The Impact of Introducing Malaria Rapid Diagnostic Tests on Fever Case Management: A Synthesis of Ten Studies from the ACT Consortium

Abstract

Abstract.Since 2010, the World Health Organization has been recommending that all suspected cases of malaria be confirmed with parasite-based diagnosis before treatment. These guidelines represent a paradigm shift away from presumptive antimalarial treatment of fever. Malaria rapid diagnostic tests (mRDTs) are central to implementing this policy, intended to target artemisinin-based combination therapies (ACT) to patients with confirmed malaria and to improve management of patients with nonmalarial fevers. The ACT Consortium conducted ten linked studies, eight in sub-Saharan Africa and two in Afghanistan, to evaluate the impact of mRDT introduction on case management across settings that vary in malaria endemicity and healthcare provider type. This synthesis includes 562,368 outpatient encounters (study size range 2,400–432,513). mRDTs were associated with significantly lower ACT prescription (range 8–69% versus 20–100%). Prescribing did not always adhere to malaria test results; in several settings, ACTs were prescribed to more than 30% of test-negative patients or to fewer than 80% of test-positive patients. Either an antimalarial or an antibiotic was prescribed for more than 75% of patients across most settings; lower antimalarial prescription for malaria test-negative patients was partly offset by higher antibiotic prescription. Symptomatic management with antipyretics alone was prescribed for fewer than 25% of patients across all scenarios. In community health worker and private retailer settings, mRDTs increased referral of patients to other providers. This synthesis provides an overview of shifts in case management that may be expected with mRDT introduction and highlights areas of focus to improve design and implementation of future case management programs.

Prioritising pathogens for the management of severe febrile patients to improve clinical care in low- and middle-income countries

“…8 Médecins Sans Frontières, Geneva, Switzerland. 9 Médecins Sans Frontières -Manson Unit, London, UK. 10 Médecins Sans Frontières, Barcelona, Spain.…”

“…As a result of increased malaria elimination efforts and the subsequent worldwide decline in malaria cases, clinicians in LMICs are now encountering an increasing number of malaria rapid diagnostic test (RDT)-negative febrile patients and/or malaria RDT-positive febrile patients who are co-infected with both Plasmodium as well as another fever-inducing pathogen [8][9][10][11]. To date, in LMICs, beyond the use of a malaria RDT and/or microscopy for some locations [12], no aetiology-based diagnostic test is currently employed or recommended by the World Health Organization (WHO) for any other fever-inducing pathogen.…”

Emerging Trends in Clinical Tropical Medicine Research

“…For example, one investigative team had a broad enough perspective to look beyond the narrow focus of the investigation protocol itself and identified unintended consequences of a well-conceived public health intervention. 6 The reality of application may differ Severe malaria manifested as shock and lactic acidosis much more commonly than severe anemia. Severe malaria had age peaks at 2-3 years and in those older than 50 years.…”

“…Severe malaria had age peaks at 2-3 years and in those older than 50 years. Bruxvoort et al 6 Effect of diagnostics on management Rapid tests improved appropriate treatment with artemisinin combination therapy for test-positive and negative cases, but many cases were not treated according to test results. Cash-Goldwater et al 11 Infection risk factors Brucellosis confirmed by blood culture, or 4-fold rise in microagglutination was confirmed or probable in 9% of febrile patients, mostly who attend animals but were not suspected by medical providers.…”

“…As part of their discussion, they observed, "A more comprehensive approach to case management is needed, rather than focusing on only a single diagnosis and treatment." 6 This points to patient-oriented outcomes, rather than mere surrogate markers, as the true indicators of success. Patient-oriented outcomes are difficult to affect and measure because of the many factors in play.…”