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Managing childhood infectious diseases


12 Oct 2011

Measles, mumps and rubella infections were virtually eliminated in the UK following the introduction of vaccines against these diseases, and in 1987 they were combined into a triple vaccine – MMR. However, uptake fell and incidence of these diseases rose dramatically following publication in 1998 of a research article claiming a link, which has since been disproven, between the vaccine and bowel disorders and autism. In recent years vaccination rates have slowly risen again and incidence of these infections has fallen back to low levels.

Before the introduction of vaccines childhood infection with these three diseases was considered to be inevitable and most children recovered without complications. But they are not trivial conditions – measles and mumps can have serious long-term consequences. And while rubella is a relatively mild illness, if it is contracted during the first 16 weeks of pregnancy it can cause congenital abnormalities in the foetus leading to deafness, heart disease and eye defects, amongst other possible problems. Other infectious diseases which have been virtually eliminated by vaccination in recent years include polio, haemophilus influenzae type b (Hib), meningitis C and pneumococcal pneumonia. Vaccination is also provided against tetanus and against human papilloma virus, two strains of which are involved in the development of cervical cancer. Chickenpox is the only common childhood infectious disease for which there is no mass vaccination in the UK.

Although levels of infectious disease in children have fallen substantially, community pharmacists still have an important role in helping to detect and deal with these illnesses as they still sometimes occur, particularly in children who have not been vaccinated, and in the early stages most conditions exhibit symptoms similar to those of minor, self-limiting illnesses. Parents and carers also want to know, if their child has contracted an infectious disease, for how long to keep them away from other children to prevent it spreading. In many cases the only treatment is symptomatic relief with OTC medicines and a GP may refer a patient back to the pharmacist for these (See Clinical features and treatment for treatment options).

Notifiable diseases
There is a list of about 30 diseases that medical practitioners are required by law to report to their local authority, from where reports are passed on to the Health Protection Agency. The intention is to monitor diseases and provide authorities with early warning of possible outbreaks. The list includes all the conditions mentioned in this article except chickenpox and human papilloma virus infection. If a pharmacist suspects that a child may have a notifiable disease, he or she must refer on to a doctor.

Alan Nathan
Pharmacy writer and consultant

Causes, epidemiology and modes of transmission of common childhood infectious diseases
(Cause~Epidemiology~Transmission)

  • Chickenpox; Varicella-zoster virus, More than 90% of the population have had chickenpox by age 15. Peak incidence is between 5-9 years of age. Airbourne respiratory droplets, direct personal contact with vesicle fluid, or contact with infected articles.
  • Haemophilus influenza (bacterial meningitis); Haemophilus influeznae type B (Hib) Primarily affects children under 2 years, peak frequency in infants 6-9 months. Through coughing, sneezing or close contact with an infected person.
  • Measles; Singled-stranded RNA morbillivirus, see main text for epidemiology. Airborne via respiratory droplets. Virus can remain viable on surfaces for up to two hours, removing need for direct person-to-person contact.
  • Mumps; Paramyxovirus, see main text for epidemiology. Droplets spread in saliva via close personal contact, eg kissing.
  • Rubella; RNA togavirus, Affects mainly young children aged 4-9 years (see also main text.) Airborne droplets between close contacts.

Clinical features and treatment

    • Chickenpox:

Clinical features; Fever, headache, backache, sore throat and general malaise may precede rash by up to six days, Rash typically begins on the face and scalp and spreads to the trunk and limbs. Skin lesions are vesicles with surrounding erythema, which develop into pustules that crust over before healing. Usually intensely itchy and appear in successive crops over 3-4 days. The rash may also extend to mucous membranes in the mouth, producing multiple aphthous-like ulcers. Total healing time for the rash is around 16 days.
Treatment; Referral to a doctor usually not necessary. Paracetamol* or ibuprofen for systemic symptoms and to reduce fever. Crotamiton cream or lotion or calamine lotion can be applied to relieve itch. Antihistamines (chlorphenamine [from one year] and promethazine [from two years]) can be given for itch and sedation. Keep skin clean to prevent secondary bacterial infection.

    • Measles:

Clinical features; Prodromal illness with fever, coryza, conjunctivitis, cough and irritability. Small, greyish, irregular lesions surrounded by an erythematous base (Koplik spots) occur on the inside of the cheeks. A maculopapular rash appears after 3-5 days, firstly behind the ears, then down the body and becoming confluent, and fading by the third day.
Treatment; Paracetamol or ibuprofen.

    • Mumps:

Clinical features; Pain at or near the angle of the jaw, and fever in small children. Swelling causes distortion of the face and neck. Skin over the parotid gland is hot and flushed but there is no rash. With severe swelling, the mouth cannot be opened and is dry because the salivary ducts are blocked. Discomfort lasts for 3-4 days but may be prolonged when one side clears and the other side swells.
Treatment; Paracetamol or ibuprofen.

    • Rubella:

Prodromal symptoms: fever, headache, malaise and upper respiratory symptoms. A pink macular rash then develops on the face and spreads to trunk and limbs over 1-2 days, fading completely within four days. There may also be swollen lymph glands (lymphadenopathy) and grittiness and redness of the eyes. (Any adult female presenting with these symptoms should be referred.)
Treatment; Paracetamol or ibuprofen.

  • Pertussis:

Clinical features; Illness progresses in three phases: catarrhal – symptoms of mild respiratory infection including sneezing, runny eyes and fever. After 1-2 weeks progresses to a paroxysmal coughing stage; catarrhal symptoms wane and a dry, hacking cough starts. Prolonged coughing episodes may be followed by the characteristic ‘whoop’. The child chokes, gasps and flails the extremities, with eyes bulging and watering and face reddened. The ferocity of coughing may cause vomiting and subconjunctival haemorrhages, and the child is often left exhausted. Cough is very persistent for long after infection is past and may last for 2-3 months.
Treatment; Although a bacterial disease, antibiotics do not alter its clinical course once established. But, erythromycin, clarithromycin or azithromycin, for 7-14 days, may shorten the infectious period. These are also useful as prophylaxis for people who have been in contact with the disease.

  • Meningitis:

Clinical features; Rapid development of fever, reduced alertness, lethargy, headache, neck ache, stiff neck, nausea and vomiting. In babies and young children, in addition to fever, early signs are severe pain in the legs or hands, hands and feet unusually cold, and/or the skin becomes pale and lips may appear blue.
Treatment; If meningitis suspected, refer urgently to A&E.

Incubation periods and length of infectiousness of common infectious illnesses
(incubation period~How long infectious~Keep off school/nursery until)

  • Chickenpox: 11-20 days, up to four days before to five days after rash appears, five days from apearance of rash
  • Measles: 9-19 days, Five days from onset of rash, Six days from onset of rash
  • Mumps: 15-24days, 10-29days infection, Five days from onset of swelling
  • Rubella: 13-20 days, one week before to approximately four days after onset of rash.

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