image: Children in sub-Saharan African settings with uncomplicated fever may be safely managed with conditional, rather than universal, three-day follow-up. view more
Credit: Joe Succaro, US Air Force
Children in sub-Saharan African settings with uncomplicated fever may be safely managed with conditional, rather than universal, 3-day follow-up with a community health worker (CHW), according to two cluster-randomized, community-based non-inferiority trials published this week in PLOS Medicine. The trials, conducted by Luke C. Mullany of the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States, and Karin Källander of Malaria Consortium, London, United Kingdom and the Karolinska Institutet, Stockholm, Sweden, and their colleagues, suggest that current World Health Organization (WHO) guidance for these children could be reconsidered.
The WHO's integrated community case management (iCCM) guidelines recommend that all children presenting with uncomplicated fever and no danger signs return for follow-up on day 3 following the initial consultation on day 1. Such fevers often resolve rapidly, however, and previous studies suggest that expectant home care for uncomplicated fever can be safely recommended. In the two trials, conducted at sites in the Democratic Republic of the Congo (DRC) and in Ethiopia, each with approximately 4000 participants, results suggest that conditional follow-up is non-inferior to universal follow-up for these children. In Mullany and colleagues' primary analysis in DRC, failure at day 8 (caregiver-reported fever, malaria, diarrhea, pneumonia, or decline of health status) was similar (difference: -0.7%, 95% CI: ??, 4.1%) in the conditional follow-up group (n = 188, 9.7%) compared to the universal follow-up group (n = 230, 10.4%). In Källander and colleagues' analysis in Ethiopia, failure at day 8 was also similar (difference: ?3.81%, 95% CI ??, 0.65%) in the conditional follow-up group (n = 16, 0.8%) compared to the universal follow-up group (n = 90, 4.6%).
The primary result from Källander and colleagues' trial in Ethiopia meets the pre-specified non-inferiority criterion, while Mullany and colleagues' trial results from the DRC suggest that any difference in failures is small. Additional trials in other sub-Saharan African settings are needed to establish generalizability. However, taken together, the current results provide evidence relevant to formulation of WHO recommendations. Källander and colleagues state, "Allowing CHWs to advise caregivers to bring children back only in case of continued symptoms might be a more efficient use of resources in these settings."
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Research Article - Mullany et al.
Funding:
This study was funded by the United States Agency for International Development under Translating Research into Action, Cooperative Agreement No. GHS-A-00-09-00015-00. The funder was involved in the design and conceptualization of the study but had no role in data collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests:
The authors have declared that no competing interests exist.
Citation:
Mullany LC, van Boetzelaer EW, Gutman JR, Steinhardt LC, Ngoy P, Barbera Lainez Y, et al. (2018) Universal versus conditional day 3 follow-up for children with non-severe unclassified fever at the community level in the Democratic Republic of the Congo: A cluster-randomized, community-based non-inferiority trial. PLoS Med 15(4): e1002552. https://doi.org/10.1371/journal.pmed.1002552
Author Affiliations:
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
International Rescue Committee, Kalemie, Democratic Republic of the Congo
Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
International Rescue Committee, New York, New York, United States of America
In your coverage please use this URL to provide access to the freely available paper: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002552
Research Article - Källander et al.
Funding:
This study was made possible by the support of the U.S. President's Malaria Initiative under the United States Agency for International Development's Translating Research into Action (TRAction) Project, Cooperative Agreement No. GHS-A-00-09- 00015-00. The funder was involved in the design and conceptualization of the study but had no role in data collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests:
The authors have declared that no competing interests exist.
Citation:
Källander K, Alfvén T, Funk T, Abebe A, Hailemariam A, Getachew D, et al. (2018) Universal versus conditional day 3 follow-up for children with non-severe unclassified fever at the community level in Ethiopia: A cluster-randomised non-inferiority trial. PLoS Med 15(4): e1002553. https://doi.org/10.1371/journal.pmed.1002553
Author Affiliations:
Malaria Consortium, London, United Kingdom
Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
Sachs' Children and Youth Hospital, Stockholm, Sweden
Malaria Consortium, Addis Ababa, Ethiopia
Health Metrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
In your coverage please use this URL to provide access to the freely available paper: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002553
Journal
PLoS Medicine