Post on 10-Apr-2015
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Session 2
IMCI Overview
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Learning Objectives
By the end of the session, the students will be able to:
(1)explain the rationale for integrated
management of childhood illnesses;
(2) specify the objectives of IMCI;
(3) describe the different components of IMCI;
(4) enumerate the benefits of IMCI
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Distribution of 10.5 million deaths among children less than 5 years old in all developing countries, 1999
Malaria
Diarrhea
Measles
Pneumonia
Perinatal
OTHERS
Undernutrition54%
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Stagnating Decline in Childhood Mortality Rates – Philippines, 2003 NDHS
Figure 1: Trend in Early Childhood Mortality Rates
26
18 17 1719
14 13
46
3431 30
12
72
52
43 42
16
28
19
12
0
20
40
60
80
1988 1993 1998 2003
Survey Period, NDHSNeonatal Mortality Postneonatal Mortality Infant Mortality
Child Mortality Under-fiv e Mortality
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Causes of Deaths among Children Under Five Years Old
Top Ten Leading Cause of Underfive Mortality 2000 Philippine Health Statistics
7.68.3
10.611.5
16.822.7
24.230.4
31.751.6
0 10 20 30 40 50 60
perinatal causesmalignant neoplasm
congeninital anomaliesmeningitis
diarrheanutritional disorders
measlessepticemiaaccidents
pneumonia
no. of Underive Deaths Per 1000LB
Source: 2000 Philippine Health Statistics
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Situation in First-Level Health Facilities
overlap of conditions irregular flow of patients diagnostic tools are minimal or non-existent drugs and equipment are scarce health workers have few opportunities to
practice complicated clinical procedures relies on history and signs and symptoms
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Features of IMCI…
not necessarily dependent on the use of sophisticated and expensive technologies
a more integrated approach to managing sick children
move beyond addressing single diseases to addressing the overall health and well-being of the child
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Features of IMCI…
careful and systematic assessment of common symptoms and specific clinical signs to guide rational and effective actions
integrates management of most common childhood problems (pneumonia, diarrhea, measles, malaria, dengue hemorrhagic fever, malnutrition and anemia, ear problems)
includes preventive interventions
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Features of IMCI…
adjusts curative interventions to the capacity and functions of the health system (evidence-based syndromic approach)
involves family members and the community in the health care process
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Objectives of IMCI
(1) reduce deaths and the frequency and severity of illness and disability; and
(2) contribute to improved growth and development
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IMCI Components
1. Improving case management skills of health workers
– standard guidelines– training (pre-service/in-service)– follow-up after training– role of private providers
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IMCI Components
2. Improving the health system to deliver IMCI
– essential drug supply and management– organization of work in health facilities– management and supervision– referral system
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IMCI Components
3. Improving family and community practices
– for physical growth and mental development– for disease prevention– for appropriate home care– for seeking care
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IMCI Components
3. Improving family and community practices
-For physical growth and mental development Breastfeeding Complementary feeding Micronutrient supplementation Psychosocial stimulation
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IMCI Components
3. Improving family and community practices - For disease prevention
immunizationhandwashingsanitary disposal of fecesuse of insecticide-treated bednetsdengue prevention and control
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IMCI Components
3. Improving family and community practices
- For appropriate home care continue feeding increase fluid intake appropriate home treatment
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IMCI Components
3. Improving family and community practices
- For seeking careFollow health workers adviceWhen to seek carePrenatal consultationPostnatal (postpartum) consultation
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The Integrated Case Management Process
Treatment•treat local infection
•give oral drugs•advise and teach
caretaker•follow up
Outpatient Health Facility
Home
Caretaker is counselled on:
•home treatment•feeding &fluids•when to return
•immediately•follow-up
•check for danger signs•assess main symptoms
•assess nutrition and Immunization status and potential feeding problems
•Check for other problems•classify conditions and
• identify treatment actions
Outpatient Health Facility
Urgent referral•pre-referral treatment
•advise parents•refer child
Outpatient Health Facility
•emergency triage &treatment
•Diagnosis & treatment•monitoring & ff-up
Referral facility
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Target Groups
Sick young infant– 1 week up to 2 months
Sick young children– 2 months up to 5 years
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Assessing the Sick Child
General Danger Signs
• lethargy or unconsciousness• inability to drink or breastfeed
• vomiting
• convulsions
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Checking the Main Symptoms
- cough and difficult breathing
- diarrhea
- fever
- ear problem
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Checking the Main Symptoms
1. Cough or difficult breathing
3 clinical signs– Respiratory rate– Lower chest wall indrawing– Stridor
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Checking the Main Symptoms
2. Diarrhea Dehydration
– General condition– Sunken eyes– Thirst– Skin elasticity
Persistent diarrhea Dysentery
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Checking the Main Symptoms
3. Fever Stiff neck Risk of malaria and other endemic
infections, e.g. dengue hemorrhagic fever
Runny nose Measles Duration of fever (e.g. typhoid fever)
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Checking the Main Symptoms
4. Ear problems Tender swelling behind the ear Ear pain Ear discharge or pus (acute or
chronic)
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Checking Nutritional Status, Feeding, Immunization Status
Malnutrition – visible severe wasting– edema of both feet– weight for age
Anemia– palmar pallor
Feeding and breastfeeding Immunization status
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Assessing Other Problems
Meningitis Sepsis Tuberculosis Conjunctivitis Others: also mother’s (caretaker’s) own health
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IMCI Essential Drugs and Supply
Appropriate antibiotics Quinine Vitamin A Paracetamol Oral antimalarial Tetracycline eye ointment ORS Mebendazole or albendazole Iron Vaccines Gentian violet
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Benefits of IMCI
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Changes in Weight-for-Age (Z-score) of children after consultation by health worker
8 days 45 days 180 days
0
0.05
0.1
0.15
0.2
-0.05
-0.1
-0.15
-0.2
by IMCI-trained health workers
by untrained health workers
* The 0 point represents the initial weight-for-age value, 8 days after the consultation. Positive Z-score values indicate improvement in nutritional status, and negative Z-score values indicate that children are not adequately gaining weight.
Changed Z-score*
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0
5028
9588
93
0
20
40
60
80
100
Comprehensiveassessment
Nutritional evaluation Review of vaccinationstatus
Before (1997) After (1999)
Quality of Care Improves With Introduction of IMCI
Proportion of children receiving
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IMCI Reduces Antibiotic Abuse Rate in Morocco
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12
0
10
20
30
40
50
Health worker NOTusing IMCI (n=132)Health worker usingIMCI (n=147)
%Proportion of sick children who received unneeded prescription of antibiotics:
33
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Comparison of Drug Use and Costs Based on Assessment of 1226 Sick Children
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77
28
95
5
0.4
82
11
56
11
53
39
8
17
drugs prescribed
% of cases prescribed:
- antibiotic
- injection
- >1 drug
- one drug
- no drug
Drug costs (US cents)
Doctors: current practice
Medical assistants using IMCI guidelines
Number of different
* Conditions not covered by IMCI were excluded (Unpublished data from Black, et al; not for citation)
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127
70
49
0
20
40
60
80
100
How to give oral medicines At least two danger signs
Before (1997) After (1999)
Proportion of mothers leaving health facility who reported correctly:
(4/33)
(17/35)
(4/57)
(56/80)
Mothers Leave the Facility Better Able to Care for their Child.
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Experience with IMCI in “Well Baby” Clinic, Bolivia 1999
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Cost-effective Packages of Public Health Interventions and Essential Clinical Services
Source: World Bank Development Report, Investing in Health, 1993
14%
6%
4%
3%
2%
1%
1%
Management of the sick child
EPI Plus
Prenatal and delivery care
Family planning
AIDS prevention programme
Treatment of STD's
Short-course chemotherapy for TB
DALY = Disability-adjusted life year
Annual cost per DALY
US$
40.0
14.5
40.0
25.0
4.0
2.0
4.0
Annual costper capita
US$
1.6
0.5
3.8
0.9
1.7
0.2
0.6
Proportion of total global disease burden averted