Feasibility of Malaria Diagnosis and Management in Burkina Faso, Nigeria, and Uganda: A Community-Based Observational Study

Abstract

Background. Malaria-endemic countries are encouraged to increase, expedite, and standardize care based on parasite diagnosis and treat confirmed malaria using oral artemisinin-based combination therapy (ACT) or rectal artesunate plus referral when patients are unable to take oral medication.Methods. In 172 villages in 3 African countries, trained community health workers (CHWs) assessed and diagnosed children aged between 6 months and 6 years using rapid histidine-rich protein 2 (HRP2)–based diagnostic tests (RDTs). Patients coming for care who could take oral medication were treated with ACTs, and those who could not were treated with rectal artesunate and referred to hospital. The full combined intervention package lasted 12 months. Changes in access and speed of care and clinical course were determined through 1746 random household interviews before and 3199 during the intervention.Results. A total of 15 932 children were assessed: 6394 in Burkina Faso, 2148 in Nigeria, and 7390 in Uganda. Most children assessed (97.3% [15 495/15 932]) were febrile and most febrile cases (82.1% [12 725/15 495]) tested were RDT positive. Almost half of afebrile episodes (47.6% [204/429]) were RDT positive. Children eligible for rectal artesunate contributed 1.1% of episodes. The odds of using CHWs as the first point of care doubled (odds ratio [OR], 2.15; 95% confidence interval [CI], 1.9–2.4; P < .0001). RDT use changed from 3.2% to 72.9% (OR, 80.8; 95% CI, 51.2–127.3; P < .0001). The mean duration of uncomplicated episodes reduced from 3.69 ± 2.06 days to 3.47 ± 1.61 days, Degrees of freedom (df) = 2960, Student's t (t) = 3.2 (P = .0014), and mean duration of severe episodes reduced from 4.24 ± 2.26 days to 3.7 ± 1.57 days, df = 749, t = 3.8, P = .0001. There was a reduction in children with danger signs from 24.7% before to 18.1% during the intervention (OR, 0.68; 95% CI, .59–.78; P < .0001).Conclusions. Provision of diagnosis and treatment via trained CHWs increases access to diagnosis and treatment, shortens clinical episode duration, and reduces the number of severe cases. This approach, recommended by the World Health Organization, improves malaria case management.Clinical Trials Registration. ISRCTN13858170.

Training Community Health Workers to Manage Uncomplicated and Severe Malaria: Experience From 3 Rural Malaria-Endemic Areas in Sub-Saharan Africa

“…The study was conducted in rural malaria-endemic areas of Burkina Faso, Nigeria, and Uganda, as a component of a larger study to evaluate access to diagnostics and antimalarials provided by CHWs in their communities [7]. …”

“…Widespread CHW-based deployment of artemisinin-based combination therapies (ACTs) and rapid diagnostic tests (RDTs) is feasible and acceptable [7, 8, 9]. The World Health Organization (WHO) recommends that all treatment be based on parasitology [6] and encourages use of quality-assured malaria RDTs where microscopy is not practical to reduce unnecessary ACT treatment and identify patients who need alternative management [6, 10, 11].…”

“…In the context of a deployment study to scale up access to RDTs, ACTs, and rectal artesunate in 3 malaria-endemic countries of Africa [7], we assessed how well CHWs could be trained in IMCI [12, 13]. We report on our experience in training CHWs in Burkina Faso, Nigeria, and Uganda and on the performance of CHWs in assessing, classifying, and treating children according to the IMCI strategy.…”

Impact of Improving Community-Based Access to Malaria Diagnosis and Treatment on Household Costs

“…We found evidence of this through a significant reduction in the proportion of children with danger signs requiring referral to hospital during the intervention: 24.7% vs 18.1% [17]. The illness recovery was shorter during the intervention, reducing from 3.69 to 3.47 days [17]. Those who went to a CHW during the intervention incurred significantly lower out-of-pocket costs compared with those who did not do so.…”

“…As part of an implementation study that trained CHWs to assess sick children, diagnose malaria using RDTs, and treat with ACTs or rectal artesunate in 3 African countries (Burkina Faso, Nigeria, and Uganda) chosen because they are among the top 10 countries contributing 80% of global malaria cases [17], we studied the private household costs for a febrile episode in a child before the intervention was launched, and after the CHWs’ training was completed and the intervention was in force. Our objective was to quantify the impact of this intervention improving access to malaria diagnosis and treatment on private household costs of illness, and to provide policy makers with reliable estimates of these costs if they were to consider scaling up the intervention at the district or national level.…”