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Background. In 2007, Malawi replaced the first-line medication for uncomplicated malaria, sulfadoxinepyrimethamine- a single-dose regimen-with artemether-lumefantrine (AL)-a 6-dose, 3-day regimen. Because of concerns about the complex dosing schedule, we assessed patient adherence to AL 2 years after routine implementation. Methods. Adults and children with uncomplicated malaria were recruited at 3 health centers. We conducted both pill counts and in-home interviews on medication consumption 72 hours after patients received AL. Complete adherence was defined as correctly taking all 6 AL doses, as assessed by pill count and dose recall. We used logistic regression to identify factors associated with complete adherence. Results. Of 386 patients, 65% were completely adherent. Patients were significantly more likely to be completely adherent if they received their first dose of AL as directly observed therapy at the health center (odds ratio [OR], 2.4; P < .01), received instructions using the medication package as a visual aid (OR, 2.5; P = .02), and preferred AL over other antimalarials (OR, 2.7; P < .001). In contrast, children <5 years of age were significantly less likely to be adherent (OR, 0.5; P = .05). Conclusions. Adherence to AL treatment for uncomplicated malaria was moderate, and children, who are the most likely to die of malaria, were less adherent than adults. Efforts to improve adherence should be focused on this vulnerable group. Interventions including the introduction of child-friendly antimalarial formulations, direct observation of the first dose, use of the AL package as a visual aid for instructions, and enhancing patient preference for AL could potentially increase AL adherence and overall effectiveness. [ABSTRACT FROM AUTHOR]

Malaria in pregnancy contributes to low birth weight and increased infant mortality. As part of WHO's Roll Back Malaria initiative, African heads of state pledged that by 2005, 60% of pregnant women will receive malaria chemoprophylaxis or intermittent preventive treatment (IPT). We performed a cluster sample survey to study the use of sulfadoxine-pyrimethamine (SP) for IPT among recently pregnant women in February 2000 in Blantyre District, Malawi. Among 391 women in the sample, 98.6% had attended antenatal clinic at least once and 90.2% knew that SP/IPT was recommended during pregnancy. Overall, only 36.8% received the full recommended two-dose regimen of SP/IPT. Using data from 187 women with antenatal clinic cards, we found that residence location, housing type and gender/age/education of the head of household were not associated with failure to receive SP/IPT. Adjusting for education, multigravid women were more likely not to receive the recommended SP/IPT regimen (RR 1.2, 95% CI 1.02-1.5, P=0.03). A substantial effort to improve the delivery and use of SP/IPT in Malawi will be necessary, but the Roll Back Malaria 2005 goal appears achievable. [ABSTRACT FROM AUTHOR]

Abstract: Malaria is a leading cause of death in children aged &#60; 5 years in Malawi. As part of the Roll Back Malariainitiative, African heads of state have pledged that by 2005, 60% of children will receive an effective antimalarial drug within 24 h of developing fever. In 1993, Malawi switched from chloroquine to sulfadoxine-pyrimethamine (SP) in its recommendations of home treatment of febrile illness in children. To study care seeking behaviour and home treatment in Blantyre District, and provide valuable follow-up to the chloroquine to SP transition, we performed a 2-stage cluster-sample survey in February 2000. Our sample of 1080 households included 672 households with children aged &#60; 5 years; 292 (32.2%, 95% CI 28.7–35.8%) of the 912 children in these households had completed a febrile episode within the past 14 d. Among recently febrile children, 210 (72.0%, 95% CI 67.0–77.1%) received medication at home during their illness, but only 36 (12.2%, 95% CI 8.4–16.0%) received an appropriate antimalarial drug. Overall, 111 (37.4%, 95% CI 30.9–43.9%) received prompt, appropriate treatment. Only rural location was statistically associated with failure to receive prompt appropriate treatment (risk ratio estimate 1.2, 95% CI 1.01–1.5). A greater effort to improve the quality of malaria home treatment or to expand health facility utilization will be necessary to achieve Roll Back Malaria goals before 2005 in Blantyre District. Current care seeking practices suggest interventions should stress promptness of health facility visits, improved access to appropriate drugs, and accurate dosing for home-based treatments. [Copyright &y& Elsevier]

Objective: To evaluate the use of insecticide-treated bednets and the effectiveness of social marketing for their distribution.Methods: Systematic cluster sample survey of 1080 households in 36 census enumeration areas across Blantyre district, Malawi, in February 2000.Results: A total of 672 households had one or more children under 5. Bednet ownership was low (20.5% of households) overall, and significantly lower in rural areas than urban areas (6.4 vs. 29.8%, P=0.001). Only 3.3% of rural children under 5 had slept under a net the previous night, compared with 24.0% of urban children (P < 0.001). When asked why they did not own a net, nearly all (94.9%) caretakers in households without nets stated they had no money to buy them. In multivariate statistical models that controlled for the influence of house structure, urban vs. rural location, gender of the head of household, and the primary caretaker's education, rural children under 5 in households without nets experienced a statistically significant higher prevalence of malaria parasitaemia [RR (risk ratio) 4.9, 95% CI (confidence interval) 2.3-10.5] than children in households with at least one bednet. This was also true for urban children under 5 (RR 2.1, 95% CI 1.0-4.2, P=0.04).Conclusion: Social marketing approaches to promoting insecticide-treated nets in Blantyre District may have produced measurable health benefits for children in those households in which residents bought and used the products. Market-based approaches may take years to achieve high levels of coverage and may exaggerate inequities between urban and rural populations. [ABSTRACT FROM AUTHOR]