Implementing a New Malaria Treatment Policy with ACT

Implementing a new malaria treatment policy with ACT: the start of a new battle

S. Gerstl,1 S. Cohuet,1 K. Edoh,2 D. Baza,3 F. Checchi1

1Epicentre, Paris, France 2Médecins Sans Frontières, France 3Programme de Lutte contre les Maladies Transmissibles et Carentielles, Bujumbura, Burundi

Introduction Beginning in November 2003, an artesunate-amodiaquine combination (AS+AQ) was introduced as the first-line treatment for uncomplicated malaria in Burundi. Treatment was delivered at low cost in subsidised health centres. As part of the evaluation process for implementation of the new malaria treatment policy, we conducted a study evaluating the field implementation of this policy, 8 months after its introduction.

Methods We conducted a community-based survey in Makamba Province using Lot Quality Assurance Sampling (LQAS). Between July and August 2004, children under 5 years of age, living in Makamba Province for more than 2 weeks, were eligible. We developed a symptomatic definition of malaria through observation of children presenting a confirmed episode of malaria (positive blood slide) on the day of the study. We then retrospectively identified those children who had had probable malaria, based on the symptomatic definition, among all children with a history of fever in the 2 weeks before the study. Finally, we identified those who had received treatment with AS+AQ.

Results Of 526 children with fever 2 weeks before the study, 165 (31.4%) were defined as probable malaria cases. Among them, 67 (weighted proportion (wp) = 40.3%, 95% CI [28.5-52.2]) had not attended any health facility. 13 probable malaria cases (wp = 9.5%, 95% CI [3.9-15.1]) had received AS+AQ within 48 hours after onset of fever in a subsidised health centre. If we consider probable malaria cases in all treatment centres and without specifying time of consultation, 19 had been treated with AS+AQ (wp = 14.1%, 95% CI [7.7-20.5]). Among probable malaria cases who had received treatment in a subsidised health centre, 5 (wp = 17.3%) had received quinine as first-line treatment and 13 (wp = 53.3%) had not received any antimalarial treatment

Discussion The low proportion of AS+AQ treatment may be related to the small fraction of patients who attended health centres. AS+AQ was the most common treatment for probable malaria patients, replacing chloroquine at subsidised health centres. A substantial proportion of cases still received quinine as first-line antimalarial or did not receive any antimalarial treatment at all. This raises questions about the access and quality of care in health centres. In the light of a general introduction of ACT in Africa, it is important to evaluate the use of this new treatment in other countries where it is implemented.

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