Managing the Sick Child in the Era of Declining Malaria Transmission: Development of ALMANACH, an Electronic Algorithm for Appropriate Use of Antimicrobials

PLoS One. 2015 Jul 10;10(7):e0127674. doi: 10.1371/journal.pone.0127674. eCollection 2015.


Objective: To review the available knowledge on epidemiology and diagnoses of acute infections in children aged 2 to 59 months in primary care setting and develop an electronic algorithm for the Integrated Management of Childhood Illness to reach optimal clinical outcome and rational use of medicines.

Methods: A structured literature review in Medline, Embase and the Cochrane Database of Systematic Review (CDRS) looked for available estimations of diseases prevalence in outpatients aged 2-59 months, and for available evidence on i) accuracy of clinical predictors, and ii) performance of point-of-care tests for targeted diseases. A new algorithm for the management of childhood illness (ALMANACH) was designed based on evidence retrieved and results of a study on etiologies of fever in Tanzanian children outpatients.

Findings: The major changes in ALMANACH compared to IMCI (2008 version) are the following: i) assessment of 10 danger signs, ii) classification of non-severe children into febrile and non-febrile illness, the latter receiving no antibiotics, iii) classification of pneumonia based on a respiratory rate threshold of 50 assessed twice for febrile children 12-59 months; iv) malaria rapid diagnostic test performed for all febrile children. In the absence of identified source of fever at the end of the assessment, v) urine dipstick performed for febrile children <2 years to consider urinary tract infection, vi) classification of 'possible typhoid' for febrile children >2 years with abdominal tenderness; and lastly vii) classification of 'likely viral infection' in case of negative results.

Conclusion: This smartphone-run algorithm based on new evidence and two point-of-care tests should improve the quality of care of <5 year children and lead to more rational use of antimicrobials.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Antimalarials / therapeutic use*
  • Child
  • Child, Preschool
  • Diagnostic Tests, Routine / methods
  • Disease Management
  • Humans
  • Infant
  • Malaria / complications
  • Malaria / diagnosis*
  • Malaria / drug therapy*
  • Malaria / epidemiology
  • Plasmodium / drug effects
  • Plasmodium / isolation & purification
  • Point-of-Care Systems
  • Smartphone
  • Tanzania / epidemiology


  • Antimalarials

Associated data

  • PACTR/PACTR201011000262218

Grants and funding

The study was part of a larger project which aimed at improving the quality of health care and rational use of drugs for children in Tanzania (PeDiAtrick project), funded by the Swiss National Science Foundation (; Grant Number IZ70Z0 – 124023). The funders played no role in study design, collection, analysis, interpretation of data, writing the report, or in the decision to submit the paper for publication. Pan Africa Clinical Trial registration number PACTR201011000262218.