title: Evaluation of case management of uncomplicated malaria in Haiti: a national health facility survey, 2012.
abstract: BACKGROUND
  Malaria is a public health concern in Haiti, although there are limited data on its burden and case management. National malaria guidelines updated in 2012 recommend treatment with chloroquine and primaquine. In December 2012, a nationally-representative cross-sectional survey of health facilities (HFs) was conducted to determine malaria prevalence among febrile outpatients and malaria case management quality at baseline before scale-up of diagnostics and case management training.
  
  
  METHODS
  Among all 833 HFs nationwide, 30 were selected randomly, in proportion to total HFs per region, for 2-day evaluations. Survey teams inventoried HF material and human resources. Outpatients of all ages were screened for temperature >37.5 °C or history of fever; those without severe symptoms were consented and enrolled. Providers evaluated and treated enrolled patients according to HF standards; the survey teams documented provider-ordered diagnostic tests and treatment decisions. Facility-based test results [microscopy and malaria rapid diagnostic tests (RDTs)] were collected from HF laboratories. Blood smears for gold-standard microscopy, and dried blood spots for polymerase chain reaction (PCR) were obtained.
  
  
  RESULTS
  Malaria diagnostic capacity, defined as completing a test for an enrolled patient or having adequate resources for RDTs or microscopy, was present in 11 (37 %) HFs. Among 459 outpatients screened, 257 (56 %) were febrile, of which 193 (75 %) were eligible, and 153 (80 %) were enrolled. Among 39 patients with facility-level malaria test results available on the survey day, 11 (28 %) were positive, of whom 6 (55 %) were treated with an anti-malarial. Twenty-seven (95 %) of the 28 patients testing negative were not treated with an anti-malarial. Of 114 patients without test results available, 35 (31 %) were presumptively treated for malaria. Altogether, 42 patients were treated with an anti-malarial, one (2 %) according to Haiti's 2012 guidelines. Of 140 gold-standard smears, none were positive, although one patient tested positive by PCR, a more sensitive technique. The national prevalence of malaria among febrile outpatients is estimated to be 0.5 % (95 % confidence interval 0-1.7 %).
  
  
  CONCLUSIONS
  Malaria is an uncommon cause of fever in Haitian outpatients, and limited, often inaccurate, diagnostic capacity at baseline contributes to over diagnosis. Scale-up of diagnostics and training on new guidelines should improve malaria diagnosis and treatment in Haiti.
authors.affiliation: Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, GA, USA. klandman@gmail.com.
authors.forename: Keren Z
authors.initials: KZ
authors.lastname: Landman
authors.affiliation: Population Services International/Organisation Haïtienne de Marketing Social pour la Santé, Port-au-Prince, Haiti. sejean@ohmasshaiti.org.
authors.forename: Samuel E
authors.initials: SE
authors.lastname: Jean
authors.affiliation: Laboratoire National de Santé Publique/Ministère de la Santé Publique et de la Population (MSPP), Port-au-Prince, Haiti. alexandre.existe@gmail.com.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Existe
authors.affiliation: Population Services International/Organisation Haïtienne de Marketing Social pour la Santé, Port-au-Prince, Haiti. eniko.akom@gmail.com.
authors.forename: Eniko E
authors.initials: EE
authors.lastname: Akom
authors.affiliation: Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, GA, USA. mchang@cdc.gov.
authors.forename: Michelle A
authors.initials: MA
authors.lastname: Chang
authors.affiliation: Programme National de Contrôle de la Malaria/MSPP, Port-au-Prince, Haiti. jflemoine@mspp.gouv.ht.
authors.forename: Jean Frantz
authors.initials: JF
authors.lastname: Lemoine
authors.affiliation: Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, GA, USA. kmace@cdc.gov.
authors.forename: Kimberly E
authors.initials: KE
authors.lastname: Mace
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019090:Case Management; D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D005260:Female; D005334:Fever / Q000175:diagnosis*; D006205:Haiti; D006268:Health Facilities; D006302:Health Services Research; D006801:Humans; D007223:Infant; D008288:Malaria / Q000175:diagnosis* / Q000188:drug therapy*; D008297:Male; D008875:Middle Aged; D011247:Pregnancy; D055815:Young Adult