Research Article: High Adherence to Antimalarials and Antibiotics under Integrated Community Case Management of Illness in Children Less than Five Years in Eastern Uganda

Date Published: March 29, 2013

Publisher: Public Library of Science

Author(s): Joan N. Kalyango, Elizeus Rutebemberwa, Charles Karamagi, Edison Mworozi, Sarah Ssali, Tobias Alfven, Stefan Peterson, Abdisalan Mohamed Noor.


Development of resistance to first line antimalarials led to recommendation of artemisinin based combination therapies (ACTs). High adherence to ACTs provided by community health workers (CHWs) gave reassurance that community based interventions did not increase the risk of drug resistance. Integrated community case management of illnesses (ICCM) is now recommended through which children will access both antibiotics and antimalarials from CHWs. Increased number of medicines has been shown to lower adherence.

To compare adherence to antimalarials alone versus antimalarials combined with antibiotics under ICCM in children less than five years.

A cohort study was nested within a cluster randomized trial that had CHWs treating children less than five years with antimalarials and antibiotics (intervention areas) and CHWs treating children with antimalarials only (control areas). Children were consecutively sampled from the CHWs’ registers in the control areas (667 children); and intervention areas (323 taking antimalarials only and 266 taking antimalarials plus antibiotics). The sampled children were visited at home on day one and four of treatment seeking. Adherence was assessed using self reports and pill counts.

Adherence in the intervention arm to antimalarials alone and antimalarials plus antibiotics arm was similar (mean 99% in both groups) but higher than adherence in the control arm (antimalarials only) (mean 96%). Forgetfulness (38%) was the most cited reason for non-adherence. At adjusted analysis: absence of fever (OR = 3.3, 95%CI = 1.6–6.9), seeking care after two or more days (OR = 2.2, 95%CI = 1.3–3.7), not understanding instructions given (OR = 24.5, 95%CI = 2.7–224.5), vomiting (OR = 2.6, 95%CI = 1.2–5.5), and caregivers’ perception that the child’s illness was not severe (OR = 2.0, 95%CI = 1.1–3.8) were associated with non-adherence.

Addition of antibiotics to antimalarials did not lower adherence. However, caregivers should be adequately counseled to understand the dosing regimens; continue with medicines even when the child seems to improve; and re-administer doses that have been vomited.

Partial Text

Following widespread drug resistance to various mono therapies for the treatment of malaria including chloroquine, sulphadoxine-pyrimethamine (SP), or amodiaquine, the World Health Organization (WHO) recommended use of combination therapies in 2001 [1]. Uganda initially adopted a combination of chloroquine and SP as the first line drugs for uncomplicated malaria. However, resistance levels to this combination rose rapidly, necessitating further changes in malaria policy in 2005, and use of artemisinin based combination therapies (ACTs) was recommended [2]. Uganda along with some other countries adopted artemether-lumefantrine (AL) as the first line treatment for uncomplicated malaria [3].

A total of 1256 children were enrolled into the study (667 from control arm (control arm), 323 from intervention arm taking antimalarials only (intervention arm AM), and 266 from the intervention arm taking antimalarials and antibiotics (intervention arm AM+AB).

We found high adherence to both antimalarials and antibiotics given by CHWs. Adherence to the combination of antimalarials and antibiotics was not significantly different from adherence to antimalarials alone. Non-adherence was associated with: no history of fever, seeking care after two days of illness or more, not understanding the medicines administration instructions given by the CHW, vomiting for the current illness episode and caregivers perceiving the illness not to be severe.

The treatment of children by CHWs with combinations of antimalarials and antibiotics did not lower adherence compared to antimalarials alone. The children achieved high levels of adherence in both situations. However, more emphasis needs to be laid on counseling caregivers to ensure that they understand the dosing regimens. In addition, caregivers need to be advised to continue with the medicines even when the child seems to improve and to re-administer doses that have been vomited. The CHWs should advise the caregivers to collect additional drugs in cases where some doses have been vomited.