Malaria remains a leading cause of underfive morbidity and mortality in sub-Saharan Africa. Effective case management is a strategy recommended by the World Health Organization for its control. A clinical audit of case management of uncomplicated malaria in underfives in health facilities in Cross River State, Nigeria, was conducted from January to March 2012. Data was extracted from patients’ case records by trained medical personnel using pretested data extraction forms. Of the 463 case records reviewed, age, gender, and weight were reported in 98.1%, 97.3%, and 49.7% of the children, respectively. A history of fever was obtained in 89.6% and a record of temperature in 74.1% of the children. General examination was performed in 203 (43.8%) children. Malaria parasite test was requested in 132 (28.5%) while Packed cell volume or haemoglobin was requested in 107 (23.1%) children. Appropriate dose of Artemisinin Combination Therapy (ACT) was instituted in 300 (64.8%), wrong dose in 109 (23.5%), and inappropriate treatment in 41 (8.9%). The utilization of ACTs for treating uncomplicated malaria in the State has improved but clinical assessment of patients and laboratory confirmation of diagnosis are suboptimum.
Malaria remains a leading cause of childhood illness and death in sub-Saharan Africa with an underfive annual mortality of approximately a million [
Effective case management of uncomplicated malaria is a major strategy for malaria control. This entails proper clinical assessment, laboratory confirmation of the disease either by light microscopy or rapid diagnostic technique (RDT) prior to treatment with an effective antimalarial [
Most cases of malaria in the country are treated in private health facilities [
The first clinical audit of case management of uncomplicated malaria in the region was conducted in 2006 just after the country officially transited from CQ or SP monotherapy to ACT as first-line treatment for uncomplicated malaria [
This clinical audit aimed at determining the extent to which the case management of uncomplicated malaria in underfives in Cross River State conforms to standard practice, identifying areas of shortfall and making recommendations to the Cross River State Ministry of Health on ways of improving the quality of care to underfives being managed for uncomplicated malaria in health facilities in the State.
This was a clinical audit on treatment of uncomplicated malaria conducted on the medical records of health facilities in Cross River State, Nigeria, between January and March 2012.
The audit was conducted on medical records of both public and private health facilities in Cross River State. In the public sector, both secondary and primary health facilities were assessed, while, in the private sector, private hospitals and clinics were assessed. Facilities located in both urban and rural areas were assessed. For the purpose of this audit, private hospitals/clinics were categorized as secondary health facilities.
Cross River State is one of the 36 political administrative states in the Federal Republic of Nigeria. Located in the south-eastern axis of the country within the tropical rain forest belt, the State has an annual rainfall of over 3500 millimetres. Malaria transmission is intense and perennial in this area.
The target population for the study was children aged less than five years receiving care at primary and secondary health facilities in Cross River State in the preceding 3–6 months. Only underfives diagnosed and treated for uncomplicated malaria were included in this audit. Those above five years and underfives treated for severe malaria or childhood illnesses other than uncomplicated malaria were excluded.
Cross River State is comprised of three senatorial districts each made up of 6-7 Local Government Areas (LGAs). A LGA was selected in each senatorial district by simple random sampling. The public primary health facilities were selected by simple random sampling from a list of health facilities in the State obtained from the Cross River State Ministry of Health. Five primary facilities (primary health centres) and five secondary facilities (1 general hospital and 4 private hospitals) were selected per LGA. For private hospitals, there was no comprehensive list of health facilities across the State. Thus, outside Calabar metropolis, the five biggest private facilities were selected based on the assumption that more information will be obtained from them for the audit. Records of patients treated for malaria as diagnosed by the clinician 3–6 months prior to the study were audited.
The target was to audit five primary health facilities in each of the 3 selected LGAs. In each facility, a putative number of 15 case records of underfives treated for uncomplicated malaria were randomly selected and audited. Likewise for each secondary (public and private) facility, we randomly selected and reviewed 15 records of underfives treated for uncomplicated malaria per facility. This number of case records was considered adequate by the investigators to reflect the current practice in the case management of malaria in underfives in health facilities in the State.
A clinical audit tool was developed from the monitoring and evaluation tools of the National Policy for Treatment of Malaria in Nigeria [
The proposal for the audit was reviewed and approved by the Cross River State Health Research Ethics Committee. Consent to audit malaria treatment records of both the public and private hospitals/clinics was also sought and obtained from the Heads of those facilities. The confidentiality of the patients’ record and clinicians’ identity were adequately protected using identification numbers and codes for the patients and clinicians, respectively. The data extraction forms were archived in a cabinet under lock.
Information extracted from the records included patient’s age, sex, weight, clinical features, diagnostic tests, and antimalarial drugs prescribed. The selected audit criteria in the data extraction form were checked as “Yes,” “NO,” or “Unclear” based on findings. “Laboratory test ordered” was classified when the attending clinician wrote down the tests to be done. “Laboratory tests done” was classified when the results were recorded in the patient’s record of the result sheets. The laboratory tests considered in this audit were those of malaria diagnosis (confirmed either by light microscopy or RDT) and haematocrit (PCV) or haemoglobin (Hb) estimation. Children with PCV ≤ 21 g/dL were classified as severely anaemic [
Data entry and analysis were done with Microsoft Excel 2007.
A total of 463 case records of underfives managed for uncomplicated malaria in 30 health facilities across the State were audited. Of this number, weight was recorded in 230 (49.7%) and temperature in 343 (74.1%) as shown in Table
Record of general characteristics of children.
General characteristics of patients | Number of patients (%) | ||
---|---|---|---|
Public | Private | Total | |
328 (70.8%) | 135 (29.2%) | 463 | |
Record of age: | |||
Yes | 327 (99.7%) | 127 (94.1%) | 454 (98.1%) |
No | 1 | 8 | 9 |
Record of gender: | |||
Yes | 309 (94.2%) | 125 (92.6%) | 434 (97.3%) |
No | 19 | 10 | 29 |
Record of weight: | |||
Yes | 179 (54.6%) | 51 (37.8%) | 230 (49.7%) |
No | 149 | 84 | 233 |
Record of temperature: | |||
Yes | 258 (78.7%) | 85 (63.0%) | 343 (74.1%) |
No | 70 | 50 | 120 |
The history of fever was obtained in about 89.6%, while general examination was performed in 43.8% of the children. General examination was performed more frequently in the private facilities as shown in Table
Record of clinical features reported in the children.
History/presenting symptoms | Public | Private | Total |
---|---|---|---|
328 | 135 | 463 | |
Fever | 292 (89.0%) | 123 (91.1%) | 415 (89.6%) |
Cough | 175 (53.4%) | 68 (50.4%) | 243 (52.5%) |
Vomiting | 76 (23.2%) | 41 (30.4%) | 117 (25.3%) |
Headache | 10 (3.0%) | 20 (14.8%) | 30 (6.5%) |
General examination done? | |||
Yes | 99 (30.2%) | 104 (77.0%) | 203 (43.8%) |
No | 185 (56.4%) | 30 (22.2%) | 215 (46.4%) |
Unclear | 44 (13.4%) | 1 (0.8%) | 45 (9.7%) |
Specific check for: | |||
Pallor | 32 (9.8%) | 55 (40.7%) | 87 (18.8%) |
Liver | 16 (4.9%) | 50 (37.0%) | 66 (14.3%) |
Spleen | 21 (6.4%) | 54 (40.0%) | 75 (16.2%) |
Malaria test was requested for in 132 (28.5%) of the cases reviewed. Light microscopy was the main laboratory diagnostic method in 114 (86.4%). High level parasitaemia (+++/numerous) was recorded in 24 (5.3%) children, all of whom presented at the private facilities. Haemoglobin or PCV was requested in 107 (23.1%) of all children seen and was performed in 95 (88.8%) of them. Of the 95 children that had PCV estimation, 13 (13.7%) had severe anaemia all of whom presented at the private health facilities as shown in Table
Record of laboratory investigations and results.
Public | Private | Total | |
---|---|---|---|
328 | 135 | 463 | |
Malaria parasite test ordered? | |||
Yes | 45 (13.7%) | 87 (64.4%) | 132 (28.5%) |
No | 283 (86.3%) | 48 (35.6%) | 331 (71.5%) |
Malaria microscopy done? | |||
Yes | 28/45 (62.2%) | 86/87 (98.9%) | 114/132 (86.4%) |
No | 17/45 (37.8%) | 1/87 (1.1%) | 18/132 (13.6%) |
Malaria RDT done? | |||
Yes | 12/45 (26.7%) | 13/87 (14.9%) | 25/132 (18.9%) |
No | 33/45 (73.3%) | 74/87 (86.1%) | 101/132 (76.5%) |
% PCV/Hb ordered |
24/328 (7.3%) |
83/135 (61.5%) |
107/463 (23.1%) |
% PCV/Hb done |
16/24 (66.7%) |
79/83 (95.2%) |
95/107 (88.8%) |
Severe anaemia: PCV ≤ 21% or Hb ≤ 7 g/dL |
0/16 (0%) | 13/79 (17.3%) |
13/95 (13.7%) |
A total of 300 (64.8%) cases were treated with an Artemisinin-based Combination Therapy (ACT). About 74% of children managed in the public facilities had an appropriate treatment regimen for uncomplicated malaria as against 42.2% in the private health facilities. Wrong dosage prescription was noted in 109 (23.5%). This was twice more likely in the private setting than in the public. The antimalarial prescription was inappropriate in 41 (8.9%) of the children treated in the facilities as shown in Table
Record of treatment administered for malaria.
Appropriateness of treatment given | Public | Private | Total |
---|---|---|---|
328 | 135 | 463 | |
Dosage and drug appropriate | 243 (74.1%) | 57 (42.2%) | 300 (64.8%) |
Drug appropriate but dosage wrong | 59 (18.0%) | 50 (37.0%) | 109 (23.5%) |
Drug not appropriate for malaria | 25 (7.6%) | 16 (11.9%) | 41 (8.9%) |
Unable to determine | 1 (0.3%) | 12 (8.9%) | 13 (2.8%) |
The inappropriate drugs prescribed in the private health facilities were limited to Chloroquine (CQ) and Artesunate as monotherapy, while the public health facilities had a wide range of medications. CQ constituted 56.1% of the total inappropriate prescriptions. This was followed by Sulfadoxine-pyrimethamine in 22.04% and inappropriate use of antibiotics in 9.8% of the cases.
The findings of this practice audit show that the overall management of uncomplicated malaria in underfives in these institutions are inconsistent with the recommendations of the treatment guidelines of the national malaria control programme and that of the World Health Organization [
Since weight and age are required to determine the dose of the recommended first-line treatment for Artemether-lumefantrine and other ACTs, failing to record or use these parameters would invariably lead to the use of inappropriate dosage of these drugs. The current ACTs deployed in the country have predetermined doses matched for weight band and age range inscribed on the packets. This has simplified the determination of correct dose of antimalarial and improved prescription pattern among health care providers in the absence of weight measurement. This is a laudable innovation given that a high proportion of children seen in health facilities in developing countries are often not weighed before being treated as observed in this audit. In low-resource settings where instruments for measurements are unavailable, obtaining the necessary demographic information could be helpful in the decision-making process in patient management.
History of fever (89.6%) or temperature measurement (74.1%) was recorded in a higher proportion of patients than weight. There is much room for improvement in this area since history of fever or measured axillary temperature ≥37.5°C is crucial for the definition of symptomatic malaria in children [
Most children were treated without parasitological confirmation of diagnosis which is a practice that is now being discouraged. The Nigeria National Malaria Treatment Policy Guidelines has recently been revised making parasitological test confirmation mandatory for diagnosis and treatment of malaria in all age groups [
Packed cell volume (PCV) or haemoglobin (Hb) was reported in less than a third of the cases reviewed. This was reported in one-third of the children managed in a health facility in Malawi [
Over 60% of the children had appropriate treatment regimen using an ACT. This finding indicates a marked improvement in the utilization of ACTs for treating uncomplicated falciparum malaria when compared with 3% recorded in the State just after the country formally transited from Chloroquine (CQ) or Sulfadoxine-pyrimethamine (SP) monotherapy to ACTs [
About 9% of the children were treated with drugs that are inappropriate for uncomplicated malaria. This is also a remarkable improvement from earlier Nigeria studies that reported higher use of CQ and SP [
The utilization of ACTs as a first-line therapy for uncomplicated malaria has significantly improved. However, there is a need to improve clinical evaluation and laboratory confirmation of malaria diagnosis in health facilities as recommended by the national and international malaria treatment guidelines. More efforts should be made to encourage and support health facilities to use RDTs for the diagnosis of malaria where light microscopy is not readily available or feasible.
The authors declare that they have no Conflict of Interests.
This paper was supported by the Effective Health Care Research Consortium which is funded by UK aid from the Department for International Development. UK aid played no role in the conduct or decision to publish this study.