Improved clinical and laboratory skills after team-based, malaria case management training of health care professionals in Uganda

Allen Namagembe 2 Umaru Ssekabira 2 Marcia R Weaver 0 Nancy Blum 1 Sarah Burnett 1 Grant Dorsey 5 Lydia Mpanga Sebuyira 0 2 Alex Ojaku 2 Gisela Schneider 4 Kelly Willis 1 Adoke Yeka 3 0 International Training and Education Center for Health, Department of Global Health, University of Washington , Seattle, WA , USA 1 Accordia Global Health Foundation , 1101 14th Street, NW, Suite 801, Washington, DC , USA 2 Infectious Diseases Institute, Makerere College of Health Sciences , Kampala , Uganda 3 Uganda Malaria Surveillance Program, c/o Infectious Disease Research Collaboration , PO Box 7475, Kampala , Uganda 4 DIFAEM , Paul Lechler Strasse 24, D 72076 Tubingen , Germany 5 Department of Medicine, University of California San Francisco , San Francisco, CA , USA Background: Deployment of highly effective artemisinin-based combination therapy for treating uncomplicated malaria calls for better targeting of malaria treatment to improve case management and minimize drug pressure for selecting resistant parasites. The Integrated Management of Malaria curriculum was developed to train multidisciplinary teams of clinical, laboratory and health information assistants. Methods: Evaluation of training was conducted in nine health facilities that were Uganda Malaria Surveillance Programme (UMSP) sites. From December 2006 to June 2007, 194 health professionals attended a six-day course. One-hundred and one of 118 (86%) clinicians were observed during patient encounters by expert clinicians at baseline and during three follow-up visits approximately six weeks, 12 weeks and one year after the course. Experts used a standardized tool for children less than five years of age and similar tool for patients five or more years of age. Seventeen of 30 laboratory professionals (57%) were assessed for preparation of malaria blood smears and ability to interpret smear results of 30 quality control slides. Results: Percentage of patients at baseline and first follow-up, respectively, with proper history-taking was 21% and 43%, thorough physical examination 18% and 56%, correct diagnosis 51% and 98%, treatment in compliance with national policy 42% and 86%, and appropriate patient education 17% and 83%. In estimates that adjusted for individual effects and a matched sample, relative risks were 1.86 (95% CI: 1.20,2.88) for history-taking, 2.66 (95%CI: 1.60,4.41) for physical examination, 1.77 (95%CI: 1.41,2.23) for diagnosis, 1.96 (95%CI: 1.46,2.63) for treatment, and 4.47 (95%CI: 2.68,7.46) for patient education. Results were similar for subsequent follow-up and in sub-samples stratified by patient age. Quality of malaria blood smear preparation improved from 21.6% at baseline to 67.3% at first follow-up (p < 0.008); sensitivity of interpretation of quality control slides increased from 48.6% to 70.6% (p < 0.199) and specificity increased from 72.1% to 77.2% (p < 0.736). Results were similar for subsequent follow-up, with the exception of a significant increase in specificity (94.2%, p < 0.036) at one year. Conclusion: A multi-disciplinary team training resulted in statistically significant improvements in clinical and laboratory skills. As a joint programme, the effects cannot be distinguished from UMSP activities, but lend support to long-term, on-going capacity-building and surveillance interventions. - Background Many malaria endemic countries have deployed artemisinin-based combination therapy (ACT) as first-line treatment for uncomplicated Plasmodium falciparum malaria [1]. To improve case management and minimize drug pressure for selecting resistant parasites, ACT should be targeted to patients who are parasite positive, and another diagnosis and treatment should be sought for patients who are not. In 2010, the World Health Organization (WHO) recommended a prompt parasitological confirmation of diagnosis in all patients suspected of having malaria before treatment is started [2]. This recommendation has drawn attention to the poor quality of care for patients with fever in general and malaria in specific, and to a search for interventions to improve the quality of care. In a review of case management of fever among children in Africa, Zurovac and Rowe [3] reported that outpatient clinics with a recent quality improvement intervention had higher median percentages of children who were treated correctly than clinics without an intervention. In a more detailed comparison of five studies with similar research design, in-service training improved the quality of treatment for children with uncomplicated malaria in one out of five studies, guidelines in one out of two studies, wall charts in two out of four studies, and supervision visits in two out of two studies. These studies pre-dated treatment with artemether + lumefantrine (AL) or Coartem, with the exception of Zurovac et al., which showed no effect of these quality improvement interventions in Zambia [4]. An update from Zambia reported increases in the percentage of children treated correctly after expanding training, wall charts, treatment guidelines and capacity for diagnostic tests [5]. A more recent study in Tanzania on the effect of introducing malaria rapid diagnostic tests and a brief training course to guide fever case management found no improvement in clinician prescribing practices [6]. Few studies have reported the effect of training programmes to improve the quality of laboratory diagnosis of malaria. Recently, Kiggundu et al. reported that a three-day laboratory training in Uganda significantly improved the sensitivity and specificity of thick blood smears, and increased the percentage of well-prepared blood smears [7]. Ngasala et al. reported the sensitivity of blood smear microscopy was 74.5% after a training programme in Tanzania, but did not report baseline data [8]. Bates et al. reported that the percentage of laboratories with accurate malaria tests increased from 84% to 91% after a training and quality assurance programme in Ghana, but did not report a statistical test [9]. The National Malaria Control Program (NMCP) of Uganda recommended AL as the first-line treatment for uncomplicated malaria in 2005 [10] due to development of resistance to chloroquine and sulphadoxinepyrimethamine (Fansidar), and initiated wide-scale distribution of AL in 2006. Accordia Global Health Foundation forged a partnership with the Infectious Diseases Institute (IDI) and the Uganda Malaria Surveillance Program (UMSP), to design and prospectively evaluate the Joint Uganda Malaria Training Program (JUMP). The evaluation used three complementary sources of data: 1) on-site observation of clinical care and laboratory testing, 2) UMSP surveillance data on four clinic-level performance indicators, and 3) quality assurance data on the laboratories. Ssekebira et al. reported the results on surveillance and quality assurance data [11]. Surveillance data for four months preceding the six-day course were compared to four months immediately after (...truncated)