Key factors predicting suspected severe malaria case management and health outcomes: an operational study in the Democratic Republic of the Congo

Abstract

Background Evidence suggests that pre-referral Rectal Artesunate (RAS) can be a life-saving intervention for severe malaria in remote settings in Africa. Recognition of danger signs indicative of severe malaria is critical for prompt and appropriate case management. Methods This was an observational study conducted in three Health Zones of the Democratic Republic of the Congo to determine the distribution of dangers signs for severe malaria and assess their impact on RAS use, referral completion, injectable treatment and ACT provision, and health outcomes including death. An individual-level analysis was carried out, using multilevel-mixed effects logistic regression models. Severely ill febrile children < 5 years seeking care from community-based healthcare providers were recruited into a patient surveillance system based on the presence of key danger signs. Clinical and case management data were collected comprehensively over a 28 days period. Treatment seeking was elicited and health outcomes assessed during 28 days home visits. Results Overall, 66.4% of patients had iCCM general danger signs. Age of 2–5 years and iCCM general danger signs predicted RAS use (aOR = 2.77, 95% CI 2.04–3.77). RAS administration positively affected referral completion (aOR = 0.63, 95% CI 0.44–0.92). After RAS rollout, 161 children died (case fatality ratio: 7.1%, 95% CI 6.1–8.2). RAS improved the health status of the children on Day 28 (aOR = 0.64, 95% CI 0.45–0.92) and there was a non-significant trend that mortality was higher in children not receiving RAS (aOR = 1.50, 95% CI 0.86–2.60). Full severe malaria treatment at the RHF including injectable anti-malarial and a course of ACT was highly protective against death (aOR = 0.26, 95% CI 0.09–0.79). Conclusions The main findings point towards the fact that danger signs are reasonably well recognized by health provider at the primary care level, and that RAS could influence positively health outcomes of such severe disease episodes and death. Its effectiveness is hampered by the insufficient quality of care at RHF, especially the provision of a full course of ACT following parenteral treatment. These are simple but important findings that requires urgent action by the health system planners and implementers.

Management of children with danger signs in integrated community case management care in rural southwestern Uganda (2014–2018)

“…The iCCM general danger signs of convulsions, vomiting up everything, not breastfeeding, not being able to drink/eat and being very sleepy/unconscious, necessitate immediate referral to a nearby health facility. 19 , 20 In the current study, appropriate management occurs when the CHW identifies a danger sign and refers that case to the nearest health facility.…”

The Phenomenon of the ‘Starry Sky’ on Blood: Lesson Learned From Severe Malaria Falciparum

“…According to the WHO/UNICEF iCCM guidelines cited by Okitawutshu et al [17], there are four general danger signs: convulsions, unusually sleepy or unconscious, not able to drink or feed anything and vomits everything. Timely identification of these non pathognomonic clinical signs actually can lead to a minimalization in malaria patients underwent fatal complications and deaths [14,17].…”

“…Clinical deterioration usually appears 3-7 days after onset of fever [1,4,25]. Complications involve the nervous, respiratory, renal, and/or hematopoietic systems like malignant anemia [5][6][7][8][9][10][16][17]25], Metabolic acidosis [26] and hypoglycemia [27] are also common systemic complications.…”

“…For early diagnosis, it is always cardinal to think malaria in every febrile patient who came to the primary health center, especially when in anamnesis, there was a history of travel to an endemic area [34] or with history of previous attack of malaria [35]. Parasite virulence factor: hyperparasitemia and schizontemia [17,18] Note: It should be remembered that numbers do not always indicate the sequence of events…”

“…It must always be remembered that clinical deterioration among malaria patient can occur rapidly and sometimes suddenly [41]. Moreover, some patients because of nausea or vomiting, induced by either disease or drug(s), are fail to eat independently by mouth and forced doctors to install parenteral treatment required by the patient [17]. Clearly, the step by step patient management will need to be tailor-made and individually adjusted [17], e.g., depending on general conditions and medical complaints, for the particular patient in a particular setting especially where appropriate diagnostic laboratories, sufficient drugs and other supporting facilities may not be accessible [39].…”