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©2013 MFMER | slide-1
Integrated Management of Childhood Illness (IMCI)Stephen P. Merry, MD, MPH, DTM&HAssistant Professor of Family Medicine
Mayo Clinic, Rochester
©2013 MFMER | slide-2
2
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
3
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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.
©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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29
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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
©2013 MFMER | slide-40
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
©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
©2013 MFMER | slide-68
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
©2013 MFMER | slide-78
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)
©2013 MFMER | slide-85
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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
91
©2013 MFMER | slide-92
Questions & Discussion