John Barber,1,2 Jen Osborn,1 Oscar Bernal,3 Ethan Guillen,3 Cassandra Kelly-Cirino,1 Sabine Dittrich1

1FIND, Geneva, Switzerland, 2University of Massachusetts Medical School, Worcester, USA, 3Doctors Without Borders (MSF), New York, USA

FEBRILE PATIENT MANAGEMENT WORLDWIDEANALYSIS OF EXISTING GUIDELINES AND ALGORITHMS

TO INFORM NOVEL DIAGNOSTIC AND ALGORITHMIC SOLUTIONS

Results z IMNCI and iCCM guidelines have been implemented globally

(Figure 2) with variable revisions by local health systems (Table 1): � Definitions of “very severe disease” in infants was variable, while

management was more consistent. � Definitions and management of “severe febrile illness” in children

was very consistent. � IMNCI implementation had the greatest impact when:3

- The health system context was favourable - A systematic approach to planning and implementation was used - Political commitment allowed for institutionalization.

� IMNCI implementation success: - Associated with a doubling in the annual rate of under-five

mortality reduction in Egypt in 2000–2012 (3.3% vs 6.3%)4 - Children were diagnosed earlier, experienced greater clinical

improvement, had better outcomes, and cost less to treat.1

� IMNCI implementation challenges:3,5

- Non-adherence to guidelines due to:• Prohibitively time-consuming to use IMNCI algorithms• HCWs disagreeing with recommendations.

- Global financial investments not sustained. - 11-day IMNCI training course too time-consuming for HCWs.

� mHealth applications: the solution for algorithm implementation? - Shown to improve guideline adherence, reduce antibiotic over-

prescription rates, and improve patient outcomes6,7

- Often developed by NGOs without the intention of national expansion,creating a redundant and inefficient system unable to maximize impact in many countries.8

z WHO hospital guidelines have not been widely adopted and national hospital guidelines remain very diverse. No standard guidelines or algorithms followed for managing febrile patients in Level 2 facilities. Hospital guideline formatting is variable, with few having symptom-based recommendations (e.g. fever management).

Background z Fever is one of the most frequently encountered paediatric problems worldwide,

at times accounting for 25% of visits to paediatric emergency rooms,1 and many more hospital visits by adults.

z The fever differential is expansive and includes: infection, autoimmune disorders, malignancy, and others.

� A 2011 systematic review of fever-of-unknown-origin in paediatric patients showed:2

- >50% due to infection - Of infectious causes: >50% due to bacterial infection.

z In 1995, WHO, in collaboration with UNICEF, published the Integrated Management of Childhood Illnesses (IMCI) guidelines to improve the care of children 1 week to 5 years of age, with specific algorithms for Level 1 healthcare workers (HCWs) targeting fever management. In 2003, WHO revised the IMCI to include the care of neonates, and in 2005 published hospital guidelines. WHO guidelines and algorithms for Level 0, 1 and 2 facilities (Figure 1):

� Level 0: Integrated Community Case Management (iCCM) � Level 1: Integrated Management of Neonatal and Childhood Illness (IMNCI) � Level 2: Pocket Book of Hospital Care for Children; Integrated Management

of Adolescent and Adult Illness (IMAI).

z Mobile health (mHealth) applications with built-in clinical algorithms offer new solutions and challenges to febrile patient management at Level 1 facilities.

z To enable appropriate integration of new diagnostic tools, it is important to understand the clinical guidelines and algorithms that are available around the world and at different levels of the health system.

z This research aimed to identify what international and national guidelines and algorithms exist for diagnosing and managing febrile patients at different levels of the healthcare system, and ask:

� Are they used? � Have they been effective? � What were the implementation challenges and lessons learned? � What has been the impact of mobile application guideline and algorithm use?

Methods

Conclusions z WHO guidelines and algorithms for the management of fever

syndromes in children at Level 0 and 1 facilities are widespread and few changes have been made to recommendations (IMNCI and iCCM).

z WHO guidelines for Level 2 facilities have not been widely adopted and few national guidelines provide specific recommendations for managing febrile patients.

z Development of a national mHealth application may improve febrile patient management by addressing many of the most critical challenges to IMNCI implementation.

*Only item removed: “Not feeding well”. Variable additional signs/symptoms included: “Grunting/wheezing/nasal flaring” most common addition. † Only item removed: “Treat to prevent low blood sugar”. ‡ Malaria not endemic, excluded malaria management.

-

National guideline compared with WHO IMNCI

Matches WHO guidelines

Some WHO instructions absent

=All WHO instructions included, plus new instructions

Some WHO instructions absent, some new added

+

+ / -

Table 1: National IMNCI guideline comparison.

Comparison of national IMNCI chart books with WHO standard

Infant with “very severe disease” or PSBI Child with “severe febrile illness”

Signs and symptoms* Management Signs and symptoms* Management

South Africa 2014 + / - + + =

Sudan 2008 + / - = = =

Uganda 2016 + + / -† = =

Afghanistan + / - = = =

Egypt 2010 + + = -‡

Iraq + = = =

Pakistan + = = =

Yemen + + = =

India + / - = + =

Health system levels Relevant guidelines

WHO & MSF National

WHO: No specific guidelines published. IMAI and Pocket Book may be appropriate at these levels.

National hospital guidelines: Not further subdivided according to health system level.

Recommendations must be interpreted and utilized according to facility capacity.

WHO: IMAI and Pocket BookMSF: 2016 Clinical Guidelines

WHO: IMNCI IMNCI widely adopted.

WHO: Integrated Community Case Management (iCCM)

iCCM widely adopted.

Figure 1: International and national guidelines by target health system level.

Community (home/mobile) Level 0

Health Post Level 1

District Hospital Level 2

Regional/Provincial Hospital Level 3

National Reference Center Level 4

IMNCI

iCCM

Figure 2: WHO 2016 Country Survey of IMCI & iCCM district coverage.

75% of districts

50-74% of districts

25-49% of districts

<25% of districts

Unknown/not applicable

Ref: WHO. A Strategic Review of Options for the Future Building on Lessons Learnt from IMNCI. http://apps.who.int/iris/bitstream/10665/251855/1/WHO-MCA-16.04-eng.pdf?ua=1

# 192367th Annual Meeting of the American Society of Tropical Medicine & Hygiene (ASTMH)

z We conducted a landscape analysis in English of clinical algorithms and guidelines used to manage febrile patients in low- and middle-income countries:

� PubMed and Cochrane literature review - 8 algorithms in literature

� Review of WHO archives and national ministry of health websites - 4 WHO and 18 national guidelines

� Review of electronic algorithms developed by non-governmental organizations (NGOs) for Level 1 HCWs. - 7 electronic algorithms on mHealth applications

� Guideline inclusion criteria: - Published since the year 2000 - Most recent publication of national guidelines - Hospital guidelines required dedicated section for “fever management”.

z Countries with active Doctors Without Borders (MSF) operations were prioritized, with an emphasis on Sub-Saharan Africa and the Middle East.

z Publications for Level 1 and Level 2 facilities were prioritized.

References 1 Sallam SA, et al. Integrated Management of Childhood Illness (IMCI) approach in management of children with high grade fever ≥ 39°. Int J Health Sci (Qassim) 2016;10(2):239–248.2 Chow A, Robinson J. Fever of unknown origin in children: a systematic review. World J Pediatr 2011;7(1):5–10.3 WHO. Towards a grand convergence for child survival and health: a strategic review of options for the future building on lessons learnt from IMNCI. WHO, 2016. Available at: www.who.int/maternal_child_adolescent/documents/strategic-review-child-health-imnci/en/4 Rakha MA, et al. Does implementation of the IMCI strategy have an impact on child mortality? A retrospective analysis of routine data from Egypt. BMJ Open 2013;3(1):e001852.5 Walter ND, et al. Why first-level health workers fail to follow guidelines for managing severe disease in children in the Coast Region, the United Republic of Tanzania. Bull World Health Organ 2009;87(2):99–107.6 Keitel K. e-POCT: improving management of fever in children in resource-poor settings through an electronic algorithm based on point-of-care tests.7 Mitchell M, et al. Using electronic technology to improve clinical care – results from a before-after cluster trial to evaluate assessment and classification of sick children according to Integrated Management of Childhood Illness (IMCI) protocol in Tanzania. Int J Healthc Technol Manag 2013;10(3):156.8 Batavia H, Kaonga N. mHealth support tools for improving the performance of frontline health workers: an inventory and analytical review. CHW Central, 2014. Available at: www.chwcentral.org/sites/default/files/1822-Inventory-and-Landscape-Report-v6-JH-screen-spreads.pdf