Validation of an Integrated Management of Childhood Illness algorithm for managing common skin conditions in Fiji

173Bull World Health Organ 2009;87:173–179 | doi:10.2471/BLT.08.052712 Research Objective To assess the sensitivity of an Integrated Management of Childhood Illness (IMCI) algorithm to detect common skin conditions in children in Fiji. Methods We collected data from the assessments of children aged between 2 months and 5 years who presented to one of two health clinics. Every child was assessed by a nurse trained in the use of the IMCI algorithm and also an expert paediatrician. We used a kappa statistic to measure agreement between the nurse/algorithm assessment method and the paediatrician’s diagnosis. Findings High sensitivity for identifying skin problems (sensitivity: 98.7%; 95% confidence interval, CI: 95.5–99.9) was found for the algorithm applied by IMCI-trained nurses, who were able to identify the one child with a severe skin infection and all three children with periorbital cellulitis. Sensitivity was high for the classification of abscess/cellulitis (sensitivity: 95%; 95% CI: 75.1–99.9) and infected scabies (sensitivity: 89.1%; 95% CI: 77.8–95.9), but lower for identification of impetigo, fungal infection and, in particular, non-infected scabies. Conclusion The IMCI skin algorithm is a robust tool that should be incorporated into the IMCI after some modifications relating to scabies and impetigo. Its use by primary health-care workers will reduce the burden of skin diseases in children in Fiji through improved case identification and management. The algorithm should be considered in other countries where skin diseases in children are a priority, particularly in the Pacific region. Une traduction en français de ce résumé figure à la fin de l’article. Al final del artículo se facilita una traducción al español. Validation of an Integrated Management of Childhood Illness algorithm for managing common skin conditions in Fiji Andrew C Steer,a Lisi V Tikoduadua,b Emmalita M Manalac,c Samantha Colquhoun,a Jonathan R Carapetis d & Carolyn Maclennan e .ةلاقلما هذهل لماكلا صنلا ةياهن في ةصلاخلا هذهل ةيبرعلا ةمجترلا a Centre for International Child Health, University of Melbourne, Vic., 3052, Australia. b Department of Paediatrics, Colonial War Memorial Hospital, Suva, Fiji. c World Health Organization, Western Pacific Regional Office, Manila, Philippines. d Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia. e Royal Darwin Hospital, Darwin, NT, Australia. Correspondence to Andrew Steer (e-mail: andrew.steer@rch.org.au). (Submitted: 5 March 2008 – Revised version received: 1 June 2008 – Accepted: 19 June 2008 – Published online: 30 January 2009 ) Introduction The Integrated Management of Childhood Illness (IMCI) is an evidence-based, cost-effective and comprehensive child health strategy developed by WHO and the United Nations Children’s Fund (UNICEF) for middle- and low-income countries.1 The strategy aims to reduce child morbidity and mortality and to enhance child growth and development in these countries. IMCI has been shown to improve the quality of care and to increase the utilization of health facilities.2 The core of the IMCI strategy is the application of clinical guide- lines for the integrated case management of sick children aged 5 years and under at first-level health facilities. The IMCI guidelines have been individually adapted for conditions in more than 100 countries since they were launched in 1996.1 The WHO/UNICEF Regional Child Survival Strategy for the Western Pacific highlights the importance of IMCI in delivering essential child survival interventions.3 The Fiji Ministry of Health adopted the IMCI strategy as a pilot project in three subdivisions of the Central Division of Fiji (Suva, Rewa and Serua Namosi) in 2003. Following a review of the pilot project in 2004, the IMCI strategy was imple- mented across the country. The review in 2004 also showed that health workers with IMCI training consistently identi- fied skin conditions as a problem that the existing algorithm did not address. Skin conditions, in particular impetigo and scabies, are common in Fiji. One study on Taveuni Island, a northern island, found that of 258 children aged 5 to 15 years, 84 (33%) had evidence of scabies infestation.4 In a study of 3462 primary-school children in the Central Division of Fiji in 2006, 1259 children (36%) had impetigo and 640 (18%) had scabies, with prevalence as high as 80% for impetigo and 40% for scabies in some areas (A Steer, unpublished data). Scabies is often not identified as a health problem by parents; the condition is so common that consultation is not sought except when skin lesions worsen. In a recent cross- sectional survey of 773 infants and their parents attending maternal and child health-care clinics, 162 (21%) parents reported that their child had infected scabies, but the actual number of cases of infected scabies diagnosed by a medical practitioner at the same visit was 509 (66%), (F Russell, per- sonal communication). Scabies and impetigo in tropical and subtropical countries are more than just nuisance problems in children, and skin diseases are among the most common reasons for attending child health clinics worldwide.5 Scabies is a neglected disease6 and lesions are often secondarily infected by bacteria, most commonly Staphylococcus aureus and Streptococcus pyogenes. In studies of invasive S. aureus and S. pyogenes infections in Australian aborigines, impetigo is associated with up to 37% 174 Bull World Health Organ 2009;87:173–179 | doi:10.2471/BLT.08.052712 Research Management of common skin conditions in Fiji Andrew C Steer et al. of cases.7,8 Such findings are also likely to apply to Fiji, where invasive infections with S. pyogenes have a higher incidence than in developed countries and carry a high case-fatality rate.9 Impetigo caused by S. pyogenes can also lead to acute post-streptococcal glomerulonephritis and may play a role in the pathogenesis of acute rheumatic fever.10 An algorithm for the identification and management of skin conditions was developed by the Fiji IMCI pilot review panel that included WHO con- sultants, Fiji Ministry of Health staff, nursing representatives and selected Fijian paediatricians. We are not aware of an IMCI algorithm for the treatment of common childhood skin conditions in any other setting. The IMCI skin algorithm focuses on the most common skin conditions among children in Fiji, including impetigo, scabies, infected scabies and tinea (ringworm) infection (Box 1, Table 1). The algorithm also guides primary health-care workers in the identification of serious skin condi- tions that require prompt referral, such as extensive cellulitis and orbital and periorbital cellulitis. Ideally, the algorithm should have very high sensitivity for identifying the presence of any skin condition, a sensi- tivity and specificity above 70–80% for classifying common skin conditions, and very high sensitivity for classifying severe skin infections. To validate this algorithm we used an approach similar to that used in the original evaluation of the IMCI core clinical guidelines.1,11–13 In these original studies, health-care workers’ decisions based on the IMCI case-management algorithm were compared with those of an expert paediatrician with or without laboratory support. In practice, the di- agnosis of common skin conditions of childhood in tropical countries is clini- cal, and laboratory and microbiological testing is rarely indicated. Therefore, we designed a study to compare the assessment and clinical classification of common skin conditions by primary health-care workers trained in the use of a skin disease algorithm with those of two expert paediatricians. Methods Setting Fiji is an independent republic of some 300 islands in the western Pacific and Box 1. Child skin assessment algorithm applied by IMCI-trained nurses in two clinics in Fiji 1. Ask the mother: “Does the child have a skin problem?” 2. Look for a skin problem. If the answer to question 1 is “yes” or if a skin problem is identified, then ask: • “Does the child have skin itchiness?” • “Does the child have pain from the skin problem?” Then, look and feel more closely: • Look for extensive warm redness and swelling. • Look for localized warm, tender swelling or redness. • Look for swelling or redness around the eyes. • Look for discrete lesions with pus or crusts. • Look for papules on the hands, knees, elbows, feet, trunk. • Look for round to oval scaly patches. Table 1. IMCI algorithm used by nurses in two clinics in Fiji to classify common childhood skin conditions Sign Diagnosis Action • Any general danger sign Very severe skin infection • Give first dose of appropriate antibiotic • Extensive warm redness or swelling • Refer URGENTLY to hospital Swelling or redness around eyes Periorbital or orbital cellulitis • Give first dose of appropriate antibiotic • Refer URGENTLY to hospital Localized warm tender swelling and redness Abscess or cellulitis • Give first dose of appropriate antibiotic • Refer to hospital Discrete sores/lesions with pus or crusts Impetigo • Give appropriate oral antibiotic for 7 days • Follow up in 5 days Itchiness AND papules AND lesions with pus or crusts Infected scabies • Give appropriate oral antibiotic for 7 days • Give appropriate topical skin cream • Treat the whole family with the cream • Follow up in 5 days and 2 weeks Itchiness AND papules Non-infected scabies • Give appropriate topical skin cream • Treat the whole family with the cream • Follow up in 2 weeks Round to oval flat scaly patches, often itchy Fungal infection • Give appropriate topical antifungal for 2 weeks • Follow up in 2 weeks If there are not enough signs to classify in any of the above boxes OR if other signs present are not found in the above boxes Other skin conditions • Refer to the doctor or skin clinic IMCI, Integrated Management of Childhood Illness. is north of the Tropic of Capricorn. In 2007 it had 827 900 inhabitants, mainly native Fijians (approximately 57%) and Indo-Fijians (about 37%)14 It is ranked 90th out of 177 countries on the United Nations Development Programme Human Development Index and has a gross domestic product per capita of 6066 United States dollars. Its infant mortality rate is 16 deaths per 1000 live births.15 This study took place in two clinics: the paediatric emergency department of the Colonial War Memorial Hospital (CWMH) in the capital Suva, and the Nausori Health Centre (NHC), a busy 175Bull World Health Organ 2009;87:173–179 | doi:10.2471/BLT.08.052712 Research Management of common skin conditions in FijiAndrew C Steer et al. periurban health centre approximately 23 km north-east of Suva. These clinics were chosen for their convenient access and because they had already partici- pated in the initial pilot project. Training Instruction on the use of the skin algo- rithm was provided to 10 nurses with IMCI training during an 8-hour work- shop taught in 1 day by the two paedia- tricians. The workshop agenda followed a standard IMCI format and included background information on skin condi- tion diagnoses. Nurses were trained in the use of the algorithm to identify, assess and classify skin conditions, to identify proper treatment, and to provide counselling to the mother. During the workshop, a writ- ten guide and a photograph booklet were used, individual and group exercises and role plays were conducted, and supervised practice assessment of clinical cases in the paediatric emergency department was performed. Validation of the algorithm Five of the nurses were from the CWMH and five were from the NHC. All nurses were experienced in child health, public health and IMCI. We chose nurses already trained in IMCI because an understanding of the IMCI system is needed to use the skin algo- rithm and because the goal is to eventu- ally instruct all IMCI-trained nurses in Fiji in the use of the algorithm. The two paediatricians chosen were very experienced in the diagnosis of common skin conditions in Fiji. Both attended the two clinics during the study, but at different times. Thus, the inter-rater reliability between the two paediatricians could not be measured. Similarly, inter-rater reliability between the nurses was not assessed. Children aged 2 months to 5 years presenting consecutively to the clin- ics for any reason were seen initially by a nurse, who assessed them using the existing IMCI guidelines with the skin algorithm inserted after the “ear problem” section and before the “assess nutritional status” section. The skin algorithm was used irre- spective of the child’s presenting com- plaint; this practice is standard, as health workers complete all parts of the IMCI assessment guidelines for every child.1 The nurse asked the parent if their child had a skin problem and then proceeded to examine the child’s skin from head to toe. It is standard procedure for the child to be properly exposed for most aspects of the IMCI guidelines, so a full skin examination does not cause the child further embarrassment.1 Following the examination, nurses completed a simple data collection form that corresponded to the assess- ment and classification portions of the skin algorithm. A paediatrician who was blinded to the nurse’s assessment results then examined the same child and completed an identical data collec- tion form. All children were examined by one IMCI-trained nurse and one paediatrician. The data collection form included pre-coded information about the presenting complaint. Statistics The primary endpoint was sensitivity of the algorithm employed by IMCI- trained nurses compared with the pae- diatricians’ diagnosis of any skin condi- tion. We calculated that a sample size of 250 children was required to detect a sensitivity of 80% with a confidence range of ±10%. Data were entered into the EpiData, version 3.1, (EpiData Asso- ciation, Odense M, Denmark) data en- try platform and analysed using STATA, version 9.0, (StataCorp. LP, College Station, TX, United States of America). Sensitivity and specificity, with bino- mial 95% confidence intervals (CIs), were calculated for all endpoints. We used a kappa statistic to mea- sure agreement between the IMCI- trained nurses and expert paediatricians for all endpoints. It is generally accepted that kappa values greater than 0.75 in- dicate excellent agreement, those from 0.4 to 0.75 indicate fair to good agree- ment, and those less than 0.4 indicate moderate or poor agreement.16 Ethics approval Ethics approval for the study was ob- tained from the Fiji National Research Ethics Committee and the Fiji National Health Research Committee. Results Participants’ characteristics In September 2007, 250 children were enrolled over an 8-day period. We excluded 2 children because one was younger than 2 months and the other older than 5 years. There were 152 boys (61.3%) and 96 girls (38.7%). Of the 248 participants, 159 were native Fijian (64.1%), 70 were Indo-Fijian (28.2%) and 19 were of other ethnicities (7.7%). Mean age at enrolment was 1 year and 11 months; 139 (56.0%) children were enrolled at CWMH and 109 (44.0%) at NHC. One paediatrician assessed 132 chil- dren (53.2%), while the other saw 116 children (46.8%). The number of chil- dren seen by the nurses was not equally divided among all 10 nurses; one nurse saw 9 children (4%), six nurses saw be- tween 14 and 20 children (42% in total) and three nurses saw 39 children or more (54% in total), with a median of 25 chil- dren and a range of 9 to 55 children. Clinical features About half of the children visited the clinic for respiratory problems (119 chil- dren, or 50.0%). The next most com- mon presenting complaint was a skin problem (67 cases, or 27%), and fever and gastrointestinal problems followed (24 cases, or 9.7%). A skin problem was diagnosed by the paediatricians in 157 patients (63.3%) and by the nurses in 163 cases (65.7%) (Table 2). Infected and non- infected scabies and impetigo were the most common diagnoses made by a paediatrician. Four children had serious skin problems: 1 had a severe skin infec- tion and 3 had periorbital cellulitis. The most common diagnosis in the group of children identified with other skin diagnoses was napkin dermatitis (10 children), followed by molluscum con- tagiosum (4 children). Of note was our finding that parents did not identify a skin condition as the primary presenting problem in their child, despite the fact that such a condition was detected by a paediatrician in 90 cases (36.3% of all children and 57.3% of children with a skin problem). Sensitivity of algorithm applied by nurses When compared with paediatricians’ diagnoses, the IMCI algorithm applied by IMCI-trained nurses showed a sen- sitivity of 98.7% (95% CI: 95.5–99.9) for detecting a skin problem; the kappa statistic was 0.91, indicative of excellent agreement (Table 2). This sensitivity changed little in patients whose primary presenting complaint was not a skin problem (sensitivity: 97.8%; 95% CI: 92.3–99.7). 176 Bull World Health Organ 2009;87:173–179 | doi:10.2471/BLT.08.052712 Research Management of common skin conditions in Fiji Andrew C Steer et al. Table 2. Overall sensitivity and specificity and agreement with paediatrician diagnosis for IMCI algorithm used by nurses to assess and classify childhood skin problems in two clinics in Fiji Variable No. of cases identified by paediatricians (%) No. of cases identified by nurses Sensitivity, in % (95% CI) Specificity, in % (95% CI) Agreement, in % Kappa statistic Detection of skin problem 157 (63.3) 163 98.7 (95.5–99.9) 91.2 (83.4–96.1) 96 0.91 Itch 97 (39.1) 88 87.1 (78.6–93.2) 88.7 (78.1–95.3) 87.7 0.75 Skin pain 41 (16.5) 45 80.5 (65.1–91.2) 89.5 (82.3–94.4) 87.1 0.68 Extensive redness or swelling 3 (1.2) 3 33.3 (0.8–90.6) 98.7 (95.3–99.8) 97.4 0.32 Eye swelling or redness 5 (2) 5 60 (14.7–94.7) 98.7 (95.2–99.8) 90.3 0.65 Localized swelling or redness 21 (8.5) 30 85.1 (63.7–97) 91 (84.9–95.3) 97.4 0.59 Lesion with crusts or pus 92 (37.1) 94 91.3 (83.6–96.2) 84.1 (72.7–92.1) 88.4 0.76 Papules 90 (36.3) 75 76.7 (66.6–84.9) 90.8 (81–96.5) 82.6 0.65 Patches 12 (4.8) 10 58.3 (27.7–84.8) 97.9 (94–99.6) 94.8 0.61 Severe skin infection 1 (0.4) 1 100 (2.5–100) 100 (97.6–100) 100 1 Periorbital cellulitis 3 (1.2) 4 75 (29.2–100) 99.3 (96.4–100) 99.4 0.85 Abscess or cellulitis 20 (8.1) 24 95 (75.1–99.9) 96.3 (91.6–98.8) 96.1 0.84 Impetigo 50 (20.2) 52 70 (55.4–82.1) 83.8 (75.4–90.3) 79.4 0.53 Infected scabies 55 (22.2) 61 89.1 (77.8–95.9) 88 (78–93.6) 88.4 0.75 Scabies 24 (9.7) 22 58.3 (36.6–77.9) 93.9 (88.3–97.3) 88.4 0.54 Fungal infection 13 (5.2) 11 69.2 (38.6–90.9) 98.6 (95–99.8) 96.1 0.73 Other 28 (11.3) 36 75 (55.1–93.2) 88.2 (81.3–93.2) 85.8 0.57 CI, confidence interval; IMCI, Integrated Management of Childhood Illness. When the nurses’ and the paediatri- cians’ assessments of skin problems were compared, sensitivity of the IMCI algo- rithm used by the nurses was > 75% for all aspects of assessment except extensive redness (33.3%), eye swelling (60%) and patches (58.3%). Extensive redness and eye swelling are important assessment features for the classification of severe skin infection and periorbital cellulitis. Importantly, the 1 child with a severe skin infection and all 3 children with periorbital cellulitis were classified cor- rectly by the nurses. When the nurses’ classification of skin problems was compared with the paediatricians’ diagnoses, the sensitivity of the IMCI-trained nurses’ algorithm was 75% or over for five of eight clas- sifications, the specificity for all aspects of the classification was > 88%, and the kappa statistic was ³ 0.73 for five of eight classification categories. The sensitivity for classifying impetigo was only 70%, but in some cases the nurses identified infected scabies, whereas the paediatrician assigned two discrete classifications of scabies and impetigo. After including infected scabies along with impetigo, the sensitivity rose to 92% (95% CI: 80.8–97.8). Sensitivity for classifying scabies alone was poor (58.3%); after including infected sca- bies along with scabies, sensitivity rose to 75% (95% CI: 53.3–90.2). More than one feature of skin dis- ease was detected on assessment in 73 children, and more than one classifica- tion was found in 35. The sensitivity and specificity of the nurses’ algorithm when compared with paediatricians’ diagnoses were 91.4% (95% CI: 85.5– 95.5) and 96.3% (95% CI: 90.8–99), respectively, for the identification of two or more features in the examination portion of the assessment. The sensitiv- ity and specificity in identifying two or more classifications were 96.8% (95% CI: 92.7–99) and 90.2% (95% CI: 82.2–95.4), respectively. Variability among nurses Because the number of children seen by each nurse differed, we calculated sensitivity, specificity and agreement for all categories for all nurses. Table 3 shows data for identification of a skin problem and for classification of impe- tigo. Overall, the uneven distribution of nurse examiners did not seem to be a major source of bias, although this effect was difficult to assess for the less com- mon classifications because of the small numbers involved. Discussion Almost two-thirds (63.6%) of children presenting to the IMCI clinic for any complaint had a skin problem diag- nosed by a paediatrician. However, a skin problem was the primary present- ing complaint among fewer than half of these children with a skin problem (42.7%). This concurs with unpublished and published findings by other re- searchers in Fiji4 and suggests that many children with skin conditions in Fiji do not present for medical care. The most common skin problems in the children in our study were infected scabies (22.2%), impetigo (20.2%), non-infected scabies (9.7%) and abscess or localized cellulitis (8.1%). Other skin problems not included in the algo- rithm accounted for 11.3% of all skin problems. Overall, the IMCI skin algorithm was found to be a robust tool when used by IMCI-trained nurses. High sensitivity and strong agreement with paediatri- cians’ diagnoses were found when nurses applied the IMCI skin algorithm, even in the group of children whose primary presenting complaint was not a skin problem. Detecting skin conditions in this group is important because a large proportion of children have a skin prob- lem as an incidental finding. Assessment by the IMCI-trained nurses showed high sensitivity for classifying children with the most serious diagnoses (severe skin infection, periorbital cellulitis, abscess and cellulitis), as well as children with infected 177Bull World Health Organ 2009;87:173–179 | doi:10.2471/BLT.08.052712 Research Management of common skin conditions in FijiAndrew C Steer et al. Table 3. Sensitivity, specificity and agreement with paediatrician diagnosis for IMCI algorithm applied by nurses in two clinics in Fiji to identify skin problems and classify impetigo among children Nurse No. children seen Identification of a skin problem Impetigo Sensitivity, in % Specificity, in % Agreement, in % Kappa Sensitivity, in % Specificity, in % Agreement, in % Kappa A 39 95.8 86.7 92.3 0.84 66.7 90.0 87 0.5 B 9 100 75 88.9 0.77 75 100 80 0.55 C 18 100 66.7 94.4 0.77 66.7 88.9 80 0.57 D 18 100 100 100 1 40 100 75 0.44 E 19 100 100 100 1 66.7 100 91 0.74 F 15 100 100 100 1 100 100 100 1 G 18 100 100 100 1 75 85.7 66 0.61 H 55 97.4 75 90.9 0.77 75.0 61.5 82 0.32 I 17 100 100 100 1 50 75 83 0.25 J 40 100 100 100 1 80 88.2 86 0.6 Total 248 98.7 91.2 96.0 0.91 70.0 83.8 79 0.53 Mean 24.8 99.3 90.3 96.7 0.9 69.5 88.9 83 0.56 IMCI, Integrated Management of Childhood Illness. scabies, which was the most common diagnosis made by the paediatricians. The major flaw in the algorithm appeared to be its low sensitivity for classifying non-infected scabies and its borderline sensitivity for classifying impetigo and fungal infections. The lower sensitivity for classifying non- infected scabies was probably due in part to lower sensitivity in identifying papules, which can be subtle. More clinical practice during the training may help improve recognition. However, the IMCI-trained nurses tended to classify children with discrete lesions of scabies and impetigo as having infected scabies, rather than as having impetigo and scabies separately. This error could be rectified by removing the classification of infected scabies from the algorithm. In this way, a child having impetigo alone would be classified as having impetigo; a child having non-infected scabies alone would be classified as having scabies; and a child having both impetigo and scabies would be classified as having both and be treated for each, whether or not there was secondary bacterial infection of the scabies lesions or the scabies and impetigo lesions were discrete. This classification system would achieve the aims of the algorithm and also be simpler. The lower sensitivity of the IMCI algorithm applied by nurses for clas- sifying fungal infections reflected lower sensitivity in classifying scaly patches. This problem could be remedied by emphasizing the issue in the training workshop, particularly by providing more clinical exposure. The design of our study was similar to that of studies that validated the original IMCI clinical algorithms; that is, we compared the classification made by primary health-care workers trained in the use of an algorithm with diag- noses made by expert paediatricians. We consider this method appropriate in view of the clinical nature of the diagnosis of common childhood skin conditions in tropical countries. Un- fortunately, for logistical reasons we were unable to measure inter-rater reli- ability between the two paediatricians and among the 10 nurses, although variability in the number of children seen by the nurses did not appear to be a major source of bias. This study was not designed to as- sess treatment or follow-up. We have assumed that if a correct classification were made, appropriate treatment would be prescribed as per the algorithm. Given the adherence to the algorithm found in this study (data not shown), appropri- ate treatment would likely follow the corresponding classification. Our study was not sufficiently powered to evaluate sensitivity for the less frequent clas- sifications, such as severe skin infection and periorbital cellulitis. We therefore advise caution in interpreting the good performance of the algorithm for these conditions. The IMCI skin algorithm will be useful in Fiji to ensure that children presenting for medical care, whether for skin conditions or not, are accurately diagnosed and treated by IMCI-trained nurses. However, there are probably many children with skin diseases who require treatment but do not pres- ent for care. Therefore, for the greater public health aim of controlling skin diseases in children in Fiji, broader public health interventions, including health education, health promotion and possibly community-based treatment and prevention programmes, require consideration. The skin algorithm is not being used in countries other than Fiji but could be considered for inclusion in IMCI programmes in other coun- tries. A decision on including a skin algorithm should be proportionate to the level of priority of skin diseases for the country in question, and this prioritization should, in turn, be based on competing causes of mortality and morbidity as well as on the burden of skin disease. The skin algorithm may not be ap- propriate for countries where diseases causing high mortality are still a priority, but it may be appropriate in countries such as Fiji that have been able to re- duce the prevalence of such diseases and where skin diseases are common. In such countries, an IMCI skin algorithm may be able to significantly reduce the burden of common tropical childhood skin diseases as well as mortality rates through the prevention of invasive bacterial infections, post-infectious renal 178 Bull World Health Organ 2009;87:173–179 | doi:10.2471/BLT.08.052712 Research Management of common skin conditions in Fiji Andrew C Steer et al. Résumé Validation d’un algorithme de gestion intégrée des maladies infantiles pour la prise en charge des maladies de peau courantes aux îles Fidji Objectif Evaluer la sensibilité d’un algorithme de gestion intégrée des maladies infantiles (PCIME) pour la détection des maladies de peau courantes chez les enfants des îles Fidji. Méthodes Nous avons recueilli des données sur l’évaluation d’enfants de 2 mois à 5 ans, présentés dans un des deux dispensaires participant à l’étude. Chaque enfant a été évalué par une infirmière formée à l’utilisation de l’algorithme de PCIME et par un pédiatre expert. Nous avons utilisé un test statistique Kappa pour mesurer l’accord entre l’évaluation par l’infirmière s’aidant de l’algorithme et le diagnostic du pédiatre. Résultats Nous avons relevé une forte sensibilité de l’algorithme pour l’identification des problèmes de peau (sensibilité : 98,7 % ; intervalle de confiance à 95 %, IC : 95,5-99,9) dans le cadre de son application par les infirmières formées à la PCIME, qui ont été capables d’identifier parmi les enfants un cas d’affection cutanée sévère et les trois cas de cellulite périorbitale. La sensibilité était également bonne pour la classification des abcès et des cellulites (sensibilité : 95 %, IC à 95 % : 75,1-99,9) et celle des gales infectées (sensibilité : 89,1 %, IC à 95 % : 77,8-95,9), mais était en revanche plus faible pour l’identification des impétigos et des infections fongiques, notamment des gales non infectées. Conclusion L’algorithme de PCIME pour les maladies de la peau est un outil solide, qui devrait être intégré à la PCIME après certaines modifications concernant la gale et l’impétigo. Son utilisation par les agents de santé primaire devrait réduire la charge d’affections cutanées chez les enfants des îles Fidji en améliorant l’identification des cas et la prise en charge. Il conviendrait d’envisager l’emploi de cet algorithme dans d’autres pays où les affections cutanées infantiles sont une priorité, notamment dans la région Pacifique. Resumen Validación de un algoritmo de la Atención Integrada a las Enfermedades Prevalentes de la Infancia para manejar enfermedades cutáneas comunes en Fiji Objetivo Determinar la sensibilidad de un algoritmo de la Atención Integrada a las Enfermedades Prevalentes de la Infancia (AIEPI) para manejar enfermedades cutáneas comunes en los niños en Fiji. Métodos Reunimos datos de las exploraciones a que se sometió a niños de entre 2 meses y 5 años atendidos en alguno de los dos dispensarios considerados. Todos los niños fueron examinados por una enfermera adiestrada en la aplicación del algoritmo AIEPI, así como por un especialista en pediatría. Empleamos el estadístico kappa para medir el grado de concordancia entre el método de evaluación algorítmica empleado por la enfermera y el diagnóstico realizado por el pediatra. Resultados Se observó una alta sensibilidad para la detección de problemas cutáneos (sensibilidad: 98,7%; intervalo de confianza del 95%: 95,5–99,9) con el algoritmo aplicado por las enfermeras adiestradas en la AIEPI, que fueron capaces de identificar al único niño que tenía una infección cutánea grave y a los tres niños que padecían celulitis periorbitaria. La sensibilidad también fue alta en lo referente a la clasificación de los abscesos/celulitis (sensibilidad: 95%; IC95%: 75,1–99,9) y la escabiosis infectada (sensibilidad: 89,1%; IC95%: 77,8–95,9), pero fue más baja en la detección del impétigo, las micosis y, en particular, la escabiosis no infectada. Conclusión El algoritmo de diagnóstico cutáneo AIEPI es un valioso instrumento que debería integrarse en la AIEPI previa introducción de algunos cambios relacionados con la escabiosis y el impétigo. Su aplicación por el personal de atención primaria permitirá reducir la carga de enfermedades cutáneas en la población infantil de Fiji mediante una mejor identificación y gestión de los casos. El uso de ese algoritmo es una posibilidad que merece considerarse también en otros países donde las enfermedades cutáneas constituyen una prioridad, sobre todo en la región del Pacífico. disease and rheumatic heart disease. Because the skin algorithm has been designed for easy incorporation into the existing IMCI algorithm, and because the treatment options recommended are all inexpensive and widely available, the algorithm could easily be adapted for use in countries other than Fiji where IMCI exists and where the identifica- tion and treatment of skin diseases are a priority. ■ Acknowledgements The authors thank the nurses from the Colonial War Memorial Hospital and Nausori Health Clinic who participated in this study, as well as the children and their parents; Laisiana Matatolu and Frances Matanatabu for their assistance in data collection and collation; and Fiona Russell, Fiji Pneumococcal Proj- ect, Suva, Fiji. Funding: UNICEF provided funding for the study. Competing interests: None declared. 179Bull World Health Organ 2009;87:173–179 | doi:10.2471/BLT.08.052712 Research Management of common skin conditions in FijiAndrew C Steer et al. References Gove S. Integrated management of childhood illness by outpatient health 1. workers: technical basis and overview. Bull World Health Organ 1997;75 Suppl 1;7-24. PMID:9529714 Multi2. -country evaluation of IMCI effectiveness, cost and impact. MCE progress report, May 2002 – April 2003. Geneva: World Health Organization; 2003. WHO3. /UNICEF regional child survival strategy: accelerated and sustained action towards MDG 4. Manila: World Health Organization, Regional Office for the Western Pacific; 2006. Thomas4. M, Woodfield G, Moses C, Amos G. Soil-transmitted helminth infection, skin infection, anaemia, and growth retardation in schoolchildren of Taveuni Island, Fiji. N Z Med J 2005;118:U1492. PMID:15937527 Epidemiology5. and management of common skin diseases in children in developing countries. Geneva: World Health Organization; 2005. Hotez6. PJ, Molyneux DH, Fenwick A, Kumaresan J, Ehrlich Sachs S, Sachs JD, et al. Control of neglected tropical diseases. N Engl J Med 2007; 357:1018-27. PMID:17804846 doi:10.1056/NEJMra064142 Skull7. SA, Krause V, Coombs G, Pearman JW, Roberts LA. Investigation of a cluster of Staphylococcus aureus invasive infection in the top end of the Northern Territory. Aust N Z J Med 1999;29:66-72. PMID:10200815 Carapetis8. JR, Walker AM, Hibble M, Sriprakash KS, Currie BJ. Clinical and epidemiological features of group A streptococcal bacteraemia in a region with hyperendemic superficial streptococcal infection. Epidemiol Infect 1999;122:59-65. PMID:10098786 doi:10.1017/S0950268898001952 Steer9. AC, Jenney AJ, Oppedisano F, Batzloff MR, Hartas J, Passmore J, et al. High burden of invasive beta-haemolytic streptococcal infections in Fiji. Epidemiol Infect 2008;136:621-7. PMID:17631691 doi:10.1017/ S095026880700917X McDonald10. M, Currie BJ, Carapetis JR. Acute rheumatic fever: a chink in the chain that links the heart to the throat? Lancet Infect Dis 2004;4:240-5. PMID:15050943 doi:10.1016/S1473-3099(04)00975-2 Weber11. MW, Mulholland EK, Jaffar S, Troedsson H, Gove S, Greenwood BM. Evaluation of an algorithm for the integrated management of childhood illness in an area with seasonal malaria in the Gambia. Bull World Health Organ 1997;75 Suppl 1;25-32. PMID:9529715 Simoes12. EAF, Desta T, Tessema T, Gerbresellasie T, Dagnew M, Gove S. Performance of health workers after training in integrated management of childhood illness in Gondar, Ethiopia. Bull World Health Organ 1997;75 Suppl 1;43-53. PMID:9529717 Kalter13. HD, Schillinger M, Hossain M, Burnham G, Saha S, de Wit V, et al. Identifying sick children requiring referral to hospital in Bangladesh. Bull World Health Organ 1997;75 Suppl 1;65-75. PMID:9529719 [14. Anonymous]. Statistical News Press Release No 52. Suva (Fiji). Fiji Islands Bureau of Statistics; 31 October 2007. Human15. development report 2006. New York, NY: UNDP; 2006. Kirkwood BR, Sterne JAC. 16. Essential medical statistics. 2nd ed. Malden, MA: Blackwell Science; 2003. صخلم يجيف في ةعئاشلا ةيدلجلا تلااحلا يربدت في لافطلأا ضارملأ لماكتلما يربدتلا ةيمزراوخ ةحص نم ق ُّقحتلا في لافطلأا ضارملأ لماكتلما يربدتلا ةيمزراوخ ةيساسح مييقت :فدهلا يجيف في ةعئاشلا ةيدلجلا تلااحلا فاشتكا حوارـتـت نيذلا لافطلأل تماييقت نم تايطعلما نوثحابلا عمج :صخللما .ينتَّيحصلا ينتدايعلا ىدحإ اوعجار نمم تاونس سمخو نيرهش ينب مهرماعأ ةيمزراوخ مادختسا لىع ةبردم ةضرمم لَبِق نم لفط لكل مييقتلا يرجأو اومدختساو .يربخ لافطأ بيبط لَبِق نمو لافطلأا ضارملأ لماكتلما يربدتلا هترجأ يذلا مييقتلا ينب قفاوتلا ىدم سايقل ”اباك“ ئياصحلإا بولسلأا .لافطلأا بيبط صيخشت ينبو ةيمزراوخلا مادختساب ةضرملما ةيدلجلا تلاكشلما لىع فُّرعتلل ةعفترم ةيساسح دوجو ّنينبت :تادوجولما 95.5 ينب ةيساسحلا تحوارت ذإ ،%95 ةقث ةلصافب ،%98.7 ةيساسحلا( نعطتسا تاب َّردم تاضرمم لَبِق نم ةيمزراوخلا قيبطت ةطساوب )99.9و ةيدلج ىودع نم نياعي ناك يذلا ةساردلا في ديحولا لفطلا لىع فُّرعتلا للهلا باهتلا نم نوناعي اوناك نيذلا ةساردلا في ةثلاثلا لافطلأا لىعو ةميخو ةبسنلاب ةيلاع ةيساسحلا تناكو .جاجحلا لوح )دلجلا تحت يولخلا جيسنلا( ةقث ةلصافب %95 ةيساسحلا تغلبف( للهلا باهتلاو ةجرخلأا فينصتل ىودعلاب فعاضتلما برجلاو )99.9و 75.1 ينب ةيساسحلا تحوارت ذإ %95 ينب ةيساسحلا تحوارتو %95 ةقث ةلصافب %89.1 ةيساسحلا تغلبف( ،ءابوقلا لىع فُّرعتلل ةبسنلاب لقأ تناك ةيساسحلا نكلو ،)95.9و 77.8 .ىودعلاب فعاضتلما يرغ برجلا ماَّيسلاو ،تايرطفلاب ىودعلاو ةيوقلا تاودلأا نم لافطلأا ضارملأ لماكتلما يربدتلا ةيمرزاوخ نإ :جاتنتسلاا لاخدإ دعب لافطلأا ضارملأ لماكتلما يربدتلا نمض اهجامدإ يغبني يتلا هذه مادختسا نإو .ءابوقلاو برجلاب صتخي ام في اهيلع تلايدعتلا ضعب ءبع نم للقيس ةيلولأا ةيحصلا ةياعرلا في ينلماعلا لَبِق نم ةيمزراوخلا لىع فُّرعتلا في ن ُّسحتلا للاخ نم يجيف في لافطلأا ىدل ةيدلجلا ضارملأا نادلبلا في رابتعلاا ينعب ةيمزراوخلا لىإ رظنلا بجيو .اهيربدت فيو تلااحلا ميلقإ في ماَّيسلاو ،ةيولوأ تاذ اهيف ةيدلجلا ضارملأا نوكت يتلا ىرخلأا .ئداهلا طيحلما