Reducing mortality from severe malaria in Sierra Leonean children by applying the World Health Organization's standard malarial protocol with additional sublingual glucose: A continuous quality improvement report

Abstract

To reduce childhood mortality from severe malaria by implementing the World Health Organization's standardized malarial treatment protocol. Design: Observational study comparing the mortality rate from malaria before and after the intervention. Setting: Inpatient pediatric ward in a district referral hospital of Sierra Leone. Participants: A total of 1298 pediatric patients (ages 0-13 years, male and female) received the intervention, representing 100% of the pediatric patients admitted with severe malaria during the dates of implementation (there were no exclusion criteria). Interventions: We implemented the World Health Organization's standardized malarial protocol on September 30, 2015. Based on monthly run reports of mortality and root cause analysis, we adapted the malaria protocol by adding sublingual glucose as a treatment to target hypoglycemia complications in March 2016. Main Outcome Measures: The primary outcome was a change in monthly percent mortality from severe malaria, and the secondary outcome was the percent of mortality attributed to hypoglycemia. Results: The monthly average percent mortality from severe malaria dropped from 9% to 3.6% after the intervention, which was borderline statistically significant (p 0.06, CI 95% 1.5 to 5.6). The secondary outcome, percent of malarial deaths attributable to hypoglycemia via chart reviews, dropped from 83% to 44% across the study period. There was an increase in the average number of admissions for severe malaria from 71 to 153 children per month in the second half of the year (range from 49-212 per month). Conclusion: Implementing the WHO malaria treatment protocol with bedside tracking of protocol steps reduced malaria mortality and improved our ward's efficiency without adding any human or medical resources.

Adherence to severe malaria treatment guidelines in children at a Ugandan regional hospital: a baseline assessment for a malaria treatment quality improvement project

“…Despite the resource barriers, there are likely potential opportunities for improvement within the existing system. As demonstrated by the research team at Koidu Government Hospital in Sierra Leone, implementing and adhering to a standardized protocol for treatment of severe malaria in a rural hospital with limited resources was effective at decreasing malaria-specific mortality [ 9 ]. Through this process they identified leading drivers of mortality and adjusted work flows to ultimately achieve a reduction in malaria-related mortality from 9% to 3.6%.…”

“…Through this process they identified leading drivers of mortality and adjusted work flows to ultimately achieve a reduction in malaria-related mortality from 9% to 3.6%. Compliance with the treatment protocol was ensured by twice daily reviews of all relevant patient records by a clinician [ 9 ].…”

“…Unfortunately, studies have shown that adherence to these guidelines by clinicians in sub-Saharan Africa is generally poor, around 50% at best [6][7][8]. Encouragingly, a recent study from Sierra Leone identified avenues to improve adherence to a standardized malaria treatment protocol with subsequent reduced mortality in children admitted to the hospital with severe malaria [9]. The goals of this study were to assess the current adherence to guidelines for severe malaria in children at a Ugandan regional hospital and identify areas for intervention to improve this adherence as part of a baseline assessment for a malaria treatment quality improvement initiative.…”

Hypoxemia, hypoglycemia and IMCI danger signs in pediatric outpatients in Malawi

“…The WHO definition of hypoglycemia as a blood glucose concentration of <2.5mmol/l is a topic of debate, following a number of studies showing that sick children with blood glucose concentrations above 2.5mmol/l and with a variable upper limit of as high as 5.0mmol/l, also suffer an increased risk of mortality compared to children with higher blood glucose concentrations [11,15,16]. While there is an absence of comparable data from primary care facilities, severely sick children with moderate hypoglycemia are likely to benefit from a higher level of monitoring [26] and it can be hypothesized that referral of children with moderate hypoglycemia could contribute to reduced mortality.…”

Safety and efficacy of hydroxychloroquine for treatment of non-severe COVID-19 among adults in Uganda: a randomized open label phase II clinical trial

“…The novel coronavirus, SARS-CoV-2, which causes Coronavirus disease 2019 (COVID-19), is the seventh human coronavirus described to date. By 3 July 2020, more than 11 million COVID-19 infections were reported worldwide resulting in more than 450,000 deaths [ 1 ] In just over a year, there have been nearly 130 million cases with more than two million deaths globally [ 2 ]. The COVID-19 pandemic has stretched the health care capacity of all systems across the globe, particularly the low-income countries with the weakest health care systems.…”