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Osoro CB, Dellicour S, Ochodo E, Young T, Ter Kuile FO, Gutman JR, Hill J. Perceptions and drivers of healthcare provider and drug dispenser practices for the treatment of malaria in pregnancy in the context of multiple first-line therapies in western Kenya: a qualitative study. Malar J 2023; 22:274. [PMID: 37710229 PMCID: PMC10503024 DOI: 10.1186/s12936-023-04698-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 09/01/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Emergence of Plasmodium falciparum resistance to artemether-lumefantrine in Africa prompted the pilot introduction of multiple first-line therapies (MFT) against malaria in Kenya, potentially exposing women-of-childbearing-age (WOCBAs) to anti-malarials with unknown safety profiles in the first trimester. This qualitative study explored knowledge and perceptions among healthcare providers providing malaria treatment to WOCBAs and pregnant women. METHODS In-depth interviews were conducted with purposively selected public and private health facility (HF) and drug outlet (DO) providers within and outside the pilot-MFT area. County health managers were interviewed about their knowledge of the national treatment guidelines. Transcripts were coded by content analysis using the World Health Organization health system building blocks (leadership/governance, financing, health workforce, health information systems, access to medicines, and service delivery). RESULTS Thirty providers (HF:21, DO:9) and three health managers were interviewed. Eighteen providers were from HFs in the pilot-MFT area; the remaining three and all nine DOs were outside the pilot-MFT area. The analysis revealed that providers had not been trained in malaria case management in the previous twelve months. DO providers were unfamiliar with national treatment guidelines in pregnancy and reported having no pregnancy tests. Health managers were unable to supervise DOs due to resource limitations. Providers from HFs and DOs noted poor sensitivity of malaria rapid diagnostic tests (RDTs) and hesitancy among patients who associated malaria-RDTs with HIV testing. Almost all providers reported anti-malarial stock-outs, with quinine most affected. Patient preference was a major factor in prescribing anti-malarials. Providers in HFs and DOs reported preferentially using artemether-lumefantrine in the first trimester due to the side effects and unavailability of quinine. CONCLUSION Knowledge of malaria case management in drug outlets and health facilities remains poor. Improved regulation of DO providers is warranted. Optimizing treatment of malaria in pregnancy requires training, availability of malaria commodities, and pregnancy tests.
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Affiliation(s)
- Caroline B Osoro
- Centre for Global Health Research, Kenya Medical Research Institute, P.O. Box 1578, Kisumu, 40100, Kenya.
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, P.O. Box 241, Cape Town, 8000, South Africa.
| | - Stephanie Dellicour
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, Liverpool, L3 5QA, UK
| | - Eleanor Ochodo
- Centre for Global Health Research, Kenya Medical Research Institute, P.O. Box 1578, Kisumu, 40100, Kenya
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, P.O. Box 241, Cape Town, 8000, South Africa
| | - Taryn Young
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, P.O. Box 241, Cape Town, 8000, South Africa
| | - Feiko O Ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, Liverpool, L3 5QA, UK
| | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, U.S. Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30333, USA
| | - Jenny Hill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, Liverpool, L3 5QA, UK
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Sayre D, Steinhardt LC, Irinantenaina J, Dentinger C, Rasoanaivo TF, Kapesa L, Razafindrakoto J, Legrand A, Prada N, Gutman J, Lewis L, Mangahasimbola RT, Andriamananjara M, Ravaoarinosy AV, Ralemary N, Garchitorena A, Harimanana A. Baseline malaria prevalence and care-seeking behaviours in rural Madagascar prior to a trial to expand malaria community case management to all ages. Malar J 2021; 20:422. [PMID: 34702255 PMCID: PMC8549293 DOI: 10.1186/s12936-021-03956-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 10/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Integrated community case management of malaria, pneumonia, and diarrhoea can reduce mortality in children under five years (CU5) in resource-poor countries. There is growing interest in expanding malaria community case management (mCCM) to older individuals, but limited empirical evidence exists to guide this expansion. As part of a two-year cluster-randomized trial of mCCM expansion to all ages in southeastern Madagascar, a cross-sectional survey was conducted to assess baseline malaria prevalence and healthcare-seeking behaviours. METHODS Two enumeration areas (EAs) were randomly chosen from each catchment area of the 30 health facilities (HFs) in Farafangana district designated for the mCCM age expansion trial; 28 households were randomly selected from each EA for the survey. All household members were asked about recent illness and care-seeking, and malaria prevalence was assessed by rapid diagnostic test (RDT) among children < 15 years of age. Weighted population estimates and Rao-Scott chi-squared tests were used to examine illness, care-seeking, malaria case management, and malaria prevalence patterns. RESULTS Illness in the two weeks prior to the survey was reported by 459 (6.7%) of 8050 respondents in 334 of 1458 households surveyed. Most individuals noting illness (375/459; 82.3%) reported fever. Of those reporting fever, 28.7% (112/375) sought care; this did not vary by participant age (p = 0.66). Most participants seeking care for fever visited public HFs (48/112, 46.8%), or community healthcare volunteers (CHVs) (40/112, 31.0%). Of those presenting with fever at HFs or to CHVs, 87.0% and 71.0%, respectively, reported being tested for malaria. RDT positivity among 3,316 tested children < 15 years was 25.4% (CI: 21.5-29.4%) and increased with age: 16.9% in CU5 versus 31.8% in 5-14-year-olds (p < 0.0001). Among RDT-positive individuals, 28.4% of CU5 and 18.5% of 5-14-year-olds reported fever in the two weeks prior to survey (p = 0.044). CONCLUSIONS The higher prevalence of malaria among older individuals coupled with high rates of malaria testing for those who sought care at CHVs suggest that expanding mCCM to older individuals may substantially increase the number of infected individuals with improved access to care, which could have additional favorable effects on malaria transmission.
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Affiliation(s)
- Dean Sayre
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA, USA. .,Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, CDC Atlanta, 1600 Clifton Rd, Atlanta, GA, USA.
| | - Laura C Steinhardt
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, CDC Atlanta, 1600 Clifton Rd, Atlanta, GA, USA
| | | | - Catherine Dentinger
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, CDC Atlanta, 1600 Clifton Rd, Atlanta, GA, USA.,U.S. President's Malaria Initiative, Centers for Disease Control and Prevention, Lot 207A, Point Liberty, Andranoro, Antehiroka, 105, Antananarivo, Madagascar
| | | | - Laurent Kapesa
- U.S. President's Malaria Initiative, USAID, Lot 207A, Point Liberty, Andranoro, Antehiroka, 105, Antananarivo, Madagascar
| | - Jocelyn Razafindrakoto
- U.S. President's Malaria Initiative, USAID, Lot 207A, Point Liberty, Andranoro, Antehiroka, 105, Antananarivo, Madagascar
| | - Agathe Legrand
- Institut Pasteur de Madagascar , BP 1274 Ambatofotsikely, 101, Antananarivo, Madagascar
| | - Nicole Prada
- Institut Pasteur de Madagascar , BP 1274 Ambatofotsikely, 101, Antananarivo, Madagascar
| | - Julie Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, CDC Atlanta, 1600 Clifton Rd, Atlanta, GA, USA
| | - Lauren Lewis
- U.S. President's Malaria Initiative, Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA, USA.,Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, CDC Atlanta, 1600 Clifton Rd, Atlanta, GA, USA
| | | | | | | | - Nicolas Ralemary
- Ministry of Public Health, Farafangana District Office, Farafangana, Madagascar
| | - Andres Garchitorena
- Institut Pasteur de Madagascar , BP 1274 Ambatofotsikely, 101, Antananarivo, Madagascar.,MIVEGEC, Univ. Montpellier, CNRS, IRD, 911 Av Agropolis, Montpellier, France
| | - Aina Harimanana
- Institut Pasteur de Madagascar , BP 1274 Ambatofotsikely, 101, Antananarivo, Madagascar
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Exploring Barriers and Facilitators of Adherence to Artemisinin-Based Combination Therapies for the Treatment of Uncomplicated Malaria in Children in Freetown, Sierra Leone. Healthcare (Basel) 2021; 9:healthcare9091233. [PMID: 34575007 PMCID: PMC8471195 DOI: 10.3390/healthcare9091233] [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: 07/28/2021] [Revised: 09/06/2021] [Accepted: 09/09/2021] [Indexed: 12/01/2022] Open
Abstract
Medication adherence is an essential step in the malaria treatment cascade. We conducted a qualitative study embedded within a randomized controlled trial comparing the adherence to the recommended dosing of two artemisinin-based combination therapies (ACT) to treat uncomplicated malaria in Freetown, Sierra Leone. This study explored the circumstances and factors that influenced caregiver adherence to the ACT prescribed for their child in the trial. In-depth interviews were conducted with 49 caregivers; all interviews were recorded, transcribed, and translated. Transcripts were coded and aggregated into themes, applying a thematic content approach. We identified four key factors that influenced optimal treatment adherence: (1) health system influences, (2) health services, (3) caregivers' experiences with malaria illness and treatment, and (4) medication characteristics. Specifically, caregivers reported confidence in the health system as facilities were well maintained and care was free. They also felt that health workers provided quality care, leading them to trust the health workers and believe the test results. Ease of medication administration and perceived risk of side effects coupled with caregivers' prior experience treating malaria influenced how medications were administered. To ensure ACTs achieve maximum effectiveness, consideration of these contextual factors and further development of child-friendly antimalarials are needed.
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Fomba S, Koné D, Doumbia B, Diallo D, Druetz T, Florey L, Eisele TP, Eckert E, Mihigo J, Ashton RA. Management of uncomplicated malaria among children under five years at public and private sector facilities in Mali. BMC Public Health 2020; 20:1888. [PMID: 33298011 PMCID: PMC7724888 DOI: 10.1186/s12889-020-09873-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 11/10/2020] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Seydou Fomba
- Programme National de Lutte contre le Paludisme, Bamako, Mali
| | - Diakalia Koné
- Programme National de Lutte contre le Paludisme, Bamako, Mali
| | | | | | - Thomas Druetz
- Center for Applied Malaria Research and Evaluation, Tulane School of Public Health and Tropical Medicine, New Orleans, LA, USA.,Department of Social and Preventive Medicine, School of Public Health, University of Montreal, Montreal, QC, Canada
| | - Lia Florey
- President's Malaria Initiative, United States Agency for International Development, Washington, DC, USA
| | - Thomas P Eisele
- Center for Applied Malaria Research and Evaluation, Tulane School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Erin Eckert
- President's Malaria Initiative, United States Agency for International Development, Washington, DC, USA.,RTI International, Washington, DC, USA
| | - Jules Mihigo
- President's Malaria Initiative, United States Agency for International Development, Bamako, Mali
| | - Ruth A Ashton
- MEASURE Evaluation, Center for Applied Malaria Research and Evaluation, Tulane School of Public Health and Tropical Medicine, New Orleans, LA, USA.
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Rathmes G, Rumisha SF, Lucas TCD, Twohig KA, Python A, Nguyen M, Nandi AK, Keddie SH, Collins EL, Rozier JA, Gibson HS, Chestnutt EG, Battle KE, Humphreys GS, Amratia P, Arambepola R, Bertozzi-Villa A, Hancock P, Millar JJ, Symons TL, Bhatt S, Cameron E, Guerin PJ, Gething PW, Weiss DJ. Global estimation of anti-malarial drug effectiveness for the treatment of uncomplicated Plasmodium falciparum malaria 1991-2019. Malar J 2020; 19:374. [PMID: 33081784 PMCID: PMC7573874 DOI: 10.1186/s12936-020-03446-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 10/10/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Anti-malarial drugs play a critical role in reducing malaria morbidity and mortality, but their role is mediated by their effectiveness. Effectiveness is defined as the probability that an anti-malarial drug will successfully treat an individual infected with malaria parasites under routine health care delivery system. Anti-malarial drug effectiveness (AmE) is influenced by drug resistance, drug quality, health system quality, and patient adherence to drug use; its influence on malaria burden varies through space and time. METHODS This study uses data from 232 efficacy trials comprised of 86,776 infected individuals to estimate the artemisinin-based and non-artemisinin-based AmE for treating falciparum malaria between 1991 and 2019. Bayesian spatiotemporal models were fitted and used to predict effectiveness at the pixel-level (5 km × 5 km). The median and interquartile ranges (IQR) of AmE are presented for all malaria-endemic countries. RESULTS The global effectiveness of artemisinin-based drugs was 67.4% (IQR: 33.3-75.8), 70.1% (43.6-76.0) and 71.8% (46.9-76.4) for the 1991-2000, 2006-2010, and 2016-2019 periods, respectively. Countries in central Africa, a few in South America, and in the Asian region faced the challenge of lower effectiveness of artemisinin-based anti-malarials. However, improvements were seen after 2016, leaving only a few hotspots in Southeast Asia where resistance to artemisinin and partner drugs is currently problematic and in the central Africa where socio-demographic challenges limit effectiveness. The use of artemisinin-based combination therapy (ACT) with a competent partner drug and having multiple ACT as first-line treatment choice sustained high levels of effectiveness. High levels of access to healthcare, human resource capacity, education, and proximity to cities were associated with increased effectiveness. Effectiveness of non-artemisinin-based drugs was much lower than that of artemisinin-based with no improvement over time: 52.3% (17.9-74.9) for 1991-2000 and 55.5% (27.1-73.4) for 2011-2015. Overall, AmE for artemisinin-based and non-artemisinin-based drugs were, respectively, 29.6 and 36% below clinical efficacy as measured in anti-malarial drug trials. CONCLUSIONS This study provides evidence that health system performance, drug quality and patient adherence influence the effectiveness of anti-malarials used in treating uncomplicated falciparum malaria. These results provide guidance to countries' treatment practises and are critical inputs for malaria prevalence and incidence models used to estimate national level malaria burden.
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Affiliation(s)
- Giulia Rathmes
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Susan F Rumisha
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
- Telethon Kids Institute, Perth, Australia.
| | - Tim C D Lucas
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Katherine A Twohig
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Andre Python
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Center for Data Science, Zhejiang University, Hangzhou, 310058, China
| | - Michele Nguyen
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Anita K Nandi
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Suzanne H Keddie
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Emma L Collins
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jennifer A Rozier
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Harry S Gibson
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Elisabeth G Chestnutt
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Katherine E Battle
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Georgina S Humphreys
- WorldWide Anti-Malarial Resistance Network (WWARN), Oxford, UK
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Punam Amratia
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rohan Arambepola
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Amelia Bertozzi-Villa
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Institute for Disease Modeling, Bellevue, WA, USA
| | - Penelope Hancock
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Justin J Millar
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Tasmin L Symons
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Ewan Cameron
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Telethon Kids Institute, Perth, Australia
- Curtin University, Perth, Australia
| | - Philippe J Guerin
- WorldWide Anti-Malarial Resistance Network (WWARN), Oxford, UK
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Peter W Gething
- Telethon Kids Institute, Perth, Australia
- Curtin University, Perth, Australia
| | - Daniel J Weiss
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Telethon Kids Institute, Perth, Australia
- Curtin University, Perth, Australia
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