Changes in health workers' malaria diagnosis and treatment practices in Kenya
Changes in health workers' malaria diagnosis and treatment practices in Kenya
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DOI：
10.1186/1475-2875-10-1
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发表时间：
2011-01-07
期刊：
影响因子：
3
通讯作者：
Zurovac, Dejan
中科院分区：
文献类型：
--
作者：
Juma, Elizabeth;Zurovac, Dejan
背景：肯尼亚对非复杂性疟疾的治疗政策从磺胺嘧啶-乙胺嘧啶改为蒿甲醚-氨苯曲明（AL），同时修订了建议，促进幼儿的推定疟疾诊断，并在可能的情况下促进较大儿童和成人的寄生虫学诊断和坚持检测结果。政策实施三年后，对卫生工作者遵守疟疾诊断和治疗建议的情况进行了评估。方法：对全国公共卫生机构进行横断面整群抽样调查。使用护理质量评估方法收集数据。分析仅限于有AL库存的工厂。主要结局是按年龄分层的发热门诊患者的诊断和治疗做法、诊断的可得性、疟疾诊断检测的使用和检测结果。结果：共纳入88家具备疟疾诊断能力机构的1096例发热患者（567例< 5岁，529例< bb1 = 5岁）和71家不具备疟疾诊断能力机构的880例发热患者（407例< 5岁，473例< bb1 = 5岁）。在所有设施中，19.8%的幼儿和28.7%的5岁患者接受了检测，而在有诊断的设施中，每个年龄组分别接受了33.5%和53.7%的检测。总体而言，63.6%的< 5岁儿童和65.0%的bb0 = 5岁患者使用AL，而仅2.0%的儿童和3.9%的大龄儿童和成人使用阿莫地喹或磺胺嘧啶-乙胺嘧啶单药。在< 5岁的儿童中，74.7%的检测阳性、40.4%的检测阴性和60.7%的未进行检测的患者开了AL处方。在bb0 = 5岁的患者中，86.7%的检测阳性患者、32.8%的检测阴性患者和58.0%的未进行检测的患者开了AL处方。56.6%的儿童和50.4%的bb0 = 5岁阴性患者至少开过一种抗疟疾药物。结论：总体而言，疟疾检测率很低，尽管针对不同年龄的建议不同，但在具有可用诊断方法的设施中，观察到两个年龄组之间的检测率仅存在适度差异。在这两个年龄组中，AL的使用普遍存在，而以前无效的抗疟疾治疗几乎不存在。绝大多数检测阳性患者接受了推荐的AL治疗；然而，对检测阴性患者的抗疟疾治疗很普遍，AL是主要的选择。肯尼亚最近将诊断政策改为普遍检测，这是提高疟疾病例管理质量的一个机会。然而，这将取决于提供全面的病例管理一揽子方案，包括大规模部署诊断方法、高质量的培训、培训后后续行动、有组织的监督访问和更密切的监测。
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 < 5 years and 529 aged >= 5 years) at 88 facilities with malaria diagnostics, and 880 febrile patients (407 aged < 5 years and 473 aged >= 5 years) at 71 facilities without malaria diagnostic capacity. At all facilities, 19.8% of young children and 28.7% of patients aged >= 5 years were tested, while at facilities with diagnostics, 33.5% and 53.7% were respectively tested in each age group. Overall, AL was prescribed for 63.6% of children aged < 5 years and for 65.0% of patients aged >= 5 years, while amodiaquine or sulphadoxine-pyrimethamine monotherapies were prescribed for only 2.0% of children and 3.9% of older children and adults. In children aged < 5 years, AL was prescribed for 74.7% of test positive, 40.4% of test negative and 60.7% of patients without test performed. In patients aged >= 5 years, AL was prescribed for 86.7% of test positive, 32.8% of test negative and 58.0% of patients without test performed. At least one anti-malarial treatment was prescribed for 56.6% of children and 50.4% of patients aged >= 5 years with a negative test result.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.