|Year : 2021 | Volume
| Issue : 2 | Page : 79-83
Evaluation of the pediatric antimalarial prescriptions in a teaching hospital in Southeastern Nigeria
Adaobi Uchenna Mosanya
Department of Clinical Pharmacy and Pharmacy Management, University of Nigeria, Nsukka, Nigeria
|Date of Submission||23-Sep-2019|
|Date of Decision||20-May-2020|
|Date of Acceptance||11-Jun-2020|
|Date of Web Publication||27-Oct-2021|
Adaobi Uchenna Mosanya
Department of Clinical Pharmacy and Pharmacy Management, University of Nigeria, Nsukka
Source of Support: None, Conflict of Interest: None
Background: Malaria in Nigeria with the highest morbidity and mortality in children between 6 months and 5 years continues to be a disease burden. In line with the World Health Organization recommendation of diagnosis in all ages before treatment, Nigeria provided guidelines on parasite-based diagnosis. Therefore, in order to achieve its preelimination and the reduction of mortality caused by it to zero by 2020, it is necessary to assess the compliance of the prescribers to the guidelines. Objectives: The objectives of this study were to determine the cases who were diagnosed based on positive malaria parasite test and the level of compliance of the prescribers to the National Malaria Treatment Guidelines. Methods: A total of 3034 prescriptions of antimalarial drugs were collected between 2003 and 2011 in the Outpatient Department of the Pediatric Clinic. Data were analyzed using Microsoft Excel and SPSS V.20.0 and grouped into two: prepolicy (2003–2005) and postpolicy (2006–2011) periods. Descriptive and inferential statistics were used at P < 0.05 level of significance. Results: The study revealed that diagnosis based on positive malaria parasite test was 4.8% of 2765 patients. There was a noticeable increase in the prescription of artemisinin combination therapy in the postpolicy period (32.6%), but the compliance to the Antimalarial Treatment Guideline was low (23.8%). Conclusion: There was a high incidence of empirical diagnoses of malaria and treatment. Many of the artemisinin-based combination therapies prescribed were not recommended.
Keywords: Antimalarials, artemisinin, child, humans, incidence, malaria, Nigeria, outpatients, parasites, prescriptions
|How to cite this article:|
Mosanya AU. Evaluation of the pediatric antimalarial prescriptions in a teaching hospital in Southeastern Nigeria. CHRISMED J Health Res 2021;8:79-83
|How to cite this URL:|
Mosanya AU. Evaluation of the pediatric antimalarial prescriptions in a teaching hospital in Southeastern Nigeria. CHRISMED J Health Res [serial online] 2021 [cited 2021 Dec 2];8:79-83. Available from: https://www.cjhr.org/text.asp?2021/8/2/79/329454
| Introduction|| |
In line with the World Health Organization (WHO) recommendation of diagnosis in all age groups before treatment, Nigeria has provided guidelines on parasite-based diagnosis. Malaria in Nigeria with the highest morbidity and mortality in children between 6 months and 5 years accounts for 60% of outpatient visits and 30% of hospitalizations. It was necessary to assess the extent of adherence of the prescribers to the guideline in order to achieve preelimination of malaria and reduction of mortality caused by it to zero by 2020. This study sought to evaluate the antimalarial prescriptions of pediatric patients between 6 months and 5 years because they are most vulnerable with higher morbidity and mortality. The objectives of this study were to determine the cases who were diagnosed based on positive malaria parasite test and the extent of adherence of the prescribers to the National Malaria Treatment Guidelines. Although some studies for the population have been carried out in South-West and South-South Nigeria, none has been carried out for the at-risk target population within 2003–2011 for the South-East Region which comprises five states, namely Enugu, Anambra, Ebonyi, Imo, and Abia.
| Methods|| |
The ethical clearance to carry out the study was sought and obtained from the Ethics Committee of Health Research of the University of Nigeria Teaching Hospital (UNTH), Enugu State. Confidentiality of all patients' data got from the prescriptions was maintained throughout the study.
Study design and setting
The research was a retrospective, cross-sectional, and descriptive study which assessed the antimalarial prescriptions in the Outpatient Department of the Pediatric Unit of the UNTH, Enugu State. This setting was chosen because of its reputation as the biggest teaching hospital in the southeastern region of Nigeria. Enugu has a population of 722,664. UNTH is a tertiary health-care facility of about 500-bed capacity, located 21 km from Enugu capital city along Enugu-Port Harcourt Expressway. The Pediatric Clinic of the UNTH 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 are usually through CHER for emergency cases, CHOP for general pediatric cases, and CC for children who were either referred for specialist care or had been previously admitted for in-patient care.
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 CHOP from 2003 to 2011 were assessed. All uncomplicated malaria cases from 2003 to 2011 were isolated and assessed. All prescriptions for patients with uncomplicated malaria below 6 months and above 5 years of age and patients with special disease conditions such as HIV/AIDS, G6PD deficiency, and sickle cell disease were excluded.
A modified prescribing indicator form which had been validated by the WHO was used to obtain the following data: demographic data such as sex, age, and weight, clinical presentation; significant signs and symptoms; laboratory investigation data; and drug use indicator such as:
These were all the drugs prescribed as generics:
This measures the tendency to prescribe by generic name.
This measures the overall level of the use of two important but commonly overused and costly forms of drug therapy.
This measures the compliance of the prescribers to the ATG.
This measures the change in the antimalarial prescription pattern after the introduction of the treatment guideline.
Data collected were entered into Microsoft Excel sheet and were grouped into two: those from the year 2003 to 2005 (prepolicy period) and those from the year 2006 to 2011 (postpolicy). Then, they were sorted, cleaned, and exported to SPSS 20.0 (SPSS Inc., Chicago, Illinois, U.S.A) for analysis. Both inferential and descriptive statistics were used. Some of the descriptive statistics were percentage of malaria cases diagnosed before and after laboratory investigation, percentage of drugs prescribed in generics e. t. c. Drug use was expressed in terms of DU90%. This reflected the number of drugs that accounted for 90% of the drug prescriptions. Adherence to the treatment guidelines was assessed. This was expressed as the number of prescribed regimens recommended by the National ATG.
Inferential statistics used were t-test. The level of statistical significance was set at P < 0.05. t-test was run to test for any significant differences in the results obtained from the prepolicy period and the postpolicy period.
| Results|| |
Patients' demographics and the clinical characteristics
Information on the patients' demographic and clinical characteristics are presented in [Table 1]. Not all the demographic data were recorded for each patient's medical record. For example, in the prepolicy period, 464 patients were recorded to be males, whereas 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. The mean age in months of the patients in the prepolicy period was 21.20 (±13.91), very close to that observed in the postpolicy period, 22.51 (±14.27). The average body temperature in degree Celsius was 37.4 (±2.94) and 37.45 (±2.40) for the pre- and postpolicy periods, respectively. The most recurrent symptom for the two periods was fever. The result shows that for the prepolicy period, 808 (92.3%) patients had fever on examination by the physician, whereas for the postpolicy period, there were 1869 (89.3%) patients with fever. Other symptoms were cough, diarrhea, and vomiting. Chill and headache were the least recorded symptoms. For the prepolicy period, five patients had headache, whereas only three patients had chill with 0.6% and 0.3% as the respective percentages.
Percentage of cases diagnosed based on laboratory investigation
In the prepolicy and postpolicy periods, only 46 (5.5%) and 95 (4.8%) patients were diagnosed with malaria after a positive malaria parasite (mp) test, respectively (P = 0.409). This meant that the difference between the number of patients diagnosed with malaria after a positive malaria parasite (mp) test in the prepolicy and postpolicy periods was not statistically significant.
Antimalarial prescribed during the pre/postpolicy periods
[Figure 1] shows the antimalarial in the DU 90% segment. In the prepolicy period, three antimalarial accounted for DU90%. These were chloroquine 356 (40.7%), sulfadoxine/pyrimethamine (SP) combination 352 (40.3%), and artesunate and amodiaquine (AA) combination 116 (13.7%). Whereas, in the postpolicy period, three antimalarial also accounted for the DU90%. They were artemether/lumefantrine (AL) combination 1318 (63.3%), AA 438 (21.2%), and Quinine 138 (6.7%).
[Table 2] has the antimalarial drugs prescribed during the study period. AL changed significantly from accounting for only 2% of the antimalarial prescriptions in the prepolicy period to 63.3% of the prescriptions in the postpolicy period (P < 0.001), whereas AA combinations moved from accounting for 13.7% of the prescriptions in the prepolicy period to 21.2% in the postpolicy period (P < 0.001).
Drug use indicators
The mean number of drugs prescribed in generics per prescription in the prepolicy period (1.91 ± 0.97266) was more than that of the postpolicy (1.61 ± 0.98125), P < 0.001. Likewise, there was a marked reduction in the average number of antimalarial prescribed per prescription from the prepolicy period (1.23 ± 0.42137) to the postpolicy period (1.03 ± 0.17507), P < 0.001. Nevertheless, there was no significant difference in the prescription pattern of antibiotics in both periods. The percentage of drugs prescribed in generics for the years 2003-2005 was 52.55% and 46.7% for the years 2006-2011 (P < 0.001)
| Discussion|| |
This study revealed that very few patients were diagnosed based on positive malaria parasite test, and there was an increase in the prescription of artemisinin-based combination medicines. However, the prescribers did not adhere strictly to the National Malaria Treatment Guidelines. In other words, there was a high incidence of empirical diagnosis/treatment of malaria as opposed to parasitological/confirmatory diagnosis/treatment. Furthermore, many of the artemisinin-based combination therapies prescribed were not the recommended ones. Although in the past, empirical treatment was allowed in areas that lack sufficient medical supplies or trained personnel, the high incidence of presumptive treatment observed in our study may have resulted in the antimalarial treatment of patients without malaria. Furthermore, this may have exposed the patients to potential risks of adverse drug reactions associated with ACTs such as gastrointestinal distress, neutropenia, hepatotoxicity, and neurotoxicity. Similar results were got from a study by Otokpa et al., where 93.7% (n = 427) of the pediatric patients were presumptively treated with antimalarials. Another study conducted in Lagos State demonstrated that the majority of the malaria cases treated were diagnosed based on only the clinical features.
Among the antimalarial drugs prescribed, only two of the artemisinin-based combination therapies (ACTs) made a significant difference. These were AL and AA combinations. Artemether/lumefantrine combination was the most prescribed antimalarial drug throughout the study period. This is a reflection of the significant increase in the prescription of artemisinin combination therapy (ACT), particularly AL following the recommendation of the ATG published in 2005. A comparable study in Abuja revealed an increase in the prescription of ACTs following the WHO recommendations. Even though AL-fixed combination was in use in 2005, the combination of AA was the most used ACT in that year. AA (Camoquin®) was in existence as individual formulations. Prescribers may have been compelled to prescribe such combinations following positive results from the trials carried out on the combination in different African countries; Burkina Faso, Mali, the Republic of the Congo, Nigeria, and Ghana.
The adherence to the ATG was quite low. This is an indicator that not all the ACTs prescribed were according to the guideline. Nevertheless, past researches have shown that the adoption of ACT use in Nigeria is posed with obstacles such as exorbitant prices, insufficient supply, and poor knowledge and attitudinal disposition of health-care workers to ACT use.
There was a significant difference in the percentage of drugs prescribed as generics between the pre and post policy periods of the study. However, both observations are higher than those made in similar researches. In a study carried out in Abuja, the overall percentage of drugs prescribed in generics was 39.56%, whereas that from Ilorin showed 41.9%.
| Conclusion|| |
This study revealed an increase in the prescription of artemisinin-based combination therapy after the introduction of the National Malarial Treatment Guideline. Nevertheless, prescribers did not adhere strictly to the guideline. Many of the artemisinin-based combination therapies 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 is a need for improvement in the prescription of drugs in generics by prescribers.
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 the rational prescription of these drugs and the implementation of the guideline.
I appreciate the help of some of the staff of the Teaching Hospital who made the patient's folders available for data collection. I acknowledge the help of Prof. C.V. Ukwe and Prof. J.M. Okonta for their supervisory contributions.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]