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Diagnosis and management of febrile children using the WHO / UNICEF guidelines for IMCI in Dhaka, Bangladesh.
Bulletin of the World Health Organization. 2001; 79(12):1096-105.In Dhaka, Bangladesh, a study was conducted to determine the effectiveness of WHO’s integrated management of childhood illnesses (IMCI) guidelines in identifying children with bacterial infections in need of antibiotics. A systematic sample of 669 sick children aged 2-59 months was enrolled in the study. Weight, tactile, measured temperature, and respiratory rate were obtained from each patient. The study revealed that had IMCI guidelines been used to evaluate the subjects, 78% of those with bacterial infections would have received antibiotics, including the majority of children with meningitis (100%), pneumonia (95%), otitis media (95%), urinary tract infection (83%), bacteremia (50%), dysentery (48%), and skin infections (30%). It was also noted that the fever module identified only one additional case of meningitis. Children with bacteraemia were more likely to be febrile, feel hot and have history of fever than those with dysentery and skin infections. Fever combined with parental perception of fast breathing provided a more sensitive fever module for the detection of bacteraemia than the current ICMI module. In an area of low malaria prevalence, the IMCI guidelines provide antibiotics to the majority of children with bacterial infections, but improvements in the fever module are possible.
SYNOPSIS. 1998 Jan; (2):1-8.The World Health Organization (WHO)/UN Children's Fund (UNICEF) Integrated Management of Childhood Illness (IMCI) guidelines were designed to maximize detection and appropriate treatment of illnesses due to the most common causes of child mortality and morbidity in developing countries: pneumonia, diarrhea, malaria, measles, bacterial infections in young infants, malnutrition, anemia, and ear problems. The health worker first examines the child and checks immunization status, then classifies the child's illness and identifies the appropriate treatment based on a color-coded triage system. By May 1997, 17 countries had introduced IMCI and 16 others were in the process of introduction. This issue reports on field tests of the guidelines conducted in Kenya, the Gambia, Uganda, Bangladesh, and Tanzania. Health workers who used the guidelines performed well when compared to physicians who had access to laboratory and radiographic findings as well as health workers trained in full case management. Of concern, however, are research findings suggesting the potential for overdiagnosis in some disease classifications. Current IMCI research priorities include the following: 1) determining health workers' ability to learn to detect lower chest wall indrawing; 2) identifying clinical signs to increase the specificity of referral for severe pneumonia; 3) identifying other clinical signs to increase the specificity of hospital referrals, thereby reducing unnecessary referrals; 4) investigating how clinical care for severely ill children could be expanded in areas where referral is not feasible; 5) finding ways to increase the specificity of the diagnosis of malaria; and 6) recognizing clinical signs to increase the specificity of the diagnosis of severe anemia and the specificity of the diagnosis of moderate or mild anemia, with the possible goal of regional adaptation of the anemia guidelines.
[Unpublished] 1988. Presented at the 13th World Conference on Health Education, Houston, Texas, August 28 - September 2, 1988. 60 p.This study is the report of a 1986 baseline survey, guided by the World Health Organization's "Guidelines for a Sample Survey of Diarrheal Diseases Morbidity, Mortality, and Treatment Rate." The survey method was the Expanded Program on Immunization 30 cluster 2-stage method. Baseline data were also gathered on the status of immunization against diphtheria, tetanus, whooping cough, poliomyelitis, measles, and tuberculosis. Primary health care services in Bahrain are generally good. The archipelago of 670 sq km has a population of 417,210 including 55,000 children under 5. There are 18 health centers and 480 physicians or 1 physician for every 860 people. All inhabitants of a catchment area live within 5 km of a health center, and medical care is free. Diarrhea is due to a number of different organisms, including typhoid, paratyphoid, salmonellosis, Escherichia coli, rotaviruses, and giardiasis, but there has been no cholera in Bahrain since 1979. The national diarrheal diseases control program, drafted by the World Health Organization in 1985, emphasized the use of oral rehydration therapy, breast feeding, and feeding during diarrhea. No vaccinations are compulsory in Bahrain, but immunization coverage has been reported annually since 1981, and vaccinations are in line with the World Health Organization's criteria. Diphtheria-Typhoid-Paratyphoid vaccinations were 1st given in Bahrain in 1957; polio vaccination began in 1958 with Salk vaccine and in 1962 with the Sabin vaccine. Measles vaccination began in 1974. BCG vaccination has been given to children entering school since 1972. All health centers in the country offer vaccination services. Vaccines are stored under refrigeration, and the central supply is at the Public Health Directorate. Adverse effects of vaccinations are monitored. The 1986 diarrheal diseases survey, using the 30 cluster method, looked at a sample of 4114 children under 5 from 2515 households. 378 (9.2%) of the children suffered from diarrhea, and 200 (52.9%) were treated with oral rehydration salts. The under-5 diarrheal mortality rate was .97/1000. The estimated number of episodes of diarrhea per child per year is 2.4, with a high of 8.7 episodes in the Northern Region and a low of 1.2 episodes in the Muharraq Region. Vaccination coverage of children under 2 for other diseases was found to be 96.5% for diphtheria, paratyphoid, and typhoid; 95% for polio; 82.5% for measles; and 59.8% for the trivalent mumps, measles and rubella vaccine. 96.4% of all vaccinations were given in government hospitals. 98.7% of mothers have been examined during pregnancy, and 98.9% of all deliveries are in hospitals. It is recommended that a health education campaign be concentrated on diarrhea, breast feeding, feeding during diarrhea, and hygiene; that both medical staff and mothers be trained in the use of oral rehydration salts; that they should also be informed of the adverse effects of treating diarrhea with antibiotics; that a system for reporting cases of diarrhea be developed; that health education campaigns emphasize the importance of receiving booster doses of vaccines and of vaccination against measles; that staff at health centers adjust their schedules so as to be available for immunizations as needed; and that this survey be repeated every 2 years.
[Unpublished] 1985. 15 p.This paper reviews the development of the global Expanded Program on Immunization (EPI) initiative, reports on program progress since the 1984 EPI conference, and identifies actions needed to meet the goal of providing immunization services to all children of the world by 1990. The central EPI strategy to date has been to deliver immunization in consonance with other health services, particularly those aimed at mothers and children. The long-term goal of such efforts is to strengthen the health infrastructure so as to ensure the continuous provision of immunization and other primary health care services. Simply by reinforcing existing health services, a coverage level of 60-70% will be achieved in developing countries by 1990. If universal coverage is to be achieved, external funds will have to be provided to meet operational costs and train national managers. Acceleration of existing efforts constitutes the main EPI priority at present. Specific areas suggested for immediate action include provision of information about immunization at every health contact; a reduction in the drop-out rates between 1st and last immunization; increased attention to the control of measles, poliomyelitis, and neonatal tetanus; improved immunization services to the disadvantaged in urban areas; and, where appropriate, acceleration of the EPI through approaches such as national immunization days. Ongoing actions that need to be pursued include strengthening disease surveillance and outbreak control, reinforcing training and supervision, and pursuing applied research and development. Overall, management capacity within national programs remains the most severe constraint for the EPI.
WORLD HEALTH STATISTICS QUARTERLY. RAPPORT TRIMESTRIEL DE STATISTIQUES SANITAIRES MONDIALES. 1988; 41(1):19-25.Routine surveillance of the incidence of vaccine-preventable diseases has not proved sensitive enough to demonstrate the impact of the Expanded Program on Immunization (EPI) in many countries. In order to document progress since the start of the EPI in 1979, data are needed for several years prior to that. In most developing countries these can be found only in major cities or large hospitals. Therefore a system of sentinel surveillance, the Local Area Monitoring Project (LAM), is being set up in selected institutions in the major cities of the developing world. The primary goal of the LAM project is to provide disease-incidence data of sufficient quality to evaluate more fully the global impact of the EPI on the 6 target diseases--diptheria, pertusis, tetanus, poliomyelitis, measles, and tuberculosis. The goal is to include the major city of each of the 25 largest developing countries, with a total population of 115 million. These 25 countries together account for 85% of all births in the developing world. The program and coverage information is used to assess the impact of individual EPI programs on disease trends. Preliminary analysis of the 12 cities with the best data suggests that the impact of the EPI on the incidence of the target diseases has been greater than previously shown by the routine system. The LAM information is useful for global and regional analysis of program impact, but for the countries themselves its utility may be even greater. It is hoped that the project will help to improve a country's surveillance system by encouraging the use of sentinel reporting as a means of supplementing routine data. The information on the impact of the EPI may further increase political and public support for a program. (Summaries in ENG, FRE)
Idrc Reports. 1984 Oct; 13(3):18-9.Every 6 seconds someone contracts a sexually transmitted disease (STD), according to Dr. Richard Morisset, chairperson of the International Conjoint STD Meeting held in June 1984 in Canada. Under the patronage of the World Health Organization (WHO), this meeting brought together 1000 specialists from more than 50 countries. Several workshops dealt with STDs in the 3rd world. The workshops revealed an urgent need for drug therapies and assistance for women and children in developing countries because these groups are most affected. A resolution to this effect had been adopted during the annual meeting of the general assembly of the International Union Against Veneral Diseases and Treponematoses (VDTI). WHO was asked to take aggressive action in this area of health. The VDTI resolution also mentioned the fatal cases of acquired immunodeficiency syndrome (AIDS), the connection between cancer and venereal diseases, and the increases in the rates of mortality, infertility, and neonatal infections resulting from chlamydia, a bacterial infection. The need to form a common front in order to review and improve diagnostic methods and various treatments was also emphasized. Dr. King Holmes, an STD researcher at the University of Washington, claimed that "even though a reduction in the number of cases of STDs is possible in the long run, the immediate future is rather bleak." Efforts of the medical world should focus primarily on chlamydis, according to Holmes. This disease is similar to gonnorrhea but is now believed to be much more widespread. Currently, it is estimated that more than 500 million people throughout the world are afflicted. The resulting infections are said to be responsible for a significant proportion of cases of pelvin inflammatory disease and of ectopic pregnancies. US show that when the disease goes undiagnosed in pregnant women, their newborns risk contracting conjunctivitis (50% chance) and penumonia (20% chance). The longterm effects of chlamydia on newborns are unknown. Women and children suffer the most serious complications for STDs. Half of all infertility in women is caused by such diseases. Cervical cancer is the result of an STD. Dr. Willard Cates from the Centers for Disease Control in Atlanta appealed to governments, WHO, and other international organizations to concentrate their efforts on pregnant women, if prevention and treatment programs for the entire population were not feasible at present. Research in progress in the US and France has identified the virus that causes AIDS, but neither group of researchers believe that the production of vaccine is imminent. 1 conclusion of the Canada conference was that without a profound change in attitude, scientists will be unable to stamp out the epidemic of STDs.