Improve adherence to malaria test results to achieve the test and treat policy: A Policy Brief

Summary

Malaria is one of the leading causes of morbidity and mortality in Uganda, with an estimated 6,000 deaths and 16 million cases reported in 2017. In 2011, Uganda changed its policy on management of malaria cases from treating every fever as malaria and adopted WHO’s ‘test and treat’ policy. The new policy recommends that every suspected malaria case is subjected to a parasitological test by either a Rapid Diagnostic Test (RDT) or microscopy prior to treatment with antimalarial drugs.

This is intended to avoid wastage of antimalarial drugs, improve management of febrile illnesses due to causes other than malaria, and possibly prevent the emergence and spread of drug resistance. We analysed data from the Uganda Malaria Surveillance Project (UMSP) routinely collected from outpatient registers in four malaria reference centres in Northern Uganda. We determined health workers’ antimalarial prescription practices to patients who tested negative for malaria during 2015 – 2016.

We found that 19% of patients who tested negative for malaria over this time period were prescribed antimalarial drugs. We recommend studies to determine reasons for health workers’ continued prescription of antimalarial drugs despite negative test results which is against the country’s test and treat policy, and institution of mechanisms to improve adherence to malaria test results.

Introduction

Malaria is one of the leading causes of morbidity and mortality in Uganda, with an estimated 6,000 deaths and 16 million cases reported in 2017 (1) The disease is responsible for about 50% of all out-patient visits, almost a quarter of hospital admissions and up to 15% hospital deaths (2). World Health Organisation (WHO) recommends early, accurate diagnosis and prompt treatment of all positive cases with an effective antimalarial drug for effective dis- ease management which is important for malaria control and elimination programs (3). To ensure that antimalarial drugs are only given to individuals that actually need them, WHO recommends that all suspected malaria cases with febrile illness should be subjected to parasitological testing using either microscopy or RDT.

Treatment should only be given to individuals with positive test results. This will avoid wastage of antimalarial drugs, improve management of febrile illnesses due to causes other than malaria, and reduce the emergence and spread of antimalarial drug resistance which is a major threat to malaria control and elimination efforts globally (4). In 2011, Uganda adopted the WHO recommended test and treat policy for malaria diagnosis and case management in the country (5). Previously malaria case management guidelines recommended treatment of every fever as a possible malaria case. We analysed malaria surveillance data from four reference centres under the UMSP to determine health-worker prescription practices given negative malaria test result.

Methods

We conducted a secondary analysis of malaria data from selected UMSP sites. These data were collected from out-patient registers of Aduku HC IV in Apac District, Anyeke HCIV in Oyam District, Lalogi HC IV in Omoro District, and Amolatar HCIV in Amolatar District for the period 2015-2016. During this period, UMSP reported treatment of patients with negative malaria test results with antimalarial drugs at these sites. We determined the proportion of outpatient visits that are suspected malaria, proportion of suspected malaria cases that are tested for malaria, proportion of patients with negative malaria test results that are prescribed anti- malarial drugs during the study period.

Results

We found out that of the 378,513 patients that reported to the malaria reference centres during this period, 181,798 (48%) were suspect- ed to have malaria. Of the suspected malaria cases, 155104 (85%) received a malaria test. Of the patients that were given a malaria test, 63058 (41%) tested negative. 19% of patients with negative malaria tests were prescribed antimalarial drugs.

Conclusion

There is sub-optimal adherence to the test and treat policy in the four malaria reference centres as evidenced by poor testing rates and prescription practices.

Implications and recommendations

The results show that Uganda’s test and treat policy is yet to be fully implemented with 15% of the suspected malaria cases not accessing a laboratory malaria diagnosis. There is non- adherence to the malaria policy and treatment guidelines as about a fifth of patients with negative malaria test are given antimalarial drugs. Prescription of antimalarial drugs to patients with negative test results has previously been recorded in a study conducted in Uganda (6). In this study, 30% of patients who tested negative for malaria using RDT but were prescribed antimalarial drugs.

Our study indicates persistence of this behaviour amongst health workers though at a slightly lower rate. To further understand and improve implementation of the malaria test and treat policy, we recommend studies to determine reasons for health worker continued prescription of antimalarial drugs despite negative test results. Institute mechanisms to improve adherence to malaria test results at health facilities.

References

1. WHO. World Malaria Report 2017. 2017. 2. MoH. AHSPR FY 2015-16. 2016.
2. WHO Malaria case management: operations manual.
3. Guidelines for the Treatment of Malaria. 2015;Third edition.
4. The Uganda Malaria Reduction Strategic Plan 2014-2020. 2014.
5. Kyabayinze DJ, Asiimwe C, Nakanjako D, Nabakooza J, Counihan H, Tibenderana JK. Use of RDTs to improve malaria diagnosis and fever case management at primary health care facilities in Uganda. Malaria 2010;9(1):200.