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Impact of home-based management of malaria on health outcomes in Africa: a systematic review of the evidence.

Hopkins H, Talisuna A, Whitty CJ, Staedke SG - Malar. J. (2007)

Bottom Line: Of the four studies with mortality endpoints only one from Ethiopia showed a positive impact, with a reduction in the under-5 mortality rate of 40.6% (95% CI 29.2 - 50.6).To optimize treatment and maximize health benefits, drug regimens and delivery strategies in HMM programmes may need to be tailored to local conditions.Additional research could help guide programme development, policy decision-making, and implementation.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Medicine, University of California, San Francisco, USA c/o MU-UCSF Malaria Research Collaboration, P,O, Box 7475, Kampala, Uganda. hhopkins@medsfgh.ucsf.edu

ABSTRACT

Background: Home-based management of malaria (HMM) is promoted as a major strategy to improve prompt delivery of effective malaria treatment in Africa. HMM involves presumptively treating febrile children with pre-packaged antimalarial drugs distributed by members of the community. HMM has been implemented in several African countries, and artemisinin-based combination therapies (ACTs) will likely be introduced into these programmes on a wide scale.

Case presentations: The published literature was searched for studies that evaluated the health impact of community- and home-based treatment for malaria in Africa. Criteria for inclusion were: 1) the intervention consisted of antimalarial treatment administered presumptively for febrile illness; 2) the treatment was administered by local community members who had no formal education in health care; 3) measured outcomes included specific health indicators such as malaria morbidity (incidence, severity, parasite rates) and/or mortality; and 4) the study was conducted in Africa. Of 1,069 potentially relevant publications identified, only six studies, carried out over 18 years, were identified as meeting inclusion criteria. Heterogeneity of the evaluations, including variability in study design, precluded meta-analysis.

Discussion and evaluation: All trials evaluated presumptive treatment with chloroquine and were conducted in rural areas, and most were done in settings with seasonal malaria transmission. Conclusions regarding the impact of HMM on morbidity and mortality endpoints were mixed. Two studies showed no health impact, while another showed a decrease in malaria prevalence and incidence, but no impact on mortality. One study in Burkina Faso suggested that HMM decreased the proportion of severe malaria cases, while another study from the same country showed a decrease in the risk of progression to severe malaria. Of the four studies with mortality endpoints only one from Ethiopia showed a positive impact, with a reduction in the under-5 mortality rate of 40.6% (95% CI 29.2 - 50.6).

Conclusion: Currently the evidence base for HMM in Africa, particularly regarding use of ACTs, is narrow and priorities for further research are discussed. To optimize treatment and maximize health benefits, drug regimens and delivery strategies in HMM programmes may need to be tailored to local conditions. Additional research could help guide programme development, policy decision-making, and implementation.

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Categorization of published articles identified by the search strategy.
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Figure 1: Categorization of published articles identified by the search strategy.

Mentions: One thousand sixty-nine (1,069) potentially relevant articles were identified, most of which were not related to community-based diagnosis or treatment of malaria. Of the remainder, the following were excluded: a study that evaluated treatment in schools [25], as well as studies that measured only process indicators [26-28], assessed only changes in care-seeking and referral patterns [18,28], or evaluated only feasibility and acceptability [29-32]. A study from Niger, published in 1985, reported differences in malaria morbidity between villages with and without village health workers who provided both chemoprophylaxis and presumptive treatment with chloroquine (CQ), but there were no data distinguishing the effects of treatment from those of chemoprophylaxis [33]. Only one study, also published in 1985, was excluded on the basis of being conducted outside Africa; this study reported on the health impact of a village-based programme for presumptive antimalarial treatment of fever in Papua New Guinea [34]. Six studies that met all inclusion criteria were identified (Figure 1).


Impact of home-based management of malaria on health outcomes in Africa: a systematic review of the evidence.

Hopkins H, Talisuna A, Whitty CJ, Staedke SG - Malar. J. (2007)

Categorization of published articles identified by the search strategy.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2170444&req=5

Figure 1: Categorization of published articles identified by the search strategy.
Mentions: One thousand sixty-nine (1,069) potentially relevant articles were identified, most of which were not related to community-based diagnosis or treatment of malaria. Of the remainder, the following were excluded: a study that evaluated treatment in schools [25], as well as studies that measured only process indicators [26-28], assessed only changes in care-seeking and referral patterns [18,28], or evaluated only feasibility and acceptability [29-32]. A study from Niger, published in 1985, reported differences in malaria morbidity between villages with and without village health workers who provided both chemoprophylaxis and presumptive treatment with chloroquine (CQ), but there were no data distinguishing the effects of treatment from those of chemoprophylaxis [33]. Only one study, also published in 1985, was excluded on the basis of being conducted outside Africa; this study reported on the health impact of a village-based programme for presumptive antimalarial treatment of fever in Papua New Guinea [34]. Six studies that met all inclusion criteria were identified (Figure 1).

Bottom Line: Of the four studies with mortality endpoints only one from Ethiopia showed a positive impact, with a reduction in the under-5 mortality rate of 40.6% (95% CI 29.2 - 50.6).To optimize treatment and maximize health benefits, drug regimens and delivery strategies in HMM programmes may need to be tailored to local conditions.Additional research could help guide programme development, policy decision-making, and implementation.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Medicine, University of California, San Francisco, USA c/o MU-UCSF Malaria Research Collaboration, P,O, Box 7475, Kampala, Uganda. hhopkins@medsfgh.ucsf.edu

ABSTRACT

Background: Home-based management of malaria (HMM) is promoted as a major strategy to improve prompt delivery of effective malaria treatment in Africa. HMM involves presumptively treating febrile children with pre-packaged antimalarial drugs distributed by members of the community. HMM has been implemented in several African countries, and artemisinin-based combination therapies (ACTs) will likely be introduced into these programmes on a wide scale.

Case presentations: The published literature was searched for studies that evaluated the health impact of community- and home-based treatment for malaria in Africa. Criteria for inclusion were: 1) the intervention consisted of antimalarial treatment administered presumptively for febrile illness; 2) the treatment was administered by local community members who had no formal education in health care; 3) measured outcomes included specific health indicators such as malaria morbidity (incidence, severity, parasite rates) and/or mortality; and 4) the study was conducted in Africa. Of 1,069 potentially relevant publications identified, only six studies, carried out over 18 years, were identified as meeting inclusion criteria. Heterogeneity of the evaluations, including variability in study design, precluded meta-analysis.

Discussion and evaluation: All trials evaluated presumptive treatment with chloroquine and were conducted in rural areas, and most were done in settings with seasonal malaria transmission. Conclusions regarding the impact of HMM on morbidity and mortality endpoints were mixed. Two studies showed no health impact, while another showed a decrease in malaria prevalence and incidence, but no impact on mortality. One study in Burkina Faso suggested that HMM decreased the proportion of severe malaria cases, while another study from the same country showed a decrease in the risk of progression to severe malaria. Of the four studies with mortality endpoints only one from Ethiopia showed a positive impact, with a reduction in the under-5 mortality rate of 40.6% (95% CI 29.2 - 50.6).

Conclusion: Currently the evidence base for HMM in Africa, particularly regarding use of ACTs, is narrow and priorities for further research are discussed. To optimize treatment and maximize health benefits, drug regimens and delivery strategies in HMM programmes may need to be tailored to local conditions. Additional research could help guide programme development, policy decision-making, and implementation.

Show MeSH
Related in: MedlinePlus