Incidence of childhood malaria is growing in Africa. This has coincided with increased resistance to first choice antimalarial drugs such as chloroquine.  In December 2002, Zambia became the first country to replace chloroquine with the artemisinin based combination therapy, artemether-lumefantrine for patients weighing 10 kilograms or more.

Artemisinin based combination therapy (ACT) is new and relatively expensive but has also proved highly effective in Africa. A research team led by the KEMRI/Wellcome Trust Collaborative Programme and Boston University, USA, evaluated treatment practices for uncomplicated malaria in Zambia following this change of drug policy.

The team conducted a survey of 944 children with uncomplicated malaria who attended 94 health facilities across four districts in Zambia: Chingola, an urban district with low or moderate rates of malaria infection; Kalomo, a semi-arid area with moderate rates of infection; Chipata, a mixed rural and urban district with moderate and high rates of infection; and Samfya, a rural, swampy area with high rates of malaria infection.

The study found that artemether-lumefantrine was not commonly used. Although programme activities such as in-service training and provision of job aids were implemented to some extent this did not seem to influence the prescribing of artemether-lumefantrine among children weighing 10 kilgrams or more. Results showed that:

• Sulfadoxine-pyrimethamine (SP) was available at 100 percent of clinics, while chloroquine was available at 76 percent and artemether-lumefantrine at just 51 percent.
• Out of all 944 children surveyed, only one child received chloroquine.
• For children weighing less than 10 kilograms, health workers commonly prescribed SP in accordance with clinical guidelines.
• Health workers prescribed artemether-lumefantrine to only 11 percent of the children weighing 10 kilograms or more, and SP to 68 percent.
• At facilities where artemether-lumefantrine was available on the day of the survey, health workers prescribed it to only 22 percent of children weighing 10 kilograms or more.
• In-service training on artemether-lumefantrine, presence of artemether-lumefantrine dosage wall charts, and possession of the guideline were not significantly associated with prescribing artemether-lumefantrine.
• There was a significantly lower use of artemether-lumefantrine among children under two years.

The researchers conclude that Zambia has successfully discontinued the use of chloroquine for treating uncomplicated malaria. Health workers were also using SP appropriately for children weighing less than 10 kilograms. However, many clinics were not using artemether-lumefantrine appropriately. They conclude that:

• Understanding possible misperceptions and concerns should be a high research priority for Zambia and other countries in the process of implementing ACT.
• There is an urgent need for a sustainable supply of ACT across Africa, however, this must be accompanied by similar investments in programme activities to ensure the proper use of drugs at the point of care.

Source(s):
'Treatment of paediatric malaria during a period of drug transition to artemether-lumefantrine in Zambia: cross sectional study', British Medical Journal (BMJ) 331(7519), page 734, by Dejan Zurovac, Robert W. Snow, Mickey Ndhlovu, Alexander K. Rowe, Davidson H. Hamer and Donald M. Thea, 2005

Funded by: Zambian-Boston University Malaria Project; US Centres for Disease Control; Wellcome Trust, United Kingdom

id21 Research Highlight: 16 June 2006

Further Information:
Dejan Zurovac
Malaria Public Health and Epidemiology Group
Centre for Geographic Medicine
KEMRI/Wellcome Trust Collaborative Programme
PO Box 43640
00100 GPO
Nairobi
Kenya

Tel: +254 20 271 5160
Fax: +254 20 271 1673
Contact the contributor: dzurovac@wtnairobi.mimcom.net

Kenya Medical Research Institute/Wellcome Trust Collaborative Programme

Boston University, USA

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