Surveillance of Acute Respiratory Infections: Meeting of the Technical Advisory Group

The first meeting of the Technical Advisory Group on Acute Respiratory Infections (ARI) was held in Geneva, Switzerland, March 7-11, 1983. In keeping with the targets of the Seventh General Program of Work, the Group discussed the feasibility and guiding principles of controlling ARI based on information now available and advised on priorities and strategies for the program.

The Group concluded that, during the past few years, considerable progress had been made in understanding the ARI problem and its susceptibility to intervention. In particular, the importance of bacteria rather than viruses as the principal cause of mortality from severe acute lower respiratory infections in developing countries is now clear; the effectiveness of antimicrobial and supportive treatment may avert these deaths; existing clinical experience has been consolidated into simple case-management plans; and the primary health care (PHC) infrastructure required to utilize these plans is being strengthened rapidly. The Group concluded that sufficient knowledge and technology were already available for countries to phase in an ARI control program.

The ARI control program, consisting of both a service and a research component, should be started by introducing simple measures at the PHC level and should progressively provide technical support at higher levels.

The Group recommended that the service component of the ARI program comprise three control measures that offer immediate potential benefits for children in developing countries:

1. Improved and standardized case-management at both the PHC and

referral levels, which includes early discrimination of mild and severe ARI by families and PHC workers, supportive measures, and antimicrobial treatment.

2. Health education of families and community involvement in child-care practices related to ARI and, in particular, strengthening of the ability of mothers to recognize early the severe forms of ARI and to provide appropriate supportive care for sick children.

3. Immunization against measles, diphtheria, pertussis, and tuberculosis, which is already part of the Expanded Program on Immunization (EPI) but which should combine with the ARI control program, as these diseases contribute heavily to ARI childhood mortality in many developing countries.

Research in the ARI program is considered essential for strengthening the service component and particularly its further development, implementation, and evaluation. Health systems research, considered a priority, should emphasize the following: 1) improved PHC through case-management of ARI; 2) development and evaluation of a simple management-oriented classification of ARI; 3) development of procedures for providing case-management at different levels of health care; 4) generation of community involvement; 5) improvement in child-care practices.

Institution-based studies relating to detailed clinical classification; development of new, and evaluation of available, rapid laboratory techniques for diagnosis; controlled treatment trials; and studies on immunology and pathophysiology of ARI should precede and complement epidemiologic studies relating to clinical and microbiologic aspects, determinants of morbidity and mortality, identification of high-risk groups, and social and behavioral determinants of ARI.

The Group recognized that, although the development of an ARI control program is a national responsibility, bilateral and multilateral international cooperation will initially be needed to overcome obstacles to program development. In addition, national seminars will be required for health administrators and trainers to provide them with the knowledge and skills necessary to initiate the ARI control program. Provisions should be made for the training of PHC workers in the case-management of ARI, and for the education of community leaders, schoolteachers, and families in the recognition and home care of children with ARI. The development of suitable manuals should be considered a priority. Within PHC, the ARI control program should develop linkages with other relevant programs, particularly with the EPI, the Diarrheal Diseases Control Program, and Maternal and Child Health programs because they share common objectives, address the same target population, can be of benefit to each other, and produce a multiplier effect. Common needs in service delivery, research and service component evaluation, supervision of PHC workers, and training should be identified.

Surveillance should constitute an integral part of the program. In selected areas a program-oriented surveillance system containing epidemiologic and laboratory components should be established. Surveillance and monitoring should be used as management tools in strengthening the national ARI control program. Reported by WHO Weekly Epidemiological Record 1983;58:117-8.

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