UMR MIVEGEC, Université de Montpellier, IRD, CNRS, Montpellier, France.
Unité d'épidémiologie et de recherche clinique, Institut Pasteur de Madagascar, Antananarivo, Madagascar.
BMC Med. 2024 Jun 10;22(1):231. doi: 10.1186/s12916-024-03441-9.
Global progress on malaria control has stalled recently, partly due to challenges in universal access to malaria diagnosis and treatment. Community health workers (CHWs) can play a key role in improving access to malaria care for children under 5 years (CU5), but national policies rarely permit them to treat older individuals. We conducted a two-arm cluster randomized trial in rural Madagascar to assess the impact of expanding malaria community case management (mCCM) to all ages on health care access and use.
Thirty health centers and their associated CHWs in Farafangana District were randomized 1:1 to mCCM for all ages (intervention) or mCCM for CU5 only (control). Both arms were supported with CHW trainings on malaria case management, community sensitization on free malaria care, monthly supervision of CHWs, and reinforcement of the malaria supply chain. Cross-sectional household surveys in approximately 1600 households were conducted at baseline (Nov-Dec 2019) and endline (Nov-Dec 2021). Monthly data were collected from health center and CHW registers for 36 months (2019-2021). Intervention impact was assessed via difference-in-differences analyses for survey data and interrupted time-series analyses for health system data.
Rates of care-seeking for fever and malaria diagnosis nearly tripled in both arms (from less than 25% to over 60%), driven mostly by increases in CHW care. Age-expanded mCCM yielded additional improvements for individuals over 5 years in the intervention arm (rate ratio for RDTs done in 6-13-year-olds, RR = 1.65; 95% CIs 1.45-1.87), but increases were significant only in health system data analyses. Age-expanded mCCM was associated with larger increases for populations living further from health centers (RR = 1.21 per km; 95% CIs 1.19-1.23).
Expanding mCCM to all ages can improve universal access to malaria diagnosis and treatment. In addition, strengthening supply chain systems can achieve significant improvements even in the absence of age-expanded mCCM.
The trial was registered at the Pan-African Clinical Trials Registry (#PACTR202001907367187).
最近，由于在普及疟疾诊断和治疗方面面临挑战，全球疟疾控制工作进展停滞不前。社区卫生工作者（CHW）可以在改善 5 岁以下儿童（CU5）获得疟疾护理方面发挥关键作用，但国家政策很少允许他们治疗年龄较大的个体。我们在马达加斯加农村地区进行了一项双臂整群随机试验，以评估扩大疟疾社区病例管理（mCCM）以覆盖所有年龄段对医疗保健获取和使用的影响。
法拉凡加纳区的 30 个卫生中心及其相关的 CHW 按照 1:1 的比例随机分为所有年龄段的 mCCM（干预组）或仅 CU5 的 mCCM（对照组）。这两个组都接受了疟疾病例管理方面的 CHW 培训、免费疟疾护理方面的社区宣传、CHW 的每月监督以及疟疾供应链的加强。在基线（2019 年 11 月至 12 月）和终点（2021 年 11 月至 12 月）进行了大约 1600 户家庭的横断面家庭调查。在 36 个月（2019-2021 年）期间，从卫生中心和 CHW 登记处每月收集数据。通过调查数据的差异分析和卫生系统数据的中断时间序列分析来评估干预的影响。
在两个组中，发热和疟疾诊断的求诊率几乎翻了三倍（从不到 25%增加到 60%以上），主要是由于 CHW 护理的增加。在干预组中，年龄扩大的 mCCM 使 5 岁以上的个体获得了额外的改善（6-13 岁儿童接受 RDT 的比率，RR=1.65；95%置信区间 1.45-1.87），但只有在卫生系统数据分析中才具有统计学意义。年龄扩大的 mCCM 与离卫生中心更远的人群的增长幅度更大（每增加 1 公里，RR=1.21；95%置信区间 1.19-1.23）。
扩大 mCCM 以覆盖所有年龄段可以改善普及疟疾诊断和治疗的机会。此外，即使没有扩大 mCCM，加强供应链系统也可以实现显著改善。
该试验在泛非临床试验注册中心（#PACTR202001907367187）注册。
