The five continuum of care criteria that should accompany rectal artesunate interventions: lessons learned from a two-arm cohort intervention study in Malawi
Authors: Oliff Monique , Muniina Pamela , Babigumira Kenneth , Phuka John , Rietveld Hans , Sande John , Nsona Humphreys , Majeres Maud L 
Published: September 2022

Introduction
Rectal artesunate (RAS) or artesunate rectal capsule (ARC) has been identified by the World Health Organization as the intervention that, when coupled with a functional referral system and correct post referral care, can save the lives of children 5 years and younger suffering from severe malaria and living in hard-to-reach areas. Access to RAS/ARC and a reliable referral system that ensures continuity of care until complete recovery remains a challenge in low resource countries, raising concerns around the development of antimalaria drug resistance and the value of this intervention.
Aim
The objective of this study was to inform rectal artesunate programming, using practical tools to enhance the continuum of care in order to reduce delays when severe malaria danger signs are encountered at the homestead, community and village health clinic levels.
Methods
A single country two-arm-controlled study was conducted in remote areas of Salima and Ntchisi districts in Malawi, representing hard-to-reach areas where pre-referral interventions are provided by community health workers/health surveillance assistants. The control and intervention populations consisted of 9 and 14 village health clinic (VHC) zones in the control and intervention arms respectively, including all households with children 5 years and younger and the community health worker responsible for their care. The community health workers in the intervention arm were trained using a tailor-made field-tested toolkit and the community had access to pictorial information, education and communication (IEC) on danger signs and actions to take, mounted in areas with high levels of foot traffic, throughout the zone. The community in the control arm had access to standard of care practices and no additional behaviour change information. Both study arms had access to a dedicated referral booklet for danger signs, as a standard of care.
Results
The study identified five continuum of care criteria (5CC Framework) to reinforce rectal artesunate programming: care transitions for the patient; consistency of supplies (commodity and referral slips) to village health clinics; comprehensiveness of carereceived by the patient at the VHC and at referral health centres; connectivity of care between all tiers; and communication between providers from different points of care. It emerged that care transition is dependent on a strong cue to action and proximity to an operational village health clinic with a resident community health worker. Consistency of supplies of the RAS commodity assured the population of the functionality of the VHC for severe danger signs. Comprehensive care ensured correct assessment and dosing. Sensitization and access to reference tools facilitated more comprehensive care. Connectivity of care using the referral slips was feasible and perceived positively by caregivers. Compliance was high throughout but was optimized when administered by a sensitized health surveillance assistant. Over 93% experienced a rapid improvement in the status of their child post RAS but still complied with referral instructions. During household follow-up, 76% of caregivers reported that upon arrival at the referral facility their child was not admitted and was managed as an outpatient, and 70% reported not receiving any form of parenteral care – either an injection or drip.
Conclusion
Effective utilization of RAS/ARC requires comprehensive approach. The impact of this lifesaving intervention for the dangerously ill child living in a hard-to-reach community can be easily lost, unless it is administered as part of a system-based approach. Taken together, the 5CC Continuum of CareFramework, identified in this study, provides a structure for future RAS/ARC practice guidelines.