Proactive community case management decreased malaria prevalence in rural Madagascar: results from a cluster randomized trial

Rila Ratovoson, Andres Garchitorena, Daouda Kassie, Jemima A Ravelonarivo, Voahangy Andrianaranjaka, Seheno Razanatsiorimalala, Avotra Razafimandimby, Fanjasoa Rakotomanana, Laurie Ohlstein, Reziky Mangahasimbola, Sandro A N Randrianirisoa, Jocelyn Razafindrakoto, Catherine M Dentinger, John Williamson, Laurent Kapesa, Patrice Piola, Milijaona Randrianarivelojosia, Julie Thwing, Laura C Steinhardt, Laurence Baril, Rila Ratovoson, Andres Garchitorena, Daouda Kassie, Jemima A Ravelonarivo, Voahangy Andrianaranjaka, Seheno Razanatsiorimalala, Avotra Razafimandimby, Fanjasoa Rakotomanana, Laurie Ohlstein, Reziky Mangahasimbola, Sandro A N Randrianirisoa, Jocelyn Razafindrakoto, Catherine M Dentinger, John Williamson, Laurent Kapesa, Patrice Piola, Milijaona Randrianarivelojosia, Julie Thwing, Laura C Steinhardt, Laurence Baril

Abstract

Background: Malaria remains a leading cause of morbidity and mortality worldwide, with progress in malaria control stalling in recent years. Proactive community case management (pro-CCM) has been shown to increase access to diagnosis and treatment and reduce malaria burden. However, lack of experimental evidence may hinder the wider adoption of this intervention. We conducted a cluster randomized community intervention trial to assess the efficacy of pro-CCM at decreasing malaria prevalence in rural endemic areas of Madagascar.

Methods: Twenty-two fokontany (smallest administrative unit) of the Mananjary district in southeast Madagascar were selected and randomized 1:1 to pro-CCM (intervention) or conventional integrated community case management (iCCM). Residents of all ages in the intervention arm were visited by a community health worker every 2 weeks from March to October 2017 and screened for fever; those with fever were tested by a rapid diagnostic test (RDT) and treated if positive. Malaria prevalence was assessed using RDTs on all consenting study area residents prior to and following the intervention. Hemoglobin was measured among women of reproductive age. Intervention impact was assessed via difference-in-differences analyses using logistic regressions in generalized estimating equations.

Results: A total of 27,087 and 20,475 individuals participated at baseline and endline, respectively. Malaria prevalence decreased from 8.0 to 5.4% in the intervention arm for individuals of all ages and from 6.8 to 5.7% in the control arm. Pro-CCM was associated with a significant reduction in the odds of malaria positivity in children less than 15 years (OR = 0.59; 95% CI [0.38-0.91]), but not in older age groups. There was no impact on anemia among women of reproductive age.

Conclusion: This trial suggests that pro-CCM approaches could help reduce malaria burden in rural endemic areas of low- and middle-income countries, but their impact may be limited to younger age groups with the highest malaria burden.

Trial registration: NCT05223933. Registered on February 4, 2022.

Keywords: Community case management; Madagascar; Malaria detection; Rural.

Conflict of interest statement

The authors declare no competing interests.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Study design of the pro-CCM cluster randomized trial in the Mananjary district. Left: map of the Mananjary district and the fokontany randomized to the intervention and control arms. Right: recruitment of study participants in each arm at baseline, follow-up, and endline
Fig. 2
Fig. 2
Follow-up of pro-CCM implementation, from March to October 2017. Graphs show the evolution of average values for fokontany in the intervention arm, estimated at each visit (every 2 weeks), with colors representing different indicators
Fig. 3
Fig. 3
Impact of pro-CCM on malaria prevalence. Graphs show the predicted change in malaria prevalence over the study period in the intervention and control arms, for the whole population and particular age groups. In-sample predictions were obtained from multivariate models by age group described in Table 4. Colors represent study arms, and dashed lines represent changes in fokontany receiving IRS

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Source: PubMed

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