title: Pre-referral Rectal Artesunate Treatment by Community-Based Treatment Providers in Ghana, Guinea-Bissau, Tanzania, and Uganda (Study 18): A Cluster-Randomized Trial.
abstract: BACKGROUND
  If malaria patients who cannot be treated orally are several hours from facilities for injections, rectal artesunate prior to hospital referral can prevent death and disability. The goal is to reduce death from malaria by having rectal artesunate treatment available and used. How best to do this remains unknown.
  
  
  METHODS
  Villages remote from a health facility were randomized to different community-based treatment providers trained to provide rectal artesunate in Ghana, Guinea-Bissau, Tanzania, and Uganda. Prereferral rectal artesunate treatment was provided in 272 villages: 109 through community-based health workers (CHWs), 112 via trained mothers (MUMs), 25 via trained traditional healers (THs), and 26 through trained community-chosen personnel (COMs); episodes eligible for rectal artesunate were established through regular household surveys of febrile illnesses recording symptoms eligible for prereferral treatment. Differences in treatment coverage with rectal artesunate in children aged <5 years in MUM vs CHW (standard-of-care) villages were assessed using the odds ratio (OR); the predictive probability of treatment was derived from a logistic regression analysis, adjusting for heterogeneity between clusters (villages) using random effects.
  
  
  RESULTS
  Over 19 months, 54 013 children had 102 504 febrile episodes, of which 32% (31 817 episodes) had symptoms eligible for prereferral therapy; 14% (4460) children received treatment. Episodes with altered consciousness, coma, or convulsions constituted 36.6% of all episodes in treated children. The overall OR of treatment between MUM vs CHW villages, adjusting for country, was 1.84 (95% confidence interval [CI], 1.20-2.83; P = .005). Adjusting for heterogeneity, this translated into a 1.67 higher average probability of a child being treated in MUM vs CHW villages. Referral compliance was 81% and significantly higher with CHWs vs MUMs: 87% vs 82% (risk ratio [RR], 1.1 [95% CI, 1.0-1.1]; P < .0001). There were more deaths in the TH cluster than elsewhere (RR, 2.7 [95% CI, 1.4-5.6]; P = .0040).
  
  
  CONCLUSIONS
  Prereferral episodes were almost one-third of all febrile episodes. More than one-third of patients treated had convulsions, altered consciousness, or coma. Mothers were effective in treating patients, and achieved higher coverage than other providers. Treatment access was low.
  
  
  BACKGROUND
  ISRCTN58046240.
authors.affiliation: Division of International Health, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Marian
authors.initials: M
authors.lastname: Warsame
authors.affiliation: Dodowa Health Research Centre, Ghana.
authors.forename: Margaret
authors.initials: M
authors.lastname: Gyapong
authors.affiliation: Malaria Consortium, Kampala, Uganda.
authors.forename: Betty
authors.initials: B
authors.lastname: Mpeka
authors.affiliation: Projecto de Saude de Bandim, Guinea-Bissau.
authors.forename: Amabelia
authors.initials: A
authors.lastname: Rodrigues
authors.affiliation: Special Programme for Research and Training in Tropical Diseases, World Health Organization, Geneva, Switzerland.
authors.forename: Jan
authors.initials: J
authors.lastname: Singlovic
authors.affiliation: Medical Research Council Clinical Trials Unit, London, United Kingdom.
authors.forename: Abdel
authors.initials: A
authors.lastname: Babiker
authors.affiliation: Makerere University Medical School, Kampala, Uganda.
authors.forename: Edison
authors.initials: E
authors.lastname: Mworozi
authors.affiliation: Greater Accra Regional Health Directorate.
authors.forename: Irene
authors.initials: I
authors.lastname: Agyepong
authors.affiliation: Dangme West District Health Directorate, Dodowa, Ghana.
authors.forename: Evelyn
authors.initials: E
authors.lastname: Ansah
authors.affiliation: National Malaria Control Programme, World Health Organization Uganda Country Office, Kampala.
authors.forename: Robert
authors.initials: R
authors.lastname: Azairwe
authors.affiliation: Projecto de Saude de Bandim, Guinea-Bissau.
authors.forename: Sidu
authors.initials: S
authors.lastname: Biai
authors.affiliation: University of Health and Allied Sciences, Ho, Ghana.
authors.forename: Fred
authors.initials: F
authors.lastname: Binka
authors.affiliation: Medical Research Council, Tygerberg, South Africa.
authors.forename: Peter
authors.initials: P
authors.lastname: Folb
authors.affiliation: University of Ghana, Accra.
authors.forename: John
authors.initials: J
authors.lastname: Gyapong
authors.affiliation: National Institute for Medical Research, Dar-es-Salaam.
authors.forename: Omari
authors.initials: O
authors.lastname: Kimbute
authors.affiliation: St Augustine University of Tanzania, Mwanza.
authors.forename: Zena
authors.initials: Z
authors.lastname: Machinda
authors.affiliation: Preparedness and Response Project, Lugogo House, Kampala, Uganda.
authors.forename: Andrew
authors.initials: A
authors.lastname: Kitua
authors.affiliation: Rakai Health Sciences Program, Rakai Project Centre, Entebbe, Uganda.
authors.forename: Tom
authors.initials: T
authors.lastname: Lutalo
authors.affiliation: National Institute for Medical Research, Gonja Field Station, Tanzania.
authors.forename: Melkzedik
authors.initials: M
authors.lastname: Majaha
authors.affiliation: Projecto de Saude de Bandim, Guinea-Bissau.
authors.forename: Jao
authors.initials: J
authors.lastname: Mamadu
authors.affiliation: National Institute for Medical Research, Dar-es-Salaam.
authors.forename: Zakayo
authors.initials: Z
authors.lastname: Mrango
authors.affiliation: Centre for Applied Biostatistics, Sahlgrenska Academy, University of Gothenburg, Sweden.
authors.forename: Max
authors.initials: M
authors.lastname: Petzold
authors.affiliation: College of Health Sciences, Makerere University, Kampala, Uganda.
authors.forename: Joseph
authors.initials: J
authors.lastname: Rujumba
authors.affiliation: Drugs for Neglected Diseases, Geneva, Switzerland.
authors.forename: Isabela
authors.initials: I
authors.lastname: Ribeiro
authors.affiliation: Special Programme for Research and Training in Tropical Diseases, World Health Organization, Geneva, Switzerland.
authors.forename: Melba
authors.initials: M
authors.lastname: Gomes
mesh_terms: D000285:Administration, Rectal; D000962:Antimalarials / Q000008:administration & dosage* / Q000627:therapeutic use*; D037621:Artemisinins / Q000008:administration & dosage / Q000627:therapeutic use; D000077332:Artesunate; D002675:Child, Preschool; D003150:Community Health Workers; D005260:Female; D005869:Ghana / Q000453:epidemiology; D006169:Guinea-Bissau / Q000453:epidemiology; D006801:Humans; D007223:Infant; D008288:Malaria / Q000188:drug therapy* / Q000453:epidemiology; D008297:Male; D012017:Referral and Consultation; D013636:Tanzania / Q000453:epidemiology; D014454:Uganda / Q000453:epidemiology
chemical_list: D000962:Antimalarials; D037621:Artemisinins; D000077332:Artesunate
keywords: Africa; CHWs; coverage; mothers; rectal artesunate