Pre-referral Rectal Artesunate Treatment by Community-Based Treatment Providers in Ghana, Guinea-Bissau, Tanzania, and Uganda (Study 18): A Cluster-Randomized Trial

Abstract

Background. If malaria patients who cannot be treated orally are several hours from facilities for injections, rectal artesunate prior to hospital referral can prevent death and disability. The goal is to reduce death from malaria by having rectal artesunate treatment available and used. How best to do this remains unknown.Methods. Villages remote from a health facility were randomized to different community-based treatment providers trained to provide rectal artesunate in Ghana, Guinea-Bissau, Tanzania, and Uganda. Prereferral rectal artesunate treatment was provided in 272 villages: 109 through community-based health workers (CHWs), 112 via trained mothers (MUMs), 25 via trained traditional healers (THs), and 26 through trained community-chosen personnel (COMs); episodes eligible for rectal artesunate were established through regular household surveys of febrile illnesses recording symptoms eligible for prereferral treatment. Differences in treatment coverage with rectal artesunate in children aged <5 years in MUM vs CHW (standard-of-care) villages were assessed using the odds ratio (OR); the predictive probability of treatment was derived from a logistic regression analysis, adjusting for heterogeneity between clusters (villages) using random effects.Results. Over 19 months, 54 013 children had 102 504 febrile episodes, of which 32% (31 817 episodes) had symptoms eligible for prereferral therapy; 14% (4460) children received treatment. Episodes with altered consciousness, coma, or convulsions constituted 36.6% of all episodes in treated children. The overall OR of treatment between MUM vs CHW villages, adjusting for country, was 1.84 (95% confidence interval [CI], 1.20–2.83; P = .005). Adjusting for heterogeneity, this translated into a 1.67 higher average probability of a child being treated in MUM vs CHW villages. Referral compliance was 81% and significantly higher with CHWs vs MUMs: 87% vs 82% (risk ratio [RR], 1.1 [95% CI, 1.0–1.1]; P < .0001). There were more deaths in the TH cluster than elsewhere (RR, 2.7 [95% CI, 1.4–5.6]; P = .0040).Conclusions. Prereferral episodes were almost one-third of all febrile episodes. More than one-third of patients treated had convulsions, altered consciousness, or coma. Mothers were effective in treating patients, and achieved higher coverage than other providers. Treatment access was low.Clinical Trials Registration. ISRCTN58046240.

Malaria: How Are We Doing and How Can We Do Better?

“…Implementation science research can help us learn how to best integrate malaria management into primary care, avoid potential adverse consequences of a solely vertical focus on malaria, and offer early and appropriate evaluation and management of children with severe malaria (e.g. rectal artemisinins followed by rapid transport to referral centers 23 ). With research advances, it is critical that these are translated into best practices within national public health policies.…”

Assessing the impact of health research on health policies: a study of the Dodowa Health Research Centre, Ghana

“…More than 400 hundred people received the research results.Main research productsProject report and Power point presentation: Done. No policy brief.2006Articles: Article published in 2016 [33]. 2016Policy impactsLevel of policy making: the project had an impact at national level, at health managers and at health providers’ level.Type of policy: the study influenced clinical practice policies on the management of malaria cases.Nature of policy impact: This was a mobilization of support where research findings supported the feasibility of including rectal articulate on guides and protocols in Ghana.Policy networks: researchers informed policy makers through the dissemination mechanisms (district, regional and national dissemination forum).Political capital: the researcher believes they gained value in reaching policy agreements.…”

“…No policy brief. 2006 Articles: Article published in 2016 [ 33 ]. 2016 Policy impacts Level of policy making: the project had an impact at national level, at health managers and at health providers’ level.…”

Research Advances on Health Effects of Edible Artemisia Species and Some Sesquiterpene Lactones Constituents

“…Consequently, when malaria patients cannot be treated orally, rectal artesunate prior to hospital referral can prevent death and disability. In fact, the WHO recommends this, to reduce the risk of death or permanent disability [ 213 ].…”