Evaluation ofanalgorithm forintegrated managementofchildhood illness inanareaof Kenyawithhighmalaria transmission

In1993, theWorldHealth Organization completed thedevelopment ofadraft algorithm fortheintegrated management ofchildhood illness (IMCI), which deals with acute respiratory infections, diarrhoea, malaria, measles, earinfections, malnutrition, andimmunization status. Thepresent study compares theperform- anceofaminimally trained health worker tomakeacorrect diagnosis using thedraft IMCIalgorithm with that ofafully trained paediatrician whohadlaboratory andradiological support. During the14-month study period, 1795children agedbetween 2months and5yearswereenrolled fromtheoutpatient paediatric clinic ofSiaya District Hospital inwestemKenya; 48%werefemale andthe median agewas13months. Fever, coughanddiarrhoea werethemostcommonchief complaints presented by907(51%), 395(22%), and199(11%) ofthechildren, respectively; 86%ofthechief complaints were directly addressed bytheIMCIalgorithm. A total of1210children (67%)hadPlasmodium falciparum infection and1432(80%) mettheWHOdefinition foranaemia (haemoglobin <11gidl). Thesensitivities and specificities forclassification ofillness bythehealth worker using theIMCIalgorithm compared todiagnosis bythephysician were:pneumonia (97%sensitivity, 49%specificity); dehydration inchildren with diarrhoea (51%,98%); malaria (100%, 0%);earproblem (98%,2%);nutritional status (96%,66%); andneedfor referral (42%,94%). Detection offever bylaying ahandontheforehead wasbothsensitive andspecific (91%, 77%). There wassubstantial clinical overlap between pneumonia andmalaria (n=895), andbetween malaria andmalnutrition (n= 811). Basedontheinitial analysis ofthese data, somechanges weremadeintheIMCIalgorithm. This study provides important technical validation oftheIMCIalgorithm, buttheperformance ofhealth workers should bemonitored during theearly partoftheir IMCItraining.