Use of malaria RDTs in various health contexts across sub-Saharan Africa: a systematic review

Matthew R Boyce,Wendy P O’Meara

doi:10.1186/s12889-017-4398-1

Abstract

BackgroundThe World Health Organization recommends parasitological confirmation of malaria prior to treatment. Malaria rapid diagnostic tests (RDTs) represent one diagnostic method that is used in a variety of contexts to overcome limitations of other diagnostic techniques. Malaria RDTs increase the availability and feasibility of accurate diagnosis and may result in improved quality of care. Though RDTs are used in a variety of contexts, no studies have compared how well or effectively RDTs are used across these contexts. This review assesses the diagnostic use of RDTs in four different contexts: health facilities, the community, drug shops and schools.MethodsA comprehensive search of the Pubmed database was conducted to evaluate RDT execution, test accuracy, or adherence to test results in sub-Saharan Africa. Original RDT and Plasmodium falciparum focused studies conducted in formal health care facilities, drug shops, schools, or by CHWs between the year 2000 and December 2016 were included. Studies were excluded if they were conducted exclusively in a research laboratory setting, where staff from the study team conducted RDTs, or in settings outside of sub-Saharan Africa.ResultsThe literature search identified 757 reports. A total of 52 studies were included in the analysis. Overall, RDTs were performed safely and effectively by community health workers provided they receive proper training. Analogous information was largely absent for formal health care workers. Tests were generally accurate across contexts, except for in drug shops where lower specificities were observed. Adherence to RDT results was higher among drug shop vendors and community health workers, while adherence was more variable among formal health care workers, most notably with negative test results.ConclusionsMalaria RDTs are generally used well, though compliance with test results is variable – especially in the formal health care sector. If low adherence rates are extrapolated, thousands of patients may be incorrectly diagnosed and receive inappropriate treatment resulting in a low quality of care and unnecessary drug use. Multidisciplinary research should continue to explore determinants of good RDT use, and seek to better understand how to support and sustain the correct use of this diagnostic tool.

Highlights

The World Health Organization recommends parasitological confirmation of malaria prior to treatment
Results for the accuracy of rapid diagnostic tests (RDTs) in the retail sector suggested that sensitivity was high, ranging from 91.7% [57] to 100% [70] when using microscopy as a gold standard (Table 1)
The same pattern held for the interpretation of faint-positive test lines as positive, which improved from 89.7% at three months to 96.7% at six months, but declined to 76.7% at 12 months. These results indicate acceptable execution of RDTs by Community health worker (CHW), which is enhanced by training, regular supervision, and feedback, and that these skills are maintained over time, presumably through practice

Summary

Introduction

The World Health Organization recommends parasitological confirmation of malaria prior to treatment. In 2010, the World Health Organization (WHO) revised their recommendations to require parasitological confirmation of malaria infection prior to treatment with artemisinin-based combination therapy (ACT), known as the “test-and-treat” strategy [5] This change was precipitated by a declining prevalence of malaria in sub-Saharan Africa, likely attributable to the use of modern control interventions, including insecticidetreated nets and indoor residual spraying [6,7,8]; evidence suggesting that malaria only causes a proportion of all febrile illness in malaria endemic regions [9,10,11]; concerns surrounding antimalarial drug resistance [12, 13] and improvements in diagnostic technologies. The confirmation of parasitological infection is important for the management of other febrile illnesses; as disease burden shifts it is necessary to know the infection status of each febrile patient so that they may receive proper care [3]

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