Need to promote effective malaria diagnosis in the midst of COVID-19

Residents of Tsate in the South Dayi District of the Volta Region have to contend with a rough rugged untarred road to travel from their village to Kpeve, the district capital of South Dayi and other neighbouring communities to access various socio-economic services.

This is a rural and poor community. It has very limited social amenities such as electricity supplies and a basic school. The community has no hospital, clinic or a functioning retail medicine facility.

It is basically a farming community with both sexes producing mainly foodstuff and some of the women engaging in petty trading including selling farm produce at the Kpeve or Dzemeni markets.

Due to some of these socio-economic reasons, some of the residents depend on herbal medicines and plants with local names such as “lilitee maakpaa” tea gbe3” and “goa maakpaa” to treat fever-related illnesses such as malaria and other conditions.

It costs about GH¢8 to travel in and out of Tsate by a vehicle and a total of GH¢15 in and out of the community when travelling by a motor bike to seek for various services including some health care.

The Tsate Story   

Located in such a small, isolated and difficult to access community, the Tsate Community-Based Health Planning and Services (CHPS) compound, has become a sanctuary for medical intervention.

This CHPS compound is situated on the hilly part of the community and very close to the only Junior High School in the community. Without this facility, majority of residents would not have been able to access very basic health services for various diseases and conditions such as malaria, maternal and child health care.

The facility has just two health personnel, a midwife and community health nurse who have to cope with extremely busy schedules in managing the CHPS compound. On average, about 20 to 25 people visit the facility each week and sometimes as many as 170 to 180 clients visit the facility for various services.

Although, the provision of drugs under the National Health Insurance Scheme (NHIS) is sometimes a challenge, however usually this CHPS compound has available drugs such as paracetamol, antimalarials, multivitamin tablets, and antibiotics to treat basic health conditions.

One major area that this CHPS compound has made some gains is what one can describe as the provision of quality malaria care. Malaria is among the top diseases that the facility handles.

During a visit to the facility in October last year, a young boy, about 10 years old was brought to the facility looking pale.

Despite very busy serving other clients, one of the nurses made time to examine the boy and because the facility has no laboratory, a rapid diagnostic test (RDT) kit was immediately used. Once the presence of malaria was confirmed, the child after being attended to was referred to the Peki Government hospital, because of the complications he presented with, including anemia.

A few weeks ago, due to the presence of the coronavirus disease, made some enquiries to find out how the COVID-19 is impacting on malaria case management at the Tsate CHPS compound and what has changed.

Information gathered shows that the health personnel have not departed from following the rule of providing free malaria tests before treating malaria.

Fortunately, the facility does not have problems with the supply of these test kits and there are currently no shortages of the kits.

The facility is also strictly enforcing the COVID-19 protocols including handwashing. Recently the community was notified to set aside a facility within the Tsate community so people suspected of having COVID-19 could be kept.

As part of the protocols, the nurses at the CHPS compound have been told not to immediately refer people suspected of having COVID-19 to the Regional hospital at Ho but to rather inform the authorities who would first visit the community to follow up with testing any suspected case before further steps are taken.

With all these protocols in place, this CHPS compound is doing well in dealing with febrile cases such as malaria or COVID-19.

More importantly, proper diagnosis is being done in managing malaria cases and this is helping in avoiding presumptuous treatment of malaria cases in the face of the COVID-19 pandemic, which also presents with some febrile conditions just like malaria.

Urgent Business

Malaria case management including proper diagnosis either through laboratory tests or the use of RDT kits and other malaria interventions have now become high on the global and national agenda due to the presence of COVID-19 and its implications on health services and impact of the outcomes of diseases such as malaria.

The National Malaria Control Programme (NMCP) in a virtual meeting with a group of Ghanaian journalists a few weeks ago stated that the coronavirus disease is threatening to divert attention from malaria, although malaria continues to kill many more children than COVID-19.

It said malaria was among the leading causes of hospital attendance between January and May, this year.

However, statistics provided by the NMCP show that malaria case management based on accurate diagnosis before treatment is high across the country’s public and private health facilities.

According to the NMCP, this improved diagnosis has resulted in over 95 per cent in terms of the proportion of suspected malaria cases tested across these facilities as at January to May, 2020.

On the global scene, key stakeholders are worried about the upsurge of malaria cases due to the COVID-19.

For instance, the World Health Organisation (WHO) in a document titled: “Tailoring malaria interventions in the COVID-19 response”, updated in May this year, noted that malaria shares some symptoms with COVID-19 such as fever, headache, body aches and weakness and called for active care-seeking for febrile illnesses.

It noted that malaria can coexist with many other infections, and thus confirming malaria infection with a diagnostic test remains a critical component of malaria case management.

Similarly, in line with its objectives, the NMCP is seeking to provide parasitological diagnosis to all suspected malaria cases with prompt and effective treatment to 100 per cent of confirmed malaria cases.

A challenging terrain

It is encouraging that health facilities are scoring high in testing before treating malaria. However, retail drug outlets, where malaria cases are also being handled show a different story in case management.

Quite a large section of Ghanaians do not visit clinics or hospitals to access malaria care but they rather choose to conveniently visit nearby local drug facilities for anti-malarials due to issues related to affordability, accessibility and convenience. Fortunately, drug facilities are found all over, especially within local communities.

For instance, residents and people doing business around the long stretch from the First Junction area at Teshie-Nungua to the Spintex Junction on the Accra-Tema beach road can easily access malaria care at several pharmacies and over-the-counter (OTC) drug facilities littered all over.

Among these are the Amex Pharmacy, Danpong Pharmacy, Grace Chemical, Deccon Pharmacy, Forson Adohkoh OTC and the Felix Asante OTC, which is very close to the Nungua market. There are even more of such drug facilities located within the inner lanes along this same beach road.

Similarly, people living around and plying their trade around the BBC area at Tema Community Two right to the Tema Community One market area also have a variety of facilities to choose from such as Gilead Balsam Chemicals, Top Pharmacy, Jenarko Pharmacy, Fresh Spring Pharmacy and Naabson Pharmacy. Indeed, the list of drug outlets at all these communities cannot be exhausted.

A visit to some facilities to find out how malaria is being diagnosed and managed in the midst of the COVID-19, showed the positioning of Veronica buckets and liquid soaps at the entrances of these facilities. A grim reminder of the impact of the COVID-19 pandemic on all human activities and businesses.

Some of the facilities also had visible sign posts and messages at the doors informing potential clients not to venture in without a facemask.

What however became clear during interactions with some of the attendants manning these facilities is that some do not see the need to do any malaria diagnosis with the test kits before selling the anti-malarials and therefore they had no kits available at their facility.

Others had previously stocked the kits but had stopped because they claim the kits are not effective and it is bad business to stock kits.

It was encouraging to find out that as compared to the OTC facilities, about 80 per cent of the pharmacies visited had the test kits available to conduct the tests.

For some, the need to test for the presence of malaria before dispensing anti-malarials is not high on the agenda and treatment for malaria is based on the symptoms presented by clients.

At one particular pharmacy the attendant bluntly stated that they had stopped using the kits because they are not effective. According to him, those of them in the pharmacy industry are also business people and cannot stock kits which are not fit for purpose.

In response to a question on the need to adhere to diagnosis before treatment, especially in these times of the COVID-19, he pointed out that the two diseases can easily be distinguished because malaria sometimes presents with pains in the joints whereas the COVID-19 presents with chest pains.

Pointing to him that the test kits are working perfectly at health facilities, he said the health facilities have their kits supplied freely by health authorities, while they, as business people, have to buy the kits in the open market.

He said some of the kits being imported into the country are possibly of poor quality or fake and the blame should be placed at the door steps of regulatory bodies like the Food and Drugs Administration.

A young man at an OTC facility in Nungua also explained that he has nothing to do with the kits because some older members of their local association had briefed younger members of bad experiences with the kits, telling them that the kits do not work.

He also feels the price for testing together with buying malaria drugs would be too much for clients in his area who have low socio-economic status as compared to residents at the adjoining Sakumono community.

The cost for malaria test at some of the facilities ranges between GH¢8 to GH¢10 while the anti-malaria drugs range from as low as GH¢6 to GH¢45, depending on the type of anti-malaria brand.

In response to a question on how one could distinguish between a COVID-19 and malaria infected client visiting retail drug outlets, since both diseases have some similarities, one attendant said he can easily distinguish between the two conditions, because people with the COVID-19, usually have a much higher temperature and therefore having a gun thermometer at his facility would help him do proper diagnosis to determine what is malaria and what is COVID-19.

Another issue that appear to be common, especially among the OTC facilities, is that they believe these RDT kits are unable to accurately diagnose the presence of malaria unless the density of the parasites present in a client is very high.

Also, what is clear is that the use of the kits is heavily dependent on the wishes of clients to test before getting treated or to just purchase drugs without testing.

The critical role being played by retail drug outlets in malaria case management is very pivotal. Their ubiquitous presence in local communities places them in a favourable and strategic position to help in the provision of effective malaria care.

However, they appear to be in a very challenging terrain that needs to be surmounted by the health authorities through effective strategies and dialogue as well as public education and awareness creation to get all drug outlets on board for an improvement in case management within local communities and households.

By Eunice Menka

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