Malaria home management: disappointing results from study in Uganda’s capital city

22 Apr 2009

Paul Chinnock

Source: Lancet (see original article)

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A village-based distributor in Uganda explains home-based malaria
treatment to a young mother.
WHO/TDR/Crump.

Many children with malaria start treatment too late or do not receive it at all. Home management of malaria has been recommended by the World Health Organization (1) as one way of addressing this situation. It involves the presumptive treatment of children who have a fever with pre-packaged antimalarial drugs that have been distributed to households by members of the community; diagnostic tests are not used. However, a trial conducted in Uganda found that children in families provided with the packaged drugs fared no better than children in other families.

Working in Uganda’s capital city, Kampala, researchers randomly assigned 437 children aged 1-6 years to receive home delivery of a pre-packaged drug (artemether-lumefantrine) for presumptive treatment of fever or to receive ‘standard care’. Carers in households assigned to the standard care group were asked to continue their current approach to managing fever in their children.

The health of all the children was followed up for a year. The home management group received nearly twice the number of antimalarial treatments (an average of 4.66 during the year) as the standard care group (2.53). However, children in the home management group showed no signs of being in better health. Blood tests showed the home management children were less likely to have malaria parasites in their blood but anaemia was equally common in both groups. One child in each group died. The authors concluded that the over-treatment of malaria in the home management was “substantial”.

The researchers point out that their research was conducted in a city (Kampala). Children in urban areas do not live as far from health facilities as those whose homes are in rural areas. The number of cases of malaria is also generally less in cities; a higher proportion of fevers are due to causes other than malaria.

“Artemether-lumefantrine provided in the home might not be appropriate for large urban areas or areas with fairly low malaria transmission,” the authors write. “However, our findings do not conflict with the existing evidence for home management of malaria in rural areas where transmission is high and distances to health facilities are often great.”

Reaction

While the authors took care not to over-interpret their findings and to avoid drawing conclusions about home management in rural areas, many media reports of the study have carried titles such as “Treating kids with malaria at home doesn’t work”. These reports do not discuss urban-rural differences.

The media reports quote the reaction of Dr Tido von-Schoen Angerer of Médecins Sans Frontièrs, who was not involved with the study: “If you just go on fever, you’re over-treating so many children and you could miss other diseases by using malaria drugs”. He added that the study underlined that standard care for malaria in Africa was appalling.

A fear is that over-treatment may result in the spread of resistance against artemisinin, which is now the mainstay of malaria treatment. Using this drug only in combination with another antimalarial, such as lumefantrine, is considered to minimise that risk. Nevertheless, according to Dr von-Schoen Angerer, “The risk of resistance is very scary. We don’t have a back-up medicine at this stage.”

Also interviewed was Richard Tren, director of the controversial campaign group Africa Fighting Malaria. He regards home management as “an untested experiment”. He said: “We need policies based on evidence and the evidence this could work is pretty shaky.”

Reference

1. WHO (2004). Scaling up home-based management of malaria: from research to implementation. Geneva: World Health Organization, 2004. Available from: http://www.who.int/malaria/docs/ScalingupHMMresearchtoimplementation.pdf