ASSESSMENT OF FACTORS INFLUENCING ADHERENCE TO MALARIA MICROSCOPY DIAGNOSIS IN THE TREATMENT OF OUT-PATIENTS AT KISUMU COUNTY REFERRAL HOSPITAL, KENYA

ABSTRACT

Malaria accounts for approximately 21% of all out-patient visits in Kenya annually. Accurate diagnosis is the key to proper treatment of the disease. In Kenya, parasitological testing using either microscopy or malaria rapid diagnostic test (mRDT) are the recommended malaria diagnostic methods. Microscopy is the „gold standard‟ for laboratory diagnosis of malaria, and is the primary method for malaria diagnosis in Kisumu county referral hospital, yet its diagnostic quality has never been evaluated. High quality malaria microscopy testing is important because it can confirm mRDT diagnosis, aid in Plasmodium species identification, quantify parasitaemia and monitor treatment failures. In western Kenya, up to 27% of out-patient consultations and up to 63% of hospital admissions are due to malaria. A recent study in this region recorded that out of 75.5% (8050/10388) malaria positive cases 84% (6745/8050) were issued with antimalarial prescriptions, while on the other hand 69% (1613/2338) were issued with antimalarial prescription despite having negative malaria test results. Kisumu County Referral Hospital Laboratory had 40,000 malaria blood smear tests for out-patients in the year prior to this study. From April to June 2018, a cross-sectional study was conducted at the Kisumu County Referral Hospital to assess factors influencing adherence to malaria microscopy diagnosis in the treatment of out-patients. Malaria blood smears were selected for re-examination using parasitology log book by systematic random sampling. Each selected blood smear was re-examined by two expert microscopists. If the two experts disagreed in parasite detection, a third tie-breaker expert microscopist provided the reference value for determining validity and reliability performance. The experts were masked to each other‟s and to the hospital laboratory‟s results. Semi-structured questionnaire was administered to microscopists and clinicians to obtain their individual characteristics. Data on adherence to the test result in the treatment of out-patients was obtained by observing practices of prescription at clinician and treatment at pharmacy-levels. All data were entered into Microsoft Excel TM 2010 from where counts, proportions, median and range were obtained to describe characteristics of microscopists and clinicians. In the process, proportions used to assess adherence to microscopy test in treatment by clinicians and pharmacy-level were also calculated. Graph Pad Prism v5.01 was used to obtain test validity and reliability at 95% Confidence Interval (CI). A total of 387 malaria slides were collected for re-examination, out of which, 375 were analyzed. Of these, 118(31.5%) were read as positive at the health facility, while 105 (28%) were read as positive by the expert microscopists, (p98%. Artemether-lumefantrin was prescribed to 13 (11%) malaria false-positives. The overall inter-reader agreement between health facility microscopists and experts was κ=0.91 (95% CI: 0.87-0.96). Sensitivity was; 89% (95% CI: 81.9-94)specificity; 99.6 (95% CI: 97.9-100), positive predictive value; 99.1% (95% CI: 94.9-100) and NPV; 95.2% (95% CI: 91.9-97.4). The health facility laboratory malaria microscopy validity and reliability measures were high, and so was the adherence to malaria microscopy diagnosis in the treatment of out-patients at both clinician and pharmacy levels.