who programme on acute respiratory infections

Indian J Pediatr 1988 : 55 : 19%205

W H O programme on acute respiratory infections

Antonio Pio

Acute Respiratoo" Infections Programme, Worm Health Organization, Geneva, Switzerland

The World Health Organization initiated in 19841 a distinct programme on acute respiratory infections (ARI) in res- ponse to the concern expressed by developing countries about the high mortality from these diseases in children. Therefore the main objective of the new programme was to reduce mortality from ARI in children under 5 years of age. It was considered that simple and effective measures could be identified that would be appli- cable within the primary health care system.

The problem

Es tima te of magnitude. Of the estimate d 15 million deaths occurring each year in children, 14 million occur in developing countries. 2 Approximately one quarter to one third are due to diarrheal diseases and the same proportion to ARI. In absolute numbers, at least 4 million ARI-related deaths occur each year, or 11000 per day.

The main respiratory syndromes which threaten children's lives are pneumonia, bronchiolitis and acute obstructive laryngi- tis. Among these, pneumonia is by far the most frequent cause of death.

*Based on the document 'Acute Respiratory Infections:Progress and Current Status of the Programme--Second Report, 1985-86, WHO/ RSD/86.30.

In terms of morbidity, acute respiratory infections are extremely common. On average, a child in an urban area suffers from five to eight attacks of ARI annually, with a mean duration of 7 to 9 days. In rural areas, the incidence appears to be somewhat lower.3 The overall incidence of ARI among chi!dren in developing countries does not appear to be higher than that among those in developed countries. The important difference lies in the relative frequency and severity of lower respiratory tract diseases. The anm~al incidence of pneumonia in 0-4 year old children ranges from 3 to 4 per 100 in the developed countries, and from 10 to 20 per 100 in the developing ones, but it may reach levels of up to 50 per 100 in the low birthweight infants and malnourished children.

The magnitude of the problem is also evident from worldwise health service statistics. These indicate that ARI is the chief reason for paediatric outpatients visits, and accounts for 20 to 40% of pe- diatric admission into hospitals.

Etiological agents. Evidence is now accumulating that in developing countries bacterial pathogens play a far greater role as a primary or secondary cause of pneumonia than in developed countries. In investigations conducted among children

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198 THE INDIAN JOURNAL OF PEDIATRICS Vol. 55, No. 2

hospitalized because of pneumonia who had received no previous antimicrobial treatment, approximately 60% of lung aspirates yielded bacterial growth (Brazil, Chile, Gambia, India, Nigeria, Papua New Guinea and the Philippines). 4 How- ever respiratory viruses are widely pre- valent and are probably the first invaders in most ARI cases. Sl.bsequent bacterial superinfection might be more frequent in developing countries owing to the poor hygienic conditions, the high nt, mber of low birthweight infants and the impair- ment of immunity on malnourished children.

Available evidence indicates that two bacteria, Streptococcus pneumoniae (pne- umococcus) and Haemophilus influenzae are the most frequent agents of pneumonia in children and generally respond well to common antibiotics (injectable penicillin, amoxycillin or co-trimoxazole).

The pattern of colonization and car- riage of pathogenic bacteria in the upper respiratory tract also differs considerably. It was found that Streptococcus pneumoniae can be isolated from up to 10070 not healthy children in developing countries, whereas this proportion is usually not higher than 507o in the developed countries. 3

to decide which children sl:ould receive antimicrobial drugs, which should not and which children should be referred. Simple guidelines have been developed so that these decisions can be made on the basis of easily recognized signs and symptoms.

Parents also have to be educated in recognizing the need to bring their children with severe respiratory infections to primary health care since studies have indicated that parental recognition often does not take place, or occurs too late.

Programme development

The main components of the programme are :

the health service component con- cerned with application of the present state of the art to the pre- vention and control of ARI in children: m the research component, directed to strengthening the scientific basis of the programme and solving problems raised in the implementation of services. The activities up to this point have

been mainly concentrated on the development of case management strategy and supporting research.

Methods for control of mortality The health service component

The importance of bacteria in causing death from acute lower respiratory infections in developing countr_~es, and the established effectiveness of antimicrobial and supportive treatment in averting such death make the improvement and up- grading of case management the strategy of choice of the ARI control programme. Primary health care workers need to be trained to use appropriate clinical criteria

Development of managerial tools. There is no better indication of the widespread neglect of ARI in developing countries than the almost complete lack of guidance on how to deal with the children with cough and other respiratory symptoms who overcrowd the health services during the winter or rainy seasons. To fill this gap, intensive work was devoted to issue appropriate technical guidelines based

PIO : WHO PROGRAMME ON ACUTE RESPIRATORY INFECTIONS 199

on the best scientific evidence. The document, "Case management of acute respiratory infections in children in developing countries" provides the rationale for the standardization of case management and an action-oriented classification of ARI in children :5

cases that require hospita/ization (severe forms), cases that can be managed as outpatients, but for whom treatment with antimicrobials is indicated (moderate forms),

- - cases for which only supportive measures without antimicrobial treatment are indicated (mild- forms).

It also gives information on the most useful simple supportive measures and reviews the advantages and disad- vantages of the most commonly used antimicrobials. It proposes a non-antimicrobial policy for most acute respiratory infections. The tse of antimiero- bials is very select.ire, restricted only to children suffering from infections which are most likely caused by bacteria, namely those with signs of pneumonia, otitis media and purulent pharyngitis.

A second technical document, "Res- piratory infections in children : management at small hospitals--Background notes and a manual for docters" is a handbook for the day-to-day work of doctors in hospitals where radiological and micro- biology facilities are limited or non- existent. 6 In a concise way, it indicates how to proceed with children presenting the most common respiratory syndromes such as cough with fast breathing, chest indrawing, wheeze, stridor, chronic cough, tuberculosis, v~hooping cough and upper respiratory tract infections, including otitis media.

On the basis of the technical guidelines, two training modules were produced : "Management of the child with cough", and "Management of the child with ear, nose andthroatinfection", These modules are addressed to mid-level supervisors in charge of training and supervising the personnel of peripheral health services and community health workers. They are similar in format and type of exercises to the EPI and CDD modules and can be easily integrated into the Supervisory Skills Courses of these programmes since the same staff will be responsible for the execution of the three programmes. ARI courses can be organized independently if there is a need to train only in this programme because it has come after many years of training in EPI and CDD activities.

For programme managers, an operational manual on the specific ARI elements to be incorporated in the planning, implementaiion and evaluation of primary health care progra~mmes has been prepared. 7

It was also considered important for the programme to invest resources in the production of audiovisual aids for training and health education as prototype material which can be adapted to the needs of each country. The following materials has been issued :

(a) Two sets of 24 slides each on the management of cough in children, one for Africa and the other for Asia, were produced by Tea- ching aids at low cost (TALC), London, under a contract with WHO. The sets illustrate the steps of the management of a child with cough exactly as recommended in the WHO technical guides and in the training module. Although


the main objective of the slides if for training health personnel, some slides can be used for health education sessions at the health centres and in the community.

(b) With the collaboration of the same institution in London, two flip-charts have been designed. They contain black and white line drawings, with the corresponding legends, on the management of children with both upper and lower respiratory infections. One chart was designed to help trainers to teach health workers how to treat a child with common respiratory infections. The other one is to use with parents and the community. They only provide examples of messages and illust- rations for training and health education.

(c) An inherent difficulty in training health personnel in ARI is the impossibility to give in a written text the exact description of the abnormal respiratory noises. To overcome this difficulty, a record cassette with the main respiratory noises in children has been produced by Graves Medical Audiovisual Library, London, and is distributed together with the learning modules and the sets of slides.

(d) A video cassette on the management of the child with cough was filmed with the cooperation of the Educational Resource Centre, Royal Children's Hospital, Melo bourne, Australia. The video illu- strates normal and fast breathing, chest indrawing, wheeze, stridor, grunting, whooping cough and

cyanosis in infants and young children.

Planning and implementation of the control strategies. National control programmes are now operational in Latin America. In this region two concerns exerted a decisive influence in moving ahead with ARI control programmes : the urge to accelerate the reduction of childhood mortality and the need to reduce the unnecessary use of antibiotics. In 1982-1983 the feasibility of the application of a standard plan of case management of ARI in the primary health care system was tested in Para state, Brazil and in Panama. The interest in the ARI programme spread rapidly throughout Brazilian states and to other Latin Ameri- can countries.

In a WHO survey conducted in 1985 among the Mit~istries of Health of the South East Asia Region about the priori- ties in communicable diseases (in respect of morbidity, mortality, availability of control technology and feasibility of control), ARI was ranked in the third place, preceded only by malaria and diarrhoeal diseases. Soon after the survey, a Regional Consultative Meeting on ARI Programme was held in New Delhi, 8-11 October 1985. The main objectives were to discuss how the WHO strategy on ARI could be implemented in the countries and the nature of the operational studies required to collect information needed to facilities the integration of ARl activities into the primary health care system. The meeting provided an overall view of the possibilities and constraints existing in the nine participating countries for the development of the ARI programme. 8 "Ihe extent of the problem was yet to be better defined but there was a

PtO : WHO PROGRAMME ON ACUTE RESPIRATORY INFECTIONS 201

clear recognition of the urgency to start programme activities in view of the huge mortality from ARI in childhood. Stress was placed on the need to adapt WHO guidelines and training material to suit local requirements and to integrate the training courses with CDD and EPI programmes. National ARI Committees or Task Forces have been created recently in Bangladesh, Burma, Indonesia, Mon- golia, Nepal and Thailand.

In the Eastern Mediterranean Region, Sudan and Tunisia have taken the initial steps for a national programme. In the Western Pacific Region, Vietnam established the programme in 1985. In the African Region the Ministries of Health of Malawi, Mauritius, Tanzania and Zimbabwe have decideo to implement the ARI control programme and have started training of health personnel.

Surveillance of bacterial drug resistance. A global surveillance system was initiated in 1986 to mointor the drug resistance of Streptococcus pneumoniae and Haemophilus influenzae, the two most common bacterial agents of lung infections in infants and young children.

Under a WHO contract, the Strepto- coccus Department, Statens Seruminstitut, Copenhagen, started the preparatory work to coordinate the surveillance of pneu, mococcal drug resistance among strains isolated from children in developing countries. So far 10 countries agreed to participate in the surveillance system (Argentina, Chile and Venezuela in Lating America, Gambia, Kenya and Mauritania in Africa, Saudi Arabia in the Eastern Mediterranean Region, India in South East Asia, and Malaysia and Papua New Guinea in the Western Pacific). Each participating laboratory should iso-

late 200 strains of Streptococcus pneumoniae from oropharyngeal swabs taken from children with ARI (100) and from healthy children (100). In addition all strains isolated from blood or from the cerebrospinal fluid during the survey period will be inch~dedin the study. The drugs to be tested will be oxacillin (indi- cator of penicillin sensitivity) and cotri- moxazole.

A similar system is being organized for the surveillance of Haemophilus influenzae drug resistance. A contract with the Pvblic Health Laboratory Ser- vice, John Radcliffe Hospital, Oxford, UK has already been signed.

Collaboration in ARI between WHO and UNICEF. Awareness of the problem of ARI in children has provided a specific incentive for further collaboration between WHO and UNICEF in their straggle for children survival in the framework of the Health for All Strategy. Both organizations agreed on the need to utilize the appropriate current technology at the community level to reduce the considerable death toll from ARI in children in developing countries. The concurrence was spelled out in a joint statement on basic principles for cc,ntrol of acute respiratory infections in children in developing countries, which was published in English, French, Portuguese and Spanish. 9

Research component

Health systems research. With support from WHO and other agencies, projects on feasibility and impact on mortality of ARI control strategies have been undertaken in 10 countries. All were designed to provide guidance to national


programmes which would subsequently be based upon them. In general the objectives are to apply and test the procedures which are to be employed in a control programme, and to observe the trend in the ARI-related mortality in children after implementing the standard plan of case management of ARI and delivering a programme of health education.

To measure changes in mortality a valid basis for comparison is necessary. The best way to ensure comparability is to observe a control area side by side with the intervention area. This metho- dology has been adopted in Kenya, India, Pakistan, Philippines and Tanzania. In other countries, a before-and-after comparison is made as the programme is applied in a particular area.

To projects, the ones in India and Tanzania, both using side by side comparison areas have been completed. The following is a summary of these results.

(a) lndia. The feasibility of standard case,management for A RI and its impact were evaluated in terms of mortality reduction in low birth weight infants, in Arnbala district, Haryana. 1o By two-stage cluster sampling 16 villages, with a popu- lation of 16,925 were allocated to the control area and 21 villages, with a popu- lation of 22,014, to the intervention area. In both areas birth weight of the new- born was recorded within 48 hours, and all babies weighing less than 2500 g were included. Thus, the study concentrated on the group at highest risk of death from ARI, low birth weight children. The households were visited each week by trained field workers until the child reached one year of age. The workers recorded details of disease and outcome as reported by the mothers. Causes of death were verified by professional staff.

The primary health care workers in the intervention area were instructed in the management of ARI, notably in discrimination between mild, moderate, and severe ARI, and they gave oral penicillin in moderate and severe cases and referred severe cases. In all other respects the standard WHO recommen- dations were followed, as part of primary health care.

There were 199 low birthweight babies in the intervention and 21I in the control area. The numbers of episodes of moderate and severe ARI were 69 and 61 (34.7~ and 28.9~) and the numbers of ARI deaths 6 and 15, (3.0H and 7.1~o) respectively. Thus, in spite of a slightly higher rate of more severe disease in the intervention area, the ARI-specific mortality rate was much lower. This reduction amounts to 58yo. The duration of the episodes of moderate and severe ARI was also lower in the intervention area (5-7 days) than in the control area (8-7 days). The efficiency of implementation can be measured in the marked increase in use of primary health care workers for initial ARI-related consul- tations.

(b) Tanzania. The feasibility and the impact on mortality of introducing ARI control measures were studied in the coastal district of Iiagamoyo, Tanzania. 11 The villages in this district were divided randomly into two groups. Training and deployment of village health workers was started in 1983 in the first group; it included instructions to visit each house- hold with children under five years of age every 6-8 weeks, giving health education about recognizing severe ARI, treating moderate and severe cases imme- diately with co-trimoxazole and referring

PIO : WHO PROGRAMME ON ACUTE RESPIRATORY INFECTIONS 203

the severe cases. Training courses were given to health centre and dispensary workers. After 12 months the training and deployment of health workers pro- ceeded to the second village group, improvement and refresher training being continued in the first group. Because of the delayed implementation in the second area there was a period in which an "intervention" and a "control" area existed. Births and deaths were reported to Medical Assistants in both areas and census surveys of births and deaths were made in 1984 and 1985.

In the first survey 8,028 children under five years old were covered in the intervention area and 8,098 in the control area. The numbers of deaths among them were 260 and 326, respectively. The interventions thus caused an apparent reduction in mortalitj, of 19~. The second survey covered 9,099 children in the intervention and 9,915 ch',_'ldren in the control area, and the numbers of deaths were 266 and 347, corresponding to a reduction of t6~. While such a reduction of mortality is of considerable value, outside observers have feft that a greater reduction could be achieved with better implementation of the case management programme. Verbal autopsies showed pneumonia to be by far the leading direct cause of death (35.1~o) and measles to be the leading associated cause (12.4~o).

Clinical research. S,~nce the management scheme for ARI in young children is based on a clinical classification to be made by primary health care workers, it is of obvious practical interest to verify how well the workers can recognize signs and symptoms after a short training period, and whether the proposed classification indeed provides the optimal result

(studies on the pathognomonic value of signs and symptoms of ARI in children). To do this, health workers are trained to recognize a variety of ARI-related signs and symptoms and deployed t o

screen children presented at a health centre, recording their observations. The children are then examined by an expert pediatrician, treated as appropriate, and carefully followed-up. The signs and symptoms recorded by the health workers are then compared with the final diagnosis made and the optimal treatment determined a posteriori. Since, by this approach the prevalence of ARI among the children is known, estimates can be made of the sensitivity and specificity of the proposed as well as possible alter- native combinations of signs and symptoms as recognized by health workers.

One such study started in Mandalay General Hospital, Burma, in May 1986. Its duration is one year; at least 200 cases of pneumonia are expected to be included among the children reporting from a defined area. A similar study will be carried out in Khartom, Sudan, where the feasibility study to select an appropriate health facility has been successfully concluded.

Indoor air pollution studies. Studies have been promoted in several countries to determine and evaluate the contribu- tion to the incidence and severity of ARI of indoor air pollution stemming from the combustion of biomass fuel. There are indications that high concentrations of acrid smoke and gaseous substances may impair pulmonary defence mecha- nisms. This problem is of particular concern in infants and young children living in rural dwellings without proper ventilation.

204 q-HE INDIAN JOURNAL OF PEDIATRICS Vol. 55, No. 2

In a first phase the project intends to ccllect data to assess the levels of indoor air pollutants (respirable parti- culate matter, carbon monoxide, nitrogen dioxide) in rural areas in which ARI studies are being conducted. The design calls for a 3-week survey in each area, during which 30 randomly selected houses are monitored with small battery-opera- ted instruments placed inside the rooms for 24 hours.

The first survey was carried out in the ARt study area in Maragua, Kenya 12. The initial census indicated that wood was used as cooking fuel in 97~o of the houses, and charcoal in 3~o. '

The mean of the 24 hour average respirable suspended particles measure- ment was 1400 microgram/mL In the evening peak levels up to 36,000 microgram/m 3 were observed. These data indicated that health effects due to excessive exposure to smoke from biomass combustion are likely to occur among young children.

Promotion and information

Interest in information on ARI has increased steadily in the last few years as a result of the growing awareness of the problem in developing countries and the efforts made by the programme and other interested organizations and agencies.

In 1985 the programme promoted the production ot ARI News under a contract with the appropriate health resources and technologies action group (AHRTAG), London, United Kingdom, and the financial support of several agencies. The publication appears regu- larly in english every four months and is distributed free cf charge.

A special series of publications is produced by the programme. It includes manuals, guidelines, technical reviews, results o:" WHO-supported projects, re- ports of the Technical Advisory Group meetings and documents of other WHO meetings on ARI. These materials and the reprints of papers published in scientific journals and periodicals by the programme are distributed, free of charge, through the WHO computerized mailing list of ARI publications, which contains about 700 addresses. Although it is a rather small list, it includes the main institutions, public health administrators and scientists in developing countries who are interested in ARI. At present the list of WHO ARI publications offers 60 titles.

A bibliography on respiratory infections in chilciren is being published in English by the Pan American Health Organization in collaboration with the US National Library of Medicine. The first volume covered the period January 1978--December 1982. Thereafter two issues a year have been issued---4000 copies each, of which 3000 are distributed free of charge to developing countries and through the programme mailing list.

Conclusion

Until now the WHO ARI programme has concentrated its efforts on the development of intervention strategies and the preparation of managerial tools to support the implementation of control activities in developing countries. Pilot studies and operational surveys have been carried out in a number of countries; guidelines on case management and health education have been worked out together

P l O : WHO PROGRAMME ON ACUTE RESPIRATORY INFECTIONS 205

with the c o r r e s p o n d i n g t ra in ing m o d u l e s , p r o t o c o l s fo r e t io logica l s tudies and d rug

res is tance survei l lance have been e labo-

r a t e d a n d a sys tem to d i s semina te in fo r -

m a t i o n has been es tab l i shed . A l t h o u g h effor ts have been largely

' p r o g r a m m e specif ic ' , the r igh t loca t ion

o f A R I wi th in p r i m a r y hea l th ca re deve- l o p m e n t has no t been over looked . There

is an urgent need to acce le ra te the implemen ta t i on o f A R I c o n t r o l in view of its grea t p o t e n t i a l to p roduce an impac t on

in fan t a n d ear ly ch i l dhood mor ta l i ty . Ped ia t r i c i ans can p lay a l ead ing role in

this ef for t .

R e f e r e n c e s

1. World Health Organization. Seventh General Programme of work covering the period 1984-1989. WHO, 1982

2. Leowski, J. Mortality from acute respiratory infections in children under 6 years of age : Global estimates. Worm Hlth Stat Quart 1986; 39 : 138-144

3. Pi t A, et al. The magnitude of the problem of acute respiratory infections. Proceedings of an International Workshop on Acute Respiratory Infections in Childhood (Sydney, August 1984). University of Adelaide, Aust- ralia, 1985, pp 3-16

4. Shann, F. Etiology of severe pneumonia in children in developing countries. Pediatr Infect Dis J 1986; 5 : 247-252

5. World Health Organization. Case management of acute respiratory infections in children in developing countr/es. Document WHO/ RSD/85. 5, Rev. 2

6. World Health Organization. Respiratory Infections in Children at Small Hospitals : Background Notes and a Manual for Doctors. Document WHO/RSD/86. 26

7. World Health Organization. Acute Respir- atory Infections : A Guide for the Planning, Implementation and Evaluation of Control Programmes within Primary Health Care. Documeflt WHO/RSD/86 29

8. World Health Organization Regional Office for South-East Asia. Acute Respiratory In- fections in South-East Asia : Report of an intercountry meeting, New Delhi, 8-11 Octo- ber, 1986. WHO, SEARO Technical Publi- cations No. 8, 1986

9. WHO~UNICEF Joint Statement on Basic Principles for Control of Acute Respiratory Infections in children in developing countries. WHO/UNICEF, Geneva 1986

10. Datta N, Kumar V, et al. Case management in the control of acute respiratory infections in low birth weight infants : a feasibility study. Bull Wld Hlth Org 1987 (in press).

11. Mtango FDE, Neuvians D. Acute respiratory infections in children under five years. Control project in Bagamoyo District, Tanzania. Trans Roy Soc Med ltyg 1986; 80 : 851-858

12. Indoor Air Pollution Study, Maragua Area, Kenya. Document WHO/PEP/87.I--WHO] RSD/87. 32, 1987

who programme on acute respiratory infections

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