Malaria management in children with fever in rural Sierra Leone. Has anything changed after the Ebola outbreak?

Introduction

A cross-sectional study conducted in 2017¹ involving 68 primary health facilities in Koinadugu district of rural Sierra Leone compared the management of children with fever for malaria for a period before, during and after the Ebola outbreak. There were two key findings. First, less than half of all confirmed malaria cases were treated for malaria during the Ebola outbreak. As fever is a common symptom of both malaria and Ebola, health workers may have “played safe” by simply referring such children to Ebola management sites². Second, monthly utilization of malaria diagnostics closely matched the number of reported fever cases, implying that fever cases were being routinely subjected to malaria testing³.

Although the post-Ebola period was included in this evaluation, it was for a relatively short period (six months) which was probably too soon to gauge health system recovery. At the primary healthcare level in the same district and among children under five, we thus performed a new analysis with a longer post-Ebola period and compared these data for similar periods before and during the Ebola outbreak. Our specific objectives were to determine: a) numbers of reported fever cases and malaria tests done, and b) numbers treated for malaria with artemisinin combination treatment (ACT) and within 24 hours of fever onset

Methods

This was a cross-sectional study using routine program data. The setting has been previously described¹. The study population included all children under five with fever who presented to 68 primary healthcare units. Malaria management was in line with national guidelines and has been described previously⁴. In brief, all individuals presenting with fever to any given health facility were subjected to a malaria diagnostic test, which may involve a Rapid Diagnostic Test (RDT) or microscopy. Only confirmed malaria cases should receive ACT.

The study spanned a pre-Ebola (June 1 2013 – April 30 2014), intra-Ebola (June 1 2014 – April 30 2015) and post Ebola (June 1 2016 – April 30 2017) periods.

Data were sourced directly from routine morbidity registers available at each health facility. A data manager was responsible for data quality, and a dedicated data entry clerk performed data entry. We used EpiData software for data entry and analysis (version 4.1 for entry and version 2.2.2.182 for analysis; EpiData Association, Odense, Denmark).

Ethics approval was obtained from the Sierra Leone Ethics and Scientific Review Committee (dated 18 December 2018) and the Union Ethics Advisory Group (International Union against Tuberculosis and Lung Disease, Paris, France; EAG number 70/18). As we used aggregated data, the need for informed consent was waived by the ethics committees.

Results

Discussion

This study shows that despite the Ebola outbreak, the number of reported fever cases progressively increased and was 1.7 times higher post-Ebola compared to the pre-Ebola period.

Reassuringly, while less than half of malaria cases received treatment with ACT drugs during Ebola, in the post-Ebola period, all cases received treatment (which included ACT and other anti-malarial drugs). ACT use declined from 99% during Ebola to 71% post-Ebola, and this was accompanied with ACT stock-outs. This could be explained by the increase in numbers needed to be treated for malaria in the post-Ebola period (2.8-times that during Ebola), which might have caused pressure on available ACT stocks and supply chains.

As part of Sierra Leone’s post-Ebola health recovery strategy⁶, more health personnel were trained in surveillance and reporting, incentives were introduced, and community involvement was promoted. Operationally, this seems to have increased health service utilisation for malaria, but the health system seemed unable to cope with the increased ACT demand. This needs to be addressed in order to ensure compliance with malaria treatment guidelines and the rational use of antimalarial drugs.

The main study strength is that we used data from all health facilities in the district and compared similar periods of time before, during and after the Ebola outbreak. A study limitation was the lack of data on complicated and uncomplicated malaria cases. Availability of such information would help to justify (or not) the use of other antimalarial drugs apart from ACT which was seen in the post-Ebola period. A short-coming in the district health information system (DHIS2) is that it does not capture severity of malaria (complicated and uncomplicated malaria). Adding this variable would improve monitoring of rational use of antimalarials.

In conclusion, what has changed since the Ebola outbreak is the increased utilisation of services for malaria. However, ACT stockouts are of concern, and this requires attention in order to ensure compliance with national malaria treatment guidelines.

Data availability