Realities in the fieldRealities in the field

FEVER

Differential Diagnosis

not possible

What happens in practice when a child presents with fever

Where malaria risk is high

Fever or history of fever?

Treated with antimalarial

Child survives

Classified as malaria

Artemisinin based Combination Therapy (ACT)

is recommended by WHO

What happens/could happen when a child presents with danger signs

DANGER SIGNS

Basic treatment started with

Artesunate suppository

Signs of a child requiring urgent

attention

Typical case:TC5022-2 – mother's description .. fever 3 days prior to death. at home for 2 days without treatment.

third day of illness, the fever intensified, and the child became very weak. Did not go to hospital. Day3 child had laboured breathing and died.

Lethargy?- baby conscious but not responding to sounds or movementUnable to feed? why – too weak, shortness of breath, disturbed consciousness, inability to swallow

Is child vomiting everything? Sign of an illness to be identified, child can become dehydratedDoes child have convulsions with illness? – Febrile seizures? But meningitis, malaria, pneumonia cannot be ruled out

If unable to eat, drink or suckUnable to sit, stand or walk unaided

Lethargy/ altered consciousnessRepeated convulsions

Repeated vomiting

REFERRED to

HOSPITAL

Classified as severe malariaWith added symptoms of chest in-drawing

+ rapid breathing classified as malaria +pneumonia

Because it was late at night, they did not go to hospital. The fever intensified and the child started having

difficulty breathing (deep breathing) .. Child dies on the 3rd day of illness at home

On return to per os status, child given oral

antimalarial

Child survives

Did not go to hospital. But the child improved and

could eat and play

NOT KNOWNWhat proportion of children treated early with

rectal artesunate are at risk of death without hospital intervention?

NOT KNOWNWhat proportion of children treated early might

safely be given a suppository plus oral ACT treatment

HIGH risk of death

Child does not respond

Child responds

What happens/could happen when a child presents with danger signs

Referral advice not

followed

REFERRED to

HOSPITAL

NOT KNOWNProportion of children treated with rectal artesunate

are at risk of death without hospital intervention?

NOT KNOWNWhat proportion of children treated early might

safely be given a suppository plus oral ACT treatment and not need hospitalisation

Should rectal artesunate be made availableOnly with ACTs?

RISK- BENEFIT

INFORMATION NEEDEDHow to really scale up rectal artesunate + ACTs?

What packagingHealth Information/Education

Pricing Supply Logisticswill be necessary

To make the intervention work at national level?

INFORMATION NEEDEDProportion of children treated with rectal artesunate

that need hospital management because they(i)Progress to severe malaria

(ii) Have anaemia, dehydration, malnutrition (iii) Have pneumonia co-infection or just pneumonia

Chest Indrawing

Strange Sounds

Fast Breathing

SOLUTION UNICEF main implementing Agency

for Child Survival(i) Make part of UNICEF – community based IMCI

(ii) Target countries & GFATM(iii) Produce product, package with ACTs(iv) Introduce Health Education, Deploy(v) Develop mechanisms for scale up

Community Integrated Management of Community Integrated Management of Childhood Illness, C-IMCIChildhood Illness, C-IMCI

C-IMCI = an integrated child care approach to improve key family and community practices likely to have greatest impact on child survival, growth and development

Practices include: breastfeeding and complementary feeding, hygiene and helping to prevent malaria - consistent use of treated nets, home management of fever episodes, and through recognizing symptoms and promptly referring severe fever cases to a health facility.

UNICEF advocates with governments to improve health systems, including ensuring that essential drugs, supplies and equipment are available.

UNICEF helps to buy and distribute these items, including vaccinations for routine immunization, Vitamin A supplements, insecticide-treated nets in malaria-affected areas, and malaria home management kits (pre-packaged anti-malarial medications).

Countries with child health

related community

interventions

IMCI Unit AFRO

Countries with Community-IMCI in more than 3 Districts

Community IMCI : Implementation Status

IMCI Unit AFRO

COUNTRIES WITH PLAN FOR C-IMCI

•Planning at national and district levels

•Partners collaborating in planning

SummarySummary

Children who obtain rectal artesunate by reason of their acute disease are likely to benefit

However, in providing the drug, we need to discourage complacency that the drug will solve all problems

The probability is high that most (>75%) children will return to per os status

For these children –co-packaging with oral ACTs makes sense; hospitalisation may not be necessary

But, there is a small, critical, risk that some children will not respond because they have same symptoms but another infection

Need to identify the non-responders quickly