Abstract
BackgroundMalaria is a public health concern in Haiti, although there are limited data on its burden and case management. National malaria guidelines updated in 2012 recommend treatment with chloroquine and primaquine. In December 2012, a nationally-representative cross-sectional survey of health facilities (HFs) was conducted to determine malaria prevalence among febrile outpatients and malaria case management quality at baseline before scale-up of diagnostics and case management training.MethodsAmong all 833 HFs nationwide, 30 were selected randomly, in proportion to total HFs per region, for 2-day evaluations. Survey teams inventoried HF material and human resources. Outpatients of all ages were screened for temperature >37.5 °C or history of fever; those without severe symptoms were consented and enrolled. Providers evaluated and treated enrolled patients according to HF standards; the survey teams documented provider-ordered diagnostic tests and treatment decisions. Facility-based test results [microscopy and malaria rapid diagnostic tests (RDTs)] were collected from HF laboratories. Blood smears for gold-standard microscopy, and dried blood spots for polymerase chain reaction (PCR) were obtained.ResultsMalaria diagnostic capacity, defined as completing a test for an enrolled patient or having adequate resources for RDTs or microscopy, was present in 11 (37 %) HFs. Among 459 outpatients screened, 257 (56 %) were febrile, of which 193 (75 %) were eligible, and 153 (80 %) were enrolled. Among 39 patients with facility-level malaria test results available on the survey day, 11 (28 %) were positive, of whom 6 (55 %) were treated with an anti-malarial. Twenty-seven (95 %) of the 28 patients testing negative were not treated with an anti-malarial. Of 114 patients without test results available, 35 (31 %) were presumptively treated for malaria. Altogether, 42 patients were treated with an anti-malarial, one (2 %) according to Haiti’s 2012 guidelines. Of 140 gold-standard smears, none were positive, although one patient tested positive by PCR, a more sensitive technique. The national prevalence of malaria among febrile outpatients is estimated to be 0.5 % (95 % confidence interval 0–1.7 %).ConclusionsMalaria is an uncommon cause of fever in Haitian outpatients, and limited, often inaccurate, diagnostic capacity at baseline contributes to over diagnosis. Scale-up of diagnostics and training on new guidelines should improve malaria diagnosis and treatment in Haiti.
Highlights
Malaria is a public health concern in Haiti, there are limited data on its burden and case management
In 2012, Haiti revised its malaria diagnosis and treatment guidelines, adding recommendations to confirm all cases of suspected malaria by a parasitological diagnostic test and to include a single dose of primaquine (0.75 mg/ kg) in combination with standard chloroquine therapy (25 mg/kg total, administered over 3 days) for treatment of all confirmed malaria cases
≤3 days 4–7 days 8–14 days >14 days Days febrile ≤3 days 4–7 days 8–14 days >14 days Own a mosquito net Slept under mosquito net last night Knows that mosquitoes transmit malaria Sought care at health facility first Education Primary school or less Secondary school or more Time to travel to facility 2 h Satisfied with care received N number of responses chart for participant enrolment
Summary
Malaria is a public health concern in Haiti, there are limited data on its burden and case management. In 2012, Haiti revised its malaria diagnosis and treatment guidelines, adding recommendations to confirm all cases of suspected malaria by a parasitological diagnostic test and to include a single dose of primaquine (0.75 mg/ kg) in combination with standard chloroquine therapy (25 mg/kg total, administered over 3 days) for treatment of all confirmed malaria cases. Prior to this revision, it was typical to diagnose malaria based on clinical symptoms including history of fever with or without other symptoms such as nausea, vomiting, diarrhoea, headache, back pain, chills, and myalgia, for which other obvious causes were excluded. The recommendation for this two-drug regimen was made with the goal of reducing malaria transmission via the gametocytocidal activity of primaquine [1], and aligned the malaria treatment policies across Hispaniola [3]
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