Prescribing patterns and compliance with World Health Organization recommendations for the management of severe malaria: a modified cohort event monitoring study in public health facilities in Ghana and Uganda

Abstract

BackgroundInjectable artesunate (AS) is the World Health Organization (WHO) recommended medication for the treatment of severe malaria followed with an oral artemisinin-based combination therapy (ACT). There are few studies indicating how physicians prescribe injectable AS, injectable quinine (Q) or injectable artemether (AR) and ACT for severe malaria. This study was undertaken to evaluate prescription compliance to the WHO recommendation in 8 public health facilities in Ghana and Uganda. This was a modified cohort event monitoring study involving patients who were administered with injectable anti-malarial for treatment of presumed or confirmed severe malaria. Patients prescribed at least one dose of injectable artesunate, artemether or quinine qualified to enrol in the study. Patients were recruited at inpatient facilities and followed up in the hospital, by phone or at home. Following WHO recommendations, patients are to be prescribed 3 doses of injectable AS, Q or AR for at least 24 h followed with oral ACT. Compliance rate was estimated as the number of patient prescriptions that met the WHO recommendation for treatment of severe malaria divided by the total number of patients who completed the study by end of follow up. Log-binomial regression model was used to identify predictors for compliance. Based on the literature and limitations of available data from the patients’ record, the diagnosis results, age, gender, weight, and country were considered as potential predictors of prescriber adherence to the WHO recommendations.ResultsA total of 1191 patients completed the study, of which 93% were prescribed injectable AS, 3.1% (injectable AR or Q) with 32.5% prescribed follow-on oral ACT and 26% on concomitant antibiotics. 391 (32.8%) were in Ghana and 800 (67.2%) in Uganda. There were 582 (48.9%) women. The median age was 3.9 years (IQR = 2, 9) and median weight was 13 kg (IQR = 10, 20). Of the 1191 patients, 329 of the prescriptions complied with the WHO recommendation (compliance rate = 27.6%; 95% CI = [25.2, 30.2]). Diagnostic results (Adjusted prevalence ratio (aPR) = 4.56; 95% = [3.42, 6.08]; p < 0.0001) and weight (20 + kg vs < 10 kg: aPR = 0.65; 95% = [0.44, 0.96]; p = 0.015) were identified as factors independently associated with compliance.ConclusionInjectable AS is the most commonly prescribed medicine in the management of severe malaria in Ghana and Uganda. However, adherence to the WHO recommendation of at least 3 doses of injectable anti-malarial in 24 h followed by a full course of ACT is low, at less than 30%.

High Rates of Malaria Microscopy but Low Turnaround of Test-results Among Inpatients in Tertiary Care: With Delayed Initiation, Monotherapy and Incomplete Dosing of Antimalarials

“…One in four inpatients who received at least one in-hospital dose of prescribed antimalarials missed the rst day of their antimalarials, which is relatively frequent. Also, monotherapy and incomplete dosing primarily associated with injectable AS and Q were common, possibly fuelled by observed disparities in prescribed, dispensed and administered antimalarials -similar to observations made elsewhere [8,10]. Possible reasons for these system lapses include; i) drug stock-outs, ii) poor communication between clinician and patient/caregiver and, iii) work overload [3].…”

“…Prompt and complete antimalarial treatment rapidly eliminates malaria parasites from a patient's bloodstream [13]. Patients with severe malaria should access timely appropriate antimalarials, avoid antimalarial monotherapy and complete full courses of prescribed antimalarials to promote therapeutic success, reduce malaria-related morbidity and mortality, and prevent the emergence and spread of drug resistance [7][8][9].…”

“…It is necessary for patients with severe malaria to access timely appropriate antimalarials, avoid antimalarial monotherapy and complete full courses of prescribed antimalarials, which promotes therapeutic success, reduces malaria-related mortality and prevents drug resistance [7][8][9]. However, SSA patients with severe malaria frequently receive incomplete doses of prescribed antimalarials, or monotherapy, and/or treatment meant for uncomplicated malaria [8,10]. We have previously shown that one-third of hospitalized patients in our setting missed Day 1 of prescribed antibiotics [3], but similar data are scarce on antimalarial use.…”

Health systems readiness and quality of inpatient malaria case-management in Kano State, Nigeria

“…Strikingly uniformed artesunate prescriptions of 120 mg for adults are unlikely to reflect 50 kg patients’ weight distribution but more likely cost considerations, minimizing of the waste and single dose rationing matching two vials of artesunate. While recently reported in Uganda [ 25 ], this study finding showing low levels of ACT follow-on treatment despite high ACT availability and high knowledge of the prescribers about this standard is the worrisome findings requiring further investigations behind the reasons for such practice which inevitably contributes to compromised cure rates [ 26 ].…”

Accounting for regional transmission variability and the impact of malaria control interventions in Ghana: A population level mathematical modelling approach.

“…LLIN coverage at 80% and IRS coverage at 80% with LLIN usage at 60% and IRS PE at baseline settings (30% in the Guinea savannah, Transitional forest and Coastal savannah respectively) Given coverage levels of LLIN and IRS were 80% but LLIN usage increased to 60% in all zones, 33.0%,65.8% and 74.6% of uncomplicated cases of malaria could be averted in the Guinea savannah, If as in the previous scenario, with an elevated LLIN coverage to 80% and usage to 60% but IRS coverage increased to 90%, the corresponding proportions of cases potentially averted, as shown on S2 Figs 3 could have been 37.7%, for reported uncomplicated in the Guinea savannah with accompanying incidence rates for all cases of malaria predicted in 2020 and 2030 of 137 (95% p.CI[86,206])/1000 and 86 (95% p.CI[23,151])/1000 population respectively,Table 4andFig 7.…”