Transcript IMCI Overview - Global Missions Health Conference

Integrated Management of
Childhood Illness (IMCI)
Stephen P. Merry, MD, MPH, DTM&H
Assistant Professor of Family Medicine
Mayo Clinic, Rochester
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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
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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:
© UNICEF-NYHQ2012-0165-Diffidenti
• 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.
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www.Gapminder.org; downloaded in 2011 sometime…
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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.
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http://www.un.org/millenniumgoals
Video 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:
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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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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
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
• HIV, malaria, TB
1990’s
• Integrated Management of Childhood Illnesses
(IMCI)
• Integrated care — viewing individual as a whole,
comprehensive care of individuals
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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
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)
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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/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
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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
• 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
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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
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
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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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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*
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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
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Access to Improved Sanitation Facilities
http://www.childinfo.org/sanitation_status_trends.html
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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
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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½ of deaths due
in part to
undernutrition
www.who.int/pmnch/media/press_materials/fs/fs_mdg4_childmortality/en/
Accessed Oct 24, 2013
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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
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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
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www.who.int/pmnch/media/press_materials/fs/fs_mdg4_childmortality/en/
Accessed Oct 24, 2013
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Cough or Difficulty of Breathing
How 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
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 5days
•Soothe the throat and releive
the cough with a safe remedy
•Advise mother when to return
immediately
•Follow-up in 2days
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
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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
= Pneumonia
• Lower chest retractions
• (Fever)
• Case management can reduce pneumonia
associated childhood mortality by 40%
S Sazawal, et al Lancet 2003
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Cough or Difficulty of Breathing
Ask: does the child have cough or difficulty
breathing?
If no, ask the next main
If 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
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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
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.
80mg TMP
400mg SMX
Syrup
40mg TMP
200mg SMX
Tablet
250mg
Syrup
125mg/5mL
1/2
5.0 mL
1/2
5.0 mL
7.5 mL
1
10 mL
12 mos – 5 yrs 1
(10-19 kg)
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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
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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/2008/9789
241597289_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)
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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
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Questions & Discussion
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