Abstract
BackgroundIn Burkina Faso, rapid diagnostic tests for malaria have been made recently available. Previously, malaria was managed clinically. This study aims at assessing which is the best management option of a febrile patient in a hyperendemic setting. Three alternatives are: treating presumptively, testing, or refraining from both test and treatment. The test threshold is the tradeoff between refraining and testing, the test-treatment threshold is the tradeoff between testing and treating. Only if the disease probability lies between the two should the test be used.Methods and FindingsData for this analysis was obtained from previous studies on malaria rapid tests, involving 5220 patients. The thresholds were calculated, based on disease risk, treatment risk and cost, test accuracy and cost. The thresholds were then matched against the disease probability. For a febrile child under 5 in the dry season, the pre-test probability of clinical malaria (3.2%), was just above the test/treatment threshold. In the rainy season, that probability was 63%, largely above the test/treatment threshold. For febrile children >5 years and adults in the dry season, the probability was 1.7%, below the test threshold, while in the rainy season it was higher (25.1%), and situated between the two thresholds (3% and 60.9%), only if costs were not considered. If they were, neither testing nor treating with artemisinin combination treatments (ACT) would be recommended.ConclusionsA febrile child under 5 should be treated presumptively. In the dry season, the probability of clinical malaria in adults is so low, that neither testing nor treating with any regimen should be recommended. In the rainy season, if costs are considered, a febrile adult should not be tested, nor treated with ACT, but a possible alternative would be a presumptive treatment with amodiaquine plus sulfadoxine-pyrimethamine. If costs were not considered, testing would be recommended.
Highlights
In health centers and dispensaries of many African countries, including Burkina Faso, malaria is the only disease for which a rapid diagnostic test (RDT) can be used in the field with immediate result
If costs are considered, a febrile adult should not be tested, nor treated with artemisinin combination treatments (ACT), but a possible alternative would be a presumptive treatment with amodiaquine plus sulfadoxine-pyrimethamine
Id., or treat for malaria with alternative regimen x = diseased; 1-x = not diseased; Tc = Treatment cost; Tmort = mortality caused by the treatment; Lv = value of a death averted; Dmort = Disease mortality; t = test threshold; tT test/treatment threshold; tc = test cost; FP = false positive rate; TP = true positive rate; FN = false negative rate; TN = true negative rate; Tb = Treatment burden ( = Tc +Tmort * Lv); Db = Disease burden ( = Dmort * Lv)
Summary
In health centers and dispensaries of many African countries, including Burkina Faso, malaria is the only disease for which a rapid diagnostic test (RDT) can be used in the field with immediate result. A test is useful if the result is susceptible to change the decision that the clinical officer would make without test This has not always been the case in previous studies on malaria RDT, showing that the negative RDT result did not prevent local health professionals from treating for malaria [2,3]. Rather than passively adhere to suggested guidelines, health workers should be trained to deal with uncertainty on the basis of the best available evidence This necessarily implies a clinical reasoning based on the threshold, a well known concept but which has not yet duly influenced clinical practice [4,5]. If the disease probability lies between the two should the test be used
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