In Tanzania and some other African rural settings, a traditional proscription of
injections for the treatment of
cerebral malaria (degedege) stems from parents' fear that
injections will kill a child with
fever and convulsions. The re-use of injection equipment in rural clinics is associated with bacterial contamination even where sterilization is practiced to prevent HIV transmission. A
secondary infection with bacterial
sepsis is indistinguishable from non-responsive
malaria on clinical examination, and may be a significantly under-reported adverse event in rural Tanzania. In a prospective survey of patients whose venous
catheter was culture positive on removal, 61% developed
bloodstream infections.
ISSUE: Parents report having witnessed a child's death following an injection for the treatment of
fever and convulsions in rural Tanzania, and some traditional healers who would refer a child with uncomplicated
malaria for Western biomedical treatment are convinced that
injections are fatal for a child with convulsions. Injection drug users learn aseptic technique to avoid what is called a 'dirty hit', a systemic
infection that is felt immediately after injecting, indicating sudden deterioration is likely in a sick child if an IV injection is unsafe. Community mistrust of injection providers has been too casually attributed to superstition; to address parents' concerns, injection safety should be a priority in rural health services.
Intravenous injections carry a 0.2% risk of acute
bacteremia when given with unsterile equipment, while unsafe infusions carry a 3.7% risk of
infection, much greater than the risk from
intramuscular injections of
vaccine.
Sepsis should be considered an important adverse event in the management of severe
malaria, but the diagnosis of nosocomial
bloodstream infections is a challenge in hospitals that cannot culture for bacteria. When the auto-disable syringe was introduced, patient safety improved at a Tanzanian district hospital; a reduction in the burden of serious
secondary infections large enough to reduce the average inpatient
length of stay was observed. Nosocomial
bloodstream infections are a common cause of
fever in Tanzanian hospitals. In Tanzania,
bacteremia is sometimes associated with more deaths in hospitals than
malaria.
LESSONS LEARNED: Although other obstacles to appropriate treatment for
malaria may be more important in rural Tanzania, the belief that
injections will kill a child is suggestive of avoidable adverse events. The intensity of
malaria treatment in rural areas and frequent recourse to informal sector health care presented a significant challenge for the prevention of adverse events including
sepsis and HIV transmission. A household survey in rural Tanzania found that 27% of
malaria treatment occurs at
drug stores, and 30% of patients seek treatment at a general shop. A majority of rural patients evaluated for
malaria in the formal sector have taken
chloroquine before coming to the clinic. A new national injection safety policy banning the import of non-auto-disable syringes prevents injection equipment re-use in the informal sector. Improving injection safety in rural Tanzania through the introduction of auto-disable syringes will ensure that parents have nothing to fear from
quinine injections and infusions that are usually life saving.