Adherence to national guidelines for the diagnosis and management of severe malaria: a nationwide, cross-sectional survey in Malawi, 2012.

Monica P Shah,Dubulao Moyo,Don P Mathanga,Kim A Lindblade,Doreen Ali,Misheck Luhanga,Alfred Chalira,Wilfred Dodoli,Andy Bauleni,Julie Gutman,Jobiba Chinkhumba,Melissa Briggs-Hagen,John Sande

doi:10.1186/s12936-016-1423-2

Abstract

BackgroundSevere malaria has a case fatality rate of 10-20 %; however, few studies have addressed the quality of severe malaria case management. This study evaluated the diagnostic and treatment practices of malaria patients admitted to inpatient health facilities (HF) in Malawi.MethodsIn July–August 2012, a nationwide, cross-sectional survey of severe malaria management was conducted in 36 HFs selected with equal probability from all eligible public sector HFs in Malawi. Patient records from all admissions during October 2011 and April 2012 (low and high season, respectively) were screened for an admission diagnosis of malaria or prescription of any anti-malarial. Eligible records were stratified by age (< 5 or ≥ 5 years). A maximum of eight records was randomly selected within each age and month stratum. Severe malaria was defined by admission diagnosis or documentation of at least one sign or symptom of severe malaria. Treatment with intravenous (IV) quinine or artesunate was considered correct. Patients without documentation of severe malaria were analysed as uncomplicated malaria patients; treatment with an artemisinin-based combination therapy (ACT) or oral quinine based on malaria test results was considered correct. All analyses accounted for HF level clustering and sampling weights.ResultsThe analysis included 906 records from 35 HFs. Among these, 42 % (95 % confidence interval [CI] 35–49) had a severe malaria admission diagnosis and 50 % (95 % CI 44–57) had at least one severe malaria sign or symptom documented. Severe malaria patients defined by admission diagnosis (93, 95 % CI 86–99) were more likely to be treated correctly compared to patients defined by a severe sign (82, 95 % CI 75–89) (p < 0.0001). Among uncomplicated malaria patients, 26 % (95 % CI 18–35) were correctly treated and 53 % (95 % CI 42–64) were adequately treated with IV quinine alone or in combination with an ACT or oral quinine.ConclusionsA majority of patients diagnosed with severe malaria received the recommended IV therapy in accordance with national treatment guidelines. However, the inconsistencies between diagnosis of severe malaria and documentation of severe signs and symptoms highlight the need to improve healthcare worker recognition and documentation of severe signs and symptoms.Electronic supplementary materialThe online version of this article (doi:10.1186/s12936-016-1423-2) contains supplementary material, which is available to authorized users.

Highlights

Severe malaria has a case fatality rate of 10-20 %; few studies have addressed the quality of severe malaria case management
Few uncomplicated malaria patients (2, 95 % confidence intervals (CIs) 0–4) were under-treated with an ineffective anti-malarial or no treatment (Fig. 5). In this nationwide health facility survey assessing inpatient management of severe malaria in Malawi, malaria accounted for a high burden of hospital admissions (52 %) and most patients admitted with severe malaria were
Malaria accounts for a considerable burden of hospital admissions in Malawi

Summary

Introduction

Severe malaria has a case fatality rate of 10-20 %; few studies have addressed the quality of severe malaria case management. Among hospitalized patients under 5 years of age, the case fatality rate for severe malaria is estimated to be between 10–20 % [4,5,6]. Optimal case management of severe malaria is complex and requires prompt recognition of clinical manifestations of severe malaria, initiation of appropriate treatment, monitoring of disease progression, and management of co-morbidities. These processes rely on the availability of health system resources such as diagnostic and treatment supplies. Given that effective case management of severe malaria is multifaceted, few studies have sought to evaluate the quality of patient care in sub-Saharan Africa. 54 % of facilities reported no stock-outs of the recommended parenteral quinine in the 3 months prior to the survey, no facilities had consistent availability of all supplies required for the management of severe malaria [8]

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Conclusion