©2013 MFMER | slide-1 Integrated Management of Childhood Illness (IMCI) Stephen P. Merry, MD, MPH,...

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©2013 MFMER | slide-1 Integrated Management of Childhood Illness (IMCI) Stephen P. Merry, MD, MPH, DTM&H Assistant Professor of Family Medicine Mayo Clinic, Rochester

Transcript of ©2013 MFMER | slide-1 Integrated Management of Childhood Illness (IMCI) Stephen P. Merry, MD, MPH,...

Page 1: ©2013 MFMER | slide-1 Integrated Management of Childhood Illness (IMCI) Stephen P. Merry, MD, MPH, DTM&H Assistant Professor of Family Medicine Mayo Clinic,

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Integrated Management of Childhood Illness (IMCI)Stephen P. Merry, MD, MPH, DTM&HAssistant Professor of Family Medicine

Mayo Clinic, Rochester

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Disclosures

• Financial Disclosures• None

• Off label drug use• None

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Learning Objectives

• Gain familiarity with IMCI• Epidemiology of diseases treated• Structure & method of integrated care• Treatment protocols

• Build capacity in medical missions rather than duplicate (or undermine) MOH efforts

• Complement WHO and UNICEF initiatives• Begin or support a community health program • Affirm or challenge appropriately treatment

protocols by CHW’s referring to your facility

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Background:

• Problem• Lots of kids are dying in LMIC• Two-thirds of deaths preventable*• Lack of access to health care in

LMIC• Lack of workers• Lack of patient transport, money,

awareness of potential benefit• Many other determinants…

*Jones, Lancet, 2003

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Background:

• Problems (Determinants of Child Mortality)

• Inequity• Lack of maternal education• Lack of access to care• Rural residence• Conflict/War/Disaster• Debt• Structural Adjustment Policies• Worldview

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Background:

• Solution (what we can do)• Increase workers

• More paraprofessionals• Community health workers

• Low cost• In community• Longitudinal care/follow up

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DO NOT USE THIS TALK IN ISOLATION

• Listen to Terry Dalrymple’s talk (breakout session 1:30 pm Friday) on community health evangelism

• I agree with every word he said.• IMCI is a naturalistic construct the content of

which CHE and other community based primary care initiatives can build.

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Good News

• Progress towards achieving MDG 4. • Under-five deaths worldwide declined from

12.6 million in 1990 to 6.6 million in 2012. • Translates into around 17,000 fewer children

dying every day in 2012 than in 1990.• Still implies the deaths of nearly 18,000

children under age five every day in 2012.

UN-IGME, Levels and Trends in Child Mortality, 2013.

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UN-IGME, Levels and Trends in Child Mortality, 2013.

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Where The 7 Million Children Are Dying Each Year…

http://www.worldmapper.org/posters/worldmapper_map261_ver5.pdf Accessed 10/11/10

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Where “Physicians” Work

http://www.worldmapper.org/display.php?selected=219 Accessed 10/11/10.

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©2013 MFMER | slide-1313www.Gapminder.org; downloaded in 2011 sometime…

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Institute of Medicine. The U.S. Commitment to Global Health: Recommendations for the New Administration Committee on the U.S. Commitment to Global Health. 2009.

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http://www.un.org/millenniumgoalsVideo MDG’s

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Why Be Involved

Institute of Medicine. The U.S. Commitment to Global Health: Recommendations for the New Administration Committee on the U.S. Commitment to Global Health. 2009.

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Why Be Involved

Institute of Medicine. The U.S. Commitment to Global Health: Recommendations for the New Administration Committee on the U.S. Commitment to Global Health. 2009.

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Why Be Involved

Institute of Medicine. The U.S. Commitment to Global Health: Recommendations for the New Administration Committee on the U.S. Commitment to Global Health. 2009.

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www.who.int/pmnch/media/press_materials/fs/fs_mdg4_childmortality/en/Accessed Oct 24, 2013

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Trends in Intervention Delivery in Child Health

• Mass campaigns—small pox eradication

• Primary Health Care (PHC)—comprehensive, intersectoral, prevention and treatment services, district hospital at the hub, community participation

• Selective PHC (SPHC)—focus on a few problems--GOBI

• HIV, malaria, TB

• Integrated Management of Childhood Illnesses (IMCI)

• Integrated care — viewing individual as a whole, comprehensive care of individuals

1950’s

1990’s

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Integrated Management of Childhood Illnesses (IMCI)• Strategy of World Health Organization (WHO)

and United Nations Children's Fund (UNICEF)

• Goal: improve child survival in resource poor settings via integrated approach

• reduce death, illness and disability, and promote growth and development

• preventive and curative elements • implemented by families, communities and

health facilities

Tulloch, Lancet, 1999

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WHO’s Integrated Management of Childhood Illness

• Preventive interventions• Immunizations• Breastfeeding support• Nutrition counseling (e.g. weaning foods)

• Curative interventions• Malaria• Pneumonia• Diarrheal illnesses• Undernutrition (co-factor in 1/3)• Also…serious infections (meningitis), other illnesses (vitamin A def. with measles)

Cause 70% of childhood deaths worldwide

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Features of IMCI

• Inexpensive

• Integrated management

• Not just disease treatment but promote health and well being of the child

• Careful assessment of common symptoms and signs to guide rational action

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Features of IMCI

• Manages most common diseases (pneumonia, diarrhea, measles, malaria, dengue, malnutrition, anemia, ear problems)

• Includes preventive interventions

• Adjusts curative interventions to the capacity and function of the health system

• Involves family and community in the process

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Training of IMCI Workers: Initiation

Use these training materials: http://www.who.int/maternal_child_adolescent/documents/9241595650/en/

Or this computerized one:

http://www.who.int/maternal_child_adolescent/documents/icatt/en/index.html

And THE flip chart:

http://whqlibdoc.who.int/publications/2008/9789241597289_eng.pdf

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Training IMCI PHC Workers

• Structured training course developed by WHO,

• Extensive learning materials

• Chart booklet containing all the IMCI guidelines - desk reference.

• 11 days of training • classroom work• hands-on clinical practice• competency by repetition• formative feedback from facilitators

Bull WHO, 1997

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Training IMCI PHC Workers

Lambrechts, Bull WHO, 1997

• Course director

• A detailed guide means content and activities largely consistent between different training sites and countries.

• All IMCI trained health workers receive at least one follow-up visit in their own health facility after training, to reinforce their skills and solve implementation problems

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Training IMCI PHC Workers

• IMCI facilitators • Chosen on the basis of their performance, • Attend an additional 5- day IMCI facilitators

training course.• Goal = one facilitator for every four

participants

Bull WHO, 1997

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IMCI Component 1: Improves Health Worker Skills

• Targets first level health facilities• Training• Case management guidelines for the

causes of at least 70% of deaths • Supervision• Monitoring

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IMCI Component 2: Improves Family and Community Practices

• Community participation

• Preventive care• Immunization• Breast-feeding and other nutritional counseling

• Home care of sick children

• Recognition of severe illness

• Care-seeking behavior

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IMCI Component 3: Improves Health Systems

• Planning and Management

• Availability of drugs and supplies

• Organization of work

• Monitoring and supervision

• Referral pathways and systems

• Health information systems

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Objectives of IMCI

• Reduce deaths and frequency and severity of illness and disability

• Contribute to improved growth and development

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The Integrated case management process

Outpatient health facility-Check for danger signs-Assess main symptoms- assess nutrition and immunization status and potential feeding problems - Check for other problems - Classify conditions -Identify treatment actions

Outpatient health facility Urgent referral -pre-referral treatment -Advise parents-Refer child

Referral facility -Emergency triage and treatment-Diagnosis and treatment-Monitoring and follow up

Outpatient health facility -Treatment - treat local infection- give oral drugs- advise and teach caretaker -Follow up

HOME-Caretaker is counseled on home treatment-Feeding & fluids -When to return immediately-Follow up

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www.who.int/pmnch/media/press_materials/fs/fs_mdg4_childmortality/en/Accessed Oct 24, 2013

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Basic Resuscitation Equipment

• Warm room • Two pieces of cloth

• Dry • Wrap up

• Suction bulb or DeLee• Positive Pressure Bag

(“Ambu”) and mask

From Tina Slusher, MD with gratitude

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Mostly NRP/ PALS*

Is my baby breathing?Is my baby breathing well?

IF no to either

Only after 30 seconds ofPPV with a HR < 60

20-30 seconds20-30 secondsONLY!!ONLY!!

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www.who.int/pmnch/media/press_materials/fs/fs_mdg4_childmortality/en/Accessed Oct 24, 2013

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Neonatal Sepsis

• Any deviation from normal in neonate can be sepsis:

• temperature, • (WBC, glucose) • Vomiting• Feeding intolerance• Lethargy• Respiratory distress beyond 1st hour

• Amp/Gent IV

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www.who.int/pmnch/media/press_materials/fs/fs_mdg4_childmortality/en/Accessed Oct 24, 2013

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Diarrhea Deaths Per Year

• United States: 6,000

• Developing world: 1.5 to 2 million (children < 5 years old)

World Gastroenterology Organization (WGO)

Practice Guideline Acute Diarrhea (March 2008)

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Preventing Diarrhea Deaths

• Spread• water, food, utensils, hands, flies

• Deaths• dehydration (water loss) • electrolytes/salts loss (sodium, potassium, bicarbonate)

World Gastroenterology Organization (WGO)

Practice Guideline Acute Diarrhea (March 2008)

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Lack of access to safe drinking water

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©2013 MFMER | slide-50http://www.childinfo.org/sanitation_status_trends.html

Access to Improved Sanitation Facilities

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Differentiating Diarrhea

• Watery stool• Secretory• Cholera, Viral, Giardia

• Bloody stool, tenesmus• Inflammation• Fever: Bacillary dysentery• No Fever: Amebiasis (Rx Flagyl)

World Gastroenterology Organization (WGO)

Practice Guideline Acute Diarrhea (March 2008)

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If the gut works, use it

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Oral rehydration solution (ORS)

Rice-based ORS is superior to glucose-based Rice-based ORS is superior to glucose-based ORS in patients with cholera ORS in patients with cholera

World Gastroenterology Organization (WGO)

Practice Guideline Acute Diarrhea (March 2008)

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Treatment Acute Diarrhea

• Zinc supplementation• Given during acute diarrhea episode reduces

duration and severity of episode• Given for 10-14 days reduces incidence of

diarrhea in following 2-3 months

• Selective use of antibiotics• Dysentery

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www.who.int/pmnch/media/press_materials/fs/fs_mdg4_childmortality/en/Accessed Oct 24, 2013

½ of deaths due in part to undernutrition

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Impact of Breastfeeding on Childhood Disease Risk in not BF vs exclusively BF

Diarrhea

7x risk death

Pneumonia

5x risk death

CG Victoria et al, Am J Epidemiol 1989

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Under-Nutrition

Vitamin A Deficiency

20-24% Risk of death from diarrhea, measles

AL Rice et al In: Comparative quantification of health risks, 2004

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Vitamin A

• Give to child every 6 months or with measles or malnutrition

• Helps resist measles virus infection in the eye and lining of lungs, gut, mouth and throat

• Prevents corneal clouding

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www.who.int/pmnch/media/press_materials/fs/fs_mdg4_childmortality/en/Accessed Oct 24, 2013

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Cough or Difficulty of BreathingHow IMCI Works…

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Cough or Difficulty of Breathing

• One of the most common infections among children

• May be pneumonia or a less serious respiratory infection

• Strep. pneumoniae is the most common bacterial cause

• Children can die from hypoxia or sepsis

• Check for fast breathing and chest indrawing to identify very sick children

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Cough or Difficulty of Breathing

•Any general danger sign or•Chest indrawing or Stridor in a clam child

SEVERE PNEUMONIA OR VERY SEVERE DISEASE

•Give first dose of an appropriate antibiotic•Refer URGENTLY to a hospital

Fast breathing PNEUMONIA •Give an appropriate oral antibiotic for 5days•Soothe the throat and releive the cough with a safe remedy•Advise mother when to return immediately•Follow-up in 2days

No signs of pneumonia or very severe disease

NO PNEUMONIA, COUGH OR COLD

If coughing >30days refer for assessment•Soothe the throat and relieve the cough with a safe remedy•Advise mother when to return immediately•Follow-up in 6days if not improving

SIGNS CLASSIFY AS IDENTIFY TREATMENT

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WHO IMCI• Cough

• Increased respiratory rate• ≥60 if age < 2 mos.• ≥50 if age 2-12 mos.• ≥40 if age 12 mos. to 5 years

• Lower chest retractions

• (Fever)

• Case management can reduce pneumonia associated childhood mortality by 40%

S Sazawal, et al Lancet 2003

= = PneumoniaPneumonia

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Cough or Difficulty of Breathing

If yes, ask: for how long?

LOOK LISTEN FEEL:• count the breaths in

one minute• look for chest

indrawing• look and listen for

stridor

If no, ask the next main symptoms: diarrhea, fever, ear problems

If the child is: fast breathing is:

2-12 months 50 bpm or more

1-5 years 40 bpm or more

Ask: does the child have cough or difficulty breathing?

CLASSIFY

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Treatment

Soothe the throat, relieve the cough with a safe remedy

• Safe remedies to recommend:• Breast milk for exclusively breastfed

infant; tamarind, calamines, ginger• Harmful remedies to discourage:

• Codeine cough syrup• Other cough syrups• Oral and nasal decongestants

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Treatment for Pneumonia or Very Severe Disease

Age or Weight

Cotrimoxazole

Give 2 times daily

for 5 days

Amoxicillin

Give 3 times daily

for 3-5 daysAdult tab.

80mg TMP 400mg SMX

Syrup

40mg TMP 200mg SMX

Tablet

250mg

Syrup 125mg/5mL

2-12 mos

(4-10 kg)

1/2 5.0 mL 1/2 5.0 mL

12 mos – 5 yrs

(10-19 kg)

1 7.5 mL 1 10 mL

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Empyema

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Pneumonia: Prevention

• Immunization (measles, pertussis)• Pneumococcal, H influenza soon - $$$$

• Nutrition• Exclusive breastfeeding / appropriate complementary

feeding• Vit A and Zinc through diet / supplementation

• Avoidance of indoor air pollution • E.g., Unprocessed household solid fuels (wood, dung,

coal) 1.8 x increased risk of pneumonia

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www.who.int/pmnch/media/press_materials/fs/fs_mdg4_childmortality/en/Accessed Oct 24, 2013

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Vaccine Coverage

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Using IMCI

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Using IMCI

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Using IMCI

• Peruse the paper (few minutes)

• Think about patients you’ve received from dispensaries

• Think about your own community health program (existing or future)

• Flip chart here: http://whqlibdoc.who.int/publications/2008/9789241597289_eng.pdf

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Does IMCI Work?

• Evaluation in 5 countries (Bryce, AJPH, 2004)• Showed improvements in health worker

performance following IMCI training• More likely to prescribe correct treatments• Communicated better with carers • Take longer but still more efficient

• Cost less than routine care in some settings (Adam, Bull WHO, 2005)

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How Are IMCI Trained Workers Doing?

• Absolute levels of health worker performance often poor.

• Uganda, less than half of children received correct treatment (Pariyo, 2004),

• Peru, as low as 10% received correct treatment (Huicho, 2005).

• Tanzania (one of the most successful implementation sites ) there was considerable room for improvement (Armstrong, 2004)

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Monitoring, Evaluation and Support

• My Recommendations:• Use the IMCI protocols for your community

health program. • Train your village health workers in them. • Vary from the protocol only with very good

reasons • Be sure the VHW’s all understand any

variations so they can tell colleagues (or the regional public health officer) why.

• Use them in your clinics for your nurses/techs/NP/PA’s.

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Monitoring, Evaluation and Support

• My Recommendations:• Train many but maintain constant contact

• Regular phone calls - availability for discussion of cases, review of morbidity/mortality when visiting their post

• Text reminders• Virtual consults• Resourcing - medications, supplies,

books/texts to supplement, conferences to refresh training.

• Close supervision improves performance* *Chaudhary, 2005

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Monitoring, Evaluation and Support

• My Recommendations:• Focus on consistent errors

• Treatment of diseases • Why did they vary from the protocol

• Patient and community expectations• Costs• Availability of meds/supplies

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Training of IMCI Workers: Follow up

Use this manual: •http://whqlibdoc.who.int/hq/1999/WHO_FCH_CAH_99.1B.pdf

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Learning Objectives

• Gain familiarity with IMCI• Epidemiology of diseases treated• Structure & method of integrated care• Treatment protocols

• Build capacity in medical missions rather than duplicate (or undermine) MOH efforts

• Complement WHO and UNICEF initiatives• Begin or support a community health program • Affirm or challenge appropriately treatment

protocols by CHW’s referring to your facility

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Questions & Discussion