Malaria case management - Essay Example

?Introduction According to United Nations , malaria is a serious medical threat to over 50 percent of the total human population in the 21st century. In tropical countries, the disease is one of the most infectious and leading cause of death. WHO (2000) estimates that about one million people die annually in the world from malaria. Moreover, it is among the leading causes of illness in the globe, especially in tropical regions (WHO 2009). Although malaria infection is one of the leading causes of death in the world, it is treatable and manageable condition. In view of these findings, the government and the global health stakeholders have formulated policies for managing and treating the chronic disease. This paper explores how governmental health policies have catalysed transformation of management and treatment of malaria in primary care services. Eradicating malaria in the world is one of the top priorities of global health organisations and is a key objective of attaining universal health related targets stipulated in the Millennium Development Goals (MDGs) (United Nations 2010). Consequently, both developed and developing countries have reinvigorated efforts to combat the disease that has remained a serious threat to health and wellbeing of people across the world for a long period. Currently, policies to control and prevent malaria infections form an important component of public health systems and primary care services play a pivotal role in their implementation. Some of malaria control and preventive measures include application of insecticide treated bed nets to prevent human contact with mosquitoes, indoor residual spraying with efficient insecticide and eradicating mosquito breeding habitats (Mathews 2011). Other measures include use of anti malarial drugs to treat the infection in all segments of affected population, including pregnant women and HIV/AIDS patients in addition to maintaining sustained malarial surveillance across the world (Mathews 2011). These policies have enhanced management and treatment of malaria in primary care service. However, before investigating impacts of government policies in management and treatment of the condition in primary care, it is important to explore the symptoms and causes of malaria and how they inform nursing practice. Causes and symptoms of malaria Malaria is a vector borne disease transmitted by female anopheles mosquito. The causative malarial parasite is a protozoan of genus plasmodium (MacDonald 1997). There are five major species of malarial parasites responsible for transmission of malaria. They include Plasmodium vivax, Plasmodium falciparum, Plasmodium malariae, Plasmodium ovale and Plasmodium knowlesi. However, plasmodium vivax and plasmodium falciparum are the most important causes of malaria infection in the world (MacDonald 1997). The initial symptoms of malaria infection are not specific and demonstrate remarkable resemblance to signs of a minor systemic viral disease (WHO 2009). The symptoms include fatigue, headache, fatigue and lassitude, normally followed by abdominal, muscle and joint pains. These symptoms are accompanied by fever, anorexia, chills, profuse sweating and vomiting. These signs are the major defining characteristics of malaria infection at the early stage (WHO 2009). People in regions where malaria is endemic are usually knowledgeable about these symptoms and consequently, incidences of self diagnosis are prevalent. Achan et al (2011) noted high incidents of malarial over diagnosis in primary care services especially in malaria endemic regions based on the demonstrated symptoms. According to Brieger (2009), the severity of malarial symptoms varies depending on the type of parasite involved. Infection by plasmodium vivax and plasmodium ovale demonstrates more pronounced symptoms of fever and chills than other malarial species. However, fatality rate at early malaria infection is rare but it increases when treatment is delayed and on prescription of ineffective drugs (Brieger 2009; WHO 2009). Delaying treatment of malaria and/or use of ineffective medicines increases the number of malaria parasites in the body and could result to development of severe and life threatening condition (WHO 2006). Within a few hours of infection, the symptoms develop into serious health problems characterised by one or more of the following conditions; cerebral malaria, anaemia, hypoglycaemia and metabolic acidosis (WHO 2009). In adults, kidney failure and pulmonary oedema often occur (WHO 2009). Failure to treat the disease effectively at severe stage often results to death. The clinical severity of malaria infection also depends on the pattern and degree of the disease transmission in the affected region (Mangham et al 2011). These two factors determine the extent of immunity acquisition in the body and the ultimate symptoms demonstrated by infected individual. In areas where people are constantly exposed to the malarial parasite (stable transmission), partial immunity to the disease develops in childhood, which reduces severity of symptoms and development of severe malaria infection (WHO 2006). Consequently, a high proportion of adolescents and adults in areas with high malaria infection are partially immune and do not develop the severe form of the condition. However, very young children in such areas do not have well developed immunity and consequently, they are at high risk of developing potentially severe and fatal malaria. This stable transmission pattern is common in many regions in sub-Saharan Africa and Oceania countries where many infants develop severe clinical malaria resulting to high mortality particularly in children below five years (WHO, 2009, 2006). In regions with unstable patterns of malaria transmission, the level of immunity in affected population fluctuate considerably over a given period of time, a situation that undermines development of immunity among people of all ages in the affected population (WHO 2009). Consequently, people in unstable malaria transmission regions including children and adults are equally prone to malaria epidemics and subsequent progression to its severe form. Areas with unstable malaria transmission patterns in the world include Latin America and Asian continent (UNICEF 2007). In such regions, malaria outbreak is a major health concern because of the high number of infected people that could strain provision of medical services. Influence of malaria on nursing practice in primary care Malarial infections present unique challenges to primary care services in different regions across the world. The diverse epidemic and morbidity patterns and resistance to treatment have influenced the nursing practice profoundly. In healthcare, primary care services are important for providing continuous and immediate medical attention to all segments in the society including children, adults, elderly and vulnerable groups. According to Kelleher et al (2009), primary care offers communities the first contact with medical services, which are provided by nurses and other mid level health professionals. These services are linked with upper levels of healthcare system where referred patients get specialised treatment from specialist doctors if necessary. These services are usually offered locally in dispensaries and health centres especially in developing countries. Thus, primary care ensures delivery of health services to marginalised communities and regions. According Richards et al (2000), services provided in primary care cater for a variety of basic medical conditions, but the health care providers follow up on the progress of the patients over the time. For the last two decades, treatment and management of malaria and other infectious diseases such as tuberculosis, HIV/AIDS have been under primary care services and these responsibilities have had profound impacts on nursing practice. Basically nurses are the primary healthcare providers, responsible for promoting health and wellbeing of patients in medical setting and the community at large. However, changes in healthcare needs in the society have increased the necessity of transforming delivery of medical services particularly in the nursing practice (Richards et al 2000). In primary health care services, which is mainly characterised by shortage of general practitioners, the demand for expanding the roles of nurses is even greater. The increasing prevalence of malaria epidemics and other infectious diseases such as HIV/AIDS across the world have exerted considerable strain on the limited health care personnel, and nurses have been compelled to take more expanded roles (Keleher et al 2009). In management and treatment of malaria, nurses in primary care have undertaken more integrated roles characterised by increased involvement in clinical care and organisation. Consequently, nurses spend less time in their conventional administrative roles, to focus more on prevention, health promotion and management of malaria and other chronic infections. Other roles include diagnosis, screening and treatment (Mangham et al 2011). In primary care of malaria infection, establishing the clinical profile of patients in a region is important because it enables nurses and other mid level health care providers to formulate and plan the most affective approach of treating and managing the disease. According to WHO (2006), malaria clinical profile of patients depends on the kind of the parasitic species and the transmission patterns or epidemiology of the disease. Therefore, different malarial endemic regions have diverse malarial clinical profiles. According to WHO (2006) clinical profile of malaria consists of three major components. The first is the age of malarial patients and malaria infection patterns in a particular population. For instance the disease could be prevalent in young children, people of all ages or affect pregnant women. The severity of malaria infection is the second important component of the clinical profile of patients. In relation to transmission patterns, malaria is severe and highly fatal in people with no acquired immune especially young children and less severe in people with partial immunity. Moreover, establishing the disease progression from minor to serious and potentially fatal level is important measure of malaria severity. Finally, the kind of clinical condition manifested by malarial infection is an important component of the clinical profile of the disease. In severe forms, malarial infection demonstrates several clinical symptoms, particularly acute anaemia, coma, and single or multiple organ failure (WHO 2006, pp36-48) Clinical profile of malarial patients plays a major role in determining treatment and management practices of the disease in primary care in a particular malaria endemic region. In areas where malaria infection is prevalent in young children, nurses and other mid level healthcare providers in primary care would focus on providing paediatric care. Similar case applies in situations where pregnant women are at high risk of contracting the infection. In regions afflicted with serious malaria and where the disease progresses rapidly to life threatening levels, primary care providers are required to be equipped with necessary facilities and support to ensure that the condition is treated early. In addition, provision of intensive care facilities is necessary to treat and manage severe malaria infections (WHO 2000). In primary care services, management and treatment of malaria depends on whether the condition is severe or uncomplicated. The main goals of treatment are to cure the infection and prevent fatalities. According to MacDonald (1997) providing cure is the primary objective of treating uncomplicated malaria, while preventing death is the primary goal of treating the severe condition. Curative intervention prevents development of malaria to serious ailment associated with the infection by eradicating the malarial parasites from the body. To ensure complete eradication of the parasitic infection, it is important for nurses in primary care to follow up on the progress of the treated patient. Effective treatment of malarial infection reduces the probability of infecting other people because the parasitic reservoirs are completely eradicated from the patient. In addition, treatment minimises development of malarial strains that are resistant to anti- malarial drugs (Speilman and Antonio 2002). Due to the rapid progression of malarial infection, it is important for primary healthcare providers to ensure that effective curative intervention is administered within the shortest time possible. Accurate and timely diagnosis of malaria is important in order to facilitate prompt treatment. The two main techniques for diagnosing malaria are clinical and parasitological diagnosis. In primary care, clinical diagnosis is based on the signs and symptoms of malaria infection (UNICEF 2007). Fever or history of abnormally high body temperature are the main symptoms that WHO (2009) recommends for diagnosing malaria clinically in primary care. In areas with low risks of malaria infection, clinical diagnosis of malaria should be made on the basis of the extent of exposure to the infection and presence of fever in a period of at least three days. However, the patient should not be suffering from other serious illnesses that demonstrate similar symptoms. In regions with high malaria prevalence, clinical diagnosis of the condition should be based on existence of fever for the past 24 hours and/ or presence of anaemic symptoms (WHO 2009, pp47-55). However, the use of clinical diagnosis techniques in primary care has very low specificity and should be supplemented by parasitological diagnosis. Parasitological diagnosis technique is a medical laboratory procedure used for detecting malarial parasites in the blood of an infected person (Connie, Donald and George, 2010). In primary care service, rapid diagnostic tests and light microscopy are the most commonly methods of parasitological diagnosis. However, the high costs associated with rapid diagnostic tests limit its widespread application in primary care setting and light microscopy is preferred in most cases. These techniques have high sensitivity and specificity which enables accurate diagnosis of malaria (Connie, Donald and George, 2010). However, the primary healthcare providers should be well trained and skilled to use them effectively during screening and diagnosis of malaria. Effective, prompt and accurate diagnosis of malaria in primary care enables the nurses to provide better care to the patients with malarial parasites. In patients without the parasites, needless exposure to malarial drugs is avoided, which minimises the risks of developing drug resistance and side effects associated with the medications (WHO 2006). Parasitological diagnosis also enables primary healthcare providers to indentify the specific malarial parasites and this facilitates appropriate prescription of anti malarial drugs. Because of the different distribution patterns of malarial parasites, WHO (2009) recommends the application of both clinical and parasitological diagnostic techniques in primary care. Therefore, nurses should be knowledgeable about malaria progression patterns in their areas of jurisdiction and apply accurate diagnosis method. The increasing resistance of malarial parasites to anti malarial drugs has drastically influenced management and treatment of the infection in primary care. According to Wiser (2010), malarial parasites have developed resistance to all drugs except artemisinin derivatives. Indiscriminate prescription of anti malarial drugs is one of the factors that have contributed significantly to increased drug resistance (Achan et al 2011). Three malarial parasitic species namely Plasmodium falciparum, Plasmodium vivax and Plasmodium malariae have shown resistance to a number of anti malarial drugs. Plasmodium falciparum is one of the most drugs resistant malarial parasites with proved resilience against all anti malarial drugs except artemisinin based medications. Plasmodium vivax is resistant to sulfadoxine-pyrimethamine drugs and chloroquine. However, resistance to chloroquine varies in different malarial endemic regions (Wiser, 2010). According to WHO (2009) Plasmodium vivax is resistant to chloroquine in Oceania and neighbouring malaria endemic countries such as Papua new guinea , Indonesia and East Timor, the but it is effective against the same malarial species in north east Africa, India, middle east , Korea peninsula and regions in south and central America. To reduce the growing resistance to drugs, WHO (2009) recommends application of anti malaria combination therapy to treat the infection. This involves prescription of two or more blood schizontocidal drugs that have separate and independent modes of action concurrently. Therefore the drugs target different and discrete biochemical sites of the malarial parasite. Currently, artemisinin based combination therapy (ACT) is more effective in treatment of malaria compared to non artemisinin combination therapies (Brieger 2009). The current and the past malaria management service models have various similarities as well as differences. Both models apply anti malarial drugs to treat the infection, an intervention that has drastically reduced mortality rates and prevalence of the infection in different malarial endemic regions in the world (MacDonald 1997). The use of anti malarial drugs has also minimised transmission of the disease by reducing malarial parasites reservoirs in human beings. Secondly, both the current and past malaria management practices apply techniques of reducing the contact between human beings and mosquitoes. The common techniques applied include spraying residential areas with the insecticides, use of insecticide treated mosquito bed nets and mosquito repellents in addition to destroying mosquito breeding grounds by use of chemical and biological control methods (Speilman and Antonio 2002). However, in the past malarial management practices, efforts to eradicate the infection were concentrated in a particular affected geographical area, where a multiple preventive and control measures were aggressively applied. Moreover, past malaria management practices were not well integrated with provision of primary care services to the affected population (MacDonald 1997). In the current practice, the malaria management is more integrated in the public health sector and primary healthcare plays a major role in providing the health services worldwide. Moreover, there is greater international cooperation in controlling malaria and it has been achieved by pooling of resources and sharing information to reduce the effects of the disease. Currently, efforts to control malaria are concentrated in regions worst affected by the infection, especially in tropical Africa. These areas have high HIV/AIDS prevalence, which has increased the need to integrate management and control of both diseases (United Nations 2010). Effect of health policies in catalysing change in management of malaria The government health policies have catalysed change in management and treatment of malaria in primary care services through various mechanisms. Collaboration with international health organisations and non governmental organisations has enhanced provision of integrated healthcare in primary care. This collaboration provides updated information, concerning malaria prevalence patterns and resistance to drugs in various malaria endemic regions, through constant surveillance. Therefore, healthcare providers in primary care are provided with adequate information, which helps them formulate appropriate disease management and treatment practices in different regions. These include adoption of more efficient and accurate diagnostic techniques such as rapid diagnostic tests (RDTs) and microscopy to supplement clinical diagnosis (WHO 2006). Efficient diagnosis has enhanced the quality of healthcare services provided in primary care and minimised inappropriate prescription of anti malaria drugs to patients. In addition prescription of anti malarial combination therapies, such as artemisinin combination therapy (ACT) has minimised application of mono therapeutic treatment in primary care in order to minimise the malarial parasites’ resistance to drugs. Efforts to control and eradicate malaria in the world have been accompanied by large-scale mobilisation of resources. A large proportion of the resources have been channelled to primary care since it plays a critical role in management and treatment of malaria and other chronic diseases. This presents formidable challenges to primary care services which lack adequate general practitioners. Therefore, most countries have been compelled to expand the role of nurses to enhance delivery of health services in primary care. Currently nurses in primary care have taken a greater role in prevention, health promotion and management of chronic infections. This has created the need of providing adequate training to the existing nurses and reviewing the nursing curriculum in medical training institutions. Conclusion Malaria is one of the most formidable health challenges facing the world today and a leading cause of death especially in developing countries. To control and eradicate the disease in the world, international community has formulated preventive policies and primary care services play a pivotal role in their implementation. The policies have reinvigorated and transformed the role of primary healthcare services in managing and treating the infection in various ways. These include expanding the roles of primary health care providers especially nurses because of increasing workload and inadequate specialist doctors in addition to adoption of anti malaria combination therapy in treating the infection. In nursing practice, the changing malaria transmission patterns and resistance to anti malarial drugs have facilitated the need to acquire appropriate skills and knowledge to enhance provision of appropriate services to patients. References Achan, J., et al. 2011. Quinine an old anti- malarial drug in a modern world: role in the treatment of malaria. Malaria Journal.10: 144-146. Brieger, W. 2009. Rapid diagnostic tests can improve the quality of malaria case management. Africa Health. 31(6): pp 13-17. Connie, M., Donald, L., and George, M.2010. Textbook of diagnostic microbiology. 4th ed. London: Saunders. Keleher, H., et al.2009. The effectiveness of primary and community care nursing in primary care settings: a systematic literature review. 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