Effectiveness of artemether-lumefantrine provided by community health workers in under-five children with uncomplicated malaria in rural Tanzania : an open label prospective study

Background: Home-management of malaria (HMM) strategy improves early access of anti-malarial medicines to high-risk groups in remote areas of sub-Saharan Africa. However, limited data are available on the effectiveness of using artemisinin-based combination therapy (ACT) within the HMM strategy. The aim of this study was to assess the effectiveness of artemether-lumefantrine (AL), presently the most favoured ACT in Africa, in under-five children with uncomplicated Plasmodium falciparum malaria in Tanzania, when provided by community health workers (CHWs) and administered unsupervised by parents or guardians at home. Methods: An open label, single arm prospective study was conducted in two rural villages with high malaria transmission in Kibaha District, Tanzania. Children presenting to CHWs with uncomplicated fever and a positive rapid malaria diagnostic test (RDT) were provisionally enrolled and provided AL for unsupervised treatment at home. Patients with microscopy confirmed P. falciparum parasitaemia were definitely enrolled and reviewed weekly by the CHWs during 42 days. Primary outcome measure was PCR corrected parasitological cure rate by day 42, as estimated by Kaplan-Meier survival analysis. This trial is registered with ClinicalTrials.gov, number NCT00454961. Results: A total of 244 febrile children were enrolled between March-August 2007. Two patients were lost to follow up on day 14, and one patient withdrew consent on day 21. Some 141/241 (58.5%) patients had recurrent infection during follow-up, of whom 14 had recrudescence. The PCR corrected cure rate by day 42 was 93.0% (95% CI 88.3%-95.9%). The median lumefantrine concentration was statistically significantly lower in patients with recrudescence (97 ng/mL [IQR 0-234]; n = 10) compared with reinfections (205 ng/mL [114-390]; n = 92), or no parasite reappearance (217 [121-374] ng/mL; n = 70; p <= 0.046). Conclusions: Provision of AL by CHWs for unsupervised malaria treatment at home was highly effective, which provides evidence base for scaling-up implementation of HMM with AL in Tanzania.

Young adults’ perceptions of and affective bonds to a rural tourism community

Many rural areas, in Sweden and worldwide, experience population decline where the young leave for education and work in urban areas. Employment has declined in several rural industries, such as agriculture, forestry, and fishing, while growing in other industries are often located in urban areas. Politicians and organizations have put much hope in tourism as a tool of rural development, but can tourism help reverse the rural out-migration trend among young adults? This paper explores how tourism affects young inhabitants’ perceptions of and affective bonds to a rural area in Sweden, the ski resort of Sälen. Students from the 1993–1995 elementary school graduating classes were interviewed about their migration history, childhood, and view of and ties to Sälen. The respondents experience that tourism contributes to a more vital community incorporating influences from elsewhere, but without eliminating the positive aspects of rural life. The regular flow of people – tourists, seasonal workers, and entrepreneurs – passing through Sälen presents opportunities to extend one’s social network that are widely appreciated by respondents. The high in and out mobility constitutes a key part of Sälen’s character. Contributions from tourism – such as employment, entertainment, leisure, and opportunities to forge new social relationships – are available during the adult transition, the life phase when rural areas are often perceived as least attractive. Even though out-migration occurs in Sälen, and some respondents still find Sälen too small, tourism has clearly increased the available opportunities and contributed significantly to making Sälen more attractive to young adults.