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Mbonye AK, Magnussen P, Lal S, Hansen KS, Cundill B, Chandler C, Clarke SE. A Cluster Randomised Trial Introducing Rapid Diagnostic Tests into Registered Drug Shops in Uganda: Impact on Appropriate Treatment of Malaria. PLoS One 2015. [PMID: 26200467 PMCID: PMC4511673 DOI: 10.1371/journal.pone.0129545] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Inappropriate treatment of malaria is widely reported particularly in areas where there is poor access to health facilities and self-treatment of fevers with anti-malarial drugs bought in shops is the most common form of care-seeking. The main objective of the study was to examine the impact of introducing rapid diagnostic tests for malaria (mRDTs) in registered drug shops in Uganda, with the aim to increase appropriate treatment of malaria with artemisinin-based combination therapy (ACT) in patients seeking treatment for fever in drug shops. METHODS A cluster-randomized trial of introducing mRDTs in registered drug shops was implemented in 20 geographical clusters of drug shops in Mukono district, central Uganda. Ten clusters were randomly allocated to the intervention (diagnostic confirmation of malaria by mRDT followed by ACT) and ten clusters to the control arm (presumptive treatment of fevers with ACT). Treatment decisions by providers were validated by microscopy on a reference blood slide collected at the time of consultation. The primary outcome was the proportion of febrile patients receiving appropriate treatment with ACT defined as: malaria patients with microscopically-confirmed presence of parasites in a peripheral blood smear receiving ACT or rectal artesunate, and patients with no malaria parasites not given ACT. FINDINGS A total of 15,517 eligible patients (8672 intervention and 6845 control) received treatment for fever between January-December 2011. The proportion of febrile patients who received appropriate ACT treatment was 72·9% versus 33·7% in the control arm; a difference of 36·1% (95% CI: 21·3 - 50·9), p<0·001. The majority of patients with fever in the intervention arm accepted to purchase an mRDT (97·8%), of whom 58·5% tested mRDT-positive. Drug shop vendors adhered to the mRDT results, reducing over-treatment of malaria by 72·6% (95% CI: 46·7- 98·4), p<0·001) compared to drug shop vendors using presumptive diagnosis (control arm). CONCLUSION Diagnostic testing with mRDTs compared to presumptive treatment of fevers implemented in registered drug shops substantially improved appropriate treatment of malaria with ACT. TRIAL REGISTRATION ClinicalTrials.gov NCT01194557.
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Affiliation(s)
- Anthony K. Mbonye
- Ministry of Health, Box 7272, Kampala, Uganda
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
- * E-mail:
| | - Pascal Magnussen
- Centre for Medical Parasitology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sham Lal
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Kristian S. Hansen
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Bonnie Cundill
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Clare Chandler
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Siân E. Clarke
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Atroosh WM, Al-Mekhlafi HM, Al-Jasari A, Sady H, Al-Delaimy AK, Nasr NA, Dawaki S, Abdulsalam AM, Ithoi I, Lau YL, Fong MY, Surin J. Genetic variation of pfhrp2 in Plasmodium falciparum isolates from Yemen and the performance of HRP2-based malaria rapid diagnostic test. Parasit Vectors 2015. [PMID: 26198252 PMCID: PMC4511234 DOI: 10.1186/s13071-015-1008-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background The genetic variation in the Plasmodium falciparum histidine-rich protein 2 (pfhrp2) gene that may compromise the use of pfhrp2-based rapid diagnostic tests (RDTs) for the diagnosis of malaria was assessed in P. falciparum isolates from Yemen. Methods This study was conducted in Hodeidah and Al-Mahwit governorates, Yemen. A total of 622 individuals with fever were examined for malaria by CareStart™ malaria HRP2-RDT and Giemsa-stained thin and thick blood films. The Pfhrp2 gene was amplified and sequenced from 180 isolates, and subjected to amino acid repeat types analysis. Results A total of 188 (30.2 %) participants were found positive for P. falciparum by the RDT. Overall, 12 different amino acid repeat types were identified in Yemeni isolates. Six repeat types were detected in all the isolates (100 %) namely types 1, 2, 6, 7, 10 and 12 while types 9 and 11 were not detected in any of the isolates. Moreover, the sensitivity and specificity of the used PfHRP2-based RDTs were high (90.5 % and 96.1 %, respectively). Conclusion The present study provides data on the genetic variation within the pfhrp2 gene, and its potential impact on the PfHRP2-based RDTs commonly used in Yemen. CareStart™ Malaria HRP2-based RDT showed high sensitivity and specificity in endemic areas of Yemen. Electronic supplementary material The online version of this article (doi:10.1186/s13071-015-1008-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Wahib M Atroosh
- Department of Parasitology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia. .,Department of Microbiology and Parasitology, Faculty of Medicine and Health Sciences University of Aden, Aden, Yemen.
| | - Hesham M Al-Mekhlafi
- Department of Parasitology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia. .,Azal National Research Centre, Azal University for Human Development, 447, Sana'a, Yemen. .,Department of Parasitology, Faculty of Medicine and Health Sciences, Sana'a University, 1247, Sana'a, Yemen.
| | - Adel Al-Jasari
- National Malaria Control programme, Ministry of Public Health and Population, Sana'a, Yemen.
| | - Hany Sady
- Department of Parasitology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
| | - Ahmed K Al-Delaimy
- Department of Parasitology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
| | - Nabil A Nasr
- Department of Parasitology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
| | - Salwa Dawaki
- Department of Parasitology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
| | - Awatif M Abdulsalam
- Department of Parasitology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
| | - Init Ithoi
- Department of Parasitology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
| | - Yee Ling Lau
- Department of Parasitology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
| | - Mun Yik Fong
- Department of Parasitology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
| | - Johari Surin
- Department of Parasitology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
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53
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Awor P, Wamani H, Tylleskar T, Peterson S. Drug seller adherence to clinical protocols with integrated management of malaria, pneumonia and diarrhoea at drug shops in Uganda. Malar J 2015; 14:277. [PMID: 26178532 PMCID: PMC4502601 DOI: 10.1186/s12936-015-0798-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 07/07/2015] [Indexed: 11/10/2022] Open
Abstract
Background Drug shops are usually the first source of care for febrile children in Uganda although the quality of care they provide is known to be poor. Within a larger quasi-experimental study introducing the WHO/UNICEF recommended integrated community case management (iCCM) of malaria, pneumonia and diarrhoea intervention for community health workers in registered drug shops, the level of adherence to clinical protocols by drug sellers was determined. Methods All drug shops (N = 44) in the intervention area were included and all child visits (N = 7,667) from October 2011–June 2012 to the participating drug shops were analysed. Drug shops maintained a standard iCCM register where they recorded the children seen, their symptoms, diagnostic test performed, treatments given and actions taken. The proportion of children correctly assessed and treated was determined from the registers. Results Malaria management: 6,140 of 7,667 (80.1%) total visits to drug shops were of children with fever. 5986 (97.5%) children with fever received a malaria rapid diagnostic test (RDT) and the RDT positivity rate was 78% (95% CI 77–79). 4,961/5,307 (93.4%) children with a positive RDT received artemisinin combination therapy. Pneumonia management: after respiratory rate assessment of children with cough and fast/difficult breathing, 3,437 (44.8%) were categorized as “pneumonia”, 3,126 (91.0%) of whom received the recommended drug—amoxicillin. Diarrhoea management: 2,335 (30.5%) child visits were for diarrhoea with 2,068 (88.6%) correctly treated with oral rehydration salts and zinc sulphate. Dual/Triple classification: 2,387 (31.1%) children had both malaria and pneumonia and 664 (8.7%) were classified as having three illnesses. Over 90% of the children with dual or triple classification were treated appropriately. Meanwhile, 381 children were categorized as severely sick (with a danger sign) with 309 (81.1%) of them referred for appropriate management. Conclusion With the introduction of the iCCM intervention at drug shops in Eastern Uganda, it was possible to achieve high adherence to the treatment protocols, which is likely compatible with increased quality of care. Electronic supplementary material The online version of this article (doi:10.1186/s12936-015-0798-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Phyllis Awor
- Department of Global Public Health and Primary Health Care, Centre for International Health, University of Bergen, PO Box 7800, 5020, Bergen, Norway. .,Department of Community Health and Behavioural Sciences, School of Public Health, College of Health Sciences, Makerere University, PO Box 7072, Kampala, Uganda.
| | - Henry Wamani
- Department of Community Health and Behavioural Sciences, School of Public Health, College of Health Sciences, Makerere University, PO Box 7072, Kampala, Uganda.
| | - Thorkild Tylleskar
- Department of Global Public Health and Primary Health Care, Centre for International Health, University of Bergen, PO Box 7800, 5020, Bergen, Norway.
| | - Stefan Peterson
- Department of Community Health and Behavioural Sciences, School of Public Health, College of Health Sciences, Makerere University, PO Box 7072, Kampala, Uganda. .,Global Health, Karolinska Institutet, Stockholm, Sweden. .,International Maternal and Child Health Unit, Uppsala University, Uppsala, Sweden.
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Cost-effectiveness of malaria diagnosis using rapid diagnostic tests compared to microscopy or clinical symptoms alone in Afghanistan. Malar J 2015; 14:217. [PMID: 26016871 PMCID: PMC4450447 DOI: 10.1186/s12936-015-0696-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 04/07/2015] [Indexed: 11/27/2022] Open
Abstract
Background Improving access to parasitological diagnosis of malaria is a central strategy for control and elimination of the disease. Malaria rapid diagnostic tests (RDTs) are relatively easy to perform and could be used in primary level clinics to increase coverage of diagnostics and improve treatment of malaria. Methods A cost-effectiveness analysis was undertaken of RDT-based diagnosis in public health sector facilities in Afghanistan comparing the societal and health sector costs of RDTs versus microscopy and RDTs versus clinical diagnosis in low and moderate transmission areas. The effect measure was ‘appropriate treatment for malaria’ defined using a reference diagnosis. Effects were obtained from a recent trial of RDTs in 22 public health centres with cost data collected directly from health centres and from patients enrolled in the trial. Decision models were used to compare the cost of RDT diagnosis versus the current diagnostic method in use at the clinic per appropriately treated case (incremental cost-effectiveness ratio, ICER). Results RDT diagnosis of Plasmodium vivax and Plasmodium falciparum malaria in patients with uncomplicated febrile illness had higher effectiveness and lower cost compared to microscopy and was cost-effective across the moderate and low transmission settings. RDTs remained cost-effective when microscopy was used for other clinical purposes. In the low transmission setting, RDTs were much more effective than clinical diagnosis (65.2% (212/325) vs 12.5% (40/321)) but at an additional cost (ICER) of US$4.5 per appropriately treated patient including a health sector cost (ICER) of US$2.5 and household cost of US$2.0. Sensitivity analysis, which varied drug costs, indicated that RDTs would remain cost-effective if artemisinin combination therapy was used for treating both P. vivax and P. falciparum. Cost-effectiveness of microscopy relative to RDT is further reduced if the former is used exclusively for malaria diagnosis. In the health service setting of Afghanistan, RDTs are a cost-effective intervention compared to microscopy. Conclusions RDTs remain cost-effective across a range of drug costs and if microscopy is used for a range of diagnostic services. RDTs have significant advantages over clinical diagnosis with minor increases in the cost of service provision. Trial Registration The trial was registered at ClinicalTrials.gov under identifier NCT00935688. Electronic supplementary material The online version of this article (doi:10.1186/s12936-015-0696-1) contains supplementary material, which is available to authorized users.
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Faust C, Zelner J, Brasseur P, Vaillant M, Badiane M, Cisse M, Grenfell B, Olliaro P. Assessing drivers of full adoption of test and treat policy for malaria in Senegal. Am J Trop Med Hyg 2015; 93:159-167. [PMID: 25962776 PMCID: PMC4497889 DOI: 10.4269/ajtmh.14-0595] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 01/22/2015] [Indexed: 11/07/2022] Open
Abstract
Malaria treatment policy has changed from presumptive treatment to targeted "test and treat" (T&T) with malaria rapid diagnostic tests (RDTs) and artemisinin combination therapy (ACT). This transition involves changing behavior among health providers, meaning delays between introduction and full implementation are recorded in almost every instance. We investigated factors affecting successful transition, and suggest approaches for accelerating uptake of T&T. Records from 2000 to 2011 from health clinics in Senegal where malaria is mesoendemic were examined (96,166 cases). The study period encompassed the implementation of national T&T policy in 2006. Analysis showed that adherence to test results is the first indicator of T&T adoption and is dependent on accumulation of experience with positive RDTs (odds ratio [OR]: 0.55 [P ≤ 0.001], 95% confidence interval [CI]: 0.53-0.58). Reliance on tests for malaria diagnosis (rather than presumptive diagnosis) followed after test adherence is achieved, and was also associated with increased experience with positive RDTs (OR: 0.60 [P ≤ 0.001], 95% CI: 0.58-0.62). Logistic models suggest that full adoption of T&T clinical practices can occur within 2 years, that monitoring these behavioral responses rather than RDT or ACT consumption will improve evaluation of T&T uptake, and that accelerating T&T uptake by focusing training on adherence to test results will reduce overdiagnosis and associated health and economic costs in mesoendemic regions.
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Affiliation(s)
- Christina Faust
- *Address correspondence to Christina Faust, Department of Ecology and Evolutionary Biology, 106A Guyot Hall, Princeton University, Princeton, NJ 08542. E-mail:
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Johansson EW, Gething PW, Hildenwall H, Mappin B, Petzold M, Peterson SS, Selling KE. Effect of diagnostic testing on medicines used by febrile children less than five years in 12 malaria-endemic African countries: a mixed-methods study. Malar J 2015; 14:194. [PMID: 25957881 PMCID: PMC4432948 DOI: 10.1186/s12936-015-0709-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 04/27/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In 2010, WHO revised guidelines to recommend testing all suspected malaria cases prior to treatment. Yet, evidence to assess programmes is largely derived from limited facility settings in a limited number of countries. National surveys from 12 sub-Saharan African countries were used to examine the effect of diagnostic testing on medicines used by febrile children under five years at the population level, including stratification by malaria risk, transmission season, source of care, symptoms, and age. METHODS Data were compiled from 12 Demographic and Health Surveys in 2010-2012 that reported fever prevalence, diagnostic test and medicine use, and socio-economic covariates (n=16,323 febrile under-fives taken to care). Mixed-effects logistic regression models quantified the influence of diagnostic testing on three outcomes (artemisinin combination therapy (ACT), any anti-malarial or any antibiotic use) after adjusting for data clustering and confounding covariates. For each outcome, interactions between diagnostic testing and the following covariates were separately tested: malaria risk, season, source of care, symptoms, and age. A multiple case study design was used to understand varying results across selected countries and sub-national groups, which drew on programme documents, published research and expert consultations. A descriptive typology of plausible explanations for quantitative results was derived from a cross-case synthesis. RESULTS Significant variability was found in the effect of diagnostic testing on ACT use across countries (e.g., Uganda OR: 0.84, 95% CI: 0.66-1.06; Mozambique OR: 3.54, 95% CI: 2.33-5.39). Four main themes emerged to explain results: available diagnostics and medicines; quality of care; care-seeking behaviour; and, malaria epidemiology. CONCLUSIONS Significant country variation was found in the effect of diagnostic testing on paediatric fever treatment at the population level, and qualitative results suggest the impact of diagnostic scale-up on treatment practices may not be straightforward in routine conditions given contextual factors (e.g., access to care, treatment-seeking behaviour or supply stock-outs). Despite limitations, quantitative results could help identify countries (e.g., Mozambique) or issues (e.g., malaria risk) where facility-based research or programme attention may be warranted. The mixed-methods approach triangulates different evidence to potentially provide a standard framework to assess routine programmes across countries or over time to fill critical evidence gaps.
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Affiliation(s)
- Emily White Johansson
- Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, SE-751 85, Uppsala, Sweden.
| | - Peter W Gething
- Spatial Ecology and Epidemiology Group, Department of Zoology, University of Oxford, South Parks Road, OX1 3PS, Oxford, UK.
| | - Helena Hildenwall
- Global Health - Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, SE-171 77, Stockholm, Sweden.
| | - Bonnie Mappin
- Spatial Ecology and Epidemiology Group, Department of Zoology, University of Oxford, South Parks Road, OX1 3PS, Oxford, UK.
| | - Max Petzold
- University of Gothenburg, The Sahlgrenska Academy, Health Metrics, Box 414, SE-405 30, Gothenburg, Sweden.
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Stefan Swartling Peterson
- Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, SE-751 85, Uppsala, Sweden.
- Global Health - Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, SE-171 77, Stockholm, Sweden.
- Makerere University School of Public Health, College of Health Sciences, PO Box 7072, Kampala, Uganda.
| | - Katarina Ekholm Selling
- Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, SE-751 85, Uppsala, Sweden.
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Aung T, White C, Montagu D, McFarland W, Hlaing T, Khin HSS, San AK, Briegleb C, Chen I, Sudhinaraset M. Improving uptake and use of malaria rapid diagnostic tests in the context of artemisinin drug resistance containment in eastern Myanmar: an evaluation of incentive schemes among informal private healthcare providers. Malar J 2015; 14:105. [PMID: 25885581 PMCID: PMC4355503 DOI: 10.1186/s12936-015-0621-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 02/22/2015] [Indexed: 11/10/2022] Open
Abstract
Background As efforts to contain artemisinin resistance and eliminate Plasmodium falciparum intensify, the accurate diagnosis and prompt effective treatment of malaria are increasingly needed in Myanmar and the Greater Mekong Sub-region (GMS). Rapid diagnostic tests (RDTs) have been shown to be safe, feasible, and effective at promoting appropriate treatment for suspected malaria, which are of particular importance to drug resistance containment. The informal private sector is often the first point of care for fever cases in malaria endemic areas across Myanmar and the GMS, but there is little published information about informal private provider practices, quality of service provision, or potential to contribute to malaria control and elimination efforts. This study tested different incentives to increase RDT use and improve the quality of care among informal private healthcare providers in Myanmar. Methods The study randomized six townships in the Mon and Shan states of rural Myanmar into three intervention arms: 1) RDT price subsidies, 2) price subsidies with product-related financial incentives, and 3) price subsidies with intensified information, education and counselling (IEC). The study assessed the uptake of RDT use in the communities by cross-sectional surveys of 3,150 households at baseline and six months post-intervention (6,400 households total, 832 fever cases). The study also used mystery clients among 171 providers to assess quality of service provision across intervention arms. Results The pilot intervention trained over 600 informal private healthcare providers. The study found a price subsidy with intensified IEC, resulted in the highest uptake of RDTs in the community, as compared to subsidies alone or merchandise-related financial incentives. Moreover, intensified IEC led to improvements in the quality of care, with mystery client surveys showing almost double the number of correct treatment following diagnostic test results as compared to a simple subsidy. Conclusions Results show that training and quality supervision of informal private healthcare providers can result in improved demand for, and appropriate use of RDTs in drug resistance containment areas in eastern Myanmar. Future studies should assess the sustainability of such interventions and the scale and level of intensity required over time as public sector service provision expands.
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Affiliation(s)
- Tin Aung
- Population Services International, Yangon, Myanmar.
| | | | - Dominic Montagu
- Global Health Sciences, University of California, San Francisco, CA, USA.
| | - Willi McFarland
- Global Health Sciences, University of California, San Francisco, CA, USA.
| | - Thaung Hlaing
- Department of Health, National Malaria Control Programme, Yangon, Myanmar.
| | | | | | - Christina Briegleb
- Global Health Sciences, University of California, San Francisco, CA, USA.
| | - Ingrid Chen
- Global Health Sciences, University of California, San Francisco, CA, USA.
| | - May Sudhinaraset
- Global Health Sciences, University of California, San Francisco, CA, USA.
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Ansah EK, Narh-Bana S, Affran-Bonful H, Bart-Plange C, Cundill B, Gyapong M, Whitty CJM. The impact of providing rapid diagnostic malaria tests on fever management in the private retail sector in Ghana: a cluster randomized trial. BMJ 2015; 350:h1019. [PMID: 25739769 PMCID: PMC4353311 DOI: 10.1136/bmj.h1019] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To examine the impact of providing rapid diagnostic tests for malaria on fever management in private drug retail shops where most poor rural people with fever present, with the aim of reducing current massive overdiagnosis and overtreatment of malaria. DESIGN Cluster randomized trial of 24 clusters of shops. SETTING Dangme West, a poor rural district of Ghana. PARTICIPANTS Shops and their clients, both adults and children. INTERVENTIONS Providing rapid diagnostic tests with realistic training. MAIN OUTCOME MEASURES The primary outcome was the proportion of clients testing negative for malaria by a double-read research blood slide who received an artemisinin combination therapy or other antimalarial. Secondary outcomes were use of antibiotics and antipyretics, and safety. RESULTS Of 4603 clients, 3424 (74.4%) tested negative by double-read research slides. The proportion of slide-negative clients who received any antimalarial was 590/1854 (32%) in the intervention arm and 1378/1570 (88%) in the control arm (adjusted risk ratio 0.41 (95% CI 0.29 to 0.58), P<0.0001). Treatment was in high agreement with rapid diagnostic test result. Of those who were slide-positive, 690/787 (87.8%) in the intervention arm and 347/392 (88.5%) in the control arm received an artemisinin combination therapy (adjusted risk ratio 0.96 (0.84 to 1.09)). There was no evidence of antibiotics being substituted for antimalarials. Overall, 1954/2641 (74%) clients in the intervention arm and 539/1962 (27%) in the control arm received appropriate treatment (adjusted risk ratio 2.39 (1.69 to 3.39), P<0.0001). No safety concerns were identified. CONCLUSIONS Most patients with fever in Africa present to the private sector. In this trial, providing rapid diagnostic tests for malaria in the private drug retail sector significantly reduced dispensing of antimalarials to patients without malaria, did not reduce prescribing of antimalarials to true malaria cases, and appeared safe. Rapid diagnostic tests should be considered for the informal private drug retail sector.Registration Clinicaltrials.gov NCT01907672.
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Affiliation(s)
- Evelyn K Ansah
- Research and Development Division, Ghana Health Service, PO Box MB-190, Accra, Ghana
| | | | | | | | - Bonnie Cundill
- London School of Hygiene & Tropical Medicine, London, UK
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Ajumobi O, Sabitu K, Nguku P, Kwaga J, Ntadom G, Gitta S, Elizeus R, Oyibo W, Nsubuga P, Maire M, Poggensee G. Performance of an HRP-2 rapid diagnostic test in Nigerian children less than 5 years of age. Am J Trop Med Hyg 2015; 92:828-33. [PMID: 25711608 DOI: 10.4269/ajtmh.13-0558] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 01/05/2015] [Indexed: 11/07/2022] Open
Abstract
The diagnostic performance of histidine-rich protein 2 (HRP-2)-based malaria rapid diagnostic test (RDT) was evaluated in a mesoendemic area for malaria, Kaduna, Nigeria. We compared RDT results with expert microscopy results of blood samples from 295 febrile children under 5 years. Overall, 11.9% (35/295) tested positive with RDT compared with 10.5% (31/295) by microscopy: sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 100%, 98.5%, 88.6%, and 100%, respectively. The RDT sensitivity was not affected by transmission season, parasite density, and age. Specificity and positive PV decreased slightly during the high-transmission season (97.5% and 83.3%). The RDT test positivity rates in the low- and high-transmission seasons were 9.4% and 13.5%, respectively. Overall, the test performance of this RDT was satisfactory. The findings of a low proportion of RDT false positives, no invalid and no false-negative results should validate the performance of RDTs in this context.
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Affiliation(s)
- Olufemi Ajumobi
- Nigeria Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria; Ahmadu Bello University, Zaria, Nigeria; National Malaria Control Programme, Federal Ministry of Health, Abuja, Nigeria; African Field Epidemiology Network, Kampala, Uganda; Makerere University, Kampala, Uganda; College of Medicine, University of Lagos, Nigeria; Global Public Health Solutions, Atlanta, Georgia; Division of Global Health Protection and Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kabir Sabitu
- Nigeria Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria; Ahmadu Bello University, Zaria, Nigeria; National Malaria Control Programme, Federal Ministry of Health, Abuja, Nigeria; African Field Epidemiology Network, Kampala, Uganda; Makerere University, Kampala, Uganda; College of Medicine, University of Lagos, Nigeria; Global Public Health Solutions, Atlanta, Georgia; Division of Global Health Protection and Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Patrick Nguku
- Nigeria Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria; Ahmadu Bello University, Zaria, Nigeria; National Malaria Control Programme, Federal Ministry of Health, Abuja, Nigeria; African Field Epidemiology Network, Kampala, Uganda; Makerere University, Kampala, Uganda; College of Medicine, University of Lagos, Nigeria; Global Public Health Solutions, Atlanta, Georgia; Division of Global Health Protection and Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jacob Kwaga
- Nigeria Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria; Ahmadu Bello University, Zaria, Nigeria; National Malaria Control Programme, Federal Ministry of Health, Abuja, Nigeria; African Field Epidemiology Network, Kampala, Uganda; Makerere University, Kampala, Uganda; College of Medicine, University of Lagos, Nigeria; Global Public Health Solutions, Atlanta, Georgia; Division of Global Health Protection and Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Godwin Ntadom
- Nigeria Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria; Ahmadu Bello University, Zaria, Nigeria; National Malaria Control Programme, Federal Ministry of Health, Abuja, Nigeria; African Field Epidemiology Network, Kampala, Uganda; Makerere University, Kampala, Uganda; College of Medicine, University of Lagos, Nigeria; Global Public Health Solutions, Atlanta, Georgia; Division of Global Health Protection and Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sheba Gitta
- Nigeria Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria; Ahmadu Bello University, Zaria, Nigeria; National Malaria Control Programme, Federal Ministry of Health, Abuja, Nigeria; African Field Epidemiology Network, Kampala, Uganda; Makerere University, Kampala, Uganda; College of Medicine, University of Lagos, Nigeria; Global Public Health Solutions, Atlanta, Georgia; Division of Global Health Protection and Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Rutebemberwa Elizeus
- Nigeria Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria; Ahmadu Bello University, Zaria, Nigeria; National Malaria Control Programme, Federal Ministry of Health, Abuja, Nigeria; African Field Epidemiology Network, Kampala, Uganda; Makerere University, Kampala, Uganda; College of Medicine, University of Lagos, Nigeria; Global Public Health Solutions, Atlanta, Georgia; Division of Global Health Protection and Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Wellington Oyibo
- Nigeria Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria; Ahmadu Bello University, Zaria, Nigeria; National Malaria Control Programme, Federal Ministry of Health, Abuja, Nigeria; African Field Epidemiology Network, Kampala, Uganda; Makerere University, Kampala, Uganda; College of Medicine, University of Lagos, Nigeria; Global Public Health Solutions, Atlanta, Georgia; Division of Global Health Protection and Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Peter Nsubuga
- Nigeria Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria; Ahmadu Bello University, Zaria, Nigeria; National Malaria Control Programme, Federal Ministry of Health, Abuja, Nigeria; African Field Epidemiology Network, Kampala, Uganda; Makerere University, Kampala, Uganda; College of Medicine, University of Lagos, Nigeria; Global Public Health Solutions, Atlanta, Georgia; Division of Global Health Protection and Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mark Maire
- Nigeria Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria; Ahmadu Bello University, Zaria, Nigeria; National Malaria Control Programme, Federal Ministry of Health, Abuja, Nigeria; African Field Epidemiology Network, Kampala, Uganda; Makerere University, Kampala, Uganda; College of Medicine, University of Lagos, Nigeria; Global Public Health Solutions, Atlanta, Georgia; Division of Global Health Protection and Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gabriele Poggensee
- Nigeria Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria; Ahmadu Bello University, Zaria, Nigeria; National Malaria Control Programme, Federal Ministry of Health, Abuja, Nigeria; African Field Epidemiology Network, Kampala, Uganda; Makerere University, Kampala, Uganda; College of Medicine, University of Lagos, Nigeria; Global Public Health Solutions, Atlanta, Georgia; Division of Global Health Protection and Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
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Cohen J, Cox A, Dickens W, Maloney K, Lam F, Fink G. Determinants of malaria diagnostic uptake in the retail sector: qualitative analysis from focus groups in Uganda. Malar J 2015; 14:89. [PMID: 25884736 PMCID: PMC4338828 DOI: 10.1186/s12936-015-0590-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 01/28/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Uganda, as in most other malaria-endemic countries, presumptive treatment for malaria based on symptoms without a diagnostic blood test is still very common. While diagnostic testing in public sector facilities is increasing, many people in Uganda who suspect malaria visit private sector outlets to purchase medications. Increasing the availability and uptake of rapid diagnostic tests (RDTs) for malaria in private outlets could help increase diagnostic testing for malaria but raises questions about the patient demand for and valuation of testing that are less critical for public sector introduction. METHODS In preparation for a behaviour change campaign to encourage and sustain the demand for RDTs in drug shops, eight focus group discussions with a total of 84 community members were conducted in six districts across Uganda's Eastern Region in November-December 2011. Focus groups explored incentives and barriers to seeking diagnosis for malaria, how people react to test results and why, and what can be done to increase the willingness to pay for RDTs. RESULTS Overall, participants were very familiar with malaria diagnostic testing and understood its importance, yet when faced with limited financial resources, patients preferred to spend their money on medication and sought testing only when presumptive treatment proved ineffective. While side effects did seem to be a concern, participants did not mention other potential costs of taking unnecessary or ineffective medications, such as money wasted on excess drugs or delays in resolution of symptoms. Very few individuals were familiar with RDTs. CONCLUSION In order to boost demand, these results suggest that private sector RDTs will have to be made convenient and affordable and that targeted behaviour change campaigns should strive to increase the perceived value of diagnosis.
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Affiliation(s)
- Jessica Cohen
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA.
| | - Alex Cox
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA.
| | - William Dickens
- Department of Economics, Northeastern University, Boston, MA, USA.
| | - Kathleen Maloney
- Malaria Control Team, Clinton Health Access Initiative, Boston, MA, USA.
| | - Felix Lam
- Essential Medicines Team, Clinton Health Access Initiative, Boston, MA, USA.
| | - Günther Fink
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA.
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Chen IT, Aung T, Thant HNN, Sudhinaraset M, Kahn JG. Cost-effectiveness analysis of malaria rapid diagnostic test incentive schemes for informal private healthcare providers in Myanmar. Malar J 2015; 14:55. [PMID: 25653121 PMCID: PMC4334415 DOI: 10.1186/s12936-015-0569-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 01/16/2015] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The emergence of artemisinin-resistant Plasmodium falciparum parasites in Southeast Asia threatens global malaria control efforts. One strategy to counter this problem is a subsidy of malaria rapid diagnostic tests (RDTs) and artemisinin-based combination therapy (ACT) within the informal private sector, where the majority of malaria care in Myanmar is provided. A study in Myanmar evaluated the effectiveness of financial incentives vs information, education and counselling (IEC) in driving the proper use of subsidized malaria RDTs among informal private providers. This cost-effectiveness analysis compares intervention options. METHODS A decision tree was constructed in a spreadsheet to estimate the incremental cost-effectiveness ratios (ICERs) among four strategies: no intervention, simple subsidy, subsidy with financial incentives, and subsidy with IEC. Model inputs included programmatic costs (in dollars), malaria epidemiology and observed study outcomes. Data sources included expenditure records, study data and scientific literature. Model outcomes included the proportion of properly and improperly treated individuals with and without P. falciparum malaria, and associated disability-adjusted life years (DALYs). Results are reported as ICERs in US dollars per DALY averted. One-way sensitivity analysis assessed how outcomes depend on uncertainty in inputs. RESULTS ICERs from the least to most expensive intervention are: $1,169/DALY averted for simple subsidy vs no intervention, $185/DALY averted for subsidy with financial incentives vs simple subsidy, and $200/DALY averted for a subsidy with IEC vs subsidy with financial incentives. Due to decreasing ICERs, each strategy was also compared to no intervention. The subsidy with IEC was the most favourable, costing $639/DALY averted compared with no intervention. One-way sensitivity analysis shows that ICERs are most affected by programme costs, RDT uptake, treatment-seeking behaviour, and the prevalence and virulence of non-malarial fevers. In conclusion, private provider subsidies with IEC or a combination of IEC and financial incentives may be a good investment for malaria control.
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Affiliation(s)
- Ingrid T Chen
- Global Health Sciences, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, 94158, USA.
| | - Tin Aung
- Population Services International Myanmar, No 16, Shwe Gon Taing Street 4, Yangon, Myanmar.
| | - Hnin Nwe Nwe Thant
- Population Services International Myanmar, No 16, Shwe Gon Taing Street 4, Yangon, Myanmar.
| | - May Sudhinaraset
- Global Health Sciences, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, 94158, USA.
| | - James G Kahn
- Global Health Sciences, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, 94158, USA.
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Diggle E, Asgary R, Gore-Langton G, Nahashon E, Mungai J, Harrison R, Abagira A, Eves K, Grigoryan Z, Soti D, Juma E, Allan R. Perceptions of malaria and acceptance of rapid diagnostic tests and related treatment practises among community members and health care providers in Greater Garissa, North Eastern Province, Kenya. Malar J 2014; 13:502. [PMID: 25519710 PMCID: PMC4300559 DOI: 10.1186/1475-2875-13-502] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 12/06/2014] [Indexed: 11/24/2022] Open
Abstract
Background Conventional diagnosis of malaria has relied upon either clinical diagnosis or microscopic examination of peripheral blood smears. These methods, if not carried out exactly, easily result in the over- or under-diagnosis of malaria. The reliability and accuracy of malaria RDTs, even in extremely challenging health care settings, have made them a staple in malaria control programmes. Using the setting of a pilot introduction of malaria RDTs in Greater Garissa, North Eastern Province, Kenya, this study aims to identify and understand perceptions regarding malaria diagnosis, with a particular focus on RDTs, and treatment among community members and health care workers (HCWs). Methods The study was conducted in five districts of Garissa County. Focus group discussions (FGD) were performed with community members that were recruited from health facilities (HFs) supported by the MENTOR Initiative. In-depth interviews (IDIs) and FGDs with HCWs were also carried out. Interview transcripts were then coded and analysed for major themes. Two researchers reviewed all codes, first separately and then together, discussed the specific categories, and finally characterized, described, and agreed upon major important themes. Results Thirty-four FGDs were carried out with a range of two to eight participants (median of four). Of 157 community members, 103 (65.6%) were women. The majority of participants were illiterate and the highest level of education was secondary school. Some 76% of participants were of Somali ethnicity. Whilst community members and HCWs demonstrated knowledge of aspects of malaria transmission, prevention, diagnosis, and treatment, gaps and misconceptions were identified. Poor adherence to negative RDT results, unfamiliarity and distrust of RDTs, and an inconsistent RDT supply were the main challenges to become apparent in FGDs and IDIs. Conclusion Gaps in knowledge or incorrect beliefs exist in Greater Garissa and have the potential to act as barriers to complete and correct malaria case management. Addressing these knowledge gaps requires comprehensive education campaigns and a reliable and constant RDT supply. The results of this study highlight education and supply chain as key factors to be addressed in order to make large scale roll out of RDTs as successful and effective as possible.
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Isiguzo C, Anyanti J, Ujuju C, Nwokolo E, De La Cruz A, Schatzkin E, Modrek S, Montagu D, Liu J. Presumptive treatment of malaria from formal and informal drug vendors in Nigeria. PLoS One 2014; 9:e110361. [PMID: 25333909 PMCID: PMC4204870 DOI: 10.1371/journal.pone.0110361] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 09/22/2014] [Indexed: 12/03/2022] Open
Abstract
Background Despite policies that recommend parasitological testing before treatment for malaria, presumptive treatment remains widespread in Nigeria. The majority of Nigerians obtain antimalarial drugs from two types of for-profit drug vendors—formal and informal medicine shops—but little is known about the quality of malaria care services provided at these shops. Aims This study seeks to (1) describe the profile of patients who seek treatment at different types of drug outlets, (2) document the types of drugs purchased for treating malaria, (3) assess which patients are purchasing recommended drugs, and (4) estimate the extent of malaria over-treatment. Methods In urban, peri-urban, and rural areas in Oyo State, customers exiting proprietary and patent medicine vendor (PPMV) shops or pharmacies having purchased anti-malarial drugs were surveyed and tested with malaria rapid diagnostic test. A follow-up phone survey was conducted four days after to assess self-reported drug administration. Bivariate and multivariate regression analysis was conducted to determine the correlates of patronizing a PPMV versus pharmacy, and the likelihood of purchasing an artemisinin-combination therapy (ACT) drug. Results Of the 457participants who sought malaria treatment in 49 enrolled outlets, nearly 92% had diagnosed their condition by themselves, a family member, or a friend. Nearly 60% pharmacy customers purchased an ACT compared to only 29% of PPMV customers, and pharmacy customers paid significantly more on average. Multivariate regression results show that patrons of PPMVs were younger, less wealthy, waited fewer days before seeking care, and were less likely to be diagnosed at a hospital, clinic, or laboratory. Only 3.9% of participants tested positive with a malaria rapid diagnostic test. Conclusions Poorer individuals seeking care at PPMVs are more likely to receive inappropriate malaria treatment when compared to those who go to pharmacies. Increasing accessibility to reliable diagnosis should be explored to reduce malaria over-treatment.
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Affiliation(s)
- Chinwoke Isiguzo
- Research and Evaluation Division, Society for Family Health, Abuja, Nigeria
- * E-mail:
| | - Jennifer Anyanti
- Technical Services Division, Society for Family Health, Abuja, Nigeria
| | - Chinazo Ujuju
- Research and Evaluation Division, Society for Family Health, Abuja, Nigeria
| | - Ernest Nwokolo
- Global Fund Malaria Division, Society for Family Health, Abuja, Nigeria
| | - Anna De La Cruz
- The Global Health Group, University of California San Francisco, San Francisco, California, United States of America
| | - Eric Schatzkin
- The Global Health Group, University of California San Francisco, San Francisco, California, United States of America
| | - Sepideh Modrek
- General Medical Disciplines, Stanford University School of Medicine, Palo Alto, California, United States of America
| | - Dominic Montagu
- Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
| | - Jenny Liu
- The Global Health Group, University of California San Francisco, San Francisco, California, United States of America
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Liu J, Modrek S, Anyanti J, Nwokolo E, De La Cruz A, Schatzkin E, Isiguzo C, Ujuju C, Montagu D. How do risk preferences relate to malaria care-seeking behavior and the acceptability of a new health technology in Nigeria? BMC Health Serv Res 2014; 14:374. [PMID: 25192615 PMCID: PMC4162956 DOI: 10.1186/1472-6963-14-374] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 09/03/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To reduce the burden of disease from malaria, innovative approaches are needed to engender behavior change. One unobservable, but fundamental trait-preferences for risk-may influence individuals' willingness to adopt new health technologies. We explore the association of risk preferences with malaria care-seeking behavior and the acceptability of malaria rapid diagnostic tests (RDTs) to inform RDT scale-up plans. METHODS In Oyo State, Nigeria, adult customers purchasing anti-malarial medications at selected drug shops took surveys and received an RDT as they exited. After an initial risk preference assessment via a simple lottery game choice, individuals were given their RDT result and treatment advice, and called four days later to assess treatment adherence. We used bivariable and multivariable regression analysis to assess the association of risk game choices with malaria care-seeking behaviors and RDT acceptability. RESULTS Of 448 respondents, 63.2% chose the lottery game with zero variance in expected payout, 27.9% chose the game with low variance, and 8.9% chose the game with high variance. Compared to participants who chose lower variance games, individuals choosing higher variance games were older, less educated, more likely to be male, and were more likely to patronize lower quality drug shops, seek care immediately, and report complete disability due to their illness. In contrast, individuals choosing lower variance games were more likely to follow the correct treatment directions and were more likely to report an increase in their willingness to pay for an RDT compared to other risk groups, our two measures of RDT acceptability. Differences in estimated associations between risk game choices and selected care-seeking behaviors remained after controlling sociodemographic confounders. CONCLUSIONS The uptake of health diagnostic information in terms of translating the RDT experience into willingness to pay for an RDT and treatment adherence to test results may vary according to risk preferences. Hence, health promotion communications may want to be crafted bearing in mind differences in uptake among people of different risk preferences to encourage wider RDT adoption and more rational malaria treatment. Estimates will serve as the basis for power calculations for an expanded study.
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Affiliation(s)
- Jenny Liu
- Global Health Sciences, University of California, San Francisco, 550 16th Street, Mission Hall: Global Health & Clinical Sciences Building, San Francisco, CA 94158, USA.
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A novel carbon nanofibers grown on glass microballoons immunosensor: a tool for early diagnosis of malaria. SENSORS 2014; 14:14686-99. [PMID: 25120159 PMCID: PMC4179075 DOI: 10.3390/s140814686] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Revised: 07/31/2014] [Accepted: 08/04/2014] [Indexed: 11/17/2022]
Abstract
This paper presents a novel method for direct detection of Plasmodium falciparum histidine rich protein-2 (PfHRP-2) antigen using carbon nanofiber (CNF) forests grown on glass microballoons (NMBs). Secondary antibodies specific to PfHRP-2 densely attached to the CNFs exhibit extraordinary ability for the detection of minute concentrations of Plasmodium species. A sandwich immunoassay protocol was employed, where a glass substrate was used to immobilize primary antibodies at designated capture zones. High signal amplification was obtained in both colorimetric and electrical measurements due to the CNFs through specific binding. As a result, it was possible to detect PfHRP-2 levels as low as 0.025 ng/mL concentration in phosphate buffered saline (PBS) using a visual signal within only 1 min of test duration. Lower limits of 0.01 ng/mL was obtained by measuring the electrical resistivity of the capture zone. This method is also highly selective and specific in identifying PfHRP-2 and other Plasmodium species from the same solution. In addition, the stability of the labeling mechanism eliminates the false signals generated by the use of dyes in current malaria rapid diagnostic test kits (MRDTs). Thus, the rapid, sensitive and high signal amplification capabilities of NMBs is a promising tool for early diagnosis of malaria and other infectious diseases.
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Leslie T, Mikhail A, Mayan I, Cundill B, Anwar M, Bakhtash SH, Mohammed N, Rahman H, Zekria R, Whitty CJM, Rowland M. Rapid diagnostic tests to improve treatment of malaria and other febrile illnesses: patient randomised effectiveness trial in primary care clinics in Afghanistan. BMJ 2014; 348:g3730. [PMID: 24948695 PMCID: PMC4064827 DOI: 10.1136/bmj.g3730] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess the impact of rapid diagnostic tests on the diagnostic accuracy and treatment of malaria and non-severe fever in an Asian setting. DESIGN Patient randomised trial in primary level clinics. SETTING Two areas of Afghanistan where Plasmodium vivax and Plasmodium falciparum are endemic; one area with moderate transmission (eastern region) and one with low transmission (northern region). PARTICIPANTS 5794 patients of all ages with suspected malaria enrolled by 80 clinicians in 22 clinics. INTERVENTIONS Malaria rapid diagnostic tests were compared with clinical diagnosis where no parasite diagnostic test was available, longer established field microscopy, and recently introduced microscopy. MAIN OUTCOME MEASURES Proportion of patients appropriately treated with an antimalarial, defined as patients with P vivax who received chloroquine, patients with P falciparum who received artemisinin based combination therapy, and patients with no malaria parasites who did not receive an antimalarial. Secondary outcomes included diagnostic test accuracy and the proportion of patients negative for malaria who received antibiotics and antimalarials. RESULTS In the low transmission area, comparing rapid diagnostic tests with clinical diagnosis, 65% (212/325) versus 12% (40/321) of febrile patients were appropriately treated for malaria (adjusted odds ratio 92.7, 95% confidence interval 12.4 to 694.1, P<0.001). The proportion of patients who were negative for malaria and received an antibiotic was 57% (185/325) in the rapid diagnostic test arm compared with 14% (46/321) in the clinical diagnosis arm (16.9, 3.8 to 75.4, P<0.001). In the comparison of rapid diagnostic test with microscopy in the moderate transmission area, 83.6% (1696/2028) versus 76.3% (1512/1983) of patients were appropriately treated for malaria (1.70, 1.30 to 2.23, P<0.001). A higher proportion of P falciparum cases received appropriate treatment with artemisinin based combination therapy when malaria was diagnosed by rapid diagnostic test (82%, 58/71 v 32%, 24/76; 9.2, 3.88 to 21.66, P<0.001). CONCLUSIONS In South and central Asian regions of low to moderate malaria transmission where clinics lack capacity for diagnosis with rapid diagnostic tests or microscopy, the introduction of the tests should be considered to improve clinical care, reduce the overuse of antimalarials, and improve disease surveillance.
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Affiliation(s)
- Toby Leslie
- London School of Hygiene and Tropical Medicine, London, UK Health Protection and Research Organisation, Kabul, Afghanistan
| | - Amy Mikhail
- London School of Hygiene and Tropical Medicine, London, UK Health Protection and Research Organisation, Kabul, Afghanistan
| | - Ismail Mayan
- Health Protection and Research Organisation, Kabul, Afghanistan
| | - Bonnie Cundill
- London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | - Habib Rahman
- Health Protection and Research Organisation, Kabul, Afghanistan
| | - Rohullah Zekria
- Health Protection and Research Organisation, Kabul, Afghanistan
| | | | - Mark Rowland
- London School of Hygiene and Tropical Medicine, London, UK
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Basu S, Modrek S, Bendavid E. Comparing decisions for malaria testing and presumptive treatment: a net health benefit analysis. Med Decis Making 2014; 34:996-1005. [PMID: 24829277 DOI: 10.1177/0272989x14533609] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Rapid tests for malaria are being distributed through vendors to individual patients, presenting the dilemma of determining how individuals are incentivized to pursue testing for malaria, versus the traditional approach of presumptively treating fevers with antimalarial drugs. METHODS AND FINDINGS We incorporated testing and treatment data from 6 African countries into a dynamic model of malaria transmission and nonmalarial causes of fever to investigate how variations in the epidemiologic risk of malaria and the prices of rapid diagnostic tests (RDTs) and treatments affect testing and treatment choices from the perspective of febrile patients, public health officials, and drug shop owners. In environments falling below a critical threshold infection rate (entomological inoculation rate) of 282 for patients older than 5 years (95% confidence interval [CI]: 275-289) or 300 for 0- to 5-year-olds (95% CI: 203-307), testing was more beneficial than presumptive therapy in terms of health and financial costs to patients. Infection and cost conditions generally aligned the best patient-level strategy with the best public health strategy to minimize an overall population's morbidity and mortality from both malaria and nonmalarial causes of fever. However, the infection and cost conditions of very high malaria transmission settings did not align patient interests or public health interests with the interests of private drug shop owners. In such settings, a further lowering of testing prices may realign the interests of all 3 parties. CONCLUSIONS A threshold transmission rate exists under which malaria testing confers more health and financial benefits to patients than presumptive treatment. Studying local transmission rates and testing and treatment costs may facilitate an approach to align the interests of individual patients, public health officials, and distributors of tests and therapies.
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Affiliation(s)
- Sanjay Basu
- Department of Medicine, Stanford University, Stanford, CA, USA (SB, SM, EB)
| | - Sepideh Modrek
- Department of Medicine, Stanford University, Stanford, CA, USA (SB, SM, EB)
| | - Eran Bendavid
- Department of Medicine, Stanford University, Stanford, CA, USA (SB, SM, EB)
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