New Approach to Old Diseases

An SPH study found that a simple rapid-diagnostic test and antibiotics can prevent the inappropriate use of antimalarial drugs in Zambia.

The one-room shack with a corrugated tin roof and no electricity in Siavonga District, Zambia, doesn’t look like much to an outsider’s eye. But in this simple structure, housing the community health post and just one community health worker, and what it represents to rural Zambians, Kojo Yeboah-Antwi sees life-saving promise.

Findings from a newly published study led by Yeboah-Antwi, a School of Public Health assistant professor of international health and a researcher for the SPH Center for Global Health and Development (CGHD), and a team of SPH researchers show that such outposts and the workers who staff them could become major assets in effectively treating the two leading causes of death among children under age five in sub-Saharan Africa—malaria and pneumonia.

The study, published online September 21 in PLos Medicine, found that sick children in Zambia who have fevers and/or difficulty breathing often are given antimalarial drugs inappropriately—a problem that can be tackled by arming community health workers with a simple rapid-diagnostic test and a supply of antibiotics.

The findings address the widespread practice of treating children with fevers with antimalarial drugs, rather than screening them first for malaria or pneumonia. The team found that having community health workers use a diagnostic test for malaria before prescribing treatment “resulted in a significant increase in the proportion of appropriately timed antibiotic treatments for nonsevere pneumonia, and in a significant decrease in inappropriate use of antimalarials.” The health workers were trained to give amoxicillin to children suspected of having pneumonia.

Traditionally, in Zambia and other parts of sub-Saharan Africa, most children brought to health personnel with fevers are treated with antimalarials, and those with suspected pneumonia are referred to health facilities. That practice leads to the overuse of artemisinin-based antimalarial drugs and also to the delay of care for children with pneumonia, some of whom live far from the nearest health facility. In addition, public health experts worry that overprescribing artemisinin-based drugs could lead to resistance to the medications.

“Pneumonia and malaria, two of the leading causes of morbidity and mortality among children under five in Zambia, often have overlapping clinical manifestations,” the research team said. “This study has demonstrated the feasibility and effectiveness of using [community health workers] to provide integrated management of pneumonia and malaria at the community level.”

The team studied treatment outcomes for more than 3,000 children, ages six months to five years, who presented with fevers, and in some cases fast respiratory rates, at community health posts. The children were randomly put in one of two groups—an intervention group, in which health workers used the rapid-diagnostic tests and doses of amoxicillin, and a control group, in which the workers gave children antimalarial drugs or referred those with suspected pneumonia to health facilities, in accordance with Zambian Ministry of Health policy.

The study found no significant difference in the overall treatment failure rates for children in the two groups. But it did find that the proportion of children given antimalarial drugs was much higher in the control group than in the intervention group—99.1 percent vs. 27.5 percent—suggesting that many of the children in the control group who were given such drugs did not need them.

Similarly, 68 percent of children in the intervention group who were classified as having pneumonia received early and appropriate treatment with antibiotics, compared to just 13 percent in the control group. That fivefold increase in the timely treatment of pneumonia was easily achieved by the trained community workers, the researchers said.

The study also found that the caregivers of more than 20 percent of the children in the control group who were referred to health centers for suspected pneumonia did not comply with the referral. Reasons for not complying were transportation obstacles, caregivers’ reluctance to believe that a child’s illness was serious enough to warrant the referral, or a belief that treatment for malaria was the right course of action, the authors said.

“Providing [community health workers] with the means to treat malaria, but not pneumonia, increases the risk of treatment delay and progression to more severe disease for children with pneumonia,” the researchers said.

They said the study’s findings bolster the idea that community health workers in rural, remote areas can and should be trained to diagnose and treat common childhood illnesses.

“We have found that by employing a small bit of technology and empowering the community health workers, we are able to save children who might not otherwise get treatment,” said Yeboah-Antwi. “Community case management of pneumonia is an effective approach to reducing child deaths in countries faced with insufficient human resources for health.”

Study coauthor David Hamer, an SPH professor of international health, a School of Medicine professor, and a CGHD researcher, noted that improving access to community-based care in regions that lack a health care infrastructure has become a focus of global health policy.

“The integrated management of common childhood illnesses by community health workers is an important component of strengthening health systems in countries in sub-Saharan Africa that will help these countries attain an important Millennium Development goal—a reduction of child mortality by two-thirds by 2015,” relative to 1990 levels, Hamer said.

The study was funded by the U.S. Agency for International Development and the President’s Malaria Initiative.

Other study authors are: Katherine Semrau, Lora Sabin, Donald Thea, William MacLeod, and Phil Seidenberg of the Center for Global Health and Development; Portipher Pilingana and Kazungu Siazeele of the Chikankata Mission Hospital, Zambia; Penelope Kalesha of the Zambian Ministry of Health, Child Health Unit; Busiku Hamainza of the National Malaria Control Center, Zambian Ministry of Health; Arthur Mazimba of the Center for International Health and Development–Zambia; and Karen Kamholz of the MED department of pediatrics.

The full study is available here.