title: Case management of malaria fever in Cambodia: results from national anti-malarial outlet and household surveys.
abstract: BACKGROUND
  Continued progress towards global reduction in morbidity and mortality due to malaria requires scale-up of effective case management with artemisinin-combination therapy (ACT). The first case of artemisinin resistance in Plasmodium falciparum was documented in western Cambodia. Spread of artemisinin resistance would threaten recent gains in global malaria control. As such, the anti-malarial market and malaria case management practices in Cambodia have global significance.
  
  
  METHODS
  Nationally-representative household and outlet surveys were conducted in 2009 among areas in Cambodia with malaria risk. An anti-malarial audit was conducted among all public and private outlets with the potential to sell anti-malarials. Indicators on availability, price and relative volumes sold/distributed were calculated across types of anti-malarials and outlets. The household survey collected information about management of recent "malaria fevers." Case management in the public versus private sector, and anti-malarial treatment based on malaria diagnostic testing were examined.
  
  
  RESULTS
  Most public outlets (85%) and nearly half of private pharmacies, clinics and drug stores stock ACT. Oral artemisinin monotherapy was found in pharmacies/clinics (9%), drug stores (14%), mobile providers (4%) and grocery stores (2%). Among total anti-malarial volumes sold/distributed nationally, 6% are artemisinin monotherapies and 72% are ACT. Only 45% of people with recent "malaria fever" reportedly receive a diagnostic test, and the most common treatment acquired is a drug cocktail containing no identifiable anti-malarial. A self-reported positive diagnostic test, particularly when received in the public sector, improves likelihood of receiving anti-malarial treatment. Nonetheless, anti-malarial treatment of reportedly positive cases is low among people who seek treatment exclusively in the public (61%) and private (42%) sectors.
  
  
  CONCLUSIONS
  While data on the anti-malarial market shows favourable progress towards replacing artemisinin monotherapies with ACT, the widespread use of drug cocktails to treat malaria is a barrier to effective case management. Significant achievements have been made in availability of diagnostic testing and effective treatment in the public and private sectors. However, interventions to improve case management are urgently required, particularly in the private sector. Evidence-based interventions that target provider and consumer behaviour are needed to support uptake of diagnostic testing and treatment with full-course first-line anti-malarials.
authors: Population Services International, Department of Malaria and Child Survival, P.O. Box 14355-00800, Nairobi, Kenya. mlittrell@psi.org
authors: Megan
authors: M
authors: Littrell
authors: Hellen
authors: H
authors: Gatakaa
authors: Sochea
authors: S
authors: Phok
authors: Henrietta
authors: H
authors: Allen
authors: Shunmay
authors: S
authors: Yeung
authors: Char Meng
authors: CM
authors: Chuor
authors: Lek
authors: L
authors: Dysoley
authors: Duong
authors: D
authors: Socheat
authors: Angus
authors: A
authors: Spiers
authors: Chris
authors: C
authors: White
authors: Tanya
authors: T
authors: Shewchuk
authors: Desmond
authors: D
authors: Chavasse
authors: Kathryn A
authors: KA
authors: O'Connell
mesh_terms: D000962:Antimalarials / Q000191:economics* / Q000600:supply & distribution*; D037621:Artemisinins / Q000191:economics* / Q000600:supply & distribution*; D002160:Cambodia; D003430:Cross-Sectional Studies; D004363:Drug Utilization / Q000706:statistics & numerical data*; D005191:Family Characteristics; D005335:Fever of Unknown Origin / Q000175:diagnosis / Q000188:drug therapy; D006801:Humans; D007783:Lactones / Q000191:economics* / Q000600:supply & distribution*; D008288:Malaria / Q000175:diagnosis* / Q000188:drug therapy*; D010594:Pharmacies
chemical_list: D000962:Antimalarials; D037621:Artemisinins; D007783:Lactones; C075875:artemisin