Impact of Community Management of Fever (Using Antimalarials With or Without Antibiotics) on Childhood Mortality: A Cluster-Randomized Controlled Trial in Ghana

Abstract

Malaria and pneumonia are leading causes of childhood mortality. Home Management of fever as Malaria (HMM) enables presumptive treatment with antimalarial drugs but excludes pneumonia. We aimed to evaluate the impact of adding an antibiotic, amoxicillin (AMX) to an antimalarial, artesunate amodiaquine (AAQ+AMX) for treating fever among children 2–59 months of age within the HMM strategy on all-cause mortality. In a stepped-wedge cluster-randomized, open trial, children 2–59 months of age with fever treated with AAQ or AAQ+AMX within HMM were compared with standard care. Mortality reduced significantly by 30% (rate ratio [RR] = 0.70, 95% confidence interval [CI] = 0.53– 0.92, P = 0.011) in AAQ clusters and by 44% (RR = 0.56, 95% CI = 0.41–0.76, P = 0.011) in AAQ+AMX clusters compared with control clusters. The 21% mortality reduction between AAQ and AAQ+AMX (RR = 0.79, 95% CI = 0.56 –1.12, P = 0.195) was however not statistically significant. Community fever management with antimalarials significantly reduces under-five mortality. Given the lower mortality trend, adding an antibiotic is more beneficial.

Where there is no doctor: can volunteer community health workers in rural Uganda provide integrated community case management?

“…Will iCCM encourage drug 'overtreatment', resulting in drug resistance? Addition of rapid diagnostic testing to iCCM (proven feasible elsewhere in Uganda and sub-Saharan Africa) 20,29,39 should be seriously considered.…”

“…20 In a multi-methods Ethiopian study, volunteer CHWs treating diarrhoea, pneumonia, and fever and were highly accessed by community members 22 . Our study is complimentary suggesting multi-illness iCCM using CHWs with variable formal education is feasible, which is supportive of work in Eastern Uganda 23,[27][28][29][30] ; however, caution is needed to further understand quality of work, an issue highlighted by a recent study from Central Uganda.…”

“…16,17 African iCCM studies are few, 14,18 and less still have assessed health outputs and outcomes. 5,14,[19][20][21][22][23] National programs in sub-Saharan Africa are new and while early studies are demonstrating implementation feasibility and early positive outcomes 7,8 , more studies are needed to understand implementation in a variety of contexts including use of volunteer CHWs with limited formal education and short iCCM training.…”

Perceived Quality of Care of Community Health Worker and Facility-Based Health Worker Management of Pneumonia in Children Under 5 Years in Western Kenya: A Cross-Sectional Multidimensional Study

“…However, other research has shown that many iCCM programs have not achieved decreases in mortality and fail to perform on intermediate outcomes. [13][14][15][16] Especially, troubling is the result of a study in which adding pneumonia management to an existing program of diarrhea and malaria community management led to no statistically significant reduction in mortality in a well-controlled randomized controlled trial. 15 Therefore, it is imperative to perform research that assesses the efficacy and acceptability of iCCM programs.…”

Making a Case for Diversion of Solid Medical Waste from Households: A Generation Study in Ga South Municipal Assembly, Accra, Ghana

“…The traditional domain of SMW is the healthcare industry, where waste is generated from a variety of healthcare activities. However, a limited variety of healthcare activities can also occur in households such as being found in home based care [3] [4], shortened hospital stay [5], care and treatment of chronic diseases in aging populations [6], and home management of illnesses such as malaria [7]. Although SMW constitutes up to 0.1% of the mixed municipal solid waste stream, its hazardous character attracts public sensitivity and poses a challenge to health and municipal authorities [8].…”