Home management of malaria with artemether-lumefantrine compared with standard care in urban Ugandan children: a randomised controlled trial.
BACKGROUND
Home management of malaria-the presumptive treatment of febrile children with antimalarial drugs-is advocated to ensure prompt effective treatment of the disease. We assessed the effect of home delivery of artemether-lumefantrine on the incidence of antimalarial treatment and on clinical outcomes in children from an urban setting with fairly low malaria transmission.


METHODS
In Kampala, Uganda, 437 children aged between 1 and 6 years from 325 households were randomly assigned by a computer-generated sequence to receive home delivery of prepackaged artemether-lumefantrine for presumptive treatment of febrile illnesses (n=225) or current standard of care (n=212). Randomisation was done by household after a pilot period of 1 month. After randomisation, study participants were followed up for an additional 12 months and information on their health and treatment of illnesses was obtained by use of monthly questionnaires and household diaries, which were completed by the participants' carers. The primary outcome was treatment incidence density per person-year. Analysis of the primary outcome was done on the modified intention-to-treat population, which included all participants apart from those excluded before data collection. This trial is registered with ClinicalTrials.gov, number NCT00115921.


RESULTS
Eight participants in the home management group and four in the standard care group were excluded before data collection; therefore, the primary analysis was done in 217 and 208 participants, respectively. The home management group received nearly twice the number of antimalarial treatments as the standard care group (4.66 per person-year vs 2.53 per person-year; incidence rate ratio [IRR] 1.72, 95% CI 1.43-2.06, p<0.0001), and nearly five times the number given to children with microscopically confirmed malaria in a comparable cohort of children (4.66 per person-year vs 1.03 per person-year, IRR 5.19, 95% CI 4.24-6.35, p<0.0001). Clinical data were available for 189 children in the home management group and 176 in the control group at study end; the main reasons for exclusion were movement out of the study area or loss to follow-up. The proportion of participants with parasitaemia at final assessment in the intervention group was lower than in the control group (four [2%] vs 17 [10%], p=0.006), but there were no other differences in standard malariometric indices, including anaemia. Serious adverse events were captured retrospectively. One child died in each group (home management-severe pneumonia and possible septicaemia; standard care-presumed respiratory failure).


CONCLUSIONS
Although home management of malaria led to prompt treatment of fever, there was little effect on clinical outcomes. The substantial over-treatment suggests that artemether-lumefantrine provided in the home might not be appropriate for large urban areas or settings with fairly low malaria transmission.


BACKGROUND
Gates Malaria Partnership.
Staedke
Sarah G
SG
London School of Hygiene and Tropical Medicine, London, UK. sarah.staedke@lshtm.ac.uk
Mwebaza
Norah
N
Kamya
Moses R
MR
Clark
Tamara D
TD
Dorsey
Grant
G
Rosenthal
Philip J
PJ
Whitty
Christopher J M
CJ
D000962:Antimalarials / Q000627:therapeutic use*; D000077611:Artemether, Lumefantrine Drug Combination; D037621:Artemisinins / Q000627:therapeutic use*; D002675:Child, Preschool; D003362:Cost-Benefit Analysis; D004338:Drug Combinations; D004983:Ethanolamines / Q000627:therapeutic use*; D005260:Female; D005334:Fever / Q000469:parasitology; D005449:Fluorenes / Q000627:therapeutic use*; D005500:Follow-Up Studies; D006699:Home Care Services / Q000458:organization & administration*; D006798:Housing; D006801:Humans; D015994:Incidence; D008288:Malaria / Q000150:complications / Q000188:drug therapy* / Q000453:epidemiology; D008297:Male; D015999:Multivariate Analysis; D010343:Patient Admission / Q000706:statistics & numerical data; D015397:Program Evaluation; D012044:Regression Analysis; D012959:Socioeconomic Factors; D016896:Treatment Outcome; D014454:Uganda / Q000453:epidemiology; D019037:Urban Health Services / Q000458:organization & administration*
D000962:Antimalarials; D000077611:Artemether, Lumefantrine Drug Combination; D037621:Artemisinins; D004338:Drug Combinations; D004983:Ethanolamines; D005449:Fluorenes