Abstract Author Name Margaret Gyapong Email margaret gyaponghrughs

Abstract Author Name: Margaret Gyapong Email: margaret. gyapong@hru-ghs. org Presenter Name: Margaret Gyapong Authors: Gyapong M, Agyepong IA , Ansah EK, Anarfi P, Gyapong JO Institution: Ghana Health Service Title: The Impact of Large Scale Rectal Artesunate Deployment in the Initial Management of Non Per Os III in under-five Children in Ghana Problem Statement: Due to the high number of deaths from severe malaria, a double blind clinical trial of Rectal Artesunate (RA) capsules on child survival in Northern Ghana is underway. For program implementation, we need to study the impact of deploying RA within the normal running of a district health system. Objectives: To examine and optimize mechanisms for the deployment of RA for the initial management of febrile Non Per Os (NPO) illnesses amongst children 0 -5 years. To evaluate the effectiveness of a multi media health education strategy for the deployment of RA. To introduce, monitor, and evaluate the use of RA through existing formal and traditional health care outlets. Design and Setting: The study is a two phase observational study. Qualitative and quantitative data will be collected. It will be conducted at community and health facility levels. The study area is rural with a population of about 96, 000. It has 4 administrative sub districts, 4 health centers, 6 community clinics, 1 mission health center and a private clinic. There about 300 traditional healers in the district with a wide range of specialties. About 45 -50% of the population have no formal education. The main occupation is subsistence farming and fishing. The district is the site of a community based health insurance scheme. Study Population: All children under five identified by a caretaker as nil per OS and are given the recommended dose of RA. Intervention: Participatory Rapid Appraisal (PRA) methods will be used to determine how caretakers define severe malaria; how these are managed; the course of action; and the various sources of care. Administration of drugs rectally for severe malaria will also be explored. All identified health care providers will be interviewed to find out their definition of and their courses of treatment for severe malaria. Based on formative data Information Education and Communication (IEC) materials and messages will be developed an education campaign embarked on to educate the community on use of RA. Morbidity surveys will be conducted. The drug will then be deployed and its used assessed in three arms (Mother/caretaker; Existing health system; and researcher-defined). Outcome measures: Impact of different treatment options chosen by caretakers on outcome of child condition. Period between insertion of RA and child’s arrival at health facility (for those who go to a health facility); % of children getting severe malaria in the district; % of children dying from malaria. Results: The study is currently ongoing and it is expected that results from phase 1, to be completed in December 2003, will be reported at the conference. Study Funding: World Health Organization/Tropical Disease Research Division ( WHO/TDR)

Background and setting • • • Population of 105, 000, mainly rural with widespread poverty Children under 5 about 20% of population (20, 000) Mainly subsistence farmers, fishermen and petty traders A greater part of the population live about 2 -6 hours walk away from the nearest main road There is no hospital but services of 5 neighboring hospitals are used for referrals 4 Health Centers & 6 community based clinics constitute the Public Health sector Additionally, there are 2 private clinics & 2 maternity homes There about 300 traditional Healers and 92 Trained Traditional Birth Attendants with 44% of traditional healers being women The district has about 20 chemical sellers

Specific Objectives • To determine community definition and treatment seeking for severe malaria in children. • To identify from the sources of care treatment and referral practice for children with severe malaria. • To design and implement a multi media health education strategy at community and health facility level in preparation for the use of Rectal Artesunate • To document the proportion of febrile Nil Per Os children who received Rectal Artesunate and sought subsequent care at a health facility. • To document the course of action of febrile Nil Per Os children who received Rectal Artesunate but did not seek care at a Health facility. • To document the outcome of the child’s condition after receiving the Rectal Artesunate.

Design and methods • Observational Study using Qualitative and Quantitative methods • Two Phases : Formative (Just Completed) and Intervention not yet started. – Formative Phase: addressed Objectives 1&2 conducted at 2 levels. • Community Level – Focus Group Discussions (Men & women with chn under 5) – Key Informant Interviews (Traditional Healer, TBA, Chemical sellers) – Non Participant Observation (chemical sellers) – Problem tree (Men & Women with chn under 5 ) • Facility Level – Key Informant Interviews (Head of Facility) – Non Participant Observation – Case Studies (Children on admission with severe malaria) – Record Review

Design and Methods • Issues discussed with Carers of children – – – How they define malaria and severe malaria Whether they can identify NPO malaria Courses of action for simple and severe malaria Sources of care Rectal use of drugs How long it takes to access care • Issues discussed with health care providers (Orthodox and Traditional) – – – How they define malaria and severe malaria How they recognize NPO malaria Kinds of treatment given Rectal use of drugs Referral practice How long it takes patients to arrive at health facility

Perception on Malaria • Local Terms for Malaria – Asra, Atridii or fever similar to findings from earlier studies (Agyepong et al 1998) – Two Types of Asra • “Eyoo” Female type which is mild. Characterized by Headache, Fever, hot body, loss of appetite • “Eku” Male Type more serious and can Kill. – Well known and recognized signs and symptoms – “Asra Eku” if not treated properly can lead to convulsion which can kill – Home treatment, traditional healers and chemical shops are the main sources of care. – The hospital is Hospital used as last resort

Area of specialization for traditional Healers

Cases From Dangme West Reporting At Referral Hospitals (2003) Hospitals Total No of Cases Total No of Malaria Cases No of deaths Total No of In Patients No. of Severe Malaria Cases St. Martins Catholic 343 336 4 113 109 Akuse Governme nt 406 399 4 209 207 Atua Governme nt 91 91 2 37 37 Battor Catholic 233 217 2 90 90 Tema General 101 87 5 57 57 TOTAL 1174 1130 17 506 500

Rectal use of drugs • Well known term “fitompuonya” • Term not used as everyday word particularly not in the presence of elders without saying “excuse me”. • The route is not used commonly in the treatment of “Asra eyo” • Route used more commonly in treating some of the signs and symtoms of “Asra Eku” • Treatments are mainly ground herbal preparations that may or may not contain one or more of the following – Ground Ginger, Ground pepper, soap diluted with water • Pellets or tablets not used rectally • Use of rectal artesunate should not be a problem so long as it will benefit the children.

Signs/symptoms and treatment for severe malaria Sign/symptom Source of care Type of treatment Loss of Blood Home, Herbalist 1. Cook leaves of “Bedro”and drink it regularly 2. Grind seeds of “Bedro” plant mix with milk and water and drink 3. Mix tomato paste with Coca cola or malt and drink 4. Eat nutritious food Ulcer in the stomach Home, Herbalist, Hospital/Health Centre 1. Boil leaves of “nunum” tree and give liquid to child to drink 2. Grind the leaves and use as enema. 3. Grind bark of “Nyaba“ 4. Standard Hospital Treatment Lump in the stomach Herbalist 1. Grind herbs for drinking and enema Convulsion Home, Herbalist, Hospital/Health Centre 1. Incantations and herbs ground with garlic and smeared on the child. 2. Scarification 3. Standard Hospital Treatment Loss of consciousness Home, Herbalist, Hospital/Health Centre 1. Put pepper in fire and put child close to it while shouting out loud the name of the child in anxiety. 2. Standard Hospital Treatment Dirty Stomach Home, 1. Grind herbs and give enema

Summary • Malaria and its complications a problem in the area • Well known terms exist for – Simple malaria – Complicated malaria – Rectum • Signs and symptoms of both conditions are easily recognized • Individual signs and symptoms of severe malaria may not always be linked to each other and are treated as such. • Various sources of care exist and are used but Hospital is last resort • Rectal use of drugs more common with signs of severe malaria

Conclusions and Recommendations • Use of Rectal artesunate may not be a problem for the main intervention • Care givers and traditional sources of care key and should be used during the intervention but with adequate training and supervision. • Health education should highlight strengths of various treatment practices but discourage harmful ones.