Availability Of Rapid Diagnostic Tests Research Articles

Use of Measles and Rubella Rapid Diagnostic Tests to Improve Case Detection and Targeting of Vaccinations.

Efforts to control and eliminate measles and rubella are aided by high-quality surveillance data-supported by laboratory confirmation-to guide decision-making on routine immunization strategies and locations for conducting preventive supplementary immunization activities (SIAs) and outbreak response. Important developments in rapid diagnostic tests (RDTs) for measles and rubella present new opportunities for the global measles and rubella surveillance program to greatly improve the ability to rapidly detect and respond to outbreaks. Here, we review the status of RDTs for measles and rubella Immunoglobulin M (IgM) testing, as well as ongoing questions and challenges regarding the operational use and deployment of RDTs as part of global measles and rubella surveillance. Efforts to develop IgM RDTs that can be produced at scale are underway. Once validated RDTs are available, clear information on the benefits, challenges, and costs of their implementation will be critical for shaping deployment guidance and informing country plans for sustainably deploying such tests. The wide availability of RDTs could provide new programmatic options for measles and rubella elimination efforts, potentially enabling improvements and flexibility for testing, surveillance, and vaccination.

Investigating rapid diagnostic testing in Kenya’s health system, 2018–2020: validating non-reporting in routine data using a health facility service assessment survey

BackgroundUnderstanding the availability of rapid diagnostic tests (RDTs) is essential for attaining universal health care and reducing health inequalities. Although routine data helps measure RDT coverage and health access gaps, many healthcare facilities fail to report their monthly diagnostic test data to routine health systems, impacting routine data quality. This study sought to understand whether non-reporting by facilities is due to a lack of diagnostic and/or service provision capacity by triangulating routine and health service assessment survey data in Kenya.MethodsRoutine facility-level data on RDT administration were sourced from the Kenya health information system for the years 2018–2020. Data on diagnostic capacity (RDT availability) and service provision (screening, diagnosis, and treatment) were obtained from a national health facility assessment conducted in 2018. The two sources were linked and compared obtaining information on 10 RDTs from both sources. The study then assessed reporting in the routine system among facilities with (i) diagnostic capacity only, (ii) both confirmed diagnostic capacity and service provision and (iii) without diagnostic capacity. Analyses were conducted nationally, disaggregated by RDT, facility level and ownership.ResultsTwenty-one per cent (2821) of all facilities expected to report routine diagnostic data in Kenya were included in the triangulation. Most (86%) were primary-level facilities under public ownership (70%). Overall, survey response rates on diagnostic capacity were high (> 70%). Malaria and HIV had the highest response rate (> 96%) and the broadest coverage in diagnostic capacity across facilities (> 76%). Reporting among facilities with diagnostic capacity varied by test, with HIV and malaria having the lowest reporting rates, 58% and 52%, respectively, while the rest ranged between 69% and 85%. Among facilities with both service provision and diagnostic capacity, reporting ranged between 52% and 83% across tests. Public and secondary facilities had the highest reporting rates across all tests. A small proportion of health facilities without diagnostic capacity submitted testing reports in 2018, most of which were primary facilities.ConclusionNon-reporting in routine health systems is not always due to a lack of capacity. Further analyses are required to inform other drivers of non-reporting to ensure reliable routine health data.

Brazilian perspective: antimicrobial stewardship in solid organ transplant.

The incidence of multidrug resistant organisms (MDROs) infections among solid organ transplant (SOT) patients is very high in Brazil. This review will discuss antimicrobial use and resistance in SOT in Brazil, highlighting the main barriers and facilitators for implementation of an antimicrobial stewardship programme (ASP). The most common group of MDROs is carbapenem-resistant Gram-negative bacteria and vancomycin-resistant Enterococcus. Carbapenem-resistant Enterobacterales (CREs) are the most frequent MDROs and have been reported as donor-derived as well. Although ASPs are mandatory in the country, there is a lack of information regarding ASPs in SOT recipients. The main barriers for the implementation of ASPs in Brazilian hospitals are lack of electronic medical records, absence of national guidelines specific to SOT recipients, lack of recommendations on surveillance culture to evaluate colonization and transmission of donor-derived MDROs, limited availability of rapid diagnostic tests, and insufficient pharmacist and clinician time allocated to ASP activities in some SOT centers. The incidence of MDRO infections caused mainly by VREs and CREs is very high in the country. There is limited data regarding antimicrobial use among SOT recipients in Brazil. The absence of antimicrobial stewardship national guidelines specific to SOT recipients is one of the main barriers for the implementation of ASPs in Brazilian hospitals.

The private sector market for malaria rapid diagnostic tests in Nigeria: results of the 2018 market survey

BackgroundTo avoid misuse of anti-malarials, correct diagnosis of fever prior to drug prescription is essential. Presumptive treatment in the private healthcare sector is a concern in Nigeria, where availability of affordable artemisinin-based combination therapy (ACT) is high following the implementation of subsidy schemes from 2010 to 2017. Similar subsidies have not, however, been implemented for malaria rapid diagnostic tests (RDTs). A market survey in 2018 predominantly designed to assess the ACT market in the private sector also collected data related to RDTs, results of which are presented herein.MethodsA 2018 market survey consisted of (i) an outlet survey targeting private pharmacies and Proprietary and Patent Medicine Vendors (PPMVs) across different regions of Nigeria to assess supply-side market factors related to availability of RDTs (defined as having stock available for purchase at the time of the survey) and (ii) a household survey to determine demand-side factors related to knowledge of RDTs, healthcare-seeking practices and affordability.ResultsAvailability of RDTs at the time of the survey was low in both outlet types and significantly lower in PPMVs (22.1%, 95% CI) among pharmacies versus (13.6%, 95% CI) among PPMVs (p < 0.01). Reasons for not restocking RDTs included low demand and no supply. The majority of households diagnose malaria based on experience, while one-third would visit a PPMV or pharmacy. Half of households had heard of RDTs (48.4%) and 38.6% thought they were affordable.ConclusionsLow availability of RDTs among PPMVs and pharmacies may be attributed to lack of demand, supply-side issues and cost. Increasing household knowledge of RDTs may aid increasing demand, while subsidized RDTs may address supply and price issues. Addressing the deficit in RDT provision is important for targeting of ACT medicines.

Determinants of malaria testing at health facilities: the case of Uganda

BackgroundThe World Health Organization (WHO) recommends prompt malaria diagnosis with either microscopy or malaria rapid diagnostic tests (RDTs) and treatment with an effective anti-malarial, as key interventions to control malaria. However, in sub-Saharan Africa, malaria diagnosis is still often influenced by clinical symptoms, with patients and care providers often interpreting all fevers as malaria. The Ministry of Health in Uganda defines suspected malaria cases as those with a fever. A target of conducting testing for at least 75% of those suspected to have malaria was established by the National Malaria Reduction Strategic Plan 2014–2020.MethodsThis study investigated factors that affect malaria testing at health facilities in Uganda using data collected in March/April 2017 in a cross-sectional survey of health facilities from the 52 districts that are supported by the US President’s Malaria Initiative (PMI). The study assessed health facility capacity to provide quality malaria care and treatment. Data were collected from all 1085 public and private health facilities in the 52 districts. Factors assessed included supportive supervision, availability of malaria management guidelines, laboratory infrastructure, and training health workers in the use of malaria rapid diagnostic test (RDT). Survey data were matched with routinely collected health facility malaria data obtained from the district health information system Version-2 (DHIS2). Associations between testing at least 75% of suspect malaria cases with several factors were examined using multivariate logistic regression.ResultsKey malaria commodities were widely available; 92% and 85% of the health facilities reported availability of RDTs and artemether–lumefantrine, respectively. Overall, 933 (86%) of the facilities tested over 75% of patients suspected to have malaria. Predictors of meeting the testing target were: supervision in the last 6 months (OR: 1.72, 95% CI 1.04–2.85) and a health facility having at least one health worker trained in the use of RDTs (OR: 1.62, 95% CI 1.04–2.55).ConclusionThe study findings underscore the need for malaria control programmes to provide regular supportive supervision to health facilities and train health workers in the use of RDTs.

High success and low recurrence with shorter treatment regimen for multidrug-resistant TB in Nepal.

SETTING:Nine drug-resistant TB centres, some of them supported by Damien Foundation in Nepal where >80% of multidrug-resistant/rifampicin-resistant TB (MDR/RR-TB) patients are treated.OBJECTIVE:To assess the uptake, effectiveness and safety of the 9–12-month shorter treatment regimen (STR) in MDR/RR-TB patients registered from January 2018 to December 2019.DESIGN:This was a cohort study involving secondary programme data.RESULTS:Of 631 patients, 301 (48.0%) started and continued STR. Key reasons for ineligibility to start/continue STR were baseline resistance or exposure to second-line drugs (62.0%), contact with extensively drug-resistant TB (XDR-TB) or pre-XDR-TB (7.0%) patients and unavailability of STR drugs (6.0%). Treatment success was 79.6%; unsuccessful outcomes were death (12.0%), lost to follow-up (5.3%), failure (2.7%) and not evaluated (0.7%). Unsuccessful outcomes were significantly associated with HIV positivity and patient age ⩾55 years, with adjusted relative risk of respectively 2.39 (95% CI 1.52–3.77) and 3.86 (95% CI 2.30–6.46). Post-treatment recurrence at 6 and 12 months was respectively 0.5% and 2.4%. Serious adverse events (SAEs) were seen in 15.3% patients — hepatotoxicity and ototoxicity were most common.CONCLUSION:STR had a modest uptake, high treatment success and low post-treatment recurrence. For proper detection and management of SAEs, improving pharmacovigilance might be considered. Availability of rapid diagnostic test for second-line drugs is crucial for correct patient management.

Management of childhood pneumonia in Nigeria.

Management of childhood pneumonia in Nigeria.

Leptospirosis onboard afloat unit: Case report of an underreported infectious disease

Rat-borne diseases including leptospirosis have been of historical importance in the military. With the risk of human–rat encounters onboard ships and vessels, encountering such an illness at sea is not rare for a primary care physician. Thus, it becomes important for those at the front, to be aware of its presentation and management. Leptospirosis must always be considered as a differential diagnosis of febrile patients, in an environment with positive risk factors. We present the case of a 30-year-old sailor managed and evacuated at sea, who presented with fever and abdominal pain. Our patient was found to have hypotension with oliguria and was administered fluid resuscitation along with broad-spectrum antibiotics while at sea, with a provisional diagnosis of acute pyelonephritis and differential diagnosis of leptospirosis. He was evacuated to a tertiary care center where he was evaluated and managed as anicteric leptospirosis. Our patient had an uneventful recovery. It is essential for primary health-care workers to have a high level of suspicion, to ensure the successful management of such atypical infections. Earliest initiation of empirical antibiotic therapy and symptomatic management along with fastest means of evacuation is suggested to ensure best outcome. The availability of rapid diagnostic tests at primary care centers is a must, to ensure early diagnosis and treatment. Although curable, prevention by rodent control and hygiene maintenance continues to be the most effective and economical methods to minimize the loss of workforce, morbidity, and mortality due to leptospirosis.

656. Prioritizing Gram-Negative Bacteremia (GNB) Cases for Rapid Detection by β-Lactam Resistance (BLR) and Patient Outcomes

BackgroundGNB is associated with significant morbidity and mortality. The availability of rapid diagnostic tests (RDTs) provides an opportunity to improve outcomes. Our goal was to review GNB and its empiric treatment at our center in order to devise rational approaches to diagnostic stewardship and use of RDTs.MethodsAll patients with GNB from 2010 to 2018 were evaluated. BLR was defined by 2019 CLSI breakpoints; phenotypes are shown in Table 1.ResultsA total of 2795 GNB cases were included (Table 2); 57% occurred within the first 24 hours of hospitalization and 29.3% in the ICU. The median length of stay (LOS) was 12 days; 17.2% of patients were re-admitted within 30 days. Fourteen- and 30-day mortality rates were 13.7% and 19.5%, respectively. Rates of death were higher (30 days; 26.3% vs. 17.1%; P < 0.001) and median LOS longer (17 vs. 11 days; P < 0.001) among patients with BLR compared with susceptible GNB. Thirty-day mortality rates were highest for CRE (30.1%) and BLR P. aeruginosa (BLR-Pa; 32.8%, Figure 1). 47.7% of BLR GNB were non-CRE/ESBL, which demonstrated higher mortality rates than CRE/ESBL (30 days; 27.6% vs. 21.2%; P = 0.048). Most common empiric regimens prescribed were piperacillin–tazobactam (TZP; 50.3%), cefepime (FEP; 24.2%), carbapenem (9.3%), or other agents (16.2%). 21.6% of GNB patients received inactive empiric treatment (IET). Empiric TZP (21.9%) was more likely to be inactive than FEP (17.5%; P = 0.05), but not a carbapenem (20.7%; P = NS). 57.6% of patients with inhibitor-resistant Enterobacteriaceae (IRE) received TZP empirically. Receipt of IET was associated with higher rates of death (30 days; 22.5% vs. 16.7, P = 0.03) and longer LOS (14 vs. 11 days; P < 0.001) than receipt of active ET. Rates of IET varied by pathogen (Figure 1).ConclusionIET is common against BLR GNB and associated with poor pt outcomes, highlighting the potential for RDTs and diagnostic stewardship teams (DSTs) to improve care. Genotypic RDTs detect most CRE/ESBL, but may miss nearly 50% of BLR GNB cases at our center. BLR-Pa and IRE are pathogens associated with prolonged LOS, and high rates of IET and death. These pathogens could be detected earlier by phenotypic RDTs and prioritized by DSTs to optimize early treatment regimens. Disclosures All authors: No reported disclosures.

Prevention and care of hepatitis B in the rural region of Fatick in Senegal: a healthcare workers\u2019 perspective using a mixed methods approach

BackgroundIn countries where hepatitis B virus (HBV) is endemic, including Senegal, the World Health Organization recommends systematic HBV screening of pregnant women and vaccination at birth to prevent mother-to-child transmission (MTCT). This study investigated healthcare workers’ (HCW) knowledge and practices regarding HBV prevention and care in the rural region of Fatick in Senegal, as well as challenges they faced in implementing prevention activities related to HBV MTCT.MethodsA mixed-methods survey was conducted between May–July 2017 among 112 HCW working in 15 healthcare facilities in two districts of the Fatick region using face-to-face questionnaires and semi-structured interviews. Descriptive statistics and chi-square/Mann-Whitney tests were used to analyze quantitative data, while qualitative data were analyzed thematically.ResultsThe study population included 87 HCW in the quantitative component (83% women, median age [interquartile range, IQR] = 35 [31–40] years) and 11 in the qualitative component. A knowledge gap was observed in key areas of HBV infection: only 24, 51 and 38%, respectively, correctly reported that early HBV acquisition is associated with a high risk of developing chronic infection, that perinatal transmission is one of the main modes of HBV transmission in Senegal, and that three to four doses of HBV vaccine are required to ensure immunization in children. Despite good acceptability of systematic screening of pregnant women and vaccination at birth, only 48% of HCW mainly involved in prenatal care and 71% of those involved exclusively in vaccination routinely performed these two key interventions. HCW reported several structural barriers that may hinder their implementation: a lack of training in HBV and in counseling, poor availability of rapid diagnostic tests (RDT), high costs of both screening and treatment, a lack of adequate information on treatment options and missed opportunities for vaccination at birth.ConclusionsHCW working in the Fatick region may be insufficiently trained and supported to effectively implement HBV prevention strategies. Our findings suggest an urgent need to strengthen MTCT prevention in this region, by improving HCW knowledge in key areas of HBV infection, providing RDT and antiviral treatment at low cost, and enhancing community-based interventions for the timely vaccination of newborns.

Quality of Malaria Case Management and Reporting at Public Health Facilities in Six Health Districts in Guinea, 2018.

Data on fever and malaria cases reported by health facilities are used for tracking incidence and quantification of malaria commodity needs in Guinea. Periodic assessments of the quality of malaria case management and routine data are a critical activity for the malaria program. In May-June 2018, survey teams visited 126 health facilities in six health districts purposefully selected to represent a spectrum (Stratum 1-high, Stratum 2-intermediate, and Stratum 3-low) of perceived quality of case management and reporting, as assessed from an a priori analysis of routine data. Surveyors performed exit interviews with 939 outpatients and compared results with registry data for interviewed patients. Availability of rapid diagnostic tests (RDTs) and artemisinin-based combination therapies (ACTs) was 100% in Strata 1 and 2, compared with 82% (95% CI: 63-92%) for RDTs and 86% (68-95%) for any formulation of ACT in Stratum 3. Correct case management for suspect malaria cases was 85% in both Stratum 1 (95% CI: 78-90%) and Stratum 2 (79-89%), but only 52% (37-67%) in Stratum 3. Concordance between exit interviews and registry entries for key malaria indicators was significantly higher in Strata 1 and 2 than in Stratum 3. Both adherence to national guidelines for testing and treatment and data quality were high in Strata 1 and 2, but substandard in Stratum 3. The survey results reflected the trends seen in the routine data, suggesting that analysis of routine data can identify areas requiring more attention to improve malaria case management and reporting.

Intermittent screening and treatment or intermittent preventive treatment compared to current policy of single screening and treatment for the prevention of malaria in pregnancy in Eastern Indonesia: acceptability among health providers and pregnant women

BackgroundThe control of malaria in pregnancy in much of Asia relies on screening asymptomatic women for malaria infection, followed by passive case detection and prevention with insecticide-treated nets. In 2012, Indonesia introduced screening for malaria by microscopy or rapid diagnostic tests (RDTs) at pregnant women’s first antenatal care (ANC) visit to detect and treat malaria infections regardless of the presence of symptoms. Acceptability among health providers and pregnant women of the current ‘single screen and treat’ (SSTp) strategy compared to two alternative strategies that were intermittent preventive treatment (IPTp) and intermittent screening and treatment (ISTp) was assessed in the context of a clinical trial in two malaria endemic provinces of Eastern Indonesia.MethodsQualitative data were collected through in-depth interviews with 121 health providers working in provision of antenatal care, heads of health facilities and District Health Office staff. Trial staff were also interviewed. Focus group discussions were conducted with 16 groups of pregnant women (N = 106) to discuss their experiences of each intervention in the trial.ResultsHealth providers and pregnant women were receptive to screening for malaria at every ANC visit due to the increased opportunity to detect and treat asymptomatic infections. A primary concern for providers was the accuracy and availability of RDTs used for screening in the SSTp and ISTp arms, which they considered less accurate than microscopy. Providers had reservations about giving anti-malarials presumptively as IPTp, due to concerns of causing potential harm to mother and baby and as a possible driver of drug resistance. Pregnant women were accepting of all three interventions. Women in the IPTp arm were happy to take anti-malarials presumptively to protect themselves and their babies against malaria.ConclusionsThe findings indicate that, within a trial context, malaria screening of pregnant women at every ANC visit ISTp was an acceptable strategy among both health providers and pregnant women owing to an existing culture of screening and treatment. The adoption of IPTp however would require a considerable shift in health provider attitudes and a clear communication strategy. By contrast, pregnant women welcomed the opportunity to prevent malaria infections during pregnancy.

Evaluation of the national policy of single screening and treatment for the prevention of malaria in pregnancy in two districts in Eastern Indonesia: health provider perceptions

BackgroundMalaria in pregnancy has devastating consequences for both the expectant mother and baby. Annually, 88.2 (70%) of the 125.2 million pregnancies in malaria endemic regions occur in the Asia–Pacific region. The control of malaria in pregnancy in most of Asia relies on passive case detection and prevention with long-lasting insecticide-treated nets. Indonesia was the first country in the region to introduce, in 2012, malaria screening at pregnant women’s first antenatal care visit to reduce the burden of malaria in pregnancy. The study assessed health providers’ acceptability and perceptions on the feasibility of implementing the single screening and treatment (SST) strategy in the context of the national programme in two endemic provinces of Indonesia.MethodsQualitative data were collected through in-depth interviews with 86 health providers working in provision of antenatal care (midwives, doctors, laboratory staff, pharmacists, and heads of drug stores), heads of health facilities and District Health Office staff in West Sumba and Mimika districts in East Nusa Tenggara and Papua provinces, respectively.ResultsHealth providers of all cadres were accepting of SST as a preventive strategy, showing a strong preference for microscopy over rapid diagnostic tests (RDTs) as the method of screening. Implementation of the policy was inconsistent in both sites, with least extensive implementation reported in West Sumba compared to Mimika. SST was predominantly implemented at health centre level using microscopy, whereas implementation at community health posts was said to occur in less than half the selected health facilities. Lack of availability of RDTs was cited as the major factor that prevented provision of SST at health posts, however as village midwives cannot prescribe medicines women who test positive are referred to health centres for anti-malarials. Few midwives had received formal training on SST or related topics.ConclusionsThe study findings indicate that SST was an acceptable strategy among health providers, however implementation was inconsistent with variation across different localities within the same district, across levels of facility, and across different cadres within the same health facility. Implementation should be re-invigorated through reorientation and training of health providers, stable supplies of more sensitive RDTs, and improved data capture and reporting.

Determinants of facility readiness for integration of family planning with HIV testing and counseling services: evidence from the Tanzania service provision assessment survey, 2014\u20132015

BackgroundGlobal policy reports, national frameworks, and programmatic tools and guidance emphasize the integration of family planning and HIV testing and counseling services to ensure universal access to reproductive health care and HIV prevention. However, the status of integration between these two services in Tanzanian health facilities is unclear. This study examined determinants of facility readiness for integration of family planning with HIV testing and counseling services in Tanzania.MethodsData from the 2014–2015 Tanzania Service Provision Assessment Survey were analyzed. Facilities were considered ready for integration of family planning with HIV testing and counseling services if they scored ≥ 50% on both family planning and HIV testing and counseling service readiness indices as identified by the World Health Organization. All analyses were adjusted for clustering effects, and estimates were weighted to correct for non-responses and disproportionate sampling. Descriptive, bivariate, and multivariate logistic regression analyses were performed.ResultsA total of 1188 health facilities were included in the study. Of all of the health facilities, 915 (77%) reported offering both family planning and HIV testing and counseling services, while only 536 (45%) were considered ready to integrate these two services. Significant determinants of facility readiness for integrating these two services were being government owned [AOR = 3.2; 95%CI, 1.9–5.6], having routine management meetings [AOR = 1.9; 95%CI, 1.1–3.3], availability of guidelines [AOR = 3.8; 95%CI, 2.4–5.8], in-service training of staff [AOR = 2.6; 95%CI, 1.3–5.2], and availability of laboratories for HIV testing [AOR = 17.1; 95%CI, 8.2–35.6].ConclusionThe proportion of facility readiness for the integration of family planning with HIV testing and counseling in Tanzania is unsatisfactory. The Ministry of Health should distribute and ensure constant availability of guidelines, availability of rapid diagnostic tests for HIV testing, and the provision of refresher training to health providers, as these were among the determinants of facility readiness.

Including refugees in disease elimination: challenges observed from a sleeping sickness programme in Uganda

BackgroundEnsuring equity between forcibly-displaced and host area populations is a key challenge for global elimination programmes. We studied Uganda’s response to the recent refugee influx from South Sudan to identify key governance and operational lessons for national sleeping sickness programmes working with displaced populations today. A refugee policy which favours integration of primary healthcare services for refugee and host populations and the availability of rapid diagnostic tests (RDTs) to detect sleeping sickness at this health system level makes Uganda well-placed to include refugees in sleeping sickness surveillance.MethodsUsing ethnographic observations of coordination meetings, review of programme data, interviews with sleeping sickness and refugee authorities and group discussions with health staff and refugees (2013–2016), we nevertheless identified some key challenges to equitably integrating refugees into government sleeping sickness surveillance.ResultsDespite fears that refugees were at risk of disease and posed a threat to elimination, six months into the response, programme coordinators progressed to a sentinel surveillance strategy in districts hosting the highest concentrations of refugees. This meant that RDTs, the programme’s primary surveillance tool, were removed from most refugee-serving facilities, exacerbating existing inequitable access to surveillance and leading refugees to claim that their access to sleeping sickness tests had been better in South Sudan. This was not intentionally done to exclude refugees from care, rather, four key governance challenges made it difficult for the programme to recognise and correct inequities affecting refugees: (a) perceived donor pressure to reduce the sleeping sickness programme’s scope without clear international elimination guidance on surveillance quality; (b) a problematic history of programme relations with refugee-hosting districts which strained supervision of surveillance quality; (c) difficulties that government health workers faced to produce good quality surveillance in a crisis; and (d) reluctant engagement between the sleeping sickness programme and humanitarian structures.ConclusionsDespite progressive policy intentions, several entrenched governance norms and practices worked against integration of refugees into the national sleeping sickness surveillance system. Elimination programmes which marginalise forced migrants risk unwittingly contributing to disease spread and reinforce social inequities, so new norms urgently need to be established at local, national and international levels.

Testing times: trends in availability, price, and market share of malaria diagnostics in the public and private healthcare sector across eight sub-Saharan African countries from 2009 to 2015

BackgroundThe World Health Organization guidelines have recommended that all cases of suspected malaria should receive a confirmatory test with microscopy or a malaria rapid diagnostic test (RDT), however evidence from sub-Saharan Africa (SSA) illustrates that only one-third of children under five with a recent fever received a test. The aim of this study was to evaluate availability, price and market share of microscopy and RDT from 2009/11 to 2014/15 in 8 SSA countries, to better understand barriers to improving access to malaria confirmatory testing in the public and private health sectors.ResultsRepeated national cross-sectional quantitative surveys were conducted among a sample of outlets stocking anti-malarial medicines and/or diagnostics. In total, 169,655 outlets were screened. Availability of malaria blood testing among all screened public health facilities increased significantly between the first survey wave in 2009/11 and the most recent in 2014/15 in Benin (36.2, 85.4%, p < 0.001), Kenya (53.8, 93.0%, p < 0.001), mainland Tanzania (46.9, 89.9%, p < 0.001), Nigeria (28.5, 86.2%, p < 0.001), Katanga, the Democratic Republic of the Congo (DRC) (76.0, 88.2%, p < 0.05), and Uganda (38.9, 95.6%, p < 0.001). These findings were attributed to an increase in availability of RDTs. Diagnostic availability remained high in Kinshasa (the DRC) (87.6, 97.6%) and Zambia (87.9, 91.6%). Testing availability in public health facilities significantly decreased in Madagascar (88.1, 73.1%, p < 0.01). In the most recent survey round, the majority of malaria testing was performed in the public sector in Zambia (90.9%), Benin (90.3%), Madagascar (84.5%), Katanga (74.3%), mainland Tanzania (73.5%), Uganda (71.8%), Nigeria (68.4%), Kenya (53.2%) and Kinshasa (51.9%). In the anti-malarial stocking private sector, significant increases in availability of diagnostic tests among private for-profit facilities were observed between the first and final survey rounds in Kinshasa (82.1, 94.0%, p < 0.05), Nigeria (37.0, 66.0%, p < 0.05), Kenya (52.8, 74.3%, p < 0.001), mainland Tanzania (66.8, 93.5%, p < 0.01), Uganda (47.1, 70.1%, p < 0.001), and Madagascar (14.5, 45.0%, p < 0.01). Blood testing availability remained low over time among anti-malarial stocking private health facilities in Benin (33.1, 20.7%), and high over time in Zambia (94.4, 87.5%), with evidence of falls in availability in Katanga (72.7, 55.6%, p < 0.05). Availability among anti-malarial stocking pharmacies and drug stores—which are the most common source of anti-malarial medicines—was rare in all settings, and highest in Uganda in 2015 (21.5%). Median private sector price of RDT for a child was equal to the price of pre-packaged quality-assured artemisinin-based combination therapy (QAACT) treatment for a two-year old child in some countries, and 1.5–2.5 times higher in others. Median private sector QAACT price for an adult varied from having parity with an RDT for an adult to being up to 2 times more expensive. The exception was in both Kinshasa and Katanga, where the median price of QAACT was less expensive than RDTs.ConclusionsSignificant strides have been made in the availability of testing, mainly through the widespread distribution of RDT, and especially in public health facilities. Significant barriers to universal coverage of diagnostic testing can be attributed to very low availability in the private sector, particularly among pharmacies and drug stores, which are responsible for most anti-malarial distribution. Where tests are available, price may serve as a barrier to uptake, particularly for young children. Several initiatives that have introduced RDT into the private sector can be modified and expanded as a means to close this gap in malaria testing availability and promote universal diagnosis.

Rapid strip tests as a decision-making tool about antibiotic treatment in children – A prospective study

BackgroundAlthough three quarters of seasonal infections of the upper respiratory tract in children are of viral etiology, majority of the patients are unnecessarily prescribed antibiotics despite the availability of rapid diagnostic tests differentiating between infections. This study aimed to assess the relation between the use of rapid strip tests which detect the antigens of group A beta-hemolytic streptococcus (Streptococcus pyogenes) in pharyngitis and/or tonsillitis and the frequency of antibiotic use in children and adolescents aged 2–15 years. MethodsThe data were collected from 1307 children from the region of southeast Poland who then were divided into a sample group (n=581) in which patients received a rapid strip test before treatment plan was established by the physician, and into a control group (n=726) in which the decision whether to administer an antibiotic was made without the use of the rapid test. Based on statistical decision-making method, a pharmacoeconomic analysis of costs and effectiveness of strip tests was performed. ResultsThe use of the rapid strip test resulted in identifying the streptococcal infection in 31.7% of children and allowed to lessen the antibiotic use by 5.1%. The number of follow-up visits decreased (86.4% vs. 96.0%) and the anticipated cost of treatment decreased by 17%. ConclusionsRapid diagnostic tests used by the family physicians in initial diagnostics of seasonal upper respiratory tract infections in children allowed to differentiate between the type of infection as well as reduce the number of follow-up visits. Also, the antibiotic spending reimbursed by the insurer decreased by 17%.

Kinerja Bidan Desa dalam Deteksi Dini Kasus Malaria pada Kehamilan di Kabupaten Bengkulu Tengah

Background: Malaria has become the health problem that cause mortality especially in high risk group such as infants, children below 5 years old and pregnant women. The incidence of malaria in Central Bengkulu, Bengkulu Province is quite high, the last three years there is an increase compared to year 2011 – 2013. Annual Malaria Incidence in 2011 was 75.68/00, where the incidence in 2012 was 66.13/00. The Annual Parasite Incidence in 2013 was 52.34/00. In 2013, the amount of pregnant women who underwent malaria screening during 1st antenatal care (K1) only 784 from 2016 pregnant women(39%). Objective: To understand the malaria screening achievement among pregnant women by village midwives in Central Bengkulu District. Method: The study was observational with cross sectional design. The subjects was all of the village midwives in Central Bengkulu District. The dependent variable in this study was midwives achievement in malaria screening during pregnancy. The independent variables were training for malaria screening during pregnancy and the availability of rapid diagnostic test (RDT). The disturbing variables were age, level of education, and the duration of work. The study’s instrument was questionnare and observational sheet. The data analysis was done with t test, correlation method, chi square and linear regression. Result and Discussion: The achievement in malaria’s screening during pregnancy by village midwives was better in the group who received training compared with the group who didn’t (RR 2.2 ; 95% CI 1.71 – 2.51). The achievement also was better in the group of midwives who had good supply of RDT compared with the group who didn’t (RR 1.5; 95% CI 1.01 – 1.94). Conclusion: The achievement of malaria’s screening during pregnancy among village midwives who received training was better compared to midwives who didn’t. The achievement was also better among midwives who had good supply of RDT compared with midwives who didn’t. There is relation between level of midwivery education and the achievement in screening b ut there was no relation between age and duration of work and achievement during screening. Keywords: Achievement of Village Midwives, Screening, Training and Availability of RDT

Rapid-Testing Technology and Systems Improvement for the Elimination of Congenital Syphilis in Haiti: Overcoming the "Technology to Systems Gap".

Background. Despite the availability of rapid diagnostic tests and inexpensive treatment for pregnant women, maternal-child syphilis transmission remains a leading cause of perinatal morbidity and mortality in developing countries. In Haiti, more than 3000 babies are born with congenital syphilis annually. Methods and Findings. From 2007 to 2011, we used a sequential time series, multi-intervention study design in fourteen clinics throughout Haiti to improve syphilis testing and treatment in pregnancy. The two primary interventions were the introduction of a rapid point-of-care syphilis test and systems strengthening based on quality improvement (QI) methods. Syphilis testing increased from 91.5% prediagnostic test to 95.9% after (P < 0.001) and further increased to 96.8% (P < 0.001) after the QI intervention. Despite high rates of testing across all time periods, syphilis treatment lagged behind and only increased from 70.3% to 74.7% after the introduction of rapid tests (P = 0.27), but it improved significantly from 70.2% to 84.3% (P < 0.001) after the systems strengthening QI intervention. Conclusion. Both point-of-care diagnostic testing and health systems-based quality improvement interventions can improve the delivery of specific evidence-based healthcare interventions to prevent congenital syphilis at scale in Haiti. Improved treatment rates for syphilis were seen only after the use of systems-based quality improvement approaches.

Public health system readiness to treat malaria in Odisha State of India

BackgroundEarly diagnosis and prompt treatment is a cornerstone of malaria control. In India, artemisinin combination therapy (ACT) became the first-line treatment for falciparum malaria and rapid diagnostic test (RDTs) kits were recommended for use at the grass-root level in the new malaria treatment policy (2010). Odisha State contributes about one-fourth of the total Indian malaria burden and 40% of falciparum infection. The present study assessed the health system readiness to deploy RDTs and ACT for malaria control across the State.MethodsData collection was carried out from February to July 2012. Five of Odisha’s 30 districts were selected through stratified random sampling, with stratification based on the phased roll-out of ACT and RDT. Two administrative 'blocks’ were selected randomly in each district and data collected through health facility, auxiliary nurse midwives (ANMs) and accredited social health activist (ASHAs) assessments. Key informant interviews were conducted with individuals involved in the implementation of the malaria control programme.ResultsOf the 220 ANMs interviewed, 51.4% had been trained in malaria case management, including the use of ACT and RDT. A high proportion of ANM (80%) and AHSA (77%) had the necessary level of knowledge to be able to use RDT for malaria diagnosis. The proportion of ASHAs trained on malaria case management was 88.9% (209/235). However, 71% of ANM and 55% of ASHAs usually referred falciparum-positive patients to the health facility for treatment, the major reason for referral being the non-availability of drugs at the ANM and ASHA level.ConclusionThe relatively high level of knowledge about how to diagnose and treat malaria at the grass-root level was undermined by the poor availability of RDTs, ACT and primaquine tablets. This was associated with an unnecessarily high referral rate and potential delays in the treatment of this potentially life-threatening infection. Improvements in the supply chain for RDTs and ACT could dramatically enhance the effectiveness of malaria control in Odisha.