KNOWLEDGE, ATTITUDES AND PRACTICES ON MALARIA IN NEONATES AMONG - - PowerPoint PPT Presentation

KNOWLEDGE, ATTITUDES AND PRACTICES ON MALARIA IN NEONATES AMONG GENERAL PRACTITIONERS IN DISTRICT HOSPITALS OF KIGALI CITY

A qualitative study

Principal Investigator: Dr Theodonata TUYISENGE Co- investigators:

Dr Faustine AGABA ;Dr Tanya ROGO; Dr Jean Claude KABAYIZA Prof Laetitia NYIRAZINYOYE; Dr Peter CARTLEDGE

Background

Infants from mothers who had malaria during pregnancy may suffer from:

• Miscarriage /Prematurity/ LBW/IUGR/IUFD
• ↑risk of anemia during infancy
• Congenital malaria (1, 2, 3)

1. http://www.who.int/mediacentre/factsheets/fs094/en/ 2. Mosha et all, Prevalence of congenital malaria among neonates at Morogoro Regional Hospital,2010 3. Moya et all ,Pregnancy-associated malaria and malaria in infants : an old problem with present

• consequences. 2014

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Background cont’d

Congenital malaria : the presence of asexual stages

• f malaria parasites in cord BS at delivery or

peripheral BS of the baby in the first 7d of life, irrespective of clinical symptoms(4,5,6,7,8) Acquired neonatal malaria can occur within first 28 days-of-life, it is due to mosquito bite (4) Neonatal malaria exist in Rwanda (9, 10).

• 4. Mohan et al, Clinical Presentation and Management of Neonatal Malaria : A Review. 2014
• 5. Uneke CJ. Congenital malaria : an overview. 2011
• 6. Stassijns et al. Prevalence and diagnostics of congenital malaria in rural Burundi , 2016.
• 7. Lesi et al, Clinical Presentation of Congenital malaria at The Lagos Univeristy Hospital, 2010

8.Natama et al, Diagnosing congenital malaria in a high-transmission setting:2017 9.Manishimwe et al. Neonates at risk of early neonatal malaria in Kigali University Teaching Hospital, 2018

• 10. Bukeyeneza et al. Malaria in Neonates : Case series, 2017

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Problem statement

Evidence shows that cases of malaria in newborns exist in Rwanda. Neonatal malaria has no specific clinical features. No specific information about diagnosis and management of neonatal malaria. 2015 WHO malaria treatment provide information for children less than 5kg (Newborns, preterm included?).

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Objectives

• 1. To evaluate GPs knowledge and attitudes on clinical

approaches to the neonate exposed to malaria and to identify the clinical features considered to be suggestive of neonatal malaria.

• 2. To assess if and how GPs classify malaria in a neonate

and inquire about medications they use in treating malaria in different categories of neonates.

• 3. To determine the education and follow up plan

provided by GPs to the families of a neonate treated for malaria

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Research methodology

Study design: qualitative study employing semi- structured face-to-face interviews Study sites : 4 DHs: Kibagabaga, Muhima, Masaka, Kacyiru Study population: GPs working at involved DHs Inclusion criteria: All GPs walking at the target DHs were eligible for our interviews Exclusion criteria : GPs who neither work in maternity nor in neonatology,

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Research methodology

Sampling: A purposive sampling method was applied. Study duration: Data were collected from November to December 2018. Data processing: Interviews were be transcribed, translated, coded and analysed in Microsoft excel Ethics: study approved by the CMSH-IRB, RBC, the NHRC, MoH and all involved district hospitals

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Demographic information

Sample size : Saturation was reached after conducting 12 interviews.

7 men and 5 women Age: 25-43 years Average duration of working as a GP: 41 months. Average time of working in neonatology: 23.8 months

The mean duration of interview was 10 minutes 54 seconds.

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Ten themes

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Theme: experience in treating neonatal malaria Our participants have seen some cases neonatal

• malaria. Others have never seen such cases

“The cases of malaria in a newborn are not frequent. In my life here at district hospital, I have seen like two cases with malaria in newborns in the period of one year ” (Interview 7, male).

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Theme: Knowledge on the acquisition of malaria in neonate Some know both congenital and acquired malaria,

• thers could mention only one way

“Ah, well, it could be from a mosquito if the mother is not very careful, I am not sure about the congenital malaria, but I think it exists” (Interview 5, female).

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Theme: Monitoring of a newborn exposed to malaria For neonates born to mother who has malaria, participants would monitor:  Vital signs  Feeding  Some would request labs for screening.  Others would give antibiotics for infection risk.

“I want to monitor for fevers, inability to breastfeed,

but, also to check for hemoglobin and platelets after 24 hours” (Interview 4, female).

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Theme: Recognition of clinical features of neonatal malaria Signs suggested by participants: fever, poor feeding, anemia, thrombocytopenia, jaundice and sepsis which is not responding to antibiotics “First of all you suspect it from the history , then also, for the baby, I think she will have persistent fevers, despite other antibiotics given and also the baby will deteriorate with time” (Interview 12, male).

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Theme: Investigations of a neonate born from a mother who has malaria Participants would exclusively use BS to screen for malaria. “I have to take full blood-count, CRP after 24 hours, and then I have to test for [pause to think] to take blood smear for this baby” (Interview 9, male). Other reported investigations include LFT, RFT, electrolytes, blood sugar, CRP, and placental pathological examination.

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Theme: Classification of neonatal malaria

Severe neonatal malaria: +ve BS plus convulsions, anemia, renal failure, respiratory distress, and hypoglycemia.  Simple malaria : +ve BS plus fever, refusal of breastfeeding, inconsolable cry. Neonatal malaria should be classified as severe.

“When the blood smear is positive for this neonate, I will consider this malaria as severe. It is severe because it is the

• neonate. If it occurs in neonatal period most of the time it

causes jaundice and anemia” (Interview 3, female).

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Theme: Management of malaria in newborns

Term stable neonate :  Artesunate iv 2.4 or 3mg/kg/dose OR coartem  Others would add antibiotics Preterm neonate  Artesunate, others don’t know “We can treat the baby as out-patient using coartem with tablets. For those who are below 15 kg, it will be 2 tabs per day during 3 days maximum 6 tabs: one in the morning one in the night, so 2 times a day for 3 days” (Interview 8, male).

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Themes: Education, follow up, references

Participant would educate the family on clinical features, diagnosis, treatment, evolution of neonatal malaria and give a RDV. Source of information: Rwanda protocols, the internet, Medscape, up-to-date, ETAT booklet and WHO guidelines, hospital protocol.

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Discussion

Most of our participants had seen neonatal malaria

• cases. However, the diagnosis can be easily
• verlooked if no screening measures are available in

working areas (9). Some authors suggest that where malaria is common, it should be considered as a differential diagnosis in any newborn with sepsis (10).

9.Olupot et al. Neonatal and congenital malaria: A case series in malaria endemic eastern Uganda, 2018

• 10. Menendez et al. Congenital malaria : The least known consequence of malaria in pregnancy, 2007

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Discussion

No GPs reported the use of a cord blood sample. The later can be +ve while peripheral BS is -ve(10). Fever is a common sign. According to Lesi et al, neonates can have only other features like jaundice

(7). Mohan et al. reported that neonatal malaria may

mimic TORCH infections (4).

 Classification? Management?

• 4. Mohan et al. Clinical Presentation and Management of Neonatal Malaria : A Review,2014
• 7.Lesi et al. Clinical Presentation of Congenital malaria at The Lagos University Teaching Hospital. 2010
• 10. Menendez et al. Congenital malaria : The least known consequence of malaria in pregnancy, 2007

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Discussion

Artesunate was mostly reported to be used to treat neonatal malaria with some reporting the use of coartem. Respondents considered giving antibacterials to neonates suffering from malaria. Different writers on congenital malaria insist on the availability of evidence based guidelines on the management of neonatal malaria (4,11).

4.Mohan et al. Clinical Presentation and Management of Neonatal Malaria : 2014;3

• 11. Okoli et al. Plasmodium falciparum infection among neonates in the North Central region of Nigeria 2013

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Study strength and limitation

 Strength: To our knowledge, this is the first qualitative study exploring the how GPs working at district hospital level take care of neonates suffering from malaria. Limitation: Our study area was limited in Kigali  No opinions of non-urban GPs

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Conclusion

The study showed the awareness of neonatal malaria, different opinions in its diagnosis, classification and management. Our study suggests a strong need in the guidelines for management of neonatal malaria, especially at district hospitals

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Recommendations

University level: To conduct research on the prevalence of neonatal malaria in Rwanda. To gather experts’ views on management of neonatal malaria. RPA: To raise the awareness of neonatal malaria through mentorship programs. To advocate and collaborate with the MoH for availability of guidelines MoH: To avail the guidelines on index of suspicion, diagnosis and management of neonatal malaria.

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Thank you !!

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