Elsie Nakirya, 66, heard her granddaughter Paula Nakafu, 6, moan uncharacteristically in her sleep. A quick check with her palm on the child's forehead "confirmed" a high temperature.
"I sponged her off until morning, then went to a drug store and bought chloroquine syrup and a tablet of Fansidar [sulphadoxine-pyremethamine (SP)]," said Nakirya, a resident of Makerere West, a suburb of Kampala.
Two days later, in spite of treating her with chloroquine and SP, Paula did not recover. Instead she developed a rash and that was when the grandmother who lives with three of her grandchildren, visited the doctor who confirmed Paula had measles.
It's hard enough for a doctor to diagnose malaria without a laboratory, but for families with limited access to health care it's even more difficult because the early symptoms are similar to those of other diseases.
While measles is relatively rare in Uganda and most cases of fever in children aged under-five can be attributed to malaria rather than other diseases, Paula's example underlines the problem of getting an accurate diagnosis. Delays in getting appropriate treatment for malaria in sub-Saharan Africa and inadequate access to that treatment can be fatal.
Paula's grandmother not only misdiagnosed her, but also treated her for the wrong disease. Yet for people with limited access to health workers and health-care facilities, this hit-and-miss approach remains the only option in Uganda and elsewhere in Africa.
One study showed that in places, such as these, where health care is not always available, home-based treatment of fever with antimalarial drugs still has the potential to dramatically reduce the number of child deaths from malaria.
In 2000, Gebreyesus Kidane and Richard Morrow reported in the Lancet a 40% reduction in under-five child mortality after mothers in Ethiopia were given simple training in recognizing fever and supplies of chloroquine for treatment at home.
Catching the malaria early with prompt treatment can stop it from progressing to a more severe and often fatal form.
In 2002, the Ugandan government formalized the already common practice of treating fevers without visiting the doctor by introducing the home-based management of fever strategy. That strategy involved teaching mothers to recognize malaria symptoms at an early stage in their children. Sick children were then taken to see a community volunteer, known as a community medicine distributor.
These volunteers were trained to distinguish between the fever of uncomplicated malaria and the signs and symptoms associated with the more severe forms of the disease, as defined by using the Integrated Management of Childhood Illness approach. If the volunteers suspected severe malaria, the child was sent to the nearest health centre with trained health personnel, otherwise, the child was given a prepackaged combination of chloroquine and SP, known as HOMAPAK.
Dr Monica Olewe from WHO's Uganda Country Office said that this chloroquine and SP combination was specially developed for home-based care, one of a number of approaches in Uganda for reducing malaria deaths.
But in 2004, in the face of widespread resistance to chloroquine and SP in Uganda, government drug policy changed. "Home-based treatment of malaria using chloroquine and SP didn't have a big effect. One major factor was that the malaria parasites were already resistant to the drugs," said Professor Umberto D'Alessandro from the Prince Leopold Institute of Tropical Medicine in Antwerp, Belgium.
Because these drugs no longer cure malaria reliably, artemisinin combination therapy (ACT) drugs, such as Coartem (artemether lumefantrine), are now recommended by WHO. …