Improving case management of malaria in African children

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Improving case management of malaria in African
children

• The vital role of NGOs
• Dr Jane Crawley, WHO/RBM

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Mortality from malaria

• 90 in African children
• Most deaths occur in the community

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Uninfected 1 Asymptomatic infection Uncompl
icated malaria 2 Severe
malaria 3 DEATH 1 Provision of
bednets 2 Recognition and prompt treatment 3
Recognition, prompt treatment and referral
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Trends in malaria mortality
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The big problems

• Drug resistance
• Weak health systems
• Poverty

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Combined failure rates with WHO in vivo test

• Place Date CQ SP 1st line
• Kenya (Kisumu) 2000 gt75 40 SP
• Tanzania (Mkuzi) 1999 gt75 34 SP
• Rwanda (Rwaza) 2000 50 16 SP/AQ
• Uganda (Aduku) 1999 21 17 CQ/SP
• Zambia (Isoka) 1999 49 16 Changing
• DRC (Kinshasa) 2001 37 9 CQ
• Mali 1999 4 4 CQ
• (Doneguebougou)

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Combination therapy
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Efficacy of combination therapy
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Favoured CT options

• SP Artesunate
• AQ Artesunate
• CoArtem (lumefantrine/artemether)
• SP AQ

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Implications for NGOs

• Drug failure
• need for careful follow-up
• consider drug efficacy monitoring
• Finance
• advanced budgeting in anticipation of increased
  drug costs
• lobby government over application to Global Fund
• Compliance
• support co-packaging initiatives

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Other drugs
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Clinical implications of drug resistance

• Recrudescent parasitaemia
• Anaemia
• Increasing mortality

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The burden of malarial anaemia

• Each year in children lt 5 years
• 1.4 - 5.7 million cases
• 190,000 - 974,000 deaths
• Case fatality rate of severe anaemia
• 13.4 - 17.2
• Highest mortality in infants

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Clinical diagnosis of anaemia

• Need to detect
• Those needing treatment (Hb lt11g/dl)
• Those needing transfusion (Hb lt5g/dl)
• Methods
• Clinical signs
• WHO Haemoglobin Colour Scale

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Diagnostic methods
Sensitivities Hb lt11 24 - 74 Hb lt11 75 -
85 Hb lt8 37 - 81 Hb lt 8 82 - 87 Both
will overestimate anaemia in areas of low
prevalence
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Treatment

• Treatment
• Iron, antimalarials, antihelminthics
• Refer for transfusion if severe
• Is transfusion possible at district hospital?
• Implications for NGOs
• Support donation programmes
• Provision of paediatric blood bags
• Laboratory consumables

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New prospects for prevention

• Intermittent presumptive treatment with SP
  (Ifakara, Tanzania)
• at 2, 3, and 9 months
• delivered via EPI
• 60 reduction in clinical malaria
• 50 reduction in severe anaemia
• BUT would it work in other settings?
• Need for large-scale implementation studies

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Severe malaria

• Triage
• Resuscitation
• Antimalarials and antibiotics
• Supportive care

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The importance of clinical triage

• Prostration
• Respiratory distress (deep breathing, chest
  indrawing)
• Easy and quick to perform
• Accurately identifies the children at highest
  risk of dying

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Resuscitation

• Check If Treatment
• Convulsions Lasts gt5 minutes Diazepam i/v
• Conscious level Not localising pain LP n/g
  tube
• Hydration Dehydrated i/v N-saline
• Circulation Shocked i/v N-saline or
  blood
• Blood glucose lt 2.2mmol/l i/v glucose
• Hb lt 5g/dl Transfuse

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Antimalarials and antibiotics

• In hospital
• i/v quinine or i/m artemether
• i/v chloramphenicol/benzyl penicillin if LP not
  possible
• At health centre (pre-referral treatment)
• i/m quinine or i/m artemether
• i/m chloramphenicol
• Role of rectal artesunate?

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Supportive care

• Fluids
• Regular observation
• conscious level
• respiratory rate
• blood glucose
• haemoglobin

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Referral systems
Shop HOME CHW HC Hospital Traditional
healer Syndromic management relies upon
functioning referral systems
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How can NGOs improve referral systems?

• The problem
• Failure of disease recognition
• Lack of transport
• Low expectations of health services

• The solution
• Community level training (mothers, CHWs, THs,
  shopkeepers)
• Transport provision
• Support local health facilities (clinics,
  hospital)

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Supporting health facilitiesNGOs can play a
vital role

• Ownership
• Staffing
• Support training and supervision
• Supply extra staff?
• Resources
• Dextrostix, 50 dextrose, blood bags?
• Transfusion service, laboratory support
• Importance of needs analysis

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Diagnostics Contact martinezgarciab_at_who.int
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Diagnosis based on clinical features
Disadvantages Lack of precision Over-treatment
Advantages Cheap Fast
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Diagnosis based on microscopy
Advantages Gold standard Quantitative Useful for
other diseases
Disadvantages Time consuming Relies upon good
microscopes, reagents, and trained technicians
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Rapid diagnostic tests

• Advantages
• Sensitive
• Fast
• Simple to perform
• No need for special equipment or electricity

• Disadvantages
• HRPII
• Not suitable for non Pf species
• Remains positive for 2 weeks after treatment
• Not quantitative
• Expensive (US0.60-2.50 per test)

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RDTs in Africa?Current situation

• Problems
• Asymptomatic parasitaemia
• Expense

• Special situations
• Complex emergencies
• Malaria epidemics
• Low transmission settings
• Military
• Travellers

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RDTs in AfricaFuture options

• Changing cost-benefit
• Rising drug costs
• Possible uses
• Confirmation of treatment failure (pLDH)
• Severe disease in peripheral settings
• BUT
• Will RDT diagnosis change clinical practice?
• Need for operational studies

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Summary

• Technical information
• Drug resistance
• Combination therapy
• Anaemia
• Severe malaria
• Diagnostics
• The unique position of NGOs
• Provision of effective drugs
• Training
• Referral systems
• Operational research

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The real challengefor NGOs and RBM

• SCALING UP district-level activities
• Need for NGO involvement in national plans
• What can RBM do to support you?

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Thank you