Ethical Issues and Treatment Policies

1. Ethical Issues and Treatment Policies

2. [This document is part of the « Malaria Indicator Survey » toolkit, developed by the RBM-MERG, with contributions from the following partners: Center for Disease Control-CDC, Swiss Tropical Institute, Johns Hopkins University, The World Bank, The Global Fund against AIDS, Tuberculosis and Malaria, Liverpool School of Tropical Medicine, MACRO International, Malaria Consortium, Malaria Control and Evaluation Partnership in Africa (MACEPA) – PATH, Malaria in Pregnancy Consortium Secretariat, MEASURE Evaluation, WHO,WHO-AFRO, RBM-PS, Tulane University, UNICEF and USAID/PMI. This toolkit also largely benefited from national programmes from countries having conducted MISs.]

3. Ethical Issues Overview • Principles • Consent • Who cannot give consent? • Children • Waiver of consent • Informed consent • Information • Comprehension • Benefits • Risks • Confidentiality • Providing useful information on malaria

4. Ethical Principles • Respect for Persons • Autonomy to make decisions • Protection of vulnerable persons • Beneficience • Do not harm • Maximise benefit and limit harms • Justice • Fair selection of subjects

5. Principle of Respect for Persons:Consent • Who cannot give consent? • Unconscious • Mentally incapable of understanding • Children under age 18 • Children: • Age 6 to 18 can give assent. If child refuses assent, parent cannot force participation • Under 6 years: parent gives consent for child

6. Principles of Respect for Persons and JusticeInformed consent • Participant must know: • The purpose of the study • How they were selected to participate • How many other people are involved • What is expected of them (procedures, time) • Who to contact if they have questions • Written or verbal consent?

7. Principle of Beneficience:Benefits • If a person is positive for malaria or anaemia, they get immediate treatment • Survey will give information on: • Malaria and anaemia distribution • Malaria intensity • Coverage of control measures e.g. spraying and net use • Use of health services for malaria treatment • The aim is to improve the malaria control program, clinical services and health knowledge • In general, benefits to individuals are quite low in this study

8. Principle of BeneficienceRisks (possible harms) • Discomfort and infection from the fingerprick • Emotional upset from talking about illness and death of children • Side effects of treatment drugs • In general, risks are also low in this study

9. Principles of Respect for Persons and Beneficience:Confidentiality • Try to conduct interview in private • Never discuss someone’s answers with another person • Potential for harm if information released • Data will be stored without names

10. Principle of Beneficience:Providing useful information on malaria prevention • People may ask during survey about • what causes malaria, malaria symptoms, getting treatment, how to prevent malaria, how to use net etc. • You must answer the questions • However, if asked during interview, say: • “Those are good questions. I will answer them to the best of my ability at the end of the interview.” • Then remember to spend a few minutes responding • Answer briefly and refer to further sources such as community health workers

11. Treatment Overview • Who will be treated? • Decision rules • Treatment schedules • What about other sick people?

12. Who will be treated? • People will be treated based only on the results of diagnostic tests performed, not on any other clinical assessment • Who will be treated? • Children with severe anaemia (<8 g/dl haemoglobin) • Anyone with positive RDT for malaria

13. Decision rules • Things to consider • Is haemoglobin <8 g? • Is the RDT positive and for which species? • Is the woman pregnant? • What is the person’s age? • Is child 2 years or older?

14. Anemia • Is Hb <8g in child under 6 years? • If yes, treat with • 1) CoArtem • 2) Iron • 3) Albendazole (if 2 years or older) • If no, do not give iron and albendazole.CoArtem depends on RDT results • Also refer to health facility based on clinical judgment

15. Anaemia treatment • Albendazole or Mebendazole: For children age 2 years and over: Tablet or syrup • Iron tablets or syrup:

16. Malaria • Is RDT positive? • If positive for Pf plus PAN: • Check if person is pregnant woman. • If not pregnant woman: treat with CoArtem • If pregnant: treat with Quinine • If positive for PAN only: • Treat with chloroquine. • If negative: • Do not treat for malaria unless Hb<8g in child under 6 • Also refer or take to health facility based on clinical judgment

17. Treatment Diagram All children <6 yr & all people in every 4th household ONLY children <6 yr RDT (+) (+) (-) Hemocue Pf & PAN Hg≥8g/dL PAN Hg<8g/dL Pregnant No Treatment No Treatment No Yes Coartem Iron Chloroquine If Age ≥2 yrs + Albendazole Quinine

18. Malaria Treatment • CoArtem: • (For RDT Pan/Pf positive or for children<6 with Hb<8g) • Tablets with 20 mg Artemether plus 120 mg Lumefantrine

20. 2. Chloroquine (for RDT Pan only positive) Tablets of 150 mg base or syrup 50 mg base per 5 ml.

21. 3. Quinine (For pregnant women and infants) Quinine 8 mg base/kg 3 times daily for 7 days

22. What about other sick people? • You will be approached by others in the village. • Do not use RDT for non-participants in other households • Explain that you are there mainly for the survey and your supplies have been calculated accordingly • Give presumptive treatment according to clinical judgment • Refer or transport to health facility if necessary