A critical view of malaria homecare and the new global malaria drug subsidy

Treating African children at home for malaria doesn't help in cities because most fevers aren't actually caused by malaria, said a new study published online in the medical journal Lancet. Experts monitored more than 400 children aged between 1 and 6 in Kampala, Uganda, from 2005-2007. Malaria drugs were distributed to households where parents had been told by researchers to automatically treat their children if they became feverish. Roughly half the children were treated at home while the other half were taken to health clinics within a day of developing a fever. The study found that children at home got twice as many medicines as those taken to clinics, but didn't do any better.

Home-based management of fever aims to improve the chances that a child with malaria will be promptly and appropriately treated. In high-prevalence settings, treatment with antimalarial drugs is likely to be appropriate, since the cause is more likely to be malaria than not. However, in settings with lower transmission rates, there is a risk that children with non-malarial fever will be treated as having malaria and the true underlying cause (such as pneumonia) will not be addressed.Some doctors said the study showed a worrying tendency to treat fevers before they were diagnosed as malaria: "If you just go on fever, you're over-treating so many children and you could miss other diseases by using malaria drugs," said Dr. Tido von-Schoen Angerer of Doctors Without Borders. Malaria medicines don't work on fevers caused by other diseases, and children can die if they are not properly treated.

Previous studies have found home treatment works in rural areas. But malaria is also a problem in cities, and will have to be tackled differently there than in the countryside. Across Africa, the World Health Organization puts the figure of children promptly treated with effective medication at only 3 percent. The United Nations and partners lately announced a $200 million strategy called the Affordable Medicines Facility for Malaria to make drugs cheaper in 11 African countries. The Affordable Medicines Facility for Malaria (AMFm) will massively subsidise the price of artemisinin-based combination therapies (ACTs), the most effective malaria treatments that exist today. The scheme seeks to reduce the price of ACTs sufficiently to drive older, ineffective treatments that are still being purchased because they are considerably cheaper, out of the market. Von-Schoen Angerer and others worry the tendency to over-treat malaria, as provn by the Lancet study, will be worsened by the strategy. They fear it will flood the market with drugs that promote resistance.

The initiative, led by WHO and the Global Fund to fight AIDS, tuberculosis and malaria, will subsidize the price of artemesinin combination therapies, the most effective malaria treatments. But the U.N. has not insisted the drugs be combined in a single pill, which would curb the resistance risk. Artemesinin combination therapies are also sold as several pills. Some cause side effects like nausea, and patients commonly throw those pills out, encouraging resistance. "The risk of resistance is very scary," von-Schoen Angerer said. "We don't have a back-up medicine at this stage." Richard Tren, director of the nonprofit Africa Fighting Malaria, called the U.N. initiative "an untested experiment," and warned the strategy could backfire. "We need policies based on evidence," he said. "And the evidence this could work is pretty shaky."