CDI Module 17: Community Management of Pneumonia
©Jhpiego Corporation
The Johns Hopkins University
A Training Program on Community-
Directed Intervention (CDI) to Improve
Access to Essential Health Services

Module 17 Objectives
By the end of this module, learners will:
 Describe the global burden of pneumonia and reasons it cannot be neglected
 Describe the signs and symptoms of pneumonia and its relationship to other acute respiratory infections (ARIs)
 Define pneumonia
 Describe methods for prevention and treatment of pneumonia
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Why We Cannot Ignore Pneumonia in Efforts to Control Malaria
 Pneumonia kills more children than any other illness
 Any effort to improve overall child survival must make the reduction of pneumonia’s death toll a priority
 More than 35 million childhood pneumonia episodes occur in African children each year
 More than one million of these children die
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Pneumonia Is Common in Africa
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Relation Between Pneumonia and Other ARIs
 Pneumonia and other ARIs share similar clinical features such as presence of:
 Fever


Cough
Vomiting (sometimes)
 Chest pain/indrawing
 Rapid breathing
 Zinc and vitamin A are useful in managing both pneumonia and ARI, especially lower ARI
 Co-trimoxazole and amoxicillin are effective drugs against pneumonias caused by some bacterial pathogens, but these do not cure ARI caused by viruses
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Recognizing Pneumonia
 Bacterial pneumonia usually causes children to become severely ill, with high fever and rapid breathing
 Viral infections, however, often come on gradually and may worsen over time
 Some common symptoms of pneumonia in children and infants include rapid or difficult breathing, cough, fever, chills, headaches, loss of appetite and wheezing
 Children under five with severe cases of pneumonia may struggle to breathe, with their chests moving in or retracting during inhalation (known as “lower chest wall indrawing”)
 Young infants may suffer convulsions, unconsciousness, hypothermia, lethargy and feeding problems
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Two Most Important Signs of Pneumonia
 Difficult Breathing
 Fast Breathing
Photo by WHO/M. Weber at http://whqlibdoc.who.int/hq/2009/WHO_FCH_CAH_NCH_09.04_eng.pdf
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Framework for Pneumonia Control
PROTECT children by providing a healthy environment
Exclusive breastfeeding for six months
Adequate nutrition
Prevent low birth weight
Reduce indoor air pollution
Handwashing
REDUCE
PNEUMONIA
MORTALITY
AND
MORBIDITY
TREAT children who become ill with pneumonia
Case management in community, health center and hospital
PREVENT children from becoming ill with pneumonia
Vaccination against measles, pertussis, Spn* and Hib**
Prevention of HIV in children
Co-trimoxazole prophylaxis for
HIV-infected and exposed children
Zinc supplementation for children with diarrhea
*Streptococcus pneumoniae
**Hemophilis influenzae b
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Protecting Children from Pneumonia
Protect children by providing a healthy environment
 Reduce indoor air pollution
 Encourage handwashing
 Promote exclusive breastfeeding for six months
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Protecting Children from Pneumonia
(continued)
Reduce low birth weight (LBW) —defined as weight at birth <2.5kg
— by :
 Preventing malaria in pregnancy
 Provide long-lasting insecticide-treated nets (LLINs) and intermittent preventive treatment in pregnancy (IPTp)
 Ensuring good maternal nutrition
 Provide food that contains zinc (e.g., vegetables, eggs, meat and fish) and iodine (e.g., fish, iodized salt and okra).
 Using a hematinic (to prevent anemia)
 Optimizing maternal health
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Preventing Pneumonia in Children
Preventing children from developing pneumonia in the first place is essential for reducing child deaths

Key prevention measures include :
 Promoting adequate nutrition (including breastfeeding and zinc intake)


Raising immunization rates
Reducing indoor air pollution
 Recent research also suggests that handwashing may play a role in reducing the incidence of pneumonia
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Preventive Measures: Breastfeeding and
Handwashing with Soap
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Countries That Have Introduced Hib Vaccine against Pneumonia
 Vaccines can prevent some forms of pneumonia
 Only around half of 193 countries worldwide have adopted Hib3 vaccine and implemented it up to 80% coverage
 We still have a long way to go with this strategy
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Status of Global Pneumococcal Conjugate
Vaccine Introduction (2008)
Here we see slow progress with a vaccine to prevent another form of pneumonia
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Preventing HIV in Children
Routine assessment for signs/symptoms of HIV
(persistent diarrhea, failure to thrive)
 HIV testing
 Pneumocystis carinii pneumonia (PCP) prophylaxis
(starting at six months)
 Prevention and treatment of TB or malaria
 Specific interventions to reduce mother-to-child transmission (MTCT) of HIV include antiretroviral
(ARV) treatment and prophylaxis, safe delivery procedures, counseling and support for safe infant feeding
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Treatment
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Chart for Classifying and Treating
Respiratory Illness
SIGNS
• Fast breathing (see below)
• Lower chest wall indrawing
• Stridor in calm child
CLASSIFY AS
Severe pneumonia
• Fast breathing (see below) Non-severe pneumonia
• No fast breathing Other respiratory illness
TREATMENT
• Refer urgently to hospital for injectable antibiotics and oxygen, if needed
• Give first dose of appropriate antibiotic
• Prescribe appropriate antibiotic
• Advise mother about other supportive measures and when to return for a follow-up visit
• Advise mother about other supportive measures and when to return if symptoms persist or get worse
What is fast breathing?
If the child is…
2 months to 12 months old
12 months to 5 years old
The child has fast breathing if you count…
50 breaths or more per minute
40 breaths or more per minute
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Treatment
 Co-trimoxazole and amoxicillin are effective drugs against bacterial pathogens and are often used to treat children with pneumonia in developing countries
 Infants under two months of age, with signs of pneumonia/sepsis:
 Are at risk of suffering severe illness and death more quickly than older children, and
 Should be immediately referred to a hospital or clinic for treatment
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Medicine for Cough, Fast Breathing, Fever
 Give an appropriate oral antibiotic
 For pneumonia, acute ear infection, severe classifications requiring first dose of antibiotics:
 First-line antibiotic co-trimoxazole
– Adult tablet = trimethoprim (80 mg) + sulfamethoxazole (400 mg)
–
Pediatric tablet = trimethoprim (20 mg) + sulfamethoxazole
(100 mg)
– Syrup/per 5 ml = 40 mg trimethoprim + 200 mg sulfamethoxazole
 Second-line antibiotic amoxicillin
– Tablet 250 mg; syrup 125 mg per 5 ml
 In all the children on co-trimoxazole prophylaxis, give amoxicillin
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Cough, Fast Breathing, Fever
Give Appropriate Dosage by Age or Weight
Age or
Weight
Adult Tablet
80 mg trimethoprim +
400 mg sulfamethoxazole
Co-Trimoxozole
Give two times daily for five days
Pediatric Tablet
20 mg trimethoprim +
100 mg sulfamethoxazole
Syrup/per 5 ml
40 mg trimethoprim
+ 200 mg sulfamethoxazole
Amoxicillin
Give three times daily for five days
Tablet
250 mg
Syrup
125 mg per 5 ml
Two months up to 12 months (4kg to <10kg)
12 months up to five years
(10kg‒19kg)
1/2
1
2
3
5 ml
7.5 ml
1/2
1
5 ml
10 ml
This is a sample schedule and dose table for oral antibiotics
Users will need to confirm and comply with specific country treatment guidelines
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Summary Points
 Infants under two months of age with signs of pneumonia/sepsis:
 Are at risk of suffering severe illness and death more quickly than older children, and
 Should be immediately referred to a hospital or clinic for treatment
 Research evidence has shown that handwashing and breastfeeding may prevent pneumonia
 Use an appropriate oral antibiotic for treatment
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