Patient-, health worker-, and health facility-level determinants of correct malaria case management at publicly funded health facilities in Malawi: results from a nationally representative health facility survey

BACKGROUND: Prompt and effective case management is needed to reduce malaria morbidity and mortality. However, malaria diagnosis and treatment is a multistep process that remains problematic in many settings, resulting in missed opportunities for effective treatment as well as overtreatment of patients without malaria. METHODS: Prior to the widespread roll-out of malaria rapid diagnostic tests (RDTs) in late 2011, a national, cross-sectional, complex-sample, health facility survey was conducted in Malawi to assess patient-, health worker-, and health facility-level factors associated with malaria case management quality using multivariate Poisson regression models. RESULTS: Among the 2,019 patients surveyed, 34% had confirmed malaria defined as presence of fever and parasitaemia on a reference blood smear. Sixty-seven per cent of patients with confirmed malaria were correctly prescribed the first-line anti-malarial, with most cases of incorrect treatment due to missed diagnosis; 31% of patients without confirmed malaria were overtreated with an anti-malarial. More than one-quarter of patients were not assessed for fever or history of fever by health workers. The most important determinants of correct malaria case management were patient-level clinical symptoms, such as spontaneous complaint of fever to health workers, which increased both correct treatment and overtreatment by 72 and 210%, respectively (p < 0.0001). Complaint of cough was associated with a 27% decreased likelihood of correct malaria treatment (p = 0.001). Lower-level cadres of health workers were more likely to prescribe anti-malarials for patients, increasing the likelihood of both correct treatment and overtreatment, but no other health worker or health facility-level factors were significantly associated with case management quality. CONCLUSIONS: Introduction of RDTs holds potential to improve malaria case management in Malawi, but health workers must systematically assess all patients for fever, and then test and treat accordingly, otherwise, malaria control programmes might miss an opportunity to dramatically improve malaria case management, despite better diagnostic tools

Effect of cytomegalovirus infection on breastfeeding transmission of HIV and on the health of infants born to HIV-infected mothers

Cytomegalovirus (CMV) infection can be acquired in utero or postnatally through horizontal transmission and breastfeeding. The effect of postnatal CMV infection on postnatal HIV transmission is unknown

Evaluating Nurses' Implementation of an Infant-Feeding Counseling Protocol for HIV-Infected Mothers: The Ban Study in Lilongwe, Malawi

A process evaluation of nurses’ implementation of an infant-feeding counseling protocol was conducted for the Breastfeeding, Antiretroviral and Nutrition (BAN) Study, a prevention of mother-to-child transmission of HIV clinical trial in Lilongwe, Malawi. Six trained nurses counseled HIV-infected mothers to exclusively breastfeed for 24 weeks postpartum and to stop breastfeeding within an additional four weeks. Implementation data were collected via direct observations of 123 infant feeding counseling sessions (30 antenatal and 93 postnatal) and interviews with each nurse. Analysis included calculating a percent adherence to checklists and conducting a content analysis for the observation and interview data. Nurses were implementing the protocol at an average adherence level of 90% or above. Although not detailed in the protocol, nurses appropriately counseled mothers on their actual or intended formula milk usage after weaning. Results indicate that nurses implemented the protocol as designed. Results will help to interpret the BAN Study’s outcomes

Adherence to extended postpartum antiretrovirals is associated with decreased breast milk HIV-1 transmission

Estimate association between postpartum antiretroviral adherence and breastmilk HIV-1 transmissio

Plasma Micronutrient Concentrations Are Altered by Antiretroviral Therapy and Lipid-Based Nutrient Supplements in Lactating HIV-Infected Malawian Women

Background: Little is known about the influence of antiretroviral therapy with or without micronutrient supplementation on the micronutrient concentrations of HIV-infected lactating women in resource-constrained settings

Quality of Malaria Case Management in Malawi: Results from a Nationally Representative Health Facility Survey

<div><p>Background</p><p>Malaria is endemic throughout Malawi, but little is known about quality of malaria case management at publicly-funded health facilities, which are the major source of care for febrile patients.</p><p>Methods</p><p>In April–May 2011, we conducted a nationwide, geographically-stratified health facility survey to assess the quality of outpatient malaria diagnosis and treatment. We enrolled patients presenting for care and conducted exit interviews and re-examinations, including reference blood smears. Moreover, we assessed health worker readiness (e.g., training, supervision) and health facility capacity (e.g. availability of diagnostics and antimalarials) to provide malaria case management. All analyses accounted for clustering and unequal selection probabilities. We also used survey weights to produce estimates of national caseloads.</p><p>Results</p><p>At the 107 facilities surveyed, most of the 136 health workers interviewed (83%) had received training on malaria case management. However, only 24% of facilities had functional microscopy, 15% lacked a thermometer, and 19% did not have the first-line artemisinin-based combination therapy (ACT), artemether-lumefantrine, in stock. Of 2,019 participating patients, 34% had clinical malaria (measured fever or self-reported history of fever plus a positive reference blood smear). Only 67% (95% confidence interval (CI): 59%, 76%) of patients with malaria were correctly prescribed an ACT, primarily due to missed malaria diagnosis. Among patients without clinical malaria, 31% (95% CI: 24%, 39%) were prescribed an ACT. By our estimates, 1.5 million of the 4.4 million malaria patients seen in public facilities annually did not receive correct treatment, and 2.7 million patients without clinical malaria were inappropriately given an ACT.</p><p>Conclusions</p><p>Malawi has a high burden of uncomplicated malaria but nearly one-third of all patients receive incorrect malaria treatment, including under- and over-treatment. To improve malaria case management, facilities must at minimum have basic case management tools, and health worker performance in diagnosing malaria must be improved.</p></div

Estimated national annual outpatient caseloads and malaria commodity needs at publically-funded health facilities in Malawi, 2011.

<p>Note: Estimates by age may not sum to total due to rounding. Estimates may overestimate the number of outpatients with malaria annually in Malawi, as the survey was conducted during the high transmission season, and annualization of malaria caseload was not adjusted for seasonality, given the lack of necessary data required to do this.</p><p>*Assuming one RDT needed for each febrile patient, not accounting for buffer stocks, etc.</p><p>**Actual number needed for RDTs and AL courses, assuming ACTs are used only for patients with malaria after they receive a diagnostic test and not accounting for buffer stocks, lost materials, expiring stocks, etc. Estimate is based on diagnosis of patients by expert microscopy, and use of RDTs at facilities may require additional ACTs, given the higher test positivity rate of RDTs compared to microscopy. In addition to ACTs, 68,705 courses of quinine are also needed for the 0.8% of malaria patients <5 kg and the0.4% who are pregnant women in their first trimester.</p

Malaria diagnosis and treatment among outpatients attending publically-funded health facilities in Malawi, 2011.

<p>*Includes positive responses for: 1) patient says illness involved a fever, 2) patient spontaneously mentioned fever complaint to health worker, 3) patient reported a symptom of fever to surveyor when probed, or temperature on re-examination was > = 37.5°C.</p><p>**If patient does not spontaneously report to health worker.</p>¶<p>Spontaneously reported by patient to health worker, reported by patient when prompted, or temperature ≥37.5°C according to health worker’s recorded temperature.</p>†<p>ACT refers to ACT (most patients) or oral quinine for pregnant women in their first trimester or patients weighing less than 5 kg.</p><p>Note: Numbers in parentheses are based on 25–49 unweighted cases.</p>∧<p>Chi-squared test with Rao-Scott correction unable to be performed to be performed due to stratum with single sampling unit.</p