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5f. Malaria: Rapid Diagnostic Tests and Patient Demand for Antimalarials
Low Reliability of Home-Based Diagnosis of Malaria in a Rural Community in Western Kenya
1Maseno University, Kenya; 2Bokoli Health Centre, Kenya
Problem statement: Home-based management of malaria is promoted as a major strategy to improve prompt delivery of effective malaria treatment in Africa. Definitive diagnosis of malaria infection, however, is still based on identifying plasmodia in blood films. Misdiagnosis of malaria contributes to a vicious cycle of increasing ill health.
Objective: To determine the proportion of children with positive routine light microscopy among those with mothers’ home-based diagnosis and treatment of malaria, in a rural community in western Kenya
Design: Descriptive cross-sectional study
Setting: Community-based study conducted at Bokoli location in Bungoma East District between November and December 2007 using quantitative data collection techniques
Study population: A random sample of 96 mothers of children age <5 years with malaria, according to the mothers’ diagnosis were interviewed using a questionnaire on demographics and treatment. Blood smears were examined by light microscopy for malaria parasites.
Outcome measure(s): The proportion of mothers who correctly diagnosed malaria in their children.
Results: Only 30/96 (31.2%) specimens were positive for Plasmodium falciparum. The mothers’ criteria for diagnosis of malaria in their children included most commonly elevated temperature (70/96; 72.9%). In 57 of the 96 cases, information was given by the mothers regarding treatment in the current malaria episode; of these, 10 (17.5%) had received treatment for malaria, but 6 (60%) of these were parasite negative. This means that only 4/21 (19.0%) with positive smear microscopy received treatment (p = 0.05). The most common antimalaria drugs used were Fansidar (37.8%) and Metakelfin (29.7%).
Conclusion: The difficulty in making home-based diagnosis of malaria increases the urgent need for improved diagnostic tools that can be used at the community level in poor populations. Intervention measures are needed to increase the treatment rate in order to reduce reservoirs and malaria parasites transmission.
Funding source(s): Information not provided
High Adherence to Artemether-lumefantrine Treatment in Children Under Real-Life Situation in Rural Tanzania
Muhimbili University, Tanzania, United Republic of
Problem statement: Artemether-lumefantrine (ALu) is highly efficacious in treating uncomplicated Plasmodium falciparum malaria. It is, however, questionable if the high levels of adherence observed under research conditions can be achieved in a real-life situation, in rural remote settings where the malaria burden is highest and access to the drug is limited.
Objective: To determine the level of adherence to an ALu treatment schedule in a real-life situation in rural settings and its determinants
Design: A longitudinal study conducted in 2008
Study settings: A community-based study conducted in Kilosa district, Tanzania
Study population: Stratified cluster sampling was done in which three of the 30 rural villages in wet-lowland areas were selected—one from villages with and two from villages without a health facility. Two nearby semi-urban villages were later added for comparison.
Method: Children were followed up for 12 months. Those who developed fever diagnosed as malaria, using a rapid diagnostic test, and treated with ALu, were identified from outpatient registers in facilities serving the respective villages. These were traced at their homes on day 7 to determine adherence to treatment using caretaker’s report and pill count. The majority of caretakers were found to have discarded packets on day 7, and a mini-study was conducted to verify adherence using pill count, on day 4. Blood samples were collected using a field-adapted blood sampling capillary method and analysed for lumefantrine blood concentration using the high-pressure liquid chromatography method. Multiple logistic regression analysis was done to determine factors influencing adherence, and log-transformation of lumefantrine concentration was done to correct for skewed distribution.
Policy: Tanzania adopted ALu as first-line antimalarial in 2006.
Results: The majority of the children (88%; 392/444) received all the doses on time irrespective of whether they resided in rural (87.5%; 281/321) or semi-urban (90.2%; 111/123) areas, p-value >0.05. Except for one child, nonadherence was due to off-schedule dosing, and the number was higher in the last two doses. A higher level of adherence (96%; 120/126) was found in the mini-study, thus, confirming findings from the main study. No statistically significant difference was found in the mean blood lumefantrine concentrations between children reported to adhere to ALu treatment and those who did not. The corresponding median lumefantrine concentration was 286 nmol/L and 261 nmol/L, respectively. Children from better-off households (quintile 1–2) were more likely to adhere to treatment schedule (OR 2.45; 95% CI 1.35–4.45; adjusted OR 2.23; 95% CI 1.20–4.13) compared to the poor (quintile 3–5).
Conclusion: The high level of adherence to ALu, in rural areas is encouraging. Further research is required on the usefulness of blood lumefantrine concentration in predicting adherence in community-based studies.
Funding source(s): Sida/SAREC
Effectiveness of Using RDTs and ACTs for Home Management of Malaria in Children Under 5 Years Old in Zambia
TROPICAL DISEASES RESEARCH CENTRE, Zambia
Problem statement: Malaria is the highest cause of morbidity and mortality in Zambia. Malaria prevalence is now 385 per 1,000 population and 8,000 deaths are recorded each year due to malaria. The country has now changed its first-line malaria treatment policy to Coartem®, (artemether-lumefantrine; AL) an artemisinin-based combination therapy (ACT) because of widespread parasite resistance to chloroquine. One of the goals of the health reforms in Zambia is ‘to provide equity of access to quality health care as close to the family (home) as possible’. The home management of malaria strategy is a WHO tool that identifies high-risk groups, such as children and pregnant women, and prescribes pre-packed antimalarial drugs for the treatment of fevers at home by way of community drug distributors. This strategy has been successfully tested in rural areas but evidence remains low on how this strategy could be used in settings adopting expensive antimalarial combination strategies in rural areas where the community health worker (CHW) is the first point of contact.
Method: This was an interventional study to evaluate the clinical outcome of children under the age of 5 years treated with AL after RDT diagnosis of malaria at community level and to assess the ability of a CHW to appropriately prescribe AL.
Results: The proportion of malaria cases among patients presenting to CHWs was 67.0%. Males had slightly higher positive rate of 68.9% (66.0-72.0%) compared to females with 66.6% (63.9-69.3%). Children under 5 represented 52.9% of the fever disease burden compared to patients older than 5 years (47.1%). Proportions of malaria cases rose up to the age of 5 (from 68% to 90%) before declining in those older than 5 years. There was a difference between peri-urban (58.0%) and rural sites (73.6%; p <0.00001). The sensitivity and specificity of using the CHWs as a delivery channel were 98.5% and 63.1%, respectively. Predictive values for a positive and negative test result for the same were 84.7% and 95.3%, respectively. The probability to test malaria positive with RDT for a younger patient from rural area presenting with fever was 0.8304.
Conclusion: There is justification for home management of malaria in endemic areas such as our sites, going by the heavy burden of malaria in under-fives. The use of CHWs is feasible and their adherence to instructions was reflected by predictive values of a positive and negative test results.
Funding source: World Bank