Universal Versus Conditional Three-day Follow-up Visit for Children With Unclassified Fever at the Community Level: A Study to be Conducted in Ethiopia

Globally, mortality in children under five years (U5MR) stands at 45.6/1000 live births and it is estimated that 6.3 million children under five (U5) die each year. Despite a seemingly impressive global decline in U5MR, Sub-Saharan Africa is the only region that has registered increasing under-five mortality in several of its countries. Most deaths are caused by pneumonia (15%), diarrhea (9%), and malaria (7%); diseases with symptoms that overlap, making differential diagnosis difficult. In response, many countries in sub-Saharan Africa have scaled up integrated community case management (iCCM) targeting malaria, pneumonia and diarrhea in children U5. The programs typically train community health workers (CHWs) to assess, classify and treat uncomplicated cases of pneumonia, diarrhea and malaria and refer children with danger signs and malnutrition. While mortality impact of iCCM has been difficult to demonstrate, there is clear evidence that it can increase the treatment rate among sick children.

In Ethiopia, U5MR stands at 68/1000 live births and it is estimated that 205,000 children under the age of five die each year. iCCM implementation started in February 2011 as part of Ethiopia's Health Extension Program (HEP), and over 38,000 female CHWs - locally referred to as Health Extension Workers (HEWs) - have been trained and deployed to communities throughout the country to provide preventive and curative health services. There are typically two HEWs assigned to a sub-district with a population of approximately 5,000. The HEWs are supervised by health centers that oversee 5 health posts each (with 2 HEWs in each). As of 2014, 29,900 of the HEWs had been trained in iCCM using the WHO guidelines.

As per the WHO ICCM guidelines, children treated for an illness and those with unclassified fever and without danger signs (for whom treatment should be withheld), should be counseled to have a follow-up visit after three days to assess treatment compliance and illness resolution. This is either done through a return visit to the health post or through a home visit by the CHW through a systematic follow-up visit. However, febrile illness is common in childhood, and is often due to viruses or other self-resolving illnesses. In a large proportion of cases fever resolves rapidly, generally within 48 hours, and almost always within 96 hours. It is suggested from a number of studies that it is safe to withhold medical treatment for children with unclassified fever. In Ethiopia, HEWs follow the integrated management of neonatal and childhood illness (IMNCI) manual which stipulates that caregivers of children seen by HEWs should only return when the child fails to respond to treatment, by way of conditional follow-up to the health post, instead of the WHO recommended iCCM guideline. There is limited evidence on which of the two recommendations is safer for the child and it is unclear whether caregivers and HEWs would comply better with the systematic follow-up advice compared to the conditional follow-up advice, and whether the systematic follow-up visit is even necessary.

The purpose of this research is therefore to assess the non-inferiority of HEW-advised systematic follow-up on day 3 compared to conditional follow-up for non-severe febrile illness in children age 2 to 59 months, in which no cause of fever can be identified and where danger signs are absent.

Methodology