Management of Prevalent Infections in Children Following a Disaster

The only vaccine that must be routinely administered during immediate emergency relief efforts is measles. A routine immunization program for other vaccines should only be considered if the population is expected to stay in the area for longer than 3 months, if it is possible to keep appropriate records, and if other assistance efforts are not disrupted or compromised by the activities needed for vaccination.

Tetanus

Tetanus immunization is not routinely recommended in disaster situations, but if the vaccine is available, it is reasonable to apply it prophylactically to individuals who have tetanus-prone wounds if the time of the last tetanus immunization is unknown or greater than 5 years, or when the child has not received the primary 3-dose vaccination series. The characteristics of tetanus-prone wounds are a wound that was first cleaned more than 6 hours after its occurrence; irregular wounds; wounds from bullets, crushing, burns, or frostbite; and presence of devitalized wound contaminants.

Specific situations requiring prophylaxis

Pertussis

The vaccine. It is well established that pertussis vaccine provides clinical protection after exposure to the disease in most people. The effectiveness of the vaccine with a regimen of 3 or more doses is around 80% to 90%. Appropriately immunized children who acquire the disease have milder symptoms and fewer complications.

Management of outbreaks. When an increase in the number of cases is suspected, mass immunization is a priority in children under 7 years old. If disease rates are higher among children over 7 years old and adolescents, use of acellular vaccines may be considered.

Household contacts—vaccination. Household contacts and other close contacts of patients under 7 years old who have had at least 4 previous doses of diphtheriatetanus-pertussis vaccine (DTP or DTaP) must receive a booster injection of DTP or DTaP, unless they have received a dose within the past 3 years. Children under 7 years old who have not been immunized or who have previously received less than 4 doses must start or continue their vaccination regimen according to the national program. A fourth dose must be administered to children who received their third dose 6 or more months before exposure.

Chemoprophylaxis. All household contacts and other close contacts, regardless of their age or immune status, should receive erythromycin (40-50 mg/kg/day orally, divided in 4 doses), for 14 days because immunity after vaccination is not total and infection may not be prevented. It has been proven that erythromycin eliminates the carrier state and is effective in limiting secondary spread. For patients who are intolerant to erythromycin, clarithromycin (15 mg/kg/day orally divided in 2 doses, for 1 week) may be administered; other options are azithromycin and trimethoprim-sulfamethoxazole.

Diphtheria

The vaccine. In diphtheria, as in tetanus, immunity relies only on the presence in blood and interstitial fluids of antitoxin IgG antibodies with titers ≥0.01 IU/mL. These antibodies work locally, where the toxin is released by the bacteria, and in blood against the toxin that reaches the circulation. After primary immunization with 3 doses of toxoid, antitoxin titers above 0.01 IU/mL can be found for 5 or more years, and after one or more booster injections they persist for 10 years. In clinical practice, vaccination has shown an efficacy rate above 99%.

Management of outbreaks. When cases of diphtheria are suspected, mass vaccination is indicated, taking into account the rates of incidence by age groups.

Household contacts—vaccination. Asymptomatic contacts whose immunization regimen is complete and who have received their last dose more than 5 years ago must receive a DTP or dT booster according to their age. Close asymptomatic contacts whose immunization regimen is incomplete (<3 doses of diphtheric toxoid) or whose immunization status is unknown must receive a dose and complete the schedule.

Chemoprophylaxis. Whatever their immunization status, close contacts must be kept under surveillance for 7 days to detect any evidence of the disease, have cultures taken for Corynebacterium diphtheriae, and receive antimicrobial prophylaxis with oral erythromycin (40-50 mg/ kg/day for 7 days, with a maximum of 2 g/day) or a single intramuscular (IM) dose of penicillin G benzathine (600,000 IU for those <30 kg and 1.2 million units for older children and adults). Obtain new throat cultures in contacts identified as carriers within 2 weeks after completion of treatment.

Meningococcal disease

Few infectious diseases cause as much concern among the general population and health workers as meningococcal infection. The estimated attack rate for household contacts is 4 cases per 1,000 exposed persons. This is 500 to 800 times higher than rates in the general population.

Chemoprophylaxis is indicated for those individuals who meet the criteria for close contacts. The goal is to eradicate N. meningitidis carriers and prevent the occurrence of secondary cases.

• Close contacts: household members, attendees at child care centers, nursery schools, schools, universities, and members of closed communities that are in contact with any individual with mening ococcal disease for more than 4 hours daily, 5 days a week; any other person directly exposed to oral secretions of the patient (e.g., sharing tableware, drinks, kisses; sneezing or coughing).
• Secondary case: any case occurring in a close contact 24 hours or more after onset of the disease in the primary case. Because there is a high rate of secondary disease during the 5 days following contact, give chemoprophylaxis within the first 24 hours. It is not indicated beyond 14 days. A nasopharyngeal culture to determine the need for chemoprophylaxis is not warranted. If the patient was treated with third generation cephalosporins, chemoprophylaxis before discharge is not needed. Rifampin is the first choice agent for chemoprophylaxis in children, but there are alternatives for adults (Table 4). Chemoprophylaxis is indicated for household members and contacts (Box 5). Monitor exposed individuals and assess if they have a febrile disease.

IM: Intramuscular.

The vaccine: immunogenicity and effectiveness. With unconjugated polysaccharide vaccines, protection is achieved 7 to 10 days after immunization. Bivalent A + C vaccine is safe and effective (85% to 90%) in children older than 2 years old and in adults. The A component induces an immune response from 3 months of age on, with a seroconversion rate of 88% after the second dose, applied in children between 7 and 12 months old.

Management of outbreaks. An outbreak of meningococcal disease is defined when the attack rate is higher than 10 cases in 100,000 persons, in a specific area, with an epidemiologic relation among cases, and with a predominating serogroup. With active epidemiologic surveillance, an outbreak is also considered when the incidence rate by age is doubled.

Where can outbreaks occur? Outbreaks can occur in an institution or an organization. In this case, an outbreak is defined by 3 or more confirmed, presumptive, or probable cases occurring in a period of 3 months or less within the same institution or organization, but without close contacts (e.g., schools, universities, military organizations, jails).

Community outbreaks are defined by 3 or more confirmed, presumptive, or probable cases that occur in 3 months or less among people who live in the same area and are not close contacts (e.g., small towns, cities, countries).