Communities of practice
Effective Management Of Childhood Malaria At The Community Level: Programme Experience To Guide The Research Agenda
3 Dec 2007
Source: WHO/TDR
Mark W Young Senior Advisor
Roll Back Malaria UNICEF, New York, USA
Paper for the WHO/TDR Scientific Working Group on Malaria, Geneva, Switzerland, 24–27 March 2003
Introduction
Approximately 1 million young children in Africa die from malaria every year. Partly as a result of the burden of malaria, mortality rates for children aged less than 5 years have generally remained stagnant over the past decade in Africa. The Millennium Development Goals and goals contained in the outcome document of the recent United Nations Special Session on Children, A world fit for children1, provide a focus for scaling-up programmes for improving child survival:
To “reduce by one-third, by 2010, the infant and under-five mortality rate, in pursuit of the goal of reducing it by two-thirds by 2015”;
To “reduce by one half the burden of disease associated with malaria by 2010”; and
To “have halted by 2015 and begun to reverse the incidence of malaria and other major diseases”.
Effective management of childhood malaria must therefore be a key element in the approach of the Roll Back Malaria programme to achieve these goals. The key coverage target included in the Abuja Malaria Declaration2 and A world fit for children serves as a guide for programmes aimed at the effective management of malaria in children: of children aged less than 5 years, 60% should have access to appropriate treatment for malaria within 24 hours of the onset of symptoms.
Most children die from malaria at home without receiving adequate therapy. Only a small number of children with fever are treated at health-care facilities, with Demographic Health Survey (DHS) data from 14 countries in Africa suggesting that between 16% and 71% of children aged less than 5 years with fever are treated in a health-care facility. This obviates the need for bringing malaria case management as close to the home as possible.
Other papers in this report deal with the management of severe illness, combination therapy, and other issues that are obviously relevant to the management of malaria in children. Therefore, this paper will not address these issues in detail but will deal specifically with “out-of-facility management of non-life-threatening febrile illness in malaria-endemic Africa”.
A number of elements are critical to management of the child with fever:
The caregiver must recognize the illness as potential malaria and provide the appropriate dose of an antimalarial drug, together with supportive care. This requires attention to care practices, communication, and drug dosing characteristics.
An efficacious antimalarial drug must be available either in the home or near the home when the child becomes ill. This requires attention to national policy formulation, monitoring of drug resistance, and drug procurement and distribution.
The drug must be affordable for the caregiver. This requires attention to drug pricing and financing.
The caregiver must recognize when the illness is severe or not improving and have the means to take the child to health-care facilities. Again, care-seeking is an important issue here, along with community capacity development and referral systems.
On the basis of these elements and drawing on extensive experience of control programmes from different countries, this paper examines critical issues and challenges, and identifies key research priorities for the effective management of childhood malaria. The critical issues that emerge in the approach to the child with malaria are:
Recognizing when therapy for malaria is indicated;
Making available the most efficacious drug as close to the child as possible;
Managing the child with chronic infection with malaria and anaemia;
“Prevention is the best medicine”.
Recognizing when therapy for malaria is indicated
Multiple disease processes often coexist in a sick child. In areas in which malaria is endemic, the child with fever may be suffering from malaria, pneumonia, diarrhoea, measles, or a combination of these, in addition to malnutrition. At health-care facilities, the management of the sick child at is generally based on symptoms, for example the Integrated Management of Childhood Illness (IMCI) algorithms, which recommend that in high-transmission, malaria-endemic areas, all children aged less than 5 years (“under-fives”) with fever be treated with antimalarials. In the absence of diagnostic laboratory facilities, some conditions are often indistinguishable, even for skilled health-care workers. As differentiation is often difficult for trained clinicians, it is unlikely that a high specificity for the diagnosis of malaria in the community setting can be achieved by community health-care workers, shopkeepers, or caregivers.
Pneumonia, for example, is also a major cause of death of children in sub-Saharan Africa, and is estimated to be the cause of about 20% of mortality in childhood. According to IMCI, “malaria” is defined as presence or history of fever, symptoms that also occur in children with pneumonia. “Pneumonia” is defined as cough or difficult breathing, with rapid breathing or chest indrawing, symptoms also indicating severe malaria. The symptom overlap between malaria and pneumonia is high, and recent studies indicate that in areas in which malaria is endemic many children who fulfil the case definition for malaria also fulfil the case definition for pneumonia. These children therefore require treatment with both an antimalarial and an antibiotic.
With programmes for the home management of malaria bringing malaria-specific education and treatment of fever to the community level, this has implications for the management of the sick child. Treating a child with fever with only an antimalarial will leave many cases of pneumonia untreated. This may result in delayed care-seeking for pneumonia and other underlying conditions, when caregivers feel that their child has been adequately treated for the current illness. The result will be continued high rates of death in childhood. There is a need to convince policy-makers and practitioners that drugs for managing pneumonia can also be safely administered in a community setting, and that lives can be saved as a result.
Considering this reality, any attempt in the current context of diagnostic capabilities in rural Africa to improve clinical diagnosis of malaria-specific illness will be difficult. Much work has gone into the study of clinical algorithms for fever, and this is what the present IMCI algorithms have attempted to address. Priority at this time should be given to developing an approach to the management of the sick child, with a focus on defining those therapies from which the child would most benefit, and assure that the “essential” efficacious drugs to manage the majority of potentially serious/fatal disease processes are available.
In areas where the prevalence of malaria parasitaemia is high, the co-administration of an antimalarial drug to a child with a febrile illness should be viewed as good medical care. This is valid even if parasitaemia is not the primary cause of the fever (which cannot be defined accurately in the community), because parasitemia can impair the capacity of the child to recover from the primary infection (e.g. pneumonia) or chronic sequelae (e.g. anaemia). The reality is that judicious “polytherapy” will produce the greatest reduction in morbidity and mortality from childhood febrile illness.
Prompt recognition of illness and danger signs by caregivers
Caregivers must recognize the signs and symptoms of illness (including danger signs) and provide appropriate treatment and care. An effective communication programme to improve care practices is therefore an essential component of any programme to support appropriate home management of malaria. It is evident that change in behaviour at the individual level is still lagging far behind expectations, in spite of a high degree of awareness generated by carefully delivered public health messages. New communication methods and strategies need to be found to respond to this reality, on the basis of the premise that sustainable change in behaviour and practices is heavily influenced by societal pressures and support systems that operate in families and communities.
Community capacity development through community dialogue has the greatest potential for inducing sustained change in behaviour and improving care practices, including care-seeking and treatment for malaria. Communities that have been mobilized through community dialogue and other participatory communication approaches demonstrate increased awareness and improved health practices.
Priorities for research include:
Investigation of drug therapy options for the co-management of malaria, pneumonia and other concurrent illness in the sick child;
Operational research programme for the effective joint treatment of malaria and pneumonia/acute respiratory infections (ARI) at the community level; and
Effective communication strategies to improve care practices at the community level.
Making available the most effective drug as close to the child as possible
There is often only “one shot” at getting adequate antimalarial therapy for a child; national programmes need to make the most of this one opportunity. At an individual level, it is known that prompt treatment with an efficacious antimalarial clears malaria parasitaemia and reduces anaemia. Therefore programmes must use treatment that will be most effective in reaching children as close to home as possible in an operational setting at the community level. Antimalarial treatment aims to save children's lives, and saving lives requires an effective programme in the “real-life situation”.
The effectiveness of a programme for the treatment of malaria is determined by multiple factors, in addition to drug efficacy. The characteristics of “close-to-home” therapy that will ensure programme effectiveness include:
Use of drugs that are efficacious, safe, and affordable;
Treatment that is available in or near the home;
The number and frequency of doses — “first-dose efficacy”;
Functioning referral systems, and community-level treatment for the ill child who is unable to take oral antimalarials.
Drugs that are efficacious, safe, and affordable
Currently, the debate around the formulation of policy regarding therapy with antimalarial drugs has several elements, which need to be addressed to assure optimal therapy.
First, it is necessary to have accurate monitoring of the efficacy of the drug against P. falciparum in subregions of Africa. For more than two decades, the resistance of Plasmodium falciparum to commonly-used antimalarial drugs has been an evolving public health challenge in the control of malaria in Africa. Resistance to chloroquine is present throughout most of Africa, with the exception of some sub-Sahel zones in west Africa. Furthermore, resistance to drugs that have been introduced to replace chloroquine (e.g. sulfadoxine/pyrimethamine or SP) is developing. During the past 5 years, there has been great attention to monitoring of the spread and intensification of drug resistance. Several nations in east Africa have responded to data demonstrating that chloroquine is no longer efficacious by changing their leading drug for antimalarial therapy to sulfadoxine/pyrimethamine (Fansidar). This change was made in 1993 in Malawi, where a significant decrease in child mortality, with no measurable increase in drug-associated adverse effects, has since been demonstrated.
Second, national regulatory authorities require information on the safety of candidate antimalarial drugs, to assess whether particular drugs can be incorporated into a national programme. Of note is the fact that co-formulated drugs containing artemisinin are not currently approved for use in young children, one of the populations that are most at risk. With regard to safety and efficacy, that there is an extensive problem with counterfeit and substandard pharmaceuticals in Africa. It has been estimated that in several countries most seriously affected by drug resistance, as many as one-third of antimalarials may be counterfeit or substandard.
Third, in the future, antimalarial drugs will cost more than chloroquine and SP, and the international community must address the financing of antimalarial drug procurement with this perspective. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) could play a pivotal role in making available substantially more effective therapy where lives can be saved.
Research priorities:
Investigation of patterns of drug sensitivity of P. falciparum, and accurate monitoring of drug efficacy.
Quality and safety of candidate antimalarial drugs. In particular, the safety of new artemisinin-containing co-formulations for use in young children, and systems for monitoring quality control and adverse drug reactions, must be assured.
Cost and financing issues should be addressed in collaboration with national governments, the World Bank, donors, and the wider international community.
Treatment that is available in or near the home: home-based management of fever
Many episodes of malaria are currently treated outside the formal health system, often with inappropriate or incorrectly used drugs. This is particularly common in more rural and remote populations and contributes both to worsening morbidity patterns and increased drug resistance. Programmes for the home management of malaria aim to improve early home-based treatment practices through improved access to, and information on, effective antimalarial drugs. Although experience with large-scale home management programmes is limited, there is evidence currently available to support this approach:
Use of pre-packaged antimalarials has significantly increased the number of children receiving treatment within 24 hours in studies in Uganda and Nigeria, and significantly reduced progression to severe disease in Burkina Faso.
A community-based programme in Ghana, which used trained volunteers to provide information, pre-packaged drugs, and follow-up of children with fever, led to effective use, improved compliance, and improved care.
Significant reduction in mortality in children aged less than 5 years was achieved in Ethiopia through training of local coordinators to teach mothers to recognize the symptoms of malaria and to give antimalarial treatment promptly.
In Kenya, training of shopkeepers in the appropriate choice and dose of antimalarial drugs for the treatment of childhood fever can lead to more effective management.
Uganda has recently started going to scale with a national programme for home-based management of fever, using pre-packaged drugs, initially started in 10 districts. Reports from Uganda indicate that, despite challenges, there is good community involvement and mothers are able to manage malaria effectively. District-level data indicate that the programme is effective, and results in the lowering of morbidity and mortality among children.
Programmes must look for “windows of opportunity” for delivering effective antimalarials. Having appropriate messages and pre-packaged efficacious antimalarials at various “contact points” between the health system and children (or their caregivers) is likely to result in increased coverage of prompt treatment for malaria. These could include:
Routine visits (static and outreach) for immunizations (Expanded Programme on Immunization, EPI);
Other routine health visits, e.g. growth monitoring (static or outreach);
Child Health Days or other campaigns (such as that for measles);
Food distribution points, and nutritional rehabilitation programmes;
Local shopkeepers;
Research priorities:
Cost and effectiveness of large-scale programmes for the home management of malaria;
Programmatic issues such as training/capacity building, drug procurement and supply, and monitoring and evaluation;
Appropriate packaging and information that should accompany the treatment;
Effectiveness of the delivery of pre-packaged antimalarials through various “contact points” in the system.
The number and frequency of doses: “first-dose efficacy”
Adherence to multiple dose/multiple day drug regimens is suboptimal when compared with simpler regimens, such as one-dose therapy. The “first-dose efficacy” of an antimalarial is therefore critical to programme effectiveness. For example, the effectiveness of SP given as part of a programme is equivalent to that of SP given by directly observed therapy. Experience suggests that antimalarials given over longer periods (e.g. 5–7 days) are unlikely to result in complete treatment, particularly as the child feels better or if any adverse effects are present.
Research priorities:
First-dose efficacy of drugs;
Identification of antimalarials with short-course dosing regimens, and investigation on how to improve compliance with regimens lasting 2–3 days.
Functioning referral systems, and community-level treatment for the ill child who is unable to take oral antimalarials
There are limitations to referral in most rural settings, generally related to health system issues such as delayed or unavailable transport. However, efforts to strengthen health systems take time, and effective treatment for complicated/severe malaria should be available close to the community for those children who cannot be quickly referred.
Artesunate suppositories, given either at home or at an entry-level health-care facility, are a potentially useful way of providing effective emergency treatment for children who are unable to take oral medication.
Research priorities:
How to best treat the child at the periphery who is unable to take oral antimalarials. What is the role of artesunate suppositories — when, where and how to use?
Mechanisms to ensure that the child is followed up, and that the present episode has been fully treated.
Management of “chronic disease” and anaemia
Effective treatment for childhood malaria is as much about the management of “chronic disease” as it is about the management of acute febrile illness. Anaemia is a frequent consequence of malaria in many parts of the world, and chronic anaemia adversely affects physical and cognitive development. Repeated episodes of malaria, and inadequately treated illness, can lead to severe, life-threatening anaemia. Blood transfusions, which may be life-saving in these circumstances, can expose the child to the risk of infection with human immunodeficiency virus (HIV) and other blood-borne agents.
The management of anaemia with the concurrent administration of antimalarials and micronutrient supplements has demonstrated marked improvement in the haematological status of young children. In addition, the management of malaria at the household level goes beyond simply “drug therapy”. The child with chronic malaria and anaemia often also suffers from overall poor nutritional status. Good feeding practices — increased fluids, increased food intake and continued feeding — lead to better health outcomes in the sick child. Front-line health workers and other managers at the community level can reinforce these practices.
Research priorities:
The implications of large-scale programmes in which iron supplements and antimalarial drugs are administered concurrently, including the role of additional micronutrients, such as vitamin A and zinc.
Strategies to improve the nutritional status of the sick child.
“Prevention is the best medicine”
Use of effective prevention measures reduces morbidity and the transmission of malaria:
Use of insecticide-treated nets (ITN) reduces fever, illness and anaemia caused by malaria;
High coverage with ITNs at the household level reduces vector transmission;
Intermittent preventive treatment (IPT) for infants reduces morbidity and anaemia caused by malaria.
Better prevention means less illness caused by malaria, and therefore fewer children requiring treatment. Prevention must be emphasized as part of an integrated malaria control programme. Ensuring that ITNs are used among the highest possible proportion of young children is a priority, and therefore financing and distribution of ITNs within large-scale national programmes targeted at young children must be assured.
Research priorities:
Defining the most effective and efficient approaches to the delivery of ITNs for use by young children;
Further research on infant IPT linked to routine EPI programmes, including large-scale programme delivery (impact on EPI coverage; cost-effectiveness; infant formulations of drugs; impact on anaemia and mortality in a programme setting).
Conclusion
The way forward is to support research that provides national programmes with information that addresses the broad range of capacities required to assure that effective antimalarial therapy is available nearby when children become sick. To accomplish this objective, national policy-makers and programme-managers will benefit from research support in the areas identified above.
While new and more efficacious drugs and drug combinations will hopefully become affordable and available in Africa in the not-too-distant future, improved services for child survival cannot wait for that day. There must be a coordinated commitment to optimizing the use of drugs that are currently available, and to support the development of effective drug procurement and delivery logistics that will be sustained, irrespective of the drugs being recommended.
A criticism of this approach could be that deployment of drugs for use by caregivers at the household level might intensify the development of drug resistance. At the present time, much of the treatment provided at the household level uses ineffective drugs in inappropriate doses. Under-dosing is associated with poorer clinical outcomes, often manifested in children as anaemia. Providing efficacious drugs through a programme approach in a format that is likely to result in complete treatment, should result in the development of fewer resistant parasites. This tension between “saving lives” and “saving drugs” can be further alleviated by the wide deployment and use of preventive measures in order to reduce the transmission of the malaria parasite.
Footnotes
1. United Nations Special Session on Children, 8–10 May 2002, http://www.unicef.org/specialsession/wffc/index.html 
2. The Abuja Malaria Declaration, http://mosquito.who.int/docs/abuja_declaration.pdf.
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