Acceptability of Rectal Artesunate as pre-referral treatment for severe malaria in children under 5 years by health workers and caregivers in the Democratic Republic of the Congo, Nigeria and Uganda

Background In children below 6 years with suspected severe malaria who are several hours from facilities providing parenteral treatment, pre-referral rectal artesunate (RAS) is recommended by the World Health Organization to prevent death and disability. A number of African countries are in the process of rolling out quality-assured RAS for pre-referral treatment of severe malaria at community-level. The success of RAS depends, among other factors, on the acceptability of RAS in the communities where it is being rolled-out. Yet to date, there is limited literature on RAS acceptability. This study aimed to determine the acceptability of RAS by health care providers and child caregivers in communities where quality assured RAS was rolled out. Methods This study was nested within the comprehensive multi-country observational research project Community Access to Rectal Artesunate for Malaria (CARAMAL). The CARAMAL project was implemented in the Democratic Republic of the Congo (DRC), Nigeria, and Uganda between 2018 and 2020. Data from three different sources were analysed to understand RAS acceptability: Interviews with health workers during three healthcare provider surveys, with caregivers of children under 5 years of age during three household surveys, and with caregivers of children who were recently treated with RAS and enrolled in the CARAMAL Patient Surveillance System. Results RAS acceptability was high among all interviewed stakeholders in the three countries. After the roll-out of RAS, 97-100% heath care providers in DRC considered RAS medication as very good or good, as well as 98-100% in Nigeria and 93-100% in Uganda. Majority of caregivers whose children had received rectal artesunate for pre-referral management of severe malaria indicated that they would want to get the medication again, if their child had the same illness (99.8% of caregivers in DRC, 100% in Nigeria and 99.9% in Uganda). Further, using data from three household surveys, 67-80% of caregivers whose children had not received RAS considered the medication as useful. Conclusion RAS was well accepted by health workers and child caregivers in DRC, Nigeria and Uganda. Acceptability is unlikely to be an obstacle to the large-scale roll-out of RAS in the studied settings.

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

10.1101/2021.09.27.21264073 ◽

2021 ◽

Author(s):

Nina C Brunner ◽

Elizabeth Omoluabi ◽

Phyllis Awor ◽

Jean Okitawutshu ◽

Antoinette Tshefu ◽

...

Keyword(s):

Severe Malaria ◽

Democratic Republic ◽

Health Workers ◽

Health Centre ◽

Rapid Improvement ◽

Primary Health ◽

Republic Of The Congo ◽

Referral Completion ◽

Rectal Artesunate ◽

Roll Out

Background: Children who receive pre-referral 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. In this study, we investigated the relationship between RAS implementation and administration and referral completion. Methods and Findings: 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 five 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, treatments received, and their health outcome. In total, 8,365 children were enrolled, 77% of whom fulfilled all inclusion criteria and had a known referral completion status. Referral completion was 67% (1,408/2,104) in DRC, 48% (287/600) in Nigeria and 58% (2,170/3,745) 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 odds ratio [aOR] = 0.48, 95% CI 0.30-0.77 and aOR = 0.72, 95% CI 0.58-0.88, respectively). Among children seeking care from a primary health centre in Nigeria, RAS users were less likely to complete referral compared to RAS non-users in the post-roll-out phase (aOR = 0.18, 95% CI 0.05-0.71). 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 1.17-2.79). 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 pre-referral 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.

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Adherence to the referral advice after introduction of rectal artesunate for pre-referral treatment of severe malaria at the community level: a noninferiority trial in the Democratic Republic of the Congo

Malaria Journal ◽

10.1186/s12936-019-3074-6 ◽

2019 ◽

Vol 18 (1) ◽

Author(s):

Patrick M. Mvumbi ◽

Jeanine Musau ◽

Ousmane Faye ◽

Hyppolite Situakibanza ◽

Emile Okitolonda

Keyword(s):

Community Health ◽

Severe Malaria ◽

Community Health Workers ◽

Democratic Republic ◽

Community Care ◽

Health Workers ◽

Post Intervention ◽

Republic Of The Congo ◽

Rectal Artesunate ◽

Children Under 5

Abstract Background The Democratic Republic of the Congo adopted the strategy of using, at the community level, a dose of rectal artesunate as a pre-referral treatment for severe malaria amongst children under 5 years who could not quickly reach a health care facility and take oral medication. However, the adherence to referral advice after the integration of this strategy and the acceptability of the strategy were unknown. Methods To assess adherence by the mothers/caretakers of children under 5 years to referral advice provided by the community health workers after pre-referral treatment of severe malaria with rectal artesunate, the authors conducted a noninferiority community trial with a pre- and post-intervention design in 63 (pre-intervention) and 51 (post-intervention) community care sites in 4 provinces (Kasaï-Oriental, Kasaï-Central, Lomami, Lualaba) from August 2014 through June 2016. The pre- and post-intervention surveys targets 387 mothers of children under 5 years and 63 community health workers and 346 mothers and 41 community health workers, respectively. A 15% margin was considered for noninferiority analyses due to the expected decrease in adherence to referral advice after the introduction of the new intervention. Results The mothers acknowledged that the rectal route was often used (60.7%), and medicines given rectally were considered more effective (63.6%) and easy to administer (69.7%). The acceptability of pre-referral rectal artesunate was relatively high: 79.4% (95% CI 75.4–83.3) among mothers, 90.3% (95% CI 82.3–96.8) among community health workers, and 97.8% (95% CI 93.3–100) among nurses. Adherence to referral advice at post-intervention [84.3% (95% CI 80.6–88.1)] was non-inferior to pre-intervention adherence [94.1% (95% CI 91.7–96.4)]. Conclusions The integration of pre-referral rectal artesunate for severe malaria into the community care site in the DR Congo is feasible and acceptable. It positively affected adherence to referral advice. However, more health education is needed for parents of children under 5 years and community health workers.

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Training health workers for enhanced monkeypox surveillance, Democratic Republic of the Congo

International Journal of Infectious Diseases ◽

10.1016/j.ijid.2014.03.990 ◽

2014 ◽

Vol 21 ◽

pp. 274-275

Author(s):

M. Reynolds ◽

J. Malekani ◽

I. Damon ◽

B. Monroe ◽

J. Kabamba ◽

...

Keyword(s):

Democratic Republic ◽

Health Workers ◽

Republic Of The Congo

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Children hospitalized with severe malaria in Kinshasa (Democratic Republic of the Congo): Household characteristics and factors associated with mortalitys

Médecine et Santé Tropicales ◽

10.1684/mst.2014.0416 ◽

2015 ◽

Vol 25 (1) ◽

pp. 75-81

Author(s):

F. Ilunga-Ilunga ◽

A. Levêque ◽

P. Donnen ◽

M. Dramaix

Keyword(s):

Severe Malaria ◽

Democratic Republic ◽

Factors Associated ◽

Household Characteristics ◽

Republic Of The Congo

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Knowledge of Antimalarials and Health Seeking Behaviour of Households in Case of Suspected Malaria in Democratic Republic of the Congo

Tropical Medicine and Infectious Disease ◽

10.3390/tropicalmed6030157 ◽

2021 ◽

Vol 6 (3) ◽

pp. 157

Author(s):

Nsengi Y. Ntamabyaliro ◽

Christian Burri ◽

Yves N. Lula ◽

Daniel Ishoso ◽

Aline B. Engo ◽

...

Keyword(s):

Secondary School ◽

Democratic Republic ◽

Health Workers ◽

Health Seeking Behaviour ◽

Health Seeking ◽

Self Medication ◽

Level Of Education ◽

Catholic Religion ◽

Republic Of The Congo ◽

Good Behaviour

(1) Background: The Democratic Republic of the Congo (DRC) is heavily affected by malaria despite availability of effective treatments. Ignorance and unrecommended behaviour toward a suspected malaria case in households may contribute to this problem. (2) Method: In communities of one rural and one urban Health Centres in each of the 11 previous provinces of DRC, all households with a case of malaria in the 15 days prior to the survey were selected. The patient or caregiver (responder) were interviewed. Logistic regression was used to assess predictors of knowledge of recommended antimalarials and adequate behaviour in case of suspected malaria. (3) Results: 1732 households participated; about 62% (1060/1721) of the responders were informed about antimalarials, 70.1% (742/1059) knew the recommended antimalarials and 58.6% (995/1699) resorted to self-medication. Predictors of knowledge of antimalarials were education to secondary school or university, information from media and smaller households. Predictors of good behaviour were Catholic religion and smaller households. Receiving information from Community Health Workers (CHWs) failed to be determinants of knowledge or adequate behaviour. (4) Conclusion: malaria control in DRC is hampered by ignorance and non-adherence to national recommendations. These aspects are influenced by unsuccessful communication, size of households and level of education.

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A Snapshot of Poverty, Diseases and War – The Democratic Republic of the Congo

Disaster Medicine and Public Health Preparedness ◽

10.1017/dmp.2021.227 ◽

2021 ◽

pp. 1-11

Author(s):

Shibu Sasidharan ◽

Harpreet Singh Dhillon

Keyword(s):

Rift Valley Fever ◽

Democratic Republic ◽

Health Workers ◽

Health Issues ◽

Valley Fever ◽

Major Health ◽

Civil Unrest ◽

Republic Of The Congo ◽

And Control ◽

Perfect Storm

Abstract DRC’s fight with EVD was just settling when WHO declared CoVid-19 to be a PHEIC on Mar 12, 2020. DRC’s economic growth decelerated from its pre-COVID level of 4.4% in 2019, to an estimated 0.8% in 2020. This has caused concomitant setbacks in the treatment and control of major health issues like HIV, tuberculosis, measles, rift valley fever and malaria in the country. This coupled with civil unrest, other infectious diseases and risk to the safety of the health workers, this is a recipe for a 'perfect storm’ waiting to unfold.

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Effectiveness of rectal artesunate as pre-referral treatment for severe malaria in children <5 years of age

10.1101/2021.09.24.21263966 ◽

2021 ◽

Author(s):

Manuel W Hetzel ◽

Jean Okitawutshu ◽

Antoinette Tshefu ◽

Elizabeth Omoluabi ◽

Phyllis Awor ◽

...

Keyword(s):

Severe Malaria ◽

Rural Areas ◽

Health Care Systems ◽

Controlled Trial ◽

Child Survival ◽

Case Fatality ◽

Community Based ◽

Rectal Artesunate ◽

Roll Out

Background To prevent child deaths from severe malaria, early parenteral treatment is essential. Yet, in remote rural areas, higher-level facilities offering parenteral antimalarials are often difficult to access. A randomised controlled trial found pre-referral rectal artesunate (RAS) to reduce death and disability in children who delay arriving at a referral facility. This study examined the effectiveness of pre-referral RAS treatment in established community-based health care systems. Methods An observational study accompanied the roll-out of RAS in the Democratic Republic of the Congo, Nigeria and Uganda. Children < 5 years presenting to a community-based health provider with a positive malaria test and signs of severe malaria were followed-up during admission and after 28 days to assess their health status and treatment history. The primary outcome was death; covariates of interest included RAS use, referral completion, and post-referral treatment. Findings Post-roll-out, RAS was administered to 88% of patients in DRC, 52% in Nigeria, and 70% in Uganda. The overall case fatality rate (CFR) was 6.7% (135/2011) in DRC, 11.7% (69/589) in Nigeria, and 0.5% (19/3686) in Uganda; 865/6286 patients were sick at follow-up. In all countries, the CFR was higher after RAS-roll-out (6.7 vs. 6.6% in DRC, 16.1 vs. 4.2% in Nigeria, 0.7 vs. 0.3% in Uganda). In DRC and Nigeria, children receiving RAS were more likely to die than those not receiving RAS (aOR = 3.31, 95% CI 1.43-7.65 and aOR = 2.42, 95% CI 1.25-4.70, respectively). In Uganda, RAS users were less likely to be dead or sick at follow-up (aOR = 0.61, 95% CI 0.46-0.80). Post-referral parenteral antimalarials were protective in all countries; however, the effect of ACT administration was inconsistent. Interpretation RAS pre-referral treatment had no beneficial effect on child survival in three highly malaria endemic settings. RAS is unlikely to reduce malaria deaths unless health system shortfalls such as referral and post-referral treatment are addressed.

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Treatment-seeking for children with suspected severe malaria attending community health workers and primary health centres in Adamawa State, Nigeria

10.1101/2021.12.01.21267130 ◽

2021 ◽

Author(s):

Tristan T. Lee ◽

Elizabeth Omoluabi ◽

Kazeem Ayodeji ◽

Ocheche Yusuf ◽

Charles Okon ◽

...

Keyword(s):

Severe Malaria ◽

Case Fatality Rate ◽

Health Workers ◽

Case Fatality ◽

Treatment Seeking ◽

Community Based ◽

Danger Signs ◽

Primary Health ◽

Primary Health Centres ◽

Rectal Artesunate

AbstractBackgroundThe Community Access to Rectal Artesunate for Malaria project investigated the feasibility of introducing pre-referral rectal artesunate into existing community-based health services. In that study, the case fatality rate of children visiting primary health centres (PHCs) was 19% compared to 6% in children first visiting community health workers, locally called Community Oriented Resource Persons (CORPs). As case management practices did not fully explain this finding, this publication investigates other reasons underlying the observed difference in case fatality.MethodsThe observational study enrolled 589 children under the age of five years with fever and danger signs indicative of severe malaria attending CORPs and PHCs in Adamawa State, Nigeria, between June 2018 and July 2020. After 28 days, follow-up visits were conducted with caregivers to understand background characteristics, severity of symptoms, home treatment administration, and treatment seeking practices during the child’s illness. These factors were compared between children visiting CORPs versus those visiting PHCs as their first health provider.ResultsChildren visiting PHCs were more likely to display danger signs indicative of central nervous system involvement (90% vs. 74%, p < 0.01) and have four or more danger signs (50% vs. 39%, p = 0.02). The delay between illness onset and visiting the community-based provider did not differ between children attending a CORP and children attending a PHC. PHC attendances more often lived in urban areas (16% vs 4%, p=0.01) and travelled farther to their first health provider, which was usually a community-based provider. Although practicing home treatment was common, especially among children attending PHCs (42% vs 33%, p=0.04), almost none of the children were given an antimalarial. PHCs were visited for their professionalism and experience while CORPs were visited for their low cost and because caregivers personally knew and trusted the provider.ConclusionsOur comparison of children with suspected severe malaria seeking care from two kinds of community-based health care providers in Nigeria suggest that illness severity may be the primary driver behind the observed difference in case fatality rate.

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Tracing Down Real Socio-Economic Trends From Household Data With Erratic Sampling Frames: The Case of the Democratic Republic of the Congo

Journal of Asian and African Studies ◽

10.1177/0021909617698842 ◽

2017 ◽

Vol 53 (4) ◽

pp. 532-552 ◽

Cited By ~ 6

Author(s):

Wim Marivoet ◽

Tom De Herdt

Keyword(s):

Democratic Republic ◽

Temporal Analysis ◽

Household Surveys ◽

Asset Ownership ◽

Sampling Frame ◽

School Enrolment ◽

Household Data ◽

Economic Trends ◽

Republic Of The Congo ◽

Survey Designs

By means of the latest seven national household surveys of the Democratic Republic of the Congo, this article uncovers the very volatile sampling frame used underneath all survey designs. As a result, the reliability of much associated survey information as well as any corresponding temporal analysis are seriously jeopardized. Relying on recent vaccination, school enrolment and election data, the article proposes a post-stratification technique to retroactively control for these erratic variations in sampling frame in an attempt to identify real socio-economic trends. Although the proposed technique did not restore full comparability of survey data in all respects, it has been able to eliminate an essential part of the spuriousness as illustrated by assessing trends in asset ownership under both the biased and stabilized sampling frames.

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