Malaria case management in Papua New Guinea prior to the introduction of a revised treatment protocol

BACKGROUND: This study aimed to document malaria case management practices in Papua New Guinea prior to the introduction of a revised national malaria treatment protocol. The revised protocol stipulates routine testing of malaria infection by rapid diagnostic test or microscopy, anti-malarial prescription to test positive cases only, and the introduction of a new artemisinin-based first-line anti-malarial. Findings presented in this paper primarily focus on diagnostic, prescription and treatment counselling practices. METHODS: In a national cross-sectional survey of 79 randomly selected health facilities, data were collected via non-participant observation of the clinical case management of patients presenting with fever or a recent history of fever. Data were recorded on a structured clinical observation instrument. RESULTS: Overall, 15% of observed fever patients (n=468) were tested for malaria infection by rapid diagnostic test and a further 3.6% were tested via microscopy. An anti-malarial prescription was made in 96.4% (451/468) of cases, including 100% (17/17) of test positive cases and 82% (41/50) of test negative cases. In all, 79.8% of anti-malarial prescriptions conformed to the treatment protocol current at the time of data collection. The purpose of the prescribed medication was explained to patients in 63.4% of cases, dosage/regimen instructions were provided in 75.7% of cases and the possibility of adverse effects and what they might look like were discussed in only 1.1% of cases. CONCLUSION: The revised national malaria treatment protocol will require a substantial change in current clinical practice if it is to be correctly implemented and adhered to. Areas that will require the most change include the shift from presumptive to RDT/microscopy confirmed diagnosis, prescribing (or rather non-prescribing) of anti-malarials to patients who test negative for malaria infection, and the provision of thorough treatment counselling. A comprehensive clinician support programme, possibly inclusive of 'booster' training opportunities and regular clinical supervision will be needed to support the change