TY - JOUR
T1 - Reduced paediatric hospitalizations for malaria and febrile illness patterns following implementation of community-based malaria control programme in rural Rwanda
AU - Sievers, Amy C.
AU - Lewey, Jenifer
AU - Musafiri, Placide
AU - Franke, Molly F.
AU - Bucyibaruta, Blaise J.
AU - Stulac, Sara N.
AU - Rich, Michael L.
AU - Karema, Corine
AU - Daily, Johanna P.
N1 - Funding Information:
We would like to thank Christine Mushashi for assisting with data extraction, the Ministry of Infrastructure for providing weather data, the Clinton Foundation and the Global Fund to Fight AIDS, TB and Malaria for providing funding, and most of all our community health workers, without whose devotion, skill, and hard work none of this would be possible. J.P.D. is supported by NIAID.
Funding Information:
Between rollout in September 2006 and study end in February 2007, 11,390 children were treated by CHWs within the communities served by the seven health centres affiliated with Rwinkwavu Hospital, and 1,408 (12%) were referred to a higher level of care. Initial training and drug supply was provided by the national malaria control programme (Programme National Intégré de Lutte contre le Paludisme, PNILP). Subsequent training, support and monitoring were provided by PIH staff and data were reported to PNILP. All therapeutic regimens were in accordance with Rwanda Ministry of Health guidelines. Drug supply was supported by the Global Fund to Combat AIDS, Tuberculosis and Malaria. The community-based treatment regimen consisted of age-based blister packs of sulphadoxine-pyrimethamine + amodiaquine (SP+AQ). Hospitalized children received intravenous quinine until able to tolerate oral medications, at which point they were switched to oral quinine to complete a 7 day course of treatment. Health centres were using AL for uncomplicated malaria but this predated the onset of the study period.
Funding Information:
The Rwandan Ministry of Health, supported by PIH and the Clinton Foundation, embarked on an intensive community-based prevention and early treatment malaria control programme. The prevention component was based on mass distribution of LLINs. Beginning in March 2006, nets were distributed by Rwinkwavu Hospital and its affiliated health centres to pregnant women as part of routine antenatal care, to all hospitalized children, to all malnourished children, and to many patients with HIV. Additionally, the Ministry of Health, supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria, organized mass distribution of LLINs to children of five years of age or less in September 2006 as part of an integrated measles vaccine campaign. A total of over 26,000 nets were distributed in southern Kayonza, an area with approximately 28,000 individual dwellings and a total population of 130,000. The majority of LLINs were distributed via the vaccination campaign. The early treatment component consisted of 300 community health workers (CHWs), who were trained to distribute antimalarials within each village to children of five years of age or less with fever and symptoms consistent with uncomplicated malaria. Additionally, CHWs were trained to identify and refer children with more severe disease, and poor po intake to their local health centres. Children who were considered more severely ill or required IV hydration by health centre clinical staff based on their clinical judgement were in turn transferred to Rwinkwavu Hospital. Finally, in December of 2006, we conducted a series of staff training programmes aimed at improving hospital-based paediatrics care and malaria care in particular. This included more rigorous guidelines for laboratory monitoring, including checking admission haemoglobin for all children with suspected malaria.
PY - 2008
Y1 - 2008
N2 - Background. Malaria control is currently receiving significant international commitment. As part of this commitment, Rwanda has undertaken a two-pronged approach to combating malaria via mass distribution of long-lasting insecticidal-treated nets and distribution of antimalarial medications by community health workers. This study attempted to measure the impact of these interventions on paediatric hospitalizations for malaria and on laboratory markers of disease severity. Methods. A retrospective analysis of hospital records pre- and post-community-based malaria control interventions at a district hospital in rural Rwanda was performed. The interventions took place in August 2006 in the region served by the hospital and consisted of mass insecticide treated net distribution and community health workers antimalarial medication disbursement. The study periods consisted of the December-February high transmission seasons pre- and post-rollout. The record review examined a total of 551 paediatric admissions to identify 1) laboratory-confirmed malaria, defined by thick smear examination, 2) suspected malaria, defined as fever and symptoms consistent with malaria in the absence of an alternate cause, and 3) all-cause admissions. To define the impact of the intervention on clinical markers of malaria disease, trends in admission peripheral parasitaemia and haemoglobin were analyzed. To define accuracy of clinical diagnoses, trends in proportions of malaria admissions which were microscopy-confirmed before and after the intervention were examined. Finally, to assess overall management of febrile illnesses antibiotic use was described. Results. Of the 551 total admissions, 268 (48.6%) and 437 (79.3%) were attributable to laboratory-confirmed and suspected malaria, respectively. The absolute number of admissions due to suspected malaria was smaller during the post-intervention period (N = 150) relative to the pre-intervention period (N = 287), in spite of an increase in the absolute number of hospitalizations due to other causes during the post-intervention period. The percentage of suspected malaria admissions that were laboratory-confirmed was greater during the pre-intervention period (80.4%) relative to the post-intervention period (48.1%, prevalence ratio [PR]: 1.67; 95% CI: 1.39 - 2.02; chi-squared p-value < 0.0001). Among children admitted with laboratory-confirmed malaria, the risk of high parasitaemia was higher during the pre-intervention period relative to the post-intervention period (age-adjusted PR: 1.62; 95% CI: 1.11 - 2.38; chi-squared p-value = 0.004), and the risk of severe anaemia was more than twofold greater during the pre-intervention period (age-adjusted PR: 2.47; 95% CI: 0.84 - 7.24; chi-squared p-value = 0.08). Antibiotic use was common, with 70.7% of all children with clinical malaria and 86.4% of children with slide-negative malaria receiving antibacterial therapy. Conclusion. This study suggests that both admissions for malaria and laboratory markers of clinical disease among children may be rapidly reduced following community-based malaria control efforts. Additionally, this study highlights the problem of over-diagnosis and over-treatment of malaria in malaria-endemic regions, especially as malaria prevalence falls. More accurate diagnosis and management of febrile illnesses is critically needed both now and as fever aetiologies change with further reductions in malaria.
AB - Background. Malaria control is currently receiving significant international commitment. As part of this commitment, Rwanda has undertaken a two-pronged approach to combating malaria via mass distribution of long-lasting insecticidal-treated nets and distribution of antimalarial medications by community health workers. This study attempted to measure the impact of these interventions on paediatric hospitalizations for malaria and on laboratory markers of disease severity. Methods. A retrospective analysis of hospital records pre- and post-community-based malaria control interventions at a district hospital in rural Rwanda was performed. The interventions took place in August 2006 in the region served by the hospital and consisted of mass insecticide treated net distribution and community health workers antimalarial medication disbursement. The study periods consisted of the December-February high transmission seasons pre- and post-rollout. The record review examined a total of 551 paediatric admissions to identify 1) laboratory-confirmed malaria, defined by thick smear examination, 2) suspected malaria, defined as fever and symptoms consistent with malaria in the absence of an alternate cause, and 3) all-cause admissions. To define the impact of the intervention on clinical markers of malaria disease, trends in admission peripheral parasitaemia and haemoglobin were analyzed. To define accuracy of clinical diagnoses, trends in proportions of malaria admissions which were microscopy-confirmed before and after the intervention were examined. Finally, to assess overall management of febrile illnesses antibiotic use was described. Results. Of the 551 total admissions, 268 (48.6%) and 437 (79.3%) were attributable to laboratory-confirmed and suspected malaria, respectively. The absolute number of admissions due to suspected malaria was smaller during the post-intervention period (N = 150) relative to the pre-intervention period (N = 287), in spite of an increase in the absolute number of hospitalizations due to other causes during the post-intervention period. The percentage of suspected malaria admissions that were laboratory-confirmed was greater during the pre-intervention period (80.4%) relative to the post-intervention period (48.1%, prevalence ratio [PR]: 1.67; 95% CI: 1.39 - 2.02; chi-squared p-value < 0.0001). Among children admitted with laboratory-confirmed malaria, the risk of high parasitaemia was higher during the pre-intervention period relative to the post-intervention period (age-adjusted PR: 1.62; 95% CI: 1.11 - 2.38; chi-squared p-value = 0.004), and the risk of severe anaemia was more than twofold greater during the pre-intervention period (age-adjusted PR: 2.47; 95% CI: 0.84 - 7.24; chi-squared p-value = 0.08). Antibiotic use was common, with 70.7% of all children with clinical malaria and 86.4% of children with slide-negative malaria receiving antibacterial therapy. Conclusion. This study suggests that both admissions for malaria and laboratory markers of clinical disease among children may be rapidly reduced following community-based malaria control efforts. Additionally, this study highlights the problem of over-diagnosis and over-treatment of malaria in malaria-endemic regions, especially as malaria prevalence falls. More accurate diagnosis and management of febrile illnesses is critically needed both now and as fever aetiologies change with further reductions in malaria.
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U2 - 10.1186/1475-2875-7-167
DO - 10.1186/1475-2875-7-167
M3 - Article
C2 - 18752677
AN - SCOPUS:53249123167
VL - 7
JO - Malaria Journal
JF - Malaria Journal
SN - 1475-2875
M1 - 167
ER -