Clinical Management in Resource-Poor Settings.
Because the most common cause of death among children under age 5 yrs is pneumonia (44), most resource-poor countries will have intravenous crystalloids and antibiotics, with fewer having means to concentrate oxygen, a generator, and a vehicle for transportation (45). Supplies will be limited and will not be able to surge with high-patient volumes (46). Oxygen shortages are common owing to the cost and complex logistics of transporting it in cylinders. Most hospitals do not have pulse oximetry, and hence, healthcare providers may not be able to recognize clinical signs of hypoxemia.
In these settings, basic delivery of antibiotics should be launched along with full immunization; if the setting can afford oxygen, then supplies should be available as needed. If ventilation services are available, it is critical that children who can potentially survive with reasonably limited intensive care resources be ventilated.
In studies of >11,000 children with pneumonia in Papua New Guinea, a combined pulse oximetry and oxygen concentrators approach was able to alleviate oxygen shortages, reduce mortality, improve quality of care, and be cost effective (47). In a Gambian study, because electrical power costs may be prohibitive, cylinders are preferred if transportation is available (48). Solar-operated systems, despite the initial investment, become cost effective, especially where 6 hrs of sunlight per day can be guaranteed, and rural hospital needs exceed 6 treatment days of oxygen per month (49). Another study found that all low-flow methods (e.g., nasopharyngeal catheters, nasal catheters and prongs) were effective in oxygenation of sick children. Nasopharyngeal and nasal catheters are less expensive. Nasal prongs were favored in small hospitals (50).
Clinical care strategies must focus on reducing all-cause premature mortality. WHO's Integrated Management of Childhood Illness (51) and Integrated Management of Adolescent and Adult Illness (52) for triage and management at the primary care level should be followed and implemented at all levels of care. Decentralization of antiviral medications in primary care settings, even in limited supply, is important to reach at-risk and disadvantaged populations. Key principles of management include: basic symptomatic care; early use of antiviral medications for high-risk populations, if available; antimicrobials for coinfections; and proactive observation for progression of illness. Hospital care requires early supplemental oxygen therapy to correct hypoxemia, with saturation monitoring at triage and during hospitalization, if possible, careful fluid replacement, antimicrobials, and other supportive care. Patients with severe hypoxemia will need high-flow oxygen delivered by face mask and options listed previously. Medical oxygen in some countries will not be available; in these situations, industrial oxygen can be used.
Severe respiratory distress requires mechanical ventilation and intensive support. Again, some countries may not offer mechanical ventilation (53). Clinical management and triage may be altered because of severity of the novel viral pathogen and particulars within the case definition, such as age and comorbidity. Additionally, healthcare providers must consider the impact of malnutrition and chronic micronutrient deficiency (especially vitamin A and zinc) on mortality, morbidity, and duration of diarrhea and pneumonia (54–59).
International Response Mechanisms
International Health Regulations and Treaty.
International health regulations have existed for years for cholera, smallpox, and yellow fever, but with the severe acute respiratory syndrome pandemic in 2005, WHO's authority and surveillance capacity was expanded to all infectious diseases of international concern. This new international health regulation became a treaty in 2007 and applies to all public health emergencies of international concern. It ensures maximum security against the international spread of diseases while addressing the need to mitigate the economic tragedy that prevails with any pandemic. Fragile states and ungoverned spaces (which by definition have little or no public health protections) may forgo international health regulation measures and represent an ideal home for future viral mutation and propagation (60). Obligations under the 2007 treaty are three-fold (61):
1) All countries are required to report to WHO all events within their respected territories that may constitute a public health emergency of international concern (Article 6.1). This includes governments of fragile states or those with ungoverned territories.
2) One provision (Article 9.1) allows WHO to receive reports of disease events from sources other than governments, such as nongovernmental organizations or the media, and to seek verification of these reports. The international health regulation (Article 9.2) requires a state party to report within 24 hrs evidence that it receives of a disaster event occurring within the territory of another state party, which could produce reports of “a public health-risk” occurrence in fragile and ungoverned areas.
3) A first step in assisting a country comes from building capacity in public health surveillance and proven community containment and mitigation strategies (e.g., social distancing, respiratory etiquette, and hand washing [62, 63]) as an incentive for fragile states to accept improvements in basic governance.
WHO Regional Organizations.
As an example of how WHO Regional Organizations provide resources to developing countries, the Pan American Health Organization focused their aid on providing technical assistance for crisis management and coordination, surveillance, and investigation of cases in the Americas during the 2009 Influenza A/H1N1 Pandemic. The Pan American Health Organization immediately activated its Emergency Operations Center, which serves as the center for strategic coordination, analysis, and decision making during a pandemic. The Center provided point-of-contact services and improved communication with country and field offices and other regional offices. It provided the logistic support to deploy technical experts to the field and to ensure timely shipment of oseltamivir antiviral medication (1 million doses were sourced), personal protective equipment, and other supplies needed by countries. The Pan American Health Organization/WHO also monitored laboratories in member states and distributed diagnostic kits, revised manuals, reagents, laboratory equipment, and Internet-based self-learning programs (64).
Rapid response teams within a country can be mobilized to carry out the following tasks:
* Conduct a rapid assessment of a possible outbreak
* Confirm the existence of an epidemic
* Assess the impact on health
* Assess the local response capacity and immediate needs
* Present results of the investigation to the department of health services and other relevant authorities (e.g., Minister of Health, local population for action)
Each rumor/report must be investigated immediately (within 24 hrs) after contacting health personnel and community leaders of the affected district or subdistrict.
As a partner, the U.S. Agency for International Development provided the Pan American Health Organization with 25,000 personal protective kits, and the U.S. Agency for International Development and Centers for Disease Control and Prevention provided 220,000 antiviral treatments in response to urgent requests made by those countries with the highest number of confirmed cases. Additional partnerships were made with the Canadian International Development Agency and the Spanish Agency for International Cooperation and Development (64).
Promoting Health Capacity
Over 57 countries, primarily from Africa and Asia, are experiencing a severe healthcare worker crisis. Africa alone is short 4.2 million health workers and loses 20,000 skilled health workers per year. Sub-Saharan Africa and Southeast Asia together have 53% of the global burden of disease but only 15% of the world's healthcare workers (65–67). Specialty trained physicians and nurses are “expected” to emigrate, with countries such as Canada, the United States, the United Kingdom, and Australia exacerbating the crisis through active recruitment of qualified health workers. Only recently has this practice been considered a crime (68).
Severe imbalances exist throughout the world and are made more severe by inequities within countries, with rural areas suffering the most. These countries cannot meet the Millennium Development Goals, and many are slipping further as the health worker shortage worsens (69). WHO emphasizes that concerns over emerging and re-emerging diseases, including novel influenzas, have drawn greater attention to this crisis by alerting countries to what the consequences would be with a devastating global pandemic. A state of even “minimal preparedness” does not exist (70).
WHO's Strategy to Improve Healthcare Capacity.
The WHO's program includes:
* More direct investment in the training and support of health workers
* A national plan for the health workforce and an increase in the number of health workers in all countries with serious shortages
* More efficient use of the existing health workforce
* Task-shifting, or the process where some simple healthcare tasks now assigned to highly skilled personnel are delegated to less skilled workers able to deliver them competently
* Protection and fairer treatment of health workers
* Access to effective human immunodeficiency virus prevention and treatment for all health workers
* Encouragement of women to enter health professions
* Decreased incentives for early retirement
* Comprehensive preparedness plans in every country for a workforce response to outbreaks and emergencies
* Reassignment of health workers during times of conflict to areas in need
* Orientation of health worker training and development of career incentives to encourage service in rural and disadvantaged areas
* Better strategies to more actively engage communities and patients in their own health care
In pandemics, WHO recommends that plans include means for health workers to collaborate with staff in the military, transport, and education sectors to maximize the efficiency of scarce human resources. In addition, WHO's Code of Practice for the Recruitment of International Health Personnel encourages countries that receive emigrant healthcare workers to assist in improving working conditions in source countries. Faculty from the University of British Columbia emphasize that countries benefiting from the healthcare worker migration have a “genuine responsibility to reciprocate with resources of their own” (71). Intensified efforts are needed in ensuring better working conditions and in integrating worker safety with patient safety.
Education, Training, Research, and Advocacy
Aside from the least-developed countries with environments commonly referred to as unstable, fragile, and nonpermissive due to human insecurity, Stidham and Novick (72) suggest that assistance from the developed world may best come in the form of “intensive care services which can serve as a foundation for further assisted development.” Specifically, they cite promoting increased access to donated equipment and supplies, basic on-site critical care training, intermittent training that elevates the level of services provided for short periods of time, building sequentially on each learning experience, development of “intellectual connections” that provide an immediate source of telephone consultation, and the potential future in computer-assisted telecommunications (72).
The World Federation of Pediatric Intensive and Critical Care Societies is based on the premise that, through educational, scientific, research, and charitable means, ways will be found to improve the care of critically ill children throughout the world, and in doing so, disseminate that knowledge available to those who care for children (73). The Federation has over 25 national, international, and regional member societies representing over 10,000 pediatric and neonatal critical care physicians, nurses, and allied healthcare workers. The Federation collaborates with the Society of Critical Care Medicine to publish the journal Pediatric Critical Care Medicine, with abstracts published in seven languages (73). Specialty societies, such as the American Academy of Pediatrics, provide a database of qualified professionals for future disasters. A similar database is appropriate for critical care specialists to provide either field expertise or subject-matter telecommunications from a distance.
The Task Force Recommends the Following:
* The definition of pediatric critical care should include “the treatment of the child with a life-threatening illness or injury in its broadest sense, without regard for the location and including prehospital, emergency, and intensive care.”
* Responses to disasters in developing countries have to take into account the available resources. Realistically, intensive care is simply not possible in these countries. However, major impacts can be achieved using local people, simple remedies, community mitigation strategies (e.g., social distancing), and basic training. The response in these countries needs to be tailored to the particular stage of development of the health services and resources.
* In the least-developed countries, emphasis must be placed on first improving primary care, prevention, and basic emergency care, where possible. Advances in care should move incrementally without compromising primary care resources.
* A first step in preparing for a pandemic in a developing country comes from building capacity in public health surveillance and proven community containment and mitigation strategies (e.g., social distancing, respiratory etiquette, and hand washing).
* Clinical care strategies must focus on reducing all-cause premature mortality and the United Nations Children's Fund/WHO guidelines and algorithms for Integrated Management of Childhood Illness and Integrated Management of Adolescent and Adult Illness. Key principles of management include: basic symptomatic care; decentralization of antiviral medications in primary care settings, even in limited supply, to reach at-risk and disadvantaged populations; antimicrobials for coinfections; and proactive observation for progression of illness.
* International assistance is provided to resource-poor countries during pandemics through mandates provided by the International Health Regulations Treaty of 2007 and the WHO Regional Organization emergency response capabilities and their partnerships.
* In public health emergencies, the WHO recommends that country plans include means for health workers to collaborate with staff in the military, transport, and education sectors as well as international healthcare workers to maximize the efficiency of scarce human resources. Rapid response teams can be augmented by international subject matter experts if these do not exist at the country level.
* Partnerships through the WHO Regional Organization with international donors, such as U.S. Agency for International Development, Australian Agency for International Development, Canadian International Development Agency, Department for International Development (United Kingdom), Japan's International Cooperation Agency, and others, will expedite the deployment of scarce resources.
The Pediatric Emergency Mass Critical Care Task Force thanks the American Academy of Pediatrics and its Disaster Preparedness Advisory Council for their review and contributions to this issue.
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Keywords:©2011The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies
children; developing countries; disasters; emergencies; emergency mass critical care; global health; pandemics; pediatric critical care; pediatrics; public health emergencies