Pharmaceutical services for endemic situations in the Brazilian Amazon: organization of services and prescribing practices for Plasmodium vivax and Plasmodium falciparum non-complicated malaria in high-risk municipalities

Abstract

BackgroundIn spite of the fact that pharmaceutical services are an essential component of all malaria programmes, quality of these services has been little explored in the literature. This study presents the first results of the application of an evaluation model of pharmaceutical services in high-risk municipalities of the Amazon region, focusing on indicators regarding organization of services and prescribing according to national guidelines.MethodsA theoretical framework of pharmaceutical services for non-complicated malaria was built based on the Rapid Evaluation Method (WHO). The framework included organization of services and prescribing, among other activities. The study was carried out in 15 primary health facilities in six high-risk municipalities of the Brazilian Amazon. Malaria individuals ≥ 15 years old were approached and data was collected using specific instruments. Data was checked by independent reviewers and fed to a data bank through double-entry. Descriptive variables were analyzed.ResultsA copy of the official treatment guideline was found in 80% of the facilities; 67% presented an environment for receiving and prescribing patients. Re-supply of stocks followed a different timeline; no facilities adhered to forecasting methods for stock management. No shortages or expired anti-malarials were observed, but overstock was a common finding. On 86.7% of facilities, the average of good storage practices was 48%. Time between diagnosis and treatment was zero days. Of 601 patients interviewed, 453 were diagnosed for Plasmodium vivax; of these, 99.3% received indications for the first-line scheme. Different therapeutic schemes were given to Plasmodium falciparum patients. Twenty-eight (4.6%) out of 601 were prescribed regimens not listed in the national guideline. Only 5.7% individuals received a prescription or a written instruction of any kind.ConclusionsThe results show that while diagnostic procedure is well established and functioning in the Brazilian malaria programme, prescribing is still an activity that is actually not performed. The absence of physicians and poor integration between malaria services and primary health services make for the lack of a prescription or written instruction for malaria patients throughout the Brazilian Amazon. This fact may lead to a great number of problems in rational use and in adherence to medication.

Challenges for malaria elimination in Brazil

“…By the end of the 1980s, SP failed to cure >90 % of P. falciparum infections in the Amazon [ 99 ], and since 1990, SP is no longer recommended for malaria chemotherapy in Brazil [ 99 ]. Before the introduction of ACT in 2006 [ 107 ], the first-line regimens for uncomplicated falciparum malaria recommended by the Ministry of Health of Brazil were quinine plus doxycycline (formerly tetracycline) for 7 days or a single dose of mefloquine. Case reports of mefloquine (e.g., [ 108 ]) and quinine–tetracycline [e.g., 109 ] failure in falciparum malaria have been published since then.…”

Dispensing and determinants of non-adherence to treatment for non complicated malaria caused by Plasmodium vivax and Plasmodium falciparum in high-risk municipalities in the Brazilian Amazon

“…The Mafalda Project (“Pharmaceutical services for non-complicated malaria by P. vivax and P. falciparum in high-risk municipalities of the Brazilian Amazon: organization of services, prescribing, dispensing and adherence to treatment”) was developed in order to provide data of the situation of pharmaceutical services for malaria in municipalities at high risk for the disease in the Amazon [ 13 , 14 , 22 , 23 ].…”

“…Previous results from the Mafalda Project have shown that in Brazil diagnostic procedures work well, but good prescribing practices are not performed in most municipalities. Other findings showed problems with organization of pharmaceutical services—especially concerning stock management and drug storage [ 14 ]. There are no written instructions for the malaria patient and only oral guidance is received from technicians in endemic areas.…”

“…The indicators included in the framework encompassed the following dimensions: context and organization of pharmaceutical services, prescribing, dispensing and (implementation) adherence to treatment. The first two dimensions were developed and published [ 14 ]. This paper will focus on the implementation phase and examine non-adherence, by means of a careful examination of determinants, which include those linked to treatment regimen and those linked to health services and care to malaria patients, including dispensing practices.…”

“…Individuals of both genders, ≥15 years of age, excluding pregnant women, with parasitological confirmed mild malaria were followed throughout the study. More detailed information on the field study and participants may be found elsewhere [ 14 ].…”