IMCI Lecture

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GOOD

MORNING

We are guilty of many errors and many faults, but our worst crime is abandoning children, neglecting the fountain of life. Many of the things we need can wait the CHILD can not

Right now is the time his bones are formed, his blood being made, and his senses are being developed

To him we cannot answer TOMORROW his name is TODAY. ~ Gabriela Mistal

Integrated Management of Childhood Illness (IMCI)Christian T. Caligagan, M.D., DPPS

IMCIWHAT IS IMCI? A strategy for reducing mortality and morbidity associated with major causes of childhood illness. A joint WHO/UNICEF initiative since 1992

IMCIOBJECTIVES To reduce SIGNIFICANTLY global mortality and morbidity associated with the major causes of diseases in children. To contribute to healthy growth and development of children.

IMCIAccording to the World Bank: The IMCI is likely to have the greatest impact in reducing the global burden of disease.

Major causes of death under five, 2002Other 25% ARI 18%

Deaths assoc. with malnutrition 54%

Diarrhea 15%

Perinatal 23% HIV/ AIDS 4%

Malaria 10% Measles 5%

IMCIThe IMCI training was designed to teach integrated management of sick infants and children to first level health workers in primary care settings that have NO laboratory support and only a limited number of essential drugs.

IMCI

Action-oriented CLASSIFICATIONS , rather than EXACT DIAGNOSES are used.

IMCIA careful balance has been struck between SENSITIVITY and SPECIFICITY.

IMCIUsing FEW CLINICAL SIGNS as possible which health workers of diverse background can be trained to recognize.

IMCIThe IMCI guidelines rely on detection of cases based on SIMPLE CLINICAL SIGNS without laboratory tests and offer EMPIRIC TREATMENT.

100 Main symptoms of 450 sick children 92.5 % 90 82.5% 80 70 60 50 45% 40 30 20 8.4% 10 0Cough Diarrhea Fever Ear problems

IMCIFrequency of presenting complaints of 450 children (as volunteered by mothers)Fever Cough Diarrhea Ear problems Skin lesions Abdominal pain Eye discharge Dental problems Neck swelling Gen. swelling Anorexia Rectal prolapse Headaches Not recorded Covered by IMCI (87 %)

Not covered by IMCI (13%)

-10

10

30

50

70

Main symptoms of 478 children VSMMC

70 60 50 40 30 20 10 0COUGHFEVER DIARRHEA EAR PROBLEM

FREQUENCY OF 4 MAIN SYMPTOMS IN EACH PATIENT VSMMC62%

ONE SYMPTOM

2 SYMPTOMS

31%

3 SYMPTOMS

4%

4 SYMPTOMS

3%

0

20

40

60

IMCICOMPONENTS 1. Improving case management skills of health workers. a. standard guidelines b. training (pre-service and in-service) c. follow-up after training

IMCI2. Improving the health system to deliver IMCI. a. essential drug supply b. organization of health facilities c. management of supervision

IMCI

3. Improving family and community practices

IMCICASE MANAGEMENT PROCESS 1. Health worker assesses the sick child. - IDENTIFY any danger sign present (unable to feed and drink, vomits everything, convulsion, difficult to awaken or abnormally sleepy) - ASK about the four(4) main symptoms cough, diarrhea, fever, and ear problem - REVIEW nutrition, Vitamin A and immunization

IMCI2. Health worker CLASSIFIES childs illness using a color-coded triage: PINK = urgent referral YELLOW = specific medical treatment and advice GREEN = simple advice on home care

IMCI

3. Heath worker then identifies SPECIFIC TREATMENT. - an INTEGRATED TREATMENT PLAN is developed

IMCI4. TREATMENT INSTRUCTIONS are carried out: oral drugs, ORS, treat local infections, signs to come back immediately, when to return for routine follow-up. 5. COUNSELING mothers. 6. FF-UP instructions when the child returns to clinic.

IMCIManagement of sick children Nutrition Immunization Other disease Prevention Promotion of growth and development

Integrated Management of Childhood Illness (IMCI)

IMCICHILD HEALTH INTERVENTIONS IN IMCI Case Management Interventions: Pneumonia Malaria Diarrhea Malnutrition - dehydration Anemia - persistent diarrhea Measles - dysentery Ear infection Meningitis Dengue Sepsis

IMCIPreventive interventions: Immunization during sick child visits Nutrition counseling Breastfeeding

Why is IMCI needed in medical education? Gives priority and emphasis to the most frequent and serious health problems of children Provides a link to real-life situations where diagnostic tools and drugs may be scarce Promotes rapid recognition of the severity of a childs illness and action, including rapid referral for severely ill children Links preventive and curative care Provides additional skills in important areas such as nutrition counselling Emphasizes action-oriented and affordable interventions Links different levels of health professionals and different levels of a health system

IMCI currently focused on first level facilities out-patient facility - initially in-patient facility - later comes as a generic guidelines for management which have been adapted to each country.

IMCIIdentification and provision of treatment Rehydration (diarrhea, DHF) Antibiotics ( e.g. pneumonias) Antimalarial Vitamin A

IMCIPreventive and Promotive elements: Reducing missed opportunities for immunization Breastfeeding and other nutritional counseling Vitamin A and iron supplementation Treatment of helminthic infestations

IMCITHE PROBLEMS: 1. The under five population is the most vulnerable group. 2. Child mortality remains UNACCEPTABLY HIGH. 3. Many of these deaths had no medical attendance or being seen by first level health facilities.

IMCI4. First-level facilities: - undermanned/underpaid - health workers are not appropriately TRAINED - drug supply inadequate/not properly managed - inaccessible - poor laboratory support

IMCI5. Family and community profile/ practices - late help seeking behavior - poor utilization of health facilities - literacy - traditional beliefs/traditions - economic - large families - crowded, dense, polluted environment

IMCITECHNICAL BASIS ARI and DIARRHEA

IMCI-ARIASSESSMENT SIGNS: 1. 2. 3. 4. BREATH RATE (FAST BREATHING) DURATION OF COUGH CHEST INDRAWING STRIDOR when CALM

IMCI-ARIChildren who have been coughing for 30 days or more are referred for FURTHER ASSESSMENT, to consider the possibility of tuberculosis and other conditions.

IMCI-ARISTRIDOR > harsh noise when the child is breathing IN. > can be reliably assessed when the child is CALM.

IMCI-ARIWhy Wheezing was not included: 1. Mortality from asthma is relatively uncommon. 2. Children with severe bronchospasm will be referred on the basis of chest indrawing. (Training is simplified, concentrate on conditions contributing SUBSTANTIALLY to mortality)

IMCI-ARIIf wheezing is included in the guidelines: 1. Improves health worker credibility in managing difficult breathing. 2. Relieves suffering in child with significant wheezing. 3. Reduced referral. 4. More complex training (in-service).

IMCI-ARIWheezing was NOT included in IMCI so that: 1. 2. 3. 4. Training less COMPLEX Special supplies not needed Training FOCUSED on pneumonia Needless referral

IMCI-ARIObjectives of the guidelines are to divide sick children with cough or difficult breathing into THREE categories:1. Those who require admission for severe pneumonia 2. Those who require ANTIBIOTICS because they are LIKELY to have pneumonia 3. Those who simply have cough or cold and do not require antibiotics.

IMCI-ARIDetecting Pneumonia by 2 key clinical signs: 1. Fast breathing 2. Lower chest wall indrawing

IMCI-ARIUse of auscultation for predicting pneumonia in children Place 1. Baltimore, Maryland 2. New Haven, Connecticut 3. Nairobi, Kenya 4. Boston, Massachusetts Sensitivity 43% 33% 66% 57%

Note: Diagnosis of pneumonia is confirmed by x-ray.

IMCI-ARIComparison of methods for detection of pneumonia in children ( 2mos up to 59mos) METHOD Stethoscope (crepitations) Simple clinical signs (fast breathing or chest indrawing) SENSITIVITY 53% SPECIFICITY 59%

77%

58%

Note: Diagnosis of pneumonia is confirmed by X-ray.

IMCI-ARI*Expert auscultation (crepitations) is less sensitive as a single sign, although when combined with FAST BREATHING, the two signs together will be more sensitive than either sign alone. *But if both SIGNS are required to be present, the two signs together will be more SPECIFIC but will lose SENSITIVITY.

IMCI-ARITECHNICAL BACKBROUND 1. Initial recommendation: 50/min or more (60% to 75% sensitive) 2. Lowered to 40/min for 12 mos. up to 59 mos. (62% to 79%) BUT at the same time SPECIFICITY fell from 92% to 77% and 80%

IMCI-ARISensitivity of the RR for Predicting Pneumonia in Young Children RR50/min RR40/min 2-11 months 12-59 months Goroka, PNG 80 74 Vellore, India 89 71 Bsse, the Gambia 85 87 Manila, Phil. 77 78 Maseru, Lesotho 79 54 Place

IMCI-ARIFAST BREATHING (as defined by WHO): 2 months - 11 months = 50 breaths/min 11 months - 59 months = 40 breaths/min

IMCI-ARI Fast breathing as defined by WHO, detects about 80% of children with pneumonia who need antibiotic treatment, and using fast breathing to detect pneumonia has been shown to reduce mortality. Sazawal S., Black R.E.

Meta analysis of Intervention Trials on Case Management of Pneumonia in community settings; Lancet, 1992

IMCI-ARI There is no uniform agreement about how to define the group of children with ARI who actually need antibiotics. The difficulty is how to distinguish those with potentially life-threatening disease from the rest by using SIMPLE SIGNS.

Radiology is helpful, but