Symptom overlap for malaria and pneumonia—policy implications for home management strategies
Introduction
Malaria and pneumonia are the leading causes of death among children in malarious countries in Sub-Saharan Africa (SSA), each contributing 20–26% of the total under-five mortality (Black et al., 2003). From a history of disease-specific programs, management of sick children at health facilities was integrated under the integrated management of childhood illness (IMCI) strategy (Gove, 1997). Under the IMCI algorithm, “malaria” in high-risk settings is defined as presence or history of fever, a symptom which also occurs in children with pneumonia. Under IMCI, “pneumonia” is defined as cough or difficult breathing with fast breathing, symptoms that may also indicate malaria (O’Dempsey et al., 1993, Chandramohan et al., 2002). Children with overlapping symptoms in health centres receive dual IMCI classifications and treatment with both antimalarials and antibiotics. The extent of this overlap has been documented in hospital based studies (Kolstad et al., 1997, Perkins et al., 1997) but not in routine IMCI practice at Health Centre level, nor in sick children at community level.
Since access to health services is limited in Sub-Saharan Africa and a majority of African children die at home (Garg et al., 2001), an integrated community component of IMCI aiming to improve home care and care seeking is now in its early implementation phase. Meanwhile, a 40% under-five mortality reduction (Kidane and Morrow, 2000) and decrease in risk of severe disease (Sirima et al., 2003) has been demonstrated through presumptive treatment of malaria. This has been achieved using trained community volunteers drug distributors holding drugs to supply their neighbours when needed, thus bringing the source of drugs closer to the sick child. Mothers’ capacity to subsequently administer antimalarial treatment adequately to children in the home has also been shown (Kofoed et al., 2003). Home and community management of malaria initiatives are now spreading across Sub-Saharan Africa with support from the Global Fund and Roll Back Malaria (Wendo, 2002). As vertical strategies, they bring health education and pre-packed antimalarials for fever treatment to community level (Sirima et al., 2003) and are highly accepted among Ugandan women in a rural setting (Kilian et al., 2003). However, they do not manage symptoms of pneumonia.
We set out to determine the frequency of the malaria-pneumonia symptom overlap at Health Centre level, in order to draw conclusions for home management of malaria initiatives.
Section snippets
Methods
During a 3-month period in the late dry and early rainy season, a total of 3671 consecutive consultations by children aged 2 months to 5 years were documented in 14 peripheral health centres, selected for their absence of inpatient beds and non-proximity to a hospital in four malaria endemic Ugandan districts. In these facilities all children were seen by one of the 16 local health workers (medical assistants, nurses, nurse-aids), trained on IMCI 1–3 years prior to the study. They recorded
Results
Fig. 1 shows the number and proportion of children in the symptom groups. Of the 3671 children, 84% reported cough or fever. Eighty percent satisfied the malaria case definition and 32% the pneumonia case definition. In total, 30% of all children fulfilled criteria for both conditions and were thus prescribed both antimalarials and antibiotics. Among children with “pneumonia”, 93% also had “malaria”. Most importantly, among the children fulfilling the malaria case definition, 37% also fulfilled
Discussion
This health-centre based study unavoidably suffers from selection bias due to care seeking practices. It relies on IMCI trained health workers’ self-recorded information and observation bias cannot be excluded. With those limitations we demonstrate that more than one third of IMCI malaria cases also fulfil the pneumonia case definition. As per WHO and Uganda’s treatment guidelines, these children need dual treatment with both an antimalarial and an antibiotic. Although symptom overlap does not
Acknowledgements
We thank health workers, children and parents who took part in this study, and Göran Tomson, Anna Mia Ekström, Marie Reilly, Tanya Guenther, Mark Young and Josephine Namboze for helpful comments.
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