).
• Give oxygen if available
• Treat to prevent low blood sugar (ORS if possible)
• Keep warm
• Refer urgently to the hospital
Scenario Continued
Your shift in the clinic is finished so you accompany the family to the local hospital.
When you arrive the pulse oxygen study shows his oxygen saturation to be 79% so you
administer oxygen with a nasal cannula and try to get his saturation over 90%.
The results of his work up are:
• Hgb 10 and HCT 35%, WBC with 14,900 76% segmented neutrophils (10% bands)
and low platelets of 75,000.
• Serum sodium 128
• Blood culture pending
• Chest x-ray reveals extensive consolidation of his left lower lobe and infiltrate in right
lower lobe.
• Influenza testing positive for H1N1
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3) How would you manage this child now?
Response:
• Admit
• IV antibiotics (consider vancomycin or cefuroxime if available)
• Oxygen
• Antiviral therapy if available
Scenario Continued
The patient was admitted to the Pediatric ICU. He deteriorated rapidly requiring
intubation and pressor support to maintain his blood pressure. His hyponatremia
related to SIADH resulted in pulmonary edema. Within 24 hours of admission to the
Pediatric ICU despite treatment with vancomycin and hypertonic saline he died in
respiratory failure. His initial blood culture grew MRSA. This new H1N1 strain seems to
be more severe than in the past few years. There are concerns that antigenic shift has
resulted in a strain that is causing more severe pneumonia and a much higher case
fatality rate especially among children and young adults.
4) What is the difference between antigenic drift and shift with regards to
influenza viruses?
Response:
Antigenic drift:
• Occurs among influenza A viruses resulting in emergence of new variants of prevailing
strains every year
• New variants result in seasonal flu each winter
• Some years are worse than others – partly related to degree of ‘drift’
Antigenic Shift:
• Major changes occur in the surface antigens of influenza A viruses
• Occurs by mutation or by ‘re-assortment’ between viruses
• Changes are more significant than those associated with antigenic drift
• Changes lead to emergence of potentially pandemic strains by creating a virus that is
markedly different from recently circulating strains.
Scenario Continued
During the next week your clinic and the local hospital are overwhelmed with patients
seeking care. The majority are worried patients with URI symptoms and uncomplicated
pneumonia without danger signs. The hospital laboratory only has a limited number of
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influenza rapid diagnostic test kits and will soon run out. The hospital also only has a
limited amount of 2 types of antiviral medication. You need to develop a policy about
who should be tested and who should be treated with Tamiflu. You know that
specimens for viral rapid diagnostic tests should be obtained during the first 72 hours of
illness, because the quantity of virus shed decreases rapidly as illness progresses
beyond that point.
5) In designing your policy for Influenza testing and treatment what are the key
clinical questions that should be addressed?
Response:
• Is the clinical presentation compatible with an influenza infection?
• How many strains of influenza are currently circulating?
• Will a direct clinical change result from viral testing? If not do not test.
• Are there high risk patients that should receive antiviral therapy? If so should they
be treated before they have very severe disease or severe pneumonia?
• Should only hospitalized children be tested and receive antiviral therapy?
• What anti-virals should be used to treat different strains of circulating influenza
infection?
Scenario Continued
You now need to develop an influenza H1N1 pandemic surge plan for the clinic and
hospital.
6) What are the critical components of a comprehensive H1N1 pandemic surge
plan?
Response:
Critical components of comprehensive plans include the following:
• Controlled access to the healthcare facility;
• Prevention strategies (isolation and cohorting, personal protective equipment use,
vaccination, antiviral prophylaxis, modification of environmental controls (i.e.
separate areas for ill and non ill patients), visitation policies, ill-staff protocols;
• Disease-specific admission criteria, treatment, and triage algorithms;
• Enabling the continuity of limited clinical operations
• Plans to handle a sustained surge of patients in terms of both staffing needs and
physical space/ treatment areas
• Provisions for additional triage areas as well as the potential for additional critical
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care needs beyond hospitals capacity
• Expanded ventilator needs and just in time training of additional respiratory
therapist equivalents.
7) What are the critical components of a surge plan for the ICU?
Response:
• Determine number of expected critical patients.
• Inventory critical care supplies, medications and equipment.
• If needs exist, work with the hospital to address these needs.
• Establish a critical care expanded staffing plan for multiple days of assignments.
• Determine ability to expand critical care spaces into other critical care sites
(NICU, CICU) as well as non-traditional sites (PACU, converting OR space or
medical floor space).
8) You hope to receive an initial shipment of 1,000 vaccine doses against the
new influenza strain. Which population groups should have the priority to
receive the vaccine?
Response:
• Camp security and first responders (EMTs, police, firemen), health care workers,
pregnant women, high risk conditions, the young and elderly.
Case 5
A 10-year-old boy is brought to the medical care center. Hi mother says he is
complaining of headache, muscle aches, and joint pain. He has felt hot to her for
several days. He has vomited a few times. He seemed to get better but the fever
restarted yesterday, and now he has a rash all over his body. Today his mother saw
that his stool looked like it was bloody. On examining him, he looks weak, dehydrated,
and has petechiae in arms and legs.
1) Which are the 2 most likely diagnoses for his initial symptoms?
Response:
• Dengue fever and Chikungunya
2) Is there a way to determine if the petechiae are due to a low platelet count
without doing a CBC?
Response:
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• A positive tourniquet test which suggests Dengue; if available, a rapid diagnostic
test for Dengue
3) How would you manage him at this moment?
Response:
• Clinical control and support therapy.
• Maintain good hydration with oral rehydration salts (ORS).
• If possible, platelet count and hematocrit control.
4) What complications can be associated with Dengue?
Response:
• The most serious complication is the dengue shock syndrome. It presents as
severe hemodynamic compromise, with or without lung involvement. Metabolic
disorders can occur: hypoglycemia, metabolic acidosis and hepatic or renal failure.
Mortality rates vary from 1% to 5%, although higher rates have been reported.
5) How are the severe forms of this disease treated?
Response:
• Volume expansion to control shock (normal saline or Ringer lactate).
• Parenteral hydration, avoiding fluid overload.
• Blood glucose control.
• Hemoglobin and hematocrit control with whole blood transfusion or packed red
blood cells.
• Antipyretic drugs as needed.
6)
Are corticosteroids useful for this disease?
Response:
• Corticosteroids do not affect the progression of the disease; thus, they are not
indicated.
Case 4
The nurse triages a 5-year-old child as having a cough or cold because there were no
danger signs, fast breathing or chest indrawing, or diarrhea. He has felt hot to the
mother for 2-3 days. On examination he seems ill and irritable but is not lethargic and
can be consoled by his mother. On examination his temperature is 39ºC and RR is 35.
He has no chest indrawing. You are impressed with his rash mostly on his face and
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neck and become very anxious when you see whitish lesions on an erythematous base
on his buccal mucosa. He also has conjunctivitis and copious nasal discharge. Both
tympanic membranes are reddish yellow, bulging, and immobile. He has metallic
sounding cough.
1) Why are you so worried?
Response:
• The rash and Köplik spots suggest measles
2) If this is measles how will the rash usually evolve?
Response:
• It starts on the forehead and spreads, in a cephalocaudal manner, to the trunk and
then towards the limbs in 3-5 days.
• It disappears over time in the same pattern.
• After disappearing, there may be fine desquamation.
3) How would you treat this patient?
Response:
• With vitamin A
- Dose: 200,000 IU (oral), particularly if the child is malnourished and has not
recently been treated.
• Treat acute otitis media
- Oral antibiotic: amoxicillin for 5 days.
• Public Health
- Notify Public Health authorities!
-If possible draw blood for measles serology testing
4) Is it necessary or even possible to isolate the child?
Response:
• Probably not possible or feasible
Scenario Continued
You receive word that the refugee camp has priority to receive the measles vaccine
which can be delivered in 48 hours once they receive the necessary information from
you about your needs and resources for maintaining the cold chain.
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5) What information to you need to obtain ASAP?
Response:
• Obtain information about the number of children “at risk” among those younger
than 5 years old.
• Ask nurses in your sector to identify all the families with children in the target age
range (6 months-5 years). Divide them in age groups (6-12/12-23/24-59 months),
measure the MUAC.
• Determine who is ill or/and who has severe and moderate acute malnutrition.
• Examine the eyes of those that seem malnourished or ill for signs of vitamin A
deficiency.
• Count and register the children in these categories.
Your list indicates the following:
456 children of 6-12 months (~180 ill or malnourished)
523 children >12-23 months (~155 ill or malnourished)
1010 children 24-59 months (~50 with ill or malnourished)
• Determine how much vitamin A is available, if there is enough to treat children now
and if you will need more delivered.
6) What is the dose of vitamin A for 6-12 months and older than 12 months?
Response:
• Dose: 6 months-12 months 100,000 IU by mouth >12 months 200,000 IU by
mouth
7) You need to put together a vaccination plan. What are some of the issues
that
you need to consider in organizing how you will vaccinate the population?
Response:
• Will you vaccinate at the clinic or sites within each sector?
• How many refrigerators will you need to have to keep the vaccine?
• What are the requirements for vaccine storage?
• Who will deliver the vaccine and how will they be freed up from their other work?
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Scenario Continued
You receive a call on the radio that vaccines will arrive first thing tomorrow, provided
the climate allows for the arrival of the plane. You are told that at this time there are
only 1500 doses of the vaccine for your camp.
8) How will you assign priorities to administer the vaccines in your camp?
Response:
• All infants from 6 to 12 months old.
• All children from 12 to 23 months old.
• The 50 ill or malnourished children from 24 to 59 months old = (subtotal) 929
doses.
Possible options for the remaining 471 doses:
• Immunize all children younger than 5 years old in the sector where the first case
appeared, close to the tent with the initial case
or:
• Immunize all children from 24 to 36 months old, then those from 36 to 48
months... until the stock of vaccines is depleted
There is no ideal answer, but students should weigh pros and cons of the different
plans, in order to use all vaccines in the best possible way.
9) How will you identify those that have been immunized if, at a later date, they
receive more vaccines?
Response:
• Giving each family/child an immunization card (the WHO team has guidelines for
immunization cards).
• Writing an X with a pen on the back of immunized children and telling them not to
wash.
• Always ask natives of reference or interpreters what is the culturally most
appropriate way to do this and explain to parents about the need to vaccinate
against measles.
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