Utility of Indian adaptation of Integrated Management of Childhood Illness (IMCI) algorithm

Abstract

Objective: To evaluate the utility of Indian adaptation of IMCI algorithm.

Methods: Children presenting to outpatient department (n=169) or casualty (n=140) among 309 cases were assessed and classified as per IMCI algorithm, the final diagnosis made after detailed evaluation and relevant investigations, served as the gold standard. The diagnostic and therapeutic agreements between the gold standard, IMCI and vertical (on the basis of primary presenting complaint) algorithms were computed.

Results: Coexistence of illness was observed in 75% of children as per IMCI algorithm. The mean (SD) number of morbidities as per the Gold standard and IMCI were 1.75 +/- 0.75 and 2.19 +/- 0.96 respectively. The referral criteria proved useful in predicting hospitalisation with high sensitivity and specificity (99.3% & 97.3%). IMCI algorithm covered majority of recorded illnesses. A total agreement with IMCI was found in 88.4% cases, while total disagreement was seen in 34.5% cases. Corresponding figures for vertical program were 88% and 18.6%. The difference was primarily due to underdiagnosis. The diagnostic discordance of IMCI and gold standard was evident for the cough category due to underdiagnosis of bronchial asthma and bronchiolitis and an overdiagnosis of pneumonia. The IMCI algorithm had a provision for preventive services of immunization (24.5% possibility of availing missed opportunity) and feeding advice.

Conclusions: There is a sound scientific basis for adopting the IMCI approach since: (1) Co-existence of morbidities is a rule rather than exception for sick under-five children. (2) The algorithm provides good sensitivity and specificity for assessing severe illness and (3) IMCI algorithm is superior to vertical disease specific programs. It is, however, important to carefully adapt the generic IMCI algorithm to reflect the local morbidity profile.