Primary Health Care Manual 3rd Edition

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DEDICATION Remembering Prof. Donald A. Hillman Professor Donald Hillman died on 4th July 2006. He was a world renowned paediatrician, a champion of International Health, and a strong advocate for improving child health worldwide, particularly in developing countries. This third edition of “The Primary Health Care manual for medical students and other health workers” is dedicated to Don Hillman. His work will forever live on through the generations of undergraduate and postgraduate medical students all over the world whom he mentored and influenced in their careers, together with his wife Liz Hillman. Dr. Donald Hillman graduated in Medicine at McGill University in Montreal, Canada in 1949. He received his postgraduate education at the Montreal Children’s Hospital, the Hospital for Sick Children in Toronto and at the Massachusetts General Hospital in Boston. He completed his PhD. in Investigative Medicine at McGill University in 1961. He subsequently became a Professor of Paediatrics and Associate Dean of Postgraduate studies at McGill University, and a Professor in Paediatrics at Memorial University in Newfoundland. From 1976 to 1989 Don Hillman and his wife Liz Hillman joined the then new Faculty of Medicine at Memorial University of Newfoundland as Professors of Paediatrics. Don Hillman became Physician-in-Chief and Liz Hillman was Director of Ambulatory Education at the Janeway Child Health Centre. In 1989 The Hillmans joined McMaster University in Hamilton in the field of international health. They later moved on to the University of Ottawa in the same field, now generally referred to as Global Health. Internationally the Hillmans have also had a long and illustrious career having worked in more than 15 countries as consultants or visiting Professors. This includes Kenya, Uganda, Tanzania, Zambia, South Africa, China, Kuwait, Singapore, Laos, Malaysia, Bhutan, India, Guyana, Philippines and Pakistan. In the early 1970s McGill University teamed up with the Canadian International Developing Agencies (CIDA) to support the development of a new medical school at the University of Nairobi in Kenya. In 1974 Don and Liz Hillman accepted a four year appointment in the Department of Paediatrics and Child Health at the University of Nairobi. They worked together with Prof. Nimrod Bwibo and Dr. Alan Ross to strengthen the teaching of Paediatrics and Child Health at the University of Nairobi. This has now grown to be one of the largest undergraduate and postgraduate medical teaching programmes in Africa. Don and Liz Hillman later moved on to Makerere University in Uganda where they managed another CIDA funded project known as CHAMP (the Child Health and Maternal Educational Programme). They also served in senior advisory positions with UNICEF Kampala

2__________________________________________________________________________ _ The McGill and Nairobi programmes and the CHAMP programme in Uganda were later to influence the development of the CIDA funded Primary Health Care East Africa (PHCEA) project in the late 1980s which was negotiated and championed by the Hillmans. The PHCEA project focused on improving the teaching of Paediatrics and Child Health in Kenya, Uganda, Tanzania and Zambia, including the exchange of students and staff. This project produced a popular teaching manual - The Primary Health Care manual for medical students and other health workers - which is still in use today in at least five medical schools and is stocked in several libraries. The Hillmans have also supported the development of new medical schools at Moi University (in Eldoret, Kenya), at Mbarara University for Science and Technology (Uganda), and at Gulu University (Uganda). Following their retirement in Canada, they continued their active involvement abroad in international health by serving as consultants or visiting professors. They undertook and completed assignments for Canadian External Services Organization (CESO) in Kenya, India, Guyana, Philippines and Pakistan. At the time of Don's death, the Hillmans were working on a project funded by the Royal College of Physicians and Surgeons of Canada in Zambia, Tanzania, Kenya and Uganda. In recognition of this lifetime commitment and tremendous contribution to Global Health spanning over thirty-five years, the Hillmans received several awards. This includes the Ross Award (1989), the prestigious Orders of Canada (1994), the James H. Graham award (1995) the Lifetime Achievement Award of the Canadian Society for International Health, recognition by the American Academy of Paediatrics, and honorary doctor of laws degrees. As we celebrate the life of Don Hillman, we thank him and his wife Liz for the tremendous contribution and lifetime commitment to international health, which will remain an inspiration for many years to come, to all of us including many generations of medical students and paediatricians all over the world. We dedicate this third edition of the “Primary Health Care Manual for medical students and other health workers” to our friend Don Hillman. May His Soul Rest in Eternal Peace! Prof. Kopano Mukelabai, Department of Paediatrics and Child Health, University of Zambia, Lusaka, Zambia Formerly: Chairman of the Department of Paediatrics and Child Health at the University of Zambia Dean School of Medicine, University of Zambia (1984-1992) Senior Health Adviser in UNICEF (1992-2009)

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PREFACE TO THE THIRD EDITION The Third Edition of the Primary Health Care manual has finally been produced. Lack of funding due to the global economic recession, has partly contributed to the delay in producing the current manual. We are very grateful to the University of British Columbia and specifically to Prof. Stuart Macleod and his wife Nancy for their concerted efforts to raise the critical funds needed to print the manual. We are also very grateful to Prof. Elizabeth Hillman and the Hillman Foundation for providing extra funds to print more copies of the manual and for providing funds to distribute the manual. The third edition of the PHC manual is dedicated to our friend and colleague the late Prof. Donald Hillman who died on 4th July 2006. Don Hillman, together with his wife Liz mooted the whole idea of the PHC East Africa Project and the subsequent publication of the PHC manual. We have written an obituary printed in this book to honour the life and work of Prof. Donald Hillman. The PHC manual is still very frequently used to teach both undergraduate and postgraduate medical students. This new edition will be distributed free of charge to seven medical schools in five countries in Eastern and Southern Africa. These are Zambia, Kenya, Tanzania, Uganda, and Ethiopia. The first two editions of the manual proved to be extremely popular among medical students and other health workers. The major preparation of the third edition of the PHC manual took place at a meeting held at the Silver Springs Hotel in Nairobi in October 2008. It was a wonderful and productive meeting with representatives of 10 Universities present, including one representative from UNICEF. Other topics covered during the meeting included; sharing information on the postgraduate curriculum, exchange of staff and students, and conduction of joint research. With five years remaining towards the attainment of the MDGs by 2015, the PHC manual will make an important contribution in assisting countries to achieve the health related MDGs. A few new chapters have been added to the manual to make it more comprehensive. We have also included the April 2008 Ouagadougou Declaration on PHC in Africa, which was signed by Ministers of Health from all countries in Africa. May the spirit of Don Hillman continue to guide the future direction of the PHC manual and its use by medical students and other health workers! Finally let me once again thank all my colleagues who participated in the production of this third edition. Their commitment was total as they showed an incredible patience and understanding in waiting for the final production of the new manual. I also wish to thank Ms. Ruth Matano and Ms. Rosemary Mwasya for assisting us in organizing an extremely successful workshop to revise the third edition of the manual. Ms. Matano also assisted in preparing the final script of the new manual.

Kopano Mukelabai,

31st March 2010.

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PREFACE TO THE FIRST EDITION This manual is designed to meet the learning needs of medical students and other health workers, to achieve competence in the understanding and management of priority problems in Primary Health Care in Zambia, Uganda, Tanzania and Kenya. It is applicable to other countries especially those in Africa with similar health problems. Each chapter of the manual, has objectives related to an important Primary Health Care topic, and defines the knowledge, skills and attitude required to meet these objectives. The manual is intended to supplement paediatric texts and other reference materials, and is a targeted aid to Primary Health Care problem solving both in tertiary and Primary Health centres, which should both be the major sites for relevant health learning. Some of the chapters contain case illustrations designed to facilitate learning by presenting real-life problems relevant to the topic. The manual contains self evaluation questions and a list of objectives. Other learning materials supplied by other institutions and organizations like W.H.O., UNICEF, etc. may be very useful. For the manual to be of continuing value, the students and the teachers must add relevant details of priority health problems in their region with particular focus and emphasis on the overall child health programmes. This should include collaborative emphasis on links between the training programmes and the country's health care system, both governmental and non-governmental. In order to adapt to the rapidly changing field of primary health care teaching, revisions and additions to the problems presented here, must be developed by teachers and students to reflect changing priorities and approaches. The editor wishes to thank the Canadian Government for providing the crucial financial support through CIDA (Canadian International Development Agency) to the Primary Health Care East Africa Project. Special thanks go to Memorial University of Newfoundland, which was the Canadian collaborating medical school, and its two dedicated faculty members Prof. Donald Hillman and Prof. Elizabeth Hillman. I wish to acknowledge with thanks the strong support of the Universities of Zambia, Dar-es-Salaam, Nairobi and Makerere, which through their Principals and Deans, gave the widest latitude to their Chairmen of Departments of Paediatrics and Child Health and their staff and students, to successfully implement the Primary Health Care East Africa (PHC/EA) project. Particular thanks go to the Chairmen of Departments of Paediatrics and Child Health and the Hillmans, who together mooted the whole idea of PHC/EA. Their congeniality, and extreme dedication ensured the smooth implementation of the project's stated objectives. To Prof. Gabriel Anabwani, the first programme manager of PHC/EA project, who worked so hard to overcome most of the teething problems encountered, I say

5__________________________________________________________________________ _ special thanks, and thanks go to all our departmental Secretaries who bore the brunt of retyping the illegible manuscripts. Particular thanks go to Mrs. Jane Thairu, University of Nairobi for typing the draft manuscript on her ACER 910, and to Mrs. Beatrice Mwanamuchende and Ms. Shirley Kapapa of University of Zambia who typed the revised final manuscripts. Finally my gratitude goes to all our students and fellows whose constant quest for more knowledge was the prime mover for the production of this manual. The following are thanked for contributing directly or indirectly to the manual: Prof. Donald Hillman, Memorial University, Newfoundland; Prof. Elizabeth Hillman, Memorial University, Newfoundland; Prof. Stuart Macleod, Dean, MacMaster University, Hamilton, Canada; Prof. Vic Neufeld, McMaster University, Canada; Prof. N. Bwibo, former Principal, University of Nairobi, College of Health Sciences; Prof. H. Pamba. former Dean, Faculty of Medicine, University of Nairobi; Prof. W. Makene - former Dean, Muhimbili Medical Center Dar-es-Salaam; Prof. G. Mwaluko, former Dean and Director General, Muhimbili Medical Centre, Dar-es-Salaam; Prof. J. W. Mugerwa, Dean Faculty of Medicine, Makerere University; Prof. R. Owor - Former Dean, Faculty of Medicine, Makerere University; Prof. Julius Meme, former Chairman, Dept. of Paediatrics and Child Health, University of Nairobi; Prof, F. Onyango, Chairman, Dept. of Paediatrics and Child Health, University of Nairobi; Prof. R. Mbise, former Chairman, Dept. of Paediatrics and Child Health, University of Dar-es-Salaam; Dr. E. Mwaikambo, Chairman, Dept. of Paediatrics and Child Health, Muhimbili Medical Center, Dar-es-Salaam; Prof. C. Ndugwa, Chairman, Dept. of Paediatrics and Child Health, Makerere University, Kampala; Prof. K. Mukelabai, Dean and former Chairman of Department of Paediatrics and Child Health, University of Zambia, Lusaka; Dr. Alfred Mutema, Nairobi; Mr. L. Dierick, Nairobi; Prof. Peter Kinyanjui, Common Wealth of Learning, University of Vancouver Canada; UNICEF; All Primary Health Care East Africa Fellows; All Faculty members of departments of Paediatrics and Child Health at Universities of Zambia ; Dar-esSalaam, Makerere and Nairobi. Finally I wish to thank all my colleagues for their maximum cooperation and patience in implementing the PHC/EA project to the end. This manual lends credit to your dedicated and excellent efforts. Prof. Kopano Mukelabai, Dean School of Medicine, University of Zambia, Former Chairman of the Department of Paediatrics. University of Zambia.

6__________________________________________________________________________ _ A MESSAGE FROM DR. HAFDAN MAHLER, FORMER DIRECTOR GENERAL OF THE WORLD HEALTH ORGANIZATION

Health Care Workers and PHC World Health will improve only if the people themselves become involved in planning, implementing and having a say about their own health and health care. But involvement will not just happen. How serious are we about involving individuals, families and communities? Are we prepared- mentally and professionally to listen to their concerns, to learn from them what they feel is important, to share with them appropriate information, encourage and support them. Are we ready to assist them in choosing from alternative solutions, in setting their own targets and evaluating their efforts? In many cases, so far, the answer is no. We can go on and on developing plans: nothing will happen unless all health workers, all health managers, and key professionals in other sectors come to realize what is at stake. First, health workers must understand that the concept of primary health care involves new roles for them and a new outlook. Not only should we be concerned with disease prevention and control, we must also be concerned with health promotion and care - and not least with development in general – and with people. Our health technologies must be based on what the people themselves want and need. In other words, the worker should learn first and foremost to act as a facilitator of action by individuals, families and communities. We must stop trying to fit communities into systems and programs we devise, without a real and deep feeling for the social aspects of health problems or the economic constraints-not to speak of the cultural dissonance that is often the backlash of such programs. Second, health workers must accept their new roles. They must accept new ideas, must be taken to try them out, to adapt them, to broaden their scope and innovate in the partnership approach. Their main concept must be to find ways of helping individuals and communities become self-reliant. It must be made clear that advocating self-reliance in health matters in no way means abdicating our responsibilities and passing them on to someone else. Both lay persons and professionals are essential. They cannot replace each other, but they must work together. This brings me to my third point: health workers must have the necessary skills to perform these new roles effectively and to make efficient use of existing knowledge. This calls for a training force fully familiar with accumulated experience and keen to provide the kind and quality of professional preparation needed. It also calls for full backing from health managers for such training. All health care workers must meet these requirements. This manual helps define the role of health workers in Primary Health Care. Your skills and commitment to this role will be of critical importance to the achievement of Health for All by the year 2000.

Halfdan Mahler, Former Director General, World Health Organization

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TABLE OF CONTENTS Page No. i iii iv ix

Dedication to Prof. Donald Hillman Preface – 3rd Edition Preface – 1st Edition A message from Hafdan Mahler former WHO Director General CHAPTERS AND AUTHORS

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PRIMARY HEALTH CARE Elizabeth Hillman, Kate Wotton, Kopano Mukelabai

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CARE OF NEW BORN Rachel Musoke, Mary Shilalukey Ngoma, Aggrey Wasunna

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INFANT AND YOUNG CHILD FEEDING (IYCF) Rachel Musoke, Ruth Nduati, Aggrey Wasunna

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CHILD NUTRITION Ruth Nduati, Ahmed Laving, Heena Hooker, Peter Ngwatu

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EARLY CHILDHOOD DEVELOPMENT Ruth Nduati

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GROWTH MONITTORING AND PROMOTION DURING EARLY CHILDHOOD Daniel Njai, Rachel Musoke, Ruth Nduati, Aggrey Wasunna

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CHILDHOOD IMMUNIZATION Amos Odiit, Esther D. Mwaikambo

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CHAPTERS AND AUTHORS

105

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CONTROL OF DIARRHOEAL DISEASES Israel Kalyesubula

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ACUTE RESPIRATORY INFECTIONS IN CHILDREN Elizabeth Maleche-Obimbo, Ezekiel M Wafula

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ASHMA IN CHILDREN Chris M. Ndugwa, Somwe Wa Somwe, Elizabeth Maleche-Obimbo, Dalton Wamalwa, Dinberu Tefera Muluwork

139

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TUBERCULOSIS IN CHILDREN Elizabeth Maleche-Obimbo, Andrew Ndamira, Catherine Chunda

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MALARIA IN CHILDREN Amos Odiit, Sarah Kiguli, Samuel Ayaya, Esther D. Mwaikambo

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HIV INFECTION AND AIDS IN CHILDREN Gabriel Anabwani, Israel Kalyesubula, Ruth Nduati, Catherine Chunda, Elizabeth Maleche-Obimbo

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ANAEMIA AND SICKLE CELL DISEASE Catherine Chunda, Chris Ndugwa, N. Kariuki, Nimrod O. Bwibo

186

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ADOLESCENT HEALTH, DRUG AND SUBSTANCE ABUSE S. Bakeera-Kitaka, Amos Odiit, Samuel Ayaya, Esther D. Mwaikambo

194

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ACCIDENTS AND POISONING FV Murila, Chris M. Ndugwa, Ruth Nduati, Somwe Wa Somwe, Dalton Wamalwa, Dinberu Tefera Muluwork

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CHAPTERS AND AUTHORS

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CARDIOVASCULAR DISEASES IN CHILDHOOD Christine Yuko-Jowi, Gabriel Anabwani

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COMMON SKIN DISEASES IN CHILDREN Samuel Ayaya, Amos Odiit, Esther D. Mwaikambo

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ESSENTIAL DRUGS AND RATIONAL USE OF ANTIBIOTICS Chris M Ndugwa, Somwe Wa Somwe, Elizabeth Maleche-Obimbo, Dalton Wamalwa, Gabriel Anabwani Dinberu Tefera Muluwork,

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CHILDREN IN ESPECIALLY DIFFICULT CIRCUMSTANCES Nimrod O Bwibo, Mary Shilalukey Ngoma

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HEALTH EDUCATION, COMMUNICATION SKILLS AND COUNSELLING Esther D. Mwaikambo, Amos Odiit

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INTERGRATED MANAGEMENT OF CHILDHOOD ILLNESS Kopano Mukelabai,

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APPROACHES TO IMPROVE QUALITY OF SERVICES FOR HOSPITALIZED SICK CHILDREN Stephen N. Kinoti

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NATIONAL HEALTH SECTOR REFORMS AND HEALTH CARE FINANCING Esther D. Mwaikambo, Stephen N. Kinoti, Amos Odiit, Samuel Ayaya

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BASIC STATISTICS FOR HEALTH CARE

10_________________________________________________________________________ __ Dalton Wamalwa and Jeremiah Banda [

CHAPTER 1 PRIMARY HEALTH CARE Elizabeth Hillman, Kate Wotton, Kopano Mukelabai “A world that is greatly out of balance in matters of health is neither stable nor secure. Viewed against current trends, primary health care looks more and more like a smart way to get health development back on track. Thirty years of well-monitored experience tell us what works and where we need to head, in rich and poor countries alike.” Margaret Chan, World Health Report, Oct 2008 Introduction Like many great and timely ideas, Primary Health Care emerged in several places at the same time. In China, the success of the barefoot doctors, local village health workers trained in first aid with a focus on prevention, improved health for rural Chinese on a grand scale. In South East Asia, the importance of prevention, local midwives, community involvement and good nutrition was documented in Health in the Developing World by John Bryant Africa too was moving towards a focus on more accessible care. In Uganda in the 1960s, Maurice King, a microbiologist teaching at Makerere undertook a locum for a friend in the Karamoja, a remote region of nomadic people with few health care workers. It was an eye-opener and led to his collecting a group of like–minded physicians in Africa for a symposium. From this meeting, a classic text on primary health care, Medical Care in the Developing World, subtitled a Primer on the Medicine of Poverty was published. For the first time the relationship between the catchment area of a health facility and the time it takes to walk to and fro appeared in print. Not unexpectedly almost 90 per cent of those seeking care from a health unit were drawn from a radius of less than 5 km – the distance a mother with a child on her back, or a toddler in tow, could walk in a day. This finding led to a reassessment of the role of hospitals and the need for more accessible care. A pediatrician working in West Africa, David Morley introduced the concept of Under- 5 Clinics dealing with mothers and children, who are the most vulnerable members of the community. In another classic, Pediatrics Priorities in the Developing World, he pioneered an improved design of such clinics to allow more and better care for children and their mothers. About the same time, important aspects of nutrition, such as the onset of kwashiorkor in the older child weaned early when a new child is born, were identified by the Jelliffes and Cecily Williams. This set the scene for the WHO, UNICEF and the NGOs to pull together the WHO Declaration of Primary Health Care in Alma Ata in 1978 with the goal of Health for All by the Year 2000. At the time there was concern that such a lofty goal was unattainable. But health workers in the developing world were insistent that the goal was needed and could be achieved.

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Objectives: At the end of this session, the student will be able to: Describe the concept of Primary Health Care. List 8 elements of PHC Clarify 8 principles of PHC. Advocate for community participation. Learning Activities: Read the Declaration of Alma Ata, WHO, 1978 Report of the International Conference of PHC; Chapter 1, UNICEF State of the World, 2008 and World Health Report 2008 on PHC and Ouagadougou Declaration on PHC and Health Systems in Africa, 2008 Meet with district and local health staff, UNICEF and NGOs to become familiar with existing PHC programs and available reference materials. Participate in a community meeting in which community involvement in a PHC issue is discussed.

Health is defined as a state of complete physical, mental, social and spiritual well being and not merely the absence of disease or infirmity. These four elements of well being influence each other. When the influence is positive the individual enjoys a healthy life. Conversely when the influence is negative the individual suffers ill health. WHO Outline a PHC approach to a specific child health issue.

Definition of PHC: PHC is spelled out in detail in Article VI of the Declaration of Alma Ata. “Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work and constitutes the first element of a continuing health care process.” Alma Ata, 1978 2

The 8 Elements of PHC The eight elements or program of PHC spell out MEDICINE and are sometimes referred to as the New Medicine M - Maternal & Child Health Child deaths are far more common when births are too many or too close together or occur to mothers who are too young. Children born to women under 20 years of age are almost twice as likely to die in infancy as children born to women in their mid 20s. Births need to be spaced to save lives. When children are born at least two years apart, infant deaths fall from 14% to 6%. For almost all children, the most important primary health care worker is the mother. E - Education Health education needs to be interactive, pervasive and eagerly taken up by all health workers. Female literacy is one of the most important ways to improve a family’s health. Globally four out of ten women are illiterate and in some countries as many as eight out of ten. Educating girls is closely associated with falling infant mortality, decreasing birth rates and improved nutrition. Teaching Other People May be More Important than Doing it Ourselves. D – Drinkable Water and Safe Sanitation Lack of clean, drinkable water causes many diseases. Efforts are needed to make water safe and available for everyone. To result in permanent solutions, women need to be involved actively in water projects. The Cold Chain The cold chain refers to the need for refrigeration of the vaccine while getting it to the most rural and remote places New technology developed: temperature monitors, cold boxes, Purchase and maintenance of kerosene refrigerators Reliable transport system Retraining of health workers first year of life.

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I – Immunization One of the greatest success stories of PHC has been immunization. Small pox was the first disease to be eradicated. Great advances have been made in controlling polio and in combining vaccines. Measles remains a challenge because it I requires an intact cold chain. Another challenge is in immunizing all children against the eight killer diseases in the

C – Control of Endemic Disease Endemic diseases are those commonly found in a region. Malaria is endemic in SubSaharan Africa and meningitis is endemic in the meningitis belt of Northern Africa. Appropriate technology has been identified to assist with control of many endemic diseases including insecticide-treated bed nets in malarial areas and ORS for treatment of diarrhea. I – Treatment of Illness and Injury Curative care for illness or injury is but one of the eight PHC programs. Care needs to be provided close to where people live. Appropriate, accessible treatment also needs to be affordable. In many developing countries poor people now pay two- ten times more out of the own pocket for their health care than is provided by the government. N - Nutrition and Food Good food is one of the basic determinants of good health. Breast feeding not only provides an excellent source of food for a child but provides important protection from disease in the first few months of life. Breastfeeding for the first two years of life provides valuable protein and energy for children. A The 4As healthy, balanced diet for women in pregnancy results in Health care and fewer low birth weight babies and fewer pregnancy prevention needs complications. In some countries low birth weight to address the 4As babies account for as many of one in five births. Acceptable E – Essential Drugs Affordable Essential drugs are the basic drugs needed to treat Accessible common illnesses and disease in a country. PED Appropriate DRUGS NEEDED Most developing countries have 20 drugs for rural dispensaries and health centers and a somewhat larger but still limited list of drugs for hospitals. A system to ensure ongoing supply, storage, dispensing and training of staff is a key part of ensuring provision of essential drugs. Some countries included other programs into the basic health program list such as dental care and mental health but all countries had the basic eight PHC elements. “A health system based on PHC cannot be realized, cannot be developed, cannot function and simply cannot exist without a network of physicians and hospitals with responsibilities for supporting primary health care, promoting community health development action, basic and continuing education of all categories of health personnel and research.” Halfdan Mahler, WHO

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Characteristics of PHC Underlying the eight PHC elements are a number of characteristics or principles. Community Participation

Support Breastfeeding Allow mothers to have their babies with them Let mothers put their babies to the breast soon after birth Help mothers overcome problems Provide correct information to mothers Eliminate routine bottle-feeding Eliminate free samples of breastmilk substitutes Remove all advertising for breast milk substitutes

Participation is more than involvement and is much more than contributing labour and time although both are often necessary. Participation means being included in planning, decision-making, implementation and evaluation. Through full participation people grow in knowledge and confidence and can be empowered to make the changes needed to improve their health and that of their families. Participation needs to involve women and the disadvantaged. Intersectoral Collaboration Health is much more than merely the absence of disease. Health involves the food we eat, the work we do, the relationship we have and the education we receive. To fully achieve health we need to work collaboratively with those in other sectors such as education, agriculture, women’s affairs, local government etc. For example, what is taught in school can be improved to ensure children are taught about important health problems, such as diarrhoea and how it can be managed using ORS.

Prevention Since there will never be sufficient resources to treat all current and possible diseases, we need to begin to prevent those that can be prevented. Prevention is not only better for people, it also saves money. Most people, given the information and opportunity are more interested in preventing health problems than dealing with disease. Appropriate Technology Appropriate technology is technology which the community can afford, implement and maintain. It needs to be simple, effective and scientifically sound so it will be sustainable. The Tippy Tap used Simple solutions have been provided which prevent many for washing hands, illnesses. Examples include: Oral rehydration salts; Child to delivers small Child programs in First Aid;

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Training of Traditional Birth Attendants (TBA) in prenatal care; Tippy Taps and energy efficient stoves. Decentralization Decentralization of health care puts control back into the hands of the local community. Decentralization devolves responsibility for health to district health teams and provides them with the training and the resources to do it. Integration of Health Services For the children and their mothers to receive good health care, it is important to provide all the care that they both need at the same place and time. When a mother has spent her day bringing a sick child to the clinic, it is important that she be provided with health education to prevent future episodes, her children are immunized and weighed and contraception advise and antenatal care are provided if appropriate. Sustainability Sustainability is the ability to carry on and maintain services. Attention to sustainability is needed at the time programs are first put in place, so that once established, they can be continued. Hopefully many health programs can be sustained by the community with minimal outside assistance. Equity and Social Justice Equity involves more than being equal. It requires that resources be distributed according to need. Those who have more need for health services should receive more. Social justice is a way to leveling the playing field for all.

Approximately three quarters of health budgets are spent on doctors and hospitals providing curative care for a small minority of people, mainly in towns and cities. Approximately three-quarters of disease in the world is preventable through primary health care. Primary health care workers cost a tiny fraction of the cost of training a doctor and are often more effective in promoting good health.

“There isn’t a single problem in global health that we don’t have the means to deal with. It is not even that expensive. It just requires commitment, expertise and resources.” Nils Daulaire, Global Health Council

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PHC Responding to a Changing World Ongoing Challenges High maternal, infant, and under-five mortality often indicates lack of access to basic services such as clean water and sanitation, immunizations and proper nutrition. Vast differences in health occur within countries and sometimes within individual cities. In Nairobi, for example, the under-five mortality rate is below 15 per 1000 in the highincome area. In a slum in the same city, the rate is 254 per 1000. Of the estimated 136 million women who will give birth this year, around 58 million will receive no medical assistance whatsoever during childbirth and the postpartum period, endangering their lives and that of their infants. After thirty years of PHC activity, WHO suggested that many health systems have lost their focus on fair access to care, their ability to invest resources wisely, and their capacity to meet the needs and expectations of people, especially in impoverished and marginalized groups. As well, inequitable access, impoverishing costs, and erosion of trust in health care constitute a threat to social stability. When countries at the same level of economic development are compared, those where health care is organized around the tenets of primary health care produce a higher level of heath for the same investment. Such lessons take on critical importance at a time of global financial crisis. 7

“It is in child health that the greatest of all gains can now be made. Today, a solid scientific consensus stands behind a body of knowledge, traditional as well as modern, discovered or rediscovered, which can enable most families to prevent as well as treat almost all the major causes of child death and malnutrition at a cost which they can afford.” Halfdan Mahler, WHO Increasing Relevance of PHC In calling for a return to primary health care, WHO and UNICEF argue that its values, principles and approaches are more relevant now and inequalities in health outcomes and access to care are much greater today than they ever were before. In far too many cases, people who are well-off and generally healthier have the best access to the best care, while the poor are left to fend for themselves. Health care is often delivered according to a model that concentrates on disease, high technology, and specialist care, with health viewed as a product of biomedical interventions and the power of prevention largely ignored. Specialists may perform tasks that are better managed by other health workers. This contributes to inefficiency, restricts access, and deprives patients of opportunities for comprehensive care. When health is skewered towards specialist care, a broad menu of protective and preventive interventions tends to be lost. WHO estimates that better use of existing preventive measures could reduce the global burden of disease by as much as 70%.

Inequities in access to care and in health outcomes are usually greatest in cases where health is treated as a commodity and care is driven by profitability. The results are predictable: unnecessary tests and procedures, more frequent and longer hospital stays, higher overall costs, and exclusion of people who cannot pay. Fragmented Health Care In the developing world, care tends to be fragmented into discrete initiatives focused on individual diseases or projects, with little attention to coherence and little investment in basic infrastructures, services, and staff. Above all, health care is failing to respond to rising social expectations for health care that is people-centred, fair, affordable and efficient. A primary health care approach, when properly implemented, protects against many of these problems. It promotes a holistic approach to health that makes prevention equally important as cure in a continuum of care that extends throughout the lifespan. As part of

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this holistic approach, it works to influence fundamental determinants of health that arise in multiple non-health sectors, offering an upstream attack on threats to health. Primary health care brings balance back to health care, and puts families and communities at the hub of the health system. With an emphasis on local ownership, it honours the resilience and ingenuity of the human spirit and makes space for solutions created by communities, owned by them, and sustained by them. Working Towards Fairness, Efficiency and Compassion The core strategy for tackling inequalities is to move towards universal coverage in a spirit of equity, social justice, and solidarity. Fairness, efficiency and compassion in service delivery especially targeting the most vulnerable populations, should be the overarching goals. Primary health care also offers the best way of coping with the ills of life in the 21st century: the globalization of unhealthy lifestyles, rapid unplanned urbanization, environmental changes and the ageing of populations. These trends contribute to a rise in chronic diseases, like heart disease, stroke, cancer, diabetes and asthma, which create new demands for long-term care and strong community support. A multisectoral approach is central to prevention, as the main risk factors for these diseases lie outside the health sector. REFERENCES: UNICEF, State of the World’s Children, 2008. Alma Ata Declaration, Report of the International Conference on Primary Health Care, 06-12 September 1978, WHO Bulletin, Geneva 1978 World Health Report 2008, PHC Ouagadougou Declaration on PHC and Health Systems in Africa, April 2008 “Too many of us still think of medical care systems or interventions rather than thinking along new lines in order to understand the determinants of the new problems and to grasp opportunities that reach beyond the health care system….we do not need just a little bit more health education here and there; we need a new approach to action and a strong alliance to move us forward.’ Halfdan Mahler

9

Upstream Downstream – a parable It was many years ago that villagers of Downstream recall spotting the first body in the river. Some old timers remember how spartan were the facilities and procedures for managing that sort of thing. Sometimes, they say, it would take hours to pull 10 people from the river, and even then only a few would recover. Though the number of victims in the river has increased greatly in recent years, the folks of Downstream have responded admirably to the challenge. Their rescue system is clearly second to none: most people discovered in the swirling waters are reached within 20 minutes; many less than 10. Only a small number drown each day before help arrives; a big improvement from the way it used to be. Talk to the people of Downstream and they'll speak with pride about the new hospital by the edge of the waters, the flotilla of rescue boats ready for service at a moment's notice, the comprehensive health plans for coordinating all the manpower involved, and the large numbers of highly trained and dedicated swimmers all ready to risk their lives to save victims from the raging currents. Sure it costs a lot but, say the people from Downstream, what else can decent people do except to provide whatever is necessary when human lives are at stake. Oh, a few people in Downstream have raised the question now and again; "What's going on Upstream? Why are these bodies in the river at all?" But most folks show little interest in what's happening Upstream. It seems there's so much to do to help those in the river that nobody's got time to check how all those bodies are getting there in the first place. That's the way things are sometimes. Don Ardell COULD USE AN ILLUSTRATION

10

When teeth are together they can break bones.

Ankole proverb

When spider webs unite they can tie up a lion.

Ethiopian proverb

The teeth which are together break bone

Runyankole proverb

There is a path to the top of highest mountain. Do not look where you fell, but where you slipped.

African proverb

If you don't stand for something, you will fall for anything

African proverb

Lack of knowledge is darker than night

Hausa proverb

When the drumbeat changes, the dance changes

Hausa proverb

Even the mightiest eagle comes down to the tree tops to rest

Ugandan proverb

A home without a mother is a desert

Eritrean proverb

Elderliness is not a disease, but a richness.

Kiganda proverb

Who digs the well should not be refused water.

Swahili proverb

When a lion roars, he does not catch game

African proverb

“A new model is needed for research in developing countries. A model that promotes locally applied research that enhances capacity and answers that arise from the community. It could be called micro-research and be based, like micro-finance, on small grants for those who have little access to funding opportunities.” Jerome Kabakyenga, Dean, Mbarara, Uganda and Noni Macdonald, ed. CMAJ

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DECLARATION BY THE International Conference on Primary Health Care and Health Systems in Africa, Ouagadougou, Burkina Faso, 28-30 April 2008 The Conference held in Ouagadougou, Burkina Faso from 28-30 April 2008, declare as follows: I. Deeply concerned by the many public health challenges that our continent is facing including: 

The high burden of disease;



The weakness of health systems with inadequate social protection and insufficient financial and human resources for health, a situation worsened by brain drain;



The widespread poverty among the majority of the population;



The impact of armed conflicts and violence;

II.

Recalling the Alma-Ata Declaration of September 1978 inviting all governments and the international community to protect and promote the health of all peoples of the world;

III.

Recalling the declaration by Heads of State and government of the Organization of African Unity at its 23rd Ordinary Session in Addis Ababa in 1987 on health as the bedrock of development;

IV. Recalling the commitment made by Heads of State of all countries in the world in September 2000 to achieve by 2015, the eight Millennium Development Goals four of which are related to health; V.

Recalling Regional Committee Resolution AFR/RC50/R1 passed in Ouagadougou in 2000 on Health-for-all Policy for the 21st Century: Agenda 2020;

VI. Recalling Resolution AFR/RC52/R5 adopted in Harare in 2002 on the strategy for accelerating the development of human resources for health and document AFR/RC57/9 on development of human resources for health in the WHO African Region: Current situation and way forward; VII. Recalling Resolution WHA 58.33 urging Member States to ensure sustainable financing for health, universal coverage and the social security system; VIII. Recalling the commitment that OAU Heads of State and Government made in 2001 on HIV/AIDS, tuberculosis, malaria and other related infectious diseases during the African Summit in Abuja to allocate 15% of national budgets to health; IX.

Recalling Regional Committee Resolution AFR/56/R6 adopted in Addis Ababa in September 2006 on revitalizing health services in the African Region using the Primary Health Care approach;

X.

Recalling Regional Committee Resolution AFR/RC56/R5 passed in Addis Ababa in September 2006 on health financing: a strategy for the African Region;

XI.

Recalling the Addis Ababa community health declaration of November 2006 urging States to create an environment conducive to the development of community health and take concrete action to strengthen health systems; 12

XII.

Recalling the declaration by the third ordinary session of the African Union conference of ministers of health in Johannesburg in April 2007 urging Member States to commit themselves to inter-ministerial collaboration for coordinated, harmonized and comprehensive response to the health challenges that Africa is facing;

XIII.

Recognizing the link between health, poverty reduction, good governance, peace and security, gender integration and global commitment to universal access to PHC in order to facilitate the achievement of the Millennium Development Goals;

XIV.

Considering that a healthy population is not only a development imperative but also a wealth for African countries;

XV.

Considering the scarcity of resources for health in African countries;

XVI.

Recognizing that notwithstanding efforts by countries, there remain challenges such as poverty, bad governance, low participation of communities especially women in decision-making process, weaknesses of health delivery systems including inadequacy of motivated and qualified human resources, limited capacity in care provision, weak interface between the community and the formal systems of health delivery resulting, very often, from lack of health awareness;

XVII. Recognizing that Africa will need to make increased efforts before it can achieve the Millennium Development Goals; XVIII. Aware of the multidimensional nature of health, the importance of, and need for, intersectoral collaboration both internally and externally in order to improve the health status of the populations; XIX.

Realizing the historic opportunity provided by the interest shown in, and importance attached to, health as a factor of development.

The Conference: 1.

Reaffirms the relevance and validity, today, of the basic principles and elements of the Alma-Ata Primary Health Care Strategy;

2.

Makes a commitment to promote systematically the involvement and increased participation of communities in health development in order to facilitate the achievement of the Millennium Development Goals and improve the well-being of the peoples of Africa;

3.

Strongly recommends;

1. To governments: (a)

To establish mechanisms for effective implementation of previous resolutions, declarations and other commitments to strengthen health systems and implement PHC;

(b)

To undertake internal and external advocacy for revitalizing the PHC strategy in order to strengthen health systems;

(c)

To accelerate the process of decentralization and deconcentration within the health system in order to meet the expressed needs of the populations; 13

(d)

To revitalize or establish an appropriate coordination mechanism that brings together the inter-ministerial committee, national health committees and other institutions with a view to harmonizing the complementary roles of the various levels of the health pyramid;

(e)

To incorporate, in their national and district plans, priority interventions for revitalizing health services based on the PHC approach;

(f)

To implement a programme of action to address the human resources for health crisis including effective deployment, stimulation of better performance and adequate response to brain drain;

(g)

To strengthen planning and training with emphasis on public health, employment and human resources management and retention;

(h)

To allocate resources in an equitable and sustainable manner based on the needs of the different levels of the health system;

(i)

To promote intersectoral collaboration and public/private partnership including civil society in order to achieve the Millennium Development Goals;

(j)

To revitalize referral systems to support integrated district health services;

(k)

To mobilize and bring together all development actors to enhance cohesiveness and synergy in the choice and delivery of the planned integrated services;

(l)

To formulate strategic health financing policies and plans fitting into the overall national development framework especially as regards medium-term expenditure and poverty reduction;

(m) To ensure that the financing plan is included in the national socioeconomic development plan; (n)

To promote health awareness among the population and strengthen the capacities of communities to provide for their own health care and be more involved in health activities;

(o)

To ensure more effective monitoring, oversight and evaluation of health activities;

(p)

To promote operational research on health systems in a manner that will facilitate evidence-based decision making;

(q)

To establish mechanisms and conditions that would enable ministries of health to perform their role of leadership, regulation and good governance;

2. To communities: (a)

To organize themselves to take ownership of the management, protection and promotion of their own health;

(b)

To be more involved in monitoring and feedback in regard to health services delivery and support within communities;

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(c)

To do advocacy among members of the Diaspora for their effective involvement in development activities.

3. To sub regional, regional and international partners: (a)

To support the implementation of health development policies and plans in response to expressed needs;

(b)

To commit themselves to proving technical and/or financial support in the long term to ensure sustainability of health actions;

(c)

To increase investments in health systems strengthening;

4. To governments and development partners: (a)

Governments should create, at national level, the conditions (meetings, laws, regulations, etc.) needed to translate into concrete deeds the orientations contained in the reference document and the recommendations of the conference to improve the health status of the populations;

(b)

Governments and partners should establish mechanisms to follow-up on the recommendations of this conference;

(c)

The WHO Regional Office for Africa should produce a report each year for the Regional Committee and partners on the progress in the implementation of the recommendations of the conference;

(d)

Governments, in collaboration with partners, should document best practices and encourage the dissemination and sharing of best experiences among countries of the region;

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CHAPTER 2 CARE OF NEW BORN Rachel Musoke, Mary Shilalukey Ngoma, Aggrey Wasunna INTRODUCTION The fourth millennium development goal (MDG) focuses on reduction of the under five mortality. Many of the programmes that have contributed to the survival of the child under five years have omitted the neonatal period. As a result 38% of all deaths in the first 5 years are in this period. If we do not address the problems of the neonate we are unlikely to meet the global goal improving child survival. Improved survival will thus depend on investment in interventions that cater for newborn care. Within the neonatal period the highest deaths occur in the first 24 hours (25-45%) and up to 75% of deaths occur in the first 7 days. Many of these deaths are also related to the health of the mother. This is the basis of continuum of care approach for mothers, newborns and children (pregnancy, delivery and postnatal care). Health care should start with the girl child ensuring adequate nutrition and growth followed by cultural changes and life skills that enable the girl to prevent adolescent pregnancy. All pregnant women should get good care during pregnancy and delivery. The aim of care is to ensure intact survival of the mother and her baby. Many problems in this period lead to permanent disability. Majority are predictable. Care starts in the community but there should be a close liaison with the health facility. The SEARCH project, India, Gadchiroli, provides a good example of a culturally appropriate, evidence based community newborn care initiative from which many countries can learn, adapt and replicate. Though for child survival we tend to stress goal 4 of the MDG all other goals are equally important. For you cannot improve child survival without reducing poverty (goal 1), improving education and equity of women (goals 2 &3), maternal health (goal 5) as well as reducing infections in the mother (goal 6) and environmental sustainability (goal 7) Objectives At the end of this chapter the student should be able to: Define all terms used in the neonatal period Describe maternal health and education and their effect on the foetus and baby State principles of antenatal and perinatal care State principles of neonatal care List common causes of morbidity and mortality in the neonate Outline strategies that will reduce morbidity and mortality Recognize a sick neonate Organize neonatal services in a district Counsel and communicate with parents about baby care

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LEARNING ACTIVITIES Examine and be familiar with a normal newborn Recognize and infant with birth asphyxia and be able to resuscitate such a baby Recognize, refer or treat and prevent infections of the newborn Learn principle of cord care Be familiar with ways of keeping baby warm Observe and participate in different methods of feeding Recognize other common features of a sick neonate Plan care of low birth weight babies Plan neonatal services in a district Definitions Newborn (neonate)/neonatal period: age/period 0-28 days of postnatal life Early neonatal period: 0-7 days of postnatal life Late neonatal period: 8-28 days of postnatal life Preterm baby: 30/min Normal rates of breathing in awake children: Age Normal Rate < 2 months < 60/min 2-12 months < 50/min 1 – 5 years < 40/min 6 – 8 years < 30/min Usually not Usually Usually

Moderate, Loud Usually loud often only end expiratory < 100 100 – 120 > 120 Guide to normal pulse rate in children Infants 2 – 12 months – normal rate < 160/min Preschool 1 – 2 years < 120/min School-age 2 – 8 years < 110/min > 95% 91 – 95% < 90% Hypercapnia (hypoventilation) develops more readily in young children than in adults and adolescents.

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Respiratory arrest imminent

Drowsy or confused

Paradoxical thoracoabdominal movement Absence of wheeze Bradycardia

Table 2. Management of acute exacerbation of asthma Mild to Moderate Severe exacerbation Life-threatening asthma exacerbation Humidified oxygen by Admit to PICU or special  Salbutamol nasal prongs or nasal ward and treat as for severe inhalation via exacerbation. spacer and mask: 2 catheter (1-2 l/min) Salbutamol inhalation or puffs every 10 mobilization as for If not improving, minutes to a moderate exacerbation Prepare for intubation and maximum of 10 PLUS Mechanical ventilation puffs Inhaled ipratropium  If good responses bromide via spacer or then reduce the nebulizer 4-6 hourly frequency to 2-4 125 mcg< 1 year puffs every 2 to 4 250 mcg if 1-5 years hours. 500 mcg>5 years AND Or prednisolone PO  Salbutamol If poor response after 1 -2 nebulisation 2.5 hours or vomiting, give IV mg2 years every 6 hours AND  Start prednisolone at beginning of treatment 1 mg/kg (Max 40 mg) PO OD for 3 days 

Discharge if improving. If poor response after 1-2 hours admit and manage as severe exacerbation

If poor response after a further 2 hours give IV aminophylline 5 mg/kg infusion over 20 min then slow infusion at the rate 1 mg/kg/hour Admit to wards Reassess every 2 hours

Adapted from GINA 2007 guidelines # SC adrenaline 1:1000 0.01 mg/kg (Max 0.5 mg) may be used where inhaled bronchodilator therapy is unavailable. Oral salbutamol may be used as an alternative < 1 year: 1mg per dose, > 1 year 2 mg per dose every 6 hourly.

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Classification of Asthma Severity by Clinical Features Before Treatment Table 3 : Classification of Asthma Severity by Clinical Features Before Treatment Intermittent Symptoms less than once a week Brief exacerbations Nocturnal symptoms not more than twice a month Peak expiratory flow (PEF) ≥ 80% predicted PEF variability < 20% Mild Persistent Symptoms more than once a week but less than once a day Exacerbations may affect activity and sleep Nocturnal symptoms more than twice a month PEF > 80% of predicted PEF variability < 20–30% Moderate Persistent Symptoms daily Exacerbations may affect activity and sleep Nocturnal symptoms more than once a week Daily use of inhaled short acting beta agonists PEF 60 - 80% of predicted PEF variability > 30% Severe Persistent Symptoms daily Frequent exacerbations Frequent nocturnal asthma symptoms Limitation of physical activities PEF ≤ 60 of predicted PEF variability > 30%

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Management of a child with chronic asthma

Patient education Patients /Caregivers should be educated on the following: a. Identification and avoidance of risk factors including  indoor cooking with charcoal, wood or paraffin stoves  parental smoking  contact with pets

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b. Correct use of asthma medication including understanding the difference between reliever and controller medication c. Correct use of inhaler and devices (inhalers, spacers, masks, age appropriate) d. Early recognition of acute asthma exacerbation and taking appropriate steps

Learning activity To make a home-made spacer using a 500 ml drink bottle refer to the WHO IMCI guidelines.

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References 1. British Thoracic Society. Management of Asthma Guidelines, April 2004 2. Standard Treatment Guidelines and Essential Drugs List for South Africa. Paediatric Hospital Level. 1st Edition 1998. 3. Papadopoulos NG and Kalobatson A. Respiratory viruses in childhood asthma. Curr Opin Allergy Clin Immunol, 2007; 7(1): 91-95 4. Tomlinson R. Postcard from Africa: Hospital management of asthma. Arch dis child, 2002; 87:356 5. AL-Hajjaj MS. Bronchial asthma in developing countries: A major social and economic burden. Annals of Thoracic Medicine, April-June 2008, vol 3, 2:39 6. Fischer GB and Camargos PAM. Paediatric asthma management in developing countries. Paediatric respiratory reviews, 2002, 3: 285-291 7. Busse VW and Lemanske RF. Asthma. New Engl Jour of Med, February 2001, Number 5, vol 344:350-362 8. GINA. Global strategy for asthma management and prevention 2007 report. 8. WHO/UNICEF Integrated management of childhood illness for high HIV settings, 2006. 9. Zar HJ et al. Home-made spacers for bronchodilator therapy in children With acute asthma: A randomised trial. Lancet 1999; 354:979-982 10. Zar HJ et al. Randomized controlled trial of the efficacy of a metered dose Inhaler with bottle spacer for bronchodilator therapy in acute lower airways obstruction. Arch Dis Chil, doi: 10, 1136/adc.2006.101642. 11. WHO. Pocketbook of Hospital Care for Children. Guidelines for the management of common illnesses with limited resources 2007. 12. Kenya association for the prevention of tuberculosis and lung disease (KAPLD). Consensus statement on the management of asthma in Kenya, 2005.

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CHAPTER 11 TUBERCULOSIS IN CHILDREN Elizabeth Maleche-Obimbo, Andrew Ndamira, Catherine Chunda INTRODUCTION Tuberculosis (TB) is a major cause of illness and death worldwide especially in Asia and Africa. Globally, there were an estimated 9.2 million new cases, and 1.7 million TB related deaths, of which approximately 400,000 were in children, and 0.2 million in HIV positive individuals in 2006. In Africa, cases of TB are on the increase due to poverty, political instability, overcrowding, malnutrition and HIV infection. Paediatric TB accounts for approximately 10 – 20% of all reported cases. The emergence of HIV infection has grossly altered epidemiological patterns of TB. About one third of the estimated 40 million people living with HIV worldwide are coinfected with TB, and they have a five-fold higher mortality than in individuals with TB alone. Learning Objectives By the end of this chapter, the student should be able to 1. 2. 3. 4. 5. 6. 7.

Discuss the epidemiology of Tuberculosis (TB) in children Understand the aetiology and pathophysiology of TB in children Describe the clinical presentation of TB in children Understand the approach to making a diagnosis of TB in a child Outline the treatment of various forms of TB in children Discuss the diagnostic and treatment challenges of TB in the immuno-compromised child Describe the principles of prevention of TB in children

Learning Experience Practice taking a history in a child suspected to have TB Assess for physical signs suggestive TB Perform a and interpret tuberculin skin test Participate in giving BCG to a newborn Find out how your country manages to do contact tracing of children of parents with sputum positive pulmonary TB Epidemiology of tuberculosis in Children Risk factors for TB infection in children include the following: Young age: the younger the child is, the higher the risk of infection and disease progression; infants are at a higher risk due to poorly developed immune system Infants in close contact with sputum positive adults 139

Children with severe malnutrition HIV infected children Post-measles or post-pertussis infection Non-immunized children (higher risk of severe tuberculous disease) Other immuno-suppressive states such as diabetes mellitus, malignancies, steroid therapy etc. Other population based factors greatly influence prevalence and epidemiological patterns of childhood TB in different geographical regions: 1. Intensity of the epidemic: In populations where TB cases are widespread, there is an increased chance of exposure of children in that population to infection. 2. Age structure of the population: The younger the population, the higher the likelihood of having many children infected with TB. (In Africa up to 50% of the population is below 18 years) 3. Delay in diagnosis and treatment of adult index cases This may be due to i) Delayed presentation of sick adults to health facilities ii) Lack of diagnostic tools: iii) Poor contact tracing and screening of child household contacts of these infected adults iv) Poor health infrastructure contributes to all the factors above. Children are more likely to progress to active TB disease than adults, with infants and children under 5 years at greatest risk. Those who do not develop active TB disease are described as having latent TB. The likelihood of developing disease is highest shortly after exposure (6 – 8 weeks) and decreases with time. Aetiology and Pathophysiology of Tuberculosis TB is caused by Mycobacterium tuberculosis, an obligate aerobic organism that is highly sensitive to light (direct sunlight kills bacilli in 5 minutes) and heat (bacilli die within 20 minutes at 60°C) but highly resistant to dry conditions (bacilli can survive for weeks and later cause infections as dust particles). Other non-tuberculous Mycobacteria may also cause disease, notably M. bovis, M. avium and M. africanum; these are described as atypical mycobacterial infections. Routes of infection The bacilli may enter the human body by any of the following routes: Inhalation Ingestion Inoculation Inhalation of bacilli through the respiratory tract is by far the most common portal of entry (over 98% of cases); inhaled bacilli settle in the lower respiratory tract. Local infection at the portal of entry is usually followed by spread to regional lymph nodes (primary complex). In most children, this primary infection remains quiescent but may result in progression of disease in any of the following ways:

140

Within the lung: multiplication of bacilli initially within alveoli and alveolar ducts before spreading to the lung parenchyma and pleura to cause tuberculous pneumonia, pleurisy, and in older children, pleural effusion and cavitation hilar lymph node inflammation and enlargement, leading to compression of bronchi which leads to lobar or segmental collapse (atelectasis) tonsillar infection: spread to cervical lymph nodes haematogenous (and lymphatic) spread, leading to military TB, involving the lung, pericardium, meninges, abdomen, bone and joint Enlarged focus (coin shadow). Development of any of the above lesions largely depends on immune status of the individual child as well as BCG vaccination status. The table below shows the approximate time frame within which each of the pathological lesions develops: Stage

Duration

Features

1

3-8 weeks

Primary complex, Tuberculin positivity

2

~ 3 months

Haematogenous spread (TBM & miliary TB)

3

3-4 months

TB pleurisy/pneumonia

4

Up to 3 yrs

Bone & Joint

5

Up to 12 yrs

Genitourinary

CLINICAL PRESENTATION OF TUBERCULOSIS Most children with symptomatic TB will present with the following common general symptoms: chronic cough, lasting more than 21 days, persistent fever and/or night sweats (>14 days) and poor weight gain or loss of weight. In addition to the general symptoms described above, depending on the site of the active TB infection, the child may develop symptoms and signs specific to the site of the active infection. These clinical features are described below: Pulmonary TB This is the commonest form of TB occurring in children. There excessive sweating, tachypnoea, respiratory distress, nausea and vomiting. Younger children may present with wheezing due to bronchial obstruction by enlarged hilar lymph nodes (primary complex). Even with more than one lobe involvement in young children respiratory signs may be absent. Older children and adolescents may present with similar disease to 141

adults with productive cough; sputum may be purulent or blood stained (haemoptysis) and there may be signs of apical lobar consolidation and in advanced disease, cavitation. Pleural effusion This tends to occur in older children. They presents with progressive breathlessness (dyspnoea), chest pain, tracheal shift away from affected side, stony dull percussion note, and may have a pleural rub (in early stages) and reduced breath sounds over the affected lung. They may or may not have cough. Lymph Node Disease Presents with progressive painless enlargement of one group of lymph nodes. Most commonly involved areas are cervical, submandibular, tonsillar and supraclavicular lymph nodes. The nodes are enlarged, discrete (but may be matted together), firm, non-tender, and fixed to surrounding structures. Eventually fistula formation may develop, discharging caseous material, which is pathognomonic of TB lymphadenitis. Abdominal TB Tuberculous infection in the abdomen may present with progressive abdominal swelling and abdominal pain associated with persistent fever and weight loss. Examination may reveal abdominal distension with ascites, abdominal mass (enlarged lymph nodes), enlarged liver and/or spleen. Progressive intestinal obstruction by enlarged lymph nodes may manifest as constipation with vomiting, and abdominal distension. Commonly involved tissues include the jejunum, ileum, Payer’s patches and appendix. Generalized peritonitis may occur, though not common. TB Meningitis The clinical presentation of TB meningitis can be described in three stages as follows: Stage I: Child presents with non-specific symptoms and signs of persistent fever, headache, irritability and drowsiness (1-2 weeks). Stage II: Progression to more specific symptoms and signs of meningeal irritation – neck stiffness, positive Kerning’s sign, positive Brudzinski sign, convulsions, hypertonia, vomiting, cranial nerve palsies and focal neurological signs. Stage III: Child develops features of severe neurological disease including coma, hemiplegia, decerebrate or decorticate posturing and abnormal vital signs. Tuberculous meningitis may be differentiated from pyogenic meningitis due to the insidious onset of symptoms (over weeks) and long history of ill health, as compared to the acute onset (over days) of pyogenic meningitis Tuberculoma Tuberculomas present with features of space occupying lesions in accordance with their location within the brain. Accompanying symptoms include headache, persistent fever, weight loss or poor weight gain. Parietal lesions will cause paraparesis or hemiparesis and progress to full paraplegia or hemiplegia. Children may in addition develop features of raised intra-cranial pressure such as vomiting and diplopia. Osteo-articular TB This is caused by haematogenous spread of TB bacilli, initially infecting the metaphyses of weight-bearing bones and joints (vertebrae, knee, hip, elbow and ankle), and may 142

manifest several months to years after the primary TB infection. The child presents with initially mild pain, swelling at the site, with minimal or no tenderness, refusal to use the limb, associated persistent low-grade fever and poor weight gain. TB of the vertebra (Pott’s disease) presents initially with mild back pain which slowly gets worse, abnormal posturing and reluctance to walk, progressing to inability to walk. Examination may reveal rigidity of spine, minimal or no tenderness and abnormal curvature of spine; in advanced stages, collapse of the vertebral body may lead to formation of a gibbus (pathognomonic of TB spine), and to spinal compression with resultant loss of motor function of the lower limbs and loss of bladder and anal sphincter control. Disseminated Disease (Miliary TB, TB Septicaemia) This is caused by haematogenous spread of TB bacilli to multiple organs of the body; it is usually associated with miliary lesions in the lungs, followed by miliary seeding of various body organs (most numerous in liver, spleen and bone marrow). It is more common in infants and severely immunosuppressed individuals (HIV infected and severely malnourished children), and usually presents as an early complication of primary disease (within 2-6 months of primary infection). Onset is usually insidious, with persistent fever, weight loss, malaise, anorexia, and features of pneumonia and abdominal involvement plus, with or without meningeal, bone marrow or urogenital involvement. DIAGNOSIS OF TUBERCULOSIS IN CHILDREN The gold standard for diagnosis of TB is the identification of Mycobacterium tuberculosis in body specimens, by microscopic examination, confirmed by positive culture of the bacillus. Specimens may be obtained from suspected site of infection, and include sputum (pulmonary TB), pleural aspirate (pleural effusion), lymph node aspirate or biopsy (TB lymphadenitis), cerebro-spinal fluid (TB meningitis), ascitic tap or fine needle aspirate (FNA) from abdominal mass (abdominal TB), joint aspirate (TB arthritis) etc. Challenges to diagnosis: Children, especially infants, malnourished and HIV infected children tend to manifest with pauci-bacillary disease, and TB bacilli may not be identified from body specimens even in the presence of active TB disease. Secondly, the majority of affected children (under 8 years) are unable to expectorate , and therefore confirmation of diagnosis of PTB, the most common form of TB in children through microbiologic confirmation is not possible. Thirdly, in resource-poor settings, many health facilities diagnostic tests may not be available. In situations where one is unable to make a microbiologic confirmation of TB infection, the World Health Organization has developed the following approach to clinical diagnosis of TB in children.

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Box 1: Key features suggestive of TB The presence of three or more of the following should strongly suggest a diagnosis of TB Chronic symptoms suggestive of TB Physical signs highly suggestive of TB A positive tuberculin skin test Chest X-ray suggestive of TB These four criteria are defined more explicitly below: 1. Chronic symptoms suggestive of TB Chronic cough: An unremitting cough that is not improving and has been present for more than 14 days Unexplained fever: Fever continuing for > 14 days, after common causes such as malaria or pneumonia have been excluded Unexplained weight loss or failure to thrive: As reported by parent/guardian or older child, take weight of child, examine child’s growth chart. History of exposure to an adult with probable or definite PTB 2. a.

Physical signs highly suggestive of TB Pulmonary TB – there are no specific clinical features that differentiate pulmonary TB from other forms of pneumonia or pulmonary disease

b. Extra pulmonary TB Physical signs highly suggestive of extra pulmonary TB include: non-painful enlarged cervical lymphadenopathy with fistula (abscess) formation Gibbus, (deformity of spine resulting from vertebral TB) especially of recent onset. Physical signs requiring investigation to exclude or support diagnosis of extra pulmonary TB Meningitis with a sub-acute onset (developing over several days to weeks), not responding to standard anti-meningitic antibiotic treatment. Pleural effusion, one sided. Distended abdomen with ascites with or without palpable lumps. Non-painful enlarged lymph nodes without fistula (abscess) formation Non-painful swelling or deformity of bone or joint. In addition, documented weight loss or failure to gain weight, especially in child with adequate nutritional intake, is a good indicator of chronic disease in children, of which TB may be the cause. Investigations relevant to rule out or support diagnosis of extra-pulmonary TB Site of Suspected TB Infection Practical approach to diagnosis Peripheral lymph nodes Lymph node biopsy or fine needle aspiration Miliary TB (disseminated) Chest X-ray and lumbar puncture TB meningitis Lumbar puncture (CT scan where available) Pleural effusion Chest Xray, pleural tap Abdominal TB Abdominal ultrasound, ascitic tap Osteo-articular X-ray of bone/joint, joint tap or synovial biopsy Pericardial TB Ultrasound, pericardial tap 144

All specimens should be subjected to microscopy (acid fast bacilli stains and white cell counts) and mycobacterial cultures. Biopsy specimens should also be subjected to histology. CSF, pleural, ascitic, and pericardial aspirates should also be subjected to biochemical analysis (protein and glucose concentrations). Laboratory tests are discussed in greater detail below. 3. A positive tuberculin skin test (TST) This is an indication that the child has been infected with the Mycobacterium tuberculosis. Tuberculin purified protein derivative antigen is injected intradermal, and an induration appearing at the site of injection within 3 days indicates that the child’s immune system has been sensitized to M.TB (therefore indicates previous infection with the bacillus). Immunocompetent children react more vigorously, immunocompromised children (HIV, severe malnutrition, or very severe forms of TB disease such as military or TB meningitis) may have blunted or absent reaction even in the presence of active TB infection. Therefore the interpretation of the TST test is as follows: High-risk children – HIV infected, severely malnourished children Positive TST = induration of 5mm or more. Negative TST = no induration, or induration 6mths after ART initiation Evidence of CD4 decline or clinical progression (other stage 3-4 defining illness) (Viral load increase - where assay available) In this scenario, anti-TB therapy should be initiated, however ARV therapy should be reevaluated by HIV specialist to identify reason for failure of ARV regimen, and plan how to proceed regarding the patients ART (meanwhile the patient should continue with their existing ART regimen alongside the anti-TB therapy) Selection of antiretroviral therapy regimen Rifampicin, an enzyme inducer, may induce rapid metabolism of non-nucleoside reverse transcriptase inhibitors (most affected is nevirapine) and most protease inhibitors (most affected is lopinavir). In general therefore, one should avoid combining rifampicin with nevirapine or with lopinavir. If these are the only drugs available, possible approaches include: increase the dose of nevirapine by 30% during the period of anti-TB therapy (monitor closely for NVP adverse effects), or boost lopinavir with additional ritonavir to achieve LPV: r in 1:1. 149

Acceptable ART regimens for use with rifampicin: Two NRTI drugs + efavirenz (age above 3 years) Two NRTI drugs + ritonavir boosted lopinavir, with supplemental ritonavir to provide LPV: r at ratio of 1:1 Two NRTI drugs + nevirapine (age below 3 years where LPV/r + r option not feasible) Vitamin B6 supplementation: HIV infected children frequently are malnourished, and care should be taken to give them concurrent vitamin B 10mg once daily during the period they are on isoniazid, to reduce risk of neurotoxic adverse effects of INH. Prevention of Tuberculosis in Children Diagnosis of paediatric TB is difficult and treatment of diagnosed cases involves meticulous calculation of optimum doses and several months of follow-up. Treatment default and poor compliance are therefore major challenges in the treatment and control of TB. Prevention of infection is therefore the most realistic way to control the TB epidemic and should form the basis of all TB control programmes. Preventive measures take different forms: 1. Prevention of infection: Prevent contact with individuals likely to have sputum-positive pulmonary TB. Prompt diagnosis and treatment of suspected cases of pulmonary TB using appropriate combination therapy. Contact tracing and treatment. 2. Prevention of drug resistance: Promotion of the DOTS policy to avoid default and non-compliance Improve surveillance to detect multi-drug resistant (MDR) TB Ensure proper dosage calculation based on patient’s body weight 3. Reduce vulnerability of children to developing TB: Improve nutritional status of children BCG vaccination of all infants at birth (protects children from severe forms of TB) Isoniazid prophylactic therapy to children exposed to open TB especially HIV infected children, and children under five years. Prevention of mother-to-child HIV infection 4. Health education: Ensure that all people (especially community leaders) understand The epidemiological importance of TB The common symptoms and signs of TB The importance of completion of therapy

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REFERENCES

Global tuberculosis control - surveillance, planning, financing. WHO Report 2008. Geneva, World Health Organization. http://www.who.int/tb/publications/global_report/2008. Guidance for national tuberculosis programmes on the management of tuberculosis in children. WHO 2006. Geneva, World Health Organization. WHO/HTM/TB/2006.371. Jeena PM, Pillay P, Pillay T and Coovadia HM. Impact of HIV-1 co-infection on presentation and hospital related mortality in children with culture proved pulmonary tuberculosis in Durban, South Africa. Int J Tuberc Lung Dis 2002;6:672-678. Mukadi YD, Wiktor SZ, Coulibaly IM et al Impact of HIV infection on the development and clinical presentation and outcome of tuberculosis among children in Cote d’Ivoire. AIDS 1997;11:1151-1158. La Porte CJ, Colbers EP, Bertz R, Voncken DS, Wikstrom K, Boeree MJ, Koopmans PP, Hekster YA, Burger DM. Pharmacokinetics of adjusted-dose lopinavir-ritonavir combined with rifampin in healthy volunteers. Antimicrob Agents Chemother. 2004 May;48(5):1553-60. Madhi SA, Huebner RE, Doedens L, Aduc T, Wesley D, and Cooper PA. HIV-1 coinfection in children hospitalised with tuberculosis in South Africa. Int J Tuberc Lung Dis 2000:448-454. Niemi M, Backman JT, Fromm MF, Neuvonen PJ, Kivisto KT. Pharmacokinetic interactions with rifampicin: clinical relevance. Clin Pharmacokinet. 2003;42(9):819-50.

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CHAPTER 12 MALARIA IN CHILDREN Amos Odiit, Sarah Kiguli, Samuel Ayaya, Esther D. Mwaikambo INTRODUCTION It has been estimated that 90% of the African population live in malarious zones and malaria is a direct cause of approximately 12% of all deaths of African children below five years of age. Malaria is, therefore a threat to child survival and development. It is a major cause of foetal loss and low birth-weight (LBW) particularly in primiparous mothers. The risk of severe malaria is greatest during pregnancy, early puerperium, early childhood and in individuals where malaria coexists with other infections, stress or chronic diseases and in individuals with little or no immunity to malaria. Over the last 10 years, management of malaria has been bogged down by high resistance of P. Falciparum to choroquine, sulphadoxine-pyrimethamine. Currently, artemesinin containing combinations are recommended at Primary Health Care level. Protein energy malnutrition (PEM), anaemia and malaria often coexist and aggravate each other. The effect of malaria, starting from pregnancy (anaemia, LBW and abortion), infancy (anaemia and death) and young children can result in:Sapping the energy and growth in children Poor education and stunted growth in children Low work output Reduced or slow economic development Therefore, control of malaria as an integral part of Primary Health Care (PHC) is very important for a health community OBJECTIVES At the end of this chapter, the student should be able to:Explain the transmission of malaria Explain the epidemiology of malaria and measure the extent of the problem in your community Explain the pathophysiology of malaria in children including:- The clinical features of uncomplicated and complicated malaria. - Diagnose uncomplicated and complicated malaria Enumerate complications of malaria in children Treat uncomplicated and severe attacks of malaria Identify and treat drug resistant malaria List methods of control and prevention of malaria

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LEARNING ACTIVITIES During your paediatric rotation, make a clinical diagnosis of malaria and confirm it by laboratory investigations During your paediatric rotation, note the number of children admitted with malaria and the major complications. During your community assignment, estimate the frequency of malaria in schools based on the frequency of anemia, hepato-splenomegaly and positive blood smear; During your community assignment, determine the availability and common use of antimalarial drugs. AETIOLOGY AND TRANSMISSION OF MALARIA Malaria is caused by protozoa of the genus plasmodium. The species which affect man are P.falciparum, P.vivax, P.malariae and P.ovale. P. falciparum is the most important cause of malaria in human beings. Transmission is from man to man by the following ways:The bite of an infected female anopheles mosquito, commonly Anopheles gambiae and Anopheles fenestus Transplacental infection from an infected mother. Through blood transfusion Factors perpetuating malaria transmission i) A reservoir of parasites in human population from which the mosquitoes can pick the infection in form of Gametocytes. ii) Presence of mosquito breeding sties. Stagnant water bodies such as in pits, puddles, fishponds, edges of swamps and creeks. iii) Suitable climatic conditions such as the mosquito to survive and the parasite to develop within the mosquito. Warm moist conditions with relative humidity of 60% and mean daily temperature of 18 oC. Methods Used to estimate Prevalence of Malaria: The following are methods used to estimate the prevalence of malaria in a community:1.

Spleen Rate This method estimates the proportion of children in the age group two to ten years who have splenomegaly (see table 1 below)

Table 1: WHO Classification of Malaria Endemicity Malarial Endemicity Spleen Rate Spleen Rate (in children 2-10 yrs of age) (in adults) Hypoendemic 0-10% Mesoendemic 11-50% Hyperendemic >50% >25% Holoendemic 75% Low The low adult spleen rates in holoendemic areas indicate considerable immunity acquired by intense exposure to perennial transmission. 153

2.

Parasite Rate This is a proportion of the population in which malaria parasites are found using blood films. 3.

Parasite Count This can be reported as parasites against leucocyte count for exact amount of blood related to a count. (parasites/µl)

PATHOGENESIS OF MALARIA Haemolysis and tissue ischaemia account for the majority of pathophysiological changes. The higher the parasite could worsen the prognosis. Release of interleukins from infected erythrocytes is responsible for clinical features such as fever. Infected erythrocytes become sticky and are coated with fibrin which causes agglutination and obstruction in small vessels, this leading to local hypoxia. In addition, the following disturbances may occur:1.

Anaemia More severe with P.Falciparum because it invades red blood cells of all ages and frequently produces a high level of parasitaemia;

Mechanisms of anaemia in malaria infection are:direct lysis of red blood cells caused by dysfunction of Na+ Pump splenic removal of parasitized red blood cells; autoimmune destruction of infected and non infected coated erythrocytes; reduced incorporation of iron into bone; impaired erythropoiesis due to direct bone marrow suppression form malarial toxin; increased intramedullary destruction of red blood cell precursors and erythrocyte maturation arrest from folic acid and PABA deficiencies. 2. Hypoglycaemia Occurs due to depleted glycogen stores and competition for serum glucose by the parasite. Reduced food intake and the increased secretion of insulin in patients treated with quinine also contribute to hypoglycemia. There may also be use of traditional herbs that contribute to protracted hypoglycaemia. 3.

Thrombocytopenia Can occur due to splenic sequestration and bone marrow depression

4.

Hypergammaglobulinaemia, hypocholesterolaemia, hyperbilirubinaemia and raised transaminases do occur frequently due to fever and liver dysfunction.

5

Hepatomegaly is due to congestion from parasitized cells in sinusoids, and centrilobular veins and due swollen parenchymal and Kupffer cells;

6.

Hyperkalemia and hyponatremia are seen in acute attacks of malaria. They are due to increased destruction of red blood cells and intravascular volume 154

expansion occurring as a compensatory response to the vasodilatation caused by malaria toxins; 7.

Acidosis can occur due to increased lactate and pyruvate production as the parasites use glucose; Splenomegaly occurs due to hyperplasia of reticuloendothelial system and vascular congestion. Tropical splenomegaly syndrome (TSS) occurs due to an abnormal immune response to persistent malarial antigen stimulation in an endemic region;

9. In the brain parasitized red blood cells are preferentially sequestrated in deep capillaries causing clogging and subsequent ischemic changes, congestion, oedema and central nervous system manifestations. Pulmonary oedema may complicate cerebral malaria, severe anaemia, high parasitaemia or be caused by fluid overload during management. CLINICAL FEATURES The clinical picture of malaria in children depends on child's age and immunity. The non-immune infants and children who contract malaria for the first time also have a variable clinical picture. They may present with restlessness, drowsiness, listlessness or refusal to feed. They may also have headache, nausea and pallor. A clear cut cold stage and rigor are uncommon. Vomiting can be severe causing dehydration and electrolyte imbalance. Fever is invariable, often continuous although it may also be irregular. Convulsions often occur. Signs of cerebral malaria include fever, impaired or loss of consciousness, convulsions, with normal cerebral-spinal findings. DIAGNOSIS OF MALARIA Definite diagnosis of malaria is made by establishing the presence of malaria parasites in the blood by examining a blood smear. However, due to delays in blood testing in developing countries, malaria should be suspected in all cases of fever in endemic areas. Proper history taking and physical examination is mandatory to differentiate malaria from other febrile conditions such as urinary tract infection, meningitis, tonsillitis, viral infection, etc. Some investigations (other than a blood smear) may be necessary in order to exclude the coexistence of other infections. A malaria negative blood slide does not exclude malaria infection. Diagnosis of malaria may also be made by detection of antibodies in the blood using the rapid diagnostic tests (RDT's). Since malarial antibodies persist in the blood of the patient after the infection, these tests are therefore only useful for surveys or research work and in subjects in whom parasites are difficult to find. Counting Malaria Parasites in a blood film using parasite per micro litre method Counting malaria parasites reflects the degree of parasitaemia, which in turn is related to prognosis. A thick blood film is made and examined under the oil objective of a microscope. Two hundred leucocytes are counted using a tally counter. At the same time using a separate tally counter, the number of malaria parasites in the fields is counted. When 155

10 malaria parasites or more are counted in the fields where 200 leucocyte have been counted, then the result is rerecorded showing parasites per 200 leucocytes. If after counting 200 leucocytes 9 or less parasites are counted, counting is continued until 500 leucocytes. Parasites are recorded per 500 leucocytes. Parasite count is then converted to parasites per micro litre using the mathematical formula below: Number of parasites x 8000 = Parasites per micro litre Number of leucocytes COMPLICATIONS OF MALARIA A. Falciparum Malaria The high invasive power of P.Falciparum leads to the rapid destruction of erythrocytes and the resulting anaemia can be very severe. Infections in which five to twenty percent of red blood cells contain parasites are uncommon. The progressive destruction of red blood cells leads to anaemia. Micro thrombi thrombi are formed by parasitized red blood cells leading to local anoxia of various organs. The resulting changes in the various organs e.g. the brain, liver, kidney, bone marrow, lungs, etc. are responsible for complications. The complications can be very severe in those with low immunity. Severe infections occur in endemic regions, most commonly between the ages of six months to three years and are responsible for almost all the deaths directly attributable to malaria in these areas. These severe attacks can develop with great suddenness and manifest themselves as:Hyperparasitaemia: The density of the asexual forms in the peripheral blood exceeds 5% of the red blood cells or parasites per micro litre Cerebral malaria; Gastrointestinal malaria with diarrhoea and vomiting; Hyperpyrexia; (T > 39o rectally) Severe anaemia (packed cell volume of less than 20%); Algid malaria which presents as peripheral vascular collapse due to adrenal failure; may have concurrent gram negative septicaemia Black water fever (massive intravascular haemolysis leading to haemoglobinuria) Acute Renal Failure (usually acute tubular necrosis due to presence of sequestrated infected red blood cells in the renal tubules and hypovolaemia). Disseminated intravascular coagulopathy (DIC) due to consumptive coagulopathy; Metabolic acidosis resulting from anaerobic tissue respiration, dehydration and renal failure; Hypoglycaemia due to starvation from anorexia, vomiting, and use of quinine and also due to competition for serum glucose by malaria parasites. Pulmonary Oedema due to sequestration of parasitized red blood cells in the lungs and from heart failure and IV fluid overload. B. Vivax, Quartan and Ovale Malaria Complications of acute attacks of vivax, quartan or ovale malaria are relatively uncommon but the infection may undermine the general condition of the growing child and aggravate other intercurrent diseases. High temperature seldom persists. Cerebral and intestinal symptoms are rare, but nephrotic syndrome is a complication often seen with chronic plasmodium malariae. 156

Vivax and Ovale malaria may be associated with relapses. This is due to some of the circulating parasites (merozoites) returning to the liver and remaining dormant until a later date when the immunity wanes and re-seeding of the blood occurs. TREATMENT OF MALARIA A. Treatment of malaria in infants and children poses special problems because of the following reasons:Acute attacks of malaria are more severe than in adults; Vomiting is common and reduces the treatment options as oral medication may not be possible; Cerebral malaria is more common than in adults; Gastrointestinal complication presenting with diarrhea and vomiting can cause severe dehydration; Anaemia may be severe enough to require blood transfusion; Compliance with medications can be poor because children cannot be made to understand its importance, therefore, parent' health education and their cooperation re absolutely vital in the treatment of malaria. Except in case of drug-resistance, quick acting schizonticides are more preferable than slow acting ones in the treatment of acute attacks of malaria. Treatment of simple versus complicated infection will be discussed separately thus:Guidelines for treatment of uncomplicated malaria The recommended first line treatment for malaria treatment is Artemesinin – based combination therapies (ACT). There are different ACT formulations in the market. Artemether (20mg)/Lumefantrine (120mg) is one such combination recommended by the World Health Organization (WHO). For dosage, see table below:

Wt Category (kg) 5-14 15-24

Age 4mo3years 3yrs-7yrs

25-34

7yrs-12yrs

>34

≥ 12yrs

Day 1 1tab, 12 hourly 2tabs, 12 hourly 3tabs, 12 hourly 4tabs hourly

Day 2 1tab, hourly 2tabs, hourly 3tabs, hourly 4tabs, hourly

Other ACT combinations available in the market are: Artesunate + Amodiaquine: a three day course Artesunate + Sulfadoxine/pyrimethamin. This regimen is given as separate tablets, not co-formulated Artesunate + Mefloquine.

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Day 3 12 1tab, hourly 12 2tabs, hourly 12 3tabs, hourly 12 4tabs, hourly

12 12 12 12

A combination of amodiaquine and sulfadoxine/pyrimethamine is also used in some areas. Second line antimalarial treatment Oral quinine is the recommended second line malaria drug. Indications or reasons for choosing second line antimalarial drug include: Failed first line antimalarial treatment ii)

First line drug contraindicated in the particular patient. in infants