Com munity drug use practices in m alaria in Cambodia: a cr oss-sectional study

1. 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

2. Part Two The quality and impact of prescribing on the Cambodian-Thai border Presented by Ros Seyha

3. 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

4. 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

5. Sufficient Duration of Treatment

6. Sufficient Duration by Source

7. 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?

8. The most commonly recommended treatment for simple cases of malaria.   Treating simple malaria(provider statements) • Referral: 25% providers said they would refer simple cases of malaria; even those with antimalarials!?   • Only 46% treatments from all providers were of at least 80% effectiveness

9. The most commonly recommended treatment for simple cases of malaria   Treating simple malaria (provider vs. household statements) • In general these claims conflicted with the findings of the household survey, which measured practice.

10. Treating Simple Malaria in Different Settings Government setting: Public Health Services Market setting: Drugs shop, Pharmacies, Clinics Village setting: Drugs shops, Clinics, General shops

11. Government: 8% were less than 80% effectiveness • Market: 35% were less than 80% effectiveness • Village: 56% were less than 80% effectiveness Case A: Drug choice and Efficacy (dose and duration)

12. 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?”

13. The most commonly recommended treatment for severe cases of malaria.   Treating severe malaria(provider statements) • Referral: 70% providers said they would refer severe cases of malaria   • Only 25% treatments from all providers were of at least 80% effectiveness

14. Treating Severe Malaria in Different Settings Government setting: Public Health Services Market setting: Drugs shop, Pharmacies, Clinics Village setting: Drugs shops, Clinics, General shops

15. Government: 43% were less than 80% effectiveness • Market: 69% were less than 80% effectiveness • Village: 78% were less than 80% effectiveness Case B: Drug choice and Efficacy (dose and duration)

16. Village: 78% were less than 80% effectiveness • 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) Case B: Drug choice and Efficacy (dose and duration)

17. 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%)

18. 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

19. 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

20. 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

21. 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 dangerousdrugs was common, especially in villages • Inappropriate use of injections and infusions increases risks and costs

22. 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

23. For further information, please contact: cnm@bigpond.com.kh Thank you