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Fever, Parasitemia and Access to Subsidized ACTs –

Evidence from Uganda’s Eastern Province

Jessica Cohen

Bill Dickens

Günther Fink

AFFORDABLE MEDICINES FACILITY-MALARIA REVIEW AND THE

FINANCING OF FEBRILE ILLNESS MANAGEMENT

September 17-18 2012

The National Academies, Washington, DC 20037

Please do not cite without permission of authors.

Uganda


RDT Study Districts


92 Study Villages:

May 2011 to April 2012

•2500 Households

•15,000 Individuals

> 30,000 Illness reports> 30,000 Illness reports


Endemicity

• At the end of the trial, free testing was offered to all

household members

• About 66% of members were present and consented to

testing, for a total of 9887 tests (96% consented)testing, for a total of 9887 tests (96% consented)

• About 50% of children and 30% of adults (all without acute

health problems) were found to test positive � highly

endemic area


Most Common Morbidity Symptoms

50%

60%

70%

80%

90%

100%

Pe

rce

nta

ge

of

res

po

nd

en

ts r

ep

ort

ing

sym

pto

m

Mean: 1.1 cases per household and month

0%

10%

20%

30%

40%

Pe

rce

nta

ge

of

res

po

nd

en

ts r

ep

ort

ing

sym

pto

m


Where Do Fever Patients Seek Treatment?

Clinic11%

Other3%

Unknown20%

Note: 23% of fevers don’t seek treatment at all.

Drug shop39%

Health Center22%

Hospital5%

3%


Most Common Drug Treatment

59.0%

33.8%35.5%

0.4

0.5

0.6

0.7F

rac

tio

n o

f fe

ve

r p

ati

en

ts g

ett

ing

…

27.7%

0

0.1

0.2

0.3

Antibiotic Painkiller ACT Other antimalarial

Fra

cti

on

of fe

ve

r p

ati

en

ts g

ett

ing

…


Other Antimalarials

Artenam7%

Chloroquine9%

SP/Fansidar6%

Other1%

Quinine77%


Change in Treatment over Time

0.3

0.35

0.4

Fra

cti

on

of fe

ve

rs s

ee

kin

g tr

ea

tme

nt g

ett

ing

tre

ate

d w

ith

C

oa

rte

m a

nd

Qu

inin

e

0.15

0.2

0.25

1 2 3 4 5 6 7 8 9 10

Fra

cti

on

of fe

ve

rs s

ee

kin

g tr

ea

tme

nt g

ett

ing

tre

ate

d w

ith

C

oa

rte

m a

nd

Qu

inin

e

FB Round

Fraction of fevers treated with quinine

Fraction of fevers treated with Coartem


15

20

25

30

Millio

n D

os

es

of A

MF

m A

CT

s

Cumulative AMFm ACTs Arriving in Public Facilities

Cumulative AMFm ACTs Arriving in Private Facilities

Timing of the AMFm

0

5

10

15

Millio

n D

os

es

of A

MF

m A

CT

s


ACT Distribution in Retail Sector:

How Many Shops Stock ACTs?

85.1%

0.6

0.7

0.8

0.9

1

Fra

cti

on

of L

ice

ns

ed

Dru

g S

ho

ps S

tockin

g C

oart

em

32.5%

0

0.1

0.2

0.3

0.4

0.5

Baseline Endline

Fra

cti

on

of L

ice

ns

ed

Dru

g S

ho

ps S

tockin

g C

oart

em


2000

2500

3000

3500

Me

an

re

po

rte

d p

ric

e in

US

HACT Pricing in the Retail Sector

0

500

1000

1500

June July August September October November December January February March

Me

an

re

po

rte

d p

ric

e in

US

H

Mean Price for Coartem

95% CI

95% CI


Malaria Testing (28% overall)

50.5% 51.5%

63.1%

0.4

0.5

0.6

0.7

Fra

cti

on

of

feve

r p

ati

en

ts g

ett

ing

te

ste

d a

t..

8.9%

0

0.1

0.2

0.3

Drug shop Clinic Health Center Hospital

Fra

cti

on

of

feve

r p

ati

en

ts g

ett

ing

te

ste

d a

t..


Self-reported Test Results (N=23,849)

0.4

0.5

0.6

0.7

Fra

cti

on

of

pa

tie

nts

ge

ttin

g…

Not tested

Report to have tested positive

Report to have tested negative

0

0.1

0.2

0.3

0.4


Fra

cti

on

of

pa

tie

nts

ge

ttin

g…


Treatment of Confirmed Malaria Tests (N=1800)

0.4

0.5

0.6

0.7

Fra

cti

on

of

pa

tie

nts

ge

ttin

g…

Positive Negative

0

0.1

0.2

0.3


Fra

cti

on

of

pa

tie

nts

ge

ttin

g…


Trends in ACT Treatment by Age Group

0.25

0.30

0.35

0.40

0.45

0.50

Fra

cti

on

of

feve

r p

ati

en

ts g

ett

ing

an

AC

T

0.00

0.05

0.10

0.15

0.20

Fra

cti

on

of

feve

r p

ati

en

ts g

ett

ing

an

AC

T

Ages 0-4 Ages 5-19 Ages 20+


Trends in ACT Treatment by Wealth Quintile (All)

0.25

0.30

0.35

0.40

0.45

0.50

Fra

cti

on

of

feve

r p

ati

en

ts g

ett

ing

an

AC

T

0.00

0.05

0.10

0.15

0.20

Fra

cti

on

of

feve

r p

ati

en

ts g

ett

ing

an

AC

T

Poorest

Asset Quintile 3

Richest


Trends in ACT Treatment by Wealth Quintile (Untested)

0.20

0.25

0.30

0.35

0.40

0.45

Fra

cti

on

of

feve

r p

ati

en

ts g

ett

ing

an

AC

T

0.00

0.05

0.10

0.15

0.20

Fra

cti

on

of

feve

r p

ati

en

ts g

ett

ing

an

AC

T

Poorest

Asset Quintile 3

Richest


Trends in ACT Treatment by Wealth Quintile (Tested Positive)

0.5909091

0.40

0.50

0.60

0.70

Fra

cti

on

of

feve

r p

ati

en

ts g

ett

ing

an

AC

T 59.1%

0.00

0.10

0.20

0.30

Fra

cti

on

of

feve

r p

ati

en

ts g

ett

ing

an

AC

T

Poorest

Asset Quintile 3

Richest


Trends in ACT Treatment by Wealth Quintile

(Tested Negative)

0.40

0.50

0.60

0.70

Fra

cti

on

of

feve

r p

ati

en

ts g

ett

ing

an

AC

T

Poorest

Asset Quintile 3

Richest

0.00

0.10

0.20

0.30

Fra

cti

on

of

feve

r p

ati

en

ts g

ett

ing

an

AC

T


Main Findings

• The percentage of fever patients getting an ACT has increased

from about 30% in June 2011 to 40% in April 2012 (and the

quinine share has fallen by about the same amount)

• Increases in ACT access are particularly large for low SES

householdshouseholds

• Testing affects but no necessarily determines treatment choice:

– about 50% don’t get an ACT even when tested positive

– about 25% get an ACT even when the test result is negative


Backup Slides


Positivity by Age Group

0.5

0.6

0.7

0.8F

ract

ion

of

RD

Ts p

osi

tiv

e

Overall, 49% of asymptomatic

patients tested positive

0

0.1

0.2

0.3

0.4

0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64

Fra

ctio

n o

f R

DTs

po

siti

ve

Age Group


Parasitemia by Sex

50%

60%

70%

80%

Pe

rce

nta

ge

of

po

siti

ve

RD

Ts

0%

10%

20%

30%

40%

0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64

Pe

rce

nta

ge

of

po

siti

ve

RD

Ts

Age group

Male Female


Malaria Seasonality

60%

65%

70%

75%

Pe

rce

nta

ge

of a

dm

inis

tere

d S

lid

es

Po

sit

ive

35%

40%

45%

50%

55%

July August September October November December January February March

Pe

rce

nta

ge

of a

dm

inis

tere

d S

lid

es

Po

sit

ive

Note: 95% confidence intervals need to be adjusted for spatial clustering


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