By
Victor Chalwe, MD, MSC.
ICIUM, Turkey
 The
home management of malaria
strategy is a WHO tool that identifies high
risks groups such as children and pregnant
women and prescribes pre-packed antimalarial drugs for the treatment of fevers
at home using community drug
distributors.
 This strategy has been successfully tested
in rural areas but evidence remains low
on how this strategy could be used in
settings adopting expensive antimalarial
combination strategies in rural areas
where the CHW is the first point of
contact.


Main aim:
 To assess the use of rapid diagnostic tests
(RDTs) and ACTs for home management of
simple malaria in children under five years
old in Zambia.
Specific objectives:
 To evaluate the clinical outcome of children
under the age of five years treated with AL
after RDT diagnosis of malaria at community
level.
 To asses the ability of a CHW to
appropriately prescribe AL to children under
five years old.
Modeling



Relationship between malaria positivity and the
variables for age/age group, sex, other complaints,
region and fever
Will employ the logistic regression model, with the
dependent variables as.factor

For the period under study, of the 2198 cases seen by
CHWs, 67.0% were positive for malaria



989 males (45.4%) who presented themselves with fever or other
complaints
vs. 1188 females (54.6%).
However, in terms of proportions of positive malaria cases,


males had a slightly higher positive rate of 68.9% (95% CI, 66.072.0%)
Vs. female counterparts with 66.6% (95% CI, 63.9-69.3%).
In terms of rural versus
peri-urban distribution of
proportion of malaria
cases, there was a
significant difference,
with the peri-urban site
having 58.% of positive
cases compared to 73.6%
in rural site (t-test, p
=<0.00001).
RDT result by Age group
700
600
number of patients

500
400
negative
300
positive
200
100
0
1
2
3
4
Age groups
5
6


In line with adherence to
the guidelines of treating
only positive malaria cases
diagnosed with RDT, the
CHWs followed the
instructions in 98.5%
(1451) of cases (those
who were positive and
were treated with
Coartem and only 1.5% of
those who were positive
did not receive treatment.
It was also noted that,
36.9% of negative RDT
malaria cases received
treatment
>table(rdtresult,Treatment)
Treatment
rdtresult
1
2
0
261
446
1
1451
22
Treated
Not treated
RDT+ve
1451
22
RDT -ve
261
446




Sensitivity: for the CHWs adhering to the instructions, the
probability to give treatment to a truly positive malaria
case:
Se = 1451/(1451+22) = 0.985 or 98.5%
Specificity: the probability not to give treatment to a
negative malaria patient:
Sp = 446/(261+446) = 0.631 or 63.1%
Predictive value of a positive test result: probability that
treatment given corresponds to a truly malaria positive
case
VP+ = 1451/ (1451+261) = 0.847 or 84.7%
Predictive value of a negative result: probability in our
situation that treatment not given corresponds to a truly
malaria negative case
VP- = 446/ (22+446) = 0.953 or 95.3%

Odds for the patient living in the rural area
compared to those living in peri-urban areas for
having a positive malaria test with RDT was 3.28

Odds for a patient with fever to those presenting
without fever was 2.34;

Odds for a patient younger by a year was 1.02

Odds for patients presenting with other
complaints compared to those with fever only
was 0.44
 Starting
with a saturated model, with the
RDT result variable as a dependent
variable and considering the variables for
region, age, presence of fever at
presenting, and complaints of other
symptoms as independent variables.
 As
such the model was expressing the
relation between the RDT result and age,
region, presence of fever and other
complaints in terms of risk (or
probability).

The log odds and probability to test malaria positive with
RDT for a older patient from rural area presenting with
fever is:

Ln(p/(1-p)) = 0.700 + 0.594 – 0.013 + 0.295
= 1.576
Therefore, the probability to test malaria positive with
RDT for a younger patient from rural area presenting with
fever is = 0.830

 CHWs
were capable of appropriately
prescribing Coartem based on RDT test
results as reflected by the PPV (84.7%) and
the NPV (95.3%)
 Use of RDT and Coartem at community level
further reduce the workload for the Health
centres
 Use of RDT and Coartem was highly
acceptable by the community
 Triggered further research for Cost
Effectiveness Assessment
Acknowledgement
The funding was made possible from the World Bank through the Ministry of
Health, Zambia.
To all the participants in the communities in which we carried this study
To the CHWs for their commitment and support of the project
Health facility workers and DHMT staff for supervising role.
Ministry of health for ensuring support and timely release of funds
QRA Class 2009, particularly, Prof Speybroeck