Abstract
BackgroundAs international funding for malaria programmes plateaus, limited resources must be rationally managed for malaria and non-malarial febrile illnesses (NMFI). Given widespread unnecessary treatment of NMFI with first-line antimalarial Artemisinin Combination Therapies (ACTs), our aim was to estimate the effect of health-systems factors on rates of appropriate treatment for fever and on use of ACTs.MethodsA decision-tree tool was developed to investigate the impact of improving aspects of the fever care-pathway and also evaluate the impact in Tanzania of the revised WHO malaria guidelines advocating diagnostic-led managementResultsModel outputs using baseline parameters suggest 49% malaria cases attending a clinic would receive ACTs (95% Uncertainty Interval:40.6–59.2%) but that 44% (95% UI:35–54.8%) NMFI cases would also receive ACTs. Provision of 100% ACT stock predicted a 28.9% increase in malaria cases treated with ACT, but also an increase in overtreatment of NMFI, with 70% NMFI cases (95% UI:56.4–79.2%) projected to receive ACTs, and thus an overall 13% reduction (95% UI:5–21.6%) in correct management of febrile cases. Modelling increased availability or use of diagnostics had little effect on malaria management outputs, but may significantly reduce NMFI overtreatment. The model predicts the early rollout of revised WHO guidelines in Tanzania may have led to a 35% decrease (95% UI:31.2–39.8%) in NMFI overtreatment, but also a 19.5% reduction (95% UI:11–27.2%), in malaria cases receiving ACTs, due to a potential fourfold decrease in cases that were untested or tested false-negative (42.5% vs.8.9%) and so untreated.DiscussionModelling multi-pronged intervention strategies proved most effective to improve malaria treatment without increasing NMFI overtreatment. As malaria transmission declines, health system interventions must be guided by whether the management priority is an increase in malaria cases receiving ACTs (reducing the treatment gap), reducing ACT waste through unnecessary treatment of NMFI or expanding appropriate treatment of all febrile illness.
Highlights
Malaria remains a major public health problem, with an estimated 216 million cases and 655,000 deaths in 2010 [1]
Using the baseline parameters obtained from studies undertaken prior to the 2010 WHO guidelines on rational case management, we estimate that 4.7% (95% uncertainty interval [UI]: 2.1–8.8%) of all malaria cases, and 14.7%
Using the decision tree model to account for the correct outcome being possible despite imperfect case management we estimate that 54% (95% UI: 48.9–59.3%) of all febrile attendees in the public sector will be correctly managed, and that 49% of malaria cases attending a public facility would receive first line Artemisinin Combination Therapies (ACTs) (95% UI: 40.6–59.2%)
Summary
Malaria remains a major public health problem, with an estimated 216 million cases and 655,000 deaths in 2010 [1]. Until recently presumptive treatment and syndromic management of all fevers as malaria was advocated in WHO guidelines and national policies, especially for children under 5 years (U5s) This has resulted in overtreatment (unnecessary prescription of antimalarials) with 47%–95% of patients with non-malarial febrile illness (NMFI) estimated to receive antimalarials [9,10,11,12,13,14,15,16,17]. Treatment solely on the basis of clinical suspicion should only be considered when a parasitological diagnosis is not accessible’’ [19] This policy change was adopted to reduce routine overtreatment of malaria and the consequent risk of drug resistance, to expand disease surveillance and to improve quality of care for both malaria and NMFI, though its likely impact remains a subject of debate [20,21,22,23,24]. Given widespread unnecessary treatment of NMFI with first-line antimalarial Artemisinin Combination Therapies (ACTs), our aim was to estimate the effect of health-systems factors on rates of appropriate treatment for fever and on use of ACTs
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