The failure of IMCI to recognise airways disease

The article by Bjornstad and co-authors, ‘Determining the quality of IMCI pneumonia care in Malawian children’, concludes that the quality of pneumonia IMCI care is alarmingly low. They call for ‘novel quality improvement interventions’, meaning the use of internet and mobile phone applications and a balanced score-card model for training and supervision. This seems an unlikely remedy, as illustrated in this commentary. A study was undertaken in Papua New Guinea 22 years ago under WHO auspices with very similar findings of poor adherence to protocols. But there were major difficulties with counting respiratory rates and assessing chest indrawing – not just for health workers, but also for the trained supervisors. It was observed that experienced health workers could identify sick children reliably, and used antibiotics more appropriately than those following the Acute Respiratory Infection (ARI) guidelines. Similar problems were encountered in running a non-research ARI programme in The Gambia which demonstrated that malaria also caused fast breathing. Instead of addressing these difficulties, WHO merely integrated the ARI programme unchanged into IMCI. This has resulted in an unsatisfactory state of affairs when training health workers to diagnose acute lower respiratory tract infections. As a paediatrician training health workers to treat respiratory infections in developing countries, the IMCI model for pneumonia has outlived its usefulness and should be changed because it does not reflect the reality of accurate paediatric lower respiratory diagnosis in low-income countries. It provides poor clinical training because it conflates parenchymal lung and airways infections, which clinicians must try to differentiate. The inaccurate diagnosis of pneumonia based on fast breathing and chest indrawing also encourages polypharmacy and overuse of antibiotics. The major challenge for paediatric educationalists in poor countries is to improve clinical practice by accurate diagnoses and evidence-based management. There is a plethora of standard treatment protocols, but they require accurate diagnoses to be useful and this is lacking when all febrile children with tachypnoea and acute respiratory infections are diagnosed as pneumonia (or bronchopneumonia in most cases). When the ARI programme commenced in the 1980s, it was clear from many studies that children with ARI were dying from sepsis, mostly caused by S. pneumoniae and H. influenzae. It made sense to train health workers to recognise this and commence antibiotics early to prevent deaths. As many studies and general experience have demonstrated, this has not been easy to implement in practice outside research projects. As always, there have been some successes, but often the claims to mortality reduction have been highly dubious. To take one example cited in the paper and also from Malawi, Enarson et al. claim that, owing to the IMCI programme, ‘the proportion of children dying of pneumonia fell from 18.6% to 8.4%, a reduction of 54.8% over the baseline. ’ However, there is no real evidence of this impressive reduction, and the paper did not even provide the total number of deaths, merely concluding the reduction from one dot point. Why did the authors accept such dubious ‘evidence’? With respect to mortality, my interpretation of these ARI/IMCI programmes is that success has been achieved when antibiotics were made available in settings where ,5% of febrile children had access to antibiotics (for example, in Tanzania in 1986), but, where they were already readily available, it has been hard to demonstrate a mortality benefit of the ARI programmes (such as in The Philippines). When I began work as a paediatrician in African, Caribbean and Pacific countries in the late 1970s and early 1980s, there were many cases every day of lobar pneumonia which was easy to recognise (e.g. fever, toxicity and bronchial breathing) and responded promptly to parenteral penicillin. With intermediate resistance to penicillin, there was a definite delay in response. However, much more striking in the last decade has been the decrease in lobar pneumonia and Correspondence to: D Brewster, Department of Paediatrics, Hospital Nacional Guido Valadares, Dili, East Timor. Email: david.brewster48@ gmail.com