Beyond ‘test and treat’ – malaria diagnosis for improved pediatric fever management in sub-Saharan Africa

Abstract

BackgroundMalaria rapid diagnostic tests (RDTs) have great potential to improve quality care and rational drug use in malaria-endemic settings although studies have shown common RDT non-compliance. Yet, evidence has largely been derived from limited hospital settings in few countries. This article reviews a PhD thesis that analyzed national surveys from multiple sub-Saharan African countries to generate large-scale evidence of malaria diagnosis practices and its determinants across different contexts.DesignA mixed-methods approach was used across four studies that included quantitative analysis of national household and facility surveys conducted in multiple sub-Saharan African countries at the outset of new guidelines (Demographic and Health Surveys and Service Provision Assessments). Qualitative methods were used to explore reasons for quantitative findings in select settings.ResultsThere was low (17%) and inequitable test uptake across 13 countries in 2009–2011/12, with greater testing at hospitals than at peripheral clinics (odds ratio [OR]: 0.62, 95% confidence interval [CI]: 0.56–0.69) or community health workers (OR: 0.31, 95% CI: 0.23–0.43) (Study I). Significant variation was found in the effect of diagnosis on antimalarial use at the population level across countries (Uganda OR: 0.84, 95% CI: 0.66–1.06; Mozambique OR: 3.54, 95% CI: 2.33–5.39) (Study II). A Malawi national facility census indicated common compliance to malaria treatment guidelines (85% clients with RDT-confirmed malaria prescribed first-line treatment), although other fever assessments were not often conducted and there was poor antibiotic targeting (59% clients inappropriately prescribed antibiotics). RDT-negative patients had 16.8 (95% CI: 8.6–32.7) times higher odds of antibiotic overtreatment than RDT-positive patients conditioned by cough or difficult breathing complaints (Study III). In Mbarara (Uganda), health workers reportedly prescribed antimalarials to RDT-negative patients if no other fever cause was identified and non-compliance seemed further driven by RDT perceptions, system constraints, and client interactions (Study IV).ConclusionsA shift from malaria-focused test and treat strategies toward IMCI with testing is needed to improve quality care and rational use of both antimalarial and antibiotic medicines. Strengthened health systems are also needed to support quality clinical care, including adherence to malaria test results, and RDT deployment should be viewed as a unique opportunity to contribute to these important efforts.

The contribution of non-malarial febrile illness co-infections to Plasmodium falciparum case counts in health facilities in sub-Saharan Africa

“…Evidence from literature suggests that clinicians show good adherence to integrated management of childhood illness (IMCI) guidelines when prescribing ACT after a positive RDT [19, 20], but information is sparse on clinicians’ propensity to investigate alternative causes of illness after either negative or positive RDT outcomes. Evidence suggests that in malaria-endemic areas, a shift from malaria-centric test-and-treat methods towards a holistic IMCI approach in clinics would both improve health outcomes and reduce unnecessary antibiotic use [21]. Studies have shown that clinicians are more likely to prescribe antibiotics to patients with a negative RDT than malaria-positive patients in a study in Zanzibar [20], and that after IMCI training clinicians do record diagnoses of malaria co-infections with NMFI [22].…”

Universal versus conditional day 3 follow-up for children with non-severe unclassified fever at the community level in Ethiopia: A cluster-randomised non-inferiority trial

“…Furthermore, primary healthcare workers often have low confidence in managing children with fever symptoms but negative tests for malaria. Recent studies show that mRDT-negative patients with cough or difficult breathing complaints in Malawi had 16.8 times higher odds of antibiotic overtreatment than mRDT-positive patients [ 41 ]; in Burkina Faso and Uganda both community and health facility workers prescribed antimalarials to mRDT-negative patients if no other fever cause was identified, often due to parental pressure [ 41 , 42 ]. However, when clear case management instructions were provided, as in this study, and non-malaria fever was introduced as a diagnostic term, HEWs felt empowered to withhold medicines, while simultaneously reassuring caregivers that their child was cared for [ 22 ].…”

Management and Follow-up Practices of Children with Unclassified Fever in Rural Ethiopia: Experiences of Health Extension Workers and Caregivers

“…19,20 In addition, although since 2010 the recommendation has been that antimalarial medication should only be given when a case is confirmed positive, 21 health workers still experience mistrust in mRDTs and insecurities about managing febrile children with negative mRDT results, thus often resorting to the use of antimalarials even when unnecessary. [22][23][24][25] It has been described that showing the test result to patients can help increase patients' trust and that a lack of communication about the test can lead to a patient misinterpreting its result. 20 Thus, particularly for negative malaria test results and low fever, where according to iCCM no medication should be given, clear communication to caregivers of sick children becomes important.…”