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"7 eu[.bg}y?Xc)eel㯬| .ir H֖;sr~ki_D琛-0s~qN1(cKmǜS3V{WXC%E$k/!̋iq#:m{7C\vs9оg7C\kvs9eDuܢ<s6d^"Fu<3fgud#S|N{:w::m[&Ahi/eXcH!yֻ;B΀wƣw<^XGz.޶Tzrx]fev*,ssڿT99ivPyA3R|'_K9gg'^Lﲴ{joX.k}3crp/ޟpк]Z@No;lg?1gz18ug;35s|%y!$d9aOJxf\wZ{`XRez2w=}_s;vs {O4/e_?YhuKZ`U3Ì6|]̴/uB!={qˍu)atuIZ2NvƭKx? %Kn|צJ.5;Ӎu)y]z%| .3vo vN9o?Gz~|6a'g&Brx\ Îdg/<ӱ`cr*o[OF? ^)pdT<88( + P ' Chart MSGraph.Chart.80*Microsoft Graph Chart) Chart MSGraph.Chart.80*Microsoft Graph Chart/ 00DTimes New Romantb\b0tbz[ 0lbDArialNew Romantb\b0tbz[ 0lb DArial Narrowantb\b0tbz[ 0lb"0DWingdingsowantb\b0tbz[ 0lb A.  @n?" dd@  @@`` <4/%     ))'(  !%&*,.-?"$ 1QcYe6fAb$%hgF5hO"$Za44|o S 0e0e A@A5%8c8c     ?1d0u0@Ty2 NP'p<'p@A)BCD|E?@8uʚ;2Nʚ;g4-d-dbz[ 0Lbppp@ <4!d!db 0b,. b<4ddddb 0b,. b <4BdBdb< 0b b80___PPT10 pp? %A-> Integrated Management of Childhood Illnesses (IMCI)zDr. Pushpa Raj Sharma DCH, DTCH, FCPS Professor of Child Health Institute of Medicine, Kathmandu, Nepal({#Bj ( .Where are10 million children dying every year?//(*!Causes of Death)Burden of the Paediatric Disease in Nepal40,000 deaths are pneumonia related. 30, 000 deaths are diarrhea related 40, 000 deaths are nutrition related 50% deaths are related with neonatal problems.$Burden of these diseases are due to:Unhygienic and unsafe environment Bad family practices Unequipped health facility Unskilled health worker Unavailability of health resources Poverty !Problems in different age groups:Neonatal period: resuscitation problems, infections, metabolic. Under five: infections, nutritional. Preadolescent: developmental, worms, skin. Adolescent: psychological, sexual habits, drugs. )Common causes of morbidity and mortality uMorbidity Acute respiratory infections. Diarrhea Fever Ear infections Malnutrition Local skin infections Oral thrush & l l Mortality Pneumonia Severe dehydration Meningitis/encephalitis Cerebral malaria Kwashiorkor/marasmus Sepsis Hypothermia Hypoglycemia : } }\$Previous programmes Training of health workers Vertical programmes Child problems were seen as a separate issues Very little counseling training Little emphasis on clinical practice $ vWhat is needed?National goal for reducing the morbidity and mortality. Holistic approach. Improving family practices. Equipping the health facility. Upgrading the health workers skills. Emphasis on counseling.   How to do it?Targeting the problem. All the components in one part. Optimal use of resources. Evidence based. Feasible. Acceptable by community. !Sensitivity and specificity  The answer 2Integrated Management of Childhood Illnesses IMCI(..$  How it helps? Targets the causes Identifies a child who needs urgent referral. Gives evidenced based clinical signs for the diagnosis of common problems. Provides guidelines for the appropriate treatment. Educates the parent. Upgrades the health care facility. Follow-ups the child. Z#Diseases that it coversRespiratory: pneumonia, cough/cold. Diarrhea: acute watery, dysentery, persistent. Fever: malaria, measles, meningitis, encephalitis. Ear problems: mastoditis, acute and chronic infections. Nutritional: kwashiorkor/marasmus, anemia, 9 $Conditions that it coversNutritional: feeding problems, breast feeding, counseling. Neonatal sepsis. Local infections. Hypoglycemia, hypothermia. Oral thrush Immunization. Vit. A supplementation Deworming. Z,  )What it contains? 2 months up to 5 years*&Simple clinical signs of severe disease. Simple clinical signs to diagnose pneumonia. Simple clinical signs to identify three clinical types of diarrhea. Simple clinical signs to identify malaria. Simple clinical signs to identify ear infections. Simple clinical signs to identify malnutrition.'' % What it contains? Young infant.$&Simple clinical signs to identify for referral. Simple clinical signs to treat at health facility. Simple signs to identify good breast feeding. ( What it contains? General(Simple guidelines for nutrition. Simple guidelines for treatment of severe diseases, pneumonia, diarrhoea, dysentery,fever,malaria, ear infections, local infections, anaemia, malnutrition. Guidelines for counseling. Home care messages, safe practices. Immunization, vit A, deworming information.  ()P` =]  What are the evidences?Trained health worker identified target disease better than doctors. Over prescriptions were reduced. Parents were more satisfied. Cost effective. Mortality and morbidity reduced. Health facility better equipped.  Some examplesSimple questions and simple observations to find out the problem: severe disease. Does child vomits every thing? Is the child able to drink? History of convulsions? Is the child lethargic or unconscious? &R{R{+Four main symptoms: 2 months up to 5 years,Does the child has cough or difficulty breathing? Does the child has diarrhea? Does the child has fever? Does the child has ear problem?.Assess every child for: 2 months up to 5 years/\Malnutrition: Weight for age Oedema anaemia Immunization Vitamin A supplementation Deworming:11>( If the answer is yes:ZFor how long? Associated symptoms? Classify the illness Identify treatment Treat the child(My child has cough for 2 days: (example)")( ^Observe for general danger signs. If present refer the child with first dose of antibiotics. Count the respiratory rate: 60/50/40. Fast breathing indicates pneumonia. Look for indrawing. If present indicates severe pneumonia and needs referral. Look and listen for stridor in a calm child. If present indicates severe disease and referral is needed. "Z;Z&Z$ZZ:Z-Z=Z";&$:-  =, POClassify the disease (example)  )Age 9 months: no general danger signs, no chest indrawing, no stridor, no fast breathing. No pneumonia (cough and cold). Age 12 months: chest indrawing. Severe pneumonia. Age 4 months: fast breathing only. Pneumonia. Age 6 months: presence of general danger sign. A child with very severe disease.ZZZ ZZ#Z Z/Z"ZZ # /  ">0 I Identify treatment (example)  No pneumonia: Safe home remedies/ paracetamol/ when to return? Counsel. Pneumonia: Antibiotic/paracetamol/safe home remedies/when to return? Counsel. Severe pneumonia/very severe disease: First dose of antibiotic/ referral note/ counsel. : C&3: C&3  ," 2 Treat the childEssential drugs. Safe home care. Duration of treatment. When to return. Change of treatment. Counsel the parent. Other problems.Other Options in IMCINeonatal problems of first week Developmental pediatrics Perinatal problems Injury & & & . YZ9 : IMCI : model for other problems in pediatric diseases; 2wEntry questions. Threading questions. Evidenced based specific clinical signs. Treatment. Follow-up. Referral. Counsel."History of IMCI in Nepalo1995 June: IMCI Introduced 1997 IMCI implemented in one district Mohattari. 1996: Orientation meeting, nutrition survey, necessary adaptations to generic materials. 1997: Nepali translation, TOT courses. 1998: Follow-up visits, review meeting, pre-service training. 1999 CDD/ARI merged with IMCI 1999 Community Based IMCI Expansion: at present 13 district. pZpK % IMCI in NepaldTrained: Doctors: 185 Paramedical/Nurses: 1667 Supervisors: 101 Instructors for CTEVT: 90 Health Workers follow-up: 582 WHO Collaborative centre: Kanti Children s Hospital: 2001.&  & IMCI in NepalCost of treatment ARI one episode: is approximately Rs. 290.0 Imapct of ARI/IMCI After Before ARI cases 609,976 439,874 Pneumonia 229,188 162,500 S.pneumo 9,440 24,641:QOQO>4T  Thank you.  IAny questions? Any clarifications? 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