Transcript IMCI updates

Update
on IMCI guidelines and tools
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SEARO Regional Planning Meeting, Nepal | 07 August 2016
Outline
 Core packages along the continuum of care
 Update IMCI chart booklet
– Update on IMCI chart booklet
 Update of training methods
 Update on the pocket book
– Scope of pocket book update
– Highlights of the new recommendations
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SEARO Regional Planning Meeting, Nepal | 07 August 2016
MNCAH CORE PACKAGES ALONG
THE TWO CONTINUA OF CARE
GUIDELINES & POLICIES
Guideline products: critical for policy adoption of the new guideline
Technical update: specific changes needed in implementation tools in response to the new guideline
STRATEGIC
PLANNING
PROGRAMME
MANAGEMENT
CAPACITY
HEALTH FACILITY
REFERRAL LEVEL CAPACITY
FIRST LEVEL CAPACITY
Managing Complications
of Pregnancy and
Childbirth (IMPAC) (IT* 3)
PCPNC training
package (IMPAC)
(IT* 6)
Pocketbook for managing
newborn problems (IT* 4)
Essential Newborn
Care Course
(including NR and
Young Infant IMCI)
(IT* 7)
COMMUNITY LEVEL
CAPACITY
M&E
CAPACITY
CHW training package
for MNCH, including
community
mobilization and
participation (IFC) (IT*
10)
Short programme
reviews (M,C,A including
rights)
(IT* 12)
Household Survey for
MNCAH (IT* 13)
MNCAH Health facility
Survey (IT* 14)
MNCAH SARA (IT* 15)
MATERNAL
NEWBORN
Strategic
planning tool
for MNCAH
including
rights
(IT* 1)
CHILD
Programme
managers course
for MNCAH
including
nutrition
(IT* 2)
Pocketbook for hospital
care of children (IT* 5)
ADOLESCENT
X
IMCI training package
(IT* 8)
Orientation
Programme (IT* 9)
Counselling materials
for teachers, parents
etc (IT* 11)
Available clinical tools for IMCI
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SEARO Regional Planning Meeting, Nepal | 07 August 2016
IMCI Updates
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SEARO Regional Planning Meeting, Nepal | 07 August 2016
New recommendations - Treatment of pneumonia in
low HIV setting
 Pneumonia (fast breathing)
– Oral amoxicillin x 3 days - oral cotrimoxazole x 3 days second choice
 Severe pneumonia (chest indrawing)
– Oral amoxicillin x 5 days - If deterioration, change to treatment for very severe
pneumonia
 Very severe pneumonia (danger signs, hospitalized)
CXR to look for complications
• Inj ampicillin or benzyl penicillin + Inj gentamicin x at least 5 days, then
switch to oral amoxicillin + gentamicin for up to another 5 days
Alternative: Chloramphenicol i.v.or i.m. then oral to total 10 days, or ceftriaxone i.v. or i.m.
If not improved switched to Cloxacillin i.v, then change to oral to total 3 weeks
Dose: Oral: Amoxicillin = 40 mg/kg/dose twice daily
Parenteral: Benzyl penicillin 50,000 Ū/kg q 6 hr, Ampicillin 50 mg/kg/dose q 6 hr + Gentamicin 7.5 mg/kg/dose once daily, Chloramphenicol 25
mg/kg/dose
| q 8 hr , Ceftriaxone 80 mg/kg/dose once daily,
| Cloxacillin 50 mg/kg/dose q 6 hr
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SEARO Regional Planning Meeting, Nepal
07 August 2016
New recommendations - Treatment of pneumonia in
HIV positive children
 Pneumonia (fast breathing)
– Oral amoxicillin x 5 days
 Severe pneumonia (chest indrawing) and very severe pneumonia
(danger signs)
– Injectable ampicillin/benzyl penicillin plus gentamicin x 10 days
or injectable ceftriaxone
– Plus high dose cotrimoxazole (8 mg of trimethoprim) x 3 weeks if
age 2-12 months. For those >12 mo, give cotrimoxazole only
when clinically indicated
PCP prophylaxis in all infants and after Rx of PCP
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SEARO Regional Planning Meeting, Nepal | 07 August 2016
New Recommendations - Treatment of non-severe
pneumonia with wheeze
 Children with non severe pneumonia (fast breathing) with a wheeze
but with no fever (< 38oC) the use of antibiotics is not recommended
as the cause is most likely to be viral.
 Children with non severe pneumonia (fast breathing) with a wheeze
AND fever (> 38oC), give up to 3 doses of inhaled bronchodilators
and reassess fast breathing. If fast breathing persists then
recommend antibiotics.
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SEARO Regional Planning Meeting, Nepal | 07 August 2016
Option 1
IMCI CHART ASSESS AND CLASSIFY THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS
SIGNS
• Any general danger sign or
• Stridor in a calm child
• Chest indrawing or
CLASSIFY
COUGH OR
DIFFICULT
BREATHING
CLASSIFY AS
TREATMENT
SEVERE
PNEUMONIA OR
VERY SEVERE
DISEASE
• Give first dose of an appropriate antibiotic
• Refer URGENTLY to hospital
PNEUMONIA †
• Give oral antibiotic for 5 days
• If wheezing (……………)
• Soothe the (……………)
• If coughing for more than 3 weeks (……………)
• Advise the mother (……………)
• Fast breathing
• Follow-up in 2 days
• No signs of pneumonia or
very severe disease
COUGH OR COLD
• If wheezing (……………)
• Soothe the (……………)
• If coughing for more than 3 weeks (……………)
• Advise the mother (……………)
• Follow up in 5 days if not improving
New WHO pneumonia classification will be consistent with international guidelines of two categories for pneumonia
i.e. pneumonia and severe pneumonia
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SEARO Regional Planning Meeting, Nepal | 07 August 2016
Option 2
IMCI CHART ASSESS AND CLASSIFY THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS
SIGNS
CLASSIFY AS
TREATMENT
• Any general danger sign or
• Stridor in a calm child
VERY SEVERE
DISEASE
• Give first dose of an appropriate antibiotic
• Refer URGENTLY to hospital
• Lower chest indrawing
SEVERE
PNEUMONIA
• Give oral antibiotic for 5 days
• If wheezing (……………)
• Soothe the (……………)
• If coughing for more than 3 weeks (……………)
• Advise the mother (……………)
•Follow-up in 2 days
CLASSIFY
COUGH OR
DIFFICULT
BREATHING
• Fast breathing
PNEUMONIA
• Give oral antibiotic for 3 days
• If wheezing (……………)
• Soothe the (……………)
• If coughing for more than 3 weeks (……………)
• Advise the mother (……………)
• Follow-up in 2 days
• No signs of pneumonia or
very severe disease
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COUGH OR COLD
SEARO Regional Planning Meeting, Nepal | 07 August 2016
• If wheezing (……………)
• Soothe the (……………)
• If coughing for more than 3 weeks (……………)
• Advise the mother (……………)
• Follow up in 5 days if not improving
Programmatic implications of revised guidelines
Advantages
ADAPTATION 1
- Simple to implement.
Health workers will have to treat
one condition with one antibiotic
for one duration.
- No need to differentiate between
non-severe and severe
pneumonia
- Possibly, higher acceptance by the
health workers
-
Disadvantages
-
Slightly more expensive
-
Duration of therapy for fast breathing
also 5 days instead of 3 days
Choice of second line antibiotic
therapy difficult. All children who
deteriorate will need to be referred
- Inconsistent with the previous
recommendation of treating fast
breathing for 3 days
-
ADAPTATION 2
-
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Consistent with the previous
recommendation of treating fast
breathing (WHO defined
pneumonia) for 3 days†
SEARO Regional Planning Meeting, Nepal | 07 August 2016
-
Two different treatments in the yellow
classification
New Recommendation: Malaria Diagnosis
 Prompt parasitological confirmation by microscopy or Rapid
Diagnostic Tests (RDTs) is recommended in ALL patients suspected
of malaria before treatment is started.
Source: WHO/GMP, Malaria treatment guidelines, 2010.
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SEARO Regional Planning Meeting, Nepal | 07 August 2016
Fever Adaptation
Test positive
=
MALARIA
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SEARO Regional Planning Meeting, Nepal | 07 August 2016
Implications for the IMCI Algorithm
 Change to three classifications in malaria high risk (RED, YELLOW & GREEN).
 RED: VERY SEVERE FEBRILE DISEASE (NO MALARIA TEST TO AVOID
DELAY) - Pre-referral treatment with antimalarial and antibiotic.
 YELLOW: MALARIA (MALARIA TEST POSITIVE) – Oral antimalarial treatment
at facility.
 GREEN: FEVER: NO MALARIA (MALARIA TEST NEGATIVE)- No antimalarial
treatment .
 Other issues:– Follow up after malaria treatment - 3 days if fever persists
– If No Malaria, F/UP in 2 days if fever persists- REASSESS AND REPEAT MALARIA
TEST.
– In high risk, where the malaria test is not available CLASSIFY ALL FEVER AS
MALARIA.
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SEARO Regional Planning Meeting, Nepal | 07 August 2016
Nutritional Assessment
Diagnostic criteria for SAM:

Severe wasting measurement
−
−

Weight for height/Length < -3 Z scores
MUAC < 115 mm RED on strap
Clinical sign
−
−
Bilateral oedema of both feet
Severe visible wasting.

Appetite test

Complicating factors
WHO/UNICEF Joint statement and policy guidelines on community-based management of
severe uncomplicated malnutrition
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SEARO Regional Planning Meeting, Nepal | 07 August 2016
IMCI clinical tools
 Ensure quality of care at all levels
– Caring for newborns and children
in the community and at home
– Integrated management at first
level facility
– Quality emergency, triage and
treatment at referral level
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SEARO Regional Planning Meeting, Nepal | 07 August 2016
 Health care providers have the
necessary skills and competencies
– IMCI in-service training
– IMCI pre-service training
– IMCI distance learning
– IMCI computerized adaptation
and training tool (ICATT)
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SEARO Regional Planning Meeting, Nepal | 07 August 2016
ICATT Software with two interfaces
Builder and
Manager
Chart
builder
Library
Training
Set
Training Player
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SEARO Regional Planning Meeting, Nepal | 07 August 2016
•
“OPEN” interface - allows to do
virtually everything
 Change/adapt guidelines and
create management flow chart etc.
 Update library of documents, and
other recourses
 Design training programme
•
“CLOSED” end-user interface used
training or self-learning
Role of ICATT in IMCI Strategy
 Speed-up adaptation of generic guidelines for country use.
Currently it is a long and cumbersome process….
 Ensure regular periodical updates of national IMCI guidelines
to respond to local health needs. Currently rarely done at
country level….
 Increase the number of available training options and
hopefully as a result training coverage. Currently it is still low
to give significant impact…
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SEARO Regional Planning Meeting, Nepal | 07 August 2016
ICATT …
 Builder & Manager software available in 4
languages with relevant updates.
 Web/server based software being tested
and finalized
 All supportive materials for adaptation and
different options of training available.
 Capacity building – plan for 3 regional
capacity building workshops conducted in
2011.
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SEARO Regional Planning Meeting, Nepal | 07 August 2016
Status of Introduction or Early
Implementation of ICATT
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SEARO Regional Planning Meeting, Nepal | 07 August 2016
To access the training please click on the following link: http://online.icatt-training.org/.
Instructions
Click on the link: http://online.icatt-training.org/
Select preferred language (English, French, and Spanish) and click “Start” button.
Register (if first time to access player) or login. To register, fill in the form fields required (name,
country, profession, email and specify your login password). Accept general terms and then
click “register”. Note: Ignore the teacher fields.
On the next page you will get information that a registration email has been sent to you. Go to
your email used for registration and click on the link to activate your account.
After activation of the account, click on the “Login” button and login with your registered email
address and password.
Select the course and start training by clicking “Next” at the lower right side. Although in most
cases the text fits on a screen view, sometimes you might need to scroll down to read more
text depending on your computer screen size. Continue training by just clicking “next”.
Additional information:
•
To see a full view picture or watch a video click on it. To return to the training click the
“back” button at the right lower side.
•
The squares on the lower left side show your progress through the course units: WHITENot begun, YELLOW- not completed, GREEN- Passed and RED- Failed.
•
Your progress is determined by the last practise test in the unit.
Paper-based IMCI Distance Learning:
principles and experiences
 Learning may be blended with many components to ensure clinical
practice and motivation:
• Face-to-face meetings with facilitators, for orientation, review
of study and practice
• Encourage group study/ group clinical practice
• Access to a mentor/tutor in person, or through mobile etc
• Practicing IMCI skills in home facilities
 May target health workers who cannot leave their clinics for too many
days; including private practitioners and those with family/children
 Has been field-tested in South Africa. In the process in Ethiopia and
Tanzania.
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SEARO Regional Planning Meeting, Nepal | 07 August 2016
DL Materials vs IMCI In-service Modules
 Modules same as for in-service except for:– Modules are re-written so that they are self-contained
i.e. from assess….. to follow up
• Opening case study
• Self-assessment exercises with answers
• Relevant photos/video DVDs
– Facilitator guide for the face-to-face meetings
• Formation of study groups
• Identification of mentors/tutors
– Logbooks created for progressive assessment
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SEARO Regional Planning Meeting, Nepal | 07 August 2016
Update on Pocket book
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SEARO Regional Planning Meeting, Nepal | 07 August 2016
Assessment of 21 hospitals in 7 countries. Key findings:
 76% of hospitalized children receive substandard care
– Lack of triage
– Drug supply inadequate, especially emergency drugs
– Inadequate assessment and late treatment
– Poor knowledge of treatment guidelines
– Inadequate oxygen supplies
– Insufficient monitoring of sick children
 Many deaths in hospital occur within 24 hours of admission
 Deaths can be prevented if very sick children are identified quickly
and treated accordingly
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SEARO Regional Planning Meeting, Nepal | 07 August 2016
Impact on mortality - emergency triage and treatment in
referral health facilities, Malawi
Molyneux E. et al. Improved triage and emergency care for children reduces inpatient mortality in a resource-constrained setting, Bull
World Health Organ, 2006
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Status of implementation
By end of 2010:
 45 had introduced quality of referral
care activities
50
45
 26 introduced/adapted pocket book
 20 conducted at least 1 ETAT course
No. of Countries
 36 conducted hospital assessment
40
35
30
25
20
15
10
5
0
 30 had some activities QoC
improvement.
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SEARO Regional Planning Meeting, Nepal | 07 August 2016
Hosp.
Assessment
Quality
Improvement
Pocket Book
QoC Activities
ETAT
Total
Scope of Pocket Book Update
 Alignment with recent new guidelines
– Infant feeding in HIV exposed, prevention and paediatric ART
treatment;
– Treatment of tuberculosis and malaria in children,
– Feeding in low birth weight infants
– Management of convulsions, and update of the essential medicines.
 Prioritized section updates (34 recommendations reviewed) for:– Fever conditions and dysentery (7)
– Cough and difficult in breathing (5)
– Use of oxygen therapy (6)
– New born conditions (9)
– Others (4)
 Editorial issues
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SEARO Regional Planning Meeting, Nepal | 07 August 2016
Highlights of New Recommendations
 Pneumonia
– Treatment of pneumonia with wheeze
– Increased amoxicillin dosage 80mg/day for pneumonia and severe pneumonia.
– Oral amoxicillin for severe pneumonia
 Acute bacterial meningitis - Ceftriaxone as 1st line treatment
 Acute Otitis Media- Amoxicillin 40mg/kg twice daily
 Chronic Suppurative Otitis Media - Quinolones drops
 Sublingual sugar for immediate ‘first aid’ management of hypoglycaemia.
 IV fluids:
– Isotonic fluids (Ringers lactate/0.9% NS) for resuscitation
– Low/NO sodium containing solutions should be avoided
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SEARO Regional Planning Meeting, Nepal | 07 August 2016