Reliability of IMCI strategy's implementation on declining an inappropriate use of antibiotics and rising the coverage of vaccinations in Al Hadbaa PHCCin Mosul city.
Ashraf K. Al-Nuaimee/ M.Sc. (Community Medicine)
Ali M. Saleem/ M.Sc. (Community Medicine)
Abstract:
Background: The World Health Organization (WHO) with The United Nations Children's Fund (UNICEF) build up guidelines for the integrated management for the childhood illness in the health facilities (IMCI) to improve the recognition and the individual management of the common reasons of death among childhood. When assessing a sick child, the checklist include collection of characteristic signs and symptoms for each illness that leads to one classification or more, rather than to a specific diagnosis. The guidelines include schemes and algorithms for checking the vaccination status of the child. The approach is planned to be use in outpatient clinical settings with restricted diagnostic tools, limited medication and limited opportunities to practice complicated clinical procedure.
Aim: To prove that by the implementation of IMCI strategy, an inappropriate use of antibiotics will be decline and the coverage of vaccinations raise.
Materials and Methods: A cross-sectional study design was arranged, where 395 children with age from two months up to below 5 years old attending Al Hadbaa PHCC from 1st of January to 31th of March 2014 suffering from one or more of the following respiratory infection, diarrheal diseases, throat infections, ear infections and fever. The children assessed separately by two clinics, "A" non adopting IMCI and "B" adopting IMCI guidelines, the Mc-Nemar test was applied. The differences between the two clinics in declining an inappropriate use of antibiotics and rising the coverage of vaccinations were evaluated.
Results: The total attendant children distributed as 239 males and 156 females complaining from fever (39.1%), throat problems (21.4%), ear problems (12.6%), cough (11.6%), diarrhea (11.1%) and pneumonia (4.2%). Their age group intervals were 15% within 2 month-1 year age group, 12% 1-2 years, 13% 2-3 years, 21% 3-4 years and 39% 4-5 years (figure 2). The difference between clinic "A" and clinic "B" regarding the chief complaints was very high significant in all complaints shown in table (1). Overall use of antibiotics is 66.1% in clinic "A" and 21.0% in clinic "B" with p-value 0.0007, furthermore the difference between oral antibiotics (80.1% in clinic "A" and 92.8% in "B" and injectable antibiotics (19.9% in "A" and 7.2% in "B") with p-value 0.0346. Regarding the immunization, the outcomes appear to have very high significant difference in both those who ask about vaccines (51.9% in "A" and 100% in "B" and those from them who send to be vaccinated 54.1% in "A" and 75.7% in "B".
Conclusion: The classification-approach to the sick child using IMCI guidelines has clear effect on decreasing an inappropriate use of the antibiotics and decreasing coverage of vaccines.
Key words: IMCI, Inappropriate use of antibiotics ,vaccinations
Introduction:
Almost 11 million of the children under five years of age in developing countries die every year, the death occurs in 7 from every 10 of those result from the acute respiratory infections (ARI), diarrhea dehydration, measles, and malaria. All are preventable and treatable illnesses. Malnutrition complicates half of these cases.1-3
The World Health Organization (WHO) developed the IMCI (Integrated Management for Childhood Illness) which is an integrated guidelines to child complain that focuses on the well-being status of the child. IMCI aims to relieve illness and/or disability with effort to minimize death, and to enhance growth and development among children under five years of age. IMCI has preventive and curative fundamentals that are realize by families, communities and also by health facilities. The strategy includes three main components:
• Improving case management attitudes and skills of medical and paramedical staff
• Advancing the health systems
• Progressing the family and community health performance.
In the health facilities, the precise identification of childhood illnesses in outpatient settings has been promoted by IMCI strategy to ensure an appropriate combined treatment of all major illnesses, build up the counseling of caretakers, and accelerate the referral of severely ill children. While when the setting was home, the suitable care inquire behaviors, enhanced nutrition and preventative care, and the accurate achievement of prescribed care, these were the targets of IMCI .4
IMCI case management training provide the health workers with skills to deal with and manage children presented with a combination of illnesses, identify those requiring urgent referral, administer appropriate treatments (especially the antibiotics mainly amoxicillin, co-trimoxazole, erythromycin or i.m. penicillin or ceftriaxone vials), and provide relevant information to child care providers. IMCI implementation has been revealed the advancement in the quality of management of sick children.5-7
Case management strategy usually depends on the clinical presentation of diseases (syndromes) rather than on the etiologies. The IMCI checklist, should be filled during the interview with children and parents, all symptoms and signs were recorded systematically, then the classification(s) were outlined using series of algorithms and written according to IMCI chart booklets, next step was the identification of treatments.8
The choose and use of antibiotics were restricted to an evidence-based and meta-analysis studies in figure of first and second lines.
The continued use of an appropriate antibiotic among medical community is very important goal. Overuse of antimicrobial agents in both community and hospital settings are common worldwide. In addition to the effect on patients.9The antibiotic misuse causing the emergence of bacterial resistance and so the health care costs increases. It is evident that optimizing antibiotic use is a challenge that deserves to be undertaken.10
The main reason physicians overprescribe antibiotics for an example RTIs relates to diagnostic uncertainty. Faced with an ill-appearing, febrile child and anxious parents, physicians are reluctant to offer only symptomatic therapy. If the physician were more certain that the infection was of a viral etiology, then a greater comfort level might exist in avoiding antibiotic therapy. Lacking such information, the tendency is to prescribe the antibiotics even if the likelihood of bacterial infection is extremely low. In the balance, the perceived risk of confronting a resistant bacteria is outweighed by the possibility of an evolving unrecognized acute bacterial infection with significant consequences.11
So resistance to antibiotics is rising due to the continues exposure of microorganisms to antimicrobial agents. When microbes exposed to antimicrobial, develop strategies to survive in the hostile situation and become resistant. Pressure on the bacteria to transform and become “robust” develops due to:
(i) an inappropriate and excessive use of antibiotics in treating infection
(ii) an extensive use of antibiotics in animal husbandry
(iii) use of antimicrobial/ antiseptic agents in agriculture and for domestic purposes.
Once resistance is established, it is hard to be reversed, only the accurate utilize of antibiotics will diminish the flourishing of resistant strains. Therefore, actions must be achieved to promote appropriate prescribing and minimizing the development and extend of the bacterial resistance.12
Conclusively, the vaccines are a cost-effective interference in the health system. It costs a little, although it presents enormous benefits for the health and welfare of populations. According to WHO records, the annual death among children under the age of 5 years reach 10.6 million; while an estimated 1.4 million of those are due to diseases that might prevented by vaccines.13
Despite the huge benefit of the vaccinations, some people still not interested with vaccinations in terms of either not vaccinating at all, or not completing their vaccination programs.14
In IMCI, vaccinations status been checked for every attending child. Any missed vaccines are given for children who do not have severe classifications.15Moreover, IMCI trained health workers communicate better with the parents.5 Because being unaware of need for immunization, uninformed about the need to return for subsequent second or third dose, unknown place and/or time of immunization, the probable side effect, the incorrect thoughts about contraindications, lack of reliance in immunization, inconvenient time of vaccination, absence of well trained heath worker and vaccine, and long waiting time at health facility were reasons for not fully immunizing the children.16
Materials and Methods:
Three hundred and ninety five child age from two months up to below five years old attending Al-Hadbaa training center for family medicine in Mosul, were enrolled in this cross-sectional study.
After obtaining the administrative agreement from the Directorate of Health of Nineveh and the informed oral consent was taken from the parents, the sample collected according to the inclusion indicators listed as :
• children between two months and up to five years old.
• Those children should presented with one or more of the following (respiratory infection, diarrheal diseases, throat infections, ear infections and fever).
• First visit for the present complain.
• The child should not have severe sickness that call for a referral.
The sample were review by the two researchers and for assessment and consent, then every child was review separately by 2 clinics; clinic "A" not adopting IMCI guidelines and clinic "B" adopting IMCI guidelines.
The data obtained from both clinics along the period from January to end of March 2014.The data were managed by using SPSS version 18. this software installed in a personal mini laptop. The Percentages, Mac-Nemar and p-value were measured.
Results:
Figure (1):Distribution of attendant children according to sex
Figure (1) illustrates the distribution of study sample according to sex and reveals that 239 of them are males and 156 are females representing 60.5% and 39.5% respectively.
Figure (2): Distribution of attendant children according to age groups
Figure (2) displays the distribution of study sample according to specific age intervals. Where 39% of them were between the age of 4 years to less than 5, while the interval 1-2 years was the lowest frequencies of 12%.
Figure (3)
The main complaints of children attending Al-Hadbaa training center in this study were shown in a descending manner starting from fever, throat problems, ear problems, cough, diarrhea and pneumonia representing 39.1%, 21.4% , 12.6%, 11.6%, 11.1% and 4.2% respectively.
Table (1): The difference between clinic "A" and clinic "B" regarding the chief complaints
Clinic "A" Clinic "B" McNemar’s Test p-value
Fever 205 (39.1%) 205 (39.1%) 24.4 0.000
Throat problems 112 (21.4%) 74
(14.1%) 233.7 0.000
Diarrhea 58
(11.1%) 58
(11.1%) 316.1 0.000
Ear problems 66
(12.6%) 84
(16.0%) 256.7 0.000
Cough 61
(11.6%) 95
(18.1%) 241.4 0.000
Pneumonia 22
(4.2%) 8
(1.6%) 476.6 0.000
This table portrays very highly significant differences between clinic "A" and clinic "B" in all complaints with p-values = 0.0000 in the all specific classifications which are 524 since that the child may presented with more than one complaint and classification.
Table (2):The difference between clinic "A" and clinic "B" regarding the overall antibiotics prescription, oral and injectable
Clinic "A" Clinic "B" McNemar’s Test p-value (1 tail) p-value (2 tails)
Overall antibiotics 261
(66.1%) 83
(21.0%) 11.5 0.0003 0.0007
Oral antibiotics 209
(80.1%) 77 (92.8%) 4.5 0.0173 0.0346
Injectable antibiotics 52 (19.9%) 6
(7.2%)
In this table a very highly significant difference between the clinic "A" and clinic "B" in overall antibiotics prescription with p-value of 0.0007, while the difference between the oral and injectable antibiotics in both clinics in ratios of 80.1%, 91.6%, 19.9% and 7.2% is just significant (p-value 0.0346).
Table (3):The difference between clinic "A" and clinic "B" regarding the vaccines coverage
Clinic
A Clinic
B McNemar’s Test p-value (1 tail) p-value (2 tails)
Those who ask about vaccines 205 (51.9%) 395 (100%) 71.1 0.000 0.000
Those who send to be vaccinated 111
(54.1%) 299 (75.7%) 105.9 0.000 0.000
The difference in asking about the vaccination status between both clinics is very highly significant with p-value=0.000 and ratio ranging from 51.9% in clinic "A" to 100% in clinic "B", moreover a very highly significant difference is allocated between those who send to be vaccinated in each clinic with frequencies of 54.1% in clinic "A" and 75.7% in clinic "B" at p-value= 0.000.
Discussion:
This study shows that 60.5% from the attendant children were males and 39.5% females (figure 1), who distributed as 15% within 2 month-1 year age group, 12% 1-2 years, 13% 2-3 years, 21% 3-4 years and 39% 4-5 years (figure 2). Similar results found in a study done in Syria19 which involve 112 sick child, were found that 32% were in the 4-5 years age group and 10% within 1-2 years interval, this may due to that the children in this older age interval start to skill the surroundings and being more predisposed to expose to pathogens, moreover the major complains were: 73 fever, 37 pharyngitis, 35 diarrhea,19 otitis media and 15 cough.19 While in our study the fever 205(39.1%), throat problems 112(21.4%), ear problems 66(12.6%), cough 61(11.6%), diarrhea 58(11.1%) and pneumonia 22 (4.2%) (figure 3).
According to a recent survey on healthcare associated infections in Europe, the point prevalence was 35.0% of the hospitalized patients in 2011 were receiving antibiotics.20Also in US, it was found that the health care workers prescribed 258.0 million course of antibiotics (833 prescriptions per 1000 persons) in 2010;Penicillins (23%) and macrolides (22%) were on the top of frequent categories prescribed.21
In this current study, a significant difference in favor of adopting IMCI was clear regarding the antibiotics uses as shown in the table (2) were 66.1% of clinic "A" and 21.0% of clinic "B" out of 395 attending children receiving antibiotics as overall. In the same manner, an increasing rate of antibiotic prescription was observed in the cohort study involving children at out-patient settings in Papua New Guinean, with 54% of cases treated (including mild and severe cases) when a maximum of 36% should have received antibiotics according to IMCI criteria8. Also identifying the correct drug, giving the right dose and dosage form, and prescribing the acceptable route of administration are other indicators on the treatment that were significantly better in clinic "B" than clinic "A" in a study done by Azza A. El Mahalli and Ola A. Akl in Egypt 2011 with frequencies of 89.3%, 87.3%, 91.3%, and 91.3%, respectively than in the clinic not adopting18. The injectable drugs were decided to be used in only 0.7% of cases in clinic "A" adopting IMCI, this may be a benefit of adopting IMCI because the cost of injection therapy is always higher than that of oral therapy18, while in the present work, the rate of the injectable antibiotics from the total antibiotic prescription was 7.2% in clinic "B" in comparison with 19.9% among clinic "A", this is run in a very high significant difference (p-value = 0.0346). While the orally prescribed antibiotics to child needing antibiotics (for pneumonia, dysentery, acute ear infection and streptococcal sore throat) steering up from (10.3%) in non IMCI to (81.3%) in IMCI adapting unit.22
Contrarily in several studies23-25, the results showed low specificity of IMCI algorithms, especially to identify bacterial infections that require antibiotics this limitations in IMCI could be explain by the defect in the available diagnostic tools or lack the concerning about the local epidemiology. Therefore, many children might be given antibiotics that they not required.
According to IMCI guideline, checking the immunization status is very important. If a child should be immunized, the health worker gives immunizations even if child was sick under condition that the referral was rolled out, so every sick child can receive vaccination if the decision was to be treated at home.26 So in this study 17.5% of children attending clinic "A" checked about their vaccinations in comparison with 100% in clinic "B", with a significant very high difference (p-value one tail= 0.0005 and two tails= 0.011).
Of those who checked in this work, 54.1% and 75.7% were sent to be vaccinated from clinic "A" and "B" respectively. The very highly significant difference could be due to the adherence and compliance to IMCI checklist, in which the care provider ticks in front the vaccines that previously taken by the child in previous visit and encircles the vaccines that the child should be taken at the current visit.
Health-care giver have a major role in achieving child immunization. The vaccination providers have a considerable task regarding familial knowledge, support and practices for guidance on immunization timing and administration. In addition, immunization providers have great effects on parental decisions related to vaccinations. It is obvious that the parents’ decisions concerning immunization can impact vaccination rates, including access to vaccinations, the communication of risks and benefits, the maintenance of precise vaccination records, and strategies for vaccination reminders.27
A retrospective work in Egypt assessing the data from the years 2000 to 2006 compared the annual mortality rates under-five in 254 districts before starting the IMCI approach and after, the post-IMCI correctly checked child for immunization status was 94.3% against 18.6% pre-IMCI.28
The health education messages significantly increased the vaccination status of children under 5 in the intervention area.29 The medical personnel are responsible forgiving the information about the vaccinations, and mothers getting regularly offered information about vaccination by medical staff at each visit, were associated with better knowledge and attitude toward vaccination.13 Health Education plus 'reminder-type' immunization cards that given to the parents in each visit designed to remind mothers of immunization appointments, appear to improve the vaccination coverage which is obvious in two studies evaluated an enlarged immunization card.30,31
Recommendations:
To the best of our awareness, this the first study in Mosul to report the benefits of IMCI on the child health. The need for further studies to evaluate the other aspects of the IMCI is imperious and how will health workers comply with IMCI guidelines in routine practice must be tested and on the effect of IMCI recommendations on health outcomes.
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