Distribution of adult respiratory illnesses at a primary health centre in Lesotho.

SETTING: Primary health centre in the highlands of Lesotho. BACKGROUND: There is limited information about the relative frequencies of common respiratory illnesses in resource-limited settings, particularly in sub-Saharan Africa. OBJECTIVE: To examine whether the distribution of respiratory illnesses in this region is unique due to the high prevalence of human immunodeficiency virus infection. DESIGN: In a prospective, cross-sectional study of adults and adolescents with cough or difficulty breathing recruited from the waiting areas of the health centre, the primary outcome was the respiratory diagnosis for each participant, which was based on history, physical examination, response to antibiotics and the results of chest radiography (CXR) and sputum examinations. RESULTS: Acute respiratory infections accounted for 65% of all diagnoses among 696 patients who were evaluated by a clinician and CXR. Pneumonia accounted for 10% of all diagnoses, and confirmed or probable tuberculosis (TB) accounted for 13%. Chronic respiratory conditions, including asthma, chronic obstructive pulmonary disease, silicosis and old TB, accounted for 14% of all diagnoses. Excluding 61 patients with an uninterpretable CXR, 36% (228) of the participants had significant pathology on CXR. CONCLUSION: A high proportion of patients presenting to a primary health centre in Lesotho with routine respiratory complaints have serious respiratory illnesses.

Children's weights: guess or measure by tape?

Children's doses of drugs are prescribed according to bodyweight but in resource-poor countries weighing scales may be unavailable, inaccurate, or broken. We designed a length/weight tape for use in our community and found it reasonably accurate for weights of 4-16 kg and better than a clinician's guess.

PIP: This article recommends the use of length/dosing tape for measuring drug dosage for children, a modified method that shows the weights-for-length which can be used in a community where weighing scales are unavailable. This recommendation was supported by a finding of an American study, showing that the use of tape to measure pediatric drug dosage was reasonably accurate in children weighing within the range of 4 kg and 16 kg. Furthermore, test results from rural health facilities indicated that the proportion of drug dosage to be prescribed was greater with the use of a tape weight than from a guessed weight. The tape also provides a very good approximation for weight in children weighing between 4 and 14 kg. This paper believes that the use of the tape could enhance pediatric health care in situations, wherein weighing them is impossible.

Development and technical basis of simplified guidelines for emergency triage assessment and treatment in developing countries. WHO Integrated Management of Childhood Illness (IMCI) Referral Care Project.

Simplified guidelines for the emergency care of children have been developed to improve the triage and rapid initiation of appropriate emergency treatments for children presenting to hospitals in developing countries. The guidelines are part of the effort to improve referral level paediatric care within the World Health Organisation/Unicef strategy integrated management of childhood illness (IMCI), based on evidence of significant deficiencies in triage and emergency care. Existing emergency guidelines have been modified according to resource limitations and significant differences in the epidemiology of severe paediatric illness and preventable death in developing countries with raised infant and child mortality rates. In these settings, it is important to address the emergency management of diarrhoea with severe dehydration, severe malaria, severe malnutrition, and severe bacterial pneumonia, and to focus attention on sick infants younger than 2 months of age. The triage assessment relies on a few clinical signs, which can be readily taught so that it can be used by health workers with limited clinical background. The assessment has been designed so that it can be carried out quickly if negative, making it functional for triaging children in queues.

Evaluation of guidelines for emergency triage assessment and treatment in developing countries.

AIM: To evaluate performance of a simplified algorithm and treatment instructions for emergency triage assessment and treatment (ETAT) of children presenting to hospital in developing countries. METHODS: All infants aged 7 days to 5 years presenting to an accident and emergency department were simultaneously triaged and assessed by a nurse and a senior paediatrician. Nurse ETAT assessment was compared to standard emergency advanced paediatric life support (APLS) assessment by the paediatrician. Sensitivity, specificity, and predictive values were calculated and appropriateness of nurse treatments was evaluated. RESULTS: The ETAT algorithm as used by nurses identified 731/3837 patients (19.05%); 98 patients (2.6%) were classified as needing emergency treatment and 633 (16.5%) as needing priority assessment. Sensitivity was 96.7% with respect to APLS assessment, 91.7% with respect to all patients given priority by the paediatrician, and 85.7% with respect to patients ultimately admitted. Specificity was 90.6%, 91.0%, and 85.2%, respectively. Nurse administered treatment was appropriate in 94/102 (92.2%) emergency conditions. CONCLUSIONS: The ETAT algorithm and treatment instructions, when carried out by nurses after a short specific training period, performed well as a screening tool to identify priority cases and as a treatment guide for emergency conditions.

Etiology of pneumonia, sepsis and meningitis in infants younger than three months of age in Ethiopia.

METHODS: Within a multicenter study coordinated by WHO, an investigation of the etiologic agents of pneumonia, sepsis and meningitis was performed among infants younger than 3 months of age seen at the Ethio-Swedish Children's Hospital in Addis Ababa for a period of 2 years. Of the 816 infants enrolled 405 had clinical indications for investigation. RESULTS: There were a total of 41 isolates from blood cultures from 40 infants. The study showed that the traditionally known acute respiratory infection pathogen Streptococcus pneumoniae was most common in this extended neonatal age group, found in 10 of 41 blood isolates. Streptococcus pyogenes was a common pathogen in this setting (9 of 41 blood isolates), whereas Salmonella group B was found in 5 of 41 isolates. Streptococcus agalactiae, which is a common pathogen in developed countries, was absent. A study of the susceptibility pattern of these organisms suggests that a combination of ampicillin with an aminoglycoside is adequate for initial treatment of these serious bacterial infections, but the combination is not optimal for the treatment of Salmonella infections. Among 202 infants on whom immunofluorescent antibody studies for viruses were performed based on nasopharyngeal aspirates, respiratory syncytial virus was found in 57 (28%) infants, and Chlamydia trachomatis was isolated in 32 (15.8%) of 203 infants.

Potential interventions for the prevention of childhood pneumonia in developing countries: improving nutrition.

Acute respiratory infections are the leading cause of childhood death in developing countries. Current efforts at mortality control focus on case management and immunization, but other preventive strategies may have a broader and more sustainable effect. This review, commissioned by the World Health Organization, examines the relations between pneumonia and nutritional factors and estimates the potential effect of nutritional interventions. Low birth weight, malnutrition (as assessed through anthropometry), and lack of breast-feeding appear to be important risk factors for childhood pneumonia, and nutritional interventions may have a sizeable effect in reducing deaths from pneumonia. For all regions except Latin America, interventions to prevent malnutrition and low birth weight look more promising than does breast-feeding promotion. In Latin America, breast-feeding promotion would have an effect similar to that of improving birth weights, whereas interventions to prevent malnutrition are likely to have less of an effect. These findings emphasize the need for tailoring interventions to specific national and even local conditions.

Development of a clinical prediction model for an ordinal outcome: the World Health Organization Multicentre Study of Clinical Signs and Etiological agents of Pneumonia, Sepsis and Meningitis in Young Infants. WHO/ARI Young Infant Multicentre Study Group.

This paper describes the methodologies used to develop a prediction model to assist health workers in developing countries in facing one of the most difficult health problems in all parts of the world: the presentation of an acutely ill young infant. Statistical approaches for developing the clinical prediction model faced at least two major difficulties. First, the number of predictor variables, especially clinical signs and symptoms, is very large, necessitating the use of data reduction techniques that are blinded to the outcome. Second, there is no uniquely accepted continuous outcome measure or final binary diagnostic criterion. For example, the diagnosis of neonatal sepsis is ill-defined. Clinical decision makers must identify infants likely to have positive cultures as well as to grade the severity of illness. In the WHO/ARI Young Infant Multicentre Study we have found an ordinal outcome scale made up of a mixture of laboratory and diagnostic markers to have several clinical advantages as well as to increase the power of tests for risk factors. Such a mixed ordinal scale does present statistical challenges because it may violate constant slope assumptions of ordinal regression models. In this paper we develop and validate an ordinal predictive model after choosing a data reduction technique. We show how ordinality of the outcome is checked against each predictor. We describe new but simple techniques for graphically examining residuals from ordinal logistic models to detect problems with variable transformations as well as to detect non-proportional odds and other lack of fit. We examine an alternative type of ordinal logistic model, the continuation ratio model, to determine if it provides a better fit. We find that it does not but that this model is easily modified to allow the regression coefficients to vary with cut-offs of the response variable. Complex terms in this extended model are penalized to allow only as much complexity as the data will support. We approximate the extended continuation ratio model with a model with fewer terms to allow us to draw a nomogram for obtaining various predictions. The model is validated for calibration and discrimination using the bootstrap. We apply much of the modelling strategy described in Harrell, Lee and Mark (Statist. Med. 15, 361-387 (1998)) for survival analysis, adapting it to ordinal logistic regression and further emphasizing penalized maximum likelihood estimation and data reduction.

Integrated management of childhood illness by outpatient health workers: technical basis and overview. The WHO Working Group on Guidelines for Integrated Management of the Sick Child.

This article describes the technical basis for the guidelines for the integrated management of childhood illness (IMCI), which are presented in the WHO/UNICEF training course on IMCI for outpatient health workers at first-level health facilities in developing countries. These guidelines include the most important case management and preventive interventions against the leading causes of childhood mortality--pneumonia, diarrhoea, malaria, measles and malnutrition. The training course enables health workers who use the guidelines to make correct decisions in the management of sick children. The guidelines have been refined through research studies and field-testing in the Gambia, Ethiopia, Kenya, and United Republic of Tanzania, as well as studies on clinical signs in the detection of anaemia and malnutrition. These studies, and two others from Uganda and Bangladesh, are presented in this Supplement to the Bulletin of the World Health Organization.

Evaluation of an algorithm for the integrated management of childhood illness in an area with seasonal malaria in the Gambia.

Most of the 12.4 million deaths occurring every year among under-5-year-olds in developing countries could be prevented by the application of simple treatment strategies. So that health professionals who have had limited training can identify and classify the common childhood diseases, WHO developed a treatment algorithm (the Integrated Management of Childhood Illness (IMCI) or Sick Child algorithm), a prototype of which was tested in 440 Gambian children aged between 2 months and 5 years. The children were first assessed by a trained field worker using the algorithm, and then by a paediatrician whose clinical diagnosis was supported by laboratory investigations and, when indicated, a chest X-ray. Compared with the paediatrician's diagnosis, the sensitivity and specificity of the draft IMCI algorithm were, respectively, 81% and 89% for the detection of pneumonia, 67% and 96% for dehydration, 87% and 8% for malaria parasitaemia (any level), 100% and 9% for malaria parasitaemia (above 5000 parasites/microliter), 100% and 99% for measles, 31% and 97% for otitis media, and 89% and 90% for malnutrition. Among the children admitted by the physician, 45% had been recommended for admission by the algorithm. Intermittent fever, chills and sweats did not help in discriminating between malaria and non-malarious fevers; shivering or shaking of the body had a sensitivity of only 35%. While the algorithm dealt with the majority of presenting complaints, the most common problems not addressed by the chart were skin rashes (21%), mouth problems (8%), and eye problems (6%). The draft IMCI algorithm proved to be effective in the diagnosis of pneumonia, gastroenteritis, measles and malnutrition, but not malaria where its use without microscopy would result in considerable over-treatment, especially in a low transmission area or during a low transmission season in countries with seasonal malaria. The current algorithm would benefit from expansion to cover management of localized infections as well as skin, mouth and eye problems.

PIP: Most mortality among children under age 5 years in developing countries could be prevented through the application of simple treatment strategies. To that end, the World Health Organization (WHO) developed the Integrated Management of Childhood Illness (IMCI) treatment algorithm to help health professionals who have had only limited training identify and classify common childhood diseases. A prototype of the IMCI was tested among 440 Gambian children aged 2 months to 5 years. The children were first assessed by a trained field worker using the algorithm, then by a pediatrician whose clinical diagnosis was supported by laboratory investigations and, when indicated, a chest X-ray. The draft IMCI algorithm was 81% sensitive and 89% specific for the detection of pneumonia compared with the physician's diagnosis; 67% and 96%, respectively, for dehydration; 87% and 8% for malaria parasitemia at any level; 100% and 9% for malaria parasitemia above 5000 parasites per mcl; 100% and 99% for measles; 31% and 97% for otitis media; and 89% and 90% for malnutrition. 45% of the children admitted by the physicians had been recommended for admission by the algorithm. While the algorithm addressed the majority of presenting complaints, skin rashes and mouth and eye problems were overlooked.

Evaluation of an algorithm for integrated management of childhood illness in an area of Kenya with high malaria transmission.

In 1993, the World Health Organization completed the development of a draft algorithm for the integrated management of childhood illness (IMCI), which deals with acute respiratory infections, diarrhoea, malaria, measles, ear infections, malnutrition, and immunization status. The present study compares the performance of a minimally trained health worker to make a correct diagnosis using the draft IMCI algorithm with that of a fully trained paediatrician who had laboratory and radiological support. During the 14-month study period, 1795 children aged between 2 months and 5 years were enrolled from the outpatient paediatric clinic of Siaya District Hospital in western Kenya; 48% were female and the median age was 13 months. Fever, cough and diarrhoea were the most common chief complaints presented by 907 (51%), 395 (22%), and 199 (11%) of the children, respectively; 86% of the chief complaints were directly addressed by the IMCI algorithm. A total of 1210 children (67%) had Plasmodium falciparum infection and 1432 (80%) met the WHO definition for anaemia (haemoglobin < 11 g/dl). The sensitivities and specificities for classification of illness by the health worker using the IMCI algorithm compared to diagnosis by the physician were: pneumonia (97% sensitivity, 49% specificity); dehydration in children with diarrhoea (51%, 98%); malaria (100%, 0%); ear problem (98%, 2%); nutritional status (96%, 66%); and need for referral (42%, 94%). Detection of fever by laying a hand on the forehead was both sensitive and specific (91%, 77%). There was substantial clinical overlap between pneumonia and malaria (n = 895), and between malaria and malnutrition (n = 811). Based on the initial analysis of these data, some changes were made in the IMCI algorithm. This study provides important technical validation of the IMCI algorithm, but the performance of health workers should be monitored during the early part of their IMCI training.

PIP: The World Health Organization (WHO) in 1993 developed the integrated management of childhood illness (IMCI) draft algorithm which offers guidelines upon the diagnosis and treatment of acute respiratory infections, diarrhea, malaria, measles, ear infections, and malnutrition, as well as immunization status. During a 14-month study period, 1795 children aged 2 months to 5 years were enrolled in the study from the outpatient pediatric clinic of Siaya District Hospital in western Kenya, of whom 52% were male and the median age was 13 months. 51% of the children complained of having fever, 22% of having a cough, and 11% of having diarrhea. 86% of the main complaints were directly addressed by the IMCI algorithm. 1210 children had Plasmodium falciparum infection and 1432 met the WHO definition for anemia. The sensitivities and specificities for classification of illness by a minimally trained health worker using the IMCI algorithm compared to diagnosis by the physician were: pneumonia, 97% sensitivity and 49% specificity; dehydration in children with diarrhea, 51% and 98%, respectively; malaria, 100% and 0%; ear problem, 98% and 2%; nutritional status, 96% and 66%; and need for referral, 42% and 94%. Detection of fever by placing a hand upon the forehead was 91% sensitive and 77% specific. Considerable clinical overlap was observed between pneumonia and malaria, and between malaria and malnutrition. Study findings led to some changes in the IMCI algorithm.

Performance of health workers after training in integrated management of childhood illness in Gondar, Ethiopia.

The performance of six primary health workers was evaluated after following a 9-day training course on integrated management of childhood illness (IMCI). The participants were selected from three primary health centres in the Gondar District, Ethiopia, and the course was focused on assessment, classification, and treatment of sick children (aged 2 months to 5 years) and on counselling of their mothers. Immediately following this training, a 3-week study was conducted in the primary health centres to determine how well these workers performed in assessing, classifying and treating the children and in counselling the mothers. A total of 449 sick children who presented at the three primary health centres during the study period were evaluated. Most of the complaints (87%) volunteered by the mothers (fever, cough, diarrhoea, and ear problems) were covered by the IMCI charts. The assessment of commonly seen signs (tachypnoea or ear pain) or easily identifiable signs (slow return after skin pinch, wasting, or pedal oedema) was good, with sensitivities of 67-91%, whereas the assessment of uncommonly seen signs (dry mouth, corneal clouding) or less easily quantifiable signs (eyelid pallor, absence of tears) had a fair or poor sensitivity of 20-45%. The classification of pneumonia, diarrhoea with signs of dehydration, and malnutrition showed sensitivities of 88%, 76%, and 85% and specificities of 87%, 98%, and 96%, respectively. However, the classification of febrile illnesses had a sensitivity of only 39% due to problems in using the draft algorithm in areas with a mixture of high, low, and no malaria risk, and due to confusion between axillary and rectal temperature thresholds. Of 39 children classified as having severe disease, 9 were misclassified, mostly by one nurse. Treatment of patients improved over the three weeks of observation, their completeness increasing from 69% to 88%. Health workers usually communicated appropriate advice to the mother. They learned to use checking questions but failed to adequately solve problems in the majority of cases. The mother's counselling card, which summarized recommendations on feeding and home fluids, and advice on when to return, was widely used to aid communication. The time taken to perform the complete management of children did not change significantly (20 to 19 minutes) during the study. Lessons from our findings have been incorporated into an improved version of the IMCI charts.

PIP: 6 outpatient clinic nurses selected from 3 primary health centers in the Gondar District of Ethiopia were trained over the course of 9 days in the integrated management of childhood illnesses (IMCI), after which their performance was evaluated. The training course focused upon the assessment, classification, and treatment of sick children aged 2 months to 5 years, and upon the counselling of their mothers. Immediately following the training, the trainees were observed working in the health centers for a 3-week period to determine how well they assessed, classified, and treated children, and counseled mothers. 449 children who presented at the centers during the study period were evaluated. 87% of the complaints noted by the mothers on fever, cough, diarrhea, and ear problems were covered by the IMCI charts. There was good assessment of commonly seen signs such as tachypnoea and ear pain, as well as of readily identifiable signs such as a slow return after skin pinch, wasting, and pedal oedema; sensitivities were 67-91%. However, sensitivities were only 20-45% for rarely seen signs such as dry mouth and corneal clouding and the more difficult to recognize signs of eyelid pallor and the absence of tears. The classification of pneumonia, diarrhea with signs of dehydration, and malnutrition had sensitivities of 88%, 76%, and 85%, and specificities of 87%, 98%, and 96%, respectively. The classification of febrile illnesses was 39% sensitive. 9 of 39 children with severe disease were misclassified, mostly by one nurse. Patient treatment improved over the 3 weeks of observation and health workers usually communicated appropriate advice to mothers.

Potential interventions for preventing pneumonia among young children in developing countries: promoting maternal education.

The views of various disciplines on the role of education in improving the health and survival of young children in developing countries are discussed, as well as the factors and processes explaining this impact of education and the influence which education could have on risk factors especially relevant to acute respiratory infections (ARI) and pneumonia. This is by reviews of the available evidence on the impact of maternal education on mortality and morbidity. Since there are hardly any data dealing with the impact of education on pneumonia mortality, we focus on post-neonatal mortality, assuming that it is a suitable proxy for pneumonia mortality. Evidence is summarized on several processes or mechanisms which could explain why there is such an impact of education on ARI mortality (and morbidity) in children below 5. An attempt is made to quantify the reduction in pneumonia mortality which has occurred during the past 10-15 years as a result of improvement in women's education. This will also give an indication of the magnitude of the potential benefits of education for health and survival in the years ahead. Throughout this report we define maternal education as the regular schooling received by women during their youth. Some may have followed additional adult education classes before they became mothers.