Uncomplicated malaria case management practises using arthether-lumefantrine in settings without microscopy in underfives in Kibaha and Kisarawe districts, 2009

Abstract

Tanzania has high burden of morbidity and mortality caused by malaria which is the leading cause of outpatients, inpatients, and admissions of children less than five years of age at health facilities in the country. This burden has been attributed to increasing malaria parasite resistance to most of the antirnalarials used as monotherapies. Tanzania has amended the malaria treatment policy twice, the first amendment being in August 2001 when SP replaced chloroquine and the second being in January 2007 when arternether-lumefantrine (Alu) replaced SP for the treatment of uncomplicated malaria. The goal of the amendments was to reduce morbidity, mortality and economic losses and to encourage rational drug use in order to minimize the development of drug resistance. Resistance can develop if artemisisnin combination therapies (ACTs) are used unjudiciously as in presumptive diagnosis and treatment of malaria, which is the case in many health care facilities. There are very few reports on the quality of clinical practices following implementation of Alu policies in Africa in general and Tanzania in particular. Furthermore, it is not known what percentage of children suffering from uncomplicated malaria receive ACTs on clinical grounds while in fact they have or have no malaria as confirmed by laboratory diagnosis. The aim of this study was to examine the quality of childhood malaria case management practices using Alu and the accuracy of clinical malaria diagnosis in settings without mlcroscopy . . Health care facility-based, cross-sectional, cluster random sample survey was conducted in 17 government health facilities to examine uncomplicated malaria case management practices using artemether-lurnefantrine in settings without microscopy in underfives in Kibaha and Kisarawe districts.

IV Using structured questionnaires data were collected and analysed from 916 children aged less than 5 years who were brought to the health facilities with history of fever and/or other symptoms of malaria. Blood smears to detect the presence of malaria parasites were taken from the selected children and were subsequently processed and examined in the Medical Parasitology Laboratory at Muhimbili University of Health and Allied Sciences. Of the 916 caregivers of under five children, 469 (51.2%) sought care within 24 hours of onset of symptoms and 572 (64.6%) knew correctly more than 3 uncomplicated malaria symptoms in underfives. This knowledge was associated with early care seeking (OR= 1.4, 95%CI: l.2- 1.7). Moderate to high socioeconomic status was associated with increasing knowledge of symptoms of uncomplicated malaria in underfives as well as knowledge on correct use of All! under directly observed therapy and subsequent use at home (OR=3.6, 95%CI: l.5-9.2). Malaria was suspected in 846 children (92.4%), 527 of whom (62.3%; 95%CI (58.9-65.6) were appropriately managed according to IMCI and malaria treatment guidelines. Suspected malaria cases were more likely to receive appropriate management than those who had not been diagnosed to have malaria (OR= 36.9, 95%CI: 16 to 118). Presence of fever or history of fever as main presenting symptom was significantly associated with the quality of management given to the patients (OR = 20, 95%CI :6-68). Of 723 children who were prescribed with Alu, 459 (63.5%) were properly counseled. Alu was more likely to be prescribed in consultations by a clinical officer (OR=1.2, 95%CI: 1.06- ] .8); which took more than 5 minutes (OR=I.9, 95%CI:l.3-3.0), and where Alu alone was available as an antimalarial (OR= 1.4, 955CI: l.05-l.8) than in consultations by non clinical officers, which took less than 5 minutes and where alu and other antimalarials where available. Quality of counselling was associated with the counselling by the clinical officer (OR=I.4, 95%CI: 1.2-1.5) and with the counseling by a provider with above 2 years of working experience (OR=l.5, 95%CI: l.3-1.7).

v Of the suspected malaria cases, 179 (26.0 %, 95%CI: 22.8-29.5) had laboratory confirmed malaria. With PPV=26%, post-test probability of absence of disease in clinically positive malaria = 74% and NPV = 88.5%, post-test probability of presence of malaria parasites in clinically negative malaria = 11.5%. LR+ >1 (1.06) and LR- <1 (0.4). Early care seeking, clinical diagnosis and treatment of malaria using Alu in underfives in settings without microscopy has not reached the set target of appropriately managing 80% malaria in children by 2010. A lot ofmisdiagnosis and mistreatment with antimalarials well as omission of true cases of malaria calls for swift deployment of specific and sensitive diagnostic facilities.