Characterization and application of multiple genetic markers for Plasmodium malariae.

Plasmodium malariae, a protozoan parasite that causes malaria in humans, has a global distribution in tropical and subtropical regions and is commonly found in sympatry with other Plasmodium species of humans. Little is known about the genetics or population structure of P. malariae. In the present study, we describe polymorphic genetic markers for P. malariae and present the first molecular epidemiological data for this parasite. Six microsatellite or minisatellite markers were validated using 76 P. malariae samples from a diverse geographical range. The repeat unit length varied from 2 to 17 bp, and up to 10 different alleles per locus were detected. Multiple genotypes of P. malariae were detected in 33 of 70 samples from humans with naturally acquired infection. Heterozygosity was calculated to be between 0.236 and 0.811. Allelic diversity was reduced for samples from South America and, at some loci, in samples from Thailand compared with those from Malawi. The number of unique multilocus genotypes defined using the 6 markers was significantly greater in Malawi than in Thailand, even when data from single genotype infections were used. There was a significant reduction in the multiplicity of infection in symptomatic infections compared with asymptomatic ones, suggesting that clinical episodes are usually caused by the expansion of a single genotype.

Therapeutic efficacy of sulphadoxine/pyrimethamine and susceptibility in vitro of P. falciparum isolates to sulphadoxine-pyremethamine and other antimalarial drugs in Malawian children.

Since 1993 sulphadoxine/pyrimethamine (SP) has been used as the first-line drug for uncomplicated Plasmodium falciparum malaria in Malawi. To investigate the current efficacy of SP and other antimalarial drug resistance, we studied in vivo and in vitro responses to SP, chloroquine (CQ), mefloquine (MF), quinine (QN), and halofantrine (HF) in Salima, central Malawi. In a follow-up of 14 days, nine (13.8%) of 65 children under five showed RII/RIII parasitological resistance, and in in vitro microtests 18 (62.1%) of 29 isolates showed < 90% inhibition of schizont maturation at pyrimethamine 75 nmol/l blood medium mixture, indicating resistance. The discrepancy between in vivo and in vitro results might be partially explained by acquired immunity in this holoendemic area. In vitro one (3.4%) of 29 isolates failed schizont inhibition at 1.6 micromol/l blood of CQ, indicating resistance. Compared with an in vitro study conducted in 1988 in another region of Malawi using the same cut-off point, the proportion of resistant isolates had decreased significantly (P < 0.01). Although 31% of isolates were borderline, showing schizont maturation at 0.8 micromol/l blood but no schizonts at 1.6 micromol/l in our study, the results suggest possible recovery of CQ sensitivity after long-term absence of drug pressure. Resistance remains a major problem in malaria control. Monitoring resistance patterns in vitro provides early warning signs of impending loss of therapeutic efficacy of the standard treatment, and may detect changing patterns in alternative drug resistance.

Efficacy of mefloquine and sulfadoxine-pyrimethamine for the treatment of uncomplicated Plasmodium falciparum infection in Machinga District, Malawi, 1998.

In response to the spread of chloroquine-resistant Plasmodium falciparum, Malawi changed its first-line antimalarial drug in 1993 from chloroquine to sulfadoxine-pyrimethamine (SP). Surveillance data has suggested that resistance to SP may be increasing. We compared the efficacy of SP with a potential successor, mefloquine (MQ). By use of a modified World Health Organization in vivo protocol, children infected with P. falciparum were randomized to receive SP (sulfadoxine 25 mg/kg) or MQ (15 mg/kg). We observed combined RII and RIII parasitologic failures of 20.0 and 22.0% in the SP and MQ arms, respectively. Among those in the MQ arm, the relative hazard of failing with a Day 2 drug level < 500 ng/mL was 10.6 times higher than those with levels > or = 500 ng/mL. Given the decreased efficacy of the first-line antimalarial drug and the high failure rates of MQ at this lower dosage, Malawi should consider assessing the efficacy and feasibility of alternative drugs to treat uncomplicated falciparum malaria.

Efficacy of sulphadoxine-pyrimethamine for acute uncomplicated malaria due to Plasmodium falciparum in Malawian children under five years old.

In 1993, Malawi replaced chloroquine (CQ) with sulphadoxine-pyrimethamine (SP) as its first-line treatment for uncomplicated malaria in children < 5 years of age. To assess the efficacy of SP after 5 years of widespread use, we undertook this study at 7 sites in 6 districts of Malawi. Febrile children < 5 years attending the outpatient clinics of selected hospitals whose parents consented were enrolled in the study if they had an axillary temperature of > or = 37.5 degrees C and pure Plasmodium falciparum parasitaemia of >or =2000 asexual parasites/mm3. They were then followed for 14 days or until clinical failure. Parasitological resistance rates (RII and RIII) ranged from 7% to 19%. Resistance was higher in the north than in the central and southern regions, although this difference was not statistically significant. Resistance rates were a mean 19% during the rainy season vs. 12% in the dry season (P > 0.05). 80% of parasitological resistance was at the RII level. Of all children who failed parasitologically (90/641), 84 (93%) had no fever on day 7 and their mothers did not report them as being ill; only 6 of 641 (0.9%) patients met the WHO criteria for clinical treatment failure. Regardless of study site, 75% of mothers reported their children as having improved by day 3; 90% reported improvement by day 7, and all reported improvement by day 14. None of the children experienced any serious adverse reactions and none died. We found that after more than 5 years of widespread use of SP in Malawi, its efficacy remains acceptable for treatment of uncomplicated malaria, and it should therefore be retained as first-line treatment.

Malaria infection in infancy in rural Malawi.

Malaria infection is thought to be relatively infrequent in infants less than 90 days of age in sub-Saharan Africa. In a rural area of Malawi with intense malaria transmission, we examined the occurrence of malaria infection during infancy and risk factors for parasitemia in the first three months of life in the cohort of infants delivered to women in the Mangochi Malaria Research Project. Among 3,915 liveborn singleton infants, 3,432 (87.7%) were seen at least once during infancy (first 12 months of life); of these, malaria blood smear results were available on 2,649 (77.2%). Overall, in a cross-sectional analysis, 23.3% of infants at three months of age were infected with Plasmodium falciparum; this proportion increased to more than 30% during the high transmission season. By the age of 10 months, 60-80% of the infants were infected, depending on the season. Geometric mean parasite density increased each month after two months of age and plateaued at seven months of age. In a life-table analysis, the median time to acquisition of a positive smear was 199 days. Factors independently associated with smear positivity at < 4 months of age included visit during high transmission season (adjusted odds ratio [AOR] = 4.1), maternal smear positivity at the same visit (AOR = 3.5), history of infant fever in the previous two weeks (AOR = 2.8), birth during the rainy season (AOR = 1.7), low socioeconomic status (AOR = 1.6), and low maternal education (AOR = 1.5). The specificity of a recent fever history for malaria infection in early infancy was high (> 70%). Intervention strategies to reduce the risk of early infant infection need to be targeted toward mothers of infants at high risk.

Evaluation of maternal practices, efficacy, and cost-effectiveness of alternative antimalarial regimens for use in pregnancy: chloroquine and sulfadoxine-pyrimethamine.

With the knowledge that an efficacious antimalarial administered to pregnant women would markedly reduce placental malaria and its associated risk of low birth weight (LBW), investigations were conducted to identify an antimalarial regimen practical for nationwide implementation through the antenatal clinic (ANC) system. Maternal practices, including ANC utilization and malaria treatment and prevention during pregnancy were evaluated as part of a national malaria knowledge, attitudes, and practices survey. A second study was conducted to evaluate the efficacy and cost of selected alternative antimalarial regimens. Women in their first or second pregnancy were placed on chloroquine (CQ) treatment (25 mg/kg) followed by weekly CQ (300 mg) (CQ/CQ); sulfadoxine-pyrimethamine (SP) treatment followed by CQ (300 mg weekly) (SP/CQ); or SP treatment during the second trimester and repeated at the beginning of the third trimester (SP/SP). With 87% of women attending ANC two or more times during pregnancy, most pregnant women in Malawi could be reached with an antimalarial intervention. Among 159 women in their first or second pregnancy receiving CQ/CQ, SP/CQ, and SP/SP, placental malaria parasitemia rates were 32%, 26%, and 9%, respectively (P = 0.006, by chi-square test). The SP/SP regimen was also markedly more cost-effective in preventing infant deaths, costing $75 per infant death prevented, compared with $481 for SP/CQ and $542 for CQ/CQ. These investigations suggest that a regimen consisting of two treatment doses of SP during pregnancy is an efficacious and cost-effective intervention to prevent placental malaria, and LBW-associated mortality, that can be delivered to pregnant women through ANCs in settings similar to those found in rural Malawi.

Testing strategies to increase use of chloroquine chemoprophylaxis during pregnancy in Malawi.

The widespread problem of low and non-compliance to antimalarial chemoprophylaxis during pregnancy demands that attention be focused on alternative approaches to programming, product acceptability and demand for preventive services. This study describes the testing of three interventions to determine their effect on use of chloroquine (currently the most widely used drug for chemoprophylaxis) during pregnancy. The strategies evolved from community-based formative research undertaken to learn about the local concept of malaria and issues surrounding malaria prevention and treatment during pregnancy. The resulting interventions were tested in four clinics, and included a change in the health education message given during antenatal sessions, distribution of a sugar-coated chloroquine tablet, and an intervention combining the two strategies. The results showed a 45% increase in chloroquine use when the health education message was changed, and a 64% increase when the product was changed. High use levels were maintained with the combined intervention; an additive effect was seen. The study shows that improving the product was the most important factor in increasing the use of the program, and that changing the health education message can also make an impact on use.

The efficacy of antimalarial regimens containing sulfadoxine-pyrimethamine and/or chloroquine in preventing peripheral and placental Plasmodium falciparum infection among pregnant women in Malawi.

To define an effective and deliverable antimalarial regimen for use during pregnancy, pregnant women at highest risk of malaria (those in their first or second pregnancy) in an area of Malawi with high transmission of chloroquine (CQ)-resistant Plasmodium falciparum were placed on CQ and/or sulfadoxine-pyrimethamine (SP). Of 38 pregnant women who received CQ treatment followed by weekly CQ prophylaxis (CQ/CQ) for at least 45 days prior to delivery, 32% had placental malaria infection, compared with 26% of 50 pregnant women who received a treatment dose of SP followed by weekly CQ prophylaxis (SP/CQ), and only 9% of 71 pregnant women who received a two-dose SP regimen (SP/SP; given once during the second trimester and repeated at the beginning of the third trimester) (P = 0.006, by chi-square test). During the peak transmission season from April to July, 47% of the women who received CQ/CQ had placental malaria infection at delivery, as compared with 37% of the women who received SP/CQ, and 10% of women who received SP/SP (P = 0.004, by chi-square test). Among women in their first or second pregnancy, two treatment doses of SP were highly effective in decreasing the proportion of women with placental malaria infection at delivery.

A nation-wide malaria knowledge, attitudes and practices survey in Malawi: objectives and methodology.

A malaria knowledge, attitudes and practices survey was conducted in Malawi during April and May, 1992, to provide policy makers and program managers with information needed to design or improve malaria control programs, to establish epidemiologic and behavioral baselines, and to identify indicators for monitoring program effectiveness. Using cluster-sample survey methodology, 1531 households, in 30 clusters of 51-52 households each, were identified and members interviewed. Interviews were conducted by trained survey teams composed of young Malawian women with secondary level education. Heads of households were asked about malaria prevention methods used and about household economics; caretakers of children were asked about treatment and health seeking behavior in a recent malaria episode in a child; and women who had been pregnant in the past 5 years were asked about their antenatal clinic utilization and malaria during pregnancy. Survey results will be used to make programmatic decisions, including developing health education messages and establishing monitoring and evaluation of malaria control activities and outcomes in Malawi.

PIP: A malaria knowledge, attitudes and practices survey was conducted in Malawi in the late rainy season, April 1-May 16, 1992, corresponding to the season of peak malaria transmission to provide policy makers and program managers with information needed to design or improve malaria control programs, to establish epidemiologic and behavioral baselines, and to identify indicators for monitoring program effectiveness. A cluster-sample survey methodology, modified from the Expanded Program for Immunization cluster-sampling methodology was used to identify and interview members of a total sample of 1531 households, in 30 clusters of 51 to 52 households each. Heads of households were asked about malaria prevention methods used and about household economic; caretakers of children were asked about treatment and health seeking behavior in a recent malaria episode in a child; and women who had been pregnant in the past 5 years were asked about their antenatal clinic utilization and malaria during pregnancy. A total of 7025 persons in 1531 households were included in the survey: 1178 adults with recent fever illness and caretakers of 724 children with recent fever illness were interviewed; 1395 households included at least one woman who had ever been pregnant, with 809 women having completed a pregnancy within the last 5 years. Preventive measures used in the households and household income were ascertained for 1531 households. In several articles, detailed results will be described for each part of the survey. These results will be used to be guide policy makers and program managers in making decisions based on current data in designing and improving malaria control programs and health education messages. Baseline epidemiologic and behavioral indicators will be identified for monitoring program impact to help focus intervention efforts on high risk groups, through channels that will most effectively reach the greatest number of people.

Malaria knowledge, attitudes and practices in Malawi: survey population characteristics.

A national knowledge, attitudes and practices (KAP) survey was conducted in March-April 1992 to examine malaria illness and the people's response to illness and malaria prevention. Fifty-one households in each of 30 randomly selected communities were sampled and information was recorded from 1,531 households and 7,025 individuals. The population is characterized by low income (average household and per capita income were US $490 and $122, respectively) and low education levels (among adult women, 45% had no formal education and only 3.9% completed more than 8 years of schooling). Characteristics of the population were similar to those found in the 1987 national census, suggesting that the survey population was representative of the larger population of Malawi. Children under 5 years of age made up 15.8% of the population and had the highest rates of fever illness; these children experienced an estimated 9.7 cases/year of fever illness consistent with malaria. Although adults reported fever less frequently, women of reproductive age experienced an estimated 6.9 episodes of fever annually. The burden of malaria morbidity in this population is extremely high and occurs in all age groups.

PIP: A national knowledge, attitudes and practices (KAP) survey was conducted in March-April 1992 to examine malaria illness and the people's response to illness and malaria prevention. 51 households in each of 30 randomly selected communities were sampled and information was recorded from 1531 households and 7025 individuals. The average annual income per household was US $490 and the average per capita income was $122. Female-headed households are most commonly in the "very low" income grouping. Among adult women, 45% had no formal education and only 3.9% had completed more than 8 years of schooling. 23% of male households and 58% of female households reported no normal education. Children under 5 years of age made up 15.8% of the population and had the highest rates of fever illness. Seasonally adjusted estimates of fever episodes by age group and gender for adults showed that these children experienced the highest reported rates: an estimated 9.7 cases/year of fever illness consistent with malaria. Infants and children under 5 years of age had the highest reported rates of fever (45.6% and 49.0%, respectively). Although adults reported fever less frequently, women of reproductive age experienced an estimated 6.9 episodes of fever annually. Reported malaria-like fever in the previous 14 days was recorded for each household member; overall, 33% of the population reported fever in this interval. Data from the National Health Information System indicate that in 1989 approximately 10% of the more than 3.7 million total outpatient cases of malaria for the year were reported in the mid-April to mid-May time interval. The burden of malaria morbidity in this population is extremely high and occurs in all age groups.

Malaria and childbearing women in Malawi: knowledge, attitudes and practices.

Information on women's use of antenatal clinic (ANC) service, including malaria prevention and treatment during pregnancy, was collected during a national malaria knowledge, attitudes, and practices survey in Malawi. Among 1531 households, 809 (53%) included a woman who had carried a pregnancy past the second trimester within the past 5 years. Of these, 756 (93%) women reported at least one ANC visit during pregnancy (median = 4); 336 (42%) attended 5 or more times. Approximately half (51%) reported delivering in a hospital; 5% delivered in a clinic; 13% delivered at home with a trained birth attendant; and 28% delivered at home with only family attending. Women at increased risk for delivery complications (e.g. primigravidas and grand multigravidas) were no more likely to attend ANC or deliver in hospital than women without increased risk. The woman's level of education was the only significant predictor of initiating ANC care, continued ANC attendance, and delivery in hospital. In a setting where 43% of women pregnant within the past 5 years had received no formal education and 70% had completed less than 5 years, this survey identified a critical need for targeting health messages towards poorly educated women to ensure proper utilization of antenatal care services, including coverage with malaria prevention throughout pregnancy.

PIP: Information on women's use of antenatal clinic (ANC) service, including malaria prevention and treatment during pregnancy, was collected during a national malaria knowledge, attitudes, and practices survey in Malawi. Among 1531 households, 809 (53%) included a woman who had carried a pregnancy past the second trimester within the past 5 years. Of these, 756 (93%) women reported at least one ANC visit during pregnancy (median = 4); 336 (42%) attended 5 or more times. Among ANC attenders, 723 (96%) reported receiving an ANC card, but only 210 (26%) could produce the card for examination by the interviewer. Delivery occurred at home with a family member attending among 225 (28%) women; 103 (13%) reported home delivery with a TBA present; 421 (51%) delivered in hospital; and 43 (5%) in a clinic. Women at an increased risk for delivery complications (e.g. primigravidas and grand multigravidas) were no more likely to attend ANC or deliver in hospital than women without increased risk. Tetanus toxoid immunization was reported by 689 (91%) ANC attenders, and 576 (76%) reported receiving iron. Women who attended ANC were significantly more likely to deliver at a hospital or clinic (452/756, 60%) than women who had never attended ANC (3/53, 6%) (p .001). For those delivering at a health care facility, 309 (68%) walked to the facility; most of the women were accompanied by a female relative (274, 60%). Most women (80%) reported waiting until the onset of labor to travel to the facility. The woman's level of education was the only significant predictor of initiating ANC care, continued ANC attendance, and delivery in hospital. In a setting where 43% of women pregnant within the past 5 years had received no formal education and 70% had completed less than 5 years, this survey identified a critical need for targeting health messages towards poorly educated women to ensure proper utilization of antenatal care services, including coverage with malaria prevention throughout pregnancy.

Treatment of malaria fever episodes among children in Malawi: results of a KAP survey.

Caretakers of children (< 10 years of age) were questioned about management of pediatric malarial fever episodes in a nation-wide knowledge, attitudes, and practices survey conducted in Malawi. A total of 1,531 households in 30 randomly selected clusters of 51 households each were sampled and interviewed. Overall 557 caretakers reported a fever in their child in the previous 2 weeks; 43%-judged the illness as severe. Fifty-two percent of caretakers brought their febrile children to clinic. Clinic attendance was positively correlated with young age of the child (< 4 years), severe illness, and higher socioeconomic status. Seventy-four percent of clinic attenders gave their child an antimalarial; in contrast, only 42% of those not attending clinic gave an antimalarial. Optimal therapy (administration of an antimalarial promptly and at the proper dosage) was received by only 7% of febrile children. Children taken to clinic were twice as likely to receive optimal therapy as were non-attenders. Identification of critical points in the optimal therapy algorithm and characteristics of caretakers linked with sub-optimal therapy may help malaria control programs target specific groups and health education messages to improve treatment of malaria fever episodes.

PIP: Caretakers of children (10 years of age) were questioned about management of pediatric malarial fever episodes in a nation-wide knowledge, attitudes, and practices survey conducted in Malawi. A total of 1531 households in 30 randomly selected clusters of 51 households each were sampled and interviewed. Overall 557 caretakers reported a fever in their child in the previous 2 weeks; and 43% judged the illness severe. 289 (52%) of caretakers brought their febrile children to clinic. Clinic attendance was linked with the age of the child, with younger children (4 years of age) being significantly more likely to be taken to clinic than older children (OR 2.7). Children judged as severely ill by their caretakers were taken to clinic significantly more often than those not thought to be severely ill (OR 1.7). Caretakers from households where the household head had a primary or secondary education were more likely to attend clinic than those were the household head reported no education (OR 1.5). Similarly, caretakers from households with moderate or high income attended clinic more frequently than did those with low income (56% vs. 49%, p = 0.15). 74% of clinic attenders reported they gave an antimalarial to the child with fever illness, compared to 42% of those who did not go to clinic (OR 4.0). Among caretakers who did not attend clinic, those from households were the head had a secondary education were more likely to give antimalarials (71%) than were those where the household head had a primary or no education (38%) (OR 4.0). Among those not attending clinic, most obtained medications at home (20%); street vendors or employers were reported as a source by only 2% of caretakers. Antipyretics were reported given to children by 62% of clinic attenders and 63% of those not attending clinics. Identification of optimal therapy and characteristics of caretakers linked with suboptimal therapy may help target specific groups to improve treatment of malaria fever episodes.

Malaria knowledge, attitudes and practices in Malawi: policy implications for the National Malaria Control Program.

PIP: Following data analysis and the presentation of the summary report to Ministry of Health officials, a group of Ministry of Health staff examined results for implications for national policy development, those elements which were relevant to 1) health education messages; 2) the development of programmatic indicators; 3) constraints on the use of services and access to treatment and prevention; and 4) direct and indirect costs of malaria in Malawi. Despite years of chloroquine use, less than 30% of children were reported to receive an appropriate dose, thereby limiting effective therapy. Plans to implement a new first line drug for therapy for use of sulfadoxine-pyrimethamine must be clearly spelled out. 10% of children attending government clinics and 43% of those attending private facilities receive an injection for malaria, a gross overuse of injectable drugs. With 83% of women perceiving malaria as a problem during pregnancy and 68% thinking that antimalarials can prevent it, there is a need for increased management of malaria in pregnancy. Use of malaria preventive measures is very low and income-dependent. Educational messages must include teaching that mosquitoes transmit malaria, as only 55% of household heads reported this as the cause of malaria fevers. In certain locally based public health projects, use of bed nets could be much higher. There is an imbalance between the average household expenditure on treatment (US $13.33) compared to prevention ($2.47). In addition, 40% of households have an annual income of less than US $110 and expenditure on treatment exceeds 10% of these family incomes. The use of malaria prevention measures was closely linked to household income and, estimated annual expenditure on sprays, coils and bed nets was high ($42.60, $12.56, and $12.42, respectively). This underscores that 1) households that do spend money on prevention tend to spend substantial amounts; and 2) the money spent might be more effective if it were spent on bed nets rather than sprays.^ieng

Malaria chemoprophylaxis compliance in pregnant women: a cost-effectiveness analysis of alternative interventions.

Compliance to malaria chemoprophylaxis among pregnant women in Malawi has historically been low. Three separate interventions, based upon an ethnographic study of malaria beliefs among pregnant women in Malawi, were introduced to increase compliance to the malaria chemoprophylaxis program provided by the Ministry of Health. Each intervention consisted of a health education message and an antimalarial drug. A cost-effectiveness analysis of the interventions was conducted to compare the interventions as alternative strategies to increase compliance among pregnant women.

In vivo efficacy of quinine treatment for Plasmodium falciparum malaria in Malawian children.

Twenty-five Malwaian children with Plasmodium falciparum infection were studied for response to quinine in an eight-hourly dosage of 10 mg salt kg-1 body weight. The mean parasite clearance time, defined as the time after initiation of treatment when the first of two consecutive 12-hourly smears was negative for P. falciparum parasites, was 67 hours. The mean fever clearance time, defined as the time after initiation of treatment when the axillary temperature first fell below 37.5 degrees C and remained below this level for 48 hours, was 36 hours. Twenty-four hours after the first dose of quinine, the geometric mean parasite density among the children studied had decreased by 84%, from 41 357-6586 parasites mm-3, and all children cleared their parasitaemia within 108 hours. Results of this study confirm that quinine remains effective in rapidly controlling P. falciparum parasitaemias in Malawi, where resistance to the 4-aminoquinolines is highly prevalent.

Oral rehydration therapy in Malawi: impact on the severity of disease and on hospital admissions, treatment practices, and recurrent costs.

In the first 2 years following refresher training of paediatric staff in oral rehydration therapy (ORT) and the establishment of an oral rehydration unit at the Kamuzu Central Hospital, Lilongwe, Malawi, there was a 50% decrease in the number of children admitted to the paediatric ward with the diagnosis of diarrhoeal diseases, a 56% decrease in the use of intravenous fluid to rehydrate such children, a threefold increase in the use of oral rehydration salts (ORS) exclusively to rehydrate children with mild or moderate dehydration, and a 39% decrease in the number of paediatric deaths associated with diarrhoeal diseases. Over the same period, there was a 32% decrease in recurrent hospital costs attributable to paediatric diarrhoeal diseases. As use of ORT continues to increase in Malawi, where diarrhoeal diseases account for 9% of paediatric hospital admissions, there should be considerable decreases in mortality from such diseases and concomitant increases in cost savings attributable to them.

PIP: In the 1st 2 years following refresher training of pediatric staff in oral rehydration therapy (ORT) and the establishment of an oral rehydration unit at the Kamuzu Central Hospital, Lilongwe, Malawi, there was a 50% decrease in the number of children admitted to the pediatric ward with the diagnosis of diarrheal diseases, a 56% decrease in the use of intravenous fluid to rehydrate such children, a 3-fold increase in the use of oral rehydration salts exclusively to rehydrate children with mild or moderate dehydration, and a 39% decrease in the number of pediatric deaths associated with diarrheal diseases. Over the same period, there was a 32% decrease in recurrent hospital costs attributable to pediatric diarrheal diseases. As use of ORT continues to increase in Malawi, where diarrheal diseases account for 9% of pediatric hospital admissions, there should be considerable decreases in mortality from such diseases and concomitant increases in cost savings attributable to them. (author's)

Oral rehydration therapy in Malawi: impact on the severity of disease and on hospital admissions; treatment practices; and recurrent costs

In the first 2 years following refresher training of paediatric staff in oral rehydration therapy (ORT) and the establishment of an oral rehydration unit at the Kamuzu Central Hospital; Lilongwe; Malawi; there was a 50 percent decrease in the number of children admitted to the paediatric ward with the diagnosis of diarrhoeal diseases; a 56 percent decrease in the use of intravenous fluid to rehydrate such children; a threefold increase in the use of oral rehydration salts (ORS) exclusively to rehydrate children with mild or moderate dehydration; and a 39 percent decrease in the number of paediatric deaths associated with diarrhoeal diseases. Over the same period; there was a 32 percent decrease in recurrent hospital costs attributable to paediatric diarrhoeal diseases. As use of ORT continues to increase in Malawi; where diarrhoeal diseases account for 9 percent of paediatric hospital admissions; there should be considerable decreases in mortality from such diseases and concomitant increases in cost savings attributable to them