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Home Based Management of Fever (Malaria Home Care, Home Management of Malaria)

Overview:

Home Based Management of Fever (HBMF) is the process by which clinical cases of fever in the under fives can be recognised and treated at home by their care givers, sometimes assisted by community health workers or medicine distributors. Where malaria is highly endemic, HBMF offers antimalarial treatment to young children with fever. As children can very rapidly develop severe malaria, which carries a high mortality risk, prompt effective treatment is crucial.

For many years, the cornerstone of malaria control across Africa has been early detection, diagnosis and treatment through primary health care services. However, numerous studies have shown that many cases of malaria are not brought to the formal health sector for treatment, that antimalarial drugs are widely available in the marketplace and that children are often treated at home with over-the-counter medication bought from shops. Home treatment with shop-bought drugs is thought to be so common that it is recognised as a valuable means of malaria control, provided that steps are taken to ensure quality. It has been proposed that fast-acting drugs be made widely available to parents for home treatment, and that communities and families become knowledgeable in giving prompt and effective treatment. It is vital that drugs are pre-packaged, rather than loose pills, as adherence to the correct dosage is then more likely.  Ideally, if there are two different antimalarial drugs to be administered as combination therapy, the two drugs should be coformulated into single tablets.

As most young children dying from malaria do so within 24 hours to 3 days of onset of severe symptoms the speed with which malaria is diagnosed and treated is critical in reducing mortality. By minimising the delay before treatment, effective treatment with antimalarials at home can save many lives. Home treatment also circumvents any inadequacies in the formal health care system. In formulating mechanisms that promote effective home treatment, it is vital to understand the factors that influence treatment-seeking behaviour, and whether or not a family self-treats with antimalarial drugs.

What is malaria home care?

Practices, decisions and actions that occur in the home that influence treatment of malaria and potential malaria illnesses, which in practice means non-complicated fevers in the under five year olds.

Why is malaria home care important?

Most malaria episodes are treated outside the formal health sector. Inappropriate use of over-the-counter drugs at home is a serious problem due to inadequate quality and inappropriate dosages.

What are the challenges to improving malaria home care?

Malaria home care practices generally are highly variable in different situations and there is limited programme experience to influence good practice. Working in an unregulated (private) market and with informal health providers of variable educational background needs carefully tested and monitored strategies. Drug quality, consistency in distribution and levels of drug resistance vary from place to place, and need to be taken into account. There may be a need to coordinate with existing home or community treatment programmes, not just for malaria but for other infectious diseases as well.

What could be achieved by improving home care?

Malaria home care can reduce the burden of disease, morbidity and mortality in under-five year olds, improve partnerships in public and private sectors and broaden community involvement in malaria control.

Key Points:

  • Home based management of fever/malaria has been shown to have an impact in reducing malaria burden
  • It is essential to make efficacious drugs of good quality consistently available pre-packaged and ideally in coformulated tablets
  • In each environment it is important to identify possible partners and promote local ownership of the programme
  • Two key elements are communication and education for recognition of symptoms and appropriate response and training of community health workers and the service providers to support them;
  • Investment in adequate supervision and monitoring is essential.

 

Programme Activities

Uganda

Home-based Management of Fever (HBMF) is a key strategy for improving malaria case management in Uganda. By making affordable, appropriate treatment available to children suffering from malaria within 24 hours of symptom onset, the Government hopes to significantly reduce malaria related morbidity and deaths in the country. Under the HBMF strategy, trained community members who are referred to as "community medicine distributors" (CMDs) treat children with fever with a pre-packaged, colour-coded, and easily administered chloroquine-SP (sulfadoxine-pryimethamine) combination pack called Homapak® (in response to rising resistance this is about to be changed to artemisinin-based combination therapy). Medicine distributors also advise caretakers of the sick children on how to continue treatment at home and on danger signs that will require referral to a health facility. Children who are brought to the drug distributors with danger signs of severe malaria or other signs of severe disease are promptly referred to the nearest health facility for care. The HBMF approach builds on experience gained from the WHO/TDR multi-country pilot study on improving home management of childhood fevers which included three districts of Uganda. The study data revealed that, in intervention communities, thirty-seven percent of children sick with fever two weeks before the survey received the appropriate antimalarial (the CQ/SP combination per national policy) for their fever. The odds of receiving an appropriate treatment for fever was almost five times as large in the intervention area (37 %) compared with the non-intervention area (7 %). A statistically significant increase in the appropriate treatment of fever was also observed over time. In the intervention area, febrile children were three times as likely to receive an appropriate antimalarial for their fever by the time of the follow-on survey than they were 12 months earlier. No such improvements in the proportion of febrile children receiving appropriate treatment were observed in non-intervention communities. There is an urgent need to sensitise caretakers and community sources of treatment on the new antimalarial drug policy using artemisinin-based combination therapy of appropriate dosage.  [Link to HBMF in Uganda]

 

Uganda - Internally Displaced Persons

Three years after its introduction in Uganda HBMF covers almost the whole country, though it is at various stages of implementation. The current treatment of choice is a prepackaged combination of sulfadoxine-pyrimethamine (SP) and chloroquine (CQ) with the trade name HOMAPAK®. Distribution relies on volunteer Community Drug Distributors (CDDs) that are trained and provided with a supply of HOMAPAK®. Monitoring and supervision of this activity is the responsibility of the nearest health facility. Evaluations have been carried out in a number of districts, but none have attempted to examine adherence to the drug regimen. Building on previous support of the Malaria Consortium to the HBMF implementation in the northern districts of Gulu, Kitgum and Pader, work was carried out to study the adherence to HOMAPAK® in caretakers of children among internally displaced persons (IDP) in this region. Results indicated that CDDs play an important role in the control of malaria in IDP camps, some of them providing presumptive malaria treatment for febrile illness to more than 60 children per month. The observed and reported adherence of caretakers to HOMAPAK® was reassuring, but there is room for improvement on knowledge and practices related to malaria. For HBMF, it is important to continue health education on the importance of fever, its diagnosis and the need to seek prompt treatment. There is a need to realize that heavy reliance on community volunteers does not make HBMF self-sustaining and that its future success depends on ongoing commitment from the MoH and international donors. [Link to UPHOLD]

 

References:

  1. * Marsh, V. & Kachur, S.P. (2003 draft) Malaria Home Management Policy to Strategy and Implementation Brief (Series Editor: S. Mehra)
  2. * Brieger., W, Unwin, A., Greer, G. and Meek, S. (2004) Interventions to improve the role of medicine sellers in malaria case management for children in Africa.  Prepared for the subgroup for Communication and Training, the Malaria Case Management Working Group, Roll Back Malaria
  3. * Greer, G., Akinpelumi, A., Madueke, L., Plowman, E., Fapohunda, B., Tawfik, Y., Holmes, R., Owor, J., Gilpin, U., Clarence, C. & Lennox. R. (2004). Improving Management of Childhood Malaria in Nigeria and Uganda by Improving Practices of Patent Medicine Vendors . Arlington, Va.: BASICS II for the United States Agency for International Development.
  4. * Nshakira, N., Kristensen, M., Ssali, F. & Reynolds Whyte, S. (2002) Appropriate treatment of malaria? Use of antimalarial drugs for children's fevers in district medical units, drug shops and home in eastern Uganda. Tropical Medicine and International Health 7: 309-316.
  5. * Goodman, C., Kachur, S.P., Abdulla, S., Mwageni, E., Nyoni, J., Schellenberg, J.A., Mills, A. & Bloland, P. (2004) Retail supply of malaria-related drugs in rural Tanzania: risks and opportunities . Tropical Medicine and International Health 9: 655-663.
  6. * Tavrow, P., Shabahang, J. & Makama, S. (2003) Vendor to vendor education to improve malaria treatment by private drug outlets in Bungoma District, Kenya. Malaria Journal 2: 10-19.
  7. * Kidane G. & Morrow, R.H. (2000) Teaching mothers to provide home treatment of malaria in Tigray, Ethiopia, a randomised trial. Lancet 356: 550-55.
  8. * Marsh. V.M., Mutemi, W.M., Muturi, J., Haaland, A., Watkins, W.M., Otieno, G. & Marsh, K. (1999) Changing home treatment of childhood fevers by training shop keepers in rural Kenya. Tropical Medicine and International Health 4: 383-389.
  9. * Marsh, V.M., Mutemi, W.M., Willetts, A., Bayah, K., Were, S., Ross, A. & Marsh, K. (2004) Improving malaria home treatment by training drug retailers in rural Kenya. Tropical Medicine and International Health 9: 451-460.
  10. McCombie, S.C. (2002) Self Treatment for malaria: the evidence and methodological issues. Health Policy and Planning 17: 333-344.
  11. Sirima, S.B., Onate, A., Tiono, A.B., Convelbo, N., Cousens, S. & Pagnoni, F. (2003) Early treatment of childhood fevers with pre-packaged antimalarial drugs in the home reduces severe malaria morbidity in Burkina Faso. Tropical Medicine and International Health 8: 133-139.
  12. Tawfik, Y., Northrup, R. & Prysor-Jones, S. (2002) Utilizing the potential of formal and informal private practitioners in child survival: situation analysis and summary of promising interventions. USAID Office for Sustainable Development.
  13. * WHO/HTM/MAL/2004.1096, TDR/IDE/HMM/04.1 (2004) Scaling up home-based management of malaria: from research to implementation
  14. * Kolaczinski, J.H., Ojok, N., Opwonya,J., Meek, S. and Collins, A. (2006) Adherence of community caretakers of children to pre-packaged antimalarial medicines (HOMAPAK®) among internally displaced people in Gulu district, Uganda Malaria Journal 5:40.
  15. * Ringstead, F.M., Bygbjerg, I.C. & Samuelsen, H. (2006) Early home-based recognition of anaemia via general danger signs, in young children, in a malaria endemic community in north-east Tanzania. Malaria Journal 5:111
  16. * Fapohunda, Bolaji M., Plowman, B.A., Azairwe, R., Bisorbowa, G., Langi, P., Kato, F. and Wang, X. (2004). Home-Based Management of Fever Strategy in Uganda: A Report of the 2003 Survey. Arlington, Virginia, USA: MOH, WHO and BASICS II
  17. Global Health Technical Brief on Malaria: Prompt Treatment Saves Lives.
  18. * Were W. (2004) Bringing malaria management closer to the home. MERA, RBM, WHO.
  19. * WHO (2004): The Roll Back Malaria Strategy for Improving Access to Treatment through Home Management of Malaria.
  20. * WHO/TDR (2007) Gyapong, M. & Garshong, B. Lessons learned from home management of malaria.  Implementation reserch in four African countries.