Case management of malaria in under-fives at primary health care facilities in a Tanzanian district.

OBJECTIVE: To study case management of malaria in children under 5 years of age at primary health care facilities in Kibaha district, Tanzania and to evaluate the accuracy of self-reported mothers'/guardians' information on chloroquine use in children.
METHOD: A random sample of 652 mothers/guardians with sick children under 5 years of age attending 10 primary health care facilities was observed and interviewed. Blood samples for determination of chloroquine levels were taken from all children and thick smears for detection of malaria parasites were taken from the children who were prescribed chloroquine. Information on diagnoses and prescriptions was collected from recording books.
RESULTS: Fever and respiratory problems were the most common complaints and accounted for 75% and 46% of the presenting conditions, respectively (some complained of both). Fifty-four per cent of the children received medication at home, most commonly antipyretics and chloroquine, 20% had been taken to another health facility and 3% to traditional healers before coming to the health facilities. There was a significantly higher use of antipyretics among home treated children compared with those taken previously to health facilities (P <or= 0.001). Use of antibiotics was higher among children who had been taken to health facilities previously (P < 0.0001). Nine per cent had received injections. The average consultation time was 3.8 min. Thirty-nine per cent of the children were physically examined, with large interfacility variations. In 71% of the children malaria was diagnosed, either as a single condition or in combination with others, and with respiratory problems as the leading overlapping condition (29%). Malaria parasites were found in 38% of the cases given a malaria diagnosis. A total of 81% of the health facility prescriptions included analgesics, 71% chloroquine and 54% antibiotics. A fourth of all prescriptions were injections. The proportions of chloroquine and antibiotic injections in relation to the total number of prescriptions varied between the facilities. Of the 529 blood samples successfully analysed for chloroquine, 98% had detectable blood drug levels. Ninety-seven per cent of the children without history of prior chloroquine treatment had detectable drug levels in the blood, 11% had high levels (>or= 1000 nmol/l). Of those prescribed chloroquine, 16% already had high blood concentrations of the drug.
CONCLUSION: Health care services, i.e. presumptive malaria diagnosis, consultation time and procedure for physical examination need to be improved.