Field trials conducted in Ethiopia and the DRC, with approximately 8,000 participants across the two studies, suggest that uncomplicated fever can be safely managed with conditional, rather than universal, three-day follow-up. This approach could save caregivers and community health workers time and money in resource-poor environments.
Universal three-day follow up for children with fever
Current World health Organization (WHO) guidelines for integrated community case management (iCCM) recommend that all children diagnosed with uncomplicated fever should undergo a follow-up consultation with a community health worker three days after initial consultation. Such fevers often resolve rapidly, however, and universal follow-up can increase the demands on busy health workers and resource-stricken caregivers.
Trials in Africa and conditional follow-up
To assess the feasibility of conditional rather than universal follow up, two cluster-randomised, community based non-inferiority trials took place, one in Ethiopia and one in the Democratic Republic of the Congo (DRC), each with approximately 4,000 participants. Their findings were published this week in PLOS medicine.
The trials were conducted by Luke C. Mullany of the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States, and Karin Källander of Malaria Consortium, London, United Kingdom and the Karolinska Institutet, Stockholm, Sweden, in collaboration with investigators from Centers for Disease Control.
In Mullany and colleagues’ primary analysis in DRC, failure at day eight (caregiver-reported fever, malaria, diarrhoea, pneumonia, or decline of health status) was similar (difference: -0.7 percent, 95 percent CI: − ¥, 4.1 percent) in the conditional follow-up group (n = 188, 9.7 percent) compared to the universal follow-up group (n = 230, 10.4 percent). In Källander and colleagues’ analysis in Ethiopia, failure at day 8 was also similar (difference: -3.81 percent, 95 percent CI −∞, 0.65 percent) in the conditional follow-up group (n = 16, 0.8 percent) compared to the universal follow-up group (n = 90, 4.6 percent). The primary result from Källander and colleagues’ trial in Ethiopia meets the pre-specified non-inferiority criterion, while Mullany and colleagues’ trial results from the DRC suggest that any difference in failures is small.
Relevance to WHO recommendations
While additional trials in other sub-Saharan settings are necessary to establish generalisability, taken together, these results suggest that current WHO iCCM guidance for children with uncomplicated fever could be reconsidered.
Results from the two trials suggest that conditional follow-up is non-inferior to universal follow-up, meaning that children in sub-Saharan African settings with uncomplicated fever may be safely managed through conditional follow up with a community health worker. This could save time and money for caregivers and community health workers in low-income settings.