Johnson Ari D, Thiero Oumar, Whidden Caroline, Poudiougou Belco, Diakité Djoumé, Traoré Fousséni, Samaké Salif, Koné Diakalia, Cissé Ibrahim, Kayentao Kassoum
Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California, USA.
Muso, Bamako, Mali, San Francisco, California, USA.
BMJ Glob Health. 2018 Mar 12;3(2):e000634. doi: 10.1136/bmjgh-2017-000634. eCollection 2018.
The majority of the world's population lives in urban areas, and regions with the highest under-five mortality rates are urbanising rapidly. This 7-year interrupted time series study measured early access to care and under-five mortality over the course of a proactive community case management (ProCCM) intervention in periurban Mali. Using a cluster-based, population-weighted sampling methodology, we conducted independent cross-sectional household surveys at baseline and at 12, 24, 36, 48, 60, 72 and 84 months later in the intervention area. The ProCCM intervention had five key components: (1) active case detection by community health workers (CHWs), (2) CHW doorstep care, (3) monthly dedicated supervision for CHWs, (4) removal of user fees and (5) primary care infrastructure improvements and staff capacity building. Under-five mortality rate was calculated using a Cox proportional hazard survival regression. We measured the percentage of children initiating effective antimalarial treatment within 24 hours of symptom onset and the percentage of children reported to be febrile within the previous 2 weeks. During the intervention, the rate of early effective antimalarial treatment of children 0-59 months more than doubled, from 14.7% in 2008 to 35.3% in 2015 (OR 3.198, P<0.0001). The prevalence of febrile illness among children under 5 years declined after 7 years of the intervention from 39.7% at baseline to 22.6% in 2015 (OR 0.448, P<0.0001). Communities where ProCCM was implemented have achieved an under-five mortality rate at or below 28/1000 for the past 6 years. In 2015, under-five mortality was 7/1000 (HR 0.039, P<0.0001). Further research is needed to elucidate the mechanisms of action and generalizability of ProCCM.
世界上大多数人口居住在城市地区，五岁以下儿童死亡率最高的地区正在迅速城市化。这项为期7年的中断时间序列研究，在马里城郊地区进行的积极社区病例管理（ProCCM）干预过程中，衡量了早期获得医疗服务的情况以及五岁以下儿童死亡率。我们采用基于整群的人口加权抽样方法，在干预地区的基线以及之后的第12、24、36、48、60、72和84个月进行了独立的横断面家庭调查。ProCCM干预有五个关键组成部分：（1）社区卫生工作者（CHW）进行主动病例检测，（2）CHW上门护理，（3）每月对CHW进行专门监督，（4）取消用户费用，（5）改善初级保健基础设施并进行工作人员能力建设。五岁以下儿童死亡率采用Cox比例风险生存回归计算。我们测量了症状出现后24小时内开始接受有效抗疟治疗的儿童百分比，以及报告在前两周内发热的儿童百分比。在干预期间，0至59个月儿童的早期有效抗疟治疗率增加了一倍多，从2008年的14.7%增至2015年的35.3%（比值比3.198，P<0.0001）。干预7年后，5岁以下儿童发热疾病的患病率从基线时的39.7%降至2015年的22.6%（比值比0.448，P<0.0001）。在过去6年里，实施ProCCM的社区五岁以下儿童死亡率达到或低于28‰。2015年，五岁以下儿童死亡率为7‰（风险比0.039，P<0.0001）。需要进一步研究以阐明ProCCM的作用机制和可推广性。
