Febrile Illness 2019 Shamim Qazi

WHO/UNICEF Integrated Management
of Childhood Illness (IMCI)

and Child Health Redesign
Shamim Qazi, Geneva

Summary
IMCI Technical Updates
• 2005
• 2008
• 2012
• 2019 and implementation research
Child Health Redesign
IMCI Updates…do we need them?
New research results are emerging from randomized,
controlled trials
Recommendations are being regularly reviewed and

updated
Changing disease epidemiology- neonatal deaths are

gaining increasing prominence in total U5 deaths
New ways of IMCI training need to be introduced

2005 IMCI Updates
The updates covered six areas:

• Antibiotic treatment of severe and non-
severe pneumonia & inclusion of wheeze
• Low osmolarity ORS, Zinc and antibiotic
treatment for bloody diarrhoea
• Treatment of malaria with ACTs
• Treatment of ear infections with topical
quinolones
• Infant and young child feeding
• Treatment of helminthiasis
2008 IMCI Updates
The updates covered mainly sick young infant

• New sections on the management of illness in the first
week of a child's life.
• Young infant module for IMCI training
• Included HIV section in high HIV settings.
Note: Training modules were

updated only in ICATT
2012 IMCI Updates
Changes in • Check general danger signs

Assessment • Cough or difficult breathing
• Diarrhoea
and
• Fever/measles
Management • Ear problem
of Children • Malnutrition
aged 2 months • Anaemia
up to 5 years • HIV infection
IMCI Technical Updates
IMCI Update 2019
Young infant up to 2 months of age

Neonatal Infections burden
Sub-Saharan Africa - 37% of
all neonatal deaths
South Asia - 35% of all

neonatal deaths
WHO AMANHI study, Lancet GH 2018

Treatment of Newborn Infections
Management of neonatal infections

• Initial diagnosis is based on clinical signs
• Treatment is IV/IM antibiotics and supportive care in a hospital
• Only 25% of newborns with possible serious infection receive hospital
treatment in high-mortality settings
AFRINEST & SATT studies (2010-2013): WHO/MCA led research

• To find deliverable, effective treatment for newborns with signs of severe
infection where referral is not possible
AFRINEST (DRC, Kenya, Nigeria) Lancet 2015 AFRINEST (DRC, Kenya, Nigeria) Lancet 2015
SATT Bangladesh Lancet Global Health 2015

SATT Pakistan Lancet Global Health 2016
WHO guideline 2015
Fast breathing as the only sign of illness (7-59d age)

should be treated with oral amoxicillin for 7 days.
Facilitate referral of all other babies with clinical signs

of severe infection to a hospital.
If referral is not feasible, outpatient treatment with

twice daily oral amoxicillin for 7 days and injection
gentamicin for 2 or 7 days.
http://apps.who.int/iris/bitstream/10665/181426/1/9789241509268_eng.pdf?ua=1
IMCI algorithm revised
Sick young infant 0-59d recognized by family or by a HW during home visit
7-59d of age with only fast 0-59d of age with signs of PSBI
breathing or local infections assessed by a trained health worker
Treated in outpatient setting Referred to hospital, facilitate referral

If referral not accepted, infant with
PSBI re-classified
0-59 days with 0-59 days with clinical 0-6 days with only fast
critical illness severe infection breathing
Continue to reinforce referral Simplified treatment in outpatient setting
Critically ill young infants for whom referral is not accepted by families after best efforts should be
treated with once daily injectable gentamicin plus at least twice daily injection ampicillin for 7 days
New implementation strategy
Improved identification of infants with PSBI by families and CHWs
Treatment of fast breathing in 7-59 day olds with oral antibiotics

at first level health facilities
Improved referral to hospital for other cases of PSBI
If referral is not possible, provided outpatient treatment at first

level health facilities
WHO led Implementation research
AFRINEST & SATT were implemented in 3 million population, but not

implemented by the health system
Policy guideline was available in India and Ethiopia but implementation

was challenging
Some countries wanted more implementation experience before making

a policy change
Implementation research as a BRIDGE to full-scale implementation

Issues with scale-up of this intervention
High risk population: severe neonatal infection
• Up to 15% mortality without treatment

• At least 2% mortality even with treatment
Complex intervention: injectable + oral antibiotics
• India ICMR Study: Few workers actually treated young infants

• India ANM guideline: Hardly any ANM treated young infants
• Ethiopia HEW guideline: low treatment rates for young infants
ESSENTIAL to have technical back up and support in early implementation

phase
Steps in Implementation Research
Orientation and Policy dialogue at country level
Informed decisions on treatment choices for early implementation in

selected sites
Establishment of early implementation sites & Technical Support Units (TSU)
[Bangladesh – two sites; Democratic Republic of Congo – one site; Ethiopia – two sites; Malawi – one site;
Nigeria – two sites; India – four sites; Pakistan – one site]
Building capacity and creating a learning platform (TSU)
Implementation, supervision, and monitoring

Looking Behind
IMNCI Strategic
Review
Conclusions and
Recommendations
Benefits of IMNCI in design and impact
Positive effects on health worker practices and
quality of care.
15% reduction in child mortality* when fully

implemented in health facilities and communities.
“IMNCI is very relevant
for the country. It is a
complete holistic
IMNCI is perceived as holistic and child-centred. module with child
health, development,
newborn, etc. Nothing
needs to be taken out.”
- Policymaker (Myanmar)
Simple, comprehensive and targeted the major
causes of mortality
* Cochrane review on IMCI (2016)
Conclusions and Recommendations– Strategic Review
Global fragmentation of child health strategies undermined
programming and limited impact.
Need for systematic evidence generation, capture and integration into
policy and programming.
Accountability for corresponding clear programme targets and strong
monitoring.
Strategies sufficiently tailored to country context, and with improved
end-user designed tools.
Child health SDG goals will not be met without adequate funding and
delivery to marginalized populations
Why child health redesign?
New global architecture: MDGs  SDGs, Universal Health Coverage
(UHC), revitalized PHC & UN secretary General’s Global MNCH Strategy
Shifting epidemiology:
• Age and structure: shifting age in mortality and morbidly patterns

• Aetiological causes: changing burden and emerging priorities
• Geospatial distribution of morbidity and mortality
Greater emphasis on health determinants requiring more community

engagement and interventions beyond the health sector*
*Kuruvilla S et al. Success factors for reducing maternal and child mortality. Bull WHO 2014
Why Child Health Redesign? (2)
Expanded scientific evidence on the best clinical interventions and
delivery strategies.
New technologies and innovations:
• new vaccines, diagnostics and treatment innovations, mHealth, eHealth, …
Demand for content that responds to the changing country context:
• harmonized and optimized content

• flexible and adaptable to country contexts
Conceptualizing Redesign
Taking a life course approach to child health in the
context of SDGs
• Redefine and reposition "the child"
Refocus and prioritize the child survival agenda
• leading causes of mortality, target age group
Define, prioritize and address emerging child health

priorities
Conceptualizing Redesign (2)
Define, prioritize, and mainstream thrive agenda
• What ? When? Where?
Harmonize and mainstream "Promote", "Prevent"

and "Treat" across all levels of care
Optimize guidance to improve flexibility and

adaptability
Conceptual Framework
Goal=Optimally healthy, appropriately educated child
socially prepared for adulthood
←Age appropriate Nutrition Interventions→
Prevent / Promote / Treat
Diversity of Settings
TRANSFORM
e.g., Housing, WASH, environmental pollution, road safety etc.
Preschool child THRIVE

Early Child developmentSchool-based Peer and Social
Development Interventions Interventions
KMC, IMCI, ICCM,

Vaccines,
SURVIVE
Prevent self harm ,
Revitalised PHC Prevent Injuries HIV, etc
0 3 6 9 12 15 18 years
Thank you

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WHO/UNICEF Integrated Management

of Childhood Illness (IMCI)

Shamim Qazi, Geneva

Recommendations are being regularly reviewed and

Changing disease epidemiology- neonatal deaths are

New ways of IMCI training need to be introduced

The updates covered six areas:

The updates covered mainly sick young infant

Note: Training modules were

Changes in • Check general danger signs

Young infant up to 2 months of age

South Asia - 35% of all

WHO AMANHI study, Lancet GH 2018

Management of neonatal infections

AFRINEST & SATT studies (2010-2013): WHO/MCA led research

SATT Bangladesh Lancet Global Health 2015

Fast breathing as the only sign of illness (7-59d age)

Facilitate referral of all other babies with clinical signs

If referral is not feasible, outpatient treatment with

Treated in outpatient setting Referred to hospital, facilitate referral

Continue to reinforce referral Simplified treatment in outpatient setting

Improved identification of infants with PSBI by families and CHWs

Treatment of fast breathing in 7-59 day olds with oral antibiotics

Improved referral to hospital for other cases of PSBI

If referral is not possible, provided outpatient treatment at first

AFRINEST & SATT were implemented in 3 million population, but not

Policy guideline was available in India and Ethiopia but implementation

Some countries wanted more implementation experience before making

Implementation research as a BRIDGE to full-scale implementation

High risk population: severe neonatal infection

• Up to 15% mortality without treatment

Complex intervention: injectable + oral antibiotics

• India ICMR Study: Few workers actually treated young infants

ESSENTIAL to have technical back up and support in early implementation

Informed decisions on treatment choices for early implementation in

Building capacity and creating a learning platform (TSU)

Implementation, supervision, and monitoring

15% reduction in child mortality* when fully

• Age and structure: shifting age in mortality and morbidly patterns

Greater emphasis on health determinants requiring more community

New technologies and innovations:

• new vaccines, diagnostics and treatment innovations, mHealth, eHealth, …

Demand for content that responds to the changing country context:

• harmonized and optimized content

Refocus and prioritize the child survival agenda

• leading causes of mortality, target age group

Define, prioritize and address emerging child health

Define, prioritize, and mainstream thrive agenda

• What ? When? Where?

Harmonize and mainstream "Promote", "Prevent"

Optimize guidance to improve flexibility and

Preschool child THRIVE

KMC, IMCI, ICCM,

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