Abstract
BackgroundMost African countries have adopted artemisinin-based combination therapy (ACT) as the first-line treatment for uncomplicated malaria. The World Health Organization now recommends limiting anti-malarial treatment to those with a positive malaria test result. Limited data exist on how these policies have affected ACT prescription practices.MethodsData were collected from all outpatients presenting to six public health facilities in Uganda as part of a sentinel site malaria surveillance programme. Training in case management, encouragement of laboratory-based diagnosis of malaria, and regular feedback were provided. Data for this report include patients with laboratory confirmed malaria who were prescribed anti-malarial therapy over a two-year period. Patient visits were analysed in two groups: those considered ACT candidates (defined as uncomplicated malaria with no referral for admission in patients ≥ 4 months of age and ≥ 5 kg in weight) and those who may not have been ACT candidates. Associations between variables of interest and failure to prescribe ACT to patients who were ACT candidates were estimated using multivariable logistic regression.ResultsA total of 51,355 patient visits were included in the analysis and 46,265 (90.1%) were classified as ACT candidates. In the ACT candidate group, 94.5% were correctly prescribed ACT. Artemether-lumefantrine made up 97.3% of ACT prescribed. There were significant differences across the sites in the proportion of patients for whom there was a failure to prescribe ACT, ranging from 3.0-9.3%. Young children and woman of childbearing age had higher odds of failure to receive an ACT prescription. Among patients who may not have been ACT candidates, the proportion prescribed quinine versus ACT differed based on if the patient had severe malaria or was referred for admission (93.4% vs 6.5%) or was below age or weight cutoffs for ACT (41.4% vs 57.2%).ConclusionsHigh rates of compliance with recommended ACT use can be achieved in resource-limited settings. The unique health facility-based malaria surveillance system operating at these clinical sites may provide a framework for improving appropriate ACT use at other sites in sub-Saharan Africa.
Highlights
Most African countries have adopted artemisinin-based combination therapy (ACT) as the first-line treatment for uncomplicated malaria
Changes in malaria case management advocated by World Health Organization (WHO), including the use of ACT and treatment based on laboratory confirmation, have the potential to efficiently reduce the burden of malaria in Africa where health
In contrast to the results presented here, neither of these studies reported high rates of diagnostic testing prior to anti-malarial prescription
Summary
Most African countries have adopted artemisinin-based combination therapy (ACT) as the first-line treatment for uncomplicated malaria. The World Health Organization recommends limiting anti-malarial treatment to those with a positive malaria test result. In 2001 the World Health Organization (WHO) recommended artemisinin-based combination therapy (ACT) for the treatment of uncomplicated Plasmodium falciparum malaria in countries with resistance to older monotherapies [1]. Limited data exist on recent anti-malarial prescription practices in Africa following these changes. In Kenya, where case management practices have been published following a policy change promoting universal parasitological diagnosis before treatment, a majority of patients were not getting diagnostic testing or treatment according to test result, those with positive tests and uncomplicated malaria did receive recommended treatment with artemether-lumefantrine (AL) in 90% of cases when AL was available [4]
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