1. health and fitness
2. disease
3. cold and flu

Clinical management of influenza and other
acute respiratory illness in resource-limited
settings: learning from the influenza pandemic
(H1N1) 2009
20–21 October 2010 – Geneva Switzerland
WHO/HSE/GIP/DAC/2011.3
© World Health Organization 2011
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WHO/HSE/GIP/DAC/2011.3
Contents
Acknowledgements ii
Abbreviations and acronyms iii
1Background 1
2 The meeting 2.1Objectives 2.2Outcomes 2.3Agenda 2.4Participants 2
2
2
3
3
3 National experience 3.1 Disease activity and impact on health-care systems 3.2 Clinical epidemiology 3.3 Clinical care 3.4 National systems and response 3.5Communication 4
4
6
10
13
17
4 Key challenges of implementing clinical guidance 4.1 Country needs assessment questionnaire 4.2 Developing clinical guidance in resource-limited settings 4.3 Development of deployable kits of medical supplies and devices to
manage hospitalized ARI in resource-limited settings 4.4 Infection prevention and control 18
18
20
5 WHO approach: training to improve patient care at all levels 5.1 Home-based care for pandemic influenza 5.2 Community case management during an influenza outbreak training package 5.3 Hospital-based training 5.4 Critical care training 5.5 Promoting oxygen use for pneumonia treatment 24
24
25
25
26
27
6 WHO action points 30
21
23
Management of acute respiratory illness in resource-limited settings | i
Annex 1 Agenda 31
Annex 2 List of participants 36
Annex 3 Oral statement on declarations of interest 42
Annex 4 Country questionnaire proforma 44
Annex 5 Calculation table for disposables and pulse oximetry for 100 severe
pneumonia cases 47
Tables
Table 1
Table 2
Table 3
Table 4
South Africa (H1N1) 2009 fatality comorbidities South Africa HIV fatality comorbidity data Clinical outcome of (H1N1) patients by time of initiation of antiviral therapy, Argentina Requirements needed to strengthen treatment of acute respiratory illness,
as identified by different countries 8
8
12
19
Figures
Figure 1
Figure 2
Figure 3
Figure 4
Figure 5
Figure 6
The 2009 influenza pandemic: key lessons learnt from countries Argentina pandemic (H1N1) 2009 mortality rates according to age and gender Severe acute respiratory illness surveillance – incidence of infection of pandemic
(a) (H1N1) 2009 and (b) H3N2 by HIV status, Soweto, South Africa Streptococcus pneumoniae and influenza detection rates and total number of samples
by week, South Africa, 2009 Early and effective primary care can forestall progression to severe disease Bed status during surge of pandemic (H1N1) 2009 cases, Mongolia, 2010 5
7
9
11
14
16
Acknowledgements
This document was prepared by Paula Lister, Justin Ortiz and Kathryn Sauven under the coordination of
Nikki Shindo of the World Health Organization (WHO) Global Influenza Programme.
We would like to acknowledge the essential contributions of the participants at the technical meeting,
and of WHO departments, including Health Action in Crisis/Emergency Preparedness and Capacity Building
(HAC/EPC), Human Immunodeficiency Virus/Systems Strengthening and HIV (HIV/SSH), Family and Community
Health Cluster/Child and Adolescent Health and Development (FCH/CAH) and Health Security and
Environment/Global Alert and Response (HSE/GAR). We would also like to acknowledge other members
of the Supporting Patient Care team of the WHO pandemic influenza functional response structure.
The report was reviewed by Dr Iryna Bobrova, Dr Rosa Bologn, Dr Bin Cao, Dr Tawee Chotpityasunondh,
Dr Santiram Dhakal, Dr Lena Napolitano, Dr Enkhtur Shonkhuuz, Dr Jagdish Chander Suri and Dr Juno Thomas.
We would also like to acknowledge the support in this project of WHO staff: Vincent Ahove, Sylvie Briand,
Meena Nathan Cherian, John Conly, Janet Diaz, Hien Doan, Sergey Eremin, Michelle Gayer, Madhu Ghimire,
Sandra Gove, Benido Impouma, Matthew Lim, Joshua Mott, Lulu Muhe, Naoko Obara, Heather Papowitz,
Charles Penn, Susan Piazza, Shamim Ahmad Qazi, Pilar Ramon-Pardo, Yu Togawa and Mari-Helene Vannson.
The final document was further strengthened by written comments, critiques and technical editing of
previous drafts from Anna Bowman, Hilary Cadman, Rebecca Harris and Tim Nguyen. This project was supported
in part by a grant from the United States Agency for International Development (USAID) and Japan.
ii | Management of acute respiratory illness in resource-limited settings
Abbreviations and acronyms
AIDS
acquired immunodeficiency syndrome
ARDS
acute respiratory distress syndrome
ARI
acute respiratory infection
CAP
community-acquired pneumonia
CHW
community health worker
ETAT
emergency triage assessment and treatment
GIP
Global Influenza Programme (of WHO)
HCW
health-care worker
HIV
human immunodeficiency virus
ICU
intensive care unit
ILI
influenza-like illness
IMAI
integrated management of adolescent and adult illness
IMCI
integrated management of childhood illness
IPC
infection prevention and control
IRDT
influenza rapid diagnostic test
MOH
ministry of health
NGO
nongovernmental organization
NIV
noninvasive ventilation
RSV
respiratory syncytial virus
SARI
severe acute respiratory illness
SARS
severe acute respiratory syndrome
TBtuberculosis
UNICEF
United Nations Children’s Fund
WHO
World Health Organization
Management of acute respiratory illness in resource-limited settings | iii
1Background
Pandemic (H1N1) 2009, the first influenza pandemic of the 21st century, reached all parts of the world within
a year, causing epidemics of varying magnitude. During the pandemic period, the World Health Organization
(WHO) received reports of over 18 000 laboratory-confirmed deaths due to infection with the virus; however,
the actual death toll is likely to have been much higher1. The hospitalization rate was highest in children
under 5 years of age, and particularly in those under 1 year of age. In contrast to seasonal influenza
epidemics, most of the deaths from the 2009 influenza pandemic occurred in those under 60 years of age,
up to half of whom had previously been healthy.
Since the start of the 2009 influenza pandemic, WHO has been supporting countries in the area of patient
care. For countries with limited resources, WHO has developed information and training materials for several
levels of health care – at home and in the community, and in district and tertiary hospitals. Information
on the pandemic disease was collected through WHO networks, including the network of clinicians at
the front line. The training materials were developed based on existing WHO guidelines and manuals
(e.g. Hospital care for children2), complemented with information specific to pandemic (H1N1) 2009.
In early August 2010, the Director General of WHO announced that the world was moving into the
post-pandemic period. During this period, however, the pandemic (H1N1) 2009 virus is expected to
continue to circulate globally and cause disease among susceptible populations, especially in countries
that did not go through the full (H1N1) 2009 epidemic. Learning lessons from the pandemic (H1N1) 2009
experiences can help to strengthen health-care systems against future epidemics of influenza and of other
epidemic-prone acute respiratory infections (ARIs).
To address resource constraints in low- and middle-income countries, the following points – raised by those
attending the First Africa Flu Alliance meeting held in Morocco in June 20103 – were considered when
developing strategies to improve care of patients with ARI:
ƒƒ further develop nurse-led primary care in communities through ARI training and the development
of care and diagnostic kits;
ƒƒ increase knowledge of influenza in the population through, for example, the mass media,
community health workers (CHWs) and social mobilization campaigns;
ƒƒ strengthen pneumonia care in hospitals through in-service training, delivery of equipment as a
package (e.g. oxygen, masks and pulse oximeter) and strategic planning that emphasizes funding
and human resources.
1 http://www.who.int/csr/disease/swineflu/notes/briefing_20091222/en/index.html
2 http://whqlibdoc.who.int/publications/2005/9241546700.pdf
3 The First Africa Flu Alliance Meeting was hosted by the WHO Global Influenza Programme. Plans to reduce influenza burden in
Africa were discussed by health authorities, health partners and international health agencies. The meeting report is available
at http://www.who.int/csr/disease/influenza/2010_06_3_afa_mtg_marrakesh_morocco.pdf (accessed March 2011)
1 | Management of acute respiratory illness in resource-limited settings
2 The meeting
This document reports on a meeting convened by WHO in October 2010 titled Clinical management
of influenza and other acute respiratory illnesses in resource-limited settings: Learning from (H1N1)
2009 influenza pandemic.
2.1Objectives
The overall goal for the meeting was to contribute to improved clinical management of influenza and other
ARI at all levels of health care during community transmission of pandemic influenza. Specific objectives
developed to achieve the overall goal were to:
ƒƒ review lessons learnt for the diagnosis and management of influenza from settings where resources
are limited;
ƒƒ list key challenges of implementing clinical guidance in resource-limited settings, and use this
information for the further development of country-specific action items, to improve clinical
management of influenza at all or at focused levels of health care;
ƒƒ introduce WHO information materials and training curricula to the participants, and assess whether
any of these can fit into the action items identified by the above-mentioned exercise;
ƒƒ engage donors and funding agencies to support the countries through implementation of the action
items or provision of resources.
2.2Outcomes
Based on the objectives listed above, the outcomes of the meeting would be:
ƒƒ a meeting report (this document) that summarizes:
–– key lessons learnt in the management of pandemic (H1N1) 2009 from resource-limited settings;
–– key challenges of implementing clinical guidance in resource-limited settings;
–– country-based needs analysis to improve clinical management of influenza at all or at focused
levels of health care during community spread of pandemic influenza;
ƒƒ a list of prioritized action items for future coordinated capacity building activities, agreed upon by
the participating partner agencies;
ƒƒ agreement on the next steps.
Management of acute respiratory illness in resource-limited settings | 2
The knowledge acquired through the meeting will be reflected in WHO training materials and used in:
ƒƒ the development of national or local plans to improve health-care preparedness during a surge of
sick people with ARI, and clinical management of ARI;
ƒƒ community awareness raising activities during transmission of pandemic influenza or other
epidemic-prone ARI.
2.3Agenda
On Day 1 experts summarized key features of pandemic (H1N1) 2009, and eight countries presented their
experiences of the pandemic. This was followed by a session on promoting oxygen use for pneumonia
treatment, and introductory presentations on WHO training curricula and a country needs survey that
participants completed at the meeting. On Day 2, the meeting was divided into working groups to discuss
a range of practical issues to improve current clinical and community care training packages and their
implementation. The full agenda is given in Annex 1.
2.4Participants
Fifty participants, predominately from resource-limited countries, were invited to the meeting. Participants
from the WHO African Region were given priority, due to the high burden of ARI in the region and the need
to align with the outcomes of the First Africa Flu Alliance meeting. The international experts participating in
the meeting were invited to share their knowledge in relevant technical areas, and of good practices for the
diagnosis and clinical management of influenza and its severe complications.
Participants included representatives from ministries of health, national authorities in patient care or
health systems, public health policy makers and clinicians from developing countries; clinical experts;
and representatives of nongovernmental organizations (NGOs) and of bilateral and multilateral funding and
donor agencies. Also in attendance were WHO staff from WHO Headquarters, Regional Offices and Country
Offices. A list of participants is given in Annex 2. Participants were asked to complete a written declaration of
interest before the meeting. An oral statement of declaration of interest was read at the start of the meeting;
it noted that no conflicts of interest were identified (Annex 3).
The meeting was organized by the WHO Global Influenza Programme (GIP), in collaboration with other
members of the Supporting patient care team of WHO pandemic influenza functional response structure
from several WHO clusters – Health Security and Environment, Health Action in Crises, HIV/AIDS
(human immunodeficiency virus/acquired immunodeficiency syndrome), TB (tuberculosis) and
Neglected Tropical Diseases, and Family and Community Health.
3 | Management of acute respiratory illness in resource-limited settings
3 National experience
All presenters reported that the pandemic (H1N1) 2009 highlighted the limitations of clinical care delivery
within their countries (Argentina, Bhutan, India, Mongolia, South Africa, Thailand, Ukraine, United States of
America). Although the overall disease impact differed, all presenters noted challenges to the pandemic
clinical response in their countries. The main lessons learnt from the presentations are given in Figure 1.
3.1 Disease activity and impact on health-care systems
Summary points
ƒƒ The disease impact of pandemic (H1N1) 2009 varied among countries.
ƒƒ Some countries experienced intense surges of pandemic cases, which stressed health-care systems.
ƒƒ Some countries experienced high incidence of ARI caused by non-pandemic influenza aetiologies
(e.g. influenza H3N2 or B, and respiratory syncytial virus [RSV]) back-to-back with the pandemic
influenza circulation; this had implications for resource allocation and aetiology-specific
clinical guidelines.
Pandemic influenza timing and intensity
Presenters reported that their countries experienced one or two peaks of pandemic influenza cases between
April 2009 and October 2010.
Several countries experienced sudden pandemic influenza disease activity over a relatively short period of
time in 2009, as outlined below.
Argentina experienced an intense, concentrated surge of hospitalized patients from mid-June to early
July 2009, during which time 10–20% of admitted patients required intensive care.
Mongolia experienced a similar intense surge of cases. The first surge was caused by pandemic (H1N1) 2009;
it occurred early in the 2009–2010 season, from mid-October to November 2009. This was followed by a
second peak, caused by influenza B virus, in January–February of 2010. The second peak was most notable
in Ulaanbaatar city, where over 1000 patients were admitted to hospital with severe ARI; three quarters
of these patients were under 5 years of age.
In Thailand, a first wave of influenza-like illness (ILI) patients comprised mostly the “worried well”. A subsequent
wave resulted in a substantial number of hospitalized ARI cases (four times greater than seen during a typical
influenza season), which stressed hospital surge capacity. During this second wave, Thailand experienced
the same number of influenza cases within a period of 2 months that it had over the previous 4 years.
Management of acute respiratory illness in resource-limited settings | 4
5 | Management of acute respiratory illness in resource-limited settings
ARI mortality was 10
times higher during the
2009 pandemic than in
the previous season
Argentina
Clinicians should be
aware of the potential for
severe hypoxaemia,
ARDS, MODS and
pulmonary thrombi
with the influenza
A(H1N1)pdm09 virus
infection even in patients
without seasonal
influenza risk factors
USA
South Africa
HIV infection was
associated with
substantial risk for
severe pandemic
influenza disease; HIV
combined with other
comorbidities greatly
increased the risk of
severe outcomes
60 000 HCW had
experienced ARI by
April 2010, Which
resulted in stressed
health-care systems
Ukraine
Preferential use of
traditional healers
delayed presentation of
patients to health care
facilities, resulting in
late initiation of
medical care
India
Communication strategy
developed to address the
“worried well” through advocacy
in educational institutions
where most cases were arising,
and dissemination of
information through village
heads back to remote areas
Bhutan
Due to rationing, hospital pharmacists
developed own oral suspension using
oseltamivir capsules, thus reducing the
cost per treatment and increasing the
treatment available
Thailand
Centralization of
intensive care facilities
made it possible to
focus intensive care
efforts and to
optimise resource
allocation
Mongolia
Figure 1. The 2009 influenza pandemic: key lessons learnt from countries
ARDS, acute respiratory distress syndrome; ARI, acute respiratory infection; HCW, health-care worker; HIV, human immunodeficiency virus;
MODS, multiple organ dysfunction syndrome
Impact on national health-care systems
In several countries, the pandemic had a substantial impact on health-care delivery. Argentina, India,
Mongolia, Thailand and Ukraine all reported that the number of ARI cases during peak pandemic influenza
activity burdened national health-care systems. While some countries (e.g. Argentina) experienced a
short period of elevated disease activity, others (e.g. India) had sustained, lower level disease activity.
Both scenarios resulted in stressed health-care systems. An additional burden on health-care delivery
was reported by Ukraine, where 60 000 health-care workers (HCWs) experienced ARI between the
beginning of the pandemic and April 2010, and there were 42 HCW deaths.
Impact of seasonal influenza and other infections
Pandemic (H1N1) 2009 was not the only influenza virus causing disease during the pandemic. As mentioned above,
Mongolia, which experienced high pandemic morbidity, found that influenza B was implicated in most of the
hospitalized and outpatient cases in early 2010 (i.e. during the second peak). Likewise the reports from India,
Thailand and Ukraine indicated that a high proportion of patients with ARI/ILI tested negative for pandemic
(H1N1) 2009 but still required medical attention. When influenza circulation is known in the community,
negative test results must be interpreted with caution.1 A high proportion of these patients had confounding
or coinfecting illnesses such as malaria, dengue, chikungunya, RSV or seasonal influenza. South Africa reported
that similar numbers of cases of pandemic (H1N1) 2009 and H3N2 were seen in 2009. These experiences
reinforced the need for robust and timely laboratory testing to inform disease surveillance and clinical care.
3.2 Clinical epidemiology
Summary points
ƒƒ High hospitalization rate in young children and increased death rate in non-elderly adults were
common in the countries represented.
ƒƒ Risk factors for severe disease were similar to those of seasonal influenza (including pregnant women),
while varying percentages of otherwise healthy persons were reported both in hospitalized and fatal cases.
ƒƒ Chronic respiratory diseases and HIV infection were highlighted as comorbidities of significant importance.
Age groups affected
Globally, the highest attack rates for pandemic (H1N1) 2009 were reported among children and young adults.
The hospitalization rate was highest in the youngest paediatric age group (particularly in those <1 year of age),
and the death rate was highest among non-elderly adults, followed by infants under 1 year of age.2
This finding was common among the countries represented in the meeting.
In Argentina, a retrospective study3 of paediatric admissions in Buenos Aires during the pandemic found
that the rate of hospitalization (20.9/100 000) was twice that seen during the preceding influenza season
(10.3/100 000), and that the overall death rate was 10 times higher during the 2009 pandemic (1.1/100 000)
than during the 2007 influenza season (0.1/100 000 population; no paediatric deaths associated with
seasonal influenza were reported in 2008). During the pandemic, most deaths were caused by refractory
hypoxaemia in infants under 1 year of age (death rate, 7.6/100 000).
1See Clinical management of human infection with pandemic (H1N1) 2009: revised guidance at http://www.who.int/csr/resources/publications/
swineflu/clinical_management/en/index.html and Use of influenza rapid diagnostic tests at http://apps.who.int/tdr/svc/publications/tdr-researchpublications/rdt_influenza
2 Writing committee of the WHO consultation on clinical aspects of pandemic (H1N1) 2009 influenza. ‘Clinical aspects of pandemic 2009
influenza A (H1N1) virus infection’. The New England Journal of Medicine, 2010, 362:1708–19
3 Libster R et al. Pediatric hospitalizations due to influenza in 2010 in Argentina. The New England Journal of Medicine, 2010, 362:45–55
Management of acute respiratory illness in resource-limited settings | 6
While young children had the highest frequency of influenza A(H1N1)pdm09 virus infection in Argentina,
the highest mortality occurred among those 50–59 years of age. Among children, however, mortality was highest
in the youngest age group (0–4 years).
Incidence rate of death due to influenza per 100 000 population
Figure 2. Argentina pandemic (H1N1) 2009 mortality rates according to age and gender
4.0
Male
Female
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
0–9
10–19
20–29
30–39
40–49
50–59
>60
Age (years)
N (total deaths) = 578
Notes: The circles show the highest rates in both the paediatric and adult populations
Source: Ministerio de Salud, Presidencia de la Nación, Argentina
Similarly, in 2009, in one study in Soweto1 – an urban area of Johannesburg, South Africa –highest severe acute
respiratory illness (SARI) incidence rates were observed in the group 0–4 years of age, for both (H1N1) 2009
and H3N2, with higher SARI hospitalization incidence for H3N2 confirmed cases.2
Notably, in Bhutan, the overwhelming majority of severe cases occurred within educational establishments
in children and young adults, whereas the general Bhutan adult population had minimal disease.
Risk factors for severe disease
In countries that reported severe disease, it was normally found among traditional influenza high-risk groups,
including those with chronic underlying disease and pregnant women. In one Argentinean hospital, 66% of
admitted children had comorbidities; this compares with 34% in the previously mentioned Buenos Aires study.
Underlying medical condition was more common in older children than in patients under 1 year of age.
The average age of children hospitalized with underlying illness was considerably higher (50 months) than
the average age of those who had been previously healthy (13 months). Among adults, most countries noted
the greatest risk of severe pandemic influenza disease among those with chronic comorbid conditions,
particularly chronic respiratory disease. In South Africa, pregnancy (2nd or 3rd trimester) or puerperium,
HIV, obesity and active TB were all associated with higher risk of death from pandemic (H1N1) 2009.
South Africa presented data suggesting that HIV infection was associated with a substantial risk for severe
pandemic influenza disease, and that HIV combined with other comorbidities greatly increased the risk of severe
outcomes (Table 1). The prevalence of HIV (20%)3 among deaths from pandemic (H1N1) 2009 was higher than
that expected in the general population (10%).
1 Lower middle class populated urban area (Wikipedia http://en.wikipedia.org/wiki/Soweto)
2 Cohen et al. Elevated incidence of hospitalisation for seasonal and pandemic influenza in HIV-infected individuals, South Africa, 2009.
Poster session presented at: Options for the Control of Influenza VII; 3–7 September 2010; Hong Kong SAR, China
3 Among 93 fatal cases investigated in 2009, 40 were tested for HIV infection and 19 were positive. The figure of 20% was derived by assuming
that all untested fatalities (i.e. 19/93) were negative for HIV.
7 | Management of acute respiratory illness in resource-limited settings
Table 1. South Africa (H1N1) 2009 fatality comorbidities
Frequency of factor/
number tested (%)
Factor
HIV infected
19/40 tested (48%)
Pregnant or puerperium
– of total cases
27/93 (29%)
– of women of childbearing age (15–49 years)
27/46 (59%)
No comorbidities
21/87 (24%)
Diabetes
12/86 (14%)
Obesity
18/87 (21%)
Cardiac disease
7/85 (8%)
Active tuberculosis
9/86 (10%)
Asthma
5/86 (6%)
HIV, human immunodeficiency virus
Source: J Thomas, National Institute for Communicable Diseases, South Africa
Of the HIV-positive pandemic (H1N1) 2009 fatalities, most had dual underlying risk conditions (Table 2).
Pregnant HIV-infected women comprised 58% of all HIV-infected fatalities. Of the 19 HIV-infected pandemic
(H1N1) 2009 fatalities, 4 had active TB. In South Africa, there were also probable cases of vertical transmission
of pandemic influenza,1 which was thought to have caused the death of two mother–child pairs, with one
mother HIV-negative, the other HIV-positive.
Table 2. South Africa HIV fatality comorbidity data
Factor
Number of cases
Pregnancy
11/19 total HIV infected (58%)
– additional comorbidities
• Obesity
1
• Active TB with COPD
1
• Asthma
1
– on HAART
Non-pregnant cases
2
8/19 total HIV infected (42%)
– additional comorbidities
• Diabetes
1
• Bronchiectasis post TB
1
• CCF with COPD
1
• Active TB
3
– on HAART
1
CCF, congestive cardiac failure; COPD, chronic obstructive pulmonary disease; HAART, highly active antiretroviral treatment; HIV,
human immunodeficiency virus; TB, tuberculosis
Source: J Thomas, National Institute for Communicable Diseases, South Africa
1 A probable vertical transmission of pandemic (H1N1) 2009 virus has been also reported from Thailand. Dulyachai W et al. Perinatal pandemic
(H1N1) 2009 infection, Thailand. Emerging Infectious Diseases, 2010, 16:343–4
Management of acute respiratory illness in resource-limited settings | 8
In the Soweto study, HIV-infected patients showed higher incidence of SARI with pandemic (H1N1) virus
infection than HIV-negative patients in all age groups. This phenomenon was also found with H3N2 virus
infection, except for the age group 0–4 years. If controlled for age, influenza virus associated SARI incidence
was five times higher in HIV-infected patients for both pandemic (H1N1) and H3N2 viruses, and the risk was
highest in ages 25–44 years (Figure 3).
(a)
Incidence per 100 000 population (95%Cl)
Figure 3.Severe acute respiratory illness surveillance ­– incidence of infection of pandemic
(a) (H1N1) 2009 and (b) H3N2 by HIV status, Soweto, South Africaa
600
HIV-infected
HIV-uninfected
500
400
300
200
100
0
0–4
RR 2.6
(95%Cl 1.6–4.3)
5–24
RR 5.1
(95%Cl 2.3–11.3)
25–44
RR 11.0
(95%Cl 6.5–18.7)
≥45
RR 3.4
(95%Cl 2.2–5.2)
Total
RR 5.3
(95%Cl 4.0–6.9)
MH adjusted
(b)
Incidence per 100 000 population (95%Cl)
Age group (years)
600
HIV-infected
HIV-uninfected
500
400
300
200
100
0
0–4
RR 1.2
(95%Cl 0.7–2.0)
5–24
RR 8.0
(95%Cl 4.1–15.7)
25–44
RR undefined
≥45
RR 3.3
(95%Cl 1.6–6.8)
Total
RR 5.1
(95%Cl 3.8–6.9)
MH adjusted
Age group (years)
CI, confidence interval; HIV, human immunodeficiency virus; MH, Mantel-Haenszel; RR, relative risk
a Reporting period 9 February to 23 December 2009; results until end of epidemiologic week (2009) 52
Source: Cohen C et al. Elevated incidence of hospitalisation for seasonal and pandemic influenza in HIV-infected individuals, South Africa, 2009.
Poster session presented at: Options for the Control of Influenza VII; 2010 Sep 3–7; Hong Kong SAR, China
9 | Management of acute respiratory illness in resource-limited settings
3.3 Clinical care
Summary points
ƒƒ Pandemic (H1N1) 2009 made obvious the limitations and capacity of critical care services in all countries.
ƒƒ Participants from resource-limited settings reported that access to medical supplies were limited
in their countries.
ƒƒ Often, physicians were unable to determine the risk of disease progression among patients with
ARI or laboratory-confirmed influenza.
ƒƒ Some participants did not have access to WHO’s clinical guidance for treatment of influenza or ARI.
ƒƒ Participants reported challenges with translating knowledge of infection prevention and control (IPC)
into practice.
ƒƒ The diagnosis of pandemic (H1N1) 2009 virus infection was often challenging in resource-limited settings.
ƒƒ A number of countries reported bacterial coinfection or secondary bacterial pneumonia at
presentation, particularly among patients requiring hospital admission and those with HIV.
ƒƒ Participants from several countries noted that their country experienced appreciable incidence
of ARI during pandemic (H1N1) 2009 that was not caused by the pandemic influenza virus.
ƒƒ A delay in the initiation of medical care and antiviral therapy (e.g. with oseltamivir) was associated
with increased severity of disease in several countries.
Clinical care delivery
Participants from resource-limited settings noted that health centres in their countries had insufficient
resources to deliver ARI treatment during the influenza pandemic. They reported that access to supplies
such as antibiotics, antivirals, oxygen, pulse oximeters and mechanical ventilators were limited in their
countries. At the primary care level, a common concern was that physicians were unable to determine the
risk of disease progression among patients with ARI or laboratory-confirmed influenza. Several participants
noted that pneumonia severity clinical prediction scores (e.g. CURB-651) appeared to be inadequate triage
tools in their settings, making decisions difficult about whom to hospitalize or refer for higher level of care.
Participants expressed a need for increased awareness of WHO guidelines and training materials at the WHO
Country Offices, as well as among community clinicians. There was a preference for the development of
influenza-specific guidelines over general ARI management guidelines. On the other hand, for management
of severe ARI, the value of a syndromic approach to clinical guidance was raised.
Despite the limitations and capacity of critical care services in some countries, participants reported success
treating the most critically ill patients. China and India managed to avoid endotracheal intubation in pandemic
influenza patients with acute respiratory distress syndrome (ARDS) by using noninvasive ventilation (NIV).2
Some participants reported modest success with salvage therapies for hypoxaemic respiratory failure
(notably prone positioning, recruitment manoeuvres and advanced ventilatory techniques). None of the
participants had access to nitric oxide or extracorporeal membrane oxygenation (ECMO) therapies. Other
participants from low-income countries reported severe shortages of medical oxygen and the essential
health technologies necessary to manage critically ill patients requiring mechanical ventilation. India and
Uganda both highlighted critical care service training needs; this is further discussed in Section 5.4.
1 http://www.aafp.org/fpm/2006/0400/fpm20060400p41-rt2.pdf
2 Bai L et al. Clinical features of pneumonia caused by influenza A (H1N1) virus in Beijing, China. Chest 2010; e-pub 10–1036
Management of acute respiratory illness in resource-limited settings | 10
Infection prevention and control
According to national response plans, some countries set up dedicated triage and treatment services
to deliver care to those with mild illness. Such services prevented their entry into mainstream services,
and therefore reduced the risk of transmission of infection to other patients and HCWs. Thailand’s outdoor
“one-stop fever clinics”, which incorporated practical hand-washing and mask-wearing promotion,
and dispensing of pharmaceuticals onsite, further facilitated IPC. This practice was feasible in mild
climates but was not considered practicable in cold climates, such as Mongolia.
Participants reported challenges with translating IPC knowledge into practice; India reported that HCWs
were reluctant to use surgical masks for routine contact, and instead favoured N95 masks, even though
these were unnecessary.
Bacterial coinfection
Bacterial coinfection at presentation or secondary bacterial pneumonia (particularly due to Streptococcus
pneumoniae) was reported by a number of countries. South Africa reported surges in cases of S. pneumoniae
coincident with influenza activity (Figure 4). Additionally, HIV patients were found to have a higher incidence
of S. pneumoniae-influenza coinfection (58%) than infection with influenza alone (44%). Argentina reported
concurrent bacterial pneumonia in 10% of paediatric admissions, with a handful of cases of empyema;
22% of hospitalized patients in one Argentinean hospital had bacterial coinfections.
140
60
120
50
100
40
80
30
60
20
40
10
20
0
Detection rate (%)
Number of samples
Figure 4.Streptococcus pneumoniae and influenza detection rates and total number of samples
by week, South Africa, 2009
7
9
11 13 15
17 19 21 23 25 27 29 31
33 35 37 39
41 43 45
47 49
51
0
Epidemic week
Respiratory and blood specimans
Respiratory specimans only
SP
Influenza
SP, Streptococcus pneumoniae
Source: J Thomas, National Institute for Communicable Diseases, South Africa
Diagnostic test limitations
The diagnosis of pandemic (H1N1) 2009 virus infection was often challenging in resource-limited settings.
In most countries, reverse transcriptase polymerase chain reaction (RT-PCR) was used; however, results were
not available in a timely fashion for use in clinical decision-making (one country participant reported results
taking a month to be available).
11 | Management of acute respiratory illness in resource-limited settings
Some countries attempted to use influenza rapid diagnostic tests (IRDTs) for screening of hospitalized ARI
patients. While acknowledging that IRDTs vary in their sensitivity and specificity, and are generally suboptimal
for diagnosis of pandemic (H1N1) 2009, participants emphasized the contribution to health care that improved
IRDTs would have in resource-limited settings. It was again emphasized that clinicians should not rely on the
test result alone, but need to use clinical judgement, taking into account the epidemiological situation. In the
meantime, strengthening country clinical laboratory capacities would aid diagnosis of influenza and would
potentially strengthen diagnostic capability for other respiratory infections.
India reported that nearly one third of high-risk patients testing positive for pandemic (H1N1) 2009 virus
infection were afebrile. Such a finding confounds the use of high body temperature in clinical specimen
collection criteria for pandemic influenza, thus expanding the number of laboratory tests to be performed
and the number of patients who may require empiric antiviral therapy.
Drug therapy, antiviral use and availability
WHO clinical management guidance on pandemic (H1N1) 2009 virus infection1 recommends the use of
antiviral therapy for patients with severe or progressive clinical illness and those at high risk of developing
severe or complicated illness.
A delay in the initiation of medical care and antiviral therapy was associated with increased severity of
disease in several countries. Argentina presented data from a small cohort of patients that showed greater
incidence of adverse outcomes in patients who experienced a delay in starting on antiviral therapy (Table 3).
This was a challenge in some countries where limited central stores of oseltamivir were deployed only
after patients tested positive for pandemic influenza virus (occurring often days after specimen collection).
In some hospitals, ministry of health officials would not permit use of oseltamivir in people who had
a laboratory-confirmed diagnosis but had experienced symptoms for more than 2 days, because of
perceptions that antiviral therapy would not be useful after such a delay. In addition, countries reported
limited supplies of paediatric and parenteral antiviral formulations, resulting in challenges to the
management of children and those with critical illness.
Table 3. Clinical outcome of (H1N1) patients by time of initiation of antiviral therapy, Argentina
Clinical outcome,
treatment or intervention
>48 hours
<48 hours
N = 48 (45%)
N = 57 (55%)
20 (66.6)
OR (95%CI)
P
10 (33.3)
3.35 (1.26–9.16)
0.006
17 (68)
8 (32)
3.35 (1.86–10)
0.01
11 (IQR: 6.5–17)
7 (IQR: 4–11)
–
0.006
Oxygen supplementation
42 (61.7)
26 (38.2)
8.07 (2.75–26)
0.0001
Mechanical ventilation (%)
15 (68.2)
7 (31.8)
3.28 (1.09–10.5)
0.002
Antibiotic use
34 (48.6)
36 (51.4)
1.41 (0.57–3.52)
0.4
4 (66.6)
2 (33.3)
2.5 (0.33–28)
0.28
Pneumonia
ICU admission
Length of hospitalization (median, days)
Death
CI, confidence interval; ICU, intensive care unit; IQR, interquartile range; OR, odds ratio
Source: Bologna R, Medicinia Infantil 2009: 285–291
1 Clinical management of human infection with pandemic (H1N1) 2009: revised guidance at
http://www.who.int/csr/resources/publications/swineflu/clinical_management/en/index.html
Management of acute respiratory illness in resource-limited settings | 12
Participants witnessed many instances of irrational or inappropriate pharmacotherapy for patients with
pandemic (H1N1) 2009 influenza, including irrational combinations of antibacterial medications and use
of high-dose steroids for the management of acute lung injury – a condition that has not been shown
to improve with steroid therapy. Participants were reminded of WHO guidance regarding the use of
corticosteroids, which state that these should be avoided in treating severely ill patients with pandemic
(H1N1) 2009 influenza unless indicated for another reason.
Delay in seeking medical care
Several countries reported that severe disease was often associated with a delay in seeking medical care.
Among the many reasons cited for late presentation to health clinics or health posts were financial obstacles,
decreased availability of primary care, difficulty assessing patients at the primary care level and preferential
use of traditional healers. For example, in India, preferential use of traditional healers delayed presentation of
patients to health-care facilities. Ukraine also reported late initiation of therapy early in the pandemic, although
this improved after a November 2009 WHO mission, which emphasized early antiviral treatment of influenza
patients. Several countries identified issues with poor assessment of patients at primary care level, lack of access
to pulse oximetry and supplemental oxygen, and delay in referral to tertiary care.
3.4 National systems and response
Summary points
ƒƒ Most countries reported inadequacies in intensive care or high-dependency care capacities.
ƒƒ Some countries used patient categorization for efficient patient management, and prioritized use
of resources during the 2009 pandemic.
ƒƒ Focusing efforts on primary care may have prevented progression of cases to severe disease.
ƒƒ The use of decentralized “fever clinics” minimized the entry of infected patients into the main health
systems, improving hospital infection control.
ƒƒ National and international clinical networks were activated to exchange real-time information
and best practice in diagnosing and treating patients.
ƒƒ Adjustment of dose of antiviral therapy for young children was challenging; also, many countries
had difficulty in procuring parenteral antivirals.
ƒƒ In many countries, surge capacity was exceeded.
Patient categorization and resource rationalization
Many encouraging examples of national systems were developed in response to the pandemic, to strengthen
capacity to respond to high disease burden. Thailand, with recent experience from severe acute respiratory
syndrome (SARS) and avian influenza A (H5N1), responded to the pandemic by establishing one-stop
fever clinics. Triaging of patients and categorization of patients into severe and mild disease, with further
categorization of the mild group into vulnerable and nonvulnerable subgroups, worked well. This rationalized
treatment helped to ensure that nonvulnerable patients with mild disease (who were in the majority) received
symptomatic treatment and advice, but no antiviral therapy unless symptoms deteriorated or persisted for
more than 48 hours. Similarly, this group of patients were not tested for pandemic (H1N1) 2009, to limit
laboratory testing. India and Mongolia also described a system of antiviral prioritization, in line with
WHO guidelines. Unlike the early containment response to the pandemic in developed countries,
antiviral prophylaxis was not given to contacts of cases in resource-limited countries other than in India
(where high-risk contacts were given prophylaxis). India and Thailand also rationalized the sampling and
testing for influenza A (H1N1) 2009 virus of severely ill patients or symptomatic vulnerable groups.
13 | Management of acute respiratory illness in resource-limited settings
Focusing care and resources at the primary care setting, and early initiation of treatment for vulnerable
groups and those with severe disease, was mentioned repeatedly as a strategy that would make the best
use of resources and reduce progression of disease (Figure 5). India was the only country to mention the
development of intensive care units (ICUs) at district level, and mobile ICUs. India and Thailand mentioned
the use of CHWs during the pandemic response. India reported that health-care personnel were initially
inadequately trained to respond to the pandemic; however, training systems were developed to address this
need. India and Thailand also both had clear guidelines for home-based care, and used these to good effect.
Most countries reported inadequacies in intensive care or high-dependency care capacities. Centralization
of intensive care facilities allowed Mongolia and Thailand to focus their intensive care efforts and to optimize
resource allocation.
Figure 5. Early and effective primary care can forestall progression to severe disease
Early supportive care may reduce complications and ITU referrals
Improved survival
High mortality
Intensive
therapy
Intensive
therapy
Good/ early
supportive care
Poor/ late
supportive care
ITU, intensive treatment unit
Syndromic versus specific influenza guideline approach
Most countries used a syndromic approach in managing high case loads of ARI patients during the peaks of
pandemic (H1N1) 2009. Thailand used a generic influenza syndromic approach to clinical care that expedited
triage and gave appropriate advice to those with non-life threatening illness ((H1N1) 2009 or otherwise)
while identifying those with severe disease or at risk of developing severe disease. Thailand did, however,
restrict prescription of antiviral therapy to doctors, to ensure appropriate and rational use of antiviral stocks.
Thailand’s syndromic approach extended to their community-acquired pneumonia (CAP) guidelines, adding
an antiviral to their CAP treatment protocol in 2009 (third generation cephalosporin + macrolide + antiviral).
Bhutan also used existing pneumonia treatment guidelines to good effect.
Management of acute respiratory illness in resource-limited settings | 14
Other countries (India, Mongolia and Saudi Arabia) requested more influenza-specific clinical guidelines,
especially in relation to admission or discharge criteria.
Advisory groups
Several countries responded to the overwhelming disease burden and public mistrust by establishing
clinical advisory working groups (Mongolia) and seeking assistance from specialist visiting WHO teams
(Mongolia and Ukraine).
Clinical networks
Both the national and international clinical networks were effective in disseminating key guidance for the
diagnosis and treatment of patients. In Ukraine, conference calls among clinicians conveyed messages and
clinical management recommendations nationwide. Clinicians who had managed severely ill pandemic
(H1N1) 2009 patients in one area of Ukraine educated their colleagues who had yet to see such cases in their
areas. Country participants reported appreciation for WHO guidance for health communications during the
pandemic, but some acknowledged challenges in adapting generic health communications plans that were
already in place before the pandemic onset.
The WHO mission to Mongolia made 10 recommendations, the most notable of which were to translate
infection control knowledge into practice, and to centralize intensive care. Ukraine found that advice from
the WHO mission helped to improve clinical outcomes. This included advice to reduce polypharmacy and
steroid use, to initiate antiviral therapy more promptly, to use pulse oximetry and adequate oxygen therapy,
and to prioritize treatment of high-risk individuals.
Both Mongolia and Ukraine described how WHO missions helped to allay public concerns about the
pandemic in their countries. In Mongolia, the WHO mission visited several tertiary, district and provincial
hospitals and primary care facilities, to observe care and to hold discussions with HCWs about clinical
management. They provided rapid recommendations to the ministry of health about how clinical
management could be improved. The mission was successful in that it returned credibility to the national
health system. Similarly, in Ukraine, a WHO mission was credited for effective clinical care recommendations,
improved public trust and improved clinical outcomes.
Drug procurement
Young children were at increased risk of severe disease with high attack rates, but antiviral therapy dose
adjustment by weight posed a challenge.1 Thailand had difficulties accessing manufactured oseltamivir
suspension due to cost (about $40/bottle). Their solution was to manufacture their own oral suspension
using oseltamivir capsules, thus reducing the inconvenience and the cost per treatment. The “homemade”
oseltamivir suspension created by hospital pharmacists was at a concentration that was easier to use
(10mg/ml) than the commercially available formulation (12mg/ml), and was found to be stable in a
refrigerator for 10 days. Multiple sources of pharmaceuticals, together with national manufacturing of
antiviral drugs, can improve access to antiviral therapy and potentially reduce procurement costs. Both India
and Ukraine produce their own generic oseltamivir. Difficulty with procurement of parenteral antivirals was
reported by many countries.
1 A report of review of extemporaneous preparations of oseltamivir is provided by WHO as Annex 8 of the WHO
Guidelines for pharmacological management of pandemic (H1N1) 2009 influenza and other influenza viruses at
http://www.who.int/csr/resources/publications/swineflu/h1n1_use_antivirals_20090820/en/index.html
15 | Management of acute respiratory illness in resource-limited settings
Surge capacity
Surge capacity was an issue of concern for many countries. Several countries described how their surge
capacity was exceeded. Typically, countries addressed surge capacity issues by increasing beds in hospitals.
In some Indian hospitals, patients had to share beds, with patients lying head-to-toe. In Mongolia surge
capacity was exceeded, as demonstrated by Figure 6. Frustrating Mongolia’s hospital surge planning
was the cold climate, which did not allow space to triage patients out of doors.
Figure 6. Bed status during surge of pandemic (H1N1) 2009 cases, Mongolia, 2010a
2500
Bed capacity
2000
1500
1000
500
0
1/1–7/1
8/1–15/1
16/1–23/1
25/1–1/2
2/2–9/2
10/2–17/2
18/2–25/2
26/2–3/3
Date
Maximum capacity
Surge capacity
Weekly average of patients
a Weekly data from January to February 2010
Source: S Enkhtur, State Maternal and Child Health Research Center, Mongolia
Management of acute respiratory illness in resource-limited settings | 16
3.5Communication
Summary point
ƒƒ Communicating effectively with the public is critical for a successful pandemic response.
Several countries reported increased numbers of “worried well” during the early days of the pandemic,
and a later shift towards a belief that the pandemic virus was benign. During the first wave of the pandemic,
Bhutan and Thailand both had high numbers of worried well seeking assessment and reassurance. In Bhutan,
the media attributed paediatric deaths to vaccination against pandemic (H1N1) 2009, leading to substantial
challenges in gaining public trust. Bhutan addressed these issues through advocacy in educational
institutions, where most cases were arising, and dissemination of information through village heads back to
remote areas. Some countries, including India and Thailand, found that CHWs were an excellent resource for
dissemination of public health messages. Mongolia used television media to address fears and promote key
educational messages, which helped to improve trust in the pandemic response.
Participants recommended that communications be strengthened throughout health-care systems,
from government level to CHWs, to make it easier to ensure that any training materials disseminated
are of the appropriate level and consistent. Rapid communication tools can also be used for effective
dissemination of health education messages and improving the speed of communication with HCWs at all
levels. Medical anthropologists familiar with a region can assist tremendously with community messaging;
they can also develop draft materials in response to a crisis.
17 | Management of acute respiratory illness in resource-limited settings
4 Key challenges of implementing clinical guidance
4.1 Country needs assessment
Summary points
ƒƒ The survey of participants identified significant gaps in the ability of health workers to diagnose
and manage ARI, with a resultant delay in initiation of treatment.
ƒƒ The survey also identified areas where lack of resources has weakened the treatment of ARI.
ƒƒ Two key areas for improvement were identified – training and resource mobilization.
The survey
WHO asked participants to complete a questionnaire (given in Annex 4) designed to identify:
ƒƒ the area and level of health care where support was needed to strengthen the treatment of ARI;
ƒƒ the nature of support needed (e.g. equipment, training and financial support).
Participating countries and territories
Participating countries and territories were Argentina, Bhutan, China, Ethiopia, Ghana, Hong Kong SAR, India,
Indonesia, Kenya, Malawi, Mongolia, Nigeria, Philippines, South Africa, Thailand and Uganda.
Analysis of responses to the questionnaire
Twenty-three responses were obtained from 16 countries. Nineteen responders were actively involved
in treating ARI patients (83%). Also, 19 responders (83%) worked at a national or tertiary level, while the
remainder worked at a district (2; 9%) or regional level (2; 9%).
In considering the overall adequacy of health systems in their country, 20 participants (87%) felt they
had a functioning health system but had insufficient resources to deliver ARI treatment in their country;
3 participants (13%) felt their country had a functioning health system with sufficient resources; none of
the participants felt their country had a weak or poorly functioning health system.
Significant weaknesses in ARI treatment among 16 participant countries or territory included:
ƒƒ deficiencies in the diagnosis of ARI;
ƒƒ nonuniversal application of simple care measures;
ƒƒ lack of provision of information to patients treated at home;
ƒƒ lack of resources such as oxygen and antiviral medication;
ƒƒ lack of surge capacity and other strategic health-care system planning.
All countries identified a need for HCW training, but varied on the level of health care at which training
was required (i.e. home based, community based, in hospital or in critical care). Some countries requested
training in all areas.
Management of acute respiratory illness in resource-limited settings | 18
Countries varied in their resource needs, with some requiring all resources (including oxygen and essential
basic medicines), and others having fewer needs.
Table 4, below, lists the requirements for strengthening ARI treatment, as identified by each of the
participating countries.
Table 4.Requirements needed to strengthen treatment of acute respiratory illness,
as identified by different countries
Training
Laboratory
IPC
Critical care
IMAI and
IMCI
Community
care
Country
Basic
essential
medicines
x
Oxygen
and
supplies
Laboratory
supplies
ARI
kit
Argentina
x
Bhutan
x
x
x
x
x
x
x
x
x
China
x
x
x
x
x
x
x
x
x
Ethiopia
x
x
x
x
x
x
x
x
x
Ghana
x
x
x
x
x
x
x
x
x
HK SAR
x
x
x
x
India
x
Indonesia
x
x
x
x
Kenya
x
Malawi
x
Mongolia
x
x
x
xa
x
x
x
x
x
xa
x
x
x
x
x
x
x
x
x
x
x
Nigeria
x
x
x
x
x
x
x
x
x
Philippines
x
x
x
x
x
x
x
x
x
South Africa
x
x
xa
xa
xa
xa
x
x
x
x
Thailand
Uganda
x
x
x
x
x
x
ARI, acute respiratory illness; HK SAR, Hong Kong Special Administrative Region; IMAI, integrated management of adolescent and adult illness;
IMCI, integrated management of childhood illness; IPC, infection prevention and control
a Not all the participants from the country checked the box.
Conclusion from the country needs assessment
Early recognition and early, good supportive care to patients with ARI can reduce the severity of disease,
and the subsequent burden of severely and critically ill patients on health-care systems; it can also reduce
mortality within populations. In every health-care system, treatment of ARI is strengthened by attention
to these aspects of care.
The survey identified significant gaps in the ability of health workers to diagnose and manage ARI in some
countries, with a resultant delay in initiation of treatment. It also identified areas where lack of resources
has weakened the treatment of ARI among the countries assessed. Countries identified two key areas
for improvement – training and resource mobilization.
19 | Management of acute respiratory illness in resource-limited settings
Based on the findings of the survey, training in the following key areas of clinical management and in
processes or systems (outlined in the points below) should be adapted locally:
ƒƒ assessment and recognition of ARI, and progression to severe disease;
ƒƒ home-based , community-based, primary and critical health care;
ƒƒ surge planning;
ƒƒ adaptation and application of appropriate national guidance;
ƒƒ identification of resource needs;
ƒƒ prioritization of resources;
ƒƒ strategic planning to support training and resource programmes.
New equipment, medicines and treatments must be supported with appropriate guidance for their use,
and appropriate training for HCWs who will use them.
4.2 Developing clinical guidance in resource-limited settings
Summary points
ƒƒ Generic guidance based on clinical syndromes (e.g. ARI) is needed and can build on established
guidance and good practice. Such guidance needs to be adapted when outbreaks occur.
ƒƒ Generic guidance should have a “whole of health-care system” approach.
ƒƒ The community, including CHWs, is essential in implementation of clinical guidance.
ƒƒ Clinical guidance should be evaluated for compliance and effectiveness, using implementation
assessment tools.
ƒƒ In resource-limited settings, where it may be difficult to implement WHO guidance in its entirety,
it will be necessary to set priorities.
Syndromic or generic guidance
The development of syndromic or generic guidance for clinical syndromes (e.g. ARI) is useful in resourcelimited settings. Multiple diseases with overlapping symptoms (e.g. malaria and dengue) can make the
diagnosis of influenza difficult, especially in areas with limited diagnostic capacity. Many health systems
will already have guidance in place to treat these infections. Therefore, influenza guidance should
supplement and build on any established guidance, rather than supplanting it. Syndromic or generic
guidance prevents the development of multiple, disease-specific guidance that can create confusion.
It also ensures that patients are treated according to clinical syndromes and allows early, empiric treatment
of a differential diagnosis, deferring confirmation of a specific infection. Early definitive diagnosis may be
hampered by lack of access to laboratory testing, particularly if there are no reliable, sensitive point-of-care
tests. In addition, paucity of local surveillance can make the infectious cause of ARI outbreaks uncertain,
and therefore make it difficult to know when to treat patients “according to the pandemic guidance”.
A whole of health-care system approach is vital for the development of clinical guidance, to ensure
involvement of all levels of care, including the community. It is essential to have high-level support for the
development of a generic approach to clinical guidance. The generic approach reduces the work load, by
overcoming the need to produce multiple, condition-specific guidelines that overlap. Health-care systems
should actively develop networks – horizontally between neighbouring facilities, and vertically through all
layers to and from regional and national centres. Such networks would support and enhance surge capacity.
Management of acute respiratory illness in resource-limited settings | 20
ƒƒ Horizontal networks can provide mutual aid.
ƒƒ Vertical networks can:
–– provide clinical expertise “downwards” using teleconferences, telemedicine and web casts;
–– allow for the real-time collection of clinical data “upwards” from front-line clinicians to centralized experts;
–– allow for communication of CHW clinical surveillance (e.g. for the numbers of ILI seen weekly).
The community is essential in the implementation of clinical guidance. For example, such guidance
may be the only source of information for some CHWs, who have a key role in public health education,
prevention of infection, early recognition of disease, assessment of severity of disease and management of
home-based care. Therefore, the guidance should be comprehensive (e.g. it should include infection control
guidance). Clinical guidance should:
ƒƒ support the key role of CHWs as a link between home-based and hospital-based care, and in public
health education, particularly in IPC;
ƒƒ support training of CHWs in the early recognition of ARI and management of mild cases;
ƒƒ emphasize the importance of frequent reassessment and provision of information to the patient,
and the referral of more complicated cases.
Consideration should be given within clinical guidance to the potential roles that community volunteers
could play.
The clarity of clinical guidance can benefit from testing in sample populations before publication. To review
compliance, evaluation of published guidance should be considered. Training materials, training assessment
tools and implementation assessment tools or “benchmarks standards” should be considered when adapting
clinical guidance, to measure compliance over time.
WHO’s clinical management guidance for pandemic (H1N1) 2009 was developed with evidence from settings
that were mainly in developed countries and thus were not resource limited. Although the guidance
considers feasibility in resource-limited settings, it needs to be tested for its efficacy in such circumstances.
Health systems of different countries vary in their quality and performance; also, there may be variations in
different areas within countries in terms of levels of service. It may not be feasible for countries with limited
resources to implement WHO guidance in its entirety; therefore, prioritization will be needed.
To help in the development of priorities, adapted clinical guidance should include a hierarchy of the
effectiveness of different aspects of treatment and care. Guidance should also provide information on
alternatives where possible. Information on high-risk groups is essential.
4.3Development of deployable kits of medical supplies and
devices to manage hospitalized ARI in resource-limited settings
Summary points
ƒƒ During the 2009 influenza pandemic, WHO produced draft documents with lists of recommended
medical supplies and health technologies to manage hospitalized patients with ARI.
ƒƒ Training and appropriate systems must be put into place before the implementation of any
technology in a health-care system.
ƒƒ Priority should be given to concurrent introduction of medical oxygen, pulse oximetry,
and consumables such as masks and tubing. For most settings, there is no single generic
(one size fits all) solution to a hospital’s oxygen needs.
21 | Management of acute respiratory illness in resource-limited settings
During the 2009 influenza pandemic, WHO was asked by Member States to assist with the identification
and procurement of necessary medical supplies and devices for the hospital management of influenza
patients. WHO consulted individual experts and professional societies to develop basic lists of minimal
recommended respiratory care supplies and devices to manage hospitalized patients with ARI. The ultimate
goal was to design and produce kits of supplies that could be rapidly deployed for outbreaks of severe ARI
to resource-limited settings.
A number of key challenges in the development of ARI kits were identified, as outlined below:
ƒƒ Before a new technology is introduced, there is a critical need to implement training and systems to
identify failure of the technology.
ƒƒ Improving access to health technology and supplies is critical if countries are to improve capacity to care
for severe ARI.
ƒƒ Training and appropriate systems must be put into place before the implementation of any technology in a
health-care system, and ARI kits should not be deployed without adequate guidance or training on their use.
ƒƒ In the United Kingdom, early warning systems have been shown to support ward nurses in their response
to deteriorating patients. Similar systems could be adopted as adjuncts to ARI kits, to ensure that there is
no over-reliance on the technology to forestall deterioration of ARI patients.
ƒƒ Priority should be given to concurrent introduction of medical oxygen, pulse oximetry, and consumables
such as masks and tubing, as outlined below.
Medical oxygen
Oxygen is available in many forms, including concentrators, liquid oxygen, canisters and industrial formulations;
each form has benefits and drawbacks. Particular needs within the hospital require different oxygen sources.
For most settings, there is no one generic (i.e. one size fits all) solution to a hospital’s oxygen needs.
Pulse oximetry
WHO guidance on pulse oximetry for hypoxaemia was last published in 20031 and needs to be updated,
especially considering advances in technology. Pulse oximetry is most useful in settings where oxygen
is available; there is limited benefit in diagnosing hypoxia when oxygen is not available to treat it. This
technique is also useful as a point-of-care diagnostic to assist with decisions about whether to hospitalize
or refer to a higher level of care, regardless of oxygen availability.
Consumables
There was limited discussion at the meeting about components of consumable products (e.g. masks and tubing)
that would be included in WHO ARI kits. Wherever possible, such items should be disposable, and guidance
should emphasize this fact, given issues relating to infection control and patient safety.
Additional components
ARI kits could also include drugs and supplies necessary to treat comorbidities (e.g. salbutamol for asthma
exacerbation and antibacterials for pneumonia). Participants also suggested the inclusion of stethoscopes
and sphygmomanometers. A list of items that could be included in such a kit is given in Annex 5.
1 http://www.who.int/surgery/collaborations/Oxygen_Meeting_Report_Geneva_2003.pdf
Management of acute respiratory illness in resource-limited settings | 22
4.4 Infection prevention and control
Summary points
ƒƒ Countries reported an erosion in quality and quantity of IPC training.
ƒƒ Countries encouraged the idea of recommending IPC training for all HCWs, and ensuring appropriate
use of personal protective equipment when resources are limited.
ƒƒ Research is required on the relative efficacy of alternative methods used in resource-limited settings
(e.g. scarves used as masks).
WHO has published interim guidelines for IPC of acute respiratory disease in health care.1 These guidelines
have been evaluated in the clinical setting using a survey taken before and after publication of the guidelines.
Overall, outcome measures have indicated some positive trends and some significant changes in relevant
IPC practices in the hospitals studied. Lessons learnt from this evaluation process have been used to assist
the development of a standard IPC guideline, which is currently in development.
Identified challenges include the practical handling of masks in relation to multiple usage, prioritization
of use in resource-limited settings, cost and procurement, and acceptability of surgical versus N95 masks.
Countries have experienced erosion in both the quality and quantity of IPC training given to trainee medical
professionals. There is a risk of potential harm to the patient and the HCW if risk of transmission is wrongly
assessed. Therefore, IPC training should be strengthened for HCWs at all levels of the health system. It was
suggested that IPC guidance be incorporated into clinical guidelines, together with implementation tools.
There are research gaps in IPC ‘best practice’ when essential supplies (e.g. water, soap and surgical masks)
are missing.
The pandemic highlighted the value of clinical networks; these need to include IPC staff, because these
staff do not always have the forum to share knowledge. To further overcome these challenges, more training
is needed.
1 http://www.who.int/csr/resources/publications/swineflu/WHO_CDS_EPR_2007_6/en/index.html
23 | Management of acute respiratory illness in resource-limited settings
5 WHO approach:
training to improve patient care at all levels
WHO developed training for the provision of good health care at different levels during a pandemic.
These include training packages on patient care at home, district hospital, critical care and
community-based care.
5.1 Home-based care for pandemic influenza
Summary points
ƒƒ Cultural perceptions of illness can have significant impacts on public health outcomes.
ƒƒ WHO developed a home-based patient care package for the prevention and treatment of
influenza for people living in remote, resource-limited communities.
ƒƒ The findings of anthropological research have been applied in the design of the package,
to overcome potential sociocultural obstacles to the acceptance and implementation of
key health messages.
ƒƒ The home-based care messages have been designed so that they can be adapted to different
cultural settings.
ƒƒ The approach has been field tested in Egypt, Lao People’s Democratic Republic, Sierra Leone
and Tajikistan. An evaluation has been carried out in Sierra Leone and is underway in Ecuador.
In 2009, WHO developed a care package for the prevention and treatment of influenza for people living in
remote, resource-limited communities receiving home-based care. The package was prepared to meet the
need for information on influenza at the household and community level in resource-limited community
settings. In developing the package, WHO used the findings of anthropological research to overcome
potential sociocultural obstacles to the acceptance and implementation of key health messages.
The care package was designed to provide countries with key messages on infection prevention and care of
patients with influenza. It also includes guidance on cultural adaptation of these messages for implementation;
the aim being that users will adapt the key messages to create feasible, user-friendly and culturally acceptable
messages for specific social and cultural contexts. The approach has been field tested in Egypt, Lao People’s
Democratic Republic, Sierra Leone and Tajikistan. An evaluation has been carried out in Sierra Leone and is
underway in Ecuador.
The package is targeted at ministries of health, NGOs and other health partners involved in the development
and implementation of community health care projects.
Management of acute respiratory illness in resource-limited settings | 24
5.2Community case management during an influenza outbreak
training package
Summary points
ƒƒ CHWs play a key role in responding to emergencies.
ƒƒ Communication channels need to be maintained from the ministry of health (MOH) through
to CHWs to use their potential in early warning capabilities.
ƒƒ CHWs can complement integrated management of childhood illness/integrated management
of adolescent and adult illness (IMCI/IMAI) as it follows a similar flowchart algorithm style.
ƒƒ CHWs need continual support beyond initial training: supplies, logistics, continued training.
The community is often the first responder in emergencies, including those caused by disease outbreaks.
CHWs can be the front-line health workers during an outbreak of communicable disease or other emergencies,
alleviating the strain and demand on HCWs in hospitals, clinics and other institutions when the health system
is overwhelmed or disrupted. They can also improve access to measures for the prevention and treatment
of epidemic diseases and other common illnesses (including severe pneumonia), and help in implementing
public health programmes and ensuring community participation, due to their close links to the community.
Therefore, communication channels from the MOH through to CHWs need to be maintained, to make best
use of the early warning capabilities of CHWs.
Training materials are being developed for CHWs to ensure that they are ready to provide health services to
communities in conjunction with home-based care and other levels of care. The package is intended to train
CHWs to manage common symptoms of ILI such as cough or difficulty in breathing, fever and diarrhoea,
and to continue critical services during an emergency such as a disease outbreak. This training approach
complements IMCI/IMAI because it follows a similar flowchart algorithm style.
The target audience to be trained using this package is CHWs:
ƒƒ with previous experience in both patient care and health education;
ƒƒ having mid-level information about patient care; for example, able to provide medication such
as antimalarial drugs, antibiotics or oral rehydration salts (ORS);
ƒƒ who have previously participated in training courses from organizations such as WHO or the
United Nations Children’s Fund (UNICEF) in topics such as IMCI.
After completion of training with this package, it is recommended that CHWs receive continual support
in the form of supplies, logistics and continued training.
5.3 Hospital-based training
Summary points
ƒƒ IMCI training material is useful at the country level.
ƒƒ For further implementation of the training, additional resources are required for
resource-limited settings.
ƒƒ Access to the training could be improved by making it available in multiple languages.
25 | Management of acute respiratory illness in resource-limited settings
In the past few years, training materials and established courses for the management of childhood illnesses
have been used in over 100 countries. Integrated clinical management of the severely ill child from emergency
presentation through to the first level of hospital care has reduced childhood mortality. A similar approach
has been used in the development of training materials and courses for hospital-based care for adults and
adolescents (IMAI).
Materials for IMCI include the paediatric “emergency triage assessment and treatment (ETAT) course” and
“severe pneumonia training”, and for IMAI they include the adult “quick check course” and “management of
severe respiratory distress and septic shock module”.
Training is aimed at building on established good practice, identifying systems and knowledge gaps,
and ensuring a systems approach to support the emergency treatment of patients. The training is
designed for HCW and ancillary or support staff who may contribute to the improved performance of
the emergency team, and for hospital administrators. Additional resources are required for implementation
in resource-limited settings.
The training packages are modular and can therefore be adapted to the needs of the health-care facility or
be used in refresher training through specific modules relevant to an infectious disease outbreak. The newer
IMAI training materials and courses are still being evaluated with field tests;1 they need to be made available
in multiple languages.
5.4 Critical care training
Summary points
ƒƒ Pandemic influenza critical care training has been developed for clinicians in tertiary hospitals
with sufficient resources to manage septic shock and hypoxic respiratory failure.
ƒƒ It is important to consider how best to recommend any therapy developed and validated in
high-resource settings for tertiary hospitals in low- and middle-income countries.
WHO has developed pandemic influenza critical care training modules for tertiary hospital clinicians.
Unlike the IMAI modules, which were developed for resource-limited hospitals, the critical care training
materials were developed for a target audience of clinicians with sufficient resources to manage septic shock
and hypoxic respiratory failure. These modules reflect international standards of care, where WHO guidance
is not available. The objectives of the course are to train participants to be able to describe how to provide
safe and quality critical care to patients with any of the following:
ƒƒ severe pneumonia;
ƒƒ acute lung injury or ARDS;
ƒƒ septic shock associated with severe influenza infection or CAP.
Training is modular and conducted over 3 days. The approach is comprehensive, with clinical training
encompassing patient arrival to the hospital through to their care in the ICU. The materials include a
compact disc (CD) with PowerPoint modules, lecture scripts and instructions for the interactive exercises.
1 The IMAI material can be accessed through the IMAI website: www.who.int/hiv/capacity/en
Management of acute respiratory illness in resource-limited settings | 26
At the meeting, there was much discussion of how best to recommend any therapy developed and validated
in high-resource settings for tertiary hospitals in low- and middle-income countries. For example, the group
discussed the potential for NIV to forestall mechanical ventilation for ARDS. Although NIV has not been
demonstrated to be better than mechanical ventilation for the management of ARDS in developed countries,
participants reported good outcomes with NIV in their hospitals during the pandemic (most notably in China
and India). If mechanical ventilation is associated with poor outcomes in some developing settings, participants
argued, then perhaps NIV should be considered as an alternative.
Participants made additional recommendations about content for the training course, including mechanical
ventilation in general (not just for the management of ARDS) and NIV. It was strongly recommended that the
modules be adaptable to fit local needs and medical cultures.
5.5 Promoting oxygen use for pneumonia treatment
Summary points
ƒƒ Hypoxaemia is a common and major cause of mortality.
ƒƒ Accurate detection of hypoxaemia and timely oxygen therapy improve survival of patients with
severe pneumonia.
ƒƒ Misperceptions about oxygen treatment (e.g. cost) are common in developing countries.
ƒƒ Investment in oxygen systems to improve the diagnosis and management of hypoxaemia should
be part of health system support.
ƒƒ Global awareness of the need to increase the availability of oxygen systems is necessary.
WHO presented information about hypoxaemia risks, identification and therapy, and summarized
organizational efforts to improve patient access to medical oxygen worldwide.
Hypoxaemia epidemiology
Pneumonia is the most common cause of hypoxaemia worldwide. It is estimated that 11–20 million children
are admitted to hospitals for treatment of pneumonia each year. Of these cases, 13–38% experience
hypoxaemia, and the condition contributes to 1.5 million deaths.1 Other common causes of hypoxaemia
include birth asphyxia, sepsis and low birth weight in the neonatal period and for adults; and exacerbation
of chronic obstructive pulmonary disease such as acute asthma exacerbation, sepsis, cardiac failure, major
trauma, obstetric emergencies and anaesthesia.
Pneumonia with hypoxaemia (as determined by below normal oxyhaemoglobin saturation) is associated
with increased risk of death. The pulse oximeter – an inexpensive and noninvasive device – can help
clinicians to risk-stratify patients with respiratory disease, and make decisions about location, type and
intensity of therapies. Incorporation of pulse oximeters in medical practice can save lives by identifying
patients who would benefit from oxygen therapy; it can also save resources by avoiding unnecessary use
of oxygen.
1 UNICEF, WHO. Pneumonia: the forgotten killer of children. 2006. http://whqlibdoc.who.int/publications/2006/9280640489_eng.pdf
(accessed 18 Nov. 2011).
27 | Management of acute respiratory illness in resource-limited settings
Identification of hypoxaemia
Pulse oximetry is a noninvasive and accurate diagnostic test that detects 20–30% more hypoxaemia cases
than physical examination alone.1 Many different categories of pulse oximeters are available, with a wide
range of functionality and cost. WHO has conducted reviews of pulse oximeters for use in resource-limited
settings, and can provide guidance to Member States considering purchasing the devices for clinical use.2
Oxygen treats hypoxaemia
Among hypoxaemic patients, oxygen therapy decreases mortality due to pneumonia. Ideally, all patients at
risk should have their oxygen saturation assessed early in their clinical evaluation, and should then start
therapy if hypoxaemia is present. In practice, oxygen is often given for the following oxygen saturation values:3
ƒƒ <90% at sea level where oxygen supplies are sufficient
ƒƒ 80–90% for pre-term neonates
ƒƒ <85% at altitude (>2500 m) or where oxygen supplies are limited.
The major sources of medical oxygen are compressed gas oxygen cylinders, oxygen concentrators and large
storage piped oxygen systems. Oxygen delivery methods should be safe, simple, effective and inexpensive.
Delivery devices include nasal prongs, head boxes and face masks. Optimal hospital oxygen systems should
include all of the following:
ƒƒ pulse oximetry for detecting and monitoring hypoxaemia
ƒƒ reliable oxygen sources
ƒƒ continuous power supply
ƒƒ oxygen tubing and delivery mechanism
ƒƒ clinical protocols for use of oxygen
ƒƒ training and supervision
ƒƒ regular maintenance and spare parts.
Challenges in delivering oxygen
A recent review4 outlined several misperceptions about oxygen therapy in developing countries; including the
belief that:
ƒƒ the burden of hypoxaemia is low and does not justify a public health approach
ƒƒ oxygen therapy is needed by only a narrow group of patients
ƒƒ there is a lack of evidence of oxygen effectiveness
ƒƒ oxygen therapy is palliative
ƒƒ oxygen therapy is expensive
ƒƒ oxygen therapy is complicated.
1 Duke T, Subhi R, Peel D and Frey B. Pulse oximetry: technology to reduce child mortality in developing countries. Annals of Tropical
Paediatrics, 2009, 29:165–175.
2 WHO, Informal consultation on clinical use of oxygen. Meeting report, 2–3 October 2003. http://www.who.int/surgery/collaborations/
Oxygen_Meeting_Report_Geneva_2003.pdf (accessed 21 Nov. 2011)
3 Subhi R, Smith K, Duke T. When should oxygen be given to children at high altitude? A systematic review to define altitude-specific
hypoxaemia. Archives of Disease in Childhood, 2009, 94:6–10.
4 The Union Oxygen Systems Working Group, The International Journal of Tuberculosis and Lung Disease, 2010, 14:1362–1368.
Management of acute respiratory illness in resource-limited settings | 28
These beliefs are clearly incorrect; however, they remain as substantial challenges to the widespread use of
oxygen therapy worldwide.
In addition, there are systemic issues in many hospitals that pose challenges to appropriate oxygen therapy.
These include ineffective triage, lack of availability of oxygen source and supplies, and failure to use oxygen
appropriately. System-wide investments are necessary for sustainable implementation of oxygen therapy.
Such investments include suitable hospital administrative policies, allocation of resources, equipment
and supply maintenance, patient monitoring, staff training and development of technical capacity for
maintenance and repair.
Oxygen availability
Oxygen is on the WHO list of essential medicines, but is not always available in hospitals. WHO and its
collaborators have conducted surveys of oxygen availability and use in low- and middle-income countries.
In a survey of 132 facilities in eight low- and middle-income countries in Asia and Africa, medical oxygen was
reported to be always available (21%), sometimes available (33%) and never available (11%).1 Another survey
in 231 facilities from 12 sub-Saharan African countries found that 44% of facilities had access to any oxygen
source, and 34% had access to supplies such as face masks and tubing to deliver oxygen to patients.2
Aware of the decreased access to oxygen therapy in many low- and middle-income country hospitals,
the International Union Against Tuberculosis and Lung Disease has recently called on the international
community to action to address this health-care inequity.3
WHO efforts to improve access to medical oxygen
WHO has developed several guidelines and supportive tools to assist clinicians with use of appropriate
oxygen therapy. These include clinical guidelines via:
ƒƒ IMCI;
ƒƒ integrated management for emergency and essential surgical care;
ƒƒ pandemic influenza emergency guidelines for the management of patients with severe respiratory
distress and shock in district hospitals in resource-limited settings;
ƒƒ IMAI (currently under development).
WHO has also produced an oxygen training video and oxygen assessment tool for clinicians. With regard to
durable medical devices, WHO has developed specifications for oxygen concentrators and pulse oximeters,
and has conducted field trials of different oxygen concentrator models.
1 Kushner AL, Cherian MN, Noel, L, Spiegel DA, Groth S, Etienne C. Addressing the Millennium Development Goals from a surgical perspective.
Archives of Surgery, 2010, 145(2):154–9.
2 Belle J, Cohen H, Shindo N, Lim M, Velazquez-Berumen A, Ndihokubwayo JB, Cherian M. Influenza preparedness in low-resource settings:
a look at oxygen delivery in 12 African countries. Journal of Infection in Developing Countries, 2010, 4(7):419–24.
3 Duke T et al. Oxygen is an essential medicine, The International Journal of Tuberculosis and Lung Disease, 2010;14(11):1362–8.
29 | Management of acute respiratory illness in resource-limited settings
6 WHO action points
Five action points were proposed at the end of the meeting, as follows:
1. Develop a meeting report.
2. Follow up the country-specific needs with WHO Regional Offices and Country Offices and partners,
including exploration of funding sources.
3. Compile lessons learnt from countries – consider publishing in a peer-reviewed journal as a
meeting proceeding.
4. Ensure that key messages and comments are sent to the relevant WHO in-house partners
(e.g. those dealing with IMAI, IMCI and patient safety).
5. Develop standard guidelines, and monitoring and evaluation programmes.
Management of acute respiratory illness in resource-limited settings | 30
Annex 1 Agenda
Day 1 – Pandemic (H1N1) 2009 influenza
Wednesday 20 October 2010
08:30–9:00
Registration
Session 1: Opening and Introduction – Plenary
09:00–9:05
Welcome, opening remarks and objectives
(Speaker: Sylvie Briand, Head, Global Influenza Programme)
09:05–9:15
Housekeeping arrangements: Declaration of Interest, meeting folder content
and distribution of questionnaire
(Speaker: Nikki Shindo)
9:15–9:30
Influenza and burden of disease
(Speaker: Nikki Shindo)
Session 2: Overview of Pandemic (H1N1) 2009 – Plenary
9:30–9:50
Clinical, virological and epidemiological features of H1N1 pandemic influenza
(Speaker: Tim Uyeki)
9:50–10:10
Clinical management of H1N1: an all level approach to prevention,
diagnosis and treatment
(Speaker: Kevin Rooney)
10:10–10:20
Other topical severe influenza treatment modalities
(Speaker: David Hui)
10:20–10:40
Questions and answers
10:40–10:50
Refreshment break
31 | Management of acute respiratory illness in resource-limited settings
Day 1 – Pandemic (H1N1) 2009 influenza continued
Wednesday 20 October 2010
Session 3: Lessons learnt – Country experiences
10:50–11:00
Introduction to the session
(Chair: Matthew Lim)
11:00–11:50
Panel discussion
Thailand: Tawee Chotpitayasunondh
Argentina: Rosa Bologna
South Africa: Juno Thomas
United States: Lena Napolitano
11:50–12:00
Summary of lessons
(Rapporteur: Tim Uyeki)
12:00–13:00
Group picture and lunch break
Session 4: Challenges in pneumonia patient care during influenza pandemic –
Country experiences
13:00–13:10
Setting the scene – Clinical management of acute respiratory diseases
(Chair: Gail Thomson)
13:10–14:00
Panel discussion
Bhutan: Santiram Dhakal
India: JC Suri
Mongolia: Enkhtur Shonkhuuz
Ukraine: Iryna Bobrova
14:00–14:10
Summary of challenges
(Rapporteur: Jamie Montoya)
Session 5: Promoting oxygen use for pneumonia treatment
14:10–14:20
Global survey on oxygen availability
(Speaker: Meena Cherian)
14:20–14:35
Optimizing oxygen in resource-limited settings
(Speaker: Shamim Qazi)
14:35–14:50
Challenges of delivering oxygen therapy in resource-limited settings
(Speaker: Janet Diaz)
14:50–15:00
Discussion
(Facilitator: Simon Mardel)
15:00–15:20
Refreshment break
Management of acute respiratory illness in resource-limited settings | 32
Day 1 – Pandemic (H1N1) 2009 influenza continued
Wednesday 20 October 2010
Session 6: Introduction to WHO approach – improving patient care at all levels
15:20–15:35
Introduction: Summary of training developed by WHO
(Speaker: Nikki Shindo, Facilitator: Rebecca Harris)
15:35–15:45
Home-based patient care
(Speaker: Anna Bowman)
15:45–15:55
Community case management
(Speaker: Marie-Helene Vannson)
15:55–16:05
IMAI district hospital training
(Speaker: Sandy Gove)
16:05–16:15
IMCI/ETAT
(Speaker: Lulu Muhe)
16:15–16:25
Tertiary hospital critical care training
(Speaker: Janet Diaz)
16:25–16:55
Promoting oxygen use (WHO video)
(Speakers: Shamim Qazi /Simon Mardel)
16:55–17:00
Closing remarks for Day 1 and information on Day 2
(Speaker: Nikki Shindo)
19:00–21:00
Networking dinner
33 | Management of acute respiratory illness in resource-limited settings
Day 2 – Improving patient care for acute respiratory illness
and pandemic influenza
Thursday 21 October 2010
Session 7: Introduction to training and mini-training sessions
9:00–9:20
Introduction to morning sessions
(Speaker: Nikki Shindo)
9:20–12:00
Clinical working group I – parallel session
IMAI Quick Check and Management of severe respiratory distress and septic shock; IMCI
ETAT and Severe pneumonia training
(Facilitators: Hillary Cohen/Lulu Muhe; Rapporteur: Paula Lister)
9:20–12:00
Clinical working group II – parallel session
Infection prevention and control in health-care facilities
(Facilitators: Sergey Eremin and John Conly; Rapporteur: Rebecca Harris)
9:20–12:00
Clinical working group III – parallel session
Critical care mini training
(Facilitator: Janet Diaz; Rapporteur: Justin Ortiz)
9:20–12:00
Community working group – parallel session
Introduction to “Community case management during an influenza outbreak”
training course for community health-care workers
(Facilitators: Heather Papowitz, Marie-Helene Vannson; Rapporteur: Kathryn Sauven)
12:00–13:30
Lunch break
Session 8: Group work
13:30–13:40
Introduction to afternoon sessions
(Speaker: Nikki Shindo)
13:40–15:00
Community working group – parallel session
Home-based care for pandemic influenza
(Facilitators: Anna Bowman, Julienne Anoko; Rapporteur: Kathryn Sauven)
13:40–15:00
Clinical working group I – parallel session
Developing clinical guidance in resource-limited settings
(Facilitator: Michelle Gayer; Rapporteur: Paula Lister)
13:40–15:00
Clinical working group II – parallel session
Developing an ARI kit for resource-limited countries
(Facilitator: Simon Mardel; Rapporteur: Justin Ortiz)
Management of acute respiratory illness in resource-limited settings | 34
Day 2 – Improving patient care for acute respiratory illness and pandemic influenza
continued
Thursday 21 October 2010
Session 9: Meeting conclusion and way forward
15:00–16:00
Feedback from working groups
(Facilitator: Sylvie Briand)
16:00–17:00
Identifying country needs – Findings from country needs assessment survey
(Facilitator: Paula Lister)
17:00–17:20
Action points and way forward
(Speaker: Nikki Shindo)
17:20–17:30
Close of meeting
(Speaker: Sylvie Briand)
35 | Management of acute respiratory illness in resource-limited settings
Annex 2 List of participants
Country and territory participants
Dr Dagnew Tadesse Abey
Ministry of Health
PO Box 1234
Addis Ababa
Ethiopia
Mr Humphreys Masuku
Chief Environmental Health Officer
Ministry of Health
PO Box 30377
Capital City, Lilongwe 3
Malawi
Dr Prince Agbenohevi
Principal Medical Officer and
Public Health Physician
Military Hospital, Accra
Independence Ave.
Accra
Ghana
Dr David Meya
Infectious Disease Institute, Makerere University
The College of Health Sciences
School of Medicine
PO Box 7072
Kampala
Uganda
Dr Sami Al Hajjar
Head, Pediatric Infectious Diseases
Associate Professor
King Faisal Specialist Hospital and Research Center
Department of Pediatrics
PO Box 3354, Riyadh 11211
Saudi Arabia
Dr Jaime Montoya
Executive Director
Philippine Council for Health Research
and Development
General Santos Avenue
Bicutan, Taguig
Philippines
Dr Afua Asabea Amoabeng
Medical Officer
University of Ghana, Legon Hospital
PO Box LG 25
Legon
Ghana
Dr David Mutonga
Head, Division of Disease Surveillance
and Response
Ministry of Public Health and Sanitation
Afya House, Cathedral Road
PO Box 30016, Nairobi
Kenya
Dr William Ampofo
Noguchi Memorial Institute for Medical Research
College of Health Sciences
University of Ghana
PO Box LG 581
Legon
Ghana
Dr Lena Napolitano
Professor of Surgery
University of Michigan Health System
Room 1C421 University Hospital
1500 East Medical Center Drive
Ann Arbor, MI 48109–0033
United States of America
Dr Musa Kalamullah Babashani
Aminu Kano Teaching Hospital
Zaria Road PMB 3452
Kano
Nigeria
Dr Julienne Ngoundoung Anoko
Socioanthropologist
Marcelo Usera 57 2 Izq
28026 Madrid
Spain
Management of acute respiratory illness in resource-limited settings | 36
Dr Frew Benson
Cluster Manager
Communicable Diseases and National Focal Point for
International Health Regulations
Civitas Building, Andries Street, Pretoria
South Africa
Dr Michael Ochoga
Coordinator
FMOH Asokoro District Hospital
2 Cassandra St. Maitama
Abuja
Nigeria
Dr Iryna Bobrova
Head of Consultative Polyclinic
Ministry of Health
Clinic of L.V. Gromashevskiy Institute of Epidemiology
and Infectious Diseases
23, I.Mazepy Street, 01015 Kyiv
Ukraine
Dr Nyeko Margaret Okello
Principal Medical Officer
Mulago Hopistal
PO Box 7051
Kampala
Uganda
Dr Rosa Bologna
Head, Hospital Nacional de Pediatria
J.P. Garrahan
Servicio de Infectologia
Combate de los Pozos 1881
1245 Buenos Aires
Argentina
Dr Bernard Toliva Opar
Principal Medical Officer
Ministry of Health
PO Box 7272
Kampala
Uganda
Dr Bin Cao
Beijing Chao-Yang Hospital
Beijing Institute of Respiratory Medicine
PO Box 100020
Beijing
China
Mr Wayne Ramkrishna
Ministry of Health
Civitas Building
Andries Street
Pretoria
South Africa
Dr George Chitope-Mwale
Director of Clinical Services
Ministry of Health
PO Box 30377
Capital City, Lilongwe 4
Malawi
Dr Kevin Rooney
Lead Clinician in Critical Care
Royal Alexandra Hospital
Corsebar Road
Paisley PA2 9 PN
United Kingdom
Dr Tawee Chotpityasunondh
Pediatric Infectious Disease Specialist
Queen Sirikit National Health Institute of Child Health
420/8 Rajvithi Road Rajthevi
Bangkok
Thailand
Dr Enkhtur Shonkhuuz
Maternal and Child Health Research Center
Children’s Internal Clinical Hospital
Bayangol District
Ulaanbaatar 210624
Mongolia
Dr Hillary Cohen
Attending Physician
Maimonides Medical Center
965 48th Street, Brooklyn
New York
United States of America
Dr Jagdish Chander Suri
Head of the Department
Room No 404, Ward-32 2nd Floor,
Casualty Building
Department of Pulmonary Critical Care
& Sleep Medicine
VMMC & Safdarjang Hospital, New Delhi 110029
India
37 | Management of acute respiratory illness in resource-limited settings
Dr Santiram Dhakal
General Duty Medical Officer
Ministry of Health
Trashigang Hosptial
Trashigang
Bhutan
Dr Milliyon Wendabeku Teklewolde
Early Warning and Response Team Expert
Ministry of Health
N/Lafto Sub City, Kebele 03/05, House 1101
Addis Ababa
Ethiopia
Dr Ndeye Mery Dia Badiane
Centre Hospitalier National Universitaire de Fann
(University of Dakar Fann Hospital)
Avenue Cheikh Anta Diop
Dakar
Senegal
Dr Juno Thomas
Head
Outbreak Response Unit
National Institute for Communicable Diseases
Private Bag X4, Sandringham 2131
South Africa
Dr Sardikin Giriputro
Director
Ministry of Health
JI Sunter Permai Raya
Jakarta Utara 14340
Indonesia
Dr Gail Thomson
Consultant in Infectious Diseases
Health Protection Agency
Porton Down, Salisbury
Wiltshire, SP4 0JG
United Kingdom
Dr Bukar A. Grema
Aminu Kano Teaching Hospital
Zaria Road P M B 3452
Kano
Nigeria
Dr Tim Uyeki
Deputy Chief, Epidemiology
and Prevention Branch
US Centers for Disease Control
and Prevention (CDC)
Mail-Stop A–20, 1600 Clifton Road, N.E. Atlanta
Georgia 30333
United States of America
Dr David Hui
Professor & Head of Division of Respiratory Medicine
Director of Stanley Ho Center for Emerging
Infectious Diseases
The Chinese University of Hong Kong
Prince of Wales Hospital
30–32 Ngan Shing Street, Shatin, NT
Hong Kong SAR
China
Dr Helen Van der Plas
Senior Specialist & Senior Lecturer
University of Cape Town
G16/63, New Main Building
Groote Schuur Hospital Observatory
7925 Cape Town
South Africa
Dr Henderson Munene Irimu
Chief Medical Specialist
Head, RIDD/HIV/TB care and treatment
Kenyatta National Hospital (KNH)
Nairobi 00202
Kenya
Dr Catherine Weil-Olivier
Professor of Pediatrics
University Paris VII
28 rue Parmentier
92200, Neuilly sur Seine
France
Management of acute respiratory illness in resource-limited settings | 38
Dr Simon Mardel
Senior Lecturer in Global Health
Consultant in Emergency Medicine
Humanitarian and Conflict Response Institute
Ellen Wilkinson Building
University of Manchester
Manchester M13 9PL
United Kingdom
Observers
Dr Marie-Claude Bottineau
Paediatrics, Neonatology & Vaccine Advisor
Médecins Sans Frontières
Rue de Lausanne 78
Case Postale 116
Geneva 21
Switzerland
Dr Amy Ginsburg
Program for Appropriate Technology in Health
(PATH)
PO Box 900922
Seattle, WA 98109
United States of America
Ms Anaïs Colombini
Economic and Financial Studies Manager
Agence de Médecine Préventive
Ferney-Voltaire
IHF – immeuble JB Say
13 Chemin du Levant
01210 Ferney-Voltaire
France
Dr Frederick Hayden
Wellcome Trust
Gibbs Building
215 Euston Road
London NW1 2BE
United Kingdom
Ms Cécile Duperray
Agence de Médecine Préventive
Paris
25–28 rue du Dr. Roux
75724 PARIS cedex 15
France
Dr Christoph Steffen
Project Coordinator
Agence de Médecine Préventive
Ferney-Voltaire
IHF – immeuble JB Say
13 chemin du Levant
01210 Ferney-Voltaire
France
Dr Sabine Flessenkaemper
Technical Advisor
Pandemic Preparedness Initiative
German Technical Cooperation (GTZ)
Postfach 5180
65726 Eschborn
Germany
39 | Management of acute respiratory illness in resource-limited settings
WHO Consultants
Dr Janet Diaz
World Health Organization
20, Avenue Appia
CH-1211 Geneva
Switzerland
Dr Justin Ortiz
Senior Fellow, Pulmonary & Critical Care
Medicine
University of Washington Medical Center
1959 N.E. Pacific, Campus Box 356522
Seattle WA 98195–6522
United States of America
Dr René Gerrets
University of Amsterdam
Spinhuis
Oudezijds Achterburgwal 185
1012DK Amsterdam
Netherland
Dr Kathryn Sauven
3A Wray Crescent
London N4 3LN
United Kingdom
Dr Paula Lister
Paediatric & Neonatal Intensivist
Great Ormond Street Hospital for Children
NHS Trust
Great Ormond Street
London WC1N 3JH
United Kingdom
WHO Regional and Country Offices
Dr Vincent Ahove
WHO Ghana Country Office
Dr Joshua Mott
WHO Europe Regional Office
Dr Madhu Ghimire
WHO South-East Asia Regional Office
Dr Pilar Ramon-Pardo
WHO Region of the Americas and Pan American
Health Organization
Dr Benido Impouma
WHO Africa Regional Office
WHO Secretariat
Dr Sylvie Briand
Global Influenza Programme
Dr Matthew Lim*
Biorisk Reduction for Dangerous Pathogens
Ms Anna Bowman*
Secretariat of the meeting
Global Influenza Programme
Dr Lulu Muhe*
Newborn and Child Health and Development
Dr Meena Nathan Cherian
Clinical Procedures
Dr Heather Papowitz*
Emergency Preparedness and Capacity Building
Management of acute respiratory illness in resource-limited settings | 40
Dr John Conly
Innovation and Translational Research for Epidemics
Dr Charles Penn*
Global Influenza Programme
Dr Sergey Eremin*
Biorisk Reduction for Dangerous Pathogens
Dr Shamim Ahmad Qazi*
Newborn and Child Health and Development
Dr Michelle Gayer*
Disease Control in Humanitarian Emergencies
Dr Nahoko Shindo*
Secretariat of the meeting
Global Influenza Programme
Dr Sandra Gove*
Capacity Building and HIV
Dr Mari-Helene Vannson*
Global Influenza Programme
Ms Rebecca Harris*
Global Influenza Programme
* Members of the H1N1 Supporting Patient Care team
41 | Management of acute respiratory illness in resource-limited settings
Annex 3 Oral statement on declarations
of interest
This annex provides the text of the statement that was read out at the start of the meeting.
We now turn to the matter of declarations of interest. There are many participants in this meeting, attending
in different capacities: experts attending in their personal capacity and representatives of governments,
national agencies or institutions, international organizations and nongovernmental organizations.
In accordance with WHO policy, the Secretariat reviewed and assessed the declarations submitted by
participants participating in this meeting in their personal expert capacity. They are:
ƒƒ Dr Rosa Bologna
ƒƒ Dr Simon Mardel
ƒƒ Dr Juno Thomas
ƒƒ Dr Tawee Chotpityasunondh
ƒƒ Dr Jaime Montoya
ƒƒ Dr Gail Thomson
ƒƒ Dr Hillary Cohen
ƒƒ Dr Lena Napolitano
ƒƒ Dr Tim Uyeki
ƒƒ Dr Santiram Dhakal
ƒƒ Dr Julienne Ngoundoung
Anoko
ƒƒ Dr Helen Van der Plas
ƒƒ Dr Sardikin Giriputro
ƒƒ Dr David Hui
ƒƒ Dr Catherine Weil-Olivier
ƒƒ Dr Kevin Rooney
In order to be as transparent as possible, we are now going to disclose to you the interests that were
declared by some of these participants and we request that each person confirm that these declarations are
still correct and up to date.
Represented by
Interest declared
Tawee Chotpityasunondh
Has declared grants received by his research unit from US CDC,
US NIH and Sanofi-pasteur to conduct influenza related research.
Sardikin Giriputro
Has declared grants received by his research unit from WHO to conduct
influenza related research.
Juno Thomas
Received travel grants from Sanofi-pasteur and US CDC to participate
in influenza related meetings.
US CDC, United States Center for Disease Control and Prevention; US NIH, United States National Institutes of Health; WHO,
World Health Organization
After review and assessment, none of these interests were determined to present a conflict with the
objectives of this meeting.
Management of acute respiratory illness in resource-limited settings | 42
Participants also include representatives of the following Member States, national agencies or institutions,
international organizations and nongovernmental organizations:
ƒƒ China
ƒƒ Mongolia
ƒƒ Ethiopia
ƒƒ Nigeria
ƒƒ Ghana
ƒƒ Saudi Arabia
ƒƒ India
ƒƒ Senegal
ƒƒ Indonesia
ƒƒ South Africa
ƒƒ Kenya
ƒƒ Uganda
ƒƒ Malawi
ƒƒ Ukraine
ƒƒ Agence de Médecine
Préventive
ƒƒ German Technical
Cooperation
ƒƒ Médecins Sans Frontières
ƒƒ Program for Appropriate
Technology in Health
(Wellcome Trust
These representatives are not here to assess or give advice as independent experts, but rather to represent
the views of their organizations. Their declared interests, if any, have therefore been assessed accordingly.
As a further measure to ensure transparency the meeting report will contain an Annex on Declarations
of Interest which will reflect the subject as we have just covered it.
Unless there are any questions related to this matter I propose that we proceed with the agenda of
the meeting.
43 | Management of acute respiratory illness in resource-limited settings
Annex 4 Country questionnaire proforma
Ad-hoc clinical management needs assessment questionnaire
Version 1.4
Purpose
The purpose of the questionnaire is to quickly assess needs in clinical management and care from
country participants in order to stimulate discussion and further action during the WHO meeting
“Clinical management of influenza and other acute respiratory illness in resource-limited settings: learning from
the influenza pandemic (H1N1) 2009”.
Interviewee
Country participants at the meeting.
Objectives
ƒƒ Identify at which health-care level/area support is needed.
ƒƒ Identify which kind of support (material/goods, training, financial, etc.) is needed.
Assessment process
Questionnaire will be distributed in the morning on Day 1 of the meeting.
Questionnaire to be collected after lunch Day 1.
Analysis by WHO / consultant Day 1.
Results presented on Day 2 of meeting.
Management of acute respiratory illness in resource-limited settings | 44
Questions
1. Please categorize the overall health/clinical care system in your country by checking one box:
‡‡ Country with weak health systems
‡‡ Country with functioning health systems but insufficient resources
‡‡ Country with functioning health systems and resources
2. Please prioritize the area where you think support is mostly needed in your country (check 1 box):
‡‡ Improving access to health care
‡‡ Increase knowledge and skills of health-care staff
‡‡ Improve health worker resources to equipment and supplies (e.g. oxygen and delivery methods)
3. Please check box if this applies to your hospital, primary care clinic or community-based outreach
service in your country:
Health-care workers are being trained/able and provided equipment to:
‡‡ Diagnose ARI (including rapid tests for influenza and/or X-rays, or clinically through assessment
and classification of illness)
‡‡ Treat ARI patient with
–– Antibiotics
–– Antivirals
–– Oxygen / O2
–– Supportive care such as hydration and antipyretics
‡‡ Manage surge capacity with increased number of patients with respiratory illnesses during a
pandemic
‡‡ Provide information on home care to patient and family
4. In order to strengthen ARI / pneumonia care (at hospitals, primary care clinics and outreach services)
we need more:
‡‡ In-service training / guidelines
–– IMAI Quick Check and Management of Severe Respiratory Distress and Septic Shock and IMCI ETAT
and Severe Pneumonia Training
–– Infection prevention and control in health-care facilities
–– Critical care training
–– Community Case Management training course for Community Healthcare Workers
–– Laboratory training
45 | Management of acute respiratory illness in resource-limited settings
‡‡ Equipment and supplies
–– basic essential medicines
–– oxygen supplies, e.g. masks, pulse oxymeter, patient delivery/interface, etc.
–– laboratory supplies (diagnostic or clinical)
–– ARI kit
‡‡ Strategic planning (funding, human resources, etc.)
‡‡ Preparedness planning for surge capacity of all resources in the event of a pandemic or other event
that can cause the health facility to become overwhelmed or cause service disruption
‡‡ (something else, please specify)
5. Please let us know any other needs that can help to improve ARI / pneumonia care in hospitals,
primary care clinics and outreach services on a routine or emergency basis.
6.Demographics
‡‡ Your country: ‡‡ In which health-care level are you mainly working (tick one)?
–– National
–– Regional
–– District
‡‡ Are you treating ARI / pneumonia patients?
–– Yes
–– No
Management of acute respiratory illness in resource-limited settings | 46
Annex 5 Calculation table for disposables and
pulse oximetry for 100 severe pneumonia cases
The table below lists the requirement for disposables and pulse oximetry for 100 severe pneumonia cases,
plus additional materials and cost margins to cover maternal and child health.
Essential
for acute
respiratory
distress
syndrome
(ARDS)
adolescent
and adult
SUBCOST Kit B
Essential
additions
for district
general
hospital
(DGH) unmet
obstetric
and child
health needs
SUBCOST Kit C
Number
Unit
cost
(US$)
Total
cost
No smoking signs caution
oxygen (symbols)
20
5
100
Yes
100
Wall chart of ages, flows,
devices and FiO2 (symbols)
10
5
50
Yes
50
Wall chart of safety advice and
contraindications
10
5
50
Yes
50
Manual use of pulse oximetry
10
5
50
Yes
50
Manual use of O2 concentrator
or cylinders
2
10
20
Yes
20
Advice manual for engineers
and managers
2
10
20
Yes
20
200
0.25
50
Yes
50
Signage and documents
Monitoring charts
Consumables
Number
Unit
cost
(US$)
Total
cost
Essential
for acute
respiratory
distress
syndrome
(ARDS)
adolescent
and adult
SUBCOST Kit B
Essential
additions
for district
general
hospital
(DGH) unmet
obstetric
and child
health needs
SUBCOST Kit C
Nasal cannulae
Infant
10
4
40
Yes
40
Nasal cannulae
Child
10
4
40
Yes
40
Nasal cannulae
Adult
50
4
200
Yes
200
Oxygen mask
Child
10
4
40
Yes
40
Oxygen mask
Adult
20
4
80
Yes
80
Non-rebreathing mask
Child
10
8
80
Yes
80
47 | Management of acute respiratory illness in resource-limited settings
Consumables continued
Essential
for acute
respiratory
distress
syndrome
(ARDS)
adolescent
and adult
SUBCOST Kit B
Essential
additions
for district
general
hospital
(DGH) unmet
obstetric
and child
health needs
SUBCOST Kit C
Number
Unit
cost
(US$)
Total
cost
100
8
800
Yes
800
Non-rebreathing mask
Adult
Suction catheters
Neonate
10
2
20
Yes
20
Suction catheters
Neonate
10
2
20
Yes
20
Suction catheters
Infant
10
2
20
Yes
20
Suction catheters
Infant
10
2
20
Yes
20
Suction catheters
Child
10
2
20
Yes
20
Suction catheters
Child
10
2
20
Yes
20
Suction catheters
Adult
10
2
20
Yes
20
Suction catheters
Adult
10
2
20
Yes
20
Catheters for newborn
oxygen (nasopharyngeal)
10
2
20
Yes
20
Catheters for infant oxygen
(nasopharyngeal)
10
2
20
Yes
20
Bubble humidifiers
10
10
100
Yes
100
100
2
200
Yes
200
Oxygen tubing
Oxygen mask with
nebuliser
Child
20
4
80
Yes
80
Oxygen mask with
nebuliser
Adult
20
4
80
Yes
80
Foot powered suction and
maintenance kit
100
1
100
Yes
100
Straps to secure cylinders
30
5
150
Yes
150
The items above in teal may be moved from this kit
Kit B+C
TOTAL
USD
2530
Essential
for ARDS
adolescent and
adult SUBCOST
USD
2370
Essential
additions for
DGH unmet
obstetric and
child health
needs SUBCOST
USD
160
Management of acute respiratory illness in resource-limited settings | 48
Pulse oximetry
Number
Unit
cost
(US$)
Total
cost
Essential
for acute
respiratory
distress
syndrome
(ARDS)
adolescent
and adult
SUBCOST Kit B
Essential for TRIAGE ONLY in DGH SUBCOST Kit A
Pulse oximeter battery
powered
5
150
750
Spare probes
Adult
5
50
250
Spare probes
Child
5
50
250
Spare probes
Infant
5
50
250
1
200
200
Hand held sensor to verify oxygen
source
1700
Feedback to
Dr Simon Mardel
[email protected]
Senior Lecturer in Global Health, Manchester University
49 | Management of acute respiratory illness in resource-limited settings
Essential
additions
for district
general
hospital
(DGH) unmet
obstetric
and child
health needs
SUBCOST Kit C
Global Influenza Programme, World Health Organization
20 Avenue Appia, CH-1211 Geneva 27, Switzerland | Fax +41 22 791 48 78 | Email [email protected]