Abstract
BackgroundMalaria accounts for a small fraction of febrile cases in increasingly large areas of the malaria endemic world. Point-of-care tests to improve the management of non-malarial fevers appropriate for primary care are few, consisting of either diagnostic tests for specific pathogens or testing for biomarkers of host response that indicate whether antibiotics might be required. The impact and cost-effectiveness of these approaches are relatively unexplored and methods to do so are not well-developed.MethodsWe model the ability of dengue and scrub typhus rapid tests to inform antibiotic treatment, as compared with testing for elevated C-Reactive Protein (CRP), a biomarker of host-inflammation. Using data on causes of fever in rural Laos, we estimate the proportion of outpatients that would be correctly classified as requiring an antibiotic and the likely cost-effectiveness of the approaches.ResultsUse of either pathogen-specific test slightly increased the proportion of patients correctly classified as requiring antibiotics. CRP testing was consistently superior to the pathogen-specific tests, despite heterogeneity in causes of fever. All testing strategies are likely to result in higher average costs, but only the scrub typhus and CRP tests are likely to be cost-effective when considering direct health benefits, with median cost per disability adjusted life year averted of approximately $48 USD and $94 USD, respectively.ConclusionsTesting for viral infections is unlikely to be cost-effective when considering only direct health benefits to patients. Testing for prevalent bacterial pathogens can be cost-effective, having the benefit of informing not only whether treatment is required, but also as to the most appropriate antibiotic; this advantage, however, varies widely in response to heterogeneity in causes of fever. Testing for biomarkers of host inflammation is likely to be consistently cost-effective despite high heterogeneity, and can also offer substantial reductions in over-use of antimicrobials in viral infections.
Highlights
Declining malaria transmission and increasing availability of malaria rapid diagnostic tests (RDTs) together suggest that the majority of febrile patients are identified as having nonmalarial causes of fever [1, 2]
We model the ability of dengue and scrub typhus rapid tests to inform antibiotic treatment, as compared with testing for elevated C-Reactive Protein (CRP), a biomarker of hostinflammation
Use of either pathogen-specific test slightly increased the proportion of patients correctly classified as requiring antibiotics
Summary
Declining malaria transmission and increasing availability of malaria rapid diagnostic tests (RDTs) together suggest that the majority of febrile patients are identified as having nonmalarial causes of fever [1, 2] For these patients, health workers in remote settings currently rely at best on syndromic algorithms to determine whether treatment with antibiotics is required. One approach to improve the management of non-malarial fevers is the use of further pathogen-specific diagnostics to identify the aetiology This can inform as to whether antibiotics are required, and for bacterial pathogens as to the most appropriate treatment. Such rapid tests are increasingly available, with the exception of those for influenza and dengue, few have demonstrated sufficient accuracy for use at point-of-care [5, 6]. The impact and cost-effectiveness of these approaches are relatively unexplored and methods to do so are not well-developed
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