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Conditional follow-up for febrile children warranted in Africa
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Following up with children who experienced unclassified fever in Ethiopia only if they experienced continuing symptoms was noninferior to universal follow-up protocol after 3 days, with only 0.8% of children failing treatment when receiving conditional follow-up.
“A large proportion of deaths globally are caused by infectious diseases such as pneumonia, diarrhea and malaria,” Karin Källander, MSc, PhD, from the Malaria Consortium, London, and the department of public health sciences at Karolinska Instituet, Stockholm, Sweden, and colleagues wrote. “In response, many countries in sub-Saharan Africa have introduced integrated community case management, where community health workers are trained to assess, classify and treat uncomplicated cases of [these diseases] in children under 5 years and refer those with danger signs and malnutrition for facility-based care.”
To evaluate whether conditional follow-up reassessment in children whose symptoms do not improve after 3 days is as safe as current WHO guidelines, which suggests that all children with an unclassified and nonsevere fever return for follow-up after 3 days, the researchers conducted a two-arm cluster-randomized control noninferiority trial. Participants were aged between 2 and 59 months and were febrile but were not affected by malaria, pneumonia, diarrhea or other danger signs.
Children included in the trial were treated by 284 community health workers (CHWs) who were located within 25 health centers throughout Ethiopia, including in Southern Nations, Nationalities and People’s Region. Källander and colleagues assessed whether children reached treatment failure after 1 week. Treatment failure included persistent fever, development of danger signs, hospital admission, death, malaria, pneumonia or diarrhea. A maximum difference of 4% in treatment failure was used to define noninferiority between conditional and universal follow-up.
Additionally, the researchers examined the number of children who were reassessed and received a prescription for antibiotics, and those who experienced serious adverse events, including hospitalization and death after 4 weeks.
Over the course of the study period (Dec. 1, 2015, to Nov. 30, 2016), 4,595 children were enrolled. Of those who participated, follow-up recommendations were adhered to by 3,946 (universal follow-up: 1,953; conditional follow-up: 1,993). These children also completed a study visit on day 8 within ±1 days.
Of the children who received conditional follow-up, 0.8% were determined to have failed treatment on day 8 (n = 16). More children met treatment failure criteria in the universal follow-up arm (4.6%; n = 90; risk difference: –3.81; 95% CI, –∞ 0.65%). According to Källander and colleagues, these percentages qualified the follow-ups for non-inferiority status. Follow-up at day 29 revealed that no deaths occurred.
The researchers observed through caregiver reports that 94.6% of children in the universal follow-up cohort returned on day 3. This number was much less in the conditional follow-up group, with only 7.5% returning on day 3 (RR, 22.0; 95% CI, 17.9-27.2). Of those who requested care from a CHW, only 3% in the conditional arm and 1.1% in the universal arm presented to another provider. Källander and colleagues did not observe a significant difference between the groups (risk difference: 1.79%; 95% CI, –1.23% to 4.82%).
On average, patients were required to travel 2.2 hours when visiting another provider in the universal follow-up group (95% CI, 0.01-5.3) and 2.6 hours in the conditional follow-up group (95% CI, 0.02-4.5). Cost of care was similar in both groups, with the universal follow-up group spending 26.5 birr and the conditional group spending 22.8 birr after visiting the CHW.
“We recommend that Integrated Management of Neonatal and Childhood Illness guidelines in Ethiopia, which stipulate conditional follow-up of children with unclassified fever, remain unchanged, as our study demonstrated that safety of this approach in comparison to universal follow-up of similar children,” Källander and colleagues wrote. “Allowing CHWs to advise caregivers to bring children back only in case of continued symptoms might be a more efficient use of resources in these settings.” – by Katherine Bortz
Disclosures: The authors report no relevant financial disclosures.
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