Home- or community-based programmes for treating malaria

Malaria is an important cause of death especially in children and pregnant women living in sub-Saharan Africa. In many rural areas, children are unable to access effective malaria treatment because health services are either too far away or antimalarial drugs are too expensive. Home- or community-based programmes for managing malaria have been proposed as a key strategy to overcome these problems. In these programmes people living in rural settings, such as mothers, volunteers, or community health workers, are trained to recognise fever and provide antimalarial medicines at a low cost or for free. Malaria is not the only cause of fever and recently rapid diagnostic tests (RDTs) have become available. They are easy to use and enable trained workers to more accurately diagnose malaria and refer sick children without malaria for care elsewhere.

We examined the research published up to 12 September 2012 and we identified 10 studies for inclusion in this systematic review. In eight studies all people with fever were treated with antimalarial drugs by community health workers and in two studies community health workers were trained to confirm malaria in people using RDTs.

Home- or community-based strategies probably increase the number of people with fever that receive an effective antimalarial within 24 hours (moderate quality evidence). They probably reduce the number of deaths in areas where malaria is common and there is poor access to health services (moderate quality evidence) but to date this has only been demonstrated in one study from a rural setting in Ethiopia. We do not know whether they reduce the number of people requiring admission to hospital (very low quality evidence), or the number of people with evidence of malaria infection in their blood (very low quality evidence). Home- or community-based programmes may have little or no effect on the number of people with anaemia (low quality evidence). None of the included studies reported on adverse effects of using home- or community-based programmes for treating malaria.

Use of RDTs instead of clinical diagnosis in home- or community-based programmes for treating malaria probably reduces the overuse of antimalarials drugs (moderate quality evidence) and may have little or no difference upon the number of childhood deaths (low quality evidence), the number of children with evidence of malaria infection in their blood (low quality evidence), or the need for children to be admitted to hospital (low quality evidence) compared to use of clinical diagnosis.

Authors' conclusions: 

Home- or community-based interventions which provide antimalarial drugs free of charge probably improve prompt access to antimalarials, and there is moderate quality evidence from rural Ethiopia that they may impact on childhood mortality when implemented in appropriate settings.

Programmes which treat all fevers presumptively with antimalarials lead to overuse antimalarials, and potentially undertreat other causes of fever such as pneumonia. Incorporating RDT diagnosis into home- or community-based programmes for malaria may help to reduce this overuse of antimalarials, and has been shown to be safe under trial conditions.

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Background: 

Malaria is an important cause of morbidity and mortality, in particular among children and pregnant women in sub-Saharan Africa. Prompt access to diagnosis and treatment with effective antimalarial drugs is a central component of the World Health Organization's (WHO) strategy for malaria control. Home- or community-based programmes for managing malaria are one strategy that has been proposed to overcome the geographical barrier to malaria treatment. 

Objectives: 

To evaluate home- and community-based management strategies for treating malaria.

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials published in The Cochrane Library; MEDLINE; EMBASE; Science Citation Index; PsycINFO/LIT; CINAHL; WHO clinical trial registry platform; and the metaRegister of Controlled Trials up to September 2012.

Selection criteria: 

Randomized controlled trials (RCTs) and non-RCTs that evaluated the effects of a home- or community-based programme for treating malaria in a malaria endemic setting.

Data collection and analysis: 

Two authors independently screened and selected studies, extracted data, and assessed the risk of bias. Where possible the effects of interventions are compared using risk ratios (RR), and presented with 95% confidence intervals (CI). The quality of the evidence was assessed using the GRADE approach.

Main results: 

We identified 10 trials that met the inclusion criteria. The interventions involved brief training of basic-level health workers or mothers, and most provided the antimalarial for free or at a highly subsidized cost. In eight of the studies, fevers were treated presumptively without parasitological confirmation with microscopy or a rapid diagnostic test (RDT). Two studies trained community health workers to use RDTs as a component of community management of fever.

Home- or community-based strategies probably increase the number of people with fever who receive an appropriate antimalarial within 24 hours (RR 2.27, 95% CI 1.79 to 2.88 in one trial; RR 9.79, 95% CI 6.87 to 13.95 in a second trial; 3099 participants, moderate quality evidence). They may also reduce all-cause mortality, but to date this has only been demonstrated in rural Ethiopia (RR 0.58, 95% CI 0.44 to 0.77, one trial, 13,677 participants, moderate quality evidence).

Hospital admissions in children were reported in one small trial from urban Uganda, with no effect detected (437 participants, very low quality evidence). No studies reported on severe malaria. For parasitaemia prevalence, the study from urban Uganda demonstrated a reduction in community parasite prevalence (RR 0.22, 95% CI 0.08 to 0.64, 365 participants), but a second study in rural Burkina Faso did not (1006 participants). Home- or community-based programmes may have little or no effect on the prevalence of anaemia (three trials, 3612 participants, low quality evidence). None of the included studies reported on adverse effects of using home- or community-based programmes for treating malaria.

In two studies which trained community health workers to only prescribe antimalarials after a positive RDT, prescriptions of antimalarials were reduced compared to the control group where community health workers used clinical diagnosis (RR 0.39, 95% CI 0.18 to 0.84, two trials, 5944 participants, moderate quality evidence). In these two studies, mortality and hospitalizations remained very low in both groups despite the lower use of antimalarials (two trials, 5977 participants, low quality evidence).

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