Summary
Objective To evaluate the accuracy of routine malaria microscopy, and appropriate use and interpretation of malaria slides under operational conditions in Kenya.
Methods Cross‐sectional ...survey, using a range of quality of care assessment tools, at government facilities with malaria microscopy in two Kenyan districts of different intensity of malaria transmission. All patients older than 5 years presenting to outpatient departments were enrolled. Two expert microscopists assessed the accuracy of the routine malaria slide results.
Results We analysed 359 consultations performed by 31 clinicians at 17 facilities. Clinical assessment was suboptimal. Blood slide microscopy was performed for 72.7% of patients, who represented 78.5% of febrile patients and 51.3% of afebrile patients. About 95.5% of patients with a positive malaria microscopy result and 79.3% of patients with a negative result received antimalarial treatment. Sulphadoxine–pyremethamine monotherapy was more commonly prescribed for patients with a negative test result (60.7%) than for patients with a positive result (32.4%). Conversely, amodiaquine or quinine were prescribed for only 14.7% of patients with a negative malaria microscopy result compared to 57.7% of patients with a positive result. The prevalence of confirmed malaria was low in both high (10.0%) and low‐(16.3%) transmission settings. Combining data from both settings, the sensitivity of routine microscopy was 68.6%; its specificity, 61.5%; its positive predictive value, 21.6% and its negative predictive value, 92.7%.
Conclusions The potential benefits of microscopy are currently not realised because of the poor quality of routine testing and irrational clinical practices. Ambiguous clinical guidelines permitting treatment of older children and adults with a negative blood slide also undermine rational use of antimalarial drugs.
Objectif Evaluer la précision de la lecture des lames et de l'interprétation des résultats dans la microscopie de la malaria sous des conditions opérationnelles.
Méthodes Etude transversale basée sur une série d'outils d’évaluation de la qualité de la prise en charge dans des services gouvernementaux réalisant une microscopie pour la malaria, dans deux districts du Kenya avec différentes intensités de la transmission de la malaria. Tous les patients de plus de 5 ans se présentant dans le département des patients ambulatoires ont été inclus dans l’étude.
Résultats 359 consultations ont été réalisées par 31 cliniciens dans 17 services. L’évaluation clinique était sub‐optimale. Une microscopie de frottis sanguin a été effectuée pour 72,7% des patients représentant 78,5% des patients fébriles et 51,3% des patients non fébriles. 95,5% des patients avec frottis microscopiquement positif et 79,3% des patients avec un frottis négatif ont reçu un traitement antimalarique. La monothérapie à sulphadoxine‐pyremethamine était plus couramment prescrite pour les patients avec un test négatif (60,7%) que pour les patients avec un test positif (32,4%). Cependant, l'amodiaquine ou la quinine était prescrite chez seulement 14,75% des patients avec un test négatif comparéà 57,7% des patients avec un test positif. La prévalence de malaria confirmée était faible autant dans la région à haute (10,0%) que dans celle à faible (16,3%) transmission de la malaria. D'après les données combinées des deux endroits, la sensitibilité de la microscopie en routine était de 68,6%, sa spécificité 61,5%; sa valeur prédictive positive 21,6% et sa valeur prédictive négative 92,7%.
Conclusion Les bénéfices potentiels de la microscopie ne sont pas actuellement atteints à cause de la faible qualité du test de routine. En plus, les directives cliniques ambiguës pour le traitement des enfants moins jeunes et des adultes à frottis sanguins négatifs compromettent l'usage rationnel des médicaments antifébriles.
Objetivo Evaluar la exactitud de la lectura por microscopía de láminas para malaria, y la interpretación correcta de los resultados, bajo condiciones operacionales en Kenia.
Métodos Estudio croseccional, utilizando una serie de herramientas para evaluar la calidad, en centros gubernamentales con microscopía para malaria en dos distritos de Kenia con diferente intensidad de transmisión de malaria. Todos los pacientes de más de 5 años que se presentaron en consultas externas fueron incluidos en el estudio. Dos microscopistas expertos evaluaron la exactitud de los resultados de las lecturas de rutina de las láminas.
Resultados Analizamos 359 consultas realizadas por 31 clínicos en 17 centros. La evaluación clínica fue deficiente: se realizaron láminas a 72.7% de los pacientes, que representaban un 78.5% de los pacientes con fiebre y 51.3% de los pacientes sin fiebre. Un 95.5% de los pacientes con un resultado positivo en la lectura de la lámina por microscopía y un 79.3% de los pacientes con un resultado negativo, recibieron tratamiento antimalárico. La monoterapia con sufadoxina‐pirimetamina más comúnmente prescrita a pacientes con una resultado negativo en la lectura de la lámina (60.7%) que a pacientes con un resultado positivo (32.4%). Por otro lado, la amodiaquina o la quinina fueron prescritas a solo un 14.7% de los pacientes con un resultado negativo por microscopía, comparado con un 57.7% de los pacientes con un resultado positivo. La prevalencia de malaria confirmada fue baja, tanto en áreas de alta (10.0%) como de baja (16.3%) transmisión. Al combinar los datos de ambos lugares, la sensibilidad de la microscopía de rutina fue del 68.6%; la especificidad del 61.5%; su valor predictivo positivo, 21.6% y su valor predictivo negativo, 92.7%.
Conclusiones Los beneficios potenciales de la microscopía no son actualmente evidentes debido a la mala calidad de las pruebas de rutina. Unas guías clínicas ambiguas que permiten el tratamiento de niños mayores y adultos con una lámina negativa, también debilitan el uso racional de los medicamentos para malaria.
To describe the quality of outpatient paediatric malaria case-management approximately 4-6 months after artemether-lumefantrine (AL) replaced sulfadoxine-pyrimethamine (SP) as the nationally ...recommended first-line therapy in Kenya. Cross-sectional survey at all government facilities in four Kenyan districts. Main outcome measures were health facility and health worker readiness to implement AL policy; quality of antimalarial prescribing, counselling and drug dispensing in comparison with national guidelines; and factors influencing AL prescribing for treatment of uncomplicated malaria in under-fives. We evaluated 193 facilities, 227 health workers and 1533 sick-child consultations. Health facility and health worker readiness was variable: 89% of facilities stocked AL, 55% of health workers had access to guidelines, 46% received in-service training on AL and only 1% of facilities had AL wall charts. Of 940 children who needed AL treatment, AL was prescribed for 26%, amodiaquine for 39%, SP for 4%, various other antimalarials for 8% and 23% of children left the facility without any antimalarial prescribed. When AL was prescribed, 92% of children were prescribed correct weight-specific dose. AL dispensing and counselling tasks were variably performed. Higher health worker's cadre, in-service training including AL use, positive malaria test, main complaint of fever and high temperature were associated with better prescribing. Changes in clinical practices at the point of care might take longer than anticipated. Delivery of successful interventions and their scaling up to increase coverage are important during this process; however, this should be accompanied by rigorous research evaluations, corrective actions on existing interventions and testing cost-effectiveness of novel interventions capable of improving and maintaining health worker performance and health systems to deliver artemisinin-based combination therapy in Africa.
Summary
Distance is a crucial feature of health service use and yet its application and utility to health care planning have not been well explored, particularly in the light of large‐scale ...international and national efforts such as Roll Back Malaria. We have developed a high‐resolution map of population‐to‐service access in four districts of Kenya. Theoretical physical access, based upon national targets, developed as part of the Kenyan health sector reform agenda, was compared with actual health service usage data among 1668 paediatric patients attending 81 sampled government health facilities. Actual and theoretical use were highly correlated. Patients in the larger districts of Kwale and Makueni, where access to government health facilities was relatively poor, travelled greater mean distances than those in Greater Kisii and Bondo. More than 60% of the patients in the four districts attended health facilities within a 5‐km range. Interpolated physical access surfaces across districts highlighted areas of poor access and large differences between urban and rural settings. Users from rural communities travelled greater distances to health facilities than those in urban communities. The implications of planning and monitoring equitable delivery of clinical services at national and international levels are discussed.
Summary
Objective The recent change of treatment policy for uncomplicated malaria from sulfadoxine‐pyrime‐thamine to artemether‐lumefantrine (AL) in Kenya was accompanied by revised malaria ...diagnosis recommendations promoting presumptive antimalarial treatment in young children and parasitological diagnosis in patients 5 years and older. We evaluated the impact of these age‐specific recommendations on routine malaria treatment practices 4–6 months after AL treatment was implemented.
Methods Cross‐sectional, cluster sample survey using quality‐of‐care assessment methods in all government facilities in four Kenyan districts. Analysis was restricted to the 64 facilities with malaria diagnostics and AL available on the survey day. Main outcome measures were antimalarial treatment practices for febrile patients stratified by age, use of malaria diagnostic tests, and test result.
Results Treatment practices for 706 febrile patients (401 young children and 305 patients ≥5 years) were evaluated. 43.0% of patients ≥5 years and 25.9% of children underwent parasitological malaria testing (87% by microscopy). AL was prescribed for 79.7% of patients ≥5 years with positive test results, for 9.7% with negative results and for 10.9% without a test. 84.6% of children with positive tests, 19.2% with negative tests, and 21.6% without tests were treated with AL. At least one antimalarial drug was prescribed for 75.0% of children and for 61.3% of patients ≥5 years with a negative test result.
Conclusions Despite different recommendations for patients below and above 5 years of age, malaria diagnosis and treatment practices were similar in the two age groups. Parasitological diagnosis was under‐used in older children and adults, and young children were still tested. Use of AL was low overall and alternative antimalarials were commonly prescribed; but AL prescribing largely followed the results of malaria tests. Malaria diagnosis recommendations differing between age groups appear complex to implement; further strengthening of diagnosis and treatment practices under AL policy is required.
Effets de la révision des recommandations de diagnostic de la malaria sur les pratiques de traitement de tous les groupes d’âge au Kenya
Objectif Le récent changement de la politique de traitement de la malaria non compliquée passant de la sulfadoxine‐pyriméthamine à l’artéméther‐luméfantrine (AL) au Kenya a été accompagné d’une révision des recommandations du diagnostic de la malaria promouvant le traitement antimalarique présomptif chez les jeunes enfants et le diagnostic parasitologique chez les patients de 5 ans et plus. Notre objectif était d’évaluer l’impact de ces recommandations spécifiées à l’âge, sur les pratiques courantes de traitement de la malaria, 4 à 6 mois après l’instauration du traitement AL.
Méthodes Etude transversale en grappes utilisant des méthodes d’analyse de la qualité des soins dans tous les services gouvernementaux de quatre districts kenyans. L’analyse a été limitée aux 64 services disposant de diagnostic de la malaria et d’AL, le jour de l’enquête. Les critères principaux d’évaluation étaient: traitements antimalariques en pratique pour les patients fébriles stratifiés selon l’âge, utilisation de tests de diagnostic de la malaria et résultat du test.
Résultats Les pratiques de traitement pour 706 patients fébriles (401 jeunes enfants et 305 patients de plus de 5 ans) ont étéévaluées. 43,0% des patients de plus de 5 ans et 25,9% des jeunes enfants ont subi des tests parasitologiques pour la malaria (87% par microscopie). AL a été prescrit pour 79,7% des patients de plus de 5 ans ayant un résultat positif pour le test, pour 9,7% de ceux ayant un résultat négatif et pour 10,9% de ceux sans test. 84,6% des jeunes enfants ayant un test positif, 19,2% de ceux ayant un test négatif et 21,6% de ceux sans test ont été traités avec AL. Au moins un médicament antimalarique a été prescrit pour 75,1% des jeunes enfants et 61,3% pour les enfants de plus de 5 ans ayant un résultat de test négatif.
Conclusions Malgré différentes recommandations pour les patients en‐dessous et au‐dessus de 5 ans, les pratiques de diagnostic et de traitement de la malaria étaient similaires dans les deux groupes d’âge. Le diagnostic parasitologique était peu utilisé chez les enfants plus âgés et les adultes et, les jeunes enfants étaient encore toujours testés. L’utilisation d’AL était globalement faible et des antimalariques alternatifs étaient couramment prescrits. Cependant, une prescription accrue d’AL suivait les résultats des tests de la malaria. Les recommandations divergentes pour le diagnostic de la malaria selon les groupes d’âge semblent complexes à appliquer. Un renforcement des pratiques de diagnostic et de traitement au sein de la politique de l’AL est nécessaire.
Efectos de las recomendaciones diagnósticas revisadas para el tratamiento de malaria en utilización para diferentes grupos de edades en Kenia
Objetivo El reciente cambio en Kenia de la política de tratamiento para malaria no complicada, de sulfadoxina‐pirimetamina a artemeter‐lumefantrina (AL), estuvo acompañada de una revisión en las recomendaciones para el diagnóstico de malaria, promoviendo un tratamiento antimalárico presuntivo en niños pequeños y el diagnóstico parasitológico en pacientes con cinco o más años de edad. Nuestro objetivo era evaluar el impacto de estas recomendaciones edad‐específicas en la práctica rutinaria del tratamiento, 4 a 6 meses después de la implementación del tratamiento con AL.
Métodos Estudio croseccional, encuesta con muestreo de agrupaciones utilizando métodos de evaluación de la calidad del cuidado en todos los centros gubernamentales en cuatro distritos Keniatas. El análisis estaba restringido a los 64 centros con diagnóstico de malaria y disponibilidad de AL el día de la encuesta. Las principales medidas de valoración eran las prácticas para pacientes febriles estratificados por edad, uso de pruebas de diagnóstico de malaria y resultados de las pruebas.
Resultados Se evaluaron las prácticas de tratamiento para 706 pacientes febriles (401 niños pequeños y 305 pacientes ≥5 años). Un 43.0% de los pacientes ≥5 años y un 25.9% de los niños fueron sometidos pruebas parasitológicas de malaria (87% por microscopía). Se prescribió AL a un 79.7% de los pacientes ≥5 años con resultados positivos en las pruebas, a un 9.7% con resultados negativos y a un 10.9% sin resultado. Un 84.6% de los niños que dieron positivos en las pruebas, un 19.2% de los que dieron negativo, y un 21.6% de aquellos que no fueron sometidos a una prueba fueron tratados con AL. Se prescribió al menos un medicamento antimaláricos a un 75.1% de los niños y a un 61.3% de los pacientes ≥5 años con un resultado negativo en la prueba.
Conclusiones A pesar de la diferencia en las recomendaciones para pacientes menores y mayores de 5 años, las prácticas de diagnóstico y tratamiento fueron similares en los dos grupos de edad. El diagnóstico parasitológico fue subutilizado en niños mayores y en adultos, y los niños pequeños seguían siendo sometidos a las pruebas. El uso de AL era bajo en general, y se prescribían antimaláricos alternativos de forma común; sin embargo la prescripción de AL seguía en gran medida los resultados de las pruebas para malaria. Parece compleja la implementación de recomendaciones para el diagnóstico de malaria con diferencias según el grupo de edad; es necesario fortalecer más las prácticas de diagnóstico y tratamiento bajo la política de AL.
Using data on clinical practices for outpatients 5 years and older, test accuracy, and malaria prevalence, we model financial and clinical implications of malaria rapid diagnostic tests (RDTs) under ...the new artemether-lumefantrine (AL) treatment policy in one high and one low malaria prevalence district in Kenya. In the high transmission district, RDTs as actually used would improve malaria treatment (61% less over-treatment but 8% more under-treatment) and lower costs (21% less). Nonetheless, the majority of patients with malaria would not be correctly treated with AL. In the low transmission district, especially because the treatment policy was new and AL was not widely used, RDTs as actually used would yield a minor reduction in under-treatment errors (36% less but the base is small) with 41% higher costs. In both districts, adherence to revised clinical practices with RDTs has the potential to further decrease treatment errors with acceptable costs.
Summary
Objective A recent observational study undertaken at 17 health facilities with microscopy in Kenya revealed that potential benefits of malaria microscopy are not realized because of ...irrational clinical practices and the low accuracy of routine microscopy. Using these data, we modelled financial and clinical implications of revised clinical practices and improved accuracy of malaria microscopy among adult outpatients under the artemether–lumefantrine (AL) treatment policy for uncomplicated malaria in Kenya.
Methods The cost of AL, antibiotics and malaria microscopy and the expected number of malaria diagnosis errors were estimated per 1000 adult outpatients presenting at a facility with microscopy under three scenarios: (1) current clinical practice and accuracy of microscopy (option A), (2) revised clinical practice with current accuracy of microscopy (option B) and (3) revised clinical practice with improved accuracy of microscopy (option C). Revised clinical practice was defined as performing a blood slide for all febrile adults and prescribing antimalarial treatment only for positive results. Improved accuracy of routine microscopy was defined as 90% sensitivity and specificity. In the sensitivity analysis, the implications of changes in the cost of drugs and malaria microscopy and changes in background malaria prevalence were examined for each option.
Results The costs of AL, antibiotics and malaria microscopy decreased from $2154 under option A to $1254 under option B and $892 under option C. Of the cost savings from option C, 72% was from changes in clinical practice, while 28% was from improvements in the accuracy of microscopy. Compared with 638 malaria overdiagnosis errors per 1000 adults under option A, 375 and 548 fewer overdiagnosis errors were estimated, respectively, under options B and C. At the same time, the number of missed malaria diagnoses remained generally low under all options. Sensitivity analysis showed that both options B and C are robust to a wide range of assumptions on the costs of drugs, costs of blood slides and malaria prevalence.
Conclusions Even with the imperfect microscopy conditions at Kenyan facilities, implementation of revised clinical practice (option B) would substantially reduce the costs and errors from malaria overdiagnosis. Additional interventions to improve the accuracy of microscopy (option C) can achieve further benefits; however, improved microscopy in the absence of revised clinical practice is unlikely to generate significant cost savings. Revision of guidelines to state explicitly age‐specific indications for the use and interpretation of malaria microscopy is urgently needed. Further prospective studies are required to evaluate the effectiveness and costs of interventions to improve clinical practice and the accuracy of malaria microscopy.
Données de base Une étude d'observation menée sur la microscopie dans 17 services de santé au Kenya a révélé que les bénéfices potentiels de la microscopie de la malaria n’étaient pas réalisés à cause de pratiques cliniques irrationnelles et de la faible précision de la microscopie de routine. Sur base de ces données, nous avons modélisé les implications financières et cliniques de la correction de la pratique clinique et de l'amélioration de la précision de la microscopie de la malaria chez les patients ambulants adultes sous les directives de traitement utilisant artemether‐lumefantrine pour la malaria non compliquée au Kenya.
Méthodes Les coûts de artemether‐lumefantrine, des antibiotiques, de la microscopie de la malaria et du nombre attendu d'erreurs de diagnostic ont été estimés par 1000 patients ambulants adultes se présentant dans un service pratiquant la microscopie sous trois scénarios: 1) Option A: pratique clinique en cours et précision de la microscopie, 2) Option B: pratique clinique corrigée avec la précision microscopique en cours et 3) Option C: pratique clinique corrigée avec amélioration de la précision de la microscopie. La correction de la pratique clinique a consistéà prescrire la pratique d'un frottis sanguin pour tout cas fébrile adulte et la prescription d'un traitement antimalarique seulement pour les résultats positifs. L'amélioration de la précision de la microscopie de routine a été définie pour 90% de spécificité et de sensibilité. Dans l'analyse de sensibilité, les implications dans les changements du coût des médicaments et de la microscopie de la malaria et les changements sous‐jacents dans la prévalence de la malaria, ont été examinées pour chacune des options.
Résultats Le coût de l'artemether‐lumefantrine, des antibiotiques et de la microscopie de la malaria ont baissé de 2154$ pour l'option A à 1254 $ pour l'option B et à 892 $ pour l'option C. 72% des coûts évités dans l'option C s'appliquaient aux changements de la pratique clinique et 28%à l'amélioration de la précision de la microscopie. Sous l'option A, 638 erreurs (faux positifs) de diagnostic par 1000 adultes ont été effectuées. 375 erreurs de diagnostic en moins ont été estimées sous l'option B et 548 en moins sous l'option C. Le nombre de malaria non diagnostiquées restait en général faible quelque soit l'option. L'analyse de sensibilité a révélé que les options B et C étaient toutes les deux robustes pour une large variété d'assomptions sur le coût des médicaments, des frottis de sang et de la prévalence de la malaria.
Conclusion Même avec des conditions imparfaites de microscopie dans les services de santé au Kenya, l'implémentation de pratique clinique corrigée (option B) réduirait substantiellement les coûts et les erreurs de diagnostic en surplus de la malaria. Des interventions supplémentaires dans l'amélioration de la précision de la microscopie (option C) peuvent permettre des bénéfices supplementaires, quoiqu'il soit improbable que l'amélioration de la microscopie en l'absence de pratique clinique corrigée permette de réduire les coûts. Des directives expliquant clairement les indications spécifiques à l’âge pour l'utilisation et l'interprétation de la microscopie de la malaria devraient être urgemment corrigées.
Antecedentes Durante un estudio observacional realizado recientemente en 17 centros sanitarios con microscopía en Kenia, se demostró que los beneficios potenciales de la microscopia de malaria no se estaban dando debido a una práctica clínica irracional y a una baja precisión en la microscopía de rutina. Utilizando estos datos, modelamos las implicaciones clínicas y financieras de unas prácticas clínicas revisadas y un aumento en la precisión de la microscopia para malaria, entre adultos que acudían a consultas externas por política de tratamiento con artemeter‐lumefantrina para malaria no complicada en Kenia.
Métodos Se estimaron el coste de artemeter‐lumefantrina, de los antibióticos y la microscopia para malaria así como el número esperado de errores en el diagnóstico de malaria por cada 1,000 pacientes adultos que se presentaban en un servicio sanitario con microscopio bajo tres escenarios:
1) práctica clínica y precisión de la microscopía actuales (Opción A); 2) práctica clínica revisada y precisión de la microscopía actual (Opción B); y 3) práctica clínica revisada con mejora en la precisión de la microscopía (Opción C). Se definió la práctica clínica revisada como el hacer una gota gruesa a todos los adultos febriles y prescribirles tratamiento antimalárico solo a los que obtuviesen un resultado positivo. Una mejora en la precisión de la microscopía de rutina se definió como una sensibilidad y especificidad del 90%. En el análisis de sensibilidad se examinaron para cada opción las implicaciones de cambio en el coste de los medicamentos y la microscopía de malaria así como los cambios en la prevalencia de la malaria de fondo.
Resultados El coste de artemeter‐lumefantrina, antibióticos y la microscopia de malaria disminuyó de $2,154 bajo la Opción A a $1,254 bajo la Opción By $892 bajo la Opción C. De los ahorros en costes de la Opción C, un 72% correspondía a cambios en las prácticas clínicas y 28% era de mejoras la precisión de la microscopía. Bajo la Opción A se sobrediagnosticaron como malaria 638 de cada 1,000 adultos; en la Opción B y C se estimaron 375 y 548 menos errores de sobrediagnóstico respectivamente. El número de diagnósticos de malaria omitidos fue en general bajo en todas las opciones. El análisis de sensibilidad mostró que ambas opciones By C eran robustas a un amplio rango de supuestos sobre el coste de los fármacos, el coste de las gotas gruesas y la prevalencia de malaria.
Conclusiones Aún con las condiciones imperfectas de microscopía existentes en las instalaciones de Kenia, la implementación de una práctica clínica revisada (Opción B) reduciría sustancialmente los costos y errores debido al sobrediagnóstico de la malaria. Intervenciones adicionales para mejorar la precisión de la microscopía (Opción C) podrían alcanzar mayores beneficios; aunque la mejora de la microscopía en ausencia de una práctica clínica revisada es poco probable que genere ahorros significativos en los costos. Es urgente revisar las directrices para que expongan explícitamente las indicaciones, especificadas por edad, del uso y la interpretación de la microscopía para malaria.
To evaluate health facility and health worker readiness to deliver new artemether-lumefantrine (AL) treatment policy for uncomplicated malaria in Kenya.
Cross-sectional survey.
Health facilities in ...four sentinel districts in Kenya.
All government facilities in study districts (n = 211) and all health workers performing outpatient consultations (n = 654).
Availability of antimalarial drugs on the survey day, stock-outs in past six months, presence of AL wall charts, health worker's exposure to in-service training on AL and access to new national malaria guidelines.
The availability of any tablets of AL, sulfadoxine-pyrimethamine and amodiaquine was nearly universal on the survey day. However, only 61% of facilities stocked all four weight-specific packs of AL. In the past six months, 67% of facilities had stock-out of at least one AL tablet pack and 15% were out of stock for all four packs at the same time. Duration of stock-out was substantial for all AL packs (median range: 27-39% of time). During the same period, the stock-outs of sulfadoxine-pyrimethamine and amodiaquine were rare. Only 19% of facilities had all AL wall charts displayed, AL in-service training was provided to 47% of health workers and 59% had access to the new guidelines.
Health facility and health worker readiness to implement AL policy is not yet optimal. Continuous supply of all four AL pack sizes and removal of not recommended antimalarials is needed. Further coordinated efforts through the routine programmatic activities are necessary to improve delivery of AL at the point of care.
Following the development of resistance to anti-malarial mono-therapies, malaria endemic countries in Africa now use artemisinin-based combination therapy (ACT) as recommended first-line treatment ...for uncomplicated malaria. Patients' adherence to ACT is an important factor to ensure treatment efficacy, as well as to reduce the likelihood of parasite resistance to these drugs. This study reports adherence to a specific ACT, artemether-lumefantrine (AL), under conditions of routine clinical practice in Kenya.
The study was undertaken in Garissa and Bunyala districts among outpatients of five government health facilities. Patients treated with AL were visited at home four days after having been prescribed the drug. Respondents (patients ≥ 15 years and caregivers of patients < 15 years) were interviewed using a standardized questionnaire, AL blister packs were physically inspected and the adherence status of patients was then recorded. Multivariate logistic regression modelling was used to determine predictors of adherence.
Of the 918 patients included in the study, 588 (64.1%) were 'probably adherent', 291 (31.7%) were 'definitely non-adherent' and 39 (4.2%) were 'probably non-adherent'. Six factors were found to be significant predictors of adherence: patient knowledge of the ACT dosing regimen (odds ratio (OR) = 1.76; 95% CI = 1.32-2.35), patient age (OR = 1.65; 95% CI = 1.02-1.85), respondent age (OR = 1.37; 95% CI = 1.10-2.48), whether a respondent had seen AL before (OR = 1.46; 95% CI = 1.08-1.98), whether a patient had reported dislikes to AL (OR = 0.62 95% CI = 0.47-0.82) and whether a respondent had waited more than 24 hours to seek treatment (OR = 0.73; 95% CI = 0.54-0.99).
Overall, adherence to AL was found to be low in both Garissa and Bunyala districts, with patient knowledge of the AL dosing regimen found to be the strongest predictor of adherence. Interventions aimed at increasing community awareness of the AL dosing regimen, use of child friendly formulations and improving health workers' prescribing practices are likely to ensure higher adherence to AL and eventual treatment success.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Shortly after Kenya introduced artemether-lumefantrine (AL) for first-line treatment of uncomplicated malaria, we conducted a pre-post cluster randomized controlled trial to assess the effect of ...providing malaria rapid diagnostic tests (RDTs) on recommended treatment (patients with malaria prescribed AL) and overtreatment (patients without malaria prescribed AL) in outpatients >/= 5 years old. Sixty health facilities were randomized to receive either RDTs plus training, guidelines, and supervision (TGS) or TGS alone. Of 1,540 patients included in the analysis, 7% had uncomplicated malaria. The provision of RDTs coupled with TGS emphasizing AL use only after laboratory confirmation of malaria reduced recommended treatment by 63%-points (P = 0.04), because diagnostic test use did not change (-2%-points), but health workers significantly reduced presumptive treatment with AL for patients with a clinical diagnosis of malaria who did not undergo testing (-36%-points; P = 0.03). Health workers generally adhered to RDT results when prescribing AL: 88% of RDT-positive and 9% of RDT-negative patients were treated with AL, respectively. Overtreatment was low in both arms and was not significantly reduced by the provision of RDTs (-12%-points, P = 0.30). RDTs could potentially improve malaria case management, but we urgently need to develop more effective strategies for implementing guidelines before large scale implementation.
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