Understanding non-malaria illness in outpatients in Mozambique: An exploration of associated symptoms, diagnoses, and treatments Public
Biddle, Haley (Spring 2020)
Published
Abstract
Background and Objective: A wide variety of illnesses prompt care-seeking at outpatient health care facilities in sub-Saharan Africa. While malaria remains a prominent threat in many of these countries, declines in prevalence over the past several decades, in addition to more readily available rapid diagnostic tests (RDTs) for malaria, have illuminated the substantial portion of non-malaria illness that exists in these settings. As such, there is a need to understand the presentation and case management of non-malaria illnesses in adults and children presenting at health facilities in low-resource areas. This study describes the symptom presentations, diagnoses, and treatments received by outpatients seeking care at health facilities in three provinces of Mozambique and examines associations between these variables.
Methods: A secondary analysis was performed using health facility survey data gathered in Maputo province, Zambezia, province, and Cabo Delgado provinces in Mozambique in 2018. Survey responses regarding symptoms, diagnoses, and treatments were analyzed for frequency by age group. Cross tabulations of risk ratios (RR) were conducted to determine associations between variables, and multivariate logistic regression was used to examine factors associated with antibiotic prescription.
Results: In total, 1,840 outpatients were interviewed and re-examined across 117 health facilities, including 629 children under five years of age (CU5) and 1,211 adults and children older than five. Fever was the most common symptom for both CU5 (74.6%) and older outpatients (60.4%). 53.1% of CU5 remained undiagnosed, as did 65.6% of patients five-and-over. Malaria was the most frequent diagnosis in each group, at 33.1% for CU5 and 16.1% for the older age group. The most commonly received medication was an antipyretic (52.6% of CU5, 51.5% of five-and-over). Nearly 40% of CU5 received a prescription for an antimalarial, while 21.6% of older children and adults received thisone. Antibiotic treatment was significantly more frequent among the older age group (50.3%) than in CU5 (43.7%, p<0.01). Crosstabulations showed that heart and chest symptoms (RR: 0.18), dermatologic symptoms (RR: 0.30), and ear, eye, neck and throat symptoms (RR: 0.31) were associated with a lower risk chance of malaria diagnosis. Remaining undiagnosed (RR: 2.42) or having a symptom listed as a diagnosis (RR: 1.57) increased the likelihood of receiving an antibiotic. For both febrile and non-febrile patients, antibiotic prescription was more common when patients were RDT-negative or reported not having a RDT performed. In the logistic regression, a positive RDT was the only factor significantly associated with decreased odds of receiving an antibiotic (aOR: 0.03, p<0.01). On average, patients received 1.37 unique treatment types.
Conclusion: Surveyed outpatients at health facilities in Mozambique reported a variety of symptom presentations. While fever was the most common symptom for both CU5 and patients 5-and-older, there was a wide spectrum of symptoms and these frequently differed significantly by age group. Reporting no diagnosis from a consult was common, and malaria was a frequent diagnosis when one could be reported. Most patients left their consult with a prescription for at least one medication, with antipyretics being the most widely prescribed. These results help to meet the need of understanding the presentation and case management of non-malaria illness in outpatients, and serve to enhance surveillance, improve algorithms, and guide surveys in similar settings.
Table of Contents
ACKNOWLEDGMENTS I
TABLE OF CONTENTS II
CHAPTER 1: Introduction 1
CHAPTER 2: Literature Review 5
Introduction 5
Etiology studies in sub-Saharan Africa 6
Prescribing practices of clinicians in outpatient clinics 14
Antibiotic-focused prescribing studies 16
Qualitative studies 18
Conclusion 20
CHAPTER 3: Methods and Results 21
Materials and Methods 21
Introduction 21
Study population 21
Analysis procedures: categorization 22
Analysis procedures: statistical analysis 23
Ethical considerations 24
Methods limitations 24
Results 25
CHAPTER 4: Discussion and public health implications 30
Discussion 30
Public health implications 33
Limitations 35
Conclusions 36
TABLES
Table 1. Symptom descriptives 37
Table 2. Diagnosis descriptives 38
Table 3. Treatment descriptives 39
Table 4. Symptom-diagnosis crosstable 40
Table 5. Diagnosis-treatment crosstable 41
Table 6. Treatment-treatment crosstable 42
Table 7. Treatment frequency by fever and RDT status 43
Table 8. Treatment quantification 44
Table 9. Logistic regression results: antibiotic use 44
APPENDICES 45
Appendix 1. Original and added survey categories 45
Appendix 2. Symptom response categorization 46
Appendix 3. Diagnosis response categorization 48
Appendix 4. Treatment response categorization 50
REFERENCES 52
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