Self-diagnosis and self-treatment of malaria in hard-to-reach and mobile populations of the Amazon: results of Malakit, an international multicentric intervention research project.

Abstract Background Illegal gold miners are currently key hosts for malaria in French Guiana (FG), with a risk of emergence of resistance linked to improper use of artemisinin-based combination therapy (ACT). The remoteness of the mines and regulatory issues hinder their access to health care. Methods A quasi-experimental researched project (Malakit) implemented in FG borders with Brazil and Suriname aimed at determining the effectiveness of distributed kits for self-diagnosis and self-treatment to illegal gold miners, after training, at strategic border staging areas. Evaluation relied on questionnaires at inclusion and follow-up visits, and pre/post intervention surveys. The primary outcome was the proportion of persons reporting a use of certified ACT after a positive malaria diagnosis. The secondary outcomes assessed antimalarial adherence, kit use and impact on malaria epidemiology. Findings The proportion of patients reporting a use of certified ACT after a positive diagnosis increased after the intervention (OR 1.8, 95%CI [1.1-3.0]). From April 2018 to March 2020, 3,733 persons participated in the intervention. The kit was used correctly by 71.7% [65.8-77.7] of the 223 persons reporting having used a malakit during the follow-up visits. No serious adverse events related to the misuse of malakit have been reported. The intervention appears to have accelerated the decline in malaria incidence in the region by 42.9%. Interpretation This innovative international project showed that people with low education can correctly self-manage their malaria symptoms. This strategy could be integrated in the malaria control programs of the countries involved and considered in other regions with residual malaria in remote areas. Funding This project was funded by the European Union, the Global Fund, Brazil MoH, Cayenne Hospital and FG Health Regional Agency. Editor's note This translation in French was submitted by the authors and we reproduce it as supplied. It has not been peer reviewed. Our editorial processes have only been applied to the original abstract in English, which should serve as reference for this manuscript. The Lancet Group takes a neutral position with respect to territorial claims in published maps and institutional affiliations. Contexte Les chercheurs d'or illegaux sont actuellement un reservoir cle du paludisme en Guyane, avec un risque d'emergence de resistance lie a une mauvaise utilisation des combinaisons therapeutiques a base d'artemisinine (ACT). L'isolement de ces sites miniers clandestins et des contraintes reglementaires entravent leur acces aux soins. Methodes Un projet de recherche operationnelle quasi-experimental (Malakit) a ete mis en œuvre aux frontieres de la Guyane avec le Bresil et le Suriname. Il visait a determiner l'efficacite de la distribution de kits d'autodiagnostic et d'autotraitement a des orpailleurs illegaux, apres une formation adaptee, dans des zones strategiques transfrontalieres. L'evaluation s'est appuyee sur des questionnaires lors des visites d'inclusion et de suivi, et sur des enquetes pre/post intervention. L'indicateur principal etait la proportion de personnes declarant avoir utilise une ACT certifiee apres un diagnostic positif de paludisme. Les indicateurs secondaires reposaient sur l'adherence aux traitements antipaludiques, l'utilisation des kits et l'impact sur l'epidemiologie du paludisme. Resultats La proportion de patients declarant une utilisation d'ACT certifiee apres un diagnostic positif a augmente apres l'intervention (OR 1,8, 95%CI [1,1-3,0]). D'avril 2018 a mars 2020, 3 733 personnes ont participe a l'intervention. Le kit a ete utilise correctement par 71,7% [65,8-77,7] des 223 personnes revues en visites de suivi ayant declare avoir utilise un malakit. Aucun evenement indesirable grave lie a une mauvaise utilisation du malakit n'a ete signale. L'intervention semble avoir accelere la diminution de l'incidence du paludisme dans la region de 42,9%. Interpretation Ce projet international innovant a montre que les personnes ayant un faible niveau d'education peuvent se prendre en charge par eux-memes pour des symptomes de paludisme. Cette strategie pourrait etre integree dans les programmes de lutte contre le paludisme des pays impliques et envisagee dans d'autres regions ou du paludisme residuel persiste dans des zones isolees. Financement Ce projet a ete finance par l'Union Europeenne, le Fonds Mondial, le Ministere de la sante du Bresil, le Centre Hospitalier de Cayenne et l'Agence Regionale de Sante de Guyane.