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      Community response to artemisinin-based combination therapy for childhood malaria: a case study from Dar es Salaam, Tanzania

      , 1 , 2

      Malaria Journal

      BioMed Central

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          New malaria treatment guidelines in Tanzania have led to the large-scale deployment of artemether-lumefantrine (Coartem ®), popularly known as ALu or dawa mseto. Very little is known about how people in malaria endemic areas interpret policy makers' decision to replace existing anti-malarials, such as sulphadoxine-pyrimethamine (SP) with "new" treatment regimens, such as ALu or other formulations of ACT. This study was conducted to examine community level understandings and interpretations of ALu's efficacy and side-effects. The paper specifically examines the perceived efficacy of ALu as articulated by the mothers of young children diagnosed with malaria and prescribed ALu.


          Participant observation, six focus group discussions in two large villages, followed by interviews with a random sample of 110 mothers of children less than five years of age, who were diagnosed with malaria and prescribed ALu. Additionally, observations were conducted in two village dispensaries involving interactions between mothers/caretakers and health care providers.


          While more than two-thirds of the mothers had an overall negative disposition toward SP, 97.5% of them spoke favourably about ALu, emphasizing it's ability to help their children to rapidly recover from malaria, without undesirable side-effects. 62.5% of the mothers reported that they were spending less money dealing with malaria than previously when their child was treated with SP. 88% of the mothers had waited for 48 hours or more after the onset of fever before taking their child to the dispensary. Mothers' knowledge and reporting of ALu's dosage was, in many cases, inconsistent with the recommended dosage schedule for children.


          Deployment of ALu has significantly changed community level perceptions of anti-malarial treatment. However, mothers continue to delay seeking care before accessing ALu, limiting the impact of highly subsidized rollout of the drug. Implementation of ACT-based treatment guidelines must be complemented with educational campaigns to insure that mothers seek prompt help for their children within 24 hours of the onset of fever. Improved communication between health care providers and mothers of sick children can facilitate better adherence to ALu's recommended dosage. Community level interpretations of anti-malarials are multifaceted; integrating knowledge of local beliefs and practices surrounding consumption of anti-malarials into programmatic goals can help to significantly improve malaria control interventions.

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          Most cited references 24

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          Treatment seeking for malaria: a review of recent research.

           S C McCombie (1996)
          A review of literature on treatment seeking for malaria was undertaken to identify patterns of care seeking, and to assess what is known about the adequacy of the treatments used. There is considerable variation in treatment seeking patterns, with use of the official sector ranging from 10-99% and self-purchase of drugs ranging from 4-87%. The majority of malaria cases receive some type of treatment, and multiple treatments are common. The response to most episodes begins with self-treatment, and close to half of cases rely exclusively on self-treatment, usually with antimalarials. A little more than half use the official health sector or village health workers at some point, with delays averaging three or more days. Exclusive reliance on traditional methods is extremely rare, although traditional remedies are often combined with modern medicines. Although use of antimalarials is widespread, underdosing is extremely common. Further research is needed to answer the question of what proportion of true malaria cases get appropriate treatment with effective antimalarial drugs, and to identify the best strategies to improve the situation. Interventions for the private and public sector need to be developed and evaluated. More information is needed on the specific drugs used, considering resistance patterns in a particular area. In order to guide future policy development, future studies should define the nature of self-treatment, record multiple treatments and attempt to identify the proportions of all cases who begin treatment with antimalarials at standardized time intervals. Hypothetical questions were found to be of limited usefulness in estimating rates of actual treatments. Whenever possible, studies should focus on actual episodes of illness and consider supplementing retrospective surveys with prospective diary-type methods. In addition, it is important to determine the specificity of local illness terms in identifying true malaria cases and the extent to which local perceptions of severity are consistent with clinical criteria for severity and symptoms of complicated malaria.
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            Time To Move from Presumptive Malaria Treatment to Laboratory-Confirmed Diagnosis and Treatment in African Children with Fever

            In this Viewpoint, Blaise Genton and colleagues argue in favor of abandoning presumptive treatment for under-fives. Mike English and colleagues present the opposing Viewpoint in a related article: English M, Reyburn H, Goodman C, Snow RW (2009) Abandoning presumptive antimalarial treatment for febrile children aged less than five years—A case of running before we can walk? PLoS Med 6(1): e1000015. doi: 10.1371/journal.pmed.1000015 Malaria has long been the number one cause of fever and the leading cause of child mortality in sub-Saharan Africa. As a result, the World Health Organization (WHO) recommends treating any fever episode in African children with antimalarial drugs to save lives. However, this approach may not be as safe as it was 20 years ago for two major reasons. Firstly, the proportion of fevers due to malaria has become significantly lower, even in highly endemic areas, and hence the relative likelihood of missing other potentially fatal diseases has become higher. Secondly, we now have new reliable rapid diagnostic tests (RDTs) to allow proper diagnosis of malaria at all levels of the health system. Evidence of Decreased Malaria Transmission in Sub-Saharan Africa, and Declining Proportion of Fevers Due To Malaria There is growing evidence documenting a substantial decline in malaria transmission, morbidity, and mortality in more than 13 African countries where malaria control interventions have been implemented at scale. This reduction is also observed in areas with previously high levels of transmission (e.g., [1]). Although available data are not always spatially congruent, and therefore cannot necessarily be viewed as representing secular changes, the sharp decline in sub-Saharan Africa of the Plasmodium falciparum prevalence rate in children aged two to ten years—from 37% in the years 1985–1999 to 17% in 2000–2007—clearly documents this trend [2]. This decrease implies that many of the areas previously defined as “high stable malaria transmission” have changed, or will soon change, into “moderate to low transmission” areas. The lower the transmission, the lower the probability that a fever episode will be due to malaria. In Tanzania, a high-endemicity country, only one to four out of ten under-five patients with fever are parasitaemic in the rural settings (A. M. Kabanywany, 2007 and V. D'Acremont, 2008, personal communications) [3]. With a decline in malaria's prevalence, the hazard of misdiagnosis of many children becomes significant. When giving an antimalarial, the health worker is less likely to look for another treatable cause of fever, and this leads to higher morbidity and mortality due to delay in giving appropriate treatment, as suggested by studies that showed higher case fatality rates among non-malaria fevers compared to malaria fevers [4]. Availability of RDTs for Malaria The shift from symptom-based diagnosis to parasite-based management of malaria requires that clinicians have a reliable, easy-to-use, and inexpensive diagnostic test. It should have good sensitivity, require minimal training and equipment, and retain accuracy even after extensive storage under tropical conditions. All these characteristics are met by the new generation of RDTs. Two meta-analyses have clearly shown that the performance of RDTs is comparable to that of expert microscopy [5,6]. Appropriate action taken on the basis of the test result is now the key element for the successful introduction of RDTs. Unfortunately, this has not always been achieved in the implementation of RDTs so far, partly because the training was insufficient to change the clinician's perception of malaria risk [7]. In addition, the ambiguous messages from WHO and national guidelines stating that malaria should be considered even in the presence of a negative test have added to the confusion [8]. At present risk levels, the risk of missing a malaria case due to a false-negative test is substantially smaller than the risk of the patient dying due to another severe disease because of the focus on malaria. The risk of a false-negative test and its potential consequences have recently been evaluated thoroughly in Uganda (using microscopy) [9] and in Tanzania (using RDTs) [10], and the safety of not treating malaria-negative children confirmed. Other compelling arguments for systematic testing are listed in Box 1 [11,12]. Box 1. Additional Arguments for a Shift from Presumptive Malaria Treatment to Laboratory-Confirmed Diagnosis and Treatment According To Test Results in Children Under Five with Fever Treating all fever patients with antimalarials leads to a huge drug wastage, and hence potential for drug shortage Inappropriate use of antimalarials leads to unnecessary adverse drug reactions Irrational use of antimalarial drugs leads to increased parasite resistance Potential mistrust on the part of the public on the real efficacy of artemisinin-based combination therapies (ACTs) due to use for inappropriate indications (viral or bacterial disease) Parasitological diagnosis and treatment with ACTs according to test results versus presumptive treatment with ACTs is costeffective in all current malaria-endemic situations (as long as test result is taken into account) [11,12] Caveat A switch from presumptive treatment to laboratory-confirmed diagnosis and treatment is now urgent but needs to be carefully planned. Large-scale deployment of RDTs is a great challenge that requires theoretical and practical training, regular supervision, and sustained financial mechanisms to ensure constant availability. It is crucial that quality control is implemented at all steps. Also, introduction of reliable diagnosis implies that clinicians need to be trained to manage the “negative syndrome” (patients with a negative malaria test). This is challenging after years of upholding the notion that fever equals malaria and requires substantial change in the behaviour of clinicians and caretakers. This is now a great opportunity to update and re-strengthen the Integrated Management of Childhood Illnesses to promote improved case management of African children. Conclusion The recent trend of malaria decline in Africa calls for a shift from presumptive treatment to laboratory-confirmed diagnosis and treatment in all areas, regardless of age and level of malaria transmission. Such a move is especially relevant with the new momentum towards elimination and is now realistic thanks to reliable RDTs. As part of renewed malaria control efforts, it is time to improve clinical management and abandon irrational use of drugs, i.e., antimalarial treatment for no malaria and no treatment for other potentially fatal causes of fevers. Genton and Colleagues' Response to English and Colleagues' Viewpoint In this section, Genton and colleagues respond to the points raised by English and colleagues in their opposing Viewpoint: English M, Reyburn H, Goodman C, Snow RW (2009) Abandoning presumptive antimalarial treatment for febrile children aged less than five years—A case of running before we can walk? PLoS Med 6(1): e1000015. doi: 10.1371/journal.pmed.1000015 We all agree that laboratory-confirmed diagnosis of malaria is the desirable goal. We disagree on the present status of evidence and the conditions needed to change the policy. Evidence on RDT Performance Evidence is accumulating showing that RDT performance is high, even when used in routine practice [13–15]. The authors of the study showing 65% sensitivity acknowledge themselves that “use of poor quality blood smear may impede reliable measurement of sensitivity and specificity and undermine confidence in the new diagnostic” [16]. The issue nowadays is no longer about RDT performance but about how to best implement quality assurance. Evidence on the Safety of the Management Strategy Based on Laboratory Confirmation of Parasites Although the debate about laboratory-confirmed diagnosis versus presumptive treatment has been ongoing for years, nobody has embarked on the definitive study to show that mortality is not higher with the former than the latter. We have recent evidence confirming that the strategy based on documented diagnosis is safe [9], even in uncontrolled settings [10]. We consider that accumulated experience in all age groups and studies including more than 3,000 children under five are enough to decide on a policy change. Evidence on Health Workers' Beliefs and Behaviour New evidence shows that clinicians trust and act upon RDT results. Indeed, in recent studies conducted under programmatic conditions, 2%–10% of all patients with negative results were given antimalarials [16] (D'Acremont et al., unpublished data). This contrasts with disappointing results published earlier [17] and illustrates the behaviour change that can be achieved through proper training and trust gained by accumulating field experience with RDTs. To align practices in formal care settings with those at community level, we propose to also use RDTs outside health facilities. It is safe and feasible [18]. Moreover, it fits with the new WHO Special Programme for Research and Training in Tropical Diseases and UNICEF initiative that promotes community-integrated management of malaria/pneumonia/diarrhoea rather than home-based management of malaria. More Data on Malaria Epidemiology Improved data on local malaria epidemiology will not help much. We already know that heterogeneity is huge and rapidly evolving. Only a uniform policy across all age groups and epidemiological settings is likely to be implemented appropriately. This is best illustrated by the conclusion made by one of the authors of the opposing Viewpoint in a recent paper: “Despite different recommendations for patients below and above 5 years of age, malaria diagnosis and treatment practices were similar in the two age groups… Malaria diagnosis recommendations differing between age groups appear complex to implement; further strengthening of diagnosis and treatment practices under AL policy is required.” [19]. Conclusion We strongly believe that the policy should be changed even if all conditions for perfect implementation are not fulfilled. In areas where RDTs have been deployed at scale, clinicians have understood that the performance and usefulness of RDTs is not different in a child under five years than in an adult. The time needed to achieve all conditions English et al. consider necessary to have a policy change will only lead to more deaths due to diseases other than malaria left untreated and to the emergence of parasite resistance consequent to irrational use of drugs. A policy change is desirable to deliver clear and simple messages. Staggered implementation will follow according to country capacity, as is done for laboratory-confirmed diagnosis and treatment in other age groups.
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              Artemisinin-based combination therapies (ACTs): best hope for malaria treatment but inaccessible to the needy!

               T Mutabingwa (2005)
              Artemisinin-based combination therapies (ACTs) are the best anti-malarial drugs available now. Artemisinin enhances efficacy and has the potential of lowering the rate at which resistance emerges and spreads. Under low transmission intensity, ACTs have an additional public health benefit of reducing the overall malaria transmission and studies are urgently needed to investigate modalities of attaining similar benefits under high transmission. Despite being recommended by WHO since 2001, overall deployment of ACT has been slow. Limiting factors are high cost, limited knowledge and public awareness on the concept of combination therapy (CT) and ACT in particular, limited knowledge on safety of ACTs in pregnancy, operational issue such as inappropriate drug use, lack of suitable drug formulations, lack of post-marketing surveillance (PMS) systems, and the imbalance between demand and supply. Through concerted efforts of multilateral organizations, the local scientific community with involvement of policy-makers progress has been on several fonts leading to improved ACT uptake rates in the last 2 years. Of 43 countries that had adopted ACT by February 2005, 18 (42%) adopted the policy in 2004. Preference to co-formulated Coartem has led to a surge in its demand with consequent shortage. Alternative ways for increased production of ACTs are urgently needed otherwise most policies will remain adopted on paper. Despite limitations, opportunities are opening up for effective malaria control. Insecticides, insecticide-treated nets (ITNs) and ACTs are proven efficacious controls available that should be accessed by many. Substantial funding is now available for biomedical malaria research and for policy implementation. While the Global Fund is the financial engine behind the scaling up of ACT uptake, delays in cash flow after grant approval has led to many countries adopting ACT in 2004 but only few (nine) implementing it. Clear policies on granted funds and minimal politics within funding agencies might improve the situation. Increased interest in drug development together with the public and private sector partnership have led to new anti-malarials, some less expensive and therefore affordable by poor malaria endemic countries. Dihydroartemisinin-piperaquine (Artekin) has a cost advantage over other ACTs (USD 1 for an adult treatment) making it a potential best candidate for deployment in Africa. Part of available funds should be invested into capacity building and strengthening (personnel, resources and infrastructure) of institutions in malaria endemic countries. This will create enabling environment and a critical mass of scientists and public health experts to spearhead ACT policy implementation. Active involvement of scientists from malaria endemic countries in recent International Scientific Forums like the Malaria in Pregnancy Working Group and the Consortium on ACT Implementation is the best way forward to emulate.

                Author and article information

                Malar J
                Malaria Journal
                BioMed Central
                26 February 2010
                : 9
                : 61
                [1 ]Department of Anthropology, University of British Columbia, Vancouver, Canada
                [2 ]Department of Political Science and Sociology, University of Dodoma, Dodoma, Tanzania
                Copyright ©2010 Kamat and Nyato; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


                Infectious disease & Microbiology


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