肯尼亚基苏木县农村社区医疗保健提供者在疟疾诊断和治疗方面的实践。
Health care provider practices in diagnosis and treatment of malaria in rural communities in Kisumu County, Kenya.
机构信息
Department of Zoology, Maseno University, Kisumu, Kenya.
International Centre of Excellence for Malaria Research, Tom Mboya University College of Maseno University, Homa Bay, Kenya.
出版信息
Malar J. 2022 Apr 22;21(1):129. doi: 10.1186/s12936-022-04156-z.
BACKGROUND
Accurate malaria diagnosis and appropriate treatment at local health facilities are critical to reducing morbidity and human reservoir of infectious gametocytes. The current study assessed the accuracy of malaria diagnosis and treatment practices in three health care facilities in rural western Kenya.
METHODS
The accuracy of malaria detection and treatment recommended compliance was monitored in two public and one private hospital from November 2019 through March 2020. Blood smears from febrile patients were examined by hospital laboratory technicians and re-examined by an expert microscopists thereafter subjected to real-time polymerase chain reaction (RT-PCR) for quality assurance. In addition, blood smears from patients diagnosed with malaria rapid diagnostic tests (RDT) and presumptively treated with anti-malarial were re-examined by an expert microscopist.
RESULTS
A total of 1131 febrile outpatients were assessed for slide positivity (936), RDT (126) and presumptive diagnosis (69). The overall positivity rate for Plasmodium falciparum was 28% (257/936). The odds of slide positivity was higher in public hospitals, 30% (186/624, OR:1.44, 95% CI = 1.05-1.98, p < 0.05) than the private hospital 23% (71/312, OR:0.69, 95% CI = 0.51-0.95, p < 0.05). Anti-malarial treatment was dispensed more at public hospitals (95.2%, 177/186) than the private hospital (78.9%, 56/71, p < 0.0001). Inappropriate anti-malarial treatment, i.e. artemether-lumefantrine given to blood smear negative patients was higher at public hospitals (14.6%, 64/438) than the private hospital (7.1%, 17/241) (p = 0.004). RDT was the most sensitive (73.8%, 95% CI = 39.5-57.4) and specific (89.2%, 95% CI = 78.5-95.2) followed by hospital microscopy (sensitivity 47.6%, 95% CI = 38.2-57.1) and specificity (86.7%, 95% CI = 80.8-91.0). Presumptive diagnosis had the lowest sensitivity (25.7%, 95% CI = 13.1-43.6) and specificity (75.0%, 95% CI = 50.6-90.4). RDT had the highest non-treatment of negatives [98.3% (57/58)] while hospital microscopy had the lowest [77.3% (116/150)]. Health facilities misdiagnosis was at 27.9% (77/276). PCR confirmed 5.2% (4/23) of the 77 misdiagnosed cases as false positive and 68.5% (37/54) as false negative.
CONCLUSIONS
The disparity in malaria diagnosis at health facilities with many slide positives reported as negatives and high presumptive treatment of slide negative cases, necessitates augmenting microscopic with RDTs and calls for Ministry of Health strengthening supportive infrastructure to be in compliance with treatment guidelines of Test, Treat, and Track to improve malaria case management.
背景
在当地卫生机构准确诊断疟疾并进行适当治疗对于降低发病率和人类感染性配子体储存至关重要。本研究评估了肯尼亚西部农村地区三家医疗保健机构的疟疾诊断和治疗实践的准确性。
方法
2019 年 11 月至 2020 年 3 月，监测了两家公立医院和一家私立医院的疟疾检测准确性和推荐治疗的依从性。医院实验室技术员检查发热患者的血涂片，然后由专家显微镜检查员进行复查，随后进行实时聚合酶链反应（RT-PCR）以保证质量。此外，对经快速诊断检测（RDT）诊断为疟疾并疑似接受抗疟治疗的患者的血涂片进行专家显微镜检查。
结果
共评估了 1131 名发热门诊患者的涂片阳性率（936 例）、RDT（126 例）和疑似诊断（69 例）。恶性疟原虫的总阳性率为 28%（257/936）。公立医院的涂片阳性率较高，为 30%（186/624，OR：1.44，95%CI=1.05-1.98，p<0.05），而私立医院的阳性率为 23%（71/312，OR：0.69，95%CI=0.51-0.95，p<0.05）。抗疟治疗在公立医院（95.2%，177/186）比私立医院（78.9%，56/71，p<0.0001）更广泛。在公立医院（14.6%，64/438）比私立医院（7.1%，17/241，p=0.004），抗疟治疗的不合理性更高，即给涂片阴性的患者使用青蒿琥酯-甲氟喹。RDT 是最敏感（73.8%，95%CI=39.5-57.4）和特异（89.2%，95%CI=78.5-95.2）的，其次是医院显微镜检查（敏感性 47.6%，95%CI=38.2-57.1）和特异性（86.7%，95%CI=80.8-91.0）。疑似诊断的敏感性最低（25.7%，95%CI=13.1-43.6）和特异性（75.0%，95%CI=50.6-90.4）。RDT 对阴性患者的非治疗率最高[98.3%（57/58）]，而医院显微镜检查的非治疗率最低[77.3%（116/150）]。卫生机构的误诊率为 27.9%（77/276）。PCR 证实 5.2%（4/43）的 77 例误诊病例为假阳性，68.5%（37/54）为假阴性。
结论
卫生机构在疟疾诊断方面存在差异，许多报告的涂片阳性病例被误诊为阴性，而且对涂片阴性病例的疑似治疗率较高，这需要用 RDT 来补充显微镜检查，并呼吁卫生部加强支持性基础设施建设，以符合“检测、治疗和跟踪”的治疗指南，从而改善疟疾病例管理。
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