When 5-year-old Alexandria Kotagora fell sick, his mother took him to see a nurse at a nearby clinic. The nurse used a rapid diagnostic test to confirm malaria, gave him a course of artemisinin-based combination therapy, vitamins and paracetamol, and sent him home. Later that day, when Alexandria wouldn’t eat and became very weak, his mother started crying because she expected that Alexandria should have been given an injection to ensure he recovers faster.
Children are the main victims of malaria and few antimalarial medicines have been developed with their needs in mind. But their correct use at the right time makes the difference between life and death. Their use alongside appropriate diagnostics can ensure that children receive the best care possible.
Malaria is treated with anti-malarial drugs given by mouth, by injection, or intravenously (into the veins). There are also child-friendly formulations of artemisinin-based combination therapy (ACT) to treat uncomplicated malaria in children.
But, preference for injections had persisted because they were perceived as quicker action, difficulty with oral medication compliance, and addiction to injectable medication. Some health care settings also encourage the abuse of injections.
Increasing preference for treatment with injections over pills remains a public health concern to health systems across the globe, especially in resource-poor settings such as Nigeria. Existing knowledge gaps on medical information among patients coupled with the insufficient implementation of health policies aggravate this challenge.
‘’On the field, we observe that most clients going to assess treatment for malaria in health facilities after they have been tested with Rapid diagnostic test (RDT) kit or the microscopy and confirmed to have uncomplicated malaria, have the culture of requesting for injections. They insist that the clinician should give them malaria injection” said Mr Thomas Okpokpolom, PMI-s Data quality Assurance officer.
U.S President’s Malaria Initiative for States (PMI-s) is implemented in eight states — Akwa Ibom, Benue, Cross River, Ebonyi, Nasarawa, Oyo, Plateau, and Zamfara — and works with health officials at all levels to improve quality and access to services, as well as reduce under-five and maternal mortality.
Mr Okpokpolom said although Nigeria’s national guideline for the treatment of malaria indicates the use of antimalarial medicines, some health practitioners were still bending the rule and giving malaria injections for treatment of uncomplicated malaria.
Uncomplicated malaria refers to when a person has symptoms but no sign of severe infection or dysfunction of the vital organs. However, without treatment, or if a person has low immunity, it can progress to severe malaria.
Mrs Grace Fasasi, Malaria Focal person for Ibadan North Local government linked the preference for injections to treat malaria to people’s misconception that medicines in their injectable forms are more effective than their tablet form.
According to her, “many misconceptions and myths still exist in the community; some believe that malaria is caused by stress or walking in the sun; some pregnant women say that malaria in pregnancy suggests that they are going to have a baby girl. These are not true; not all fevers are malaria.
“All cases of fever need to be tested with and confirmed as malaria either with the RDT kit or the microscopy. And the only drug of choice for children with malaria is still ACT tablets and not artesunate or chloroquine injection. The amount that is needed is also determined based on the child’s age and body weight. But they must complete the dose.”
Dr Babatunde Ogunbosi a consultant paediatrician at the University College Hospital (UCH), Ibadan, stated that the use of malaria injection is only acceptable in children when the malaria is severe. Severe malaria is a life-threatening medical emergency.
Signs of dehydration, convulsions, anaemia and other complications that can affect the brain, kidneys, or spleen in children are suggestive of severe malaria. A patient may need fluids, blood transfusions, and help with breathing.
DrOgunbosi stated that some antimalarial medicines are bitter and a child already nauseous from malaria may vomit the medicine and not receive a complete curative dose but that child-friendly formulations of artemisinin-based combination therapy (ACT) could be given.
In addition, he stated that where these are not available, the antimalarial medicines can be dissolved in little water and sweetened to mask the taste to ensure the child can take it.
Child-friendly formulations of ACT such as syrups, granules, powders or tablets that can be dissolved in water, and which may be flavoured probably work as well as crushed tablets to treat uncomplicated malaria in children, and probably cause fewer unwanted effects.
Also, he added, “Giving children medicines can sometimes be a struggle. If the drug is vomited within 30 minutes, the dose should be repeated; but if the time interval is more than 30 minutes, there is no need for the child to be given another dose.”
Dr Ogunbosi, however, called for increased public education for clients and health providers to control the indiscriminate use of antimalarial injections in health care settings for uncomplicated malaria to promote the safety of patients.
“Giving injections on the buttocks, for instance, can damage their nerves in that area. Children should be given injections on the outer part of the thigh, where there are a lot of muscles. Injections have their challenges when it is not properly done, like abscess formation,” he added.
Empirical studies have shown that about 70% of therapeutic injections administered are unnecessary as oral medications could have worked in most cases. Existing policy regulations on the rational use of drugs need to be rigorously enforced to stem the abuse of therapeutic injections. It is central to patient safety and quality healthcare delivery.