AFRO-NETS> Invitation to multi-country trials: home management of malaria

[Dieter Neuvians MD <neuvians@mweb.co.zw>]

Invitation to multi-country trials: home management of malaria
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Source: tdr-scientists@who.ch

Call for Letters of interest

Multi-country trials of an integrated package of approaches for home 
management of malaria and pneumonia to assess operational feasibility 
and impact on under-five mortality

In low-income countries where both malaria and pneumonia are common 
killers of children, where, because of constraints of the health sys-
tem and the care seeking practices, most deaths occur at home, in-
vestments in efforts to empower poor families in treatment and pre-
vention of both these diseases are necessary for achieving acceler-
ated, profound, sustainable and equitable impact on child survival. 
This is especially important for sub-Saharan Africa where there has 
been very little overall improvement in the under-five mortality in 
the past decade, despite well recognised efforts.

When investigating approaches for empowering poor families in the 
treatment and prevention for malaria and pneumonia, several important 
characteristics that the two diseases share become important. Initial 
symptoms (fever, fast breathing, cough) and signs of severe illness 
(inability to eat, convulsions and difficulty breathing) are similar 
and indistinguishable even by trained health workers in the absence 
of laboratory investigations. Progression from mild symptoms to se-
vere complications and death is rap id and immediate, appropriate 
treatment is necessary to save life. Effective, inexpensive treat-
ments exist (US$ 0.05 for malaria and US$ 0.30 for pneumonia) are al-
ready being used (often inappropriately) by families for self treat-
ment.

To date, community and home-based interventions have been implemented 
for malaria and pneumonia separately, despite a significant, docu-
mented, overlap in presentation in the two conditions. Attempts to 
investigate the effectiveness of improved management of both presump-
tive malaria and pneumonia have been opposed by concerns regarding 
increased resistance to antimalarials and antibiotics and the consid-
ered inability of mothers to comply with the complicated diagnosis 
and dosing schedule that proper treatment would require.

However, research over the last several years has helped alleviate 
some of the concerns regarding the provision of antimicrobials at the 
community and home levels. Innovations in drug packaging have proven 
to increase patient compliance dramatically. Ethnographic studies 
have elucidated the knowledge, attitudes and practices of caretakers 
with regard to malaria and pneumonia so that education strategies and 
programmes can be developed that encourage good practice without un-
dermining existing beliefs. Mortality from malaria can be reduced 
significantly through early treatment. The potential for saving addi-
tional lives lost to pneumonia and malaria together is likely to be 
much higher. It is therefore considered that a community-based inter-
vention to improve the home management of these overlapping and 
clinically indistinguishable conditions and establish the survival 
benefit should be explored further in research.

The UNDP/World Bank/WHO Special Programme for Research and Training 
in Tropical Diseases (TDR) and the Home Management of Malaria and 
Pneumonia (HMMP) Working Group, an interagency collaboration between 
researchers from the Department of Epidemiology and Community Medi-
cine at the University of Ottawa, the Division of International 
Health of the Karolinska Institute, UNICEF, and the World Health Or-
ganization (WHO) invite letters of interest from country teams to 
participate in multi-country trials of an integrated package of ap-
proaches for home management of malaria and pneumonia to assess op-
erational feasibility and impact on under-five mortality.

Successful research teams will be expected to establish, support and 
implement an effective intervention for community and home-based 
treatment of fever episodes presumed to be caused by malaria and 
pneumonia, among children living in malaria endemic communities that 
are under-served by health facilities and assess the impact of the 
intervention on under-5 mortality through a staggered randomised 
trial design. In addition, the teams will explore and evaluate ap-
proaches for improving and measuring adherence to antimalarial and 
antibiotic recommended treatment regimens, explore and evaluate ap-
propriate ways of monitoring and reporting drug related adverse 
events resulting from community and home-based treatment, monitor the 
development of drug resistance/failure in treatment response and 
evaluate the cost-effectiveness of the intervention.

The letters of interest should include the following:

* A mechanism and plan for collaboration with the relevant national 
  control programme officials in the Ministry of Health, to ensure co-
  authorship of the project proposal and full ownership of the results 
  by the implementing authorities. This collaboration between research-
  ers and Ministry of Health officials should be clearly demonstrable 
  at all levels of future project implementation.

* Names and summary CVs of a principal investigator and a co-PI, one 
  from a university or research institution and the other from a na-
  tional control programme, or visa-versa.

* An indication of any experiences with approaches for community and
  home management for malaria and/or ARI including:
- unit dose packaging of treatment for children 
- working with community members as to improve treatment and referral
  (CHWs, shop keepers, drug peddlers etc) 
- IEC to mothers and other care providers.

* Experience with the qualitative and quantitative measurement of the
  following outcomes: 
- changes in behaviour and practices as relevant to the intervention 
- home level assessments of access and compliance. 
- level of exposure of the target group(s) to the intervention. 
- anti-parasitic resistance (where feasible). 
- costing of inputs (operational, research, monitoring and evalua
  tion).

* How the anticipated ethical and regulatory issues in the local con-
  text will be addressed should be spelt out.

TDR/IDE's Steering Committee responsible for Home Management strate-
gies will meet 08-12 April 2002 to review letters of interest and to 
recommend potential teams. This will be followed by a workshop in 
June 2002 to finalize proposals and implementation plans aiming to 
initiate the trial sites in the last quarter of 2002.

Closing date for submission: 01 April 2002.

Submit your letters to Dr Jane F. Kengeya-Kayondo (see address be-
low).

For further information, please contact:

Dr Jane F. Kengeya-Kayondo 
Coordinator
Intervention Development and Implementation Research (IDE) TDR
World Health Organization 
1211 Geneva 27, Switzerland
Tel: +41-22-791-3737/3738 
Fax: +41-22-791-4774
mailto:kengeyakayondo@who.int

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