Malaria kills up to three million people a year. Most research into managing the disease has focused on areas of high transmission, where many have developed resistance and initially treat symptoms at home. But how do people respond to malaria in areas of low transmission where there is little immunity?

Researchers from the Danish DBL-Institute for Health Research and Development, Ugandan Ministry of Health and the UK’s London School of Hygiene and Tropical Medicine studied malaria treatment-seeking and prescription practices in Kabale district, south-western Uganda. Malaria transmission in this district is low but unstable, with epidemics tending to occur after peaks of rainfall.

The study included both children and adults who were suspected of having malaria. Government workers used active case detection, conducting community surveys and home visits where they examined any household member who had had a fever within the last 24 hours and interviewed them using semi-structured questionnaires. Staff at health centres practiced passive case detection, using similar questionnaires to interview all outpatients with fever and treating those whose symptoms matched a presumptive diagnosis for malaria (diagnosis based on symptoms rather than causes of infection).

The researchers found that there was widespread local knowledge of malaria symptoms, transmission and risks. Knowledge of prevention methods was higher among health service users, 59 percent of whom mentioned using mosquito nets or insecticide-treated nets (ITNs), compared with 47 percent of community patients. However, few from either group were actually using ITNs or other insecticide products. Results showed that:

• patients interviewed at health centres were much more likely to attribute their symptoms to malaria than patients interviewed in home visits
• just 30 percent of patients received treatment at a health facility within 24 hours of the start of symptoms
• a quarter of patients had received treatment before visiting a health facility, mainly from drug shops and ordinary general stores
• some shops dispensed quinine, a second-line antimalarial drug recommended for complicated malaria
• only 3.5 percent of community patients received chloroquine (CQ) and sulfadoxine-pyrimethamine (SP) in combination, as recommended in national guidelines
• health staff also failed to comply with guidelines in their prescription practices, with a third of health centre patients receiving CQ alone rather than SP and CQ

The authors highlight the failure of both public and private sectors to comply with national drug policy. This is of particular concern in a time of rapid policy change and growing malaria drug resistance. They recommend:

• developing campaigns at the community level, with information on prompt treatment and home-based management of fever
• targeting the wider community of commercial drug vendors with information on national drug policy changes
• training health staff and drug vendors to improve their malaria diagnostic and treatment skills
• introducing policy measures to protect second-line drugs such as quinine from misuse, and supervision of the private sector to ensure compliance with drug regulations
• use of blister packaging (pre-formed clear plastic cases holding individual doses of drugs), and co-formulation (combining more than one drug in a single pill) to help health workers and drug vendors prescribe drug combinations correctly
• improving health education on the benefits of ITN use

Source(s):
'Malaria Treatment-seeking Behaviour and Drug Prescription Practices in an Area of Low Transmission in Uganda: Implications for Prevention and Control', Transactions of the Royal Society of Tropical Medicine and Hygiene 101(3),  pages 209-215, by Richard Ndyomugyenyi, Pascal Magnussen and Siân Clarke, 2007 (PDF)

Funded by: DBL-Institute for Health Research and Development, Denmark

id21 Research Highlight: 19 December 2007

Further Information:
Pascal Magnussen
DBL-Institute for Health Research and Development
Jaegersborg Allé 1 D
2920 Charlottenlund
Denmark

Contact the contributor: pm@bilharziasis.dk

DBL, Institute for Health Research and Development, Copenhagen

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