INTEGRATED MANAGMENT OF CHILDHOOD ILLNESSES

I. Description

Surveys reveal that many sick children are not properly assessed and treated by
these health care providers, and that their parents are poorly advised. At first-level
health facilities in low-income countries, diagnostic supports such as radiology and
laboratory services are minimal or non-existent, and drugs and equipment are often
scarce. Limited supplies and equipment, combined with an irregular flow of patients,
leave health workers at this level with few opportunities to practice complicated clinical
procedures. Instead, they often rely on history and signs and symptoms to determine a
course of management that makes the best use of the available resources.

These factors make providing quality care to sick children a serious challenge.
WHO and UNICEF have addressed this challenge by developing a strategy called the
Integrated Management of Childhood Illness (IMCI).

What is IMCI?

This is an innovative approach which was started in 1995 by WHO and UNICEF
with the aim of introducing a comprehensive and timely management of the 5 most
common causes of ill health and death among the under-fives. These illnesses are:

Pneumonia
Diarrhea
Malaria
Measles
Malnutrition

IMCI is an integrated approach to child health that focuses on the well-being of

the whole child. IMCI aims to reduce death, illness and disability, and to promote
improved growth and development among children under five years of age. IMCI
includes both preventive and curative elements that are implemented by families and
communities as well as by health facilities.

In health facilities, the IMCI strategy promotes the accurate identification of

childhood illnesses in outpatient settings, ensures appropriate combined treatment of all
major illnesses, strengthens the counselling of caretakers, and speeds up the referral of
severely ill children. In the home setting, it promotes appropriate care seeking
behaviours, improved nutrition and preventative care, and the correct implementation
of prescribed care.
Components of IMCI

Improving case management skills of health workers

11-day Basic Course for RHMs, PHNs and MOHs
5 - day Facilitators course
5 day Follow-up course for IMCI Supervisors

Improving over-all health systems

Improving family and community health practices

Objectives of IMCI

Reduce death and frequency and severity of illness and disability

Contribute to improved growth and development

Strategies/Principles of IMCI

All sick children aged 2 months up to 5 years are examined for GENERAL
DANGER signs and all Sick Young Infants Birth up to 2 months are examined for
VERY SEVERE DISEASE AND LOCAL BACTERIAL INFECTION. These
signs indicate immediate referral or admission to hospital

The children and infants are then assessed for main symptoms. For sick children,
the main symptoms include: cough or difficulty breathing, diarrhea, fever and ear
infection. For sick young infants, local bacterial infection, diarrhea and jaundice.
All sick children are routinely assessed for nutritional, immunization and
deworming status and for other problems

Only a limited number of clinical signs are used

A combination of individual signs leads to a childs classification within one or

more symptom groups rather than a diagnosis.

IMCI management procedures use limited number of essential drugs and

encourage active participation of caretakers in the treatment of children

Counseling of caretakers on home care, correct feeding and giving of fluids, and
when to return to clinic is an essential component of IMCI
 BASIS FOR CLASSIFYING THE CHILDS ILLNESS

The childs illness is classified based on a color-coded triage system:

PINK- indicates urgent hospital referral or admission

YELLOW- indicates initiation of specific Outpatient Treatment

GREEN indicates supportive home care

Steps of the IMCI Case management Process

The following is the flow of the iMCI process:

At the out-patient health facility, the health worker should routinely do

basic demographic data collection, vital signs taking, and asking the mother about
the child's problems. Determine whether this is an initial or a follow-up visit. The
health worker then proceeds with the IMCI process by checking for general
danger signs, assessing the main symptoms and other processes indicated in the
chart below.

Take note that for the pink box, referral facility includes district,
provincial and tertiary hospitals. Once admitted, the hospital protocol is used in
the management of the sick child.

Interventions
A key aspect of IMCI was the integration of effective interventions to
improve child health and nutrition into a coordinated strategy. IMCI has three
components, each of which was meant to be adapted at the country level according
to local epidemiology, health system characteristics, and culture.

Improving Health Worker Performance

The first component of IMCI includes health worker training and the
reinforcement of correct performance. Training is based on a set of adapted
algorithms that guide health workers through a process of assessing signs and
symptoms, classifying the illness according to treatment needs, and providing
 appropriate treatment and education to the child's caregiver. Sick children
attending a first-level health facility are initially checked for danger signs and for
the main symptoms of the key IMCI diseases: diarrhea, malaria, pneumonia,
measles, and other severe infections. Next, all children are assessed for
malnutrition and anemia, and vaccination status is verified. Children under two
years of age, as well as older children presenting low weight for age, receive
nutrition counseling. Other health problems related by caretakers are then
assessed, and children are classified according to a color code: pink (immediate
referral), yellow (management in the outpatient facility), or green (home
management). Separate case-management algorithms are available for children
under two months of age. IMCI health worker training emphasizes the integration
of curative care with preventive measures, including nutrition and vaccinations. A
special training module addresses how to communicate effectively with mothers.
The training course was originally designed to last 11 days, including a large
amount of hands-on experience.

Improving Health Systems

The second component of IMCI is aimed at providing support for child
health service delivery, including drug availability, effective supervision, referral
services, and health information systems. Tools were developed for implementing
specific system-strengthening interventions, including a planning guide for
national and district managers, an integrated health facility assessment tool, and a
tool for improving referral level care.

Improving Family and Community Practices

This focuses on 12 key family practices relevant to child health and
development. Community IMCI supports the development and implementation of
community-and household-based messages and interventions to increase the
proportions of children exposed to these practices. These behaviors address
breastfeeding, complementary feeding, micronutrients, personal hygiene,
immunizations, insecticide-treated nets, mental and social development, continued
feeding and increased fluids during illness, home treatment of infections, care-
seeking practices, compliance with health worker recommendations, and prenatal
care.
II. Extent of Implementation

Children covered by the IMCI protocol

Sick children birth up to 2 months (Sick Young Infant)

Sick children 2 months up to 5 years old (Sick child)
 Implementation of IMCI

Introducing and implementing the IMCI strategy in a country is a phased process

that requires a great deal of coordination among existing health programmes and
services. It involves working closely with local governments and ministries of health to
plan and adapt the principles of the approach to local circumstances.

The main steps are:

Adopting an integrated approach to child health and development in the national

health policy.

Adapting the standard IMCI clinical guidelines to the countrys needs, available
drugs, policies, and to the local foods and language used by the population.

Upgrading care in local clinics by training health workers in new methods to examine
and treat children, and to effectively counsel parents.

Making upgraded care possible by ensuring that enough of the right low-cost
medicines and simple equipment are available.

Strengthening care in hospitals for those children too sick to be treated in an

outpatient clinic.

Developing support mechanisms within communities for preventing disease, for

helping families to care for sick children, and for getting children to clinics or
hospitals when needed.

IMCI has already been introduced in more than 75 countries around the world.
 EXPANDED PROGRAM ON IMMUNIZATION

I. Description

The Expanded Program on Immunization (EPI) was established in 1976 to ensure

that infants/children and mothers have access to routinely recommended infant/childhood
vaccines. Six vaccine-preventable diseases were initially included in the EPI: tuberculosis,
poliomyelitis, diphtheria, tetanus, pertussis and measles.

Over-all Goal

To reduce the morbidity and mortality among children against the most common
vaccine-preventable diseases.

Specific Goals

1. To immunize all infants/children against the most common vaccine-preventable

diseases.
2. To sustain the polio-free status of the Philippines.
3. To eliminate measles infection.
4. To eliminate maternal and neonatal tetanus
5. To control diphtheria, pertussis, hepatitis b and German measles.
6. To prevent extra pulmonary tuberculosis among children.

Future Plan/ Action

1. Strengthening the Cold Chain to support the Immunization Program.

2. Capacity Building for Health Workers for the Introduction of New Vaccines.
3. Advocacy for the financial sustainability for the newly introduced vaccines for
expansion.
4. Development of the comprehensive multi-year plan for immunization program.

Schedule of Immunization

1. Bacillus Calmette-Gurin

Minimum age at 1st dose: at birth

Number of doses: 1 dose
Dose: 0.05 mL
 Minimum Interval between doses: none
Route: Intradermal
Site: Right deltoid

2. Hepatitis B vaccine

Minimum age at 1st dose: at birth

Number of doses: 3 doses
Dose: 0.5 mL
Minimum Interval between doses: 4 weeks interval
Route: Intramuscular
Site: antero lateral thigh muscle

3. Pentavalent (DPT, HB, Hib)

Minimum age at 1st dose: 6 weeks

Number of doses: 3 doses
Dose: 0.5 mL
Minimum Interval between doses: 6 weeks (1), 10 weeks (2), 14 weeks (3)
Route: Intramuscular
Site: antero lateral thigh muscle

4. Oral Polio Vaccine

Minimum age at 1st dose: 6 weeks

Number of doses: 3 doses
Dose: 2 gtts
Minimum Interval between doses: 6 weeks (1), 10 weeks (2), 14 weeks (3)
Route: oral
Site: mouth

5. Anti- Measles vaccine

Minimum age at 1st dose: 9 -11 months

Number of doses: 1 dose
Dose: 0.5 mL
Minimum Interval between doses: none
Route: Subcutaneous
Site: Outer part of the upper arm
 6. MMR

Minimum age at 1st dose: 12-15 months

Number of doses: 1 dose
Dose: 0.5 mL
Minimum Interval between doses: none
Route: Subcutaneous
Site: Outer part of the upper arm

7. Rotavirus Vaccine

Minimum age at 1st dose: 6 weeks

Number of doses: 2 doses
Dose: 1.5 mL
Minimum Interval between doses: 6 weeks (1), 10 weeks (2)
Route: oral
Site: mouth

Computation of Vaccine Requirements

To compute vaccine requirements, use the following formula:

Vaccine requirement for the year

= eligible population X number of doses X wastage multiplier

The following are the given wastage multipliers for some EPI vaccines:
DPT, OPV and tetanus toxoid = 1.67
Hepatitis B vaccine = 1.20
AMV = 2.00
BCG = 2.50

The wastage multiplier may also be computed using the following formula:

Wastage multiplier
= Total number of doses per unit (ampule or vial)

Number of doses used:

To convert the vaccine requirement for the year to number of units
(ampules, vials, or bottles), divided by number of doses per unit.
 Sample computation

To determine OPV requirement for a municipality with a total population

of 15,000:

Eligible population = total population x 2.7 %

= 15,000 x .027
= 405 infants

OPV requirement for the year = eligible population x number of doses x 1.67
= 405 infants x 3 doses x 1.67
= 2029 doses

There are 20 doses/bottle of OPV. To convert doses to bottles:

Requirement for the year in bottles

= Requirement for the year in doses
number of doses per bottle
= 2,029 doses
20 doses per bottle
= 101.45 bottles

If requisition of immunization supplies is done monthly, divide the

number of bottles by 12.

Monthly OPV requirement = 101.45 bottles

12
= 8.45 or 9 bottles per month

Note: A reserve stock of 25% of the supply period should be maintained at the
facility.

Maintaining the potency of EPI vaccine

Vaccines confer immunity only when they are potent, and to retain their potency,
vaccines must be properly stored, handled, and transported. The following points are
important considerations to maintain the potency of EPI vaccines:
 Maintain the cold chain

The cold chain is a system for ensuring the potency of a vaccine from the time of
manufacture to the time it is given to an eligible client.

The person directly responsible for the cold chain management of each level is
called the Cold Chain Officer.

EPI vaccines and the special diluents have the following cold chain requirements:

OPV: -15 to -25 oC. OPV has to be stored in the freezer. In the vaccine bag,
OPV is placed in contact with cold packs.

All other vaccines, including measles vaccine, MMR and Rotavirus vaccine
have to be stored in the refrigerator at a temperature of +2 to +8 0C. These
vaccines should be stacked neatly on the shelves of the refrigerator. Do not
stock the vaccines at the refrigerator door shelves.

Hepatitis B vaccine, Pentavalent vaccine, Rotavirus vaccine and TT are

damaged by freezing, so they should not be stored in the freezer. Wrap the
containers of these vaccines with paper before putting them in the vaccine
bag with cold packs

Keeps diluents cold by storing them in the refrigerator in the lower or door
shelves

Other consideration to maintain potency

Observe the first expiry- first out (FEFO) policy

Comply with the recommended duration of storage and transport
Take note if the vaccines container has a vaccine vial monitor (VVM) and act
accordingly
Abide by the open vial policy of the DOH

II. Laws

R.A. 10152 (Mandatory Infants and Children Health Immunization Act of 2011)

Mandates basic immunization covering the vaccine preventable diseases.

 PD 996

Free mandatory basic immunization to infants and children up to 5 years of age.

R.A. 7846

Compulsory immunization against hepatitis B immunization within 24 hours after

birth of babies of women with hepatitis B.

III. Incidence

The 2008 National Demographic and Health Survey showed that 3 out of 4 births were
protected against neonatal tetanus, that is, women whose last birth was protected against
neonatal tetanus was 76%. Across regions, tetanus toxoid coverage ranged from 39% in
ARMM to 88% in Central Visayas and Cagayan Valley. By level of education, TT
coverage was lowest for women with no education at 34% and highest for women with
high school education at 80%.

Polio Eradication

The Philippines has sustained its polio-free status since October 2000.

Declining Oral Polio Vaccine (OPV) third dose coverage since 2008 from 91%
to 83%. A least 95% OPV3 coverage need to be achieved to produce the
required herd immunity for protection.

There is an on-going polio mass immunization to all children ages 6 weeks up

to 59 months old in the 10 highest risk areas for neonatal tetanus. These areas
are the: Abra, Banguet, Isabela City and Basilan, Lanao Norte, Cotabato City,
Maguindanao, Lanao Sur, Marawi City and Sulu.

Acute Flaccid Paralysis (AFP) reporting rate has decreased from 1.44 in 2010
to 1.38 in 2011. Only regions III, V and VIII have achieved the AFP rate of
2/100,000 children below 15 years old. A decreasing AFP rate means we may
not be able to find true cases of polio and may experience resurgence of polio
cases
 On Arpril 2016, the Philippines joined the rest of the world in replacing the
trivalent Oral Polio Vaccine with the bivalent type (tOPV to bOPV). bOPV
lacks the type 2 component, while tOPV contains the weakened versions of all
the poliovirus types (types 1, 2 and 3). The removal of the type 2 component
enables better protection and lower risk from polio outbreaks. The Inactivated
Polio Vaccine is given along with the third OPV dose to strengthen the childs
immunity against polioviruses.

Measles Elimination

Conducted 4 rounds of mass measles campaign: 1998, 2004, 2007 and 2011.

Implemented and strengthened the laboratory surveillance for confirmation of

measles. Blood samples are withdrawn from all measles suspect to confirm the case
as measles infection.

A supplemental immunization campaign for measles and rubella (German measles)

was done in 2011. This was dubbed as Iligtas sa Tigdas ang Pinas. 15.6 million
(84%) out of the 18.5 million children ages 9 months to 8 years old were given 1
dose of the measles-rubella (MR) vaccine between April and June 2011.

Rapid coverage assessment (RCA) was conducted in selected areas to validate

immunization coverage, assess high quality and that there are NO missed child in
every barangay. Overall RCA results showed that 70,594 (97.6%) out of 72,353 9
months to 8 years old living in the randomly selected barangays were vaccinated.
There are 3,494 barangays with a population of 1000 and above that were randomly
selected. 97.6% of all eligible children were given the MR vaccine during the
immunization campaign.

As of Morbidity Week 8 of 2012, there were 92 confirmed cases: 60 cases were

laboratory confirmed, 5 cases were epidemiologically-linked and 27 clinically
confirmed. This means we have at least 60 true measles at present. Measles is
said to be eliminated if we have 1 case per million or below 100 cases in a year.

Control of other common vaccine-preventable diseases (Diphtheria, Pertussis, Hepatitis

B and Meningitis/Encephalitis secondary to H. influenzae type B)

Continuous vaccination for infants and children with the DPT or the combination
DPT-HepB-HiB Type B. Annex1 EPI Annual Accomplishment Report. DOH procures all
the vaccines and needles and syringes for the immunization activities targeted to
infants/children/mothers.
 Hepatitis B Control

One strategy to strengthen Hepatitis B coverage is to integrate birth dose in

the Essential Intrapartum and Newborn Care Package (EINC). In 2011, 11
tertiary hospitals are already EINC compliant.

The goal of Hepatitis B control is to reduce the chronic hepatitis B infection

rate as measured by HBsAg prevalence to less than 1% in five-year-olds
born after routine vaccination started 100% Hepatitis B at birth vaccination.

Vaccines and cold chain management

Upgraded the cold chain equipment in the 80 provinces, 38 cities and 16

regions since 2003.

An effective vaccine management assessment was conducted last December

2011 and revealed cold chain capacity gaps from the national up to the
implementers level.

A total of PhP 267 million is required to address the gaps identified during
the assessment

Introduction to New Vaccines

From 2012, Rotavirus and Pneumococcal vaccines were introduced in the

national immunization program. Immunization were prioritized among the
infants of families listed in the National Housing and Targeting System
(NHTS) for Poverty Reduction nationwide.

The Government of the Philippines has allocated PhP 1.6 billion for the
procurement of these 2 vaccines.

IV. Extent of Implementation

Strategies

Conduct of Routine Immunization for Infants/Children/Women through

the Reaching Every Barangay (REB) strategy

REB strategy, an adaptation of the WHO-UNICEF Reaching Every District

(RED), was introduced in 2004 aimed to improve the access to routine immunization
and reduce drop-outs. There are 5 components of the strategy, namely: data analysis for
 action, re-establish outreach services, strengthen links between the community and
service, supportive supervision and maximizing resources.

Supplemental Immunization Activity (SIA)

Supplementary immunization activities are used to reach children who have not
been vaccinated or have not developed sufficient immunity after previous vaccinations.
It can be conducted either national or sub-national in selected areas.

Strengthening Vaccine-Preventable Diseases Surveillance

This is critical for the eradication/elimination efforts, especially in identifying

true cases of measles and indigenous wild polio virus

Procurement of adequate and potent vaccines and needles and syringes to

all health facilities nationwide.

Status of implementation/ Accomplishment

All health facilities (health centers and barangay health stations) have at
least one health staff trained on REB.