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Joseph JJ, Mkali HR, Reaves EJ, Mwaipape OS, Mohamed A, Lazaro SN, Aaron S, Chacky F, Mahendeka A, Rulagirwa HS, Mwenesi M, Mwakapeje E, Ally AY, Kitojo C, Serbantez N, Nyinondi S, Lalji SM, Wilillo R, Al-mafazy AW, Kabula BI, John C, Bisanzio D, Eckert E, Reithinger R, Ngondi JM. Improvements in malaria surveillance through the electronic Integrated Disease Surveillance and Response (eIDSR) system in mainland Tanzania, 2013-2021. Malar J 2022; 21:321. [PMID: 36348409 PMCID: PMC9641756 DOI: 10.1186/s12936-022-04353-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 10/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tanzania has made remarkable progress in reducing malaria burden and aims to transition from malaria control to sub-national elimination. In 2013, electronic weekly and monthly reporting platforms using the District Health Information System 2 (DHIS2) were introduced. Weekly reporting was implemented through the mobile phone-based Integrated Disease Surveillance and Response (eIDSR) platform and progressively scaled-up from 67 to 7471 (100%) public and private health facilities between 2013 and 2020. This study describes the roll-out and large-scale implementation of eIDSR and compares the consistency between weekly eIDSR and monthly DHIS2 malaria indicator data reporting, including an assessment of its usefulness for malaria outbreak detection and case-based surveillance (CBS) in low transmission areas. METHODS The indicators included in the analysis were number of patients tested for malaria, number of confirmed malaria cases, and clinical cases (treated presumptively for malaria). The analysis described the time trends of reporting, testing, test positivity, and malaria cases between 2013 and 2021. For both weekly eIDSR and monthly DHIS2 data, comparisons of annual reporting completeness, malaria cases and annualized incidence were performed for 2020 and 2021; additionally, comparisons were stratified by malaria epidemiological strata (parasite prevalence: very low < 1%, low 1 ≤ 5%, moderate 5 ≤ 30%, and high > 30%). RESULTS Weekly eIDSR reporting completeness steadily improved over time, with completeness being 90.2% in 2020 and 93.9% in 2021; conversely, monthly DHIS2 reporting completeness was 98.9% and 98.7% in 2020 and 2021, respectively. Weekly eIDSR reporting completeness and timeliness were highest in the very low epidemiological stratum. Annualized malaria incidence as reported by weekly eIDSR was 17.5% and 12.4% lower than reported by monthly DHIS2 in 2020 and 2021; for both 2020 and 2021, annualized incidence was similar across weekly and monthly data in the very low stratum. CONCLUSION The concurrence of annualized weekly eIDSR and monthly DHIS2 reporting completeness, malaria cases and incidence in very low strata suggests that eIDSR could be useful tool for early outbreak detection, and the eIDSR platform could reliably be expanded by adding more indicators and modules for CBS in the very low epidemiological stratum.
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Affiliation(s)
| | | | - Erik J. Reaves
- U.S. President’s Malaria Initiative, U.S. Center for Disease Control and Prevention, Dar es Salaam, United Republic of Tanzania
| | | | - Ally Mohamed
- grid.415734.00000 0001 2185 2147Ministry of Health, Dodoma, United Republic of Tanzania ,grid.415734.00000 0001 2185 2147National Malaria Control Programme, Dodoma, United Republic of Tanzania
| | - Samwel N. Lazaro
- grid.415734.00000 0001 2185 2147Ministry of Health, Dodoma, United Republic of Tanzania ,grid.415734.00000 0001 2185 2147National Malaria Control Programme, Dodoma, United Republic of Tanzania
| | - Sijenunu Aaron
- grid.415734.00000 0001 2185 2147Ministry of Health, Dodoma, United Republic of Tanzania ,grid.415734.00000 0001 2185 2147National Malaria Control Programme, Dodoma, United Republic of Tanzania
| | - Frank Chacky
- grid.415734.00000 0001 2185 2147Ministry of Health, Dodoma, United Republic of Tanzania ,grid.415734.00000 0001 2185 2147National Malaria Control Programme, Dodoma, United Republic of Tanzania
| | - Anna Mahendeka
- grid.415734.00000 0001 2185 2147Ministry of Health, Dodoma, United Republic of Tanzania ,grid.415734.00000 0001 2185 2147National Malaria Control Programme, Dodoma, United Republic of Tanzania
| | - Hermes S. Rulagirwa
- grid.415734.00000 0001 2185 2147Ministry of Health, Dodoma, United Republic of Tanzania
| | - Mwendwa Mwenesi
- grid.415734.00000 0001 2185 2147Ministry of Health, Dodoma, United Republic of Tanzania
| | - Elibariki Mwakapeje
- grid.415734.00000 0001 2185 2147Ministry of Health, Dodoma, United Republic of Tanzania
| | - Ally Y. Ally
- grid.415734.00000 0001 2185 2147Ministry of Health, Dodoma, United Republic of Tanzania
| | - Chonge Kitojo
- U.S. President’s Malaria Initiative, U.S. Agency for International Development, Dar es Salaam, United Republic of Tanzania
| | - Naomi Serbantez
- U.S. President’s Malaria Initiative, U.S. Agency for International Development, Dar es Salaam, United Republic of Tanzania
| | - Ssanyu Nyinondi
- RTI International, Dar es Salaam, United Republic of Tanzania
| | | | | | | | | | - Claud John
- U.S. President’s Malaria Initiative, U.S. Center for Disease Control and Prevention, Dar es Salaam, United Republic of Tanzania
| | - Donal Bisanzio
- grid.62562.350000000100301493RTI International, Washington, DC USA
| | - Erin Eckert
- grid.62562.350000000100301493RTI International, Washington, DC USA
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Bohle LF, Abdallah AK, Galli F, Canavan R, Molesworth K. Knowledge, attitudes and practices towards malaria diagnostics among healthcare providers and healthcare-seekers in Kondoa district, Tanzania: a multi-methodological situation analysis. Malar J 2022; 21:224. [PMID: 35864543 PMCID: PMC9306200 DOI: 10.1186/s12936-022-04244-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 07/08/2022] [Indexed: 12/04/2022] Open
Abstract
Background Despite the large-scale rollout of malaria rapid diagnostic tests (RDTs) in Tanzania, many healthcare providers (HCPs) continue using blood film microscopy (BFM) and clinical examination to diagnose malaria, which can increase the risk of mal-diagnosis and over-prescribing of anti-malarials. Patients disregarding negative test results and self-treating exacerbate the problem. This study explored the knowledge, attitudes and practices of HCPs and healthcare-seekers regarding RDTs in comparison to BFM testing. Methods A situational analysis was, therefore, conducted in Kondoa District, Dodoma Region, Tanzania. A multi-methodological approach was adopted including (i) a health facility inventory and screening of logbooks from May 2013 to April 2014 with 77,126 patient entries from 33 health facilities; (ii) a survey of 40 HCPs offering malaria services; and iii) a survey of 309 randomly selected household members from the facilities’ catchment area. Surveys took place in April and May 2014. Results Health facility records revealed that out of 77,126 patient entries, 22% (n = 17,235) obtained a malaria diagnosis. Of those, 45% were made with BFM, 33% with RDT and 22% with clinical diagnosis. A higher rate of positive diagnoses was observed with BFM compared with RDT (71% vs 14%). In the HCP survey, 48% preferred using BFM for malaria testing, while 52% preferred RDT. Faced with a negative RDT result for a patient presenting with symptoms typical for malaria, 25% of HCPs stated they would confirm the result with a microscopy test, 70% would advise or perform a clinical diagnosis and 18% would prescribe anti-malarials. Interviews with household members revealed a preference for microscopy testing (58%) over RDT (23%), if presented with malaria symptoms. For participants familiar with both tests, a second opinion was desired in 45% after a negative microscopy result and in 90% after an RDT. Conclusions Non-adherence to negative diagnostics by HCPs and patients continues to be a concern. Frequent training and supportive supervision for HCPs diagnosing and treating malaria and non-malaria febrile illnesses is essential to offer quality services that can instil confidence in HCPs and patients alike. The introduction of new diagnostic devices should be paired with context-specific behaviour change interventions targeting healthcare-seekers and healthcare providers. Supplementary Information The online version contains supplementary material available at 10.1186/s12936-022-04244-0.
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Affiliation(s)
- Leah F Bohle
- Swiss Tropical and Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
| | - Ally-Kebby Abdallah
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Health Promotion and System Strengthening Project (HPSS), Dodoma, Tanzania
| | - Francesco Galli
- Veterinary Public Health Institute, University of Bern, Bern, Switzerland
| | - Robert Canavan
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Kate Molesworth
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
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Gindola Y, Getahun D, Sugerman D, Tongren E, Tokarz R, Wossen M, Demissie K, Zemelak E, Okugn A, Wendimu J, Hailu G, Tegistu M, Begna D. Adherence to national malaria clinical management and testing guidelines in selected private clinics of Gambela Town, Gambela Region, Ethiopia: a mixed method study. Malar J 2022; 21:164. [PMID: 35658968 PMCID: PMC9166442 DOI: 10.1186/s12936-022-04206-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 05/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The World Health Organization World Malaria Report of 2019 indicated an estimated 228 million cases of malaria occurred worldwide in 2018. More than 75% of the total area of Ethiopia is malarious, making malaria a leading public health problem in Ethiopia. Adherence to clinical guidelines improves the quality of care received by patients, thus improving patient outcomes. This study investigates healthcare workers' adherence to malaria testing and treatment guidelines in selected private clinics of Gambela Town, Ethiopia. METHODS A mixed study design involving a retrospective review of 425 patient files and 20 healthcare worker interviews in private clinics was implemented. Data were collected using pre-tested data collection forms. The collected data were then cleaned and entered into statistical software for analysis, with a level of significance set at < 0.05. A qualitative analysis was also conducted using healthcare worker interviews to identify the existing barriers to guideline adherence. RESULTS Among the 430 cases of suspected malaria, only 65% were tested for malaria. Of those tested, 75% tested positive and 25% tested negative. The most common co-morbidity in patients treated for malaria was anaemia (30%), followed by gastroenteritis (10%). Patients with co-morbidities were more likely to receive appropriate treatment (p = 0.03) compared to those without co-morbidities. All healthcare workers interviewed were aware of the existence of the malaria treatment guidelines. However, many were not aware of the contents of the guidelines and only 40% had been trained to understand the guidelines. Overall, 85% of the workers claimed to adhere to guidelines, with 15% claiming non-adherence. CONCLUSION The gap between knowledge of the malaria treatment guidelines and their application by healthcare workers remains wide. The level of knowledge of these guidelines was also low. Continuous training, follow-up, supportive supervision, and improved adherence to the malaria guidelines are therefore recommended.
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Affiliation(s)
- Yamlak Gindola
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia.
| | | | - David Sugerman
- Centers for Disease Control and Prevention, Atlanta, USA
| | - Eric Tongren
- Centers for Disease Control and Prevention, Atlanta, USA
| | - Ryan Tokarz
- Centers for Disease Control and Prevention, Atlanta, USA
| | - Mesfin Wossen
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | | | | | - Akuma Okugn
- Gambela Regional Health Bureau, Gambela, Gambela Regional, Ethiopia
| | - Jimmawork Wendimu
- Department of Public Health, St'Paul Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Girmay Hailu
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Mesfin Tegistu
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Dumesa Begna
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
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Oyegoke OO, Maharaj L, Akoniyon OP, Kwoji I, Roux AT, Adewumi TS, Maharaj R, Oyebola BT, Adeleke MA, Okpeku M. Malaria diagnostic methods with the elimination goal in view. Parasitol Res 2022; 121:1867-1885. [PMID: 35460369 PMCID: PMC9033523 DOI: 10.1007/s00436-022-07512-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 04/01/2022] [Indexed: 01/08/2023]
Abstract
Malaria control measures have been in use for years but have not completely curbed the spread of infection. Ultimately, global elimination is the goal. A major playmaker in the various approaches to reaching the goal is the issue of proper diagnosis. Various diagnostic techniques were adopted in different regions and geographical locations over the decades, and these have invariably produced diverse outcomes. In this review, we looked at the various approaches used in malaria diagnostics with a focus on methods favorably used during pre-elimination and elimination phases as well as in endemic regions. Microscopy, rapid diagnostic testing (RDT), loop-mediated isothermal amplification (LAMP), and polymerase chain reaction (PCR) are common methods applied depending on prevailing factors, each with its strengths and limitations. As the drive toward the elimination goal intensifies, the search for ideal, simple, fast, and reliable point-of-care diagnostic tools is needed more than ever before to be used in conjunction with a functional surveillance system supported by the ideal vaccine.
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Affiliation(s)
- Olukunle O Oyegoke
- Discipline of Genetics School of Life Sciences, University of KwaZulu-Natal, Westville, Durban, South Africa
| | - Leah Maharaj
- Discipline of Genetics School of Life Sciences, University of KwaZulu-Natal, Westville, Durban, South Africa
| | - Oluwasegun P Akoniyon
- Discipline of Genetics School of Life Sciences, University of KwaZulu-Natal, Westville, Durban, South Africa
| | - Illiya Kwoji
- Discipline of Genetics School of Life Sciences, University of KwaZulu-Natal, Westville, Durban, South Africa
| | - Alexandra T Roux
- Discipline of Genetics School of Life Sciences, University of KwaZulu-Natal, Westville, Durban, South Africa
| | - Taiye S Adewumi
- Discipline of Genetics School of Life Sciences, University of KwaZulu-Natal, Westville, Durban, South Africa
| | - Rajendra Maharaj
- Office of Malaria Research, Medical Research Council, Durban, South Africa
| | | | - Matthew A Adeleke
- Discipline of Genetics School of Life Sciences, University of KwaZulu-Natal, Westville, Durban, South Africa
| | - Moses Okpeku
- Discipline of Genetics School of Life Sciences, University of KwaZulu-Natal, Westville, Durban, South Africa.
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Amboko B, Stepniewska K, Macharia PM, Machini B, Bejon P, Snow RW, Zurovac D. Trends in health workers' compliance with outpatient malaria case-management guidelines across malaria epidemiological zones in Kenya, 2010-2016. Malar J 2020; 19:406. [PMID: 33176783 PMCID: PMC7659071 DOI: 10.1186/s12936-020-03479-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 11/02/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Health workers' compliance with outpatient malaria case-management guidelines has been improving, specifically regarding the universal testing of suspected cases and the use of artemisinin-based combination therapy (ACT) only for positive results (i.e., 'test and treat'). Whether the improvements in compliance with 'test and treat' guidelines are consistent across different malaria endemicity areas has not been examined. METHODS Data from 11 national, cross-sectional, outpatient malaria case-management surveys undertaken in Kenya from 2010 to 2016 were analysed. Four primary indicators (i.e., 'test and treat') and eight secondary indicators of artemether-lumefantrine (AL) dosing, dispensing, and counselling were measured. Mixed logistic regression models were used to analyse the annual trends in compliance with the indicators across the different malaria endemicity areas (i.e., from highest to lowest risk being lake endemic, coast endemic, highland epidemic, semi-arid seasonal transmission, and low risk). RESULTS Compliance with all four 'test and treat' indicators significantly increased in the area with the highest malaria risk (i.e., lake endemic) as follows: testing of febrile patients (OR = 1.71 annually; 95% CI = 1.51-1.93), AL treatment for test-positive patients (OR = 1.56; 95% CI = 1.26-1.92), no anti-malarial for test-negative patients (OR = 2.04; 95% CI = 1.65-2.54), and composite 'test and treat' compliance (OR = 1.80; 95% CI = 1.61-2.01). In the low risk areas, only compliance with test-negative results significantly increased (OR = 2.27; 95% CI = 1.61-3.19) while testing of febrile patients showed declining trends (OR = 0.89; 95% CI = 0.79-1.01). Administration of the first AL dose at the facility significantly increased in the areas of lake endemic (OR = 2.33; 95% CI = 1.76-3.10), coast endemic (OR = 5.02; 95% CI = 2.77-9.09) and semi-arid seasonal transmission (OR = 1.44; 95% CI = 1.02-2.04). In areas of the lowest risk of transmission and highland epidemic zone, none of the AL dosing, dispensing, and counselling tasks significantly changed over time. CONCLUSIONS There is variability in health workers' compliance with outpatient malaria case-management guidelines across different malaria-risk areas in Kenya. Major improvements in areas of the highest risk have not been seen in low-risk areas. Interventions to improve practices should be targeted geographically.
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Affiliation(s)
- Beatrice Amboko
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya.
| | - Kasia Stepniewska
- WorldWide Antimalarial Resistance Network, Oxford, UK
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Peter M Macharia
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
| | - Beatrice Machini
- Division of National Malaria Programme, Ministry of Health, Nairobi, Kenya
| | - Philip Bejon
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Robert W Snow
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Dejan Zurovac
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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Cohen JL, Leslie HH, Saran I, Fink G. Quality of clinical management of children diagnosed with malaria: A cross-sectional assessment in 9 sub-Saharan African countries between 2007-2018. PLoS Med 2020; 17:e1003254. [PMID: 32925906 PMCID: PMC7489507 DOI: 10.1371/journal.pmed.1003254] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 08/10/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Appropriate clinical management of malaria in children is critical for preventing progression to severe disease and for reducing the continued high burden of malaria mortality. This study aimed to assess the quality of care provided to children under 5 diagnosed with malaria across 9 sub-Saharan African countries. METHODS AND FINDINGS We used data from the Service Provision Assessment (SPA) survey. SPAs are nationally representative facility surveys capturing quality of sick-child care, facility readiness, and provider and patient characteristics. The data set contained 24,756 direct clinical observations of outpatient sick-child visits across 9 countries, including Uganda (2007), Rwanda (2007), Namibia (2009), Kenya (2010), Malawi (2013), Senegal (2013-2017), Ethiopia (2014), Tanzania (2015), and Democratic Republic of the Congo (2018). We assessed the proportion of children with a malaria diagnosis who received a blood test diagnosis and an appropriate antimalarial. We used multilevel logistic regression to assess facility and provider and patient characteristics associated with these outcomes. Subgroup analyses with the 2013-2018 country surveys only were conducted for all outcomes. Children observed were on average 20.5 months old and were most commonly diagnosed with respiratory infection (47.7%), malaria (29.7%), and/or gastrointestinal infection (19.7%). Among the 7,340 children with a malaria diagnosis, 32.5% (95% CI: 30.3%-34.7%) received both a blood-test-based diagnosis and an appropriate antimalarial. The proportion of children with a blood test diagnosis and an appropriate antimalarial ranged from 3.4% to 57.1% across countries. In the more recent surveys (2013-2018), 40.7% (95% CI: 37.7%-43.6%) of children with a malaria diagnosis received both a blood test diagnosis and appropriate antimalarial. Roughly 20% of children diagnosed with malaria received no antimalarial at all, and nearly 10% received oral artemisinin monotherapy, which is not recommended because of concerns regarding parasite resistance. Receipt of a blood test diagnosis and appropriate antimalarial was positively correlated with being seen at a facility with diagnostic equipment in stock (adjusted OR 3.67; 95% CI: 2.72-4.95) and, in the 2013-2018 subsample, with being seen at a facility with Artemisinin Combination Therapies (ACTs) in stock (adjusted OR 1.60; 95% CI:1.04-2.46). However, even if all children diagnosed with malaria were seen by a trained provider at a facility with diagnostics and medicines in stock, only a predicted 37.2% (95% CI: 34.2%-40.1%) would have received a blood test and appropriate antimalarial (44.4% for the 2013-2018 subsample). Study limitations include the lack of confirmed malaria test results for most survey years, the inability to distinguish between a diagnosis of uncomplicated or severe malaria, the absence of other relevant indicators of quality of care including dosing and examinations, and that only 9 countries were studied. CONCLUSIONS In this study, we found that a majority of children diagnosed with malaria across the 9 surveyed sub-Saharan African countries did not receive recommended care. Clinical management is positively correlated with the stocking of essential commodities and is somewhat improved in more recent years, but important quality gaps remain in the countries studied. Continued reductions in malaria mortality will require a bigger push toward quality improvements in clinical care.
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Affiliation(s)
- Jessica L. Cohen
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
- * E-mail:
| | - Hannah H. Leslie
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Indrani Saran
- Boston College School of Social Work, Chestnut Hill, Massachusetts, United States of America
| | - Günther Fink
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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7
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Bath D, Goodman C, Yeung S. Modelling the cost-effectiveness of introducing subsidised malaria rapid diagnostic tests in the private retail sector in sub-Saharan Africa. BMJ Glob Health 2020; 5:bmjgh-2019-002138. [PMID: 32439690 PMCID: PMC7247415 DOI: 10.1136/bmjgh-2019-002138] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 03/17/2020] [Accepted: 03/21/2020] [Indexed: 11/18/2022] Open
Abstract
Background Over the last 10 years, there has been a huge shift in malaria diagnosis in public health facilities, due to widespread deployment of rapid diagnostic tests (RDTs), which are accurate, quick and easy to use and inexpensive. There are calls for RDTs to be made available at-scale in the private retail sector where many people with suspected malaria seek care. Retail sector RDT use in sub-Saharan Africa (SSA) is limited to small-scale studies, and robust evidence on value-for-money is not yet available. We modelled the cost-effectiveness of introducing subsidised RDTs and supporting interventions in the SSA retail sector, in a context of a subsidy programme for first-line antimalarials. Methods We developed a decision tree following febrile patients through presentation, diagnosis, treatment, disease progression and further care, to final health outcomes. We modelled results for three ‘treatment scenarios’, based on parameters from three small-scale studies in Nigeria (TS-N), Tanzania (TS-T) and Uganda (TS-U), under low and medium/high transmission (5% and 50% Plasmodium falciparum (parasite) positivity rates (PfPR), respectively). Results Cost-effectiveness varied considerably between treatment scenarios. Cost per disability-adjusted life year averted at 5% PfPR was US$482 (TS-N) and US$115 (TS-T) and at 50% PfPR US$44 (TS-N) and US$45 (TS-T), from a health service perspective. TS-U was dominated in both transmission settings. Conclusion The cost-effectiveness of subsidised RDTs is strongly influenced by treatment practices, for which further evidence is required from larger-scale operational settings. However, subsidised RDTs could promote increased use of first-line antimalarials in patients with malaria. RDTs may, therefore, be more cost-effective in higher transmission settings, where a greater proportion of patients have malaria and benefit from increased antimalarial use. This is contrary to previous public sector models, where RDTs were most cost-effective in lower transmission settings as they reduced unnecessary antimalarial use in patients without malaria.
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Affiliation(s)
- David Bath
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Catherine Goodman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Shunmay Yeung
- Department of Clinical Research, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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8
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Thomson R, Beshir KB, Cunningham J, Baiden F, Bharmal J, Bruxvoort KJ, Maiteki-Sebuguzi C, Owusu-Agyei S, Staedke SG, Hopkins H. pfhrp2 and pfhrp3 Gene Deletions That Affect Malaria Rapid Diagnostic Tests for Plasmodium falciparum: Analysis of Archived Blood Samples From 3 African Countries. J Infect Dis 2020; 220:1444-1452. [PMID: 31249999 PMCID: PMC6761929 DOI: 10.1093/infdis/jiz335] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 06/27/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Malaria rapid diagnostic tests (mRDTs) that target histidine-rich protein 2 (HRP2) are important tools for Plasmodium falciparum diagnosis. Parasites with pfhrp2/3 gene deletions threaten the use of these mRDTs and have been reported in Africa, Asia, and South America. We studied blood samples from 3 African countries to determine if these gene deletions were present. METHODS We analyzed 911 dried blood spots from Ghana (n = 165), Tanzania (n = 176), and Uganda (n = 570). Plasmodium falciparum infection was confirmed by 18S rDNA polymerase chain reaction (PCR), and pfhrp2/3 genes were genotyped. True pfhrp2/3 gene deletions were confirmed if samples were (1) microscopy positive; (2) 18S rDNA PCR positive; (3) positive for merozoite surface protein genes by PCR or positive by loop-mediated isothermal amplification; or (4) quantitative PCR positive with >5 parasites/µL. RESULTS No pfhrp2/3 deletions were detected in samples from Ghana, but deletions were identified in Tanzania (3 pfhrp2; 2 pfhrp3) and Uganda (7 pfhrp2; 2 pfhrp3). Of the 10 samples with pfhrp2 deletions, 9 tested negative by HRP2-based mRDT. CONCLUSIONS The presence of pfhrp2/3 deletions in Tanzania and Uganda, along with reports of pfhrp2/3-deleted parasites in neighboring countries, reinforces the need for systematic surveillance to monitor the reliability of mRDTs in malaria-endemic countries.
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Affiliation(s)
- Rebecca Thomson
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Khalid B Beshir
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Frank Baiden
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jameel Bharmal
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Katia J Bruxvoort
- London School of Hygiene and Tropical Medicine, London, United Kingdom.,Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | | | - Seth Owusu-Agyei
- London School of Hygiene and Tropical Medicine, London, United Kingdom.,University or Health and Allied Sciences, Kintampo Health Research Centre, Ghana
| | - Sarah G Staedke
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Heidi Hopkins
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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O'Boyle S, Bruxvoort KJ, Ansah EK, Burchett HED, Chandler CIR, Clarke SE, Goodman C, Mbacham W, Mbonye AK, Onwujekwe OE, Staedke SG, Wiseman VL, Whitty CJM, Hopkins H. Patients with positive malaria tests not given artemisinin-based combination therapies: a research synthesis describing under-prescription of antimalarial medicines in Africa. BMC Med 2020; 18:17. [PMID: 31996199 PMCID: PMC6990477 DOI: 10.1186/s12916-019-1483-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 12/17/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND There has been a successful push towards parasitological diagnosis of malaria in Africa, mainly with rapid diagnostic tests (mRDTs), which has reduced over-prescribing of artemisinin-based combination therapies (ACT) to malaria test-negative patients. The effect on prescribing for test-positive patients has received much less attention. Malaria infection in endemic Africa is often most dangerous for young children and those in low-transmission settings. This study examined non-prescription of antimalarials for patients with malaria infection demonstrated by positive mRDT results, and in particular these groups who are most vulnerable to poor outcomes if antimalarials are not given. METHODS Analysis of data from 562,762 patients in 8 studies co-designed as part of the ACT Consortium, conducted 2007-2013 in children and adults, in Cameroon, Ghana, Nigeria, Tanzania, and Uganda, in a variety of public and private health care sector settings, and across a range of malaria endemic zones. RESULTS Of 106,039 patients with positive mRDT results (median age 6 years), 7426 (7.0%) were not prescribed an ACT antimalarial. The proportion of mRDT-positive patients not prescribed ACT ranged across sites from 1.3 to 37.1%. For patients under age 5 years, 3473/44,539 (7.8%) were not prescribed an ACT, compared with 3833/60,043 (6.4%) of those aged ≥ 5 years. The proportion of < 5-year-olds not prescribed ACT ranged up to 41.8% across sites. The odds of not being prescribed an ACT were 2-32 times higher for patients in settings with lower-transmission intensity (using test positivity as a proxy) compared to areas of higher transmission. mRDT-positive children in low-transmission settings were especially likely not to be prescribed ACT, with proportions untreated up to 70%. Of the 7426 mRDT-positive patients not prescribed an ACT, 4121 (55.5%) were prescribed other, non-recommended non-ACT antimalarial medications, and the remainder (44.5%) were prescribed no antimalarial. CONCLUSIONS In eight studies of mRDT implementation in five African countries, substantial proportions of patients testing mRDT-positive were not prescribed an ACT antimalarial, and many were not prescribed an antimalarial at all. Patients most vulnerable to serious outcomes, children < 5 years and those in low-transmission settings, were most likely to not be prescribed antimalarials, and young children in low-transmission settings were least likely to be treated for malaria. This major public health risk must be addressed in training and practice. TRIAL REGISTRATION Reported in individual primary studies.
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Affiliation(s)
| | - Katia J Bruxvoort
- London School of Hygiene and Tropical Medicine, London, UK.,Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, USA
| | - Evelyn K Ansah
- Centre for Malaria Research, University of Health and Allied Sciences, Accra, Ghana
| | | | | | - Siân E Clarke
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Wilfred Mbacham
- Public Health Biotechnology, University of Yaoundé I, Yaoundé, Cameroon
| | | | - Obinna E Onwujekwe
- Department of Pharmacology and Therapeutics, University of Nigeria, Enugu, Nigeria
| | | | - Virginia L Wiseman
- London School of Hygiene and Tropical Medicine, London, UK.,School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | | | - Heidi Hopkins
- London School of Hygiene and Tropical Medicine, London, UK
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10
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Meless DG, Hounsa AE, Sangaré AD, Pongathié AS, Kouakou JS, Samba M, Kouadio L. [Evaluation of the operational capacity of first-line health facilities in the management of malaria in Ivory Coast]. Pan Afr Med J 2019; 34:16. [PMID: 31762885 PMCID: PMC6859026 DOI: 10.11604/pamj.2019.34.16.19932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 08/14/2019] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Do health facilities (HF) have basic resources needed to manage malaria? The purpose of our study was to analyze the operational capacity (OC) of first-line health facilities in Ivory Coast in the management of malaria. METHODS SARA methodology was used to conduct a descriptive cross-sectional study from 10 to 30 July 2016. The operational capacity in the management showed an average availability of 9 identification tracers divided in 3 areas: (i) staff and guidelines; (ii) capacity of diagnosis; (iii) drugs and products. This operational capacity was assessed through the calculation of an index and then compared with the health facilities according to the management authority and the geographical area using Chi-square test with p-values α fixed at 0.05. RESULTS Out of 818 HFs, 651(79.6%) were in the public sector and 487(59.5%) were located in the rural area. The operational capacity of first line health facilities was 74.5%. This OC was higher in the public sector (81.3%) than in the private sector (48.8%) (p < 10-3) as well as in the rural area (82.7%) compared to the urban area (62.9%) (p < 10-3). CONCLUSION In 2016, first line health facilities in Ivory Coast had basic resources needed to manage malaria. It is necessary to focus on the need to strengthen health facility services in addition to prevention.
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Affiliation(s)
- David Guanga Meless
- Département de Santé Publique, UFR Odontostomatologie, Université Félix Houphouët-Boigny, Abidjan, Côte d'Ivoire
| | - Annita Emeline Hounsa
- Département de Santé Publique, Hydrologie et Toxicologie, UFR des Sciences Pharmaceutiques et Biologiques, Université Félix Houphouët-Boigny, Abidjan, Côte d'Ivoire
| | - Abou Dramane Sangaré
- Département de Santé Publique, UFR Odontostomatologie, Université Félix Houphouët-Boigny, Abidjan, Côte d'Ivoire
| | - Adama Sanogo Pongathié
- Direction de l'Information et de l'Informatique Sanitaire, Ministère de la Santé et de l'Hygiène Publique, Abidjan, Côte d'Ivoire
| | - Julie Sackou Kouakou
- Département de Santé Publique, Hydrologie et Toxicologie, UFR des Sciences Pharmaceutiques et Biologiques, Université Félix Houphouët-Boigny, Abidjan, Côte d'Ivoire
| | - Mamadou Samba
- Département de Santé Publique, UFR Odontostomatologie, Université Félix Houphouët-Boigny, Abidjan, Côte d'Ivoire
| | - Luc Kouadio
- Département de Santé Publique, Hydrologie et Toxicologie, UFR des Sciences Pharmaceutiques et Biologiques, Université Félix Houphouët-Boigny, Abidjan, Côte d'Ivoire
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11
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Palafox B, Goodman C, Hanson K. Malaria, medicines and miles: A novel approach to measuring access to treatment from a household perspective. SSM Popul Health 2019; 7:100376. [PMID: 30906843 PMCID: PMC6411512 DOI: 10.1016/j.ssmph.2019.100376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 10/19/2018] [Accepted: 02/10/2019] [Indexed: 11/28/2022] Open
Abstract
Nearly a decade after the adoption of confirmed diagnosis and artemisinin combination therapy (ACT) for the treatment of uncomplicated falciparum malaria, a large treatment gap persists. We describe a novel approach of combining data from households and the universe of treatment sources in their vicinities to produce nationally representative indicators of physical and financial access to malaria care from the household's perspective in Benin, Nigeria, Uganda and Zambia. We compare differences in access across urban and rural areas, countries, and over time. In 2009, more urban households had a provider stocking ACT within 5 km than rural households. By 2012, this physical ACT access gap had largely been closed in Uganda, and progress had been made in Benin and Nigeria; but the gap persisted in Zambia. The private sector helped to fill this gap in rural areas. Improvements in Nigeria and Uganda were driven largely by increased ACT availability in licensed drug stores, and in Benin by increased availability in unregulated open-air market stalls. Free or subsidised ACT from public and non-profit facilities continued to be available to many households by 2012, but much less so in rural areas. Where private sector expansion increased physical access to ACT, these additional options were on average more expensive. Also by 2012, the majority of urban households in all four countries had access to a provider nearby offering malaria diagnostic services; however, this access remained low for rural households in Benin, Nigeria and Zambia. The methods developed in this study could improve how access to healthcare is measured in low- and middle-income country settings, particularly where private for-profit providers are an important source of care, and for conditions that may be treated by informal providers. The method could also lead to better explanations of the performance of complex interventions aiming to improve healthcare access.
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Key Words
- ACT, artemisinin combination therapy
- AETD, adult equivalent treatment dose
- AMFm, Affordable Medicines Facility–malaria
- AMT, artemisinin monotherapy
- Access to healthcare
- Antimalarials
- CI, 95% confidence interval
- DHS, Demographic and Health Survey
- Health Equity
- IQR, interquartile range
- Malaria
- PPMV, proprietary patented medicine vendor
- PSU, primary sampling unit
- Population metrics
- Private sector
- Public sector
- RDT, rapid diagnostic test (for malaria)
- USD, United States dollar
- WHO, World Health Organization
- nAT, non-artemisinin therapy
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Affiliation(s)
- Benjamin Palafox
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
| | - Catherine Goodman
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
| | - Kara Hanson
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
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12
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Usman R, Umar AA, Gidado S, Gobir AA, Obi IF, Ajayi I, Ajumobi O. Predictors of malaria Rapid Diagnostic Tests' utilisation among healthcare workers in Zamfara State. PLoS One 2018; 13:e0200856. [PMID: 30550562 PMCID: PMC6294357 DOI: 10.1371/journal.pone.0200856] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 11/28/2018] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Early diagnosis and prompt and effective treatment is one of the pillars of malaria control. Malaria case management guidelines recommend diagnostic testing before treatment using malaria Rapid Diagnostic Test (mRDT) or microscopy and this was adopted in Nigeria in 2010. However, despite the deployment of mRDT, the use of mRDTs by health workers varies by settings. This study set out to assess factors influencing utilisation of mRDT among healthcare workers in Zamfara State, Nigeria. METHODS A cross-sectional study was carried out among 306 healthcare workers selected using multistage sampling from six Local Government Areas between January and February 2017. Mixed method was used for data collection. A pre-tested self-administered questionnaire was used to collect information on knowledge, use of mRDT and factors influencing utilization. An observational checklist was used to assess the availability of mRDT in the six months prior to this study. Data were analyzed using descriptive statistics such as means and proportions. Association between mRDT use and independent variables was tested using Chi square while multiple regression was used to determine predictors of use at 5% level of significance. RESULTS Mean age of respondents was 36.0 ± 9.4years. Overall, 198 (64.7%) of health workers had good knowledge of mRDT; mRDT was available in 33 (61.1%) facilities. Routine use of mRDT was reported by 253 (82.7%) healthcare workers. This comprised 89 (35.2%) laboratory scientists/technicians, 89 (35.2%) community health extension workers/community health officers; 59 (23.3%) nurses and 16 (6.3%) doctors. Health workers' good knowledge of mRDT, trust in mRDT results, having received prior training on mRDT, and non-payment for mRDT were predictors of mRDT utilisation. CONCLUSION This study demonstrated that healthcare worker utilisation of mRDT was associated with health worker and health system-related factors that are potentially modifiable. There is need to sustain training of healthcare workers on benefits of using mRDT and provision of free mRDT in health facilities.
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Affiliation(s)
- Rabi Usman
- Nigeria Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria
| | - Ahmad A. Umar
- Department of Community Medicine, Ahmadu Bello University, Zaria, Nigeria
| | - Saheed Gidado
- Nigeria Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria
- African Field Epidemiology Network, Abuja, Nigeria
| | | | - Izuchukwu F. Obi
- Nigeria Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria
- Department of Community Medicine, University of Nigeria Teaching Hospital Enugu, Enugu, Nigeria
| | - IkeOluwapo Ajayi
- Department of Epidemiology and Medical Statistics, University of Ibadan, Ibadan, Nigeria
| | - Olufemi Ajumobi
- Nigeria Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria
- African Field Epidemiology Network, Abuja, Nigeria
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13
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Baynes C, Mboya D, Likasi S, Maganga D, Pemba S, Baraka J, Ramsey K, Semu H. Quality of Sick Child-Care Delivered by Community Health Workers in Tanzania. Int J Health Policy Manag 2018; 7:1097-1109. [PMID: 30709085 PMCID: PMC6358652 DOI: 10.15171/ijhpm.2018.63] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 07/02/2018] [Indexed: 11/17/2022] Open
Abstract
Background: Community health worker (CHW) interventions to manage childhood illness is a strategy promoted by
the global health community which involves training and supporting CHW to assess, classify and treat sick children
at home, using an algorithm adapted from the Integrated Management of Childhood Illness (IMCI). To inform CHW
policy, the Government of Tanzania launched a program in 2011 to determine if community case management (CCM)
of malaria, pneumonia and diarrhea could be implemented by CHW in that country.
Methods: This paper reports the results of an observational study on the CCM service delivery quality of a trial cohort
of CHW in Tanzania, called WAJA. In 2014, teams of data collectors, employees of the Ministry of Health and Social
Welfare trained in IMCI, assessed the IMCI skills rendered by a sample of WAJA on sick children who presented to
WAJA with illness signs and symptoms in their communities. The assessment included direct observations of WAJA
IMCI episodes and expert re-assessment of the same children seen by WAJA to assess the congruence between the
assessment, classification and treatment outcomes of WAJA cases and those from cases conducted by expert re-assessors.
Results: In the majority of cases, WAJA correctly assess sick children for CCM-treatable illnesses (malaria, pneumonia,
and diarrhea) and general danger signs (90% and 89%, respectively), but too few correctly assess for physical danger signs
(39%); on classification in the majority of cases (73%) WAJA correctly classified illness, though more for CCM-treatable
illnesses (83%). In majority of cases (78%) WAJA treated children correctly (84% of malaria, 74% pneumonia, and 71%
diarrhea cases). Errors were often associated with lapses in health systems support, mainly supervision and logistics.
Conclusion: CCM is a feasible strategy for CHW in Tanzania, who, in the majority of cases, implemented the approach
as well as IMCI expert re-assessors. Nevertheless, for CCM to be effective, in Tanzania, a strategy to implement it must
be coordinated with efforts to strengthen local health systems
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Affiliation(s)
- Colin Baynes
- Mailman School of Public Health, Columbia University, New York City, NY, USA
| | | | | | | | - Senga Pemba
- Tanzania Training Center for International Health, Ifakara, Tanzania
| | | | - Kate Ramsey
- Mailman School of Public Health, Columbia University, New York City, NY, USA
| | - Helen Semu
- Ministry of Health and Social Welfare, Dar es Salaam, Tanzania
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14
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Gallay J, Mosha D, Lutahakana E, Mazuguni F, Zuakulu M, Decosterd LA, Genton B, Pothin E. Appropriateness of malaria diagnosis and treatment for fever episodes according to patient history and anti-malarial blood measurement: a cross-sectional survey from Tanzania. Malar J 2018; 17:209. [PMID: 29784001 PMCID: PMC5963060 DOI: 10.1186/s12936-018-2357-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 05/14/2018] [Indexed: 12/28/2022] Open
Abstract
Background Monitoring the impact of case management strategies at large scale is essential to evaluate the public health benefit they confer. The use of methodologies relying on objective and standardized endpoints, such as drug levels in the blood, should be encouraged. Population drug use, diagnosis and treatment appropriateness in case of fever according to patient history and anti-malarials blood concentration was evaluated. Methods A cross-sectional survey took place between May and August 2015 in three regions of Tanzania with different levels of malaria endemicity. Interviews were conducted and blood samples were collected by dried blood spots through household surveys for further anti-malarial measurements. Appropriate testing when individuals attended care was defined as a patient with history of fever being tested for malaria and appropriate treatment as (i) having anti-malarial in the blood if the test result was positive (ii) having anti-malarial in the blood if the person was not tested, and (iii) no anti-malarial in the blood when the test result was negative. Results Amongst 6391 participants included in the anti-malarial analysis, 20.8% (1330/6391) had anti-malarial drug detected in the blood. Only 28.0% (372/1330) of the individuals with anti-malarials in their blood reported the use of anti-malarials within the previous month. Amongst all participants, 16.0% (1021/6391) reported having had a fever in the previous 2 weeks and 37.5% of them (383/1021) had detectable levels of anti-malarials in the blood. Of the individuals who sought care in health facilities, 69.4% (172/248) were tested and 52.0% (129/248) appropriately treated. When other providers were sought, 6% (23/382) of the persons were appropriately tested and 44.2% (169/382) appropriately treated. Overall, the proportion of individuals treated was larger than that being tested [47.3% (298/630) treated, 31.0% (195/630) tested]. Conclusion This study showed high prevalence of circulating anti-malarial drug in the sampled population. Efforts should be made to increase rapid diagnostic tests use at all levels of health care and improve compliance to test result in order to target febrile patients that are sick with malaria and reduce drug pressure. Objective drug measurements collected at community level represent a reliable tool to evaluate overall impact of case management strategies on population drug pressure.
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Affiliation(s)
- Joanna Gallay
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, P.O. Box 4002, Basel, Switzerland. .,University of Basel, Basel, Switzerland. .,Service and Laboratory of Clinical Pharmacology, University Hospital, Lausanne, Switzerland.
| | | | | | | | | | | | - Blaise Genton
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, P.O. Box 4002, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Division of Infectious Diseases and Department of Community Health, University Hospital, Lausanne, Switzerland
| | - Emilie Pothin
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, P.O. Box 4002, Basel, Switzerland.,University of Basel, Basel, Switzerland
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15
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Mokuolu OA, Ajumobi OO, Ntadom GN, Adedoyin OT, Roberts AA, Agomo CO, Edozieh KU, Okafor HU, Wammanda RD, Odey FA, Maikore IK, Abikoye OO, Alabi AD, Amajoh C, Audu BM. Provider and patient perceptions of malaria rapid diagnostic test use in Nigeria: a cross-sectional evaluation. Malar J 2018; 17:200. [PMID: 29769072 PMCID: PMC5956734 DOI: 10.1186/s12936-018-2346-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 05/07/2018] [Indexed: 11/24/2022] Open
Abstract
Background Nigeria commenced a phased programmatic deployment of rapid diagnostic tests (RDT) at the primary health care (PHC) facility levels since 2011. Despite various efforts, the national testing rate for malaria is still very low. The uptake of RDT has been variable. This study was undertaken to determine the provider and patient perceptions to RDT use at the PHC level in Nigeria with their implications for improving uptake and compliance. Methods A cross-sectional survey was conducted in 120 randomly selected PHCs across six states, across the six-geopolitical zones of Nigeria in January 2013. Health facility staff interviews were conducted to assess health workers (HW) perception, prescription practices and determinants of RDT use. Patient exit interviews were conducted to assess patient perception of RDT from ten patients/caregivers who met the eligibility criterion and were consecutively selected in each PHC, and to determine HW’s compliance with RDT test results indirectly. Community members, each selected by their ward development committees in each Local Government Area were recruited for focus group discussion on their perceptions to RDT use. Results Health workers would use RDT results because of confidence in RDT results (95.4%) and its reduction in irrational use of artemisinin-based combination therapy (ACT) (87.2%). However, in Enugu state, RDT was not used by health workers because of the pervasive notion RDT that results were inaccurate. Among the 1207 exit interviews conducted, 549 (45.5%) had received RDT test. Compliance rate (administering ACT to positive patients and withholding ACT from negative patients) from patient exit interviews was 90.2%. Among caregivers/patients who had RDT done, over 95% knew that RDT tested for malaria, felt it was necessary and liked the test. Age of patients less than 5 years (p = 0.04) and “high” educational status (p = 0.0006) were factors influencing HW’s prescription of ACT to RDT negative patients. Conclusion The study demonstrated positive perception to RDT use by HW and among community members with good compliance rate among health workers at the PHC level. This positive perception should be explored in improving the current low level of malaria testing in Nigeria while addressing the influence of age on HW administration of ACT to RDT negative cases.
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Affiliation(s)
| | - Olufemi O Ajumobi
- National Malaria Control Programme, Federal Ministry of Health, Abuja, Nigeria.,African Field Epidemiology Network, Abuja, Nigeria
| | - Godwin N Ntadom
- National Malaria Control Programme, Federal Ministry of Health, Abuja, Nigeria
| | | | | | | | - Kate U Edozieh
- New Initiative for the Enhancement of Life and Health (NELAH) Ibadan, Ibadan, Nigeria
| | | | | | | | - Ibrahim K Maikore
- National Malaria Control Programme, Federal Ministry of Health, Abuja, Nigeria
| | - Olatayo O Abikoye
- National Malaria Control Programme, Federal Ministry of Health, Abuja, Nigeria
| | | | | | - Bala M Audu
- National Coordinator National Malaria Elimination Programme, Federal Ministry of Health, Abuja, Nigeria
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16
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Bruxvoort KJ, Leurent B, Chandler CIR, Ansah EK, Baiden F, Björkman A, Burchett HED, Clarke SE, Cundill B, DiLiberto DD, Elfving K, Goodman C, Hansen KS, Kachur SP, Lal S, Lalloo DG, Leslie T, Magnussen P, Mangham-Jefferies L, Mårtensson A, Mayan I, Mbonye AK, Msellem MI, Onwujekwe OE, Owusu-Agyei S, Rowland MW, Shakely D, Staedke SG, Vestergaard LS, Webster J, Whitty CJM, Wiseman VL, Yeung S, Schellenberg D, Hopkins H. The Impact of Introducing Malaria Rapid Diagnostic Tests on Fever Case Management: A Synthesis of Ten Studies from the ACT Consortium. Am J Trop Med Hyg 2017; 97:1170-1179. [PMID: 28820705 PMCID: PMC5637593 DOI: 10.4269/ajtmh.16-0955] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Since 2010, the World Health Organization has been recommending that all suspected cases of malaria be confirmed with parasite-based diagnosis before treatment. These guidelines represent a paradigm shift away from presumptive antimalarial treatment of fever. Malaria rapid diagnostic tests (mRDTs) are central to implementing this policy, intended to target artemisinin-based combination therapies (ACT) to patients with confirmed malaria and to improve management of patients with nonmalarial fevers. The ACT Consortium conducted ten linked studies, eight in sub-Saharan Africa and two in Afghanistan, to evaluate the impact of mRDT introduction on case management across settings that vary in malaria endemicity and healthcare provider type. This synthesis includes 562,368 outpatient encounters (study size range 2,400-432,513). mRDTs were associated with significantly lower ACT prescription (range 8-69% versus 20-100%). Prescribing did not always adhere to malaria test results; in several settings, ACTs were prescribed to more than 30% of test-negative patients or to fewer than 80% of test-positive patients. Either an antimalarial or an antibiotic was prescribed for more than 75% of patients across most settings; lower antimalarial prescription for malaria test-negative patients was partly offset by higher antibiotic prescription. Symptomatic management with antipyretics alone was prescribed for fewer than 25% of patients across all scenarios. In community health worker and private retailer settings, mRDTs increased referral of patients to other providers. This synthesis provides an overview of shifts in case management that may be expected with mRDT introduction and highlights areas of focus to improve design and implementation of future case management programs.
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Affiliation(s)
- Katia J Bruxvoort
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Baptiste Leurent
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | | | | | | | | | - Siân E Clarke
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Bonnie Cundill
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | | | | | - Catherine Goodman
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Kristian S Hansen
- University of Copenhagen, Copenhagen, Denmark.,London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Sham Lal
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - David G Lalloo
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Toby Leslie
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Pascal Magnussen
- Department for Veterinary and Animal Sciences, University of Copenhagen, Copenhagen, Denmark.,Centre for Medical Parasitology, University of Copenhagen and Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | - Ismail Mayan
- Health Protection Research Organisation, Kabul, Afghanistan
| | - Anthony K Mbonye
- Makerere University School of Public Health, Kampala, Uganda.,Ministry of Health, Kampala, Uganda
| | | | - Obinna E Onwujekwe
- Department of Pharmacology and Therapeutics, University of Nigeria, Enugu, Nigeria
| | | | - Mark W Rowland
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Delér Shakely
- Centre for Malaria Research, Karolinska Institutet, Stockholm, Sweden.,Karolinska Institutet, Stockholm, Sweden.,Health Metrics at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Sarah G Staedke
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Lasse S Vestergaard
- Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark.,Centre for Medical Parasitology, University of Copenhagen and Copenhagen University Hospital, Copenhagen, Denmark
| | - Jayne Webster
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Virginia L Wiseman
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia.,London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Shunmay Yeung
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Heidi Hopkins
- London School of Hygiene & Tropical Medicine, London, United Kingdom
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17
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Phok S, Phanalasy S, Thein ST, Likhitsup A. Private sector opportunities and threats to achieving malaria elimination in the Greater Mekong Subregion: results from malaria outlet surveys in Cambodia, the Lao PDR, Myanmar, and Thailand. Malar J 2017; 16:180. [PMID: 28464945 PMCID: PMC5414126 DOI: 10.1186/s12936-017-1800-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 04/05/2017] [Indexed: 11/10/2022] Open
Abstract
Background The aim of this paper is to review multi-country evidence of private sector adherence to national regulations, guidelines, and quality-assurance standards for malaria case management and to document current coverage of private sector engagement and support through ACTwatch outlet surveys implemented in 2015 and 2016. Results Over 76,168 outlets were screened, and approximately 6500 interviews were conducted (Cambodia, N = 1303; the Lao People’s Democratic Republic (PDR), N = 724; Myanmar, N = 4395; and Thailand, N = 74). There was diversity in the types of private sector outlets providing malaria treatment across countries, and the extent to which they were authorized to test and treat for malaria differed. Among outlets stocking at least one anti-malarial, public sector availability of the first-line treatment for uncomplicated Plasmodium falciparum or Plasmodium vivax malaria was >75%. In the anti-malarial stocking private sector, first-line treatment availability was variable (Cambodia, 70.9%; the Lao PDR, 40.8%; Myanmar P. falciparum = 42.7%, P. vivax = 19.6%; Thailand P. falciparum = 19.6%, P. vivax = 73.3%), as was availability of second-line treatment (the Lao PDR, 74.9%; Thailand, 39.1%; Myanmar, 19.8%; and Cambodia, 0.7%). Treatment not in the National Treatment Guidelines (NTGs) was most common in Myanmar (35.8%) and Cambodia (34.0%), and was typically stocked by the informal sector. The majority of anti-malarials distributed in Cambodia and Myanmar were first-line P. falciparum or P. vivax treatments (90.3% and 77.1%, respectively), however, 8.8% of the market share in Cambodia was treatment not in the NTGs (namely chloroquine) and 17.6% in Myanmar (namely oral artemisinin monotherapy). In the Lao PDR, approximately 9 in 10 anti-malarials distributed in the private sector were second-line treatments—typically locally manufactured chloroquine. In Cambodia, 90% of anti-malarials were distributed through outlets that had confirmatory testing available. Over half of all anti-malarial distribution was by outlets that did not have confirmatory testing available in the Lao PDR (54%) and Myanmar (59%). Availability of quality-assured rapid diagnostic tests (RDT) amongst the RDT-stocking public sector ranged from 99.3% in the Lao PDR to 80.1% in Cambodia. In Cambodia, the Lao PDR, and Myanmar, less than 50% of the private sector reportedly received engagement (access to subsidized commodities, supervision, training or caseload reporting), which was most common among private health facilities and pharmacies. Conclusions Findings from this multi-country study suggest that Cambodia, the Lao PDR, Myanmar, and Thailand are generally in alignment with national regulations, treatment guidelines, and quality-assurance standards. However, important gaps persist in the private sector which pose a threat to national malaria control and elimination goals. Several options are discussed to help align the private sector anti-malarial market with national elimination strategies. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-1800-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Sochea Phok
- Population Services Khmer, 29 334 St, Boeung Keng Kang, P. O. Box 258, Phnom Penh, Cambodia
| | - Saysana Phanalasy
- Population Services International Lao PDR, T4 Road Unit 16, Donkai Village, P. O. Box 8723, Vientiane, Lao People's Democratic Republic
| | - Si Thu Thein
- Population Services International Myanmar, 16 West Shwe Gone Dine 4th St, Bahan Township, Yangon, Myanmar
| | - Asawin Likhitsup
- , 108/210 Siphraya River View Condo, Yotha Rd, Sampanthawong, Bangkok, 10100, Thailand
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Atake EH. Sustaining Gains in Health Programs: Technical Efficiency and its Determinants in Malaria Programs in Sub-Saharan Africa. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2017; 15:249-259. [PMID: 27943164 DOI: 10.1007/s40258-016-0294-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Since the year 2000, Africa has made significant progress in the fight against malaria. Between 2000 and 2015, the incidence and death from malaria fell by 42 and 66%, respectively. However, the African region still accounts for most global cases of malaria. In 2015, the region was home to 89% of malaria cases and 91% of malaria death. OBJECTIVE This study aimed to evaluate efficiency of policies against malaria in 30 malaria-endemic Sub-Saharan African (SSA) countries, from the perspective of sustaining gains. METHODS The data came from World Malaria Report 2013. Data were analyzed using the double bootstrap method. We first estimated bootstrapped efficiency scores. Then, bootstrapped truncated regression was used to determine factors associated with malaria program efficiency. RESULTS This study showed that most malaria programs in SSA are technically inefficient. We also found that aid from international institutions and public expenditures on malaria programs do not significantly affect the efficiency of malaria programs. However, in an enhanced governance context, international aid and public expenditure impact positively on the efficiency of malaria programs. Moreover, intermittent preventive treatment for pregnant women is associated with a positive effect on the efficiency. Surprisingly, the free care policies-artemisinin-based combinations for under five-year-old children in the public facilities, rapid diagnostic tests, and distribution of insecticide-treated bed nets and long-lasting insecticide-impregnated nets-does not significantly affect the efficiency of malaria programs. CONCLUSION Financing alone does not ensure efficiency of malaria programs. Good governance and the targeting of the most vulnerable segments of the population are necessary to reduce malaria deaths and improve efficiency of malaria programs in SSA.
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Affiliation(s)
- Esso-Hanam Atake
- Department of Economics Sciences, University of Lome, Lomé, Togo.
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Hopkins H, Bruxvoort KJ, Cairns ME, Chandler CIR, Leurent B, Ansah EK, Baiden F, Baltzell KA, Björkman A, Burchett HED, Clarke SE, DiLiberto DD, Elfving K, Goodman C, Hansen KS, Kachur SP, Lal S, Lalloo DG, Leslie T, Magnussen P, Jefferies LM, Mårtensson A, Mayan I, Mbonye AK, Msellem MI, Onwujekwe OE, Owusu-Agyei S, Reyburn H, Rowland MW, Shakely D, Vestergaard LS, Webster J, Wiseman VL, Yeung S, Schellenberg D, Staedke SG, Whitty CJM. Impact of introduction of rapid diagnostic tests for malaria on antibiotic prescribing: analysis of observational and randomised studies in public and private healthcare settings. BMJ 2017; 356:j1054. [PMID: 28356302 PMCID: PMC5370398 DOI: 10.1136/bmj.j1054] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2017] [Indexed: 01/21/2023]
Abstract
Objectives To examine the impact of use of rapid diagnostic tests for malaria on prescribing of antimicrobials, specifically antibiotics, for acute febrile illness in Africa and Asia.Design Analysisof nine preselected linked and codesigned observational and randomised studies (eight cluster or individually randomised trials and one observational study).Setting Public and private healthcare settings, 2007-13, in Afghanistan, Cameroon, Ghana, Nigeria, Tanzania, and Uganda.Participants 522 480 children and adults with acute febrile illness.Interventions Rapid diagnostic tests for malaria.Main outcome measures Proportions of patients for whom an antibiotic was prescribed in trial groups who had undergone rapid diagnostic testing compared with controls and in patients with negative test results compared with patients with positive results. A secondary aim compared classes of antibiotics prescribed in different settings.Results Antibiotics were prescribed to 127 052/238 797 (53%) patients in control groups and 167 714/283 683 (59%) patients in intervention groups. Antibiotics were prescribed to 40% (35 505/89 719) of patients with a positive test result for malaria and to 69% (39 400/57 080) of those with a negative result. All but one study showed a trend toward more antibiotic prescribing in groups who underwent rapid diagnostic tests. Random effects meta-analysis of the trials showed that the overall risk of antibiotic prescription was 21% higher (95% confidence interval 7% to 36%) in intervention settings. In most intervention settings, patients with negative test results received more antibiotic prescriptions than patients with positive results for all the most commonly used classes: penicillins, trimethoprim-sulfamethoxazole (one exception), tetracyclines, and metronidazole.Conclusions Introduction of rapid diagnostic tests for malaria to reduce unnecessary use of antimalarials-a beneficial public health outcome-could drive up untargeted use of antibiotics. That 69% of patients were prescribed antibiotics when test results were negative probably represents overprescription.This included antibiotics from several classes, including those like metronidazole that are seldom appropriate for febrile illness, across varied clinical, health system, and epidemiological settings. It is often assumed that better disease specific diagnostics will reduce antimicrobial overuse, but they might simply shift it from one antimicrobial class to another. Current global implementation of malaria testing might increase untargeted antibiotic use and must be examined.
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Affiliation(s)
- Heidi Hopkins
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | - Matthew E Cairns
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | - Baptiste Leurent
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | | | | | | | | | - Siân E Clarke
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | | | | | - Kristian S Hansen
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- University of Copenhagen, Copenhagen, DK1014, Denmark
| | | | - Sham Lal
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | - Toby Leslie
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Health Protection Research Organisation, Kabul, Afghanistan
| | - Pascal Magnussen
- Centre for Medical Parasitology, University of Copenhagen and Copenhagen University Hospital, and Department for Veterinary Disease Biology, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Ismail Mayan
- Health Protection Research Organisation, Kabul, Afghanistan
| | - Anthony K Mbonye
- Ministry of Health, Kampala, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | | | - Obinna E Onwujekwe
- Department of Pharmacology and Therapeutics, University of Nigeria, Enugu, Nigeria
| | - Seth Owusu-Agyei
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Kintampo Health Research Centre, Kintampo, Ghana
| | - Hugh Reyburn
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Mark W Rowland
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Delér Shakely
- Centre for Malaria Research, Karolinska Institutet, Stockholm, Sweden, and Health Metrics at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lasse S Vestergaard
- Department of Infectious Disease Epidemiology, Statens Serum Institut, Copenhagen, Denmark
| | - Jayne Webster
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Virginia L Wiseman
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Shunmay Yeung
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | | | - Sarah G Staedke
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
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Chandler CIR, Webb EL, Maiteki-Sebuguzi C, Nayiga S, Nabirye C, DiLiberto DD, Ssemmondo E, Dorsey G, Kamya MR, Staedke SG. The impact of an intervention to introduce malaria rapid diagnostic tests on fever case management in a high transmission setting in Uganda: A mixed-methods cluster-randomized trial (PRIME). PLoS One 2017; 12:e0170998. [PMID: 28288172 PMCID: PMC5347994 DOI: 10.1371/journal.pone.0170998] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 01/12/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Rapid diagnostic tests for malaria (mRDTs) have been scaled-up widely across Africa. The PRIME study evaluated an intervention aiming to improve fever case management using mRDTs at public health centers in Uganda. METHODS A cluster-randomized trial was conducted from 2010-13 in Tororo, a high malaria transmission setting. Twenty public health centers were randomized in a 1:1 ratio to intervention or control. The intervention included training in health center management, fever case management with mRDTs, and patient-centered services; plus provision of mRDTs and artemether-lumefantrine (AL) when stocks ran low. Three rounds of Interviews were conducted with caregivers of children under five years of age as they exited health centers (N = 1400); reference mRDTs were done in children with fever (N = 1336). Health worker perspectives on mRDTs were elicited through semi-structured questionnaires (N = 49) and in-depth interviews (N = 10). The primary outcome was inappropriate treatment of malaria, defined as the proportion of febrile children who were not treated according to guidelines based on the reference mRDT. FINDINGS There was no difference in inappropriate treatment of malaria between the intervention and control arms (24.0% versus 29.7%, adjusted risk ratio 0.81 [95% CI: 0.56, 1.17] p = 0.24). Most children (76.0%) tested positive by reference mRDT, but many were not prescribed AL (22.5% intervention versus 25.9% control, p = 0.53). Inappropriate treatment of children testing negative by reference mRDT with AL was also common (31.3% invention vs 42.4% control, p = 0.29). Health workers appreciated mRDTs but felt that integrating testing into practice was challenging given constraints on time and infrastructure. CONCLUSIONS The PRIME intervention did not have the desired impact on inappropriate treatment of malaria for children under five. In this high transmission setting, use of mRDTs did not lead to the reductions in antimalarial prescribing seen elsewhere. Broader investment in health systems, including infrastructure and staffing, will be required to improve fever case management.
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Affiliation(s)
| | - Emily L. Webb
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Susan Nayiga
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | | | - Grant Dorsey
- Department of Medicine, University of California, San Francisco, United States of America
| | - Moses R. Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Sarah G. Staedke
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- Infectious Diseases Research Collaboration, Kampala, Uganda
- * E-mail:
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Burchett HED, Leurent B, Baiden F, Baltzell K, Björkman A, Bruxvoort K, Clarke S, DiLiberto D, Elfving K, Goodman C, Hopkins H, Lal S, Liverani M, Magnussen P, Mårtensson A, Mbacham W, Mbonye A, Onwujekwe O, Roth Allen D, Shakely D, Staedke S, Vestergaard LS, Whitty CJM, Wiseman V, Chandler CIR. Improving prescribing practices with rapid diagnostic tests (RDTs): synthesis of 10 studies to explore reasons for variation in malaria RDT uptake and adherence. BMJ Open 2017; 7:e012973. [PMID: 28274962 PMCID: PMC5353269 DOI: 10.1136/bmjopen-2016-012973] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The overuse of antimalarial drugs is widespread. Effective methods to improve prescribing practice remain unclear. We evaluated the impact of 10 interventions that introduced rapid diagnostic tests for malaria (mRDTs) on the use of tests and adherence to results in different contexts. DESIGN A comparative case study approach, analysing variation in outcomes across different settings. SETTING Studies from the ACT Consortium evaluating mRDTs with a range of supporting interventions in 6 malaria endemic countries. Providers were governmental or non-governmental healthcare workers, private retail sector workers or community volunteers. Each study arm in a distinct setting was considered a case. PARTICIPANTS 28 cases from 10 studies were included, representing 148 461 patients seeking care for suspected malaria. INTERVENTIONS The interventions included different mRDT training packages, supervision, supplies and community sensitisation. OUTCOME MEASURES Analysis explored variation in: (1) uptake of mRDTs (% febrile patients tested); (2) provider adherence to positive mRDTs (% Plasmodium falciparum positive prescribed/given Artemisinin Combination Treatment); (3) provider adherence to negative mRDTs (% P. falciparum negative not prescribed/given antimalarial). RESULTS Outcomes varied widely across cases: 12-100% mRDT uptake; 44-98% adherence to positive mRDTs; 27-100% adherence to negative mRDTs. Providers appeared more motivated to perform well when mRDTs and intervention characteristics fitted with their own priorities. Goodness of fit of mRDTs with existing consultation and diagnostic practices appeared crucial to maximising the impact of mRDTs on care, as did prior familiarity with malaria testing; adequate human resources and supplies; possible alternative treatments for mRDT-negative patients; a more directive intervention approach and local preferences for ACTs. CONCLUSIONS Basic training and resources are essential but insufficient to maximise the potential of mRDTs in many contexts. Programme design should respond to assessments of provider priorities, expectations and capacities. As mRDTs become established, the intensity of supporting interventions required seems likely to reduce.
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Affiliation(s)
- Helen E D Burchett
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Baptiste Leurent
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Frank Baiden
- Epidemiology Unit, Ensign College of Public Health, Kpong, Ghana
| | - Kimberly Baltzell
- Department of Family Health Care Nursing, and Global Health Science, University of California, Berkeley, California, USA
| | - Anders Björkman
- Department of Microbiology, Tumour and Cell Biology, Karolinska Institute, Stockholm, Sweden
| | - Katia Bruxvoort
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Siân Clarke
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Deborah DiLiberto
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Kristina Elfving
- Department of Infectious Diseases, Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
- Department of Paediatrics, Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
- Department of Microbiology, Tumour and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Catherine Goodman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Heidi Hopkins
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Sham Lal
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Marco Liverani
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Pascal Magnussen
- Faculty of Health and Medical Sciences, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark
| | - Andreas Mårtensson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Wilfred Mbacham
- Laboratory for Public Health Research Biotechnologies, The Biotechnology Center, University of Yaoundé, Yaoundé, Cameroon
| | - Anthony Mbonye
- School of Public Health- Makerere University and Commissioner Health Services, Ministry of Health, Uganda
| | - Obinna Onwujekwe
- Department of Pharmacology and Therapeutics, University of Nigeria Enugu-Campus, Nigeria
| | | | - Delér Shakely
- Department of Microbiology, Tumour and Cell Biology, Karolinska Institute, Stockholm, Sweden
- Department of Medicine, Kungälv Hospital, Sweden
| | - Sarah Staedke
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Lasse S Vestergaard
- Centre for Medical Parasitology, University of Copenhagen and Copenhagen University Hospital Rigshospitalet, Denmark
- Department of Infectious Disease Epidemiology, Statens Serum Institut, Denmark
| | - Christopher J M Whitty
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
- School of Public Health and Community Medicine, Australia
| | - Clare I R Chandler
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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Namuyinga RJ, Mwandama D, Moyo D, Gumbo A, Troell P, Kobayashi M, Shah M, Bauleni A, Vanden Eng J, Rowe AK, Mathanga DP, Steinhardt LC. Health worker adherence to malaria treatment guidelines at outpatient health facilities in southern Malawi following implementation of universal access to diagnostic testing. Malar J 2017; 16:40. [PMID: 28114942 PMCID: PMC5260110 DOI: 10.1186/s12936-017-1693-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 01/12/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Appropriate diagnosis and treatment are essential for reducing malaria mortality. A cross-sectional outpatient health facility (HF) survey was conducted in southern Malawi from January to March 2015 to determine appropriate malaria testing and treatment practices four years after implementation of a policy requiring diagnostic confirmation before treatment. METHODS Enrolled patients were interviewed, examined and had their health booklet reviewed. Health workers (HWs) were asked about training, supervision and access to the 2013 national malaria treatment guidelines. HFs were assessed for malaria diagnostic and treatment capacity. Weighted descriptive analyses and logistic regression of patient, HW and HF characteristics related to testing and treatment were performed. RESULTS An evaluation of 105 HFs, and interviews of 150 HWs and 2342 patients was completed. Of 1427 suspect uncomplicated malaria patients seen at HFs with testing available, 1072 (75.7%) were tested, and 547 (53.2%) tested positive. Testing was more likely if patients spontaneously reported fever (odds ratio (OR) 2.6; 95% confidence interval (CI) 1.7-4.0), headache (OR 1.5; 95% CI 1.1-2.1) or vomiting (OR 2.0; 95% CI 1.0-4.0) to HWs and less likely if they reported skin problems (OR 0.4; 95% CI 0.2-0.6). Altogether, 511 (92.7%) confirmed cases and 98 (60.3%) of 178 presumed uncomplicated malaria patients (at HFs without testing) were appropriately treated, while 500 (96.6%) of 525 patients with negative tests did not receive anti-malarials. Only eight (5.7%) suspect severe malaria patients received appropriate pre-referral treatment. Appropriate treatment was more likely for presumed uncomplicated malaria patients (at HFs without testing) with elevated temperature (OR 1.5/1 °C increase; 95% CI 1.1-1.9), who reported fever to HWs (OR 5.7; 95% CI 1.9-17.6), were seen by HWs with additional supervision visits in the previous 6 months (OR 1.2/additional visit; 95% CI 1.0-1.4), or were seen by older HWs (OR 1.1/year of age; 95% CI 1.0-1.1). CONCLUSIONS Correct testing and treatment practices were reasonably good for uncomplicated malaria when testing was available. Pre-referral treatment for suspect severe malaria was unacceptably rare. Encouraging HWs to elicit and appropriately respond to patient symptoms may improve practices.
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Affiliation(s)
- Ruth J Namuyinga
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Dyson Mwandama
- Malaria Alert Centre, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Dubulao Moyo
- National Malaria Control Programme, Ministry of Health, Lilongwe, Malawi
| | - Austin Gumbo
- National Malaria Control Programme, Ministry of Health, Lilongwe, Malawi
| | - Peter Troell
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Miwako Kobayashi
- National Center for Immunization and Respiratory Diseases, Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Monica Shah
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Andrew Bauleni
- Malaria Alert Centre, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Jodi Vanden Eng
- Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Alexander K Rowe
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Don P Mathanga
- Malaria Alert Centre, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Laura C Steinhardt
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Saweri OPM, Hetzel MW, Mueller I, Siba PM, Pulford J. The treatment of non-malarial febrile illness in Papua New Guinea: findings from cross sectional and longitudinal studies of health worker practice. BMC Health Serv Res 2017; 17:10. [PMID: 28056949 PMCID: PMC5217620 DOI: 10.1186/s12913-016-1965-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 12/20/2016] [Indexed: 11/17/2022] Open
Abstract
Background The Papua New Guinea Department of Health recently shifted from a presumptive to a ‘test and treat’ malaria case management policy. This shift was supported by the widespread introduction of malaria rapid diagnostic tests in health facilities across the country. Health workers received training and job-aids detailing how to conduct and interpret a malaria rapid diagnostic test and how to treat test positive cases; however, little instruction on treating non-malaria febrile cases was provided. Accordingly, this study examined health worker case management of non-malarial febrile patients in the 12-month period immediately following the introduction of the revised malaria case management policy. Methods Data were collected from a country-wide cross-sectional survey of febrile case management at randomly selected health facilities and from longitudinal surveillance at sentinel health facilities. Analysis was restricted to febrile patients who tested negative for malaria infection by rapid diagnostic test (N=303 and 5705 outpatients, respectively). Results and Discussion 96.8% of non-malarial febrile patients received a diagnosis in the longitudinal sample, compared to 52.4% of the cross-sectional sample. Respiratory tract infections were the most commonly reported diagnoses. Over 90% of patients in both samples were prescribed one or more medications, most commonly an analgesic (71.3 & 72.9% of the longitudinal and cross-sectional samples, respectively), some form of antibiotic (72.7 & 73.4%, respectively) and/or an anthelminthic (17.9 & 16.5%, respectively). Prescribing behaviour was adherent with the recommendations in the standard treatment guidelines in fewer than 20% of cases (longitudinal sample only). Conclusion Many non-malarial febrile patients are not provided with a diagnosis. When diagnoses are provided they are typically some form of respiratory tract infection. Antibiotics and analgesics are widely prescribed, although medications prescribed rarely adhere to the Papua New Guinea standard treatment guidelines. These findings indicate that Papua New Guinea health workers require support for non-malarial febrile illness case management. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1965-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Olga P M Saweri
- Papua New Guinea Institute of Medical Research (PNGIMR), PO Box 60, Goroka, EHP 441, Papua New Guinea
| | - Manuel W Hetzel
- Swiss Tropical and Public Health Institute, PO Box, 4002, Basel, Switzerland.,University of Basel, Petersplatz 1, 4003, Basel, Switzerland
| | - Ivo Mueller
- Barcelona Centre for International Health Research (CRESIB, Hospital Clínic-Universitat de Barcelona), Barcelona, Spain.,Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
| | - Peter M Siba
- Papua New Guinea Institute of Medical Research (PNGIMR), PO Box 60, Goroka, EHP 441, Papua New Guinea
| | - Justin Pulford
- Papua New Guinea Institute of Medical Research (PNGIMR), PO Box 60, Goroka, EHP 441, Papua New Guinea. .,Liverpool School of Tropical Medicine, Liverpool, UK.
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Rambaud-Althaus C, Shao A, Samaka J, Swai N, Perri S, Kahama-Maro J, Mitchell M, D'Acremont V, Genton B. Performance of Health Workers Using an Electronic Algorithm for the Management of Childhood Illness in Tanzania: A Pilot Implementation Study. Am J Trop Med Hyg 2016; 96:249-257. [PMID: 28077751 DOI: 10.4269/ajtmh.15-0395] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 07/20/2016] [Indexed: 11/07/2022] Open
Abstract
In low-resource settings, where qualified health workers (HWs) are scarce and childhood mortality high, rational antimicrobial prescription for childhood illnesses is a challenge. To assess whether smartphones running guidelines, as compared with paper support, improve consultation process and rational use of medicines for children, a pilot cluster-randomized controlled study was conducted in Tanzania. Nine primary health-care facilities (HFs) were randomized into three arms: 1) paper algorithm, 2) electronic algorithm on a smartphone, and 3) control. All HWs attending children aged 2-59 months for acute illness in intervention HFs were trained on a new clinical algorithm for management of childhood illness (ALMANACH) either on 1) paper or 2) electronic support; 4 months after training, consultations were observed. An expert consultation was the reference for classification and treatment. Main outcomes were proportion of children checked for danger signs, and antibiotics prescription rate. A total of 504 consultations (166, 171, and 167 in control, paper, and phone arms, respectively) were observed. The use of smartphones versus paper was associated with a significant increase in children checked for danger signs (41% versus 74%, P = 0.04). Antibiotic prescriptions rate dropped from 70% in the control to 26%, and 25% in paper and electronic arms. The HWs-expert agreement on pneumonia classification remained low (expert's pneumonia identified by HWs in 26%, 30%, and 39% of patients, respectively).Mobile technology in low-income countries is implementable and has a potential to improve HWs' performance. Additional point-of-care diagnostic tests are needed to ensure appropriate management. Improving the rational use of antimicrobial is a challenge that ALMANACH can help to take up.
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Affiliation(s)
- Clotilde Rambaud-Althaus
- Swiss Tropical and Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.,Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Amani Shao
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Tukuyu Medical Research Center, National Institute for Medical Research, Dar es Salaam, United Republic of Tanzania
| | - Josephine Samaka
- City Medical Office of Health, Dar es Salaam City Council, Tanzania
| | - Ndeniria Swai
- City Medical Office of Health, Dar es Salaam City Council, Tanzania
| | | | | | - Marc Mitchell
- Harvard School of Public Health, Boston, Massachusetts
| | - Valérie D'Acremont
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Travel Clinic, Department of Ambulatory Care and Community Medicine, and Infectious Disease Service, University of Lausanne, Lausanne, Switzerland
| | - Blaise Genton
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Travel Clinic, Department of Ambulatory Care and Community Medicine, and Infectious Disease Service, University of Lausanne, Lausanne, Switzerland
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25
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Burnett SM, Mbonye MK, Martin R, Ronald A, Zawedde-Muyanja S, Willis KS, Colebunders R, Manabe YC, Weaver MR. Effect of On-Site Support on Laboratory Practice for Human Immunodeficiency Virus, Tuberculosis, and Malaria Testing. Am J Clin Pathol 2016; 146:469-77. [PMID: 27686173 DOI: 10.1093/ajcp/aqw138] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To evaluate the effect of on-site support in improving human immunodeficiency virus (HIV) rapid testing, tuberculosis (TB) sputum microscopy, and malaria microscopy among laboratory staff in a low-resource setting. METHODS This cluster randomized trial was conducted at 36 health facilities in Uganda. From April to December 2010, laboratory staff at 18 facilities participated in monthly on-site visits, and 18 served as control facilities. After intervention, 128 laboratory staff were observed performing 587 laboratory tests across three diseases: HIV rapid testing, TB sputum microscopy, and malaria microscopy. Outcomes were the proportion of laboratory procedures correctly completed for the three laboratory tests. RESULTS Laboratory staff in the intervention arm performed significantly better than the control arm in correctly completing laboratory procedures for all three laboratory tests, with an adjusted relative risk (95% confidence interval) of 1.18 (1.10-1.26) for HIV rapid testing, 1.29 (1.21-1.40) for TB sputum microscopy, and 1.19 (1.11-1.27) for malaria microscopy. CONCLUSIONS On-site support significantly improved laboratory practices in conducting HIV rapid testing, TB sputum microscopy, and malaria microscopy. It could be an effective method for improving laboratory practice, without taking limited laboratory staff away from health facilities for training.
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Affiliation(s)
- Sarah M Burnett
- From Accordia Global Health Foundation, Washington, DC Department of Epidemiology and Social Medicine, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Martin K Mbonye
- Infectious Diseases Institute, College of Health Sciences, University Research Co, LLC, Kampala, Uganda
| | - Robert Martin
- International Training and Education Center for Health (I-TECH), Department of Global Health, University of Washington, Seattle
| | - Allan Ronald
- Department of Medicine, University of Manitoba, Winnipeg, Canada
| | - Stella Zawedde-Muyanja
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Robert Colebunders
- Epidemiology for Global Health Institute, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Yukari C Manabe
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Marcia R Weaver
- International Training and Education Center for Health (I-TECH), Department of Global Health, University of Washington, Seattle
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26
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Msellemu D, Namango HI, Mwakalinga VM, Ntamatungiro AJ, Mlacha Y, Mtema ZJ, Kiware S, Lobo NF, Majambere S, Dongus S, Drakeley CJ, Govella NJ, Chaki PP, Killeen GF. The epidemiology of residual Plasmodium falciparum malaria transmission and infection burden in an African city with high coverage of multiple vector control measures. Malar J 2016; 15:288. [PMID: 27216734 PMCID: PMC4877954 DOI: 10.1186/s12936-016-1340-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 05/11/2016] [Indexed: 12/11/2022] Open
Abstract
Background In the Tanzanian city of Dar es Salaam, high coverage of long-lasting insecticidal nets (LLINs), larvicide application (LA) and mosquito-proofed housing, was complemented with improved access to artemisinin-based combination therapy and rapid diagnostic tests by the end of 2012. Methods Three rounds of city-wide, cluster-sampled cross-sectional surveys of malaria parasite infection status, spanning 2010 to 2012, were complemented by two series of high-resolution, longitudinal surveys of vector density. Results Larvicide application using a granule formulation of Bacillus thuringiensis var. israelensis (Bti) had no effect upon either vector density (P = 0.820) or infection prevalence (P = 0.325) when managed by a private-sector contractor. Infection prevalence rebounded back to 13.8 % in 2010, compared with <2 % at the end of a previous Bti LA evaluation in 2008. Following transition to management by the Ministry of Health and Social Welfare (MoHSW), LA consistently reduced vector densities, first using the same Bti granule in early 2011 [odds ratio (OR) (95 % confidence interval (CI)) = 0.31 (0.14, 0.71), P = 0.0053] and then a pre-diluted aqueous suspension formulation from mid 2011 onwards [OR (95 % CI) = 0.15 (0.07, 0.30), P ≪ 0.000001]. While LA by MoHSW with the granule formulation was associated with reduced infection prevalence [OR (95 % CI) = 0.26 (0.12, 0.56), P = 0.00040], subsequent liquid suspension use, following a mass distribution to achieve universal coverage of LLINs that reduced vector density [OR (95 % CI) = 0.72 (0.51, 1.01), P = 0.057] and prevalence [OR (95 % CI) = 0.80 (0.69, 0.91), P = 0.0013], was not associated with further prevalence reduction (P = 0.836). Sleeping inside houses with complete window screens only reduced infection risk [OR (95 % CI) = 0.71 (0.62, 0.82), P = 0.0000036] if the evenings and mornings were also spent indoors. Furthermore, infection risk was only associated with local vector density [OR (95 % CI) = 6.99 (1.12, 43.7) at one vector mosquito per trap per night, P = 0.037] among the minority (14 %) of households lacking screening. Despite attenuation of malaria transmission and immunity, 88 % of infected residents experienced no recent fever, only 0.4 % of these afebrile cases had been treated for malaria, and prevalence remained high (9.9 %) at the end of the study. Conclusions While existing vector control interventions have dramatically attenuated malaria transmission in Dar es Salaam, further scale-up and additional measures to protect against mosquito bites outdoors are desirable. Accelerated elimination of chronic human infections persisting at high prevalence will require active, population-wide campaigns with curative drugs. Electronic supplementary material The online version of this article (doi:10.1186/s12936-016-1340-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daniel Msellemu
- Environmental Health and Ecological Sciences Thematic Group, Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania.,Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, UK
| | - Hagai I Namango
- Environmental Health and Ecological Sciences Thematic Group, Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania.,School of Biological Sciences, University of Nairobi, Nairobi, Kenya
| | - Victoria M Mwakalinga
- Environmental Health and Ecological Sciences Thematic Group, Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alex J Ntamatungiro
- Environmental Health and Ecological Sciences Thematic Group, Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania.,Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, UK
| | - Yeromin Mlacha
- Environmental Health and Ecological Sciences Thematic Group, Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania.,Department of Vector Biology, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Zacharia J Mtema
- Environmental Health and Ecological Sciences Thematic Group, Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Samson Kiware
- Environmental Health and Ecological Sciences Thematic Group, Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania.,Department of Mathematics, Statistics and Computer Science, Marquette University, Milwaukee, WI, USA
| | - Neil F Lobo
- Eck Institute for Global Health, Notre Dame University, Notre Dame, IN, USA
| | - Silas Majambere
- Environmental Health and Ecological Sciences Thematic Group, Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania.,Department of Vector Biology, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Stefan Dongus
- Environmental Health and Ecological Sciences Thematic Group, Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania.,Department of Vector Biology, Liverpool School of Tropical Medicine, Liverpool, UK.,Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Christopher J Drakeley
- Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, UK
| | - Nicodem J Govella
- Environmental Health and Ecological Sciences Thematic Group, Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania.,Department of Vector Biology, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Prosper P Chaki
- Environmental Health and Ecological Sciences Thematic Group, Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania.,Department of Vector Biology, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Gerry F Killeen
- Environmental Health and Ecological Sciences Thematic Group, Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania. .,Department of Vector Biology, Liverpool School of Tropical Medicine, Liverpool, UK.
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27
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Zurovac D, Guintran JO, Donald W, Naket E, Malinga J, Taleo G. Health systems readiness and management of febrile outpatients under low malaria transmission in Vanuatu. Malar J 2015; 14:489. [PMID: 26630927 PMCID: PMC4668700 DOI: 10.1186/s12936-015-1017-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 11/24/2015] [Indexed: 11/17/2022] Open
Abstract
Background Vanuatu, an archipelago country in Western Pacific harbouring low Plasmodium falciparum and Plasmodium vivax malaria transmission, has been implementing a malaria case management policy, recommending parasitological testing of patients with fever and anti-malarial treatment for test-positive only patients. A health facility survey to evaluate the health systems readiness to implement the policy and the quality of outpatient management for patients with fever was undertaken. Methods A cross-sectional, cluster sample survey, using a range of quality-of-care methods, included all health centres and hospitals in Vanuatu. The main outcome measures were coverage of health facilities and health workers with commodities and support interventions, adherence to test and treatment recommendations, and factors influencing malaria testing. Results The survey was undertaken in 2014 during the low malaria season and included 41 health facilities, 67 health workers and 226 outpatient consultations for patients with fever. All facilities had capacity for parasitological diagnosis, 95.1 % stocked artemether-lumefantrine and 63.6 % primaquine. The coverage of health workers with support interventions ranged from 50 to 70 %. Health workers’ knowledge was high only regarding treatment policy for uncomplicated P. falciparum malaria (83.4 %). History taking and clinical examination practices were sub-optimal. Some 35.0 % (95 % CI 23.4–48.6) of patients with fever were tested for malaria, of which all results were negative and only one patient received anti-malarial treatment. Testing was significantly higher for patients age 5 years and older (OR = 2.33; 95 % CI 1.48–5.02), seen by less qualified health workers (OR = 2.73; 95 % CI 1.48–5.02), health workers who received malaria case management training (OR = 2.39; 95 % CI 1.28–4.47) and patients with increased temperature (OR = 2.56; 95 % CI 1.17–5.57), main complaint of fever (OR = 5.82; 95 % CI 1.26–26.87) and without runny nose (OR = 3.75; 95 % CI 1.36–10.34). Antibiotic use was very high (77.4 %) with sub-optimal dispensing and counselling practices. Conclusions Health facility and health worker readiness to implement policy is higher for falciparum than vivax malaria. Clinical and malaria testing practices are sub-optimal, however adherence to test negative results is nearly universal. Use of antibiotics is irrational. Quantitative and qualitative improvements of ongoing interventions are needed to re-inforce clinical practices in this area characterized by difficult access, human resource shortages but aspiring towards malaria elimination.
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Affiliation(s)
- Dejan Zurovac
- Department of Public Health Research, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya. .,Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK. .,Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA.
| | - Jean-Olivier Guintran
- Malaria, Other Vector Borne and Parasitic Diseases Programme, World Health Organization, Port Vila, Vanuatu.
| | - Wesley Donald
- National Vector Borne Disease Control Programme, Ministry of Health, Port Vila, Vanuatu.
| | - Esau Naket
- National Vector Borne Disease Control Programme, Ministry of Health, Port Vila, Vanuatu.
| | - Josephine Malinga
- Department of Public Health Research, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.
| | - George Taleo
- National Vector Borne Disease Control Programme, Ministry of Health, Port Vila, Vanuatu.
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28
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Hutchinson E, Reyburn H, Hamlyn E, Long K, Meta J, Mbakilwa H, Chandler C. Bringing the state into the clinic? Incorporating the rapid diagnostic test for malaria into routine practice in Tanzanian primary healthcare facilities. Glob Public Health 2015; 12:1077-1091. [PMID: 26457440 PMCID: PMC5526135 DOI: 10.1080/17441692.2015.1091025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The roles that rapid, point-of-care tests will play in healthcare in low-income settings are likely to expand over the coming years. Yet, very little is known about how they are incorporated into practice, and what it means to use and rely upon them. This paper focuses on the rapid diagnostic test for malaria (mRDT), examining its introduction into low-level public health facilities in Tanzania within an intervention to improve the targeting of costly malaria medication. We interviewed 26 health workers to explore how a participatory training programme, mobile phone messages, posters and leaflets shaped the use and interpretation of the test. Drawing on notions of biopolitics, this paper examines how technologies of the self and mechanisms of surveillance bolstered the role mRDT in clinical decision-making. It shows how the significance of the test interacted with local knowledge, the availability of other medication, and local understandings of good clinical practice. Our findings suggest that in a context in which care is reduced to the provision of medicines, strict adherence to mRDT results may be underpinned by increasing the use of other pharmaceuticals or may leave health workers with patients for whom they are unable to provide care.
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Affiliation(s)
- Eleanor Hutchinson
- a Department of Global Health and Development , London School of Hygiene and Tropical Medicine , London , UK
| | - Hugh Reyburn
- b Department of Disease Control and Vector Biology , London School of Hygiene and Tropical Medicine , London , UK
| | - Eleanor Hamlyn
- a Department of Global Health and Development , London School of Hygiene and Tropical Medicine , London , UK
| | - Katie Long
- a Department of Global Health and Development , London School of Hygiene and Tropical Medicine , London , UK
| | - Judith Meta
- c Joint Malaria Programme , Kilimanjaro Christian Medical Centre , Moshi , Tanzania
| | - Hilda Mbakilwa
- c Joint Malaria Programme , Kilimanjaro Christian Medical Centre , Moshi , Tanzania
| | - Clare Chandler
- a Department of Global Health and Development , London School of Hygiene and Tropical Medicine , London , UK
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29
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Boyce RM, Muiru A, Reyes R, Ntaro M, Mulogo E, Matte M, Siedner MJ. Impact of rapid diagnostic tests for the diagnosis and treatment of malaria at a peripheral health facility in Western Uganda: an interrupted time series analysis. Malar J 2015; 14:203. [PMID: 25971788 PMCID: PMC4435913 DOI: 10.1186/s12936-015-0725-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 05/06/2015] [Indexed: 11/29/2022] Open
Abstract
Background The World Health Organization recommends that all suspected malaria cases receive a parasitological diagnosis prior to treatment with artemisinin-based combination therapy. A recent meta-analysis of clinical trials evaluating RDTs for the management of patients with fever found substantial reductions in anti-malarial prescriptions when health workers adhered to treatment protocols based on test results. However few studies have reported on the impact of RDTs on health systems outside research settings. Methods The study comprised a retrospective interrupted time series analysis, comparing rates of malaria diagnosis, treatment, and resource utilization before and after introduction of RDTs at a peripheral health facility in rural Western Uganda. The use of malaria diagnostic tests was graphically depicted throughout the study period and fit regression models to identify correlates of three outcomes of interest: (1) length of stay (2) the proportion of patients referred to a higher-level health facility, and (3) administration of antibiotics. Results Over the course of the study period, 14,357 individuals underwent diagnostic testing for malaria with either a RDT (9,807) or microscopy (4,550). The proportion of patients with parasite-based diagnoses more than tripled to 34 % after the introduction of RDTs. RDTs largely replaced microscopy as the diagnostic method of choice. Compared to patients admitted during the pre-RDT period, patients admitted to the health centre with malaria in the post-RDT period had significantly reduced odds of being referred to another health centre (AOR = 0.49, P = 0.038), receiving antibiotics (AOR = 0.42, P < 0.001), and a significantly shorter mean length of stay (β = −0.32 days, 95 %CI −0.52 to −0.13). Conclusions This study is one of the few to demonstrate significant improvement in clinical outcomes and process measures following the introduction of RDTs for the diagnosis of malaria at a rural health facility in Uganda. The results show a reduction in referrals and shorter mean inpatient LOS even as antibiotics were prescribed less frequently. This change greatly increased laboratory throughput and the resultant proportion of patients receiving a parasite-based diagnosis.
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Affiliation(s)
- Ross M Boyce
- Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, 02114, USA.
| | - Anthony Muiru
- Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, 02114, USA. .,Center for Global Health, Massachusetts General Hospital, 100 Cambridge Street #1540, Boston, 02114, USA.
| | - Raquel Reyes
- Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, 02114, USA.
| | - Moses Ntaro
- Department of Community Health, Mbarara University of Science & Technology, P.O. Box 1410, Mbarara, Uganda.
| | - Edgar Mulogo
- Department of Community Health, Mbarara University of Science & Technology, P.O. Box 1410, Mbarara, Uganda.
| | - Michael Matte
- Department of Community Health, Mbarara University of Science & Technology, P.O. Box 1410, Mbarara, Uganda.
| | - Mark J Siedner
- Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, 02114, USA. .,Center for Global Health, Massachusetts General Hospital, 100 Cambridge Street #1540, Boston, 02114, USA.
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30
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Faust C, Zelner J, Brasseur P, Vaillant M, Badiane M, Cisse M, Grenfell B, Olliaro P. Assessing drivers of full adoption of test and treat policy for malaria in Senegal. Am J Trop Med Hyg 2015; 93:159-167. [PMID: 25962776 PMCID: PMC4497889 DOI: 10.4269/ajtmh.14-0595] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 01/22/2015] [Indexed: 11/07/2022] Open
Abstract
Malaria treatment policy has changed from presumptive treatment to targeted "test and treat" (T&T) with malaria rapid diagnostic tests (RDTs) and artemisinin combination therapy (ACT). This transition involves changing behavior among health providers, meaning delays between introduction and full implementation are recorded in almost every instance. We investigated factors affecting successful transition, and suggest approaches for accelerating uptake of T&T. Records from 2000 to 2011 from health clinics in Senegal where malaria is mesoendemic were examined (96,166 cases). The study period encompassed the implementation of national T&T policy in 2006. Analysis showed that adherence to test results is the first indicator of T&T adoption and is dependent on accumulation of experience with positive RDTs (odds ratio [OR]: 0.55 [P ≤ 0.001], 95% confidence interval [CI]: 0.53-0.58). Reliance on tests for malaria diagnosis (rather than presumptive diagnosis) followed after test adherence is achieved, and was also associated with increased experience with positive RDTs (OR: 0.60 [P ≤ 0.001], 95% CI: 0.58-0.62). Logistic models suggest that full adoption of T&T clinical practices can occur within 2 years, that monitoring these behavioral responses rather than RDT or ACT consumption will improve evaluation of T&T uptake, and that accelerating T&T uptake by focusing training on adherence to test results will reduce overdiagnosis and associated health and economic costs in mesoendemic regions.
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Affiliation(s)
- Christina Faust
- *Address correspondence to Christina Faust, Department of Ecology and Evolutionary Biology, 106A Guyot Hall, Princeton University, Princeton, NJ 08542. E-mail:
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31
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Johansson EW, Gething PW, Hildenwall H, Mappin B, Petzold M, Peterson SS, Selling KE. Effect of diagnostic testing on medicines used by febrile children less than five years in 12 malaria-endemic African countries: a mixed-methods study. Malar J 2015; 14:194. [PMID: 25957881 PMCID: PMC4432948 DOI: 10.1186/s12936-015-0709-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 04/27/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In 2010, WHO revised guidelines to recommend testing all suspected malaria cases prior to treatment. Yet, evidence to assess programmes is largely derived from limited facility settings in a limited number of countries. National surveys from 12 sub-Saharan African countries were used to examine the effect of diagnostic testing on medicines used by febrile children under five years at the population level, including stratification by malaria risk, transmission season, source of care, symptoms, and age. METHODS Data were compiled from 12 Demographic and Health Surveys in 2010-2012 that reported fever prevalence, diagnostic test and medicine use, and socio-economic covariates (n=16,323 febrile under-fives taken to care). Mixed-effects logistic regression models quantified the influence of diagnostic testing on three outcomes (artemisinin combination therapy (ACT), any anti-malarial or any antibiotic use) after adjusting for data clustering and confounding covariates. For each outcome, interactions between diagnostic testing and the following covariates were separately tested: malaria risk, season, source of care, symptoms, and age. A multiple case study design was used to understand varying results across selected countries and sub-national groups, which drew on programme documents, published research and expert consultations. A descriptive typology of plausible explanations for quantitative results was derived from a cross-case synthesis. RESULTS Significant variability was found in the effect of diagnostic testing on ACT use across countries (e.g., Uganda OR: 0.84, 95% CI: 0.66-1.06; Mozambique OR: 3.54, 95% CI: 2.33-5.39). Four main themes emerged to explain results: available diagnostics and medicines; quality of care; care-seeking behaviour; and, malaria epidemiology. CONCLUSIONS Significant country variation was found in the effect of diagnostic testing on paediatric fever treatment at the population level, and qualitative results suggest the impact of diagnostic scale-up on treatment practices may not be straightforward in routine conditions given contextual factors (e.g., access to care, treatment-seeking behaviour or supply stock-outs). Despite limitations, quantitative results could help identify countries (e.g., Mozambique) or issues (e.g., malaria risk) where facility-based research or programme attention may be warranted. The mixed-methods approach triangulates different evidence to potentially provide a standard framework to assess routine programmes across countries or over time to fill critical evidence gaps.
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Affiliation(s)
- Emily White Johansson
- Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, SE-751 85, Uppsala, Sweden.
| | - Peter W Gething
- Spatial Ecology and Epidemiology Group, Department of Zoology, University of Oxford, South Parks Road, OX1 3PS, Oxford, UK.
| | - Helena Hildenwall
- Global Health - Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, SE-171 77, Stockholm, Sweden.
| | - Bonnie Mappin
- Spatial Ecology and Epidemiology Group, Department of Zoology, University of Oxford, South Parks Road, OX1 3PS, Oxford, UK.
| | - Max Petzold
- University of Gothenburg, The Sahlgrenska Academy, Health Metrics, Box 414, SE-405 30, Gothenburg, Sweden.
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Stefan Swartling Peterson
- Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, SE-751 85, Uppsala, Sweden.
- Global Health - Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, SE-171 77, Stockholm, Sweden.
- Makerere University School of Public Health, College of Health Sciences, PO Box 7072, Kampala, Uganda.
| | - Katarina Ekholm Selling
- Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, SE-751 85, Uppsala, Sweden.
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32
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Aung T, White C, Montagu D, McFarland W, Hlaing T, Khin HSS, San AK, Briegleb C, Chen I, Sudhinaraset M. Improving uptake and use of malaria rapid diagnostic tests in the context of artemisinin drug resistance containment in eastern Myanmar: an evaluation of incentive schemes among informal private healthcare providers. Malar J 2015; 14:105. [PMID: 25885581 PMCID: PMC4355503 DOI: 10.1186/s12936-015-0621-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 02/22/2015] [Indexed: 11/10/2022] Open
Abstract
Background As efforts to contain artemisinin resistance and eliminate Plasmodium falciparum intensify, the accurate diagnosis and prompt effective treatment of malaria are increasingly needed in Myanmar and the Greater Mekong Sub-region (GMS). Rapid diagnostic tests (RDTs) have been shown to be safe, feasible, and effective at promoting appropriate treatment for suspected malaria, which are of particular importance to drug resistance containment. The informal private sector is often the first point of care for fever cases in malaria endemic areas across Myanmar and the GMS, but there is little published information about informal private provider practices, quality of service provision, or potential to contribute to malaria control and elimination efforts. This study tested different incentives to increase RDT use and improve the quality of care among informal private healthcare providers in Myanmar. Methods The study randomized six townships in the Mon and Shan states of rural Myanmar into three intervention arms: 1) RDT price subsidies, 2) price subsidies with product-related financial incentives, and 3) price subsidies with intensified information, education and counselling (IEC). The study assessed the uptake of RDT use in the communities by cross-sectional surveys of 3,150 households at baseline and six months post-intervention (6,400 households total, 832 fever cases). The study also used mystery clients among 171 providers to assess quality of service provision across intervention arms. Results The pilot intervention trained over 600 informal private healthcare providers. The study found a price subsidy with intensified IEC, resulted in the highest uptake of RDTs in the community, as compared to subsidies alone or merchandise-related financial incentives. Moreover, intensified IEC led to improvements in the quality of care, with mystery client surveys showing almost double the number of correct treatment following diagnostic test results as compared to a simple subsidy. Conclusions Results show that training and quality supervision of informal private healthcare providers can result in improved demand for, and appropriate use of RDTs in drug resistance containment areas in eastern Myanmar. Future studies should assess the sustainability of such interventions and the scale and level of intensity required over time as public sector service provision expands.
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Affiliation(s)
- Tin Aung
- Population Services International, Yangon, Myanmar.
| | | | - Dominic Montagu
- Global Health Sciences, University of California, San Francisco, CA, USA.
| | - Willi McFarland
- Global Health Sciences, University of California, San Francisco, CA, USA.
| | - Thaung Hlaing
- Department of Health, National Malaria Control Programme, Yangon, Myanmar.
| | | | | | - Christina Briegleb
- Global Health Sciences, University of California, San Francisco, CA, USA.
| | - Ingrid Chen
- Global Health Sciences, University of California, San Francisco, CA, USA.
| | - May Sudhinaraset
- Global Health Sciences, University of California, San Francisco, CA, USA.
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Bruxvoort K, Kalolella A, Cairns M, Festo C, Kenani M, Lyaruu P, Kachur SP, Schellenberg D, Goodman C. Are Tanzanian patients attending public facilities or private retailers more likely to adhere to artemisinin-based combination therapy? Malar J 2015; 14:87. [PMID: 25889767 PMCID: PMC4340668 DOI: 10.1186/s12936-015-0602-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 02/02/2015] [Indexed: 11/30/2022] Open
Abstract
Background Artemisinin combination therapy (ACT) is first-line treatment for malaria in most endemic countries and is increasingly available in the private sector. Most studies on ACT adherence have been conducted in the public sector, with minimal data from private retailers. Methods Parallel studies were conducted in Tanzania, in which patients obtaining artemether-lumefantrine (AL) at 40 randomly selected public health facilities and 37 accredited drug dispensing outlets (ADDOs) were visited at home and questioned about doses taken. The effect of sector on adherence, controlling for potential confounders was assessed using logistic regression with a random effect for outlet. Results Of 572 health facility patients and 450 ADDO patients, 74.5% (95% CI: 69.8, 78.8) and 69.8% (95% CI: 64.6, 74.5), respectively, completed treatment and 46.0% (95% CI: 40.9, 51.2) and 34.8% (95% CI: 30.1, 39.8) took each dose at the correct time (‘timely completion’). ADDO patients were wealthier, more educated, older, sought care later in the day, and were less likely to test positive for malaria than health facility patients. Controlling for patient characteristics, the adjusted odds of completed treatment and of timely completion for ADDO patients were 0.65 (95% CI: 0.43, 1.00) and 0.69 (95% CI: 0.47, 1.01) times that of health facility patients. Higher socio-economic status was associated with both adherence measures. Higher education was associated with completed treatment (adjusted OR = 1.68, 95% CI: 1.20, 2.36); obtaining AL in the evening was associated with timely completion (adjusted OR = 0.35, 95% CI: 0.19, 0.64). Factors associated with adherence in each sector were examined separately. In both sectors, recalling correct instructions was positively associated with both adherence measures. In health facility patients, but not ADDO patients, taking the first dose of AL at the outlet was associated with timely completion (adjusted OR = 2.11, 95% CI: 1.46, 3.04). Conclusion When controlling for patient characteristics, there was some evidence that the adjusted odds of adherence for ADDO patients was lower than that for public health facility patients. Better understanding is needed of which patient care aspects are most important for adherence, including the role of effective provision of advice. Electronic supplementary material The online version of this article (doi:10.1186/s12936-015-0602-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | - Matthew Cairns
- London School of Hygiene and Tropical Medicine, London, UK.
| | | | - Mitya Kenani
- Ifakara Health Institute, Dar es Salaam, Tanzania.
| | - Peter Lyaruu
- Ifakara Health Institute, Dar es Salaam, Tanzania.
| | - S Patrick Kachur
- Malaria Branch, Centers for Disease Control and Prevention, Atlanta, USA.
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Sudhinaraset M, Briegleb C, Aung M, Khin HSS, Aung T. Motivation and challenges for use of malaria rapid diagnostic tests among informal providers in Myanmar: a qualitative study. Malar J 2015; 14:61. [PMID: 25889046 PMCID: PMC4328784 DOI: 10.1186/s12936-015-0585-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 01/25/2015] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Rapid diagnostic tests (RDTs) for malaria enable proper diagnosis and have been shown to reduce overuse of artemisinin combination therapy. Few studies have evaluated the feasibility and use of RDTs in the private sector in Myanmar. The objectives of the study were to: 1) understand the acceptability of using RDTs in the informal sector in Myanmar; 2) examine motivations for use among informal providers; and, 3) highlight decision-making and knowledge of providers for diagnostic testing and treatment. METHODS Qualitative interviews were conducted with 30 informal providers. Purposeful sampling was used to enrol study participants in the Mon and Shan State in Myanmar. All interviews were conducted in Burmese, translated into English, and two researchers coded all interviews using Atlas ti. RESULTS Major themes identified included: 1) informal provider and outlet characteristics, including demographic and background characteristics; 2) the benefits and challenges of using RDTs according to providers; 3) provider experiences with using RDTs, including motivations for using the RDT; 4) adherence to test results, either positive or negative; and, 5) recommendations from informal providers to promote increased use of RDTs in their communities. This study found that introducing RDTs to informal providers in Myanmar was feasible, resulting in improved provider empowerment and patient-provider relationships. Specific challenges included facility infrastructure to use and dispose RDTs and provider knowledge. This varied across the type of informal provider, with itinerant drug vendors more comfortable and knowledgeable about RDTs compared to general retail sellers and medical drug representatives. CONCLUSIONS This study found informal providers in Myanmar found the introduction of RDTs to be highly acceptable. Providers discussed improvement in service quality including provider empowerment and patient-provider relationships. The study also highlighted a number of challenges that informal providers face which may be used for future development of interventions.
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Affiliation(s)
- May Sudhinaraset
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA.
- Global Health Group, Global Health Sciences, University of California, San Francisco, CA, USA.
| | - Christina Briegleb
- Global Health Group, Global Health Sciences, University of California, San Francisco, CA, USA.
| | - Moe Aung
- Population Services International, Yangon, Myanmar.
| | | | - Tin Aung
- Population Services International, Yangon, Myanmar.
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Chandler CIR, Meta J, Ponzo C, Nasuwa F, Kessy J, Mbakilwa H, Haaland A, Reyburn H. The development of effective behaviour change interventions to support the use of malaria rapid diagnostic tests by Tanzanian clinicians. Implement Sci 2014; 9:83. [PMID: 24969367 PMCID: PMC4227094 DOI: 10.1186/1748-5908-9-83] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 06/09/2014] [Indexed: 12/30/2022] Open
Abstract
Background Parasitological confirmation is now recommended for all cases of suspected malaria. The roll-out of rapid diagnostic tests (RDTs) is hoped to enable this goal in low resource settings through point of care testing. However, simply making RDTs available has not led to high uptake of the tests or adherence to results by clinicians, with malaria continuing to be overdiagnosed in many settings. We undertook to design an evidence-based intervention package that would be sufficient to support the introduction of RDTs at dispensaries in Tanzania, to be evaluated through the Targeting Artemisinin Combination Therapy (TACT) cluster randomised controlled trial. Methods We describe five steps in our intervention design: formative research, review of existing evidence and theory, a workshop to define the intervention approach and content and results of formative research, engagement with behaviour change theory and literature, detailed design of intervention materials and piloting and pretesting of intervention materials. This involved fieldwork with a total of 19 health workers and 212 community members in northeast Tanzania. Results The formative research suggested that RDTs were a potential source of conflict in the health worker-patient interaction, but that health workers used various techniques to resolve this, including provision of antimalarial drugs for RDT-negative patients. Our reviews showed that evidence was mixed regarding the effectiveness of different methods and theories to support change in prescribing practice. Our design process is presented, drawing from this collective evidence. We describe the final TACT intervention package (including interactive small group workshops, feedback text messages, motivational text messages and patient information leaflets and posters) in terms of its programme theory and implementation theory. Conclusions Our study suggests that evidence-based design of complex interventions is possible. The use of formative research to understand malaria overdiagnosis in context was central to the design of the intervention as well as empirical research to test materials and methods prior to implementation. The TACT interventions may be appropriate for other settings where clinicians face similar challenges with malaria diagnostics. Trial registration NCT01292707.
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Affiliation(s)
- Clare I R Chandler
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK.
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Ruizendaal E, Dierickx S, Peeters Grietens K, Schallig HDFH, Pagnoni F, Mens PF. Success or failure of critical steps in community case management of malaria with rapid diagnostic tests: a systematic review. Malar J 2014; 13:229. [PMID: 24924295 PMCID: PMC4084582 DOI: 10.1186/1475-2875-13-229] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 04/22/2014] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Malaria still causes high morbidity and mortality around the world, mainly in sub-Saharan Africa. Community case management of malaria (CCMm) by community health workers (CHWs) is one of the strategies to combat the disease by increasing access to malaria treatment. Currently, the World Health Organization recommends to treat only confirmed malaria cases, rather than to give presumptive treatment. OBJECTIVES This systematic review aims to provide a comprehensive overview of the success or failure of critical steps in CCMm with rapid diagnostic tests (RDTs). METHODS The databases of Medline, Embase, the Cochrane Library, the library of the 'Malaria in Pregnancy' consortium, and Web of Science were used to find studies on CCMm with RDTs in SSA. Studies were selected according to inclusion and exclusion criteria, subsequently risk of bias was assessed and data extracted. RESULTS 27 articles were included. CHWs were able to correctly perform RDTs, although specificity levels were variable. CHWs showed high adherence to test results, but in some studies a substantial group of RDT negatives received treatment. High risk of bias was found for morbidity and mortality studies, therefore, effects on morbidity and mortality could not be estimated. Uptake and acceptance by the community was high, however negative-tested patients did not always follow up referral advice. Drug or RDT stock-outs and limited information on CHW motivation are bottlenecks for sustainable implementation. RDT-based CCMm was found to be cost effective for the correct treatment of malaria in areas with low to medium malaria prevalence, but study designs were not optimal. DISCUSSION Trained CHWs can deliver high quality care for malaria using RDTs. However, lower RDT specificity could lead to missed diagnoses of non-malarial causes of fever. Other threats for CCMm are non-adherence to negative test results and low referral completion. Integrated CCM may solve some of these issues. Unfortunately, morbidity and mortality are not adequately investigated. More information is needed about influencing sociocultural aspects, CHW motivation and stock supply. CONCLUSION CCMm is generally well executed by CHWs, but there are several barriers for its success. Integrated CCM may overcome some of these barriers.
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Affiliation(s)
- Esmée Ruizendaal
- Royal Tropical Institute/Koninklijk Instituut voor de Tropen (KIT), Amsterdam, The Netherlands
| | - Susan Dierickx
- Institute of Tropical Medicine/ Instituut Tropische Geneeskunde (ITG), Antwerp, Belgium
| | - Koen Peeters Grietens
- Institute of Tropical Medicine/ Instituut Tropische Geneeskunde (ITG), Antwerp, Belgium
- Nagasaki University, School of International Health Development, Nagasaki, Japan
| | - Henk DFH Schallig
- Royal Tropical Institute/Koninklijk Instituut voor de Tropen (KIT), Amsterdam, The Netherlands
| | - Franco Pagnoni
- Global Malaria Programme, 20 Avenue Appia, CH 1211 Geneva 27, Switzerland
| | - Petra F Mens
- Royal Tropical Institute/Koninklijk Instituut voor de Tropen (KIT), Amsterdam, The Netherlands
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Community knowledge and attitudes and health workers' practices regarding non-malaria febrile illnesses in eastern Tanzania. PLoS Negl Trop Dis 2014; 8:e2896. [PMID: 24852787 PMCID: PMC4031176 DOI: 10.1371/journal.pntd.0002896] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 04/11/2014] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Although malaria has been the leading cause of fever for many years, with improved control regimes malaria transmission, morbidity and mortality have decreased. Recent studies have increasingly demonstrated the importance of non-malaria fevers, which have significantly improved our understanding of etiologies of febrile illnesses. A number of non-malaria febrile illnesses including Rift Valley Fever, dengue fever, Chikungunya virus infection, leptospirosis, tick-borne relapsing fever and Q-fever have been reported in Tanzania. This study aimed at assessing the awareness of communities and practices of health workers on non-malaria febrile illnesses. METHODS Twelve focus group discussions with members of communities and 14 in-depth interviews with health workers were conducted in Kilosa district, Tanzania. Transcripts were coded into different groups using MaxQDA software and analyzed through thematic content analysis. RESULTS The study revealed that the awareness of the study participants on non-malaria febrile illnesses was low and many community members believed that most instances of fever are due to malaria. In addition, the majority had inappropriate beliefs about the possible causes of fever. In most cases, non-malaria febrile illnesses were considered following a negative Malaria Rapid Diagnostic Test (mRDT) result or persistent fevers after completion of anti-malaria dosage. Therefore, in the absence of mRDTs, there is over diagnosis of malaria and under diagnosis of non-malaria illnesses. Shortages of diagnostic facilities for febrile illnesses including mRDTs were repeatedly reported as a major barrier to proper diagnosis and treatment of febrile patients. CONCLUSION Our results emphasize the need for creating community awareness on other causes of fever apart from malaria. Based on our study, appropriate treatment of febrile patients will require inputs geared towards strengthening of diagnostic facilities, drugs availability and optimal staffing of health facilities.
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Prins HAB, Mugo P, Wahome E, Mwashigadi G, Thiong'o A, Smith A, Sanders EJ, Graham SM. Diagnosing acute and prevalent HIV-1 infection in young African adults seeking care for fever: a systematic review and audit of current practice. Int Health 2014; 6:82-92. [PMID: 24842982 PMCID: PMC4049276 DOI: 10.1093/inthealth/ihu024] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Fever is a common complaint in HIV-1 infected adults and may be a presenting sign of acute HIV-1 infection (AHI). We investigated the extent to which HIV-1 infection was considered in the diagnostic evaluation of febrile adults in sub-Saharan Africa (SSA) through a systematic review of published literature and guidelines in the period 2003–2014. We also performed a detailed audit of current practice for the evaluation of febrile young adults in coastal Kenya. Our review identified 43 studies investigating the aetiology of fever in adult outpatients in SSA. While the guidelines identified recommend testing for HIV-1 infection, none mentioned AHI. In our audit of current practice at nine health facilities, only 189 out of 1173 (16.1%) patients, aged 18–29 years, were tested for HIV-1. In a detailed record review, only 2 out of 39 (5.1%) young adults seeking care for fever were tested for HIV-1, and the possibility of AHI was not mentioned. Available literature on adult outpatients presenting with fever is heavily focused on diagnosing malaria and guidelines are poorly defined in terms of evaluating aetiologies other than malaria. Current practice in coastal Kenya shows poor uptake of provider-initiated HIV-1 testing and AHI is not currently considered in the differential diagnosis.
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Affiliation(s)
- Henrieke A B Prins
- Kenya Medical Research Institute, Centre for Geographic Medicine Research-Coast, P.O. Box 230, Kilifi, Kenya
| | - Peter Mugo
- Kenya Medical Research Institute, Centre for Geographic Medicine Research-Coast, P.O. Box 230, Kilifi, Kenya
| | - Elizabeth Wahome
- Kenya Medical Research Institute, Centre for Geographic Medicine Research-Coast, P.O. Box 230, Kilifi, Kenya
| | - Grace Mwashigadi
- Kenya Medical Research Institute, Centre for Geographic Medicine Research-Coast, P.O. Box 230, Kilifi, Kenya
| | - Alexander Thiong'o
- Kenya Medical Research Institute, Centre for Geographic Medicine Research-Coast, P.O. Box 230, Kilifi, Kenya
| | - Adrian Smith
- Nuffield Department of Population Health, University of Oxford, Oxford OX3 7BN, UK
| | - Eduard J Sanders
- Kenya Medical Research Institute, Centre for Geographic Medicine Research-Coast, P.O. Box 230, Kilifi, Kenya Nuffield Department of Clinical Medicine, University of Oxford, Oxford OX3 7BN, UK
| | - Susan M Graham
- Kenya Medical Research Institute, Centre for Geographic Medicine Research-Coast, P.O. Box 230, Kilifi, Kenya University of Washington, Seattle, WA 98195, USA
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Thomson R, Festo C, Johanes B, Kalolella A, Bruxvoort K, Nchimbi H, Tougher S, Cairns M, Taylor M, Kleinschmidt I, Ye Y, Mann A, Ren R, Willey B, Arnold F, Hanson K, Kachur SP, Goodman C. Has Tanzania embraced the green leaf? Results from outlet and household surveys before and after implementation of the Affordable Medicines Facility-malaria. PLoS One 2014; 9:e95607. [PMID: 24816649 PMCID: PMC4015933 DOI: 10.1371/journal.pone.0095607] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 03/28/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The Affordable Medicines Facility-malaria (AMFm) is primarily an artemisinin combination therapy (ACT) subsidy, aimed at increasing availability, affordability, market share and use of quality-assured ACTs (QAACTs). Mainland Tanzania was one of eight national scale programmes where AMFm was introduced in 2010. Here we present findings from outlet and household surveys before and after AMFm implementation to evaluate its impact from both the supply and demand side. METHODS Outlet surveys were conducted in 49 randomly selected wards throughout mainland Tanzania in 2010 and 2011, and data on outlet characteristics and stocking patterns were collected from outlets stocking antimalarials. Household surveys were conducted in 240 randomly selected enumeration areas in three regions in 2010 and 2012. Questions about treatment seeking for fever and drugs obtained were asked of individuals reporting fever in the previous two weeks. RESULTS The availability of QAACTs increased from 25.5% to 69.5% among all outlet types, with the greatest increase among pharmacies and drug stores, together termed specialised drug sellers (SDSs), where the median QAACT price fell from $5.63 to $0.94. The market share of QAACTs increased from 26.2% to 42.2%, again with the greatest increase in SDSs. Household survey results showed a shift in treatment seeking away from the public sector towards SDSs. Overall, there was no change in the proportion of people with fever obtaining an antimalarial or ACT from baseline to endline. However, when broken down by treatment source, ACT use increased significantly among clients visiting SDSs. DISCUSSION Unchanged ACT use overall, despite increases in QAACT availability, affordability and market share in the private sector, reflected a shift in treatment seeking towards private providers. The reasons for this shift are unclear, but likely reflect both persistent stockouts in public facilities, and the increased availability of subsidised ACTs in the private sector.
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Affiliation(s)
- Rebecca Thomson
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- Ifakara Health Institute, Dar es Salaam, Tanzania
- * E-mail:
| | | | | | | | - Katia Bruxvoort
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | | | - Sarah Tougher
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Matthew Cairns
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Mark Taylor
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- Department of Public Health, Trnava University, Trnava, Slovakia
| | - Immo Kleinschmidt
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Yazoume Ye
- International Health Division, ICF International, Calverton, Maryland, United States of America
| | - Andrea Mann
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Ruilin Ren
- International Health Division, ICF International, Calverton, Maryland, United States of America
| | - Barbara Willey
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Fred Arnold
- International Health Division, ICF International, Calverton, Maryland, United States of America
| | - Kara Hanson
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - S. Patrick Kachur
- Malaria Branch, Centers for Disease Control & Prevention, Atlanta, Georgia, United States of America
| | - Catherine Goodman
- London School of Hygiene & Tropical Medicine, London, United Kingdom
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Johansson EW, Gething PW, Hildenwall H, Mappin B, Petzold M, Peterson SS, Selling KE. Diagnostic testing of pediatric fevers: meta-analysis of 13 national surveys assessing influences of malaria endemicity and source of care on test uptake for febrile children under five years. PLoS One 2014; 9:e95483. [PMID: 24748201 PMCID: PMC3991688 DOI: 10.1371/journal.pone.0095483] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 03/26/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In 2010, the World Health Organization revised guidelines to recommend diagnosis of all suspected malaria cases prior to treatment. There has been no systematic assessment of malaria test uptake for pediatric fevers at the population level as countries start implementing guidelines. We examined test use for pediatric fevers in relation to malaria endemicity and treatment-seeking behavior in multiple sub-Saharan African countries in initial years of implementation. METHODS AND FINDINGS We compiled data from national population-based surveys reporting fever prevalence, care-seeking and diagnostic use for children under five years in 13 sub-Saharan African countries in 2009-2011/12 (n = 105,791). Mixed-effects logistic regression models quantified the influence of source of care and malaria endemicity on test use after adjusting for socioeconomic covariates. Results were stratified by malaria endemicity categories: low (PfPR2-10<5%), moderate (PfPR2-10 5-40%), high (PfPR2-10>40%). Among febrile under-fives surveyed, 16.9% (95% CI: 11.8%-21.9%) were tested. Compared to hospitals, febrile children attending non-hospital sources (OR: 0.62, 95% CI: 0.56-0.69) and community health workers (OR: 0.31, 95% CI: 0.23-0.43) were less often tested. Febrile children in high-risk areas had reduced odds of testing compared to low-risk settings (OR: 0.51, 95% CI: 0.42-0.62). Febrile children in least poor households were more often tested than in poorest (OR: 1.63, 95% CI: 1.39-1.91), as were children with better-educated mothers compared to least educated (OR: 1.33, 95% CI: 1.16-1.54). CONCLUSIONS Diagnostic testing of pediatric fevers was low and inequitable at the outset of new guidelines. Greater testing is needed at lower or less formal sources where pediatric fevers are commonly managed, particularly to reach the poorest. Lower test uptake in high-risk settings merits further investigation given potential implications for diagnostic scale-up in these areas. Findings could inform continued implementation of new guidelines to improve access to and equity in point-of-care diagnostics use for pediatric fevers.
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Affiliation(s)
- Emily White Johansson
- International Maternal and Child Health, Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
- * E-mail:
| | - Peter W. Gething
- Spatial Ecology and Epidemiology Group, Department of Zoology, University of Oxford, Oxford, United Kingdom
| | - Helena Hildenwall
- Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Bonnie Mappin
- Spatial Ecology and Epidemiology Group, Department of Zoology, University of Oxford, Oxford, United Kingdom
| | - Max Petzold
- Center for Applied Biostatistics, University of Gothenburg, Gothenburg, Sweden
| | - Stefan Swartling Peterson
- International Maternal and Child Health, Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
- Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Katarina Ekholm Selling
- International Maternal and Child Health, Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
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Briggs MA, Kalolella A, Bruxvoort K, Wiegand R, Lopez G, Festo C, Lyaruu P, Kenani M, Abdulla S, Goodman C, Kachur SP. Prevalence of malaria parasitemia and purchase of artemisinin-based combination therapies (ACTs) among drug shop clients in two regions in Tanzania with ACT subsidies. PLoS One 2014; 9:e94074. [PMID: 24732258 PMCID: PMC3986050 DOI: 10.1371/journal.pone.0094074] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 03/11/2014] [Indexed: 11/17/2022] Open
Abstract
Background Throughout Africa, many people seek care for malaria in private-sector drug shops where diagnostic testing is often unavailable. Recently, subsidized artemisinin-based combination therapies (ACTs), a first-line medication for uncomplicated malaria, were made available in these drug shops in Tanzania. This study assessed the prevalence of malaria among and purchase of ACTs by drug shop clients in the setting of a national ACT subsidy program and sub-national drug shop accreditation program. Method and Findings A cross-sectional survey of drug shop clients was performed in two regions in Tanzania, one with a government drug shop accreditation program and one without, from March-May, 2012. Drug shops were randomly sampled from non-urban districts. Shop attendants were interviewed about their education, training, and accreditation status. Clients were interviewed about their symptoms and medication purchases, then underwent a limited physical examination and laboratory testing for malaria. Malaria prevalence and predictors of ACT purchase were assessed using univariate analysis and multiple logistic regression. Amongst 777 clients from 73 drug shops, the prevalence of laboratory-confirmed malaria was 12% (95% CI: 6–18%). Less than a third of clients with malaria had purchased ACTs, and less than a quarter of clients who purchased ACTs tested positive for malaria. Clients were more likely to have purchased ACTs if the participant was <5 years old (aOR: 6.6; 95% CI: 3.9–11.0) or the shop attendant had >5 years, experience (aOR: 2.8; 95% CI: 1.2–6.3). Having malaria was only a predictor of ACT purchase in the region with a drug shop accreditation program (aOR: 3.4; 95% CI: 1.5–7.4). Conclusion Malaria is common amongst persons presenting to drug shops with a complaint of fever. The low proportion of persons with malaria purchasing ACTs, and the high proportion of ACTs going to persons without malaria demonstrates a need to better target who receives ACTs in these drug shops.
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Affiliation(s)
- Melissa A Briggs
- Malaria Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | | | - Katia Bruxvoort
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ryan Wiegand
- Malaria Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Gerard Lopez
- Malaria Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | | | | | - Mitya Kenani
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | | | - Catherine Goodman
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - S Patrick Kachur
- Malaria Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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Zurovac D, Githinji S, Memusi D, Kigen S, Machini B, Muturi A, Otieno G, Snow RW, Nyandigisi A. Major improvements in the quality of malaria case-management under the "test and treat" policy in Kenya. PLoS One 2014; 9:e92782. [PMID: 24663961 PMCID: PMC3963939 DOI: 10.1371/journal.pone.0092782] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 02/26/2014] [Indexed: 11/29/2022] Open
Abstract
Background Monitoring implementation of the “test and treat” case-management policy for malaria is an important component of all malaria control programmes in Africa. Unfortunately, routine information systems are commonly deficient to provide necessary information. Using health facility surveys we monitored health systems readiness and malaria case-management practices prior to and following implementation of the 2010 “test and treat” policy in Kenya. Methods/Findings Between 2010 and 2013 six national, cross-sectional, health facility surveys were undertaken. The number of facilities assessed ranged between 172 and 176, health workers interviewed between 216 and 237 and outpatient consultations for febrile patients evaluated between 1,208 and 2,408 across six surveys. Comparing baseline and the last survey results, all readiness indicators showed significant (p<0.005) improvements: availability of parasitological diagnosis (55.2% to 90.7%); RDT availability (7.5% to 69.8%); total artemether-lumefantrine (AL) stock-out (27.2% to 7.0%); stock-out of one or more AL packs (59.5% to 21.6%); training coverage (0 to 50.2%); guidelines access (0 to 58.1%) and supervision (17.9% to 30.8%). Testing increased by 34.0% (23.9% to 57.9%; p<0.001) while testing and treatment according to test result increased by 34.2% (15.7% to 49.9%; p<0.001). Treatment adherence for test positive patients improved from 83.3% to 90.3% (p = 0.138) and for test negative patients from 47.9% to 83.4% (p<0.001). Significant testing and treatment improvements were observed in children and adults. There was no difference in practices with respect to the type and result of malaria test (RDT vs microscopy). Of eight dosing, dispensing and counseling tasks, improvements were observed for four tasks. Overall AL use for febrile patients decreased from 63.5% to 35.6% (p<0.001). Conclusions Major improvements in the implementation of “test and treat” policy were observed in Kenya. Some gaps towards universal targets still remained. Other countries facing similar needs and challenges may consider health facility surveys to monitor malaria case-management.
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Affiliation(s)
- Dejan Zurovac
- Malaria Public Health Department, Kenya Medical Research Institute-Wellcome Trust-University of Oxford Research Programme, Nairobi, Kenya; Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom; Center for Global Health and Development, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Sophie Githinji
- Malaria Public Health Department, Kenya Medical Research Institute-Wellcome Trust-University of Oxford Research Programme, Nairobi, Kenya
| | - Dorothy Memusi
- Division of Malaria Control, Ministry of Health, Nairobi, Kenya
| | - Samuel Kigen
- Division of Malaria Control, Ministry of Health, Nairobi, Kenya
| | | | - Alex Muturi
- Management Sciences for Health, Nairobi, Kenya
| | - Gabriel Otieno
- Malaria Public Health Department, Kenya Medical Research Institute-Wellcome Trust-University of Oxford Research Programme, Nairobi, Kenya
| | - Robert W Snow
- Malaria Public Health Department, Kenya Medical Research Institute-Wellcome Trust-University of Oxford Research Programme, Nairobi, Kenya; Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
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Githinji S, Kigen S, Memusi D, Nyandigisi A, Wamari A, Muturi A, Jagoe G, Ziegler R, Snow RW, Zurovac D. Using mobile phone text messaging for malaria surveillance in rural Kenya. Malar J 2014; 13:107. [PMID: 24642130 PMCID: PMC3995152 DOI: 10.1186/1475-2875-13-107] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 03/14/2014] [Indexed: 11/25/2022] Open
Abstract
Background Effective surveillance systems are required to track malaria testing and treatment practices. A 26-week study “SMS for Life” was piloted in five rural districts of Kenya to examine whether SMS reported surveillance data could ensure real-time visibility of accurate data and their use by district managers to impact on malaria case-management. Methods Health workers from 87 public health facilities used their personal mobile phones to send a weekly structured SMS text message reporting the counts of four basic surveillance data elements to a web-based system accessed by district managers. Longitudinal monitoring of SMS reported data through the web-based system and two rounds of cross-sectional health facility surveys were done to validate accuracy of data. Results Mean response rates were 96% with 87% of facilities reporting on time. Fifty-eight per cent of surveillance data parameters were accurately reported. Overall mean testing rates were 37% with minor weekly variations ranging from 32 to 45%. Overall test positivity rate was 24% (weekly range: 17-37%). Ratio of anti-malarial treatments to test positive cases was 1.7:1 (weekly range: 1.3:1–2.2:1). District specific trends showed fluctuating patterns in testing rates without notable improvement over time but the ratio of anti-malarial treatments to test positive cases improved over short periods of time in three out of five districts. Conclusions The study demonstrated the feasibility of using simple mobile phone text messages to transmit timely surveillance data from peripheral health facilities to higher levels. However, accuracy of data reported was suboptimal. Future work should focus on improving quality of SMS reported surveillance data.
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Affiliation(s)
- Sophie Githinji
- Malaria Public Health Department, KEMRI-Wellcome Trust - University of Oxford Collaborative Programme, Nairobi, Kenya.
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Pulford J, Kurumop SF, Ura Y, Siba PM, Mueller I, Hetzel MW. Malaria case management in Papua New Guinea following the introduction of a revised treatment protocol. Malar J 2013; 12:433. [PMID: 24279720 PMCID: PMC4222867 DOI: 10.1186/1475-2875-12-433] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Accepted: 11/25/2013] [Indexed: 11/10/2022] Open
Abstract
Background This paper reports on the availability of diagnostic tools and recommended anti-malarials in the 12-month period immediately following the implementation of a new national malaria treatment protocol (NMTP) in Papua New Guinea (PNG). Health worker adherence to the new NMTP is also examined and comparisons made with previously reported pre-implementation findings. Methods A countrywide cross-sectional survey in randomly selected primary health care facilities (n = 88). Data were collected via passive observation of the clinical case management of fever or suspected malaria patients and via an interviewer administered questionnaire completed with the officer in charge of each participating health care facility. Results Malaria rapid diagnostic tests (RDTs) and the new first-line anti-malarial medication, artemether-lumefantrine (AL), were available in 53.4% and 51.1% of surveyed heath facilities, respectively. However, they were more widely available in the larger health centres as compared to the smaller aid-posts (90.2% vs. 21.3% and 87.8% vs. 19.2%, respectively). Overall, 68.3% of observed fever cases (n = 445) were tested for malaria by RDT and 39% prescribed an anti-malarial, inclusive of 98.2% of RDT positive patients and 19.8% of RDT negative cases. The availability and use of malaria RDTs was greater in the current survey as compared to pre-implementation of the new NMTP (8.9% vs. 53.4% & 16.2% vs. 68.3%, respectively) as was the availability of AL (0% vs. 51.1%). The percentage of fever patients prescribed anti-malarials decreased substantially post implementation of the new NMTP (96.4% vs. 39.0%). Conclusions PNG has achieved high coverage of malaria RDTs and AL at the health centre level, but these resources have yet to reach the majority of aid-posts. Malaria case management practice has substantially changed in the 12-month period immediately following the new NMTP, although full protocol adherence was rarely observed.
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Affiliation(s)
- Justin Pulford
- Papua New Guinea Institute of Medical Research (PNGIMR), Goroka, EHP 441, Papua New Guinea.
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