Malaria Case Management Research Articles

Community acceptance, satisfaction, and support for case management of malaria of various degrees in selected rural communities in Ibadan, Oyo-State.

This study aimed to assess communities' perception and adoption of the evidenced-based malaria diagnosis and case management intervention targeted at under-five children. The effectiveness of trained Volunteer Community Health Workers (VCHWs) to diagnose malaria among under-five children using rapid diagnostic testing kit, provide treatment using Artemisinin Combination Therapy and rectal Artesunate were assessed. A qualitative evaluation study was conducted in October 2015. Communities in the 6 rural wards in Ona-Ara Local Government Area, Oyo State Nigeria. Caregivers of under-five children, community-based frontline health workers, and community leaders selected using purposively sampling. Nine Focus Group Discussions and 15 Key Informant Interviews were conducted using a pre-tested guide. Data were subjected to thematic analysis. It was disclosed that VCHWs promoted people's access to prompt and appropriate malaria treatment. The communities accepted the VCHWs; the reasons given for this included the following: effectiveness of VCHWs in case management of malaria; good inter-personal relationship with caregivers; and the positive health outcomes associated with services provided by them. In addition, community members expressed satisfaction with the VCHWs and provided them with all the support needed to function throughout the malaria case management intervention. The VCHWs considered the support as a great source of encouragement. The use of VCHWs to treat malaria was adjudged to be effective and considered acceptable to the communities. The adoption of the intervention and its integration into the primary health system by the government is advocated for in medically underserved rural communities. This work was supported by UNICEF/UNDP/World Bank/WHO Special Programme for Research & Training in Tropical Diseases, World Health Organization, Geneva, Switzerland (project ID: A80550 [Nigeria] through funds made available by the European Commission (FP7) for research to improve community access to health interventions in Africa.

Development and application of immunoassays for rapid quality control of the antimalarial drug combination artesunate-mefloquine

Artesunate-mefloquine is one of the commonly-used artemisinin-based combination therapies (ACTs). Given the significance of drug quality in the management of malaria cases, the objective of this study was to develop antibody-based assays as the point-of-care (POC) tests for monitoring the quality of this ACT. Using mefloquine conjugated to a carrier protein as the immunogen, we selected a specific monoclonal antibody (mAb) against mefloquine with no cross-reactivity to other antimalarial drugs. Using this mAb, we developed a direct competitive enzyme-linked immunosorbent assay (dcELISA) and a lateral flow immunoassay (LFIA) to measure the mefloquine contents. The dcELISA for mefloquine showed a 50% inhibitory concentration (IC50) and a working range of 2.79 ng/mL and 0.58–16.37 ng/mL, respectively. With the aid of a portable optical scanner, the LFIA had a working range of 0.15–2.67 µg/mL for mefloquine. When used to measure mefloquine contents in commercial drugs, the dcELISA and LFIA results were compatible with those determined using high-performance liquid chromatography. Using the same LFIA format, we developed a combination LFIA, which correctly estimated the artesunate and mefloquine contents in commercial ACTs. Therefore, both LFIAs could be used as POC devices for rapid quality control of artesunate and mefloquine in ACTs.

Evaluation of a Rapid Diagnostic Test Currently Being Used in the Management of Malaria in Patients of the Hia/Chu-Parakou and the Boko Zone Hospital in Northern Benin

Parasitological diagnosis is a fundamental element in the adequate management of the disease. In the last decade, there has been a resurgence of interest in the development of malaria Rapid Diagnostic Test (RDT) kits. This is the case with SD Bioline Malaria Ag Pf, which searches for HRP2 antigen by immunochromatography. The objective of this study is to compare the results of RDT SD Bioline Malaria Ag Pf in use with the results of Thick Gout (TG) in the biological diagnosis of malaria. This was a cross-sectional, descriptive and evaluative study carried out at the Hôpital d’Instruction des Armées-Center Hospitalier et Universitaire de Parakou and at the Boko zone hospital from April 20 to July 30, 2015. Patient identification, we used the non-probabilistic method and the convenience choice technique. The study involved 503 patients. The results of this study showed a good performance of the RDT SD Bioline Malaria Ag Pf. Among the 503 patients, 199 or 39.6% were positive for the RDT against 180 or 35.8% positive for the Thick Gout (TG). Sensitivity, specificity, positive and negative predictive values of the test compared to the thick film were respectively (91.7%, 89.5%, 82.9, 95) and the Kappa coefficient of 0.88 testifies a good match. False positive cases are noted in patients on treatment and even after recovery due to the persistence of the HRP2 antigen in the blood. However, it constitutes an interesting alternative to the management of malaria. At the end of this study, we suggest continuing the use of RDTs in health centers where microscopy is absent and/or reinforcing microscopy, and to strengthen staff training in the management of malaria cases.

The influence of training outcome and competency on effective utilization of malaria microscopy result amongst health professionals in South Eastern Nigeria

Malaria diagnosis in Nigeria mostly relied on clinical manifestations until 2011, when the government issued a policy requiring parasitological confirmation of all suspected malaria cases prior to treatment. Poor usage of malaria test results in health care delivery is one of the possible causes of over-diagnosis and over-treatment of malaria in Nigeria. This study demonstrated the influence of in-service training on malaria microscopy amongst medical laboratory scientists on the utilization of malaria microscopy results in a selected Government Health Facility in Nigeria. In 2014, a baseline study was conducted, and a follow-up study was conducted in which end users of laboratory results in selected secondary health facilities were given a pre-tested questionnaire on perception and utilization of malaria microscopy results by health care providers in malaria case management. Medical laboratory scientists working in these selected facilities were then given basic malaria microscopy training in accordance with the World Health Organization's (WHO) basic microscopy training manual. The training was followed by a supporting supervision visit to the Medical Laboratories, where other factors that can skew microscopy results, such as the need for special equipment, were addressed during the basic and refresher training. We conducted paired t-test to determine statistically significant differences between pre-test and post-test results at 0.05 significance level and ANOVA to determine if there were differences in knowledge level before and after the training and between the basic and refresher training. The study demonstrates a significant improvement in both the basic and refresher training mean parasite detection pre-and post-tests scores from 56.3% (95% CI 53.6-58.8%) to 77.7% (95% CI 74.4-80.2%) and 76.7 (95% CI 74.2-79.2%) to 91.2% (95% CI 88.3-94.1%)(P< 0.001). When comparing the rate of utilization of malaria results from trained Medical Laboratory Scientists to the baseline and follow-up studies, as well as the assessment of facilities' malaria test requests and utilization pattern during the study period, there was a substantial difference (p< 0.001). The increase in utilization of malaria microscopy result for effective case management of malaria in the study area was influenced by training outcome and competency of Medical Laboratory Scientists. Key words: Malaria results, microscopy T raining, medical Laboratory scientists, health care providers.

An assessment of the knowledge, practices and resources during the delivery of malaria health care services among private health care practitioners: a cross section study in the Mid-Western Region of Uganda

BackgroundApproximately 50 % of the population in Uganda seeks health care from private facilities but there is limited data on the quality of care for malaria in these facilities. This study aimed to document the knowledge, practices and resources during the delivery of malaria care services, among private health practitioners in the Mid-Western region of Uganda, an area of moderate malaria transmission.MethodsThis was a cross sectional study in which purposive sampling was used to select fifteen private-for-profit facilities from each district. An interviewer-administered questionnaire that contained both quantitative and open-ended questions was used. Information was collected on availability of treatment aides, knowledge on malaria, malaria case management, laboratory practices, malaria drugs stock and data management. We determined the proportion of health workers that adequately provided malaria case management according to national standards.ResultsOf the 135 health facilities staff interviewed, 61.48 % (52.91–69.40) had access to malaria treatment protocols while 48.89 % (40.19–57.63) received malaria training. The majority of facilities, 98.52 % (94.75–99.82) had malaria diagnostic services and the most commonly available anti-malarial drug was artemether-lumefantrine, 85.19 % (78–91), followed by Quinine, 74.81 % (67–82) and intravenous artesunate, 72.59 % (64–80). Only 14.07 % (8.69–21.10) responded adequately to the acceptable cascade of malaria case management practice. Specifically, 33.33 % (25.46–41.96) responded correctly to management of a patient with a fever, 40.00 % (31.67–48.79) responded correctly to the first line treatment for uncomplicated malaria, whereas 85.19 % (78.05–90.71) responded correctly to severe malaria treatment. Only 28.83 % submitted monthly reports, where malaria data was recorded, to the national database.ConclusionsThis study revealed sub-optimal malaria case management knowledge and practices at private health facilities with approximately 14 % of health care workers demonstrating correct malaria case management cascade practices. To strengthen the quality of malaria case management, it is recommended that the NMCD distributes current guidelines and tools, coupled with training; continuous mentorship and supportive supervision; provision of adequate stock of essential anti-malarials and RDTs; reinforcing communication and behavior change; and increasing support for data management at private health facilities.

Determinants of quality in home-based management of malaria by community health volunteers in rural Kenya.

Kenya adopted the World Health Organization's recommendation of community case management of malaria (CCMM) in 2012. Trained community health volunteers (CHVs) provide CCMM but information on quality of services is limited. This study aimed to establish determinants of quality of service of CCMM conducted by CHVs. A cross-sectional survey was conducted in November 2016 in Bungoma County, Kenya. Data were collected through observing CHVs perform routine CCMM and through interviews of CHVs using structured questionnaires. A ≥ 75% score was considered as quality provision. Descriptive statistics were performed to describe basic characteristics of the study, followed by Chi-Square test and binary logistic regression to examine the differences and associations between the categorical variables. A total of 147 CHVs participated; 62% of CHVs offered quality services. There was a direct association between quality of services and stock-outs of artemether-lumefantrine (AL), stock-outs of malaria rapid diagnostic tests (RDT) and support supervision. CHVs who were supervised during the year preceding the assessment were four times more likely to perform better than those not supervised (uOR 4.2, 95% CI: 1.38-12.85). CHVs with reliable supplies of AL and RDT kits performed three times better than those who experienced stock outs (uOR = 3.2, 95% CI: 1.03-10.03 and 3.3, 95% CI: 1.63-6.59 respectively). Biosafety and documentation were the most poorly performed. The majority of CHVs offered quality CCMM services despite safety gaps. Safety, continuous supplies of RDT, AL and supervision are essential for quality performance by CHV in delivering CCMM.

Usability of a point-of-care diagnostic to identify glucose-6-phosphate dehydrogenase deficiency: a multi-country assessment of test label comprehension and results interpretation

BackgroundPoint-of-care glucose-6-phosphate dehydrogenase (G6PD) testing has the potential to make the use of radical treatment for vivax malaria safer and more effective. Widespread use of G6PD tests as part of malaria case management has been limited, in part due to due concerns regarding product usability, user training, and supervision. This study seeks to assess how well end users can understand the Standard™ G6PD Test (SD Biosensor, Suwon, South Korea) workflow, result output, and label after training. This will ultimately help inform test registration and introduction.MethodsPotential G6PD test users who provide malaria case management at three sites in Brazil, Ethiopia, and India were trained on the use of the SD Biosensor Standard G6PD Test and assessed based on their ability to understand the test workflow and interpret results. The assessment was done through a questionnaire, designed to assess product usability against key technical product specifications and fulfill regulatory evidence requirements. Any participant who obtained 85% or above correct responses to the questionnaire was considered to adequately comprehend how to use and interpret the test.ResultsForty-five participants, including malaria microscopists, laboratory staff, nurses, and community health workers took part in the study. Seventy-eight percent of all participants in the study (35/45) obtained passing scores on the assessment with minimal training. Responses to the multiple-choice questions indicate that most participants understood well the test intended use, safety claims, and warnings. The greatest source of error regarding the test was around the correct operating temperature. Most test results were also read and interpreted correctly, with the haemoglobin measurement being a more problematic output to interpret than the G6PD measurement.ConclusionsThese data results show how a standardized tool can be used to assess a user’s ability to run a point-of-care diagnostic and interpret results. When applied to the SD Biosensor Standard G6PD Test, this tool demonstrates that a range of users across multiple contexts can use the test and suggests improvements to the test instructions and training that can improve product usability, increase user comprehension, and ultimately contribute to more widespread effective use of point-of-care G6PD tests.Trial registration: NCT04033640

Mass drug administration for the acceleration of malaria elimination in a region of Myanmar with artemisinin-resistant falciparum malaria: a cluster-randomised trial

To contain multidrug-resistant Plasmodium falciparum, malaria elimination in the Greater Mekong subregion needs to be accelerated while current antimalarials remain effective. We evaluated the safety, effectiveness, and potential resistance selection of dihydroartemisinin-piperaquine mass drug administration (MDA) in a region with artemisinin resistance in Myanmar. We did a cluster-randomised controlled trial in rural community clusters in Kayin (Karen) state in southeast Myanmar. Malaria prevalence was assessed using ultrasensitive quantitative PCR (uPCR) in villages that were operationally suitable for MDA (villages with community willingness, no other malaria control campaigns, and a population of 50-1200). Villages were eligible to participate if the prevalence of malaria (all species) in adults was greater than 30% or P falciparum prevalence was greater than 10% (or both). Contiguous villages were combined into clusters. Eligible clusters were paired based on P falciparum prevalence (estimates within 10%) and proximity. Community health workers provided routine malaria case management and distributed long-lasting insecticidal bed-nets (LLINs) in all clusters. Randomisation of clusters (1:1) to the MDA intervention group or control group was by public coin-flip. Group allocations were not concealed. Three MDA rounds (3 days of supervised dihydroartemisinin-piperaquine [target total dose 7 mg/kg dihydroartemisinin and 55 mg/kg piperaquine] and single low-dose primaquine [target dose 0·25 mg base per kg]) were delivered to intervention clusters. Parasitaemia prevalence was assessed at 3, 5, 10, 15, 21, 27, and 33 months. The primary outcomes were P falciparum prevalence at months 3 and 10. All clusters were included in the primary analysis. Adverse events were monitored from the first MDA dose until 1 month after the final dose, or until resolution of any adverse event occurring during follow-up. This trial is registered with ClinicalTrials.gov, NCT01872702. Baseline uPCR malaria surveys were done in January, 2015, in 43 villages that were operationally suitable for MDA (2671 individuals). 18 villages met the eligibility criteria. Three villages in close proximity were combined into one cluster because a border between them could not be defined. This gave a total of 16 clusters in eight pairs. In the intervention clusters, MDA was delivered from March 4 to March 17, from March 30 to April 10, and from April 27 to May 10, 2015. The weighted mean absolute difference in P falciparum prevalence in the MDA group relative to the control group was -10·6% (95% CI -15·1 to -6·1; p=0·0008) at month 3 and -4·5% (-10·9 to 1·9; p=0·14) at month 10. At month 3, the weighted P falciparum prevalence was 1·4% (0·6 to 3·6; 12 of 747) in the MDA group and 10·6% (7·0 to 15·6; 56 of 485) in the control group. Corresponding prevalences at month 10 were 3·2% (1·5 to 6·8; 34 of 1013) and 5·8% (2·5 to 12·9; 33 of 515). Adverse events were reported for 151 (3·6%) of 4173 treated individuals. The most common adverse events were dizziness (n=109) and rash or itching (n=20). No treatment-related deaths occurred. In this low-transmission setting, the substantial reduction in P falciparum prevalence resulting from support of community case management was accelerated by MDA. In addition to supporting community health worker case management and LLIN distribution, malaria elimination programmes should consider using MDA to reduce P falciparum prevalence rapidly in foci of higher transmission. The Global Fund to Fight AIDS, Tuberculosis and Malaria.

Genetic diversity and genetic relatedness in Plasmodium falciparum parasite population in individuals with uncomplicated malaria based on microsatellite typing in Eastern and Western regions of Uganda, 2019\u20132020

BackgroundGenetic diversity and parasite relatedness are essential parameters for assessing impact of interventions and understanding transmission dynamics of malaria parasites, however data on its status in Plasmodium falciparum populations in Uganda is limited. Microsatellite markers and DNA sequencing were used to determine diversity and molecular characterization of P. falciparum parasite populations in Uganda.MethodsA total of 147 P. falciparum genomic DNA samples collected from cross-sectional surveys in symptomatic individuals of 2–10 years were characterized by genotyping of seven highly polymorphic neutral microsatellite markers (n = 85) and genetic sequencing of the Histidine Rich Protein 2 (pfhrp2) gene (n = 62). ArcGIS was used to map the geographical distribution of isolates while statistical testing was done using Student's t-test or Wilcoxon's rank-sum test and Fisher’s exact test as appropriate at P ≤ 0.05.ResultsOverall, 75.5% (95% CI 61.1–85.8) and 24.5% (95% CI14.2–38.9) of parasites examined were of multiclonal (mixed genotype) and single clone infections, respectively. Multiclonal infections occurred more frequently in the Eastern region 73.7% (95% CI 48.8–89.1), P < 0.05. Overall, multiplicity of infection (MOI) was 1.9 (95% CI 1.7–2.1), P = 0.01 that was similar between age groups (1.8 vs 1.9), P = 0.60 and regions (1.9 vs 1.8), P = 0.43 for the < 5 and ≥ 5 years and Eastern and Western regions, respectively. Genomic sequencing of the pfhrp2 exon2 revealed a high level of genetic diversity reflected in 96.8% (60/62) unique sequence types. Repeat type AHHAAAHHATD and HRP2 sequence Type C were more frequent in RDT−/PCR + samples (1.9% vs 1.5%) and (13% vs 8%), P < 0.05 respectively. Genetic relatedness analysis revealed small clusters of gene deleted parasites in Uganda, but no clustering with Eritrean parasites.ConclusionHigh level of genetic diversity of P. falciparum parasites reflected in the frequency of multiclonal infections, multiplicity of infection and variability of the pfhrp2 gene observed in this study is consistent with the high malaria transmission intensity in these settings. Parasite genetic analysis suggested spontaneous emergence and clonal expansion of pfhrp2 deleted parasites that require close monitoring to inform national malaria diagnosis and case management policies.

Policy Challenges Facing the Scale Up of Integrated Community Case Management (iCCM) in Uganda.

Integrated Community Case Management (iCCM) of malaria, pneumonia and diarrhoea is an equity focused strategy, to increase access to care for febrile illness in children under-5 years of age, in rural communities. Lay community members are trained to diagnose and treat malaria, pneumonia and diarrhoea in children, and to identify and refer very ill children. Today, many low-income countries including Uganda, have a policy for iCCM which is being rolled out through public sector community health workers (CHWs). Ten years after the introduction of the iCCM strategy in Uganda, it is important to take stock and understand the barriers and facilitators affecting implementation of the iCCM policy. We conducted an iCCM policy analysis in order to identify the challenges, enablers and priorities for scale-up of the iCCM strategy in Uganda. This was a qualitative case study research which included a document review (n=52) and key informant interviews (n=15) with Ugandan stakeholders. Interviews were conducted in 2017 and the desk review included literature up to 2019. This paper highlights the iCCM policy trajectory since 2010 in Uganda and includes a policy timeline. The iCCM policy process was mainly led by international agencies from inception, with little ownership of the government. Many implementation challenges including low government funding, weak coordination and contradicting policies were identified, which could contribute to the slow scale up of the iCCM program. Despite the challenges, many enablers and opportunities also exist within the health system, which should be further harnessed to scale up iCCM in Uganda. These enabling factors include strong community commitment, existing policy instruments and the potential of utilizing also the private sector for iCCM implementation. The iCCM program in Uganda needs to be strengthen through increased domestic funding, strong coordination and a focus on monitoring, evaluation and operational research.

Costing electronic private sector malaria surveillance in the Greater Mekong Subregion

BackgroundPrivate sector malaria programmes contribute to government-led malaria elimination strategies in Cambodia, Lao PDR, and Myanmar by increasing access to quality malaria services and surveillance data. However, reporting from private sector providers remains suboptimal in many settings. To support surveillance strengthening for elimination, a key programme strategy is to introduce electronic surveillance tools and systems to integrate private sector data with national systems, and enhance the use of data for decision-making. During 2013–2017, an electronic surveillance system based on open source software, District Health Information System 2 (DHIS2), was implemented as part of a private sector malaria case management and surveillance programme. The electronic surveillance system covered 16,000 private providers in Myanmar (electronic reporting conducted by 200 field officers with tablets), 710 in Cambodia (585 providers reporting through mobile app), and 432 in Laos (250 providers reporting through mobile app).MethodsThe purpose of the study was to document the costs of introducing electronic surveillance systems and mobile reporting solutions in Cambodia, Lao PDR, and Myanmar, comparing the cost in different operational settings, the cost of introduction and maintenance over time, and assessing the affordability and financial sustainability of electronic surveillance. The data collection methods included extracting data from PSI’s financial and operational records, collecting data on prices and quantities of resources used, and interviewing key informants in each setting. The costing study used an ingredients-based approach and estimated both financial and economic costs.ResultsAnnual economic costs of electronic surveillance systems were $152,805 in Laos, $263,224 in Cambodia, and $1,310,912 in Myanmar. The annual economic cost per private provider surveilled was $82 in Myanmar, $371 in Cambodia, and $354 in Laos. Cost drivers varied depending on operational settings and number of private sector outlets covered in each country; whether purchased or personal mobile devices were used; and whether electronic (mobile) reporting was introduced at provider level or among field officers who support multiple providers for case reporting.ConclusionThe study found that electronic surveillance comprises about 0.5–1.5% of national malaria strategic plan cost and 7–21% of surveillance budgets and deemed to be affordable and financially sustainable.

Performance Evaluation of Malaria HRP-2 Rapid Diagnostic Test among Febrile Patients with Malaria in Iwo, Osun State, Nigeria

Diagnosis of malaria is a fundamental component of malaria case management. Parasitological confirmation of malaria before treatment was recommended for endemic countries. Microscopy diagnosis of malaria, the gold standard as constraints such as: level of expertise, quality of equipment and reagents may lead to misdiagnosis. The histidine rich protein 2 (HRP-2) based rapid diagnostic test (RDT) detects <em>Plasmodium falciparum</em> only.

Strengthening community and stakeholder participation in the implementation of integrated vector management for malaria control in western Kenya: a case study

BackgroundIntegrated vector management (IVM) is defined as a rational decision-making process for the optimal use of resources for vector control. The IVM approach is based on the premise that effective control of vectors and the diseases they transmit is not the sole preserve of the health sector. It requires the collaboration and participation of communities and other stakeholders in public and private sectors. Community participation is key to the success of IVM implementation at the local level.Case descriptionThe study was conducted in Nyabondo, a rural area of Kenya where malaria is endemic. The objective of the project was to promote adoption and sustainability of IVM and scale up IVM-related activities as well as increase community participation and partnership in malaria control through outreach, capacity-building and collaboration with other stakeholders in the area. Collaboration was pursued through forging partnership with various government departments and ministries, particularly the fisheries department, ministry of education, ministry of health, forestry department and the social services. In total, 33 community-based organizations working within the area were identified and their role documented. Through distribution of information, education and communication (IEC) materials alone, the project was able to reach 10,670 people using various social mobilization methods, such as convening of sensitization meetings—dubbed 'mosquito days'—mainly spearheaded by primary school pupils. A total of 23 local primary schools participated in creating awareness on malaria prevention and control during the project phase. The collaboration with other departments like fisheries led to stocking of more than 20 fishponds with a total of 18,000 fingerlings in the years 2017 and 2018. Fish ponds provided an opportunity for income generation to the community. In partnership with the county government health department, the project was able to re-train 40 CHVs on IVM and malaria case management in the area. Additionally, 40 fish farmers were re-trained on fish farming as part of income generating activity (IGA) while 10 CBOs made up of 509 members received both eucalyptus and Ocimum kilimandscharicum seedlings that were distributed to four CBOs composed of 152 members. Four primary schools made up of 113 health club members also received eucalyptus seedlings as part of IGA in addition to fish farming. In total, around 20,000 eucalyptus seedlings were distributed to the community as part of IGA initiatives. By the end of 2018, the project was able to reach 25,322 people in the community during its two-year advocacy and social mobilization initiatives.ConclusionThrough advocacy and social mobilization, the IVM strategy improved inter-sectoral collaboration, enhanced capacity building and community participation. However, more IVM related activities are needed to effectively mobilize available resources and increase community participation in malaria control.

Community and healthcare providers\u2019 perceptions of quality of private sector outpatient malaria care in North-western Ethiopia: a qualitative study

BackgroundMalaria is one of the most important public health problems in Ethiopia contributing to significant patient morbidity and mortality. Prompt diagnosis and effective malaria case management through public, private and community health facilities has been one of the key malaria prevention, control and elimination strategies. The objective of this study was to evaluate adult malaria patients and healthcare providers’ perception of the quality of malaria management at private sector outpatient facilities.MethodsAn exploratory, descriptive, contextual and qualitative research methodology was conducted with 101 participants (33 in-depth interviews (INIs) and ten focus group discussions (FGDs) with 68 participants). All interview and focus group discussions were audio recorded, transcribed verbatim and analysed, using eight steps of Tesch.ResultsDuring data analysis a single theme, two categories and six sub-categories emerged, namely (1) perceived quality of malaria management at outpatient facilities; (a) essential resources; (a1) safe outpatient services; (a2) anti-malarial drugs and supplies; (a3) health workers; (b) factors influencing service utilization; (b1) physical accessibility; (b2) “art of care’’; and (b3) efficient malaria diagnosis and treatment services. Both FGDs and INIs participants had a positive perception of the quality of malaria outpatient services at private health facilities. The positive perceptions include safe and clean facility; availability of supplies and comprehensive services; convenient working hours; short waiting hours and motivated, competent and compassionate health workers. However, some participants raised their safety concerns due to perceived poor infection control practices, small working areas, interruption of anti-malarial supplies and inefficient malaria diagnosis and treatment services.ConclusionBoth community members and healthcare providers had more positive perceptions towards outpatient malaria services offered at private health facilities. However, positive behaviour must be maintained and concerns must be dealt with by enhancing functional public private partnership for malaria care services to improve private sector malaria case management; build the service providers’ capacity; ensure uninterrupted anti-malarial supplies and empower the community with early health-seeking behaviour.

Needs assessment of community health workers to enhance efficient delivery of their services for community case management of malaria in Kenya

BackgroundMalaria continues to be the leading cause of morbidity and mortality in Africa. Community Case Management of malaria (CCMm) which is undertaken by engaging Community Health Workers (CHWs) to effectively address management of malaria cases in some endemic communities was explored in this study. The aim was to assess the needs of CHWs that would help sustain and retain their services to enhance the efficient delivery of CCMm.MethodsUsing semi-structured questionnaires, data on the needs of CHWs was gathered through a qualitative study consisting of in-depth interviews and focus group discussions (FGDs) conducted among study participants in five districts in western Kenya. The study participants comprised of 100 CHWs, 100 mothers of children under five years and 25 key informants made up of public health officers and clinicians involved in the CCMm. The interviews were conducted in English and Swahili or Dholuo, the local language. The recorded audio interviews were transcribed later. The analysis was done using NVivo version 7 software and transcripts were coded after which themes related to the objectives of the study were identified.ResultsAll the study participants recognized the need to train and update CHWs on their work as well as remunerating them for their services to enhance efficient delivery of services. The CHWs on their part perceived the provision of gloves, rapid diagnostic test kits (RDTs), lancets, cotton wool and ethanol, bins (to dispose of RDTs and lancets), together with drugs for treating clients as the essential needs to undertake CCMm in the communities. Other logistical needs and incentives mentioned by CHWs and key informants for the successful delivery of CCMm included: gumboots, raincoats, torch lights, mobile phones, means of transportation (bicycles and motorbikes), uniforms and ID cards for identification.ConclusionsCHWs would perform tasks better and their services retained for a sustainable CCMm if: properly incentivized; offered refresher trainings (and updates) on malaria; and equipped with the requisite tools identified in this study.

Predictive Performance of Rapid Diagnostic Tests for Falciparum Malaria and Its Modeled Impact on Integrated Community Case Management of Malaria in Sub-Saharan African Febrile Children.

BackgroundIntegrated community case management (iCCM) of malaria complements public health services to improve access to timely diagnosis and treatment of malaria. ICCM relies on standardized test-and-treat algorithms implemented by community health workers using malaria rapid diagnostic tests (RDTs). However, due to a changing epidemiology of fever causes in Africa, positive RDT results might not correctly reflect malaria. In this study, we modeled diagnostic predictive values for all malaria-endemic African regions as an indicator of the programmatic usefulness of RDTs in iCCM campaigns on malaria.MethodsPositive predictive values (PPVs) and negative predictive values (NPVs) of RDTs for clinical malaria were modeled. Assay-specific performance characteristics stem from the Cochrane Library and data on the proportion of malaria-attributable fevers among African febrile children aged <5 years were used as prevalence matrix.ResultsAverage country-level PPVs vary considerably. Ethiopia had the lowest PPVs (histidine-rich protein II [HRP2] assay, 17.35%; parasite lactate dehydrogenase [pLDH] assay, 39.73%), and Guinea had the highest PPVs (HRP2 assay, 95.32%; pLDH assay, 98.46%). On the contrary, NPVs were above 90% in all countries (HRP2 assay, ≥94.87%; pLDH assay, ≥93.36%).ConclusionsPPVs differed considerably within Africa when used to screen febrile children, indicating unfavorable performance of RDT-based test-and-treat algorithms in low-PPV settings. This suggests that the administration of antimalarials alone may not constitute causal treatment in the presence of a positive RDT result for a substantial proportion of patients, particularly in low-PPV settings. Therefore, current iCCM algorithms should be complemented by information on other setting-specific major causes of fever.

Incentivizing appropriate malaria case management in the private sector: a study protocol for two linked cluster randomized controlled trials to evaluate provider- and client-focused interventions in western Kenya and Lagos, Nigeria

BackgroundA large proportion of artemisinin-combination therapy (ACT) anti-malarial medicines is consumed by individuals that do not have malaria. The over-consumption of ACTs is largely driven by retail sales in high malaria-endemic countries to clients who have not received a confirmatory diagnosis. This study aims to target ACT sales to clients receiving a confirmatory diagnosis using malaria rapid diagnostic tests (mRDTs) at retail outlets in Kenya and Nigeria.MethodsThis study comprises two linked four-arm 2 × 2 factorial cluster randomized controlled trials focused on malaria diagnostic testing and conditional ACT subsidies with the goal to evaluate provider-directed and client-directed interventions. The linked trials will be conducted at two contrasting study sites: a rural region around Webuye in western Kenya and the urban center of Lagos, Nigeria. Clusters are 41 and 48 participating retail outlets in Kenya and Nigeria, respectively. Clients seeking care at participating outlets across all arms will be given the option of paying for a mRDT—at a study-recommended price—to be conducted at the outlet. In the provider-directed intervention arm, the outlet owner receives a small monetary incentive to perform the mRDT. In the client-directed intervention arm, the client receives a free ACT if they purchase an mRDT and receive a positive test result. Finally, the fourth study arm combines both the provider- and client-directed interventions. The diagnosis and treatment choices made during each transaction will be captured using a mobile phone app. Study outcomes will be collected through exit interviews with clients, who sought care for febrile illness, at each of the enrolled retail outlets.ResultsThe primary outcome measure is the proportion of all ACTs that are sold to malaria test-positive clients in each study arm. For all secondary outcomes, we will evaluate the degree to which the interventions affect purchasing behavior among people seeking care for a febrile illness at the retail outlet.ConclusionsIf our study demonstrates that malaria case management can be improved in the retail sector, it could reduce overconsumption of ACTs and enhance targeting of publicly funded treatment reimbursements, lowering the economic barrier to appropriate diagnosis and treatment for patients with malaria.Trial registrationClinicalTrials.govNCT04428307, registered June 9, 2020, and NCT04428385, registered June 9, 2020.

Knowledge and practices regarding malaria and the National Treatment Guidelines among public health workers in Equatorial Guinea

BackgroundIn 2018, an estimated 228 million cases of malaria occurred worldwide. Countries are far from having achieved reasonable levels of national protocol compliance among health workers. Lack of awareness of treatment protocols and treatment resistance by prescribers threatens to undermine progress when it comes to reducing the prevalence of this disease. This study sought to evaluate the degree of knowledge and practices regarding malaria diagnosis and treatment amongst prescribers working at the public health facilities of Bata, Equatorial Guinea.MethodsA cross-sectional survey was conducted in October-December 2017 amongst all public health professionals who attended patients under the age of 15 years, with suspected malaria in the Bata District of Equatorial Guinea. Practitioners were asked about their practices and knowledge of malaria and the National Malaria Treatment Guidelines. A bivariate analysis and a logistic regression model were used to determine factors associated with their knowledge.ResultsAmong the 44 practitioners interviewed, 59.1% worked at a Health Centre and 40.9% at the District Hospital of Bata. Important differences in knowledge and practices between hospital and health centre workers were found. Clinical diagnosis was more frequently by practitioners at the health centres (p = 0.059), while microscopy confirmation was more frequent at regional hospital (100%). Intramuscular artemether was the anti-malarial most administrated at the health centres (50.0%), while artemether-lumefantrine was the treatment most used at the regional hospital (66.7%). Most practitioners working at public health facilities (63.6%) have a low level of knowledge regarding the National Malaria Treatment Guidelines. While knowledge regarding malaria, the National Malaria Treatment Guidelines and treatment resistances is low, it was higher amongst hospital workers than amongst practitioners at health centres.ConclusionsIt is essential to reinforce practitioners’ knowledge, treatment and diagnosis practices and use of the National Malaria Treatment Guidelines in order to improve malaria case management and disease control in the region. A specific malaria training programme ensuring ongoing updates training is necessary in order to ensure that greater experience does not entail obsolete knowledge and, consequently, inadequate diagnosis and treatment practices.

Deletions of pfhrp2 and pfhrp3 genes were uncommon in rapid diagnostic test-negative Plasmodium falciparum isolates from Uganda

BackgroundRapid diagnostic tests (RDTs) play a key role in malaria case management. The most widely used RDT identifies Plasmodium falciparum based on immunochromatographic recognition of P. falciparum histidine-rich protein 2 (PfHRP2). Deletion of the paralogous pfhrp2 and pfhrp3 genes leads to false-negative PfHRP2-based RDTs, and has been reported in P. falciparum infections from South America and Africa. However, identification of pfhrp2/pfhrp3 deletions has usually been based only on failure to amplify these genes using PCR, without confirmation based on PfHRP2 protein expression, and understanding of the true prevalence of deletions is incomplete.MethodsDeletions of pfhrp2/pfhrp3 in blood samples were investigated from cross-sectional surveys in 2012-13 in three regions of varied malaria transmission intensity in Uganda. Samples with positive Giemsa-stained thick blood smears, but negative PfHRP2-based RDTs were evaluated by PCR amplification of conserved subunit ribosomal DNA for Plasmodium species, PCR amplification of pfhrp2 and pfhrp3 genes to identify deletions, and bead-based immunoassays for expression of PfHRP2.ResultsOf 3516 samples collected in cross-sectional surveys, 1493 (42.5%) had positive blood smears, of which 96 (6.4%) were RDT-negative. Of these 96 RDT-negative samples, P. falciparum DNA was identified by PCR in 56 (58%) and only non-falciparum plasmodial DNA in 40 (42%). In all 56 P. falciparum-positive samples there was a failure to amplify pfhrp2 or pfhrp3: in 25 (45%) pfhrp2 was not amplified, in 39 (70%) pfhrp3 was not amplified, and in 19 (34%) neither gene was amplified. For the 39 P. falciparum-positive, RDT-negative samples available for analysis of protein expression, PfHRP2 was not identified by immunoassay in only four samples (10.3%); these four samples all had failure to amplify both pfhrp2 and pfhrp3 by PCR. Thus, only four of 96 (4.2%) smear-positive, RDT-negative samples had P. falciparum infections with deletion of pfhrp2 and pfhrp3 confirmed by failure to amplify the genes by PCR and lack of expression of PfHRP2 demonstrated by immunoassay.ConclusionFalse negative RDTs were uncommon. Deletions in pfhrp2 and pfhrp3 explained some of these false negatives, but most false negatives were not due to deletion of the pfhrp2 and pfhrp3 genes.

Malaria Diagnosis and Treatment: Perception of Community Pharmacists in Abuja Metropolis, Nigeria

Malaria is a life threatening infectious disease that constitutes a major global public health and economic concern. Consequently, the WHO has recommended a T3 initiative (Test, Treat & Track) to help curb the scourge globally. This study aimed to ascertain the efficacy of malaria diagnosis in malaria case management and perception of community pharmacists on the WHO recommended standard of parasitological diagnosis before commencement of treatment within Abuja metropolis. A descriptive cross sectional study was performed amongst 207 community pharmacists within Abuja Metropolis. Data was obtained through structured, self-administered questionnaire. The association of respondent characteristics with the awareness, practice, and perception of malaria testing, and treatment was evaluated by Chi-square analysis for proportion. Where the number of categories was less than five, Fisher exact test was used. Seventy-two percent (72.9%) were aware of the WHO recommended T3 initiative on malaria case management. However, less than 10% of respondents had training in all the three components. On practice, 28.5% of community pharmacists carry out malaria diagnosis with a confirmatory test before instituting treatment. Ninety-two percent (92.3%) treat malaria based on clinical signs and symptoms only. Despite the high rate of clinical diagnosis, a majority (84.1%) agreed that the confirmatory test is more effective and efficient in malaria case management than clinical diagnosis. Most respondents (60.4%) reported that the confirmatory test most readily available was mRDT. Eighty-seven percent (87%) have good perception on parasitological confirmatory testing for malaria diagnosis and most respondents have confidence in results from the malaria confirmatory test while 68.6% trust their malaria confirmatory test skill. A little above half (52.7%) of the respondents treat for malaria regardless of negative confirmatory test results when the patient insists on treatment. A higher proportion (39%) of male community Pharmacists compared to females carry out malaria diagnosis with a confirmatory test before treatment. There was significant association of perception on the efficacy of a parasitological confirmatory test for malaria with age and work experience and there was significant association of work experience with the practice of confirmatory testing before treatment (P<0.05). Inferentially, this is call to action for government, professional bodies in the health sector and all committed to fight the scourge of malaria for more awareness to the general public on importance of the WHO T3 and capacity strengthening for the frontline health workers – community pharmacy attending to community needs on malaria case management.