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Referral and warning signs
When to refer
VHTs refer children with: Any General Danger Sign, Chest indrawing (pneumonia), Signs of dehydration, Blood in stool (dysentery), Negative RDT but fever persists, Severe malnutrition, Any condition beyond their scope.
Red flags
- All General Danger Signs.
- Chest indrawing.
- Signs of dehydration.
- Blood in stool.
Signs and symptoms
- Focus on recognizing key symptoms for classification:
- - Pneumonia: Cough/Difficult breathing + Fast breathing (age-specific) +/- Chest indrawing (referral).
- - Diarrhoea: Loose stools +/- Dehydration signs +/- Blood (referral).
- - Malaria: Fever +/- Danger signs.
- - General Danger Signs (prompting referral): Convulsions, Lethargy/Unconscious, Unable to drink/feed, Vomits everything.
Risk factors
- Limited access to facility-based care.
- High burden of malaria, pneumonia, diarrhoea.
Diagnosis
Clinical assessment
Assessment using simplified algorithms based on IMCI principles, focusing on key signs and symptoms.
Investigations
- Respiratory Rate counting (using timer).
- Malaria RDT.
- Temperature check (or tactile assessment).
- Assessment for danger signs.
Diagnostic criteria
Classification based on simplified algorithms leading to treatment or referral decision.
Management
Non-pharmacological management
- Counseling on home care (fluids, feeding, danger signs).
- Referral coordination.
- Community health promotion (hygiene, nets, immunization).
Pharmacological treatment
- Treatments Provided by VHTs:
- - Pneumonia (Fast breathing only): Amoxicillin Dispersible Tablets (DT) 250mg (Dose packs: RED 2-11m = 1 tab BID; GREEN 1-5y = 2 tabs BID) for 5 days.
- - Diarrhoea (No dehydration/blood): ORS + Zinc (10mg <6m, 20mg >6m) for 10 days.
- - Malaria (Fever + Positive RDT, no danger signs): Artemether-Lumefantrine (AL) ACT (Dose packs: YELLOW 4m-2y = 1 tab BID; BLUE 2-5y = 2 tabs BID) for 3 days.
- - Pre-referral for Severe Malaria/Fever with Danger Signs: Rectal Artesunate (Dose by age band: 4-11m=1; 1-3y=2; 3-5y=3 capsules).
- (Note: VHTs may manage other conditions based on specific program training e.g., deworming, Vitamin A).
Monitoring
Follow-up mechanisms vary by program (e.g., home visits, linkage to facility). Track referrals.
Complications
- Delayed referral of severe cases.
- Incorrect classification or treatment.
- Stock-outs of essential medicines.
Prevention
- Strengthening health system linkage (supervision, supply chain).
- Continuous VHT training and support.
- Community engagement.
Patient education
- (VHT counseling to caregiver):
- Diagnosis and treatment given.
- How to administer medicines correctly.
- Importance of completing treatment.
- Need for fluids and continued feeding.
- Danger signs requiring immediate referral to health facility.
- Prevention messages.
Uganda-specific notes
iCCM implemented nationally through Village Health Teams (VHTs). Aims to improve access to care for the 3 main childhood killers. Relies heavily on VHT training, supervision, commodity supply, and linkage with health facilities.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 17, Section 17.4
- National iCCM Guidelines and Job Aids, MOH Uganda
(Specific VHT protocols)