In this study from rural Tanzania, we found that children had a higher probability of presenting at the district hospital with severe disease if they had utilized PHC facilities for the same illness, had obtained the first treatment other than paracetamol from local sources and drug shops, and if they had received SP as the only treatment for malaria. Presenting with severe disease was also associated with caretakers’ low level of education and poor nutritional status of children.
An increased risk of severe disease among children of caretakers who reported having utilized their nearer PHC facilities for the same illness might have resulted from selection bias. Caretakers of children who improved after having utilized PHC facilities obviously needed not to come to the district hospital. In addition to that, caretakers of children with severe disease who do not recover after utilizing PHC facilities might be more often referred to and seen at the district hospitals than those with severe disease who do not seek care at PHC facilities. However it is worth noting that, the majority of caretakers who reported having utilized their nearer PHC facilities had obtained the first treatment other than paracetanol much later (on the third day or later) as compared to those who did not utilize them. Delays in treatment initiation among PHC users could be explained by the reported frequent shortages of drugs at these facilities [13
], also reported in the study area [14
]. Unavailability of drugs at PHC facilities may result in delays of several days, from the time drugs are prescribed until when caretakers are able to purchase them from the drug shops. This finding needs further investigation.
The preference for drugs from local shops as the first option of care shown in this study is not a new finding [15
]. The positive association between obtaining the first treatment other than paracetamol from these shops and severe disease in children is worth noting. Drug shops in Tanzania are very poorly regulated and some of them sell unregistered and sometimes expired drugs [18
]. On the other hand, the reported use of drugs kept at home from previous consultations needs further investigation as this practice could be associated with treatment failures resulting from the use of expired drugs. Oral suspensions of some of the commonly prescribed syrups like amoxicillin and cotrimoxazole should be used only for a maximum of 7
days and then discarded. Caretakers might be using these syrups for extended periods of time.
A quarter of our study participants had experienced at least one child death in the past. This depressing finding calls for urgent measures to improve the situation. The high number of deaths among children may be linked to some of the reported unexpected practices at PHC facilities in the study area [19
], including the ongoing provision of SP for malaria treatment in children. Malaria is still the number one killer of children below five years in Africa [20
], as well as in Tanzania [21
]. Resistance of malaria parasites to SP was commonly reported in many parts of Africa as well as Tanzania between 1999–2000 [22
]. In a study conducted in 2000 in Muheza district (one of our study districts), it was found that 45% of the patients treated with SP failed to clear their parasitemias to below patency levels on day 7 [23
]. In 2004, the World Health Organization (WHO) recommended that all countries revise their malaria treatment policies and opt for a combination treatment, preferably an artemisinin-based combination therapy (ACT) [24
]. Hence, Tanzania changed its first-line treatment for malaria from sulphadoxine-pyrimethamine (SP) to artemether-lumefantrine (ALu®) in 2005 [25
]. With funding from the Global Fund, Tanzania began, in December 2006, providing ACTs through public and mission health facilities free of charge to all children under five years and at a subsidized price for the rest of the population [26
]. Surprisingly, five out of nineteen children who received SP as the only treatment for malaria reported having received it from public hospitals.
At the time of this study (2009/2010), subsidized ALu® was not yet available outside public facilities in the study area [27
]. Hence we predict that SP use for malaria treatment at the community level could be even higher than we have reported in this hospital – based study, and even much higher among caretakers who do not utilize public health facilities (not represented in this study). Further research is needed to ascertain the extent to which this drug is still in use for malaria treatment in children, as this drug was highly associated with severe malaria and death in our sample of children.
Availability of ACT products in the private sector has generally been limited to registered pharmacies in urban areas where the price of a course of therapy is around 8–10 U.S. dollars [28
]. The new treatment is well beyond the reach of individuals living in rural and peri-urban communities who need them the most. This has left millions of Tanzanians in rural areas, including the study area, to rely on public sector facilities for access to the recommended first-line treatment for malaria. If they seek treatment from other sources they may end up receiving suboptimal therapies, such as SP, which is more affordable and widely available. However, a few caretakers in our study had reported to occasionally having bought the specially packed subsidized ALu® for public facilities in their nearby local drug shops when these drugs were out of stock at their nearby PHC facilities. This finding raises an alarm.
There have been efforts to make subsidized ACTs available through Accredited Drug Dispensing Outlets (ADDOs) after realizing an important role played by this sector in provision of malaria treatment [28
]. In 2007, using funding from the President's Malaria Initiative (PMI) and technical support from Rational Pharmaceutical Management Plus (RPM Plus) Program, Tanzania Food and Drugs Authority (TFDA) and National Malaria Control Programme (NMCP) began a pilot program to make subsidized ACTs available through ADDOs in 10 districts of Morogoro and Ruvuma regions [28
]. The program resulted in a gradual increase in the number of malaria patients treated with ACTs, from 3% of all antimalarials sold in July 2007 to 26% in June 2008. At the same time, the use of non-ACT antimalarials like SP declined. Currently, the government of Tanzania is trying to expand the provision of the subsidized ALu® through ADDOs countrywide.
In line with our findings, several previous studies had established severe disease to be more common among younger children and children of caretakers with lower level of education and SES [3
]. In one hospital-based study conducted in southern Kerala, India, they found that severe pneumonia was less frequent in children over 2
]. Likewise in our study severe disease was found to be more common in children less than two years as compared to those aged two years and above. In the Indian study above [30
], paternal and maternal education of up to middle school and above was found to be protective against development of severe pneumonia. Similarly, our study showed an inverse association between severe disease and caretakers’ level of education. One community-based study in rural southern Tanzania found that it was more likely for caretakers with higher SES to seek care from an appropriate provider as compared to those with lower SES [8
]. In the same study, the frequency of antibiotic use for probable pneumonia among children with the lowest SES was less than half of those with the highest SES, and children in the lowest SES group were half as likely to have been given antimalarials as those in the highest SES category.
The observed positive association between severe disease and more number of children may be due to confounding; explained by the fact that caretakers with low education and SES also tend to have more children. However, the association persisted even after controlling for education and SES. This finding needs more investigation as it could provide another target group for the fight towards child mortality from treatable illnesses.
Methodological strengths and limitations
The present study has reported factors associated with severe disease from the three main childhood killers (malaria, pneumonia and diarrhea), thus providing more areas for further intervention towards child mortality from treatable illnesses. This study inquired care-seeking information related to the current child illness. By using this approach, we believe we minimized recall bias as we were able to pick up easily forgettable care-seeking information which community based studies may miss, often relying on past illness episodes of preceding weeks.
Our study was hospital-based and was conducted at district referral hospitals because this was the most convenient way to study factors associated with severe disease. To avoid the selection bias, the study should ideally have been community-based, including all children with the three diseases in the area. However, it would be very difficult to identify and include a high enough number of severely ill children at the community level. Hence, we acknowledge that we missed mild and severe cases that used other options of care and did not come to the district hospitals. However, biased associations would only arise if an interaction is present between severity of disease and potential predictors in relation to the frequency of seeking hospital care. As discussed above, this might be the case when attending PHC facilities is studied as a risk factor, but seems less likely to influence the findings of the other predictors. Furthermore, our findings are similar to findings from previously community-based studies on risk factors for early childhood deaths [8
Thirty seven children had more than one diagnoses; one child had all three diagnoses. We do not think this influenced our findings significantly as the number of children with more than one severe disease was very small. The fact that we did not include caretakers of fifteen children who died before the interviews could be conducted could have biased our findings towards milder disease. However since the number is too small we think the bias should be minimal.