Bull Pan Am Health Orgarl 19(l), 1985
ACUTE RESPIRATORY
INFECTIONS
IN CHILDREN:
POSSIBLE
CONTROL MEASURES1
Edgar Mohs2
The experiences of Costa Rica and that countryk National Chil- dren ‘s Hospital since 1970 suggest a variety of measures that can help to reduce the impact of acute respiratory infections. This arti- cle provides a brief overview of those experiences and measures.
Introduction
,Acute respiratory infections (ARI) are pres- ently considered to be among the most impor- tant causes of morbidity and mortality around the world (I-2). In the less developed coun- tries, where mortality due to AR1 tends to be between five and 25 times greater than in the industrial nations (Table l), these illnesses account for over 50% of the notifiable disease cases and between 50 and 60% of all pediatric outpatient consultations (3).
In a similar vein, patients with acute respi- ratory infections account for approximately 10% of all pediatric hospital discharges and some 10% of all hospital deaths (4). Most of
the outpatient infections are caused by vi-
ruses, but many of the hospitalized cases, es- pecially those ending in death, have a bacte- rial etiology (5-6).
In recent years, advances in the control of acute diarrhea1 diseases have caused the acute respiratory infections to emerge as a singu-
larly important public health problem and
have tended to focus increased attention upon them. Despite this, however, the major role played by AR1 as a cause of isolated infections and disease outbreaks among hospitalized patients is not widely recognized and under-
’ Also appearing in Spanish in the Boletin de lu O.fi- cinu Scmitcrriu Ptrrttrr~~rricc~rrtr. 1985.
2 Director, National Children’s Hospital, San Jo&. Costa Rica: Investigator, Institute of Health Research (INISA). Costa Rica: and Professor of Pediatrics. Uni- versity of Costa Rica.
stood. Even where AR1 are considered impor- tant nosocomial infections (7-8), the magni-
tude of this hospital-related problem in less
developed countries has not been accurately established. And since the number of hospital beds in developing countries will continue to grow, it seems essential to learn more about the risks of respiratory infections among hos-
pitalized children-in particular because pe-
diatric hospitals with an excess of patients
and limited human and technological re-
sources may pose a grave hazard to children’s health and survival.
ARI at the National Children’s Hospital in Costa Rica
The National Children’s Hospital in San Jose, Costa Rica, is a 430-bed facility provid- ing tertiary pediatric care. In 1982, AR1 were responsible for most of the nosocomial out- breaks at this hospital, an AR1 outbreak be- ing defined as the presence of three or more hospital-acquired AR1 cases in the same ward on the same day. Overall, hospital-acquired AR1 cases accounted for over 35% of all noso- comial infections (Table 21, with infections of the skin and mucosa being the next most nu- merous category.
In general, the prognosis for nosocomially acquired infections is poor, partly because of the disease agents’ multiple resistance to anti- biotics and the debilitated status of the pa- tient; in the group referred to here, half of the
Table 1. Reported influenza and pneumonia deaths per 100,000 among children O-4 years of age in seven countries of the Americas during
1968 or 1969 and during 1974, 1976, or 1977.
Deaths from influenza and pneumonia per 100,000 in the indicated age group: country
Argentina Costa Rica Chile Mexico
Dominican Republic Venezuela
United States
Years < 1 year 1-4 years
1969 932.8 217.8
1977 426.9 125.9
1968 586.0 144.7
1977 280.4 76.1
1968 2,897.2 669.8
1977 917.0 191.7
1969 1,825.2 557.4
1974 1,160.O 337.4
1968 218.4 67.4
1976 258.4 82.1
1968 554.2 162.7
1977 426.1 128.9
1968 225.8 51.8
1977 50.6 13.3
Source: Pan American Health Organization, PAHO Epidemiological Bulletin l(S),
Table 2. The numbers of nosocomial infections (showing the types of acute respiratory infections
involved) that were reported at the National Children’s Hospital in San Jose, Costa Rica,
for 1982.
Rhinopharyngitis Pneumonia and broncho-
pneumonia Acute otitis media Laryngotracheobronchitis Tonsillitis
Purulent tracheitis Mastoiditis
Total (ARI) Total (all infections)
336 148 62 25 7 1 1 580 1,568
rhinopharyngitis, but as many as 25% in-
volved bronchopneumonia or pneumonia. Of
the latter, 10% were confirmed as being due to bacteria, and 16% of the afflicted patients died as a consequence of these acquired infec- tions. It is also noteworthy that in nearly all of
the 15 pneumonia or bronchopneumonia
cases diagnosed by lung or pleural puncture, gram-negative bacilli were found; this is in contrast to bacteria responsible for pneumo- pathies in the general population, which are mainly caused by Streptococcus pneumoniae.
Staphylococcus aureus, or Hemophiius in-
fluenzae (9).
Source: Nosocomial Infections Committee, National Children’s Hospital. San Jos6.
ARI Control Measures nosocomial AR1 cases occurred in neonates
and the other half occurred in patients with devastating diseases. In all, 24 outbreaks of nosocomial AR1 infections were recorded at the National Children’s Hospital in 1982, and there were at least six patients with AR1 cases in each ward every month. The great majority
of the infections were cases of rhinitis or
Health Measures
Short-term health measures, if widely ap- plied to the community, region, or country in-
volved, can produce important positive
84 PAHO BULLETIN l vol. 19, no. 1, 1985
mentation of well-known technologies in our country (10) reduced infant AR1 mortality by about 70% between 1970 and 1980 (Figure 1).
Immunization (especially against measles,
diphtheria, and whooping cough) has pre-
vented illness (Figure 2). Concurrently, the
pneumonia case-fatality rate, as well as the need for mastoidectomies and the numbers performed, at the National Children’s Hospi- tal has declined sharply (Figure 3 and Table
3) following the introduction of benzathine
penicillin, erythromycin, and sulfa-trimetho-
Figure 1. Mortality from pneumonia among in- fants and young children in Costa Rica, 1970- 1980, as reported by the General Statistics and
Census Bureau.
30 c g
s
l \
oz
20
-
L
‘1
< 1 Year Of age 2
+ 10 I l-4YBXSOi 9 l . age
'\.,
l -•-.-.
Q x.-e* \ \ .-.-.
-8 .- -.e-.--.-
r.m,,l,, . __-- -
70 72 74 76 78 80 YEAR
Figure 2. Mortality from diseases preventable by vaccination in Costa Rica, 1970-1980, as reported by the General Statistics and Census Bureau. The diseases in question are diphtheria, pertussis, teta- nus, measles, and poliomyelitis. Since 1974 no deaths due to diphtheria or poliomyelitis have been
reported.
YEAR
prim throughout Costa Rica as a result of the extension of medical services and develop- ment of a rural health program in which aux- iliary staff members provide effective cover- age through door-to-door visits.
Figure 3. Mortality among pneumonia patients at the National Children’s Hospital, Costa Rica, in 1970-1982, as reported by the hospital’s statistics
department.
01 I I I I
70 74 78 82
YEAR
Table 3. The numbers of pleural decortications and mastoidectomies performed at the National
Children’s Hospital in San Jose, Costa Rica, 1972-1982.
No. of patients undergoing:
Year
Pleural
decortications Mastoidectomies
1972 27 120
1973 3 116
1974 7 102
1975 1
1976 1 1:;
1977 2 122
1978 2 127
1979 0 92
1980 0 82
1981 0 76
1982 0 5.5
Adequate oral rehydration, nasal aspira- tion, provision of oxygen, and maintenance of
proper nutrition are measures that require
only simple technologies but that can mark- edly reduce mortality. In less developed coun-
tries, however, the infrastructure needed to
provide such simple services to the entire pop- ulation at risk is generally lacking. Unques- tionably, then, the first step needed is to cre-
ate this infrastructure and to establish an
effective referral system between the different health care levels.
With specific regard to hospital-acquired cases of ARI, the main actions needed are re- duction in the density of hospital occupation and improvement or encouragement of cer- tain basic hospital practices such as hand- washing by staff members and maternal breast-feeding of infants and newborns.
Studies of Mayan children in Guatemala (111, among others, have shown that low birth-weight is a major determinant of death in infancy. Therefore, it would appear that improving the weight of newborns in the com- munity will enhance disease resistance among newborns and infants, and will probably re- duce mortality from AR1 at this critical age. This line of reasoning is compatible with re- cent experience in Costa Rica, where a major effort was made to reduce the proportion of
low birth-weight deliveries (low birth-weight
being defined as a birth-weight of 2,500
grams or less). More specifically, it is possible that the improved birth-weights attained (the proportion of low birth-weight deliveries was reduced by 28%) contributed indirectly to the 74% reduction in AR1 mortality observed be- tween 1970 and 1980 (Table 4).
Other Measures An Overview
Factors such as undernutrition, crowding
and poor housing, poor education, and low socioeconomic status show direct correlations with morbidity and mortality. Therefore, de- spite the powerful potential of medical tech- nology against certain diseases, and despite
the broader beneficial impact of general
health measures, it is necessary to adopt other appropriate policies directed at improving the
quality of life. Unfortunately, general inter-
ventions having a direct impact on the quality of life require many years of sustained social effort, and the effects will be observed only af- ter considerable time has elapsed.
From the biomedical viewpoint, develop-
ment of new antibacterial and antiviral vac-
cines is of great importance, because such
vaccines will be able to reduce morbidity, complications, sequelae, and mortality just as the known vaccines and the antimicrobial agents have done. However, what is more pressing in the less developed countries is epi- demiologic and etiologic research on ARI, to- gether with establishment of adequate diag- nostic criteria and of treatment norms for the
various health care levels. It is also essential
to increase the coverage provided by the health services, to maintain the proper use of
Table 4. A comparison of ARI mortality in children O-4 years of age and low-weight births in Costa Rica during the years 1970, 1975, and 1980.
Year
Deaths from AR1 per
100,000
Reduction compared to 1970
No. of low-weight Reduction newborns (5 2SOOg) compared per 100 live births to 1970
1970 230 9
1975 80 -65% 7.2 -20% .
1980 60 - 74% 6.5 -28%
86 PAHO BULLETIN l vol. 19, no. 1, 1985
antibiotics, to solve logistics problems in- volved in the distribution of drugs and oxy- gen, and to provide adequate training in the judicious application of these items.
In addition, the general population should be educated about the importance of ARI, about simple ways to avoid transmitting these infections, and about ways of recognizing clinical AR1 signs that indicate severe disease capable of threatening a child’s life. Overall, interest in AR1 should be encouraged and promoted just as intensely as interest in diar- rhea1 diseases has been encouraged and pro- moted over the last two decades.
As a complement to such measures, it should also be recognized that effective con-
trol of AR1 and a drastic reduction in AR1 morbidity in developing countries can only oc- cur quickly if additional knowledge becomes available from biomedical, epidemiologic, and health services research. Such knowledge is required in order to provide a rational basis for implementing health programs and devel- oping new strategies. The critical need is not for new vaccines or for new antibacterial and antiviral drugs; for although useful, these will only add to the powerful tools already avail- able. Rather, the need is for a holistic ap- proach that is effective and that takes into ac- count the many factors involved in AR1 control.
ACKNOWLEDGMENT
The author is grateful to Dr. Idis Faingezicht for providing data regard- ing nosocomial ARI.
SUMMARY
Acute respiratory infections, which account for roughly half the notifiable disease cases and pedi- atric outpatient consultations in developing coun- tries, are also a major cause of hospital-acquired disease and nosocomial disease mortality. In 1982, for example, they produced some 35% of all nosocomial infections at the National Children’s Hospital in San Jo&, Costa Rica; up to 25% of these patients were afflicted with pneumonia or bronchopneumonia; and, partly because of other serious health problems, 16% of these afflicted pa- tients died.
Nevertheless, Costa Rica is making marked progress against acute respiratory infections, hav- ing reduced infant mortality from this cause by about 70% between 1970 and 1980. Specific mea-
sures believed responsible include effective exten- sion of health service coverage nationwide, immu- nization against childhood diseases, and prompt use of appropriate antibiotics. To date, Costa Rica’s experience suggests that developing country efforts against acute respiratory infections could focus most profitably on epidemiologic and etio- logic research: on establishing adequate diagnostic and treatment norms; on increasing health service coverage; on solving problems related to the proper supply, distribution, and application of oxygen and antibiotic drugs; and on developing a holistic approach that is effective and that takes account of the many factors involved in controlling acute res- piratory disease.
REFERENCES
(I) Bulla, A., and K. L. Hitze. Acute respira- (3) Castro, B., P. JimCnez, L. Mata, M. Vives, tory infections: A review. Bull WHO 56:481, 1978. and M. Garcia. Estudio de Puriscal: IV. Morbili-
en Costa Rica, 1965-1980: Prevalencia, gravedad y letalidad. Bol Of Sanit Panam 94535, 1983.
(5) Mimica, I., E. Donoso, J. E. Howard, and W. Lederman. Lung puncture in the etiological di- agnosis of pneumonia. Am J Dis Child 122~278, 1971.
16) Albornoz, C., L. Vasquez, and C. Bello. La puncidn pulmonar en las neumopatias agudas de1 lactante y su condicibn clinico-bacteriol6gica. Bol Med Hosp Infant Mex 30:301, 1973.
(7) Hall, C. B., and R. G. Douglas, Jr. Modes of transmission of respiratory syncytial virus. J Pe- diutr 99:100, 1981.
(8) Doyle, A. Incidence of illness in early group and family day-care. Pediatrics 58:607, 1976.
(9) Gonzalez, R., E. Duran, 0. Castro, E. Mohs, and J. Jir6n. Puncibn pleural o pulmonar en neumopatias graves. Rev&a Mtdica del Hospital National de Niiios (Costa Rica) 11:33, 1976.
(10) Mohs, E. Infectious diseases and health in Costa Rica: The development of a new paradigm. Pediatr Infect Dis 1:212, 1982.
(11) Mata, L. J. The Children of Santa Maria Cauque’: A Prospective Field Study of Health and Growth. MIT Press, Cambridge, Massachusetts, 1978.
WHO CREATES NEiVSLETTER ON ACUTE RESPIRATORY INFECTIONS
The need to introduce effective control programs directed against acute respira- tory infections (ARI) in developing countries represents a challenge that remains largely unmet. One major reason for this is lack of available information-both about the causes of AR1 and about possible approaches to the problem.
In an attempt to reduce this information gap and to complement its own expand- ing AR1 control program, WHO recently proposed establishing a newsletter on acute respiratory infections that would be aimed at health administrators, educa- tors, pediatricians, research workers, clinicians, and others working in this field.
Since then, sufficient funding has been obtained from the Edna McConnell Clark Foundation and the Pan American Health and Education Foundation (PAHEF) to publish three issues, and an international team of technical editors has been assigned to produce the newsletter. Known as ARZ News, the newsletter is being published by the Appropriate Health Resources and Technologies Action Group (AHRTAG), a resource center based in London that disseminates informa- tion on primary health care. Besides ARZ News, AHRTAG also publishes three other health newsletters- Diarrhoea Dialogue, Aids for Living, and Dental Health News.
The goal of ARZ News is to serve as a medium for disseminating new research information and ideas, and to provide a focal point for reader discussion of practi- cal issues and approaches relating to AR1 control.
