Malaria deaths as sentinel events to monitor healthcare delivery and antimalarial drug safety

Summary Objectives To identify case management, health system and antimalarial drug factors contributing to malaria deaths. Method 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. Conclusion 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. Objectifs Identifier les facteurs dans la prise en charge des cas, du système de santé et des médicaments antimalariques contribuant aux décès par malaria. Méthode Nous avons étudié les décès liés à la malaria dans trois provinces endémiques pour la malaria en Afrique du Sud de janvier 2002 à juillet 2004. Les registres des services de santé et un entretien semi structuré avec les contacts des patients ont été passés en revue par une équipe d'experts qui a cherchéà atteindre un consensus sur les facteurs contribuant au décès. Cela comprenait: les échecs possibles du système de santé, les réactions adverses des médicaments antimalariques, l'utilisation inadéquate des médicaments et l'absence de réponse au traitement. Résultats 177 sur 197 cas répondaient aux critères d'inclusion pour l’étude. Ceux qui ont fait recours à la médecine traditionnelle avaient un retard significativement plus