Piloting multiple first-line artemisinin-based combination therapies as an innovative approach for managing uncomplicated malaria in the healt district of Kaya, Burkina Faso

Despite coordinated control efforts, sub-Saharan Africa (SSA) still bears the major burden of malaria, a preventable and treatable infectious disease. 95% of the 247 million new cases and 96% of the 625’000 deaths occurred on this continent in 2021. The disease is also responsible for an unacceptable number of hospital admissions and outpatient visits and greatly contributes to poverty in most of SSA countries. In Burkina Faso, malaria remains the leading cause of morbidity (39.8%), and mortality (27.4%) and the country ranked among the six countries with the highest number of malaria cases worldwide, contributing for 3.4% of all cases. The World Health Organization (WHO) recommends a three-day treatment course of artemisinin-based combination therapy (ACTs) for treatment of uncomplicated malaria. The deployment of ACTs contributed substantially to reducing malaria burden. However, partial resistance to artemisinin derivatives or ACT partner drugs has recently emerged and is threatening all gains made in the past decades. To mitigate this threat, a strategy to optimize the use of the ACTs for malaria treatment in SSA countries is urgently needed. As demonstrated in mathematical models, the simultaneous deployment of multiple first-line therapies (MFT) for uncomplicated malaria may extend the useful therapeutic life of the current ACTs. The expected effect was to reduce drug pressure and slowing the spread of resistance without putting patients’ life at risk. We hypothesized that a simultaneous deployment of three different ACTs in Burkina Faso is feasible, acceptable, and can achieve a high coverage rate if potential barriers are properly identified and addressed. We conducted a quasi- experimental study in the health district of Kaya in order to generate evidence on the operational aspects of implementing MFT strategy in malaria endemic settings.
In the framework of this study, this PhD project aimed to assess the feasibility and the acceptability of the MFT strategy deployment for uncomplicated malaria cases management in Burkina Faso. The specific objectives included i) to investigate the treatment-seeking and case management practices for suspected uncomplicated malaria before the deployment of MFT; ii) to understand stakeholder’s perceptions about the deployment of this new strategy; iii) to assess the feasibility and the acceptability of the MFT strategy for uncomplicated malaria management.
As a prelude to the implementation of a pilot MFT program, we conducted a cross-sectional mixed methods study to identify potential facilitators or barriers and to inform a health district-wide implementation of the program. Findings showed that local populations have a good knowledge about malaria. A majority of 76.4% of those interviewed used health facilities (HF) as first recourse to care when they experienced fever / malaria episode, and 66.5% did so within 24 hours of fever onset. We also
confirmed that only one ACT (artemether-lumefantrine) was used for malaria case management (98.2
%). Visiting HF was associated with geographical proximity to the HF (AOR=1.5, 95%CI: 1.2-2.1) and free care of vulnerable populations (children under five and pregnant women). This first part showed that the community has an appropriate knowledge about malaria and positive care-seeking behaviour at health centres for fever/malaria episodes. This was considered to potentially facilitate the implementation of a MFT pilot program in public health facilities (PHF) of the district.
A qualitative survey performed with key stakeholders in the health system and community members revealed a positive perception of stakeholders on the implementation of the MFT programme. This strategy was perceived as an opportunity to strengthen the supply of antimalarial drugs and improve the management of fever and malaria. Thus, the success of this pilot programme was likely dependent on the efficacy of the proposed drugs, low frequency of side effects, affordability and availability of ACTs used.
After one year of deploying the MFT strategy at PHFs, we assessed its feasibility and acceptability. The findings showed good compliance with the strategy guidelines. We also noted a good management of study drugs stocks. 86.1% of malaria cases were treated according the study guidelines. The odds of using PHF as the first source of care increased after the intervention (aOR = 1.6; 95% CI, 1.3–1.9). Qualitative results showed a good acceptance of the MFT strategy with positive opinions from all stakeholders.
This PhD thesis established the feasibility, acceptability and the effect of MFT strategy in Burkina Faso. Implementing an MFT strategy is operationally feasible and acceptable by stakeholders in the health systems in Burkina Faso. As a pre-emptive approach to malaria drug-resistance management, this study provides evidence to support the simultaneous use of multiple first-line artemisinin combination therapies in malaria-endemic countries such as Burkina Faso.