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

Katia Bruxvoort ,Shunmay Yeung,Catherine Goodman,S Patrick Kachur,Pascal Magnussen,Kristina Elfving,Jayne Webster,Sarah G Staedke,Toby Leslie,Frank Baiden,Anthony K Mbonye,Heidi Hopkins,Baptiste Leurent,David G Lalloo,Ismail Mayan,Delér Shakely,Sham Lal,Andreas Mårtensson,Anders Björkman,Siân E Clarke,David Schellenberg,Lindsay Mangham-Jefferies,Christopher J M Whitty,Bonnie Cundill,Lasse S Vestergaard ,Mark Rowland ,Clare I R Chandler ,Kristian Schultz Hansen ,Seth Owusu‐Agyei ,Helen Burchett ,Mwinyi Msellem ,Obinna Onwujekwe ,Deborah Diliberto ,Virginia Wiseman ,Evelyn Ansah

doi:10.4269/ajtmh.16-0955

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.

Highlights

Providing appropriate antimalarial treatment to patients who have malaria has been a long-standing challenge in fever case management and has traditionally relied on presumptive symptom-based diagnosis
artemisinin-based combination therapies (ACT) Consortium studies were included in this analysis if they collected data on patient consultations for suspected malaria, evaluated an intervention to implement malaria rapid diagnostic tests (mRDTs) by healthcare providers, and included a comparison group without the mRDT intervention
The proportion of patients tested is not reported in Afgh[1] or Ghan[1], where patients were individually randomized to mRDTs or microscopy (Afgh1/a, Afg1/b, and Ghan1/a), and to mRDTs or symptom-based diagnosis (Afgh1/c and Ghan1/b)

Summary

Introduction

Providing appropriate antimalarial treatment to patients who have malaria has been a long-standing challenge in fever case management and has traditionally relied on presumptive symptom-based diagnosis. Many of those who receive antimalarials do not have malaria and are suffering from a nonmalaria illness which may need alternative treatment.[1] To improve the rational use of artemisinin-based combination therapies (ACTs), the World Health Organization (WHO) recommended in 2010 that all suspected cases of malaria should have parasitological confirmation before treatment.[2,3] These changes represent a paradigm shift from presumptive antimalarial treatment of fever to targeted use of ACTs only for those with a positive malaria test Central to implementing this policy change are malaria rapid diagnostic tests (mRDTs), relatively simple, inexpensive, and Clinical trials and early pilot projects before the widespread adoption of mRDTs supported their use, though with some heterogeneity of results.[15] Compared with presumptive treatment with antimalarials, case management based on mRDTs generally reduced antimalarial prescription, in settings with relatively high provider adherence to test results and low malaria prevalence.[16,17,18,19,20,21,22] On the other hand, provider adherence to negative mRDT results was high in some studies,[16,17,23,24] it was low in others.[25,26,27]

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Results

Conclusion