There are so many problems facing children and enviromental health problems contribute to the �burden of disease� in children under 5years. DALY stands for ��Disability adjusted life years�� and it it a common measurement unit for morbidity and mortality.DALYs reflect the total amount of healthy life lost,to all causes,whether from premature mortality or some degree of disability during a period of time .The attractiveness of this measurement lies in the fact that it combines information about morbidity and mortality in a single number .DALYs allow the losses due to disability and the losses due to premature death to be expressed in the same unit
According to the World Health Report(2000),the biggest contributor to poor health in the world�s children is underweight.The second most important contributor is unsafe water ,sanitation and hygiene,and the third most important contributor is indoor smoke from solid fuels.In 2000 ambient (outdoor)air pollution contribute far less to poor health in young children.This is not to say that it is not important.But its influence on young children�s health is comparatively less than that of indoor air pollution because young children spend most of their time indoors where levels of air pollution can be much higher than levels outdoors.
The use of biomass and solid fuels for household cooking and heating is associated with increase in acute respiratory infections.Indoor air pollution with enviromental tobacco smoke is linked to acute otitis media.Outdoor exposure to ozone is linked to bronchospasm and asthma attacks in some children.Exposure to indoor molds is associated with acute pulmonary haemorrhage among infants.High exposure to particulate and secondhand smoke is associated with sudden infant death syndrome(SIDS)(World Health Organization,2009).
Prajapati(2011), in a cross sectional study on the prevalence of acute respiratory tract infections(ARI) in under five children in urban and rural communities of ahmedabad district,gujarat concluded that in the rural area lack of basic health services,lack of awareness,and other associated factors like overcrowding,enviromental factors,defects in immune system,overuse and misuse of antibiotics,poverty absence of ventilation,indoor air pollution,are responsible factors.(Prajapati et al,2011)
Selvaraj(2014), in a situational analysis on acute respiratory infections among under five children in india stated that several small scale community-based studies have reported poor socioeconomic factors,low level of literacy,suboptimal breastfeeding,malnutrition,unsatisfactory level of immunization coverage,cooking fuel used other than liquefied petroleum gas as risk factors contributing to increasing the burden of acute respiratory infections among children.Also, the emmergence of newer pathogenic organisms,reemmergence of disease previously controlled,wide spread antibiotic resistance,and suboptimal immunization coverage even after many innovative efforts are major factors responsible for the incidence and prevalence of acute respiratory infections.(Selvaraj et al ,2014).
PREVENTION AND CONTROL OF RESPIRATORY DISEASES IN UNDER FIVE CHILDREN
Breast feeding
In developing countries, children who are exclusive breast fed for 6 months had 30%-42% lower incidence of acute respiratory infections compared to children who did not received for same duration of breast feeding.(Ladomenou et al,2010). A recent research report from longitudinal cohort by Mihrshahi et al.,(2008), reported the increased risk of acute respiratory infections (relative risk = 2.3) among children not breast fed adequately.(Mihrshahi et al,2008). Breast feeding is included under one of the life-saving tool in prevention of various childhood diseases. Hence, breast feeding is among the World Health Organization/United Nations Children Education Fund global action plan to stop pneumonia. In addition, hand washing, improved nutrition, and reduction of indoor air pollution are suggested as primary strategies to protect from pneumonia among children under five years age.(Selvaraj et al,2014)
Hand washing and respiratory infections
Quantitative systematic review of studies from developed countries estimated hand washing reduces the incidence of respiratory infections by 24% (ranging from 6% to 44%). Evidences from developing countries are lacking on this issue.(Selvaraj et al,2014). According to the World Health Organization Training Package for the Health Sector on Childhood Respiratory Diseases linked to the Enviroment (2009),since upper respiratory infections are transmitted by contaminated hands or by sneezes,frequent handwashing after contact with an infected person reduces the risk of secondary infection.(World health Organization,2009).
Indoor air pollution from solid bio mass fuel
Exposure to indoor air pollution has 2.3 (1.9-2.7) times increased risk of respiratory infections (especially lower respiratory tract infections).(Ladomenou et al ,2010). Hence, use of cleaner fuels or improvised stoves have proven to be the cost-effective interventions to reduce incidence of indoor air pollution.(Selvaraj et al ,2014).According to a nationally-representative case-control study on child mortality from solid fuel use in india, million deaths study has also reported increasing prevalence ratio (PR = 1.54 among males, 1.94 among females) of respiratory infections due to use of solid fuel.(Child mortality from solid fuel use in india,2010).
Vaccines in preventing respiratory tract infections
Severity and transmissibility of respiratory tract infections by major pathogens, limited availability of laboratory diagnostics, and antibiotic resistance to wide range of drugs makes vaccines as a potential intervention against acute respiratory infections. While conventional fatality due to pertussis, diphtheria, and measles is reduced by routine immunization, infections due to other bacterial organisms such as Haemophilus. influenza, Streptococcus pneumonia remains responsible for major burden of the disease. Despite the proven efficacy of vaccines and assistance through Global Alliance for Vaccines and Immunization (GAVI), wide scale implementation is lacking due to non availability of community-based studies to establish the evidence of acute respiratory infections/pneumonia due to above organisms(World Health Organization,2009).
Vaccines against pertussis
Reemergence of increasing number of pertussis cases are evident. This has led to the change in National Immunization Schedule to introduce Diphtheria, Pertussis and Tetanus, (DPT-booster) at five years of age instead of Diphtheria and Tetanus DT and raising the upper age limit for DPT vaccine to seven years of age.(Selvaraj et al,2014).
Measles
The recent multiyear strategic plan of India gives an opportunity for Indian children to receive the second dose of measles vaccine. According to this plan, Measles, Mumps and Rubella (MMR) at 15-18 months of age is suggested in states with greater than 80% immunization coverage, while catch up campaigns are suggested in states where less than 80% routine coverage is reported.(Selvaraj et al,2014)
Influenza vaccines among children
For children 6-23 months, two doses of trivalent influenza vaccine is recommended if country can afford, make it feasible, and cost-effective analysis is made in favour of vaccination. Children less than 6 months are exempted from vaccination, but protection of mother during pregnancy is recommended as a means to protect these young infants. However, for developing countries appropriate target groups for influenza vaccination is not well-defined. .(Selvaraj et al,2014)
Vaccines against Haemophilus influenza(immediate candidate to be included in National Immunization Schedule)
More than 95% Haemophilus influenza infections occur only among children. According to the recent estimates Haemophilus influenza contributes to annual burden of 8.13 million serious illnesses and 371,000 deaths worldwide.(Watt et al,2009). From the first Haemophilus influenza vaccine trial conducted in 1973- 1974 showed the efficacy of vaccine against all types of invasive pathogens. Conjugated vaccines are shown to be more immunogenic and less reactogenic. Various vaccine trials reported efficacy in the range of 98%-100% after three doses of vaccination, in contrast 35%-47% of the children had low level of immunoglobulin G antibodies against this organism when they did not receive any booster dose. The estimated overall efficacy for three doses of Polyribosylribitol Phosphate-Tetanus Conjugate (Hib-Haemophilus influeza Type B) Vaccine was 98.1% (95% confidence interval 97.3%-98.7%). Efficacy in infants aged 5-11 months was 99.1%, 12-23 months 97.3%, and 24-35 months 94.7%. This vaccine not only protects against severe pneumonia but also prevents the colonization, thereby helping in prevention of disease transmission. In spite of its safety, efficacy, feasibility to insert in routine immunization schedule and protection against huge number of avertable deaths most of the developing countries are hesitant to adopt this mode of intervention. Only impediment factor is cost and fear of reactions. Despite financial and technical assistance offered by the Global Alliance for Vacines and Immunization (GAVI) introduction of this vaccine in National Immunization Schedule is slow due to questionable affordability toward long-term commitment. A recent study has shed some insight into vaccine safety wherein use of 1.25 �g(microgram) dose of vaccine has given equivalent sero conversion with less reaction compared to conventional 5 �g(microgram) doses. This dose reduction can further reduce cost of vaccination.(Selvaraj et al,2014)
Pneumococcal vaccines
Scope for inclusion under National Immunization Schedule: Pneumococcal infections alone contribute to 11% of all deaths among children under five years of age. Randomized trial reports from nationwide finish group of children had proven 100% efficacy of vaccine against vaccine serotypes when the 3 + 1 schedule (6, 10, 14 weeks infant series and 1 year post toddler) was adopted.(Madhi et al,2012) Vaccine efficacy against this 2 + 1 schedule was reported to be 92%.(Palmu et al,2013) Safety profiles were confirmed from many trials including the recent trial reported from 12 sites in India.(World Health Organization Publication,2012) Like Hib-Haemophilus influenza Type B vaccines, this also prevents colonization thereby facilitates the protection against the disease transmission.(Ota et al,2012) While the currently available Pneumoccocal Vaccine 7 gives protection against only seven serotypes, rest of the serotypes are left out. Unfortunately, vaccine which covers all 23 serotypes cannot be used among children under 2 years which is a most vulnerable period to get this disease. To widen the protection against additional serotypes Pneumococcal Vaccine-13 is suggested. Trial reports from various countries again confirmed the safety profile and added protection by Pneumococcal Vaccine13 compared to Pneumococcal Vaccine 7(Durando et al,2012) However, issues on revaccination of children in 5 years age group remains a challenge. With these scientific evidences, political commitment toward acceptance for inclusion under routine vaccination is yet to be achieved(Selvaraj et al,2014).
Measles,Mumps, Rubella(MMR) and Chickenpox Vaccine
Secondary pneumonia due to exanthematous illnesses like measles and chicken pox are next common cause for acute respiratory infections among children. Despite their high incidence, prevention efforts with these vaccines are not under priority since other vaccines like Haemophilus influenza, Hepatitis B are yet to be included in nationwide plan. Varicella and Measles,Mumps,Rubella can be given in two ways. Giving vaccines to adolescents and adults alone will protect the vulnerable group without changing the epidemiology of disease. Vaccination of children without focusing for high coverage level (coverage less than 80%) will result in epidemiological shift leading to onset of cases (rubella and varicella) at adult age group which is more harmful than the existing scenario. For countries like India where second dose of measles is proposed recently (Measles,Mumps,Rubella at the age of 15-18 months) is recommended with emphasis on high coverage. Vaccine against varicella is not recommended at present under National Immunization Schedule considering the other priorities. Adults who are at risk of contacting varicella are advised to get vaccinated within 48 hours of exposure. This prophylactic method has the proven efficacy of 90%(Indian Journal of Public Health,2013).
Mile stones in control of acute respiratory infections in India
On the basis of burden and effectiveness of simple primary health care interventions shown from the field,acute respiratory infection control program was started in India during 1990. Since then, various community-based interventions are implemented under ,acute respiratory infection control program. Identification of severe respiratory infections by health care worker from rural area, wide access to antibiotics, and its administration by health care workers, was seen as a successful model. Increasing coverage of vaccines against major vaccine-preventable diseases through various strategies under National Rural Health Mission, measles second dose implementation and newer introduction of pentavalent vaccines are the major primary health care measures currently implemented in India. . Algorithm development and respiratory tract infection group education modules are the major steps taken by professional bodies toward management of acute respiratory infections and irrational use of antibiotics(Selvaraj et al,2014)
Role of zinc in prevention of acute respiratory infections
Controversial evidences are reported over the effect of zinc in prevention of acute respiratory infections. While some of the evidences support its impact on reducing acute lower respiratory tract infections(Roth et al ,2010), other studies contradict this(Srinivasan et al ,2012) Considering the tolerability and high threshold for toxic effects, the further recommendations on zinc in acute respiratory infections will be based on the conclusions from ongoing community trials. However, global action plan to prevent pneumonia by the World Health Organization (WHO)/United Nations Children Education Fund(UNICEF) insists on routine zinc prophylaxis for children affected by acute diarrheal diseases.
For developing countries to take decision on various modes of interventions against acute respiratory infection, cost-effective analysis is necessary. The assessment of various interventions against acute respiratory infections has shown the high impact from interventions like breast feeding, zinc prophylaxis, access to clean fuel for cooking, and community/facility-based case management. These interventions are applicable even in resource poor settngs to combat the burden of acute respiratory infection drastically(Selvaraj et al,2014).
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