Rate of co-infection with malaria parasites and Salmonella typhi in Zaria, Kaduna State, Nigeria

Background: Typhoid and malaria co-infection is a major public health problem in many developing countries. Most of the co-infections treated are based on methods of diagnosis plagued with assumptions which possibly exaggerate the situation. Thus the aim of this work was to investigate the rate of co-infection with respect to the use of Widal test and blood culture methods for diagnosing typhoid fever in Zaria, Nigeria. Method: A total of 218 blood samples were collected from patients with a clinical suspicion of malaria and typhoid fever and examined for malaria parasites and S. typhi infection. Results: Sixty samples were positive for malaria parasites, 22 of which were positive for typhoid by the Widal test and only one by the culture method. The rate of co-infection was significantly high when typhoid was diagnosed by Widal (10.1%) than by blood culture method (0.5%). A correlation analysis showed no specific relationship between malaria parasite load and the level of Salmonella antibody titres in malaria patients (r = 0.05 and 0.08 for somatic and flagella antigens of S. typhi respectively). Conclusion: The incidence of typhoid and malaria co-infection will greatly reduce if the diagnosis of typhoid fever in malaria endemic areas such as Zaria is bases on blood culture. Keywords: Malaria, typhoid fever, co-infection Annals of African Medicine Vol.2(2) 2003: 64-6

Rate of Co-infection with Malaria Parasites and Salmonella Typhi in Zaria, Kaduna State, Nigeria

Background: Typhoid and malaria co-infection is a major public health problem in many developing countries. Most of the co-infections treated are based on methods of diagnosis plagued with assumptions which possibly exaggerate the situation. Thus the aim of this work was to investigate the rate of co-infection with respect to the use of Widal test and blood culture methods for diagnosing typhoid fever in Zaria, Nigeria. Method: A total of 218 blood samples were collected from patients with a clinical suspicion of malaria and typhoid fever and examined for malaria parasites and S. typhi infection. Results: Sixty samples were positive for malaria parasites, 22 of which were positive for typhoid by the Widal test and only one by the culture method. The rate of co-infection was significantly high when typhoid was diagnosed by Widal (10.1%) than by blood culture method (0.5%). A correlation analysis showed no specific relationship between malaria parasite load and the level of Salmonella antibody titres in malaria patients (r = 0.05 and 0.08 for somatic and flagella antigens of S. typhi respectively). Conclusion: The incidence of typhoid and malaria co-infection will greatly reduce if the diagnosis of typhoid fever in malaria endemic areas such as Zaria is bases on blood culture

Basic or enhanced clinician training to improve adherence to malaria treatment guidelines: a cluster-randomised trial in two areas of Cameroon

Background The scale-up of malaria rapid diagnostic tests (RDTs) is intended to improve case management of fever and targeting of artemisinin-based combination therapy. Habitual presumptive treatment has hampered these intentions, suggesting a need for strategies to support behaviour change. We aimed to assess the introduction of RDTs when packaged with basic or enhanced clinician training interventions in Cameroon. Methods We did a three-arm, stratifi ed, cluster-randomised trial at 46 public and mission health facilities at two study sites in Cameroon to compare three approaches to malaria diagnosis. Facilities were randomly assigned by a computer program in a 9:19:19 ratio to current practice with microscopy (widely available, used as a control group); RDTs with a basic (1 day) clinician training intervention; or RDTs with an enhanced (3 days) clinician training intervention. Patients (or their carers) and fi eldworkers who administered surveys to obtain outcome data were masked to study group assignment. The primary outcome was the proportion of patients treated in accordance with WHO malaria treatment guidelines, which is a composite indicator of whether patients were tested for malaria and given appropriate treatment consistent with the test result. All analyses were by intention to treat. This study is registered at ClinicalTrials. gov, number NCT01350752. Findings The study took place between June 7 and Dec 14, 2011. The analysis included 681 patients from nine facilities in the control group, 1632 patients from 18 facilities in the basic-training group, and 1669 from 19 facilities in the enhanced-training group. The proportion of patients treated in accordance with malaria guidelines did not improve with either intervention; the adjusted risk ratio (RR) for basic training compared with control was 1·04 (95% CI 0·53–2·07; p=0·90), and for enhanced training compared with control was 1·17 (0·61–2·25; p=0·62). Inappropriate use of antimalarial drugs after a negative test was reduced from 84% (201/239) in the control group to 52% (413/796) in the basic-training group (unadjusted RR 0·63, 0·28–1·43; p=0·25) and to 31% (232/759) in the enhanced-training group (0·29, 0·11–0·77; p=0·02). Interpretation Enhanced clinician training, designed to translate knowledge into prescribing practice and improve quality of care, has the potential to halve overtreatment in public and mission health facilities in Cameroon. Basic training is unlikely to be suffi cient to support the behaviour change required for the introduction of RDTs

Designing and implementing interventions to change clinicians' practice in the management of uncomplicated malaria: lessons from Cameroon.

BACKGROUND: Effective case management of uncomplicated malaria is a fundamental pillar of malaria control. Little is known about the various steps in designing interventions to accompany the roll out of rapid diagnostic tests (RDTs) and artemisinin-based combination therapy (ACT). This study documents the process of designing and implementing interventions to change clinicians' practice in the management of uncomplicated malaria. METHODS: A literature review combined with formative quantitative and qualitative research were carried out to determine patterns of malaria diagnosis and treatment and to understand how malaria and its treatment are enacted by clinicians. These findings were used, alongside a comprehensive review of previous interventions, to identify possible strategies for changing the behaviour of clinicians when diagnosing and treating uncomplicated malaria. These strategies were discussed with ministry of health representatives and other stakeholders. Two intervention packages - a basic and an enhanced training were outlined, together with logic model to show how each was hypothesized to increase testing for malaria, improve adherence to test results and increase appropriate use of ACT. The basic training targeted clinicians' knowledge of malaria diagnosis, rapid diagnostic testing and malaria treatment. The enhanced training included additional modules on adapting to change, professionalism and communicating effectively. Modules were delivered using small-group work, card games, drama and role play. Interventions were piloted, adapted and trainers were trained before final implementation. RESULTS: Ninety-six clinicians from 37 health facilities in Bamenda and Yaounde sites attended either 1-day basic or 3-day enhanced training. The trained clinicians then trained 632 of their peers at their health facilities. Evaluation of the training revealed that 68% of participants receiving the basic and 92% of those receiving the enhanced training strongly agreed that it is not appropriate to prescribe anti-malarials to a patient if they have a negative RDT result. CONCLUSION: Formative research was an important first step, and it was valuable to engage stakeholders early in the process. A logic model and literature reviews were useful to identify key elements and mechanisms for behaviour change intervention. An iterative process with feedback loops allowed appropriate development and implementation of the intervention. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01350752

A cost-effectiveness analysis of provider interventions to improve health worker practice in providing treatment for uncomplicated malaria in Cameroon: a study protocol for a randomized controlled trial

BACKGROUND: Governments and donors all over Africa are searching for sustainable, affordable and cost-effective ways to improve the quality of malaria case management. Widespread deficiencies have been reported in the prescribing and counselling practices of health care providers treating febrile patients in both public and private health facilities. Cameroon is no exception with low levels of adherence to national guidelines, the frequent selection of non-recommended antimalarials and the use of incorrect dosages. This study evaluates the effectiveness and cost-effectiveness of introducing two different provider training packages, alongside rapid diagnostic tests (RDTs), designed to equip providers with the knowledge and practical skills needed to effectively diagnose and treat febrile patients. The overall aim is to target antimalarial treatment better and to facilitate optimal use of malaria treatment guidelines. METHODS/DESIGN: A 3-arm stratified, cluster randomized trial will be conducted to assess whether introducing RDTs with provider training (basic or enhanced) is more cost-effective than current practice without RDTs, and whether there is a difference in the cost effectiveness of the provider training interventions. The primary outcome is the proportion of patients attending facilities that report a fever or suspected malaria and receive treatment according to malaria guidelines. This will be measured by surveying patients (or caregivers) as they exit public and mission health facilities. Cost-effectiveness will be presented in terms of the primary outcome and a range of secondary outcomes, including changes in provider knowledge. Costs will be estimated from a societal and provider perspective using standard economic evaluation methodologies. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00981877

Life cycle, population dynamics and schistosome infection in Bulinus spp from a crater lake in the South West Province, Cameroon

No Abstract. JCAS Vol. 6 (2) 2006: pp. 99-10