Chest infections, of which pneumonia is the most serious form, are usually one of the five major causes of death in any emergency situation. The others are diarrhoea, malnutrition, measles and malaria. Even in non-emergency situations, chest infections are probably second only to diarrhoea in terms of the number of deaths they cause in developing countries.
The most serious type of chest infection is bronchopneumonia. It affects young children, and may start as a simple cold. Then the lungs become affected and the child has a high fever, cough, and can be seen to be breathing rapidly. Listening to the chest with a stethoscope one hears sounds like sandpaper on wood - these are called crepitations, and are quite distinct from the gentle breath sounds of a normal chest. Any child with bronchopneumonia is at serious risk of death.
How pneumonia kills
Often pneumonia starts as a simple cold which goes down onto the chest. There, the virus causes inflammation of the lung tissue, and this allows any bacteria that are there to get past the local immune defences and set up a secondary infection. This is especially likely to happen if the child is already weakened from malnutrition. This bacterial infection then spreads quickly through the child's lungs.
The air sacks of the lungs fill with fluid, which may thicken into phlegm. This prevents air exchange between the lung and the blood. The child is thus starved for oxygen, and struggles to breathe. The disease progresses quickly, and often a child who had a mild cough in the morning will be gravely ill by the night. Without treatment the end is inevitable. Death occurs because of asphyxiation.
Managing an outbreak
Chest infections can occur at any time if the year but they are more common during the cold months. Even in hot climates, such as the Sahara desert and the Sahel region of Africa, temperatures can drop very low at night. MSF teams have found high rates of bronchopneumonia among nomad children in countries such as Mauritania and Mali. Because chest infections can be fatal to a child so quickly it is essentially that antibiotic treatment should be given early.
This may be difficult in isolated rural situations, where people may be several days' walk from the nearest dispensary or hospital. The solution found by MSF teams is to train community health workers to diagnose and treat chest infections. These health workers may have only minimal medical skills and knowledge and they are not able to use a stethoscope. They are taught to diagnose bronchopneumonia by the signs of fever, cough, and rapid breathing. If the child is breathing at a rate of 40 or more breaths per minute, this is probably pneumonia and the child should be started on an antibiotic.
If, in addition, there is chest indrawing, which means that with each inspiration the skin above or below the rib cage is drawn in, this is a sign of severe pneumonia. In this case the child must be started on the antibiotics and sent on to the nearest dispensary or hospital.
Preventing pneumonia
It is difficult to prevent chest infections because the micro-organisms that cause them are spread by coughing and sneezing. Especially in the crowded conditions of a refugee camp these germs can spread quickly.
MSF teams generally try to work on the problem from several different directions:
- in refugee camps, advocacy with the authorities and the United Nations in order to have more space for the refugees. A minimum dwelling area of 3.5 square metres per person is recommended. In some camps people have only one quarter of this standard and in such conditions of crowding infections spread very quickly;
- advocacy also for provision of adequate blankets and clothing to refugees. It is generally the responsibility of the United Nations to organise this;
- health education of families on the importance of adequate ventilation in their dwellings. In many cultures the cooking fire burns all day and is inside the hut - for people living there the smoke irritates the linings of the respiratory tract, making it more vulnerable to infection;
- early treatment of cases of pneumonia so as to limit the period of infectivity;
- prophylactic (preventive) treatment with vitamin A every 3 months for all children. As well as preventing blindness due to vitamin A deficiency, this treatment helps protect the lungs against pneumonia. An example - Preventing chest infections among the Kurds Historically, most refugee emergencies in the past thirty years have occurred in hot climates. One of the major exceptions has been the exodus of Kurds from Iraq. Refugees entered Iran and Turkey on several occasions in the late 1980s and early 1990s, and most massively during the Gulf War. The winters in these areas are extremely harsh, with temperatures well below zero and heavy falls of snow. The Kurdish refugees were at risk not only of pneumonia but also of sheer cold exposure, known as hypothermia. To protect them required the urgent collaboration of the local authorities, the United Nations and medical staff to provide:
- thermal underwear and other warm clothing
- diesel-powered heaters to blow warmed air into tents
- cooking fuel so that people could have fires
- rapid treatment of chest infections with antibiotics
How MSF teams treat pneumonia patients
Ideally, a child with bronchopneumonia should be admitted to hospital for treatment and observation. In practice, however, this is not always possible, especially in isolated rural areas. MSF teams will often treat milder cases on an outpatient basis, which means that the child is given enough treatment for one day and its mother is requested to return for follow-up in the morning. Most cases of bronchopneumonia respond well to antibiotics. The ones used most commonly in the field are penicillin, ampicillin, and cotrimoxazole.
These are all relatively cheap and MSF teams stock them in all their dispensaries and hospitals. If the child is too ill to take them by mouth an MSF nurse of doctor will set up an IV drip to give the antibiotics through the vein. Alternatively, some forms of penicillin can be given by an intramuscular injection. Cough mixtures are not used, because they tend to suppress the cough reflex and thus prolong the pneumonia.
Instead, MSF nurses teach the mothers how to perform simple chest physiotherapy on their children. They lie the child face down over their lap and pat its back with a cupping action of the hands. This helps loosen the phlegm so that the child can clear it from its chest and breathe more easily.