Treating Malaria by Health Extension Workers: A Case Study from Ethiopia

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For many years the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) have been promoting an Integrated Management of Childhood Illness (IMCI) training package to ensure that nurses and doctors are capable of treating sick children at health facilities.  Over the years, with the realization that many children did not have access to health facilities and therefore were not being ttreated, the two organizations published a Joint Statement on Managing Pneumonia in Community Settings (2004)[1].  This groundbreaking document calls on countries to bring treatment of childhood illness – pneumonia as well as malaria and diarrhea closer to communities that need it, by empowering trained community health workers to identify and manage these problems. Many countries have followed this advice with excellent results.  Here is a story from Ethiopia.

Aminata is a health extension worker (HEW) at the Tebisa health post, located in a rural, hilly area of East Amhara, some 400 kilometers away from Addis Ababa, the capital city of Ethiopia. Aminata received training on integrated community based management of common childhood illnesses (iCCM) in early 2011. After the training, she carried the essential materials and supplies with her back to the health post, and started treating children suffering from pneumonia, malaria, diarrhoea and/or severe acute malnutrition.  In the last two months, she has treated 35 children under five.

HEW Ethiopia
A Health Extension Worker (HEW) with Almaz and her family. Photo: Dr. L. Pearson

One of the children suffering from malaria is a five year old girl, Almaz (which means diamond in Amharic). She developed fever one night in April. Her mother took her to the health post and she was seen immediately. Aminata checked her temperature (39.0 OC), and respiratory rate (children sometimes have pneumonia and malaria at the same time) and pricked her finger to obtain a drop of blood to perform a Rapid Test for Malaria (RTM) to look for malaria parasites [Ed: Rapid Diagnostic Tests, or RDTs, are another, more general term for these tests].

Almaz did not have rapid breathing, an indication of pneumonia, but she did have falciparum malaria (the most severe and deadly of the types of malaria found in humans, and caused by the Plasmodium falciparum parasite).  She was given Coartem (Arthemeter-Lumefentrine) treatment by mouth for three days.  Aminata gave the first dose of medicine and gave the mother the rest of the tablets, explaining when to give them. Aminata made a point to discuss how important it is to feed a sick child so they do not lose weight, and to be alert to certain ‘danger signs’ in case the child is not getting better, in which case they should return immediately to the health post.

On the second day of treatment her mother brought her back to the health post for a follow up check.   Almaz’s mother expressed her gratitude. “If the HEWs are not providing treatment for sick children, I would have to carry Almaz to the health center some 4 hours away by foot. I would also have to pay for the treatment.  We were frustrated before iCCM started because we were not able to help children with malaria and pneumonia”.

malaria medicines at health post Ethiopia
Malaria medicine available, for free, at the Tebisa health post in Ethiopia. Photo: Dr L. Pearson

“The communities trust and support us even more now”, said Aminata. “Now the mothers are so happy, they even bring the children for immunization without us having to push them”.

In the next two years, about 20,000 HEWs will be trained and supported to provide iCCM in 10,000 rural villages. Hundreds and thousands of young children in Ethiopia will benefit from the iCCM programme jointly supported by the government of Ethiopia, Catalytic Initiative of Canada, UNICEF and other development partners. Program implementation will focus on remote and harder to reach villages and households, to ensure every child is covered, no matter where they are and who they are.

The iCCM is be an important opportunity to further improve quality of care provided at the health posts, and accelerate toward the achievement of Millennium Development Goal 4, to reduce deaths of children under 5 by two-thirds by 2015.

[1] Management of Pneumonia in Community Settings (PDF)

Is it rare to die if you get malaira?

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QUESTION:

Is it rare to die if you get malaria? I know that every 45 seconds somebody dies from malaira, I just want to know if it is rare or not. What percentage of people who get malaria die?

ANSWER:

There isn’t an easy answer to this question.  The risk of death depends on the kind of malaria you get, your previous exposure to malaria and how fast you get treatment.  P. falciparum is mostly found in Africa and parts of Asia,  is the most serious and deadly type of malaria, and children are especially at risk of dying from it.  In your question you mentioned someone dying every 45 seconds….that quote comes from the World Health Organization where experts estimate that in Africa, a child dies from malaria every 45 seconds.

Globally, international agencies estimate that between 300-500 million people get malaria every year and about 1 million people die from it. So it isn’t a rare occurrence to die from malaria but it should be because we have the knowledge to prevent and treat the disease which would drastically lower the number of deaths.   People can take drugs as prevention and avoid mosquito bites by sleeping under a treated bednet; using mosquito repellent and avoiding being outside from dawn to dusk when mosquitoes bite.  If you do get malaria, recognizing the symptoms and getting treatment quickly can be life saving.

However even the estimated 1,000,000  malaria deaths each year may not be accurate because it’s not easy to get trusted statistics. This is because many people (especially in rural Africa and Asia) don’t go to the hospitals or clinics when they get sick—either they don’t recognize the symptoms or they can’t reach a clinic or hospital in time.  Even if they do get treatment, oftentimes medical reporting systems are weak.

Another issue is that sometimes deaths are not attributed to malaria but to another disease—for example in a young child a malaria death may be attributed to an acute respiratory infection which can also present with a high fever.

So in a nut shell, malaria is a serious disease, but we know how to lower the risk of getting it and we know that in most cases prompt treatment will prevent death.   The challenge is to raise awareness in countries with malaria to promote prevention measures and to improve access to effective health care.

Traveling and Pregnant

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QUESTION:

Hi, I am 3 months pregnant but thinking about going on vacation to Belize in a few weeks time. Should I think about taking something against malaria?

ANSWER:

It’s good you asked because getting malaria while pregnant can be much more serious than when not pregnant, and can cause terrible problems to both you and your baby.  Therefore, it is always advisable to consult your own health care provider before traveling.

The good news is that while there is malaria in Belize it is not found everywhere and where it is found, it is not resistant to chloroquine, a drug considered safe to use during pregnancy.

According to the US Centers for Disease Control (CDC),   Belize City and the islands where tourists mostly visit are largely malaria free, and the risk of getting malaria in these areas is ‘low’. So, if you are heading to Belize City or a resort on one of the islands, you may just want to follow practical advice to avoid mosquito bites: sleep in a screened room and under an insecticide treated bed-net, avoid being outside between dusk and dawn, and if you are, wear long-sleeves and long pants or skirt, and use mosquito repellent (containing DEET, and especially during pregnancy, in my opinion a  roll-on repellent if preferable to a spray to avoid inhaling the chemicals).

However, if you are heading off the beaten track, you should take all the mosquito bite precautions mentioned above but also take chloroquine as prophylaxis. Take chloroquine (500 mg tablet containing 300 mg base drug) one time a week starting 1 – 2 weeks before traveling to an area with malaria. Continue taking one pill once a week (on the same day and the same time) while in country and for another 4 weeks after leaving the malaria area.