1. WHO
Community drug use practices in malaria in Cambodia: a cross-sectional study
National Malaria Centre of Cambodia
Rational Pharmaceutical Management Plus Program
World Health Organization
European Commission Cambodian Malaria Control Programme
Wellcome Trust Mahidol Oxford Trop. Med. Research Programme

2. Part Two
The quality and impact of prescribing on the Cambodian-Thai border
Presented by Ros Seyha

3. Most common treatments
Single Artemisinins (mainly Artesunate) were the most common treatments (31% fever cases)
92% of those who said they received single artemisinins at all facilities did not receive mefloquine
87% of those who received artemisinins separately at public/NGO* facilities did not receive mefloquine

4. Most common treatments (2)
Quinine was the second most popular treatment
58% of those who received quinine at all facilities did not receive tetracycline
70% of those who received quinine at public/NGO* facilities received it without tetra/doxycycline
Public/NGO* facilities performed only slightly better at following their own guidelines, due to 23% A+M use
* NB this pattern remains unchanged when NGO treatments are removed

5. Sufficient Duration of Treatment
A+M= 3 days- 7 days – 3 days – 2 days – 3 days – 1 day – 7 days

6. Sufficient Duration by Source

7. Provider knowledge Treating simple malaria (hypothetical case)
Case A: “An adult man presents with symptoms of simple malaria and a positive blood slide.”
How would you treat him?

8. Treating simple malaria (provider statements)
Referral: 25% providers said they would refer simple cases of malaria; even those with antimalarials!?  
The most commonly recommended treatment for simple cases of malaria.  
Only 46% treatments from all providers were of at least 80% effectiveness

9. Treating simple malaria (provider vs. household statements)
The most commonly recommended treatment for simple cases of malaria  
In general these claims conflicted with the findings of the household survey, which measured practice.

10. Treating Simple Malaria in Different Settings
Government setting: Public Health Services
Market setting: Drugs shop, Pharmacies, Clinics
Village setting: Drugs shops, Clinics, General shops

11. Case A: Drug choice and Efficacy (dose and duration)
Government: 8% were less than 80% effectiveness
Market: 35% were less than 80% effectiveness
Village: 56% were less than 80% effectiveness

12. Provider knowledge Treating severe malaria
Case B: “An adult man presents with symptoms of severe malaria and a positive blood slide.
How would you treat him?”

13. Treating severe malaria (provider statements)
Referral: 70% providers said they would refer severe cases of malaria  
The most commonly recommended treatment for severe cases of malaria.  
This slide shows the behavioral practices of providers, given the scenario
Only 25% treatments from all providers were of at least 80% effectiveness

14. Treating Severe Malaria in Different Settings
Government setting: Public Health Services
Market setting: Drugs shop, Pharmacies, Clinics
Village setting: Drugs shops, Clinics, General shops

15. Case B: Drug choice and Efficacy (dose and duration)
Government: 43% were less than 80% effectiveness
Market: 69% were less than 80% effectiveness
Village: 78% were less than 80% effectiveness

16. Case B: Drug choice and Efficacy (dose and duration)
Higher numbers of dangerous, unnecessary prescriptions strongly associated with village providers: odds ratio of 4.86 (95% CI 1.24, 19.07) compared against market setting (OR 1.0) and public health setting (OR 1.73)
Village: 78% were less than 80% effectiveness

17. Treatment of At Risk Groups: Children
No child aged >6 months to <6 years received the government recommended treatment for that age group: artesunate suppositories for 5 days, plus mefloquine (household report)
The single most frequently received therapy was artesunate oral form (44%)
The next most commonly used drug was chloroquine (12%)

18. Treatment of At Risk Groups: Pregnant women
Only 4 of the 27 pregnant women in the sample received the recommended treatment,
quinine monotherapy
14 received no antimalarials, but we cannot presume infection

19. Treatment of At Risk Groups: Severe Malaria
Rectal artesunate, for the immediate treatment of severe patients, was recommended by
……….only one provider and
……this was not a public health facility
This recommended first line therapy
……..is potentially lifesaving

20. Summary (1)
Poor prescribing practices were demonstrated by providers in all settings, partly due to gaps in knowledge
Knowledge gaps included correct choice of
drugs
duration
frequency
dose
…………..is worst in outlying areas

21. Summary (2)
Prescribers widely recommended artesunate and quinine monotherapy for short durations (< 7 days)
Ineffective for ensuring treatment and may, theoretically, encourage drug resistance.
Polypharmacy with unnecessary or potentially dangerous drugs was common, especially in villages
Inappropriate use of injections and infusions increases risks and costs

22. Summary (3) Government facilities had gaps between
government guidelines and
staff recommendations,
……particularly for severe malaria.
Explanation for the inconsistency between reported and actual behaviors may require additional study

23. For further information, please contact:
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