News Release

Study shows home management of malaria not appropriate for large urban settings

Peer-Reviewed Publication

The Lancet_DELETED

Home management of malaria using artemether-lumefantrine had little effect on clinical outcomes and led to overuse of the drug compared with standard care, and is thus inappropriate for large urban areas or settings with fairly low malaria transmission. These are the conclusions of authors of an Article published Online First and in an upcoming edition of The Lancet, written by Dr Sarah Staedke, London School of Hygiene and Tropical Medicine, UK, and MU-UCSF Research Collaboration, Kampala, Uganda, and colleagues.

In this randomised controlled trial in Kampala, 437 children aged 1-6 years from 325 households were assigned to receive home delivery of prepackaged artemether-lumefantrine for treatment of febrile (fever-like) illness (225 children) or standard care, in which carers were asked to continue their current approach to managing fever in their children (212 children). Children were followed up for one year after randomisation and information about their health status was obtained using questionnaires and household diaries, completed by their carers. The researchers showed that the home management group received nearly twice the number of antimalarial treatments as the standard care group (4.66 per child per year vs 2.53). The proportion of patients with parasitaemia (malaria parasities in the blood) at final assessment in the intervention group was lower than in the control group (2% vs 10%), but there were no other difference in standard malaria outcomes, including anaemia.

The cost of delivering the home management intervention in the trial was estimated at $33•83 per child per year, which was more expensive than the estimate for delivery of antimalarial drugs via the national programme ($23•16 per child per year), even after exclusion of research-related costs. The authors discuss say the cost-effectiveness of home delivery strategies will vary substantially with factors such as transmission intensity and alternative access to good-quality health care. They add, however: "In view of the high cost and the modest health benefit of the home management intervention in our study, cost-effectiveness ratios based on these estimates will probably prove unattractive compared with other interventions known to be cost effective in Africa."

The authors say: "Although home management of malaria led to prompt treatment of fever, there was little effect on clinical outcomes. The substantial over-treatment suggests that artemether-lumefantrine provided in the home might not be appropriate for large urban areas or settings with fairly low malaria transmission."

They conclude: "To achieve the best possible effect on health and to keep unnecessary over-treatment to a minimum, approaches that target treatment to laboratory-confirmed cases of malaria and strengthen delivery of care via health facilities might be preferable in urban settings. As opportunities for malaria control expand across Africa, strategies might need to be tailored to specific settings and account for local malaria transmission and availability of health services. A universal approach to deploying home management of malaria is unlikely to be appropriate."

In an accompanying Comment, Dr Karin Källander, Karolinska Institutet, Stockholm, Sweden, and Dr Jesca Nsungwa-Sabiiti, Ministry of Health, Kampala, Uganda, say: "Staedke and colleagues conclude that home management for malaria with artemether–lumefantrine is not the answer, and argue that fevers are better handled in health facilities in which diagnostic tools are available. While we agree that this approach would be ideal, the reality is that artemisinin combinations and diagnostics are largely unavailable in public facilities and too expensive in the private sector—resulting in high use of ineffective drugs such as chloroquine or monotherapy with artemisinin."

They conclude: "Strategies for the control of malaria that favour people who are poor are also essential for urban areas, especially for slums. Meanwhile, better evidence of the equity impact of interventions in the private sector is needed. Additionally, appropriate, practical, and cost-effective tools for monitoring coverage of and adherence to drugs in the urban context must be developed."

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Dr Sarah Staedke, London School of Hygiene and Tropical Medicine, UK, and MU-UCSF Research Collaboration, Kampala, Uganda T) +256 414 530692 E) sarah.staedke@lshtm.ac.uk

Dr Karin Källander, Karolinska Institutet, Stockholm, Sweden T) +256 782 310013 E) Karin.kallander@ki.se

For full Article and Comment, see: http://press.thelancet.com/malariauganda.pdf


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