title: Malaria deaths as sentinel events to monitor healthcare delivery and antimalarial drug safety.
abstract: OBJECTIVE
  To identify case management, health system and antimalarial drug factors contributing to malaria deaths.
  
  
  METHODS
  We investigated malaria-related deaths in South Africa's three malaria endemic provinces from January 2002 to July 2004. Data from healthcare facility records and a semi-structured interview with patients' contacts were reviewed by an expert panel, which sought to reach consensus on factors contributing to the death. This included possible health system failures, adverse reactions to antimalarials, inappropriate medicine use and failing to respond to treatment.
  
  
  RESULTS
  Approximately 177 of 197 cases met inclusion criteria for the study. Delay in seeking formal health care was significantly longer for patients who sought traditional health care [median 4; inter-quartile range (IQR) 3-7 days] than for patients who did not (median 3; IQR 1-5 days; P = 0.033). Patients with confirmed or suspected HIV/AIDS were significantly more likely to use traditional approaches (25%) than those with other comorbidities (0%; P = 0.002). Malaria was neither suspected nor tested for at a primary care facility in 23% of cases with adequate records. Initial hospital assessment was considered inadequate in 74% of cases admitted to hospital and in-patient monitoring and management was adequate in only 27%. There were 32 suspected adverse reactions to antimalarial therapy.
  
  
  CONCLUSIONS
  A confidential enquiry into malaria-related deaths is a useful tool for identifying preventable factors, health system failures and adverse events affecting malaria case management.
authors: Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa. umehta@uctgshl.uct.ac.za
authors: U
authors: U
authors: Mehta
authors: D N
authors: DN
authors: Durrheim
authors: L
authors: L
authors: Blumberg
authors: S
authors: S
authors: Donohue
authors: F
authors: F
authors: Hansford
authors: A
authors: A
authors: Mabuza
authors: P
authors: P
authors: Kruger
authors: J K
authors: JK
authors: Gumede
authors: E
authors: E
authors: Immelman
authors: A
authors: A
authors: Sánchez Canal
authors: J J
authors: JJ
authors: Hugo
authors: G
authors: G
authors: Swart
authors: K I
authors: KI
authors: Barnes
mesh_terms: D000293:Adolescent; D000328:Adult; D000962:Antimalarials / Q000008:administration & dosage* / Q000009:adverse effects; D002648:Child; D002675:Child, Preschool; D003695:Delivery of Health Care / Q000379:methods*; D004334:Drug Administration Schedule; D019353:Endemic Diseases; D005260:Female; D015658:HIV Infections / Q000150:complications / Q000453:epidemiology; D006760:Hospitalization; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D016778:Malaria, Falciparum / Q000150:complications / Q000188:drug therapy / Q000401:mortality*; D008297:Male; D016488:Medicine, African Traditional; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000523:psychology; D011320:Primary Health Care; D011803:Quinine / Q000008:administration & dosage / Q000009:adverse effects; D012017:Referral and Consultation; D013019:South Africa / Q000453:epidemiology
chemical_list: D000962:Antimalarials; D011803:Quinine