de Klerk, E

Hussey, G

Loening, W

Mhlanga, E

Zar, H

English

AJOL - African Journals Online

EDITORIAL24. WlSner B. GOBl versus PHC? Some dangers of selective primary health care. Sac Sei Med1988; 26, 963-%9.25. Klein R. Defining a package of healthcare services the ~ll-iS is responsible for. The caseagainst. BMI 1997; 314, 506-509.26. Sikosana PLN, Dlamini QQD, lssakov A. Health sector reform in SUb-Saha~Africa: Areview of infonnation gaps and research needs. Geneva; Division of AnalysIs, Research andAssessment, World Health Organisation, 1996.INTEGRATED MANAGEMENT OFCHILDHOOD ILLNESS - A NEWAPPROACH TO OLD DISEASESThe World Health Organisation (WHO) has estimated thatapproximately 24% of the world's disease burden is caused byfive conditions - pneumonia, diarrhoea, measles, malaria andsevere malnutrition.! These illnesses primarily affect children.In sub-Saharan Africa their contribution to the burden ofchildhood disease is substantially greater and is estimated to bemore than 40%. These five conditions account for over 70% ofthe mortality in children under 5 years of age.' Moreover, theWHO global burden of disease analysis projections indicatethat these conditions will continue to be significantcontributors to childhood mortality well into the next century.Pneumonia is responsible for approximately 4 million of theestimated 12 million deaths that occur in children under 5years of age in developing countries. Most deaths occur inchildren under 2 years of age, and over 60% of deaths follow S.pneumoniae and H. influenzae infections. Pneumonia is also theleading cause of death in children with measles. Diarrhoealdisease kills another 3 million children and ranks secondamong all causes of disease burden. More than half ofdiarrhoea-associated deaths are caused by dehydration due tofluid losses. Measles and malaria are each responsible forapproximately a million deaths, and malnutrition is estimatedto be associated with approximately 3.5 million deaths. This ISprobably an underestimate, since malnutrition is a significantrisk factor for the other conditions. Recent estimates from asurvey of 53 developing countries indicate that 56% of childdeaths were attributable to the potentiating effects ofmalnutrition.'These clinical problems are also the most common reasonsfor health service utilisation, accoUIlting for at least 75% of allvisits to health centres and admissions to hospital. Data fromhospital-based studies report overall case fatality rates of7 - 10%, with 30 - 60% of deaths occurring within 24 hours ofadmission. Reasons for this high mortality within the first dayfollowing admission are probably related to delay in seekingcare (lack of caregiver knowledge) or inadequacy of care(unavailability, inaccessibility and inadequacy of care andreferral mechanisms). The WHO, together with otherinternational agencies, have over the last 2 decades facilitatedimplementation of disease-specific case management strategiesto reduce the burden of these diseases.Specific interventions for the five main childhood diseasesinclude oral rehydration therapy (ORT) for diarrhoea,'antibiotics for pneumonia,' feeding and micronutrientsupplementation for malnutrition,' vitamin A supplementationfor measles' and anti-parasitic drugs for malaria· These casemanagement strategies have proved very effective in reducingchildhood morbidity and mortality in developing countries.Significant reductions in hospital admissions and case fatalityrates from diarrhoea have occurred following theimplementation of ORT in a number of countries' A meta-analysis of the effectiveness of pneumonia case managementguidelines demonstrated a 35% and 53% reduction inpneumonia mortality in infants and children (1 - 4 years),respectively.' A study of severely malnourished childrenshowed a reduction in mortality from 20% to 7% following theinstitution of a malnutrition case management initiative.'Vitamin A supplementation has resulted in a significantreduction in case fatality rates from measles and in theincidence and severity of measles-related complications.'Studies evaluating the impact of malaria case managementhave reported improvements in malaria case detection andmanagement.sHowever, a single diagnosis for a sick child is ofteninappropriate, since children frequently present with multipleclinical problems! Pneumonia and diarrhoea are frequentcomplications in children who present with either measles ormalnutrition.'" Multiple clinical problems increase diseaseseverity and mortality. Pneumonia, measles and malnutritionhave been identified as significant risk factors for fataldiarrhoea.11 ln addition, the clinical signs and symptoms of themajor paediatric conditions frequently overlap. Rapidbreathing and chest indrawing, which are cardinal signs for thediagnosis of pneumonia in the context of the WHO acuterespiratory infection (ARI) guidelines, also occur inter alia insevere dehydration with metabolic acidosis and in malaria. 12Although the relatively inexpensive disease-specific casemanagement strategies have contributed to a reduction ofdisease burden, efficiency and effectiveness can be improvedby adjressing the sick child as a whole rather than focusing ona single disease. For these reasons the Integrated Managementof Childhood illness (IMC!) programme was launched in 1993.This is a more comprehensive approach to the care of the illchild, ensuring appropriate and combined treatment of the fivemajor diseases. ln addition IMCl emphasises preventive andpromotive strategies that are integral to the maintenance andwell-being of the child. These include immunisation, breast-feeding, nutrition and maternal education.lMC! contains guidelines for the management of the fivemajor diseases in Wants and children. The process involvesassessirIg and classifying the extent of illness, treating the child,counselling the caregiver and advising on follow-up of theEDITORIALIrepatient. Sick children are assessed according to their symptomsand signs. This process uses the fewest reliable clinical signs toclassify illness according to the level of intervention required:severely ill and requiring hospital referral, moderately illrequiring specific treatment at a primary health care facilityand at home, or mildly ill requiring supportive therapy andcounselling. The disease-specific interventions described aboveare used. Health care workers are taught to rationalisetreatment, prescribing the minimum number of essentialmedicines. The caregiver is counselled about the child's illness,feeding and follow-up. When the mother is the caregiver, she isalso counselled on issues pertaining to her own health such asnutrition, irnmt¥lisation, family planning and sexuallytransmitted diseases.Although IMCr focuses on five specific diseases, many morechildhood illnesses can be identified and treated using theseguidelines. Furthermore, guidelines can be expanded toinclude additional priority childhood diseases such as asthma.Thus, !MC! can be adapted to accommodate different childhealth problems identified in various geographical areas. Anadditional advantage is the cost efficiency of this project.According to the 1993 World Bank Report !MC! is likely tohave the greatest impact in reducing global disease burden inchildren under the age of 5 years at an annual cost of $1.6 percapita, which ranks among the most cost-effective interventionsin low- and middle-income countries."The Department of Health (OOH), recognising the potentialimpact of IMC! on child health in South Africa, has embarkedon a national programme to institute this approach. This timelyintervention is consistent with the National Programme ofAction (NPA) for children that stresses provision of preventiveand curative services at a primary level and appropriateutilisation of health care resources. A technical task team (TIT)consisting of members from the provinces, academicinstitutions, non-governmental organisations and the WHOwas established by the OOH in 1996 to advise on theimplementation and monitoring of this initiative. The TIT arsoincludes members of other national departments such asnutrition, communicable diseases, environmental health andwater affairs, underscoring the importance of the involvementof other sectors in this project. A national workshop ofprovincial delegates and TIT members established a consensusand need for this project. Subsequently the heads of thenational and provincial departments of health gave theimplementation of !MC! enthusiastic support. Plans forimplementation, monitoring, surveillance and socialmobilisation around the project are currently underway.The impact of !MC! has not yet been evaluated as it is arelatively new programme. However, given the success of thecase management approach it is probable that !MCr maysignificantly improve child health, particularly in areas that areunder-resourced and have a high under-5 mortality rate. Thesuccess of this initiative will depend on several factors.December 1998, Vo!. 88, No. 12 SAMJContinued support from the OOH and effectiveimplementation and training at a provincial level are essential.Efficient functioning of the health care system is a fundamentalcomponent for the success of this strategy. Drug supply,efficient referral mechanisms and an appropriate healthinformation system at primary level are also essential elements.Support from the medical and nursing professions is vital andideally IMC! needs be incorporated into the formal medicaleducation of health care workers. Moreover, communityparticipation and social mobilisation must be part of effectiveimplementation. Finally, it will be important to evaluate theefficacy of IMC! in different areas of South Africa once thisinitiative is implemented.Besides the impact on childhood morbidity and mortalityand cost efficiency, this approach may ultimately promoteequity of care by promoting access to simple, effective andaHordable treatment for children. !MCr should form part of abroad strategy to improve the health of all of our children.HZarG HusseyChild Health UnitDepartment of Paediatrics and Child HealthUniversity of Cape TownE MhlangaW LoeningE de KlerkDirectorate: Maternal, Child and Women's HealthDepartment of HealthPretoria1. World Health Organisation. Investing in Health Research and Develapmrot. Report of the ad hocCommittee on Health Research Relating to Future Intervention Options (WHO/TDR/Gen %.1).Geneva: WHO.2. World Health Organisation. Division of Diarrhoea! and Acute Respiratory Disease Control.Integrated. management of the sick child. Bull World Health Organ 1995; 73: 735-740.3. Pellitier DL, Frongillo EA, Schroeder CX::;, Habicht JP. The effects of malnutrition on childmortality in developing countries. Bull World Health Organ 1995; 73: 443-448.4. World Health Organisation. Diarrhoeal Diseases Control Programme. Impact of oralrehydration therapy on hospital admission and case fatality rates for diarrheal disease. WklyEpidemiol Rec 1988; 63, 49-52.5. Sazawai 5, Black RE. Meta-analysis of intervention trials on case management of pneumoniain community settings. LAncet 1~; 340: 528-533.6. Khanum S. Ashworth A, Huttly SRA. Controlled trial of three approaches to the treatment ofsevere malnutrition. LAncet 1994; 344: 1728-1732.7. Hussey GO, Klein M. A randomised controlled trial of vitamin A in children with severemeasles. N Engl JMed 1990; 323, 16(}-j64.8. Reeve PA. Malaria treatment in Vanuata: new national treatment guidelines. PNG Med /1994;37, 18J.188.9. Gove 5, Tulloch J, Cattani J, Schapira A. Usefulness of clinical case-definitions in treatment ofchildhood pneumonia or malaria. LAncet 1993; 341: 304-305.10. Hussey G, Clements J. Oinical problems in measles. Ann Trap Paedintr 1996; 16: 307-317.11. Griffin PM. Ryan CA. Nyaphisi M, Hargrett-Bean N, Waldman RI. Blake PA. Risk factors lorfatal diarrhea: a case control-study of African children. Am / EpidernioI1988; 128: 1322-1329.12. Marsh K, Forster 0, Waruiru C et al. Indicators of life threatening malaria in Africanchildren. N Engl JMed 1995; 3320 1399-1404.13. The World Bank. World Development Report 1993: Investing in Health. New York: OxfordUniversity Press, 1993.

Integrated management of childhood illness - A new approach to old diseases

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Integrated management of childhood illness - A new approach to old diseases

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