FEASIBILITY AND IMPACT OF DEPLOYING ARTEMETHER-

LUMEFANTRINE (AL) AT COMMUNITY LEVEL WITH THE INTRODUCTION OF

RAPID DIAGNSOTIC TEST

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H. Lemma,P. Byass, A. Desta et al.( 2010) Deploying artemether-lumefantrine with rapid testing in Ethiopian communities: impact on malaria morbidity, mortality and healthcare resources. Tropical Medicine and International Health, 15 (2), 241-250

Background-The Tigray region, Ethiopia Tigray, most northern region of Ethiopia (~50,000 km2)

Population ~4.5 million (81% rural)

75% of Tigray is malarious, inhabited by

~56% of the population

P.falciparum(~60%) & P.vivax (~40%)

Transmission: Seasonal & hypo-endemic

Low levels of immunity, prone to epidemics

AL introduced in 2004,with large-scale deployment in 2005

Background..., cont’d

In Tigray, a large-scale, community-based malaria diagnosis and treatment programme (1994–2002) was operated.

However, the cost of AL has challenged the existed community- based malaria case management

Feasibility and impact assessment study was required if using ACT at a community-based …..

An important component of this project was use of RDT to confirm a diagnosis of malaria before treatment with ACT

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Objectives

To assess the feasibility and impact of AL deployment at community level, combined with phased introduction of RDTs on;

malaria transmission and morbidity, malaria-specific mortality (verbal

autopsy), Health care resource utilization and Improving health services; in a resource-constrained rural setting of

Ethiopia

M JJ A S NO D J F M A M J J A S O N D J F M A

Intervention district

Control district

Malaria parasite

survey

MortalitysurveyInterVA

x x x x

A

Studystart

Health facilities AL after clinical or confirmed (microscopy or RDT) diagnosis

Health facilitiesAL after clinical or confirmed (microscopy or

RDT) diagnosis

33 CHWsAL after clinical

diagnosis

17 CHWs AL after clinical

diagnosis

2005 2006 2007

Methods and study designStud

yend

16 CHWs AL after RDT confirmation

Intervention district

Control district

54,774

100,535

75,654

0

Health facilitiesMalaria patient

CHWsMalaria patient

Results (1): ≈60% of malaria patients in intervention district treated by CHWs, reduce health facilities burden

Malaria was 4-5 fold lower

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Results (2): Malaria parasite reservoir was 3-fold lower in intervention district during high transmission season

Low transmission

2005

High transmission2005

Low transmission

2006

High transmission2006

Crude parasite rate

P. falciparum parasite rate

P. falciparum gametocyte rate

% b

loo

d f

ilms

test

ed

Intervention district

Control district

Result(3): Early diagnosis and prompt treatment reduced malaria progression to severity

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42% of 293079% of 4371

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Poisson regression mortality

Result(4): Adjusted rate for malaria-specific mortality was significantly lower in the intervention district

Adjusted IRR 95% CI P-value

All cause mortality

Intervention district

Control district

1.03

Reference

0.87, 1.21

–

0.751

–

Malaria-specific mortality

Intervention district

Control district

0.60

Reference

0.40, 0.90

–0.013

–

Results: Summary

Community deployment of AL in rural population: Almost 60% of suspected cases managed by CHWs• Lowered the malaria case load for general health

services•achieving a major global strategy (prompt diagnosis and

treatment) Decreased malaria transmission•3-fold reduction in crude and P. falciparum parasite rate Reduced malaria mortality by~40% during a major

malaria epidemic Use of RDTs permitted exclusion of patients without

P. falciparum malaria in approximately 90% of cases

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Concusion/implication

AL deployment with RDT at a community level is feasible and significantly lowered the malaria burden providing that CHWs are committed, appropriately trained, well equipped and supported through frequent supervision

Therefore; suspending the CHWs form the service would only be a compromise; the fear on the consequences of overtreatment is not rational

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