Improved Diagnostic Testing and Malaria Treatment Practices in Zambia

Abstract

Context Improving the accuracy of malaria diagnosis using rapid diagnostic tests (RDT) has been proposed as an approach for reducing over-treatment of malaria in the current era of widespread implementation of artemisinin-based combination therapy in sub-Saharan Africa. Objective To assess the impact of microscopy and RDT use on prescription of antimalarials. Design, Setting, and Participants Cross-sectional, cluster sample survey of all sick outpatients seen at a health facility during one working day that included all public and mission health facilities in four sentinel districts in Zambia. Main Outcome Measures Proportions of patients undergoing malaria diagnostic procedures and receiving anti-malarial treatment. Results 17% of the 104 health facilities surveyed had functional microscopy, 63% had RDTs available, and 73% had at least one type of malaria diagnostics. 27.8% of subjects with fever (suspected malaria) seen in health facilities with malaria diagnostics were tested and 44.6% were positive. 58.4% of patients with negative blood smears were prescribed an antimalarial as were 35.5% of those with a negative RDT result. 65.9% of the subjects with fever who did not have diagnostic tests done were also prescribed antimalarials. In facilities with artemether-lumefantrine in stock, this antimalarial was prescribed to a larger proportion of febrile patients with a positive diagnostic test (blood smear 75.0%; RDT 70.4%) than those with a negative diagnostic test (blood smear 30.4%; RDT 26.7%). Conclusion Despite efforts to scale up the provision of malaria diagnostics in Zambia they continue to be under-utilized and patients with negative test results frequently receive antimalarials. The provision of new tools to reduce the inappropriate use of new expensive antimalarial treatments must be accompanied by a paradigm shift in clinical management of patients without evidence of malaria infection.

‘As a clinician, you are not managing lab results, you are managing the patient’: How the enactment of malaria at health facilities in Cameroon compares with new WHO guidelines for the use of malaria tests

“…In many settings where RDTs have been introduced, the tests have been underused and the overuse of antimalarial drugs has remained high. Even when tests are carried out, findings are accumulating from studies in different countries that show between 35 and 85% of RDT negative patients have been prescribed antimalarials Bisoffi et al, 2009;Chinkhumba et al, 2010;Elmardi et al, 2009;Hamer et al, 2007;Kyabayinze et al, 2010;Reyburn et al, 2007;Skarbinski et al, 2009). By contrast, other studies have found a reduction in overdiagnosis, down to between 4% and 16% RDT negative patients receiving antimalarials after the introduction of RDTs with various supporting interventions (Bastiaens et al, 2011;D'Acremont et al, 2009;Hopkins, 2008;Masanja et al, 2010;Mawili-Mboumba et al, 2009;Msellem et al, 2009;Thiam et al, 2011;Williams et al, 2008).…”

Factoring Quality Laboratory Diagnosis into the Malaria Control Agenda for Sub-Saharan Africa

“…Malaria diagnosis in Africa is still largely based on clinical signs and symptoms, with the role of laboratories significantly diminished or nonexistent. 5,6 A consequence of the prolonged neglect of laboratories in malaria case management is that, even when quality laboratory services are available, clinicians too frequently ignore negative results. [7][8][9][10][11][12] The reduction in clinical malaria in several countries [13][14][15][16] and the use of expensive artemisinin-based combination therapeutic (ACT) antimalarial drugs call for case management practices that emphasize parasitologic confirmation, because continued use of ACTs in non-malaria cases represents a waste of resources and eventually, is unsustainable.…”

Prevalence of Malaria among Acute Febrile Patients Clinically Suspected of Having Malaria in the Zeway Health Center, Ethiopia

“…A large proportion of patients with febrile illness in places where malaria is common is treated with antimalarial drugs without a specific diagnosis (19,20). Prescription of antibiotics to febrile patients is also high (21).…”