Patients with positive malaria tests not given artemisinin-based combination therapies: a research synthesis describing under-prescription of antimalarial medicines in Africa

Abstract

Background: There has been a successful push towards parasitological diagnosis of malaria in Africa, mainly with rapid diagnostic tests (mRDTs), which has reduced over-prescribing of artemisinin-based combination therapies (ACT) to malaria test-negative patients. The effect on prescribing for test-positive patients has received much less attention. Malaria infection in endemic Africa is often most dangerous for young children and those in low-transmission settings. This study examined non-prescription of antimalarials for patients with malaria infection demonstrated by positive mRDT results, and in particular these groups who are most vulnerable to poor outcomes if antimalarials are not given. Methods: Analysis of data from 562,762 patients in 8 studies co-designed as part of the ACT Consortium, conducted 2007-2013 in children and adults, in Cameroon, Ghana, Nigeria, Tanzania, and Uganda, in a variety of public and private health care sector settings, and across a range of malaria endemic zones. Results: Of 106,039 patients with positive mRDT results (median age 6 years), 7426 (7.0%) were not prescribed an ACT antimalarial. The proportion of mRDT-positive patients not prescribed ACT ranged across sites from 1.3 to 37.1%. For patients under age 5 years, 3473/44,539 (7.8%) were not prescribed an ACT, compared with 3833/60,043 (6.4%) of those aged ≥ 5 years. The proportion of < 5-year-olds not prescribed ACT ranged up to 41.8% across sites. The odds of not being prescribed an ACT were 2-32 times higher for patients in settings with lower-transmission intensity (using test positivity as a proxy) compared to areas of higher transmission. mRDT-positive children in low-transmission settings were especially likely not to be prescribed ACT, with proportions untreated up to 70%. Of the 7426 mRDTpositive patients not prescribed an ACT, 4121 (55.5%) were prescribed other, non-recommended non-ACT antimalarial medications, and the remainder (44.5%) were prescribed no antimalarial. Conclusions: In eight studies of mRDT implementation in five African countries, substantial proportions of patients testing mRDT-positive were not prescribed an ACT antimalarial, and many were not prescribed an antimalarial at all. Patients most vulnerable to serious outcomes, children < 5 years and those in low-transmission settings, were most likely to not be prescribed antimalarials, and young children in low-transmission settings were least likely to be treated for malaria. This major public health risk must be addressed in training and practice.

Trends in health workers’ compliance with outpatient malaria case-management guidelines across malaria epidemiological zones in Kenya, 2010–2016

“…Since 2010, despite the increased availability of parasitological diagnostics and ACT, studies among outpatients have reported sub-optimal health workers' compliance with 'test and treat' malaria guidelines [9][10][11][12][13][14][15][16][17][18][19][20][21][22], including poor ACT dosing, dispensing and counselling practices [10,17,[22][23][24]. These studies have been undertaken on a small, often single facility sample [16,19,21,23,[25][26][27]; at a single point of time [9, 10, 13, 15-17, 22, 23, 28]; have measured only a few indicators (e.g., treatment practices only) [14,20,25,29,30], or were limited to specific outpatient groups (e.g., children only) [12,13,19,26,28,29,31]. Several larger outpatient studies have suggested improvements in specific compliance indicators, such as testing of febrile patients or compliance with test-negative results [17,22,32,33].…”

Appropriateness of Care for Common Childhood Infections at Low-Level Private Health Facilities in a Rural District in Western Uganda

“…Mbonye et al in their research among private clinics and drug shops found that children with normal respiratory rates received unnecessary antibiotics for pneumonia [44], while Kjaergaad et al found inappropriate prescription rate of antibiotics for viral upper respiratory tract infections of 23-68% in Uganda and other countries across the globe [45]. Other studies carried out in private and public health facilities in Uganda and other African countries found that 7-24% children testing positive for malaria never received the correct malaria medicine [46,47]. In a study from Nigeria, over 85% of children with watery diarrhea were given unnecessary antibiotics, while in a study from Ethiopia, the assessment, as well as treatment of children for cough, fever, and diarrhea in clinics was of poor quality [48,49].…”

Management of uncomplicated malaria among children under five years at public and private sector facilities in Mali

“…The use of injectable antimalarials in the current study is in contrast to findings from other settings. ACT Consortium studies across five countries found a substantial proportion of patients with confirmed uncomplicated malaria receiving drugs other than ACTs; but most commonly amodiaquine, chloroquine or SP rather than injectable antimalarials [ 19 ]. Two studies in Sudan identified relatively high proportions of children with uncomplicated malaria receiving injectable quinine [ 36 ], but with receipt of injectables more frequent in those over five than under 5 years [ 37 ].…”

“…Limitations in case management identified by previous studies included failure to perform diagnostic testing on all suspected malaria cases [13][14][15], prescription of antimalarial drugs for test negative patients [14,16,17], or ACT not being prescribed to patients with confirmed malaria [18,19]. Additional shortcomings in other settings include 'poly-pharmacy' whereby multiple antimalarials are given at once, incorrect dose prescription [13,20], and lack of referral/admission or pre-referral treatment for severe malaria [21].…”