Health worker compliance with severe malaria treatment guidelines in the context of implementing pre-referral rectal artesunate: an operational study in three high burden countries

Abstract

BackgroundAppropriate clinical management of severe malaria is critical to avert morbidity and death. Recommended treatment consists of an injectable antimalarial followed by a full course of oral artemisinin-based combination therapy (ACT). Children who cannot access prompt parenteral treatment should be administered a single dose of rectal artesunate (RAS) and promptly referred to an appropriate facility for further care. This study aimed to assess compliance with the treatment recommendation in children under 5 years diagnosed with severe malaria and admitted to referral facilities in 3 high-burden sub-Saharan African countries.Methods and FindingsThis study accompanied the implementation of RAS as a pre-referral treatment in the Democratic Republic of the Congo (DRC), Nigeria and Uganda. Children under 5 who were admitted at a referral health facility (RHF) with a diagnosis of severe malaria were included. Type and dosage of antimalarial treatment at RHFs was assessed for children referred from a community-based provider and those directly attending the RHF. We used multivariable regression models to assess factors associated with administration of compliant treatment.RHF data of 7,983 children was analysed for compliance with regards to antimalarials, a subsample of 3,449 children was assessed in more detail for schedule and dosage compliance and method of ACT provision. Overall, 42.0% (3,356/7,983) of admitted children were administered full treatment consisting of a parenteral antimalarial and an ACT, with large variation among study countries (2.7% in Nigeria, 44.5% in Uganda and 50.3% in DRC). Children receiving RAS from a community-based provider were more likely to be administered compliant post-referral medication at RHFs in DRC (adjusted odds ratio (aOR)=2.19, 95% CI 1.60-2.99), but less likely in Uganda (aOR = 0.43, 95% CI 0.19-0.96). Use of injectable antimalarials was very high in all three countries (99.2% (1,344/1,355) in Uganda, 98.1% (413/421) in Nigeria and 94.4% (1,580/1,673) in DRC), with most children receiving the recommended minimum of three doses (99.0% (1,331/1,344) in Uganda, 95.5% (1,509/1,580) in DRC and 92.0% (380/413) in Nigeria). Rather than being administered in the RHF, ACTs were often prescribed at discharge in Nigeria (54.4%, 229/421) and Uganda (53.0%, 715/1,349), while this was rarely done in DRC (0.8%, 14/1,669) where inpatient administration was more common.ConclusionsDirectly observed treatment with both a parenteral antimalarial and an ACT was rare and variable between countries, bearing a high risk for incomplete parasite clearance and disease recrudescence. Parenteral artesunate not followed up with a full course of oral ACT constitutes an artemisinin monotherapy and may favour the selection or development of resistant parasites. Stricter health worker compliance with the WHO severe malaria treatment guidelines is therefore needed to effectively manage this disease and further reduce child mortality.

Key factors predicting suspected severe malaria case management and health outcomes: an operational study in the Democratic Republic of the Congo

“…The same strong effect (a 74% reduction in the risk of dying) was seen for the combination of parenteral malaria treatment followed by an ACT, as recommended by the WHO treatment guidelines [6]. Again, this is consistent with findings in the other two CARAMAL countries as reviewed by Signorell et al [45]. This importance of the oral anti-malarial treatment following injectable treatment in RHF is a very important finding from our study for three reasons: (1) its favorable effect on the health outcomes of these children, (2) because of the threat posed by artesunate monotherapy for the development of drug resistance (Awor et al pers.…”

Pre-referral rectal artesunate and referral completion among children with suspected severe malaria in the Democratic Republic of the Congo, Nigeria and Uganda

“…As opposed to previous studies, this study considered referral to be completed only if the patient arrived at a RHF with the capacity to manage severe malaria cases. However, an analyses of the quality of care at RHFs in the CARAMAL study areas found that the treatment of children with severe malaria was often inadequate [19]. Meanwhile, some children sought post-referral treatment from a lower-level public or from a non-public provider.…”

“…This manuscript aimed to assess referral completion of children with suspected severe malaria and its relationship with RAS implementation and administration, taking into consideration other factors influencing referral completion. The key study results are described elsewhere [18] and the treatment patterns in the RHF are described in [19].…”

Starting at the community: Treatment seeking pathways of children with suspected severe malaria in Uganda

“…More details about the CARAMAL project and key results are described elsewhere (Lengeler et al manuscript in preparation). 8 18 19…”