Transcript Community drug use practices in malaria in Cambodia: a cross

WHO
Community drug use practices
in malaria in Cambodia:
a cross-sectional study
National Malaria Centre of Cambodia
Rational Pharmaceutical Management Plus Program
World Health Organization
European Commission Cambodian Malaria Control Programme
Wellcome Trust Mahidol Oxford Trop. Med. Research Programme
Part Two
The quality and impact of prescribing
on the Cambodian-Thai border
Presented by Ros Seyha
Most common treatments

Single Artemisinins (mainly Artesunate) were the
most common treatments (31% fever cases)
– 92% of those who said they received single
artemisinins at all facilities did not receive
mefloquine
– 87% of those who received artemisinins
separately at public/NGO* facilities did not
receive mefloquine
Most common treatments (2)

Quinine was the second most popular treatment

58% of those who received quinine at all facilities did
not receive tetracycline
– 70% of those who received quinine at public/NGO*
facilities received it without tetra/doxycycline

Public/NGO* facilities performed only slightly better at
following their own guidelines, due to 23% A+M use
* NB this pattern remains unchanged when NGO treatments are removed
Sufficient Duration of Treatment
3
100
90
80
60
insufficient info
50
inappropriate
95
94
40
appropriate
72
30
46
20
22
10
(7
da
ys
)
Q
ui
n
e
al
ar
in
M
in
e
(3
da
ys
)
Ar
te
kin
ni
ne
isi
Ar
te
m
(2
da
ys
)
(5
da
ys
)
(3
da
ys
)
0
A+
M
percentage
70
Sufficient Duration by Source
% persons with receiving first modern treatment
100
90
80
70
60
50
40
46.15
41.74
40.18
43.58
39.12
32.11
30
21.74
20
17.23
17.13
10
0
other
private
public/NGO
Insufficient Information
appropriate
inappropriate
no antimalarials
Provider knowledge
Treating simple malaria (hypothetical
case)
 Case A: “An adult man presents with
symptoms of simple malaria and a
positive blood slide.”

How would you treat him?
Treating simple malaria (provider statements)

The most commonly
recommended treatment for
simple cases of malaria.
Quinine
alone
7%

Only 46% treatments
from all providers
were of at least 80%
effectiveness
Art. Der.
23%
Other
14%
Q+T
28%
Combine
d A+M
28%
Treating simple malaria (provider vs. household statements)
The most commonly recommended treatment for simple cases of malaria
Q+T
A+M
Art. Der.
Quinine
Others
100%
In general these
claims conflicted
with the findings of
the household
survey, which
measured practice.
90%
80%
Percentage (%)

70%
14
7
34
23
60%
15
50%
40%
28
28
30%
20%
10%
28
13
10
Providers
Household
0%
Treating Simple Malaria
in Different Settings
Government setting: Public Health Services
Market setting: Drugs shop, Pharmacies, Clinics
Village setting: Drugs shops, Clinics, General shops
Case A: Drug choice and Efficacy
(dose and duration)
A+M
Q+T
Art. Der.
Quinine
Others

Government: 8% were less
than 80% effectiveness

Market: 35% were less
than 80% effectiveness

Village: 56% were less
than 80% effectiveness
100%
17
90%
15
18
9
80%
19
70%
26
60%
13
50%
83
40%
30%
39
50
20%
10%
11
G
ov
ge
ill
a
V
M
ar
ke
t
er
nm
en
t
0%
Provider knowledge
Treating severe malaria
 Case B: “An adult man presents with
symptoms of severe malaria and a
positive blood slide.

How would you treat him?”
Treating severe malaria (provider statements)

The most commonly
recommended treatment for
severe cases of malaria.
Other
17%

Only 25% treatments
from all providers
were of at least 80%
effectiveness
Quinine
alone
26%
Q+T
6%
Combine
d A+M
16%
Art. Der.
35%
Treating Severe Malaria
in Different Settings
Government setting: Public Health Services
Market setting: Drugs shop, Pharmacies, Clinics
Village setting: Drugs shops, Clinics, General shops
Case B: Drug choice and Efficacy
(dose and duration)
A+M
Art. Der.
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Art+Q+T
Others
7
Quinine

Government: 43% were less
than 80% effectiveness

Market: 69% were less
than 80% effectiveness

Village: 78% were less
than 80% effectiveness
20
29
37
14
35
14
15
11
35
43
30
e
ill
ag
V
ke
t
ar
M
nm
en
t
10
er
G
ov
Q+T
No drugs
Case B: Drug choice and Efficacy
(dose and duration)
Art+Q+T
Others
Q+T
No drugs
7
Quinine
20
29
37
14
35
14
15
11
35
43
30
ill
ag
e
V
M
ar
ke
t
10
nm
en
t
– Higher numbers of dangerous,
unnecessary prescriptions
strongly associated with
village providers: odds ratio of
4.86 (95% CI 1.24, 19.07)
compared against market
setting (OR 1.0) and public
health setting (OR 1.73)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
er
Village: 78% were less
than 80% effectiveness
G
ov

A+M
Art. Der.
Treatment of At Risk Groups: Children



No child aged >6 months to <6 years
received the government recommended
treatment for that age group: artesunate
suppositories for 5 days, plus mefloquine
(household report)
The single most frequently received
therapy was artesunate oral form (44%)
The next most commonly used drug was
chloroquine (12%)
Treatment of At Risk Groups: Pregnant women


Only 4 of the 27 pregnant women in the sample
received the recommended treatment,
– quinine monotherapy
14 received no antimalarials, but we cannot
presume infection
Treatment of At Risk Groups: Severe Malaria

Rectal artesunate, for the immediate treatment
of severe patients, was recommended by
……….only one provider and
……this was not a public health facility

This recommended first line therapy
……..is potentially lifesaving
Summary (1)


Poor prescribing practices were
demonstrated by providers in all settings,
partly due to gaps in knowledge
Knowledge gaps included correct choice of
• drugs
• duration
• frequency
• dose
…………..is worst in outlying areas
Summary (2)

Prescribers widely recommended artesunate
and quinine monotherapy for short durations
(< 7 days)
– Ineffective for ensuring treatment and may,
theoretically, encourage drug resistance.

Polypharmacy with unnecessary or
potentially dangerous drugs was common,
especially in villages
– Inappropriate use of injections and infusions
increases risks and costs
Summary (3)

Government facilities had gaps
between
government guidelines and
staff recommendations,
……particularly for severe malaria.

Explanation for the inconsistency between reported
and actual behaviors may require additional study

For further information, please
contact:
[email protected]
Thank you