Abstract
BackgroundPresumptive treatment of all febrile patients with anti-malarials leads to massive over-treatment. The aim was to assess the effect of implementing malaria rapid diagnostic tests (mRDTs) on prescription of anti-malarials in urban Tanzania.MethodsThe design was a prospective collection of routine statistics from ledger books and cross-sectional surveys before and after intervention in randomly selected health facilities (HF) in Dar es Salaam, Tanzania. The participants were all clinicians and their patients in the above health facilities. The intervention consisted of training and introduction of mRDTs in all three hospitals and in six HF. Three HF without mRDTs were selected as matched controls. The use of routine mRDT and treatment upon result was advised for all patients complaining of fever, including children under five years of age. The main outcome measures were: (1) anti-malarial consumption recorded from routine statistics in ledger books of all HF before and after intervention; (2) anti-malarial prescription recorded during observed consultations in cross-sectional surveys conducted in all HF before and 18 months after mRDT implementation.ResultsBased on routine statistics, the amount of artemether-lumefantrine blisters used post-intervention was reduced by 68% (95%CI 57-80) in intervention and 32% (9-54) in control HF. For quinine vials, the reduction was 63% (54-72) in intervention and an increase of 2.49 times (1.62-3.35) in control HF. Before-and-after cross-sectional surveys showed a similar decrease from 75% to 20% in the proportion of patients receiving anti-malarial treatment (Risk ratio 0.23, 95%CI 0.20-0.26). The cluster randomized analysis showed a considerable difference of anti-malarial prescription between intervention HF (22%) and control HF (60%) (Risk ratio 0.30, 95%CI 0.14-0.70). Adherence to test result was excellent since only 7% of negative patients received an anti-malarial. However, antibiotic prescription increased from 49% before to 72% after intervention (Risk ratio 1.47, 95%CI 1.37-1.59).ConclusionsProgrammatic implementation of mRDTs in a moderately endemic area reduced drastically over-treatment with anti-malarials. Properly trained clinicians with adequate support complied with the recommendation of not treating patients with negative results. Implementation of mRDT should be integrated hand-in-hand with training on the management of other causes of fever to prevent irrational use of antibiotics.
Highlights
Presumptive treatment of all febrile patients with anti-malarials leads to massive over-treatment
Routine statistics from ledger books - longitudinal study most required data could be retrieved from the MTUHA books with a few exceptions: among a total of 3,960 monthly data points to be collected (10 variables measured in 12 health facilities (HF) during 33 months), only 36 were missing
When only looking at the last six months of the study to assess the sustainability of malaria rapid diagnostic tests (mRDTs) implementation the results were even better (PP ratio 0.25, 95% confidence intervals (CI) 0.13-0.37)
Summary
Presumptive treatment of all febrile patients with anti-malarials leads to massive over-treatment. Because of the scarce availability of laboratory facilities and the high mortality of malaria in young children, presumptive treatment in case of fever was seen as the only practical solution to improve child survival. This strategy became part of the Integrated Management of Childhood Illness (IMCI) decision chart. The strategy of presumptive treatment was and rapidly adopted by health workers to such an extent that it started to be applied beyond the initial high-risk group: 1) to children older than five years and even adults; 2) in low endemicity areas; and 3) in setting where laboratory diagnosis was available [2]. The strategy of presumptive treatment of all fevers with anti-malarials leads clinicians to believe that all fevers are due to malaria, resulting in a massive over-diagnosis [3,4], and more importantly to ignoring non-malaria causes of fever that have similar, or even higher case fatality rates than malaria [5,6]
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