Realities in the field

FEVER Differential Diagnosis not possible What happens in practice when a child presents with fever Where malaria risk is high Fever or history of fever? Treated with antimalarial Child survives Classified as malaria Artemisinin based Combination Therapy (ACT) is recommended by WHO

What happens/could happen when a child presents with danger signs DANGER SIGNS Basic treatment started with Artesunate suppository Signs of a child requiring urgent attention Typical case:TC – mother's description.. fever 3 days prior to death. at home for 2 days without treatment. third day of illness, the fever intensified, and the child became very weak. Did not go to hospital. Day3 child had laboured breathing and died. Lethargy?- baby conscious but not responding to sounds or movement Unable to feed? why – too weak, shortness of breath, disturbed consciousness, inability to swallow Is child vomiting everything? Sign of an illness to be identified, child can become dehydrated Does child have convulsions with illness? – Febrile seizures? But meningitis, malaria, pneumonia cannot be ruled out If unable to eat, drink or suck Unable to sit, stand or walk unaided Lethargy/ altered consciousness Repeated convulsions Repeated vomiting REFERRED to HOSPITAL Classified as severe malaria With added symptoms of chest in-drawing + rapid breathing classified as malaria +pneumonia

Because it was late at night, they did not go to hospital. The fever intensified and the child started having difficulty breathing (deep breathing).. Child dies on the 3rd day of illness at home On return to per os status, child given oral antimalarial Child survives Did not go to hospital. But the child improved and could eat and play NOT KNOWN What proportion of children treated early with rectal artesunate are at risk of death without hospital intervention? NOT KNOWN What proportion of children treated early might safely be given a suppository plus oral ACT treatment HIGH risk of death Child does not respond Child responds What happens/could happen when a child presents with danger signs Referral advice not followed REFERRED to HOSPITAL

NOT KNOWN Proportion of children treated with rectal artesunate are at risk of death without hospital intervention? NOT KNOWN What proportion of children treated early might safely be given a suppository plus oral ACT treatment and not need hospitalisation Should rectal artesunate be made available Only with ACTs? RISK- BENEFIT INFORMATION NEEDED How to really scale up rectal artesunate + ACTs? What packaging Health Information/Education Pricing Supply Logistics will be necessary To make the intervention work at national level? INFORMATION NEEDED Proportion of children treated with rectal artesunate that need hospital management because they (i)Progress to severe malaria (ii) Have anaemia, dehydration, malnutrition (iii) Have pneumonia co-infection or just pneumonia Chest Indrawing Strange Sounds Fast Breathing SOLUTION UNICEF main implementing Agency for Child Survival (i) Make part of UNICEF – community based IMCI (ii) Target countries & GFATM (iii) Produce product, package with ACTs (iv) Introduce Health Education, Deploy (v) Develop mechanisms for scale up

Community Integrated Management of Childhood Illness, C-IMCI C-IMCI = an integrated child care approach to improve key family and community practices likely to have greatest impact on child survival, growth and development Practices include: breastfeeding and complementary feeding, hygiene and helping to prevent malaria - consistent use of treated nets, home management of fever episodes, and through recognizing symptoms and promptly referring severe fever cases to a health facility. UNICEF advocates with governments to improve health systems, including ensuring that essential drugs, supplies and equipment are available. UNICEF helps to buy and distribute these items, including vaccinations for routine immunization, Vitamin A supplements, insecticide-treated nets in malaria-affected areas, and malaria home management kits (pre-packaged anti-malarial medications).

Countries with child health related community interventions IMCI Unit AFRO Countries with Community-IMCI in more than 3 Districts Community IMCI : Implementation Status

IMCI Unit AFRO COUNTRIES WITH PLAN FOR C-IMCI Planning at national and district levels Partners collaborating in planning

Summary Children who obtain rectal artesunate by reason of their acute disease are likely to benefit However, in providing the drug, we need to discourage complacency that the drug will solve all problems The probability is high that most (>75%) children will return to per os status For these children –co-packaging with oral ACTs makes sense; hospitalisation may not be necessary But, there is a small, critical, risk that some children will not respond because they have same symptoms but another infection Need to identify the non-responders quickly