Integrated community case management (iCCM) of pneumonia, malaria and diarrhea among children under 5years in Homabay County, Kenya

The intervention that will be carried out in this research is integrated community case management (iCCM) of pneumonia, malaria and diarrhoea. However, because zinc and Oral Rehydration Solution (ORS), Rapid Diagnostic Test (RDTs) and anti-malarials have been ratified for use in the community by the Kenya Ministry of health, our focus shall be on pneumonia home case management primarily and on diarrhoea secondarily. Community Health Workers (CHWs) will be trained to diagnose and treat these three ailments as described below 1. Giving antibiotic to a child with fast breathing and or chest indrawing 2. Giving an antimalarial to a child with a positive RDT 3. Giving Oral Rehydration Solution (ORS) and Zinc to a child with diarrhea Training of community health workers The CHWs will be trained to classify and treat children with diarrhoea, pneumonia or malaria and also manage stock of appropriate drugs and supplies. The CHWs will also be trained to perform RDTs for malaria diagnosis. They will also require skills to be able to accurately complete the relevant registers and data collection forms as well as counseling of caregivers and general health education. The training will last for 6 days. The training manual that will be used has already been developed by the Kenya iCCM taskforce. This manual was adapted from the WHO’s Community Health Workers’ Handbook. The training will be conducted by a training team experienced in Integrated Management of Childhood illnesses skills with support from the County and district iCCM CHW trainers of trainers. The training will be conducted in groups of 30 at link health facilities. The training will use a variety of methodologies including lectures, presentations, discussions, case studies, demonstrations, practice, role-plays, and video shows. The CHWs will take quality time to go through and practice the use of a diagnostic tool that will be developed to assist them to classify cases. The trainer/supervisors will follow up the CHWs one month after the initial training to ensure that they acquired the necessary skills. There will be refresher courses at approximately week 6 and week 10 after the first training and subsequently every six months. This will be hands on 1-2 day trainings. Children aged 2–59 months with cough, fever, and difficult breathing during regular home visitation schedule, or whose mothers seek care from the CHW will be assessed and classified children according to the WHO classification for pneumonia as below. 1. No pneumonia: cough or cold a. No signs of pneumonia or severe pneumonia 2. Pneumonia Fast breathing: a. Greater than or equal to 50 breaths/min in a child aged 2–11 months b. Greater than or equal to 40 breaths/min in a child aged 1–5 years 3. Severe pneumonia (Pneumonia with danger signs) Cough or difficulty in breathing with a. Severe respiratory distress (e.g. grunting, very severe chest indrawing) b. Signs of pneumonia with a general danger sign (inability to breastfeed or drink, lethargy or reduced level of consciousness, convulsions) CHWs will provide oral amoxicillin 80–90 mg/kg per day twice a day to infants aged 2–11 months and twice a day for those aged 12–59 months) for 5 days to children with pneumonia (includes both chest in drawing pneumonia and fast breathing pneumonia) and give the mother specific guidance about its use. This dosage has been found to be safe and efficacious for treatment of even severe pneumonia in community settings. Children will be seen by the CHW either in the patient's home or at the CHW’s house on day 4. This day 4 visit is recommended by the WHO. At this visit, adherence to the oral antibiotic will be assessed, as well as the child's clinical status and the presence of any danger sign and adverse events. The child will be regarded as lost to follow-up if contact cannot be made on day 4. CHWs will also be trained as follows:- If child has fever (less than 7 days) 1. If RDT is positive, give oral antimalarial i.e. Artemether-Lumefantrine (AL). One tablet of AL contains 20mg Artemether and 120mg Lumefantrine). It is to be given twice daily for 3 days as follows Age 2 months up to 5 months -1/2 tablet (total 3 tabs) Age 5 months up to 3 years—1 tablet (total 6 tabs) Age 3 years up to 5 years—2 tablets (total 12 tabs) 2. Help caregiver give first dose. Advise to give 2nd dose after 8 hours, and to give dose twice daily for 2 more days. If child has diarrhoea less than 14 days Give ORS. Help caregiver give child ORS solution in front of you until child is no longer thirsty. The ORS being utilized is low osmolar ORS (245mmol/l) and contains approximately 2.6g/l of sodium chloride, 13.5g/l of anhydrous glucose, 1.5g/l of potassium chloride and 2.9g/l of trisodium citrate, dehydrate. The ORS come in Sachets of powder for dilution in 500 ml and 1 liter. Instructions: Give caregiver 4 ORS packets to take home. Advise to give as much as child wants, but at least 50-100 ml (or a quarter to half a large cup of fluid) for children under 2 years and 100-200 ml (one half to one large cup of fluid) for children ages 2-5 years after each loose stool until diarrhea stops. In addition to the ORS, CHWs will be trained to give Zinc supplementation. The zinc formulation to be used in this study is the dispersible formulation. Each dispersible tablet contains 10 mg or 20 mg of elemental zinc only. It does not contain any other vitamins or chemicals. The Zinc is packaged in blister packs of 10 tablets. The 20mg tablets of elemental zinc are scored. The CHW will be trained as follows Give zinc supplement (20mg tablet). Give 1 dose daily for 10 days: Age 2 months up to 6 months—1/2 tablet (total 5 tabs) Age 6 months up to 5 years—1 tablet (total 10 tabs) Help caregiver to give first dose Children will be referred if they have pneumonia with danger signs or very severe disease, have diarrhoea with severe dehydration, are severely malnourished, their caregiver refuses home case or are already on antibiotics for more than 48hrs with no improvement. CHWs will also be trained to administer Vitamin A supplementation described as vitamin A capsules for the right child age as defined in the Kenya government vitamin A guidelines i.e. giving a vitamin A capsule of 100,000 IU to children aged 6 to 11 months and 200,000 IU capsules to children aged 12 to 59 months. Vitamin A will be given to all children who have not received supplementation in the last 6 months regardless of what health condition except if the child has bilateral pitting edema as per the training manual. ESTIMATED TIMELINE This study will be completed in a period of 24 months. Start up activities will take place during the first 3 months during which ethical approval will be sought, all stakeholders sensitized. During the 4th to 6th month, the community health units will be mapped and the baseline surveys at the household level and with the community health workers conducted. From the 7th to the 9th month, iCCM will be set up, CHWs trained and the interventions piloted. The ensuing 12 months (month 10-21) will involve the actual implementation of the interventions as well as a midline survey during month 16. The final three months (22-24) of the study period will be used for data management, data cleaning, analyses, and write-up of study results.