The treatment of non-malarial febrile illness in Papua New Guinea: findings from cross sectional and longitudinal studies of health worker practice

Saweri, Olga PM; Hetzel, Manuel W; Müeller, Ivo; Siba, Peter; Pulford, Justin

doi:10.1186/s12913-016-1965-6

Cited by 14 publications

(9 citation statements)

References 25 publications

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“…Additionally, patients in this study who were older were less likely to improve, and although non-communicable diseases are thought to be increasingly responsible for morbidity in older adults 11 , infectious disease remains a primary driver of illness in rural Malawi. Similar to other non-malarial fever studies, this study found that most non-malarial fevers were assigned a diagnosis of respiratory illness and the majority of patients were given analgesics, followed by antibiotics 12,13 . None of the adult patients in this study were given anti-malarials, unlike similar settings where providers may prescribe anti-malarials despite a negative mRDT 14 .…”

Section: Discussionsupporting

confidence: 78%

A 14-day follow-up of adult non-malarial fever patients seen by mobile clinics in rural Malawi

et al. 2020

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BackgroundWhile health providers consistently use malaria rapid diagnostic tests to rule out malaria, they often lack tools to guide treatment for those febrile patients who test negative. Without the tools to provide an alternative diagnosis, providers may prescribe unnecessary antibiotics or miss a more serious condition, potentially contributing to antibiotic resistance and/or poor patient outcomes. MethodsThis study ascertained which diagnoses and treatments might be associated with poor outcomes in adults who test negative for malaria. Adult patients for rapid diagnostic test of malaria seen in mobile health clinics in Mulanje and Phalombe districts were followed for 14 days. Participants were interviewed on sociodemographic characteristics, health-seeking behaviour, diagnosis, treatment and access to care. Mobile clinic medical charts were reviewed. Two weeks (±2 days) following clinic visit, follow-up interviews were conducted to assess whether symptoms had resolved.ResultsInitially, 115 adult patients were enrolled and 1 (0.88%) was lost to follow-up. Of the 114 adult patients remaining in the study, 55 (48%) were seen during the dry season and 59 (52%) during the wet season. Symptoms resolved in 90 (80%) patients at the 14-day follow-up visit (n=90) with the rest (n=24) reporting no change in symptoms. None of the patients in the study died or were referred for further care. Almost all patients received some type of medication during their clinic visit (98.2%). Antibiotics were given to 38.6% of patients, and virtually all patients received pain or fever relief (96.5%). However, no anti-malarials were prescribed.ConclusionsMobile clinics provide important health care where access to care is limited. Although rapid tests have guided appropriate treatment, challenges remain when a patient’s presenting complaint is less well defined. In rural areas of southern Malawi, simple diagnostics are needed to guide treatment decisions.

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Section: Discussionsupporting

confidence: 78%

A 14-day follow-up of adult non-malarial fever patients seen by mobile clinics in rural Malawi

et al. 2020

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“…Health worker distrust of RDT negative results has been widely documented internationally [ 6 – 10 ] and is likely exacerbated by a dearth of cheap and reliable diagnostic point of care tests for other febrile illnesses [ 33 ]. In the absence of a reliable means of differential diagnosis, or intensive training to support differential diagnosis, then health workers may revert to a previous practice of clinically diagnosing malaria or they may adopt other ‘convenience’ diagnoses and prescription practices, as may already be evident by high rates of antibiotic prescription in RDT negative cases [ 34 – 36 ]. Adhering to RDT results has been proven safe in the PNG context [ 37 ], so the continued distrust suggests further clinical education is warranted.…”

Section: Discussionmentioning

confidence: 99%

Health Worker Compliance with a ‘Test And Treat’ Malaria Case Management Protocol in Papua New Guinea

et al. 2016

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The Papua New Guinea (PNG) Department of Health introduced a ‘test and treat’ malaria case management protocol in 2011. This study assesses health worker compliance with the test and treat protocol on a wide range of measures, examines self-reported barriers to health worker compliance as well as health worker attitudes towards the test and treat protocol. Data were collected by cross-sectional survey conducted in randomly selected primary health care facilities in 2012 and repeated in 2014. The combined survey data included passive observation of current or recently febrile patients (N = 771) and interviewer administered questionnaires completed with health workers (N = 265). Across the two surveys, 77.6% of patients were tested for malaria infection by rapid diagnostic test (RDT) or microscopy, 65.6% of confirmed malaria cases were prescribed the correct antimalarials and 15.3% of febrile patients who tested negative for malaria infection were incorrectly prescribed an antimalarial. Overall compliance with a strictly defined test and treat protocol was 62.8%. A reluctance to test current/recently febrile patients for malaria infection by RDT or microscopy in the absence of acute malaria symptoms, reserving recommended antimalarials for confirmed malaria cases only and choosing to clinically diagnose a malaria infection, despite a negative RDT result were the most frequently reported barriers to protocol compliance. Attitudinal support for the test and treat protocol, as assessed by a nine-item measure, improved across time. In conclusion, health worker compliance with the full test and treat malaria protocol requires improvement in PNG and additional health worker support will likely be required to achieve this. The broader evidence base would suggest any such support should be delivered over a longer period of time, be multi-dimensional and multi-modal.

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“…However, many NMFI patients are not receiving a more intensive or varied diagnostic examination (as may be expected following ‘the ruling out’ of malaria infection by RDT) and the rate of antibiotic prescription (83%) is alarmingly high. A recent study of health worker adherence to national prescription guidelines in PNG found antibiotics were overprescribed in 41% of over 3000 NMFI cases across 10 specified illnesses [ 25 ] and international evidence suggests antibiotic over prescription in NMFI is a growing concern [ 26 ]. Ensuring appropriate management of NMFI is increasingly important in PNG as malaria case positivity rates have dropped (often well) below fifty percent [ 27 ] in response to an effective national malaria control programme [ 17 ].…”

Section: Discussionmentioning

confidence: 99%

The impact of the scale-up of malaria rapid diagnostic tests on the routine clinical diagnosis procedures for febrile illness: a series of repeated cross-sectional studies in Papua New Guinea

Pulford

Kurumop

Müeller

et al. 2018

Malar J

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BackgroundThis paper examines the impact of the scale-up of malaria rapid diagnostic tests (RDT) on routine clinical diagnosis procedures for febrile illness in primary healthcare settings in Papua New Guinea.MethodsRepeat, cross-sectional surveys in randomly selected primary healthcare services were conducted. Surveys included passive observation of consecutive febrile case management cases and were completed immediately prior to RDT scale-up (2011) and at 12- (2012) and 60-months (2016) post scale-up. The frequency with which specified diagnostic questions and procedures were observed to occur, with corresponding 95% CIs, was calculated for febrile patients prescribed anti-malarials pre- and post-RDT scale-up and between febrile patients who tested either negative or positive for malaria infection by RDT (post scale-up only).ResultsA total of 1809 observations from 120 health facilities were completed across the three survey periods of which 915 (51%) were prescribed an anti-malarial. The mean number of diagnostic questions and procedures asked or performed, leading to anti-malarial prescription, remained consistent pre- and post-RDT scale-up (range 7.4–7.7). However, alterations in diagnostic content were evident with the RDT replacing body temperature as the primary diagnostic procedure performed (observed in 5.3 and 84.4% of cases, respectively, in 2011 vs. 77.9 and 58.2% of cases in 2016). Verbal questioning, especially experience of fever, cough and duration of symptoms, remained the most common feature of a diagnostic examination leading to anti-malarial prescription irrespective of RDT use (observed in 96.1, 86.8 and 84.8% of cases, respectively, in 2011 vs. 97.5, 76.6 and 85.7% of cases in 2016). Diagnostic content did not vary substantially by RDT result.ConclusionsRapid diagnostic tests scale-up has led to a reduction in body temperature measurement. Investigations are very limited when malaria infection is ruled out as a cause of febrile illness by RDT.

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The treatment of non-malarial febrile illness in Papua New Guinea: findings from cross sectional and longitudinal studies of health worker practice

Cited by 14 publications

References 25 publications

A 14-day follow-up of adult non-malarial fever patients seen by mobile clinics in rural Malawi

A 14-day follow-up of adult non-malarial fever patients seen by mobile clinics in rural Malawi

Health Worker Compliance with a ‘Test And Treat’ Malaria Case Management Protocol in Papua New Guinea

The impact of the scale-up of malaria rapid diagnostic tests on the routine clinical diagnosis procedures for febrile illness: a series of repeated cross-sectional studies in Papua New Guinea

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