The Implementation of Integrated Management of Childhood Illness ...

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ii. Malaria More than a half of children U5 who attended the five health facilities in the Monkey Bay health zone were classified with malaria. Malaria is clearly an immense burden on the community in the area. It is therefore imperative that drugs for malaria be sufficient and health workers be able to correctly identify malaria and treat it. Neonates have a significant degree of resistance to malaria by an unexplained mechanism although maternal antibodies are believed to play a role (59, 60). Hence, the proportion of children in the age group of less than two months classified with malaria should be minimal. Consequently, the high proportion of children less than two months (13/15) classified with malaria in Nankhwali is questionable and presumably too high. In Nankhwali, a high proportion of the children in other age groups were likewise classified with malaria. The Nankhwali health centre is situated in the same area as the other four health facilities and should therefore have similar transmission of malaria (61). As the only clinical sign needed to classify malaria is fever, the classification is obviously an overestimate of the number of children with clinical malaria. Fever in children may be caused by many viral infections and bacterial infections such as pneumonia (62). However, a laboratory to examine blood films and thus confirm the malaria classification is not available in the four health centres (although it is available at MBCH). Thus, the health workers need to rely on clinical signs alone. There are concerns about the over-classification and the massive overtreatment of malaria as malaria drugs are becoming more expensive and toxic as the years pass by (18). On the other hand, even though the specificity of fever in the diagnosis of malaria is very low (18), the risk of missing and not treating malaria cases cannot be taken. In addition, blood films (that can be examined at MBCH) are not an absolute indicator of the severity or presence of malaria (63). It is therefore necessary to provide children who have fever with antimlarials and suspiciously high numbers of malaria cases should be acceptable to some degree. iii. Malaria versus Pneumoniaa In the present study, pneumonia was commonly classified along with malaria. 44
This is interesting in the light of a previous study conducted in 1992 in Malawi. The aim was to evaluate usefulness of clinical case definitions in managing pneumonia and malaria in an outpatient department in Lilongwe, Malawi (64). The group found that 95% of children meeting the WHO clinical definition of pneumonia also met the clinical definition of malaria. Fever was not associated with malaria (while splenomegaly was associated) and cough was not associated with pneumonia (though crepitations were) in the study (64). Recently, a study conducted in Uganda revealed that 32% of children seeking care in the first two days of fever have overlapping symptoms with pneumonia (cough or fast breathing) and 43% of children seeking care after two days of fever have overlapping symptoms with pneumonia (62). With the resources available today, children who have symptoms that, according to IMCI, indicate both pneumonia and malaria need to receive treatments for both diseases. This example highlights the importance of an integrated appraoch such as the IMCI where children are treated on the basis of symptoms rather than diagnoses. iv. Diarrhoeaa Diarrhoea is the second most common cause of U5 death in the world (26) and each child has on average three episodes of diarrhoea per year (65). Diarrhoea has been a common problem for decades and probably will continue to be so. In the Child Survival series that was published in Lancet in 2003, it is stated that diarrhoea and pneumonia will continue to be considerable contributors to child mortality until mortality rates become very low (7). The proportion of diarrhoea classifications in the Monkey Bay area was very low during the research period. Considering the mortality and morbidity of diarrhoea in the world, the low proportion of children with diarrhoea is striking but difficult to explain. It may be that caretakers are not bringing children with diarrhoea to health facilities. It may also be that health care workers are not detecting the diarrhoea cases. Finally, the incidence of diarrhoea may have been low during the research period or may be generally low in the area. 45
Page 1 and 2: The Implementation of Integrated Ma
Page 3 and 4: . Diagnoses .......................
Page 5 and 6: List of Abbreviations ARI………
Page 7 and 8: Since 1970 there has been a conside
Page 9 and 10: over half of all deaths associated
Page 11 and 12: (16). The vertical programmes were
Page 13 and 14: The case-management guidelines are
Page 15 and 16: The childhood deaths resulting from
Page 17 and 18: though ear infection is not one of
Page 19 and 20: guidelines after training seems unn
Page 21 and 22: 3. Material and Methods a. The Sett
Page 23 and 24: perform surgical procedures. Illnes
Page 25 and 26: workload at the Mangochi District h
Page 27 and 28: The respiratory tract infections in
Page 29 and 30: 4. Results a. Health Care Workers I
Page 31 and 32: In all health facilities there were
Page 33 and 34: c. Diagnoses Children could be clas
Page 35 and 36: Pro ii. Pneumonia In total, about 7
Page 37 and 38: iv. Diarrhoea As shown in Figure 4-
Page 39 and 40: Table 4-10: Availability of IMCI-re
Page 41 and 42: 5. Discussion The results of this s
Page 43: . Diagnoses The fact that around 84
Page 47 and 48: In the present study, of the just l
Page 49 and 50: eceived care from the trained healt
Page 51 and 52: Acknowledgments This project is a c
Page 53 and 54: area of Kenya with high malaria tra
Page 55 and 56: 53. Creese A, Kutzin J. Lessons fro
Page 57 and 58: Annexes 57
Page 59 and 60: Annex 2 59
Page 61 and 62: Annex 4 61

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