Feasibility and acceptability of artemisinin-based combination therapy for the home management of malaria in four African sites

BACKGROUND: The Home Management of Malaria (HMM) strategy was developed using chloroquine, a now obsolete drug, which has been replaced by artemisinin-based combination therapy (ACT) in health facility settings. Incorporation of ACT in HMM would greatly expand access to effective antimalarial therapy by the populations living in underserved areas in malaria endemic countries. The feasibility and acceptability of incorporating ACT in HMM needs to be evaluated. METHODS: A multi-country study was performed in four district-size sites in Ghana (two sites), Nigeria and Uganda, with populations ranging between 38,000 and 60,000. Community medicine distributors (CMDs) were trained in each village to dispense pre-packaged ACT to febrile children aged 6-59 months, after exclusion of danger signs. A community mobilization campaign accompanied the programme. Artesunate-amodiaquine (AA) was used in Ghana and artemether-lumefantrine (AL) in Nigeria and Uganda. Harmonized qualitative and quantitative data collection methods were used to evaluate CMD performance, caregiver adherence and treatment coverage of febrile children with ACTs obtained from CMDs. RESULTS: Some 20,000 fever episodes in young children were treated with ACT by CMDs across the four study sites. Cross-sectional surveys identified 2,190 children with fever in the two preceding weeks, of whom 1,289 (59%) were reported to have received ACT from a CMD. Coverage varied from 52% in Nigeria to 75% in Ho District, Ghana. Coverage rates did not appear to vary greatly with the age of the child or with the educational level of the caregiver. A very high proportion of children were reported to have received the first dose on the day of onset or the next day in all four sites (range 86-97%, average 90%). The proportion of children correctly treated in terms of dose and duration was also high (range 74-97%, average 85%). Overall, the proportion of febrile children who received prompt treatment and the correct dose for the assigned duration of treatment ranged from 71% to 87% (average 77%). Almost all caregivers perceived ACT to be effective, and no severe adverse events were reported. CONCLUSION: ACTs can be successfully integrated into the HMM strategy

A qualitative study of the feasibility and community perception on the effectiveness of artemether-lumefantrine use in the context of home management of malaria in south-west Nigeria

<p>Abstract</p> <p>Background</p> <p>In Nigeria ACT use at the community level has not been evaluated and the use of antimalarial drugs (commonly chloroquine (CQ)) at home has been shown to be largely incorrect. The treatment regimen of ACT is however more complicated than that of CQ. There is thus a need to determine the feasibility of using ACT at the home level and determine community perception on its use.</p> <p>Methods</p> <p>A before and after qualitative study using key informant interviews (KII) and focus group discussions (FGDs) was conducted in selected villages in Ona-Ara local government area. At baseline, 14 FGDs and 14 KIIs were conducted. Thereafter, community medicine distributors (CMDs) were trained in each village to dispense artemeter-lumenfantrine (AL) to febrile children aged 6–59 months presumed to have uncomplicated malaria. After one year of drug distribution, nine KIIs and 10 FGDs were conducted. Participants and key informants were mothers and fathers with children under five years, traditional heads of communities, opinion leaders and health workers.</p> <p>Results</p> <p>None of the participants have heard of AL prior to study. Participants were favourably disposed to introduction of AL into the community. Mothers/caregivers were said to have used AL in place of the orthodox drugs and herbs reported commonly used prior to study after commencement of AL distribution. The use of CMDs for drug distribution was acceptable to the participants and they were judged to be efficient as they were readily available, distributed correct dose of AL and mobilised the community effectively. AL was perceived to be very effective and no significant adverse event was reported. Major concerns to the sustainability of the program were the negative attitudes of health workers towards discharge of their duties, support to the CMDs and the need to provide CMDs incentives. In addition regular supply of drugs and adequate supervision of CMDs were advised.</p> <p>Conclusion</p> <p>Our findings showed that the use of AL at home and community level is feasible with adequate training of community medicine distributors and caregivers. Community members perceived AL to be effective thus fostering acceptability. The negative attitudes of the health workers and issue of incentives to CMDs need to be addressed for successful scaling-up of ACT use at community level.</p

Study of knowledge, attitudes and practices relating to visceral leishmaniasis (Kala-azar) in Tseikuru location, Kitui district, Kenya

Thesis, University of Nairobi, 1986Project number related to IDRC support could not be determine

Making decisions on health care: household management of malaria and visceral leishmaniasis (Kala-azar) in Baringo, Kenya

When confronted with illness, households have to make decisions on the type of health cars to seek. Studies in social medicine have in recent years attempted to delineate the factors which influence illness behaviour (health seeking behaviour). In medical anthropology, the major focus has been on the role of aetiological beliefs and cultural factors while sociologists have identified enabling and predisposing factors as the key factors behind health seeking behaviour. This paper discusses from these two perspectives, household management and decision making on two illnesses; malaria and visceral leishmaniasis (Kala-azar). Data from this study shows that the factors influencing illness behaviour in relation to the two diseases include: cost, perceived efficacy of treatment, quality of care, accessibility and symptom identification. Gender and social networks also play an important role in influencing household decisions on health care. Multiple use of therapies emerged in the treatment of malaria and kala-azar. The decision to use more than one health resource (provider) seemed to have been largely'due to the failure of an earlier treatment to effect cure and the perception that the resource used as an alternative would be able to cure the disease. Households utilised these various health resources either simultaneously or sequentially during a single illness episode. The study argues that constraints to seeking health care can be traced to the structural organisation of the health care system and to some extent to households' social conditions. The paper concludes with policy suggestions whose implementation could lead to better maximisation of health care resources by household

Still on the road : decentralisation and women's citizenship in Kenya

In Africa, the 1960s witnessed a strong desire by the new governments to replace colonial administrative arrangements. This led to many countries introducing different forms of decentralisation. Many argued that transferring legal, administrative and political authority from the central government to the lower units would foster efficient management of public resources and by that enable the states to meet the huge post-colonial expectations. But actual implementation revealed that governments were much concerned with deconcentration or transfer of administrative responsibilities to the lower units. There were generally very few attempts at giving autonomous powers to lower units and regions - devolution. Many were concerned about retaining control powers at the centre and giving the regions only administrative responsibilities....This concept paper is an attempt to outline key issues concerning decentralisation and women's citizenship in Kenya. It seeks to find out the implications of decentralisation for women's citizenship and in particular what decentralisation implies for women's social and economic rights. This concept paper provides an overview of gender and development, and further spells out whether decentralisation provides opportunities for women's participation in local decision making and access to justice. The paper further attempts to examine politics of ethnicity in relation to decentralisation and women's citizenship. For each of these issues, we have identified key research questions

Impact evaluation of malaria control interventions on morbidity and all-cause child mortality in Rwanda, 2000-2010

The impressive decline in child mortality that occurred in Rwanda from 1996-2000 to 2006-2010 coincided with a period of rapid increase of malaria control interventions such as indoor residual spraying (IRS); insecticide-treated net (ITN) distribution and use, and improved malaria case management. The impact of these interventions was examined through ecological correlation analysis, and robust decomposition analysis of contextual factors on all-cause child mortality. Child mortality fell 61% during the evaluation period and prevalence of severe anemia in children 6-23 months declined 71% between 2005 and 2010. These changes in malaria morbidity and mortality occurred concurrently with a substantial increase in vector control activities. ITN use increased among children under five, from 4% to 70%. The IRS program began in 2007 and covered 1.3 million people in the highest burden districts by 2010. At the same time, diagnosis and treatment with an effective antimalarial expanded nationally, and included making services available to children under the age of 5 at the community level. The percentage of children under 5 who sought care for a fever increased from 26% in 2000 to 48% in 2010. Multivariable models of the change in child mortality between 2000 and 2010 using nationally representative data reveal the importance of increasing ITN ownership in explaining the observed mortality declines. Taken as a whole, the evidence supports the conclusion that malaria control interventions contributed to the observed decline in child mortality in Rwanda from 2000 to 2010, even in a context of improving socioeconomic, maternal, and child health conditions

Emergence and clonal expansion of in vitro artemisinin-resistant Plasmodium falciparum kelch13 R561H mutant parasites in Rwanda

International audienceArtemisinin resistance (delayed P. falciparum clearance following artemisinin-based combination therapy), is widespread across Southeast Asia but to date has not been reported in Africa1-4. Here we genotyped the P. falciparum K13 (Pfkelch13) propeller domain, mutations in which can mediate artemisinin resistance5,6, in pretreatment samples collected from recent dihydroarteminisin-piperaquine and artemether-lumefantrine efficacy trials in Rwanda7. While cure rates were >95% in both treatment arms, the Pfkelch13 R561H mutation was identified in 19 of 257 (7.4%) patients at Masaka. Phylogenetic analysis revealed the expansion of an indigenous R561H lineage. Gene editing confirmed that this mutation can drive artemisinin resistance in vitro. This study provides evidence for the de novo emergence of Pfkelch13-mediated artemisinin resistance in Rwanda, potentially compromising the continued success of antimalarial chemotherapy in Africa