Translation of artemether-lumefantrine treatment policy into paediatric clinical practice: an early experience from Kenya.

OBJECTIVE: To describe the quality of outpatient paediatric malaria case-management approximately 4-6 months after artemether-lumefantrine (AL) replaced sulfadoxine-pyrimethamine (SP) as the nationally recommended first-line therapy in Kenya. METHODS: Cross-sectional survey at all government facilities in four Kenyan districts. Main outcome measures were health facility and health worker readiness to implement AL policy; quality of antimalarial prescribing, counselling and drug dispensing in comparison with national guidelines; and factors influencing AL prescribing for treatment of uncomplicated malaria in under-fives. RESULTS: We evaluated 193 facilities, 227 health workers and 1533 sick-child consultations. Health facility and health worker readiness was variable: 89% of facilities stocked AL, 55% of health workers had access to guidelines, 46% received in-service training on AL and only 1% of facilities had AL wall charts. Of 940 children who needed AL treatment, AL was prescribed for 26%, amodiaquine for 39%, SP for 4%, various other antimalarials for 8% and 23% of children left the facility without any antimalarial prescribed. When AL was prescribed, 92% of children were prescribed correct weight-specific dose. AL dispensing and counselling tasks were variably performed. Higher health worker's cadre, in-service training including AL use, positive malaria test, main complaint of fever and high temperature were associated with better prescribing. CONCLUSIONS: Changes in clinical practices at the point of care might take longer than anticipated. Delivery of successful interventions and their scaling up to increase coverage are important during this process; however, this should be accompanied by rigorous research evaluations, corrective actions on existing interventions and testing cost-effectiveness of novel interventions capable of improving and maintaining health worker performance and health systems to deliver artemisinin-based combination therapy in Africa.

Effects of revised diagnostic recommendations on malaria treatment practices across age groups in Kenya.

OBJECTIVE: The recent change of treatment policy for uncomplicated malaria from sulfadoxine-pyrime-thamine to artemether-lumefantrine (AL) in Kenya was accompanied by revised malaria diagnosis recommendations promoting presumptive antimalarial treatment in young children and parasitological diagnosis in patients 5 years and older. We evaluated the impact of these age-specific recommendations on routine malaria treatment practices 4-6 months after AL treatment was implemented. METHODS: Cross-sectional, cluster sample survey using quality-of-care assessment methods in all government facilities in four Kenyan districts. Analysis was restricted to the 64 facilities with malaria diagnostics and AL available on the survey day. Main outcome measures were antimalarial treatment practices for febrile patients stratified by age, use of malaria diagnostic tests, and test result. RESULTS: Treatment practices for 706 febrile patients (401 young children and 305 patients > or =5 years) were evaluated. 43.0% of patients > or =5 years and 25.9% of children underwent parasitological malaria testing (87% by microscopy). AL was prescribed for 79.7% of patients > or =5 years with positive test results, for 9.7% with negative results and for 10.9% without a test. 84.6% of children with positive tests, 19.2% with negative tests, and 21.6% without tests were treated with AL. At least one antimalarial drug was prescribed for 75.0% of children and for 61.3% of patients > or =5 years with a negative test result. CONCLUSIONS: Despite different recommendations for patients below and above 5 years of age, malaria diagnosis and treatment practices were similar in the two age groups. Parasitological diagnosis was under-used in older children and adults, and young children were still tested. Use of AL was low overall and alternative antimalarials were commonly prescribed; but AL prescribing largely followed the results of malaria tests. Malaria diagnosis recommendations differing between age groups appear complex to implement; further strengthening of diagnosis and treatment practices under AL policy is required.

Health facility and health worker readiness to deliver new national treatment policy for malaria in Kenya.

OBJECTIVE: To evaluate health facility and health worker readiness to deliver new artemether-lumefantrine (AL) treatment policy for uncomplicated malaria in Kenya. DESIGN: Cross-sectional survey. SETTING: Health facilities in four sentinel districts in Kenya. PARTICIPANTS: All government facilities in study districts (n = 211) and all health workers performing outpatient consultations (n = 654). MAIN OUTCOME MEASURES: Availability of antimalarial drugs on the survey day, stock-outs in past six months, presence of AL wall charts, health worker's exposure to in-service training on AL and access to new national malaria guidelines. RESULTS: The availability of any tablets of AL, sulfadoxine-pyrimethamine and amodiaquine was nearly universal on the survey day. However, only 61% of facilities stocked all four weight-specific packs of AL. In the past six months, 67% of facilities had stock-out of at least one AL tablet pack and 15% were out of stock for all four packs at the same time. Duration of stock-out was substantial for all AL packs (median range: 27-39% of time). During the same period, the stock-outs of sulfadoxine-pyrimethamine and amodiaquine were rare. Only 19% of facilities had all AL wall charts displayed, AL in-service training was provided to 47% of health workers and 59% had access to the new guidelines. CONCLUSION: Health facility and health worker readiness to implement AL policy is not yet optimal. Continuous supply of all four AL pack sizes and removal of not recommended antimalarials is needed. Further coordinated efforts through the routine programmatic activities are necessary to improve delivery of AL at the point of care.