Access to primaquine in the last mile: challenges at the service delivery points in pre-elimination era, Myanmar

Abstract

BackgroundAlongside monitoring of the disease burden, the successful move towards malaria elimination relies on the readiness of the health care delivery system. However, there is a lack of evidence in the gap of existing National Guidelines and access to low dose primaquine in real practice under varying degrees of antimalarial resistance in the pre-elimination phase in Myanmar. Therefore, this study addressed the essential information from the service delivery points (SDPs) of public and private sectors on the availability and the use of primaquine in both supply and demand side. Concomitantly, the study aimed to underscore challenges in health system infrastructure to promote the sustained flow in rolling out primaquine in line with National Guidelines for malaria elimination.MethodsA cross-sectional study conducted from September 2017 to February 2018 included six townships of three states/regions. The team used an observation checklist for documenting primaquine supplies at SDPs. Semi-structured interviews, key informant, and in-depth interviews focused both public and private sectors including staff from the Vector-Borne Diseases Control (VBDC) teams in each state/region and rural health centers (n = 25), those from the non-governmental organizations (NGOs), general practitioners and drug sellers (n = 11), and recently infected malaria patients (n = 11). Triangulation of quantitative and qualitative data provided meaningful interpretations.ResultsPublic sector staff reported an adequate stock of primaquine, but it was unavailable at the general practitioners’ clinics without any connection to NGOs and also at the unlicensed drug shops. Health care providers of the public sector experienced challenges in poor compliance of malaria patients to primaquine treatment in conjunction with an artemisinin-based combination therapy, loss-to-follow-ups especially in conflict areas, and delays in timely substitution of new batches of primaquine. Respondents from the private sector demanded for the refresher training course on updated antimalarial treatment guidelines.ConclusionMonitoring compliance and safety of primaquine treatment was found as a barrier especially among mobile migrant workers and those who were in conflict areas. An alternative strategy by the NMCP could enable to prevent the underutilization of primaquine in vivax malaria to reach the malaria elimination targets.

Towards the elimination of Plasmodium vivax malaria: Implementing the radical cure

“…Major barriers to the roll out of radical cure at community level are concerns over the capacity and training needs for correct G6PDd testing, adherence to test and treatment algorithms, as well as the capacity to detect adverse events, stop further doses of PQ and provide blood transfusions, when needed. Operational research in this area has largely focused on G6PD testing, including user-friendliness, acceptability, feasibly, training needs, and procurement issues, but less on broader health system issues or actual delivery mechanism [81][82][83]. It remains to be explored what delivery model is best suited to provide safe radical cure and what level of training and supervision might be required.…”

The acceptability of targeted mass treatment with primaquine for local elimination of vivax malaria in a northern Myanmar township: a mixed-methods study

“…Full compliance with the treatment is necessary for achieving radical cure by clearing both blood- and liver-stage P. vivax parasites [ 11 – 13 ]. However, poor compliance among P. vivax patients and relatively high numbers of patients lost to follow-up regarding completing the full PQ course were reported [ 14 ]. The underlying reasons for not completing the 14-day course included complacency among patients after resolution of the symptoms, which often occurs before completing the full course, and simply forgetting to take the medication or carry the medication to the workplace [ 14 ].…”

Do we need to go further to train healthcare providers in the targeted regions for malaria elimination in Myanmar? A mixed-methods study

“…Challenges perceived for malaria elimination were distinct in conflict-affected areas as well as in areas of high population mobility and this might affect foci classification such as active foci, residual non-active foci and clear foci. Moreover, the provision of health education to community members could not be carried out adequately in these areas, as found in other studies in Myanmar and elsewhere [9,10,18]. The findings indicate a window of opportunity to strengthen the coordinated efforts between the NMCP and partner organizations for future training, refresher training and continuing technical support and to further promote community engagement in malaria elimination.…”