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ADHERENCE TO ANTIMALARIAL COMBINATION THERAPY WITH SULFADOXINE-PYRIMETHAMINE AND ARTESUNATE IN RURAL TANZANIA

Artemisinin-containing antimalarial combination therapies are recommended to confront drug-resistant Plasmodium falciparum malaria. Among the questions surrounding whether these complex multidose treatments will be practical is to what extent patients complete the recommended doses. Combination therapy through coadministration of sulfadoxine-pyrimethamine plus artesunate was introduced as a first-line treatment for uncomplicated malaria in one district in Tanzania. Interventions to optimize correct use were also implemented. We observed 453 patient encounters at one health facility and recorded key practices as health workers dispensed the combination. A total of 253 patients were followed-up at 24 or 48 hours. Complete adherence measured at 48 hours reached 75.0%, based on self-report and tablet counts. This is substantially better than reported elsewhere and compares favorably with intervention studies to optimize adherence to chloroquine. Counseling about what to do if a patient vomits appears to have been an independent risk factor for nonadherence.

Received January 30, 2004. Accepted for publication June 22, 2004.

Acknowledgments: Ellen Kaizer took part in this project through the International Health Track of the Pediatric Medicine Residency at Rainbow Babies and Children’s Hospital of Case Western Reserve University (Cleveland, OH). Susan S. Fox participated through the epidemiology elective program at the Epidemiology Program Office at CDC. We are grateful to Bernard Mumba and Idd Mkilalu, who served as data collectors, and to the staff and patients at the Ikwiriri Health Centre for their participation in this study. The support of Dr. Hassan Mshinda (Director, Ifakara Health Research and Development Centre) and Dr. Saidi Mkikima (District Medical Officer in Rufiji) is particularly appreciated.

Financial support: This work was supported primarily by the United States Agency for International Development. The particular contributions of Dr. Mary Ettling are appreciated.

Disclaimer: Trade names are used for purposes of identification only and do not constitute endorsement by the United States Public Health Service or the Centers for Disease Control and Prevention.

Author’s addresses: S. Patrick Kachur, Centers for Disease Control and Prevention Malaria Program in Tanzania, PO Box 78373, Dar es Salaam, Tanzania, Telephone: 255-22-213-6689, Fax: 255-22-213-6687, E-mail: skachur{at}cdc.gov. Rashid A. Khatib and Salim M. Abdulla, Ifakara Health Research and Development Centre, Ifakara, Tanzania. Ellen Kaizer and Susan S. Fox, Centers for Disease Control and Prevention Malaria Program in Tanzania, Dar es Salaam, Tanzania. Peter B. Bloland, Malaria Case Management Unit, Malaria Branch, Division of Parasitic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30341.

^* The Interdisciplinary Monitoring Project for Antimalarial Combination Therapy in Tanzania (IMPACT-Tz) is a multiyear implementation research evaluation project that rests on a collaborative platform comprising the United States Centers for Disease Control and Prevention, the Ifakara Health Research and Development Centre, the National Institute for Medical Research, Muhimbili University College of Health Sciences, the London School of Hygiene and Tropical Medicine, and the Tanzanian Ministry of Health, including its National Malaria Control Programme, the Tanzania Essential Health Interventions Project, the Adult Morbidity and Mortality Project, and the Council Health Management Teams of Rufiji, Morogoro, Kilombero, and Ulanga Districts. IMPACT-Tz is primarily supported by funding from the United States Agency for International Development.

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