Potential implications of the integrated management of childhood illness (IMCI) for hospital referral and pharmaceutical usage in western Uganda.

The integrated management of childhood illness approach (IMCI) is currently being implemented by a number of countries worldwide. This is the second report from a study in western Uganda comparing the assessment and classification of disease by medical assistants using the IMCI algorithm with that of hospital-based general medical officers, who used their clinical judgement to assess and provide treatment. Treatment prescribed by the hospital medical officers was compared to that indicated by IMCI disease classifications. The study population comprised 1226 children aged 2-59 months. Medical assistants had some difficulty in completing the IMCI assessment, leading to incorrect classification of findings in 138 of 1086 completed forms (13%). If their classifications had been used to decide on hospital referral, 37 children who met IMCI criteria for referral would have been sent home. Consultations took on average 7.2 min, longer than usual for several African countries. Use of the IMCI guidelines would have referred 16.2% of children to hospital, compared with 22% referred by the medical officers. Use of IMCI could have reduced the cost of medication to US$0.17 per child compared to the treatment cost of US$0.82 as prescribed by medical officers. Medical officers prescribed both a greater number and a greater variety of drugs than indicated by the IMCI algorithm. Compared to the present management of sick children by medical officers at Kabarole district hospital, using the IMCI algorithm would bring major changes in pharmaceutical use and referral practices. However, there is concern about the difficulty medical assistants had in using it, and the potential for longer consultation times.

The integrated management of childhood illness in western Uganda.

Bringing together various disease-specific guidelines for sick children, WHO and UNICEF have developed an Integrated Management of Childhood Illness (IMCI) algorithm, one component of which (assess and classify) was tested in the outpatient department of a rural district hospital in western Uganda. Children aged 2-59 months were seen first by a Ugandan medical assistant trained in IMCI, and then evaluated by a medical officer. Sensitivity, specificity and positive predictive values were determined by comparing the IMCI classifications with a reference standard based on the medical officers' diagnoses and laboratory tests. Of the 1226 children seen, 69% were classified into more than one symptom category, 7% were not classified in any symptom category, 8% had a danger sign, and 16% were classified into a severe category, for which the IMCI approach recommended urgent hospital referral. Specificity for most classifications was good, though sensitivity and positive predictive values were variable. We conclude that the IMCI algorithm is an important advance in the primary care of sick children in developing countries.

PIP: The World Health Organization (WHO) and UNICEF have developed the Integrated Management of Childhood Illness (IMCI) algorithm which incorporates the existing guidelines for the management of diarrhea and respiratory diseases, and adds new guidelines for measles, malaria, malnutrition, and anemia into one comprehensive case management approach. The assessment and classification component of the algorithm was tested in the outpatient department of a rural district hospital in western Uganda. 1226 children aged 2-59 months were first seen by a Ugandan medical assistant trained in IMCI, then evaluated by a medical officer. Sensitivity, specificity, and positive predictive values were determined by comparing the IMCI classifications with a reference standard based upon the medical officers' diagnoses and laboratory tests. 69% of the 1226 children seen were classified into more than one symptom category, 7% were not classified into any category, 8% had a danger sign, and 16% were classified into a severe category. The IMCI approach recommends that patients in this latter, severe category be urgently referred for hospital care. While specificity for most classifications was good, sensitivity and positive predictive values were variable. The IMCI algorithm is, however, an important advance in the primary care of sick children in developing countries.

Evaluation of clinical signs to diagnose anaemia in Uganda and Bangladesh, in areas with and without malaria.

The object of this study was to assess the ability of pallor and other clinical signs, including those in the Integrated Management of Childhood Illness (IMCI) guidelines developed by WHO and UNICEF, to identify severe anaemia and some anaemia in developing country settings with and without malaria. A total of 1226 and 668 children aged 2 months to 5 years were prospectively sampled from patients presenting at, respectively, a district hospital in rural Uganda and a children's hospital in Dhaka, Bangladesh. The study physicians obtained a standardized history and carried out a physical examination that included pallor, signs of respiratory distress, and the remaining IMCI referral signs. The haematocrit or haemoglobin level was determined in all children with conjunctival or palmar pallor, and in a sample of the rest. Children with a blood level measurement and assessment of pallor at both sites were included in the anaemia analysis. Using the haematocrit or haemoglobin level as the reference standard, the correctness of assessments using severe and some pallor and other clinical signs in classifying severe and some anaemia was determined. While the full IMCI process would have referred most of the children in Uganda and nearly all the children in Bangladesh with severe anaemia to hospital, few would have received a diagnosis of severe anaemia. Severe palmar and conjunctival pallor, individually and together, had 10-50% sensitivity and 99% specificity for severe anaemia; the addition of grunting increased the sensitivity to 37-80% while maintaining a reasonable positive predictive value. Palmar pallor did not work as well as conjunctival pallor in Bangladesh for the detection for severe or some anaemia. Combining "conjunctival or palmar pallor" detected 71-87% of moderate anaemia and half or more of mild anaemia. About half the children with no anaemia were incorrectly classified as having "moderate or mild" anaemia. Anaemia was more easily diagnosed in Uganda in children with malaria. Our results show that simple clinical signs can correctly classify the anaemia status of most children. Grunting may serve as a useful adjunct to pallor in the diagnosis of severe anaemia. Conjunctival pallor should be added to the IMCI anaemia box, or the guidelines need to be adapted in regions where palmar pallor may not readily be detected.

PIP: The capability of pallor and other clinical signs to identify anemia was evaluated in developing country settings with malaria (Uganda) and without malaria (Bangladesh). Enrolled were 1226 children, 2 months to 5 years of age, who presented to a rural district hospital in Fort Portal, Uganda, and 668 children from a children's hospital in Dhaka, Bangladesh. Physicians examined the children for conjunctival pallor, respiratory distress, and other clinical signs of anemia (i.e., palmar pallor) included in the World Health Organization's Integrated Management of Childhood Illness (IMCI) guidelines. 58% of Ugandan and 47% of Bangladeshi children had pallor of at least one site. Hematocrit or hemoglobin levels were measured in all children with pallor of the conjunctiva or palms and in a sample of the remaining children. In both locations, 2% of children had severe anemia; 13% and 17%, respectively, in Uganda and Bangladesh had moderate anemia, and 42% and 62%, respectively, had mild anemia. Comparison of these findings with the clinical signs indicated that use of the full IMCI process would have referred 68-90% of children with severe anemia to the hospital. Severe palmar and conjunctival pallor, individually and together, had a sensitivity of 10-50% and a specificity of 99% for severe anemia; the addition of grunting increased the sensitivity to 37-80% while maintaining a reasonable positive predictive value. Palmar pallor was not as effective as conjunctival pallor for detecting anemia in Bangladesh. Combining conjunctival and palmar pallor detected 71-87% of cases of moderate anemia and half the cases of mild anemia. Anemia was more easily diagnosed in Uganda in children with malaria. These findings confirm the usefulness of clinical signs in the detection of anemia in developing countries, but suggest the feasibility of adding conjunctival pallor, and possibly grunting, to the IMCI algorithm.

Evaluation of clinical signs to diagnose anaemia in Uganda and Bangladesh, in areas with and without malaria

The object of this study was to assess the ability of pallor and other clinical signs, including those in the Integrated Management of Childhood Illness (IMCI) guidelines developed by WHO and UNICEF, to identify severe anaemia and some anaemia in developing country settings with and without malaria. A total of 1226 and 668 children aged 2 months to 5 years were prospectively sampled from patients presenting at, respectively, a district hospital in rural Uganda and a children's hospital in Dhaka, Bangladesh. The study physicians obtained a standardized history and carried out a physical examination that included pallor, signs of respiratory distress, and the remaining IMCI referral signs. The haematocrit or haemoglobin level was determined in all children with conjunctival or palmar pallor, and in a sample of the rest. Children with a blood level measurement and assessment of pallor at both sites were included in the anaemia analysis. Using the haematocrit or haemoglobin level as the reference standard, the correctness of assessments using severe and some pallor and other clinical signs in classifying severe and some anaemia was determined. While the full IMCI process would have referred most of the children in Uganda and nearly all the children in Bangladesh with severe anaemia to hospital, few would have received a diagnosis of severe anaemia. Severe palmar and conjunctival pallor, individually and together, had 10-50% sensitivity and 99% specificity for severe anaemia; the addition of grunting increased the sensitivity to 37-80% while maintaining a reasonable positive predictive value. Palmar pallor did not work as well as conjunctival pallor in Bangladesh for the detection for severe or some anaemia. Combining "conjunctival or palmar pallor" detected 71-87% of moderate anaemia and half or more of mild anaemia. About half the children with no anaemia were incorrectly classified as having "moderate or mild" anaemia. Anaemia was more easily diagnosed in Uganda in children with malaria. Our results show that simple clinical signs can correctly classify the anaemia status of most children. Grunting may serve as a useful adjunct to pallor in the diagnosis of severe anaemia. Conjunctival pallor should be added to the IMCI anaemia box, or the guidelines need to be adapted in regions where palmar pallor may not readily be detected