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2f. Malaria: Scaling up Access to Antimalarials - Opportunities
Impact of Training, Monitoring, and Mentoring on Drug and Therapeutic Committees in Ghana
1Management Sciences for Health, United States of America; 2Management Sciences for Health, Ghana; 3Consultant
Problem statement: Although Ghana’s antimalaria drug policy (AMDP) was changed in 2004 to include use of artemisinin-based combination therapy (ACT) to treat uncomplicated malaria, monotherapies were still in circulation, particularly in the private sector. Also, locally manufactured amodiaquine-artesunate (AS/AQ) tablets at a higher than recommended strength resulted in negative publicity for ACTs due to adverse drug effects. The AMDP was revised again to include 2 second-line ACTs—artemether-lumefantrine (AL) and dihydoartemisinin–piperaquine—but health facilities still did not comply with the AMDP recommendations.
Objectives: To improve facility drug and therapeutics committee (DTC) understanding of the new AMDP and highlight their role in supporting health facility compliance; to improve rational medicine use and compliance to AMDP at public and private health facilities
Setting: 48 public and private health facilities in Greater Accra, Western, and Central regions in Ghana; the post-intervention study was conducted in 2 health facilities, Maamobi and Kaneshie polyclinics, in the Greater Accra region. Public and private health facilities were selected based on criteria that included their level within the Ghana Health Services hierarchy, such as tertiary and primary facilities, and presence or absence of a functional DTC.
Study population: Doctors, pharmacists, administrators, procurement officers, nurses, medical assistants, technical officers, and pharmacy assistants
Intervention: Trained 155 DTC members from 48 facilities on rational medicine use and the new AMDP; conducted supportive supervisory visits at 20 of the 48 health facilities and mentored DTC members to improve practices
Outcome measures: Percentages of indicators related to AMDP compliance
Results: Maamobi polyclinic baseline: 85% of prescriptions for uncomplicated malaria cases conformed to AMDP (prescribed ACTs); 20% of cases were prescribed AS/AQ, while 80% were prescribed AL. Post-intervention, AMDP conformity increased to 92%; prescriptions for AS/AQ increased to 65% and AL decreased to 35%. Kaneshie polyclinic baseline: AMDP conformity was 80%; 53% of cases were prescribed AS/AQ and 47% were prescribed AL. The post-intervention visit showed that prescriptions conforming to AMDP increased to 87%; AS/AQ prescriptions increased to 75% and AL prescriptions decreased to 25%.
Conclusions: Although training, supervisory visits, and mentoring can be resource-intensive, the survey showed that these interventions improve rational medicine use in health facilities.
Funding source: United States Agency for International Development-President’s Malaria Initiative
Improving the Use of Artemesinin-Based Combination Therapy in Rural Zambia
1Center for Global Health and Development, Boston University, Boston, MA, USA; 2Department of International Health, Boston University School of Public Health, Boston, MA, USA; 3Chikankata Mission Hospital, Chikankata, Zambia
Problem statement: Zambia, like many malaria endemic sub-Saharan African countries, has changed its first-line drug for uncomplicated malaria to the more expensive and effective artemether-lumefantrine (AL). There are valid concerns about potential overuse of AL and development of resistance if AL use at the community level by community health workers (CHWs) is not guided by rapid diagnostic tests.
Objectives: The primary objective was to assess whether the use of RDTs by CHWs will reduce the overuse of AL. The secondary objective was to assess the feasibility and safety of CHWs performing RDTs.
Design: This was a cluster randomized, controlled trial with a cluster defined as the catchment area of a community health post. CHWs in control clusters prescribed AL to all children with fever whereas those in intervention clusters used RDTs to guide treatment with AL. We also carried out focus group discussions and in-depth interviews to assess the community’s opinions and perceptions about the intervention.
Setting: The study was conducted in the Chikankata Mission Hospital catchment area (estimated population 70,000), which extends across parts of Siavonga and Mazabuka Districts in Zambia’s Southern Province. The study area is a typical rural area with poor roads, which is served by the mission hospital and 5 official Ministry of Health rural health centers. Most sick children are seen by CHWs who work in a fixed location called the community health post, which serves a number of villages.
Study population: Children aged between 6 months and 5 years who presented to a CHW at a health post with fever were enrolled. Children with signs or symptoms of severe illness were excluded and referred; 3125 children were enrolled over a 12-month period in both the intervention and control arms.
Intervention: Both the intervention and control CHWs received 4 days of training in classification and treatment of febrile children and were supplied with AL. The intervention arm received an additional half-day training in the performance and interpretation of RDT results and how to respond to both positive and negative results. They were also supplied with RDTs.
Outcome measure: Proportion of children presenting with fever who received AL
Results: The proportion of children presenting with a history of fever that received AL in the intervention arm was 27.5% compared to 99.1% in the control arm (RR 0.23, 95% CI 0.14–0.38). Minor side effects associated with the pricking the finger for RDT included bleeding longer than caregiver’s expectation (1.5%), bruises (0.4%), and local skin infection (0.2%). Caregivers and community leaders indicated their acceptance for CHWs to perform RDTs and prescribe antipyretics for children with RDT negative results.
Conclusions: The potential for CHWs to use RDTs to guide prescription of AL for treatment of malaria at the community level is promising and has great potential to reduce overuse of AL.
Funding sources: United States Agency for International Development and the President’s Malaria Initiative
Feasibility and Impact of Deploying Artemether-Lumefantrine (AL) At Community Level with the Introduction of Rapid Diagnostic Test (RDT)
1Tigray Health Bureau, Ethiopia, Ethiopia; 2Umea° Centre for Global Health Research, Umea University, Sweden; 3Global Malaria Programme;WHO, Geneva; 4Italian Ministry of Labour, Health and Social Policies, Rome, Italy; 5Italian Dermatological Center of Mekelle,Tigray, Ethiopia; 6Novartis Pharma AG, Nairobi, Keneya; 7Novartis Farma S.P.A, Rome, Italy; 8San Gallicano Dermatological Institute, Rome, Italy; 9Novartis Pharma AG, Basel, Switzerland
Problem statement: Rural African communities have limited access to health facilities for malaria diagnosis and treatment because of poor communication, lack of knowledge, as well as distance.
Objective: To assess the feasibility and impact of deploying artemether-lumefantrine (AL) at the community level with the introduction of rapid diagnostic test (RDT)
Design: Two homogenous districts were selected. A two-year interventional and observational study with times series comparison with random assignment of the intervention to one district and the other serving as control.
Setting: This community-based malaria control intervention study was conducted in two districts with similar malaria eco-epidemiological features in Tigray region, Ethiopia in 2005–07.
Study population: The average population of the intervention and control districts was 89,377 and 118,693, respectively. We consider the population lives below 2,000 masl which was 81% and 98.5%, in respective districts. The basic characteristics of the populations in the two districts were similar.
Intervention: AL was dispensed at health facilities in both districts after clinical assessment and/or confirmed. In the intervention district, community health workers (CHWs) dispensed AL based on clinical diagnosis of malaria during year 1. In year 2, 50% of CHWs in the intervention district were equipped with RDTs to dispense AL only to RDT-positive individuals.
Policy: The national guideline does not include any intervention on community-based diagnosis and treatment of malaria. Health workers are too overworked, with vast catchment areas and multiple responsibilities. Therefore suspending the CHWs would only be a reasonable compromise, not a substitute for the community-based health service.
Outcome measure(s): Malaria transmission rate, malaria morbidity and admission, malaria specific mortality rate (verbal autopsy), and health care resource utilization
Results: In the intervention district, about 60% of all patients treated for malaria were managed by CHWs, close to home. The prevalence survey revealed that the crude parasite rate was less by threefold (7.4%) in the intervention district vs. 20.8% in the control district despite the fact it was higher in the control before the intervention. Over the two-year study, multivariate modelling indicated no significant difference in risk of all-cause mortality between the intervention and control districts (adjusted incidence rate ratio [aIRR] 1.03, 95% CI 0.87–1.21, p=0.751), but risk of malaria-specific mortality was lower in the intervention district (aIRR 0.60, 95% CI 0.40–0.90, p=0.013). Use of RDTs by CHWs in year 2 led to exclusion of non–P. falciparum in 90% of suspected cases.
Conclusions: AL deployment with RDT at a community level lowered malaria burden and is feasible if CHWs are committed, appropriately trained, well equipped, and supported through frequent supervision.
Funding source(s): Novartis Farma S.P.A., The Italian Ministry of Labour, Health and Social Policies and World Health Organization