Prevention

In general, the most effective prevention of ARIs, like many diseases, is vaccination. The vaccines for diphtheria, pertussis, and tetanus, regularly included in immunization programs, are effective in preventing some infections that can lead to ARIs. Vaccines also exist for H. influenzae serotype b (Hib) and S. pneumoniae (pnuemococcus) infection, and are frequently used in the United States and other developed countries (Dagan, 2010). However, the high cost of procuring and storing these vaccines in resource poor settings has kept many developing countries from utilizing them in the past. Fortunately, many initiatives are being introduced to make these vaccines widely available throughout the developing world (WHO, 2005). In fact, the Bill & Melinda Gates Foundation have developed a vision, called the Decade of Vaccines, supported by 200 other countries, that is striving to extend the benefits of vaccines to every person by the year 2020 (Bill & Melinda Gates Foundation).

The effectiveness of the Hib vaccine has been shown in different studies based in developing countries, specifically in South America, Southeast Asia, and parts of Africa, and it reduces the occurrence of disease caused by Hib despite irregular supply of the vaccine (Child Health Research Project). Studies in Gambia have demonstrated the efficacy of a pneumococcal conjugate vaccine, substantially improving child survival (Child Health Research Project).  Not only was the vaccine very effective in reducing the number of children with pneumonia, but of those who were given the vaccine, there were 16% fewer deaths from any cause, not just pneumonia. It is believed that this vaccine can prevent 1 in every 7 deaths in the rural developing world setting (CDC, 2010).

In 2006, the WHO's Strategic Advisory Group of Experts (SAGE) recommended the Hib vaccine for all of their developing countries. The pneumococcal conjugate vaccine was recommended by SAGE in 2007 for all countries, especially those with high child mortality rates (CDC, 2010).

There are multiple global initiatives to accelerate the introduction of these two vaccines to all the developing countries. The Global Alliance for Vaccines and Immunizations (GAVI) is a public-private partnership of the existing major players in global immunization including UN agencies, vaccine industry leaders, bilateral aid agencies, and major foundations that target the lowest income "GAVI eligible" countries (GAVI Alliance 2012).  The Hib initiative, through this funding, has already reached 62 of the 72 GAVI eligible countries (GAVI Alliance, 2011: CDC, 2010). Another initiative, the Accelerating Vaccine Introduction (AVI), aims to widely introduce and speed up the uptake of the pneumococcal and rotavirus vaccines to developing countries. Forty seven countries could be using the pneumococcal vaccine by 2015 though this initiative (CDC, 2010).    

Due to the high costs of these vaccinations, researchers and physicians at Boston Children's Hospital realized there is a demand for inexpensive Pneumoccoccal vaccines that can be used in developing countries. Please see video below for a description of the project.

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Despite the above efforts, primary prevention in the form of vaccination remains difficult in developing countries. Thus, other prevention efforts are focused on reducing the environmental and behavioral factors that can lead to ARIs.  The primary risk factors for pneumonia include:

• Lack of exclusive breastfeeding
• Under nutrition
• exposure to indoor air pollution (including tobacco smoke and smoke from cooking and/or heating stoves)
• Low-birth weight
• Crowding
• Incomplete or absent immunizations
• Poor hygiene

(Rudan et al, 2011)(WHO, 2009)(Yadav et al., 2013)

Possible interventions for ARI's related to indoor air pollution include: the installation of smoke outlets and windows in the room where the child spends most of his/her time, discouragement of mosquito coil use, lessening of time the child spends around cooking stove, and increased usage of cleanburning fuels (Azad, Bahauddin, Uddin, & Parveen, 2014); Gurley et al., 2014; Suguna, Kumar, & Roy, 2014;).

Treatment

Early recognition of symptoms and the use of affordable antibiotics can prevent 30 to 60% of ARI related deaths (Child Health Research Project). The most effective intervention for ARI is treatment with an appropriate, low-cost antibiotic such as cotrimoxazole, amoxicillin, ampicillin, and procaine penicillin. However, both S. pneumoniae and H. influenzae have shown significant resistance to these standard antimicrobial drugs in the past decade. This poses a serious problem in both industrialized and developing countries (McCracken, 2000). New antibiotics, such as azithromycin, levofloxacin, or cefuroxime are effective against drug resistant strains but are more costly, making them impractical for routine treatment in the developing world (Merck, 2008).

While treatment with antibiotics is the cornerstone of ARI intervention, health workers, both within the clinic settings and in the community, must also encourage appropriate health-seeking behavior for caretakers of children. According to UNICEF, only 53% of caretakers seek care for their children with ARI symptoms. Factors contributing to lack of access include:

• Local health facilities not well stocked with necessary supplies (Acharya and Cleland, 2000)
• Distance and travel time to a health facility (Simoes et al, 2003)
• Cost, cultural reasons, and lack of child care for other children at home (Peterson et al, 2004)

Problems with the referral system for pneumonia have led to several recent study interventions aiming to make treatment available in the home, even for severe pneumonia. This will be discussed in more detail in the section on new developments. 

IMCI Guidelines 

To address dangerous co-morbidities resulting from these factors and others, the WHO introduced the Integrated Management of Childhood Illness (IMCI) (Ghimire et al, 2010). This approach trains health technicians and community health workers to assess and treat several childhood complications at once, and has been shown to reduce child mortality.

Future efforts of the IMCI include working to:

• improve the specificity of the diagnosis of non-severe pneumonia
• limit unnecessary antibiotic use
• develop alternative antibiotic regimes for the management of severe pneumonia
• determine the appropriateness of fluid restriction in severe pneumonia
• monitor antimicrobial resistance among organisms responsible for pneumonia
• research the management of wheezing and of otitis media (WHO, 2008)

It is over ten years since the IMCI has been introduced. During this period, the Department of Child and Adolescent Health and Development (CAH) and many WHO partners have continued to support work to evaluate the performance and increase the evidence base for the technical guidelines. The technical updates provided in this document reflect the results from this work, as provided by new research findings and technical consultations. The updates cover six areas, and give an organized tool to assess sick children from 2 months to 5 years. 

Technical Issues and Access

In order to implement IMCI strategies, as well as more focused ARI prevention and treatment programs, several technical issues need to be considered. These include potential abuse and resistance to available antibiotics, vaccine development, the availability of oxygen, and the availability of other essential tools in diagnosing and treating ARIs. 

• Antibiotic resistance: Within the past two decades, significant resistance to standard antibiotics has emerged for the two main respiratory bacteria, S. pneumonia and H. influenza type b.  Inappropriate use of antibiotics contributes to the development of resistance to standard low cost drugs. Often, health promoters will provide caretakers with antibiotics as a misguided form of prevention or to appease the client's expectations. IMCI strategies that focus on promoting accurate diagnosis, case management and home treatment of early upper respiratory infections are helping to reduce inappropriate use of antibiotics (LaForce and Sogunro, 2001). Notably, the use of the pneumococcal conjugate vaccines have decreased the prevalence of the drug resistant strains of S. pneumonia, allowing the monitored use of some primary lines of antibiotics (Nuermberger, 2004).

• Resources: Other equipment and tools are essential for appropriate diagnosis and treatment. To effectively diagnose and treat ARI, clinics and rural dispensaries require stop watches, weighing scales, calculators, patient registers, and drug stock cards. In addition to receiving antibiotics, children with severe pneumonia and hypoxia may need oxygen therapy to prevent brain damage. However, the availability of oxygen in hospitals in developing countries is limited. 

Management Issues 

In addition to the above tools, there are a number of management issues surrounding strategies combating ARI, such as IMCI. To be considered properly trained, health workers should be able to use equipment correctly, recognize the signs of pneumonia in children, give correct doses of the oral antibiotics, refer severe cases when feasible, and instruct families on essential supportive measures (McCracken, 2000).  IMCI is designed to assure that health workers are properly trained, and that training is reinforced. Nevertheless, there are some considerable challenges in implementing and expanding IMCI. These include capacity building, structural changes within ministries of health, incorporating IMCI into ongoing district and national efforts to improve child health, and designing effective support and supervisory systems for health workers (Huicho et al, 2005).

Monitoring and Evaluation 

Monitoring and evaluating ARI interventions at the individual, district, and national level is key to improved understanding of the changing epidemiology of pneumonia; therefore, a country-wide health information system is essential. Monitoring of ARIs should flow roughly through the steps in the model that follows.

Some key indicators to monitor for improved ARI treatment and prevention include:

• % of caregivers who know that difficult or fast breathing is a sign to seek care immediately
• % of children under five with pneumonia taken to an appropriate health care provider
• % of deaths in children under 5 years old due to pneumonia
• % of children under 5 with pneumonia who received antibiotics (UNICEF/WHO, 2006)
• % of children prescribed and treated with an antibiotic of any class
• % of children prescribed and treated with cotrimoxazole
• % of children prescribed and treated with amoxicillin
• % of children treated with an antibiotic obtained over-the-counter
• % of children treated with a safe home remedy
• % of caregivers consulting a community health worker
• % of caregivers consulting a health facility (Holloway, 2009)