Case Management Guidelines Research Articles

Caregivers\u2019 compliance with referral advice: evidence from two studies introducing mRDTs into community case management of malaria in Uganda

BackgroundSeveral malaria endemic countries have implemented community health worker (CHW) programmes to increase access to populations underserved by health care. There is considerable evidence on CHW adherence to case management guidelines, however, there is limited evidence on the compliance to referral advice and the outcomes of children under-5 referred by CHWs. This analysis examined whether caregivers complied with CHWs referral advice.MethodsData from two cluster (village) randomised trials, one in a moderate-to-high malaria transmission setting, another in a low-transmission setting conducted between January 2010–July 2011 were analysed. CHW were trained to recognise signs and symptoms that required referral to a health centre. CHW in the intervention arm also had training on; malaria rapid diagnostic tests (mRDT) and administering artemisinin based combination therapy (ACT); CHW in the control arm were trained to treat malaria with ACTs based on fever symptoms. Caregivers’ referral forms were linked with CHW treatment forms to determine whether caregivers complied with the referral advice. Factors associated with compliance were examined with logistic regression.ResultsCHW saw 18,497 child visits in the moderate-to-high transmission setting and referred 15.2% (2815/18,497) of all visits; in the low-transmission setting, 35.0% (1135/3223) of all visits were referred. Compliance to referral was low, in both settings < 10% of caregivers complied with referral advice. In the moderate-to-high transmission setting compliance was higher if children were tested with mRDT compared to children who were not tested with mRDT. In both settings, nearly all children treated with pre-referral rectal artesunate failed to comply with referral and compliance was independently associated with factors such as health centre distance and day of referral by a CHW. In the moderate-to-high transmission setting, time of presentation, severity of referral were also associated with compliance, whilst in the low-transmission setting, compliance was low if an ACT was prescribed.ConclusionsThis analysis suggests there are several barriers to comply with CHWs referral advice by caregivers. This is concerning for children who received rectal artesunate. As CHW programmes continue scale-up, barriers to referral compliance need to be addressed to ensure a continuum of care from the community to the health centre.Trial registrationThe study was registered with ClinicalTrials.gov. Identifier NCT01048801, 13th January 2010.

Universal versus conditional day 3 follow-up for children with non-severe unclassified fever at the community level in the Democratic Republic of the Congo: A cluster-randomized, community-based non-inferiority trial

BackgroundThe World Health Organization’s integrated community case management (iCCM) guidelines recommend that all children presenting with uncomplicated fever and no danger signs return for follow-up on day 3 following the initial consultation on day 1. Such fevers often resolve rapidly, however, and previous studies suggest that expectant home care for uncomplicated fever can be safely recommended. We aimed to determine if a conditional follow-up visit was non-inferior to a universal follow-up visit for these children.Methods and findingsWe conducted a cluster-randomized, community-based non-inferiority trial among children 2–59 months old presenting to community health workers (CHWs) with non-severe unclassified fever in Tanganyika Province, Democratic Republic of the Congo. Clusters (n = 28) of CHWs were randomized to advise caregivers to either (1) return for a follow-up visit on day 3 following the initial consultation on day 1, regardless of illness resolution (as per current WHO guidelines; universal follow-up group) or (2) return for a follow-up visit on day 3 only if illness continued (conditional follow-up group). Children in both arms were assessed again at day 8, and classified as a clinical failure if fever (caregiver-reported), malaria, diarrhea, pneumonia, or decline of health status (development of danger signs, hospitalization, or death) was noted (failure definition 1). Alternative failure definitions were examined, whereby caregiver-reported fever was first restricted to caregiver-reported fever of at least 3 days (failure definition 2) and then replaced with fever measured via axillary temperature (failure definition 3). Study participants, providers, and investigators were not masked. Among 4,434 enrolled children, 4,141 (93.4%) met the per-protocol definition of receipt of the arm-specific advice from the CHW and a timely day 8 assessment (universal follow-up group: 2,210; conditional follow-up group: 1,931). Failure was similar (difference: –0.7%) in the conditional follow-up group (n = 188, 9.7%) compared to the universal follow-up group (n = 230, 10.4%); however, the upper bound of a 1-sided 95% confidence interval around this difference (−∞, 5.1%) exceeded the prespecified non-inferiority margin of 4.0% (non-inferiority p = 0.089). When caregiver-reported fever was restricted to fevers lasting ≥3 days, failure in the conditional follow-up group (n = 159, 8.2%) was similar to that in the universal follow-up group (n = 200, 9.1%) (difference: −0.8%; 95% CI: −∞, 4.1%; p = 0.053). If caregiver-reported fever was replaced by axillary temperature measurement in the definition of failure, failure in the conditional follow-up group (n = 113, 5.9%) was non-inferior to that in the universal follow-up group (n = 160, 7.2%) (difference: −1.4%; 95% CI: −∞, 2.5%; p = 0.012). In post hoc analysis, when the definition of failure was limited to malaria, diarrhea, pneumonia, development of danger signs, hospitalization, or death, failure in the conditional follow-up group (n = 108, 5.6%) was similar to that in the universal follow-up group (n = 147, 6.7%), and within the non-inferiority margin (95% CI: −∞, 2.9%; p = 0.017). Limitations include initial underestimation of the proportion of clinical failures as well as substantial variance in cluster-specific failure rates, reducing the precision of our estimates. In addition, heightened security concerns slowed recruitment in the final months of the study.ConclusionsWe found that advising caregivers to return only if children worsened or remained ill on day 3 resulted in similar rates of caregiver-reported fever and other clinical outcomes on day 8, compared to advising all caregivers to return on day 3. Policy-makers could consider revising guidelines for management of uncomplicated fever within the iCCM framework.Trial registrationClinicalTrials.gov NCT02595827

Incidence and degree of hypoxaemia in Malawian infants under 2 months of age presenting to district hospitals and its correlation with mortality: a retrospective analysis

Abstract Background Pneumonia is a leading cause of death in Malawian infants under 2 months of age. Consensus defines hypoxaemia in infants as a peripheral capillary oxygen saturation (SpO 2 ) of less than 90%. We aimed to estimate the incidence and degree of hypoxaemia and its correlation with mortality in infants younger than 2 months presenting to district hospitals in Malawi. Methods We retrospectively analysed a child pneumonia surveillance dataset prospectively collected during routine care at seven hospitals in Malawi between 2011 and 2014. Infants aged 0–2 months with pneumonia according to 2012 WHO case management guidelines were included. We used logistic regression to determine correlation between degree of hypoxaemia and in-hospital death. Findings 1810 infant pneumonia admissions were analysed. The case fatality rate was 3·6% (n=65). SpO 2 could not be measured in 8·5% (n=154) of patients. Median SpO 2 was 96% (IQR 91–98). Infants for whom SpO2 measurement was successful versus unsuccessful had a similar prevalence of chest indrawing (85·6% vs 79·2%) and WHO danger signs (68·4% vs 61·0%; p=0·064), and the distribution of girls (40·9% vs 39·6%) was also comparable. Compared with infants with an SpO 2 of 93–100% (n=1160), infants with an SpO 2 of 90–92% (n=187) or 2 was not measurable (n=154) had a greatly increased adjusted odds of death compared with infants with a SpO2 of 93–100% (aOR 17·5, 95% CI 7·5–40·8). Interpretation The case definition of hypoxaemia in infants less than 2 months of age warrants re-evaluation. Infants with an SpO 2 of 90–92% have a higher odds of death than those with a SpO 2 of 93–100%. Infants for whom SpO 2 could not be measured, despite having similar demographic and physical examination findings, had a higher odds ratio for death than any other observed group. Interestingly, these infants had a lower rate of WHO danger signs, but probably had severe disease such as shock with diminished peripheral perfusion resulting in inability to measure SpO 2 . WHO danger signs may not adequately capture such physiological derangements. The inability to measure pulse oximetry is clinically meaningful in our setting. Implementation of compulsory SpO 2 measurement could result in improved referral rates and recognition of severe disease in infants younger than 2 months of age with pneumonia. Funding None.

Goal Attainment Rate for Parameters of Metabolic Adjustment in Elderly Patients with Type 2 Diabetes Taking a Hypoglycemic Agent

Background: This study aimed to investigate the goal attainment rates for hemoglobin A1c (HbA1c), blood pressure (BP), and low-density lipoprotein cholesterol (LDL-C) in elderly patients with type 2 diabetes. Methods: The subjects were 762 over 65 years old patients with type 2 diabetes taking a hypoglycemic agent. Data were collected by reviewing medical records and included general characteristics, biochemical tests, prescribed pharmacologic agents, and complications. Results: The goal attainment rates (mean value) for HbA1c, BP, and LDL-C were 50.4% (7.3% ± 1.2%), 78.9% (126.0 ± 15.1/72.1 ± 10.0 mm Hg), and 60.6% (88.6 ± 29.9 mg/dL). Diabetes-related complications for retinopathy, nephropathy, neuropathy, and cardio-cerebral vascular disease were 36.3%, 37.2%, 23.6%, and 31.9%, respectively. Life habit-related variables positively associated with goal attainment were not drinking alcohol and exercise for HbA1c, not smoking for BP and not drinking alcohol for LDL-C. Metabolic adjustment indicator-related significant variables for complications were HbA1c in retinopathy, BP in nephropathy, and LDL-C in cardio-cerebral disease. Conclusion: We found that goal attainment rates for parameters of metabolic adjustment were not high in elderly patients with type 2 diabetes. Thus, diabetes educators should be concerned about metabolic adjustment indicators. Also, case management guidelines according to elderly patient health and functional status should be developed to help manage metabolic adjustment.

Prevalence of reproductive tract infection symptoms and treatment-seeking behavior among women: A community-based study.

Introduction:Reproductive tract infection (RTI) is a public health problem affecting women's health, especially in developing country like India. The associated stigma with this reproductive morbidity is often a deterrent in seeking health care.Aims and Objectives:The aim was to study the prevalence of RTI symptoms and treatment-seeking behavior among married women of reproductive age group.Methodology:It was a community-based cross-sectional study. A total of 276 women were interviewed in the community by trained medical social workers. RTI symptoms were defined according to the syndromic case management guideline developed by the World Health Organization. Statistical analysis was performed using the Epi Info software for Windows (CDC Atlanta).Results:About one-third (98/276; 35.5%) of women reported symptoms suggestive of RTI. The most commonly experienced symptoms were foul-smelling vaginal discharge (68/98; 69.4%) followed by lower abdominal pain not associated with menstruation (51/98; 52.0%). Around half of those having RTI symptoms sought treatment for their problem (57.1%).Conclusion:Health-care professionals in India should focus on strengthening women knowledge of RTI symptoms and encouraging them to seek health care.

Household beliefs about malaria testing and treatment in Western Kenya: the role of health worker adherence to malaria test results

BackgroundAlthough use of malaria diagnostic tests has increased in recent years, health workers often prescribe anti-malarial drugs to individuals who test negative for malaria. This study investigates how health worker adherence to malaria case management guidelines influences individuals’ beliefs about whether their illness was malaria, and their confidence in the effectiveness of artemisinin-based combination therapy (ACT).MethodsA survey was conducted with 2065 households in Western Kenya about a household member’s treatment actions for a recent febrile illness. The survey also elicited the individual’s (or their caregiver’s) beliefs about the illness and about malaria testing and treatment. Logistic regressions were used to test the association between these beliefs and whether the health worker adhered to malaria testing and treatment guidelines.ResultsOf the 1070 individuals who visited a formal health facility during their illness, 82% were tested for malaria. ACT rates for malaria-positive and negative individuals were 89 and 49%, respectively. Overall, 65% of individuals/caregivers believed that the illness was “very likely” malaria. Individuals/caregivers had higher odds of saying that the illness was “very likely” malaria when the individual was treated with ACT, and this was the case both among individuals not tested for malaria [adjusted odds ratio (AOR) 3.42, 95% confidence interval (CI) [1.65 7.10], P = 0.001] and among individuals tested for malaria, regardless of their test result. In addition, 72% of ACT-takers said the drug was “very likely” effective in treating malaria. However, malaria-negative individuals who were treated with ACT had lower odds of saying that the drugs were “very likely” effective than ACT-takers who were not tested or who tested positive for malaria (AOR 0.29, 95% CI [0.13 0.63], P = 0.002).ConclusionIndividuals/caregivers were more likely to believe that the illness was malaria when the patient was treated with ACT, regardless of their test result. Moreover, malaria-negative individuals treated with ACT had lower confidence in the drug than other individuals who took ACT. These results suggest that ensuring health worker adherence to malaria case management guidelines will not only improve ACT targeting, but may also increase patient/caregivers’ confidence in malaria testing and treatment.

Implementation of a comprehensive intervention for patients at high risk of cardiovascular disease in rural China: A pragmatic cluster randomized controlled trial.

ObjectiveThis study aims to assess whether a standard intervention package of cardiovascular disease (CVD) care was being delivered effectively, and if it was associated with improved lifestyle and biomedical indicators.MethodsIn rural China, we implemented a pragmatic cluster randomized controlled trial for 12 months, randomized at the township hospital level, and compared with usual care. Intervention case management guideline, training and performance monitoring meeting and patient support activities were designed to fit within the job description of family doctors in the township hospitals and comprised: 1) prescription of a standardised package of medicines targeted at those with hypertension or diabetes; 2) advice about specific lifestyle interventions; and 3) advice about medication adherence. Participants were 50–74 years old, had hypertension and CVD risk scores >20% or diabetes, but were excluded if a history of severe CVD events. We also randomly selected 100 participants from six selected clusters per arm as a panel to collect intermediate biomedical indicators over time.ResultsA total of 28,130 participants, in 33 intervention and 34 control township hospitals, were recruited. Compared with the control arm, participants in the intervention arm had substantially improved prescribing rates of anti-hypertensives, statins and aspirin (P<0.001), and had higher medication taking rates of aspirin and statins (P<0.001). Mean systolic and diastolic blood pressures were similar across both arms (0.15 mmHg, P = 0.79, and 0.52 mmHg, P = 0.05, respectively). In the panel, (950) rates of smoking (OR = 0.23, P = 0.02) and salt intake (OR = 2.85, P = 0.03) were significantly reduced in the intervention versus control arms, but there were no statistically significant improvement over the 12 month follow-up period in biomedical indicators (P>0.05).ConclusionImplementation of the package by family doctors was feasible and improved prescribing and some lifestyle changes. Additional measures such as reducing medication costs and patient education are required.Trial registrationCurrent Controlled Trials ISRCTN58988083

Pediatric Spinal Cord Injury Due to Acute Flaccid Myelitis: Epidemiology, Clinical Management, and Implications for Rehabilitation

Acute flaccid myelitis (AFM) is a recently described rare syndrome causing spinal cord injury in children. The purpose of this review is to describe the epidemiology of AFM, clinical presentation, and management. We further describe outcomes, rehabilitation strategies, and future directions for this group of children. Outbreaks of Enterovirus D-68 (EV D-68) starting in 2014 coincided with increase in acute flaccid paralysis cases in children which were tracked by the Centers for Disease Control and Prevention (CDC). CDC provided guidelines for identification and management of cases of AFM. Long-term follow-up has not been sufficient but children with AFM have a wide range of presentation and residual disability following the illness. Further studies are needed to assess long-term outcomes and to help prevent AFM. The epidemiology and acute management of AFM is well described in the literature but long-term follow-up and outcomes remain needed, especially regarding long-term disability from spinal cord injury. Additional studies are needed to provide further evidence of best practice and possible prevention.

Aetiology and Outcomes of Suspected Infections of the Central Nervous System in Children in Mbarara, Uganda

Infections of the central nervous system (CNS) are severe conditions, leading to neurological sequelae or death. Knowledge of the causative agents is essential to develop guidelines for case management in resource-limited settings. Between August 2009 and October 2012, we conducted a prospective descriptive study of the aetiology of suspected CNS infections in children two months to 12 years old, with fever and at least one sign of CNS involvement in Mbarara Hospital, Uganda. Children were clinically evaluated on admission and discharge, and followed-up for 6 months for neurological sequelae. Pathogens were identified from cerebrospinal fluid (CSF) and blood using microbiological and molecular methods. We enrolled 459 children. Plasmodium falciparum (36.2%) and bacteria in CSF (13.3%) or blood (3.3%) were the most detected pathogens. Viruses were found in 27 (5.9%) children. No pathogen was isolated in 207 (45.1%) children. Patterns varied by age and HIV status. Eighty-three (18.1%) children died during hospitalisation, and 23 (5.0%) during follow-up. Forty-one (13.5%) children had neurological sequelae at the last visit. While malaria remains the main aetiology in children with suspected CNS infections, no pathogen was isolated in many children. The high mortality and high rate of neurological sequelae highlight the need for efficient diagnosis.

Use of standardised patients to assess quality of healthcare in Nairobi, Kenya: a pilot, cross-sectional study with international comparisons

IntroductionThe quality of clinical care can be reliably measured in multiple settings using standardised patients (SPs), but this methodology has not been extensively used in Sub-Saharan Africa. This study validates...

Universal versus conditional three-day follow up visit for children with uncomplicated fever at the community level: design of a cluster-randomized, community-based, non-inferiority trial in Tanganyika, Democratic Republic of Congo

BackgroundThe current recommendation within integrated Community Case Management guidelines that all children presenting with uncomplicated fever and no danger signs be followed up after three days may not be necessary. Such fevers often resolve rapidly (usually within 48–96 h), and previous studies suggest that expectant home care for uncomplicated fever can be safely recommended. We aim to determine the non-inferiority of a conditional versus a universal follow-up visit for these children.MethodsWe are conducting a cluster-randomized, community-based, non-inferiority trial enrolling ~4300 children (ages 2–59 months) presenting to community health workers (CHWs) with uncomplicated fever in Tanganyika Province, Democratic Republic of the Congo. Clusters (n = 28) of CHWs are randomized to advise caretakers of such children to either 1) return for a follow-up visit on Day 3 following the initial consultation (Day 1), regardless of illness resolution (as per current guidelines) or 2) return for a follow-up visit on Day 3 only if the child’s signs have not resolved. Enrolled children are followed up at Day 7 for a repeat assessment and recording of the primary outcome of the study, “failure”, which is defined as having fever, diarrhea, pneumonia or decline of health status (e.g. hospitalization, presenting danger signs, or death).DiscussionThe results of this trial will be interpreted in conjunction with a similarly designed trial currently ongoing in Ethiopia. If a follow-up visit conditional on continued illness is shown to be non-inferior to current guidelines stipulating universal follow-up, appropriate updating of such guidelines could reduce time and human resource pressures on both providers and caregivers throughout communities of sub-Saharan Africa and South Asia.Trial registrationThis trial was registered at ClinicalTrials.gov (NCT02595827) on November 2nd, 2015

Community-based health care is an essential component of a resilient health system: evidence from Ebola outbreak in Liberia

BackgroundTrained community health workers (CHW) enhance access to essential primary health care services in contexts where the health system lacks capacity to adequately deliver them. In Liberia, the Ebola outbreak further disrupted health system function. The objective of this study is to examine the value of a community-based health system in ensuring continued treatment of child illnesses during the outbreak and the role that CHWs had in Ebola prevention activities.MethodsA descriptive observational study design used mixed methods to collect data from CHWs (structured survey, n = 60; focus group discussions, n = 16), government health facility workers and project staff. Monthly data on child diarrhea and pneumonia treatment were gathered from CHW case registers and local health facility records.ResultsCoverage for community-based treatment of child diarrhea and pneumonia continued throughout the outbreak in project areas. A slight decrease in cases treated during the height of the outbreak, from 50 to 28% of registers with at least one treatment per month, was attributed to directives not to touch others, lack of essential medicines and fear of contracting Ebola. In a climate of distrust, where health workers were reluctant to treat patients, sick people were afraid to self-identify and caregivers were afraid to take children to the clinic, CHWs were a trusted source of advice and Ebola prevention education. These findings reaffirm the value of recruiting and training local workers who are trusted by the community and understand the social and cultural complexities of this relationship. “No touch” integrated community case management (iCCM) guidelines distributed at the height of the outbreak gave CHWs renewed confidence in assessing and treating sick children.ConclusionsInvestments in community-based health service delivery contributed to continued access to lifesaving treatment for child pneumonia and diarrhea during the Ebola outbreak, making communities more resilient when facility-based health services were impacted by the crisis. To maximize the effectiveness of these interventions during a crisis, proactive training of CHWs in infection prevention and “no touch” iCCM guidelines, strengthening drug supply chain management and finding alternative ways to provide supportive supervision when movements are restricted are recommended.

Non-treatment of children with community health worker-diagnosed fast-breathing pneumonia in rural Malawi: exploratory subanalysis of a prospective cohort study

BackgroundDespite recent progress, pneumonia remains the largest infectious killer of children globally. This paper describes outcomes of not treating community-diagnosed fast-breathing pneumonia on patient recovery.MethodsWe conducted an exploratory subanalysis of...

Does health-related quality of life among adults with pulmonary tuberculosis improve across the treatment period? A hospital-based cross sectional study in Mbale Region, Eastern Uganda.

BackgroundMost tuberculosis (TB) case management guidelines emphasize microbiological cure as treatment goal without highlighting quality of life outcomes. This study assessed health-related quality of life (HRQoL) and related factors in the pre-treatment, intensive and continuation phases of anti-TB therapy among sputum smear positive pulmonary TB patients in Mbale region, Eastern Uganda.MethodsIn this cross-sectional study, questionnaires and 36-Item Short-Form Health Survey Version 2.0 (UK English SF36v2) forms were administered to 210 participants of whom 64.8 % were males. The mean age was 35.48 ± 12.21 years. For each of the three treatment phases, different patients were studied. Responses were translated into the standard 00–100 scale. Means and standard deviations were used to express HRQoL as physical composite scores (PCS) and mental composite scores (MCS). Analysis of variance was used to compare scores across phases. Multiple linear regression methods were used to model relationships between predictor variables and HRQoL for each treatment phase.ResultsHRQoL scores were different across treatment phases. General health (38.8 ± 17.5) and mental health (52.7 ± 18.6) had the lowest and highest sub-scale scores respectively. Mean PCS scores in pretreatment, intensive and continuation phases were 29.9 ± 19.4, 41.9 ± 14.2 and 62.2 ± 18.8 respectively. Mean MCS scores in the pretreatment, intensive and continuation phases were 38.8 ± 18.3, 49.4 ± 13.1 and 60.6 ± 18.8 respectively. Prior to treatment initiation, having an informal occupation (β = −28.66 (<0.001) was associated with poor HRQoL. Being unmarried (β = 11.94, p = 0.028) and belonging to the highest tertile of socioeconomic status (SES) (β = 14.56, p = 0.007) were associated with good HRQoL in the intensive phase. In the continuation phase, SES (β = 10.83, p = 0.021 for MCS and β = 13.14, p = 0.004 for PCS) predicted good HRQoL. Older age (β = −0.43 p = 0.013 for PCS and β = −0.36 p = 0.040 for MCS) was associated with poor HRQoL.ConclusionsTB treatment improved patients’ perceived health and having means of income was particularly associated with high HRQoL. Strategies to strengthen treatment support that include income generation and specific close monitoring of older patients may help improve overall TB treatment experience, by sustaining acceptable levels of physical, social and emotional functioning.

Knowledge and Adherence to the National Guidelines for Malaria Case Management in Pregnancy among Healthcare Providers and Drug Outlet Dispensers in Rural, Western Kenya

BackgroundAlthough prompt, effective treatment is a cornerstone of malaria control, information on provider adherence to malaria in pregnancy (MIP) treatment guidelines is limited. Incorrect or sub-optimal treatment can adversely affect the mother and fetus. This study assessed provider knowledge of and adherence to national case management guidelines for uncomplicated MIP.MethodsWe conducted a cross-sectional study from September to November 2013, in 51 health facilities (HF) and a randomly-selected sample of 39 drug outlets (DO) in the KEMRI/CDC Health and Demographic Surveillance System area in western Kenya. Provider knowledge of national treatment guidelines was assessed with standardized questionnaires. Correct practice required adequate diagnosis, pregnancy assessment, and treatment with correct drug and dosage. In HF, we conducted exit interviews in all women of childbearing age assessed for fever. In DO, simulated clients posing as first trimester pregnant women or as relatives of third trimester pregnant women collected standardized information.ResultsCorrect MIP case management knowledge and practice were observed in 45% and 31% of HF and 0% and 3% of DO encounters, respectively. The correct drug and dosage for pregnancy trimester was prescribed in 62% of HF and 42% of DO encounters; correct prescription occurred less often in first than in second/ third trimesters (HF: 24% vs. 65%, p<0.01; DO: 0% vs. 40%, p<0.01). Sulfadoxine-pyrimethamine, which is not recommended for malaria treatment, was prescribed in 3% of HF and 18% of DO encounters. Exposure to artemether-lumefantrine in first trimester, which is contraindicated, occurred in 29% and 49% of HF and DO encounters, respectively.ConclusionThis study highlights knowledge inadequacies and incorrect prescribing practices in the treatment of MIP. Particularly concerning is the prescription of contraindicated medications in the first trimester. These issues should be addressed through comprehensive trainings and increased supportive supervision. Additional innovative means to improve care should be explored.

The Role of Laboratory Supervision in Improving the Quality of Malaria Diagnosis: A Pilot Study in Huambo, Angola.

In 2006, the Angolan National Malaria Control Program introduced clinical guidelines for malaria case management, which included diagnostic confirmation of malaria before administration of treatment; however, diagnostic practices were inconsistent and of unknown quality. In 2009, a laboratory supervision program was implemented in Huambo Province, with the goal of assessing and improving diagnosis of malaria within the confines of available in-country resources. Supervisions were carried out from 2009 to 2014 using a standardized supervision tool by national laboratory trainers. Data from the first supervision were compared with that from the final supervision. Over the study period, the number and level of training of laboratory technicians increased, and there was a nonstatistically significant trend toward improved laboratory conditions. There was a significant reduction in false-positive microscopy slide reading (P = 0.0133). Laboratory infrastructural capacity to diagnose other communicable diseases, including syphilis, human immunodeficiency virus and hepatitis B virus infections (P = 0.0012, 0.0233 and 0.0026, respectively), also improved significantly. Laboratory supervision for malaria diagnosis found significant areas for improvement, and in combination with concurrent capacity-building activities, it improved the diagnostic capacity for malaria and other diseases. Importantly, this study demonstrates that locally available resources can be used to improve the accuracy of malaria diagnosis.

Changes in chlamydia control activities in Europe between 2007 and 2012: a cross-national survey.

Background: In 2012, the levels of chlamydia control activities including primary prevention, effective case management with partner management and surveillance were assessed in 2012 across countries in the European Union and European Economic Area (EU/EEA), on initiative of the European Centre for Disease Control (ECDC) survey, and the findings were compared with those from a similar survey in 2007. Methods: Experts in the 30 EU/EEA countries were invited to respond to an online questionnaire; 28 countries responded, of which 25 participated in both the 2007 and 2012 surveys. Analyses focused on 13 indicators of chlamydia prevention and control activities; countries were assigned to one of five categories of chlamydia control. Results: In 2012, more countries than in 2007 reported availability of national chlamydia case management guidelines (80% vs. 68%), opportunistic chlamydia testing (68% vs. 44%) and consistent use of nucleic acid amplification tests (64% vs. 36%). The number of countries reporting having a national sexually transmitted infection control strategy or a surveillance system for chlamydia did not change notably. In 2012, most countries (18/25, 72%) had implemented primary prevention activities and case management guidelines addressing partner management, compared with 44% (11/25) of countries in 2007. Conclusion: Overall, chlamydia control activities in EU/EEA countries strengthened between 2007 and 2012. Several countries still need to develop essential chlamydia control activities, whereas others may strengthen implementation and monitoring of existing activities.

Adherence to case management guidelines of Integrated Management of Childhood Illness (IMCI) by healthcare workers in Tshwane, South Africa

Background. Integrated Management of Childhood Illness (IMCI) is an essential strategy known to deliver childhood interventions that reduce the under-five mortality rate. Objective. To evaluate the adherence to the IMCI case management guidelines by primary healthcare workers in the Tshwane area, South Africa. Methods. The study was conducted between July and December 2012 on children referred from clinics to Kalafong Hospital. Data on IMCI clinical symptoms and signs, classification and treatment given at the clinics before referral to the hospital were collected from patients’ referral letters. An interview with the caregiver on counselling received at the clinic was done using an adapted World Health Organization health facility survey tool. Results. Eighty children between 2 and 60 months referred from 12 local clinics were included in the study. IMCI classification was done in just over half (52.9%) of 34 children with cough and 73% of 15 children with diarrhoea. Only 18% of children with chest indrawing and fast breathing were classified correctly. Prereferral treatment for all children with severe dehydration had been given correctly but not so for children with severe pneumonia and severe malnutrition. None of the children with severe disease had been checked for glucose levels before referral. Conclusions. The IMCI guidelines had not been adhered to in all children referred to the hospital. Children, particularly those with severe disease, had been incorrectly classified, leading to inadequate prereferral treatment. Healthcare workers had not given the expected treatment at the clinic before referral.

Can We Predict Oral Antibiotic Treatment Failure in Children with Fast-Breathing Pneumonia Managed at the Community Level? A Prospective Cohort Study in Malawi.

BackgroundPneumonia is the leading cause of infectious death amongst children globally, with the highest burden in Africa. Early identification of children at risk of treatment failure in the community and prompt referral could lower mortality. A number of clinical markers have been independently associated with oral antibiotic failure in childhood pneumonia. This study aimed to develop a prognostic model for fast-breathing pneumonia treatment failure in sub-Saharan Africa.MethodWe prospectively followed a cohort of children (2–59 months), diagnosed by community health workers with fast-breathing pneumonia using World Health Organisation (WHO) integrated community case management guidelines. Cases were followed at days 5 and 14 by study data collectors, who assessed a range of pre-determined clinical features for treatment outcome. We built the prognostic model using eight pre-defined parameters, using multivariable logistic regression, validated through bootstrapping.ResultsWe assessed 1,542 cases of which 769 were included (32% ineligible; 19% defaulted). The treatment failure rate was 15% at day 5 and relapse was 4% at day 14. Concurrent malaria diagnosis (OR: 1.62; 95% CI: 1.06, 2.47) and moderate malnutrition (OR: 1.88; 95% CI: 1.09, 3.26) were associated with treatment failure. The model demonstrated poor calibration and discrimination (c-statistic: 0.56).ConclusionThis study suggests that it may be difficult to create a pragmatic community-level prognostic child pneumonia tool based solely on clinical markers and pulse oximetry in an HIV and malaria endemic setting. Further work is needed to identify more accurate and reliable referral algorithms that remain feasible for use by community health workers.

Cohorting Dengue Patients Improves the Quality of Care and Clinical Outcome.

IntroductionThe increasing incidence of dengue among adults in Malaysia and other countries has important implications for health services. Before 2004, in order to cope with the surge in adult dengue admissions, each of the six medical wards in a university hospital took turns daily to admit and manage patients with dengue. Despite regular in-house training, the implementation of the WHO 1997 dengue case management guidelines by the multiple medical teams was piecemeal and resulted in high variability of care. A restructuring of adult dengue inpatient service in 2004 resulted in all patients being admitted to one ward under the care of the infectious disease unit. Hospital and Intensive Care Unit admission criteria, discharge criteria and clinical laboratory testing were maintained unchanged throughout the study period.ObjectivesTo evaluate the impact of cohorting adult dengue patients on the quality of care and the clinical outcome in a university hospital in Malaysia.MethodsA pre (2003) and post-intervention (2005–6) retrospective study was undertaken.InterventionCohorting all dengue patients under the care of the Infectious Disease team in a designated ward in 2004.ResultsThe number of patients enrolled was 352 in 2003, 785 in 2005 and 1158 in 2006. The evaluation and detection of haemorrhage remained high (>90%) and unchanged throughout the study period. The evaluation of plasma leakage increased from 35.4% pre-intervention to 78.8% post-intervention (p = <0.001) while its detection increased from 11.4% to 41.6% (p = <0.001). Examination for peripheral perfusion was undertaken in only 13.1% of patients pre-intervention, with a significant increase post-intervention, 18.6% and 34.2% respectively, p = <0.001. Pre-intervention, more patients had hypotension (21.5%) than detected peripheral hypoperfusion (11.4%), indicating that clinicians recognised shock only when patients developed hypotension. In contrast, post-intervention, clinicians recognised peripheral hypoperfusion as an early sign of shock. The highest haematocrit was significantly higher post-intervention but the lowest total white cell counts and platelet counts remained unchanged. A significant and progressive reduction in the use of platelet transfusions occurred, from 21.7% pre-intervention to 14.6% in 2005 and 5.2% in 2006 post-intervention, p<0.001. Likewise, the use of plasma transfusion decreased significantly from 6.1% pre-intervention to 4.0% and 1.6% in the post-intervention years of 2005 and 2006 respectively, p<0.001. The duration of intravenous fluid therapy decreased from 3 days pre-intervention to 2.5 days (p<0.001) post-intervention; the length of hospital stay reduced from 4 days pre- to 3 days (p<0.001) post-intervention and the rate of intensive care admission from 5.8% pre to 2.6% and 2.5% post-intervention, p = 0.005.ConclusionCohorting adult dengue patients under a dedicated and trained team of doctors and nurses led to a substantial improvement in quality of care and clinical outcome.