Definitions of Severity in Treatment Seeking Studies of Febrile Illness in Children in Low and Middle Income Countries: A Scoping Review

Health system effectiveness of symptomatic malaria case management in Papua New Guinea

Effective case management is crucial for malaria control efforts and is a cornerstone of malaria control programmes. Yet, although efficacious treatments exist, malaria case management often faces challenges, such as poor access to treatment providers, supply-chain issues, non-compliance with guidelines or substandard medication. In Papua New Guinea (PNG), progress in control efforts has stagnated in recent years. This study identifies barriers to and areas for improvement in malaria case management in PNG.A cascade of care model was used to estimate the health system effectiveness of malaria case management. Data from nationwide surveys conducted between 2013 and 2021 were used to quantify steps along a symptomatic case management pathway. Potential risk factors for cascade decay, including demographic, socioeconomic and health system characteristics, were investigated using mixed-effect logistic regression.The main bottleneck along the case management cascade was treatment-seeking, with only 40% (95% CI: 37% to 46%) of symptomatic malaria cases attending a formal health facility. A further important bottleneck was confirmatory parasitological diagnosis, provided to 77% (95% CI: 68% to 80%) of patients attending a health facility. Younger patients and those living in high transmission regions were more likely to receive a diagnostic test.Measures to improve the effectiveness of malaria case management in PNG should include increasing access to, utilisation and quality of formal health services. Further investigations to elucidate local determinants of treatment-seeking may support the National Malaria Strategic Plan's emphasis to optimise the delivery of proven interventions within the existing system.

Care Seeking and Treatment of Febrile Children with and without Danger Signs of Severe Disease in Northern Uganda: Results from Three Household Surveys (2018-2020)

Identification, stabilization, and prompt referral of children with signs of severe febrile disease (danger signs) in rural communities are crucial for preventing complications and death from severe malaria, pneumonia, and diarrhea. We set out to determine the treatment-seeking practices and treatment patterns for children < 5 years of age with an acute febrile illness, with or without danger signs of severe disease, in a highly malaria-endemic area of northern Uganda. Three household surveys were conducted from November through December each year in 2018, 2019, and 2020. Overall, 30% of the children in the study were reported to have had a WHO-classified danger sign including convulsions, unconsciousness/unusually sleepy, inability to feed or drink, and vomiting everything. Only half of the children in this study sought care from a health provider. However, significantly more children with danger signs of severe disease sought and received treatment and diagnostics from a health provider, compared with those without danger signs (adjusted odds ratio: 1.6, 95% confidence interval: 1.2-2.0; P < 0.01). In the total population studied, care seeking in the public sector was 26% and similar to care seeking in the private sector (24%). Community health workers were used as the first source of care by 12% of the children. Approximately 38% of the children who were reported to have danger signs of severe disease requiring prompt referral and treatment did not seek care from a health provider. Understanding and addressing barriers to accessing healthcare could contribute to better treatment seeking practices.

Prereferral rectal artesunate and referral completion among children with suspected severe malaria in the Democratic Republic of the Congo, Nigeria and Uganda

INTRODUCTION

Children who receive prereferral rectal artesunate (RAS) require urgent referral to a health facility where appropriate treatment for severe malaria can be provided. However, the rapid improvement of a child's condition after RAS administration may influence a caregiver's decision to follow this recommendation. Currently, the evidence on the effect of RAS on referral completion is limited.

METHODS

An observational study accompanied the roll-out of RAS in three malaria endemic settings in the Democratic Republic of the Congo (DRC), Nigeria and Uganda. Community health workers and primary health centres enrolled children under 5 years with suspected severe malaria before and after the roll-out of RAS. All children were followed up 28 days after enrolment to assess their treatment-seeking pathways.

RESULTS

Referral completion was 67% (1408/2104) in DRC, 48% (287/600) in Nigeria and 58% (2170/3745) in Uganda. In DRC and Uganda, RAS users were less likely to complete referral than RAS non-users in the pre-roll-out phase (adjusted OR (aOR)=0.48, 95% CI 0.30 to 0.77 and aOR=0.72, 95% CI 0.58 to 0.88, respectively). Among children seeking care from a primary health centre in Nigeria, RAS users were less likely to complete referral compared with RAS non-users in the post-roll-out phase (aOR=0.18, 95% CI 0.05 to 0.71). In Uganda, among children who completed referral, RAS users were significantly more likely to complete referral on time than RAS non-users enrolled in the pre-roll-out phase (aOR=1.81, 95% CI 1.17 to 2.79).

CONCLUSIONS

The findings of this study raise legitimate concerns that the roll-out of RAS may lead to lower referral completion in children who were administered prereferral RAS. To ensure that community-based programmes are effectively implemented, barriers to referral completion need to be addressed at all levels. Alternative effective treatment options should be provided to children unable to complete referral.

TRIAL REGISTRSTION NUMBER

NCT03568344; ClinicalTrials.gov.