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.

Prevalence and determinants of microalbuminuria in children suffering from sickle cell anemia in steady state

Background

Sickle cell anemia (SCA) is considered a major risk factor for renal complications. The main goal of this study was to determine the frequency of macroalbuminuria and microalbuminuria in Congolese children <18 years of age suffering from Sickle cell anemia and to identify associated factors.

Methods

The cross-sectional study was completed in 150 hemoglobin-SS children (77 boys and 73 girls). Microalbuminuria was defined by a urine albumin:creatinine ratio of 30–299 mg/g.

Results

The mean age of this group was 8.8 ± 4.3 years (range 2–18). Microalbuminuria was found in 27 children (18%). In multivariate logistic regression, only age emerged as a determinant of microalbuminuria odds ratio 1.11 (95% confidence interval 1.00–1.22); P = 0.042].

Conclusions

In our series, only age was a major determinant of the occurrence of microalbuminuria. These results confirm the need for early screening of microalbuminuria in Congolese children suffering from Sickle cell anemia in a context where access to renal and bone marrow transplant is nonexistent.

Presence of species within the Anopheles gambiae complex in the Democratic Republic of Congo

BACKGROUND

Anopheles gambiae s.l. is the primary vector of malaria in the Democratic Republic of Congo, however, there is little data on the species from this complex present in the country.

METHODS

This paper presents the species collected (as determined by PCR) between 2004 and 2011 in 16 locations across the country.

RESULTS AND CONCLUSIONS

The two species from the An. gambiae complex that were detected were An. coluzzii and An. gambiae s.s. An. gambiae s.s. was predominant in eastern DRC, whereas An. coluzzii was the main species found in several locations in Bandundu. The species were also found in sympatry in several locations (Kinshasa, Kisangani, Lodja). These results provide a basis for future work, which is needed to accurately describe the distribution of the An. gambiae complex species in DRC.

Falciparum malaria molecular drug resistance in the Democratic Republic of Congo: a systematic review

Background

Malaria cases were estimated to 207 million in 2013. One of the problems of malaria control is the emergence and spread of Plasmodium falciparum strains that become resistant to almost all drugs available. Monitoring drug resistance is essential for early detection and subsequent prevention of the spread of drug resistance by timely changes of treatment policy. This review was performed to gather all data available on P. falciparum molecular resistance in DR Congo, as baseline for future assessments.

Methods

The search for this review was undertaken using the electronic databases PubMed and Google Scholar using the terms “malaria”, “Congo”, “resistance”, “molecular”, “antimalarial”, “efficacy”. Articles were classified based on year of collecting, year of publication, sample size and characteristics, molecular markers analysed and polymorphisms detected.

Results

Thirteen articles were included and five genes have been analysed in these studies: pfcrt, pfdhps, pfdhfr, pfmdr1 and K13-propeller. The majority of studies included were not representative of the whole country.

Conclusion

This systematic review demonstrates the lack of molecular resistance studies in DRC. Only 13 studies were identified in almost 15 years. The MOH must implement a national surveillance system for monitoring malaria drug resistance and this surveillance should be conducted frequently and country-representative.

Malaria epidemic outbreaks in the Democratic Republic of Congo, part I: cross-sectional survey in Mweka District

Background

A series of outbreaks of fever has previously been reported in the DR Congo. The occurrence of similar outbreaks in Mweka district presented the opportunity to investigate these occurrences.

Materials and Methods

Health facilities and communities were visited. Permission was obtained to access to health records and a questionnaire was competed in the community. Blood samples for malaria, salmonellosis, Chikungunya, dengue and filovirus testing were obtained both in health facilities and the communities. Capture of mosquitoes and larvae in breeding sites was done and used bednets were collected. Excel, SPSS and Stats Direct were used for analyses of epidemiological data and malaria case management, with the Chi-square test and Fisher's Exact test used for assessing relationships resulting from contingency table analyses.

Results

An increase in the number of malaria cases beyond the expected number for the study period was observed in the two health districts located in the savannah zone (p<0.05) and in one health centre among sixteen located in the forest zone (p<0.05). In the health facilities and households visited (653 people), 141 persons had fever of which 82.2% was attributed to Plasmodium falciparum malaria. An incidence of 5.87% was recorded in the first half of 2013. Hundred and sixty patients (6.9%) died among 2,304 admitted for severe malaria in the three referral hospitals, 118 of them were children of under five years old. PCR testing of the blood samples obtained during home visits revealed malaria parasites in 63 (73.3%) of the 86 analysed samples. The test was negative for other parasites and bacteria and one dengue virus case was detected. Anopheles gambiae from Mweka were found to be resistant to permethrin using the WHO susceptibility test, with a knock down rate of ≤ 50% and mortality of ≤ 30%.

Conclusion

These investigations confirmed epidemic outbreaks in Mweka District caused by malaria with a high mortality rate in children below five years of age.

Severe malaria in children: A descriptive report from Kinshasa, the Democratic Republic of Congo

The decline of susceptibility of Plasmodium falciparum to chloroquine and sulfadoxine-pyrimethamine resulted in the change of drug policy. This policy has probably changed the facies of the severe form of malaria. A prospective study was conducted in Kinshasa, the Democratic Republic of Congo. Data on children aged ≤13 years, diagnosed with severe malaria were analyzed. In total, 378 children were included with an overall median age of 8 years (age range: 1-13 years). Dark urine was seen in 25.1% of cases. Metabolic acidosis (85.2%), hypoglycemia (62.2%) and hemoglobin ≤5 g/dl (39.1%) were the common laboratories features. Severe malaria anemia, cerebral malaria and Blackwater fever (BWF) were found in 39.1, 30.1 and 25.4%, respectively. Mortality rate was 4%. BWF emerges as a frequent form of severe malaria in our midst. Availing artemisin-based combination treatments in the health care system is a priority to reduce the incidence of BWF in our environment.

Black water fever associated with acute renal failure among Congolese children in Kinshasa

Acute renal failure (ARF) is reported in some severe forms of malaria such as black water fever (BWF). It is associated with a high mortality rate and can be managed effectively with adequate renal replacement. A prospective survey of children with dark urine after a malarial infection with Plasmodium falciparum was coupled with a chart review study of patients managed in the past 11 years in the Pediatrics' Kinshasa University Hospital. Eighty-nine cases of ARF were identified, but data from only 63 patients were available, of whom 44 (69.8%) had severe malaria (39 with BWF and 5 with cerebral malaria). The mean age of the patients was 8.2±1.73 years. Of the 39 cases of BWF, an association with quinine ingestion was observed in 32 children (82%). Urea and creatinine levels were elevated in all cases (135.4±88.2 and 3.83±2.81 mg/dL, respectively). Oligo-anuria was observed in 44.4%, severe metabolic acidosis (bicarbonate<15 mEq/L) in 61.5% and hyponatremia (<130 mEq/L) in 33.3%. Peritoneal dialysis was required in 36 patients, including 20 with BWF. The remaining patients were managed with conservative treatment. Twenty-eight children (44.4%), including 20 on dialysis, fully recovered and 14 died (22.2%), including eight cases of BWF. Our study suggests that ARF is commonly associated with BWF in Congolese children. Elevated urea and creatinine and severe metabolic acidosis were observed more often than other clinical/metabolic disturbances. Severe renal impairment remains a significant complication with a high mortality rate in low-resource settings.

Acute renal failure in Congolese children: a tertiary institution experience

AIM

Published data on acute renal failure in children from the Democratic Republic of Congo are rare. The objective of this study was to review clinical manifestations, aetiologies and outcome in hospitalized children with acute renal failure.

METHODS

A retrospective study at Pediatric Nephrology Unit of University Hospital of Kinshasa was carried out.

RESULTS

Fifty-six children with acute renal failure were eligible. There were 31 boys (55.4%) and 25 girls (44.6%) with a sex ratio of 1.24. The median age was 6.7 years (range 1-13 years). Fever (80.3%), oligo-anuria (73.2%), jaundice (67.9%) were the common clinical presentation. Blackwater fever (42.8%) was the leading cause of Acute Renal Failure. The incidence of severe dehydration because of gastroenteritis was low (5.3%). Around 12.5% of patients' misused herbal plants. Acute Peritoneal Dialysis was indicated in 15/56 children and only performed in four patients. Fourteen children (25%) died.

CONCLUSION

A wide spectrum of features was seen in hospitalized Acute Renal Failure children and limited access to Acute Peritoneal Dialysis remained an important mortality risk factor.

[Evaluation of vaccine coverage in children under two years of age in Kinshasa (Zaire)]

BACKGROUND

Despite efforts to make immunization against preventable diseases available to all children in Zaire, only about 33% of the children living at Kinshasa were immunized in 1986.

METHODS

The compliance with the vaccination schedules was evaluated in 211 children less than 2 years of age consulting in the largest medical center of Kinshasa during one week in September 1989. Socio-demographic data on the parents and histories of infectious preventable diseases in children were also collected.

RESULTS

93% of the children were immunized against tuberculosis, 85% against diphtheria, tetanus, pertussis and poliomyelitis, 76% against measles. Compliance with the vaccination schedule was higher when the mothers were better educated, or when they worked in the public service. 25% of the children had not been immunized against measles at the age of 9 months.

CONCLUSION

The vaccine schedule and the strategy must still be improved.