Artemether-lumefantrine for treating uncomplicated falciparum malaria

The effect of health education intervention on the home management of malaria among the caregivers of children aged under 5 years in Ogun State, Nigeria

Background

Malaria is currently the most important cause of death and disability in children aged under 5 years in Africa. A health education interventional study of this nature is essential in primary control of an endemic communicable disease such as malaria. This study was therefore designed to determine the effect of health education on the home management of Malaria among the caregivers of children under 5 years old in Ogun State, Nigeria.

Methods

The study design was a quasi-experimental study carried out in Ijebu North Local Government Area of Ogun State. A multistage random sampling technique was used in choosing the required samples for this study and a semi-structured questionnaire was used to collect relevant information. The intervention consisted of a structured educational program based on a course content adapted from the national malaria control program. A total of 400 respondents were recruited into the study, with 200 each in both the experimental and control groups, and were followed up for a period of 3 months when the knowledge and uptake of insecticide treated net was reassessed.

Results

There was no statistically significant differences observed between the experimental and control groups in terms of sociodemographic characteristics such as age (P = 0.99), marital status (P = 0.48), religion (P = 0.1), and income (P = 0.51). The majority in both the experimental (75.0%) and control (71.5%) groups use arthemisinin-based combination therapy as first line home treatment drugs pre intervention. Post health education intervention, the degree of change in the knowledge of referral signs and symptoms in the experimental group was 52.8% (P < 0.0001) while it was 0.2% in the control group (P = 0.93). Tepid sponging improved by 45.0%, paracetamol use by 55.3%, and the use of herbs and other drugs were not significantly influenced in the experimental (P = 0.65 and 0.99) and control group (P = 0.89 and 0.88), respectively. Furthermore, there was a 55.7% (P = 0.001) increase in the proportion of respondents using the correct dose of arthemisinin-based combination therapy in the home management of malaria and 23.9% (P < 0.001) in the proportion using it for the required time.

Conclusions

The study concludes that there is a shift in the home management of malaria with the use of current and effective antimalarial drugs. It also demonstrated the effect of health education on the promptness of appropriate actions taken among the respondents for early diagnosis and treatment. Early diagnosis and appropriate treatment can be guaranteed if caregivers are knowledgeable on prompt actions to be taken in the home management of malaria.

Cost-effectiveness analysis of the available strategies for diagnosing malaria in outpatient clinics in Zambia

BACKGROUND

Malaria in Zambia accounts for about 4 million clinical cases and 8 000 deaths annually. Artemether-lumefantrine (ACT), a relatively expensive drug, is being used as first line treatment of uncomplicated malaria. However, diagnostic capacity in Zambia is low, leading to potentially avoidable wastage of drugs due to unnecessary anti malarial treatment.

METHODS

A cost-effectiveness evaluation of the three current alternatives to malaria diagnosis (clinical, microscopy and Rapid Diagnostic Tests- RDT) was conducted in 12 facilities from 4 districts in Zambia. The analysis was conducted along an observational study, thus reflecting practice in health facilities under routine conditions. Average and incremental cost effectiveness ratios were estimated from the providers' perspective. Effectiveness was measured in relation to malaria cases correctly diagnosed by each strategy.

RESULTS

Average cost-effectiveness ratios show that RDTs were more efficient (US$ 6.5) than either microscopy (US$ 11.9) or clinical diagnosis (US$ 17.1) for malaria case correctly diagnosed. In relation to clinical diagnoses the incremental cost per case correctly diagnosed and treated was US$ 2.6 and US$ 9.6 for RDT and microscopy respectively. RDTs would be much cheaper to scale up than microscopy. The findings were robust to changes in assumptions and various parameters.

CONCLUSION

RDTs were the most cost effective method at correctly diagnosing malaria in primary health facilities in Zambia when compared to clinical and microscopy strategies. However, the treatment prescription practices of the health workers can impact on the potential that a diagnostic test has to lead to savings on antimalarials. The results of this study will serve to inform policy makers on which alternatives will be most efficient in reducing malaria misdiagnosis by taking into account both the costs and effects of each strategy.

A randomized trial on effectiveness of artemether-lumefantrine versus artesunate plus amodiaquine for unsupervised treatment of uncomplicated Plasmodium falciparum malaria in Ghanaian children

Background

Numerous trials have demonstrated high efficacy and safety of artemisinin-based combination therapy (ACT) under supervised treatment. In contrast, effectiveness studies comparing different types of ACT applied unsupervised are scarce. The aim of this study was to compare effectiveness, tolerability and acceptance of artesunate plus amodiaquine (ASAQ) against that of artemether-lumefantrine (AL) in Ghanaian children with uncomplicated Plasmodium falciparum malaria.

Methods

A randomized open-label trial was conducted at two district hospitals in the Ashanti region, Ghana, an area of intense malaria transmission. A total of 246 children under five years of age were randomly assigned to either ASAQ (Arsucam^®) or AL (Coartem^®). Study participants received their first weight-adjusted dose under supervision. After the parent/guardian was advised of times and mode of administration the respective three-day treatment course was completed unobserved at home. Follow-up visits were performed on days 3, 7, 14 and 28 to evaluate clinical and parasitological outcomes, adverse events, and haematological recovery. Length polymorphisms of variable regions of msp1 and msp2 were determined to differentiate recrudescences from reinfections. Acceptance levels of both treatment regimens were assessed by means of standardized interviews.

Results

Adequate clinical and parasitological responses after AL and ASAQ treatment were similar (88.3% and 91.7%, respectively). Interestingly, more late clinical failures until day 28 occurred in AL-treated children than in those who received ASAQ (17.5% and 7.3%, respectively; Hazard Ratio 2.41, 95% CI 1.00–5.79, p < 0.05).

Haematological recovery and drug tolerability were not found to be significantly different in both study arms. The acceptance of treatment with ASAQ was higher than that with AL (rank-scores 10.6 and 10.3, respectively; p < 0.05).

Conclusion

Unobserved AL and ASAQ treatment showed high adequate clinical and parasitological responses, though AL was inferior in preventing late clinical failures.

Artemether-lumefantrine versus artesunate plus amodiaquine for treating uncomplicated childhood malaria in Nigeria: randomized controlled trial

BACKGROUND

The therapeutic efficacy of artesunate plus amodiaquine and artemether/lumefantrine were assessed in an area of Nigeria with high levels of Plasmodium falciparum resistance to chloroquine and sulphadoxine-pyrimethamine.

PARTICIPANTS

Children aged 6 to 59 months with uncomplicated P. falciparum infection and parasite density 1,000 to 200,000 parasites/microL enrolled following informed consent by parents.

METHODS

Eligible children were randomly assigned to receive either a 3-day course of artesunate (4 mg/kg) plus amodiaquine (10 mg/kg) or 6-dose course of artemether/lumefantrine (20/120 mg tablets) over three days. Patients were followed up with clinical and laboratory assessments until day 14 using standard WHO in-vivo antimalarial drug test protocol.

RESULTS

A total 119 eligible children were enrolled but 111 completed the study. Adequate clinical and parasitological response (ACPR) was 47 (87.0%) and 47 (82.5%) for artemether-lumefantrine (AL) and artesunate+amodiaquine (AAMQ) respectively (OR 0.7, 95% confidence interval 0.22 to 2.22). Early treatment failure (ETF) occurred in one participant (1.8%) treated with AAQ but in none of those with AL. Two (3.7%) patients in the AL group and none in the AAQ group had late clinical failure. Late parasitological failure was observed in 9 (15.8) and 5 (9.3%) of patients treated with AAQ and AL respectively. None of participants had a serious adverse event.

CONCLUSION

Artemether-lumenfantrine and artesunate plus amodiaquine have high and comparable cure rates and tolerability among under-five children in Calabar, Nigeria.

Artemether-lumefantrine (six-dose regimen) for treating uncomplicated falciparum malaria

BACKGROUND

The World Health Organization recommends artemether-lumefantrine for treating uncomplicated malaria. We sought evidence of superiority of the six-dose regimen over existing treatment regimens as well as its effectiveness in clinical situations.

OBJECTIVES

To evaluate the six-dose regimen of artemether-lumefantrine for treating uncomplicated falciparum malaria.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group Specialized Register (April 2005), CENTRAL (The Cochrane Library Issue 1, 2005), MEDLINE (1966 to April 2005), EMBASE (1974 to April 2005), LILACS (1982 to April 2005), conference proceedings, and reference lists of articles. We also contacted experts in malaria research and the pharmaceutical company that manufactures artemether-lumefantrine.

SELECTION CRITERIA

Randomized controlled trials comparing six doses of artemether-lumefantrine administered orally with standard treatment regimens (single drug or combination), or supervised with unsupervised treatment, for uncomplicated falciparum malaria.

DATA COLLECTION AND ANALYSIS

Two authors independently applied inclusion criteria to potentially relevant trials, assessed trial quality, and extracted data, including adverse events. Total failure by day 28 (day 42 for sulfadoxine-pyrimethamine and day 63 for mefloquine) was the primary outcome.

MAIN RESULTS

Nine trials (4547 participants) tested the six-dose regimen. Total failure at day 28 for artemether-lumefantrine was lower when compared with amodiaquine (270 participants, 1 trial), amodiaquine plus sulfadoxine-pyrimethamine (507 participants, 1 trial), but not with chloroquine plus sulfadoxine-pyrimethamine (201 participants, 2 trials). In comparisons with artemisinin derivative combinations, artemether-lumefantrine performed better than amodiaquine plus artesunate (668 participants, 2 trials), worse than mefloquine plus artesunate (270 participants, 4 trials), and no differently to dihydroartemisinin-napthoquine-trimethoprim (89 participants, 1 trial).

AUTHORS' CONCLUSIONS

The six-dose regimen of artemether-lumefantrine appears more effective than antimalarial regimens not containing artemisinin derivatives.

Therapy of falciparum malaria in sub-saharan Africa: from molecule to policy

The burden of falciparum malaria remains as great as ever, and, as has probably always been the case, it is carried mainly by tropical Africa. Of the various means available for the control of malaria, the use of effective drugs remains the most important and is likely to remain so for a considerable time to come. Unfortunately, the extensive development of resistance by the parasite threatens the utility of most of the affordable classes of drug: the development of novel antimalarials has never been more urgently needed. Any attempt to understand the vast complexities of falciparum malaria in Africa requires an ability to think "from molecule to policy." In consequence, the review ambitiously tries to examine the current pharmacopeia, the process by which new drugs are developed and the ways in which drugs are actually used, in both the formal and informal health sectors. The informal sector is particularly important in Africa, where around half of all antimalarial treatments are bought from informal outlets and taken at home without supervision by health care professionals: the potential impact of adherence on clinical outcome is discussed. Given that the full costs are carried by the patient in a large proportion of cases, the importance of drug affordability is explored. The review also discusses the splicing of new drugs into national policy. The various parameters that feed into deliberations on changes in drug policy are discussed.

[Therapy of tropical diseases after returning from travel]

Most tropical diseases imported by travelers can be treated quite effectively. Human endoparasites belong to the protozoa and worms. Protozoa can be seen as microparasites, characterized by short generation periods and high rates of reproduction within a host--consequently the diseases mainly are of short duration. Effective drugs are available for malaria, amebiasis and other intestinal protozoa as well as for leishmaniasis. Resistance, however, sometimes is a problem. Worms are macroparasites that generally do not reproduce within a host--teleologically speaking because otherwise they would rapidly damage their own basis of living. Accordingly, severe worm disease is rarely found in travelers. Levels of anthelminthic resistances so far are low. The most important worm disease in travelers is schistosomiasis, a disease that also can be treated effectively if diagnosed early.