In remote settings, community healthcare workers provide an initial diagnosis, prescribe basic medications and, if necessary, refer patients to more advanced facilities. As part of efforts by MMV and partners to support the continuum of care from the community level to referred health centres, the Rectal Artesunate Information Education and Communication (RASIEC) study was conducted in Malawi.1 The overall goal of this cohort case-control study was to evaluate the introduction of the RASIEC toolkit (consists of information pamphlet, poster, indication and step-by-step administration of artesunate rectal capsules) alongside appropriate training. The study investigated whether these measures could increase early presentation at village clinics for pre-referral administration of artesunate rectal capsules. Additional metrics investigated include increased acceptability of artesunate rectal capsules by caregivers, improvement in community healthcare worker diagnosis and treatment, as well as enhanced, prompt compliance with referral instructions by caregivers.
After completion of the study in 2020, findings indicated that providing healthcare workers with RASIEC toolkits and a formalized referral slip protocol successfully increased the likelihood of a positive treatment outcome for patients. These findings have now been disseminated to key stakeholders in Malawi and were shared at the American Society of Tropical Medicine and Hygiene 2020 Annual Meeting, as well as online through the Severe Malaria Observatory project.2 A publication of results is planned for 2021.
Dr Michael Kayange discusses severe malaria in Malawi and the RASIEC cohort case-control study.
1. What is the burden of malaria and, in particular, severe malaria in Malawi and what impact does the disease have on individuals, communities, and the country as a whole?
Each year there are about six million cases of malaria (one-third of the total population) in Malawi, resulting in approximately 2,300 deaths. Patients tend to travel to the hospital with at least one guardian, meaning at least 12 million people could be entering a hospital due to malaria each year. This keeps adults away from work and children away from school, sometimes for days at a time, which leads to economic and educational impacts on local communities and the country as a whole.
2. What is Malawi’s national strategy to manage severe malaria? What is the role of injectable artesunate and rectal artesunate?
Our policy for severe malaria includes entry at the health facility or community levels. At the health facility level, patients are assessed by a clinician or nurse and admitted for microscopy diagnosis and treatment if there are signs of severe malaria. Patients with a positive diagnosis receive intravenous artesunate for a minimum of three doses before switching to oral antimalarial drugs. Most patients improve within 24 hours after the first three doses, they are then given oral drugs and discharged.
At the community level, health surveillance assistants manage mild malaria but are trained in detecting severe malaria and administering rectal artesunate. They then refer cases to the health facility. This means that severe malaria signs can be detected quickly and drugs can be given at the community level.
3. What are the main challenges you face in the management of severe malaria?
At the health facility level, delayed diagnosis is a challenge. Some patients admitted with signs of severe malaria do not get a diagnosis within 24 hours, however, this does not stop us from managing cases by starting treatment with intravenous artesunate. If the result is positive, we continue with intravenous artesunate and, if not, we stop and move to other treatments. At the community level, compliance with pre-referral management is a challenge. We train health surveillance assistants in severe malaria management, but most cases are still referred without rectal artesunate administration.
4. Last year, together with MMV you conducted the RASIEC study. What were the key findings?
The greatest impact was observed in health surveillance assistants. The study showed that additional training of health surveillance assistants was needed to maintain correct administration of rectal artesunate. With the RASIEC toolkit, acceptability and use of rectal artesunate increased compared with the control district, and the capacity to identify symptoms of severe malaria also increased, leading to appropriate care. There was no difference in referrals compared with the control district, showing that health surveillance assistants referred patients appropriately. However, the introduction of a referral slip did improve the reception of patients and caregivers at the next healthcare level.
5. What are the next steps to implement changes based on these findings?
We plan to present study findings to the Case Management Technical Working Group and Malaria Social and Behaviour Change Communication Technical Working Group for possible inclusion in the upcoming community engagement campaign. Unfortunately, this has been delayed due to the COVID-19 pandemic.
6. What has it been like to work with MMV on this study?
We were privileged to work with MMV on this project and appreciate their support. We would like to engage with them again on future projects targeting the same or different malaria issues in Malawi.
1. Partners include University of Malawi College of Medicine and Malawi Ministry of Health with funding by Unitaid.
2. Severe Malaria Observatory: https://www.severemalaria.org/