Background: Malaria is one of the most common infectious diseases in the world with more than 40 percent of the world's population at risk and one of the greatest public health concerns especially in sub-Saharan Africa. In Bungoma South district, malaria is the leading cause of morbidity, accounting for 49 percent of the top ten diseases in the district. In 2006, Kenya implemented a new malaria treatment policy recommending the use of Artemether-Lumefantrine (AL) as the first line of treatment. National guidelines on the diagnosis, treatment and prevention and job aids were developed and disseminated to health workers alongside in-service training. The survey investigated if treatment of uncomplicated malaria conformed to national malaria treatment guidelines in Kenya.Methods: In September 2009, face to face interviews for 31 health workers routinely performing consultations at out-patient departments in 17 health facilities were conducted. Data on health facility inventory control practices and stock status was retrospectively collected from records available. Outcome measures: availability of antimalarial drugs on the survey day, stock-outs in past six months, presence of job aids, health worker's exposure to in-service training on AL and access to new national malaria treatment guidelines.Results: 35 percent of the health facilities had access to job aids and current treatment guidelines, 76 percent of the health workers had been trained on malaria case management. AL was almost universally available in all the health facilities. All facilities had recorded stock outs of AL six months prior to the survey and the duration of the stock outs was substantial lasting two months on average.Conclusion: Treatment practices in uncomplicated malaria after policy change, do not fully conform to the national malaria treatment guidelines. Targets set for key implementation indicators by the division of malaria control, in terms of availability of recommended drug and training of health workers, have not been fully achieved. If the government does not ensure uninterrupted supply of recommended treatment, high quality focused training and appropriate patient education, and if provider prescription practices do not fully conform to the recommended treatment guidelines, the major potential public health benefits of AL may not be realized.
Background: Plasmodium vivax resistance to chloroquine has been observed in several endemic countries. In Cambodia, up to 17% clinical treatment failure following 3-days standard chloroquine treatment was reported in vivax malaria patients in 2009. The loss of chloroquine efficacy was solely described in northeast area of Cambodia while chloroquine seemed to remain fully effective in other provinces. This led to the withdrawn of chloroquine and its replacement by dihydroartemisinin-piperaquine in 2012. To rigorously assess the extent of P. vivax chloroquine-resistance in Cambodia, we conducted a comprehensive therapeutic efficacy study with extensive genotyping of the parasites.Methods & Materials: The study was conducted in Rattanakiri, in northeastern Cambodia in 2014. 40 enrolled patients were treated with chloroquine (30 mg/kg) for three days and followed for two months. Reinfection was controlled for half of the patients by relocating them to a no-transmission area. The 2-months followup consisted in frequent clinical examination and capillary blood collection for microscopic, molecular parasite detection and drug concentration measure. The entire genomes of the initial and recurrent parasites were sequenced and complemented by genotyping of more than 100 SNPs for each PCR-positive blood samples collected during follow-up.Results: Recurrences occurred in 24/40 (60%) patients within the follow-up. No difference was observed between relocated and non-relocated patients. Recurrent parasites were always detected when chloroquine concentration in blood was below therapeutic level. Genotyping revealed that all P. vivax clones, within a given infection, responded similarly to CQ. In addition, whole genome sequencing unambiguously showed that most relapsing parasites were different from those in the initial infections.Conclusion: Recurrences within two months are frequent among Cambodian vivax malaria patients and originate from relapsing parasites from the liver. Pharmacological and genetic analyses revealed no evidence of CQ resistance and suggest that CQ is fully effective against P. vivax episodes in Rattanakiri Cambodia. Our results suggest that CQ resistance might be over-diagnosed and confounded with relapses from liver parasites. Our clinical and analytical framework has the potential to differentiate between relapse and resistance and should be implemented in vivax malaria endemic areas with suspected drug resistance.
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