Deployment of Rectal Artesunate for the initial management of Nil Per Os under 5 children

Margaret Gyapong, Irene Agyepong, Evelyn Ansah, John Gyapong, Patricia Anaarfi

Ghana Health Service

Rationale Mortality from malaria on the increase: 1-2m deaths each

year Over 90% in African children due to

Access to and cost of care Poor quality of care Perceptions about disease causation

WHO commission use of Artesunate for severe malaria in clinical trials Rectal Formulation Achieves 99-100%reduction in parasitaemia within 24hrs Permits emergency treatment of Nil Per Os Patients

Double blind placebo controlled trials are currently underway ?Survival benefit

Current study Examining and optimising mechanisms for deployment in a rural

district.

Specific Objectives

To determine community definition and treatment seeking for severe malaria in children.

To identify from the sources of care treatment and referral practice for children with severe malaria.

To design and implement a multi media health education strategy at community and health facility level in preparation for the use of Rectal Artesunate

To document the proportion of febrile Nil Per Os children who received Rectal Artesunate and sought subsequent care at a health facility.

To document the course of action of febrile Nil Per Os children who received Rectal Artesunate but did not seek care at a Health facility.

To document the outcome of the child’s condition after receiving the Rectal Artesunate.

Design and Methods 1 Observational Study using Qualitative and Quantitative

methods and in two phases (Formative, Intervention) Formative just completed

Addressed Objectives 1&2 conducted at 2 levels. Community Level

Focus Group Discussions Key Informant Interviews Non Participant Observation Problem tree

Facility Level Key Informant Interviews Non Participant Observation Case Studies Record Review

Design and Methods 2 Issues discussed with Carers of children

How they define malaria and severe malaria Whether they can identify NPO malaria Courses of action for simple and severe malaria Sources of care Rectal use of drugs How long it takes to access care

Issues discussed with health care providers How they define malaria and severe malaria How they recognize NPO malaria Kinds of treatment given Rectal use of drugs Referral practice How long it takes patients to arrive at health facility

Study area

Study Area

Population about 100,000 Rural Subsistence farmers,

fishermen and petty traders 4 health Centers 6

community clinics Private Maternity homes

and clinics No hospital Malaria number 1 90% of <5 admissions due

to severe malaria 2% of inpatients die

Community sources of care

Home Traditional Healers Chemical Shops Drug Peddlers Health Centers Community Clinics Hospitals

Perceptions on malaria Local Terms for Malaria

Asra, Atridii or fever similar to findings from earlier studies (Agyepong et al 1998)

Two Types of Asra “Eyoo” Female type which is mild.

Headache, Fever, hot body, loss of appetite, bitterness in the mouth,

Easily treated with orthodox tablets and herbal preparations

“Eku” Male Type more serious and can Kill inability to eat or drink, convulsions, change in

mental status, anaemia,lump or sore in stomach not easy to treat since there may be spiritual

connotations

Rectal use of drugs

Well known term “fitompuonya” Term not used as everyday word particularly not in

the presence of elders without saying “excuse me”. The route is not used commonly in the treatment of

“Asra eyo” Route used more commonly in treating some of the

signs and symtoms of “Asra Eku” Treatments are mainly ground herbal preparations

that may or may not contain one or more of the following Ground Ginger, Ground pepper, soap diluted

with water Pellets or tablets not used rectally

symptom Source of Care Type of treatment

Loss of Blood “Muo ta”

Home, Herbalist, chemical seller

Cook leaves of “Bedro”and drink it regularlyGrind seeds of “Bedro” plant mix with milk and water and drinkMix tomato paste with Coca cola or malt and drinkEat nutritious food, haematinics

Ulcer in the stomach“mimi pa”

Home, Herbalist, Hospital/Health Center

Boil leaves of “nunum” tree and give liquid to child to drinkGrind the leaves and use as enema.Grind bark of “Nyaba“Standard Hospital Treatment

Lump in the stomach“mimi kpo”

Herbalist Grind herbs for drinking and enema

Convulsion“hiowe”

Home, Herbalist, Hospital/Health Center

Incantations and herbs ground with garlic and smeared on the child.Smear mud from bathroom drain on childPour overnight water from cooking pot on child Standard Hospital Treatment

Loss of consciousness“eheli” “etomu”

Home, Herbalist, Hospital/Health Center

Put pepper in fire and put child close to it while shouting out loud the name of the child.Standard Hospital Treatment

Dirty Stomach“mimi semu”

Home, Grind herbs and give enema

Key Issues

Specific terms exist for various signs and symptoms of severe malaria

Signs and symptoms of severe malaria(depending on line of questioning) may not always be linked to each other and and affects help seeking.

Various sources of care exist and are used but Hospital is last resort

Traditional health care providers have strengths which can be adopted for use in health care provision

Rectal use of drugs common with severe malaria due to perceived ability to offer quick relief

Policy/program issues

Use of Rectal Artesunate may not be a problem for the main intervention.

Care givers and traditional sources of care are key and should be used during the intervention but with adequate training and supervision.

Health education should highlight strengths of various treatment practices but discourage harmful ones.

Areas for future research

Community understanding of severe malaria

Rationale for various treatment practices for severe malaria

THANK YOU