The impact of response to the results of diagnostic tests for malaria: cost-benefit analysis

Diagnostic Accuracy of a Thick Blood Smear Compared to qPCR for Malaria Associated with Pregnancy in Colombia

This study aimed to evaluate the accuracy of the thick blood smear (TBS) versus quantitative polymerase chain reaction (qPCR) for the diagnosis of malaria associated with pregnancy (MAP) caused by P. falciparum or P. vivax in Colombia in its gestational malaria (GM), placental malaria (PM), and congenital malaria (CM) forms as well as to compare its accuracy in different subgroups of pregnant women according to the presence of fever, anemia and a history of malaria. This was a diagnostic evaluation of 829 pregnant women, 579 placentas, 381 umbilical cord samples, and 221 neonatal peripheral blood samples. Accuracy was evaluated based on the parameters of sensitivity, specificity, predictive values, likelihood ratios, and validity index, with their 95% confidence intervals. The frequency of GM was 36% (n = 297/829), PM 27% (n = 159/579), and CM 16.5% (n = 63/381) in umbilical cord samples and 2% (n = 5/221) in neonatal peripheral blood samples. For GM, the sensitivity was 55%, with higher rates in those infected with P. vivax (68%), with a history of malaria (69%), and with fever (96%). These three subgroups presented the best results in terms of the negative likelihood ratio and validity index. For PM, sensitivity was 8%; in subgroup analyses in terms of species, symptomatology (anemia and fever), and history of malaria, it was 1-18%, and the negative likelihood ratio was >0.80 in all subgroups. No false positives were recorded in any of the subgroups. The TBS did not detect any cases of CM. This study found the TBS yielded satisfactory results in terms of diagnosing GM for P. vivax, pregnant women with previous malaria and febrile. It also showed that the TBS is not useful for diagnosing PM and CM. It is necessary to conduct surveillance of MAP with molecular methods in in groups where TBS is deficient (asymptomatic GM, P. falciparum, and pregnant women without history of malaria) to optimize the timely treatment of PM and CM, avoid the deleterious effects of MAP and achieve the malaria elimination goals in Colombia.

Cost-Utility Analysis of Community Case Management for Malaria Control in Burundi

BACKGROUND

The community case management (CCM) program for malaria control is a community-based strategy implemented to regulate malaria in children in Burundi. This study compared the cost and utility of implementing the CCM program combined with health facility management (HFM) versus HFM alone for malaria control in children under five in Burundi.

METHODS

This study constructed a five-year Markov model with one-week cycles to estimate cost-utility and budget impact analysis (BIA). The model defined 10 health states, simulating the progression of the disease and the risk of recurrent malaria in children under five years of age. Cost data were empirically collected and presented for 2019. Incremental cost per disability-adjusted life year (DALY) averted, and a five-year budget was estimated. One-way and probabilistic sensitivity analyses (PSAs) were then performed.

RESULTS

From provider and societal perspectives, combining the CCM program with HFM for malaria control in Burundi was more cost-effective than implementing HFM alone. The addition of CCM, using artesunate amodiaquine (ASAQ) as the first-line treatment, increased by US$1.70, and US$ 1.67 per DALY averted from the provider and societal perspectives, respectively. Using Artemether Lumefantrine (AL) as the first-line treatment, adding the CCM program to HFM increased by US$ 1.92, and US$ 1.87 per DALY averted from the provider and societal perspectives. At a willingness-to-pay of one GDP/capita, the CCM program remained a 100% chance of being cost-effective. In addition, implementing the program for five years requires a budget of US$ 15 800 486-19 765 117.

CONCLUSION

Implementing the CCM program and HFM is value for money for malaria control in Burundi. The findings can support decision-makers in Burundi in deciding on resource allocation, especially during the program's scale up.

Accuracy of rapid diagnostic test to diagnose malaria in children under 5 years of age, a meta-analysis

OBJECTIVE

To assess the accuracy of the rapid diagnostic test for malaria diagnosis in children under 5 years of age.

METHODS

As of August 31, 2020, PubMed, Web of Science and Cochrane Library databases had been systematically searched. Relevant data were extracted and meta-analysis was carried out. A random effects model was used for subgroup analysis.

RESULTS

According to the inclusion criteria, a total of 26 studies were included in this meta-analysis. The pooled sensitivity and specificity were 0.92 (95% confidence interval 0.83-0.96) and 0.92 (0.86-0.95), the parasite-specific lactate dehydrogenase-based test were 0.96 (0.85-0.98) and 0.93 (0.86-0.95), the histidine-rich protein 2-based test were 0.94 (0.84-0.98) and 0.86 (0.77-0.91).

CONCLUSIONS

This meta-analysis showed that rapid diagnostic test had good accuracy in diagnosing malaria in children under 5 years of age. And the diagnostic performance of parasite-specific lactate dehydrogenase test was better than that of the histidine-rich protein 2 test.

Trends in health workers' compliance with outpatient malaria case-management guidelines across malaria epidemiological zones in Kenya, 2010-2016

BACKGROUND

Health workers' compliance with outpatient malaria case-management guidelines has been improving, specifically regarding the universal testing of suspected cases and the use of artemisinin-based combination therapy (ACT) only for positive results (i.e., 'test and treat'). Whether the improvements in compliance with 'test and treat' guidelines are consistent across different malaria endemicity areas has not been examined.

METHODS

Data from 11 national, cross-sectional, outpatient malaria case-management surveys undertaken in Kenya from 2010 to 2016 were analysed. Four primary indicators (i.e., 'test and treat') and eight secondary indicators of artemether-lumefantrine (AL) dosing, dispensing, and counselling were measured. Mixed logistic regression models were used to analyse the annual trends in compliance with the indicators across the different malaria endemicity areas (i.e., from highest to lowest risk being lake endemic, coast endemic, highland epidemic, semi-arid seasonal transmission, and low risk).

RESULTS

Compliance with all four 'test and treat' indicators significantly increased in the area with the highest malaria risk (i.e., lake endemic) as follows: testing of febrile patients (OR = 1.71 annually; 95% CI = 1.51-1.93), AL treatment for test-positive patients (OR = 1.56; 95% CI = 1.26-1.92), no anti-malarial for test-negative patients (OR = 2.04; 95% CI = 1.65-2.54), and composite 'test and treat' compliance (OR = 1.80; 95% CI = 1.61-2.01). In the low risk areas, only compliance with test-negative results significantly increased (OR = 2.27; 95% CI = 1.61-3.19) while testing of febrile patients showed declining trends (OR = 0.89; 95% CI = 0.79-1.01). Administration of the first AL dose at the facility significantly increased in the areas of lake endemic (OR = 2.33; 95% CI = 1.76-3.10), coast endemic (OR = 5.02; 95% CI = 2.77-9.09) and semi-arid seasonal transmission (OR = 1.44; 95% CI = 1.02-2.04). In areas of the lowest risk of transmission and highland epidemic zone, none of the AL dosing, dispensing, and counselling tasks significantly changed over time.

CONCLUSIONS

There is variability in health workers' compliance with outpatient malaria case-management guidelines across different malaria-risk areas in Kenya. Major improvements in areas of the highest risk have not been seen in low-risk areas. Interventions to improve practices should be targeted geographically.

Diagnosis of clinical malaria in endemic settings

INTRODUCTION

Malaria continues to be a major global health problem, with over 228 million cases and 405,000 deaths estimated to occur annually. Rapid and accurate diagnosis of malaria is essential to decrease the burden and impact of this disease, particularly in children. We aimed to review the main available techniques for the diagnosis of clinical malaria in endemic settings and explore possible future options to improve its rapid recognition.

AREAS COVERED

literature relevant to malaria diagnosis was identified through electronic searches in Pubmed, with no language or date restrictions and limited to humans.

EXPERT OPINION

Light microscopy is still considered the gold standard method for malaria diagnosis and continues to be at the frontline of malaria diagnosis. However, technologies as rapid diagnostic tests, mainly those who detect histidine-rich protein-2, offer an accurate, rapid and affordable alternative for malaria diagnosis in endemic areas. They are now the technique most extended in endemic areas for parasitological confirmation. In these settings, PCR-based assays are usually restricted to research and they are not currently helpful in the management of clinical malaria. Other technologies, such as isothermal methods could be an interesting and alternative approach to PCR in the future.

To screen or not to screen: an interactive framework for comparing costs of mass malaria treatment interventions

BACKGROUND

Mass drug administration and mass-screen-and-treat interventions have been used to interrupt malaria transmission and reduce burden in sub-Saharan Africa. Determining which strategy will reduce costs is an important challenge for implementers; however, model-based simulations and field studies have yet to develop consensus guidelines. Moreover, there is often no way for decision-makers to directly interact with these data and/or models, incorporate local knowledge and expertise, and re-fit parameters to guide their specific goals.

METHODS

We propose a general framework for comparing costs associated with mass drug administrations and mass screen and treat based on the possible outcomes of each intervention and the costs associated with each outcome. We then used publicly available data from six countries in western Africa to develop spatial-explicit probabilistic models to estimate intervention costs based on baseline malaria prevalence, diagnostic performance, and sociodemographic factors (age and urbanicity). In addition to comparing specific scenarios, we also develop interactive web applications which allow managers to select data sources and model parameters, and directly input their own cost values.

RESULTS

The regional-level models revealed substantial spatial heterogeneity in malaria prevalence and diagnostic test sensitivity and specificity, indicating that a "one-size-fits-all" approach is unlikely to maximize resource allocation. For instance, urban communities in Burkina Faso typically had lower prevalence rates compared to rural communities (0.151 versus 0.383, respectively) as well as lower diagnostic sensitivity (0.699 versus 0.862, respectively); however, there was still substantial regional variation. Adjusting the cost associated with false negative diagnostic results to included additional costs, such as delayed treated and potential lost wages, undermined the overall costs associated with MSAT.

CONCLUSIONS

The observed spatial variability and dependence on specified cost values support not only the need for location-specific intervention approaches but also the need to move beyond standard modeling approaches and towards interactive tools which allow implementers to engage directly with data and models. We believe that the framework demonstrated in this article will help connect modeling efforts and stakeholders in order to promote data-driven decision-making for the effective management of malaria, as well as other diseases.

Modelling the cost-effectiveness of introducing subsidised malaria rapid diagnostic tests in the private retail sector in sub-Saharan Africa

Background

Over the last 10 years, there has been a huge shift in malaria diagnosis in public health facilities, due to widespread deployment of rapid diagnostic tests (RDTs), which are accurate, quick and easy to use and inexpensive. There are calls for RDTs to be made available at-scale in the private retail sector where many people with suspected malaria seek care. Retail sector RDT use in sub-Saharan Africa (SSA) is limited to small-scale studies, and robust evidence on value-for-money is not yet available. We modelled the cost-effectiveness of introducing subsidised RDTs and supporting interventions in the SSA retail sector, in a context of a subsidy programme for first-line antimalarials.

Methods

We developed a decision tree following febrile patients through presentation, diagnosis, treatment, disease progression and further care, to final health outcomes. We modelled results for three ‘treatment scenarios’, based on parameters from three small-scale studies in Nigeria (TS-N), Tanzania (TS-T) and Uganda (TS-U), under low and medium/high transmission (5% and 50% Plasmodium falciparum (parasite) positivity rates (PfPR), respectively).

Results

Cost-effectiveness varied considerably between treatment scenarios. Cost per disability-adjusted life year averted at 5% PfPR was US$482 (TS-N) and US$115 (TS-T) and at 50% PfPR US$44 (TS-N) and US$45 (TS-T), from a health service perspective. TS-U was dominated in both transmission settings.

Conclusion

The cost-effectiveness of subsidised RDTs is strongly influenced by treatment practices, for which further evidence is required from larger-scale operational settings. However, subsidised RDTs could promote increased use of first-line antimalarials in patients with malaria. RDTs may, therefore, be more cost-effective in higher transmission settings, where a greater proportion of patients have malaria and benefit from increased antimalarial use. This is contrary to previous public sector models, where RDTs were most cost-effective in lower transmission settings as they reduced unnecessary antimalarial use in patients without malaria.

Malaria case management in Zambia: A cross-sectional health facility survey

Misdiagnosis of malaria could lead to the overuse of antimalarials resulting in the progression of underlying illness as well as increased risk of mortality. Misdiagnosis is an important consideration as a significant proportion of febrile illnesses in sub-Saharan Africa are attributable to conditions other than malaria. A health facility survey was carried out for a simple random sample of health facilities across 4 provinces of central Zambia in 2014. Twenty-nine facilities with at least 10 outpatients per day were included in the final sample. A modified service provision assessment questionnaire was used for data collection along with several other instruments. Primary outcomes included the quality and accuracy of diagnostic testing for malaria as well as health worker diagnostic and treatment practices. Laboratory technicians displayed 65.5% sensitivity and 86.0% specificity in performing malaria microscopy. Rapid diagnostic test results as reported by health workers were cross-checked by survey staff revealing 99.8% (95% CI: 98.0%-100.0%) concordance. Overall, 69.5% (177/286) (95% CI [58.8%-78.4%]) of patients were reported as febrile of which 37.0% (68/177) (95% CI [21.0%-56.6%]) had a malaria test requested or conducted by their health worker. Appropriate health worker adherence to recommended malaria case management practices (i.e. requesting/conducting malaria tests for febrile patients and providing appropriate antimalarial treatment for test positive cases or forgoing antimalarial treatment for test negative cases) was 30.5% (57/177) (95% CI [17.1%-48.4%]). Presence of fever (aOR = 10.6; 95% CI [3.6-31.2]) and self-reported headache (aOR = 2.2; 95% CI [1.0-4.9]) were significant factors in explaining health worker practices of requesting or performing malaria tests. Routine practice of IQA activities (aOR = 4.8; 95% CI [1.5-15.1]) and self-reported headache (aOR = 3.3; 95% CI [1.1-10.1])) were both significant predictors of antimalarial drug treatment or prescription among malaria untested patients. Prescriber adherence to malaria diagnostic test results in central Zambia is good, but the overall testing rate of febrile patients was low. Additionally, a number of patients observed during this survey were found to have received a clinical diagnosis of malaria without parasitological confirmation and many patients without test results received antimalarial treatment.

A comparison of thick-film microscopy, rapid diagnostic test, and polymerase chain reaction for accurate diagnosis of Plasmodium falciparum malaria

Background

Accurate diagnosis of malaria is important for effective disease management and control. In Cameroon, presumptive clinical diagnosis, thick-film microscopy (TFM), and rapid diagnostic tests (RDT) are commonly used to diagnose cases of Plasmodium falciparum malaria. However, these methods lack sensitivity to detect low parasitaemia. Polymerase chain reaction (PCR), on the other hand, enhances the detection of sub-microscopic parasitaemia making it a much-needed tool for epidemiological surveys, mass screening, and the assessment of interventions for malaria elimination. Therefore, this study sought to determine the frequency of cases missed by traditional methods that are detected by PCR.

Methods

Blood samples, collected from 551 febrile Cameroonian patients between February 2014 and February 2015, were tested for P. falciparum by microscopy, RDT and PCR. The hospital records of participants were reviewed to obtain data on the clinical diagnosis made by the health care worker.

Results

The prevalence of malaria by microscopy, RDT and PCR was 31%, 45%, and 54%, respectively. However, of the 92% of participants diagnosed as having clinical cases of malaria by the health care worker, 38% were malaria-negative by PCR. PCR detected 23% and 12% more malaria infections than microscopy and RDT, respectively. A total of 128 (23%) individuals had sub-microscopic infections in the study population. The sensitivity of microscopy, RDT, and clinical diagnosis was 57%, 78% and 100%; the specificity was 99%, 94%, and 17%; the positive predictive values were 99%, 94%, and 59%; the negative predictive values were 66%, 78%, and 100%, respectively. Thus, 41% of the participants clinically diagnosed as having malaria had fever caused by other pathogens.

Conclusions

Malaria diagnostic methods, such as TFM and RDT missed 12–23% of malaria cases detected by PCR. Therefore, traditional diagnostic approaches (TFM, RDT and clinical diagnosis) are not adequate when accurate epidemiological data are needed for monitoring malaria control and elimination interventions.

Predictors of malaria Rapid Diagnostic Tests' utilisation among healthcare workers in Zamfara State

INTRODUCTION

Early diagnosis and prompt and effective treatment is one of the pillars of malaria control. Malaria case management guidelines recommend diagnostic testing before treatment using malaria Rapid Diagnostic Test (mRDT) or microscopy and this was adopted in Nigeria in 2010. However, despite the deployment of mRDT, the use of mRDTs by health workers varies by settings. This study set out to assess factors influencing utilisation of mRDT among healthcare workers in Zamfara State, Nigeria.

METHODS

A cross-sectional study was carried out among 306 healthcare workers selected using multistage sampling from six Local Government Areas between January and February 2017. Mixed method was used for data collection. A pre-tested self-administered questionnaire was used to collect information on knowledge, use of mRDT and factors influencing utilization. An observational checklist was used to assess the availability of mRDT in the six months prior to this study. Data were analyzed using descriptive statistics such as means and proportions. Association between mRDT use and independent variables was tested using Chi square while multiple regression was used to determine predictors of use at 5% level of significance.

RESULTS

Mean age of respondents was 36.0 ± 9.4years. Overall, 198 (64.7%) of health workers had good knowledge of mRDT; mRDT was available in 33 (61.1%) facilities. Routine use of mRDT was reported by 253 (82.7%) healthcare workers. This comprised 89 (35.2%) laboratory scientists/technicians, 89 (35.2%) community health extension workers/community health officers; 59 (23.3%) nurses and 16 (6.3%) doctors. Health workers' good knowledge of mRDT, trust in mRDT results, having received prior training on mRDT, and non-payment for mRDT were predictors of mRDT utilisation.

CONCLUSION

This study demonstrated that healthcare worker utilisation of mRDT was associated with health worker and health system-related factors that are potentially modifiable. There is need to sustain training of healthcare workers on benefits of using mRDT and provision of free mRDT in health facilities.

Model-based economic evaluations of diagnostic point of care tests were rarely fit for purpose

OBJECTIVES

Linked evidence models are recommended to predict health benefits and cost-effectiveness of diagnostic tests. We considered how published models accounted for changes in patient pathways that occur with point of care tests (POCTs) and their impact on patient health and costs.

STUDY DESIGN AND SETTING

Model-based evaluations of diagnostic POCTs published from 2004 to 2017 were identified from searching six databases. For each model, we assessed the outcomes considered, and whether reduced time to diagnosis and increased access to testing affected patient health and costs.

RESULTS

Seventy-four model-based evaluations were included: 95% incorporated evidence on test accuracy, but 34% only assessed intermediate outcomes such as rates of correct diagnosis. Of 54 models where POCTs reduced testing time, 39% addressed the economic and 37% addressed the health benefits of faster diagnosis. No model considered differences in access to tests.

CONCLUSION

Many models fail to capture the effects of POCTs in increasing access, advancing speed of diagnosis and treatment, and reducing anxiety and the associated costs. Many only consider the impact of testing from changes in accuracy. Ensuring models incorporate changes in patient pathways from faster and more accessible testing will lead to economic evaluations that better reflect the impact of POCTs.

Enumerating the economic cost of antimicrobial resistance per antibiotic consumed to inform the evaluation of interventions affecting their use

Background

Antimicrobial resistance (AMR) poses a colossal threat to global health and incurs high economic costs to society. Economic evaluations of antimicrobials and interventions such as diagnostics and vaccines that affect their consumption rarely include the costs of AMR, resulting in sub-optimal policy recommendations. We estimate the economic cost of AMR per antibiotic consumed, stratified by drug class and national income level.

Methods

The model is comprised of three components: correlation coefficients between human antibiotic consumption and subsequent resistance; the economic costs of AMR for five key pathogens; and consumption data for antibiotic classes driving resistance in these organisms. These were used to calculate the economic cost of AMR per antibiotic consumed for different drug classes, using data from Thailand and the United States (US) to represent low/middle and high-income countries.

Results

The correlation coefficients between consumption of antibiotics that drive resistance in S. aureus, E. coli, K. pneumoniae, A. baumanii, and P. aeruginosa and resistance rates were 0.37, 0.27, 0.35, 0.45, and 0.52, respectively. The total economic cost of AMR due to resistance in these five pathogens was $0.5 billion and $2.9 billion in Thailand and the US, respectively. The cost of AMR associated with the consumption of one standard unit (SU) of antibiotics ranged from $0.1 for macrolides to $0.7 for quinolones, cephalosporins and broad-spectrum penicillins in the Thai context. In the US context, the cost of AMR per SU of antibiotic consumed ranged from $0.1 for carbapenems to $0.6 for quinolones, cephalosporins and broad spectrum penicillins.

Conclusion

The economic costs of AMR per antibiotic consumed were considerable, often exceeding their purchase cost. Differences between Thailand and the US were apparent, corresponding with variation in the overall burden of AMR and relative prevalence of different pathogens. Notwithstanding their limitations, use of these estimates in economic evaluations can make better-informed policy recommendations regarding interventions that affect antimicrobial consumption and those aimed specifically at reducing the burden of AMR.

Electronic supplementary material

The online version of this article (10.1186/s13756-018-0384-3) contains supplementary material, which is available to authorized users.

The epidemiology of febrile illness in sub-Saharan Africa: implications for diagnosis and management

BACKGROUND

Fever is among the most common symptoms of people living in Africa, and clinicians are challenged by the similar clinical features of a wide spectrum of potential aetiologies.

AIM

To summarize recent studies of fever aetiology in sub-Saharan Africa focusing on causes other than malaria.

SOURCES

A narrative literature review by searching the MEDLINE database, and recent conference abstracts.

CONTENT

Studies of multiple potential causes of fever are scarce, and for many participants the infecting organism remains unidentified, or multiple co-infecting microorganisms are identified, and establishing causation is challenging. Among ambulatory patients, self-limiting arboviral infections and viral upper respiratory infections are common, occurring in up to 60% of children attending health centres. Among hospitalized patients there is a high prevalence of potentially fatal infections requiring specific treatment. Bacterial bloodstream infection and bacterial zoonoses are major causes of fever. In recent years, the prevalence of antimicrobial resistance among bacterial isolates has increased, notably with spread of extended spectrum β-lactamase-producing Enterobacteriaceae and fluoroquinolone-resistant Salmonella enterica. Among those with human immunodeficiency virus (HIV) infection, Mycobacterium tuberculosis bacteraemia has been confirmed in up to 34.8% of patients with sepsis, and fungal infections such as cryptococcosis and histoplasmosis remain important.

IMPLICATIONS

Understanding the local epidemiology of fever aetiology, and the use of diagnostics including malaria and HIV rapid-diagnostic tests, guides healthcare workers in the management of patients with fever. Current challenges for clinicians include assessing which ambulatory patients require antibacterial drugs, and identifying hospitalized patients infected with organisms that are not susceptible to empiric antibacterial regimens.

Improving rational use of ACTs through diagnosis-dependent subsidies: Evidence from a cluster-randomized controlled trial in western Kenya

BACKGROUND

More than half of artemisinin combination therapies (ACTs) consumed globally are dispensed in the retail sector, where diagnostic testing is uncommon, leading to overconsumption and poor targeting. In many malaria-endemic countries, ACTs sold over the counter are available at heavily subsidized prices, further contributing to their misuse. Inappropriate use of ACTs can have serious implications for the spread of drug resistance and leads to poor outcomes for nonmalaria patients treated with incorrect drugs. We evaluated the public health impact of an innovative strategy that targets ACT subsidies to confirmed malaria cases by coupling free diagnostic testing with a diagnosis-dependent ACT subsidy.

METHODS AND FINDINGS

We conducted a cluster-randomized controlled trial in 32 community clusters in western Kenya (population approximately 160,000). Eligible clusters had retail outlets selling ACTs and existing community health worker (CHW) programs and were randomly assigned 1:1 to control and intervention arms. In intervention areas, CHWs were available in their villages to perform malaria rapid diagnostic tests (RDTs) on demand for any individual >1 year of age experiencing a malaria-like illness. Malaria RDT-positive individuals received a voucher for a discount on a quality-assured ACT, redeemable at a participating retail medicine outlet. In control areas, CHWs offered a standard package of health education, prevention, and referral services. We conducted 4 population-based surveys-at baseline, 6 months, 12 months, and 18 months-of a random sample of households with fever in the last 4 weeks to evaluate predefined, individual-level outcomes. The primary outcome was uptake of malaria diagnostic testing at 12 months. The main secondary outcome was rational ACT use, defined as the proportion of ACTs used by test-positive individuals. Analyses followed the intention-to-treat principle using generalized estimating equations (GEEs) to account for clustering with prespecified adjustment for gender, age, education, and wealth. All descriptive statistics and regressions were weighted to account for sampling design. Between July 2015 and May 2017, 32,404 participants were tested for malaria, and 10,870 vouchers were issued. A total of 7,416 randomly selected participants with recent fever from all 32 clusters were surveyed. The majority of recent fevers were in children under 18 years (62.9%, n = 4,653). The gender of enrolled participants was balanced in children (49.8%, n = 2,318 boys versus 50.2%, n = 2,335 girls), but more adult women were enrolled than men (78.0%, n = 2,139 versus 22.0%, n = 604). At baseline, 67.6% (n = 1,362) of participants took an ACT for their illness, and 40.3% (n = 810) of all participants took an ACT purchased from a retail outlet. At 12 months, 50.5% (n = 454) in the intervention arm and 43.4% (n = 389) in the control arm had a malaria diagnostic test for their recent fever (adjusted risk difference [RD] = 9 percentage points [pp]; 95% CI 2-15 pp; p = 0.015; adjusted risk ratio [RR] = 1.20; 95% CI 1.05-1.38; p = 0.015). By 18 months, the ARR had increased to 1.25 (95% CI 1.09-1.44; p = 0.005). Rational use of ACTs in the intervention area increased from 41.7% (n = 279) at baseline to 59.6% (n = 403) and was 40% higher in the intervention arm at 18 months (ARR 1.40; 95% CI 1.19-1.64; p < 0.001). While intervention effects increased between 12 and 18 months, we were not able to estimate longer-term impact of the intervention and could not independently evaluate the effects of the free testing and the voucher on uptake of testing.

CONCLUSIONS

Diagnosis-dependent ACT subsidies and community-based interventions that include the private sector can have an important impact on diagnostic testing and population-wide rational use of ACTs. Targeting of the ACT subsidy itself to those with a positive malaria diagnostic test may also improve sustainability and reduce the cost of retail-sector ACT subsidies.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02461628.

Adherence to Ebola-specific malaria case management guidelines at health facilities in Guinea during the West African Ebola epidemic

BACKGROUND

Malaria case management in the context of the 2014-2016 West African Ebola virus disease (EVD) epidemic was complicated by a similar initial clinical presentation of the two diseases. In September 2014, the World Health Organization (WHO) released recommendations titled, "Guidance on temporary malaria control measures in Ebola-affected countries", which aimed at reducing the risk of EVD transmission and improving malaria outcomes. This guidance recommended malaria diagnostic testing of fever cases only if adequate personal protective equipment (PPE) was available, defined as examination gloves, face shield, disposable gown, boots, and head cover; otherwise presumptive anti-malarial treatment was recommended. The extent to which health workers adhered to these guidelines in affected countries has not been assessed.

METHODS

A cross-sectional survey was conducted in 118 health units in Guinea in November 2014 to produce a representative and probabilistic sample of health facilities and patients. Adherence to the EVD-specific malaria case management guidelines during the height of the EVD epidemic was assessed. Associations between case management practices and possible determinants were calculated using multivariate logistic regression, controlling for expected confounders and the complex sample design.

RESULTS

Most (78%) facilities reported availability of examination gloves, but adequate PPE was available at only 27% of facilities. Only 28% of febrile patients received correct malaria case management per the WHO temporary malaria case management guidelines. The most common error was diagnostic testing in the absence of adequate PPE (45% of febrile patients), followed by no presumptive treatment in the absence of adequate PPE (14%). Having had a report of an EVD case at a health facility and health worker-reported participation in EVD-specific malaria trainings were associated with lower odds of diagnostic testing and higher odds of presumptive treatment.

CONCLUSIONS

Adherence to guidance on malaria case management in EVD-affected countries was low at the height of the EVD epidemic in Guinea, and there was substantial malaria diagnostic testing in the absence of adequate PPE, which could have contributed to increased EVD transmission in the healthcare setting. Conversely, low presumptive treatment when diagnostic tests were not performed may have led to additional morbidity and mortality among malaria positive patients. National malaria control programs may consider preparing contingency plans for future implementation of temporary changes to malaria case management guidelines to facilitate uptake by health workers. Additional training on standard and transmission-based precautions should help health workers understand how to protect themselves in the face of emerging and unknown pathogens.

Enumerating the economic cost of antimicrobial resistance per antibiotic consumed to inform the evaluation of interventions affecting their use

BACKGROUND

Antimicrobial resistance (AMR) poses a colossal threat to global health and incurs high economic costs to society. Economic evaluations of antimicrobials and interventions such as diagnostics and vaccines that affect their consumption rarely include the costs of AMR, resulting in sub-optimal policy recommendations. We estimate the economic cost of AMR per antibiotic consumed, stratified by drug class and national income level.

METHODS

The model is comprised of three components: correlation coefficients between human antibiotic consumption and subsequent resistance; the economic costs of AMR for five key pathogens; and consumption data for antibiotic classes driving resistance in these organisms. These were used to calculate the economic cost of AMR per antibiotic consumed for different drug classes, using data from Thailand and the United States (US) to represent low/middle and high-income countries.

RESULTS

The correlation coefficients between consumption of antibiotics that drive resistance in S. aureus, E. coli, K. pneumoniae, A. baumanii, and P. aeruginosa and resistance rates were 0.37, 0.27, 0.35, 0.45, and 0.52, respectively. The total economic cost of AMR due to resistance in these five pathogens was $0.5 billion and $2.9 billion in Thailand and the US, respectively. The cost of AMR associated with the consumption of one standard unit (SU) of antibiotics ranged from $0.1 for macrolides to $0.7 for quinolones, cephalosporins and broad-spectrum penicillins in the Thai context. In the US context, the cost of AMR per SU of antibiotic consumed ranged from $0.1 for carbapenems to $0.6 for quinolones, cephalosporins and broad spectrum penicillins.

CONCLUSION

The economic costs of AMR per antibiotic consumed were considerable, often exceeding their purchase cost. Differences between Thailand and the US were apparent, corresponding with variation in the overall burden of AMR and relative prevalence of different pathogens. Notwithstanding their limitations, use of these estimates in economic evaluations can make better-informed policy recommendations regarding interventions that affect antimicrobial consumption and those aimed specifically at reducing the burden of AMR.

Cost-effectiveness of an ambulance-based referral system for emergency obstetrical and neonatal care in rural Ethiopia

Background

To estimate the cost-effectiveness of an ambulance-based referral system an dedicated to emergency obstetrics and neonatal care (EmONC) in remote sub-Saharan settings.

Methods

In this prospective study performed in Oromiya Region (Ethiopia), all obstetrical cases referred to the hospital with the ambulance were consecutively evaluated during a three-months period. The health professionals who managed the referred cases were requested to identify those that could be considered as undoubtedly effective. Pre and post-referral costs included those required to run the ambulance service and the additional costs necessary for the assistance in the hospital. Local life expectancy tables were used to calculate the number of year saved.

Results

A total of 111 ambulance referrals were recorded. The ambulance was undoubtedly effective for 9 women and 4 newborns, corresponding to 336 years saved. The total cost of the intervention was 8299 US dollars. The cost per year life saved was 24.7 US dollars which is below the benchmarks of 150 and 30 US dollars that define attractive and very attractive interventions. Sensitivity analyses on the rate of effective referrals, on the costs of the ambulance and on the discount rate confirmed the robustness of the result.

Conclusions

An ambulance-based referral system for EmONC in remote sub-Saharan areas appears highly cost-effective.

Use of malaria rapid diagnostic tests by community health workers in Afghanistan: cluster randomised trial

BACKGROUND

The World Health Organisation (WHO) recommends parasitological diagnosis of malaria before treatment, but use of malaria rapid diagnostic tests (mRDTs) by community health workers (CHWs) has not been fully tested within health services in south and central Asia. mRDTs could allow CHWs to diagnose malaria accurately, improving treatment of febrile illness.

METHODS

A cluster randomised trial in community health services was undertaken in Afghanistan. The primary outcome was the proportion of suspected malaria cases correctly treated for polymerase chain reaction (PCR)-confirmed malaria and PCR negative cases receiving no antimalarial drugs measured at the level of the patient. CHWs from 22 clusters (clinics) received standard training on clinical diagnosis and treatment of malaria; 11 clusters randomised to the intervention arm received additional training and were provided with mRDTs. CHWs enrolled cases of suspected malaria, and the mRDT results and treatments were compared to blind-read PCR diagnosis.

RESULTS

In total, 256 CHWs enrolled 2400 patients with 2154 (89.8%) evaluated. In the intervention arm, 75.3% (828/1099) were treated appropriately vs. 17.5% (185/1055) in the control arm (cluster adjusted risk ratio: 3.72, 95% confidence interval 2.40-5.77; p < 0.001). In the control arm, 85.9% (164/191) with confirmed Plasmodium vivax received chloroquine compared to 45.1% (70/155) in the intervention arm (p < 0.001). Overuse of chloroquine in the control arm resulted in 87.6% (813/928) of those with no malaria (PCR negative) being treated vs. 10.0% (95/947) in the intervention arm, p < 0.001. In the intervention arm, 71.4% (30/42) of patients with P. falciparum did not receive artemisinin-based combination therapy, partly because operational sensitivity of the RDTs was low (53.2%, 38.1-67.9). There was high concordance between recorded RDT result and CHW prescription decisions: 826/950 (87.0%) with a negative test were not prescribed an antimalarial. Co-trimoxazole was prescribed to 62.7% of malaria negative patients in the intervention arm and 15.0% in the control arm.

CONCLUSIONS

While introducing mRDT reduced overuse of antimalarials, this action came with risks that need to be considered before use at scale: an appreciable proportion of malaria cases will be missed by those using current mRDTs. Higher sensitivity tests could be used to detect all cases. Overtreatment with antimalarial drugs in the control arm was replaced with increased antibiotic prescription in the intervention arm, resulting in a probable overuse of antibiotics.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01403350 . Prospectively registered.

Improving the Specificity of Plasmodium falciparum Malaria Diagnosis in High-Transmission Settings with a Two-Step Rapid Diagnostic Test and Microscopy Algorithm

Poor specificity may negatively impact rapid diagnostic test (RDT)-based diagnostic strategies for malaria. We performed real-time PCR on a subset of subjects who had undergone diagnostic testing with a multiple-antigen (histidine-rich protein 2 and pan-lactate dehydrogenase pLDH [HRP2/pLDH]) RDT and microscopy. We determined the sensitivity and specificity of the RDT in comparison to results of PCR for the detection of Plasmodium falciparum malaria. We developed and evaluated a two-step algorithm utilizing the multiple-antigen RDT to screen patients, followed by confirmatory microscopy for those individuals with HRP2-positive (HRP2⁺)/pLDH-negative (pLDH^-) results. In total, dried blood spots (DBS) were collected from 276 individuals. There were 124 (44.9%) individuals with an HRP2⁺/pLDH⁺ result, 94 (34.1%) with an HRP2⁺/pLDH^- result, and 58 (21%) with a negative RDT result. The sensitivity and specificity of the RDT compared to results with real-time PCR were 99.4% (95% confidence interval [CI], 95.9 to 100.0%) and 46.7% (95% CI, 37.7 to 55.9%), respectively. Of the 94 HRP2⁺/pLDH^- results, only 32 (34.0%) and 35 (37.2%) were positive by microscopy and PCR, respectively. The sensitivity and specificity of the two-step algorithm compared to results with real-time PCR were 95.5% (95% CI, 90.5 to 98.0%) and 91.0% (95% CI, 84.1 to 95.2), respectively. HRP2 antigen bands demonstrated poor specificity for the diagnosis of malaria compared to that of real-time PCR in a high-transmission setting. The most likely explanation for this finding is the persistence of HRP2 antigenemia following treatment of an acute infection. The two-step diagnostic algorithm utilizing microscopy as a confirmatory test for indeterminate HRP2⁺/pLDH^- results showed significantly improved specificity with little loss of sensitivity in a high-transmission setting.

Improving health-care delivery in low-resource settings with nanotechnology: Challenges in multiple dimensions

In the two decades after 1990, the rates of child and maternal mortality dropped by over 40% and 47%, respectively. Despite these improvements, which are in part due to increased access to medical technologies, profound health disparities exist. In 2015, a child born in a developing region is nearly eight times as likely to die before the age of 5 than one born in a developed region and developing regions accounted for nearly 99% of the maternal deaths. Recent developments in nanotechnology, however, have great potential to ameliorate these and other health disparities by providing new cost-effective solutions for diagnosis or treatment of a variety of medical conditions. Affordability is only one of the several challenges that will need to be met to translate new ideas into a medical product that addresses a global health need. This article aims to describe some of the other challenges that will be faced by nanotechnologists who seek to make an impact in low-resource settings across the globe.

Advances in Molecular Diagnosis of Malaria

Malaria is a mosquito-borne disease caused by five species of Plasmodium parasites. Accurate diagnosis of malaria plays an essential part in malaria control. With traditional diagnostic methodologies, malaria control programs have achieved remarkable success during the past decade, and are now heading toward malaria elimination in many areas. This new situation, however, calls for novel diagnostics with improved sensitivity, throughput, and reduced cost for active screening of malaria parasites, as all transfected individuals have to be identified in order to block transmission. In this chapter, we provide a brief introduction of malaria, the requirement of diagnostic advances in the age of malaria elimination, and a comprehensive overview of the currently available molecular malaria diagnostics, ranging from well-known tests to platforms in early stages of evaluation. We also discussed several practical issues for the application of molecular tests in malaria identification.

Simulations Show Diagnostic Testing For Malaria In Young African Children Can Be Cost-Saving Or Cost-Effective

Malaria imposes a substantial global disease burden. It disproportionately affects sub-Saharan Africans, particularly young children. In an effort to improve disease management, the World Health Organization (WHO) recommended in 2010 that countries test children younger than age five who present with suspected malaria fever to confirm the diagnosis instead of treating them presumptively with antimalarial drugs. Costs and concerns about the overall health impact of such diagnostic testing for malaria in children remain barriers to full implementation. Using data from national Malaria Indicator Surveys, we estimated two-stage microsimulation models for Angola, Tanzania, and Uganda to assess the policy's cost-effectiveness. We found that diagnostic testing for malaria in children younger than five is cost-saving in Angola. In Tanzania and Uganda the cost per life-year gained is $5.54 and $94.28, respectively. The costs projected for Tanzania and Uganda are less than the WHO standard of $150 per life-year gained. Our results were robust under varying assumptions about cost, prevalence of malaria, and behavior, and they strongly suggest the pursuit of policies that facilitate full implementation of testing for malaria in children younger than five.

Laboratory systems as an antibacterial resistance containment tool in Africa

INTRODUCTION

As crucial as clinical laboratories are to preventing, identifying and managing resistance problems, laboratory scientists are among the most overlooked stakeholders. This review outlines the contributions that diagnostic laboratory systems should make toward all five of the World Health Organization's 2015 strategic objectives for antimicrobial resistance containment.

LABORATORY SYSTEMS IN RESISTANCE CONTAINMENT

Antimicrobial susceptibility testing and surveillance are central to antibacterial resistance management and control and need to be implemented more commonly and closer to sick patients. However, the scope of tests that promote judicious antimicrobial use extend beyond susceptibility testing. Laboratory tests for pathogens or their associated biomarkers confirm or rule out specific causes of signs and symptoms associated with infection. Laboratory systems also provide critical support to infection control programmes. All of these functions promote rational antimicrobial use and contain the spread of resistance. Routine laboratory data supports the development of vaccines and other technologies that could ease the pressure placed by antimicrobials. Laboratories are also a rich source of information for health professionals, policymakers and the general public about the urgency of the resistance problem and progress in containing it.

CONCLUSION

Laboratory systems are integral to antimicrobial resistance containment and contributions from African laboratories to addressing resistance need to be enhanced.

Cost-Effectiveness Analysis of Test-Based versus Presumptive Treatment of Uncomplicated Malaria in Children under Five Years in an Area of High Transmission in Central Ghana

Background

The presumptive approach of confirming malaria in health facilities leads to over-diagnosis of malaria, over use of anti-malaria drugs and the risk of drug resistance development. WHO recommends parasitological confirmation before treatment with artemisinin-based combination therapy (ACT) in all suspected malaria patients. The use of malaria rapid diagnostic tests (mRDTs) would make it possible for prescribers to diagnose malaria at point-of-care and better target the use of antimalarials. Therefore, a cost-effectiveness analysis was performed on the introduction of mRDTs for management of malaria in under-five children in a high transmission area in Ghana where presumptive diagnosis was the norm in public health centres.

Methods

A cluster-randomised controlled trial where thirty-two health centres were randomised into test-based diagnosis of malaria using mRDTs (intervention) or clinical judgement (control) was used to measure the effect of mRDTs on appropriate treatment: ‘a child with a positive reference diagnosis prescribed a course of ACT or a child with a negative reference diagnosis not given an ACT’. Cost data was collected from five purposively selected health centres and used to estimate the health sector costs of performing an mRDT and treat children for malaria and other common febrile illnesses. Costs of training healthcare personnel and supervision in the study period were also collected. A sample of caregivers to children participating in the trial was interviewed about household cost incurred on transport, drugs, fees, and special food during a period of one week after the health centre visit as well as days unable to work. A decision model approach was used to calculate the incremental cost-effectiveness ratios (ICERs). Univariate and multivariate sensitivity analyses were applied to assess the robustness of ICERs.

Results

The availability of mRDTs for malaria diagnosis resulted in fewer ACT treatments compared to the clinical judgement approach (73% versus 81%) and more children appropriately treated (70% versus 57%). The introduction of mRDT-based diagnosis would cost the Ministry of Health US$18.6 per extra appropriately treated child under five compared to clinical judgement while the ICER from a societal perspective was lower at US$11.0 per appropriately treated child. ICERs were sensitive to a decrease in adherence to negative mRDTs, malaria positivity rate and specificity of the mRDT.

Conclusion

The introduction of mRDTs is likely to be considered cost-effective in this high transmission setting as this intervention increased the number of appropriately treated children at low cost.

Trial Registration

ClinicalTrials.gov NCT00832754

Adherence to malaria diagnosis and treatment guidelines among healthcare workers in Ogun State, Nigeria

Background

Malaria case management remains a vital component of malaria control strategies. Despite the introduction of national malaria treatment guidelines and scale-up of malaria control interventions in Nigeria, anecdotal evidence shows some deviations from the guidelines in malaria case management. This study assessed factors influencing adherence to malaria diagnosis and treatment guidelines among healthcare workers in public and private sectors in Ogun State, Nigeria.

Methods

A comparative cross-sectional study was carried out among 432 (216 public and 216 private) healthcare workers selected from nine Local Government Areas using a multistage sampling technique. A pre-tested interviewer administered questionnaire was used to collect information on availability and use of malaria Rapid Diagnostic Test (mRDT) and artemisinin combination therapy (ACT), for management of uncomplicated malaria. Adherence was defined as when choice of antimalarials for parasitological confirmed malaria cases was restricted to recommended antimalarial medicines. Association between adherence and independent variables were tested using Chi-square at 5 % level of significance.

Results

Malaria RDT was available in 81.9 % of the public health facilities and 19.4 % of the private health facilities (p = 0.001). Its use was higher among public healthcare workers (85.2 %) compared to 32.9 % in private facilities (p = 0.000). Presumptive diagnosis of malaria was higher among private healthcare workers (94.9 %) compared to 22.7 % public facilities (p = <0.0001). The main reason for non-usage of mRDT among private healthcare workers was its perceived unreliability of mRDT (40.9 %). Monotherapy including artesunate (58.3 % vs 12.5 %), amodiaquine (38.9 % vs 8.3 %) and chloroquine (26.4 % vs 4.2 %) were significantly more available in private than public health facilities, respectively. Adherence to guidelines was significantly higher among public healthcare workers (60.6 %) compared to those in private facilities (27.3 %). Availability of antimalarial medicine was the main factor that influenced treatment prescription in both healthcare settings (p = 0.27). However, drug promotion by manufactures (45.8 %) has a major influence on private healthcare workers’ prescription practice.

Conclusion

The findings of this study demonstrate significant difference between public and private healthcare workers on adherence to national malaria diagnosis and treatment guidelines. Interventions to improve private sector engagement in implementation of the guidelines, training and supply of recommended antimalarial medicines should be intensified.

Appropriate targeting of artemisinin-based combination therapy by community health workers using malaria rapid diagnostic tests: findings from randomized trials in two contrasting areas of high and low malaria transmission in south-western Uganda

Objective

To compare the impact of malaria rapid diagnostic tests (mRDTs), used by community health workers (CHWs), on the proportion of children <5 years of age receiving appropriately targeted treatment with artemisinin‐based combination therapy (ACT), vs. presumptive treatment.

Methods

Cluster‐randomized trials were conducted in two contrasting areas of moderate‐to‐high and low malaria transmission in rural Uganda. Each trial examined the effectiveness of mRDTs in the management of malaria and targeting of ACTs by CHWs comparing two diagnostic approaches: (i) presumptive clinical diagnosis of malaria [control arm] and (ii) confirmatory diagnosis with mRDTs followed by ACT treatment for positive patients [intervention arm], with village as the unit of randomisation. Treatment decisions by CHWs were validated by microscopy on a reference blood slide collected at the time of consultation, to compare the proportion of children <5 years receiving appropriately targeted ACT treatment, defined as patients with microscopically‐confirmed presence of parasites in a peripheral blood smear receiving artemether‐lumefantrine or rectal artesunate, and patients with no malaria parasites not given ACT.

Results

In the moderate‐to‐high transmission area, ACT treatment was appropriately targeted in 79.3% (520/656) of children seen by CHWs using mRDTs to diagnose malaria, vs. 30.8% (215/699) of children seen by CHWs using presumptive diagnosis (P < 0.001). In the low transmission area, 90.1% (363/403) children seen by CHWs using mRDTs received appropriately targeted ACT treatment vs. 7.8% (64/817) seen by CHWs using presumptive diagnosis (P < 0.001). Low mRDT sensitivity in children with low‐density parasitaemia (<200 parasites/μl) was identified as a potential concern.

Conclusion

When equipped with mRDTs, ACT treatments delivered by CHWs are more accurately targeted to children with malaria parasites. mRDT use could play an important role in reducing overdiagnosis of malaria and improving fever case management within iCCM, in both moderate‐to‐high and low transmission areas. Nonetheless, missed treatments due to the low sensitivity of current mRDTs in patients with low parasite density are a concern. For community‐based treatment in areas of low transmission and/or non‐immune populations, presumptive treatment of all fevers as malaria may be advisable, until more sensitive diagnostic assays, suitable for routine use by CHWs in remote settings, become available.

Can Rapid Diagnostic Testing for Malaria Increase Adherence to Artemether-Lumefantrine?: A Randomized Controlled Trial in Uganda

Most patients with suspected malaria do not receive diagnostic confirmation before beginning antimalarial treatment. We investigated the extent to which uncertainty about malaria diagnosis contributes to patient nonadherence to artemether-lumefantrine (AL) treatment through a randomized controlled trial in central Uganda. Among 1,525 patients purchasing a course of AL at private drug shops, we randomly offered 37.6% a free malaria rapid diagnostic test (RDT) and then assessed adherence through home visits 3 days later. Of these subjects, 68.4% tested positive for malaria and 65.8% adhered overall. Patients who tested positive did not have significantly higher odds of adherence than those who were not offered the test (adjusted odds ratio [OR]: 1.07, 95% confidence interval [CI]: 0.734-1.57,P= 0.719). Patients who received a positive malaria test had 0.488 fewer pills remaining than those not offered the test (95% CI: -1.02 to 0.043,P= 0.072). We found that patients who felt relatively healthy by the second day of treatment had lower odds of completing treatment (adjusted OR: 0.532, 95% CI: 0.394-0.719,P< 0.001). Our results suggest that diagnostic testing may not improve artemisinin-based combination therapy adherence unless efforts are made to persuade patients to continue taking the full course of drugs even if symptoms have resolved.

Incorporating Demand and Supply Constraints into Economic Evaluations in Low-Income and Middle-Income Countries

Global guidelines for new technologies are based on cost and efficacy data from a limited number of trial locations. Country-level decision makers need to consider whether cost-effectiveness analysis used to inform global guidelines are sufficient for their situation or whether to use models that adjust cost-effectiveness results taking into account setting-specific epidemiological and cost heterogeneity. However, demand and supply constraints will also impact cost-effectiveness by influencing the standard of care and the use and implementation of any new technology. These constraints may also vary substantially by setting. We present two case studies of economic evaluations of the introduction of new diagnostics for malaria and tuberculosis control. These case studies are used to analyse how the scope of economic evaluations of each technology expanded to account for and then address demand and supply constraints over time. We use these case studies to inform a conceptual framework that can be used to explore the characteristics of intervention complexity and the influence of demand and supply constraints. Finally, we describe a number of feasible steps that researchers who wish to apply our framework in cost-effectiveness analyses.

Field evaluation of the 22 rapid diagnostic tests for community management of malaria with artemisinin combination therapy in Cameroon

BACKGROUND

All suspected cases of malaria should receive a diagnostic test prior to treatment with artemisinin-based combinations based on the new WHO malaria treatment guidelines. This study compared the accuracy and some operational characteristics of 22 different immunochromatographic antigen capture point-of- malaria tests (RDTs) in Cameroon to inform test procurement prior to deployment of artemisinin-based combinations for malaria treatment.

METHODS

One hundred human blood samples (50 positive and 50 negative) collected from consenting febrile patients in two health centres at Yaoundé were used for evaluation of the 22 RDTs categorized as "Pf Only" (9) or "Pf + PAN" (13) based on parasite antigen captured [histidine rich protein II (HRP2) or lactate dehydrogenase (pLDH) or aldolase]. RDTs were coded to blind technicians performing the tests. The sensitivity, specificity, and predictive values of the positive and negative tests (PPV and NPV) as well as the likelihood ratios were assessed. The reliability and some operational characteristics were determined as the mean values from two assessors, and the Cohen's kappa statistic was then used to compare agreement. Light microscopy was the referent.

RESULTS

Of all RDTs tested, 94.2 % (21/22) had sensitivity values greater than 90% among which 14 (63.6%) were 'Pf + PAN' RDTs. The specificity was generally lower than the sensitivity for all RDTs and poorer for "Pf Only" RDTs. The predictive values and likelihood ratios were better for non-HRP2 analytes for "Pf + PAN" RDTs. The Kappa value for most of the tests obtained was around 67% (95% CI 50-69%), corresponding to a moderate agreement.

CONCLUSION

Overall, 94.2% (21/22) of RDTs tested had accuracy within the range recommended by the WHO, while one performed poorly, below acceptable levels. Seven "Pf + PAN" and 3 "Pf Only" RDTs were selected for further assessment based on performance characteristics. Harmonizing RDT test presentation and procedures would prevent mistakes of test performance and interpretation.

Malaria burden and anti-malarial drug efficacy in Owando, northern Congo

Background

In the Republic of Congo, previous epidemiological studies have only been conducted in the south of the country where it is most accessible. Nationally representative data on the efficacy of new anti-malarial tools are lacking in the country. As an initial step to close the gap, clinical efficacy of two artemisinin-based combinations, artesunate-amodiaquine (ASAQ) and artemether-lumefantrine (AL), was assessed in Owando, a city in equatorial flooded forest in northern Republic of Congo.

Methods

Under 12 years old febrile children attending public health facilities were screened for malaria parasites using lactate dehydrogenase (LDH)-based rapid diagnostic test (RDT) for malaria and microscopic examination of thick blood films. Patients with at least 1,000 asexual Plasmodium falciparum parasites/µl of blood were clinically examined, included after informed consent, and followed up for 28 days, according to the 2009 World Health Organization protocol. Patients were randomly assigned to co-formulated ASAQ (Coarsucam^®) or AL (Coartem^®) treatment groups. Plasmodium falciparum recrudescent isolates were compared to pre-treatment isolates by polymerase chain reaction (PCR) using msp1, msp2, and glurp genes to distinguish between re-infection and recrudescence.

Results

Between November 2012 and February 2013, 857 under 12 years old febrile children were screened, of whom 198 (23.1 %) had positive RDT and 167 (19.5 %) positive thick films. ASAQ and AL efficacies were 92.7 and 94.2 % before PCR correction, respectively. After genotyping, the overall efficacy was 100 % for ASAQ and 98.0 % for AL.

Conclusion

The data reported here represent partially the burden of malaria in 0–11 years old febrile children examined in public health centres of Owando city and serve as reference for further studies. Both artemisinin-based combinations were highly efficacious in patients under 12 years old with acute uncomplicated malaria. ASAQ was associated with more adverse events, which may reduce compliance in unsupervised treatment.

Trial registration: ACTRN12612000940875

Exploring health practitioners' acceptability of a prospective semi-quantitative pfHRP2 device to define severe malaria in the Democratic Republic of Congo

BACKGROUND

A rapid diagnostic tool is being developed to discern severely ill children with severe malaria from children who are ill with alternative febrile diseases but have coincidental peripheral blood parasitaemia. The device semi-quantitatively measures plasma pfHRP2 and has the potential to reduce mortality in children with severe febrile illnesses by improving diagnosis. The aim of this study is to identify contributing and inhibiting factors that affect healthcare practitioners' acceptability of this prospective diagnostic device in a high malaria transmission setting in the Democratic Republic of Congo.

METHODS

Data were collected qualitatively by conducting semi-structured interviews with a purposeful sample of health professionals in Kinshasa, capital of Democratic Republic of Congo. In total, 11 interviews were held with professionals at four different institutes.

RESULTS

Four key findings emerged: (1) Congolese practitioners perceive the semi-quantitative pfHRP2 device as a welcome intervention as they recognize the limited reliability of their current diagnostic and therapeutic approaches to severe febrile illnesses; (2) compatibility of the semi-quantitative pfHRP2 device with clinical equipment and competences of Congolese health practitioners is considered to be limited, especially in rural settings; (3) a formal training programme is crucial for correct understanding and application of the semi-quantitative pfHRP2 device; and, (4) provision of evidence to practitioners, and support from health authorities would be important to establish confidence in the semi-quantitative pfHRP2 device.

CONCLUSIONS

Congolese practitioners perceive the prospective semi-quantitative pfHRP2 device as a welcome addition to their clinical equipment. The device could improve current diagnostic work-up of severe febrile illness, which might consequently improve treatment choices. However, despite this recognized potential, several hurdles and drivers need to be taken into account when implementing this device in DR Congo.

Integrated community case management of fever in children under five using rapid diagnostic tests and respiratory rate counting: a multi-country cluster randomized trial

Evidence on the impact of using diagnostic tests in community case management of febrile children is limited. This effectiveness trial conducted in Burkina Faso, Ghana, and Uganda, compared a diagnostic and treatment package for malaria and pneumonia with presumptive treatment with anti-malarial drugs; artemisinin combination therapy (ACT). We enrolled 4,216 febrile children between 4 and 59 months of age in 2009–2010. Compliance with the malaria rapid diagnostic test (RDT) results was high in the intervention arm across the three countries, with only 4.9% (17 of 344) of RDT-negative children prescribed an ACT. Antibiotic overuse was more common: 0.9% (4 of 446) in Uganda, 38.5% (114 of 296) in Burkina Faso, and 44.6% (197 of 442) in Ghana. Fever clearance was high in both intervention and control arms at both Day 3 (97.8% versus 96.9%, P = 0.17) and Day 7 (99.2% versus 98.8%, P = 0.17). The use of diagnostic tests limits overuse of ACTs. Its impact on antibiotic overuse and on fever clearance is uncertain.

Performance Requirements to Achieve Cost-Effectiveness of Point-of-Care Tests for Sepsis Among Patients with Febrile Illness in Low-Resource Settings

Bacterial sepsis is an important cause of mortality in low- and middle-income countries, yet distinguishing patients with sepsis from those with other illnesses remains a challenge. Currently, management decisions are based on clinical assessment using algorithms such as Integrated Management of Adolescent and Adult Illness. Efforts to develop and evaluate point-of-care tests (POCTs) for sepsis to guide decisions on the use of antimicrobials are underway. To establish the minimum performance characteristics of such a test, we varied the characteristics of a hypothetical POCT for sepsis required for it to be cost-effective and applied a decision tree model to a population of febrile patients presenting at the district hospital level in a low-resource setting. We used a case fatality probability of 20% for appropriately treated sepsis and of 50% for inappropriately treated sepsis. On the basis of clinical assessment for sepsis with established sensitivity of 0.83 and specificity of 0.62, we found that a POCT for sepsis with a sensitivity of 0.83 and a specificity of 0.94 was cost-effective, resulting in parity in survival but costing $1.14 less per live saved. A POCT with accuracy equivalent to the best malaria rapid diagnostic test was cheaper and more effective than clinical assessment.

Addressing Barriers to the Development and Adoption of Rapid Diagnostic Tests in Global Health

Immunochromatographic rapid diagnostic tests (RDTs) have demonstrated significant potential for use as point-of-care diagnostic tests in resource-limited settings. Most notably, RDTs for malaria have reached an unparalleled level of technological maturity and market penetration, and are now considered an important complement to standard microscopic methods of malaria diagnosis. However, the technical development of RDTs for other infectious diseases, and their uptake within the global health community as a core diagnostic modality, has been hindered by a number of extant challenges. These range from technical and biological issues, such as the need for better affinity agents and biomarkers of disease, to social, infrastructural, regulatory and economic barriers, which have all served to slow their adoption and diminish their impact. In order for the immunochromatographic RDT format to be successfully adapted to other disease targets, to see widespread distribution, and to improve clinical outcomes for patients on a global scale, these challenges must be identified and addressed, and the global health community must be engaged in championing the broader use of RDTs.

Cost-effectiveness of malaria diagnosis using rapid diagnostic tests compared to microscopy or clinical symptoms alone in Afghanistan

Background

Improving access to parasitological diagnosis of malaria is a central strategy for control and elimination of the disease. Malaria rapid diagnostic tests (RDTs) are relatively easy to perform and could be used in primary level clinics to increase coverage of diagnostics and improve treatment of malaria.

Methods

A cost-effectiveness analysis was undertaken of RDT-based diagnosis in public health sector facilities in Afghanistan comparing the societal and health sector costs of RDTs versus microscopy and RDTs versus clinical diagnosis in low and moderate transmission areas. The effect measure was ‘appropriate treatment for malaria’ defined using a reference diagnosis. Effects were obtained from a recent trial of RDTs in 22 public health centres with cost data collected directly from health centres and from patients enrolled in the trial. Decision models were used to compare the cost of RDT diagnosis versus the current diagnostic method in use at the clinic per appropriately treated case (incremental cost-effectiveness ratio, ICER).

Results

RDT diagnosis of Plasmodium vivax and Plasmodium falciparum malaria in patients with uncomplicated febrile illness had higher effectiveness and lower cost compared to microscopy and was cost-effective across the moderate and low transmission settings. RDTs remained cost-effective when microscopy was used for other clinical purposes. In the low transmission setting, RDTs were much more effective than clinical diagnosis (65.2% (212/325) vs 12.5% (40/321)) but at an additional cost (ICER) of US$4.5 per appropriately treated patient including a health sector cost (ICER) of US$2.5 and household cost of US$2.0. Sensitivity analysis, which varied drug costs, indicated that RDTs would remain cost-effective if artemisinin combination therapy was used for treating both P. vivax and P. falciparum. Cost-effectiveness of microscopy relative to RDT is further reduced if the former is used exclusively for malaria diagnosis. In the health service setting of Afghanistan, RDTs are a cost-effective intervention compared to microscopy.

Conclusions

RDTs remain cost-effective across a range of drug costs and if microscopy is used for a range of diagnostic services. RDTs have significant advantages over clinical diagnosis with minor increases in the cost of service provision.

Trial Registration

The trial was registered at ClinicalTrials.gov under identifier NCT00935688.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-015-0696-1) contains supplementary material, which is available to authorized users.

Prescriber and patient-oriented behavioural interventions to improve use of malaria rapid diagnostic tests in Tanzania: facility-based cluster randomised trial

BACKGROUND

The increasing investment in malaria rapid diagnostic tests (RDTs) to differentiate malarial and non-malarial fevers, and an awareness of the need to improve case management of non-malarial fever, indicates an urgent need for high quality evidence on how best to improve prescribers' practices.

METHODS

A three-arm stratified cluster-randomised trial was conducted in 36 primary healthcare facilities from September 2010 to March 2012 within two rural districts in northeast Tanzania where malaria transmission has been declining. Interventions were guided by formative mixed-methods research and were introduced in phases. Prescribing staff from all facilities received standard Ministry of Health RDT training. Prescribers from facilities in the health worker (HW) and health worker-patient (HWP) arms further participated in small interactive peer-group training sessions with the HWP additionally receiving clinic posters and patient leaflets. Performance feedback and motivational mobile-phone text messaging (SMS) were added to the HW and HWP arms in later phases. The primary outcome was the proportion of patients with a non-severe, non-malarial illness incorrectly prescribed a (recommended) antimalarial. Secondary outcomes investigated RDT uptake, adherence to results, and antibiotic prescribing.

RESULTS

Standard RDT training reduced pre-trial levels of antimalarial prescribing, which was sustained throughout the trial. Both interventions significantly lowered incorrect prescribing of recommended antimalarials from 8% (749/8,942) in the standard training arm to 2% (250/10,118) in the HW arm (adjusted RD (aRD) 4%; 95% confidence interval (CI) 1% to 6%; P = 0.008) and 2% (184/10,163) in the HWP arm (aRD 4%; 95% CI 1% to 6%; P = 0.005). Small group training and SMS were incrementally effective. There was also a significant reduction in the prescribing of antimalarials to RDT-negatives but no effect on RDT-positives receiving an ACT. Antibiotic prescribing was significantly lower in the HWP arm but had increased in all arms compared with pre-trial levels.

CONCLUSIONS

Small group training with SMS was associated with an incremental and sustained improvement in prescriber adherence to RDT results and reducing over-prescribing of antimalarials to close to zero. These interventions may become increasingly important to cope with the wider range of diagnostic and treatment options for patients with acute febrile illness in Africa.

Assessing drivers of full adoption of test and treat policy for malaria in Senegal

Malaria treatment policy has changed from presumptive treatment to targeted "test and treat" (T&T) with malaria rapid diagnostic tests (RDTs) and artemisinin combination therapy (ACT). This transition involves changing behavior among health providers, meaning delays between introduction and full implementation are recorded in almost every instance. We investigated factors affecting successful transition, and suggest approaches for accelerating uptake of T&T. Records from 2000 to 2011 from health clinics in Senegal where malaria is mesoendemic were examined (96,166 cases). The study period encompassed the implementation of national T&T policy in 2006. Analysis showed that adherence to test results is the first indicator of T&T adoption and is dependent on accumulation of experience with positive RDTs (odds ratio [OR]: 0.55 [P ≤ 0.001], 95% confidence interval [CI]: 0.53-0.58). Reliance on tests for malaria diagnosis (rather than presumptive diagnosis) followed after test adherence is achieved, and was also associated with increased experience with positive RDTs (OR: 0.60 [P ≤ 0.001], 95% CI: 0.58-0.62). Logistic models suggest that full adoption of T&T clinical practices can occur within 2 years, that monitoring these behavioral responses rather than RDT or ACT consumption will improve evaluation of T&T uptake, and that accelerating T&T uptake by focusing training on adherence to test results will reduce overdiagnosis and associated health and economic costs in mesoendemic regions.

Poor adherence to the malaria management protocol among health workers attending under-five year old febrile children at Omdurman Hospital, Sudan

Background

In spite of the World Health Organization recommendations for the treatment of malaria, febrile patients are still infrequently tested and erroneously treated for malaria. This study aimed to investigate the adherence to malaria national protocol for the management of malaria among under five years old children.

Methods

A cross sectional hospital-based study was conducted during the period from September through December 2013 among febrile children below the age of five years attending the outpatient department of Omdurman Children Hospital, Sudan. Demographic, clinical and laboratory data [blood film, rapid diagnostic test (RDTs), haemoglobin, WBCs and chest X ray] and anti-malarials and/or antibiotics prescription were recorded.

Results

A total of 749 febrile children were enrolled. The mean (SD) age was 37.51 (41.6) months. Less than a half, (327, 43.7%) of children were investigated for malaria using microscopy (271, 82.9%), RDT (4, 1.2%) or both (52, 15.9%). Malaria was not investigated for more than a half, (422, 56.3%) however investigations targeting other causes of fever were requested for them. Malaria was positive in 72 (22%) of the 327 investigated children. Five (1.6%) out of 255 with negative malaria tests were treated by an anti-malarials. Quinine was the most frequently prescribed anti-malarials (65, 72.2%) then artemisinin-based combination therapy (ACT) (2, 27.8%). The majority of the 749 children (655, 87.4%) were prescribed an antibiotic.

Conclusion

There is a poor adherence to malaria management protocol in Sudan among physicians treating children below five years of age. There was a high rate of antibiotic prescription needs.

Economic evaluation of a cluster randomized trial of interventions to improve health workers' practice in diagnosing and treating uncomplicated malaria in Cameroon

BACKGROUND

Malaria rapid diagnostic tests (RDTs) are a valid alternative to malaria testing with microscopy and are recommended for the testing of febrile patients before prescribing an antimalarial. There is a need for interventions to support the uptake of RDTs by health workers.

OBJECTIVE

To evaluate the cost-effectiveness of introducing RDTs with basic or enhanced training in health facilities in which microscopy was available, compared with current practice.

METHODS

A three-arm cluster randomized trial was conducted in 46 facilities in central and northwest Cameroon. Basic training had a practical session on RDTs and lectures on malaria treatment guidelines. Enhanced training included small-group activities designed to change health workers' practice and reduce the consumption of antimalarials among test-negative patients. The primary outcome was the proportion of febrile patients correctly treated: febrile patients should be tested for malaria, artemisinin combination therapy should be prescribed for confirmed cases, and no antimalarial should be prescribed for patients who are test-negative. Individual patient data were obtained from facility records and an exit survey. Costs were estimated from a societal perspective using project reports and patient exit data. The analysis used bivariate multilevel modeling and adjusted for imbalance in baseline covariates.

RESULTS

Incremental cost per febrile patient correctly treated was $8.40 for the basic arm and $3.71 for the enhanced arm. On scale-up, it was estimated that RDTs with enhanced training would save $0.75 per additional febrile patient correctly treated.

CONCLUSIONS

Introducing RDTs with enhanced training was more cost-effective than RDTs with basic training when each was compared with current practice.

Mind the gap: knowledge and practice of providers treating uncomplicated malaria at public and mission health facilities, pharmacies and drug stores in Cameroon and Nigeria

Background Artemisinin combination therapy (ACT) has been the first-line treatment for uncomplicated malaria in Cameroon since 2004 and Nigeria since 2005, though many febrile patients receive less effective antimalarials. Patients often rely on providers to select treatment, and interventions are needed to improve providers’ practice and encourage them to adhere to clinical guidelines.

Methods Providers’ adherence to malaria treatment guidelines was examined using data collected in Cameroon and Nigeria at public and mission facilities, pharmacies and drug stores. Providers’ choice of antimalarial was investigated separately for each country. Multilevel logistic regression was used to determine whether providers were more likely to choose ACT if they knew it was the first-line antimalarial. Multiple imputation was used to impute missing data that arose when linking exit survey responses to details of the provider responsible for selecting treatment.

Results There was a gap between providers’ knowledge and their practice in both countries, as providers’ decision to supply ACT was not significantly associated with knowledge of the first-line antimalarial. Providers were, however, more likely to supply ACT if it was the type of antimalarial they prefer. Other factors were country-specific, and indicated providers can be influenced by what they perceived their patients prefer or could afford, as well as information about their symptoms, previous treatment, the type of outlet and availability of ACT.

Conclusions Public health interventions to improve the treatment of uncomplicated malaria should strive to change what providers prefer, rather than focus on what they know. Interventions to improve adherence to malaria treatment guidelines should emphasize that ACT is the recommended antimalarial, and it should be used for all patients with uncomplicated malaria. Interventions should also be tailored to the local setting, as there were differences between the two countries in providers’ choice of antimalarial, and who or what influenced their practice.

An assessment of malaria diagnostic capacity and quality in Ghana and the Republic of Benin

BACKGROUND

In malaria-endemic countries, the absence of parasitological confirmation of malaria infection potentially results in overtreatment of non-malaria febrile illness with antimalarial drugs; this may lead to healthcare workers (HCW) missing other treatable illness or wastage of resources. This paper presents results from nationally representative assessments of malaria diagnostic accuracy, quality and capacity in Ghana and the Republic of Benin.

METHODS

Cross-sectional surveys were conducted in December 2012 among a representative sample of health facilities (n=30 per country), using a modified service provision assessment, followed by HCW observations and interviews. To analyze the data we used χ(2) statistics and logistic regression.

RESULTS

Malaria microscopy and rapid diagnostic test interpretation was accurate most of the time in both countries. Drugs were generally prescribed in line with positive malaria test results (Ghana: 85.4%, 95% CI: 72.2-98.7; Benin: 83.6%, 95% CI: 68.7-98.4), although some patients with negative malaria test results still received treatment (Ghana: 30.1%, 95% CI: 11.1-49.0; Benin: 37.8%, 95% CI: 22.6-53.0).

CONCLUSIONS

Diagnostics for malaria are often performed adequately and accurately in Ghana and Benin, although diagnostic coverage within facilities remains incomplete and some individuals who test negative for malaria receive antimalarial drugs.

Rapid diagnostic tests to improve treatment of malaria and other febrile illnesses: patient randomised effectiveness trial in primary care clinics in Afghanistan

OBJECTIVE

To assess the impact of rapid diagnostic tests on the diagnostic accuracy and treatment of malaria and non-severe fever in an Asian setting.

DESIGN

Patient randomised trial in primary level clinics.

SETTING

Two areas of Afghanistan where Plasmodium vivax and Plasmodium falciparum are endemic; one area with moderate transmission (eastern region) and one with low transmission (northern region).

PARTICIPANTS

5794 patients of all ages with suspected malaria enrolled by 80 clinicians in 22 clinics.

INTERVENTIONS

Malaria rapid diagnostic tests were compared with clinical diagnosis where no parasite diagnostic test was available, longer established field microscopy, and recently introduced microscopy.

MAIN OUTCOME MEASURES

Proportion of patients appropriately treated with an antimalarial, defined as patients with P vivax who received chloroquine, patients with P falciparum who received artemisinin based combination therapy, and patients with no malaria parasites who did not receive an antimalarial. Secondary outcomes included diagnostic test accuracy and the proportion of patients negative for malaria who received antibiotics and antimalarials.

RESULTS

In the low transmission area, comparing rapid diagnostic tests with clinical diagnosis, 65% (212/325) versus 12% (40/321) of febrile patients were appropriately treated for malaria (adjusted odds ratio 92.7, 95% confidence interval 12.4 to 694.1, P<0.001). The proportion of patients who were negative for malaria and received an antibiotic was 57% (185/325) in the rapid diagnostic test arm compared with 14% (46/321) in the clinical diagnosis arm (16.9, 3.8 to 75.4, P<0.001). In the comparison of rapid diagnostic test with microscopy in the moderate transmission area, 83.6% (1696/2028) versus 76.3% (1512/1983) of patients were appropriately treated for malaria (1.70, 1.30 to 2.23, P<0.001). A higher proportion of P falciparum cases received appropriate treatment with artemisinin based combination therapy when malaria was diagnosed by rapid diagnostic test (82%, 58/71 v 32%, 24/76; 9.2, 3.88 to 21.66, P<0.001).

CONCLUSIONS

In South and central Asian regions of low to moderate malaria transmission where clinics lack capacity for diagnosis with rapid diagnostic tests or microscopy, the introduction of the tests should be considered to improve clinical care, reduce the overuse of antimalarials, and improve disease surveillance.

Major improvements in the quality of malaria case-management under the "test and treat" policy in Kenya

Background

Monitoring implementation of the “test and treat” case-management policy for malaria is an important component of all malaria control programmes in Africa. Unfortunately, routine information systems are commonly deficient to provide necessary information. Using health facility surveys we monitored health systems readiness and malaria case-management practices prior to and following implementation of the 2010 “test and treat” policy in Kenya.

Methods/Findings

Between 2010 and 2013 six national, cross-sectional, health facility surveys were undertaken. The number of facilities assessed ranged between 172 and 176, health workers interviewed between 216 and 237 and outpatient consultations for febrile patients evaluated between 1,208 and 2,408 across six surveys. Comparing baseline and the last survey results, all readiness indicators showed significant (p<0.005) improvements: availability of parasitological diagnosis (55.2% to 90.7%); RDT availability (7.5% to 69.8%); total artemether-lumefantrine (AL) stock-out (27.2% to 7.0%); stock-out of one or more AL packs (59.5% to 21.6%); training coverage (0 to 50.2%); guidelines access (0 to 58.1%) and supervision (17.9% to 30.8%). Testing increased by 34.0% (23.9% to 57.9%; p<0.001) while testing and treatment according to test result increased by 34.2% (15.7% to 49.9%; p<0.001). Treatment adherence for test positive patients improved from 83.3% to 90.3% (p = 0.138) and for test negative patients from 47.9% to 83.4% (p<0.001). Significant testing and treatment improvements were observed in children and adults. There was no difference in practices with respect to the type and result of malaria test (RDT vs microscopy). Of eight dosing, dispensing and counseling tasks, improvements were observed for four tasks. Overall AL use for febrile patients decreased from 63.5% to 35.6% (p<0.001).

Conclusions

Major improvements in the implementation of “test and treat” policy were observed in Kenya. Some gaps towards universal targets still remained. Other countries facing similar needs and challenges may consider health facility surveys to monitor malaria case-management.

Scale-up of malaria rapid diagnostic tests and artemisinin-based combination therapy: challenges and perspectives in sub-Saharan Africa

Guido Bastiaens and colleagues describe barriers to achieving scale-up and appropriate use of rapid diagnostic tests and artemisinin-based combination therapy for malaria in sub-Saharan Africa. Please see later in the article for the Editors' Summary

Malaria diagnosis and treatment practices following introduction of rapid diagnostic tests in Kibaha District, Coast Region, Tanzania

Background

The success of the universal parasite-based malaria testing policy for fever patients attending primary health care (PHC) facilities in Tanzania will depend highly on health workers’ perceptions and practices. The aim of this study was, therefore, to assess the present use of malaria diagnostics (rapid diagnostic tests (RDTs) and microscopy), prescription behaviour and factors affecting adherence to test results at PHC facilities in Kibaha District, Coast Region, Tanzania.

Methods

Exit interviews were conducted with fever patients at PHC facilities and information on diagnostic test performed and treatment prescribed were recorded. Interviews with prescribers to assess their understanding, perceptions and practices related to RDTs were conducted, and health facility inventory performed to assess availability of staff, diagnostics and anti-malarial drugs.

Results

The survey was undertaken at ten governmental PHC facilities, eight of which had functional diagnostics. Twenty health workers were interviewed and 195 exit interviews were conducted with patients at the PHC facilities. Of the 168 patients seen at facilities with available diagnostics, 105 (63%) were tested for malaria, 31 (30%) of whom tested positive. Anti-malarial drugs were prescribed to all patients with positive test results, 14% of patients with negative results and 28% of patients not tested for malaria. Antibiotics were more likely to be prescribed to patients with negative test results compared to patients with positive results (81 vs 39%, p < 0.01) and among non-tested compared to those tested for malaria (84 vs 69%, p = 0.01). Stock-outs of RDTs and staff shortage accounted for the low testing rate, and health worker perceptions were the main reason for non-adherence to test results.

Conclusions

Anti-malarial prescription to patients with negative test results and those not tested is still practiced in Tanzania despite the universal malaria testing policy of fever patients. The use of malaria diagnostics was also associated with higher prescription of antibiotics among patients with negative results. Strategies to address health system factors and health worker perceptions associated with these practices are needed.

Cost-effectiveness analysis of introducing RDTs for malaria diagnosis as compared to microscopy and presumptive diagnosis in central and peripheral public health facilities in Ghana

Cost-effectiveness information on where malaria rapid diagnostic tests (RDTs) should be introduced is limited. We developed incremental cost-effectiveness analyses with data from rural health facilities in Ghana with and without microscopy. In the latter, where diagnosis had been presumptive, the introduction of RDTs increased the proportion of patients who were correctly treated in relation to treatment with antimalarials, from 42% to 65% at an incremental societal cost of Ghana cedis (GHS)12.2 (US$8.3) per additional correctly treated patients. In the "microscopy setting" there was no advantage to replacing microscopy by RDT as the cost and proportion of correctly treated patients were similar. Results were sensitive to a decrease in the cost of RDTs, which cost GHS1.72 (US$1.17) per test at the time of the study and to improvements in adherence to negative tests that was just above 50% for both RDTs and microscopy.