Evaluation of the WHO/UNICEF algorithm for integrated management of childhood illness between the ages of one week to two months.

ABSTRACT

OBJECTIVE: To evaluate the utility of the WHO/UNICEF algoritham for integrated management of childhood illness (IMCI) between the ages of 1 week to 2 months. DESIGN: Prospective observational. SETTING: The Outpatient Department and Emergency Room of a medical college hospital. METHODS: 129 infants presenting to Outpatient Department (n=70) or Emergency Room (n=59) were assessed and classified as per 'IMCI' algorithm and treatment required was identified. A detailed evaluation with all relevant investigations was also done for these subjects. The final diagnoses made and therapies instituted on this basis served as 'gold standard'. The diagnostic and therapeutic agreement between 'gold standard and the 'IMCI' was computed. RESULTS: More than one illness was present in 97(75.2%) of subjects as per 'gold standard' (mean 2.1). Subjects having any referral criteria as per 'IMCI' algorithm had a greater (p=0.002) co-existence of illnesses (mean 2.3 vs. 1.8 illnesses per child, respectively. IMCI algorithm covered majority (81-84%) of the recorded diagnoses either partly (40-41%) or fully (40-44%). The referral criteria proved quite sensitive (86-87%) in predicting hospitalization but had a lower specificity (53-58%). a total agreement with IMCI was found in 60-66% cases. The mismatch (34-40%) was more commonly of overdiagnosis (21-23%) rather than underdiagnosis (15-21%). The sensitivity of the algorithm to identify serious bacterial infection was high (96.1-96.5%) while the specificity was relatively low (51. 8-59.7%). Upper respiratory infection (URI)emerged as an important cause resulting in unnecessary referrals (13 out of 21 cases). Of the 43 cases identified as diarrhea by the algorithm, 6 had breast fed stools, which do not require any therapy. The 'IMCI' algorithm had a provision for preventive services of immunization and breastfeeding counseling (18% possibility of availing missed opportunities in both). CONCLUSION: There is a sound scientific basis for adopting IMCI approach even in young infants as there is a need to improve the specificity of referral criteria. Two important conditions identified for possible refinement are URI and breast fed stools