Program Evaluation of Community Case Management with Reactive Test and Treat for Malaria in a High-Transmission Setting

Community case management (CCM) combined with reactive test-and-treat (RTAT) for malaria was implemented by the National Malaria Elimination Program in a holoendemic region of Zambia. We assessed the impact of CCM + RTAT activities on malaria care seeking, health facility cases, and hospital mortality. We analyzed data from community surveys, a health facility-based passive surveillance network, and a hospital-based severe malaria surveillance system to compare metrics across the program eras (July 2016-July 2018, August 2018-October 2019, and November 2019-July 2021). Geospatial mapping was used to visualize trends in referrals and mortality. Clinical profiles of 696 hospitalized children with malaria were compared and in-hospital mortality were analyzed across periods using multiple logistic regression. There were more frequent health contacts for malaria reported by community members and a corresponding decrease in health facility malaria cases during CCM + RTAT. Pediatric patients admitted to the hospital with malaria during CCM + RTAT had less severe disease and shorter lengths of stay and in-hospital mortality was lower (odds ratio: 0.24, 95% CI: 0.07-0.84, P = 0.025). Geospatial mapping of the home villages of children hospitalized with malaria showed a wider catchment during CCM + RTAT than before or after. In this high malaria transmission setting, CCM + RTAT increased access to care, shifted malaria case burden from health facilities to community health workers, and improved in-hospital outcomes for malaria, likely from earlier referral. However, RTAT + CCM in this high-transmission area proved unsustainable because of excessive consumption of malaria commodities.