Factors associated with mortality from childhood malaria in Navrongo DSS Site, Ghana, 1995-2000

ABSTRACT: Background: Malaria is endemic throughout Ghana and continues to be a major public health concern especially among pregnant women and children under the age of five. The Ministry of Health (MoH) estimates that over the past ten years, there have been 2-3 million cases of malaria each year, representing 40 percent of outpatient cases, while severe malaria accounts for 33-36 percent of in-patients. Malaria also accounts for 25 percent of the deaths in children under the age of five (GHS, 2001). Correct identification of risk factors could focus interventions at reducing malaria mortality in children. Demographic Surveillance System (DSS) sites have been established and they generate high quality population based longitudinal health and demographic data. The DSS conduct Verbal Autopsies to determine probable causes of death. Objective: This study examines factors affecting childhood malaria mortality in Northern Ghana, using longitudinal data collected by the Navrongo DSS during the period 1995- 2000. It deals especially with the role of socioeconomic factors (mother’s education, family wealth index based on the possessions and housing characteristics and residence, and possession of bed net) and the demographic characteristics (child’s sex and age, and mother’s age). Design: Secondary data analysis of longitudinal data collected by the Navrongo Health Research Centre. Multinomial logistic regression was used to compare the relative risk in three groups of children i.e. those who died of Malaria and those who died of other causes to those who survived as base. Results: Overall, for the deaths due to malaria, older children (1-5years) had a higher risk (RRR 1.4, 95%CI 1.25-1.57 P <0.0001) of dying compared to the infants. Equally, children born of older mothers (maternal age at birth of child >30 years) had a higher risk (RRR 1.28, 95%CI 1.15-1.42 P <0.0001). However, maternal education and residence had a protective effect, with children born of mothers who had some education (RRR 0.79, 95%CI 0.67-0.93 P=0.004) and residing in urban area (RRR 0.61, 95%CI 0.46-0.82 P=0.001) having a lower risk. Similarly, those children whose families are in the highest wealth index had a lower risk (RRR 0.76, 95%CI 0.63-0.91 P=0.003). Interestingly, the same factors were associated with deaths occurring due to other causes, but with varying degree of association. Whereas sex of child was not associated with malaria deaths, being female offered a lower risk of dying from other causes (RRR 0.9, 95%CI 0.84-0.98 P=0.017). It was observed that children in the older age group (1-5 years) were at higher risk of dying (RRR 1.14, 95%CI 1.05-1.25 P=0.002) just as those born of older mothers (RRR 1.16, 95%CI 1.07-1.26 P <0.0001). Even in this group, maternal education (RRR 0.87, 95%CI 0.76-0.98 P=0.023), a higher wealth index (RR 0.87, 95%CI 0.77-0.99 P=0.032 and RRR 0.63 95%CI 0.54-0.73 P <0.0001 for the two highest categories of wealth indices respectively), and area of residence (RRR 0.67, 95%CI 0.55-0.83 P <0.0001) offered a reduction in the risk of dying. Conclusion: The study identified the risk factors (age and sex of the child and mother’s age, maternal education, wealth and residence of the family) associated with malaria mortality and other causes of death in childhood in northern Ghana and this should help formulate cost effective interventions such as health education

Community case management of malaria using ACT and RDT in two districts in Zambia: achieving high adherence to test results using community health workers

<p>Abstract</p> <p>Background</p> <p>Access to prompt and effective treatment is a cornerstone of the current malaria control strategy. Delays in starting appropriate treatment is a major contributor to malaria mortality. WHO recommends home management of malaria using artemisininbased combination therapy (ACT) and Rapid Diagnostic tests (RDTs) as one of the strategies for improving access to prompt and efective malaria case management.</p> <p>Methods</p> <p>A prospective evaluation of the effectiveness of using community health workers <b>(</b>CHWs) as delivery points for ACT and RDTs in the home management of malaria in two districts in Zambia.</p> <p>Results</p> <p>CHWs were able to manage malaria fevers by correctly interpreting RDT results and appropriately prescribing antimalarials. All severe malaria cases and febrile non-malaria fevers were referred to a health facility for further management. There were variations in malaria prevalence between the two districts and among the villages in each district. 100% and 99.4% of the patients with a negative RDT result were not prescribed an antimalarial in the two districts respectively. No cases progressed to severe malaria and no deaths were recorded during the study period. Community perceptions were positive.</p> <p>Conclusion</p> <p>CHWs are effective delivery points for prompt and effective malaria case management at community level. Adherence to test results is the best ever reported in Zambia. Further areas of implementation research are discussed.</p

Increased Risk for Severe Malaria in HIV-1–infected Adults, Zambia

In areas in which malaria and HIV-1 are coendemic, adults with severe malaria who show no clinical signs of immunosuppression are likely to be infected with HIV-1

A comparison of fluoroquinolones versus other antibiotics for treating enteric fever: meta-analysis

Objectives To review evidence supporting use of fluoroquinolones as first line agents over other antibiotics for treating typhoid and paratyphoid fever (enteric fever)

Safety and efficacy of lumefantrine-artemether (Coartem) for the treatment of uncomplicated Plasmodium falciparum malaria in Zambian adults.

BACKGROUND: In Zambia, unacceptably high resistance to commonly used antimalarial drugs prompted the choice of artemether-lumefantrine (AL) as first line treatment for uncomplicated Plasmodium falciparum malaria. Although the safety and efficacy of AL have been extensively documented, no clinical trials had been carried out in Zambia. METHODS: Nine hundred seventy one adult patients with uncomplicated malaria were randomized to either sulfadoxine-pyrimethamine (SP)(486) or AL (485) and followed up for 45 days. Outcome of treatment was defined according to the standard WHO classification. Recurrent parasitaemia were genotyped to distinguish between recrudescence and new infection. RESULTS: Fever at day 3 was significantly lower (AL: 0.9%; 4/455; SP: 3,5%; 15/433; p = 0.007) and the mean haemoglobin at day 45 significantly higher (AL: 134 g/l; SP 130 g/l; p = 0.02) in the AL group. Almost all clinical symptoms cleared faster with AL. Early treatment failure was significantly higher in the SP (25/464) than in the AL (2/463) (OR: 13.1 95% CI: 3.08-55.50; P < 0.001). The rate of new infections was similar in both groups (18 with SP and 19 with AL). Late clinical failure (OR: 2.55; 95% CI: 1.34-4.84; P = 0.004) and late parasitological failure (OR:3.18; 95% CI: 1.25-8.09; P = 0.02) were significantly higher in the SP group. Total treatment failure was significantly higher in the SP group (96/393; 19.3%) as compared to the AL (22/403; 5.4%) group (OR: 4.15; 95% CI: 2.52-6.83; P < 0.001). CONCLUSION: In Zambia, the new first line regimen AL is far more efficacious than SP in treating uncomplicated P. falciparum malaria in adults. Data on safety and efficacy of AL in pregnant women are urgently needed

Relative costs and effectiveness of treating uncomplicated malaria in two rural districts in Zambia: implications for nationwide scale-up of home-based management

<p>Abstract</p> <p>Background</p> <p>Malaria case management is one of the key strategies to control malaria. Various studies have demonstrated the feasibility of home management of malaria (HMM). However, data on the costs and effectiveness of artemisinin-based combination therapy (ACT) and rapid diagnostic tests via HMM is limited.</p> <p>Method</p> <p>Cost-effectiveness of home management versus health facility-based management of uncomplicated malaria in two rural districts in Zambia was analysed from a providers' perspective. The sample included 16 community health workers (CHWs) and 15 health facilities. The outcome measure was the cost per case appropriately diagnosed and treated. Costs of scaling-up HMM nationwide were estimated based on the CHW utilisation rates observed in the study.</p> <p>Results</p> <p>HMM was more cost effective than facility-based management of uncomplicated malaria. The cost per case correctly diagnosed and treated was USD 4.22 for HMM and USD 6.12 for facility level. Utilization and adherence to diagnostic and treatment guidelines was higher in HMM than at a health facility.</p> <p>Conclusion</p> <p>HMM using ACT and RDTs was more efficient at appropriately diagnosing and treating malaria than the health facility level. Scaling up this intervention requires significant investments.</p

Early results of integrated malaria control and implications for the management of fever in under-five children at a peripheral health facility: a case study of Chongwe rural health centre in Zambia

<p>Abstract</p> <p>Background</p> <p>Zambia has taken lead in implementing integrated malaria control so as to attain the National Health Strategic Plan goal of "reducing malaria incidence by 75% and under-five mortality due to malaria by 20% by the year 2010". The strategic interventions include the use of long-lasting insecticide-treated nets and indoor residual spraying, the use of artemisinin-based combination therapies (ACT) for the treatment of uncomplicated malaria, improving diagnostic capacity (both microscopy and rapid diagnostic tests), use of intermittent presumptive treatment for pregnant women, research, monitoring and evaluation, and behaviour change communication. Financial barriers to access have been removed by providing free malaria prevention and treatment services.</p> <p>Methods</p> <p>Data involving all under-five children reporting at the health facility in the first quarter of 2008 was evaluated prospectively. Malaria morbidity, causes of non-malaria fever, prescription patterns treatment patterns and referral cases were evaluated</p> <p>Results</p> <p>Malaria infection was found only in 0.7% (10/1378), 1.8% (251378) received anti-malarial treatment, no severe malaria cases and deaths occurred among the under-five children with fever during the three months of the study in the high malaria transmission season. 42.5% (586/1378) of the cases were acute respiratory infections (non-pneumonia), while 5.7% (79/1378) were pneumonia. Amoxicillin was the most prescribed antibiotic followed by septrin.</p> <p>Conclusion</p> <p>Malaria related OPD visits have reduced at Chongwe rural health facility. The reduction in health facility malaria cases has led to an increase in diagnoses of respiratory infections. These findings have implications for the management of non-malaria fevers in children under the age of five years.</p

A Head-to-Head Comparison of Four Artemisinin-Based Combinations for Treating Uncomplicated Malaria in African Children: A Randomized Trial

BackgroundArtemisinin-based combination therapies (ACTs) are the mainstay for the management of uncomplicated malaria cases. However, up-to-date data able to assist sub-Saharan African countries formulating appropriate antimalarial drug policies are scarce.Methods and findingsBetween 9 July 2007 and 19 June 2009, a randomized, non-inferiority (10% difference threshold in efficacy at day 28) clinical trial was carried out at 12 sites in seven sub-Saharan African countries. Each site compared three of four ACTs, namely amodiaquine-artesunate (ASAQ), dihydroartemisinin-piperaquine (DHAPQ), artemether-lumefantrine (AL), or chlorproguanil-dapsone-artesunate (CD+A). Overall, 4,116 children 6-59 mo old with uncomplicated Plasmodium falciparum malaria were treated (1,226 with AL, 1,002 with ASAQ, 413 with CD+A, and 1,475 with DHAPQ), actively followed up until day 28, and then passively followed up for the next 6 mo. At day 28, for the PCR-adjusted efficacy, non-inferiority was established for three pair-wise comparisons: DHAPQ (97.3%) versus AL (95.5%) (odds ratio [OR]: 0.59, 95% CI: 0.37-0.94); DHAPQ (97.6%) versus ASAQ (96.8%) (OR: 0.74, 95% CI: 0.41-1.34), and ASAQ (97.1%) versus AL (94.4%) (OR: 0.50, 95% CI: 0.28-0.92). For the PCR-unadjusted efficacy, AL was significantly less efficacious than DHAPQ (72.7% versus 89.5%) (OR: 0.27, 95% CI: 0.21-0.34) and ASAQ (66.2% versus 80.4%) (OR: 0.40, 95% CI: 0.30-0.53), while DHAPQ (92.2%) had higher efficacy than ASAQ (80.8%) but non-inferiority could not be excluded (OR: 0.35, 95% CI: 0.26-0.48). CD+A was significantly less efficacious than the other three treatments. Day 63 results were similar to those observed at day 28.ConclusionsThis large head-to-head comparison of most currently available ACTs in sub-Saharan Africa showed that AL, ASAQ, and DHAPQ had excellent efficacy, up to day 63 post-treatment. The risk of recurrent infections was significantly lower for DHAPQ, followed by ASAQ and then AL, supporting the recent recommendation of considering DHAPQ as a valid option for the treatment of uncomplicated P. falciparum malaria.Trial registrationClinicalTrials.gov NCT00393679; Pan African Clinical Trials Registry PACTR200901000091175