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Describe the problem briefly. State the purpose of the study and summarise previously related publication and
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 Discussion
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present status of knowledge. Do not repeat data from the introduction or findings from the results section unless
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Philadelphia: JB Lippincott company 1991.
Methods: Describe the sampling procedure, design, equipments, methods of study, and statistical analysis insuffi-
cient details to allow reproduction by other workers.
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vant study and present status of knowledge. Do not repeat data from the introduction or findings from the results
section unless warranted.

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 Hadhramout Journal of Medical Sciences (HJMS) is a periodic peer-reviewed journal published
biannually by the College of Medicine, Hadhramout University.
The editorial team of HJMS welcomes original research articles, case reports, and brief communications
in English language, on current developments in medical practice and research, and in all fields of medical
sciences. Review articles are usually by invitation only, however review articles of high standard will be
considered.

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Prof. Hashim Abdulrahman
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Ass. Prof. Abdulkader Bayazid

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info@hjms.info - Hadhramout Journal of Medical Sciences (HJMS) Volume 4, Number 1+2, June-Dec. 2015
CONTENTS Volume 4, Issue 1+2, June-Dec. 2015
Instruction to Authors
In this issue

342
314
Pattern of mental health disorders among
Yemeni population
Age And Sex Differences Among Stroke Pa-
tients In Mukalla, Hadramout: Analysis Of
*JameelA.Raheem , *SeenaA.Yousuf , *Omer Al-Zain ,
1072 Cases
*Mohamed A. Hadi

Hussain Saeed Alghazali1, Rasheed Mohammed Bamekhlah2

350
321 Predisposing Factors of Obstetric Fis-
tula & its Surgical Outcomes, among
Al-Sabeen maternal Hospital attendanc-
Association between Internet overuse es, Sana`a –Yemen...
and mental health in Hadhramaut Uni-
versity students Dr. Athmar Hussein Ali, Dr. Rajaa Mohammed Saad Al-Azzi
Professor: Tawfik Al-busaili, Dr. Taha Ali Al-Sorori
Abdullah Alyahri

357
326 Psychological Stresses among cancer pa-
tients in Hadramout ( Yemen )
Low back pain among primary school
teachers in AL-Mukalla district
Omer M. Bameer, Ahmed M. Badheeb, Omer O. Basaad,
Khalid A. Baeassa*, Ali M. Ramadan, Ali M. Alhasani, Saeed O. Alfadly
Abdulla Bulgehar, Muaad Al-Murfadi

363
333 A Study On Some Virulence Factors And Its
Relation To Drug Resistance Of Escherichia
Knowledge and practices of malaria case Coli Isolated From Urinary Tract Infection
management as per the national guideline:
A survey among physicians in Aden, Yemen *Samia Mohammad H.,Alshahwani,, Anfal mohammad
Khdaier& Loai., A., Saaid
Dr. Khaled Al-Sakkaf, PhD, Dr. Huda Ba Saleem, PhD*,
Dr. Awsan Bahattab, MScIH
 Hadhramout Journal of Medical Sciences June-Dec. 2015; vol.4, issue1+2: 333-341

Knowledge And Practices Of Malaria Case Management As Per

The National Guideline: A Survey Among Physicians In Aden,
Dr. Khaled Al-Sakkaf, PhD - Dr. Huda Ba Saleem, PhD - Dr. Awsan Bahattab, MScIH

Abstract:

Background:
Malaria is a public health problem in Yemen where 84.8%, 66.7%, 49.0 % and 6.2% mentioned the
78% of people are at some risk to contract it. After correct drugs to treat adult, children, first trimester
the emergence of chloroquine resistance in Yemen, and the second and third trimesters of pregnan-
the national anti-malaria policy has been changed cy respectively. No significant difference in the
in 2009 to artemisinin-based combination therapy. knowledge was detected between specialists and
To ensure that treatment is effectively utilized and general practitioners except for first line treatment
to prevent drug resistance development, it is im- for complicated malaria in first pregnancy trimes-
portant to assess knowledge and practices of phy- ter. The highest percentage (92.7%) rely on parasi-
sicians regarding the recent national guideline for tological confirmation in malaria diagnosis.
anti-malaria case management recommended by
the National Malaria Control Program. Conclusion:
This study reveals poor knowledge among phy-
Methods: sicians regarding national anti-malaria guideline,
A cross-sectional survey was conducted in Aden especially regarding the treatment of uncompli-
(March to April 2014). Two hundreds and ten cated malaria of the vulnerable groups. Involve-
physicians involved in managing malaria patients ment of all stakeholders during the adoption and
were enrolled from selected public and private implementation of new national policies, provid-
hospitals. A self-administered semi structured ing training sessions and refresher courses is rec-
questionnaire was used to obtain information on ommended to ensure correct and effective use of
socio-demographic characteristics, and knowl- current policy.
edge about the national anti-malaria case manage-
ment guideline Statistical analysis was done using Key words :
SPSS-20. Different descriptive tests were used as Knowledge, Practices, Malaria case management,
appropriate. Bivariate analysis was set at a signifi- National guideline for anti-malaria drugs, Yemen
cance level of P˂0.05.

Result:
Sixty percent of the participants didn’t know about
the national guideline; 23.8% had the guideline
and only 11% received training on it. The first
line drug treatment for uncomplicated malaria was Corresponding author:
identified correctly by the following percentages:
Dr. Huda Ba Saleem, PhD*
3.3% for adult, 3.8% for children, and 27.1% for Assoc. Prof, Head, Department. Community Medicine and
first trimester of pregnancy, whereas none of them Public Health
mentioned the correct first line anti-malaria drug Director, Aden Cancer Registry and Research Center
Faculty of Medicine and Health Sciences, Aden University,
for the second and third trimesters of pregnan-
Yemen
cy. Regarding physicians’ knowledge about the hudabasaleem92@yahoo.com, hudabasaleem@gmail.com
first line drug treatment for complicated malaria,

333
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 Hadhramout Journal of Medical Sciences June-Dec. 2015; vol.4, issue1+2: 333-341

334
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 Knowledge And Practices Of Malaria Case Management As Per The National Guideline: A Survey Among...

used as monotherapy [9,11].

Introduction : In Yemen, the generalization of the treatment with
Malaria is acknowledged to be by far the most im- ACT rolled out since 2009 after several anti-malaria
portant parasitic disease globally. Nearly 40% of the drug efficacy studies that targeted the public and pri-
world’s population at risk of contracting it [1] and vate sectors[2]. The national malaria treatment policy
most of the victims are children under- five and preg- recommended that the first-line treatment for uncom-
nant women [2,3]. Despite the fact that the disease plicated (simple) malaria is Artesunate + Sulphadox-
is preventable and treatable, it is estimated that 214 ine-Pyrimethamine (AS+SP) and the second-line is
million new cases of malaria and around 0.5 million Artemether-Lumefantrine (AL). Recommended treat-
deaths occurred in 2015 [4]. ment for severe malaria is Quinine (QN). For preg-
According to the World Malaria Report 2015 [4], nant women, QN is used for the treatment of both un-
malaria remains a major public health problem in Ye- complicated and complicated (severe) malaria in the
men, where 78% of the population are at some risk first trimester of pregnancy. In the second and third
of contracting malaria and 25% at high risk of trans- trimesters, AS+SP is used for uncomplicated malaria
mission, and with confirmed reported 67513 and es- while Artemether (AM) is used for the treatment of
timated 290000-710000 malaria cases. The reported complicated malaria [10].
number of deaths was 19 with an estimated number of Therefore, there is a need to assess the knowledge
35-2500 in 2013. The dangerous species Plasmodium and practices of physicians with regard the use of
falciparum is responsible for 99% of the cases. national malaria treatment policy. Therefore, the ob-
In Aden, malaria control activities started very early jective of this study is to assess the knowledge and
in the 1900s [5]. However, the social and political un- practice of physicians in Aden, Yemen regarding the
rest, as well as the environmental factor in the coun- recommendations of NMCP guidelines of anti-malar-
try lead to the resurgence of malaria with a high level ia drugs policy.
of endemicity reach to a similar level to that of highly
endemic African countries at the end of the 20th cen-
tury [6]. This lead to the reestablishment of National Methods:
Malaria Control Program (NMCP) in the Unified Re- Study design, area and study population
public of Yemen under the presidential appointment This is a cross-sectional study carried out in March
of a Supreme National Malaria Control Committee, to April 2014 in Aden city, which is the economic cap-
which has developed a multi-strategic plan to control ital of Yemen. Aden has eight districts with major five
malaria [2,6,7]. The latest national strategy (2011- public and ten private hospitals in which services for
2015) states that by the end of 2015, the burden of malaria diagnosis and treatment are offered to those
malaria disease in Yemen will be reduced by 75% and people who are in need.
near zero mortality [2]. One of these strategies is the The study population was general medical practi-
early diagnosis and treatment to reduce morbidity and tioners or specialists, from medical, gynecology and
to prevent mortality [2,7]. However, several factors pediatrics wards as well as from the outpatients and
can affect the efficacy of treatment, including drug emergency departments, who involved in managing
resistance. patients attending these hospitals seeking for malaria
The irrational prescription of anti-malaria drugs diagnosis and treatment.
for treating fever in malaria endemic areas (even in
the absence of malaria) increases the risk of drug Sampling
resistance [8]. As a result, WHO recommends para- The enrolled sample of studied physicianswas
sitological confirmation of malaria infection before calculated assuming that the expected proportion of
treatment of suspected malaria cases [9]. This rec- anti- malaria policy knowledge among the physicians
ommendation had also adopted by Yemen national is 21% (as found by a recent study in nearby Yeme-
malaria case management policy [2,10]. Additionally, ni governorates) [12] with absolute precision of 5%.
the WHO issued a new guidance in 2001, calling on The needed sample size was estimated using Lwan-
all countries with high levels of treatment failures to ga and Lemeshow practical manual [13] to be 204.
change to Artemisinin Combination Therapy (ACT) In addition, we added 10% of the estimated sample
as first-line treatment in order to reduce the spread of size in order to compensate for the non-response rate.
resistance that may arise when artemisinin derivative Thus, the targeted sample size was 225.
335

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 Knowledge And Practices Of Malaria Case Management As Per The National Guideline: A Survey Among...

To obtain this sample, the first step was the random

selection of 50% of all public and private hospitals Results:
in the city. Three public hospitals and five private The responses were obtained from 210 participants
hospitals were selected. All physicians in the selected giving a response rate of 93.3%.
hospitals who were present at the time of the study Characteristics of the study population
and who were eligible and agreed to take part in the The mean age of the participants was 34.1 years
study were recruited until the required number of 225 and median duration of their experience was 5 years.
respondents was completed. After providing consent, Most of the studied physicians were females (67.0%),
the participants were given the questionnaire from general practitioners (61.4%), and were from public
one of the study members by hand. Physicians who hospitals (58.7%). Further information on the charac-
were not involved in managing malaria patients or teristics of the participants is shown in Table 1.
who did not provide consent to participate were ex-
Table 1: The characteristics of the participants (n=210).
cluded from the study.

Measures
A self-administered, structured, pre-tested ques-
tionnaire was used as a data collection instrument for
this study. Data collected included socio-demograph-
ic characteristics of the study participants, Malaria
diagnosis practices, knowledge about the national
policy, first line treatment for malaria, and physicians’
knowledge on the ACTs. The Yemen national guide-
line for anti-malaria drugs,2009 were used in this
study as the benchmark for recommended malaria
treatment practices[10]. The participants either re-
turned back the questionnaire at the same day or it
was collected during the following two days from Knowledge on anti-malaria national policy:
their hospitals. Table (2) revealed that less than half (n=85/210) of the
participant shad heard about the national anti-malaria
Data analysis drug policy and only around one quarter (n=50/210)
Data were entered and analyzed by using SPSS and about one tenth (n=23/210) of the studied physi-
(version 20.0) software. Categorical variables were cians were having the national guidelines of anti-ma-
described by using frequency distribution and per- laria drug policy and had received training on this
centage while continuous variables were described guideline respectively.
using means, standard deviations, medians and inter-
quartile ranges. Comparison of categorical data was Table 2: Knowledge on anti-malaria management national pol-
performed using the Chi-square test or Fisher’s Exact icy guideline (n=210).
test if necessary. P value <0.05 was considered statis-
tically significant.
Ethics approval and consent to participate
Permission was obtained from the Research Ethics
Committee of the Faculty of Medicine and Health
Sciences, University of Aden before initiating the
research. Before any data were obtained, physicians
were informed about the aim of the study and the con-
sent for participation was obtained from each of them
after including information about the purpose of the
study and its scope in the questionnaire itself. To en-
sure confidentiality, each questionnaire was assigned
a study number and the participants were asked not to
336 provide their names.

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 Knowledge And Practices Of Malaria Case Management As Per The National Guideline: A Survey Among...

Physicians’ knowledge regarding the first line treat- QN was correctly mentioned by high percentage of
ment of malaria: participants (84.8% for adults and 66.7% for chil-
When the participants were asked to mention the dren). Other drugs were mentioned less frequently.
first line treatment, the answers were as follow for However, 25.2% stated that they don’t know the drug
different targeted groups: recommended for children as first line treatment of
- Uncomplicated malaria in adults and children complicated malaria. Regarding treatment of severe
(Figure 1): malaria ; authors wish to clarify that this study was
The AS+ SP was reported by 10% for adults and conducted before the recent recommendation of the
5.7% for children. Of them only 3.3% and 3.8% re- national malaria control program regarding change
ported the correct combination respectively. The most the drug of first choice for treatment of severe malar-
frequent drugs reported to treat uncomplicated malar- ia from QN to artesusnate injection s, so the obtained
ia in adult and children were artemisinin mono thera- answer of respondents about QN is the drug of choice
py (AS or AM) followed by chloroquin (CQ). is considered correct answer.

Fig. 1: The percentage of the reported drugs by physicians as a

first line treatment for uncomplicated malaria in adult.

- Uncomplicated malaria in pregnant women (Figure 2): Fig. 3: The percentage of the reported drugs by physicians as a
Drugs which were frequently reported to treat malar- first line treatment for complicated malaria in adult and chil-
dren
ia in pregnant women were QN, artemisinin mono-
therapy and CQ. Only 27.1% mentioned QN as a
correct answered. In addition, 38.1%, 19.0% of the - Complicated malaria in pregnant women (Figure 4):
physicians claimed that they don’t know the first line Forty nine percent and 6.2% had mentioned the
anti-malaria for the pregnant women in the first tri- correct answer for the first and second and third tri-
mester, and second and third trimesters respectively. mesters of pregnancy respectively. The highest “don’t
know” answer was reported here with 39.4% for the
first the trimester and 37.1% for the second and third
trimesters of pregnancy.
In Table 3, neither the general practitioners nor the
specialists could identify the correct answer for the
first line treatment of uncomplicated malaria in the
second and third trimester of pregnancy. There is no
statistically significant differences between general
practitioners and specialists in their knowledge about
the first line treatment of all groups, except for com-
plicated malaria treatment during the first trimester
of pregnancy (p=0.0056) where specialists has higher
Fig. 2: The percentage of the reported drugs by physicians as percentages of correct answers (61.7%) compared to
a first line treatment for uncomplicated malaria in pregnant general practitioners (41.1%).
women.

- Complicated malaria in adults and children (Figure 3):

337

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 Knowledge And Practices Of Malaria Case Management As Per The National Guideline: A Survey Among...

Malaria diagnosis practices

Table 5 shows that the majority of the respondents
reported that they diagnosed malaria using micros-
copy and / or Rapid Diagnostic Test (RDTs) (92.7%,
n=191/206). The use of blood film among the respon-
dents was particularly high (86.9%, n=179/206).

Table 5: Methods used for malaria diagnosis (n=206).

Fig. 4: The percentage of the reported drugs by physicians as a

first line treatment for complicated malaria in pregnant wom-
en.

Table 3: Correct responses regarding the first line treatment of

malaria by physicians’ professional degree.

* Percentages were taken from the total 206

† Percentages cannot be summed to 100% due to multiple
responses.

Discussion:
This study has been conducted to assess the knowl-
edge of physicians of anti-malaria case management
and their practices regarding the current NMCP
* Statistically significant by Chi square test guidelines. The study reveals a poor knowledge of
the current national anti-malaria management policy.
Knowledge on ACTs Despite the fact that the guideline has implemented
Knowledge drugs comprising ACTs are shown in Ta- since 2009, 59.5% did not know about the national
ble 4. Out of 205 respondents, 145 (71.7%) claimed anti-malaria policy. This is a serious and critical issue
that they know ACTs. When asked to mention ACTs concerning the communication of the information be-
they know, 77.9% (n=113/145) of the participants tween the policy makers and the frontline implement-
mentioned AS+SP and / or AL. However, anti- malar- er of the policy. Earlier studies conducted in India
ia drugs other than ACTs were mentioned 34.5% of [14] and some African countries [8,15–17] on health
the time as being ACTs. professional practices following anti- malaria policy
change, have shown their inappropriate level of ad-
Table 4: Drugs mentioned as ACTs by the respondents (n=145). herence to the new policy, even after several years
from the introduction of the new guidelines. More-
over, a study conducted in Yemen showed that, only
23% of the participants describe AS+ SP as first- line
treatment [12]. However, in our study, AS+SP was
described as the first line drug by only 10% of the
participants for the adult group.
Our findings have revealed that the participants’
* Percentages were taken from the total 145. knowledge was low regarding the treatment of un-
† Percentages cannot be summed to 100% due to multiple respons-
complicated malaria in the most vulnerable popula-
es.
tion; children and pregnant women. In areas where
the malaria is endemic, such as Yemen [18,19], the
burden of uncomplicated malaria in these groups is
338

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 Knowledge And Practices Of Malaria Case Management As Per The National Guideline: A Survey Among...

substantial; and effective treatment is necessary to result. However, the public health impact of this drug
prevent severe complications [3,20]. This finding is misuse would be significant, as resistances to these
concordant with other studies conducted in Yemen two drugs have already reported in Southeast Asian
[12] and Africa [16,17] that has shown a lower level of countries [24–27].
knowledge regarding the anti-malaria treatment poli- The diagnosis practice, through microscopy and /
cy in these groups in comparison to the knowledge in or RDT besides the clinical symptoms of the majority
the adult group. The participants’ poor knowledge re- of the respondent (92.7%) complies with WHO rec-
garding ACTs in general was obvious, as 34.5% from ommendation and NMCP recommendation [2,9,10].
the participants who claimed knowledge on ACTs Nevertheless, more sensitization to the recommended
confused it with other anti-malaria drug class. malaria diagnosis and the complicated malaria treat-
Since educating and training the health profession- ment is essential, since malaria has a substantial bur-
als among others, are essential prerequisites for effec- den on the Yemen public health and the health system.
tive implementation of new policy [11], we claim that The study has the following limitations: the study
the low training level among the participants (11%) population was physicians in hospitals and they ap-
and the percentage of the participants who possess the proached through convenient sampling. Thus, they
guideline (23.8%) were contributing factors to their may differ from other health care provider, such as
poor knowledge [17]. physicians in primary health centers, pharmacist
Yet, a similar study in Malawi [16], research par- and other health allies and non-sampled population.
ticipant level of knowledge was higher than the per- Therefore, the generalizability of the study findings
centage of those received training in the new policy may be dealt with caution. In addition, the survey tool
implementation. Nevertheless, the knowledge re- was a self-administrated questionnaire and some par-
garding the first line treatment in our study was even ticipants did not fill in all the required information.
lower than their level of training (10%, 5.7% and 0% Moreover, the participants’ knowledge and claimed
in the adult, children and second and third trimesters practices may also differ from their actual prescrip-
of pregnancy, respectively). Thus, further studies to tion practices as previously reported [12].
identify and correct these poor knowledge’s contrib-
uting factors must be carried out. On the other hand, Conclusion:
despite that knowledge regarding the treatment of This study reveals serious knowledge gap regard-
complicated malaria was generally goods among both ing the current national policy among physicians es-
groups of physicians except for second and third tri- pecially for the first line treatment of uncomplicated
mester of pregnancy; still, it is not sufficient. malaria in vulnerable groups. Inadequate endorse-
In contrast to a study conducted in Pakistan [21], ment for the national policies, unaffordable guidelines
there were no statistical differences between the gen- for the physicians and inadequate training was a con-
eral practitioners’ knowledge and that of the special- tributing factor for the physicians’ poor knowledge.
ists except for first line treatment for complicated The guidelines must be available to all health care
malaria in the first pregnancy trimester. This could providers. Universal training and refresher courses
indicate the need for planned training and knowledge for physicians on using the current anti-malaria pol-
upgrading activities for both groups. icy must be scaled up. We recommend engaging all
Although this study has revealed the poor knowl- the stakeholders (including academia) in the adoption
edge regarding the current malaria policy among the and implementation of the national guidelines in or-
physicians, the drugs mentioned by them as being the der to emphasize the adherence to national policies
first line could represent two trends: for common endemic diseases in both undergraduate
1. The use of the earlier guideline drugs such as CQ and postgraduate medical curricula. We also are rec-
[22] which may improve the patients’ clinical symp- ommending further studies to evaluate the factors af-
toms without clearing the parasitemia [23] and fecting the utilization of the national guidelines.
2. The use of artemisinin monotherapy and /or QN. List of abbreviations: ACT: Artemisinin Combina-
Many physicians seem aware of anti -malaria drug tion Therapy; AM: Artemether; AL: Artemether-Lume-
resistance to CQ through their practice, but not in the fantrine; AS: Artesunate; CQ: Chloroquine; QN: Qui-
current national policy, and thus they use the arte- nine; NMCP: National Malaria Control Program; SP:
misinin monotherapy or QN to treat uncomplicated Sulphadoxine-Pyrimethamine; RDTs: Rapid Diagnos-
malaria. These drugs may have a satisfactory clinical tic Tests; WHO: World Health Organization. 339

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 Knowledge And Practices Of Malaria Case Management As Per The National Guideline: A Survey Among...

Competing interests: The authors declare that they tion 2006; 2006.
have no competing interests 10. Ministry of public health and population (Ye-
Funding: The study is self-funded men). The national guideline for anti-malaria
Authors’ contributions drugs. 2009.
All authors contributed to the work presented in 11. World Health Organization. Malaria case man-
this manuscript, read and approved the final manu- agement: operations manual. Geneva: World
script. KA designed the study, developed the study Health Organization; 2009.
tools, analyzed the data, and participated in writing 12. Bin Ghouth AS. Availability and prescription
the manuscript. HB designed the study, developed practice of anti-malaria drugs in the private
the study tools, and participated in writing the man- health sector in Yemen. J Infect Dev Ctries.
uscript. AB designed the study, developed the study 2013;7(5):404–12.
tools, performed the field work, analyzed the data and 13. Lwanga SK, Lemeshow S. Sample size determi-
participated in writing the manuscript. nation in health studies: a practical manual. Ge-
neva: World Health Organization; 1991.
Acknowledgements 14. Ahir G, Bala D V. Perceptions and attitudes of
Our thank goes to the physicians participated in resident doctors about malaria treatment as per
the study. Deep gratitude extends to the colleagues national drug policy in malaria. Natl J Commu-
helped in collecting back the filled questionnaires. nity Med. 2012;3(1):71–3.
15. Manirakiza A, Njuimo SP, Le Faou A, Malvy
References: D, Millet P. Availability of antimalarial drugs
1. World Health Organization. Global technical and evaluation of the attitude and practices for
strategy for malaria 2016–2030. Geneva: World the treatment of uncomplicated malaria in ban-
Health Organization; 2016. gui, Central African Republic. J Trop Med.
2. Ministry of Public Health and Population (Ye- 2010;2010:10–5.
men). Yemen ’ s National Malaria Control and 16. Kalilani-phiri L V, Lungu D, Coghlan R. Knowl-
Elimination Strategic Plan 2011-2015. 2011. edge and malaria treatment practices using ar-
3. Sevene E, González R, Menéndez C. Current temisinin combination therapy ( ACT ) in Ma-
knowledge and challenges of antimalarial drugs lawi : survey of health professionals. Malar J.
for treatment and prevention in pregnancy. Ex- 2011;10(279).
pert Opin Pharmacother. 2010;11(8):1277–93. 17. Harrison NE, Olufunlayo TF, Agomo CO. Uti-
4. World Health Organization. World malaria report lization of the current national antimalarial
2015. Geneva; 2016. treatment guidelines among doctors in army
5. Colbourne M, Smith S. Problem of malaria in hospitals in Lagos , Nigeria. Open J Prev Med.
Aden protectorate: (report on a visit). England; 2012;2(3):390–3.
1964. 18. Al-mekhlafi AMQ, Mahdy MAK, Azazy AA.
6. Snow RW, Amratia P, Zamani G, Mundia CW, Clinical situation of endemic malaria in Yemen.
Noor AM, Atta H. The malaria transition on the Trop Biomed. 2010;27(3):551–8.
Arabian Peninsula : progress toward a malar- 19. Bamaga O a, Mahdy M a, Mahmud R, Lim Y
ia-free region between 1960 – 2010. In: Roll- a. Malaria in Hadhramout, a southeast province
inson D, editor. Advances in Parasitology. Else- of Yemen: prevalence, risk factors, knowledge,
vier Ltd; 2013. p. 205–51. attitude and practices (KAPs). Parasit Vectors.
7. Ministry of Public Health and Population (Ye- 2014;7(1):351.
men). Report on the final results of the national 20. Brabin B, Romagosa C, Abdelgalil S, Menén-
malaria indicators survey. 2009. dez C, Verhoeff F, McGready R, et al. The Sick
8. Kamuhabwa AA, Silumbe R. Knowledge among Placenta—The Role of Malaria. Placenta [Inter-
drug dispensers and antimalarial drug prescrib- net]. 2004;25(5):359–78. Available from: http://
ing practices in public health facilities in Dar es www.sciencedirect.com/science/article/pii/
Salaam. Drug Healthc Patient Saf. 2013;5:181–9. S0143400403003072
9. World Health Organization. WHO briefing on 21. Malik M, Shafie AA, Hussain A. Knowledge and
Malaria Treatment Guidelines and artemisinin perceptions of prescribers regarding adherence
340 monotherapies. Geneva: World Health Organiza- to standard treatment guidelines for malaria : a

info@hjms.info - Hadhramout Journal of Medical Sciences (HJMS) Volume 4, Number 1+2, June-Dec. 2015
 Knowledge And Practices Of Malaria Case Management As Per The National Guideline: A Survey Among...

comparative cross-sectional study from Pakistan.

EMHJ. 2014;20(4):221–8.
22. Bashrahil KA, Bingouth AS, Baruzaig AS.
Antimalarial drugs : availability and mode
of prescribing in Mukalla , Yemen. EMHJ.
2010;16(2):146–50.
23. Vestergaard LS, Ringwald P. Responding to the
challenge of antimalarial drug resistance by rou-
tine monitoring to update national malaria treat-
ment policies. Am J Trop Med Hyg [Internet].
2007 Dec;77(6 Suppl):153–9. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/18165488
24. World Health Organization. Status report on arte-
misinin resistance. Geneva; 2014.
25. Cui L, Mharakurwa S, Ndiaye D, Rathod PK,
Rosenthal PJ. Antimalarial drug resistance :
literature review and activities and findings of
the ICEMR network. Am Soc Trop Med Hyg.
2015;93(Suppl 3):57–68.
26. Tun KM, Imwong M, Lwin KM, Win AA, Hlaing
TM, Hlaing T, et al. Spread of artemisinin-re-
sistant Plasmodium falciparum in Myanmar:
A cross-sectional survey of the K13 molecular
marker. Lancet Infect Dis. 2015;15(4):415–21.
27. Achan J, Talisuna AO, Yeka A, James K Tibend-
erana FNB, Rosenthal PJ, D’Alessandro U. Qui-
nine , an old anti ¬ malarial drug in a modern
world : role in the treatment of malaria. Malar J.
2011;10(144).

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