Home Management Of Malaria Research Articles

Evaluation of knowledge on home management of malaria in under-fives among mothers and caregivers in Bende Local Government Area (LGA), Abia State, Nigeria

Background: In Nigeria, pregnant mothers and under-five children are the vulnerable who are most at risk of malarial infections. Despite the presence of numerous accessible health facilities, the community-based home management of childhood fevers remains a very common practice in the country. Objectives: To evaluate knowledge on home management of malaria in under-fives among mothers and caregivers in Bende LGA, Abia State, Nigeria. Methods and materials: A descriptive cross-sectional study was conducted among 375 heads of household Bende LGA. A semi-structured questionnaire was used to obtain data from participants and was self-administered. Data were cleaned and coded into SPSS version 26 for analysis. Numerical variables were summarized using mean and standard deviation, categorical variables were summarized using frequency and proportions. Chi-Square test was used to test association, p<0.05. Results: A total of 375 household heads with a response rate of 360 (96.0%) participated in the study with a mean age of 37.2 ± 0.8724, A good number of the participants 136 (37.8%) were in the age range of 35 – 39 years. Majority of them 310 (86.0%) were married. Majority of them 204 (56.6%) had secondary education. One hundred and fifty-eight (43.8%) of them responded that mosquito bite was the cause of malaria. Prevalence of home management of malaria was 117(32.4%) and overall knowledge level of mothers and caregivers was 202 (56.1%). There association between age range, marital status and level of education was statistically significant, p<0.05. Conclusion: There were several gaps in the participants’ level of knowledge relating to home management of under-five children, however, overall knowledge level of mothers and caregivers was 202 (56.1%) and prevalence of home management was low as majority of the under-fives were taken to the hospital for their management.

English

Knowledge and practices in preventing malaria infection were assessed in a cross-sectional study in Morogoro Municipal. Malaria is a life-threatening parasitic disease transmitted caused by plasmodial species which are plasmodium falciparum, plasmodium vivax, plasmodium ovale, and plasmodium malariae. With most of the cases of malaria being due to Plasmodium falciparum accounting for more than 95% of infections. A total of sixty families were randomly selected from five study areas (Chamwino, Mafiga, Kichangani, Misufini and Manzese) to participate in the study. The questionnaire consisting of closed and open-ended questions was administered. The results indicated that knowledge on malaria transmission and prevention was reasonable as the respondents declared to have a significant knowledge (85%) on malaria transmission and prevention, though there was a knowledge gap among respondents. Breeding sites were also assessed and the results showed that 26.7% reported dark places as breeding sites, 40% mentioned the edges of ponds and stagnant water, 26.7% tagged dirty areas as breeding sites, 1.7% mentioned cattle sheds, and 5% were not aware at all. Methods used for management of malaria in their homes indicate that most of the respondents (73.3%) agreed with indoor residual spraying (IRS) while (26.7%) did not agree with IRS. Most respondents commented on the effectiveness of Home Management of Malaria (HMM) to be somehow helpful in reducing malaria infection cases, while 31.7% strongly agreed that HMM has been effective in reducing malaria infection cases. Therefore, there is a need to improve the emphasis of HMM to ensure that the effectiveness of HMM is being achieved at a great level. Key words: Knowledge, mosquito, indoor residual spraying, home management of malaria.&nbsp

Effectiveness and safety of artesunate\u2013amodiaquine versus artemether\u2013lumefantrine for home-based treatment of uncomplicated Plasmodium falciparum malaria among children 6\u2013120\xa0months in Yaound\xe9, Cameroon: a randomized trial

BackgroundMany studies have reported high efficacy and safety of artesunate-amodiaquine (AS-AQ) and artemether-lumefantrine (AL) when administered under direct observation in Cameroon. There is paucity of data to support their continuous use in home-based treatment of uncomplicated Plasmodium falciparum malaria in Cameroon. Hence, this study aimed to assess the effectiveness and safety of AS-AQ versus AL for home-based treatment of uncomplicated P. falciparum malaria among children 6–120 months in Yaoundé, Cameroon.MethodsA two-arm, open-label, randomized, controlled trial comparing the equivalence of AS-AQ (experimental group) and AL (control group) was carried out from May 2019 to April 2020 at two secondary hospitals in Yaoundé. Participants were randomized to receive either AS-AQ or AL. After the first dose, antimalarial drugs were given at home, rather than under direct observation by a study staff. The conventional on-treatment and post-treatment laboratory and clinical evaluations were not done until day 3 of the full antimalarial treatment course. The evaluation of effectiveness was mainly based on per protocol polymerase chain reaction adjusted adequate clinical and parasitological response (PP PCR adjusted ACPR) on day 28 post-treatment. Safety was based on assessment of adverse events (AEs) and severe adverse events (SAEs) from day 1 to day 28.ResultsA total of 242 children were randomized to receive AS-AQ (n = 114) and AL (n = 128). The PP PCR adjusted day 28 cure rates were [AS-AQ = 96.9% (95% CI, 91.2–99.4) versus AL = 95.5% (95% CI, 89.9–98.5), P = 0.797]. Expected mild to moderate adverse events were reported in both arms [AS-AQ = 83 (84.7%) versus AL = 99 (86.1%), P = 0.774]. The most common adverse events included: transient changes of hematologic indices and fever.ConclusionsThis study demonstrated that AS-AQ and AL are effective and safe for home management of malaria in Yaoundé. The evidence from this study supports the parallel use of the two drugs in routine practice. However, the findings from this study do not describe the likely duration of antimalarial effectiveness in holoendemic areas where multiple courses of treatment might be required.Trial registration: This study is a randomized controlled trial and it was retrospectively registered on 23/09/2020 at ClinicalTrials.gov with registration number NCT04565184.

The fidelity of implementation of recommended care for children with malaria by community health workers in Nigeria

BackgroundIn the context of task shifting, a promoted approach to healthcare delivery in resource-poor settings, trained community health workers (CHWs) have been shown to be effective in delivering quality care of malaria for febrile under-5 children. While their effectiveness has been documented, the fidelity of implementation (FOI) has not been adequately studied. By understanding and measuring whether an intervention has been performed with fidelity, researchers and practitioners gain a better understanding of how and why an intervention works, and the extent to which outcomes can be improved. The objective of this study was to assess the FOI of a recommended protocol for malaria care by CHWs in a resource-poor setting in Nigeria.MethodsThirty-five female CHWs who participated in a 3-day training on home management of malaria among under-5 children were studied. They managed 1,646 children over the implementation period and then underwent evaluation via a one-time hospital-based observation by the trainers. During the evaluation, a pre-tested standard checklist was used to compute performance scores for CHWs; doctors and nurses were selected to serve as the gold standard for comparison. Performance scores (PS) recorded during the evaluation were used to assess adherence and compliance with the recommended treatment protocol.ResultsOf the 4 skill domains assessed, adherence was greatest for compliance with malaria treatment recommendations (94%) and lowest for post-treatment initiation counseling of home-based caregivers (69%). The average overall adherence of 83% was comparable to adherence by gold standard comparators. Mean PS was not found to be significantly associated with CHW demographics. Scores for clinical evaluation among those whose occupation was not healthcare-related were significantly lowered by 0.52 [95% CI (1.05–0.01), p = 0.05]. Compliance with the treatment protocol increased by 23% for every unit increase in total PS (p = 0.07) and doubled for every unit increase in scores for post-treatment initiation counseling of caregivers (p = 0.002).ConclusionsStudying intervention fidelity stands to identify the shortcomings of implementation and specific areas to target for improvement in future adoption or implementation. This study concludes that future trainings should emphasize clinical evaluation and post-treatment counseling of caregivers by CHWs to ensure the best outcome for children.

Strengthening primary health care at district-level in Malawi - determining the coverage, costs and benefits of community-directed interventions

BackgroundCommunity-Directed Interventions (CDI) is a participatory approach for delivery of essential healthcare services at community level. It is based on the values and principles of Primary Health Care (PHC). The CDI approach has been used to improve the delivery of services in areas that have previously applied Community-Directed Treatment with ivermectin (CDTi). Limited knowledge is available about its added value for strengthening PHC services in areas without experience in CDTi. This study aimed to assess how best to use the CDI approach to strengthen locally identified PHC services at district level.MethodsThis was a comparative intervention study carried out over a period of 12 months and involving four health centres and 16 villages assigned to 1) a conventional Essential Health Package (EHP)/PHC approach at health centre level or 2) an EHP/PHC/CDI approach at community level in addition to EHP/PHC at health centre level. Communities decided which intervention components to be included in the intervention. These were home management of malaria (HMM), long lasting insecticide treated nets (LLIN), vitamin A and treatment against schistosomiasis. The outcomes of the two strategies were compared quantitatively after the intervention was completed with regard to intervention component coverage and costs. Qualitative in-depth interviews with involved health professionals, implementers and beneficiaries were carried out to determine the benefits and challenges of applied intervention components.ResultsImplementation of the EHP/PHC/CDI approach at community level as an add-on to EHP/PHC services is feasible and acceptable to health professionals, implementers and beneficiaries. Statistically significant increases were observed in intervention components coverage for LLIN among children under 5 years of age and pregnant women. Increases were also observed for HMM, vitamin A among children under 5 years of age and treatment against schistosomiasis but these increases were not statistically significant. Implementation was more costly in EHP/PHC/CDI areas than in EHP/PHC areas. Highest costs were accrued at health centre level while transport was the most expensive cost driver. The study identified certain critical factors that need to be considered and adapted to local contexts for successful implementation.ConclusionThe CDI approach is an effective means to increase accessibility of certain vital services at community level thereby strengthening delivery of EHP/PHC services. The approach can therefore complement regular EHP/PHC efforts.Trial registrationThe study was retrospectively registered with the Pan African Clinical Trial Registry TRN: PACTR201903883154921.

Home Management of Malaria: Knowledge, Attitude and Awareness of Mothers in Babcock University

Malaria is an endemic disease in Nigeria that is a major cause of morbidity and mortality in children, especially those under the age of five years old. The home management of malaria has been shown to reduce the rate of morbidity and mortality linked to malaria. The objectives of this study were therefore to determine the knowledge on cause, signs and symptoms of malaria, health seeking behaviour of respondents, preventive measures and Knowledge, Attitude and Practice (KAP) of home management of malaria among mothers in Babcock University for their children. This research was done between April and June, 2018 in Babcock University, Ilishan-Remo, Ogun State. A descriptive study with a cross sectional study design was used. The study population was 274 mothers. A structured questionnaire was used as the instrument for this study. This study revealed that 96.7% of the respondents knew about malaria as a disease. 72.6% of them attributed it to the vector, mosquito, while 4.7% attributed it to the malaria parasite, Plasmodium. The commonest recognisable clinical symptom of malaria was headache (75.5%) of the study population. None of the respondents took their children to the native doctor or to Church when symptoms of malaria arose. Rather, they took them to the hospital (80.3%) or to the Pharmacy (11.3%). Regarding preventive measures, 76.6% of them made use of insecticides, which was the commonest preventive measure. In the modality of treatment, it is shown in this study that 69.0% of the mothers knew about Artemisinin Combination Therapy (ACT), which is the recommended treatment drug for malaria treatment by the World Health Organization (WHO). It was also the commonest treatment modality used (68.6%). The commonest ACT combination used was Coartem (Artemether/Lumefantrine) with 59.5% of the respondents patronizing it. The study also showed that mothers in Babcock University are well aware of the dangers of poor compliance (86.5%) and thus ensure that their children completed the drug dose. The mothers in Babcock University have good knowledge, attitude and awareness of home management practices of malaria for their children. These practices are effective in reducing malaria incidence, owing to the fact that majority of them are well educated, as proven by statistical analysis.

Home management of malaria among caregivers of under-five children in Owo, Ondo State, Nigeria

Home management of malaria among caregivers of under-five children in Owo, Ondo State, Nigeria

English

This paper introduces the concept of supportive supervision in community-based nursing intervention as a supervisory tool among health consumers. It provides overview of supportive supervision as management tool to facilitate delivery of quality service by the health care providers. It also describes the adaptability of this concept to supervision of community members following heath education and training with a view to enhancing and sustaining health promotion and prevention of diseases. The author describes utilisation of this tool in promoting and sustaining mothers’ skills in home management and prevention of malaria at a community level and recommends its usage by community health workers as a substitute to home visit for different populations within a community where there is dwindling human and material resources to carry out home visits so as to promote effective outcome. Key words: Supportive supervision, health education, sustaining, home management of malaria.

The Impact of Health Seeking Behaviour, Educational Attainment and Financial Strength on Home Management of Malaria in Rural Communities in Imo State, Nigeria

Aims: The objectives were to determine the impact of health seeking behaviour, educational attainment and financial Strength on home management of malaria in rural communities in Imo State, Nigeria. Study Design: A descriptive survey design was used. Place and Duration of Study: Imo State, Nigeria, between February 2013 and April 2013 Methodology: The sample size was 2674 adults (1650 males, 1024 females, age range 20-70 years). A structured, validated and reliable questionnaire (r=0.81) was used to collect data from 2674 consenting respondents. Results: The result showed that the health seeking behaviours of respondents when they suspect malaria was as follows; 25.7 percent patronized patent medicine stores/chemist, 22.3 percent visited health centers/ hospitals,18.6 percent consulted family members/friends/ neighbor for help. This statistically had a significant influence on the pattern adopted in managing malaria at home ( Chi-square = 263.98, P -value <

The effect of health education intervention on the home management of malaria among the caregivers of children aged under 5 years in Ogun State, Nigeria

BackgroundMalaria is currently the most important cause of death and disability in children aged under 5 years in Africa. A health education interventional study of this nature is essential in primary control of an endemic communicable disease such as malaria. This study was therefore designed to determine the effect of health education on the home management of Malaria among the caregivers of children under 5 years old in Ogun State, Nigeria.MethodsThe study design was a quasi-experimental study carried out in Ijebu North Local Government Area of Ogun State. A multistage random sampling technique was used in choosing the required samples for this study and a semi-structured questionnaire was used to collect relevant information. The intervention consisted of a structured educational program based on a course content adapted from the national malaria control program. A total of 400 respondents were recruited into the study, with 200 each in both the experimental and control groups, and were followed up for a period of 3 months when the knowledge and uptake of insecticide treated net was reassessed.ResultsThere was no statistically significant differences observed between the experimental and control groups in terms of sociodemographic characteristics such as age (P = 0.99), marital status (P = 0.48), religion (P = 0.1), and income (P = 0.51). The majority in both the experimental (75.0%) and control (71.5%) groups use arthemisinin-based combination therapy as first line home treatment drugs pre intervention. Post health education intervention, the degree of change in the knowledge of referral signs and symptoms in the experimental group was 52.8% (P < 0.0001) while it was 0.2% in the control group (P = 0.93). Tepid sponging improved by 45.0%, paracetamol use by 55.3%, and the use of herbs and other drugs were not significantly influenced in the experimental (P = 0.65 and 0.99) and control group (P = 0.89 and 0.88), respectively. Furthermore, there was a 55.7% (P = 0.001) increase in the proportion of respondents using the correct dose of arthemisinin-based combination therapy in the home management of malaria and 23.9% (P < 0.001) in the proportion using it for the required time.ConclusionsThe study concludes that there is a shift in the home management of malaria with the use of current and effective antimalarial drugs. It also demonstrated the effect of health education on the promptness of appropriate actions taken among the respondents for early diagnosis and treatment. Early diagnosis and appropriate treatment can be guaranteed if caregivers are knowledgeable on prompt actions to be taken in the home management of malaria.

Sustainability of Intervention for Home Management of Malaria: The Nigerian Experience

Background: An important challenge to community-based intervention is sustainability. This study evaluated sustainability of an intervention to improve Home Management of Malaria (HMM) in Ona-Ara Local Government Area of Oyo State, Nigeria two years after end of intervention. Methods: A total of 13 FGDs was conducted among trained Community Medicine Distributors (CMDs), mothers of children aged 0-5 years and community members; 14 Key Informant Interviews were held with community leaders, Primary Health Care (PHC) Coordinator and Rollback Malaria Manager.Observation was carried out on 13 CMDs to check AL stock and registers. Thematic approach was used to analysed the data. Results: Utilization of CMDs was said to be high when the project started but dwindled after the researchers left the community. Some of the CMDs have not had drug to distribute in the two years preceding this study. Thus, majority of the caregivers sought care at other alternative care providers or used herbs. While some CMDs have abandoned the assignment, a few continued to provide care to febrile children as their own contribution to the good of the community. The functioning CMDs prescribed paracetamol, sulfadoxine-pyrimethamine, amoxycillin and chloroquine when out of AL stock or referto PHC center. Source of AL was still the nearest government health facilitiesbut supply was irregular and hindered by incessant transfer of trained health workers. All the CMDs mentioned they did not receive any support from the community as promised and this wascorroborated by community members/leaders and health facility workers. None of the CMDs observed had AL in stock orrecord of patronage in the last one year. They mentioned that health centres have not had AL stockedin recent times. Conclusion: Mechanisms to draw unflinching commitments from the government and community to sustain community-based intervention, the major sustainability challenge identified in this study, should be explored.

The continued relevance of home management of malaria strategy in the effective and sustainable control of malaria in endemic areas

Malaria remains one of the World’s most devastating diseases, killing millions of people yearly. The disease is naturally transmitted through the bite of an adult female Anopheles mosquito and accompanied by symptoms which include fever, headache, chills and nausea among others. A wide range of childhood illnesses are accompanied by fever, many of which are treated at home prior to presentation in hospital. Home management is an important strategy adopted for the reduction of its fatality. A mothers/caregiver’s knowledge and ability to recognize fever in their child, as well as, induce management at home is very important. There has been a renewed emphasis on preventive measures at community and individual levels which includes the use of insecticide treated nets (ITNs), indoor residual spraying, wearing of protective clothes, and use of gauze for windows and doors, and use of ACTs. Home management of malaria is a very crucial and important factor that should be adopted as it entails the caregiver recognizing the symptoms and administering drugs to the sick individual before they seek medical attention. This is a very simple and effective way of treating malaria which prevents its progression the critical stage. Key words: Malaria, Home management, symptoms, early recognition, prompt treatment, antimalaria.

Impact of combining intermittent preventive treatment with home management of malaria in children less than 10 years in a rural area of Senegal: a cluster randomized trial

BackgroundCurrent malaria control strategies recommend (i) early case detection using rapid diagnostic tests (RDT) and treatment with artemisinin combination therapy (ACT), (ii) pre-referral rectal artesunate, (iii) intermittent preventive treatment and (iv) impregnated bed nets. However, these individual malaria control interventions provide only partial protection in most epidemiological situations. Therefore, there is a need to investigate the potential benefits of integrating several malaria interventions to reduce malaria prevalence and morbidity.MethodsA randomized controlled trial was carried out to assess the impact of combining seasonal intermittent preventive treatment in children (IPTc) with home-based management of malaria (HMM) by community health workers (CHWs) in Senegal. Eight CHWs in eight villages covered by the Bonconto health post, (South Eastern part of Senegal) were trained to diagnose malaria using RDT, provide prompt treatment with artemether-lumefantrine for uncomplicated malaria cases and pre-referral rectal artesunate for complicated malaria occurring in children under 10 years. Four CHWs were randomized to also administer monthly IPTc as single dose of sulphadoxine-pyrimethamine (SP) plus three doses of amodiaquine (AQ) in the malaria transmission season, October and November 2010. Primary end point was incidence of single episode of malaria attacks over 8 weeks of follow up. Secondary end points included prevalence of malaria parasitaemia, and prevalence of anaemia at the end of the transmission season. Primary analysis was by intention to treat. The study protocol was approved by the Senegalese National Ethical Committee (approval 0027/MSP/DS/CNRS, 18/03/2010).ResultsA total of 1,000 children were enrolled. The incidence of malaria episodes was 7.1/100 child months at risk [95% CI (3.7-13.7)] in communities with IPTc + HMM compared to 35.6/100 child months at risk [95% CI (26.7-47.4)] in communities with only HMM (aOR = 0.20; 95% CI 0.09-0.41; p = 0.04). At the end of the transmission season, malaria parasitaemia prevalence was lower in communities with IPTc + HMM (2.05% versus 4.6% p = 0.03). Adjusted for age groups, sex, Plasmodium falciparum carriage and prevalence of malnutrition, IPTc + HMM showed a significant protective effect against anaemia (aOR = 0.59; 95% CI 0.42-0.82; p = 0.02).ConclusionCombining IPTc and HMM can provide significant additional benefit in preventing clinical episodes of malaria as well as anaemia among children in Senegal.

Factors Associated with Use of Guideline in Home Management of Malaria among Children in Rural South West Nigeria.

The dosage regimen for artemether-lumefantrine which is the standard of care for malaria in most of Sub-Saharan countries requires use of treatment guidelines and instructions to enhance caregivers' performance in the treatment of malaria. As part of a larger study evaluating its effectiveness in a rural local government area in southwestern Nigeria, 552 caregivers whose children had fever two weeks preceeding the survey were recruited. Information was collected with interviewer administered questionnaire. A multilevel logistic regression model was fitted using the gllamm approach in Stata to determine the factors associated with use of guideline. Age and educational background of caregiver were significantly associated with guideline use. Caregivers aged 26–30 years were 4 times more likely to use guideline than those aged >40 years. Caregivers with primary education were 4 times more likely to use guideline compared with caregivers with no formal education. Between-village variance was 0.00092 ± 0.3084. Guideline use reduced with increasing age and lower education.

Relative costs and effectiveness of treating uncomplicated malaria in two rural districts in Zambia: implications for nationwide scale-up of home-based management

BackgroundMalaria case management is one of the key strategies to control malaria. Various studies have demonstrated the feasibility of home management of malaria (HMM). However, data on the costs and effectiveness of artemisinin-based combination therapy (ACT) and rapid diagnostic tests via HMM is limited.MethodCost-effectiveness of home management versus health facility-based management of uncomplicated malaria in two rural districts in Zambia was analysed from a providers' perspective. The sample included 16 community health workers (CHWs) and 15 health facilities. The outcome measure was the cost per case appropriately diagnosed and treated. Costs of scaling-up HMM nationwide were estimated based on the CHW utilisation rates observed in the study.ResultsHMM was more cost effective than facility-based management of uncomplicated malaria. The cost per case correctly diagnosed and treated was USD 4.22 for HMM and USD 6.12 for facility level. Utilization and adherence to diagnostic and treatment guidelines was higher in HMM than at a health facility.ConclusionHMM using ACT and RDTs was more efficient at appropriately diagnosing and treating malaria than the health facility level. Scaling up this intervention requires significant investments.

Assessing the Progress of Malaria Control in Nigeria

One third of the world's malaria deaths occur in Nigeria. It is doubtful whether Nigeria will meet the malaria control target of the Millennium Development Goals by 2015, having failed to meet the Abuja target to halve the burden of malaria by 2010. This paper assesses the current malaria burden and progress toward malaria control. Substantial data were obtained from the 2008 Nigeria Demographic and Health Survey and other secondary sources. Data showed that the malaria burden is still enormous because of inadequate control efforts. In 2008, only 17% of Nigerians owned at least one net, compared with 12% in 2003. Eight percent owned an insecticide-treated mosquito net (ITN), but only 6% of under-five children and 5% of pregnant women slept under an ITN. Only one third of under-five children with fever received antimalarial drugs, while one fifth of pregnant women took antimalarial drugs for prevention. Chloroquine is still the most common drug used in malaria treatment, despite its ban in first-line treatment since 2005. The paper concludes that scaling up home management of malaria and a community-centred approach to ITN and artemisinin-based combination therapy provisioning should be prioritized.

A trial of intermittent preventive treatment and home-based management of malaria in a rural area of The Gambia

BackgroundIndividual malaria interventions provide only partial protection in most epidemiological situations. Thus, there is a need to investigate whether combining interventions provides added benefit in reducing mortality and morbidity from malaria. The potential benefits of combining IPT in children (IPTc) with home management of malaria (HMM) was investigated.MethodsDuring the 2008 malaria transmission season, 1,277 children under five years of age resident in villages within the rural Farafenni demographic surveillance system (DSS) in North Bank Region, The Gambia were randomized to receive monthly IPTc with a single dose of sulphadoxine/pyrimethamine (SP) plus three doses of amodiaquine (AQ) or SP and AQ placebos given by village health workers (VHWs) on three occasions during the months of September, October and November, in a double-blind trial. Children in all study villages who developed an acute febrile illness suggestive of malaria were treated by VHWs who had been taught how to manage malaria with artemether-lumefantrine (Coartem™). The primary aims of the project were to determine whether IPTc added significant benefit to HMM and whether VHWs could effectively combine the delivery of both interventions.ResultsThe incidence of clinical attacks of malaria was very low in both study groups. The incidence rate of malaria in children who received IPTc was 0.44 clinical attacks per 1,000 child months at risk while that for control children was 1.32 per 1,000 child months at risk, a protective efficacy of 66% (95% CI -23% to 96%; p = 0.35). The mean (standard deviation) haemoglobin concentration at the end of the malaria transmission season was similar in the two treatment groups: 10.2 (1.6) g/dL in the IPTc group compared to 10.3 (1.5) g/dL in the placebo group. Coverage with IPTc was high, with 94% of children receiving all three treatments during the study period.ConclusionDue to the very low incidence of malaria, no firm conclusion can be drawn on the added benefit of IPTc in preventing clinical episodes of malaria among children who had access to HMM in The Gambia. However, the study showed that VHWs can successfully combine provision of HMM with provision of IPTc.Trial RegistrationClinicalTrials.gov NCT00944840

The clinical impact of combining intermittent preventive treatment with home management of malaria in children aged below 5 years: cluster randomised trial

To investigate the impact of seasonal intermittent preventive treatment (IPTc) on malaria-related morbidity in children <5 years of age who already had access to home-based management of malaria (HMM) for presumptive treatment of fevers. Thirty community-based drug distributors (CDDs) from all 13 communities of a rural subdistrict in Ghana were trained to provide prompt treatment for presumptive malaria using artesunate-amodiaquine (AS+AQ) to all children under 5 years of age. Six communities were randomised to also receive bimonthly courses of seasonal IPTc with AS+AQ in May, July and September of 2007. The primary outcome was the incidence rate of febrile episodes diagnosed presumptively as malaria by the CDDs in the communities in each intervention group. Cross-sectional surveys were conducted to determine the prevalence of parasitaemia and anaemia among the study children. During the 6 months in which IPTc was delivered, incidence of fevers in communities given HMM+IPTc was lower than in communities given HMM alone, but this difference was not statistically significant (protective efficacy: 37.0%(95% CI: -9.7 to 63.8; P = 0.14). However, incidence of presumptive malaria was significantly lower in IPTc communities when only children who received all three courses of IPTc were included in the analysis: protective efficacy 61.5% (95% CI:31.2-78.5; P = 0.018). Protection with IPTc was not followed by rebound morbidity in the following year. At the end of the intervention period, prevalence of asymptomatic parasitaemia was lower in communities that had received IPTc, but there were no differences in anaemia or haemoglobin concentration. In this study area, incidence of fevers was lower in communities given three courses of IPTc during the time of peak transmission than in communities that received only HMM. However, high levels of coverage for IPTc will be necessary for maximum impact.

An Economic Evaluation of Home Management of Malaria in Uganda: An Interactive Markov Model

BackgroundHome management of malaria (HMM), promoting presumptive treatment of febrile children in the community, is advocated to improve prompt appropriate treatment of malaria in Africa. The cost-effectiveness of HMM is likely to vary widely in different settings and with the antimalarial drugs used. However, no data on the cost-effectiveness of HMM programmes are available.Methods/Principal FindingsA Markov model was constructed to estimate the cost-effectiveness of HMM as compared to conventional care for febrile illnesses in children without HMM. The model was populated with data from Uganda, but is designed to be interactive, allowing the user to adjust certain parameters, including the antimalarials distributed. The model calculates the cost per disability adjusted life year averted and presents the incremental cost-effectiveness ratio compared to a threshold value. Model output is stratified by level of malaria transmission and the probability that a child would receive appropriate care from a health facility, to indicate the circumstances in which HMM is likely to be cost-effective. The model output suggests that the cost-effectiveness of HMM varies with malaria transmission, the probability of appropriate care, and the drug distributed. Where transmission is high and the probability of appropriate care is limited, HMM is likely to be cost-effective from a provider perspective. Even with the most effective antimalarials, HMM remains an attractive intervention only in areas of high malaria transmission and in medium transmission areas with a lower probability of appropriate care. HMM is generally not cost-effective in low transmission areas, regardless of which antimalarial is distributed. Considering the analysis from the societal perspective decreases the attractiveness of HMM.ConclusionSyndromic HMM for children with fever may be a useful strategy for higher transmission settings with limited health care and diagnosis, but is not appropriate for all settings. HMM may need to be tailored to specific settings, accounting for local malaria transmission intensity and availability of health services.

Community-directed interventions for integrated delivery of a health package against major health problems in rural Uganda: perceptions on the strategy and its effectiveness

Despite growing interest at national and international levels to use community-directed interventions (CDI) for delivery of health interventions in Africa, inadequate information on its acceptability and effectiveness remains. This study aimed to examine community perceptions on CDI strategy and its effectiveness for integrated delivery of health interventions with different degrees of complexity (insecticide treated nets, vitamin A supplements to children, home management of malaria and direct observation treatment of tuberculosis), using community-directed treatment with ivermectin (CDTI) as an entry point, compared to conventional delivery channels. The interventions were implemented in an incremental manner and both qualitative and quantitative methods were used at evaluation, three years after implementation. Coverage was significantly higher in CDI arm, compared to conventional delivery channels for all interventions (P < 0.05), except for direct observation treatment of tuberculosis (P > 0.05). Community members expressed interest in CDI because it responds to their perceived health problems, actively engages them and improves access to health care services. CDI seemed to be appropriate for interventions that are relatively simple, intervention materials are available, the disease is perceived as a health problem affecting all sections of the community and can be easily integrated into their daily lives, and community structures with full community participation.