Child Health - Community-acquired infectious diseases

Preventing the unnecessary spread of common viral diseases requires clear and accurate advice for parents, writes Siobhan MacDermott

Community-acquired infectious disease in childhood can range from a mild illness of short duration to a severe and life-threatening infection. Common pathogens such as rhINOvirus and enterovirus are increasingly seen in children with more serious diseases such as asthma and cystic fibrosis exacerbations, and meningitis.1

Communication regarding incubation periods, transmission of disease, contact avoidance and immunisation availability is fundamental to the management of such infections. In addition recent advances have improved our ability to treat such infection.1

Common viral diseases in childhood
Name Description Transmission Avoidance of contact Immunisation
Respiratory syncytial virus (RSV) Bronchiolitis, pneumonia or upper respiratory illness Spread by direct and indirect contact Nosocomial Strict isolation. Viral shedding can last for 7 (up to 21 days) Not currently available. High risk infants born during RSV season can be offered IM injectipalivizumab (Synagis) giving some antibody protection
Fifth disease (Parvovirus B19) Red hot rash appears on face (slapped) cheeks followed by maculopapular type rash on body   No need to keep children out of school due to mild nature once rash appears Development of a vaccine is feasible but there is no commercial Thought to be non infectious interest7
Varicella zoster virus (chicken pox) Small itchy dark red spots that appear in crops over 3-4 days Spread by droplet infection, occasionally after rash appears3 indirect contact and airborne transmission Children advised not to attend school 5-7 days on named patient basis only. A live attenuated vaccine available (licensed in US since 1995), not licensed in UK or Ireland. Available on named patient basis only. Indications are immunocompromised children
Roseola infantum Rose pink maculopapular eruption on neck and trunk Highly contagious. Spread by droplet infection Can return to childcare once temperature is normal Self limiting disease No known vaccine

Some of the more common community-acquired childhood infections are highlighted in this article and preventative measures are outlined. This article focuses on non-vaccine preventable diseases and discusses ways to identify and prevent such disease in children.

Respiratory syncytial virus (RSV)
RSV is a common respiratory tract pathogen that can cause significant morbidity. Outbreaks tend to occur annually in winter and spring but it can occur throughout the year. By the age of three most children worldwide have been infected by RSV, in the form of an upper respiratory tract infection, bronchiolitis or pneumonia.3 Primary infection in children less than six months carries a greater mortality, particularly in those with chronic cardiac disease.

For children at risk, early identification and isolation is essential. It is spread through coughing and sneezing and can survive up to six hours on hands and the surfaces of environmental objects.

Education and communication plays a major role in the control of RSV infection. Parents of at-risk children should be advised on isolation procedures such as hand-washing, cleaning and disinfecting infant toys, separate bedrooms for infants and school-going children, and avoiding crowded areas such as crèches and shopping centres, especially during RSV season.

While the significance of RSV as a respiratory pathogen has been recognised for more than 30 years, a vaccine is not yet available because of several problems associated with RSV vaccine development, eg. the need to immunise very young infants who may respond inadequately to vaccination.4 However, antibody cover in the form of an intramuscular injection of the licensed product palivizumab (Synagis) is available for high-risk newborn infants.

Parvovirus B19 (fifth disease)
Another common, self limiting illness in childhood includes Parvovirus B19 (erythema infectiosum), otherwise known as fifth disease.2 A relatively benign virus presents with fever, malaise, red (slapped) cheeks, followed four to14 days later by an itchy, full body rash that often lasts up to three weeks.

The name fifth disease stems from the fact that when diseases causing childhood rashes were enumerated, it was the fifth listed. The list of such diseases is:

Any age may be affected by Parvovirus B19, although it is most common in children aged six to 10 years. By the time adulthood is reached about half the population will have become immune following infection at some time in their past. Outbreaks can arise especially in crèches and schools.

Varicella-zoster virus (VZV)
This is a common benign childhood infection. VZV is a herpes virus causing the childhood disease chicken pox and shingles. Primary infection results in an acute exanthematous illness, varicella. The virus lies dormant in the dorsal root ganglia and may reactivate later as shingles when immunity in the host is lowered.3 Shingles (zoster) is always due to a reactivation of an old chicken pox (varicella) infection.

Varicella is characterised by a generalised, pruritic rash that appears in crops. It is highly contagious, spreading mainly by respiratory secretions particularly two days before the rash appears. The period of infectivity lasts until all lesions have crusted. Siblings tend to have more severe illness because of the prolonged contact.5

There is often confusion amongst parents regarding the period of infectivity of this virus. For instance contact with shingles in pregnancy poses no risk, whereas chicken pox can have a serious effect on the foetus.

Children should not attend school until five to seven days after the rash starts. Parents must also be advised to avoid contact with immunocompromised patients and pregnant women where possible, for example attending hospitals or clinics. While the management of the disease is mainly symptomatic, complications are rare but when they do occur, they can be serious.3 However, parents are often unaware of such complications.

Varicella vaccine is available but is administered on a named patient basis only, both in Ireland and the UK. Risk groups include patients with acute leukaemia in remission, awaiting transplant surgery, cystic fibrosis and those receiving immunosuppressive therapy.

Roseola infantum
Roseola infantum (sixth disease) often referred to as ‘three day fever’ is another common childhood illness that presents with a rash. The disease is caused by the human herpes virus-6. Primary infection with this virus tends to occur in infants aged six months to three years6 presenting with fever followed by the sudden appearance of a fine macular rose-coloured rash over thighs and buttocks that generally persists for about two days.

One of the lesser known childhood diseases, it is highly contagious and is often confused with measles and rubella.6

Prevention
The association between lack of hand hygiene and the transfer of infection in hospital has been long established. However the role of hand hygiene in the transfer of community-acquired viral and bacterial infection is less well appreciated, both by health professionals and the public.

Community-acquired infections are mostly disseminated by contact, therefore more attention to hand hygiene by health professionals could reduce the risk of infection in primary care settings. Greater awareness of the role of hand hygiene on the part of the general public could reduce the disease burden caused by both respiratory and enteric infections.

Clear advice to parents is vital in preventing misdiagnosis and the unnecessary spread of infection, particularly to those patients at risk.

Parents, in particular first-time parents, often have little experience of common childhood illnesses and may be reluctant to attend the GP with symptoms of fever or rash. Health education and promotion can assist parents with decisions such as when to attend general practitioners and A&E departments.

Education
Community-acquired viral infection is often the most common reason for the prescribing of antibiotics in the developed world. New developments are being sought all the time to reduce the disease burden and cost, both to the patient and society.

Health promotion campaigns for both vaccine preventable and non-vaccine preventable disease should be more accessible to parents.

Preventing the unnecessary spread of community-acquired disease in childhood requires clear accurate advice and education for parents and families. In addition with Ireland’s changing society special awareness of literacy, culture and language skills must also be taken into consideration.

Siobhan MacDermott is a nurse tutor at the Children’s University Hospital, Temple Street, Dublin

References

  1. Harley A. Rotart. Picornavirus Infections. Arch Family Med 2000; 9 (9)
  2. McCarter-Spaulding D. Parvovirus B19 in pregnancy. J Obstet Gynecologic Neonatal Nursing 2002; 31 (1)
  3. Morgan M. Management of varicella zoster. Practice Nursing 1996; 7 (16)
  4. Dudas RA, Karron RA. Respiratory syncytial virus vaccines. Clin Microbiol Rev 1998; 11 (3)
  5. McKendrick MW. Aciclovir for childhood chickenpox. Cost is unjustified. BMJ 1995; 310
  6. Dereck RT. Measles and rubella misdiagnosed in infants as exanthema subitum (roseola infantum). BMJ 1996; 312: 101
  7. Weir E. Parvovirus B19: fifth disease and more. Can Med Assoc J, Ottawa, 2005; 172 (6)

 Child Health - Community-acquired infectious diseases

 


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