1. Integrated Management of Childhood Illnesses (IMCI) Dr. Pushpa Raj Sharma DCH, DTCH, FCPS Professor of Child Health Institute of Medicine, Kathmandu, Nepal

2. Burden of the Paediatric Disease in Nepal • 40,000 deaths are pneumonia related. • 30, 000 deaths are diarrhea related • 40, 000 deaths are nutrition related • 50% deaths are related with neonatal problems.

3. Burden of these diseases are due to: • Unskilled health worker • Bad family health practices • Unequipped health facility • Unavailability of health resources

4. Problems in different age groups: • Neonatal period: resuscitation problems, infections, metabolic. • Under five: infections, nutritional. • Preadolescent: developmental, worms, skin. • Adolescent: psychological, sexual habits, drugs.

5. Morbidity Acute respiratory infections. Diarrhea Fever Ear infections Malnutrition Local skin infections Oral thrush Mortality Pneumonia Severe dehydration Meningitis/encephalitis Cerebral malaria Kwashiorkor/marasmus Sepsis Hypothermia Hypoglycemia Common causes of morbidity and mortality

6. Previous programmes • Training of health workers • Vertical programmes • Child problems were seen as a separate issues • Very little counseling training • Little emphasis on clinical practice

7. What is needed? • National goal for reducing the morbidity and mortality. • Holistic approach. • Improving family practices. • Equipping the health facility. • Upgrading the health workers skills. • Emphasis on counseling.

8. How to do it? • Targeting the problem. • All the components in one part. • Optimal use of resources. • Evidence based. • Feasible. • Acceptable by community.

9. Sensitivity and specificity 100% Sensitivity Specificity Clinical signs Investigations Sensitivity: positive with disease Specificity: negative without disease

10. The answer • Integrated • Management of • Childhood • Illnesses • IMCI

11. How it helps? • Identifies a child who needs urgent referral. • Gives evidenced based clinical signs for the diagnosis of common problems. • Provides guidelines for the appropriate treatment. • Educates the parent. • Upgrades the health care facility. • Follow-ups the child.

12. Conditions that it covers • Respiratory: pneumonia, cough/cold. • Diarrhea: acute watery, dysentery, persistent. • Fever: malaria, measles, meningitis, encephalitis. • Ear problems: mastoditis, acute and chronic infections. • Nutritional: kwashiorkor/marasmus, anemia

13. Conditions that it covers • Nutritional: feeding problems, breast feeding, counseling. • Neonatal sepsis. • Local infections. • Hypoglycemia, hypothermia. • Oral thrush • Immunization. • Vit. A supplementation • Deworming.

14. What it contains? 2 months up to 5 years • Simple clinical signs of severe disease. • Simple clinical signs to diagnose pneumonia. • Simple clinical signs to identify three clinical types of diarrhea. • Simple clinical signs to identify malaria. • Simple clinical signs to identify ear infections. • Simple clinical signs to identify malnutrition.

15. What it contains? Young infant. • Simple clinical signs to identify for referral. • Simple clinical signs to treat at health facility. • Simple signs to identify good breast feeding.

16. What it contains?General • Simple guidelines for nutrition. • Simple guidelines for treatment of severe diseases, pneumonia, diarrhoea, dysentery,fever,malaria, ear infections, local infections, anaemia, malnutrition. • Guidelines for counseling. • Home care messages, safe practices. • Immunization, vit A, deworming information.

17. What are the evidences? • Trained health worker identified target disease better than doctors. • Over prescriptions were reduced. • Parents were more satisfied. • Cost effective. • Mortality and morbidity reduced. • Health facility better equipped.

18. Some examples • Simple questions and simple observations to find out the problem: severe disease. • Does child vomits every thing? • Is the child able to drink? • History of convulsions? • Is the child lethargic or unconscious?

19. Four main symptoms: 2 months up to 5 years • Does the child has cough or difficulty breathing? • Does the child has diarrhea? • Does the child has fever? • Does the child has ear problem?

20. Assess every child for:2 months up to 5 years • Malnutrition: • Weight for age • Oedema • anaemia • Immunization • Vitamin A supplementation • Deworming

21. If the answer is yes: • For how long? • Associated symptoms? • Classify the illness • Identify treatment • Treat the child

22. My child has cough for 2 days: (example) • Observe for general danger signs. • If present refer the child with first dose of antibiotics. • Count the respiratory rate: 60/50/40. • Fast breathing indicates pneumonia. • Look for indrawing. • If present indicates severe pneumonia and needs referral. • Look and listen for stridor in a calm child. • If present indicates severe disease and referral is needed.

23. Classify the disease (example) • Age 9 months: no general danger signs, no chest indrawing, no stridor, no fast breathing. • No pneumonia (cough and cold). • Age 12 months: chest indrawing. • Severe pneumonia. • Age 4 months: fast breathing only. • Pneumonia. • Age 6 months: presence of general danger sign. • A child with very severe disease.

24. Identify treatment (example) • No pneumonia: • Safe home remedies/ paracetamol/ when to return? Counsel. • Pneumonia: • Antibiotic/paracetamol/safe home remedies/when to return? Counsel. • Severe pneumonia/very severe disease: • First dose of antibiotic/ referral note/ counsel.

25. Treat the child • Essential drugs. • Safe home care. • Duration of treatment. • When to return. • Change of treatment. • Counsel the parent. • Other problems.

26. Other Options in IMCI • Neonatal problems of first week • Developmental pediatrics • Perinatal problems • Injury • ……….

27. IMCI : model for other problems in pediatric diseases • Entry questions. • Threading questions. • Evidenced based specific clinical signs. • Treatment. • Follow-up. • Referral. • Counsel.

28. History of IMCI in Nepal • 1995: IMCI Activities started. District identified, Saptari. • 1996: Orientation meeting, nutrition survey, necessary adaptations to generic materials. • 1997: Nepali translation, TOT courses. • 1998: Follow-up visits, review meeting, pre-service training. • Expansion: at present 13 district.

29. Thank you. Any questions? Any clarifications? Any suggestions for this presentation?