“The model and implementation of IMCI:

Integrated Management of Childhood Illness”

Dr. Yehuda Benguigui Senior Advisor

Child and Neonatal Health

Healthy Living Course Project

Family and Community Health

THE 1st GLOBAL CONGRESS FOR CONSENSUS IN

PEDIATRICS AND CHILD HEALTH February 17-20, 2011

Paris, France

IMCI

Pan American

Health

Organization

Pan American

Health

Organization

THE 1st GLOBAL CONGRESS FOR CONSENSUS IN PEDIATRICS

AND CHILD HEALTH

I. Mortality and morbidity among

children under 5 years old at the

global level

II. The situation in the Region of the

Americas

III. The IMCI Strategy

IV. Future challanges

Pan American

Health

Organization

THE 1st GLOBAL CONGRESS FOR CONSENSUS IN PEDIATRICS

AND CHILD HEALTH

I. Mortality and morbidity

among children under 5

years old at the global level

Pan American

Health

Organization

Progress has been significant, with the number of

deaths among children under 5 years old reduced

from 12.5 million in 1990 to less than 9 million in

2008.

Correspondingly, the rate of under-five mortality fell

from 90 deaths per 1,000 live births to 65 deaths

per 1,000 live births over the same period.

MORTALITY IN CHILDREN <5 AT THE

GLOBAL LEVEL

Pan American

Health

Organization

MORTALITY IN CHILDREN <5 AT THE

GLOBAL LEVEL

Around 14 per cent of children are born weighing

less than 2,500 grams – a condition that often

derives from the mother’s poor health and

nutritional status.

Inadequate health care and nutrition for women

also contribute to high numbers of neonatal

deaths, with 4 million newborns dying within the

first month after birth each year.

Pan American

Health

Organization

MORTALITY IN CHILDREN <5 AT THE

GLOBAL LEVEL

Pneumonia and diarrhoeal diseases are the

biggest killers of children under five, accounting for

almost 40 per cent of deaths for this age cohort.

Yet access to antibiotics and oral rehydration

therapy – simple, proven interventions to combat

these diseases and conditions – remains low in

many developing countries.

Pan American

Health

Organization

MORTALITY IN CHILDREN <5 AT THE

GLOBAL LEVEL

Children of income-poor families have

far higher rates of under-five mortality and are

less likely to be in school than children from

wealthier families. The primary school net

attendance ratio in 2000–2006 was 65 per cent

for children from the poorest fifth of households

in developing countries, compared with 88 per

cent for children from the richest households.

Pan American

Health

Organization

MORTALITY IN CHILDREN <5 AT THE

GLOBAL LEVEL

Violence may affect between 500 million and

1.5 billion children, and an estimated 150

million children aged 5–14 are engaged in

child labor. More than 70 million women and

girls aged 15–49 in 29 countries have been

subjected to female genital

mutilation/cutting.

Pan American

Health

Organization

0

10

20

30

40

50

60

70

80

90

100

1990 1995 2000 2005 2009

Developed regions

Decline

1990-2009

(%)

33

22

68

53

56

50

YEAR

Pe

r 1000 liv

e b

irth

s

Source: The Lancet, September 2010

LEVELS AND TRENDS IN

UNDER-5 MORTALITY RATE

Pan American

Health

Organization

THE 1st GLOBAL CONGRESS FOR CONSENSUS IN PEDIATRICS

AND CHILD HEALTH

II. The situation in

the Region of the

Americas

MORTALITY IN CHILDREN <5 IN

THE AMERICAS REGION

More than 300,000 deaths annually of children

under 5 years

Infectious diseases are still the cause of 27% of

deaths

Peri-neonatal affections are the cause of 58% of

deaths

Big gaps between countries & areas within

countries regarding mortality rates

Pan American

Health

Organization

Malnutrition 3 %

Pneumonia & ARI

12 %

Diarrhea 12 %

Respiratory & infectious

diseases: 27%

Other 6 %

Accidents 6 %

Peri-

neonatal

58%

Sepsis 32%

Asphyxia 29%

LWB &

Prematurity

24%

Congenital

anomalies 10%

CAUSES OF DEATH IN CHILDREN < 5 IN THE

AMERICAS REGION

Source: Estimates of FCH /HL-based PAHO/HSD/HA data, 2009 Pan American

Health

Organization

42.4

33.6

27.4

23.821

18

0

5

10

15

20

25

30

35

40

45

1990 1995 2000 2005 2010 2015

EVOLUTION OF MORTALITY IN CHILDREN

UNDER 5 YEARS IN THE REGION OF THE

AMERICAS. RATES PER 1000 LIVE BIRTHS P

er

10

00

liv

e b

irth

s

ODM

Source: Estimates of FCH /HL-based PAHO/HSD/HA data, 2009

52%

14

Pan American

Health

Organization

66%

0

50

100

150

200

250

300

350

< 5 years < 1 year

58% 71%

42%

29%

NEONATAL MORTALITY RATE IN RELATION TO

TOTAL NUMBER OF DEAD IN < 5 YEARS AND

< 1 YEAR

Neonatal mortality

Pe

r 1

00

0 liv

e b

irth

s

Post neonatal mortality

Source: Estimates of FCH /HL-based PAHO/HSD/HA data, 2009

Pan American

Health

Organization

MORBILITY IN CHILDREN

<5 YRS.

Peri neonatal diseases are the most common

cause of morbidity and mortilidad (58%)

Infectious diseases continue to be a frequent

cause of disease (27%):

ARI

Diarrheal disease

Nutritional deficiencies affect growth &

development: malnutrition, deficient

micronutrients (Fe, Vit. A, zinc)

Pan American

Health

Organization

Pan American

Health

Organization

76

5957

39

35

3129 28

2624 24 23 22 22 21 20 19

16 1614

119 8 7 6

HAI GUY BOL GUT NIC JAM DOR MEX Total ELS HON PAN PAR ECU COL BRA VEN ARG BLZ URU COR CHI USA CUB CAN

8% of births

18% of deaths 32% of births

13% of deaths

Source: Estimates of FCH /HL-based PAHO/HSD/HA data, 2009

80

70

60

50

40

30

20

10

0

> 30 < 15

RR = 5

MORTALITY IN CHILDREN UNDER 5 YEARS IN

THE REGION OF THE AMERICAS.

Pe

r 1

00

0 liv

e b

irth

s

Pan American

Health

Organization

THE 1st GLOBAL CONGRESS FOR CONSENSUS IN PEDIATRICS

AND CHILD HEALTH

III. The IMCI Strategy

IMCI: INTEGRATED STRATEGY

Changes the approach to child healthcare:

From treatment of specific diseases,

To an evaluation of the child’s health status

Looks for signs of disease & most prevalent

pediatric problems regardless of the reason to

consult

Integrates actions of prevention & health

promotion as part of healthcare in a systematic

fashion Pan American

Health

Organization

IMCI AS A KEY STRATEGY FOR

IMPROVING CHILD HEALTH

Nutrition Immunization Other disease

prevention

Promotion of

growth and

development

Management

of sick

children

Integrated Management

of Childhood Illness

Pan American

Health

Organization

IMCI

MAIN OBJECTIVES

Prevent

mortality

Reduce incidence &

severity of morbidity

Improve growth &

development

Pan American

Health

Organization

IMCI

MAIN ACTIONS.

Early diagnosis & appropriate & effective

treatment by healthcare team

Early recognition of child’s health problems

by the parents & family.

Teach parents to seek the appropriate care

Better home care:

Feeding practices, Early stimulation, BF

Preventive interventions: immunizations,

Vit. A Pan American

Health

Organization

CONCEPTUAL FRAMEWORK OF CAUSES OF DEATH

DURING CHILDHOOD PERIOD

Barriers in

seeking

care

Low health

care

quality

Deleted

recognition of

the problem

Inadequate

newborn care

at home

DELAYS

Direct

medical

reasons

Underlying

causes

attributable

to the

community

and the

health

system

Root Causes Low priority given to

women and newborns

Source: The Healthy Newborn: A Reference Manual for Program Managers. CDC,CCHI, CARE, 1987

Cultural barriers Education

Malnutrition 3%

Diarrhea and

other infections

12% Peri-

neonatal

58%

Malnutrition

(associated to

other causes): 19%

IMCI CASE MANAGEMENT AT FIRST

LEVEL, REFERRAL LEVEL AND AT HOME

FIRST-LEVEL OUTPATIENT HEALTH FACILITY

Give FOLLOW-UP care when the child returns, and if necessary, reassess for new problems

“PINK” - PRE-

REFERRAL

TREATMENT AND

REFERRAL

“YELLOW” -

SPECIFIC

TREATMENT AT

FIRST LEVEL

FACILITY

“GREEN” - HOME

MANAGEMENT

Ask about CHILD’S PROBLEMS

Check for GENERAL DANGER SIGNS

ASSESS for MAIN SYMPTOMS:

COUGH OR DIFFICULT BREATHING

DIARRHOEA

FEVER

ASSESS for

MALNUTRITION AND ANAEMIA

Check for OTHER PROBLEMS

CLASSIFY

CHLID’S

CONDITIONS

AND

IDENTIFY

TREATMENT

ADVISE

parents about

REFERRAL

TEACH

parents about

treatment

COUNSEL

them about

feeding and

when to

return

FIRST-LEVEL REFERRAL HEALTH FACILITY

HOME

EMERGENCY TRIAGE

ASSESSMENT AND

TREATMENT

(ETAT)

DIAGNOSE AND TREAT

COMMON SERIOUS

CONDITIONS

MONITOR PATIENT

PROGRESS

GIVE ORAL DRUGS

AND/OR

TREAT LOCAL INFECTION

GIVE FOOD AND FLUIDS

(follow feeding recommendations)

RETURN TO HEALTH FACILITY

WHEN NEDED

Pan American

Health

Organization

Over 100 countries have adopted IMCI

WHY IMCI?

Takes advantage of the child’s contact with the

health system to:

Answer parents questions regarding the reason for

the visit to the health facility.

Look for early signs & symptoms of other diseases &

problems that might affect the child’s health.

Treat all problems found.

Check immunization status.

Assess nutritional condition, development & feeding

practices as well as home care.

Inform & educate parents to improve health &

development.

Pan American

Health

Organization

BASICS IMCI COMPONENTS

Danger signs recognition

ARI

Diarrhea:

Dehydration, persistent

diarrhea, dysentery

Fever:

Malaria, measles

Ear problems

Parasitosis

Nutrition & feeding

practices

Immunizations

Perinatal-neonatal

The continuum and

care approach

Pan American

Health

Organization

Wash your hands before and after examining the newborn. Prevent hypothermia.

ASK • Premature rupture

of membranes? How

long?

Has mother had

fever?

Medical problems

during this pregnancy

(Table 1)?

Was resuscitation

needed?

1 of the following signs:

Birthweight < 2,000g or > 4000g

Gestational age < 35 wks..

Body temperature < 36.5 o > 38.0ºC

Difficult breathing

Maternal fever or corioamnioitis

>12 hrs of ruptured membranes

Pallor or plethora

Intrauterine infection (TORCH/HIV)

Major birth defects

Severe birth trauma injuries

Resuscitation w/ positive pressure

ventilation or chest compressions

HIGH

RISK

AT

BIRTH

Refer URGENTLY to hospital, follow

stabilization & transport guidelines (pg. 9)

Encourage skin to skin care

If possible, initiate breast feeding

Keep warm

Premature rupture of membranes >12 hrs.

give first dose antibiotics

Provide routine newborn care (pg. 12)

Update mother on reasons for transfer

Regular breathing

Strong cry

Pink

Active

Weight 2500g or < 4000g

Gestational age >37 & <42wks.

LOW RISK

AT BIRTH

Encourage skin to skin

Initiate breast feeding

Keep warm

Provide routine newborn care (pg. 12)

Orient mother on home care

Teach danger signs

Follow-up visit in 3 days

Initiate vaccination according to schedule

1 of the following signs:

Birthweight between 2000g

2500g

Gestational age between 35 &

37 wks.

Gestational age 42 wks

Minor birth defects

Resuscitation w/o positive ventilation

or chest compressions

MODERATE

RISK

AT BIRTH

Refer for follow-up visit

Encourage skin to skin care

Initiate breast feeding

Keep warm

Provide routine care (pg12)

Teach danger signs

ASSESS CLASSIFY TREAT

Adequate thermal environment for

newborn 24º to 26º C w/o air currents

in delivery room & 36º C at

examination table

OBSERVE

Color

Breathing

Cry

Vitality

Birth defects

Signs of intrauterine

infection (TORCH/HIV)

Severe birth trauma

injuries

DETERMINE

Weight & gestational age

Body temperature

CLASSIFY RISK

ASSESS RISKS AT BIRTH

CLASSIFY

IMCI

NEW COMPONENTS

Development

Asthma & broncho

obstructive disease

Child abuse

Diabetes & obesity

HIV / AIDS

Disasters

Oral health

Dengue & Chagas

disease

Accidents & Violence

Epilepsy

Dermatologic

Nursing Pan American

Health

Organization

IMCI EXPANSION

New Components

Health Facilities

Referral Hospitals

Family &

Community

•Community health

workers

•Volunteers

•NGOs

•Hospital &

ambulatory

rotations

•Rural service

•Medical,

Nursing,

Nutrition Schools

•Others

Information, Education & Social Communication

Operational & Epidemiological Research

Pan American

Health

Organization

THE 1st GLOBAL CONGRESS FOR CONSENSUS IN PEDIATRICS

AND CHILD HEALTH

IV. Future Challanges

Pan American

Health

Organization

ACTIONS AND INTERVENTIONS

WITH POTENTIAL IMPACT

Increased Coverage of IMCI strategy

Incorporate new tools

Incorporating new evidence-based interventions

New components translate into different languages

Ensure the sustainability of the strategies built into

the university curricula

Maintain and expand strategic partnerships

Community interventions – LAC 30%

1990 2000 2015

Necessary decline for

fulfilling MDG:

annual 6.3%

Necessary

increase in

decline speed

671.300

522.600

224.700

364.600

40

30

20

10

Source: Estimates of FCH /HL-based PAHO/HSD/HA data, 2009

GAP TO ACHIEVE MDG # 4 FOR MORTALITY IN

CHILDREN LESS THAN 5 YEARS OLD BY 2015

Pan American

Health

Organization

THE CHALLENGE

Effective

Interventions

Impact

Childhood

Mortality

Reduction

Public Health

Priority Areas

Vulnerable

People

Strategies

THE 1st GLOBAL CONGRESS FOR CONSENSUS IN

PEDIATRICS AND CHILD HEALTH February 17-20, 2011

Paris, France

IMCI Pan American

Health

Organization