Symptom overlap for malaria and pneumonia—policy implications for home management strategies

Abstract

Malaria and pneumonia are the leading causes of child death in Sub-Saharan Africa (SSA). Integrated management of childhood illness (IMCI) at health facilities is presumptive: fever for malaria, and cough/difficult breathing with fast breathing for pneumonia. Of 3671 Ugandan under-fives at 14 health centres, 30% had symptoms compatible both with malaria and pneumonia, necessitating dual treatment. Of 2944 “malaria” cases, 37% also had “pneumonia”. The Global Fund and Roll Back Malaria are now supporting home management of malaria strategies across SSA. To adequately treat the sick child, these community strategies need to address the malaria-pneumonia symptom overlap and manage both conditions.

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.