FACTORS LIMITING THE UTILIZATION OF PRIMAQUINE FOR RADICAL TREATMENT OF VIVAX MALARIA IN FAR WESTERN REGION OF NEPAL

Research Completed entitled "FACTORS LIMITING THE UTILIZATION OF PRIMAQUINE FOR RADICAL TREATMENT OF VIVAX MALARIA IN FAR WESTERN REGION OF NEPAL" 

funded by 

Ministry of Education, Science and Technology, Singhadurbar, Kathmandu

Research Team: 

Nabaraj Adhikari, Prakash Ghimire, Megha Raj banjara, Komal Raj Rijal and Upendra Thapa Shrestha

SUMMARY

Backround: Plasmodium vivax malaria remains an important public health problem in many parts of the world. The World Health Organization (WHO) estimates that P. vivax was responsible for 8.5 million cases of malaria globally in 2015. Malaria remains a priority public health problem in Nepal, where approximately 50% of the population is at risk of malaria and the threat of an outbreak is still real primarily as a result of receptivity and vulnerability characteristics of the country. The trend of malaria during the last decade indicates that substantial progress has been made towards elimination in Nepal. All districts now have an API less than 1/1000 and the country is moving towards “vision of malaria free Nepal by 2025”. An essential element to achieving the elimination of malaria will be killing both the blood and liver stages of the parasite. Primaquine (PQ), an 8-amnoquinoline, is the only licensed drug that effectively kills P. vivax hypnozoites. While it is well tolerated in the majority of recipients, primaquine and related compounds can cause severe side effects (haemolysis) in individuals with the inherited enzymopathy glucose-6-phosphate dehydrogenase (G6PD) deficiency. Prioritization of radical cure for P. vivax malaria has become better recognized recently, along with malaria elimination. Though the national malaria treatment protocol has lucidly states the use of primaquine for the treatment of vivax malaria after screening of G6PD status of the patient, many health care personnels are reluctant to use this drug in endemic districts of the country.

Aim: This study has been designed to explore the factors limiting utilization of primaquine for the management of vivax malaria in far western region of Nepal. In addition, the patient’s perspective in the provided treatment, limitations in laboratory facilities will also be explored during the study period.

Study sites: Mahakali Zonal Hospital Kanchanpur, Malkheti and Tikapur Hospital of Kailai district.

Study Population: The study population were the malaria patients (infected with vivax malaria) and drug prescribers (physicians, health assistants and nurses).

Sample size: Altogether 125 (75 malaria patients and 50 drug prescribers) individuals were enrolled in the study.

Study tools: A semi structured questionnaire was developed for interview of the patients and the drug prescribers. In addition to individual questionnaire, a focus group discussion of drug prescribers was also conducted as part of qualitative research.

Results: during the course of study majority of the patents were Dalits (56%). Around three-fourth of the patients were male and most of the patients were in the age group of 16-45 years. Maximum patients had their job in India (37.3%) and higher number of patients had formal primary level education (42.6%). About 78.7% of the patients had heard about malaria and 56% had knowledge about the transmission of malaria. However, only 20% of the patients had knowledge regarding the signs and symptoms of malaria. About 50.7% of the patients were aware about the preventive measures of malaria. Only 33.3% of the patients had known that the diagnosis and treatment of malaria is free in the government health facilities of Nepal. Majority of the patients (50.7%) had come to the health care facilities 3 or more days after the onset of fever. In addition, 36% of the patients visited repeatedly in the health care facilities in the last 3 months. Only 33.3% of the patients were found sure that the malaria can be cured by antimalarial drugs. About 34.7% of the patients did not understand the counseling by drug prescribers on how to take the antimalarial drugs. About 36% of the patients reported that there is no need of taking the drugs after the fever subsides. About 84% of the patients reported that they were not advised by the drug prescribers for follow up. About 40% of the drug prescribers had experience in the field of malaria for 10 or more than 10 years. About 92% of the drug prescribers believed vivax malaria as the problem in their catchment area. About 84% of the drug prescribers had told that they follow the new malaria treatment guidelines 2015. However only 40% of the drug prescribers have received training on new treatment guidelines. About 80% of the drug prescribers had reported that they use to treat vivax malaria with 14 days primaquine therapy. About 82% of the drug prescribers use to review the result of G6PD test before administration of 14 days primaquine to the patient. No one of the drug prescriber had ever noticed the adverse effects after primaquine treatment.

Conclusion: The study finds some gaps between the patients and drug prescribers for the effective management of vivax malaria in the study sites.

Recommendation: The stakeholders must address and hit in those gaps for the timely elimination of malaria from Nepal.