Packaged treatment for first-line care in cerebral malaria and meningitis

Abstract

Described are the results of a trial carried out from January to June 1996 in southern Malawi to determine the effectiveness of a treatment pack for infants and children under the age of 6 years, who presented as emergencies to rural health centres with presumptive diagnoses of severe/cerebral malaria or meningitis. Each complete treatment pack (approximate cost, US$ 6) contained, inter alia, intramuscular quinine, intramuscular choloramphenicol, dextrose, paraldehyde, a nasogastric tube, prepacked syringes, and sterile water. A modified coma score and drug dosage nomogram were also included in the package. Despite a considerable drop in overall mortality, problems arose with regard to the incomplete treatment of possible meningitis and in the development of a rational referral policy.The majority of infants and young children in Malawi receive their medical care from rural health centers that are minimally equipped for emergencies and lack laboratory facilities. A pilot project conducted in southern Malawi's Mangochi District in December-June 1996 assessed the effectiveness of a treatment pack for children under 6 years of age who presented to rural health centers with presumptive diagnoses of severe/cerebral malaria or meningitis. Each pack (cost, US$6) contained intramuscular quinine and chloramphenicol, dextrose, paraldehyde, a nasogastric tube, prepackaged syringes, sterile water, a modified coma score, and a drug dosage nomogram. Records for 64 infants and children admitted to 10 health centers with malaria or meningitis in the 6 months preceding the trial (July-December 1995) were compared with those for 96 infants and children who presented to 19 centers during the study period with these diagnoses. Only 63% of children in the latter group received the full treatment outlined in the study protocol. 52% of children in the pretrial group and 31% of those in the intervention group were completely treated in the health center; the remainder were referred for hospital care. The case fatality rate was 51% in the pretrial period and 23% in the trial phase--a rate comparable to that obtained in hospital settings. Most children died awaiting transport to the hospital. Of concern are difficulties differentiating between meningitis and severe or cerebral malaria at the health center level. The estimated cost of each life saved at the health center was $29 compared with $30 when cases were transferred by ambulance to the hospital. Further controlled studies are needed to determine whether these treatment packs can be used routinely at the periphery.