Abstract:
Background: The use of artemisinin-based combination therapy (ACT) at the community level
has been advocated as a means to increase access to effective antimalarial medicines by high risk
groups living in underserved areas, mainly in sub-Saharan Africa. This strategy has been shown to
be feasible and acceptable to the community. However, the parasitological effectiveness of ACT
when dispensed by community medicine distributors (CMDs) within the context of home
management of malaria (HMM) and used unsupervised by caregivers at home has not been
evaluated.
Methods: In a sub-set of villages participating in a large-scale study on feasibility and acceptability
of ACT use in areas of high malaria transmission in Ghana, Nigeria and Uganda, thick blood smears
and blood spotted filter paper were prepared from finger prick blood samples collected from
febrile children between six and 59 months of age reporting to trained CMDs for microscopy and
PCR analysis. Presumptive antimalarial treatment with ACT (artesunate-amodiaquine in Ghana,
artemether-lumefantrine in Nigeria and Uganda) was then initiated. Repeat finger prick blood
samples were obtained 28 days later for children who were parasitaemic at baseline. For children
who were parasitaemic at follow-up, PCR analyses were undertaken to distinguish recrudescence
from re-infection. The extent to which ACTs had been correctly administered was assessed
through separate household interviews with caregivers having had a child with fever in the previous
two weeks.
Results: Over a period of 12 months, a total of 1,740 children presenting with fever were enrolled
across the study sites. Patent parasitaemia at baseline was present in 1,189 children (68.3%) and
varied from 60.1% in Uganda to 71.1% in Ghana. A total of 606 children (51% of infected children)
reported for a repeat test 28 days after treatment. The crude parasitological failure rate varied
from 3.7% in Uganda (C.I. 1.2%–6.2%) to 41.8% in Nigeria (C.I. 35%–49%). The PCR adjusted
parasitological cure rate was greater than 90% in all sites, varying from 90.9% in Nigeria (C.I. 86%–
95%) to 97.2% in Uganda (C.I. 95%–99%). Reported adherence to correct treatment in terms of
dose and duration varied from 81% in Uganda (C.I. 67%–95%) to 97% in Ghana (C.I. 95%–99%) with
an average of 94% (C.I. 91%–97%).
Conclusion: While follow-up rates were low, this study provides encouraging data on
parasitological outcomes of children treated with ACT in the context of HMM and adds to the
evidence base for HMM as a public health strategy as well as for scaling-up implementation of HMM
with ACTs.
