Malaria and Pneumonia – collaboration, not competition

Nicholas Kristof in the New York Times in a column entitled, “Pssst. Pneumonia. Pass it on,” is rightfully implying that while there has been much attention to malaria, HIV and tuberculosis, it is almost as if the international health community were keeping childhood killer diseases like pneumonia a secret.  Kristof goes on to explain that –

One of those active in the malaria campaign is Lance Laifer, and he’s now plotting a new effort to take on pneumonia. Respiratory tract infections are a huge problem in the developing world and kill vast numbers of kids, and so some attention could make a huge difference. More power to him and others trying to focus on pneumonia.

The answer to the problem is not trying to decide which disease is a worse killer, but how to tackle both diseases in an integrated way.

About eight years ago I was part of the Nigerian team in a four-country project sponsored by WHO/TDR to look at how home management of febrile illness could be managed in the community using prepackaged drugs.  Prior to this time most children were treated by breaking adult dose drugs into pieces or giving syrups, which could be unstable over time.  Parents did not like breaking the drugs and doubted their skills in doing so correctly.  The project therefore developed child dose pre-packs of drugs for both malaria and pneumonia and tested whether these would be acceptable and used correctly.

The reality was that both malaria and pneumonia presented with fever in children, and that both parents and front line health workers could become confused when selecting a course of treatment.  Training of village health workers, patent medicine vendors and front line health staff on distinguishing the two conditions went along with providing them the age-appropriate pre-packs of chloroquine (the malaria drug used on those days) and cotrimoxazole (for pneumonia). WHO explains that –

As a result of these studies, HMM has become a cornerstone of malaria case-management and, more generally, of malaria control in sub-Saharan Africa. Many countries have incorporated HMM (home management of malaria) in their strategic plans to roll back malaria, or in their successful applications to the Global Fund to fight AIDS, Tuberculosis and Malaria, and are now moving to large-scale implementation of HMM.

In fact many organizations have taken the concept of HMM to a broader level of community case management (CCM). This includes the two febrile conditions – malaria and pneumonia – and other conditions.  The Core Group is bringing together the lessons learned in 27 countries to develop an operations manual for organizing CCM. The draft manual offers the following definition/description:

Community case management (CCM) is a strategy to deliver life-saving curative interventions for common, serious childhood infections. Priority infections are those that cause the most child death in developing countries: pneumonia, diarrhea, malaria, and newborn sepsis. The interventions are: antibiotics for pneumonia, dysentery and newborn sepsis; oral rehydration therapy; antimalarials; zinc; and Vitamin A. The CCM strategy targets children because they are the most vulnerable to these infections and, once infected, the most likely to die.

WHO/TDR has also tested community mechanisms for treating malaria and providing preventive services through the Community Directed Interventions (CDI) approach that has made onchocerciasis control successful in tens of thousands of villages throughout Africa. CDI encourages communities to make decisions about how they will manage the supply of basic health commodities and results in better coverage than facility-based services alone.

In summary, models exist for integrating the management of a number of health problems at the community level.  We need to ensure that community committees and volunteers have access to all that is necessary to save their children’s lives, including drugs for malaria and pneumonia and also ITNs, supplements like Vitamin A and zinc and other essential health commodities.

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