Adherence to treatment guidelines for uncomplicated malaria at two public health facilities in Nigeria; Implications for the 'test and treat' policy of malaria case management

Fidelity of implementation of national guidelines on malaria diagnosis for children under-five years in Rivers State, Nigeria

BACKGROUND

Malaria is still a disease of global public health importance and children under-five years of age are the most vulnerable to the disease. Nigeria adopted the "test and treat" strategy in the national malaria guidelines as one of the ways to control malaria transmission. The level of adherence to the guidelines is an important indicator for the success or failure of the country's roadmap to malaria elimination by 2030. This study aimed to assess the fidelity of implementation of the national guidelines on malaria diagnosis for children under-five years and examine its associated moderating factors in health care facilities in Rivers State, Nigeria.

METHODS

This was a descriptive, cross-sectional study conducted in Port Harcourt metropolis. Data were collected from 147 public, formal private and informal private health care facilities. The study used a questionnaire developed based on Carroll's Conceptual Framework for Implementation Fidelity. Frequency, mean and median scores for implementation fidelity and its associated factors were calculated. Associations between fidelity and the measured predictors were examined using Mann Whitney U test, Kruskal Wallis test, and multiple linear regression modelling using robust estimation of errors. Regression results are presented in adjusted coefficient (β) and 95% confidence intervals.

RESULTS

The median (IQR) score fidelity score for all participants was 65% (43.3, 85). Informal private facilities (proprietary patent medicine vendors) had the lowest fidelity scores (47%) compared to formal private (69%) and public health facilities (79%). Intervention complexity had a statistically significant inverse relationship to implementation fidelity (β = - 1.89 [- 3.42, - 0.34]). Increase in participant responsiveness (β = 8.57 [4.83, 12.32]) and the type of malaria test offered at the facility (e.g., RDT vs. no test, β = 16.90 [6.78, 27.03]; microscopy vs. no test, β = 21.88 [13.60, 30.16]) were positively associated with fidelity score.

CONCLUSIONS

This study showed that core elements of the "test and treat" strategy, such as testing all suspected cases with approved diagnostic methods before treatment, are still not fully implemented by health facilities. There is a need for strategies to increase fidelity, especially in the informal private health sector, for malaria elimination programme outcomes to be achieved.

Prescription patterns and compliance with World Health Organization recommendations for the management of uncomplicated and severe malaria: A prospective, real-world study in sub-Saharan Africa

BACKGROUND

This study aimed to evaluate the gap between guidelines and local clinical practice for diagnosis and treatment of uncomplicated and severe malaria, the patient characteristics, diagnostic approach, treatment, and compliance to standard guideline recommendations.

METHODS

This was a multicentre, observational study conducted between October 2020 and March 2021 in which patients of all ages with symptoms suggestive of malaria and who visited a healthcare facility were prospectively enrolled in six countries in sub-Saharan Africa (The Democratic Republic of the Congo, Mozambique, Nigeria, Rwanda, The United Republic of Tanzania, and Zambia).

RESULTS

Of 1001 enrolled patients, 735 (73.4%) patients had confirmed malaria (based on overall judgment by investigator) at baseline (uncomplicated malaria: 598 [81.4%] and severe malaria: 137 [18.6%]). Of the confirmed malaria patients, 533 (72.5%) were administered a malaria rapid diagnostic test. The median age of patients was 11 years (range: 2 weeks-91 years) with more patients coming from rural (44.9%) than urban (30.6%) or suburban areas (24.5%). At the community level, 57.8% of patients sought advice or received treatment for malaria and 56.9% of patients took one or more drugs for their illness before coming to the study site. In terms of early access to care, 44.1% of patients came to the study site for initial visit ≥ 48 h after symptom onset. In patients with uncomplicated malaria, the most prescribed treatments were artemisinin-based combination therapy (ACT; n = 564 [94.3%]), primarily using artemether-lumefantrine (82.3%), in line with the World Health Organization (WHO) treatment guidelines. In addition, these patients received antipyretics (85.6%) and antibiotics (42.0%). However, in those with severe malaria, only 66 (48.2%) patients received parenteral treatment followed by oral ACT as per WHO guidelines, whereas 62 (45.3%) received parenteral treatment only. After receiving ambulatory care, 88.6% of patients with uncomplicated malaria were discharged and 83.2% of patients with severe malaria were discharged after hospitalization. One patient with uncomplicated malaria having multiple co-morbidities and three patients with severe malaria died.

CONCLUSIONS

The findings of this study suggest that the prescribed treatment in most patients with uncomplicated malaria, but not of those with severe malaria, was in alignment with the WHO recommended guidelines.

Overtreatment of malaria in the Nigerian healthcare setting: prescription practice, rationale and consequences

Nigeria is one of the countries in the world with the highest burden of malaria, accounting for a quarter of all cases in Africa. According to the Centers for Disease Control and Prevention, microscopic examination remains the gold standard for laboratory confirmation of malaria. However, the policy and practice of presumptive treatment of malaria for all febrile illnesses has been widely advocated in sub-Saharan Africa. Presumptive management of fevers and/or other symptoms of malaria results in over-diagnosis, and consequently overtreatment. This article discusses the overtreatment of malaria as practiced in Nigeria and other African regions against standard treatment guidelines, highlights a wide range of its associated effects on patients and proffers possible solutions to curb the unethical practice of malaria overtreatment.

Perception and awareness towards malaria vaccine policy implementation in Nigeria by health policy actors

BACKGROUND

This study aimed to assess the perception and awareness of malaria vaccine policy implementation among health policy actors in Nigeria.

METHODS

A descriptive study was conducted to assess the opinions and perceptions of policy actors on the implementation of a vaccination programme against malaria in Nigeria. Descriptive statistics were carried out to study the characteristics of the population and the univariate analysis of the responses to questions presented to the participants. Multinomial logistic regression was conducted to evaluate the association between demographic characteristics and the responses.

RESULTS

The study revealed that malaria vaccine awareness was poor, with only 48.9% of the policy actors having previous knowledge of the malaria vaccine. The majority of participants (67.8%) declared that they were aware of the importance of vaccine policy in efforts to manage disease transmission. As the number of years of work experience of the participants increased, the odds of being more likely to be aware of the malaria vaccine increased [OR 2.491 (1.183-5.250), p value < 0.05].

CONCLUSION

It is recommended that policy-makers develop methods of educating populations, increase awareness of the acceptability of the vaccine and ensure that an affordable malaria vaccine programme is implemented in the population.

Clinical management and outcomes of acute febrile illness in children attending a tertiary hospital in southern Ethiopia

Background

The management of febrile illnesses is challenging in settings where diagnostic laboratory facilities are limited, and there are few published longitudinal data on children presenting with fever in such settings. We have previously conducted the first comprehensive study of infectious aetiologies of febrile children presenting to a tertiary care facility in Ethiopia. We now report on clinicians’ prescribing adherence with guidelines and outcomes of management in this cohort.

Methods

We consecutively enrolled febrile children aged 2 months and under 13 years, who were then managed by clinicians based on presentation and available laboratory and radiologic findings on day of enrolment. We prospectively collected outcome data on days 7 and 14, and retrospectively evaluated prescribing adherence with national clinical management guidelines.

Results

Of 433 children enrolled, the most common presenting syndromes were pneumonia and acute diarrhoea, diagnosed in 177 (40.9%) and 82 (18.9%), respectively. Antibacterial agents were prescribed to 360 (84.7%) of 425 children, including 36 (34.0%) of 106 children without an initial indication for antibacterials according to guidelines. Antimalarial drugs were prescribed to 47 (11.1%) of 425 children, including 30 (7.3%) of 411 children with negative malaria microscopy. Fever had resolved in 357 (89.7%) of 398 children assessed at day 7, and in-hospital death within 7 days occurred in 9 (5.9%) of 153 admitted patients. Among children with pneumonia, independent predictors of persisting fever or death by 7 days were young age and underweight for age. Antibacterial prescribing in the absence of a guideline-specified indication (overprescribing) was more likely among infants and those without tachypnea, while overprescribing antimalarials was associated with older age, anaemia, absence of cough, and higher fevers.

Conclusion

Our study underscores the need for improving diagnostic support to properly guide management decisions and enhance adherence by clinicians to treatment guidelines.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07424-0.

Management of uncomplicated malaria among children under five years at public and private sector facilities in Mali

Background

Prompt and effective malaria diagnosis and treatment is a cornerstone of malaria control. Case management guidelines recommend confirmatory testing of suspected malaria cases, then prescription of specific drugs for uncomplicated malaria and for severe malaria. This study aims to describe case management practices for children aged 1–59 months seeking treatment with current or recent fever from public and private, rural and urban health providers in Mali.

Methods

Data were collected at sites in Sikasso Region and Bamako. Health workers recorded key information from the consultation including malaria diagnostic testing and result, their final diagnosis, and all drugs prescribed. Children with signs of severe diseases were ineligible. Consultations were not independently observed. Appropriate case management was defined as both 1) tested for malaria using rapid diagnostic test or microscopy, and 2) receiving artemisinin combination therapy (ACT) and no other antimalarials if test-positive, or receiving no antimalarials if test-negative.

Results

Of 1602 participating children, 23.7% were appropriately managed, ranging from 5.3% at public rural facilities to 48.4% at community health worker sites. The most common reason for ‘inappropriate’ management was lack of malaria diagnostic testing (50.4% of children). Among children with confirmed malaria, 50.8% received a non-ACT antimalarial (commonly artesunate injection or artemether), either alone or in combination with ACT. Of 215 test-negative children, 44.2% received an antimalarial drug, most commonly ACT. Prescription of multiple drugs was common: 21.7% of all children received more than one type of antimalarial, while 51.9% received an antibiotic and antimalarial. Inappropriate case management increased in children with increasing axillary temperatures and those seeking care over weekends.

Conclusions

Multiple limitations in management of febrile children under five were identified, including inconsistent use of confirmatory testing and apparent use of severe malaria drugs for uncomplicated malaria. While we cannot confirm the reasons for these shortcomings, there is a need to address the high use of non-ACT antimalarials in this context; to minimize potential for drug resistance, reduce unnecessary expense, and preserve life-saving treatment for severe malaria cases. These findings highlight the challenge of managing febrile illness in young children in a high transmission setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-09873-1.

Adherence, Awareness, Access, and Use of Standard Diagnosis and Treatment Guideline for Malaria Case Management among Healthcare Workers in Meatu, Tanzania

Background

Effective case management is a vital component of malaria control and elimination strategies. However, the level of adherence to the malaria diagnostic test and treatment guideline is not known, particularly at Meatu district. Therefore, this study aimed at determining the adherence, awareness, access, and use of standard diagnosis and treatment guidelines among healthcare workers in Meatu district.

Method

This was a descriptive cross-sectional study, which enrolled a total of 196 healthcare workers in Meatu district. Healthcare workers were sampled purposively to reach the required sample size. A structured questionnaire was used for data collection.

Results

Generally, 189 (96.4%) were aware of malaria treatment guidelines, while 148 (75.5%) had access and 98 (50.0%) used malaria treatment guidelines. One hundred and seven (54.6%) of all the healthcare workers adhered strictly to the diagnosis and national treatment guidelines. Ten (5.1%) partially adhered to the guideline when choosing antimalarials without confirmed malaria cases. Nonadherence to the prescription of recommended antimalarial drugs and laboratory confirmation was 79 (40.3%).

Conclusion

Half of healthcare worker's adhere to malaria diagnostic test and treatment guidelines. Most the healthcare workers are aware of the malaria diagnostic test and treatment guidelines. Continued education and assessment of the personal attitudes towards malaria diagnostic test and treatment guidelines are recommended.

Failures in the case management of children with uncomplicated malaria in Bata district of Equatorial Guinea and associated factors

Background

In Equatorial Guinea, malaria continues to be one of the main causes of morbidity and mortality among children. The National Therapeutic Guide established artesunate-amodiaquine (ASAQ) as first-line treatment for uncomplicated malaria, but compliance with this treatment is low. The aim of this study was to assess, for the first time, the performance of public healthcare workers in the diagnosis and treatment of uncomplicated malaria, their compliance with first-line Malaria National Therapeutic Guide and the associated factors.

Methods

A cross-sectional survey was conducted at the nine public health facilities in the Bata District of Equatorial Guinea to assess the management of uncomplicated malaria in children < 15 years of age. Bivariate and multivariate statistical analyses were used to determine the recommended treatment compliance and related factors.

Results

A total of 227 children with uncomplicated malaria were recorded from 9 public health facilities. Most of the treatments prescribed (83.3%) did not follow the first-line treatment recommended for uncomplicated malaria. The diagnosis was established with parasite confirmation in 182 cases (80.2%). After adjustment for other variables, children under 2 months of age, the use of parasite confirmation to the diagnosis of malaria and being familiar with the national therapeutic guide were significantly associated with the prescription of the first-line recommended treatment. Cases attended at the hospital or in a health facility with ASAQ in the pharmacy at the time of the study were also more likely to be prescribed with the recommended treatment, but with non-significant association after adjustment for other variables.

Conclusions

This study identified the factors associated with the low compliance with the first-line treatment by the public healthcare facilities of Bata District of Equatorial Guinea. It seems necessary to improve case management of children with uncomplicated malaria; to reinforce the use of Malaria National Therapeutic Guide and to inform about the danger of using artemisinin monotherapy. Furthermore, it is crucial to provide recommended first-line treatment to the pharmacies of all public health facilities to ensure access to this treatment.

Economic and Resource Use Associated With Management of Malaria in Children Aged <5 Years in Sub-Saharan Africa: A Systematic Literature Review

Background. Malaria is a major health, economic, and social burden in sub-Saharan Africa. Purpose. The objective is to help understanding the economic impact of malaria and informing estimates of the potential economic impact of malaria prevention. To achieve this, we conducted a systematic review of published information on health system costs, health care resource use, and household costs for the management of malaria episodes in children aged <5 years in sub-Saharan Africa. Data Sources and Study Selection. We conducted searches in Medline, EMBASE, and Cochrane Library for studies reporting data on economic cost or resource use associated with management of malaria in children aged <5 years in sub-Saharan Africa. Searches were limited to articles published in English or French between January 1, 2006, and September 1, 2016. Conference abstracts from 2014 to 2016 were hand-searched. Data Extraction and Data Synthesis. We identified 1846 publications, of which 17 met the selection criteria. The studies covered nine countries: The Democratic Republic of Congo, Ghana, Kenya, Malawi, Mozambique, Nigeria, Tanzania, Uganda, and Zambia. All costs were standardized to 2016 US dollars (US$). Seven studies estimated the costs of a malaria episode to health systems, and 10 publications plus one abstract reported household costs. The cost to the health system was US$1.94 to US$31.53 for outpatient malaria cases to US$20 to US$136 for inpatient cases. Families bear a large share of the burden through out-of-pocket payments of medical care and lost income due to time off work. Limitations. Data were missing for many countries and few comparisons could be made. Conclusions. Severe malaria is associated with much higher costs than uncomplicated malaria, and families bear a large share of the cost burden.

Quality of malaria services offered in public health facilities in three provinces of Mozambique: a cross-sectional study

BACKGROUND

Fever associated with malaria is the leading cause of health care-seeking in Mozambique, yet there is limited evidence on the quality of malaria case management. This study evaluated the quality of malaria service provision offered in public health facilities in Mozambique.

METHODS

A cross-sectional assessment was conducted in April-May 2018 in three provinces of Mozambique: Maputo Province (low malaria burden), Cabo Delgado (high), and Zambézia (high). The study included all secondary and tertiary facilities and a random sample of primary facilities in each province. Data collection included exit interviews and re-examinations of 20 randomly selected outpatient service patients, interviews with up to five health care providers and the health facility director, a stockroom inventory and routine data abstraction.

RESULTS

A total of 319 health care providers and 1840 patients from 117 health facilities were included. Of these, 1325 patients (72%) had suspected malaria (fever/history of fever) and 550 (30%) had febrile, confirmed malaria with the highest burden in Cabo Delgado (43%), followed by Zambézia (34%) and Maputo Province (2%). Appropriate management of malaria cases, defined as testing malaria suspects and treating confirmed cases with the correct dose of anti-malarial, was highest in Zambézia and Cabo Delgado where 52% (95% CI 42-62) and 49% (42-57) of febrile malaria cases were appropriately managed, respectively. Only 14% (5-34) of febrile cases in Maputo Province were appropriately managed. The biggest gap in the malaria case management pathway was failure to test febrile patients, with only 46% of patients with this indication tested for malaria in Maputo Province. Additionally, anti-malarial treatment of patients with a negative malaria test result was common, ranging from 8% (2-23) in Maputo Province to 22% (14-32) of patients with a negative test in Zambézia. Only 58-62% of patients prescribed an anti-malarial correctly recited dosing instructions. Provider training and malaria knowledge was low outside of Zambézia and supervision rates were low in all provinces. Factors associated with correct case management varied by province and included patient age, facility type, treatment and testing availability, supervision, and training.

CONCLUSION

These findings underscore the need to strengthen provider testing of all patients with fever, provider adherence to negative test results, and effective counselling of patients across epidemiological settings in Mozambique.

The impact of the scale-up of malaria rapid diagnostic tests on the routine clinical diagnosis procedures for febrile illness: a series of repeated cross-sectional studies in Papua New Guinea

BACKGROUND

This paper examines the impact of the scale-up of malaria rapid diagnostic tests (RDT) on routine clinical diagnosis procedures for febrile illness in primary healthcare settings in Papua New Guinea.

METHODS

Repeat, cross-sectional surveys in randomly selected primary healthcare services were conducted. Surveys included passive observation of consecutive febrile case management cases and were completed immediately prior to RDT scale-up (2011) and at 12- (2012) and 60-months (2016) post scale-up. The frequency with which specified diagnostic questions and procedures were observed to occur, with corresponding 95% CIs, was calculated for febrile patients prescribed anti-malarials pre- and post-RDT scale-up and between febrile patients who tested either negative or positive for malaria infection by RDT (post scale-up only).

RESULTS

A total of 1809 observations from 120 health facilities were completed across the three survey periods of which 915 (51%) were prescribed an anti-malarial. The mean number of diagnostic questions and procedures asked or performed, leading to anti-malarial prescription, remained consistent pre- and post-RDT scale-up (range 7.4-7.7). However, alterations in diagnostic content were evident with the RDT replacing body temperature as the primary diagnostic procedure performed (observed in 5.3 and 84.4% of cases, respectively, in 2011 vs. 77.9 and 58.2% of cases in 2016). Verbal questioning, especially experience of fever, cough and duration of symptoms, remained the most common feature of a diagnostic examination leading to anti-malarial prescription irrespective of RDT use (observed in 96.1, 86.8 and 84.8% of cases, respectively, in 2011 vs. 97.5, 76.6 and 85.7% of cases in 2016). Diagnostic content did not vary substantially by RDT result.

CONCLUSIONS

Rapid diagnostic tests scale-up has led to a reduction in body temperature measurement. Investigations are very limited when malaria infection is ruled out as a cause of febrile illness by RDT.

The Cross-Sectional Evaluation of the Use of Artemisinin-Based Combination Therapy for Treatment of Malaria Infection at a Tertiary Hospital in Nigeria

In 2005, Nigeria changed its antimalarial drug policy to Artemisinin-based Combination Therapies (ACTs) for the treatment of malaria infection, and it is imperative for prescribers to strictly comply with this guideline to harmonize malaria management practices within the country. This study aims to evaluate prescribers' adherence with the National Antimalarial Treatment Guideline (NATG) in the treatment of malaria infections and to describe the determinants of antimalarial drugs coprescription with antibiotics at a tertiary hospital in Nigeria. A cross-sectional, retrospective study of antimalarial drug prescriptions of one-year period of 2013 was conducted. A simple method for assessing the quality of drug prescribing (DU90%) was adopted. Logistic regression was used to predict antimalarial drugs coprescription with antibiotics. Overall, 95.8% of the total prescriptions contained ACTs, out of which 80.8% were Artemether/Lumefantrine. However, adherence to NATG was 88.2% with an adjusted value of 100.0%. Age was the only predictor for antimalarial drugs coprescription with antibiotics. This study showed high concordance with NATG at the studied hospital. Age less than 5 years is a significant risk factor for antimalarial drugs coprescription with antibiotics.

Drug use in the management of uncomplicated malaria in public health facilities in the Democratic Republic of the Congo

Background

Malaria the first causes of death from parasitic infection worldwide. Interventions to reduce the burden of malaria have produced a tremendous drop in malaria morbidity and mortality. However, progress is slower in DRC, which shares with Nigeria 39% of deaths related to malaria globally. Inappropriate use of drugs may be one of the factors of this below-average performance. The aim of this study was to describe the use of drugs in the management of uncomplicated malaria in public health facilities in DRC.

Methods

A drug use study was carried out in DRC from January to March 2014. In each of the former 11 provinces of DRC, one Rural Health Centre, one Urban Health Centre and one General Hospital were selected. In each of them, 100 patient’s files containing prescription of anti-malarials from January to December 2013 were randomly selected. Among them, all of the files with diagnosis of uncomplicated malaria were included in this study. Prescribed anti-malarials, co-prescribed drugs and their indications were collected. Descriptive analyses were performed.

Results

A total of 2300 files out of 3300 (69.7%) concerned uncomplicated malaria and were included in analysis. Malaria treatment was initiated after a positive RDT or microscopy in 51.5% of cases, upon suspicion without requesting biological confirmation in 37% and despite negative results in 11%. Twenty-nine (29) different treatment regimens were used. The drugs recommended by the National Malaria Control Programme were used in 54.3% of cases (artesunate–amodiaquine 37.4% or artemether–lumefantrine 16.9%). The second most used anti-malarial was quinine (32.4%). Apart from anti-malarials, an average of 3.1 drugs per patient were prescribed, among which antibiotics (67.9%), analgesics and non-steroidal anti-inflammatory (NSAIDs) (all abbreviations to be explicated on first use) (70.6%), vitamins (29.1%), anaemia drugs, including blood transfusion (9.1%) and corticosteroids (5.7%), In 51.4% of cases there was no indication for the concomitant medication.

Conclusion

Management of uncomplicated malaria in DRC is characterized by a low adherence to treatment policy, numerous treatment regimens, and abundant concomitant medication potentially harmful to the patient. This may contribute to the low performance of DRC in malaria control. Determinant of this irrational use of drugs need to be assessed in order to formulate and implement efficient corrective measures.

The use and preference of artemether as a first-choice treatment for malaria: results from a cross-sectional survey in the Bata district, Equatorial Guinea

BACKGROUND

Malaria is endemic in Equatorial Guinea with stable transmission, and it remains a major cause of morbidity and mortality in children under 5 years of age. Adherence to artemisinin-based combination therapy (ACT) as a first-line treatment for uncomplicated malaria is critical to malaria control. Six years after the introduction of artesunate-amodiaquine (AS/AQ) therapy in Equatorial Guinea, adherence to the first-line treatment seems to be low in the Bata district. The factors associated with the choice of malaria treatment have not been studied previously in this area; therefore, this study aimed to analyse the preference and use of artemether as malaria treatment and its related factors in the Bata district of Equatorial Guinea.

METHODS

In 2013, a cross-sectional study was conducted in the Bata district, which involved 428 households. Bivariate and multivariate statistical analyses were conducted to determine the relevance of socio-economic, geographical, and behavioural factors that played a role in the preference and use of artemether as malaria treatment.

RESULTS

Artemether was considered the best treatment for malaria by 110 caregivers (26%), and was the antimalarial most administrated in the Bata district. It was prescribed to 117 children (27.34%); while, only 6.78% were administered AS/AQ. Caregivers living ≤ 3 km from the nearest health facility were almost two times more likely to consider artemether as the best treatment than those living farther away (95% CI 0.31-0.86). Caregivers with at least a secondary school education were 2.7 times more likely to consider artemether as the best treatment than those less educated. Children whose caregivers considered artemether the best treatment against malaria were five times more likely to be treated with artemether than children with caregivers who did not consider it the best (OR 5.07, 95% CI 2.93-8.78). In contrast, children that reported weakness as a symptom were less likely to be treated with artemether than those with other symptoms (OR 0.47, 95% CI 0.28-0.78).

CONCLUSION

Caregivers, public and private health staff, and drug sellers need to understand the importance of using ACT to treat uncomplicated malaria and the dangers of using artemisinin monotherapy.

Prescription audit in a paediatric sickle cell clinic in South-West Nigeria: A cross-sectional retrospective study

Background

Sickle cell disease (SCD) is a genetic haematological disorder that affects millions of people around the world especially people of African heritage. The treatment of the symptoms of SCD includes the use of analgesics, antibiotics, and anti-malarial drugs. Studying the pattern of drug prescription is a veritable tool for establishing the current practice and how it conforms to existing guidelines.

Objectives

The main objective of this study was to assess the pattern of drug prescription in children with sickle cell disease (SCD) attending the paediatric outpatients' clinic of a tertiary care centre in Ado-Ekiti, South-West Nigeria.

Methods

This was a cross-sectional retrospective study carried out using the medical records of all patients with SCD who attended the paediatric outpatient clinic of the teaching hospital between January 1 and December 31, 2014. The information retrieved from the case notes included the bio-demographic data, associated co-morbid conditions and the list of prescribed drugs.

Results

A total of 202 SCD patients aged below 18 years were seen in the clinic during the study period with males accounting for 61.9% of them. The mean age of all patients was 6.9 ±3.8 yrs. A total of 1015 medications were prescribed during the study period giving a mean of 5.02 ± 1.9. Vitamins/micronutrients, anti-malarial drugs, antibiotics and analgesics accounted for 41.4%, 29.0%, 15.7% and 13.9% of all prescribed drugs respectively. Antibiotics from the penicillin group were the most commonly prescribed followed by macrolides and cephalosporins while Ibuprofen (60.3%) and Acetaminophen (32.6%) were the commonly prescribed analgesics.

Conclusion

High rate of antibiotic prescription, low use of opioid analgesics and non-prescription of prophylactic penicillin/pneumococcal vaccination were the main findings in this study. There is need for the introduction of standard treatment protocols for this group of patients.

Evaluating the Treatment Costs for Uncomplicated Malaria at a Public Healthcare Facility in Nigeria and the Implications

BACKGROUND

Accurate information on the facility costs of treatment is essential to enhance decision making and funding for malaria control.

OBJECTIVE

The objective of this study was to estimate the costs of providing treatment for uncomplicated malaria through a public health facility in Nigeria.

METHODS

Hospital costs were estimated from a provider perspective, applying a standard costing procedure. Capital and recurrent expenditures were estimated using an ingredient approach combined with step-down methodology. Costs attributable to malaria treatment were calculated based on the proportion of malaria cases to total outpatient visits. The costs were calculated in local currency [Naira (N)] and converted to US dollars at the 2013 exchange rate.

RESULTS

Total annual costs of N28.723 million (US$182,953.65) were spent by the facility on the treatment of uncomplicated malaria, at a rate of US$31.49 per case, representing approximately 25% of the hospital's total expenditure in the study year. Personnel accounted for over 82.5% of total expenditure, followed by antimalarial medicines at 6.6%. More than 45% of outpatients visits were for uncomplicated malaria. Changes in personnel costs, drug prices and malaria prevalence significantly impacted on the study results, indicating the need for improved efficiency in the use of hospital resources.

CONCLUSION

Malaria treatment currently consumes a considerable amount of resources in the facility, driven mainly by personnel cost and a high proportion of malaria cases. There is scope for enhanced efficiency to prevent waste and reduce costs to the provider and ultimately the consumer.

Antimalarial prescription in a public hospital outpatient setting in Kenya: A best practice implementation project

BACKGROUND

Important gaps still exist in malaria case management despite implementation of the World Health Organization parasitological diagnosis before treatment recommendation. This calls for evidence-based strategies to improve health providers' adherence to these guidelines.

OBJECTIVE

The goal of this project was to improve adherence of confirmed parasitological diagnosis prior to antimalarial prescription in the outpatient department.

METHODS

The Joanna Briggs Institute Practical Application of Clinical Evidence System program was used to facilitate collection of baseline and post-audit data. The Getting Research into Practice program was also utilized to analyze the potential barriers and for designing the intervention strategies. This study was done during a 7-month period in an outpatient department of public health facility in Kenya.

RESULTS

Baseline and post-implementation audit results comparison indicate that there was a clinically significant improvement in all three criteria. One hundred percent of health providers underwent training on malaria case management, an improvement from 24% at baseline. Almost all (98%) suspected cases for malaria were tested for malaria parasite, and 98% doses of antimalarial drug dispensed had documentation indicating that the malaria test result was positive, an increase of 74%.

CONCLUSION

This study successfully increased the adherence to malaria parasitological confirmation before the treatment recommendation. The interdepartmental collaboration facilitated improvements that led to a reduction in presumptive prescription of antimalarial drugs, antimalarial medication costs, and potentially the emergence of drug resistance.

Physicians' compliance with the National Drug Policy on Malaria in a tertiary teaching hospital, India, from 2010 to 2015: a mixed method study

Background

National drug policies are formulated to encourage rational use of drugs and to reduce drug resistance. This study assessed physicians' compliance with the National Drug Policy on Malaria at a tertiary care hospital in north India.

Methods

This mixed method study extracted data from adult malaria inpatient records of the hospital from 2010-2015, and assessed drug supply at pharmacies. Physicians' practices and perspectives were explored by in-depth interviews. Compliance was assessed by severity, type of species and pregnancy status. Thematic analysis was done for the qualitative data.

Results

A total of 247 case files were reviewed. Vivax malaria (41.0%) was more common than falciparum malaria (37.2%). The majority (90.8%) of cases were severe malaria. Overall compliance for use of schizonticidal drug was 73.0% in severe malaria and was only 9.5% in uncomplicated malaria. Compliance for use of gametocidal drug (primaquine) was 15.3%. Schizonticidal drugs were available in all pharmacies except the public one. Primaquine was available in only one. The main themes emerging in the thematic network analysis were physicians' misconceptions, physician-related factors, and hospital-related and drug access factors.

Conclusions

The degree of compliance for severe malaria treatment was reasonably good but low for radical cure. Raising knowledge and awareness among health care providers, by using written treatment protocols and continuing medical education would improve compliance.

Antimalarial treatment patterns among pregnant women attending antenatal care clinics in south east Nigeria and the future implications

BACKGROUND

Prompt and effective treatment of malaria in pregnancy in accordance with recommended guidelines is essential to help prevent adverse events among pregnant mothers and the foetus.

AIM

The aim of this study was to assess current prescribing of antimalarial medicines in pregnancy against policy guidelines in south east Nigeria to provide future guidance.

METHODS

A review of prescription records of pregnant women treated for malaria over a 6-month period between August 2013 and January 2014 was carried out to assess the prescribing patterns for both the prevention and treatment of malaria in each trimester and analyzed for conformity to recommended guidelines.

RESULTS

Among 859 antenatal records reviewed, the majority (83.2%) were in the second and third trimesters. Artemisinin-based combination therapies (40.9%) and sulfadoxine-pyrimethamine (37.5%) were the most prescribed antimalarial medicines for both treatment and prophylaxis (prevention), respectively, in all trimesters. Overall, 68.5% of the prescriptions conformed to guideline recommendations, with the prescriptions for non-recommended drugs occurring most often in the first trimester. In the second and three trimesters, up to 79.9% of pregnant women received appropriate medicines for both treatment and prevention of malaria, with artemether-lumefantrine the most prescribed regimen.

CONCLUSION

Current practice indicates greater conformity with guidelines particularly in the second and three trimesters vs previous studies. However, there are still concerns with prescribing practices in the first trimester, especially in private health facilities. This needs addressing.

Health Worker Compliance with a 'Test And Treat' Malaria Case Management Protocol in Papua New Guinea

The Papua New Guinea (PNG) Department of Health introduced a ‘test and treat’ malaria case management protocol in 2011. This study assesses health worker compliance with the test and treat protocol on a wide range of measures, examines self-reported barriers to health worker compliance as well as health worker attitudes towards the test and treat protocol. Data were collected by cross-sectional survey conducted in randomly selected primary health care facilities in 2012 and repeated in 2014. The combined survey data included passive observation of current or recently febrile patients (N = 771) and interviewer administered questionnaires completed with health workers (N = 265). Across the two surveys, 77.6% of patients were tested for malaria infection by rapid diagnostic test (RDT) or microscopy, 65.6% of confirmed malaria cases were prescribed the correct antimalarials and 15.3% of febrile patients who tested negative for malaria infection were incorrectly prescribed an antimalarial. Overall compliance with a strictly defined test and treat protocol was 62.8%. A reluctance to test current/recently febrile patients for malaria infection by RDT or microscopy in the absence of acute malaria symptoms, reserving recommended antimalarials for confirmed malaria cases only and choosing to clinically diagnose a malaria infection, despite a negative RDT result were the most frequently reported barriers to protocol compliance. Attitudinal support for the test and treat protocol, as assessed by a nine-item measure, improved across time. In conclusion, health worker compliance with the full test and treat malaria protocol requires improvement in PNG and additional health worker support will likely be required to achieve this. The broader evidence base would suggest any such support should be delivered over a longer period of time, be multi-dimensional and multi-modal.

Using pay for performance incentives (P4P) to improve management of suspected malaria fevers in rural Kenya: a cluster randomized controlled trial

BACKGROUND

Inappropriate treatment of non-malaria fevers with artemisinin-based combination therapies (ACTs) is a growing concern, particularly in light of emerging artemisinin resistance, but it is a behavior that has proven difficult to change. Pay for performance (P4P) programs have generated interest as a mechanism to improve health service delivery and accountability in resource-constrained health systems. However, there has been little experimental evidence to establish the effectiveness of P4P in developing countries. We tested a P4P strategy that emphasized parasitological diagnosis and appropriate treatment of suspected malaria, in particular reduction of unnecessary consumption of ACTs.

METHODS

A random sample of 18 health centers was selected and received a refresher workshop on malaria case management. Pre-intervention baseline data was collected from August to September 2012. Facilities were subsequently randomized to either the comparison (n = 9) or intervention arm (n = 9). Between October 2012 and November 2013, facilities in the intervention arm received quarterly incentive payments based on seven performance indicators. Incentives were for use by facilities rather than as payments to individual providers. All non-pregnant patients older than 1 year of age who presented to a participating facility and received either a malaria test or artemether-lumefantrine (AL) were eligible to be included in the analysis. Our primary outcome was prescription of AL to patients with a negative malaria diagnostic test (n = 11,953). Our secondary outcomes were prescription of AL to patients with laboratory-confirmed malaria (n = 2,993) and prescription of AL to patients without a malaria diagnostic test (analyzed at the cluster level, n = 178 facility-months).

RESULTS

In the final quarter of the intervention period, the proportion of malaria-negative patients in the intervention arm who received AL was lower than in the comparison arm (7.3% versus 10.9%). The improvement from baseline to quarter 4 in the intervention arm was nearly three times that of the comparison arm (ratio of adjusted odds ratios for baseline to quarter 4 = 0.36, 95% CI: 0.24-0.57). The rate of prescription of AL to patients without a test was five times lower in the intervention arm (adjusted incidence rate ratio = 0.18, 95% CI: 0.07-0.48). Prescription of AL to patients with confirmed infection was not significantly different between the groups over the study period.

CONCLUSIONS

Facility-based incentives coupled with training may be more effective than training alone and could complement other quality improvement approaches.

TRIAL REGISTRATION

This study was registered with ClinicalTrials.gov (NCT01809873) on 11 March 2013.