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Home management of malaria – Authors' reply
Correspondence
in different epidemiological settings, and WHO and the Special Programme for Research and Training in Tropical Diseases are engaged in such studies. Home management of malaria is an evolving strategy, and the introduction of rapid diagnostic tests to minimise overtreatment is very much the next stage of this evolution. However, studies need to be very clear with their terminology and their objectives. In the case of the Article by Staedke and colleagues, lack of attention to this resulted in misleading headlines that home management of malaria was inappropriate in urban settings.3 If such statements are allowed to go uncorrected, they could have an unjustified negative effect on home management programmes and their funding, and ultimately cost lives. I declare that I have no conflicts of interest.
Franco Pagnoni [email protected] UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), 1211 Geneva 27, Switzerland 1
2 3
Staedke SG, Mwebaza N, Kamya MR, et al. Home management of malaria with artemether-lumefantrine compared with standard care in urban Ugandan children: a randomised controlled trial. Lancet 2009; 373: 1623–31. Källander K, Nsungwa-Sabiiti J. Home-based management of malaria in the era of urbanisation. Lancet 2009; 373: 1582–84. Cheng M. Treating kids with malaria at home doesn’t work. The Guardian April 16, 2009.
Authors’ reply Franco Pagnoni argues that we did not assess home management of malaria, as advocated by WHO, in our study. We agree. As we acknowledged, we provided artemether-lumefantrine directly to households for presumptive treatment of febrile children, thus assessing true “home” management. This intervention is different from the approach currently used in Uganda’s home-based management of fever programme in which antimalarial drugs are distributed by trained community medicine distributors. We intentionally used the term “home management of malaria” rather than www.thelancet.com Vol 374 July 25, 2009
“home-based management of fever” to avoid confusion with Uganda’s programme. The terminology in this area is potentially misleading. Although the method of delivering treatment advocated by WHO and adopted as policy in Uganda is referred to as “home” management, this strategy is a community-based intervention. Home management of malaria emphasises management of “malaria”, but treatment is given presumptively to children with fever, rather than to those proven to have malaria (which in the area we studied will be a minority of fevers). Irrespective of terminology, evidence that home management of malaria, by any name, improves the health of children in urban areas is lacking. With the exception of our study, all published studies to assess the health effects of home management of malaria in Africa were done in rural areas.1 The epidemiology of malaria in rural and urban areas is different, and interventions appropriate for rural settings might not be transferable to urban areas, or vice versa. The results of our study should not be generalised to rural areas, or be taken to imply that home management of malaria is not effective in rural settings. There is increasing evidence that malaria transmission and the burden of disease is decreasing in many parts of Africa.2 As malaria transmission is reduced, and the proportion of febrile illnesses that are attributable to malaria decreases, the potential risks of presumptive treatment of febrile children with antimalarials could outweigh the benefits. With decreasing malaria incidence, arguments for a shift in the approach to treating malaria, limiting treatment to laboratory-confirmed cases, will become stronger.3,4 Strategies to target antimalarial treatment and to strengthen delivery of care through the public or private sectors might be preferable, particularly in urban settings.
Methods to improve prompt, effective antimalarial treatment are essential. However, as opportunities for malaria control expand across Africa, strategies will need to be tailored to specific settings, taking into account malaria epidemiology and existing health services. We declare that we have no conflicts of interest.
*S G Staedke, N Mwebaza, M R Kamya, P J Rosenthal, C J M Whitty [email protected] London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK (SGS, CJMW); Makerere University Medical School, Kampala, Uganda (NM, MRK); and Department of Medicine, San Francisco General Hospital, University of California, San Francisco, CA, USA (PJR) 1
2
3
4
Hopkins H, Talisuna A, Whitty CJ, Staedke SG. Impact of home-based management of malaria on health outcomes in Africa: a systematic review of the evidence. Malar J 2007; 6: 134. WHO. Global malaria control and elimination: report of a technical review. Geneva: World Health Organization, 2008. Hamer DH, Ndhlovu M, Zurovac D, et al. Improved diagnostic testing and malaria treatment practices in Zambia. JAMA 2007; 297: 2227–31. Talisuna AO, Meya DN. Diagnosis and treatment of malaria. BMJ 2007; 334: 375–76.
Practising in rural west Africa, it becomes galling to see the Abuja target of treating 80% of malaria patients presented as if its goals are a stark contrast with the “percentage of febrile children given any form of malaria treatment”.1 Have people forgotten that malarious areas are also overwhelmed by numerous other real causes of fever, including viruses, teething, otitis, urinary-tract infections, and pneumonia? Indeed most patients have these other causes of fever even during times of high malaria transmission. Have they also forgotten that in many areas the “history of fever” is merely a statement that the patient is not well? Blindly accepting such a history broadens the treatment umbrella to include any form of ache, bruise, headache, anxiety, or other pathology of any kind. 289
in different epidemiological settings, and WHO and the Special Programme for Research and Training in Tropical Diseases are engaged in such studies. Home management of malaria is an evolving strategy, and the introduction of rapid diagnostic tests to minimise overtreatment is very much the next stage of this evolution. However, studies need to be very clear with their terminology and their objectives. In the case of the Article by Staedke and colleagues, lack of attention to this resulted in misleading headlines that home management of malaria was inappropriate in urban settings.3 If such statements are allowed to go uncorrected, they could have an unjustified negative effect on home management programmes and their funding, and ultimately cost lives. I declare that I have no conflicts of interest.
Franco Pagnoni [email protected] UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), 1211 Geneva 27, Switzerland 1
2 3
Staedke SG, Mwebaza N, Kamya MR, et al. Home management of malaria with artemether-lumefantrine compared with standard care in urban Ugandan children: a randomised controlled trial. Lancet 2009; 373: 1623–31. Källander K, Nsungwa-Sabiiti J. Home-based management of malaria in the era of urbanisation. Lancet 2009; 373: 1582–84. Cheng M. Treating kids with malaria at home doesn’t work. The Guardian April 16, 2009.
Authors’ reply Franco Pagnoni argues that we did not assess home management of malaria, as advocated by WHO, in our study. We agree. As we acknowledged, we provided artemether-lumefantrine directly to households for presumptive treatment of febrile children, thus assessing true “home” management. This intervention is different from the approach currently used in Uganda’s home-based management of fever programme in which antimalarial drugs are distributed by trained community medicine distributors. We intentionally used the term “home management of malaria” rather than www.thelancet.com Vol 374 July 25, 2009
“home-based management of fever” to avoid confusion with Uganda’s programme. The terminology in this area is potentially misleading. Although the method of delivering treatment advocated by WHO and adopted as policy in Uganda is referred to as “home” management, this strategy is a community-based intervention. Home management of malaria emphasises management of “malaria”, but treatment is given presumptively to children with fever, rather than to those proven to have malaria (which in the area we studied will be a minority of fevers). Irrespective of terminology, evidence that home management of malaria, by any name, improves the health of children in urban areas is lacking. With the exception of our study, all published studies to assess the health effects of home management of malaria in Africa were done in rural areas.1 The epidemiology of malaria in rural and urban areas is different, and interventions appropriate for rural settings might not be transferable to urban areas, or vice versa. The results of our study should not be generalised to rural areas, or be taken to imply that home management of malaria is not effective in rural settings. There is increasing evidence that malaria transmission and the burden of disease is decreasing in many parts of Africa.2 As malaria transmission is reduced, and the proportion of febrile illnesses that are attributable to malaria decreases, the potential risks of presumptive treatment of febrile children with antimalarials could outweigh the benefits. With decreasing malaria incidence, arguments for a shift in the approach to treating malaria, limiting treatment to laboratory-confirmed cases, will become stronger.3,4 Strategies to target antimalarial treatment and to strengthen delivery of care through the public or private sectors might be preferable, particularly in urban settings.
Methods to improve prompt, effective antimalarial treatment are essential. However, as opportunities for malaria control expand across Africa, strategies will need to be tailored to specific settings, taking into account malaria epidemiology and existing health services. We declare that we have no conflicts of interest.
*S G Staedke, N Mwebaza, M R Kamya, P J Rosenthal, C J M Whitty [email protected] London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK (SGS, CJMW); Makerere University Medical School, Kampala, Uganda (NM, MRK); and Department of Medicine, San Francisco General Hospital, University of California, San Francisco, CA, USA (PJR) 1
2
3
4
Hopkins H, Talisuna A, Whitty CJ, Staedke SG. Impact of home-based management of malaria on health outcomes in Africa: a systematic review of the evidence. Malar J 2007; 6: 134. WHO. Global malaria control and elimination: report of a technical review. Geneva: World Health Organization, 2008. Hamer DH, Ndhlovu M, Zurovac D, et al. Improved diagnostic testing and malaria treatment practices in Zambia. JAMA 2007; 297: 2227–31. Talisuna AO, Meya DN. Diagnosis and treatment of malaria. BMJ 2007; 334: 375–76.
Practising in rural west Africa, it becomes galling to see the Abuja target of treating 80% of malaria patients presented as if its goals are a stark contrast with the “percentage of febrile children given any form of malaria treatment”.1 Have people forgotten that malarious areas are also overwhelmed by numerous other real causes of fever, including viruses, teething, otitis, urinary-tract infections, and pneumonia? Indeed most patients have these other causes of fever even during times of high malaria transmission. Have they also forgotten that in many areas the “history of fever” is merely a statement that the patient is not well? Blindly accepting such a history broadens the treatment umbrella to include any form of ache, bruise, headache, anxiety, or other pathology of any kind. 289