Antimalarial Drug Prescribing Practice in Pediatrics in a University Teaching Hospital
CHAPTER ONE
OBJECTIVES OF THE STUDY
The general objective of this research was to study the prescribing practice of antimalarial drugs for children with uncomplicated malaria in a teaching hospital.
The specific objectives:
- To determine the cases that were diagnosed based on laboratory investigation and/or clinical manifestation.
- To find out the anti-malarial drugs used in the treatment of uncomplicated malaria cases from 2003 to 2011.
- To determine the changes if any in the prescription pattern following the implementation of the National Treatment Guidelines of 2005.
- To assess the level of compliance of the prescribers to the National treatment guidelines.
CHAPTER TWO
METHODS
RESEARCH DESIGN
The research was a retrospective study which assessed the antimalarial prescriptions in the Out Patients’ Department of the Paediatrics’ Clinic of the University of Nigeria Teaching Hospital, Enugu. In order to compare the prescription pattern before the recommendation of the National Antimalarial Treatment Guidelines in 2005 and afterwards; patients files from 2003 to 2011 were used.
STUDY SETTING
The study was carried out in the out –patients department of the pediatric Clinic of the University of Nigeria Teaching Hospital, Enugu.
The capital of Enugu State is Enugu. It has a population of 722,664 and a population density of 6,400/km2. In Enugu, health care services can be obtained at several institutions including Enugu State University of Science and Technology (ESUT) Teaching Hospital, and University of Nigeria, Enugu Teaching Hospital.
University of Nigeria Enugu Teaching Hospital is located 21 Kilometers from Enugu capital city along Enugu-Port Harcourt express way. The Paediatric Clinic of the University of Nigeria Teaching Hospital consists of the Children Emergency Room (CHER) and the Children Outpatient Clinic (CHOP) and the Consultant Clinic (CC). Admissions into the ward of the hospital is usually via CHER for emergency cases, CHOP for general Paediatric cases and CC for children who were either referred for specialist care or had been previously admitted for in-patient care.
POPULATION FOR THE STUDY
There were some missing registers of all the malaria cases over the years, and it was impossible to have got the population size for the sampling. Therefore all the medical files in the Children Outpatient Clinic (CHOP) from 2003 to 2011 were assessed. All uncomplicated malaria cases from 2003 till 2011 were isolated and assessed. Following the inclusion criteria, a total of 3034 prescriptions were collected for data extraction and analysis.
EXCLUSION CRITERIA
All prescriptions for patients with uncomplicated malaria below six months and above 5 years of age were excluded from this study. Also patients with special disease conditions like HIV/AIDS, G6PD deficiency and Sickle Cell Disease were excluded.
INCLUSION CRITERIA
All prescriptions for patients with uncomplicated malaria between the ages of six months and 5 years were included.
DATA COLLECTION
A modified prescribing indicator form was used. The form has been validated by the World Health Organization (WHO). With the use of the prescribing indicator form the following data were collected:
- Demographic data; such as sex, age and weight.
- Clinical presentation; significant signs and symptoms
- Laboratory investigation data.
In addition to the yearly data grouping, data were grouped into two i.e. those from the year 2003-2005 and those from the year 2006-2011. This facilitated the comparison between the prescriptions before the introduction of the guidelines and those afterwards.
The data were compared with the standard treatment guideline adopted by the FMOH in 2005. Thus the level of adherence was studied.
CHAPTER THREE
RESULTS
DEMOGRAPHIC AND CLINICAL CHARACTERISTICS
Patients’ gender
Most of the results show that not all the demographic data were recorded for each patient’s medical record. For example, in the pre-policy period, 464 patients were recorded to be males while 407 patients were recorded to be females giving a total of 871. This meant that out of the 883 prescriptions assessed in this period (2003-2005) the medical charts of 12 patients had no information on their gender. Likewise, in the post-policy period, 1125 out of the 2151 patients were males, in other words 54.2%.
Age, weight and body temperature
The mean age in months of the patients in the pre-policy period was 21.20, very close to that observed in the post-policy period, 22.51.
The mean weight in kg for the patients in the pre-policy period was 10.05 while that for the post policy was 11.30.
The average body temperature in degrees Celsius was 37.4 and 37.45 for the pre and post policy periods respectively.
Symptoms/comorbidities
The most recurrent symptom for the two periods was fever. Result shows that for the pre-policy period, 808(92.3%) patients had fever on examination by the physician while for the post policy period there were 1869(89.3%) patients with fever.
Other symptoms were cough, diarrhoea and vomiting.
Chill and headache were the least recorded symptoms. For the pre-policy period, only 5 patients had headache while only 3 patients had chill with 0.6% and 0.3% as the respective percentages.
CHAPTER FOUR
DISCUSSION AND CONCLUSION
DISCUSSION
Result of the analysis revealed that only 4.8% of all the 3034 malaria cases were diagnosed based on Laboratory investigation (c.f. table 3). 5.3% of the 883 malaria cases in the pre-policy period were diagnosed following a laboratory investigation while for the post-policy period, only 4.6% of the 2151 malaria cases. In all, 95.2% of the 3034 malaria cases were diagnosed presumptively, that is, based mainly on the presence of fever. This was far removed from the directives of the National Antimalarial Treatment Policy which states that a parasitological diagnosis is required in all suspected cases of malaria. Presumptive treatment is permissible in areas where either supplies or trained persons are not available (FMOH, 2011). In a Teaching Hospital, most likely there were trained personnel and the supplies of the laboratory reagents. Additionally, the physicians prescribed the antimalarial drugs for empirical treatment. In the past, presumptive diagnosis based on presentation with fever had been the practice especially in areas of stable malaria or high transmission like Nigeria, however, it has been demonstrated that such practices has its potential risks. For instance the children are exposed to unnecessary adverse drug reactions like gastrointestinal disturbances, neutropenia, hepatoxicity and neurotoxicity which may be associated with artemisinin-based therapies (Ukwaja, 2010). It also has the shortcoming that some of the patients without malaria may have been treated with antimalarial drugs, which would have been a waste. In a similar study carried out in Lagos State University Teaching Hospital (Oshikoya, 2007), it was found out that most cases of malaria were treated based only on clinical features. Another finding similar to this was made after a study carried out in Ogun State, Nigeria which revealed that more than half of under-five children with malaria-pneumonia overlap did not have malaria parasitaemia using RDT. Thus more than half of all antimalarial drugs prescribed presumptively to children with overlap were unnecessary (Ukwaja et al, 2010).
CHAPTER FIVE
LIMITATIONS OF THE STUDY
The primary limitation of this study was that the prescription data collection was retrospective, the parasitological or clinical improvement data could not be collected. A major weakness of retrospective data is that they are often incomplete (WHO, 1993).
Secondly, only one teaching hospital was used for the study, thus, the results do not give room to generalizations. Thirdly, in this study, the data collection focused only on the pattern of drug use, therefore there could be no reference to the quality of drug use, the determinants of drug use and the outcome of drug use.
CONCLUSION
This study revealed an increase in the prescription of Artemisinin-based combination therapy after the introduction of the National Antimalarial Treatment Guideline. Nevertheless, prescribers did not adhere strictly to the guideline. Many of the Artemisinin-based combination therapy prescribed were not the recommended ones. There was a high incidence of empirical diagnosis/treatment of malaria as opposed to parasitological/confirmatory diagnosis/treatment. Among the WHO drug use indicators, there was still a lot of room for improvement in the prescription of drugs in generics by prescribers.
Malaria is still considered a global health problem and a major killer. Morbidity and mortality burden of malaria could be reduced strengthening prevention, improving malaria diagnosis, using correct therapies based on artemisinin combination and adopting strategies aimed at preventing drug resistances.
RECOMMENDATION
The policy for malaria treatment in Nigeria should not be limited only to change in the guidelines, but also include continuous drug utilization studies sponsored by the Federal Ministry of Health to ensure the rational prescription of these drugs and the implementation of the guideline.
Secondly, health workers in all the different levels of health care should have in-service training to keep them abreast with evidence-based medicine. This will reduce a lot the erroneous/inappropriate prescriptions.
Above all, in order to reduce the incidence of malaria cases, antimalarials utilization and consequences of possible irrational exposure to antimalarial drugs, efforts should be geared towards the prevention and vector control measures and complete eradication of malaria in Nigeria.
REFERENCES
- Abanyie FA, Arguin PM and Gutman J, 2011: State of malaria diagnostic testing at clinical laboratories in the United States. Malaria Journal 10:340
- Achan J, Kahuru A, Ikilezi G, Ruel T, Clark T, Charlebois E, Rosenthal P, Dorsey G, Havlir D, Kamya M, 2012: Significant reduction in risk of malaria among HIV+ children receiving Lopinavir/Ritonavir-based ART compared to NNRTI- based ART, a randomized open-label trial. Abstract presented at CROI 2012.
- Adesanmi TA, Okafor HU, Okoro AB, Mafe AG, 2011: Diagnosis of malaria parasitaemia in children using a rapid diagnostic test. Nigerian Journal of Clinical Practice 14 (2):195-200.
- Aghaji MN, 2002: Injection practices in Enugu, Nigeria. Journal of College of Medicine 7: 118-120.
- Akande TM and Ologe MO, 2007: Prescription pattern at a secondary health care facilicity in Ilorin, Nigeria. Annals of African medicine 6 (4):186-189.
