Acute respiratory infections (ARIs) are classified as upper res-piratory tract infections (URIs) or lower respiratory tract infec-

tions (LRIs). The upper respiratory tract consists of the airwaysfrom the nostrils to the vocal cords in the larynx, including

theparanasal sinuses and the middle ear. The lower respiratorytract covers the continuation of the airways from the

tracheaand bronchi to the bronchioles and the alveoli. ARIs are notconfined to the respiratory tract and have systemic

effectsbecause of possible extension of infection or microbial toxins,inflammation, and reduced lung function. Diphtheria,

per-tussis (whooping cough), and measles are vaccine-preventablediseases that may have a respiratory tract component but

alsoaffect other systems; they are discussed in chapter 20.

Except during the neonatal period, ARIs are the most com-mon causes of both illness and mortality in children under

five,who average three to six episodes of ARIs annually regardless ofwhere they live or what their economic situation is

(Kamathand others 1969; Monto and Ullman 1974). However, the pro-portion of mild to severe disease varies between high-

and low-income countries, and because of differences in specific etiolo-gies and risk factors, the severity of LRIs in children

under fiveis worse in developing countries, resulting in a higher case-fatality rate. Although medical care can to some extent

mitigateboth severity and fatality, many severe LRIs do not respond totherapy, largely because of the lack of highly effective

antiviraldrugs. Some 10.8 million children die each year (Black, Morris,and Bryce 2003). Estimates indicate that in 2000, 1.9

million ofthem died because of ARIs, 70 percent of them in Africa andSoutheast Asia (Williams and others 2002). The World

HealthOrganization (WHO) estimates that 2 million children underfive die of pneumonia each year (Bryce and others 2005).

CAUSES OF ARIS AND THE BURDEN OF DISEASE

ARIs in children take a heavy toll on life, especially where med-
ical care is not available or is not sought.
Upper Respiratory Tract Infections

URIs are the most common infectious diseases. They includerhinitis (common cold), sinusitis, ear infections, acute pharyn-

gitis or tonsillopharyngitis, epiglottitis, and laryngitis—ofwhich ear infections and pharyngitis cause the more

severecomplications (deafness and acute rheumatic fever, respec-tively). The vast majority of URIs have a viral

etiology.Rhinoviruses account for 25 to 30 percent of URIs; respiratorysyncytial viruses (RSVs), parainfluenza and influenza

viruses,human metapneumovirus, and adenoviruses for 25 to 35 per-cent; corona viruses for 10 percent; and unidentified

viruses forthe remainder (Denny 1995). Because most URIs are self-limit-

ing,theircomplicationsaremoreimportantthantheinfections.Acute viral infections predispose children to bacterial infectionsof

the sinuses and middle ear (Berman 1995a), and aspirationofinfected secretions and cells can result in LRIs.

Acute Pharyngitis.Acute pharyngitis is caused by viruses in

more than 70 percent of cases in young children. Mild pharyn-geal redness and swelling and tonsil enlargement are

typical.Streptococcal infection is rare in children under five and morecommon in older children. In countries with crowded

livingconditions and populations that may have a genetic predispo-sition, poststreptococcal sequelae such as acute rheumatic

feverand carditis are common in school-age children but may also

occur in those under five. Acute pharyngitis in conjunctionwith the development of a membrane on the throat is nearlyalways

caused by Corynebacterium diphtheriae in developingcountries. However, with the almost universal vaccination ofinfants with

the DTP (diphtheria-tetanus-pertussis) vaccine,diphtheria is rare.

CONCLUSIONS: PROMISES AND PITFALLS

The evidence clearly shows that the WHO case-managementapproach and the wider use of available vaccines will reduceARI

mortality among young children by half to two-thirds. Thesystematic application of simplified case management alone,the

cost of which is low enough to be affordable by almost anydeveloping country, will reduce ARI mortality by at least one-third.

The urgent need is to translate this information intoactual implementation.

The case-management strategy has to be applied andprospectively evaluated so that emerging problems of antimi-crobial

resistance, reduced efficacy of current treatment withthe recommended antimicrobials, or emergence of

unexpectedpathogens can be detected early and remedial steps can be takenrapidly. If community-level action by health

workers is supple-mented by the introduction of the IMCI strategy at all levels ofprimary care, then both applying and

evaluating this strategywill be easier. Such synergy may also help in gathering infor-mation that will help further fine-tune

clinical signs, so thateven village health workers can better distinguish bronchiolitisand wheezing from bacterial pneumonia.

The criticism that thecase-management steps may result in overuse of antimicrobialsshould be countered by documenting

their current overuse andincorrect use by doctors and other health workers. Althoughthere is a resurgent interest in basing

interventions at the com-munity level, our analysis suggests that doing so may not becost-effective. Indeed, ARI case

management at the first-levelfacility may still be the most cost-effective when coupled withbetter care-seeking behavior

interventions.

The international medical community is only beginning toappreciate the potential benefits of Hib and pneumococcal vac-

cines. They are currently expensive compared with ExpandedProgram on Immunization vaccines, but the price of Hib

vaccine may fall with the entry of more manufacturers into themarket in the next few years. Nevertheless, convincing

evidenceof the vaccines’ cost-effectiveness is required to facilitatenational decisions on introducing the vaccine and using it

sus-tainedly. In low-income countries, positive cost-benefit andcost-effectiveness ratios alone appear to be insufficient

toenable the introduction of these vaccines into national immu-nization programs