Home care of malaria-infected children of less than 5 years of age in a rural area of the Republic of Guinea.

Home care of malaria-infected children of less than 5 years of age in a rural area of the Republic of Guinea Amadou Baı¨lo Diallo,1 Gaston De Serres,2 Abdoul Habib Be´avogui,1 Claude Lapointe,3 & Pierre Viens3 Objectives To assess the ability of mothers in a rural area of the Republic of Guinea to identify fever in their children, and to estimate the proportion of children who received antimalarial drugs. Methods Children under 5 years of age in 41 villages were selected by a two-step cluster sampling technique. During home visits we examined the children and questioned their mothers about the child’s symptoms and treatment. Findings Of 784 children examined, 23% were febrile and more than half of them also had a positive smear result for Plasmodium. Mothers reported 63% of children with a temperature537.5oC as sick. Among all children reported as feverish by their mother, 55% had a normal temperature (<37.5oC). In contrast, a temperature537.5oC was found in 38% of children identified as sick but afebrile by their mother and in 13% of children considered healthy. Among febrile children, 18% were given chloroquine at home or had consulted at the health centre or a dispensary. Conclusion In areas where malaria is endemic, recognition of fever and its presumptive treatment with antimalarial drugs is an essential part of the strategy of the World Health Organization (WHO) to reduce the morbidity due to this disease. This population study shows that mothers often failed to identify fever in their children and to consult or to provide antimalarial treatment. Without great efforts to improve home care, it is unlikely that the morbidity and mortality due to malaria in young children will be greatly reduced. Keywords: malaria, diagnosis; malaria, drug therapy; child, preschool; home nursing; maternal behavior; chloroquine, therapeutic use; rural population; sampling studies; Guinea. Mots cle´s: paludisme, diagnostic; paludisme, chimiothe´rapie; enfant d’aˆge pre´scolaire; soins infirmiers a` domicile; comportement maternel; chloroquine, usage the´rapeutique; population rurale; enqueˆte par sondage; Guine´e. Palabras clave: paludismo, diagno´stico; paludismo, quimioterapia; infante; cuidados domiciliarios de salud; conducta materna; cloroquina, uso terape´utico; poblacio´n rural; muestreo; Guinea. Bulletin of the World Health Organization, 2001, 79: 28–32. Voir page 31 le re´sume´ en franc¸ais. En la pa´gina 32 figura un resumen en espan˜ol. Introduction Malaria is a major public health problem in sub- Saharan Africa (1, 2). It represents 20% to 50% of all consultations in health centres and is the greatest cause of mortality in hospitals (3). Mortality is estimated at 2 million deaths annually, mainly in children less than 5 years of age (1, 2). In Africa, 10% of mortality in children less than 5 years of age is directly attributable to malaria. To reduce the morbidity and mortality of malaria, the World Health Organization (WHO) has developed a strategy which includes, as one of its main components, the early diagnosis and treatment of malaria (4). It is recommended that antimalarial drugs be given at home to all febrile children (4). Asmany deaths occur within 48 hours of onset of symptoms, this strategy will have optimal impact if treatment is given early. Generally, it is themothers who identify fever in their children and provide presumptive treatment, but there are few data on these initial steps. Most studies focus on people presenting at health centres and dispensaries, who represent a highly selected propor- tion of the infected population as most febrile children will not be brought to consultations (5, 6). Taking their children to health centres is the last thing that mothers consider when a sick child has failed to respond to home treatment or the condition is 1 Me´decin chercheur, Centre National de Formation et de Recherche en Sante´ Rurale, Mafe`rinyah, Conakry, BP 2649, Re´publique de Guine´e. Correspondence should be sent to Dr Diallo at the following address: Unite´ de Recherche en Sante´ Publique, Centre hospitalier universitaire de Que´bec, 2400 d’Estimauville, Beauport, G1E 7G9 Que´bec, Canada. 2 Associate Professor, De´partement de Me´decine Sociale et Pre´ventive, Faculte´ de Me´decine, Universite´ Laval, 2180 chemin Sainte-Foy, G1K 7P4 Que´bec, Canada. 3 Professor, De´partement de Me´decine Sociale et Pre´ventive, Faculte´ de Me´decine, Universite´ Laval, Que´bec, Canada. Ref. No. 00-0701 Research 28 # World Health Organization 2001 Bulletin of the World Health Organization, 2001, 79 (1) exceptionally severe (5, 7, 8). In rural areas, where about 75% of the population live, consultation is less frequent than in urban areas (5). Glick found that 33% of mothers in rural areas of Guinea reported taking their sick children to a health care worker during the last episode of fever compared with 69% of mothers in urban areas (9). Although not unexpected, failure to use chloroquinewas associated with mothers’ lack of access to health services. Mothers living closer to health care facilities were more likely to consult and to give chloroquine early than mothers living farther away (9). The preferred home treatments are antipyretic and analgaesic drugs and herbal preparations (5, 9). Generally, antimalarial drugs are given to less than 30% of febrile children, and they are mostly bought in shops (5, 9–11). The objectives of this study were both to assess the ability of mothers to identify fever in their children and to estimate the proportion of children who received antimalarial drugs as recommended by WHO. Methods This transversal study was conducted between 1 Feb- ruary and30 June 1996 in the prefecture ofMafe`rinyah, a rural area located 75 km from Conakry in Guinea. This area spreads over 650 km2 and comprises 41 villages, one health centre and five dispensaries. The population is estimated at 18 000 people ofwhom 17% are less than 5 years of age (12). Malaria is mesoendemic, with high transmission between May and November during the rainy season. Children were selected by a two-step cluster sampling technique, comprising villages and house- holds (13). Children had to be less than 5 years of age and had to have lived in the study area for at least 6 months. All selected households agreed to partici- pate in the study. Data were collected during a home visit. For every child of the household themother was asked ‘‘Is this child sick today?’’. If the mother answered yes, she was asked to describe the symptoms and their duration and to name the disease. The mothers were also asked ‘‘By which symptoms and signs do you identify malaria?’’ and ‘‘How did you treat your child?’’. Malaria is designated as foulakoka, dembadimi and dannawali in Soussous, as dembale in Malinke´ and as dionte` in Peuhl. Fever was designated as fate´gangni in Soussous, fadikalaya in Malinke´ and bande no wouli or ngouleedi bhandu in Peuhl (all meaning ‘‘hot body’’). Used in isolation these words are not synonymous with malaria in these languages. All the children had their axillary temperature taken for 5 minutes with a mercury thermometer and the arm held firmly. They all had a complete physical examination by a physician (ADBor AHB), including palpation of the spleen and blood taken by finger- prick for thick and thin blood smears. The thick smear served to confirm the presence or the absence of Plasmodium, whereas the thin smear was fixed with methanol and stained with Giemsa to identify the species. Microscopic examination was under 1006 magnification, and 100 fields were examined before a negative result was confirmed. Parasitic density was calculated with the following formula: parasitic density/ml of blood = number of parasites in 100 microscopic fields 6 8000/number of leuko- cytes (14). Proportions were compared by using the w2 test. Analyses were done with Epi-Info (version 5.1, Centers for Disease Control and Prevention, Atlanta) and SAS software (SAS Institute, Cary, NC). The study was approved by the ethics committee of the Ministry of Health. Verbal consent from the local authorities and the head of the household was also obtained before the interviews and blood sampling. Children found to be sick were immediately treated by the physicians. Results The sample consisted of 784 children less than five years of age, 376 boys (48%) and 408 girls. The children’s mean age was 31 months. The 784 children had552mothers fromwhomdatawere collected.Only 38 (7%) of the mothers were able to read and write. Malaria infection Overall, 36%of the children had a positive thick smear result (plasmodial index) and 33% had splenomegaly (splenic index). The proportion of children with splenomegaly and positive thick smear results in- creased with age, ranging from 7% in infants less than 12 months of age to 52% in children more than 48 months of age. The proportion of children with positive thick smear results also increased with age, ranging from12% in infants less than 12months of age to 51% in children more than 48 months of age. The proportion of children with a parasitic density of 4000/ml was similar for all those who were more than 1 year of age, with a mean of 8.5%. Plasmodium falciparumwas found in 95.3%of smears giving positive results whereas Plasmodium malariae and Plasmodium ovale were each present in 1.4%. Both P. falciparum and P. malariae were observed in 1.9% of smears. Objective morbidity Of the 784 children, 179 (23%) were febrile (axillary temperature537.5 oC) and more than half (99 chil- dren) also had a positive smear result. The proportion of positive smear results was twice as high in febrile children than in those without fever (55% vs 29%, P<0.001). The proportion of children with a parasitic density54000/ml was also four times greater than in febrile children (17% vs 3.6%, P<0.001) and 2.4 times greater in those with a temperature538.5 oC than in those with temperatures between 37.5 oC and 38.4 oC (32% vs 14%, P = 0.01). Subjective morbidity Of the 179 children who had had a temperature 537.5 oC, 63% (112) were considered sick by their 29Bulletin of the World Health Organization, 2001, 79 (1) Home care of malaria-infected children in Guinea mother; 64% (63/99) of children with a temperature 537.5 oC and a positive smear result and 84% (26/31) of children with a temperature 538.5 oC were also reported sick by mothers. Of children reported as feverish by their mother, 55% had a normal temperature. In contrast, a temperature of537.5 oC was found in 38% of children identified as sick but afebrile by their mothers and in 13% of children considered healthy (Table 1). The proportion of children with a temperature 537.5 oC was not significantly higher among those identified by their mothers as sick and febrile than among those considered sick but not febrile (45%vs 38%,P=0.37). Of those children considered sick, 33% (87/ 260) were affected by malaria according to their mother. Among these, the distribution of symptoms was similar to that reported when mothers gave another diagnosis, with only two minor differences: fever was reported more frequently with malaria (90% vs 80%, P= 0.05) and diarrhoea less frequently (10% vs 27%, P = 0.002). If we considered that only the 99 children with a temperature537.5 oC and a positive smear result were true malaria cases, the sensitivity of the maternal diagnosis for this disease was 32% (32/99), its specificity 92% (630/685), its positive predictive value 37% (32/87) and its negative predictive value 90% (630/697) (Table 2). Therapeutic attitudes Of the 179 children with a temperature 537.5 oC, 18% were given chloroquine at home or had consulted at the health centre or a dispensary (Table 3). By using clinical case definitions with different temperatures or parasitic densities, the proportion of cases who received chloroquine or who consulted at the health centre or a dispensary varied between 14% and 24%. These treatments were given to 34% of the children diagnosed by their mother as having malaria (Table 3). Discussion This study, conducted in a rural area ofGuinea where a high proportion of children are infected by malaria, showed that mothers had a low ability to identify fever and to diagnose malaria, and that only a small proportion of children affected by malaria received chloroquine at home or consulted the heath system. The 37% estimate of the positive predictive value of maternal diagnosis of malaria is low considering that the study was conducted in a mesoendemic area. As the period of high transmission of malaria in Guinea occurs between May and November and because the five months of data collection included only two of these months (May and June), the positive predictive value of maternal diagnosis is likely to be better than the 37% we estimated. However, as the incidence of malaria remains high throughout the year, despite seasonal variation, our estimate is likely to be representative of that calculated on an annual basis. In the Gambia, 76% of malaria cases diagnosed by the mothers were confirmed by clinical examination and blood smears, whereas in Cameroon and Uganda the results were 45% and 40% respectively, similar to ours (15, 16). The ability of health care workers to identify malaria on clinical grounds is also poor (16–18). Of greater concern is the low ability of mothers to identify fever. Axillary temperature is not as accurate as rectal temperature. The most likely bias associated with this technique is the underestimation of real body temperature. This may have led to an underestimation of the accuracy of mothers who Table 1. Comparison between fever reported by mothers and axillary temperature at clinical examination Mother’s perception % Children with temperature No. children <37.5 oC 37.5–38.4 oC 538.5 oC Sick and feverish 215 55 35 10 Sick but not feverish 45 62 31 7 Healthy 524 87 12 1 Total 784 77 19 4 Table 2. Comparison of the diagnosis of malaria by mothers with the presence of a temperature 537.5 oC and positive thick smear result Mother’s diagnosis No. of children Temperature 537.5 oC and positive thick smear result % positive % negative Positive for malaria 87 37 63 Sick but no malaria 173 18 82 Healthy 524 7 93 Total 784 13 87 Table 3. Treatment given according to different case definitions Case definition No. No Traditional Chloro- Consul- of treat- treat- quine and tation in children ment menta antipyretic health centre Sick according to mother 260 37 31 19 13 Sick and feverish 215 35 33 19 14 according to mother Malaria according to mother 87 45 21 18 16 Temperature 537.5 oC 179 63 19 14 4 Temperature 537.5 oC 99 64 20 11 4 and positive thick smear result Temperature 5 37.5 oC 31 58 29 7 7 and parasitic index 54000/ml Temperature 538.5 oC 21 57 19 19 5 and positive thick smear result Temperature 538.5 oC 11 55 27 9 9 and parasitic density 54000/ml a For example, herbal medicine. 30 Bulletin of the World Health Organization, 2001, 79 (1) Research reported fever, but it does makes our results conservative with respect to the underdiagnosis of fever by mothers, which is the critical issue for early treatment of malaria. Even if fever was the most often reported symptom in children considered sick (215/260), the comparison of the history of fever and the measured temperature shows that mothers have great difficulty in correctly identifying fever. In theory, two situations may erroneously lead to that conclusion. First, fever may have disappeared between the time it was identified by the mother and the clinical examination. This may have occurred because mothers were asked ‘‘Is this child sick today?’’ and not ‘‘Is this child running a temperature now?’’ With the latter question they may have answered negatively. Second, fever may have appeared recently and may have gone undetected by the mothers. For prevention of deaths from malaria and complications, this second type of error is of greater concern. Nevertheless, the large discord- ance between the mothers’ observations and the measured temperature strongly suggests that fever is not well identified especially when low (37.5– 38.4 oC). This contrasts with results from the Republic of Ghana where Binka found that febrile illness was well recognized by mothers (19). In this study, more than half of the children with a temperature 537.5 oC had a positive thick smear result. This confirms the need to give antimalarial treatment to febrile children and supports the WHO recommendation to use an axillary temperature 537.5 oC as the criterion to providemalaria treatment in endemic areas if laboratory confirmation is not available. As few febrile children are brought to the dispensaries (Table 3), mothers will essentially decide their child’s treatment. As the sensitivity of maternal diagnosis of malaria identified only one out of three cases, and among those 45% received no treatment and 21% received only a traditional treatment, the proportion of cases that received proper treatment was small. Approaches to therapy vary from country to country (20–23). In rural Gambia, 2.3% of mothers give chloroquine and 79% give acetaminophen or aspirin when they suspect malaria (24). In Cameroon, one out of two families has chloroquine at home (24). In our study, the small proportion of mothers that used chloroquine when they suspected malaria may reflect local beliefs about the proper care of this disease or may be attributable to cost or availability of chloroquine. These possibilities should be explored before considering any intervention to improve the treatment of malaria. Studies on the diagnosis and treatment of malaria generally assess what happens in the dispensaries and health centres (20, 25, 26). This study demonstrates that the vast majority of children affected by malaria do not consult the official health system. Even if a consultation is more likely if a child is sick, the objectives of the malaria programme are likely to be reached only if home care is enhanced. This population-based study shows that there are severe deficiencies with the care received at home. Without great efforts to improve these deficiencies, it is unlikely that the morbidity and mortality due to malaria in young children will be greatly reduced. n Acknowledgements This study has been funded by the UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR). Amadou Baı¨lo Diallo was a fellow of TDR for training in epidemiology. The authors are grateful to the Guinea sanitary authorities for their unconditional support during all this work. We acknowledge the authorities, the communities and the population of Mafe`rinyah for their great collaboration. Re´sume´ Prise en charge domiciliaire des cas de paludisme chez les enfants de moins de 5 ans dans une zone rurale de Re´publique de Guine´e Objectif Evaluer l’aptitude des me`res d’une zone rurale de Re´publique de Guine´e a` de´celer la fie`vre chez leurs enfants, et estimer la proportion d’enfants ayant rec¸u un traitement antipalude´en. Me´thodes Nous avons se´lectionne´ des enfants de moins de 5 ans dans 41 villages par sondage en grappes a` deux degre´s. Au cours des visites domiciliaires, nous avons examine´ les enfants et interroge´ leur me`re a` propos des symptoˆmes et du traitement. Re´sultats Sur 784 enfants examine´s, 23 % e´taient fie´vreux et plus de la moitie´ pre´sentaient un frottis sanguin positif pour Plasmodium. Les me`res ont signale´ comme malades 63 % des enfants dont la tempe´rature e´tait 537,5oC. Parmi les enfants de´clare´s fie´vreux par leur me`re, 55 % avaient une tempe´rature normale (<37,5oC). En revanche, 38 % des enfants conside´re´s comme malades mais non fie´vreux par leur me`re et 13 % des enfants conside´re´s comme en bonne sante´ avaient une tempe´rature 537,5oC. Parmi les enfants fie´vreux, 18 % avaient rec¸u de la chloroquine a` la maison ou avaient e´te´ amene´s en consultation dans un centre de sante´ ou un dispensaire. Conclusion Dans les zones ou` le paludisme est ende´mique, le traitement pre´somptif par les anti- palude´ens des enfants fie´vreux est un e´le´ment essentiel de la strate´gie de l’Organisation mondiale de la Sante´ (OMS) pour re´duire la morbidite´ palustre. Cette e´tude en population montre que les me`res ne parviennent pas toujours a` de´celer la fie`vre chez leur enfant et ne consultent pas toujours ou ne donnent pas toujours de traitement antipalude´en lorsqu’il le faudrait. Faute d’efforts importants pour ame´liorer la prise en charge a` domicile, il est peu probable que l’on parvienne a` re´duire sensiblement la morbidite´ et la mortalite´ dues au paludisme chez les jeunes enfants. 31Bulletin of the World Health Organization, 2001, 79 (1) Home care of malaria-infected children in Guinea Resumen Atencio´n domiciliaria a los menores de cinco an˜os afectados de paludismo en una zona rural de la Repu´blica de Guinea Objetivos Evaluar la capacidad de las madres de una zona rural de la Repu´blica de Guinea para detectar la fiebre en sus hijos, y estimar la proporcio´n de nin˜os tratados con medicamentos antipalu´dicos. Me´todos Se selecciono´ una muestra de menores de 5 an˜os de 41 aldeas mediante una te´cnica de muestreo por conglomerados en dos etapas. Realizamos visitas domiciliarias para examinar a los nin˜os e interrogar a sus madres respecto a los sı´ntomas y el tratamiento empleado. Resultados De los 784 nin˜os examinados, el 23% te- nı´an fiebre, y ma´s de la mitad de ellos presentaban adema´s un frotis positivo para Plasmodium. Las madres consideraban enfermos al 63% de los nin˜os que presentaban una temperatura 537,5oC. Entre todos los nin˜os descritos por su madre como febriles, el 55% tenı´an una temperatura normal (< 37,5oC). En cambio, se hallo´ una temperatura 537,5oC en el 38% de los nin˜os considerados por su madre enfermos pero afebriles, y en el 13% de los nin˜os considerados sanos. Entre los nin˜os febriles, el 18% recibı´an cloroquina en el hogar o habı´an visitado el centro de salud o un dispensario. Conclusio´n En las zonas donde el paludismo es ende´mico, el reconocimiento de la fiebre y el tratamiento de los casos sospechosos con medicamentos anti- palu´dicos es un componente fundamental de la estrategia desplegada por la Organizacio´n Mundial de la Salud (OMS) para reducir la morbilidad causada por esa enfermedad. 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