Dispensing and determinants of non-adherence to treatment for non complicated malaria caused by Plasmodium vivax and Plasmodium falciparum in high-risk municipalities in the Brazilian Amazon

Spatiotemporal analysis of within-country imported malaria in Brazilian municipalities, 2004-2022

Human mobility has challenged malaria elimination efforts and remains difficult to routinely track. In Brazil, administrative records from the Ministry of Health allow monitoring of mobility locally and internationally. Although most imported malaria cases are between municipalities in Brazil, detailed knowledge of patterns of mobility is limited. Here, we address this gap by quantifying and describing patterns of malaria-infected individuals across the Amazon. We used network analysis, spatial clustering, and linear models to quantify and characterize the movement of malaria cases in Brazil between 2004 and 2022. We identified sources and sinks of malaria within and between states. We found that between-state movement of cases has become proportionally more important than within-state, that source clusters persisted longer than sink clusters, that movement of cases into sinks was seasonal while movement out of sources was not, and that importation is an impediment for subnational elimination in many municipalities. We elucidate the vast travel networks of malaria infected individuals that characterize the Amazon region. Uncovering patterns of malaria case mobility is vital for effective microstratification within Brazil. Our results have implications for intervention stratification across Brazil in line with the country's goal of malaria elimination by 2035.

Methods to Assess Adult and Adolescent Patients' Adherence to Antimalarial Treatment: A Systematic Review

Malaria is a curable disease for which early diagnosis and treatment, together with the elimination of vectors, are the principal control tools. Non-adherence to antimalarial treatment may contribute to therapeutic failure, development of antimalarial resistance, introduction or resurgence of malaria in non-endemic areas, and increased healthcare costs. The literature describes several methods to directly or indirectly assess adherence to treatment, but no gold standard exists. The main purpose of this review is to systematize the methods used to assess patient adherence to antimalarial treatment. A systematic review was performed, in accordance with the PRISMA statement, of the following databases: LILACS, EMBASE, PUBMED, COCHRANE, GOOGLE SCHOLAR, WEB OF SCIENCE, SCOPUS, and OPENGREY, through 14 December 2021. A snowball search was also performed by screening the references of the included studies as well as those cited in relevant reviews. Inclusion criteria were reporting assessment of the patient's adherence to antimalarials in individuals with laboratory diagnosis of malaria, the description of antimalarials prescribed, and adherence estimates. Exclusion criteria were studies exclusively about directly observed therapy, studies of populations ≤12 yo and guidelines, commentaries, reviews, letters, or editorials. Study quality was assessed using MINORS and the Cochrane Risk of Bias Tool. Proportions were calculated to measure frequencies considering the number of articles as the denominator. Twenty-one studies were included in this review. Most of them (76.5%) assessed adherence to falciparum malaria treatment. Seventeen studies (80.9%) used a combination of methods. The methods described were pill counts, self-reports, biological assays, use of electronic pillboxes, and clinical cure. It was possible to identify different adherence classifications for all the methods used. Our review found that indirect methods like pill counts and self-reports are the most commonly used. Combining an method that gives solid proof of the ingestion of medication and a method that completes the research with information regarding factors, beliefs or barrier of adherence seems to be the best approach. Future studies of antimalarial treatment should standardize adherence classifications, and collect data on the types and causes of nonadherence, which can contribute to the development of tools to promote medication adherence. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020148054, identifier CRD42020148054.

Strengthening therapeutic adherence and pharmacovigilance to antimalarial treatment in Manaus, Brazil: a multicomponent strategy using mHealth

BACKGROUND

Public health initiatives for improving adherence to primaquine based regimens and enhancing effective pharmacovigilance are needed to support the efforts for malaria elimination in real world conditions.

METHODS

A multicomponent patient-oriented strategy using a Smart Safety Surveillance (3S) approach including: (1) educational materials for treatment counselling and identification of warning symptoms of haemolytic anaemia; (2) an mHealth component using Short Message Service (SMS) treatment reminders and (3) development and implementation of follow-up phone surveys three days after treatment completion, using a web-based platform linked to the local information system of malaria. Adherence was measured using the Morisky Medication Adherence Scale. Self-reported events were registered using a structured questionnaire and communicated to the Brazilian Health Regulatory Agency.

RESULTS

Educational materials were disseminated to 5594 patients, of whom 1512 voluntarily entered the mHealth component through the local information system; 7323 SMS were sent, and 1062 participants completed a follow-up survey after treatment. The mean age of patients was 37.36 years (SD 13.65), 61.24% were male, 98.54% were infected with. Plasmodium vivax and 95.90% received a short regimen of chloroquine plus primaquine (CQ + PQ 7 days), as per malaria case management guidelines in Brazil. From the 1062 surveyed participants 93.31% were considered adherent to the treatment. Most of the patients (95.20%) reported at least one adverse event. Headache, lack of appetite and nausea/vomiting were the most frequently reported adverse events by 77.31%, 70.90% and 56.78% of the patients respectively. A quarter of the patients reported anxiety or depression symptoms; 57 (5.37%) patients reported 5 to 6 warning symptoms of haemolytic anaemia including jaundice and dark urine in 44 (4.14%). Overall, three patients presenting symptoms of haemolytic anaemia attended a hospital and were diagnosed with G6PD deficiency, and one had haemolysis. All of them recovered.

CONCLUSIONS

Under real world conditions, a multicomponent patient-oriented strategy using information and communication technologies allowed health care providers to reinforce treatment adherence and enhance safety surveillance of adverse events associated with regimens using primaquine. Active monitoring through phone surveys also reduced under-reporting of ADRs. This approach is low-cost, scalable and able to support prioritized activities of the national malaria programme.

Effect of weekly versus daily primaquine on Plasmodium vivax malaria recurrences: A real-life cohort study

Background:

Although primaquine (PQ) is indicated for G6PD-deficient patients, data on weekly PQ use in Brazil are limited.

Methods:

We aimed to investigate malaria recurrences among participants receiving daily and weekly PQ treatments in a real-life setting of two municipalities in the Amazon between 2019 and 2020.

Results:

Patients receiving weekly PQ treatment had a lower risk of recurrence than those receiving daily PQ treatment (risk ratio: 0.62, 95% confidence interval: 0.41-0.94), using a model adjusted for study site.

Conclusions:

Weekly PQ use did not increase the risk of malaria recurrence. Further studies with larger populations are warranted.

Dispensing practices for anti-malarials in the La Nkwantanang-Madina municipality, Greater Accra, Ghana: a cross-sectional study

Background

Despite recent strides made towards reducing the emergence of artemisinin resistance, inappropriate dispensing practices for anti-malarials in both private and public sectors affect treatment outcomes negatively. In Ghana, private retail pharmacies are the most accessible health facilities for managing diseases of common occurrence. However, there is growing concern about the number of patients harmed by dispensing errors in the management of malaria in retail pharmacies. Although considerable work has been done in this area, several questions regarding dispensing practices remain unanswered. This study, therefore, sought to investigate the predictors of appropriate dispensing practices for anti-malarials in community pharmacies in the La Nkwantanang-Madina municipality of Greater Accra, Ghana.

Methods

A cross-sectional analytic study was conducted in sixty-one randomly selected community pharmacies in the La Nkwantanang-Madina. Data from 230 clients and 106 dispensers were analysed. It was checked for internal consistency and completeness then entered and analysed using STATA I/C version 14.0. Frequencies, Chi square tests, and logistic regression analyses were conducted, accounting for clustering.

Results and discussion

Of the 106 dispensers interviewed, 71.4% were medicine counter assistants. The mean age of dispensers was 30.4 years (SD 8.8). Over 88.0% of clients were advised to complete the full course of their anti-malarials. However, the 8-h loading dose principle for artemether-lumefantrine was not explained to 88.3% of the clients. More than half of the clients (52.2%) were given appropriate dispensing information on anti-malarial use. Most clients (66.1%), were dispensed anti-malarials without malaria tests. Dispensers with more than a 10-years experience were less likely to dispense artemisinin-based combinations appropriately relative to dispensers with less than 2 years experience (AOR = 0.04, 95% CI 0.002–0.802 p-value = 0.036) while pharmacy interns were about 19 times more likely (AOR = 18.5, 95% CI 1.40–245.6 p-value = 0.03) to dispense artemisinin-based combinations appropriately compared to pharmacists.

Conclusion

Dispensing practices for anti-malarials is unsatisfactory. There is a need to enforce existing legislation with educational programmes directed towards dispensers especially those with more than 10 years experience. Specific adherence to the World Health Organization Test, Treat and Track initiative should be encouraged to ensure effective use of anti-malarials.

Predictors of antimalarial self-medication in illegal gold miners in French Guiana: a pathway towards artemisinin resistance

Background

Malaria is endemic in French Guiana (FG), South America. Despite the decrease in cases in the local population, illegal gold miners are very affected by malaria (22.3% of them carried Plasmodium spp.). Self-medication seems to be very common, but its modalities and associated factors have not been studied. The aim of this study was to evaluate parasite susceptibility to drugs and to document behaviours that could contribute to resistance selection in illegal gold miners.

Methods

This multicentric cross-sectional study was conducted in resting sites along the FG-Surinamese border. Participating gold miners working in FG completed a questionnaire and provided a blood sample.

Results

From January to June 2015, 421 illegal gold miners were included. Most were Brazilian (93.8%) and 70.5% were male. During the most recent malaria attack, 45.5% reported having been tested for malaria and 52.4% self-medicated, mainly with artemisinin derivatives (90%). Being in FG during the last malaria attack was the main factor associated with self-medication (adjusted OR = 22.1). This suggests that access to malaria diagnosis in FG is particularly difficult for Brazilian illegal gold miners. Treatment adherence was better for persons who reported being tested. None of the 32 samples with Plasmodium falciparum presented any mutation on the pfK13 gene, but one isolate showed a resistance profile to artemisinin derivatives in vitro.

Conclusions

The risk factors for the selection of resistance are well known and this study showed that they are present in FG with persons who self-medicated with poor adherence. Interventions should be implemented among this specific population to avoid the emergence of artemisinin resistance.

Use of pharmacy records to measure treatment adherence: a critical review of the literature

The current frame of reference on adherence to pharmacotherapy includes a set of behaviors experienced by the user, with observation of the detailed and continuous history of the use of each dose of the medication. Indicators based on pharmacy records have been used to measure adherence. The current review aimed to identify and describe indicators based on pharmacy records and to discuss their adequacy and limitations for measuring adherence. An exploratory literature review was conducted in three databases using the terms "adherence", "pharmacy records/administrative data", and "measure" to compose the descriptors for the selection of 81 articles and the elaboration of a chart with the denomination, sources, methods for calculation, description, and interpretation of the operational and referential meaning of 14 indicators. Given the most recent taxonomy for adherence proposed in the literature, we concluded that the indicators can be useful for identifying patients with medication-seeking behavior-related problems and analysis of persistence. The distance between supply-related events and difficulties in treatment follow-up can influence an analysis based exclusively on the use of these indicators.