Malaria management in children with fever in rural Sierra Leone. Has anything changed after the Ebola outbreak?

Abstract

<ns4:p><ns4:bold>Background: </ns4:bold>Sierra Leone is one of the highest malaria burden countries in the world and was severely affected by the 2014-15 Ebola outbreak. As fever is a common symptom of both malaria and Ebola, it might have affected the management of fever in children. Among under-fives in Koinadugu district, Sierra Leone, we determined fever cases that had malaria diagnostic testing and treated with Artemisinin-based Combination Therapy (ACT) during pre-Ebola, intra-Ebola and post-Ebola periods.</ns4:p><ns4:p> <ns4:bold>Methods:</ns4:bold> The study population included all children under five with fever who presented to 68 primary healthcare facilities in Koinadugu district. Malaria management was in line with national guidelines. All individuals presenting with fever should be subjected to a malaria diagnostic test, which may involve a Rapid Diagnostic Test (RDT) or microscopy. Only confirmed malaria cases should receive ACTs.</ns4:p><ns4:p> The study spanned pre-Ebola (June 1, 2013 – April 30, 2014), intra-Ebola (June 1, 2014 – April 30, 2015) and post-Ebola (June 1, 2016 – April 30 ,2017) periods. Data were sourced directly from routine morbidity registers available at each health facility.</ns4:p><ns4:p> <ns4:bold>Results: </ns4:bold>In the 68 health facilities, fever cases increased from 43,245 pre-Ebola to 74,367 post-Ebola (1.7-fold increase). Diagnosed malaria ranged between 66% and 75%. Only 47% of malaria cases were treated during Ebola. ACT use was 95% pre-Ebola, 99% intra-Ebola and dropped to 71% post-Ebola. Post-Ebola, an average of 40 (59%) facilities had monthly stock-outs of ACT (range 28-45).</ns4:p><ns4:p> <ns4:bold>Conclusion:</ns4:bold> What has changed since the Ebola outbreak is the increased utilisation of services for malaria. However, ACT stockouts are of concern, and this requires attention in order to ensure compliance with national malaria treatment guidelines.</ns4:p>

Operational research: did health systems in Sierra Leone recover after the 2014-15 Ebola outbreak?

“…After a decline of health service provision and utilisation during the outbreak 2, 3 , present findings show recovery over time in the post-Ebola period. There are some encouraging signs that some health indicators may even be better than before the outbreak.…”

“…There are some encouraging signs that some health indicators may even be better than before the outbreak. Following investments in staff and community involvement, a steep increase of utilization of malaria diagnostic testing was reported post-Ebola 3 . In addition, post-Ebola childhood mortality is reported to be lower compared to pre-Ebola 4 .…”

“…Medical staff and non-medical staff deficits hover around 60% and 90%, respectively, and did not substantially change post-Ebola 6 . The recovering health system was unable to cope with the increased demand for anti-malaria drugs, which resulted in stock outs 3 . In addition, a 12-fold increase of measles cases post-Ebola is an alarming indicator of reduced herd immunity and requires urgent action 4 .…”