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SUPPLEMENT No 1 TO VOLUME 75, 1997, OF THE

BULLEFTIN

OF THE WORLD HEALTH ORGANIZATION DE L'ORGANISATION MONDIALE DE LA SANTE

THE SCIENTIFIC JOURNAL OF WHO*LA REVUE SCIENTIFIQUE DE L'OMS

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS:

A WHO/UNICEF INITIATIVE

WORLD HEALTH ORGANIZATION, GENEVA * ORGANISATION MONDIALE DE LA

SANTE,

_

© Organisation mondiale de laSante 1997

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SUPPLEMENTNO. TOVOLUME 75, 1997, OF THE

BULETIN

OF THE WORLD HEALTH ORGANIZATION DE L'ORGANISATIONMONDIALE DE LA SANTE

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS:

A WHO/UNICEF INITIATIVE

Integrated Management of Childhood Illness (IMCI) is a strategy that aims to reduce child deaths and the frequency and severity

of illness and disability among children in developing countries, and to contribute to improved growth and development. The strategy addresses the five major life-threatening conditions of childhood: acute respiratory infections (ARI), diarrhoea, mea- sles, malaria and malnutrition. It includes activities designed to improve the performance of health workers, to improve health systems, and to improve family and community practices. The core of the MCI strategy, and the first intervention made available to countries, is the application of clinical guidelines for integrated case management at first-level health facilities.

These guidelines were developed based on existing scientific evidence, on formal evaluations of their effectiveness in selected developing country settings, and on specially designed studies to address remaining questions about the most appropriate clinical signs to be used in assessing specific illnesses. The refined clinical guidelines were then used as the basis for the development and field testing of a training course for health workers who manage children in first-level health facilities. The IMCI guidelines and training course are adapted to the specific epidemiological and other ocal conditions in individua coun- tries, and have served as a starting point for broader IMCI

planning and implementation in nearly 40 countries since 1 996.

Price: Sw fr. 20.-

Price in developingcountries: Sw fr. 14^- ISBN 92 4 068750 5

CONTENTS

Preface ..5

Integrated management ofchildhood illnessby outpatient healthworkers: technical basis and overview-S. Covefor the WHO WorkingGrouipon GutidelinesforIntegrated Management of

theSick Child ...7... ... ... 7 Evaluationofanalgorithm for the integrated managementofchildhood illnessinan areawith

seasonal malaria inthe Gambia-M.W. Weber, E.K. Mulholland, S.Jaffar, H. Troedsson, S. Cove,

& B.M. Greenwood. ... 25

Evaluation ofanalgorithm forintegrated managementofchildhoodillness inan area ofKenya with high malariatransmission-B.A. Perkins.JR. Zuicker,J. Otieno, H.S.Jafari, L. Paxton, S.C. Redd, B.L. Nahlen, B. Schwartz, A.J. Oloo, C. Olango, S. Gove, & C.C. Canmpbell .33

Performance ofhealth workers after trainingin integrated management ofchildhoodillnessin Gondar, Ethiopia-E.A.F. Sinmoes T Desta, T. Tessenma, T. Gerbresellassie, MI. Dagnew, & S. Gove .43 Integratedmanagement ofchildhood illness: fieldtest ofthe WHO/UNICEFtraining course in Arusha,

United Republic of Tanzania-WHO Divisionof Child Health andDevelopnment& WHO Regional Office for Africa ... ... ... 55 Identifying sick children requiringreferral tohospital in Bangladesh-H.D. Kalter, J.A. Schillinger,

M. Hossain, G. Blurnhanm, S. Saha, V. de Wit, N.Z. Khan, B. Schwartz, & R.E. Black .65 Theintegrated management of childhoodillness in western Uganda-P.R. Kolstad, G. Bulrnham,

H.D. Kalter, N. Kenva-Mulgisha, & R.E. Black... ... ... 77 Assessmentofpotential indicatorsforprotein-energy malnutritionin thealgorithm for integrated

management ofchildhood illness-C. Bern,J.R. Zlucker, B.A. Perkins, J. Otieno, A.J. Oloo,

& R. Yip ... ... ...7... 87 Clinical signsforthe recognition of children with moderate or severeanaemia inwesternKenya-

J.R. Zlucker, B.A. Perkins, H.Jafari, J. Otieno, C. Obonvo, & C.C. Capbell.97

Evaluation ofclinicalsignstodiagnose anaemiain Uganda and Bangladesh, in areaswith and without malaria-H.D. Kalter, G. Bulrnhanm, P.R. Kolstad, M. Hossain,J.A. Schillinger, N.Z. Khan, S. Saha, V. de Wit, N. Kenya-Mugisha, B. Schwartz, & R.E. Black ... ... ... 103 Pallor as aclinical signofsevere anaemiainchildren: aninvestigation in the Gambia-M.W. Weber,

S.D. Kellingray, A. Palmer, S. Jaffor, E.K. Mlulholland, & B.M. Greenwood.113 Integrated management ofchildhood illness: conclusions-WHO Division of ChildHealth

andDevelopment... ... ... ... 119

WHO BulletinOMS. Vol75. Suppl.1. 1997

PREFACE

Every year more than 11 millionchildren in developing countries die beforethey reach theirfifth birthday, manyduring thefirstyearoflife. Seven in tenofthesedeaths aredueto acute respiratoryinfections (mostly pneumonia), diarrhoea, measles, malaria ormalnutrition-and often to a combination ofthese conditions.

Much has been learned fromdisease-specific child survivalprogrammes inthepast 15 years.The challenge now is to apply the lessons from these programmes to strategies that promote coordination and, where appropriate,greaterintegration of activitiesinordertoimprove the prevention and managementof childhood illness. The WHO Division of Child Health and Development (CHD), in collaboration with ten otherWHO programmes, UNICEF,theWorld Bankand numerous other agencies andinstitutions, hasrespondedtothis challenge by developing the Integrated Management of Childhood Illness (IMCI) strategy.

Usingasetof interventions for the integratedtreatmentand prevention of major childhoodillnesses, the IMCI strategy aimsto reduce death andthefrequencyandseverity of illnessanddisability, andtocontribute to improved growth and development. This set of interventions aims to improve practices both in health facilitiesand in the home.

The coreofthe IMCI strategy, and the firstintervention to bemade available tocountries, is a setof guidelines forintegrated casemanagementof the five mostimportantcausesof childhood deaths-acute respiratory infections (ARI), diarrhoea, measles, malaria and malnutrition - and of common associated conditions, inoutpatientsettings. This supplementtothe Bulletin of the World HealthOrganization provides the technical basis for the IMCI case management guidelines, and reports on the development and field testing of the WHO/UNICEF IMCI training course forfirst-level health workers.

In individual countries, the combination of clinical guidelines that constitute IMCI may be modified to include other important conditions for which effective treatment and/or preventive practices have been identified. The main interventions of the global IMCI strategy will evolve as experience is gained in implementation andas newfindings from health research become available.

IMCI hasprovided a newimpetus foreffortsto promote childhealthanddevelopment. Theresponse to IMCI onthepartofMinistries of Health has beenfargreaterthan expected inthe 20 monthssince the first guidelines and training course became available. As of September 1997, 39 countries in the developing world had committed themselves to moving forward with IMCI, and discussions had started in seven additional countries.Agencies and institutions committedtoimproving child health have providedsupportfor IMCI at country, regional and global levels, and are undertaking significant research and development efforts. As the momentum for the IMCI strategy builds, the importance of generating and disseminating scientific evidenceon theefficacy and effectiveness ofspecific IMCI interventions increases. This volume seekstocontributeto acontinuing scientific dialogue about IMCI and its potential for improving child health anddevelopment.

WHO Bulletin OMS. Vol75,Suppl.1, 1997

PREFACE

Chaqueann6e, plusde 11 millions d'enfants despays end6veloppementmeurent avant d'avoir atteint leur cinquieme anniversaire, etbeaucoup d'entre eux pendant leur premiereann6e. Sur dixde ces d6ces,sept sont imputables aux infections respiratoires aigues (pneumonie essentiellement), a la diarrh6e, a la rougeole, au paludisme ou a la malnutrition - et souventa une association de ces pathologies. Ces 15 dernieres ann6es les programmes de survie de 1'enfant visant des maladies specifiques ont et6 riches d'enseignements. 11convient maintenantd'appliquerlesle9ons tireesde ces programmes auxstrat6giesqui favorisent lacoordination, ets'il y alieu laplus grande int6grationdes activit6s, demaniere aam6liorerla prevention et la prise en charge desmaladiesdel'enfant. LaDivision de laSant6etduD6veloppement de l'Enfant (CHD), encollaboration avec dix autres programmes de l'OMS, l'UNICEF, la Banque mondiale et des agences et organismes nombreux etvari6s, a repondu en elaborant la strategie de prise en charge integree desmaladies de 1'enfant (IMCI).

S'appuyantsur un ensemble coh6rentd'interventionspour parvenir aun traitement et uneprevention int6gr6s des grandes maladies de 1'enfant, I'IMCI vise a r6duire tant la mortalite que la fr6quence et la gravit6de lamaladieetde l'incapacit6,etaam6liorer lacroissance etled6veloppement. Ces interventions ontpourbutd'am6liorer les pratiquesau centre desant6 comme au domicile.

Le fondement de l'IMCI, et lapremiere intervention a mettrea ladisposition despays, est un groupe de recommandationspour lapriseenchargeint6gr6e des cinq plus importantescausesded6ces de l'enfant

-infections respiratoires aigues (ARI), diarrhee, rougeole, paludisme et malnutrition-et despathologies courantes associ6es, dans le cadre ambulatoire. Le pr6sent suppl6ment du Bulletin de l'Organisation mondialede laSant6fournit les basestechniques des recommandations pour la prise encharge dans le cadrede l'IMCI, etrend comptede la miseaupointetde l'essaisur leterrain du coursde formation OMS/

UNICEF a l'IMCI destine auxagents de sant6de premier niveau.

Les recommandations cliniques dont le corps forme l'IMCI peuvent etre modifi6es par un pays, pour inclure d'autres affections importantes pourlesquellesexistent untraitementetlouunepr6ventionefficaces.

Les principales interventionsdel'IMCI al'echelle mondiale evoluerontpour tenir compte del'experience tir6e de sa miseen ceuvreetdesdecouvertes de la recherche ensant6.

L'IMCIa donne un nouvel 6lan auxactionsde promotion de lasanteetdu d6veloppementdel'enfant.

Dans les 20 mois qui ont suivi la mise a disposition des premieres recommandations et du cours de formation, la r6ponsedes ministeres de la sant6vis-a-vis de l'IMCI ad6pass6 lesattentes. Enseptembre 1997, 39 pays du monde endeveloppement s'6taient engages en faveur del'IMCI et sept autresavaient entam6des discussions. Lesagences etles institutionsquiconsacrentleursactivit6sal'am6liorationde la sant6de l'enfantont apport6leur soutien a l'IMCI au niveau du pays, de la region etde laplanete, et ont entrepris des efforts de recherche et de d6veloppement importants. La strat6gie de l'IMCI prenant une importance croissante, il importe de plusenplus defourniretdefaireconnaitrelesargumentsscientifiques quiattestentl'utilit6etl'efficacite des interventionssp6cifiquesdecettestrat6gie.Ce volumeapourobjet de contribuer a la poursuite du dialogue scientifique sur l'IMCI et sa capacite a am6liorer la sante et le d6veloppement ^de l'enfant.

WHO BulletinOMS. Vol75,Suppl.1, 1997 6