Home management of malaria is a widely implemented and long-running strategy delivered in malaria-endemic regions across sub-Saharan Africa, where antimalarial drugs are distributed by trained community health workers or community drug distributors, complemented with more recent integration of rapid diagnostic testing through the evolution of community-based programme and point-of-care technologies to minimise overtreatment or antimalarial drug resistance [13, 44]. Nevertheless, the impact of home management intervention on malaria disease burden and patient outcomes remains less understood [8]. Our systematic review and meta-analysis provides the most comprehensive evidence synthesis of the scientific literature on home-based management of malaria for children and adults in communities. It included 47 studies from 17 countries in sub-Saharan Africa, comprising over 230 thousand participants in studies conducted between 1981 and 2020. Considering all health-related outcomes at different time periods that the underlying studies have assessed, our main findings showed that home management of malaria significantly reduced malaria mortality, all-cause mortality, and risks of severe anaemia among patients presenting with symptoms of uncomplicated malaria. The strategy was also associated with better access to treatments for febrile illnesses, effective antimalarial treatments, and good adherence to medications. However, the clinical effect of deploying home-based intervention for preventive malaria treatment remained uncertain.
Our review found that the number of studies performed in rural populations far exceeds the number of studies in urban populations. Therefore, the collated evidence might not be directly and appropriately translatable to urban communities, including slum households in light of different intensity of malaria transmission [45], geographic proximity and access to health facilities [46], barriers of affordability and symptom recognition, availability of subsidised artemisinin combinations, and communication strategies for urban context [7]. Notably, over 70% of malaria cases in rural areas and 50% of malaria cases in urban areas of Africa are self-treated and formal medical care from health providers is only sought when initial treatment fails [12]. Such health care seeking behaviour underlines the importance of extending the siloed approach of home management intervention beyond rural settings so as to address the plight of populations at risk of malaria living all types of environment. The scarcity of research in urban and peri-urban settings included in this review mirrors a lack of robust, reliable data to prove the health benefits of home malaria management strategy in urban neighbourhoods [19–25]. Notwithstanding, the findings generally support the feasibility of providing home management of malaria intervention at the level of households in urban environment.
Several studies (21.3%) utilised rapid diagnostic techniques for the detection of malaria parasites. Timely and accurate techniques for diagnosis are central to effective disease management [47]. Our study showed that rapid diagnostic tests used in the home management intervention had high sensitivity (82.9%), but moderate specificity (69.2%). False positives can arise, thus contributing to inappropriate prescribing or overtreatment with antimalarial agents, with possible undertreatment of alternative causes of febrile illness [48]. Conventional rapid diagnostic tests are unable to detect low density infections under 200 parasites/µL, particularly in non-falciparum infections and Plasmodium falciparum parasites with histidine-rich protein 2 (pfhrp2) and pfhrp3 gene deletions that have been reported to exist in Africa, Asia, and South America [49, 50]. As rapid, point-of-care diagnosis technologies has become a fundamental tool to support home-based malaria management, there is a clear need for reliable, easy-to-use, inexpensive tests that can be conducted at home settings, for instance, CRISPR (clustered regularly interspaced short palindromic repeat)-based malaria diagnostic assay [49] and haemozoin-based malaria diagnostic device [51] to provide robust clinical sensitivity and specificity that help inform decision-making in real time.
Home malaria management tackles barriers to accessing health care services and optimal health for deprived places and socioeconomically disadvantaged, underserved communities. We anticipate that the clinical burden attributable to malaria infections would be alleviated if the intervention is implemented with adequate intensity and over a sufficiently long period or in routine home visits and continuous monitoring of patients infected with malaria via phone calls or physical visits by care providers. The intensity of home management intervention will depend on the number of households in the target population being reached, the frequency of household visitations, diagnostic algorithms being performed, education on malaria preventative measures for patients and their relatives, as well as cascades for seeking medical care at primary health facilities and emergency services. In addition, only five studies in the review evaluated costs of delivering home management intervention [20, 23, 27–29]. Therefore, we do not have much information on the costs or opportunity costs of home malaria management as compared to other community-based interventions that could be undertaken to mitigate burden of morbidity and mortality of the infection. The cost-effectiveness of home malaria management is likely to be influenced by factors, such as transmission intensity, environmental changes, and alternative access to quality health care [23, 52]. Exploration and understanding of implementation processes and context along with economic evaluation will provide imperative information to understand what worked, what didn’t work, and why, as well as inform potential for scale-up and public health policy for malaria control and elimination.
It is noteworthy that the current pooled analysis for the outcomes of malaria mortality and all-cause mortality employed data of studies in rural areas that used chloroquine, which may be now essentially obsolete. Home malaria management had no effect on child mortality rates, likely to be due to waning of maternally transferred antibodies and lack of innate immune responses to malaria infections [53, 54]. None of the studies in our review ascertained the use of triple artemisinin-based combination therapies, such as dihydroartemisinin-piperaquine-mefloquine or artemether-lumefantrine-amodiaquine for home treatment of malaria. With the increasing treatment failures of conventional artemisinin-based combination therapy, recent studies have revealed that triple artemisinin-based combination therapies are efficacious, well tolerated, and safe for the treatment of uncomplicated falciparum malaria in regions with multidrug-resistant parasites, such as Southeast Asia and South Asia, while prolonging the useful therapeutic lifetime of existing antimalarial drugs that contain lumefantrine [55, 56]. Given that artemisinin-based combination therapies are more complex regimens that would likely compromise treatment adherence and fixed-dose combination has yet been developed, home management of malaria is a key way to improve patients' adherence to medication regimens.
Our results provide insights on the clinical effects of home malaria management in settings with scarce health care resources. The main limitations of our research largely pertain to the constraints inherent in the individual studies and data summarised in the meta-analysis. We included only manuscripts published in English. Although we reviewed manuscripts drawn from six online scientific databases, we did not systematically search unpublished data or grey literature. To avoid compositional bias stemming from differences in study-level sociodemographic characteristics in our analysis regardless of geographical region, age, and year. However, due to a paucity of studies published in peer-reviewed journals, we could not identify any relevant research in malaria endemic countries outside of sub-Saharan Africa, thus precluding us to estimate the health outcomes differentially by race, ethnicity, and geographical location. Moreover, we detected considerable heterogeneity of effect estimates between studies, including febrile episodes treated with antimalarial drugs, effective treatment, parasitaemia, and other clinical outcomes. This could be due several possible explanations, such as study designs, intensity of home management intervention assessed, follow-up durations, lack of standardised data collection tools, and variation between communities and countries in population values and preferences concerning acceptability of home-based approach to managing malaria. Furthermore, a number of randomised controlled trials were performed from 1980s until mid-2000s. Owing to unavailability of reporting guidelines at the time, these studies may lack details of trial conduct and reporting. For that reason, additional randomised controlled trials evaluating the effects of home malaria intervention, in particular with the use of better logistical support, diagnostic tests, and combination therapies spanning a range of geographical regions are warranted to consolidate the evidence basis for shaping policy solutions to sustainably combat the continuing challenges of malaria elimination [57, 58]. As for urban settings, digital health interventions may yield some encouraging results [59]. Albeit the current evidence suggests that the role of home-based preventive antimalarial treatment is ineffective, the integration of innovative vector control strategies, such as household-level educational programme, insecticide-treated, nets, covers, or blankets to complement antimalarial chemoprophylaxis, and interventions to address human and local vector population behaviours, as well as house designs for improving health [60].