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Gildner TE, Eick GN, Schneider AL, Madimenos FC, Snodgrass JJ. After Theranos: Using point-of-care testing to advance measures of health biomarkers in human biology research. Am J Hum Biol 2022; 34:e23689. [PMID: 34669210 DOI: 10.1002/ajhb.23689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/21/2021] [Accepted: 09/29/2021] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES The rise and fall of the health technology startup Theranos is emblematic of the promise and peril of point-of-care testing (POCT). Instruments that deliver immediate results from minimally invasive samples at the location of collection can provide powerful tools to deliver health data in clinical and public health contexts. Yet, POCT availability is driven largely by market interests, which limits the development of inexpensive tests for diverse health conditions that can be used in resource-limited settings. These constraints, combined with complex regulatory hurdles and substantial ethical challenges, have contributed to the underutilization of POCT in human biology research. METHODS We evaluate current POCT capabilities and limitations, discuss promising applications for POCT devices in resource-limited settings, and discuss the future of POCT. RESULTS As evidenced by publication trends, POCT platforms have rapidly advanced in recent years, gaining traction among clinicians and health researchers. We highlight POCT devices of potential interest to population-based researchers and present specific examples of POCT applications in human biology research. CONCLUSIONS Several barriers can limit POCT applications, including cost, lack of regulatory approval for non-clinical use, requirements for expensive equipment, and the dearth of validation in remote field conditions. Despite these issues, we see immense potential for emerging POCT technology capable of analyzing new sample types and used in conjunction with increasingly common technology (e.g., smart phones). We argue that the fallout from Theranos may ultimately provide an opportunity to advance POCT, leading to more ethical data collection and novel opportunities in human biology research.
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Affiliation(s)
- Theresa E Gildner
- Department of Anthropology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Geeta N Eick
- Department of Anthropology, University of Oregon, Eugene, Oregon, USA
| | - Alaina L Schneider
- Department of Anthropology, Washington University in St. Louis, St. Louis, Missouri, USA
| | | | - J Josh Snodgrass
- Department of Anthropology, University of Oregon, Eugene, Oregon, USA.,Center for Global Health, University of Oregon, Eugene, Oregon, USA
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2
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Shu T, Hunter H, Zhou Z, Sun Y, Cheng X, Ma J, Su L, Zhang X, Serpe MJ. Portable point-of-care diagnostic devices: an updated review. ANALYTICAL METHODS : ADVANCING METHODS AND APPLICATIONS 2021; 13:5418-5435. [PMID: 34787609 DOI: 10.1039/d1ay01643a] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
The global pandemic caused by the SARS-CoV-2 (COVID) virus indiscriminately impacted people worldwide with unquantifiable and severe impacts on all aspects of our lives, regardless of socioeconomic status. The pandemic brought to light the very real possibility of pathogens changing and shaping the way we live, and our lack of preparedness to deal with viral/bacterial outbreaks. Importantly, the quick detection of pathogens can help prevent and control the spread of disease, making the importance of diagnostic techniques undeniable. Point-of-care diagnostics started as a supplement to standard lab-based diagnostics, and are gradually becoming mainstream. Because of this, and their importance in detecting pathogens (especially in the developing world), their development has accelerated at an unprecedented rate. In this review, we highlight some important and recent examples of point-of-care diagnostics for detecting nucleic acids, proteins, bacteria, and other biomarkers, with the intent of making apparent their positive impact on society and human health.
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Affiliation(s)
- Tong Shu
- Research Center for Biosensor and Nanotheranostic, Shenzhen Key Laboratory for Nano-Biosensing Technology, School of Biomedical Engineering, Shenzhen University Health Science Center, Shenzhen 518060, P. R. China
- Beijing Key Laboratory for Bioengineering and Sensing Technology, Research Center for Bioengineering and Sensing Technology, School of Chemistry and Biological Engineering, University of Science and Technology Beijing, Beijing 100083, P. R. China
| | - Haley Hunter
- Department of Chemistry, University of Alberta, Edmonton, Alberta, Canada, T6G 2G2.
| | - Ziping Zhou
- Research Center for Biosensor and Nanotheranostic, Shenzhen Key Laboratory for Nano-Biosensing Technology, School of Biomedical Engineering, Shenzhen University Health Science Center, Shenzhen 518060, P. R. China
- Beijing Key Laboratory for Bioengineering and Sensing Technology, Research Center for Bioengineering and Sensing Technology, School of Chemistry and Biological Engineering, University of Science and Technology Beijing, Beijing 100083, P. R. China
| | - Yanping Sun
- Research Center for Biosensor and Nanotheranostic, Shenzhen Key Laboratory for Nano-Biosensing Technology, School of Biomedical Engineering, Shenzhen University Health Science Center, Shenzhen 518060, P. R. China
- Beijing Key Laboratory for Bioengineering and Sensing Technology, Research Center for Bioengineering and Sensing Technology, School of Chemistry and Biological Engineering, University of Science and Technology Beijing, Beijing 100083, P. R. China
| | - Xiaojun Cheng
- Research Center for Biosensor and Nanotheranostic, Shenzhen Key Laboratory for Nano-Biosensing Technology, School of Biomedical Engineering, Shenzhen University Health Science Center, Shenzhen 518060, P. R. China
- Beijing Key Laboratory for Bioengineering and Sensing Technology, Research Center for Bioengineering and Sensing Technology, School of Chemistry and Biological Engineering, University of Science and Technology Beijing, Beijing 100083, P. R. China
| | - Jianxin Ma
- Research Center for Biosensor and Nanotheranostic, Shenzhen Key Laboratory for Nano-Biosensing Technology, School of Biomedical Engineering, Shenzhen University Health Science Center, Shenzhen 518060, P. R. China
- Beijing Key Laboratory for Bioengineering and Sensing Technology, Research Center for Bioengineering and Sensing Technology, School of Chemistry and Biological Engineering, University of Science and Technology Beijing, Beijing 100083, P. R. China
| | - Lei Su
- Research Center for Biosensor and Nanotheranostic, Shenzhen Key Laboratory for Nano-Biosensing Technology, School of Biomedical Engineering, Shenzhen University Health Science Center, Shenzhen 518060, P. R. China
| | - Xueji Zhang
- Research Center for Biosensor and Nanotheranostic, Shenzhen Key Laboratory for Nano-Biosensing Technology, School of Biomedical Engineering, Shenzhen University Health Science Center, Shenzhen 518060, P. R. China
| | - Michael J Serpe
- Department of Chemistry, University of Alberta, Edmonton, Alberta, Canada, T6G 2G2.
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3
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Boon HA, Struyf T, Bullens D, Van den Bruel A, Verbakel JY. Diagnostic value of biomarkers for paediatric urinary tract infections in primary care: systematic review and meta-analysis. BMC FAMILY PRACTICE 2021; 22:193. [PMID: 34565335 PMCID: PMC8474745 DOI: 10.1186/s12875-021-01530-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 08/24/2021] [Indexed: 12/28/2022]
Abstract
Background Accurate diagnosis of urinary tract infection is essential as children left untreated may suffer permanent renal injury. Aim To compare the diagnostic values of biomarkers or clinical prediction rules for urinary tract infections in children presenting to ambulatory care. Design and setting Systematic review and meta-analysis of ambulatory care studies. Methods Medline, Embase, WOS, CINAHL, Cochrane library, HTA and DARE were searched until 21 May 2021. We included diagnostic studies on urine or blood biomarkers for cystitis or pyelonephritis in children below 18 years of age. We calculated sensitivity, specificity and likelihood ratios. Data were pooled using a bivariate random effects model and a Hierarchical Summary Receiver Operating Characteristic analysis. Results Seventy-five moderate to high quality studies were included in this review and 54 articles in the meta-analyses. The area under the receiver-operating-characteristics curve to diagnose cystitis was 0.75 (95%CI 0.62 to 0.83, n = 9) for C-reactive protein, 0.71 (95% CI 0.62 to 0.80, n = 4) for procalcitonin, 0.93 (95% CI 0.91 to 0.96, n = 22) for the dipstick test (nitrite or leukocyte esterase ≥trace), 0.94 (95% CI 0.58 to 0.98, n = 9) for urine white blood cells and 0.98 (95% CI 0.92 to 0.99, n = 12) for Gram-stained bacteria. For pyelonephritis, C-reactive protein < 20 mg/l had LR- of 0.10 (95%CI 0.04–0.30) to 0.22 (95%CI 0.09–0.54) in children with signs suggestive of urinary tract infection. Conclusions Clinical prediction rules including the dipstick test biomarkers can support family physicians while awaiting urine culture results. CRP and PCT have low accuracy for cystitis, but might be useful for pyelonephritis. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01530-9.
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Affiliation(s)
- Hanne A Boon
- EPI-Centre, Academic Centre for General Practice, KU Leuven, Kapucijnenvoer 7, 3000, Leuven, Belgium
| | - Thomas Struyf
- EPI-Centre, Academic Centre for General Practice, KU Leuven, Kapucijnenvoer 7, 3000, Leuven, Belgium
| | - Dominique Bullens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Herestraat 49, Box 811, 3000, Leuven, Belgium.,Clinical Division of Pediatrics, UZ Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Ann Van den Bruel
- EPI-Centre, Academic Centre for General Practice, KU Leuven, Kapucijnenvoer 7, 3000, Leuven, Belgium
| | - Jan Y Verbakel
- EPI-Centre, Academic Centre for General Practice, KU Leuven, Kapucijnenvoer 7, 3000, Leuven, Belgium. .,Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
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4
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C-Reactive Protein for the Early Assessment of Non-Malarial Febrile Patients: A Retrospective Diagnostic Study. Diagnostics (Basel) 2021; 11:diagnostics11091728. [PMID: 34574070 PMCID: PMC8469932 DOI: 10.3390/diagnostics11091728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 09/17/2021] [Accepted: 09/17/2021] [Indexed: 12/04/2022] Open
Abstract
Biomarkers, especially CRP, have demonstrated their relevance to differentiate viral from bacterial infection, even though a reliable threshold is far to being found. In low- and middle-income countries, affordable and user-friendly rapid diagnostic tests based on biomarkers can be widely adopted to help health workers in the management of non-malarial fever. The primary objective of this study is to assess the best CRP cut-off to distinguish viral from bacterial infections. Other biomarkers were evaluated for the same purpose, alone or in combination with CRP. We retrospectively collected data from two referral hospital departments for infectious and tropical diseases in Italy. Areas under the ROC curve (AUC) were calculated and then compared using the DeLong test. Overall, we included 1193 febrile cases (viral 20.74% vs. bacterial 79.25%). We also collected malaria (n = 202) and intestinal parasite (n = 186) cases to establish their impact on biomarkers. CRP had the best accuracy in differentiating viral from bacterial infections. The best performance of CRP was a cut-off of 11 mg/L. All other biomarkers studied had significantly lower accuracy. Median CRP values were within the normal ranges in parasitic infections, while they were higher in malaria. None of the combinations of CRP with other biomarkers significantly increased the accuracy of CRP alone.
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5
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Emgård M, Mwangi R, Mayo C, Mshana E, Nkini G, Andersson R, Msuya SE, Lepp M, Muro F, Skovbjerg S. Tanzanian primary healthcare workers' experiences of antibiotic prescription and understanding of antibiotic resistance in common childhood infections: a qualitative phenomenographic study. Antimicrob Resist Infect Control 2021; 10:94. [PMID: 34176486 PMCID: PMC8237496 DOI: 10.1186/s13756-021-00952-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 05/17/2021] [Indexed: 11/30/2022] Open
Abstract
Background Antibiotic resistance is a threat to global child health. Primary healthcare workers play a key role in antibiotic stewardship in the community, but few studies in low-income countries have described their experiences of initiating antibiotic treatment in children. Thus, the present study aimed to describe primary healthcare workers’ experiences of antibiotic prescription for children under 5 years of age and their conceptions of antibiotic resistance in Northern Tanzania. Methods A qualitative study involving individual in-depth interviews with 20 prescribing primary healthcare workers in Moshi urban and rural districts, Northern Tanzania, was performed in 2019. Interviews were transcribed verbatim, translated from Kiswahili into English and analysed according to the phenomenographic approach. Findings Four conceptual themes emerged during the analysis; conceptions in relation to the prescriber, the mother and child, other healthcare actors and in relation to outcome. The healthcare workers relied mainly on clinical examination and medical history provided by the mother to determine the need for antibiotics. Confidence in giving advice concerning non-antibiotic treatment varied among the participants and expectations of antibiotic treatment were perceived to be common among the mothers. Antibiotic resistance was mainly perceived as a problem for the individual patient who was misusing the antibiotics. Conclusions To increase rational antibiotic prescription, an awareness needs to be raised among Tanzanian primary healthcare workers of the threat of antibiotic resistance, not only to a few individuals, but to public health. Guidelines on childhood illnesses should be updated with advice concerning symptomatic treatment when antibiotics are not necessary, to support rational prescribing practices and promote trust in the clinician and mother relationship. Supplementary Information The online version contains supplementary material available at 10.1186/s13756-021-00952-5.
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Affiliation(s)
- Matilda Emgård
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. .,Centre for Antibiotic Resistance Research (CARe), University of Gothenburg, Gothenburg, Sweden. .,Department of Paediatrics, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Rose Mwangi
- Institute of Public Health, Kilimanjaro Christian Medical University College (KCMUCo), Sokoine Road, Moshi, Tanzania
| | - Celina Mayo
- Department of Community Health, Kilimanjaro Christian Medical Centre (KCMC), Moshi, Tanzania
| | - Ester Mshana
- Institute of Public Health, Kilimanjaro Christian Medical University College (KCMUCo), Sokoine Road, Moshi, Tanzania
| | - Gertrud Nkini
- Institute of Public Health, Kilimanjaro Christian Medical University College (KCMUCo), Sokoine Road, Moshi, Tanzania
| | - Rune Andersson
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Centre for Antibiotic Resistance Research (CARe), University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Microbiology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Sia E Msuya
- Institute of Public Health, Kilimanjaro Christian Medical University College (KCMUCo), Sokoine Road, Moshi, Tanzania
| | - Margret Lepp
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Østfold University College, Fredrikstad, Norway.,School of Nursing and Midwifery, Griffith University, Gold Coast, QLD, Australia
| | - Florida Muro
- Institute of Public Health, Kilimanjaro Christian Medical University College (KCMUCo), Sokoine Road, Moshi, Tanzania.,Department of Community Health, Kilimanjaro Christian Medical Centre (KCMC), Moshi, Tanzania
| | - Susann Skovbjerg
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Centre for Antibiotic Resistance Research (CARe), University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Microbiology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
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6
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Escadafal C, Incardona S, Fernandez-Carballo BL, Dittrich S. The good and the bad: using C reactive protein to distinguish bacterial from non-bacterial infection among febrile patients in low-resource settings. BMJ Glob Health 2021; 5:bmjgh-2020-002396. [PMID: 32467355 PMCID: PMC7259834 DOI: 10.1136/bmjgh-2020-002396] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/14/2020] [Accepted: 04/17/2020] [Indexed: 12/29/2022] Open
Abstract
C reactive protein (CRP), a marker for the presence of an inflammatory process, is the most extensively studied marker for distinguishing bacterial from non-bacterial infections in febrile patients. A point-of-care test for bacterial infections would be of particular use in low-resource settings where other laboratory diagnostics are not always available, antimicrobial resistance rates are high and bacterial infections such as pneumonia are a leading cause of death. This document summarises evidence on CRP testing for bacterial infections in low-income and middle-income countries (LMICs). With a push for universal health coverage and prevention of antimicrobial resistance, it is important to understand if CRP might be able to do the job. The use of CRP polarised the global health community and the aim of this document is to summarise the ‘good and the bad’ of CRP in multiple settings in LMICs. In brief, the literature that was reviewed suggests that CRP testing may be beneficial in low-resource settings to improve rational antibiotic use for febrile patients, but the positive predictive value is insufficient to allow it to be used alone as a single tool. CRP testing may be best used as part of a panel of diagnostic tests and algorithms. Further studies in low-resource settings, particularly with regard to impact on antibiotic prescribing and cost-effectiveness of CRP testing, are warranted.
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Affiliation(s)
- Camille Escadafal
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Sandra Incardona
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | | | - Sabine Dittrich
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland .,Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Bertoli G, Ronzoni N, Silva R, Spinicci M, Perlini C, Omega L, Ursini T, Bartoloni A, Olliaro P, Bisoffi Z, Buonfrate D. Usefulness of C-Reactive Protein and Other Host BioMarker Point-of-Care Tests in the Assessment of Non-Malarial Acute Febrile Illnesses: A Systematic Review with Meta-Analysis. Am J Trop Med Hyg 2020; 103:1797-1802. [PMID: 32901594 DOI: 10.4269/ajtmh.19-0935] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
In low- and middle-income countries, in resource-limited settings, the implementation of diagnostic tools discriminating bacterial from nonbacterial fever is a matter of primary concern. The introduction of malaria rapid diagnostic tests highlighted the need for point-of-care tests (POCTs) supporting clinical decision-making for non-malarial febrile illnesses. The purpose of this work was to review the use of host biomarker POCTs for the assessment of acute non-malarial fever in resource-constraint settings. Specific objectives were as follows: 1) to estimate the accuracy of such tests in differentiating fever of bacterial from nonbacterial origin and 2) to assess the impact of host biomarkers on antibiotic prescription and clinical outcome. We conducted a systematic review searching PubMed, Embase, the Cochrane Library, and Bireme. The protocol was registered with PROSPERO (n CRD42019141735). Data on the accuracy of C-reactive protein (CRP) for the detection of bacterial infections were meta-analyzed using the hierarchical summary receiver operating characteristic model, obtaining a summary ROC (SROC). We identified 2,192 articles, eight of which were included in the review. Among the different biomarkers evaluated, CRP was the one most frequently studied. The SROC presented an area under the curve = 0.77 (CI: 0.73-0.81), which indicates good accuracy to distinguish bacterial from nonbacterial infections. However, the optimal cutoff of CRP could not be assessed, and we found insufficient evidence about its impact on antibiotic prescription and clinical outcome. The role of CRP and other host biomarker POCTs for the assessment of acute non-malarial febrile illnesses in resource-constraint settings deserves further studies.
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Affiliation(s)
- Giulia Bertoli
- Department of Infectious, Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Verona, Italy
| | - Niccolò Ronzoni
- Department of Infectious, Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Verona, Italy
| | - Ronaldo Silva
- Department of Infectious, Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Verona, Italy
| | - Michele Spinicci
- Dipartimento di Medicina Sperimentale e Clinica, Università degli Studi di Firenze, Firenze, Italy
| | - Chiara Perlini
- Scuola di Medicina, Università degli studi di Verona, Verona, Italy
| | - Luca Omega
- Scuola di Specializzazione in Malattie Infettive, Università degli Studi di Verona, Verona, Italy
| | - Tamara Ursini
- Department of Infectious, Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Verona, Italy
| | - Alessandro Bartoloni
- Dipartimento di Medicina Sperimentale e Clinica, Università degli Studi di Firenze, Firenze, Italy
| | - Piero Olliaro
- Foundation for Innovative Diagnostics (FIND), Geneva, Switzerland.,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Zeno Bisoffi
- Diagnostic and Public Health Department, Infectious Diseases and Tropical Medicine Section, University of Verona, Verona, Italy.,Department of Infectious, Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Verona, Italy
| | - Dora Buonfrate
- Department of Infectious, Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Verona, Italy
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van Griensven J, Cnops L, De Weggheleire A, Declercq S, Bottieau E. Point-of-Care Biomarkers to Guide Antibiotic Prescription for Acute Febrile Illness in Sub-Saharan Africa: Promises and Caveats. Open Forum Infect Dis 2020; 7:ofaa260. [PMID: 32818139 PMCID: PMC7423291 DOI: 10.1093/ofid/ofaa260] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/26/2020] [Indexed: 01/21/2023] Open
Abstract
Empiric malaria treatment in Sub-Saharan Africa has significantly decreased with the scaling-up of malaria rapid diagnostic tests; this coincided with a pronounced increase in empiric antibiotic prescriptions. In high-income countries, guidance for antibiotic prescriptions using biomarkers such as C-reactive protein (CRP) and procalcitonin (PCT) has reduced antibiotic use while safe-guarding patient safety. Importantly, several low-cost point-of-care CRP/PCT tests are currently available. However, only a few studies on the role of CRP/PCT in differentiating bacterial vs viral infections in acute febrile illness have been conducted in Sub-Saharan Africa. Studies from Central and West Africa (most of which is malaria-endemic) are particularly scarce, and only 1 has included adults. The evidence base for point-of-care use of CRP/PCT biomarkers in acute fever in Sub-Saharan Africa should be urgently built. Before engaging in clinical trials to assess clinical impact, pilot studies should be conducted to address key knowledge gaps including recommended CRP/PCT cutoff values and the effect of malaria coinfection.
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Kasundriya SK, Dhaneria M, Mathur A, Pathak A. Incidence and Risk Factors for Severe Pneumonia in Children Hospitalized with Pneumonia in Ujjain, India. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17134637. [PMID: 32605136 PMCID: PMC7369688 DOI: 10.3390/ijerph17134637] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 06/21/2020] [Accepted: 06/24/2020] [Indexed: 11/05/2022]
Abstract
Childhood pneumonia is a major public health problem. The aim of this prospective hospital-based study is to determine the incidence and risk factors for community-acquired severe pneumonia in children in Ujjain, India. The study includes 270 children, 161 (60%) boys and 109 (40%) girls, aged between 2 months and 5 years with World Health Organization defined and radiologically confirmed severe pneumonia. Considering the 270 children, 64% (95% confidence interval (CI) 57.9–69.4) have severe pneumonia. The following are identified as risk factors for severe pneumonia from the generalized logistic regression model: Born premature (adjusted odds ratio (AOR) 7.50; 95% CI 2.22–25.31; p = 0.001); history of measles (AOR 6.35; 95% CI 1.73–23.30; p = 0.005); incomplete vaccination (AOR 2.66; 95% CI 1.09–6.48; p = 0.031); acyanotic congenital heart disease (AOR 9.21; 95% CI 2.29–36.99; p = 0.002); home treatment tried (AOR 3.84; 95% CI 1.42–10.39; p = 0.008); living in a kuchha house (AOR 3.89; 95% CI 1.51–10.01; p = 0.027); overcrowding (AOR 4.50; 95% CI 1.75–11.51; p = 0.002);poor ventilation in living area (AOR 16.37; 95% CI 4.67–57.38; p < 0.001); and practicing open defecation (AOR 16.92; 95% CI 4.95–57.85; p < 0.001). Awareness of these risk factors can reduce mortality due to severe pneumonia.
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Affiliation(s)
- Sunil Kumar Kasundriya
- Department of Pediatrics, Ruxmaniben Deepchand Gardi Medical College, Ujjain 456006, Madhya Pradesh, India; (S.K.K.); (M.D.); (A.M.)
- All India Institute of Medical Science, Raipur 492001, Chhattisgarh, India
| | - Mamta Dhaneria
- Department of Pediatrics, Ruxmaniben Deepchand Gardi Medical College, Ujjain 456006, Madhya Pradesh, India; (S.K.K.); (M.D.); (A.M.)
| | - Aditya Mathur
- Department of Pediatrics, Ruxmaniben Deepchand Gardi Medical College, Ujjain 456006, Madhya Pradesh, India; (S.K.K.); (M.D.); (A.M.)
| | - Ashish Pathak
- Department of Pediatrics, Ruxmaniben Deepchand Gardi Medical College, Ujjain 456006, Madhya Pradesh, India; (S.K.K.); (M.D.); (A.M.)
- Department of Women and Children’s Health, International Maternal and Child Health Unit, Uppsala University, SE-751 85 Uppsala, Sweden
- Global Health—Health Systems and Policy: Medicines, Focusing Antibiotics, Department of Public Health Sciences, Karolinska Institutet, SE-171 76 Stockholm, Sweden
- Correspondence: ; Tel.: +91-93-0223-9899
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10
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Althaus T, Lubell Y, Maro VP, Mmbaga BT, Lwezaula B, Halleux C, Biggs HM, Galloway RL, Stoddard RA, Perniciaro JL, Nicholson WL, Doyle K, Olliaro P, Crump JA, Rubach MP. Sensitivity of C-reactive protein for the identification of patients with laboratory-confirmed bacterial infections in northern Tanzania. Trop Med Int Health 2020; 25:291-300. [PMID: 31808588 DOI: 10.1111/tmi.13358] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Identifying febrile patients requiring antibacterial treatment is challenging, particularly in low-resource settings. In South-East Asia, C-reactive protein (CRP) has been demonstrated to be highly sensitive and moderately specific in detecting bacterial infections and to safely reduce unnecessary antibacterial prescriptions in primary care. As evidence is scant in sub-Saharan Africa, we assessed the sensitivity of CRP in identifying serious bacterial infections in Tanzania. METHODS Samples were obtained from inpatients and outpatients in a prospective febrile illness study at two hospitals in Moshi, Tanzania, 2011-2014. Bacterial bloodstream infections (BSI) were established by blood culture, and bacterial zoonotic infections were defined by ≥4 fold rise in antibody titre between acute and convalescent sera. The sensitivity of CRP in identifying bacterial infections was estimated using thresholds of 10, 20 and 40 mg/l. Specificity was not assessed because determining false-positive CRP results was limited by the lack of diagnostic testing to confirm non-bacterial aetiologies and because ascertaining true-negative cases was limited by the imperfect sensitivity of the diagnostic tests used to identify bacterial infections. RESULTS Among 235 febrile outpatients and 569 febrile inpatients evaluated, 31 (3.9%) had a bacterial BSI and 61 (7.6%) had a bacterial zoonosis. Median (interquartile range) CRP values were 173 (80-315) mg/l in bacterial BSI, and 108 (31-208) mg/l in bacterial zoonoses. The sensitivity (95% confidence intervals) of CRP was 97% (83%-99%), 94% (79%-98%) and 90% (74%-97%) for identifying bacterial BSI, and 87% (76%-93%), 82% (71%-90%) and 72% (60%-82%) for bacterial zoonoses, using thresholds of 10, 20 and 40 mg/l, respectively. CONCLUSION C-reactive protein was moderately sensitive for bacterial zoonoses and highly sensitive for identifying BSIs. Based on these results, operational studies are warranted to assess the safety and clinical utility of CRP for the management of non-malaria febrile illness at first-level health facilities in sub-Saharan Africa.
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Affiliation(s)
- Thomas Althaus
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Yoel Lubell
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Venance P Maro
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Blandina T Mmbaga
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania.,Duke Global Health Institute, Durham, NC, USA
| | | | - Christine Halleux
- Special Programme for Research and Training in Tropical Diseases, WHO, Geneva, Switzerland
| | - Holly M Biggs
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, NC, USA
| | - Renee L Galloway
- Bacterial Special Pathogens Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Robyn A Stoddard
- Bacterial Special Pathogens Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jamie L Perniciaro
- Rickettsial Zoonoses Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - William L Nicholson
- Rickettsial Zoonoses Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kelly Doyle
- Intermountain Central Laboratory, Intermountain Healthcare, Murray, UT, USA
| | - Piero Olliaro
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Special Programme for Research and Training in Tropical Diseases, WHO, Geneva, Switzerland
| | - John A Crump
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania.,Duke Global Health Institute, Durham, NC, USA.,Division of Infectious Diseases, Department of Medicine, Duke University, Durham, NC, USA.,Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Matthew P Rubach
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Duke Global Health Institute, Durham, NC, USA.,Division of Infectious Diseases, Department of Medicine, Duke University, Durham, NC, USA.,Programme in Emerging Infectious Diseases, Duke-National University of Singapore Medical School, Singapore, Singapore
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11
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Boumbanda Koyo CS, Oyegue-Liabagui SL, Mediannikov O, Cortaredona S, Kouna LC, Raoult D, Lekana-Douki JB, Fenollar F. High Circulation of Malaria and Low Prevalence of Bacteremia in Febrile and Afebrile Children in Northeastern Gabon. Am J Trop Med Hyg 2019; 102:121-129. [PMID: 31769404 DOI: 10.4269/ajtmh.19-0368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The epidemiology of febrile illness etiologies is under-explored in resource-poor settings. Establishing a local repertory of microorganisms circulating in blood of febrile and afebrile people is important for physicians. Blood was collected from 428 febrile and 88 afebrile children in Makokou (Gabon) and analyzed using polymerase chain reaction. Plasmodium spp. were the pathogens, which were most detected in febrile children (69.6%; 298/428) and in afebrile children (31.8%; 28/88) (P < 0.0001). Plasmodium falciparum was the most prevalent species in both febrile and afebrile children (66.8% and 27.3%, respectively). No differences were observed between febrile and afebrile children for Plasmodium malariae and Plasmodium ovale (8.2% versus 10.2% and 3.3% versus 3.4%, respectively). Triple infection with P. falciparum, P. malariae, and P. ovale was also detected in 1% of febrile children (4/428). Filariasis due to Mansonella perstans was detected in 10 febrile patients (2.3%), whereas Loa loa was detected in both febrile and afebrile children (1.4% and 2.3%, respectively). Bacterial DNA was detected in only 4.4% (19/428) of febrile children, including 13 (68.4%) who were coinfected with at least one Plasmodium species. These were Haemophilus influenzae (1.6%, 7/428), Streptococcus pneumoniae and Staphylococcus aureus (1.2%, 5/428), and Rickettsia felis (0.9%, 4/428). Coxiella burnetii, Bartonella spp., Borrelia spp., Tropheryma whipplei, Anaplasma spp., Leptospira spp., Streptococcus pyogenes, and Salmonella spp. were not detected. This study also highlights the over-prescription and the overuse of antibiotics and antimalarials. Overall, malaria remains a major health problem in Makokou. Malaria control measures must be reconsidered in this region.
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Affiliation(s)
- Célia Scherelle Boumbanda Koyo
- Aix Marseille University, Institut de Recherche pour le Développement (IRD), Assistance Publique-Hôpitaux de Marseille (AP-HM), Service de Santé des Armées (SSA), Vecteurs-Infections Tropicales et Méditerranéennes (VITROME), Marseille, France.,IHU-Méditerranée Infection, Marseille, France.,Unité d'Evolution, Epidémiologie et Résistances Parasitaires (UNEEREP), Centre International de Recherches Médicales de Franceville (CIRMF), Franceville, Gabon.,Ecole Doctorale Régionale en Infectiologie Tropicale d'Afrique Centrale, Franceville, Gabon
| | - Sandrine Lydie Oyegue-Liabagui
- Laboratoire d'Immunologie, Parasitologie et Microbiologie, École Doctorale Régionale d'Afrique Centrale en Infectiologie Tropicale, Université des Sciences et Techniques de Masuku, Franceville, Gabon
| | - Oleg Mediannikov
- Aix Marseille University, IRD, AP-HM, Microbes, Evolution, Phylogénie et Infection (MEPHI), Institut Hospitalo-Universitaire (IHU), Méditerranée Infection, Marseille, France.,IHU-Méditerranée Infection, Marseille, France
| | - Sébastien Cortaredona
- IHU-Méditerranée Infection, Marseille, France.,Aix Marseille University, Institut de Recherche pour le Développement (IRD), Assistance Publique-Hôpitaux de Marseille (AP-HM), Service de Santé des Armées (SSA), Vecteurs-Infections Tropicales et Méditerranéennes (VITROME), Marseille, France
| | - Lady Charlene Kouna
- Unité d'Evolution, Epidémiologie et Résistances Parasitaires (UNEEREP), Centre International de Recherches Médicales de Franceville (CIRMF), Franceville, Gabon
| | - Didier Raoult
- Aix Marseille University, IRD, AP-HM, Microbes, Evolution, Phylogénie et Infection (MEPHI), Institut Hospitalo-Universitaire (IHU), Méditerranée Infection, Marseille, France.,IHU-Méditerranée Infection, Marseille, France
| | - Jean Bernard Lekana-Douki
- Département de Parasitologie-Mycologie Médecine Tropicale, Faculté de Médecine, Université des Sciences de la Santé (USS), Libreville, Gabon.,Ecole Doctorale Régionale en Infectiologie Tropicale d'Afrique Centrale, Franceville, Gabon.,Unité d'Evolution, Epidémiologie et Résistances Parasitaires (UNEEREP), Centre International de Recherches Médicales de Franceville (CIRMF), Franceville, Gabon
| | - Florence Fenollar
- Aix Marseille University, Institut de Recherche pour le Développement (IRD), Assistance Publique-Hôpitaux de Marseille (AP-HM), Service de Santé des Armées (SSA), Vecteurs-Infections Tropicales et Méditerranéennes (VITROME), Marseille, France.,IHU-Méditerranée Infection, Marseille, France
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12
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Keitel K, Kilowoko M, Kyungu E, Genton B, D'Acremont V. Performance of prediction rules and guidelines in detecting serious bacterial infections among Tanzanian febrile children. BMC Infect Dis 2019; 19:769. [PMID: 31481123 PMCID: PMC6724300 DOI: 10.1186/s12879-019-4371-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 08/12/2019] [Indexed: 12/03/2022] Open
Abstract
Background Health-workers in developing countries rely on clinical algorithms, such as the Integrated Management of Childhood Illnesses (IMCI), for the management of patients, including diagnosis of serious bacterial infections (SBI). The diagnostic accuracy of IMCI in detecting children with SBI is unknown. Prediction rules and guidelines for SBI from well-resourced countries at outpatient level may help to improve current guidelines; however, their diagnostic performance has not been evaluated in resource-limited countries, where clinical conditions, access to care, and diagnostic capacity differ. The aim of this study was to estimate the diagnostic accuracy of existing prediction rules and clinical guidelines in identifying children with SBI in a cohort of febrile children attending outpatient health facilities in Tanzania. Methods Structured literature review to identify available prediction rules and guidelines aimed at detecting SBI and retrospective, external validation on a dataset containing 1005 febrile Tanzanian children with acute infections. The reference standard, SBI, was established based on rigorous clinical and microbiological criteria. Results Four prediction rules and five guidelines, including IMCI, could be validated. All examined rules and guidelines had insufficient diagnostic accuracy for ruling-in or ruling-out SBI with positive and negative likelihood ratios ranging from 1.04–1.87 to 0.47–0.92, respectively. IMCI had a sensitivity of 36.7% (95% CI 29.4–44.6%) at a specificity of 70.3% (67.1–73.4%). Rules that use a combination of clinical and laboratory testing had better performance compared to rules and guidelines using only clinical and or laboratory elements. Conclusions Currently applied guidelines for managing children with febrile illness have insufficient diagnostic accuracy in detecting children with SBI. Revised clinical algorithms including simple point-of-care tests with improved accuracy for detecting SBI targeting in tropical resource-poor settings are needed. They should undergo careful external validation against clinical outcome before implementation, given the inherent limitations of gold standards for SBI. Electronic supplementary material The online version of this article (10.1186/s12879-019-4371-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kristina Keitel
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland. .,Department of Pediatric Emergency Medicine, University Hospital of Bern, Bern, Switzerland.
| | | | - Esther Kyungu
- Tanzanian Training Centre for International Health, Ifakara, Tanzania
| | - Blaise Genton
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland.,Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland.,Infectious Diseases Service, University Hospital Lausanne, Lausanne, Switzerland
| | - Valérie D'Acremont
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland.,Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
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13
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Haenssgen MJ, Charoenboon N, Do NTT, Althaus T, Khine Zaw Y, Wertheim HFL, Lubell Y. How context can impact clinical trials: a multi-country qualitative case study comparison of diagnostic biomarker test interventions. Trials 2019; 20:111. [PMID: 30736818 PMCID: PMC6368827 DOI: 10.1186/s13063-019-3215-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 01/19/2019] [Indexed: 11/10/2022] Open
Abstract
Background Context matters for the successful implementation of medical interventions, but its role remains surprisingly understudied. Against the backdrop of antimicrobial resistance, a global health priority, we investigated the introduction of a rapid diagnostic biomarker test (C-reactive protein, or CRP) to guide antibiotic prescriptions in outpatient settings and asked, “Which factors account for cross-country variations in the effectiveness of CRP biomarker test interventions?” Methods We conducted a cross-case comparison of CRP point-of-care test trials across Yangon (Myanmar), Chiang Rai (Thailand), and Hanoi (Vietnam). Cross-sectional qualitative data were originally collected as part of each clinical trial to broaden their evidence base and help explain their respective results. We synthesised these data and developed a large qualitative data set comprising 130 interview and focus group participants (healthcare workers and patients) and nearly one million words worth of transcripts and interview notes. Inductive thematic analysis was used to identify contextual factors and compare them across the three case studies. As clinical trial outcomes, we considered patients’ and healthcare workers’ adherence to the biomarker test results, and patient exclusion to gauge the potential “impact” of CRP point-of-care testing on the population level. Results We identified three principal domains of contextual influences on intervention effectiveness. First, perceived risks from infectious diseases influenced the adherence of the clinical users (nurses, doctors). Second, the health system context related to all three intervention outcomes (via the health policy and antibiotic policy environment, and via health system structures and the ensuing utilisation patterns). Third, the demand-side context influenced the patient adherence to CRP point-of-care tests and exclusion from the intervention through variations in local healthcare-seeking behaviours, popular conceptions of illness and medicine, and the resulting utilisation of the health system. Conclusions Our study underscored the importance of contextual variation for the interpretation of clinical trial findings. Further research should investigate the range and magnitude of contextual effects on trial outcomes through meta-analyses of large sets of clinical trials. For this to be possible, clinical trials should collect qualitative and quantitative contextual information for instance on their disease, health system, and demand-side environment. Trial registration ClinicalTrials.gov, NCT02758821 registered on 3 May 2016 and NCT01918579 registered on 7 August 2013. Electronic supplementary material The online version of this article (10.1186/s13063-019-3215-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marco J Haenssgen
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7FZ, UK. .,CABDyN Complexity Centre, Saïd Business School, University of Oxford, Park End Street, Oxford, OX1 1HP, UK. .,Global Sustainable Development, University of Warwick, Ramphal Building, Coventry, CV4 7AM, UK. .,Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand.
| | - Nutcha Charoenboon
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Nga T T Do
- Oxford University Clinical Research Unit (OUCRU), National Hospital for Tropical Diseases, 78 Giai Phong Street, Hanoi, Vietnam
| | - Thomas Althaus
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7FZ, UK.,Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Yuzana Khine Zaw
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand.,Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Heiman F L Wertheim
- Oxford University Clinical Research Unit (OUCRU), National Hospital for Tropical Diseases, 78 Giai Phong Street, Hanoi, Vietnam.,Medical Microbiology Department, Radboudumc, Geert Grooteplein Zuid 10, Nijmegen, 6525, Netherlands
| | - Yoel Lubell
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7FZ, UK.,Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
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14
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Khine Zaw Y, Charoenboon N, Haenssgen MJ, Lubell Y. A Comparison of Patients' Local Conceptions of Illness and Medicines in the Context of C-Reactive Protein Biomarker Testing in Chiang Rai and Yangon. Am J Trop Med Hyg 2018; 98:1661-1670. [PMID: 29633689 PMCID: PMC6086164 DOI: 10.4269/ajtmh.17-0906] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Antibiotic resistance is not solely a medical but also a social problem, influenced partly by patients' treatment-seeking behavior and their conceptions of illness and medicines. Situated within the context of a clinical trial of C-reactive protein (CRP) biomarker testing to reduce antibiotic over-prescription at the primary care level, our study explores and compares the narratives of 58 fever patients in Chiang Rai (Thailand) and Yangon (Myanmar). Our objectives are to 1) compare local conceptions of illness and medicines in relation to health-care seeking and antibiotic demand; and to 2) understand how these conceptions could influence CRP point-of-care testing (POCT) at the primary care level in low- and middle-income country settings. We thereby go beyond the current knowledge about antimicrobial resistance and CRP POCT, which consists primarily of clinical research and quantitative data. We find that CRP POCT in Chiang Rai and Yangon interacted with fever patients' preexisting conceptions of illness and medicines, their treatment-seeking behavior, and their health-care experiences, which has led to new interpretations of the test, potentially unforeseen exclusion patterns, implications for patients' self-assessed illness severity, and an increase in the status of the formal health-care facilities that provide the test. Although we expected that local conceptions of illness diverge from inbuilt assumptions of clinical interventions, we conclude that this mismatch can undermine the intervention and potentially reproduce problematic equity patterns among CRP POCT users and nonusers. As a partial solution, implementers may consider applying the test after clinical examination to validate rather than direct prescription processes.
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Affiliation(s)
- Yuzana Khine Zaw
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Nutcha Charoenboon
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Marco J Haenssgen
- CABDyN Complexity Centre, Saïd Business School, University of Oxford, Oxford, United Kingdom.,Green Templeton College, United Kingdom.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Yoel Lubell
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
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15
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The social role of C-reactive protein point-of-care testing to guide antibiotic prescription in Northern Thailand. Soc Sci Med 2018; 202:1-12. [PMID: 29499522 PMCID: PMC5910303 DOI: 10.1016/j.socscimed.2018.02.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 02/17/2018] [Accepted: 02/20/2018] [Indexed: 11/24/2022]
Abstract
New and affordable point-of-care testing (POCT) solutions are hoped to guide antibiotic prescription and to help limit antimicrobial resistance (AMR)—especially in low- and middle-income countries where resource constraints often prevent extensive diagnostic testing. Anthropological and sociological research has illuminated the role and impact of rapid point-of-care malaria testing. This paper expands our knowledge about the social implications of non-malarial POCT, using the case study of a C-reactive-protein point-of-care testing (CRP POCT) clinical trial with febrile patients at primary-care-level health centres in Chiang Rai province, northern Thailand. We investigate the social role of CRP POCT through its interactions with (a) the healthcare workers who use it, (b) the patients whose routine care is affected by the test, and (c) the existing patient-health system linkages that might resonate or interfere with CRP POCT. We conduct a thematic analysis of data from 58 purposively sampled pre- and post-intervention patients and healthcare workers in August 2016 and May 2017. We find widespread positive attitudes towards the test among patients and healthcare workers. Patients’ views are influenced by an understanding of CRP POCT as a comprehensive blood test that provides specific diagnosis and that corresponds to notions of good care. Healthcare workers use the test to support their negotiations with patients but also to legitimise ethical decisions in an increasingly restrictive antibiotic policy environment. We hypothesise that CRP POCT could entail greater patient adherence to recommended antibiotic treatment, but it could also encourage riskier health behaviour and entail potentially adverse equity implications for patients across generations and socioeconomic strata. Our empirical findings inform the clinical literature on increasingly propagated point-of-care biomarker tests to guide antibiotic prescriptions, and we contribute to the anthropological and sociological literature through a novel conceptualisation of the patient-health system interface as an activity space into which biomarker testing is introduced. Novel social research contribution to the study of antimicrobial resistance. Examines increasingly popular diagnostic point-of-care testing (POCT). Analyses POCT introduction at the patient – health system interface. Reveals interferences of test with patient and health worker behaviour. Provides evidence of un-/intended behavioural effects of point-of-care tests.
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