Community case management of fever due to malaria and pneumonia in children under five in Zambia: a cluster randomized controlled trial.
BACKGROUND
Pneumonia and malaria, two of the leading causes of morbidity and mortality among children under five in Zambia, often have overlapping clinical manifestations. Zambia is piloting the use of artemether-lumefantrine (AL) by community health workers (CHWs) to treat uncomplicated malaria. Valid concerns about potential overuse of AL could be addressed by the use of malaria rapid diagnostics employed at the community level. Currently, CHWs in Zambia evaluate and treat children with suspected malaria in rural areas, but they refer children with suspected pneumonia to the nearest health facility. This study was designed to assess the effectiveness and feasibility of using CHWs to manage nonsevere pneumonia and uncomplicated malaria with the aid of rapid diagnostic tests (RDTs).


RESULTS
Community health posts staffed by CHWs were matched and randomly allocated to intervention and control arms. Children between the ages of 6 months and 5 years were managed according to the study protocol, as follows. Intervention CHWs performed RDTs, treated test-positive children with AL, and treated those with nonsevere pneumonia (increased respiratory rate) with amoxicillin. Control CHWs did not perform RDTs, treated all febrile children with AL, and referred those with signs of pneumonia to the health facility, as per Ministry of Health policy. The primary outcomes were the use of AL in children with fever and early and appropriate treatment with antibiotics for nonsevere pneumonia. A total of 3,125 children with fever and/or difficult/fast breathing were managed over a 12-month period. In the intervention arm, 27.5% (265/963) of children with fever received AL compared to 99.1% (2066/2084) of control children (risk ratio 0.23, 95% confidence interval 0.14-0.38). For children classified with nonsevere pneumonia, 68.2% (247/362) in the intervention arm and 13.3% (22/203) in the control arm received early and appropriate treatment (risk ratio 5.32, 95% confidence interval 2.19-8.94). There were two deaths in the intervention and one in the control arm.


CONCLUSIONS
The potential for CHWs to use RDTs, AL, and amoxicillin to manage both malaria and pneumonia at the community level is promising and might reduce overuse of AL, as well as provide early and appropriate treatment to children with nonsevere pneumonia.


BACKGROUND
ClinicalTrials.govNCT00513500
Yeboah-Antwi
Kojo
K
Center for Global Health and Development, Boston University School of Public Health, Boston, Massachusetts, United States of America. kyantwi@bu.edu
Pilingana
Portipher
P
Macleod
William B
WB
Semrau
Katherine
K
Siazeele
Kazungu
K
Kalesha
Penelope
P
Hamainza
Busiku
B
Seidenberg
Phil
P
Mazimba
Arthur
A
Sabin
Lora
L
Kamholz
Karen
K
Thea
Donald M
DM
Hamer
Davidson H
DH
D000962:Antimalarials / Q000008:administration & dosage* / Q000627:therapeutic use; D000077611:Artemether, Lumefantrine Drug Combination; D037621:Artemisinins / Q000008:administration & dosage* / Q000627:therapeutic use; D019090:Case Management; D002675:Child, Preschool; D003150:Community Health Workers; D004338:Drug Combinations; D004983:Ethanolamines / Q000008:administration & dosage* / Q000627:therapeutic use; D005334:Fever / Q000188:drug therapy* / Q000209:etiology; D005449:Fluorenes / Q000008:administration & dosage* / Q000627:therapeutic use; D006801:Humans; D007223:Infant; D008288:Malaria / Q000150:complications / Q000188:drug therapy*; D011014:Pneumonia / Q000150:complications / Q000188:drug therapy*; D012424:Rural Population; D015024:Zambia
D000962:Antimalarials; D000077611:Artemether, Lumefantrine Drug Combination; D037621:Artemisinins; D004338:Drug Combinations; D004983:Ethanolamines; D005449:Fluorenes