Search

Background Health workers’ knowledge deficiencies about artesunate-based severe malaria treatment recommendations have been reported. However, predictors of the treatment knowledge have not been examined. In this paper, predictors of artesunate-based treatment knowledge among inpatient health workers in two hospital sectors in Kenya are reported. Methods Secondary analysis of 367 and 330 inpatient health workers randomly selected and interviewed at 47 government hospitals in 2016 and 43 faith-based hospitals in 2017 respectively, was undertaken. Multilevel ordinal and binary logistic regressions examining the effects of 11 factors on five knowledge outcomes in government and faith-based hospital sectors were performed. Results Among respective government and faith-based health workers, about a third of health workers had high knowledge of artesunate treatment policies (30.8% vs 32.9%), a third knew all dosing intervals (33.5% vs 33.3%), about half knew preparation solutions (49.9% vs 55.8%), half to two-thirds knew artesunate dose for both weight categories (50.8% vs 66.7%) and over three-quarters knew the preferred route of administration (78.7% vs 82.4%). Eight predictors were significantly associated with at least one of the examined knowledge outcomes. In the government sector, display of artesunate administration posters, paediatric ward allocation and repeated surveys were significantly associated with more than one of the knowledge outcomes. In the faith-based hospitals, availability of artesunate at hospitals and health worker pre-service training were associated with multiple outcomes. Exposure to in-service malaria case-management training and access to malaria guidelines were only associated with higher knowledge about artesunate treatment policy. Conclusion Programmatic interventions ensuring display of artesunate administration posters in the wards, targeting of health workers managing adult patients in the medical wards, and repeated knowledge assessments are likely to be beneficial for improving the knowledge of government health workers about artesunate-based severe malaria treatment recommendations. The availability of artesunate and focus on improvements of nurses’ knowledge should be prioritized at the faith-based hospitals.

The use of mobile technologies in medicine, or mHealth, holds promise to improve health worker (HW) performance, but evidence is mixed. We conducted a cluster-randomized controlled trial to evaluate the effect of text message reminders to HWs in outpatient health facilities (HFs) on quality of care for malaria, pneumonia, and diarrhea in Malawi. After a baseline HF survey (2,360 patients) in January 2015, 105 HFs were randomized to three arms: 1) text messages to HWs on malaria case management; 2) text messages to HWs on malaria, pneumonia, and diarrhea case management (latter two for children < 5 years); and 3) control arm (no messages). Messages were sent beginning April 2015 twice daily for 6 months, followed by an endline HF survey (2,536 patients) in November 2015. An intention-to-treat analysis with difference-in-differences binomial regression modeling was performed. The proportion of patients with uncomplicated malaria managed correctly increased from 42.8% to 59.6% in the control arm, from 43.7% to 55.8% in arm 1 (effect size −4.7%-points, 95% confidence interval (CI): −18.2, 8.9, P = 0.50) and from 30.2% to 50.9% in arm 2 (effect size 3.9%-points, 95% CI: −14.1, 22.0, P = 0.67). Prescription of first-line antibiotics to children < 5 years with clinically defined pneumonia increased in all arms, but decreased in arm 2 (effect size −4.1%-points, 95% CI: −42.0, 33.8, P = 0.83). Prescription of oral rehydration solution to children with diarrhea declined slightly in all arms. We found no significant improvements in malaria, pneumonia, or diarrhea treatment after HW reminders, illustrating the importance of rigorously testing new interventions before adoption.

Background Health workers’ compliance with outpatient malaria case-management guidelines has been improving in Africa. This study examined the factors associated with the improvements. Methods Data from 11 national, cross-sectional health facility surveys undertaken from 2010–2016 were analysed. Association between 31 determinants and improvement trends in five outpatient compliance outcomes were examined using interactions between each determinant and time in multilevel logistic regression models and reported as an adjusted odds ratio of annual trends (T-aOR). Results Among 9,173 febrile patients seen at 1,208 health facilities and by 1,538 health workers, a higher annual improvement trend in composite “test and treat” performance was associated with malaria endemicity-lake endemic (T-aOR = 1.67 annually; p25 febrile patients (T-aOR = 1.46; p = 0.003); and with under-five children compared to older patients (T-aOR = 1.07; p = 0.013). Other factors associated with the improvement trends in the “test and treat” policy components and artemether-lumefantrine administration at the facility included the absence of previous RDT stock-outs, community health workers dispensing drugs, access to malaria case-management and Integrated Management of Childhood Illness (IMCI) guidelines, health workers’ gender, correct health workers’ knowledge about the targeted malaria treatment policy, and patients’ main complaint of fever. The odds of compliance at the baseline were variable for some of the factors. Conclusions Targeting of low malaria risk areas, low caseload facilities, male and government health workers, continuous availability of RDTs, improving health workers’ knowledge about the policy considering age and fever, and dissemination of guidelines might improve compliance with malaria guidelines. For prompt treatment and administration of the first artemether-lumefantrine dose at the facility, task-shifting duties to community health workers can be considered.

Background Health workers' compliance with outpatient malaria case-management guidelines has been improving, specifically regarding the universal testing of suspected cases and the use of artemisinin-based combination therapy (ACT) only for positive results (i.e., ‘test and treat’). Whether the improvements in compliance with ‘test and treat’ guidelines are consistent across different malaria endemicity areas has not been examined. Methods Data from 11 national, cross-sectional, outpatient malaria case-management surveys undertaken in Kenya from 2010 to 2016 were analysed. Four primary indicators (i.e., ‘test and treat’) and eight secondary indicators of artemether-lumefantrine (AL) dosing, dispensing, and counselling were measured. Mixed logistic regression models were used to analyse the annual trends in compliance with the indicators across the different malaria endemicity areas (i.e., from highest to lowest risk being lake endemic, coast endemic, highland epidemic, semi-arid seasonal transmission, and low risk). Results Compliance with all four ‘test and treat’ indicators significantly increased in the area with the highest malaria risk (i.e., lake endemic) as follows: testing of febrile patients (OR = 1.71 annually; 95% CI = 1.51–1.93), AL treatment for test-positive patients (OR = 1.56; 95% CI = 1.26–1.92), no anti-malarial for test-negative patients (OR = 2.04; 95% CI = 1.65–2.54), and composite ‘test and treat’ compliance (OR = 1.80; 95% CI = 1.61–2.01). In the low risk areas, only compliance with test-negative results significantly increased (OR = 2.27; 95% CI = 1.61–3.19) while testing of febrile patients showed declining trends (OR = 0.89; 95% CI = 0.79–1.01). Administration of the first AL dose at the facility significantly increased in the areas of lake endemic (OR = 2.33; 95% CI = 1.76–3.10), coast endemic (OR = 5.02; 95% CI = 2.77–9.09) and semi-arid seasonal transmission (OR = 1.44; 95% CI = 1.02–2.04). In areas of the lowest risk of transmission and highland epidemic zone, none of the AL dosing, dispensing, and counselling tasks significantly changed over time. Conclusions There is variability in health workers' compliance with outpatient malaria case-management guidelines across different malaria-risk areas in Kenya. Major improvements in areas of the highest risk have not been seen in low-risk areas. Interventions to improve practices should be targeted geographically.

Background Nigeria was among the first African countries to adopt and implement change of treatment policy for severe malaria from quinine to artesunate. Seven years after the policy change health systems readiness and quality of inpatient malaria case-management practices were evaluated in Kano State of Nigeria. Methods A cross-sectional survey was undertaken in May 2019 at all public hospitals. Data collection comprised hospital assessments, interviews with inpatient health workers and data extraction from medical files for all suspected malaria patients admitted to the paediatric and medical wards in April 2019. Descriptive analyses included 22 hospitals, 154 health workers and 1,807 suspected malaria admissions analysed from malaria test and treat case-management perspective. Results 73% of hospitals provided malaria microscopy, 27% had rapid diagnostic tests and 23% were unable to perform any parasitological malaria diagnosis. Artemisinin-based combination therapy (ACT) was available at 96% of hospitals, artemether vials at 68% while injectable quinine and artesunate were equally stocked at 59% of hospitals. 32%, 21% and 15% of health workers had been exposed to relevant trainings, guidelines and supervision respectively. 47% of suspected malaria patients were tested while repeat testing was rare (7%). 60% of confirmed severe malaria patients were prescribed artesunate. Only 4% of admitted non-severe test positive cases were treated with ACT, while 76% of test negative patients were prescribed an anti-malarial. Artemether was the most common anti-malarial treatment for non-severe test positive (55%), test negative (43%) and patients not tested for malaria (45%). In all categories of the patients, except for confirmed severe cases, artemether was more commonly prescribed for adults compared to children. 44% of artesunate-treated patients were prescribed ACT follow-on treatment. Overall compliance with test and treat policy for malaria was 13%. Conclusions Translation of new treatment policy for severe malaria into inpatient practice is compromised by lack of malaria diagnostics, stock-outs of artesunate and suboptimal health workers’ practices. Establishment of the effective supply chain and on-going supportive interventions for health workers accompanied with regular monitoring of the systems readiness and clinical practices are urgently needed.

Background Change of severe malaria treatment policy from quinine to artesunate, a major malaria control advance in Africa, is compromised by scarce data to monitor policy translation into practice. In Kenya, hospital surveys were implemented to monitor health systems readiness and inpatient malaria case-management. Methods All 47 county referral hospitals were surveyed in February and October 2016. Data collection included hospital assessments, interviews with inpatient health workers and retrospective review of patients’ admission files. Analysis included 185 and 182 health workers, and 1162 and 1224 patients admitted with suspected malaria, respectively, in all 47 hospitals. Cluster-adjusted comparisons of the performance indicators with exploratory stratifications were performed. Results Malaria microscopy was universal during both surveys. Artesunate availability increased (63.8–85.1%), while retrospective stock-outs declined (46.8–19.2%). No significant changes were observed in the coverage of artesunate trained (42.2% vs 40.7%) and supervised health workers (8.7% vs 12.8%). The knowledge about treatment policy improved (73.5–85.7%; p = 0.002) while correct artesunate dosing knowledge increased for patients < 20 kg (42.7–64.6%; p < 0.001) and > 20 kg (70.3–80.8%; p = 0.052). Most patients were tested on admission (88.6% vs 92.1%; p = 0.080) while repeated malaria testing was low (5.2% vs 8.1%; p = 0.034). Artesunate treatment for confirmed severe malaria patients significantly increased (69.9–78.7%; p = 0.030). No changes were observed in artemether– lumefantrine treatment for non-severe test positive patients (8.0% vs 8.8%; p = 0.796). Among test negative patients, increased adherence to test results was observed for non-severe (68.6–78.0%; p = 0.063) but not for severe patients (59.1–62.1%; p = 0.673). Overall quality of malaria case-management improved (48.6–56.3%; p = 0.004), both for children (54.1–61.5%; p = 0.019) and adults (43.0–51.0%; p = 0.041), and in both high (51.1–58.1%; p = 0.024) and low malaria risk areas (47.5–56.0%; p = 0.029). Conclusion Most health systems and malaria case-management indicators improved during 2016. Gaps, often specific to different inpatient populations and risk areas, however remain and further programmatic interventions including close monitoring is needed to optimize policy translation.

Background Malaria is one of the major causes of childhood death in sub-Saharan countries. A reliable estimation of malaria prevalence is important to guide and monitor progress toward control and elimination. The aim of the study was to estimate the true prevalence of malaria in children under five in the Democratic Republic of the Congo, Uganda and Kenya, using a Bayesian modelling framework that combined in a novel way malaria data from national household surveys with external information about the sensitivity and specificity of the malaria diagnostic methods used in those surveys—i.e., rapid diagnostic tests and light microscopy. Methods Data were used from the Demographic and Health Surveys (DHS) and Malaria Indicator Surveys (MIS) conducted in the Democratic Republic of the Congo (DHS 2013–2014), Uganda (MIS 2014–2015) and Kenya (MIS 2015), where information on infection status using rapid diagnostic tests and/or light microscopy was available for 13,573 children. True prevalence was estimated using a Bayesian model that accounted for the conditional dependence between the two diagnostic methods, and the uncertainty of their sensitivities and specificities obtained from expert opinion. Results The estimated true malaria prevalence was 20% (95% uncertainty interval [UI] 17%–23%) in the Democratic Republic of the Congo, 22% (95% UI 9–32%) in Uganda and 1% (95% UI 0–3%) in Kenya. According to the model estimations, rapid diagnostic tests had a satisfactory sensitivity and specificity, and light microscopy had a variable sensitivity, but a satisfactory specificity. Adding reported history of fever in the previous 14 days as a third diagnostic method to the model did not affect model estimates, highlighting the poor performance of this indicator as a malaria diagnostic. Conclusions In the absence of a gold standard test, Bayesian models can assist in the optimal estimation of the malaria burden, using individual results from several tests and expert opinion about the performance of those tests. Electronic supplementary material The online version of this article (10.1186/s12936-018-2211-y) contains supplementary material, which is available to authorized users.

Background Adherence to anti-malarial medication is highly variable but frequently suboptimal. Numerous interventions with a variety of methodological approaches have been implemented to address the problem. A recently conducted, randomized, controlled trial in western Kenya evaluated the effects of short message service (SMS) reminders on paediatric adherence to artemether–lumefantrine (AL) and found over 97% adherence rates in both intervention and control arms. The current study was undertaken to explore participants’ experiences in the trial and identify the factors contributing to the high adherence rates. Methods In July 2016, 5 months after the trial completion, focus group discussions (FGDs) were undertaken with caregivers of children who had been treated in the intervention (n = 2) or control (n = 2) arms and who, post-trial, had received malaria treatment from the same facilities. The FGDs explored similarities and differences in perceptions and experiences of the care they received during and after the trial. Results Intervention-arm participants reported that SMS messages were effective dosing reminders. Participants from both arms reported that trial instructions to keep empty AL packs for verification during a home visit by a health worker affected their dosing and adherence practices. Differences between trial and post-trial treatment experiences included: administration of the first AL dose by health workers with demonstration of dispersible tablets dilution; advice on what to do if a child vomited; clear instructions on timing of dosing with efforts made to ensure understanding; and, information that dose completion was necessary with explanation provided. Participants reported that after the trial AL was not available at facilities, constraining their ability to adhere to recommended malaria treatment. They emphasized receiving respectful and personal treatment from trial health workers contributing to perceptions of high quality care and enhanced readiness to adhere to dosing instructions. Conclusions This study highlights the complex range of factors that influence AL adherence. The results suggest that in addition to standardized definitions and measurement of adherence, and the influence of enrolment procedures, AL adherence trials need to take account of how intervention impact can be influenced by differences in the quality of care received under trial and routine conditions.

Background The correct knowledge of standard case definition is necessary for frontline health workers to diagnose suspected diseases across Africa. However, surveillance evaluations commonly assume this prerequisite. This study assessed the knowledge of case definitions for health workers and their supervisors for disease surveillance activities in rural Kenya. Methods A cross-sectional survey including 131 health workers and their 11 supervisors was undertaken in two counties in Kenya. Descriptive analysis was conducted to classify the correctness of knowledge into four categories for three tracer diseases (dysentery, measles, and dengue). We conducted a univariate and multivariable logistic regression analyses to explore factors influencing knowledge of the case definition for dysentery. Results Among supervisors, 81.8% knew the correct definition for dysentery, 27.3% for measles, and no correct responses were provided for dengue. Correct knowledge was observed for 50.4% of the health workers for dysentery, only 12.2% for measles, and none for dengue. Of 10 examined factors, the following were significantly associated with health workers’ correct knowledge of the case definition for dysentery: health workers’ cadre (aOR 2.71; 95% CI 1.20–6.12; p = 0.017), and display of case definition poster (aOR 2.24; 95% CI 1.01–4.98; p = 0.048). Health workers’ exposure to the surveillance refresher training, supportive supervision and guidelines were not significantly associated with the knowledge. Conclusion The correct knowledge of standard case definitions was sub-optimal among health workers and their supervisors, which is likely to impact the reliability of routine surveillance reports generated from health facilities.

Background Short Message Service (SMS) reminders have been suggested as a potential intervention for improving adherence to medications and health facility attendance. Methods An open-label, randomized, controlled trial to test the efficacy of automated SMS reminders in improving adherence to artemether–lumefantrine (AL) and post-treatment attendance in comparison with standard care was conducted at four health facilities in western Kenya. Children below five years of age with uncomplicated malaria were randomized to intervention (SMS reminders) or control groups. Within each study group they were further randomized to three categories, which determined the timing of home visits to measure adherence to complete AL course and to individual AL doses. A sub-set of caregivers was advised to return to the facility on day 3 and all were advised to return after 28 days. The primary outcomes were adherence to medication and return on day 3. The primary analysis was by intention-to-treat. Results Between 9 June, 2014 and 26 February, 2016, 1677 children were enrolled. Of 562 children visited at home on day 3, all AL doses were completed for 97.6% (282/289) of children in the control and 97.8% (267/273) in the intervention group (OR = 1.10; 95% CI = 0.37–3.33; p = 0.860). When correct timing in taking each dose was considered a criteria for adherence, 72.3% (209/289) were adherent in the control and 69.2% (189/273) in the intervention group (OR = 0.82; 95% CI = 0.56–1.19; p = 0.302). Sending SMS reminders significantly increased odds of children returning to the facility on day 3 (81.4 vs 74.0%; OR = 1.55; 95% CI = 1.15–2.08; p = 0.004) and on day 28 (63.4 vs 52.5%; OR = 1.58; 95% CI = 1.30–1.92; p Conclusions In this efficacy trial, SMS reminders increased post-treatment return to the health facility, but had no effect on AL adherence which was high in both control and intervention groups. Further effectiveness studies under the real world conditions are needed to determine the optimum role of SMS reminders. Trial registration ISRCTN39512726

BACKGROUND: Effective surveillance systems are required to track malaria testing and treatment practices. A 26-week study "SMS for Life" was piloted in five rural districts of Kenya to examine whether SMS reported surveillance data could ensure real-time visibility of accurate data and their use by district managers to impact on malaria case-management. METHODS: Health workers from 87 public health facilities used their personal mobile phones to send a weekly structured SMS text message reporting the counts of four basic surveillance data elements to a web-based system accessed by district managers. Longitudinal monitoring of SMS reported data through the web-based system and two rounds of cross-sectional health facility surveys were done to validate accuracy of data. RESULTS: Mean response rates were 96% with 87% of facilities reporting on time. Fifty-eight per cent of surveillance data parameters were accurately reported. Overall mean testing rates were 37% with minor weekly variations ranging from 32 to 45%. Overall test positivity rate was 24% (weekly range: 17-37%). Ratio of anti-malarial treatments to test positive cases was 1.7:1 (weekly range: 1.3:1-2.2:1). District specific trends showed fluctuating patterns in testing rates without notable improvement over time but the ratio of anti-malarial treatments to test positive cases improved over short periods of time in three out of five districts. CONCLUSIONS: The study demonstrated the feasibility of using simple mobile phone text messages to transmit timely surveillance data from peripheral health facilities to higher levels. However, accuracy of data reported was suboptimal. Future work should focus on improving quality of SMS reported surveillance data.

BACKGROUND: When replacing failing drugs for malaria with more effective drugs, an important step towards reducing the malaria burden is that health workers (HW) prescribe drugs according to evidence-based guidelines. Past studies have shown that HW commonly do not follow guidelines, yet few studies have explored with appropriate methods why such practices occur. METHODS: We analysed data from a survey of government health facilities in four Kenyan districts in which HW consultations were observed, caretakers and HW were interviewed, and health facility assessments were performed. The analysis was limited to children 2-59 months old with uncomplicated malaria. Treatment was defined as recommended (antimalarial recommended by national guidelines), a minor error (effective, but non-recommended antimalarial), or inappropriate (no effective antimalarial). RESULTS: We evaluated 1006 consultations performed by 135 HW at 81 facilities: 567 children received recommended treatment, 314 had minor errors, and 125 received inappropriate treatment (weighted percentages: 56.9%, 30.4%, and 12.7%). Multivariate logistic regression analysis revealed that programmatic interventions such as in-service malaria training, provision of guidelines and wall charts, and more frequent supervision were significantly associated with better treatment quality. However, neither in-service training nor possession of the guideline document showed an effect by itself. More qualified HW made more errors: both major and minor errors (but generally more minor errors) when second-line drugs were in stock, and more major errors when second-line drugs were not in stock. Child factors such as age and a main complaint of fever were also associated with treatment quality. CONCLUSIONS: Our results support the use of several programmatic strategies that can redress HW deficiencies in malaria treatment. Targeted cost-effectiveness trials would help refine these strategies and provide more precise guidance on affordable and effective ways to strengthen and maintain HW practices.

diagnosis in patients 5 years and older. We evaluated the impact of these age-specific recommendations on routine malaria treatment practices 4‐6 months after AL treatment was implemented. methods Cross-sectional, cluster sample survey using quality-of-care assessment methods in all government facilities in four Kenyan districts. Analysis was restricted to the 64 facilities with malaria diagnostics and AL available on the survey day. Main outcome measures were antimalarial treatment practices for febrile patients stratified by age, use of malaria diagnostic tests, and test result. results Treatment practices for 706 febrile patients (401 young children and 305 patients ‡5 years) were evaluated. 43.0% of patients ‡5 years and 25.9% of children underwent parasitological malaria testing (87% by microscopy). AL was prescribed for 79.7% of patients ‡5 years with positive test results, for 9.7% with negative results and for 10.9% without a test. 84.6% of children with positive tests, 19.2% with negative tests, and 21.6% without tests were treated with AL. At least one antimalarial drug was prescribed for 75.0% of children and for 61.3% of patients ‡5 years with a negative test result. conclusions Despite different recommendations for patients below and above 5 years of age, malaria diagnosis and treatment practices were similar in the two age groups. Parasitological diagnosis was under-used in older children and adults, and young children were still tested. Use of AL was low overall and alternative antimalarials were commonly prescribed; but AL prescribing largely followed the results of malaria tests. Malaria diagnosis recommendations differing between age groups appear complex to implement; further strengthening of diagnosis and treatment practices under AL policy is required.

Background Vanuatu, an archipelago country in Western Pacific harbouring low Plasmodium falciparum and Plasmodium vivax malaria transmission, has been implementing a malaria case management policy, recommending parasitological testing of patients with fever and anti-malarial treatment for test-positive only patients. A health facility survey to evaluate the health systems readiness to implement the policy and the quality of outpatient management for patients with fever was undertaken. Methods A cross-sectional, cluster sample survey, using a range of quality-of-care methods, included all health centres and hospitals in Vanuatu. The main outcome measures were coverage of health facilities and health workers with commodities and support interventions, adherence to test and treatment recommendations, and factors influencing malaria testing. Results The survey was undertaken in 2014 during the low malaria season and included 41 health facilities, 67 health workers and 226 outpatient consultations for patients with fever. All facilities had capacity for parasitological diagnosis, 95.1 % stocked artemether-lumefantrine and 63.6 % primaquine. The coverage of health workers with support interventions ranged from 50 to 70 %. Health workers’ knowledge was high only regarding treatment policy for uncomplicated P. falciparum malaria (83.4 %). History taking and clinical examination practices were sub-optimal. Some 35.0 % (95 % CI 23.4–48.6) of patients with fever were tested for malaria, of which all results were negative and only one patient received anti-malarial treatment. Testing was significantly higher for patients age 5 years and older (OR = 2.33; 95 % CI 1.48–5.02), seen by less qualified health workers (OR = 2.73; 95 % CI 1.48–5.02), health workers who received malaria case management training (OR = 2.39; 95 % CI 1.28–4.47) and patients with increased temperature (OR = 2.56; 95 % CI 1.17–5.57), main complaint of fever (OR = 5.82; 95 % CI 1.26–26.87) and without runny nose (OR = 3.75; 95 % CI 1.36–10.34). Antibiotic use was very high (77.4 %) with sub-optimal dispensing and counselling practices. Conclusions Health facility and health worker readiness to implement policy is higher for falciparum than vivax malaria. Clinical and malaria testing practices are sub-optimal, however adherence to test negative results is nearly universal. Use of antibiotics is irrational. Quantitative and qualitative improvements of ongoing interventions are needed to re-inforce clinical practices in this area characterized by difficult access, human resource shortages but aspiring towards malaria elimination.

Background Patients’ low adherence to artemisinin-based combination therapy has been reported in areas of Kenya bordering the Lake Victoria region, where the burden of malaria remains high. A randomized controlled trial is underway to determine the efficacy of short message service (SMS) text reminders on adherence to artemether-lumefantrine and post-treatment review of children under the age of five. This paper reports on the iterative process of intervention and delivery system development. Methods An intervention development workshop involving the research team and other stakeholders was held to determine the content of the text messages. Three focus group discussions were conducted to test caregivers’ understanding of the messages developed during the workshop. The tested messages were refined and incorporated into an automated SMS distribution system and piloted with 20 caregivers drawn from facilities neighbouring the study sites. The automated SMS distribution system was repeatedly refined following the pilot and implemented at the start of the trial. Results The content of SMS messages underwent major revisions following the focus group discussions. Technical terms and abbreviations were replaced with simplified general terms. Message sign-off was modified to reflect the name of health facility, removing references to health workers. Day 3 post-treatment review visit reminder was modified to state the purpose of the visit while wording ‘day 28’ was added to the last post-treatment review visit reminder to help the caregiver recall the appointment date. The unscheduled visit prompt was modified to reflect flexibility and practicality of taking the child back to the facility if unwell. Reception of SMS reminders during the pilot was low with only 169/240 (70%) of scheduled messages delivered to the caregivers. The automated distribution system underwent major refinement and repeated testing following the pilot until effective delivery of all scheduled messages was achieved and sustained over a period of 3 months. Conclusions Text message interventions should be carefully developed, tested and refined before implementation to ensure they are written in the most appropriate way for their target population. SMS distribution systems should be rigorously tested to ensure efficient delivery of the messages before they are deployed.

Background: Mobile phone short messaging services (SMS) have been investigated in health information reporting, provider performance, drug and diagnostic stock management and patient adherence to treatment for chronic diseases. However, their potential role in improving patients’ adherence to malaria treatment and day 3 post treatment reviews remains unclear. Methods/Design: A “proof of concept” open label randomised controlled trial will be conducted at four sites in Western Kenya. Principal research questions are: 1) Can mobile phone SMS reminders improve patient adherence to malaria treatment? 2) Can mobile phone SMS reminders improve day 3 post treatment reviews? Eligible caregivers (n=1000 per arm) of children under five years old with uncomplicated malaria will be randomly assigned (one to one) to: a) the current standard of care (provider counselling and health education); and b) the current standard of care plus SMS reminders. Within each arm, caregivers will be further randomized to three different categories. In categories 1 and 300 caregivers per arm per category will be visited at home on day 1 and 2 of follow up respectively, to measure appropriate timing and adherence of the second Artemether-Lumefantrine (AL) dose and doses 3 and 4. Further, caregivers in categories 1 and 2 will be required to come to the health facility for the day 3 post treatment reviews. Finally, in category 400 caregivers per arm will be visited at home on day 3 to measure adherence for the full AL course. Each category will be visited at home only once to avoid biases in the measures of adherence as a result of home consultations. Primary outcomes will be adherence to the full AL course (category 3), as well as, the proportion of patients reporting back for day 3 post treatment reviews (categories 1 and 2). The primary analysis will be intention-to-treat. Costs of the intervention will be measured over the period of the intervention, and a cost-effectiveness ratio will be estimated. Discussion: If successful, evidence from this trial could improve malaria treatment adherence and offer pragmatic approaches for antimalarial drug resistance surveillance and risk mitigation in Africa. Current Controlled Trials: ISRCTN39512726

For the prompt and effective management of malaria cases (a key strategy for reducing the enormous burden of the disease), healthworkers must prescribe antimalarial drugs according to evidence-based guidelines. In sub-Saharan Africa, the guidelines for use in outpatient settings generally recommend that febrile illness in children should be suspected to be malaria and be treated with an antimalarial drug. The quality of treatment offered to febrile children at outpatient facilities in this region has now been investigated in a literature review. The results of five methodologically comparable studies were also used to explore the determinants of malaria-treatment practices. The quality of treatment prescribed to febrile children was found to have been generally sub-optimal, with low levels of adherence to national guidelines, the frequent selection of non-recommended antimalarials, and the use of incorrect dosages. Several factors might be to responsible for these shortcomings. Although interventions such as the Integrated Management of Childhood Illness (IMCI) strategy can lead to improvements, a better understanding of the practices of the healthworkers responsible for treating febrile children will be needed before treatment is made much better. The failure to provide treatment of good quality will become an increasingly important problem as antimalarial policies involving drugs with more complex dosing regimens, such as artemisinin-based combination therapies (ACT), are implemented. If the malaria burden in Africa is to be greatly reduced, the deployment of ACT must be accompanied by interventions to ensure the correct treatment of children at the point of care. Some interventions, such as IMCI, can improve the treatment of not only malaria but also other potentially life-threatening illnesses.

The objective was to evaluate the accuracy of routine malaria microscopy and appropriate use and interpretation of malaria slides under operational conditions in Kenya. Cross-sectional survey using a range of quality of care assessment tools at government facilities with malaria microscopy in two Kenyan districts of different intensity of malaria transmission. All patients older than 5 years presenting to outpatient departments were enrolled. Two expert microscopists assessed the accuracy of the routine malaria slide results. We analysed 359 consultations performed by 31 clinicians at 17 facilities. Clinical assessment was suboptimal. Blood slide microscopy was performed for 72.7% of patients who represented 78.5% of febrile patients and 51.3% of afebrile patients. About 95.5% of patients with a positive malaria microscopy result and 79.3% of patients with a negative result received antimalarial treatment. Sulphadoxine-pyremethamine monotherapy was more commonly prescribed for patients with a negative test result (60.7%) than for patients with a positive result (32.4%). Conversely amodiaquine or quinine were prescribed for only 14.7% of patients with a negative malaria microscopy result compared to 57.7% of patients with a positive result. The prevalence of confirmed malaria was low in both high (10.0%) and low- (16.3%) transmission settings. Combining data from both settings the sensitivity of routine microscopy was 68.6%; its specificity 61.5%; its positive predictive value 21.6% and its negative predictive value 92.7%. The potential benefits of microscopy are currently not realised because of the poor quality of routine testing and irrational clinical practices. Ambiguous clinical guidelines permitting treatment of older children and adults with a negative blood slide also undermine rational use of antimalarial drugs. (authors)

Background Health facility stock-outs of artemether-lumefantrine (AL), the common first-line therapy for uncomplicated malaria across Africa, adversely affect effective malaria case-management. They have been previously reported on various scales in time and space, however the magnitude of the problem and trends over time are less clear. Here, 2010-2011 data are reported from public facilities in Kenya where alarming stock-outs were revealed in 2008. Methods Data were collected between January 2010 and June 2011 as part of 18 monthly cross-sectional surveys undertaken at nationally representative samples of public health facilities. The primary monitoring indicator was total stock-out of all four weight-specific AL packs. The secondary indicators were stock-outs of at least one AL pack and individual stock-outs for each AL pack. Monthly proportions and summary means of the proportions over the monitoring period were measured for each indicator. Stock-out trends were assessed using linear regression. Results The number of surveyed facilities across 18 time points ranged between 162 and 176 facilities. The stock-out means of the proportion of health facilities were 11.6% for total AL stock-out, 40.6% for stock-out of at least one AL pack, and between 20.5% and 27.4% for stock-outs of individual AL packs. Monthly decrease of the total AL stock-out was 0.005% (95% CI: -0.5 to +0.5; p = 0.983). Monthly decrease in the stock-out of at least one AL pack was 0.7% (95% CI: -1.5 to +0.3; p = 0.058) while stock-outs of individual AL packs decreased monthly between 0.2% for AL 24-pack and 0.7% for AL six-pack without statistical significance for any of the weight-specific packs. Conclusions Despite lower levels of AL stock-outs compared to the reports in 2008, the stock-outs at Kenyan facilities during 2010-2011 are still substantial and of particular worry for the most detrimental:- simultaneous absence of any AL pack. Only minor decrease was observed in the stock-outs of individual AL packs. Recently launched interventions to eliminate AL stock-outs in Kenya are fully justified.

Dejan Zurovac and colleagues discuss six areas where text messaging could improve the delivery of health services and health outcomes in malaria in Africa.

Background: Implementation of WHO case management guidelines for serious common childhood illnesses remains a challenge in hospitals in low-income countries. The impact of locally adapted clinical practice guidelines (CPGs) on the quality-of-care of patients in tertiary hospitals has rarely been evaluated. Methods and Findings: We conducted, in Kenyatta National Hospital, an uncontrolled before and after study with an attempt to explore intervention dose-effect relationships, as CPGs were disseminated and training was progressively implemented. The emergency triage, assessment and treatment plus admission care (ETAT+) training and locally adapted CPGs targeted common, serious childhood illnesses. We compared performance in the pre-intervention (2005) and post-intervention periods (2009) using quality indicators for three diseases: pneumonia, dehydration and severe malnutrition. The indicators spanned four domains in the continuum of care namely assessment, classification, treatment, and follow-up care in the initial 48 hours of admission. In the pre-intervention period patients' care was largely inconsistent with the guidelines, with nine of the 15 key indicators having performance of below 10%. The intervention produced a marked improvement in guideline adherence with an absolute effect size of over 20% observed in seven of the 15 key indicators; three of which had an effect size of over 50%. However, for all the five indicators that required sustained team effort performance continued to be poor, at less than 10%, in the post-intervention period. Data from the five-year period (2005-09) suggest some dose dependency though the adoption rate of the best-practices varied across diseases and over time. Conclusion: Active dissemination of locally adapted clinical guidelines for common serious childhood illnesses can achieve a significant impact on documented clinical practices, particularly for tasks that rely on competence of individual clinicians. However, more attention must be given to broader implementation strategies that also target institutional and organisational aspects of service delivery to further enhance quality-of-care. © 2012 Irimu et al.

Summary Background Health workers' malaria case-management practices often differ from national guidelines. We assessed whether text-message reminders sent to health workers' mobile phones could improve and maintain their adherence to treatment guidelines for outpatient paediatric malaria in Kenya. Methods From March 6, 2009, to May 31, 2010, we did a cluster-randomised controlled trial at 107 rural health facilities in 11 districts in coastal and western Kenya. With a computer-generated sequence, health facilities were randomly allocated to either the intervention group, in which all health workers received text messages on their personal mobile phones on malaria case-management for 6 months, or the control group, in which health workers did not receive any text messages. Health workers were not masked to the intervention, although patients were unaware of whether they were in an intervention or control facility. The primary outcome was correct management with artemether-lumefantrine, defined as a dichotomous composite indicator of treatment, dispensing, and counselling tasks concordant with Kenyan national guidelines. The primary analysis was by intention to treat. The trial is registered with Current Controlled Trials, ISRCTN72328636. Findings 119 health workers received the intervention. Case-management practices were assessed for 2269 children who needed treatment (1157 in the intervention group and 1112 in the control group). Intention-to-treat analysis showed that correct artemether-lumefantrine management improved by 23·7 percentage-points (95% CI 7·6–40·0; p=0·004) immediately after intervention and by 24·5 percentage-points (8·1–41·0; p=0·003) 6 months later. Interpretation In resource-limited settings, malaria control programmes should consider use of text messaging to improve health workers' case-management practices. Funding The Wellcome Trust.

Background Widespread urbanization over the next 20 years has the potential to drastically change the risk of malaria within Africa. The burden of the disease, its management, risk factors and appropriateness of targeted intervention across varied urban environments in Africa remain largely undefined. This paper presents a combined historical and contemporary review of the clinical burden of malaria within one of Africa's largest urban settlements, Nairobi, Kenya. Methods A review of historical reported malaria case burdens since 1911 within Nairobi was undertaken using archived government and city council reports. Contemporary information on out-patient case burdens due to malaria were assembled from the National Health Management and Information System (HMIS). Finally, an audit of 22 randomly selected health facilities within Nairobi was undertaken covering 12 months 2009-2010. The audit included interviews with health workers, and a checklist of commodities and guidelines necessary to diagnose, treat and record malaria. Results From the 1930's through to the mid-1960's malaria incidence declined coincidental with rapid population growth. During this period malaria notification and prevention were a priority for the city council. From 2001-2008 reporting systems for malaria were inadequate to define the extent or distribution of malaria risk within Nairobi. A more detailed facility review suggests, however that malaria remains a common diagnosis (11% of all paediatric diagnoses made) and where laboratories (n = 15) exist slide positivity rates are on average 15%. Information on the quality of diagnosis, slide reading and whether those reported as positive were imported infections was not established. The facilities and health workers included in this study were not universally prepared to treat malaria according to national guidelines or identify foci of risks due to shortages of national first-line drugs, inadequate record keeping and a view among some health workers (17%) that slide negative patients could still have malaria. Conclusion Combined with historical evidence there is a strong suggestion that very low risks of locally acquired malaria exist today within Nairobi's city limits and this requires further investigation. To be prepared for effective prevention and case-management of malaria among a diverse, mobile population in Nairobi requires a major paradigm shift and investment in improved quality of malaria diagnosis and case management, health system strengthening and case reporting.

Background Improving the way artemether-lumefantrine (AL) is provided to patients attending clinics is critical to maximize the benefit of this new medicine. In 2007, a new initiative was launched in one part of Kenya to improve malaria case-management through enhanced in-service training and provision of job aids. Methods An evaluation of the intervention using pre- and post-intervention cross sectional health facility surveys was conducted in Bondo district. The surveys included: audit of government health facilities, health worker structured interviews and exit interviews with caretakers of sick children below five years of age. The outcome indicators were the proportions of febrile children who had AL prescribed, AL dispensed, and four different dispensing and counseling tasks performed. Results At baseline 33 government health facilities, 48 health workers and 386 febrile child consultations were evaluated. At follow-up the same health facilities were surveyed and 36 health workers and 390 febrile child consultations evaluated. The findings show: 1) no health facility or health worker was exposed to all components of the intervention; 2) the proportion of health workers who received the enhanced in-service training was 67%; 3) the proportion of febrile children with uncomplicated malaria treated with the first-line anti-malarial drug, artemether-lumefantrine (AL), at health facilities where AL was in stock increased from 76.9% (95%CI: 69.4, 83.1) to 87.6% (95% CI: 82.5, 91.5); 4) there were modest but non-significant improvements in dispensing and counseling practices; and 5) when the analyses were restricted to health workers who received the enhanced in-service training and/or had received new guidelines and job aids, no significant improvements in reported case-management tasks were observed compared to baseline. Conclusion In-service training and provision of job aids alone may not be adequate to improve the prescribing, dispensing and counseling tasks necessary to change malaria case-management practices and the inclusion of supervision and post-training follow-up should be considered in future clinical practice change initiatives.

Background Case-management with artemether-lumefantrine (AL) is one of the key strategies to control malaria in many African countries. Yet, the reports on translation of AL implementation activities into clinical practice are scarce. Here the quality of AL case-management is reported from Uganda; approximately one year after AL replaced combination of chloroquine and sulphadoxine-pyrimethamine (CQ+SP) as recommended first line treatment for uncomplicated malaria. Methods A cross-sectional survey, using a range of quality of care assessment tools, was undertaken at all government and private-not-for-profit facilities in four Ugandan districts. Main outcome measures were AL prescribing, dispensing and counseling practices in comparison with national guidelines, and factors influencing health workers decision to 1) treat for malaria, and 2) prescribe AL. Results 195 facilities, 232 health workers and 1,763 outpatient consultations were evaluated. Of 1,200 patients who needed treatment with AL according to guidelines, AL was prescribed for 60%, CQ+SP for 14%, quinine for 4%, CQ for 3%, other antimalarials for 3%, and 16% of patients had no antimalarial drug prescribed. AL was prescribed in the correct dose for 95% of patients. Only three out of seven AL counseling and dispensing tasks were performed for more than 50% of patients. Patients were more likely to be treated for malaria if they presented with main complaint of fever (OR = 5.22; 95% CI: 3.61–7.54) and if they were seen by supervised health workers (OR = 1.63; 95% CI: 1.06–2.50); however less likely if they were treated by more qualified health workers (OR = 0.61; 95% CI: 0.40–0.93) and presented with skin problem (OR = 0.29; 95% CI: 0.15–0.55). AL was more likely prescribed if the appropriate weight-specific AL pack was in stock (OR = 6.15; 95% CI: 3.43–11.05) and when CQ was absent (OR = 2.16; 95% CI: 1.09–4.28). Routine AL implementation activities were not associated with better performance. Conclusion Although the use of AL was predominant over non-recommended therapies, the quality of AL case-management at the point of care is not yet optimal. There is an urgent need for innovative quality improvement interventions, which should be rigorously tested. Adequate availability of ACTs at the point of care will, however, ultimately determine the success of any performance interventions and ACT policy transitions.

Objective: To evaluate health facility and health worker readiness to deliver new artemetherlumefantrine (AL) treatment policy for uncomplicated malaria in Kenya. Design: Cross-sectional survey. Setting: Health facilities in four sentinel districts in Kenya. Participants: All government facilities in study districts (n = 211) and all health workers performing outpatient consultations (n = 654). Main outcome measures: Availability of antimalarial drugs on the survey day, stock-outs in past six months, presence of AL wall charts, health worker\'s exposure to in-service training on AL and access to new national malaria guidelines. Results: The availability of any tablets of AL , sulfadoxine-pyrimethamine and amodiaquine was nearly universal on the survey day. However, only 61% of facilities stocked all four weight-specific packs of AL . In the past six months, 67% of facilities had stock-out of at least one AL tablet pack and 15% were out of stock for all four packs at the same time. Duration of stock-out was substantial for all AL packs (median range: 27-39% of time). During the same period, the stock-outs of sulfadoxine-pyrimethamine and amodiaquine were rare. Only 19% of facilities had all AL wall charts displayed, AL in-service training was provided to 47% of health workers and 59% had access to the new guidelines. Conclusion: Health facility and health worker readiness to implement AL policy is not yet optimal. Continuous supply of all four AL pack sizes and removal of not recommended antimalarials is needed. Further coordinated efforts through the routine programmatic activities are necessary to improve delivery of AL at the point of care. East African Medical Journla Vol. 85 (5) 2008: pp. 213-221

Summary Objective A recent observational study undertaken at 17 health facilities with microscopy in Kenya revealed that potential benefits of malaria microscopy are not realized because of irrational clinical practices and the low accuracy of routine microscopy. Using these data, we modelled financial and clinical implications of revised clinical practices and improved accuracy of malaria microscopy among adult outpatients under the artemether–lumefantrine (AL) treatment policy for uncomplicated malaria in Kenya. Methods The cost of AL, antibiotics and malaria microscopy and the expected number of malaria diagnosis errors were estimated per 1000 adult outpatients presenting at a facility with microscopy under three scenarios: (1) current clinical practice and accuracy of microscopy (option A), (2) revised clinical practice with current accuracy of microscopy (option B) and (3) revised clinical practice with improved accuracy of microscopy (option C). Revised clinical practice was defined as performing a blood slide for all febrile adults and prescribing antimalarial treatment only for positive results. Improved accuracy of routine microscopy was defined as 90% sensitivity and specificity. In the sensitivity analysis, the implications of changes in the cost of drugs and malaria microscopy and changes in background malaria prevalence were examined for each option. Results The costs of AL, antibiotics and malaria microscopy decreased from $2154 under option A to $1254 under option B and $892 under option C. Of the cost savings from option C, 72% was from changes in clinical practice, while 28% was from improvements in the accuracy of microscopy. Compared with 638 malaria overdiagnosis errors per 1000 adults under option A, 375 and 548 fewer overdiagnosis errors were estimated, respectively, under options B and C. At the same time, the number of missed malaria diagnoses remained generally low under all options. Sensitivity analysis showed that both options B and C are robust to a wide range of assumptions on the costs of drugs, costs of blood slides and malaria prevalence. Conclusions Even with the imperfect microscopy conditions at Kenyan facilities, implementation of revised clinical practice (option B) would substantially reduce the costs and errors from malaria overdiagnosis. Additional interventions to improve the accuracy of microscopy (option C) can achieve further benefits; however, improved microscopy in the absence of revised clinical practice is unlikely to generate significant cost savings. Revision of guidelines to state explicitly age-specific indications for the use and interpretation of malaria microscopy is urgently needed. Further prospective studies are required to evaluate the effectiveness and costs of interventions to improve clinical practice and the accuracy of malaria microscopy. Donnees de base Une etude d'observation menee sur la microscopie dans 17 services de sante au Kenya a revele que les benefices potentiels de la microscopie de la malaria n’etaient pas realises a cause de pratiques cliniques irrationnelles et de la faible precision de la microscopie de routine. Sur base de ces donnees, nous avons modelise les implications financieres et cliniques de la correction de la pratique clinique et de l'amelioration de la precision de la microscopie de la malaria chez les patients ambulants adultes sous les directives de traitement utilisant artemether-lumefantrine pour la malaria non compliquee au Kenya. Methodes Les couts de artemether-lumefantrine, des antibiotiques, de la microscopie de la malaria et du nombre attendu d'erreurs de diagnostic ont ete estimes par 1000 patients ambulants adultes se presentant dans un service pratiquant la microscopie sous trois scenarios: 1) Option A: pratique clinique en cours et precision de la microscopie, 2) Option B: pratique clinique corrigee avec la precision microscopique en cours et 3) Option C: pratique clinique corrigee avec amelioration de la precision de la microscopie. La correction de la pratique clinique a consistea prescrire la pratique d'un frottis sanguin pour tout cas febrile adulte et la prescription d'un traitement antimalarique seulement pour les resultats positifs. L'amelioration de la precision de la microscopie de routine a ete definie pour 90% de specificite et de sensibilite. Dans l'analyse de sensibilite, les implications dans les changements du cout des medicaments et de la microscopie de la malaria et les changements sous-jacents dans la prevalence de la malaria, ont ete examinees pour chacune des options. Resultats Le cout de l'artemether-lumefantrine, des antibiotiques et de la microscopie de la malaria ont baisse de 2154$ pour l'option A a 1254 $ pour l'option B et a 892 $ pour l'option C. 72% des couts evites dans l'option C s'appliquaient aux changements de la pratique clinique et 28%a l'amelioration de la precision de la microscopie. Sous l'option A, 638 erreurs (faux positifs) de diagnostic par 1000 adultes ont ete effectuees. 375 erreurs de diagnostic en moins ont ete estimees sous l'option B et 548 en moins sous l'option C. Le nombre de malaria non diagnostiquees restait en general faible quelque soit l'option. L'analyse de sensibilite a revele que les options B et C etaient toutes les deux robustes pour une large variete d'assomptions sur le cout des medicaments, des frottis de sang et de la prevalence de la malaria. Conclusion Meme avec des conditions imparfaites de microscopie dans les services de sante au Kenya, l'implementation de pratique clinique corrigee (option B) reduirait substantiellement les couts et les erreurs de diagnostic en surplus de la malaria. Des interventions supplementaires dans l'amelioration de la precision de la microscopie (option C) peuvent permettre des benefices supplementaires, quoiqu'il soit improbable que l'amelioration de la microscopie en l'absence de pratique clinique corrigee permette de reduire les couts. Des directives expliquant clairement les indications specifiques a l’âge pour l'utilisation et l'interpretation de la microscopie de la malaria devraient etre urgemment corrigees. Antecedentes Durante un estudio observacional realizado recientemente en 17 centros sanitarios con microscopia en Kenia, se demostro que los beneficios potenciales de la microscopia de malaria no se estaban dando debido a una practica clinica irracional y a una baja precision en la microscopia de rutina. Utilizando estos datos, modelamos las implicaciones clinicas y financieras de unas practicas clinicas revisadas y un aumento en la precision de la microscopia para malaria, entre adultos que acudian a consultas externas por politica de tratamiento con artemeter-lumefantrina para malaria no complicada en Kenia. Metodos Se estimaron el coste de artemeter-lumefantrina, de los antibioticos y la microscopia para malaria asi como el numero esperado de errores en el diagnostico de malaria por cada 1,000 pacientes adultos que se presentaban en un servicio sanitario con microscopio bajo tres escenarios: 1) practica clinica y precision de la microscopia actuales (Opcion A); 2) practica clinica revisada y precision de la microscopia actual (Opcion B); y 3) practica clinica revisada con mejora en la precision de la microscopia (Opcion C). Se definio la practica clinica revisada como el hacer una gota gruesa a todos los adultos febriles y prescribirles tratamiento antimalarico solo a los que obtuviesen un resultado positivo. Una mejora en la precision de la microscopia de rutina se definio como una sensibilidad y especificidad del 90%. En el analisis de sensibilidad se examinaron para cada opcion las implicaciones de cambio en el coste de los medicamentos y la microscopia de malaria asi como los cambios en la prevalencia de la malaria de fondo. Resultados El coste de artemeter-lumefantrina, antibioticos y la microscopia de malaria disminuyo de $2,154 bajo la Opcion A a $1,254 bajo la Opcion By $892 bajo la Opcion C. De los ahorros en costes de la Opcion C, un 72% correspondia a cambios en las practicas clinicas y 28% era de mejoras la precision de la microscopia. Bajo la Opcion A se sobrediagnosticaron como malaria 638 de cada 1,000 adultos; en la Opcion B y C se estimaron 375 y 548 menos errores de sobrediagnostico respectivamente. El numero de diagnosticos de malaria omitidos fue en general bajo en todas las opciones. El analisis de sensibilidad mostro que ambas opciones By C eran robustas a un amplio rango de supuestos sobre el coste de los farmacos, el coste de las gotas gruesas y la prevalencia de malaria. Conclusiones Aun con las condiciones imperfectas de microscopia existentes en las instalaciones de Kenia, la implementacion de una practica clinica revisada (Opcion B) reduciria sustancialmente los costos y errores debido al sobrediagnostico de la malaria. Intervenciones adicionales para mejorar la precision de la microscopia (Opcion C) podrian alcanzar mayores beneficios; aunque la mejora de la microscopia en ausencia de una practica clinica revisada es poco probable que genere ahorros significativos en los costos. Es urgente revisar las directrices para que expongan explicitamente las indicaciones, especificadas por edad, del uso y la interpretacion de la microscopia para malaria.

BackgroundMonitoring implementation of the "test and treat" case-management policy for malaria is an important component of all malaria control programmes in Africa. Unfortunately, routine information systems are commonly deficient to provide necessary information. Using health facility surveys we monitored health systems readiness and malaria case-management practices prior to and following implementation of the 2010 "test and treat" policy in Kenya.Methods/findingsBetween 2010 and 2013 six national, cross-sectional, health facility surveys were undertaken. The number of facilities assessed ranged between 172 and 176, health workers interviewed between 216 and 237 and outpatient consultations for febrile patients evaluated between 1,208 and 2,408 across six surveys. Comparing baseline and the last survey results, all readiness indicators showed significant (pConclusionsMajor improvements in the implementation of "test and treat" policy were observed in Kenya. Some gaps towards universal targets still remained. Other countries facing similar needs and challenges may consider health facility surveys to monitor malaria case-management.

A key bench mark of successful therapeutic policy implementation, and thus effectiveness, is that the recommended drugs are available at the point of care. Two years after artemether-lumefathrine (AL) was introduced for the management of uncomplicated malaria in Kenya, we carried out a cross-sectional survey to investigate AL availability in government facilities in seven malaria-endemic districts. One of four of the surveyed facilities had none of the four AL weight-specific treatment packs in stock; three of four facilities were out of stock of at least one weight-specific AL pack, leading health workers to prescribe a range of inappropriate alternatives. The shortage was in large part caused by a delayed procurement process. National ministries of health and the international community must address the current shortcomings facing antimalarial drug supply to the public sector.

Background Simple interventions for improving health workers' adherence to malaria case-management guidelines are urgently required across Africa. A recent trial in Kenya showed that text-message reminders sent to health workers' mobile phones improved management of pediatric outpatients by 25 percentage points. In this paper we examine costs and cost-effectiveness of this intervention. Methods/Findings We evaluate costs and cost-effectiveness in 2010 USD under three implementation scenarios: (1) as implemented under study conditions in study areas; (2) if the intervention was routinely implemented by the Ministry of Health (MoH) in the same areas; and (3) if the intervention was scaled up nationally. Under study conditions, intervention costs were 19,342 USD, of which 45% were for developing and pretesting text-messages, 12% for developing text-message distribution system, 29% for collecting health workers' phone numbers, and 13% were costs of sending text-messages and monitoring of the system. If the intervention was implemented in the same areas by the MoH, the costs would be 28% lower (13,920 USD) due to lower costs of collecting health workers' numbers. The cost of national scale-up would be 97,350 USD, and the majority of these costs (66%) would be for sending text-messages. The cost per additional child correctly managed was 0.50 USD under study conditions, 0.36 USD if implemented by the MoH in the same area, and estimated at only 0.03 USD if implemented nationally. Even if the effect size was only 5% or the cost on the national scale was 400% higher than estimated, the cost per additional child correctly managed would be only 0.16 USD. Conclusions A simple text-messaging intervention improving health worker adherence to malaria guidelines is effective and inexpensive. Further research is justified to optimize delivery of the intervention and expand targets beyond children and malaria disease.

CONTEXT: Improving the accuracy of malaria diagnosis with rapid antigen-detection diagnostic tests (RDTs) has been proposed as an approach for reducing overtreatment of malaria in the current era of widespread implementation of artemisinin-based combination therapy in sub-Saharan Africa. OBJECTIVE: To assess the association between use of microscopy and RDT and the prescription of antimalarials. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional, cluster sample survey, carried out between March and May 2006, of all outpatients treated during 1 working day at government and mission health facilities in 4 sentinel districts in Zambia. MAIN OUTCOME MEASURE: Proportions of patients undergoing malaria diagnostic procedures and receiving antimalarial treatment. RESULTS: Seventeen percent of the 104 health facilities surveyed had functional microscopy, 63% had RDTs available, and 73% had 1 or more diagnostics available. Of patients with fever (suspected malaria), 27.8% (95% confidence interval [CI], 13.1%-42.5%) treated in health facilities with malaria diagnostics were tested and 44.6% had positive test results. Of patients with negative blood smear results, 58.4% (95% CI, 36.7%-80.2%) were prescribed an antimalaria drug, as were 35.5% (95% CI, 16.0%-55.0%) of those with a negative RDT result. Of patients with fever who did not have diagnostic tests done, 65.9% were also prescribed antimalarials. In facilities with artemether-lumefantrine in stock, this antimalarial was prescribed to a large proportion of febrile patients with a positive diagnostic test result (blood smear, 75.0% [95% CI, 51.7%-98.3%]; RDT, 70.4% [95% CI, 39.3%-100.0%]), but also to some of those with a negative diagnostic test result (blood smear, 30.4% [95% CI, 8.0%-52. 9%]; RDT, 26.7% [95% CI, 5.7%-47.7%]). CONCLUSIONS: Despite efforts to expand the provision of malaria diagnostics in Zambia, they continue to be underused and patients with negative test results frequently receive antimalarials. Provision of new tools to reduce inappropriate use of new expensive antimalarial treatments must be accompanied by a major change in clinical treatment of patients presenting with fever but lacking evidence of malaria infection.

Using data on clinical practices for outpatients 5 years and older, test accuracy, and malaria prevalence, we model financial and clinical implications of malaria rapid diagnostic tests (RDTs) under the new artemether-lumefantrine (AL) treatment policy in one high and one low malaria prevalence district in Kenya. In the high transmission district, RDTs as actually used would improve malaria treatment (61% less over-treatment but 8% more under-treatment) and lower costs (21% less). Nonetheless, the majority of patients with malaria would not be correctly treated with AL. In the low transmission district, especially because the treatment policy was new and AL was not widely used, RDTs as actually used would yield a minor reduction in under-treatment errors (36% less but the base is small) with 41% higher costs. In both districts, adherence to revised clinical practices with RDTs has the potential to further decrease treatment errors with acceptable costs.

Background Effective malaria case-management based on artemisinin-based combination therapy (ACT) and parasitological diagnosis is a major pillar within the 2007-2012 National Malaria Strategic Plan in the Sudan. Three years after the launch of the strategy a health facility survey was undertaken to evaluate case-management practices and readiness of the health facilities and health workers to implement a new malaria case-management strategy. Methods A cross-sectional, cluster sample survey was undertaken at public health facilities in 15 states of Sudan. Data were collected using quality-of-care assessment methods. The main outcomes were the proportions of facilities with ACTs and malaria diagnostics; proportions of health workers exposed to malaria related health systems support activities; and composite and individual indicators of case-management practices for febrile outpatients stratified by age, availability of ACTs and diagnostics, use of malaria diagnostics, and test result. Results We evaluated 244 facilities, 294 health workers and 1,643 consultations for febrile outpatients (425 < 5 years and 1,218 ≥ 5 years). Health facility and health worker readiness was variable: chloroquine was available at only 5% of facilities, 73% stocked recommended artesunate and sulfadoxine/pyrimethamine (AS+SP), 51% had the capacity to perform parasitological diagnosis, 53% of health workers had received in-service training on ACTs, 24% were trained in the use of malaria Rapid Diagnostic Tests, and 19% had received a supervisory visit including malaria case-management. At all health facilities 46% of febrile patients were parasitologically tested and 35% of patients were both, tested and treated according to test result. At facilities where AS+SP and malaria diagnostics were available 66% of febrile patients were tested and 51% were both, tested and treated according to test result. Among test positive patients 64% were treated with AS+SP but 24% were treated with artemether monotherapy. Among test negative patients only 17% of patients were treated for malaria. The majority of ACT dispensing and counseling practices were suboptimal. Conclusions Five years following change of the policy from chloroquine to ACTs and 3 years before the end of the new malaria strategic plan chloroquine was successfully phased out from public facilities in Sudan, however, an important gap remained in the availability of ACTs, diagnostic capacities and coverage with malaria case-management activities. The national scale-up of diagnostics, using the findings of this survey as well as future qualitative research, should present an opportunity not only to expand existing testing capacities but also to implement effective support interventions to bridge the health systems gaps and support corrective case-management measures, including the discontinuation of artemether monotherapy treatment.

Objective To evaluate treatment practices for uncomplicated malaria after the policy change from chloroquine to sulfadoxine-pyrimethamine and to artemether-lumefantrine in Zambia. Design Cross sectional survey. Setting Outpatient departments of all government and mission facilities in four districts in Zambia. Participants 944 children with uncomplicated malaria seen by 103 health workers at 94 health facilities. Main outcome measures Antimalarial prescriptions in accordance with national guidelines and influence of factors on health workers9 decision to prescribeartemether-lumefantrine. Results Artemether-lumefantrine, sulfadoxine-pyrimethamine, and chloroquine were available, respectively, at 48 (51%), 94 (100%), and 71 (76%) of the 94 facilities. Of 944 children with uncomplicated malaria, only one child (0.1%) received chloroquine. Among children weighing less than 10 kg, sulfadoxine-pyrimethamine was commonly prescribed in accordance with guidelines (439/550, 79.8%). Among the children weighing 10 kg or more, sulfadoxine-pyrimethamine was commonly prescribed (266/394, 68%), whereas recommended artemether-lumefantrine was prescribed for only 42/394 (11%) children. Among children weighing 10 kg or more seen at facilities where artemether-lumefantrine was available, the same pattern was observed: artemether-lumefantrine was prescribed for only 42/192 (22%) children and sulfadoxine-pyrimethamine remained the drug of choice (103/192, 54%). Programmatic activities such as in-service training and provision of job aids did not seem to influence the prescribing of artemether with lumefantrine. Conclusion Although the use of chloroquine for uncomplicated malaria was succesfully discontinued in Zambia, the change of drug policy towards artemether-lumefantrine does not necessarily translate into adequate use of this drug at the point of care.

Background Following the development of resistance to anti-malarial mono-therapies, malaria endemic countries in Africa now use artemisinin-based combination therapy (ACT) as recommended first-line treatment for uncomplicated malaria. Patients' adherence to ACT is an important factor to ensure treatment efficacy, as well as to reduce the likelihood of parasite resistance to these drugs. This study reports adherence to a specific ACT, artemether-lumefantrine (AL), under conditions of routine clinical practice in Kenya. Method The study was undertaken in Garissa and Bunyala districts among outpatients of five government health facilities. Patients treated with AL were visited at home four days after having been prescribed the drug. Respondents (patients ≥ 15 years and caregivers of patients < 15 years) were interviewed using a standardized questionnaire, AL blister packs were physically inspected and the adherence status of patients was then recorded. Multivariate logistic regression modelling was used to determine predictors of adherence. Results Of the 918 patients included in the study, 588 (64.1%) were 'probably adherent', 291 (31.7%) were 'definitely non-adherent' and 39 (4.2%) were 'probably non-adherent'. Six factors were found to be significant predictors of adherence: patient knowledge of the ACT dosing regimen (odds ratio (OR) = 1.76; 95% CI = 1.32-2.35), patient age (OR = 1.65; 95% CI = 1.02-1.85), respondent age (OR = 1.37; 95% CI = 1.10-2.48), whether a respondent had seen AL before (OR = 1.46; 95% CI = 1.08-1.98), whether a patient had reported dislikes to AL (OR = 0.62 95% CI = 0.47-0.82) and whether a respondent had waited more than 24 hours to seek treatment (OR = 0.73; 95% CI = 0.54-0.99). Conclusion Overall, adherence to AL was found to be low in both Garissa and Bunyala districts, with patient knowledge of the AL dosing regimen found to be the strongest predictor of adherence. Interventions aimed at increasing community awareness of the AL dosing regimen, use of child friendly formulations and improving health workers' prescribing practices are likely to ensure higher adherence to AL and eventual treatment success.

Background Change of Kenyan treatment policy for uncomplicated malaria from sulphadoxine-pyrimethamine to artemether-lumefantrine (AL) was accompanied by revised recommendations promoting presumptive malaria diagnosis in young children and, wherever possible, parasitological diagnosis and adherence to test results in older children and adults. Three years after the policy implementation, health workers' adherence to malaria diagnosis and treatment recommendations was evaluated. Methods A national cross-sectional, cluster sample survey was undertaken at public health facilities. Data were collected using quality-of-care assessment methods. Analysis was restricted to facilities with AL in stock. Main outcomes were diagnosis and treatment practices for febrile outpatients stratified by age, availability of diagnostics, use of malaria diagnostic tests, and test result. Results The analysis included 1,096 febrile patients (567 aged Conclusions Overall, malaria testing rates were low and, despite different age-specific recommendations, only moderate differences in testing rates between the two age groups were observed at facilities with available diagnostics. In both age groups, AL use prevailed, and prior ineffective anti-malarial treatments were nearly non-existent. The large majority of test positive patients were treated with recommended AL; however, anti-malarial treatments for test negative patients were widespread, with AL being the dominant choice. Recent change of diagnostic policy to universal testing in Kenya is an opportunity to improve upon the quality of malaria case management. This will be, however, dependent upon the delivery of a comprehensive case management package including large scale deployment of diagnostics, good quality of training, post-training follow-up, structured supervisory visits, and more intense monitoring.

Background Zambia was the first African country to change national antimalarial treatment policy to artemisinin-based combination therapy – artemether-lumefantrine. An evaluation during the early implementation phase revealed low readiness of health facilities and health workers to deliver artemether-lumefantrine, and worryingly suboptimal treatment practices. Improvements in the case-management of uncomplicated malaria two years after the initial evaluation and three years after the change of policy in Zambia are reported. Methods Data collected during the health facility surveys undertaken in 2004 and 2006 at all outpatient departments of government and mission facilities in four Zambian districts were analysed. The surveys were cross-sectional, using a range of quality of care assessment methods. The main outcome measures were changes in health facility and health worker readiness to deliver artemether-lumefantrine, and changes in case-management practices for children below five years of age presenting with uncomplicated malaria as defined by national guidelines. Results In 2004, 94 health facilities, 103 health workers and 944 consultations for children with uncomplicated malaria were evaluated. In 2006, 104 facilities, 135 health workers and 1125 consultations were evaluated using the same criteria of selection. Health facility and health worker readiness improved from 2004 to 2006: availability of artemether-lumefantrine from 51% (48/94) to 60% (62/104), presence of artemether-lumefantrine dosage wall charts from 20% (19/94) to 75% (78/104), possession of guidelines from 58% (60/103) to 92% (124/135), and provision of in-service training from 25% (26/103) to 41% (55/135). The proportions of children with uncomplicated malaria treated with artemether-lumefantrine also increased from 2004 to 2006: from 1% (6/527) to 27% (149/552) in children weighing 5 to 9 kg, and from 11% (42/394) to 42% (231/547) in children weighing 10 kg or more. In both weight groups and both years, 22% (441/2020) of children with uncomplicated malaria were not prescribed any antimalarial drug. Conclusion Although significant improvements in malaria case-management have occurred over two years in Zambia, the quality of treatment provided at the point of care is not yet optimal. Strengthening weak health systems and improving the delivery of effective interventions should remain high priority in all countries implementing new treatment policies for malaria.