Macter’s Clinical Excellence & Leadership Program (CELP)
Issues and updates on Pediatrics & Dermatology, discussed in the ninth session of CELP’s National CME Series 2008
Immunization saves 3 million lives every year:
Dr Ghaffar Billo
KARACHI – ‘Vaccines are one of the public health’s greatest successes and immunization is one of the most cost effective health interventions in existence’, said Professor Ghaffar Billo, Head of the Pediatrics Department, Aga Khan University Hospital, Karachi. He was addressing the 9th session of the National CME Series at Liquat National Hospital (LNH) Auditorium. The series is being conducted under the Clinical Excellence and Leadership Program (CELP) of Macter International.
Dr Billo, speaking at the occasion, stated that the use of vaccines had resulted in eradication of small pox, elimination of poliomyelitis from most of the industrialized countries, and control of measles, diphtheria, rubella, Hib, tetanus and other disease in many parts of the world.
The speaker was of the view that considerable progress in immunization had done much to prevent mortality in young children. ‘Almost 3 million lives have been saved each year, and 750 000 children are saved from disability’, he said.
He informed that out of 130 million children born each year, almost 30 million children have no access to immunization. ‘One in four children in the world remains without immunization against the six diseases i.e. measles, polio, pertussis, diphtheria, tetanus and tuberculosis’.
Dr Billo highlighted the role of Global Alliance for Vaccines and Immunization (GAVI) and informed that it was an international coalition of partners that included governments, international organizations such as the United Nations Children's Fund (UNICEF), the World Health Organization (WHO) and the World Bank; philanthropic institutions, such as the Bill and Melinda Gates Children's Vaccine Program and the Rockefeller Foundation.
Regarding combined vaccine use, he stated that combined products had a number of potential benefits including fewer injections, transportation and storage volumes, as well as less form filling.
Dr Billo said that by choosing not to vaccinate, one takes on the risk of disease. ‘Children unvaccinated against measles are 35 times more likely than immunized children to catch the disease’.
He informed that vaccines for dengue, E.Coli, Group A Streptococcus, malaria, respiratory syncytial virus, SARS, Shigella and West Nile fever are expected to be licensed in 2010-2015. Informing about the anticipated immunization supportive technologies, he stated that Thermostable vaccines, Jet Injectors (needle-free delivery), vaccine aerosols, vaccine nasal sprays and vaccine patches are expected to be available by 2015
Dr Billo, emphasizing the importance of vaccination, termed vaccines as an essential right of every child irrespective of origin and socio-economic factors.
Dr Sobia Qamar, in her presentation on diarrhea, stated that 15 percent deaths in children under five years of age were due to diarrhea. She defined diarrhea as ‘passage of 3 or more stools in a day, of consistency softer than usual for the child, or one watery stool’. ‘Diarrhea that lasts for less than 14 days is called acute, while that lasting for more than 14 days is termed as chronic diarrhea’, she informed, further stating that 10 percent episodes of diarrhea become persistent.
She stated that common organisms responsible for diarrhea include Rotavirus, Adenovirus, E. Coli, Shigella, Salmonella, Vibrio Cholera, Staph. Aureus (food poisoning), Compylobacter jejuni, Yersinia enterocolitica, Entamoeba Histolytica, Giardia Lambliia, Cryptosporidium and Candida albicans. ‘Rotavirus is the single most common organism which is responsible for 40 percent cases of diarrhea’, she informed.
Factors increasing the risk of acute diarrhea, she explained, include malnutrition, vitamin A deficiency, zinc deficiency, lack of exclusive breast feeding during first four months and use of bovine milk.
Danger signs in diarrhea, she informed, include unconsciousness, convulsions, lethargy, vomiting and inability to drink or breastfeed. She informed that in order to assess a child with diarrhea, the clinician should inquire about the duration, presence of blood in stool and passage of urine. She advised that the clinician should look for restlessness, irritability, lethargy, unconsciousness, sunken eyes and by offering fluid to the child, note whether the child is not able to drink, drinking poorly or drinking eagerly. In skin pinch test, she described, skin of the abdomen is pinched and the time taken by the skin pinch to revert back to the original position gives the clue about dehydration.
Dr Qamar advised that the food that should be given to the children in diarrhea include milk mixed with cereals, yogurt, vegetable oil and cereal based ORS; while lactose free milk should be used in persistent diarrhea.
Dr Sadia Tabassum, Assistant Professor, Department of Dermatology (LNH), speaking about common skin infection stated that these are acquired by close contact, sharing of clothes and shoes, handshake, swimming pools, soil, animals etc.
She informed that common bacteria that cause skin infection include staphylococci and streptococci; while the common bacterial skin infections are impetigo, erysipelas, cellulites, folliculitis, boils (furuncles), carbuncles and acute paronychia.
Impetigo, she explained, is a contagious superficial pyogenic infection caused by staphylococcus aureaus and streptococcus pyogenes and presents as crusted erosions, ulcers or bullae.
“Erysipelas is a bacterial infection of the dermis and upper subcutaneous tissue and its hallmark is a well defined, raised edge”, said Dr Tabassum.
Concerning cellulitis, she stated that it is an acute infection of dermal and subcutaneous tissue characterized by a red, hot, indurated, tender area of skin. She informed that cellulitis is caused most frequently by group A beta-hemolytic streptococci or staph. aureus and occurs most commonly on extremities. Informing about the complications of cellulitis, she stated that the disease my result in fasciitis, myositis, subcutaneous abscess, septicaemia and nephritis (in streptococcal cases).
Elaborating upon the infections of hair follicles, she stated that in folliculitis, inflammatory changes are confined to the ostium of hair follicle and it is characterized by crops of small pustules centered around the hair shaft. She informed that furuncle or boil refers to acute, deep-seated, red, hot, tender nodule or abscess; while carbuncle is a deep infection of a group of contiguous follicles, accompanied by intense inflammatory changes in the surrounding & underlying tissues, seen more commonly in diabetics, malnourished and immuno-compromised people.
Common viral infections of skin, she informed, include herpes simplex (herpex simplex virus 1 & 2), chicken pox (vericella zoster), herpes zoster (varicella zoster), molluscum contagiousum and viral warts (human papilloma virus).
“Herpes Simplex is one of the most common infections of humans worldwide. HSV 1 is classically associated with facial infections; while HSV 2 is typically genital. Transmission is through direct contact or droplets from infected secretions. Primary HSV 1 infections are usually sub clinical and rarely produce painful vesicular stomatitis, while primary HSV 2 infections are more commonly symptomatic.”
Dr Tabassum informed that chicken pox (caused by varicella zoster virus) has an incubation period of 14-17 days and is transmitted by droplet infection from naso-pharynx, while vesicle fluid contains large amount of virus as well. Complications of chicken pox include fever, pneumonia, encephalitis and hepatitis, she informed.
Discussing about the fungal infections of the skin, she stated that dermatophytes were related fungi, capable of causing skin changes of the type known as “Ringworm” or “Dermatophytosis”. ‘The causal fungi are all moulds belonging to Microsporum, Trichophyton and Epidermophyton groups’, Dr Tabassum informed. Clinical forms of dermatophyte infection, she explained, include Tinea Corporis (resulting from invasion & proliferation of the causal fungi in the stratum corneum), Tinea Capitis (scalp infection, in which the essential feature is invasion of hair shafts by the dermatophyte), Tinea Barbae (infection of the beard & moustache areas), Tinea Faciei (infection of the glabrous skin of face), Tinea Cruris (infection of the groins), Tinea Pedis (infection of feet or toes), Tinea Manuum (infection of the palmar skin), Tinea Incognito (infection modified by corticosteroids).
Dr Tabassum said that systemic antifungal therapy is required to cure fungal infections of scalp and nail. She said that candidiasis is caused by the yeast candida albicans or occasionally by other species of candidia, and at times there may be serious involvement of internal organs such as septicemia, endocarditis or meningitis.
Pityriasis versicolor, she explained, is a mild chronic infection of skin caused by malassezia furfur yeast, characterized by discrete or concresent, scaly, discoloured or depigmented areas mainly on upper trunk.
Dr Anila Haroon, Consultant Pediatrician, speaking at the occasion, stated that respiratory tract infections in children were one of the most important cause of morbidity and mortality in developing countries. She informed that respiratory tract infections could be divided into Upper Respiratory Tract Infections (URTI) and Lower Respiratory Tract Infections (LRTI). ‘URTI includes pharyngitis, croup, laryngitis and bacterial epiglottitis’, said Dr Haroon.
She informed that clinical features of pharyngitis included fever, vomiting and dysphagia and it may be viral or bacterial in origin. Complications like otitis media, peritonsillar abscess and bactremia may arise from pharyngitis, she added.
‘Croup manifests itself as respiratory distress and low grade fever and is caused by parainfluenza, RSV, influenza, measles and adenoviruses’, she informed.
“Clinical features of bacterial epiglottitis include high grade fever and toxic look and the causative organisms are hemophilus inflenza type B and streptococcus pyogens group A and C.”
Referring to a recent study published in Bulletin of World Health Organisation, she stated that Acute Respiratory tract Infections (ARIs) were responsible for almost 20 percent of all deaths in children under the age of five, worldwide.
