Session 2

IMCI Overview

1

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
2

Distribution of 10.5 million deaths among children less than 5 years old in all developing countries, 1999

Malaria Diarrhea

Undernutrition 54%

Measles Pneumonia Perinatal OTHERS

3

Stagnating Decline in Childhood Mortality Rates – Philippines, 2003 NDHS
F u e 1 T n in E rly Ch h o M r a y R t s ig r : re d a ild o d o t lit ae
80

7 2
60

5 2 46
40

43 34 1 9 1 8 1 6 31

42 30 1 7 1 3 1 2

28 26
20

1 9

1 7 1 4 1 2

0

1 988

1 993
S ur vey P er i d, NDHS o

1 998

2003

Ne n t l M r a y o aa o t lit

Po n o a a M r a y st e n t l o t lit Un e -f d r ive M r a y o t lit

Ina t M r a y f n o t lit

4

Ch M r a y ild o t lit

Causes of Deaths among Children Under Five Years Old
Top Ten Leading C ause of Underfive M ortality 2000 Philippine Health Statistics
pneumonia accidents septicemia measles nutritional disorders diarrhea meningitis congeninital anomalies malignant neoplasm perinatal causes 51 .6 31 .7 30.4 24.2 22.7 1 1.5 10.6 8.3 7.6 1 6.8

0

1 0

20

30

40

50

60

no. of Underive Deaths P er 1000LB

5

Source: 2000 Philippine Health Statistics

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
6

Features of IMCI…
 not

necessarily dependent on the use of sophisticated and expensive technologies more integrated approach to managing sick children beyond addressing single diseases to addressing the overall health and well-being of the child

a

 move

7

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

8

Features of IMCI…
 adjusts

curative interventions to the capacity and functions of the health system (evidence-based syndromic approach) family members and the community in the health care process

 involves

9

Objectives of IMCI
(1) reduce deaths and the frequency and severity of illness and disability; and (2) contribute to improved growth and development

10

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

11

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

12

IMCI Components
3. Improving family and community practices
– – – –

for physical growth and mental development for disease prevention for appropriate home care for seeking care

13

IMCI Components
3. Improving family and community practices -For physical growth and mental development
   

Breastfeeding Complementary feeding Micronutrient supplementation Psychosocial stimulation

14

IMCI Components
3. Improving family and community practices - For disease prevention
immunization handwashing sanitary

disposal of feces use of insecticide-treated bednets dengue prevention and control

15

IMCI Components
3. Improving family and community practices - For appropriate home care
  

continue feeding increase fluid intake appropriate home treatment

16

IMCI Components
3. Improving family and community practices - For seeking care
Follow

health workers advice When to seek care Prenatal consultation Postnatal (postpartum) consultation

17

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 and • identify treatment actions
Outpatient Health Facility

Urgent referral
•pre-referral treatment •advise parents •refer child
Outpatient Health Facility

Home

Referral facility

18

•emergency triage & treatment •Diagnosis & treatment •monitoring & ff-up

Treatment •treat local infection •give oral drugs •advise and teach caretaker •follow up

Caretaker is counselled on: •home treatment •feeding &fluids •when to return •immediately •follow-up

 Sick –

young infant 1 week up to 2 months young children 2 months up to 5 years

 Sick –

19

Assessing the Sick Child
• lethargy or unconsciousness • inability to drink or breastfeed • vomiting • convulsions

General Danger Signs

20

Checking the Main Symptoms
- cough and difficult breathing - diarrhea - fever - ear problem

21

Checking the Main Symptoms
1. Cough or difficult breathing

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

22

Checking the Main Symptoms
2. Diarrhea  Dehydration – General condition – Sunken eyes – Thirst – Skin elasticity  Persistent diarrhea  Dysentery
23

Checking the Main Symptoms
3. Fever
 

 

24

Stiff neck Risk of malaria and other endemic infections, e.g. dengue hemorrhagic fever Runny nose Measles Duration of fever (e.g. typhoid fever)

Checking the Main Symptoms
4. Ear problems  Tender swelling behind the ear  Ear pain  Ear discharge or pus (acute or chronic)

25

Checking Nutritional Status, Feeding, Immunization Status

26

Malnutrition – visible severe wasting – edema of both feet – weight for age Anemia – palmar pallor Feeding and breastfeeding Immunization status

Assessing Other Problems Meningitis  Sepsis  Tuberculosis  Conjunctivitis  Others: also mother’s (caretaker’s) own health

27

IMCI Essential Drugs and Supply

         

28

Appropriate antibiotics Quinine Vitamin A Paracetamol Oral antimalarial Tetracycline eye ointment ORS Mebendazole or albendazole Iron Vaccines Gentian violet

Benefits of IMCI

29

Changes in Weight-for-Age (Z-score) of children after consultation by health worker
0.2 0.15 0.1 0.05 0 -0.05 -0.1 -0.15 -0.2 by IMCI-trained health workers by untrained health workers

8 days

45 days

180 days

30

Changed Z-score*

* 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

Current Best Estimates of Efficacy for Interventions in the IMCI Strategy
Intervention
ARI case management ORT Measles immunization

Decline in U5M
35%

Source
Sazawal & Black, 1992 Oberle et al, 1990; Chen et al, 1983 The Kasengo Project Team, 1981; Koenig, 1992

4-14%

20%

31

Quality of Care Improves With Introduction of IMCI
100 80
88 95 Proportion of children receiving

60 40 20 0 0

93

50 28

32

Comprehensive assessment
Before (1997)

Nutritional evaluation Review of vaccination status
After (1999)

IMCI Reduces Antibiotic Abuse Rate in Morocco
%
Proportion of sick children who received unneeded prescription of antibiotics:

50 40 30 20 10 0 12 34 Health worker NOT using IMCI (n=132) Health worker using IMCI (n=147)

33

33

Comparison of Drug Use and Costs Based on Assessment of 1226 Sick Children
Number of different drugs prescribed % of cases prescribed: - antibiotic - injection - >1 drug - one drug - no drug Drug costs (US cents)
Doctors: current practice
5 0.4 8 39 28 11 53 77 56 95 50 11

82 17

34

Medical assistants using IMCI guidelines

* Conditions not covered by IMCI were excluded (Unpublished data from Black, et al; not for citation)

Mothers Leave the Facility Better Able to Care for their Child.
Proportion of mothers leaving health facility who reported correctly:
100 80 60 40 20 0

(56/80) (17/35)
49 70

(4/33)
12

(4/57)
7

35

How to give oral medicines Before (1997)

At least two danger signs After (1999)

Experience with IMCI in “Well Baby” Clinic, Bolivia 1999

36

Cost-effective Packages of Public Health Interventions and Essential Clinical Services
Proportion of total global disease burden averted
Annual cost per DALY Annual cost per capita

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
2% 4% 6%

14%

US$

US$ 1.6

40.0

14.5

0.5

40.0

3.8

3%

25.0 4.0

0.9 1.7

1%

2.0

0.2

1%

4.0

0.6

37
Source: World Bank Development Report, Investing in Health, 1993 DALY = Disability-adjusted life year