Integrated Management of Childhood Illness (IMCI)

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

2. Disclosures • Financial Disclosures • None • Off label drug use • None 2

3. 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

4. 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

5. 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

6. Background: • Solution (what we can do) • Increase workers • More paraprofessionals • Community health workers • Low cost • In community • Longitudinal care/follow up

7. 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.

9. 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.

10. UN-IGME, Levels and Trends in Child Mortality, 2013.

11. Where The 7 Million Children Are Dying Each Year… http://www.worldmapper.org/posters/worldmapper_map261_ver5.pdf Accessed 10/11/10

12. Where “Physicians” Work http://www.worldmapper.org/display.php?selected=219 Accessed 10/11/10.

13. www.Gapminder.org; downloaded in 2011 sometime…

14. 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.

15. http://www.un.org/millenniumgoals Video MDG’s

16. 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.

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. 17

18. 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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20. www.who.int/pmnch/media/press_materials/fs/fs_mdg4_childmortality/en/Accessed Oct 24, 2013

24. 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

25. 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

26. 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

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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. Objectives of IMCI • Reduce deaths and frequency and severity of illness and disability • Contribute to improved growth and development

37. 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

38. www.who.int/pmnch/media/press_materials/fs/fs_mdg4_childmortality/en/Accessed Oct 24, 2013

39. 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

40. Warm, Dry, Position Suction, Stimulate 20-30 seconds ONLY!! Is my baby breathing? Is my baby breathing well? IF no to either Postive Pressure Ventilation Maybe Intubation Decreasing success Room Air or Supplemental Oxygen Okay Only after 30 seconds of PPV with a HR < 60 Chest Compressions Meds Mostly NRP/ PALS*

42. www.who.int/pmnch/media/press_materials/fs/fs_mdg4_childmortality/en/Accessed Oct 24, 2013

43. 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

44. www.who.int/pmnch/media/press_materials/fs/fs_mdg4_childmortality/en/Accessed Oct 24, 2013

45. 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)

46. 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)

47. Lack of access to safe drinking water

48. Access to Improved Sanitation Facilities http://www.childinfo.org/sanitation_status_trends.html

49. 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)

50. If the gut works, use it