Malaria case management by community health workers in the Central African Republic from 2009–2014: overcoming challenges of access and instability due to conflict

The CAR is a vast but sparsely populated country of about 623,000 sq km with an estimated population of 4.9 million [16]. It is bordered by Cameroon to the west, Chad to the north, Sudan and Southern Sudan to the east, and the Democratic Republic of Congo (DRC) and the Republic of Congo to the south.

The intervention and study site is located in Ouham and Ouham-Pendé Prefectures in northwest CAR, where it is estimated that over 200,000 persons are displaced. More specifically, the community-based malaria control programme is located in Paoua sub-prefecture (Ouham-Pendé) and Markounda sub-Prefecture (Ouham) (Fig. 1). The total population in these sub-prefectures is an estimated at 222,000 (200,000 in Paoua and 22,000 in Markounda). While it is difficult to have a clear picture of the number and exact locations of internally displaced persons, many are thought to be in the programme areas. The region is holo-endemic for malaria, with peaks during the rainy season (May–October).

The CHW intervention was designed to target the most vulnerable displaced and host populations with the aim of reducing morbidity and mortality by improving access to quality health care at community level. It began in 2008 in Paoua and in 2011 in Markounda. It is ongoing in both areas. The focus is on malaria case management for children under 5 years and pregnant women, the groups most vulnerable to severe forms of the disease if they are not treated immediately. The programme began with 30 CHWs, known locally as malaria agents, in Paoua and expanded to 60 by 2011, with an additional 20 CHWs that began activities in Markounda in December 2011. In these 80 villages, literate volunteers were selected by the NGO programme management in close collaboration with community leaders. The CHWs were then trained by NGO-employed nurses or physicians over 5 days to implement basic health interventions in their homes, and sensitize their community members on prevention and treatment against infectious diseases. A 3 day refresher training took place every 6 months. Priority of the essential health services was given to malaria diagnosis and treatment. Every patient visiting a CHW from the surrounding area was tested with an RDT (SD Bioline Ag Pf^®, Standard Diagnostics, Kyonggi, Republic of Korea) and all positive cases were treated with artemether–lumefantrine (AL). For patients with signs of severe malaria, according to the WHO severe malaria management guidelines [17], CHWs administered rectal artesunate (Artesiane^® Suppogel Artemether 40 mg (Dafra Pharma GmbH, Basel, Switzerland)) before referring them to the nearest health facility. The CHWs also conducted malnutrition screening using the mid-upper arm circumference measurement (MUAC) for all children from 6 to 59 months, classifying them into four categories: well-nourished (>135 mm); at risk of acute malnutrition (125–135 mm); moderate acute malnutrition (110–125 mm); severe acute malnutrition (<110 mm). All children identified as severely malnourished were referred to the nearest NGO-supported treatment centre.

Additional components of the intervention for children under 5 included de-worming with mebendalzole every 6 months, rehydration treatment with oral rehydration solution in case of diarrhoea and administration of vitamin A. For pregnant women, additional interventions included intermittent preventive treatment with sulfadoxine-pyrimethamine, and folic acid supplements, and when available, provision of home delivery kits. Limited prevention campaigns were conducted in this area throughout the study period. In 2010, CHWs distributed 41,194 long-lasting, insecticidal bed nets (LLINs) in Paoua and 4458 in Markounda (totalling approximately one LLIN per household). Additionally, 3830 LLINs were distributed to pregnant women consulting with CHWs in 2010. No LLINs or indoor residual spraying (IRS) campaigns took place in the project area during 2011 and 2012. In the second half of 2013, CHWs distributed 32,900 LLINs in Paoua and Markounda.

All necessary materials and supplies were delivered every month to the CHWs at their homes. Trained staff employed by the NGO supervised each CHW two times per month, enabling quality control and stock replenishment. During these visits, the CHWs received 1 month of anti-malarial stock (based on the consumption from the previous month) plus 2 weeks of buffer stock. During times of increasing insecurity when supervisory visits were sometimes less frequent, the CHWs received 1 full month of buffer stock. To deter falsification of RDT results by CHWs, supervisors cross checked all RDTs during these supervision visits with the number of ACTs given out each month. CHWs were required to pay a financial penalty for any ACTs distributed without a corresponding positive RDT. As additional CHWs were recruited for new villages, the numbers of supervisors also increased proportionally. Each CHW was also responsible for conducting regular information education communication/behaviour change communication sessions on communicable diseases in their villages, as well as being available for specific campaigns, such as distribution of LLINs.

CHWs were responsible for keeping daily registers to record each patient consultation, including basic demographic information, symptoms, test results, and treatment given. The NGO-employed nurses were responsible for collecting the records during their supervision visits and then entering them into a database for basic analysis and reporting. CHWs received a financial stipend for their work, equalling an estimated US$30/month (20,000 CFA) to encourage them to be available for their community without need for additional employment. This amount was decreased from approximately US$50 (30,000 CFA)/month in May 2012 to align with the few Médecins Sans Frontières and International Committee of the Red Cross supported CHWs in other areas of the country.

To assess the ability of this community-based malaria control programme to provide malaria case management services and surveillance in a crisis setting, a retrospective descriptive study was done based on malaria case management data routinely collected by CHWs between December 2009 and April 2014 (53 months). Whilst the programme was launched in Paoua in 2008, reliable data recording tools were only fully established and implemented in December 2009. Therefore, only data after this date were included in the analysis. The programme in Markounda began activities in December 2011. After April 2014 activities and monthly summary data analysis continued but the detailed data entry of individual patient data stopped due to decrease in funding.

The study population consisted of all suspected malaria cases (defined as patients presenting with fever >37.5 °C or having a history of fever in the last 24 h) as recorded by a CHW as well as pregnant women attending for intermittent preventive treatment. Patients of all ages and from any location were included in the study.

The routinely collected data recorded by CHWs were the basis for this analysis. The CHW registers were collected during monthly supervision sessions and the data were entered into EpiInfo (version 7, CDC, Atlanta, GA, USA) and retrospectively reviewed. Basic clinical and demographic data were recorded (age, gender, village of residence, symptoms, temperature), as well as diagnostic test results, any treatment given and whether the patient was referred to the nearest NGO-supported facility (for example in the case of signs of severe malaria). Data were analysed using STATA 11 (STATA Corp, College Station, TX, USA) to observe trends in malaria incidence during different stages of conflict, to assess the ability of the CHWs to manage uncomplicated malaria cases, and to evaluate the ability of such a programme to continue activities and conduct surveillance during conflict. Annual rainfall data were obtained from The World Bank Group [18].

Malaria incidence rate was calculated as the number of RDT-confirmed cases per month divided by the total population at risk in the area covered by the CHW. Average RDT positivity rates were calculated per CHW instead of exact numbers of cases to take into account the increasing number of CHWs covering a larger area and therefore seeing more patients. The denominator of each monthly calculation also excluded the CHWs that did not report data for that month.

A total of 198,382 people consulted with a trained CHW between December 2009 and April 2014 across both study sites. In total, 68.7% (136,265) were children under 5 years old and 8.9% (17,658) were pregnant women. The ages of patients ranged from newborn to 89 years, and 52.5% were female. In total, 90.3% of these patients presented to CHWs in Paoua sub-prefecture where data were included since December 2009. Only 9.7% presented to CHWs in Markounda which has a much smaller population size and where activities did not begin until December 2011.

Each person visiting a CHW was tested for malaria using an RDT. The overall test positivity rate from both study sites was 81.2% (161,052/198,382). Test positivity was higher in children <5 years [83.6% (113,875/136,266)] compared to pregnant women [64.9% (11,463/17,658)] (Table 1).

Malaria incidence rates calculated separately for Paoua and Markounda populations are plotted in Fig. 2. Data collected during the first year of the programme activities in Markounda (which began 4 years after Paoua) saw higher incidences than in Paoua, which decreased over time from an average of 314 per 1000 population per month in 2012 to 273 per 1000 population per month in 2013. Conversely, the annual incidence in Paoua increased from 140 per 1000 population in 2010 to 197 per 1000 population in 2013. There was also a distinct seasonality in the malaria incidence rate at both sites with a peak occurring every year during the rainy season (May–October). Rainfall did not significantly differ between years, although the data are nationwide and not specific to the study sites.

Figure 3 shows the average number of patients consulting with a CHW by their RDT test result. It shows a reduction in the proportion of RDT negative cases over time from 25.6% in 2010 to 11.9% in 2013. It also shows that on average, CHW consulted the most patients per month in the first year of data collection.

In total, 99.2% of RDT-positive cases received either ACT or rectal artesunate (Table 1).

Most [98.9% (159,279/161,052)] RDT-positive cases were appropriately treated with an ACT. Furthermore, 416 RDT-positive cases that showed signs of complicated malaria received rectal artesunate instead of ACT before referral to the nearest health facility. There were 1962 RDT-positive cases that received both ACT and rectal artesunate, giving a total of 99.2% of RDT-positive cases that received either ACT or rectal artesunate.

Very few RDT-negative cases [1.2% (439/37,330)] were treated with an ACT. However, 298 RDT-negative cases (0.8%) received rectal artesunate resulting in a total of 2% (n = 737) of RDT negative cases receiving either ACT or rectal artesunate. There was only one RDT negative case that received both ACT and rectal artesunate. Paracetamol was administered to 70.0% (26,125/37,330) of RDT negative cases and 1.3% (2125/158,927) of RDT positive cases.

In total 94.1% (127,654/135,595) of children 6–59 months old were tested for malnutrition using MUAC during the data collection period (Table 2). Despite the conflict situation, the majority of children (84.4%) were well nourished. However, 364 children (0.3%) were classified as severely malnourished, 54.5% of whom were female. The proportion of severely malnourished children was not significantly different across the study period, including during the most severe times of conflict. In total, 301 of these severely malnourished children were referred to the nearest health facility.

Of those who had diarrhoea (34,379), 88.0% (30,358) received oral rehydration solution. In total 57,276 doses of mebendazole were given for deworming to children under 5 years, and 704 doses were given to pregnant women. In total, 15,797 people were referred to a health facility for additional follow-up but compliance with this advice to proceed to the nearest health facility was not measured.

During the first year of the study period (2010), 100% of CHWs reported their data each month with the exception of April, October and November when 4% of CHWs did not report. During 2011 and 2012, less than 4% of CHWs consistently did not report their data monthly and in general it was the same CHWs who did not report. Some peaks in non-reporting can be seen in Fig. 4. From the beginning of 2013 when the insecurity increased and political violence peaked, reporting decreased. The most notable increase in non-reporting is seen in the months immediately following March 2013, when the coup d’état occurred.