Combination treatments for malaria found safe and effective for children when provided by volunteers
Research shows potential to save many lives
"For a year now, no child has died and we have not sent any of them to the hospital."
ACCRA, Ghana, 11 June, 2007: Lucy Vulley, a 45-year-old wife, mother of five children and nursery school teacher, had an unusual lesson to teach today. Meeting with top health officials from WHO, UNICEF and the government of Ghana, she explained how she and other community volunteers have been able to dramatically increase the number of children who get malaria medications right at home without having to walk for hours to find a doctor or healthcare facility. Lucy was a participant in an innovative research study to assess a distribution method called home management of malaria, or HMM.
The research showed that almost 80% of caregivers went to trained community members for malaria medications, a figure above the Abuja target set by African heads of state in 2000 for getting 60% of those with malaria to treatment within 24 hours. The WHO Ghana Representative, Dr Joachim Saweka, said, "These results suggest that ACTs do work in the community setting in Ghana, and that they can be delivered by trained community members. Reaching the Abuja targets is possible."
Every year nearly 25,000 children and 200 pregnant mothers die from malaria in Ghana. The disease is transmitted through the bite of an infected anopheline mosquito, resulting in fevers, fatigue and often life threatening symptoms like convulsions and severe anaemia. The parasites have developed resistance to the cheapest and most widely used drugs -- chloroquine and sulfadoxine-pyrimethamine (SP). So WHO now recommends using only the newer combination treatments with artemisinin and at least one other medication. The combination reduces the speed at which parasites can develop resistance.
But it is important to know if community members living far from medical facilities can manage these drugs, since they have never been used in these settings which require different regimens from traditionally used drugs. Widespread use of combination drugs would also have major cost implications, as the new drugs are much more expensive than the old ones.
Three research studies were conducted in Ejisu-Juaben, Ho and Dangme West districts using one of the new artemisinin-combination treatments (ACTs) in community settings – 2 studies used artemesinin-amodiaquine (AS+AQ) and 1 study used artemether+lumefantrine (Coartem).
The unique aspect of this delivery being studied is that the drugs are dispensed outside health care facilities and managed by trained local volunteers, like farmers, mothers and shop keepers. Both the mothers and the health care providers praised the process. Mothers can get to drug distributors easily and quickly so they can catch the illness at an early stage. They don't have to travel long distances to get to the hospital, which costs them not only time away from the family but also money to travel. Health workers believe their workload has reduced as a result of the community-level case management of malaria. When a serious case arises, the people are appropriately referred from the community to the nearest health facility.
Researchers provided not only the numbers and data, but also quotes from anonymous interviews with mothers and community leaders. A community drug distributor in the Kpetoi Ziope subdistrict said, “The change is that, previously, when children fall sick, we take some time to look for money and walk all the distance to go to the hospital. Sometimes before we get there the child’s condition becomes worse. If you are lucky to get to the hospital early, after treatment you walk the same distance back or are referred to the big hospital. The unlucky ones either die before they get to the clinic or die at the clinic. But ever since the introduction of this program, we have seen a change. For a year now, no child has died and we have not sent any of them to the hospital."
An opinion leader in Dededo pointed out that "Traveling to buy the medicine involves transport cost and then paying for the medicine. If the drug is close to you, it reduces expenses for child care."
Dr. Edmund N.L Browne, one of the primary investigators, pointed out, "Having the community in charge of this is the reason why this has been so successful. With the local drug distributors who know the community and live close by, we can save many lives."
The studies were conducted by the Ghana Health Service and Kwame Nkrumah University of Science and Technology, and supported by TDR, the Special Programme for Research and Training in Tropical Diseases based at WHO, and UNICEF Ghana. Approximately 70% of feverish children got treatment through trained community workers, and more than 85% of them within 24 hours of onset of symptoms and with the correct dose of ACTs (artesunate-amodiaquine).
The Director General of Ghana Health Services, Dr. E. K. Sory, is recommending that the country implement policies to scale up their use throughout the country. “One of the strategic objectives of the GHS is to improve geographical access by ensuring availability of community based services. Home management of malaria is a promising strategy to provide access to prompt, appropriate and effective drugs to children who suffer from malaria. The Home Management strategy is surely the way forward. Priority health interventions include promoting home based care of fevers with emphasis on symptom detection and early treatment. If we want to reach the MDG’s then we need to find ways of decreasing child morbidity and mortality.”
Lucy Vulley completing her home management of malaria training.
Press Officer Contacts:
WHO Ghana: Mrs. Sophia Twun-Barima
Phone: +233 21 731003
Email: Twum-BarimaS@gh.afro.who.int
Ghana Health Service: Edith K. Wellington
Phone: +233 21 681109
Mobile: +233 24 4221284
Email: Edith.Wellington@hru-ghs.org
TDR: Mrs. Jamie Guth, Communications Manager, Geneva, Switzerland
Contact Jamie Guth
Questions on malaria and the home management of malaria research
What is malaria?
Malaria is a common and serious tropical diseases, killing almost 1 million people worldwide each year. The vast number of malaria deaths occur among young children in Africa, especially in remote rural areas with poor access to health services.
How is it caused?
Malaria is transmitted through the bite of an infected anopheline mosquito, but can also be transmitted by blood transfusion, contaminated needles and syringes, and from mother to child before and/or during birth.
What are ACTs?
Artemisinin is a drug manufactured from a plant that has been shown to be highly effective in killing malaria parasites. It will cure falciparum malaria in 7 days, but studies have shown that in combination with certain synthetic drugs they produce higher cure rates in 3 days with higher adherence to treatment. Furthermore, there is some evidence that the use of such combinations in areas with low to moderate transmission can retard the development of resistance to the partner drug.
Consequently, WHO recommends that all countries experiencing resistance to conventional monotherapies, such as chloroquine, amodiaquine or sulfadoxine– pyrimethamine, should use combination therapies, preferably those containing artemisinin derivatives (ACTs – artemisinin-based combination therapies) for falciparum malaria.
WHO recommends that Ghana use artemesinin with amodiaquine (AS+AQ) for its first line of treatment.
What is home management of malaria?
Home management of malaria (HMM) is a deceptively simple plan -- train local mothers and other community members to recognize fevers, provide pre-packaged medications, and keep the medicines properly stored and recorded. HMM was developed to increase access to medicines in areas where there is no nearby health facility or provider, so that medicines can be provided quickly to children with malaria, preventing the risks of serious illness and death.
The first results in Ethiopia using chloroquine showed a 40% reduction in under-five child mortality, and were published in the Lancet. Later, the work of Sodiomon Sirima and Franco Pagnoni showed that catching the malaria early with prompt treatment stopped it from progressing to a more severe and fatal form.
In addition to Ghana, studies using ACTs in home management settings are underway in Benin, Burkina Faso, Cameroon, Ethiopia, Malawi, Nigeria, Uganda and the United Republic of Tanzania.
How many people were involved in the Ghana study and where?
In the Ho District, 76 Community Drug Distributors were trained in 49 communities with a population of 42,000 and supervised by 11 public health providers within the three sub districts. They were assisted by two social scientists who provided technical support.
In an article from an earlier research study on home management of malaria published in Tropical Medicine and International Health (TMIH) in July 2006, the researchers showed that about 90% of caregivers in Ghana gave the correct artemether– lumefantrine dose.
How much do ACTs cost?
In this study, drugs for children aged 6-11 months cost ¢1000 and those for children aged 12-59 months cost ¢2000 -- approximately 10 and 20 cents respectively. Caregivers could collect the drug and pay later if they did not have the money to pay at the time of child’s illness. However, most mothers were able to pay for drug since the cost was affordable.