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

of 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, others 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 overlooked 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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