Integrated Management of Childhood Illness IMCI Stephen P

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

Disclosures • Financial Disclosures • None • Off label drug use • None 2 © 2013 MFMER | slide-2

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 3 © 2013 MFMER | slide-3

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 © 2013 MFMER | slide-4

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 © 2013 MFMER | slide-5

Background: • Solution (what we can do) • Increase workers • More paraprofessionals • Community health workers • Low cost • In community • Longitudinal care/follow up © 2013 MFMER | slide-6

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. © 2013 MFMER | slide-7

© 2013 MFMER | slide-8

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. © 2013 MFMER | slide-9

UN-IGME, Levels and Trends in Child Mortality, 2013. © 2013 MFMER | slide-10

Where The 7 Million Children Are Dying Each Year… http: //www. worldmapper. org/posters/worldmapper_map 261_ver 5. pdf Accessed 10/11/10 © 2013 MFMER | slide-11

Where “Physicians” Work http: //www. worldmapper. org/display. php? selected=219 Accessed © 201310/11/10. MFMER | slide-12

www. gapminder. org; downloaded in 2011 sometime… © 2013 MFMER | slide-13

We Are Making Progress… 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. © 2013 MFMER | slide-14

http: //www. un. org/millenniumgoals Video MDG’s © 2013 MFMER | slide-15

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. © 2013 MFMER | slide-16

Why Be Involved Institute of Medicine. The U. S. Commitment to Global Health: 17 Recommendations for the New Administration Committee on the U. S. Commitment to Global Health. 2009. © 2013 MFMER | slide-17

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. © 2013 MFMER | slide-18

29 © 2013 MFMER | slide-19

www. who. int/pmnch/media/press_materials/fs/fs_mdg 4_childmortality/en/ Accessed Oct 24, 2013 © 2013 MFMER | slide-20

© 2013 MFMER | slide-21

© 2013 MFMER | slide-22

© 2013 MFMER | slide-23

Trends in Intervention Delivery in Child Health 1950’s • 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 1990’s • HIV, malaria, TB • Integrated Management of Childhood Illnesses (IMCI) • Integrated care — viewing individual as a whole, comprehensive care of individuals © 2013 MFMER | slide-24

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 © 2013 MFMER | slide-26

WHO’s Integrated Management of Childhood Illness • Preventive interventions • Immunizations • Breastfeeding support • Nutrition counseling (e. g. weaning foods) • Curative interventions Cause 70% of • Malaria childhood • Pneumonia deaths • Diarrheal illnesses worldwide • Undernutrition (co-factor in 1/3) • Also…serious infections (meningitis), other illnesses (vitamin A def. with measles) © 2013 MFMER | slide-27

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 © 2013 MFMER | slide-29

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 © 2013 MFMER | slide-30

Training of IMCI Workers: Initiation Use these training materials: http: //www. who. int/maternal_child_adolescent/do cuments/9241595650/en/ Or this computerized one: http: //www. who. int/maternal_child_adolescent/do cuments/icatt/en/index. html And THE flip chart: http: //whqlibdoc. who. int/publications/2008/97892 41597289_eng. pdf © 2013 MFMER | slide-31

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 © 2013 MFMER | slide-32

Training IMCI PHC Workers • 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 Lambrechts, Bull WHO, 1997 © 2013 MFMER | slide-33

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 © 2013 MFMER | slide-34

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 © 2013 MFMER | slide-35

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 © 2013 MFMER | slide-36

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 © 2013 MFMER | slide-37

Objectives of IMCI • Reduce deaths and frequency and severity of illness and disability • Contribute to improved growth and development © 2013 MFMER | slide-38

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 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 Referral facility -Emergency triage and treatment -Diagnosis and treatment -Monitoring and follow up © 2013 MFMER | slide-39

www. who. int/pmnch/media/press_materials/fs/fs_mdg 4_childmortality/en/ Accessed Oct 24, 2013 © 2013 MFMER | slide-40

Basic Resuscitation Equipment • Warm room • Two pieces of cloth • Dry • Wrap up • Suction bulb or De. Lee • Positive Pressure Bag (“Ambu”) and mask From Tina Slusher, MD with gratitude © 2013 MFMER | slide-41

20 -30 seconds ONLY!! Is my baby breathing? Is my baby breathing well? IF no to either Only after 30 seconds of PPV with a HR < 60 Mostly NRP/ PALS* © 2013 MFMER | slide-42

© 2013 MFMER | slide-43

www. who. int/pmnch/media/press_materials/fs/fs_mdg 4_childmortality/en/ Accessed Oct 24, 2013 © 2013 MFMER | slide-44

Neonatal Sepsis • Any deviation from normal in neonate can be sepsis: • temperature, • ( WBC, glucose) • Vomiting • Feeding intolerance • Lethargy • Respiratory distress beyond 1 st hour • Amp/Gent IV © 2013 MFMER | slide-45

www. who. int/pmnch/media/press_materials/fs/fs_mdg 4_childmortality/en/ Accessed Oct 24, 2013 © 2013 MFMER | slide-46

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) © 2013 MFMER | slide-47

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) © 2013 MFMER | slide-48

Lack of access to safe drinking water © 2013 MFMER | slide-49

Access to Improved Sanitation Facilities http: //www. childinfo. org/sanitation_status_trends. html © 2013 MFMER | slide-50

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) © 2013 MFMER | slide-51

If the gut works, use it © 2013 MFMER | slide-52

Oral rehydration solution (ORS) Rice-based ORS is superior to glucose-based ORS in patients with cholera World Gastroenterology Organization (WGO) Practice Guideline Acute Diarrhea (March 2008) © 2013 MFMER | slide-53

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 © 2013 MFMER | slide-54

½ of deaths due in part to undernutrition www. who. int/pmnch/media/press_materials/fs/fs_mdg 4_childmortality/en/ Accessed Oct 24, 2013 © 2013 MFMER | slide-55

Impact of Breastfeeding on Childhood Disease Risk in not BF vs exclusively BF Diarrhea 7 x risk death Pneumonia 5 x risk death © 2013 MFMER | slide-56

Under-Nutrition Vitamin A Deficiency 20 -24% Risk of death from diarrhea, measles AL Rice et al In: Comparative quantification of health risks, 2004 © 2013 MFMER | slide-57

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 © 2013 MFMER | slide-58

www. who. int/pmnch/media/press_materials/fs/fs_mdg 4_childmortality/en/ Accessed Oct 24, 2013 © 2013 MFMER | slide-68

Cough or Difficulty of Breathing How IMCI Works… © 2013 MFMER | slide-69

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 © 2013 MFMER | slide-70

Cough or Difficulty of Breathing SIGNS • Any general danger sign or • Chest indrawing or Stridor in a clam child Fast breathing No signs of pneumonia or very severe disease CLASSIFY AS SEVERE PNEUMONIA OR VERY SEVERE DISEASE IDENTIFY TREATMENT • Give first dose of an appropriate antibiotic • Refer URGENTLY to a hospital PNEUMONIA • Give an appropriate oral antibiotic for 5 days • Soothe throat and releive the cough with a safe remedy • Advise mother when to return immediately • Follow-up in 2 days NO PNEUMONIA, COUGH OR COLD If coughing >30 days refer for assessment • Soothe throat and relieve the cough with a safe remedy • Advise mother when to return immediately • Follow-up in 6 days if not improving © 2013 MFMER | slide-71

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 = Pneumonia • Lower chest retractions • (Fever) • Case management can reduce pneumonia associated childhood mortality by 40% S Sazawal, et al Lancet 2003 © 2013 MFMER | slide-72

Cough or Difficulty of Breathing Ask: does the child have cough or difficulty breathing? üIf no, ask the next main üIf yes, ask: for how long? symptoms: diarrhea, fever, LOOK LISTEN FEEL: ear problems • count the breaths in one minute If the child is: fast breathing is: • look for chest 2 -12 months 50 bpm or more indrawing 1 -5 years 40 bpm or more • look and listen for stridor CLASSIFY © 2013 MFMER | slide-73

Treatment Soothe 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 © 2013 MFMER | slide-74

Treatment for Pneumonia or Very Severe Disease Cotrimoxazole Give 2 times daily for 5 days Age or Weight 2 -12 mos (4 -10 kg) Amoxicillin Give 3 times daily for 3 -5 days Adult tab. 80 mg TMP 400 mg SMX Syrup 40 mg TMP 200 mg SMX Tablet 250 mg Syrup 125 mg/5 m. L 1/2 5. 0 m. L 7. 5 m. L 1 10 m. L 12 mos – 5 yrs 1 (10 -19 kg) © 2013 MFMER | slide-75

Empyema © 2013 MFMER | slide-76

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 © 2013 MFMER | slide-77

www. who. int/pmnch/media/press_materials/fs/fs_mdg 4_childmortality/en/ Accessed Oct 24, 2013 © 2013 MFMER | slide-78

Vaccine Coverage © 2013 MFMER | slide-79

Using IMCI © 2013 MFMER | slide-80

Using IMCI © 2013 MFMER | slide-81

© 2013 MFMER | slide-82

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/2008/9789 241597289_eng. pdf © 2013 MFMER | slide-83

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) © 2013 MFMER | slide-84

© 2013 MFMER | slide-85

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) © 2013 MFMER | slide-86

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. © 2013 MFMER | slide-87

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 © 2013 MFMER | slide-88

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 © 2013 MFMER | slide-89

Training of IMCI Workers: Follow up Use this manual: • http: //whqlibdoc. who. int/hq/1999/WHO_FCH_ CAH_99. 1 B. pdf © 2013 MFMER | slide-90

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 91 © 2013 MFMER | slide-91

Questions & Discussion © 2013 MFMER | slide-92