Malaria deaths as sentinel events to monitor healthcare delivery and antimalarial drug safety

Abstract

Summaryobjectives To identify case management, health system and antimalarial drug factors contributing to malaria deaths.method We investigated malaria-related deaths in South Africa's three malaria endemic provinces from January 2002 to July 2004. Data from healthcare facility records and a semi-structured interview with patients' contacts were reviewed by an expert panel, which sought to reach consensus on factors contributing to the death. This included possible health system failures, adverse reactions to antimalarials, inappropriate medicine use and failing to respond to treatment.results Approximately 177 of 197 cases met inclusion criteria for the study. Delay in seeking formal health care was significantly longer for patients who sought traditional health care [median 4; interquartile range (IQR) 3-7 days] than for patients who did not (median 3; IQR 1-5 days; P ¼ 0.033).Patients with confirmed or suspected HIV/AIDS were significantly more likely to use traditional approaches (25%) than those with other comorbidities (0%; P ¼ 0.002). Malaria was neither suspected nor tested for at a primary care facility in 23% of cases with adequate records. Initial hospital assessment was considered inadequate in 74% of cases admitted to hospital and in-patient monitoring and management was adequate in only 27%. There were 32 suspected adverse reactions to antimalarial therapy.conclusion A confidential enquiry into malaria-related deaths is a useful tool for identifying preventable factors, health system failures and adverse events affecting malaria case management.

Epidemiology of malaria in South Africa: From control to elimination

“…This resulted in delays in diagnosis and the quality of microscopy was enormously variable with poor diagnostic concordance found between diagnostic services. [20] Delays in diagnosis contributed to higher case fatality ratios [19] and treatment delays which resulted in increased gametocytes thereby contributing to higher transmission potential.…”

“…[19] Failed first-line malaria therapy and health system weaknesses, particularly in ensuring availability of appropriate antimalarial drugs were implicated in avoidable treatment delay. Malaria epidemiology in SA has been revolutionised by the availability of prompt accurate diagnosis, particularly through programme-wide implementation of rapid diagnostic tests (RDTs).…”

Case management of malaria: Treatment and chemoprophylaxis

“…Late presentation, lack of awareness of malaria in communities, and a low index of suspicion in healthcare workers, particularly in non-endemic provinces in the country, [15][16][17][18] are major contributing factors to malaria-related deaths. Even in the endemic provinces, case fatality rates (CFRs), defined as the number of deaths per 100 cases of malaria is above the national target of <0.5% (Fig.…”

Case management of malaria: Diagnosis

“…HIV has a detrimental effect on malaria disease recognition and management, and this has been documented in the course of confidential enquiries into malaria-related deaths in SA. [16] The clinical threshold for malaria testing should be lowered in HIV-positive patients who present with fever in endemic areas. [16] Previously, the SA provincial malaria control programmes undertook extensive active surveillance (case detection) in endemic areas, with control personnel sampling communities in which they were working at the time [13] (P Kruger, personal communication).…”

“…[16] The clinical threshold for malaria testing should be lowered in HIV-positive patients who present with fever in endemic areas. [16] Previously, the SA provincial malaria control programmes undertook extensive active surveillance (case detection) in endemic areas, with control personnel sampling communities in which they were working at the time [13] (P Kruger, personal communication). In many insecticide-sprayed areas, prevalence has dropped to such low levels that this is no longer widely done, and the inadequate sensitivity of microscopy or rapid diagnostic tests (RDTs) constrains their usefulness.…”