GHF2008 – PS34 – New Approaches to Field-based Malaria Treatment

Session Outline

Parallel session PS34, Wednesday, May 28 2008, 14:00-15:30, Room 17
Chair(s): Christian Lengeler, Epidemiology and Public Health, Swiss Tropical Institute, Switzerland 
Feasibility and Acceptability of Artemisinin-Based Combination Therapy for the Home Management of Malaria at Four African Sites
Ikeoluwapo Ajayi, Malaria Research Laboratories, College of Medicine, University of Ibadan, Nigeria
Reaching the Un-Reached in the Event of Severe Malaria in Under Five Children in a Rural District in Ghana
Margaret Gyapong, Dodowa  Health Research Centre, Ghana Health Service, Ghana
Intermittent Preventive Treatment of Malaria among Children (IPTc) in The Gambia and Ghana: How Different Delivery Strategies May Lead to Different Cost, Coverage and Equity Conclusions
Lesong Conteh, Swiss Centre for International Health, Swiss Tropical Institute, Switzerland 
Understanding and Improving Access to Malaria Treatment in Tanzania (ACCESS)
Manuel Hetzel, Research Scientist, Swiss Tropical Institute, Switzerland

Session Documents

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Session Report

Contributors: Suzie Abessolo (ICVolunteers)

The professor of epidemiology at the Swiss Tropical Institute, Christian Lengeler, introduced the session by asking "How can we improve and reach innovative ways of Malaria treatment?" This question was answered by four NGOs working in different African countries.

Ms. I. O. Ajayi, Department of Epidemiology, Medical Statistics and Environmental Health for Nigeria, presented the feasibility and acceptability of Artemisin-Based Combination (ACT) therapy for the home management of malaria at four sites in Africa. This study, funded by UNICEF, the UN Development Programme, the World Bank and the WHO/Tropical Diseases Research, was carried out in Nigeria, Uganda and two sites in Ghana representing different health system and epidemiological settings. The study was conducted in three phases: pre-intervention, intervention and finally monitoring and evaluation. The pre-intervention activities involved advocacy, community sensitization and mobilization, situation analysis and selection of drugs distributor. The intervention phase consisted of preparing training manuals and training key implementers, developing and executing Information Education and Communication (IEC) strategies, dispensing and using drugs at the community level. Monitoring and evaluation involves the recognition of early signs of malaria and prompt treatment by caregivers and community medicine distributors (CMD), adherence to treatment regimen by drug distributors and CMDs, danger identification signs and prompt referral, availability of drugs, adequacy and effectiveness of IEC messages. Some 20 000 fever episodes in young children were treated with ACT by CMDs in four sites. The range of children correctly treated is from 74% to 97%. These results provide evidence that ACT use can be successfully used in the home.

Ms. Margaret Gyapong, health researcher at Dodowa Health Research Centre, explained how to reach the unreached in the event of severe malaria in rural Ghana. The purpose is to make an effective drug available to caretakers as close to the patient's home as possible. Ninety percent of the deaths among African children are due to poor access to medication, cost of care and perceptions about disease causation. Patients with acute malaria, who are unable to take medication by mouth and are not at a health centre, can be given a Rectal Artesunate (RA) plus referral. The study showed a 25% reduction in mortality when the rectal formulation is given as pre-referral treatment at community level. Of the babies saved, 84% were administered the drug by their mothers. The study was conducted in 4 health centres, 6 community clinics and 3 private clinics serving a population of 100 000 people. More than 100 children less than 5 years old were selected for the study divided into 3 groups: Mother Caretaker (MUM), Community Directed (COM), and Health System (MOH).

All the caretakers gave informed consent and 85% of the children received accurate dosages. Half of the recruited children were sent to the Drugs dispenser and over 80% of caretakers went to a health facility within 24 hours. Further education is needed to reduce the almost 20% who did not comply with referral advice (www.ghanahealthservice.org).

Ms. L. Conteh from the Swiss Tropical Institute explained the use of intermittent preventive treatment of malaria among children (IPTc) in Gambia and Ghana: how different delivery strategies may lead to different coverage, cost and equity. Intermittent preventive treatment is administered to the population at risk at a specified time, limiting morbidity and preventing mortality. The study randomly assessed three rounds of three doses during September, October and November 2006 in Gambia. An average of 12 329 children were enrolled and received IPTc, delivered by clinic or volunteer health workers who trekked in. However, in Ghana, four rounds of 3 doses were distributed in May, June, September and October 2006. Community-based volunteer or government health workers delivered IPTc to 1039 children enrolled in the study. Preliminary results show that IPTc can be a cost effective intervention in reducing malaria morbidity and mortality in areas with a high level of seasonal malaria. The costs of community health workers delivering IPTc are driven by the drugs costs, delivery of drugs and supervision. Preliminary findings suggest that delivering IPTc via community health workers does not appear to exclude certain socio-economic status. More studies are needed to enlighten the relationship between equity outcomes and cost effectiveness ratios of different delivery strategies.

Mr. Hetzel, from the Novartis Foundation for Sustainable Development in Switzerland, summarized the improving access to malaria treatment in Tanzania due to the Access programme. The Access project was carried out between 2003 and 2007 in two rural districts in Tanzania to improve the delivery of quality health care using malaria as a tracer condition. This was achieved through three complementary interventions: 1) social marketing; 2) improvements in quality of public health care services through training and supervisory support; 3) the development of high-quality commercial drug outlets. Semi-quantitative cross-sectional community surveys were used to investigate disease perception and treatment seeking behaviour, completed by quantitative and qualitative studies on drug availability and quality of care. Mortality was assessed longitudinally using a demographic surveillance system. The outcomes show that social marketing works. The quality of public health care is poor and represents the biggest obstacle to appropriate treatment. There are limited resources to support and strengthen entire health systems. The commercial drug sector is an essential component of care delivery in resource-poor countries and its quality can be improved.

Following the presentations, discussion centred on some related questions. What level of knowledge is required for community health workers? Ms. Ajayi answered that primary education is sufficient. How do we inform mothers about the preventive treatment? Ms. Conteh explained that there are now staff in the health centres tasked with getting the message out to the population.

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