An importantcomplication of

acute respiratoryinfections is

inflammation ofthe middle ear,

which can lead tohearing loss.

ACUTE RESPIRATORY

INFECTIONS

F rom the common cold to influenza, respiratory infection is a universal experi-ence and in most instances only a minor, though miserable, illness. However,not all cases are so benign: every year acute respiratory infections, particular-ly pneumonia, prove fatal to more than 100,000 children under one and more

than 40,000 children one to four years old in the Americas. Even in their milder forms,

respiratory infections are so frequent (an average of four or more episodes per year inchildren under five) that they place a tremendous burden on health services, generating30% to 60% of all pediatric consultations. More serious cases account for 20% to 40%of child hospitalizations.

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Although the diseases are ubiquitous, there isa great disparity between the industrialized anddeveloping countries in the toll they exact. Only1% to 3% of deaths among children under five inthe developed countries of the Region are due topneumonia, whereas in the developing countriespneumonia accounts for 10% to 25% of thesedeaths. Degree of access to health services is a keyelement explaining this difference.

For many years PAHO’s work has addressedaspects of the acute respiratory infection problem.As far back as 1929 the Pan American SanitaryBureau was publishing periodic updates on theoccurrence, diagnosis, and treatment of influenzaand pneumonia in its Boletín de la Oficina SanitariaPanamericana. When prevention of three danger-ous acute respiratory infections became possiblewith the advent of effective vaccines against diph-theria and pertussis (whooping cough) in the1940s and against measles in the 1960s, theOrganization assisted in the development of vac-cine production laboratories and the planning ofmass vaccination campaigns in the MemberCountries, even before the start of the ExpandedProgram on Immunization (EPI) in the Americasin 1977. Nevertheless, it became clear that thecomplex problems posed by acute respiratory

PAHO helps trainhealth care profes-sionals to diagnoseand properly managecases of acute respi-ratory infection.

infections—diseases of diverse etiologies, requir-ing varying treatments and giving rise to severalimportant complications—called for a compre-hensive approach to aid the countries in prevent-ing and managing them.

Since 1978, the program of work of the WorldHealth Organization has included a section specif-ically dealing with the control of acute respiratoryinfections. The 32nd World Health Assembly(1979) adopted a resolution which urged theMember States of WHO to give priority to thefight against respiratory infections and called onthe international funding agencies to lend supportto this new initiative as an important element inprimary health care. The Program for the Controlof Acute Respiratory Infections (ARI) was estab-lished as a distinct WHO program in 1982, withfunding beginning in 1984.

In the meantime, PAHO and the countries ofthe Americas had also begun to work in this area.As early as 1970, Costa Rica had established ARIcontrol activities. By 1980 several countries hadexpressed interest in starting national ARI pro-grams, and an ARI program was organized withPAHO support in Pará State, Brazil. The experi-ence of Costa Rica and Brazil was instrumental toWHO’s design of control strategies in the late

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1980s. The regional ARI initiative became a majoractivity of PAHO technical cooperation in 1983.

One goal of the regional program is to aid thecountries in setting up national ARI programsthat will reduce child mortality through correctcase management of acute respiratory infections,particularly pneumonia. About one in every 50episodes of respiratory illness in children devel-ops into pneumonia, most commonly caused bythe bacteria Streptococcus pneumoniae andHaemophilus influenzae. Without adequate treat-ment 10-20% of these cases result in death. Propercase management depends on early recognitionof pneumonia and treatment with antibiotics.Training to recognize pneumonia must bedirected not only to medical and nursing person-nel and community health workers, but to fami-lies as well, so that they will quickly seek medicalattention for the child. Prompt treatment withantibiotics is crucial in cases of bacterial pneumo-nia. However, most acute respiratory infectionsare caused by viruses, which are not affected by

antibiotics. Unnecessary antibiotic treatment isnot only a waste of resources, it is dangerousbecause it can lead to the emergence of drug-resis-tant bacterial strains, produce toxic side effects,and deplete the supply of these drugs, makingthem unavailable to patients who really needthem. The regional ARI program has promotedguidelines to reduce the inappropriate use ofantibiotics and is working to train health workersin this regard. Clinical training is carried out inARI treatment training units, which PAHO ishelping to establish in some health services thatsee a high volume of acute respiratory cases.Twenty such units are now in operation in sevencountries.

Other training activities carried out by PAHOhave included sponsorship of numerous coursesand seminars for ARI program managers, devel-opment and distribution of technical standardsfor case management, and production of manualsand other teaching materials, including trainingmodules for supervisors, primary care and hospi-

re

Parents must beeducated to

cognize the signs

of a respiratoryinfection that

requires medicalattention.

tal personnel, and community health workers.The regional program also translates and dis-tributes a Spanish version of the internationalnewsletter ARI News (“Noticias sobre IRA”), andsince 1983, in collaboration with the U.S.National Library of Medicine, has been producinga periodic bibliography of scientific works onacute respiratory infections.

Another component in the fight against theseillnesses is research. PAHO is supporting re-search on diagnostic criteria for pneumonia ininfants and older children, on the behavior offamilies with regard to seeking medical carewhen a child becomes ill, and on the effective-ness and efficiency of health services in treatingARI. Other studies are directed toward testingpromising new vaccines against the pneumonia-causing bacteria—research that potentially willadd to the already—important role immunizationplays in preventing deaths from acute respiratoryinfections.

Other interventions besides vaccination canreduce mortality and complications from respira-tory infections, since certain preexisting condi-tions tend to make the illnesses more severe. Themost important risk factors are low birth weight

The smoke producedby indoor cooking

fires-as well asother forms of airpollution-poses ahazard. Childrensubjected to heavilypolluted air suffer

from more frequent

and more seriousrespiratoryinfections.

and malnutrition, which weaken a child’s resis-tance to disease and ability to fight it. Indoor airpollution, especially smoke from cooking fires inpoorly ventilated areas and parental tobaccosmoke, also has been shown to increase the inci-dence of respiratory infections and aggravatetheir severity. Therefore, the aims of the ARI pro-gram are closely linked to those of other maternaland child health initiatives, and its work is inter-connected with that of other PAHO programs,such as nutrition, environmental health, essentialdrugs, and health services development.

Control of acute respiratory infections is oneof the most important elements in the overalleffort to improve children’s health and develop-ment to which heads of State committed theircountries at the U.N.-sponsored World Summitfor Children in September 1990. The goal ofreducing deaths from acute respiratory infectionsby one-third is one of the six child health targets.Those countries with the highest infant mortalityrates (above 40 per 1,000 live births), whichaccount for most of the ARI mortality, will be thepriority focus of program activities in the period1992-1994. In addition to activities related to thecountries, the regional program is working to

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Proper nutrition for

young children helpskeep a minor

respiratory infectionfrom becoming a

serious one.

coordinate and establish support from interna-tional agencies of the United Nations system andother nongovernmental organizations. For thispurpose, PAHO, WHO, UNICEF, and the UnitedNations Development Program (UNDP) orga-nized the International Consultation Meeting onthe Control of ARI, held in Washington, D.C., inDecember 1991, which brought together special-ists and representatives of international agenciesto analyze progress and declare their commitmentto support the project. An InteragencyCoordinating Committee for the Control of ARI,made up of PAHO, UNICEF, and the UnitedStates Agency for International Development, hasbeen established, and the countries are being

encouraged to include an acute respiratory infec-tion component in the national committeescharged with pursuing the goals of the WorldSummit for Children.

To date, all the countries have designated afocal point for ARI control and have adopted theWHO technical guidelines for ARI prevention andtreatment. Sixteen countries have prepared ARIcontrol plans that follow these criteria, 20 havedone a profile of the problem in their country, and20 already use PAHO training modules. As moreof the countries put control plans into operation,the toll of these diseases will be reduced signifi-cantly, and the effectiveness of the health serviceswill be strengthened in the process.

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