Efficacy of mobile phone short message service (SMS) on malaria treatment adherence and post-treatment review. (360G-Wellcome-100079_Z_12_Z)

Artemisinin resistant falciparum malaria has emerged in south East Asia (SEA), an ominous repetition of the spread ofchloroquine and later of sulfadoxine-pyrimethamine resistance, several decades ago. Recent evidence suggestsartemisinin resistance foci in Western Cambodia, Western Thailand, and Burma. This poses a major global public healththreat, with the greatest potential effects in sub-Saharan Africa where the disease burden is greatest and systems forresistance monitoring and containment are weakest. A public health disaster is imminent, unless mitigation and earlywarning/early detection measures are urgently set up. The mechanisms underlying artemisinin resistance are currently notfully understood. The main phenotype associated with resistance is a substantial delay in parasite clearance, so farobserved in SEA but not yet unequivocally confirmed in Africa. Poor patient adherence to treatment and drug misuse areone of the drivers of antimalarial resistance. Poor adherence decreases cure rates, because parasites are exposed to sub therapeutic drug concentrations, favouring the emergence of resistance. Recent evidence suggests that the traditionalapproaches (provider counselling and caregiver aids) for improving patient adherence in routine settings are suboptimal.Urgent research is thus needed to investigate innovative approaches to address this problem. Secondly, the most widelyused methodological approaches for adherence measurement, conducted after the completion of a full dose of artemetherlumefantrine(AL)-the most widely used artemisinin combination therapy (ACT) in rural Africa, have inherent recall bias anddo not capture the timing of dosing which is critical for AL. Better patient adherence to malaria treatment is likely to improvehealth outcomes and mitigate the emergence of falciparum drug resistance in Africa. Detecting emerging artemisininresistance in Africa is likely to require wide coverage surveillance, beyond the traditional sentinel surveillance. Bettersurveillance through routine health information systems (HIS), of the proportion of patients who remain parasite positive atday 3 and the proportion requiring rescue therapy during one month after ACT treatment could offer new opportunities totrack highly sensitive and pragmatic markers for emerging ACT resistance. However, malaria post treatment review tocapture these surrogate markers, outside the context of clinical trial, is rare in most of rural Africa and innovative ways ofpromoting this practice are urgently needed. Mobile phone communication has been suggested as a method to improve thedelivery of health services in Africa and its role has been investigated in improving health information reporting, providerperformance, drug and diagnostic stock management and patient adherence to treatment for chronic diseases such asHIV/AIDs. However, the efficacy of mobile phone text messaging in improving patients' adherence and promoting posttreatment review for acute diseases such as malaria has not been investigated. Here, we propose to investigate theefficacy of mobile phone SMS text messaging in improving malaria treatment adherence and promoting post treatmentreview, in an endeavor to provide novel approaches for the mitigation, early warning and early detection of emerging drugresistance in Africa. We will conduct a "proof of concept" multi-centre randomised controlled clinical trial to assess theefficacy of mobile phone short message service (SMS) on treatment adherence and day 3 and 28 post treatment review.Our principal research questions are twofold: First, can innovative ways such as SMS text messaging improve patientadherence to malaria treatment? Second, can SMS text messaging bring back more patients for post treatment review.Thelatter will enable the assessment of the operational feasibility of collecting, in routine settings, the clinical andparasitological cure rates at day 3 and 28.