Developing countries subcommittee of the clinical pharmacology division : The medicines utilization research in Africa (MURIA) group and IUOHAR co-organized a workshop in botswana for the promotion of rational use of medicines

The improper use of medicines is a major cause of poor therapeutic effect as well as adverse drug reactions, and has considerable financial consequences (1-4). In the present era of global economic recession, there is a need for the judicious use of resources to benefit all citizens in developing countries. Therefore, the promotion of the Rational Use of Medicines (RUM) should be a healthcare priority in African countries. Still, there is limited information available on how appropriately medicines are prescribed and used in Africa (5)

Impact of laboratory diagnosis for improving the management of uncomplicated malaria at peripheral health care settings in Coast region, Tanzania

Malaria is a disease caused by parasites of the genus Plasmodium. Five species cause human disease, but the most common in tropical areas, and the cause of severe disease is Plasmodium falciparum. Control of morbidity and mortality is mainly achieved through appropriate malaria case management, which includes prompt diagnosis and treatment with effective antimalarial drugs. While definitive diagnosis of malaria is made by demonstration of parasites in the patient blood through microscopic examination of giemsa stained blood smears, in most clinical settings in Africa, diagnosis is limited by lack of facilities and personnel. The availability of malaria rapid diagnostic tests (RDTs) offers an opportunity to extend diagnostic services to areas previously not covered by conventional microscopy services. Two intervention trials were conducted, one at primary health care (PHC) facilities using microscopy, and the other at community level, through community health workers (CHWs), using rapid diagnostic tests (RDTs) for malaria diagnosis, and the impact of the interventions on antimalarial drugs prescription practices, antibiotic prescriptions and health outcome was investigated (Study I and II). A descriptive, cross sectional study was conducted to assess health workers diagnostic and prescription practices following introduction of RDTs for universal testing of malaria at PHC level in Tanzania (Study III). An exploratory study was also carried out to assess the usefulness of Histidine rich protein 2 (HRP2) and lactate dehydrogenase (LDH) based RDTs for treatment monitoring and detection of recurrent infection following artemisinin-based combination therapy (ACT) during a 42 day follow up period (Study IV). The use of parasite-based diagnostics significantly reduced antimalarial prescriptions at health facility and community level without affecting the health outcome of patients not treated with antimalarials (study I and II). The prescriptions of antimalarial drugs were 61% at intervention health facilities, whereas in the clinical and control arms the prescription rates remained high, 95% and 99%, respectively (study I). Similarly, 53% of patients tested with RDT at community level were provided antimalarial drugs compared to 96% among patients treated based on clinical diagnosis only (Study II). The availability of parasite-based diagnostics and antimalarial drugs within the community allowed early access to treatment as 67% of patients consulted CHWs within 24 hours of onset of fever (Study II). The rate of non adherence to test results was low in both study I and II. Study III observed low use of parasite-based diagnostics among fever patients (63%), low non adherence to test results (14%), substantial prescription of antimalarial drugs to non-tested patients (28%) and high prescriptions of antibiotics among patients with negative RDT results (81%), as well as frequent stock outs of both RDTs and ACTs. HRP2 based tests performed poorly when compared to LDH based tests for treatment monitoring, with median clearance times of 28 (7-42) and 7 (2-14) days respectively (Study IV). HRP2 based tests were unable to detect 8/10 recurrent infections during follow up compared to only two recurrent infections missed by LDH based tests. These studies lead to a conclusion that the availability of parasite-based diagnostics helps to restrict treatment with antimalarial drugs to patients with malaria. However, non adherence to malaria test results could undermine the potential of RDTs, and in-depth studies should be conducted to identify its causes. As the relative contribution of malaria as a cause of fever is declining in Tanzania, there is need to improve the overall management of non-malarial fevers. The longer the persistence of HRP2 antigen in blood makes HRP2 based tests not suitable for treatment monitoring and detection of recurrent infection calling for alternative diagnostic strategies for this purpose

PRESCRIBING HABITS IN CHURCH-OWNED PRIMARY HEALTH CARE FACILITIES IN DAR ES SALAAM AND OTHER TANZANIAN COAST REGIONS

Objective: To assess prescribing practice of Primary Health Care (PHC) workers in churchowned health care facilities using WHO drug use indicators.Design: Across-!iectional study in which twenty primary health care facilities were randomlyselected. Prescribing indicators were obtained by analysing outpatient records retrospectivelyfor the past 14 months between January 1997 and February 1998. This period was chosenbecause of compete records of outpatient attendances. Patient care and facility indicatorswere recorded prospectively during the study period.Setting: The study was conducted in the Coast and Dar es Salaam regions of Tanzania. Sixdistricts were randomly selected from both regions. The selected districts included llala,Temeke and Kinondoni in Dar es Salaam, Kibiti, Bagamoyo and Kisarawe in Coast region.Subjects/materiaCs: Twenty primary health care facilities were randomly selected from thechosen districts. Patient registers were collected and patients' characteristics including age,sex, diagnosis, ;and drugs prescribed for the period January 1997 to February 1998 wererecorded on data collection forms. Patient care indicators were measured by recordingconsultation tirne, dispensing time, per cent of drugs actually dispensed and adequatelylabelled whereas patients' knowledge of correct drug dosage was obtained using exitinterviews. Verification of facility indicators was done by direct observation.Results: The average number of drugs per prescription was 2.3 (range 1.8 - 2.8). Genericprescribing prevailed with a mean of 75.W0 of all drugs. Antibiotic and injection encounters perprescription was 35.4 and 19%, respectively. Most drugs were prescribed according to theessential drug Ikt of Tanzania (NEDLIT). Patient's average consultation time was 3.6 minuteswhereas average dispensing time was 39.9 seconds. On average, 87% of all drugs dispensed wereadequately labelled and patients' knowledge of correct dose was adequate. All facilities possesseddrugs for treating important illnesses, all had reference educational materials.Conclusion: The study shows that there is an overuse of injections 19% + 1.7 (range 0-73% )compared to the recommended figure of 15%. The use of antibiotics appears appropriatewhen compared with the morbidity patterns in the study areas. A focus group discussion withprescribers in these facilities to address the question of overuse of injections is needed in orderto plan an appropriate intervention