Use of RDTs to improve malaria diagnosis and fever case management at primary health care facilities in Uganda

Abstract

BackgroundEarly and accurate diagnosis of malaria followed by prompt treatment reduces the risk of severe disease in malaria endemic regions. Presumptive treatment of malaria is widely practised where microscopy or rapid diagnostic tests (RDTs) are not readily available. With the introduction of artemisinin-based combination therapy (ACT) for treatment of malaria in many low-resource settings, there is need to target treatment to patients with parasitologically confirmed malaria in order to improve quality of care, reduce over consumption of anti-malarials, reduce drug pressure and in turn delay development and spread of drug resistance. This study evaluated the effect of malaria RDTs on health workers' anti-malarial drug (AMD) prescriptions among outpatients at low level health care facilities (LLHCF) within different malaria epidemiological settings in Uganda.MethodsAll health workers (HWs) in 21 selected intervention (where RDTs were deployed) LLHF were invited for training on the use RDTs. All HWs were trained to use RDTs for parasitological diagnosis of all suspected malaria cases irrespective of age. Five LLHCFs with clinical diagnosis (CD only) were included for comparison. Subsequently AMD prescriptions were compared using both a 'pre - post' and 'intervention - control' analysis designs. In-depth interviews of the HWs were conducted to explore any factors that influence AMD prescription practices.ResultsA total of 166,131 out-patient attendances (OPD) were evaluated at 21 intervention LLHCFs. Overall use of RDTs resulted in a 38% point reduction in AMD prescriptions. There was a two-fold reduction (RR 0.62, 95% CI 0.55-0.70) in AMD prescription with the greatest reduction in the hypo-endemic setting (RR 0.46 95% CI 0.51-0.53) but no significant change in the urban setting (RR1.01, p-value = 0.820). Over 90% of all eligible OPD patients were offered a test. An average of 30% (range 25%-35%) of the RDT-negative fever patients received AMD prescriptions. When the test result was negative, children under five years of age were two to three times more likely (OR 2.6 p-value <0.001) to receive anti-malarial prescriptions relative to older age group. Of the 63 HWs interviewed 92% believed that a positive RDT result confirmed malaria, while only 49% believed that a negative RDT result excluded malaria infection.ConclusionUse of RDTs resulted in a 2-fold reduction in anti-malarial drug prescription at LLHCFs. The study demonstrated that RDT use is feasible at LLHCFs, and can lead to better targetting of malaria treatment. Nationwide deployment of RDTs in a systematic manner should be prioritised in order to improve fever case management. The process should include plans to educate HWs about the utility of RDTs in order to maximize acceptance and uptake of the diagnostic tools and thereby leading to the benefits of parasitological diagnosis of malaria.

The treatment of non-malarial febrile illness in Papua New Guinea: findings from cross sectional and longitudinal studies of health worker practice

“…Antimalarials were provided in 18.8 and 13.2% of OS and CS cases, respectively, despite the negative mRDT result. This rate of antimalarial prescription to mRDT negative patients is lower than that reported in other settings [24–26] and represents a substantial reduction in the rate of antimalarial prescription to febrile patients compared to the practice observed prior to the change in treatment protocol [27]. Thus, while not fully compliant with the revised protocol, PNG health workers have seemingly made radical and appropriate adjustments to their antimalarial prescription practices in a relatively brief time frame and perhaps at a faster rate than their international peers in similar circumstances.…”

‘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).…”

“…This persists even when they perform the test themselves and particularly when the results clash with observed signs and symptoms (Kyabayinze et al, 2010;Moonasar et al, 2007;Rowe et al, 2009;Uzochukwu et al, 2010). Results from a recent survey of health facilities in Cameroon in 2009 indicate malaria is significantly overdiagnosed and mistreated (Mangham et al, 2011).…”

Prescribing practices for malaria in a rural Ugandan hospital: evaluation of a new malaria treatment policy

“…There is limited information on the prescription practices of health workers after implementation of the 2005 antimalarial policy in Uganda. Some of the studies that have been done have focused mainly on the prescription of Artemether-Lumefantrine 12 while others have looked at the management of malaria with the aid of rapid diagnostic tests 13 . In addition, factors associated with the prescription practices have not been well studied.…”