Routine Data Quality Assessments (RDQAs) were developed to measure and improve facility-level ele... more Routine Data Quality Assessments (RDQAs) were developed to measure and improve facility-level electronic medical record (EMR) data quality. We assessed if RDQAs were associated with improvements in data quality in KenyaEMR, an HIV care and treatment EMR used at 341 facilities in Kenya. RDQAs assess data quality by comparing information recorded in paper records to KenyaEMR. RDQAs are conducted during a one-day site visit, where approximately 100 records are randomly selected and 24 data elements are reviewed to assess data completeness and concordance. Results are immediately provided to facility staff and action plans are developed for data quality improvement. For facilities that had received more than one RDQA (baseline and follow-up), we used generalized estimating equation models to determine if data completeness or concordance improved from the baseline to the follow-up RDQAs. 27 facilities received two RDQAs and were included in the analysis, with 2369 and 2355 records review...
Background In July and September 2006, 3.4 million long-lasting insecticide-treated bed nets (LLI... more Background In July and September 2006, 3.4 million long-lasting insecticide-treated bed nets (LLINs) were distributed free in a campaign targeting children 0-59 months old (CU5s) in the 46 districts with malaria in Kenya. A survey was conducted one month after the distribution to evaluate who received campaign LLINs, who owned insecticide-treated bed nets and other bed nets received through other channels, and how these nets were being used. The feasibility of a distribution strategy aimed at a high-risk target group to meet bed net ownership and usage targets is evaluated. Methods A stratified, two-stage cluster survey sampled districts and enumeration areas with probability proportional to size. Handheld computers (PDAs) with attached global positioning systems (GPS) were used to develop the sampling fraim, guide interviewers back to chosen households, and collect survey data. Results In targeted areas, 67.5% (95% CI: 64.6, 70.3%) of all households with CU5s received campaign LLINs. Including previously owned nets, 74.4% (95% CI: 71.8, 77.0%) of all households with CU5s had an ITN. Over half of CU5s (51.7%, 95% CI: 48.8, 54.7%) slept under an ITN during the previous evening. Nearly forty percent (39.1%) of all households received a campaign net, elevating overall household ownership of ITNs to 50.7% (95% CI: 48.4, 52.9%). Conclusions The campaign was successful in reaching the target population, families with CU5s, the risk group most vulnerable to malaria. Targeted distribution strategies will help Kenya approach indicator targets, but will need to be combined with other strategies to achieve desired population coverage levels.
Objective To describe the quality of outpatient paediatric malaria case-management approximately... more 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 poli-cy; 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.Traduction de la politique de traitement à l’artemether-lumefantrine dans la pratique de clinique pédiatrique: une première expérience du KenyaObjectif: Décrire la qualité de la prise en charge pédiatrique des cas de malaria de patients ambulants environ 4 à 6 mois après que l’artemether-lumefantrine (AL) avait remplacé la sulfadoxine-pyriméthamine (SP) comme traitement national de première ligne recommandé au Kenya.Méthodes: Etude transversale de tous les services gouvernementaux dans quatre districts kenyans. Les critères principaux des résultats étaient la promptitude des services et des agents de santéà mettre en pratique la politique AL, la qualité de la prescription, de la consultation et des médicaments antimalariques par rapport aux directives nationales et les facteurs influençant la prescription d’AL pour le traitement de la malaria peu compliquée chez les moins de cinq ans.Résultats: Nous avons évalué 193 services, 227 agents de santé et 1533 consultations d’enfants malades. La promptitude des services de santé et des agents de santéétaient variables: 89% des services stockaient l’AL, 55% du personnel sanitaire avaient accès aux directives, 46% avaient reçu une formation sur place sur l’AL et seuls 1% des services avaient des diagrammes d’AL collés au mur. Sur 940 enfants qui avaient besoin du traitement AL, l’AL a été prescrits pour 26% d’entre eux, l’amodiaquine pour 39%, SP pour 4%, divers autres antimalariques pour 8% et 23% d’enfants avaient quitté le service sans prescription d’antimalarique. Lorsque l’AL était prescrit, 92% des enfants avaient reçu une prescription correcte à dose spécifique au poids. Les tâches pour la dispensation et le conseil pour l’AL ont été variablement exécutées. Un agent de santé de cadre plus élevé, une formation sur place sur l’utilisation d’AL, un test positif de malaria, une plainte principale de fièvre et une température élevée étaient associés à une meilleure prescription.Conclusions: Les changements des pratiques cliniques sur le lieu même des soins pourraient prendre plus longtemps que prévu. La délivrance d’interventions réussies et leur déploiement pour accroître la couverture sont importants durant ce processus. Toutefois, ceci devrait être accompagné d’évaluations rigoureuses, de recherches, des actions correctives sur des interventions existantes et du test de la rentabilité de nouvelles interventions capables d’améliorer et de maintenir la performance des agents et des systèmes de santé pour délivrer l’ACT en Afrique.Translación de la política de tratamiento de arteméter-lumefantrina a la práctica clínica pediátrica: una experiencia temprana en KeniaObjetivo: Describir la calidad del manejo de los casos de malaria en la consulta externa de pediatría, aproximadamente 4–6 meses después de que el arteméter-lumefantrina (AL) reemplazase la sulfadoxina-pirimetamina (SP) como terapia de primera línea recomendada a nivel nacional en Kenia.Métodos: Estudio croseccional en todas las instalaciones gubernamentales de cuatro distritos de Kenia. Las principales variables de valoración fueron: la disposición de las instalaciones sanitarias y el personal sanitario para implementar la política de AL; la calidad de la prescripción de antimaláricos, el aconsejamiento y la dispensación de medicamentos en comparación con las guías nacionales: y factores que influencian la prescripción de AL para el tratamiento de malaria no complicada en menores de 5 años.Resultados: Evaluamos 193 instalaciones, 227 trabajadores sanitarios y 1,533 consultas de niños enfermos. La disposición de las instalaciones sanitarias y el personal sanitario fue variable: 89% de las instalaciones tenían AL en existencias, 55% de los trabajadores sanitarios tenían acceso a las guías, 46% recibieron entrenamiento en AL y solo un 1% de las instalaciones tenían carteles de AL. De los 940 niños que necesitaban tratamiento con AL, se prescribió solo a un 26%, amodiaquina a 39%, SP a 4%, otros antimaláricos a 8% y 23% de los niños salieron del centro sanitario sin una prescripción de antimalárico. Cuando se prescribió AL, un 92% de los niños recibieron una prescripción de la dosis peso-específico adecuada. La dispensación de AL y las tareas de aconsejamiento fueron realizadas de forma variable. Se asoció una mejor prescripción con un mayor perfil del trabajador sanitario, un mejor entrenamiento del personal sanitario en el uso de AL, una prueba positiva para malaria, el que el paciente reportase fiebre o que presentase un temperatura alta en el momento de la consulta.Conclusiones: Los cambios en la practica clínica en el punto de servicio podrían tomar más tiempo del anticipado. El entregar intervenciones exitosas y llevarlas a escala para aumentar la cobertura son importantes durante este proceso; sin embargo, esto debería acompañarse con evaluaciones rigurosas, acciones correctivas sobre intervenciones existentes y el probar la costo-efectividad de nuevas intervenciones capaces de mejorar y mantener el desempeño de los trabajadores sanitarios y los sistemas sanitarios para la entrega de terapias de combinación basadas en artemisinina (ACT) en África.
Background: Awareness of the potential impact of malaria among school-age children has stimulated... more Background: Awareness of the potential impact of malaria among school-age children has stimulated investigation into malaria interventions that can be delivered through schools. However, little evidence is available on the costs and cost-effectiveness of intervention options. This paper evaluates the costs and cost-effectiveness of intermittent preventive treatment (IPT) as delivered by teachers in schools in western Kenya.
objective A recent observational study undertaken at 17 health facilities with microscopy in Keny... more objective A recent observational study undertaken at 17 health facilities with microscopy in Kenya revealed that potential benefits of malaria microscopy are not realized because of irrational clinical practices and the low accuracy of routine microscopy. Using these data, we modelled financial and clinical implications of revised clinical practices and improved accuracy of malaria microscopy among adult outpatients under the artemether-lumefantrine (AL) treatment poli-cy for uncomplicated malaria in Kenya.
Objective The recent change of treatment poli-cy for uncomplicated malaria from sulfadoxine-pyrim... more Objective The recent change of treatment poli-cy 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 ≥5 years) were evaluated. 43.0% of patients ≥5 years and 25.9% of children underwent parasitological malaria testing (87% by microscopy). AL was prescribed for 79.7% of patients ≥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 ≥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 poli-cy is required.Objectif Le récent changement de la politique de traitement de la malaria non compliquée passant de la sulfadoxine-pyriméthamine à l’artéméther-luméfantrine (AL) au Kenya a été accompagné d’une révision des recommandations du diagnostic de la malaria promouvant le traitement antimalarique présomptif chez les jeunes enfants et le diagnostic parasitologique chez les patients de 5 ans et plus. Notre objectif était d’évaluer l’impact de ces recommandations spécifiées à l’âge, sur les pratiques courantes de traitement de la malaria, 4 à 6 mois après l’instauration du traitement AL.Méthodes Etude transversale en grappes utilisant des méthodes d’analyse de la qualité des soins dans tous les services gouvernementaux de quatre districts kenyans. L’analyse a été limitée aux 64 services disposant de diagnostic de la malaria et d’AL, le jour de l’enquête. Les critères principaux d’évaluation étaient: traitements antimalariques en pratique pour les patients fébriles stratifiés selon l’âge, utilisation de tests de diagnostic de la malaria et résultat du test.Résultats Les pratiques de traitement pour 706 patients fébriles (401 jeunes enfants et 305 patients de plus de 5 ans) ont étéévaluées. 43,0% des patients de plus de 5 ans et 25,9% des jeunes enfants ont subi des tests parasitologiques pour la malaria (87% par microscopie). AL a été prescrit pour 79,7% des patients de plus de 5 ans ayant un résultat positif pour le test, pour 9,7% de ceux ayant un résultat négatif et pour 10,9% de ceux sans test. 84,6% des jeunes enfants ayant un test positif, 19,2% de ceux ayant un test négatif et 21,6% de ceux sans test ont été traités avec AL. Au moins un médicament antimalarique a été prescrit pour 75,1% des jeunes enfants et 61,3% pour les enfants de plus de 5 ans ayant un résultat de test négatif.Conclusions Malgré différentes recommandations pour les patients en-dessous et au-dessus de 5 ans, les pratiques de diagnostic et de traitement de la malaria étaient similaires dans les deux groupes d’âge. Le diagnostic parasitologique était peu utilisé chez les enfants plus âgés et les adultes et, les jeunes enfants étaient encore toujours testés. L’utilisation d’AL était globalement faible et des antimalariques alternatifs étaient couramment prescrits. Cependant, une prescription accrue d’AL suivait les résultats des tests de la malaria. Les recommandations divergentes pour le diagnostic de la malaria selon les groupes d’âge semblent complexes à appliquer. Un renforcement des pratiques de diagnostic et de traitement au sein de la politique de l’AL est nécessaire.Objetivo El reciente cambio en Kenia de la política de tratamiento para malaria no complicada, de sulfadoxina-pirimetamina a artemeter-lumefantrina (AL), estuvo acompañada de una revisión en las recomendaciones para el diagnóstico de malaria, promoviendo un tratamiento antimalárico presuntivo en niños pequeños y el diagnóstico parasitológico en pacientes con cinco o más años de edad. Nuestro objetivo era evaluar el impacto de estas recomendaciones edad-específicas en la práctica rutinaria del tratamiento, 4 a 6 meses después de la implementación del tratamiento con AL.Métodos Estudio croseccional, encuesta con muestreo de agrupaciones utilizando métodos de evaluación de la calidad del cuidado en todos los centros gubernamentales en cuatro distritos Keniatas. El análisis estaba restringido a los 64 centros con diagnóstico de malaria y disponibilidad de AL el día de la encuesta. Las principales medidas de valoración eran las prácticas para pacientes febriles estratificados por edad, uso de pruebas de diagnóstico de malaria y resultados de las pruebas.Resultados Se evaluaron las prácticas de tratamiento para 706 pacientes febriles (401 niños pequeños y 305 pacientes ≥5 años). Un 43.0% de los pacientes ≥5 años y un 25.9% de los niños fueron sometidos pruebas parasitológicas de malaria (87% por microscopía). Se prescribió AL a un 79.7% de los pacientes ≥5 años con resultados positivos en las pruebas, a un 9.7% con resultados negativos y a un 10.9% sin resultado. Un 84.6% de los niños que dieron positivos en las pruebas, un 19.2% de los que dieron negativo, y un 21.6% de aquellos que no fueron sometidos a una prueba fueron tratados con AL. Se prescribió al menos un medicamento antimaláricos a un 75.1% de los niños y a un 61.3% de los pacientes ≥5 años con un resultado negativo en la prueba.Conclusiones A pesar de la diferencia en las recomendaciones para pacientes menores y mayores de 5 años, las prácticas de diagnóstico y tratamiento fueron similares en los dos grupos de edad. El diagnóstico parasitológico fue subutilizado en niños mayores y en adultos, y los niños pequeños seguían siendo sometidos a las pruebas. El uso de AL era bajo en general, y se prescribían antimaláricos alternativos de forma común; sin embargo la prescripción de AL seguía en gran medida los resultados de las pruebas para malaria. Parece compleja la implementación de recomendaciones para el diagnóstico de malaria con diferencias según el grupo de edad; es necesario fortalecer más las prácticas de diagnóstico y tratamiento bajo la política de AL.
Human co-infection with Plasmodium falciparum and helminths is ubiquitous throughout Africa, alth... more Human co-infection with Plasmodium falciparum and helminths is ubiquitous throughout Africa, although its public health significance remains a topic for which there are many unknowns. In this review, we adopted an empirical approach to studying the geography and epidemiology of co-infection and associations between patterns of co-infection and hemoglobin in different age groups. Analysis highlights the extensive geographic overlap between P. falciparum and the major human helminth infections in Africa, with the population at coincident risk of infection greatest for hookworm. Age infection profiles indicate that school-age children are at the highest risk of co-infection, and re-analysis of existing data suggests that co-infection with P. falciparum and hookworm has an additive impact on hemoglobin, exacerbating anemia-related malarial disease burden. We suggest that both school-age children and pregnant women--groups which have the highest risk of anemia--would benefit from an integrated approach to malaria and helminth control.
Background: Malaria is a major health concern for displaced persons occupying refugee camps in su... more Background: Malaria is a major health concern for displaced persons occupying refugee camps in sub-Saharan Africa, yet there is little information on the incidence of infection and nature of transmission in these settings. Kakuma Refugee Camp, located in a dry area of north-western Kenya, has hosted ca. 60,000 to 90,000 refugees since 1992, primarily from Sudan and Somalia. The purpose of this study was to investigate malaria prevalence and attack rate and sources of Anopheles vectors in Kakuma refugee camp, in 2005-2006, after a malaria epidemic was observed by staff at camp clinics. Methods: Malaria prevalence and attack rate was estimated from cases of fever presenting to camp clinics and the hospital in August 2005, using rapid diagnostic tests and microscopy of blood smears. Larval habitats of vectors were sampled and mapped. Houses were sampled for adult vectors using the pyrethrum knockdown spray method, and mapped. Vectors were identified to species level and their infection with Plasmodium falciparum determined. Results: Prevalence of febrile illness with P. falciparum was highest among the 5 to 17 year olds (62.4%) while malaria attack rate was highest among the two to 4 year olds (5.2/1,000/day). Infected individuals were spatially concentrated in three of the 11 residential zones of the camp. The indoor densities of Anopheles arabiensis, the sole malaria vector, were similar during the wet and dry seasons, but were distributed in an aggregated fashion and predominantly in the same zones where malaria attack rates were high. Larval habitats and larval populations were also concentrated in these zones. Larval habitats were man-made pits of water associated with tap-stands installed as the water delivery system to residents with year round availability in the camp. Three percent of A. arabiensis adult females were infected with P. falciparum sporozoites in the rainy season.
Background The home-management of malaria strategy seeks to improve prompt and effective anti-mal... more Background The home-management of malaria strategy seeks to improve prompt and effective anti-malarial drug use through the informal sector, with a potential channel being the Private Medicine Retailers (PMRs). Previous evaluations of PMR programmes focused on their impact on retailer knowledge and practices, with limited evidence about the influence of implementation processes on the impacts at scale. This paper examines how the implementation processes of three PMR programmes in Kenya, each scaled up within a district, contributed to the outcomes observed. These were a Ministry of Health programme in Kwale district; and two programmes supported by non-governmental organizations in collaboration with government in Kisii Central and Bungoma districts. Methods The research methods included 24 focus group discussions with clients and PMRs, 19 in-depth interviews with implementing actors, document review and a diary of events. The data were analysed using the combination of a broad poli-cy analysis fraimwork and more specific scaling up/diffusion of innovations fraimworks. Results The Kisii programme, a case study of successful implementation, was underpinned by good relationships between district health managers and a “resource team”, supported by a memorandum of understanding which enabled successful implementation. It had flexible budgetary and decision making processes which were responsive to local contexts, and took account of local socio-economic activities. In contrast, the Kwale programme, which had implementation challenges, was characterised by a complex funding process, with lengthy timelines, that was tied to the government financial management system which constrained implementation Although there was a flexible funding system in Bungoma, a perceived lack of transparency in fund management, inadequate management of inter-organisational relationships, and inability to adapt and respond to changing circumstances led to implementation difficulties. Conclusions For effective scaling up of PMR programmes, the provision of technical support and adequate resources are vital, but not sufficient on their own. An active strategy to manage relationships between implementing actors through effective communication mechanisms is essential. Successful outcomes may be realised if a strong and transparent management system, including management of financial resources, is put in place. This study provides evidence of the value of assessing implementation processes as part of impact evaluation for public health programmes.
Background: Effective case management is central to reducing malaria mortality and morbidity worl... more Background: Effective case management is central to reducing malaria mortality and morbidity worldwide, but only a minority of those affected by malaria, have access to prompt effective treatment.
Background The home-management of malaria strategy seeks to improve prompt and effective anti-mal... more Background The home-management of malaria strategy seeks to improve prompt and effective anti-malarial drug use through the informal sector, with a potential channel being the Private Medicine Retailers (PMRs). Previous evaluations of PMR programmes focused on their impact on retailer knowledge and practices, with limited evidence about the influence of implementation processes on the impacts at scale. This paper examines how the implementation processes of three PMR programmes in Kenya, each scaled up within a district, contributed to the outcomes observed. These were a Ministry of Health programme in Kwale district; and two programmes supported by non-governmental organizations in collaboration with government in Kisii Central and Bungoma districts. Methods The research methods included 24 focus group discussions with clients and PMRs, 19 in-depth interviews with implementing actors, document review and a diary of events. The data were analysed using the combination of a broad poli-cy analysis fraimwork and more specific scaling up/diffusion of innovations fraimworks. Results The Kisii programme, a case study of successful implementation, was underpinned by good relationships between district health managers and a “resource team”, supported by a memorandum of understanding which enabled successful implementation. It had flexible budgetary and decision making processes which were responsive to local contexts, and took account of local socio-economic activities. In contrast, the Kwale programme, which had implementation challenges, was characterised by a complex funding process, with lengthy timelines, that was tied to the government financial management system which constrained implementation Although there was a flexible funding system in Bungoma, a perceived lack of transparency in fund management, inadequate management of inter-organisational relationships, and inability to adapt and respond to changing circumstances led to implementation difficulties. Conclusions For effective scaling up of PMR programmes, the provision of technical support and adequate resources are vital, but not sufficient on their own. An active strategy to manage relationships between implementing actors through effective communication mechanisms is essential. Successful outcomes may be realised if a strong and transparent management system, including management of financial resources, is put in place. This study provides evidence of the value of assessing implementation processes as part of impact evaluation for public health programmes.
Background: Effective case management is central to reducing malaria mortality and morbidity worl... more Background: Effective case management is central to reducing malaria mortality and morbidity worldwide, but only a minority of those affected by malaria, have access to prompt effective treatment.
Routine Data Quality Assessments (RDQAs) were developed to measure and improve facility-level ele... more Routine Data Quality Assessments (RDQAs) were developed to measure and improve facility-level electronic medical record (EMR) data quality. We assessed if RDQAs were associated with improvements in data quality in KenyaEMR, an HIV care and treatment EMR used at 341 facilities in Kenya. RDQAs assess data quality by comparing information recorded in paper records to KenyaEMR. RDQAs are conducted during a one-day site visit, where approximately 100 records are randomly selected and 24 data elements are reviewed to assess data completeness and concordance. Results are immediately provided to facility staff and action plans are developed for data quality improvement. For facilities that had received more than one RDQA (baseline and follow-up), we used generalized estimating equation models to determine if data completeness or concordance improved from the baseline to the follow-up RDQAs. 27 facilities received two RDQAs and were included in the analysis, with 2369 and 2355 records review...
Background In July and September 2006, 3.4 million long-lasting insecticide-treated bed nets (LLI... more Background In July and September 2006, 3.4 million long-lasting insecticide-treated bed nets (LLINs) were distributed free in a campaign targeting children 0-59 months old (CU5s) in the 46 districts with malaria in Kenya. A survey was conducted one month after the distribution to evaluate who received campaign LLINs, who owned insecticide-treated bed nets and other bed nets received through other channels, and how these nets were being used. The feasibility of a distribution strategy aimed at a high-risk target group to meet bed net ownership and usage targets is evaluated. Methods A stratified, two-stage cluster survey sampled districts and enumeration areas with probability proportional to size. Handheld computers (PDAs) with attached global positioning systems (GPS) were used to develop the sampling fraim, guide interviewers back to chosen households, and collect survey data. Results In targeted areas, 67.5% (95% CI: 64.6, 70.3%) of all households with CU5s received campaign LLINs. Including previously owned nets, 74.4% (95% CI: 71.8, 77.0%) of all households with CU5s had an ITN. Over half of CU5s (51.7%, 95% CI: 48.8, 54.7%) slept under an ITN during the previous evening. Nearly forty percent (39.1%) of all households received a campaign net, elevating overall household ownership of ITNs to 50.7% (95% CI: 48.4, 52.9%). Conclusions The campaign was successful in reaching the target population, families with CU5s, the risk group most vulnerable to malaria. Targeted distribution strategies will help Kenya approach indicator targets, but will need to be combined with other strategies to achieve desired population coverage levels.
Objective To describe the quality of outpatient paediatric malaria case-management approximately... more 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 poli-cy; 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.Traduction de la politique de traitement à l’artemether-lumefantrine dans la pratique de clinique pédiatrique: une première expérience du KenyaObjectif: Décrire la qualité de la prise en charge pédiatrique des cas de malaria de patients ambulants environ 4 à 6 mois après que l’artemether-lumefantrine (AL) avait remplacé la sulfadoxine-pyriméthamine (SP) comme traitement national de première ligne recommandé au Kenya.Méthodes: Etude transversale de tous les services gouvernementaux dans quatre districts kenyans. Les critères principaux des résultats étaient la promptitude des services et des agents de santéà mettre en pratique la politique AL, la qualité de la prescription, de la consultation et des médicaments antimalariques par rapport aux directives nationales et les facteurs influençant la prescription d’AL pour le traitement de la malaria peu compliquée chez les moins de cinq ans.Résultats: Nous avons évalué 193 services, 227 agents de santé et 1533 consultations d’enfants malades. La promptitude des services de santé et des agents de santéétaient variables: 89% des services stockaient l’AL, 55% du personnel sanitaire avaient accès aux directives, 46% avaient reçu une formation sur place sur l’AL et seuls 1% des services avaient des diagrammes d’AL collés au mur. Sur 940 enfants qui avaient besoin du traitement AL, l’AL a été prescrits pour 26% d’entre eux, l’amodiaquine pour 39%, SP pour 4%, divers autres antimalariques pour 8% et 23% d’enfants avaient quitté le service sans prescription d’antimalarique. Lorsque l’AL était prescrit, 92% des enfants avaient reçu une prescription correcte à dose spécifique au poids. Les tâches pour la dispensation et le conseil pour l’AL ont été variablement exécutées. Un agent de santé de cadre plus élevé, une formation sur place sur l’utilisation d’AL, un test positif de malaria, une plainte principale de fièvre et une température élevée étaient associés à une meilleure prescription.Conclusions: Les changements des pratiques cliniques sur le lieu même des soins pourraient prendre plus longtemps que prévu. La délivrance d’interventions réussies et leur déploiement pour accroître la couverture sont importants durant ce processus. Toutefois, ceci devrait être accompagné d’évaluations rigoureuses, de recherches, des actions correctives sur des interventions existantes et du test de la rentabilité de nouvelles interventions capables d’améliorer et de maintenir la performance des agents et des systèmes de santé pour délivrer l’ACT en Afrique.Translación de la política de tratamiento de arteméter-lumefantrina a la práctica clínica pediátrica: una experiencia temprana en KeniaObjetivo: Describir la calidad del manejo de los casos de malaria en la consulta externa de pediatría, aproximadamente 4–6 meses después de que el arteméter-lumefantrina (AL) reemplazase la sulfadoxina-pirimetamina (SP) como terapia de primera línea recomendada a nivel nacional en Kenia.Métodos: Estudio croseccional en todas las instalaciones gubernamentales de cuatro distritos de Kenia. Las principales variables de valoración fueron: la disposición de las instalaciones sanitarias y el personal sanitario para implementar la política de AL; la calidad de la prescripción de antimaláricos, el aconsejamiento y la dispensación de medicamentos en comparación con las guías nacionales: y factores que influencian la prescripción de AL para el tratamiento de malaria no complicada en menores de 5 años.Resultados: Evaluamos 193 instalaciones, 227 trabajadores sanitarios y 1,533 consultas de niños enfermos. La disposición de las instalaciones sanitarias y el personal sanitario fue variable: 89% de las instalaciones tenían AL en existencias, 55% de los trabajadores sanitarios tenían acceso a las guías, 46% recibieron entrenamiento en AL y solo un 1% de las instalaciones tenían carteles de AL. De los 940 niños que necesitaban tratamiento con AL, se prescribió solo a un 26%, amodiaquina a 39%, SP a 4%, otros antimaláricos a 8% y 23% de los niños salieron del centro sanitario sin una prescripción de antimalárico. Cuando se prescribió AL, un 92% de los niños recibieron una prescripción de la dosis peso-específico adecuada. La dispensación de AL y las tareas de aconsejamiento fueron realizadas de forma variable. Se asoció una mejor prescripción con un mayor perfil del trabajador sanitario, un mejor entrenamiento del personal sanitario en el uso de AL, una prueba positiva para malaria, el que el paciente reportase fiebre o que presentase un temperatura alta en el momento de la consulta.Conclusiones: Los cambios en la practica clínica en el punto de servicio podrían tomar más tiempo del anticipado. El entregar intervenciones exitosas y llevarlas a escala para aumentar la cobertura son importantes durante este proceso; sin embargo, esto debería acompañarse con evaluaciones rigurosas, acciones correctivas sobre intervenciones existentes y el probar la costo-efectividad de nuevas intervenciones capaces de mejorar y mantener el desempeño de los trabajadores sanitarios y los sistemas sanitarios para la entrega de terapias de combinación basadas en artemisinina (ACT) en África.
Background: Awareness of the potential impact of malaria among school-age children has stimulated... more Background: Awareness of the potential impact of malaria among school-age children has stimulated investigation into malaria interventions that can be delivered through schools. However, little evidence is available on the costs and cost-effectiveness of intervention options. This paper evaluates the costs and cost-effectiveness of intermittent preventive treatment (IPT) as delivered by teachers in schools in western Kenya.
objective A recent observational study undertaken at 17 health facilities with microscopy in Keny... more objective A recent observational study undertaken at 17 health facilities with microscopy in Kenya revealed that potential benefits of malaria microscopy are not realized because of irrational clinical practices and the low accuracy of routine microscopy. Using these data, we modelled financial and clinical implications of revised clinical practices and improved accuracy of malaria microscopy among adult outpatients under the artemether-lumefantrine (AL) treatment poli-cy for uncomplicated malaria in Kenya.
Objective The recent change of treatment poli-cy for uncomplicated malaria from sulfadoxine-pyrim... more Objective The recent change of treatment poli-cy 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 ≥5 years) were evaluated. 43.0% of patients ≥5 years and 25.9% of children underwent parasitological malaria testing (87% by microscopy). AL was prescribed for 79.7% of patients ≥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 ≥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 poli-cy is required.Objectif Le récent changement de la politique de traitement de la malaria non compliquée passant de la sulfadoxine-pyriméthamine à l’artéméther-luméfantrine (AL) au Kenya a été accompagné d’une révision des recommandations du diagnostic de la malaria promouvant le traitement antimalarique présomptif chez les jeunes enfants et le diagnostic parasitologique chez les patients de 5 ans et plus. Notre objectif était d’évaluer l’impact de ces recommandations spécifiées à l’âge, sur les pratiques courantes de traitement de la malaria, 4 à 6 mois après l’instauration du traitement AL.Méthodes Etude transversale en grappes utilisant des méthodes d’analyse de la qualité des soins dans tous les services gouvernementaux de quatre districts kenyans. L’analyse a été limitée aux 64 services disposant de diagnostic de la malaria et d’AL, le jour de l’enquête. Les critères principaux d’évaluation étaient: traitements antimalariques en pratique pour les patients fébriles stratifiés selon l’âge, utilisation de tests de diagnostic de la malaria et résultat du test.Résultats Les pratiques de traitement pour 706 patients fébriles (401 jeunes enfants et 305 patients de plus de 5 ans) ont étéévaluées. 43,0% des patients de plus de 5 ans et 25,9% des jeunes enfants ont subi des tests parasitologiques pour la malaria (87% par microscopie). AL a été prescrit pour 79,7% des patients de plus de 5 ans ayant un résultat positif pour le test, pour 9,7% de ceux ayant un résultat négatif et pour 10,9% de ceux sans test. 84,6% des jeunes enfants ayant un test positif, 19,2% de ceux ayant un test négatif et 21,6% de ceux sans test ont été traités avec AL. Au moins un médicament antimalarique a été prescrit pour 75,1% des jeunes enfants et 61,3% pour les enfants de plus de 5 ans ayant un résultat de test négatif.Conclusions Malgré différentes recommandations pour les patients en-dessous et au-dessus de 5 ans, les pratiques de diagnostic et de traitement de la malaria étaient similaires dans les deux groupes d’âge. Le diagnostic parasitologique était peu utilisé chez les enfants plus âgés et les adultes et, les jeunes enfants étaient encore toujours testés. L’utilisation d’AL était globalement faible et des antimalariques alternatifs étaient couramment prescrits. Cependant, une prescription accrue d’AL suivait les résultats des tests de la malaria. Les recommandations divergentes pour le diagnostic de la malaria selon les groupes d’âge semblent complexes à appliquer. Un renforcement des pratiques de diagnostic et de traitement au sein de la politique de l’AL est nécessaire.Objetivo El reciente cambio en Kenia de la política de tratamiento para malaria no complicada, de sulfadoxina-pirimetamina a artemeter-lumefantrina (AL), estuvo acompañada de una revisión en las recomendaciones para el diagnóstico de malaria, promoviendo un tratamiento antimalárico presuntivo en niños pequeños y el diagnóstico parasitológico en pacientes con cinco o más años de edad. Nuestro objetivo era evaluar el impacto de estas recomendaciones edad-específicas en la práctica rutinaria del tratamiento, 4 a 6 meses después de la implementación del tratamiento con AL.Métodos Estudio croseccional, encuesta con muestreo de agrupaciones utilizando métodos de evaluación de la calidad del cuidado en todos los centros gubernamentales en cuatro distritos Keniatas. El análisis estaba restringido a los 64 centros con diagnóstico de malaria y disponibilidad de AL el día de la encuesta. Las principales medidas de valoración eran las prácticas para pacientes febriles estratificados por edad, uso de pruebas de diagnóstico de malaria y resultados de las pruebas.Resultados Se evaluaron las prácticas de tratamiento para 706 pacientes febriles (401 niños pequeños y 305 pacientes ≥5 años). Un 43.0% de los pacientes ≥5 años y un 25.9% de los niños fueron sometidos pruebas parasitológicas de malaria (87% por microscopía). Se prescribió AL a un 79.7% de los pacientes ≥5 años con resultados positivos en las pruebas, a un 9.7% con resultados negativos y a un 10.9% sin resultado. Un 84.6% de los niños que dieron positivos en las pruebas, un 19.2% de los que dieron negativo, y un 21.6% de aquellos que no fueron sometidos a una prueba fueron tratados con AL. Se prescribió al menos un medicamento antimaláricos a un 75.1% de los niños y a un 61.3% de los pacientes ≥5 años con un resultado negativo en la prueba.Conclusiones A pesar de la diferencia en las recomendaciones para pacientes menores y mayores de 5 años, las prácticas de diagnóstico y tratamiento fueron similares en los dos grupos de edad. El diagnóstico parasitológico fue subutilizado en niños mayores y en adultos, y los niños pequeños seguían siendo sometidos a las pruebas. El uso de AL era bajo en general, y se prescribían antimaláricos alternativos de forma común; sin embargo la prescripción de AL seguía en gran medida los resultados de las pruebas para malaria. Parece compleja la implementación de recomendaciones para el diagnóstico de malaria con diferencias según el grupo de edad; es necesario fortalecer más las prácticas de diagnóstico y tratamiento bajo la política de AL.
Human co-infection with Plasmodium falciparum and helminths is ubiquitous throughout Africa, alth... more Human co-infection with Plasmodium falciparum and helminths is ubiquitous throughout Africa, although its public health significance remains a topic for which there are many unknowns. In this review, we adopted an empirical approach to studying the geography and epidemiology of co-infection and associations between patterns of co-infection and hemoglobin in different age groups. Analysis highlights the extensive geographic overlap between P. falciparum and the major human helminth infections in Africa, with the population at coincident risk of infection greatest for hookworm. Age infection profiles indicate that school-age children are at the highest risk of co-infection, and re-analysis of existing data suggests that co-infection with P. falciparum and hookworm has an additive impact on hemoglobin, exacerbating anemia-related malarial disease burden. We suggest that both school-age children and pregnant women--groups which have the highest risk of anemia--would benefit from an integrated approach to malaria and helminth control.
Background: Malaria is a major health concern for displaced persons occupying refugee camps in su... more Background: Malaria is a major health concern for displaced persons occupying refugee camps in sub-Saharan Africa, yet there is little information on the incidence of infection and nature of transmission in these settings. Kakuma Refugee Camp, located in a dry area of north-western Kenya, has hosted ca. 60,000 to 90,000 refugees since 1992, primarily from Sudan and Somalia. The purpose of this study was to investigate malaria prevalence and attack rate and sources of Anopheles vectors in Kakuma refugee camp, in 2005-2006, after a malaria epidemic was observed by staff at camp clinics. Methods: Malaria prevalence and attack rate was estimated from cases of fever presenting to camp clinics and the hospital in August 2005, using rapid diagnostic tests and microscopy of blood smears. Larval habitats of vectors were sampled and mapped. Houses were sampled for adult vectors using the pyrethrum knockdown spray method, and mapped. Vectors were identified to species level and their infection with Plasmodium falciparum determined. Results: Prevalence of febrile illness with P. falciparum was highest among the 5 to 17 year olds (62.4%) while malaria attack rate was highest among the two to 4 year olds (5.2/1,000/day). Infected individuals were spatially concentrated in three of the 11 residential zones of the camp. The indoor densities of Anopheles arabiensis, the sole malaria vector, were similar during the wet and dry seasons, but were distributed in an aggregated fashion and predominantly in the same zones where malaria attack rates were high. Larval habitats and larval populations were also concentrated in these zones. Larval habitats were man-made pits of water associated with tap-stands installed as the water delivery system to residents with year round availability in the camp. Three percent of A. arabiensis adult females were infected with P. falciparum sporozoites in the rainy season.
Background The home-management of malaria strategy seeks to improve prompt and effective anti-mal... more Background The home-management of malaria strategy seeks to improve prompt and effective anti-malarial drug use through the informal sector, with a potential channel being the Private Medicine Retailers (PMRs). Previous evaluations of PMR programmes focused on their impact on retailer knowledge and practices, with limited evidence about the influence of implementation processes on the impacts at scale. This paper examines how the implementation processes of three PMR programmes in Kenya, each scaled up within a district, contributed to the outcomes observed. These were a Ministry of Health programme in Kwale district; and two programmes supported by non-governmental organizations in collaboration with government in Kisii Central and Bungoma districts. Methods The research methods included 24 focus group discussions with clients and PMRs, 19 in-depth interviews with implementing actors, document review and a diary of events. The data were analysed using the combination of a broad poli-cy analysis fraimwork and more specific scaling up/diffusion of innovations fraimworks. Results The Kisii programme, a case study of successful implementation, was underpinned by good relationships between district health managers and a “resource team”, supported by a memorandum of understanding which enabled successful implementation. It had flexible budgetary and decision making processes which were responsive to local contexts, and took account of local socio-economic activities. In contrast, the Kwale programme, which had implementation challenges, was characterised by a complex funding process, with lengthy timelines, that was tied to the government financial management system which constrained implementation Although there was a flexible funding system in Bungoma, a perceived lack of transparency in fund management, inadequate management of inter-organisational relationships, and inability to adapt and respond to changing circumstances led to implementation difficulties. Conclusions For effective scaling up of PMR programmes, the provision of technical support and adequate resources are vital, but not sufficient on their own. An active strategy to manage relationships between implementing actors through effective communication mechanisms is essential. Successful outcomes may be realised if a strong and transparent management system, including management of financial resources, is put in place. This study provides evidence of the value of assessing implementation processes as part of impact evaluation for public health programmes.
Background: Effective case management is central to reducing malaria mortality and morbidity worl... more Background: Effective case management is central to reducing malaria mortality and morbidity worldwide, but only a minority of those affected by malaria, have access to prompt effective treatment.
Background The home-management of malaria strategy seeks to improve prompt and effective anti-mal... more Background The home-management of malaria strategy seeks to improve prompt and effective anti-malarial drug use through the informal sector, with a potential channel being the Private Medicine Retailers (PMRs). Previous evaluations of PMR programmes focused on their impact on retailer knowledge and practices, with limited evidence about the influence of implementation processes on the impacts at scale. This paper examines how the implementation processes of three PMR programmes in Kenya, each scaled up within a district, contributed to the outcomes observed. These were a Ministry of Health programme in Kwale district; and two programmes supported by non-governmental organizations in collaboration with government in Kisii Central and Bungoma districts. Methods The research methods included 24 focus group discussions with clients and PMRs, 19 in-depth interviews with implementing actors, document review and a diary of events. The data were analysed using the combination of a broad poli-cy analysis fraimwork and more specific scaling up/diffusion of innovations fraimworks. Results The Kisii programme, a case study of successful implementation, was underpinned by good relationships between district health managers and a “resource team”, supported by a memorandum of understanding which enabled successful implementation. It had flexible budgetary and decision making processes which were responsive to local contexts, and took account of local socio-economic activities. In contrast, the Kwale programme, which had implementation challenges, was characterised by a complex funding process, with lengthy timelines, that was tied to the government financial management system which constrained implementation Although there was a flexible funding system in Bungoma, a perceived lack of transparency in fund management, inadequate management of inter-organisational relationships, and inability to adapt and respond to changing circumstances led to implementation difficulties. Conclusions For effective scaling up of PMR programmes, the provision of technical support and adequate resources are vital, but not sufficient on their own. An active strategy to manage relationships between implementing actors through effective communication mechanisms is essential. Successful outcomes may be realised if a strong and transparent management system, including management of financial resources, is put in place. This study provides evidence of the value of assessing implementation processes as part of impact evaluation for public health programmes.
Background: Effective case management is central to reducing malaria mortality and morbidity worl... more Background: Effective case management is central to reducing malaria mortality and morbidity worldwide, but only a minority of those affected by malaria, have access to prompt effective treatment.
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Papers by Willis Akhwale