In rural areas of Africa, access to health facilities for treatment of severe malaria (and other conditions) is generally extremely poor. An analysis published Online First and in an upcoming Lancet shows that use of rectal artesunate at the time of referral is a cost-effective intervention, which can substantially improve the management of severe childhood malaria in rural African settings in which programmes for community health workers are in place. The Article is by Dr Yesim Tozan, Boston University School of Public Health, Boston, MA, USA, and colleagues.
Severely ill patients with vomiting, prostration, and altered consciousness cannot tolerate oral treatment and need parenteral antimalarial drugs, adjunctive therapy, and supportive care. In rural areas, access to health facilities that provide parenteral treatment is poor, laboratory diagnosis is not available, and quality of inpatient care is variable. Hence, safe and effective treatment of most cases of severe malaria is greatly delayed or not achieved. In this study, the authors assessed the cost-effectiveness of community-based prereferral artesunate treatment of children suspected to have severe malaria in areas with poor access to formal health care.
This modelling study looked at a hypothetical cohort of 1000 newborn babies until 5 years of age. The analysis assessed how the cost-effectiveness results changed with low (25%), moderate (50%), high (75%), and full (100%) referral compliance and intervention uptake. The researchers found that, at low intervention uptake and referral compliance (25%), the intervention was estimated to avert 19 years lived with disability (DALYs) and to cost 1173 International dollars (I$) per DALY averted. Under the full uptake and compliance scenario (100%), the intervention could avert 967 DALYs at a cost of I$77 per DALY averted. The authors note that "Compared with the interventions that target key childhood illnesses in sub-Saharan Africa, pre-referral [rectal] artesunate treatment is among the most cost-effective, especially if the intervention uptake is moderate or higher".
The authors conclude: "Improvement in management of sick children at the household and community level is urgent. This life-saving, cost-effective intervention has the potential to significantly improve management of severe childhood malaria. Prereferral rectal artesunate merits serious consideration by health policy makers as part of an intervention package to facilitate progress towards internationally set malaria and child survival targets. Nevertheless, the success of interventions in the community ultimately depends on whether formal health systems can provide front-line health workers with drugs and other necessary health commodities, regular monitoring and supervision, and linkages to referral systems."
In a linked Comment, Dr Yoel Lubell, Mahidol Oxford Tropical Medicine Research Unit, Department of Tropical Medicine, Mahidol University, Bangkok, Thailand, says: "Despite the growing arsenal of interventions being deployed for the prevention, diagnosis, and treatment of malaria, it is important to remember that none of these tools have an inherent degree of cost-effectiveness. Rather, it is the manner in which they are deployed and the identification of those areas where they are most suitable that determines whether they are cost effective. Prereferral artesunate is no exception. Deployment in appropriate circumstances by community health workers trained to distinguish between malaria and other illnesses could offer a critical stop-gap where access to health care is limited, as Tozan and colleagues showed. However, indiscriminate use, particularly in areas of low endemicity could result in misallocation of scarce resources in parts of the world that can least afford it."
Dr Yesim Tozan, Boston University School of Public Health, Boston, MA, USA. T) +1 617 414 1209 E) tozan@bu.edu
Dr Yoel Lubell, Mahidol Oxford Tropical Medicine Research Unit, Department of Tropical Medicine, Mahidol University, Bangkok, Thailand. T) +66 (0)85 7201350 E) yoel@tropmedres.ac
For full Article and Comment, see: http://press.thelancet.com/childartes.pdf
NOTE: THE ABOVE LINK IS FOR JOURNALISTS ONLY; IF YOU WISH TO PROVIDE A LINK TO THE FREE ABSTRACT OF THIS PAPER FOR YOUR READERS, PLEASE USE THE FOLLOWING, WHICH WILL GO LIVE AT THE TIME THE EMBARGO LIFTS: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61460-2/abstract
Journal
The Lancet