Download - IMCI Session 2- An Overview of the IMCI

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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

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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


-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


- For appropriate home care continue feeding increase fluid intake appropriate home treatment

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IMCI Components


- 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


Urgent referral•pre-referral treatment

•advise parents•refer child


•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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1. Cough or difficult breathing

3 clinical signs– Respiratory rate– Lower chest wall indrawing– Stridor

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2. Diarrhea Dehydration

– General condition– Sunken eyes– Thirst– Skin elasticity

Persistent diarrhea Dysentery

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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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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