Cost-effectiveness of malaria microscopy and rapid diagnostic tests versus presumptive diagnosis: implications for malaria control in Uganda

Targeted Testing and Treatment To Reduce Human Malaria Transmission in High-Risk Populations: A Systematic Review

As countries approach elimination of malaria, groups with increased exposure to malaria vectors or poor access to health services may serve as important human reservoirs of infection that help maintain transmission in the community. Parasitological testing and treatment targeted to these groups may reduce malaria transmission overall. This systematic review assessed the effectiveness of targeted testing and treatment (TTaT) to reduce malaria transmission, the contextual factors, and the results of modeling studies that estimated the intervention's potential impact. Bibliographic searches were conducted in March 2021 and updated in April 2022, and a total of 1,210 articles were identified. Three studies were included for outcome data: one factorial cluster randomized controlled trial (cRCT) in Kenya (5,233 participants), one cRCT in Ghana (3,046 participants), and one controlled before-and-after cohort study in schoolchildren in Malawi (786 participants). Nine reports were included for contextual factors, and two were included for mathematical modeling. Data on outcomes from the three studies suggested that at the community level, TTaT would result in little to no difference in the incidence of malaria infection (measured via active surveillance), adverse events, and severe AEs. In contrast, the effects of TTaT on prevalence (malaria parasitemia) among those targeted by the intervention were found to include a short-term impact on reducing transmission but little to no impact on transmission for extended periods. Future iterations of this review should ensure consideration for populations proven to host the vast majority of the reservoir of infection in lower-transmission settings to determine the effectiveness of the intervention.

Rapid Diagnostic Test Value and Implementation in Antimicrobial Stewardship Across Low-to-Middle and High-Income Countries: A Mixed-Methods Review

Despite technological advancements in infectious disease rapid diagnostic tests (RDTs) and use to direct therapy at the per-patient level, RDT utilisation in antimicrobial stewardship programmes (ASPs) is variable across low-to-middle income and high-income countries. Key insights from a panel of seven infectious disease experts from Colombia, Japan, Nigeria, Thailand, the UK, and the USA, combined with evidence from a literature review, were used to assess the value of RDTs in ASPs. From this, a value framework is proposed which aims to define the benefits of RDT use in ASPs, separate from per-patient benefits. Expert insights highlight that, to realise the value of RDTs within ASPs, effective implementation is key; actionable advice for choosing an RDT is proposed. Experts advocate the inclusion of RDTs in the World Health Organization Model List of essential in vitro diagnostics and in iterative development of national action plans.

Achieving malaria testing and treatment targets for children under five in Mozambique: a cost-effectiveness analysis

Background

The entire population of Mozambique is at risk for malaria, which remains one of the leading causes of death. The 2017–2022 National Malaria Strategic Plan focuses on reducing malaria morbidity and mortality in high- and low-transmission areas. This study aimed to estimate the costs and health benefits of six variations of the World Health Organization’s “test-and-treat” strategy among children under five.

Methods

A decision tree model was developed that estimates the costs and health outcomes for children under five. Data on probabilities, costs, weights for disability-adjusted life years (DALYs), and quality-adjusted life years (QALYs) were based on peer-reviewed, grey literature, and primary data analysis of the 2018 Malaria Indicator Survey. Six scenarios were compared to the status quo and calculated the incremental cost-effectiveness ratio (ICER) in terms of cost per QALY gained, DALY averted, and life saved. Deterministic and probabilistic sensitivity analyses were conducted to understand the effect of parameter uncertainty on the findings.

Results

In the base case, reaching the target of 100% testing with rapid diagnostic tests (RDTs; Scenario 1) is more cost-effective than improving the testing rate alone by 10% (Scenario 2). Achieving a 100% (Scenario 3) or a 10% increase in treatment rate (Scenario 4) have ICERs that are lower than Scenarios 1 and 2. Both Scenarios 5 and 6, which represent combinations of Scenarios 1–4, have lower ICERs than their constituent strategies on their own, which suggests that improvements in treatment are more cost-effective than improvements in testing alone. These results held when DALYs averted or lives saved were used as health outcomes. Deterministic and probabilistic sensitivity analyses revealed that the cost-effectiveness of Scenarios 1–6 are subject sensitive to parameter uncertainty, though Scenarios 4 and 5 are the optimal choice when DALYs averted or QALYs gained were used as the measure of health outcomes across all cost-effectiveness thresholds.

Conclusions

Improving testing rates alone among children at risk for malaria has the potential to improve health but may not be the most efficient use of limited resources. Instead, small or large improvements in treatment, whether alone or in conjunction with improvements in testing, are the most cost-effective strategies for children under five in Mozambique.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-022-04354-9.

A cost analysis of the diagnosis and treatment of malaria at public health facilities and communities in three districts in Rwanda

Background

Malaria is a potentially fatal disease spread by the bites of Plasmodium-infected Anopheles mosquitoes. Despite long-term efforts to control malaria in Rwanda, malaria incidence increased from 48 to 403 cases/1000 individuals between 2012 and 2016. The diagnosis and treatment of malaria occurs at multiple levels, but the costs of these activities are not well understood. This research was conducted to estimate the direct medical costs incurred by the Ministry of Health in diagnosing and treating malaria in three districts of Rwanda in 2018.

Methods

A cross-sectional and retrospective costing analysis was conducted in three districts that represented low (5–200 cases per 1000 individuals), moderate (> 200–400 cases per 1000 individuals), and high (> 400 cases per 1000 individuals) endemicity regions. Data on malaria cases managed at three healthcare levels (community, health centre, district hospital) was obtained from national databases. The direct medical costs of cases per malaria severity (‘simple malaria’, ‘simple malaria with minor digestive symptoms’, and ‘severe malaria’) were calculated based on the minimum package of health services provided. Total costs for each of the three districts were also calculated.

Results

A total of 298,381 malaria cases were recorded in Burera, Kirehe, and Southern Kayonza districts in 2018. The average unit cost per case ranged from USD 1.36 (for simple malaria at the community level) to USD 92.80 (for severe malaria with cerebral complications at district hospitals). Simple malaria cases managed at health centres and district hospitals were more than two-fold (USD 2.99–USD 3.00) and more than eight-fold (USD 12.10–USD 12.12) higher, respectively, than those managed in the community (USD 1.36). Overall, the Ministry of Health incurred USD 645,647.68 in direct medical costs related to malaria management across the three districts in 2018. Changes in disease rates from different endemicity regions and costs of anti-malarial oral medications significantly impacted the study results.

Conclusion

In Rwanda, severe malaria results in much higher expenses compared to other malaria types. Prompt diagnosis and appropriate treatment are crucial to prevent the progression of simple malaria to severe malaria, to reduce Ministry of Health malaria expenditures, and to reduce community transmission.

Factors influencing health workers' compliance with outpatient malaria 'test and treat' guidelines during the plateauing performance phase in Kenya, 2014-2016

Background

Health workers’ compliance with outpatient malaria ‘test and treat’ guidelines has improved since 2010 but plateaued from 2014 at suboptimal levels in Kenya. This study examined the factors associated with high but suboptimal compliance levels at facilities with available malaria tests and drugs.

Methods

Data from four national, cross-sectional health facility surveys undertaken between 2014 and 2016 in Kenya were analysed. Association between 31 factors and compliance with malaria testing (survey range (SR): 65–69%) and no anti-malarial treatment for test negative patients (SR: 90–92%) were examined using multilevel logistic regression models.

Results

A total of 2,752 febrile patients seen by 594 health workers at 486 health facilities were analysed. Higher odds of malaria testing were associated with lake endemic (aOR = 12.12; 95% CI: 5.3–27.6), highland epidemic (aOR = 5.06; 95% CI: 2.7–9.5) and semi-arid seasonal (aOR = 2.07; 95% CI: 1.2–3.6) compared to low risk areas; faith-based (FBO)/ non-governmental organization (NGO)-owned compared to government-owned facilities (aOR = 5.80; 95% CI: 3.2–10.6); health workers’ perception of malaria endemicity as high-risk (aOR = 3.05; 95% CI: 1.8–5.2); supervision with feedback (aOR = 1.84; 95% CI: 1.2–2.9); access to guidelines (aOR = 1.96; 95% CI: 1.1–3.4); older patients compared to infants, higher temperature measurements and main complaints of fever, diarrhoea, headache, vomiting and chills. Lower odds of testing were associated with febrile patients having main complaints of a cough (aOR = 0.65; 95% CI: 0.5–0.9), a rash (aOR = 0.32; 95% CI: 0.2–0.7) or a running nose (aOR = 0.59; 95% CI: 0.4–0.9). Other factors associated with compliance with test negative results included the type of diagnostic test available at the facility, in-service training, health workers’ age, and correct knowledge of the targeted treatment policy.

Conclusions

To optimize outpatient malaria case-management, reduce testing compliance gaps and eliminate overtreatment of test negative patients, there is a need to focus on compliance within low malaria risk areas in addition to ensuring the universal and continuous availability of ‘test and treat’ commodities. Targeting of older and government health workers; dissemination of updated guidelines; and continuing with in-service training and supportive supervision with feedback is essential. Lastly, there is a need to improve health workers’ knowledge about malaria testing criteria considering their perceptions of endemicity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-022-04093-x.

Study of epidemiological behaviour of malaria and its control in the Purulia district of West Bengal, India (2016-2020)

Purulia is a malaria-prone district in West Bengal, India, with approximately half of the blocks defined as malaria endemic. We analyzed the malaria case in each block of the Purulia district from January 1, 2016, to December 31, 2020. As per the API, 20 blocks of Purulia were assigned to four different categories (0-3) and mapped using ArcGIS software. An exponential decay model was fitted to forecast the trend of malaria cases for each block of Purulia (2021-2025). There was a sharp decrease in total malaria cases and API from 2016 to 2020 due to the mass distribution of LLINs. The majority of cases (72.63%) were found in ≥ 15-year age group. Males were more prone to malaria (60.09%). Malaria was highly prevalent among Scheduled Tribes (48.44%). Six blocks were reported in Category 3 (high risk) and none in Category 0 (no risk) in 2016, while no blocks were determined to be in Category 3, and three blocks were in Category 0 in 2020. The exponential decay model prediction is oriented towards gaining malaria-free status in thirteen blocks of Purulia by 2025. This study will incite the government to uphold and strengthen the current efforts to meet the malaria elimination goals.

Assessing the Impact of Substandard and Falsified Antimalarials in Benin

Substandard and falsified antimalarials contribute to the global malaria burden by increasing the risk of treatment failures, adverse events, unnecessary health expenditures, and avertable deaths, yet no study has examined this impact in western francophone Africa to date. In Benin, where malaria remains endemic and is the leading cause of mortality among children younger than 5 years, there is a lack of robust data to combat the issue effectively and inform policy decisions. We adapted the Substandard and Falsified Antimalarial Research Impact model to assess the health and economic impact of poor-quality antimalarials in this population. The model simulates population characteristics, malaria infection, care-seeking behavior, disease progression, treatment outcomes, and associated costs of malaria. We estimated approximately 1.8 million cases of malaria in Benin among children younger than 5 years, which cost $193 million (95% CI, $192-$193 million) in treatment costs and productivity losses annually. Substandard and falsified antimalarials were responsible for 11% (n = 693) of deaths and nearly $20.8 million in annual costs. Moreover, we found that replacing all antimalarials with quality-ensured artemisinin combination therapies (ACTs) could result in $29.6 million in cost savings and prevent 1,038 deaths per year. These results highlight the value of improving access to quality-ensured artemisinin combination therapies for malaria treatment and increasing care-seeking in Benin. Policymakers and key stakeholders should use these findings to advocate for increased access to quality-ensured antimalarials, inform policies and interventions to improve health-care access and quality, and reduce the burden of malaria.

Determinants of improvement trends in health workers' compliance with outpatient malaria case-management guidelines at health facilities with available "test and treat" commodities in Kenya

BACKGROUND

Health workers' compliance with outpatient malaria case-management guidelines has been improving in Africa. This study examined the factors associated with the improvements.

METHODS

Data from 11 national, cross-sectional health facility surveys undertaken from 2010-2016 were analysed. Association between 31 determinants and improvement trends in five outpatient compliance outcomes were examined using interactions between each determinant and time in multilevel logistic regression models and reported as an adjusted odds ratio of annual trends (T-aOR).

RESULTS

Among 9,173 febrile patients seen at 1,208 health facilities and by 1,538 health workers, a higher annual improvement trend in composite "test and treat" performance was associated with malaria endemicity-lake endemic (T-aOR = 1.67 annually; p<0.001) and highland epidemic (T-aOR = 1.35; p<0.001) zones compared to low-risk zone; with facilities stocking rapid diagnostic tests only (T-aOR = 1.49; p<0.001) compared to microscopy only services; with faith-based/non-governmental facilities compared to government-owned (T-aOR = 1.15; p = 0.036); with a daily caseload of >25 febrile patients (T-aOR = 1.46; p = 0.003); and with under-five children compared to older patients (T-aOR = 1.07; p = 0.013). Other factors associated with the improvement trends in the "test and treat" policy components and artemether-lumefantrine administration at the facility included the absence of previous RDT stock-outs, community health workers dispensing drugs, access to malaria case-management and Integrated Management of Childhood Illness (IMCI) guidelines, health workers' gender, correct health workers' knowledge about the targeted malaria treatment policy, and patients' main complaint of fever. The odds of compliance at the baseline were variable for some of the factors.

CONCLUSIONS

Targeting of low malaria risk areas, low caseload facilities, male and government health workers, continuous availability of RDTs, improving health workers' knowledge about the policy considering age and fever, and dissemination of guidelines might improve compliance with malaria guidelines. For prompt treatment and administration of the first artemether-lumefantrine dose at the facility, task-shifting duties to community health workers can be considered.

Costs and Cost-Effectiveness of Malaria Control Interventions: A Systematic Literature Review

OBJECTIVES

To systematically review the literature on the unit cost and cost-effectiveness of malaria control.

METHODS

Ten databases and gray literature sources were searched to identify evidence relevant to the period 2005 to 2018. Studies with primary financial or economic cost data from malaria endemic countries that took a provider, provider and household, or societal perspective were included.

RESULTS

We identified 103 costing studies. The majority of studies focused on individual rather than combined interventions, notably insecticide-treated bed nets and treatment, and commonly took a provider perspective. A third of all studies took place in 3 countries. The median provider economic cost of protecting 1 person per year ranged from $1.18 to $5.70 with vector control and from $0.53 to $5.97 with chemoprevention. The median provider economic cost per case diagnosed with rapid diagnostic tests was $6.06 and per case treated $9.31 or $89.93 depending on clinical severity. Other interventions did not share enough similarities to be summarized. Cost drivers were rarely reported. Cost-effectiveness of malaria control was reiterated, but care in methodological and reporting standards is required to enhance data transferability.

CONCLUSIONS

Important information that can support resource allocation was reviewed. Given the variability in methods and reporting, global efforts to follow existing standards are required for the evidence to be most useful outside their study context, supplemented by guidance on options for transferring existing data across settings.

Modelling the impact of rapid diagnostic tests on Plasmodium vivax malaria in South Korea: a cost-benefit analysis

Background

Rapid diagnostic tests (RDTs) are widely used for diagnosing Plasmodium vivax malaria, especially in resource-limited countries. However, the impact of RDTs on P. vivax malaria incidence and national medical costs has not been evaluated. We assessed the impact of RDT implementation on P. vivax malaria incidence and overall medical expenditures in South Korea and performed a cost–benefit analysis from the payer’s perspective.

Methods

We developed a dynamic compartmental model for P. vivax malaria transmission in South Korea using delay differential equations. Long latency and seasonality were incorporated into the model, which was calibrated to civilian malaria incidences during 2014–2018. We then estimated averted malaria cases and total medical costs from two diagnostic scenarios: microscopy only and both microscopy and RDTs. Medical costs were extracted based on data from a hospital in an at-risk area for P. vivax malaria and were validated using Health Insurance Review and Assessment Service data. We conducted a cost–benefit analysis of RDTs using the incremental benefit:cost ratio (IBCR) considering only medical costs and performed a probabilistic sensitivity analysis to reflect the uncertainties of model parameters, costs and benefits.

Results

The results showed that 55.3% of new P. vivax malaria cases were averted, and $696 214 in medical costs was saved over 10 years after RDT introduction. The estimated IBCR was 2.5, indicating that RDT implementation was beneficial, compared with microscopy alone. The IBCR was sensitive to the diagnosis time reduction, infectious period and short latency period, and provided beneficial results in a benefit over $10.6 or RDT cost under $39.7.

Conclusions

The model simulation suggested that RDTs could significantly reduce P. vivax malaria incidence and medical costs. Moreover, cost–benefit analysis demonstrated that the introduction of RDTs was beneficial over microscopy alone. These results support the need for widespread adoption of RDTs.

Plasmodium falciparum Histidine-Rich Protein 2 and 3 Gene Deletions in Strains from Nigeria, Sudan, and South Sudan

Deletion of histidine-rich protein genes pfhrp2/3 in Plasmodium falciparum causes infections to go undetected by HRP2-based malaria rapid diagnostic tests. We analyzed P. falciparum malaria cases imported to Australia (n = 210, collected 2010–2018) for their pfhrp2/3 status. We detected gene deletions in patients from 12 of 25 countries. We found >10% pfhrp2-deletion levels in those from Nigeria (13.3%, n = 30), Sudan (11.2%, n = 39), and South Sudan (17.7%, n = 17) and low levels of pfhrp3 deletion from Sudan (3.6%) and South Sudan (5.9%). No parasites with pfhrp2/3 double deletions were detected. Microsatellite typing of parasites from Nigeria, Sudan, and South Sudan revealed low relatedness among gene-deleted parasites, indicating independent emergences. The gene deletion proportions signify a risk of false-negative HRP2-RDT results. This study’s findings warrant surveillance to determine whether the prevalence of gene-deleted parasites justifies switching malaria rapid diagnostic tests in Nigeria, Sudan, and South Sudan.

Accuracy of rapid diagnostic test to diagnose malaria in children under 5 years of age, a meta-analysis

OBJECTIVE

To assess the accuracy of the rapid diagnostic test for malaria diagnosis in children under 5 years of age.

METHODS

As of August 31, 2020, PubMed, Web of Science and Cochrane Library databases had been systematically searched. Relevant data were extracted and meta-analysis was carried out. A random effects model was used for subgroup analysis.

RESULTS

According to the inclusion criteria, a total of 26 studies were included in this meta-analysis. The pooled sensitivity and specificity were 0.92 (95% confidence interval 0.83-0.96) and 0.92 (0.86-0.95), the parasite-specific lactate dehydrogenase-based test were 0.96 (0.85-0.98) and 0.93 (0.86-0.95), the histidine-rich protein 2-based test were 0.94 (0.84-0.98) and 0.86 (0.77-0.91).

CONCLUSIONS

This meta-analysis showed that rapid diagnostic test had good accuracy in diagnosing malaria in children under 5 years of age. And the diagnostic performance of parasite-specific lactate dehydrogenase test was better than that of the histidine-rich protein 2 test.

High value of rapid diagnostic tests to diagnose malaria within children: A systematic review and meta-analysis

Background

Children aged under five years accounted for 61% of all malaria deaths worldwide in 2017, and quicker differential diagnosis of malaria fever is vital for them. Rapid diagnostic tests (RDTs) are strips to detect

Plasmodium

specific antigens promptly and are helpful in resource-limited areas. Thus, our aim is to assess the diagnostic accuracy of RDTs for malaria in children against the gold standard.

Methods

MEDLINE, Web of Science, EMBASE, Cochrane Library, the China National Knowledge Infrastructure, Wanfang, and Sinomed databases were systematically searched on August 23, 2019. Studies that compared RDTs with microscopy or polymerase chain reaction in malaria diagnoses for children were eligible. Relevant data were extracted. The quality of studies was evaluated using the revised Quality Assessment of Diagnostic Accuracy Studies instrument. Meta-analyses were carried out to calculate the pooled estimates and 95% confidence intervals of sensitivity and specificity.

Results

51 articles were included. For diagnostic accuracy, the pooled estimates of the sensitivity and specificity of RDTs were 0.93 (95% confidence interval (CI) = 0.90, 0.95) and 0.93 (95% CI = 0.90, 0.96) respectively. Studies were highly heterogeneous, and subgroup analyses showed that the application of RDTs in high malaria transmission areas had higher sensitivity but lower specificity than those in low-to-moderate areas.

Conclusions

RDTs have high accuracy for malaria diagnosis in children, and this characteristic is more prominent in high transmission areas. As they also have the advantages of rapid-detection, are easy-to-use, and can be cost-effective, it is recommended that the wider usage of RDTs should be promoted, especially in resource-limited areas. Further research is required to assess their performance in WHO South-East Asia and Americas Region.

Cost-effectiveness analysis of malaria rapid diagnostic test in the elimination setting

BACKGROUND

As more and more countries approaching the goal of malaria elimination, malaria rapid diagnostic tests (RDT) was recomendated to be a diagnostic strategy to achieve and maintain the statute of malaria free, as it's less requirments on equipment and experitise than microscopic examination. But there are very few economic evaluations to confirm whether RDT was cost-effective in the setting of malaria elimination. This research aimed to offer evidence for helping decision making on malaria diagnosis strategy.

METHODS

A cost-effectiveness analysis was conducted to compare RDT with microscopy examination for malaria diagnosis, by using a decision tree model. There were three strategies of malaria diagnostic testing evaluated in the model, 1) microscopy, 2) RDT, 3) RDT followed by microscopy. The effect indicator was defined as the number of malaria cases treated appropriately. Based on the joint perspective of health sector and patient, costs data were collected from hospital information systems, key informant interviews, and patient surveys. Data collection was conducted in Jiangsu from September 2018 to January 2019. Epidemiological data were obtained from local malaria surveillance reports. A hypothetical cohort of 300 000 febrile patients were simulated to calculate the total cost and effect of each strategy. One-way, two-way, and probabilistic sensitivity analysis were performed to test the robustness of the result.

RESULTS

The results showed that RDT strategy was the most effective (245 cases) but also the most costly (United States Dollar [USD] 4.47 million) compared to using microscopy alone (238 cases, USD 3.63 million), and RDT followed by microscopy (221 cases, USD 2.75 million). There was no strategy dominated. One-way sensitivity analysis reflected that the result was sensitive to the change in labor cost and two-way sensitivity analysis indicated that the result was not sensitive to the proportion of falciparum malaria. The result of Monte Carlo simulation showed that RDT strategy had higher effects and higher cost than other strategies with a high probability.

CONCLUSIONS

Compared to microscopy and RDT followed by microscopy, RDT strategy had higher effects and higher cost in the setting of malaria elimination.

Digging for care-seeking behaviour among gold miners in the Guyana hinterland: a qualitative doer non-doer analysis of social and behavioural motivations for malaria testing and treatment

BACKGROUND

Although Guyana has made significant progress toward malaria control, limited access to malaria testing and treatment services threatens those gains. Mining activities create breeding environments for mosquitoes, and the migrant and mobile mining populations are hard to reach with information and services. The Ministry of Public Health (MoPH) has trained volunteers to test and treat malaria cases in remote regions. However, it remains unclear how miners perceive these testers, the services they provide, or what their malaria care-seeking behaviour is in general. To better address these challenges, Breakthrough ACTION Guyana and MoPH conducted qualitative research from October to November 2018 in Regions 7 and 8 in Guyana.

METHODS

A total of 109 individuals, 70 miners, 17 other mining camp staff, and 22 other key stakeholders (e.g. community health workers, pharmacists, and regional leadership), participated in semi-structured interviews and focus group discussions. Results were derived using a framework analysis, with an adjusted doer and non-doer analysis, and organized using the integrated behaviour framework.

RESULTS

Miners sought MoPH-approved services because of close geographic proximity to testing services, a preference for public service treatment, and a desire to correctly diagnose and cure malaria rather than just treat its symptoms. Those who chose to initiate self-treatment-using unregulated medications from the private and informal sector-did so out of convenience and the belief that self-treatment had worked before. Miners who completed the full MoPH-approved treatment understood the need to complete the treatment, while those who prematurely stopped treatment did so because of medication side effects and a desire to feel better as soon as possible.

CONCLUSION

Reasons why miners do and do not pursue malaria testing and treatment services are diverse. These results can inform better MoPH programming and new solutions to improve malaria outcomes in Guyana.

Poor-quality antimalarials further health inequities in Uganda

Substandard and falsified medications are a major threat to public health, directly increasing the risk of treatment failure, antimicrobial resistance, morbidity, mortality and health expenditures. While antimalarial medicines are one of the most common to be of poor quality in low- and middle-income countries, their distributional impact has not been examined. This study assessed the health equity impact of substandard and falsified antimalarials among children under five in Uganda. Using a probabilistic agent-based model of paediatric malaria infection (Substandard and Falsified Antimalarial Research Impact, SAFARI model), we examine the present day distribution of the burden of poor-quality antimalarials by socio-economic status and urban/rural settings, and simulate supply chain, policy and patient education interventions. Patients incur US$26.1 million (7.8%) of the estimated total annual economic burden of substandard and falsified antimalarials, including $2.3 million (9.1%) in direct costs and $23.8 million (7.7%) in productivity losses due to early death. Poor-quality antimalarials annually cost $2.9 million to the government. The burden of the health and economic impact of malaria and poor-quality antimalarials predominantly rests on the poor (concentration index −0.28) and rural populations (98%). The number of deaths among the poorest wealth quintile due to substandard and falsified antimalarials was 12.7 times that of the wealthiest quintile, and the poor paid 12.1 times as much per person in out-of-pocket payments. Rural populations experienced 97.9% of the deaths due to poor-quality antimalarials, and paid 10.7 times as much annually in out-of-pocket expenses compared with urban populations. Our simulations demonstrated that interventions to improve medicine quality could have the greatest impact at reducing inequities, and improving adherence to antimalarials could have the largest economic impact. Substandard and falsified antimalarials have a significant health and economic impact, with greater burden of deaths, disability and costs on poor and rural populations, contributing to health inequities in Uganda.

Cost-effectiveness analysis of malaria rapid diagnostic tests: a systematic review

BACKGROUND

Rapid diagnostic tests (RDT) can effectively manage malaria cases and reduce excess costs brought by misdiagnosis. However, few studies have evaluated the economic value of this technology. The purpose of this study is to systematically review the economic value of RDT in malaria diagnosis.

MAIN TEXT

A detailed search strategy was developed to identify published economic evaluations that provide evidence regarding the cost-effectiveness of malaria RDT. Electronic databases including MEDLINE, EMBASE, Biosis Previews, Web of Science and Cochrane Library were searched from Jan 2007 to July 2018. Two researchers screened studies independently based on pre-specified inclusion and exclusion criteria. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist was applied to evaluate the quality of the studies. Then cost and effectiveness data were extracted and summarized in a narrative way. Fifteen economic evaluations of RDT compared to other diagnostic methods were identified. The overall quality of studies varied greatly but most of them were scored to be of high or moderate quality. Ten of the fifteen studies reported that RDT was likely to be a cost-effective approach compared to its comparisons, but the results could be influenced by the alternatives, study perspectives, malaria prevalence, and the types of RDT.

CONCLUSIONS

Based on available evidence, RDT had the potential to be more cost-effective than either microscopy or presumptive diagnosis. Further research is also required to draw a more robust conclusion.

The economic burden of malaria on households and the health system in a high transmission district of Mozambique

Background

Malaria remains a leading cause of morbidity and mortality in Mozambique. Increased investments in malaria control have reduced the burden, but few studies have estimated the costs of malaria in the country. This paper estimates the economic costs associated with malaria care to households and to the health system in the high burden district of Mopeia in central Mozambique.

Methods

Malaria care-seeking and morbidity costs were routinely collected among 1373 households with at least one child enrolled in an active case detection (ACD) cohort in Mopeia, and through cross-sectional surveys with 824 families in 2017 and 805 families in 2018. Household costs included direct medical expenses, transportation and opportunity costs of the time lost due to illness. Structured questionnaires were used to estimate the health system costs associated with malaria care in all 13 district health facilities. Cost estimations followed an ingredient-based approach with a top-down allocation approach for health system expenses.

Results

Among participants in cross-sectional studies, households sought care for nine severe malaria cases requiring hospital admission and for 679 uncomplicated malaria cases. Median household costs associated with uncomplicated malaria among individuals of all ages were US$ 3.46 (IQR US$ 0.07–22.41) and US$ 81.08 (IQR US$ 39.34–88.38) per severe case. Median household costs were lower among children under five (ACD cohort): US$ 1.63 (IQR US$ 0.00–7.79) per uncomplicated case and US$ 64.90 (IQR US$ 49.76–80.96) per severe case. Opportunity costs were the main source of household costs. Median health system costs associated with malaria among patients of all ages were US$ 4.34 (IQR US$ 4.32–4.35) per uncomplicated case and US$ 26.56 (IQR US$ 18.03–44.09) per severe case. Considering household and health system costs, the overall cost of malaria care to society was US$ 7.80 per uncomplicated case and US$ 107.64 per severe case, representing an economic malaria burden of US$ 332,286.24 (IQR US$ 186,355.84–1,091,212.90) per year only in Mopeia.

Conclusions

Despite the provision of free malaria services, households in Mopeia incur significant direct and indirect costs associated with the disease. Furthermore, the high malaria cost on the Mozambican health system underscores the need to strengthen malaria prevention to reduce the high burden and improve productivity in the region.

Development of an agent-based model to assess the impact of substandard and falsified anti-malarials: Uganda case study

BACKGROUND

Global efforts to address the burden of malaria have stagnated in recent years with malaria cases beginning to rise. Substandard and falsified anti-malarial treatments contribute to this stagnation. Poor quality anti-malarials directly affect health outcomes by increasing malaria morbidity and mortality, as well as threaten the effectiveness of treatment by contributing to artemisinin resistance. Research to assess the scope and impact of poor quality anti-malarials is essential to raise awareness and allocate resources to improve the quality of treatment. A probabilistic agent-based model was developed to provide country-specific estimates of the health and economic impact of poor quality anti-malarials on paediatric malaria. This paper presents the methodology and case study of the Substandard and Falsified Antimalarial Research Impact (SAFARI) model developed and applied to Uganda.

RESULTS

The total annual economic impact of malaria in Ugandan children under age five was estimated at US$614 million. Among children who sought medical care, the total economic impact was estimated at $403 million, including $57.7 million in direct costs. Substandard and falsified anti-malarials were a significant contributor to this annual burden, accounting for $31 million (8% of care-seeking children) in total economic impact involving $5.2 million in direct costs. Further, 9% of malaria deaths relating to cases seeking treatment were attributable to poor quality anti-malarials. In the event of widespread artemisinin resistance in Uganda, we simulated a 12% yearly increase in costs associated with paediatric malaria cases that sought care, inflicting $48.5 million in additional economic impact annually.

CONCLUSIONS

Improving the quality of treatment is essential to combat the burden of malaria and prevent the development of drug resistance. The SAFARI model provides country-specific estimates of the health and economic impact of substandard and falsified anti-malarials to inform governments, policy makers, donors and the malaria community about the threat posed by poor quality medicines. The model findings are useful to illustrate the significance of the issue and inform policy and interventions to improve medicinal quality.

Model-based economic evaluations of diagnostic point of care tests were rarely fit for purpose

OBJECTIVES

Linked evidence models are recommended to predict health benefits and cost-effectiveness of diagnostic tests. We considered how published models accounted for changes in patient pathways that occur with point of care tests (POCTs) and their impact on patient health and costs.

STUDY DESIGN AND SETTING

Model-based evaluations of diagnostic POCTs published from 2004 to 2017 were identified from searching six databases. For each model, we assessed the outcomes considered, and whether reduced time to diagnosis and increased access to testing affected patient health and costs.

RESULTS

Seventy-four model-based evaluations were included: 95% incorporated evidence on test accuracy, but 34% only assessed intermediate outcomes such as rates of correct diagnosis. Of 54 models where POCTs reduced testing time, 39% addressed the economic and 37% addressed the health benefits of faster diagnosis. No model considered differences in access to tests.

CONCLUSION

Many models fail to capture the effects of POCTs in increasing access, advancing speed of diagnosis and treatment, and reducing anxiety and the associated costs. Many only consider the impact of testing from changes in accuracy. Ensuring models incorporate changes in patient pathways from faster and more accessible testing will lead to economic evaluations that better reflect the impact of POCTs.

Utilization of Long-Lasting Insecticide Treated Nets and Parasitaemia at 6 Months after a Mass Distribution Exercise among Households in Mbarara Municipality, Uganda: A Cross-Sectional Community Based Study

Background

Utilization of long-lasting insecticide treated nets (LLINs) after free and mass distribution exercise has not been adequately studied. The objectives of this study were to assess ownership and utilization of LLINs following a mass distribution campaign in a Ugandan urban municipality.

Methods

We conducted a cross-sectional study in western Uganda among households with children under 5 years, at 6 months after a mass LLIN distribution exercise. We administered a questionnaire to measure LLIN ownership and utilization. We also measured parasitaemia among children under five years.

Results

Of the 346 households enrolled, 342 (98.8%) still owned all the LLINs. LLIN use was reported among 315 (91.1%) adult respondents and among 318 (91.9%) children under five. Parasitaemia was detected among 10 (2.9%) children under five. Males (OR=2.65, 95% CI 0.99-7.07), single respondents (OR=10.35, 95% CI 1.64-65.46), having a fitting bed net size (OR= 3.59, 95% CI 1.71-7.59), and no childhood malaria episode reported in the home in the last 12 months (OR=1.69, 95% CI 1.02-2.83) were all associated with LLIN use.

Conclusions

Ownership of LLIN is very high, and parasitaemia among the children was very low. Low parasitaemia may be attributed to high LLIN utilization. Long term follow-up should be done to determine durability of the ownership and utilization.

Provider and patient perceptions of malaria rapid diagnostic test use in Nigeria: a cross-sectional evaluation

Background

Nigeria commenced a phased programmatic deployment of rapid diagnostic tests (RDT) at the primary health care (PHC) facility levels since 2011. Despite various efforts, the national testing rate for malaria is still very low. The uptake of RDT has been variable. This study was undertaken to determine the provider and patient perceptions to RDT use at the PHC level in Nigeria with their implications for improving uptake and compliance.

Methods

A cross-sectional survey was conducted in 120 randomly selected PHCs across six states, across the six-geopolitical zones of Nigeria in January 2013. Health facility staff interviews were conducted to assess health workers (HW) perception, prescription practices and determinants of RDT use. Patient exit interviews were conducted to assess patient perception of RDT from ten patients/caregivers who met the eligibility criterion and were consecutively selected in each PHC, and to determine HW’s compliance with RDT test results indirectly. Community members, each selected by their ward development committees in each Local Government Area were recruited for focus group discussion on their perceptions to RDT use.

Results

Health workers would use RDT results because of confidence in RDT results (95.4%) and its reduction in irrational use of artemisinin-based combination therapy (ACT) (87.2%). However, in Enugu state, RDT was not used by health workers because of the pervasive notion RDT that results were inaccurate. Among the 1207 exit interviews conducted, 549 (45.5%) had received RDT test. Compliance rate (administering ACT to positive patients and withholding ACT from negative patients) from patient exit interviews was 90.2%. Among caregivers/patients who had RDT done, over 95% knew that RDT tested for malaria, felt it was necessary and liked the test. Age of patients less than 5 years (p = 0.04) and “high” educational status (p = 0.0006) were factors influencing HW’s prescription of ACT to RDT negative patients.

Conclusion

The study demonstrated positive perception to RDT use by HW and among community members with good compliance rate among health workers at the PHC level. This positive perception should be explored in improving the current low level of malaria testing in Nigeria while addressing the influence of age on HW administration of ACT to RDT negative cases.

Fabrication of a Lab-on-Chip Device Using Material Extrusion (3D Printing) and Demonstration via Malaria-Ab ELISA

Additive manufacturing, such as fused deposition modeling (FDM), has been increasingly employed to produce microfluidic platforms due to ease of use, wide distribution of affordable 3D printers and relatively inexpensive materials for printing. In this work, we discuss fabrication and testing of an FDM-printed fully automated colorimetric enzyme-linked immunosorbent assay (ELISA) designed to detect malaria. The detection platform consists of a disposable 3D-printed fluidic cartridge (with elastomeric silicone domes on top of reagent-storage reservoirs) and a nondisposable frame with servomotors and electronic controls such as an Arduino board and a rechargeable battery. The system is controlled by a novel interface where a music file (so-called “song”) is sent to the Arduino board, where the onboard program converts the set of frequencies into action of individual servomotors to rotate their arms a certain amount, thus depressing specific elastomeric domes atop reagent reservoirs and displacing the specific reagents into the detection wells, where bioassay steps are executed. Another of the distinguished characteristics of the demonstrated system is its ability to aspirate the fluid from the detection wells into the waste reservoir. Therefore, the demonstrated automated platform has the ability to execute even the most complex multi-step assays where dilution and multiple washes are required. Optimization of 3D-printer settings and ways to control leakages typical of FDM-printed fluidic systems are also discussed.

Cost-effectiveness analysis of introducing malaria diagnostic testing in drug shops: A cluster-randomised trial in Uganda

BACKGROUND

Private sector drug shops are an important source of malaria treatment in Africa, yet diagnosis without parasitological testing is common among these providers. Accurate rapid diagnostic tests for malaria (mRDTs) require limited training and present an opportunity to increase access to correct diagnosis. The present study was a cost-effectiveness analysis of the introduction of mRDTs in Ugandan drug shops.

METHODS

Drug shop vendors were trained to perform and sell subsidised mRDTs and artemisinin-based combination therapies (ACTs) in the intervention arm while vendors offered ACTs following presumptive diagnosis of malaria in the control arm. The effect on the proportion of customers with fever 'appropriately treated of malaria with ACT' was captured during a randomised trial in drug shops in Mukono District, Uganda. Health sector costs included: training of drug shop vendors, community sensitisation, supervision and provision of mRDTs and ACTs to drug shops. Household costs of treatment-seeking were captured in a representative sample of drug shop customers.

FINDINGS

The introduction of mRDTs in drug shops was associated with a large improvement of diagnosis and treatment of malaria, resulting in low incremental costs for the health sector at US$0.55 per patient appropriately treated of malaria. High expenditure on non-ACT drugs by households contributed to higher incremental societal costs of US$3.83. Sensitivity analysis showed that mRDTs would become less cost-effective compared to presumptive diagnosis with increasing malaria prevalence and lower adherence to negative mRDT results.

CONCLUSION

mRDTs in drug shops improved the targeting of ACTs to malaria patients and are likely to be considered cost-effective compared to presumptive diagnosis, although the increased costs borne by households when the test result is negative are a concern.

NMR relaxation properties of the synthetic malaria pigment β-hematin

200 million patients suffer from malaria, a parasitic disease caused by protozoans of the genus Plasmodium. Reliable diagnosis is crucial since it allows the early detection of the disease. The development of rapid, sensitive and low-cost diagnosis tools is an important research area. Different studies focused on the detection of hemozoin, a major by-product of hemoglobin detoxification by the parasite. Hemozoin and its synthetic analog, β-hematin, form paramagnetic crystals. A new detection method of malaria takes advantage of the paramagnetism of hemozoin through the effect that such magnetic crystals have on Nuclear Magnetic Resonance (NMR) relaxation of water protons. Indeed, magnetic microparticles cause a shortening of the relaxation times. In this work, the magnetic properties of two types of β-hematin are assessed at different temperatures and magnetic fields. The pure paramagnetism of β-hematin is confirmed. The NMR relaxation of β–hematin suspensions is also studied at different magnetic fields and for different echo-times. Our results help to identify the best conditions for β–hematin detection by NMR: T₂ must be selected, at large magnetic fields and for long echo-times. However, the effect of β-hematin on relaxation does not seem large enough to achieve accurate detection of malaria without any preliminary sample preparation, as microcentrifugation.

Cost-effectiveness analysis of malaria rapid diagnostic tests for appropriate treatment of malaria at the community level in Uganda

In Sub-Saharan Africa, malaria remains a major cause of morbidity and mortality among children under 5, due to lack of access to prompt and appropriate diagnosis and treatment. Many countries have scaled-up community health workers (CHWs) as a strategy towards improving access. The present study was a cost-effectiveness analysis of the introduction of malaria rapid diagnostic tests (mRDTs) performed by CHWs in two areas of moderate-to-high and low malaria transmission in rural Uganda. CHWs were trained to perform mRDTs and treat children with artemisinin-based combination therapy (ACT) in the intervention arm while CHWs offered treatment based on presumptive diagnosis in the control arm. Data on the proportion of children with fever 'appropriately treated for malaria with ACT' were captured from a randomised trial. Health sector costs included: training of CHWs, community sensitisation, supervision, allowances for CHWs and provision of mRDTs and ACTs. The opportunity costs of time utilised by CHWs were estimated based on self-reporting. Household costs of subsequent treatment-seeking at public health centres and private health providers were captured in a sample of households. mRDTs performed by CHWs was associated with large improvements in appropriate treatment of malaria in both transmission settings. This resulted in low incremental costs for the health sector at US$3.0 per appropriately treated child in the moderate-to-high transmission area. Higher incremental costs at US$13.3 were found in the low transmission area due to lower utilisation of CHW services and higher programme costs. Incremental costs from a societal perspective were marginally higher. The use of mRDTs by CHWs improved the targeting of ACTs to children with malaria and was likely to be considered a cost-effective intervention compared to a presumptive diagnosis in the moderate-to-high transmission area. In contrast to this, in the low transmission area with low attendance, RDT use by CHWs was not a low cost intervention.

Evaluation of the knowledge and attitude of pharmacists about the national malaria control policy in southern Benin

Background

The national strategy against malaria in an endemic country should involve all the health stakeholders. In Benin, the private sector is rarely present in the activities of the National Malaria Control Programme (NMCP), and its surveillance system does not cover private sector outlets that are a non-negligible part of the healthcare system.

Objective

The aim of this study was to describe the drug delivery practices within private pharmacies of Cotonou and Porto-Novo and the awareness of medicine providers concerning the national policy of malaria treatment.

Methods

A survey was performed among pharmacy staff members responsible for dispensing medicines and providing advice to patients within pharmacies of Cotonou and Porto-Novo. Dispensing/pharmacy assistants (‘dispensators’) from 82 pharmacies in Cotonou and 19 in Porto-Novo were surveyed. Data entry was performed using Epidata 3.1 software and data analysis was carried out using SPSS software version 21.1. Chi square test was used to compare proportions. A significance threshold of 0.05 was defined for the p value.

Results

46% of providers did not know the artemisinin-based combination therapy recommended by the NMCP for treating uncomplicated malaria. 58.7% were not able to recognize the gravity signs of malaria. 89.8% of dispensators were used to deliver an anti-malarial upon patient request, without prior biological confirmation as requested by the NMCP policy.

Conclusions

Dispensing practices within the studied pharmacies from Cotonou and Porto-Novo were not in adequacy with the NMCP guidelines for uncomplicated malaria, which is a striking weakness in the training of drug providers on key elements of the guidelines for managing malaria. The NMCP needs to help dispensator from private pharmacies sector to standardize drug delivery practices according to its guidelines.

Defining the next generation of Plasmodium vivax diagnostic tests for control and elimination: Target product profiles

The global prevalence of malaria has decreased over the past fifteen years, but similar gains have not been realized against Plasmodium vivax because this species is less responsive to conventional malaria control interventions aimed principally at P. falciparum. Approximately half of all malaria cases outside of Africa are caused by P. vivax. This species places dormant forms in human liver that cause repeated clinical attacks without involving another mosquito bite. The diagnosis of acute patent P. vivax malaria relies primarily on light microscopy. Specific rapid diagnostic tests exist but typically perform relatively poorly compared to those for P. falciparum. Better diagnostic tests are needed for P. vivax. To guide their development, FIND, in collaboration with P. vivax experts, identified the specific diagnostic needs associated with this species and defined a series of three distinct target product profiles, each aimed at a particular diagnostic application: (i) point-of-care of acutely ill patients for clinical care purposes; (ii) point-of-care asymptomatic and otherwise sub-patent residents for public health purposes, e.g., mass screen and treat campaigns; and (iii) ultra-sensitive not point-of-care diagnosis for epidemiological research/surveillance purposes. This report presents and discusses the rationale for these P. vivax-specific diagnostic target product profiles. These contribute to the rational development of fit-for-purpose diagnostic tests suitable for the clinical management, control and elimination of P. vivax malaria.

Plasmodium vivax is the second most prevalent Plasmodium species amongst the five that can infect humans and cause malaria. The control and elimination of P. vivax is complicated by its specific biology, such as hard-to-detect low densities of blood-circulating parasites in infected individuals, the existence of persistent liver forms causing relapse, or the early appearance of sexual stages of the parasite during the course of an infection, which facilitates its transmission. These difficulties are reinforced by the fact that most antimalarial tools have been developed primarily for P. falciparum, the most prevalent malaria species, and are not always as effective for P. vivax. Current tools for the diagnosis of P. vivax are of limited effectiveness. Rapid diagnostic tests exist but show, in average, lower performance than similar test for P. falciparum. P. vivax diagnosis often relies on light microscopy which is challenging to maintain at a high quality and not sensitive enough to detect a large fraction of all infections. Recognizing that better diagnostic tools for P. vivax are needed, we report in this study the development of new target product profiles to define the specific characteristics of such tests. The establishment of these consensus-based documents is an important first step to guide research and development efforts toward better diagnostic solutions for P. vivax malaria and to accelerate the elimination of this species alongside P. falciparum.

Analytical sensitivity of current best-in-class malaria rapid diagnostic tests

BACKGROUND

Rapid diagnostic tests (RDTs) are today the most widely used method for malaria diagnosis and are recommended, alongside microscopy, for the confirmation of suspected cases before the administration of anti-malarial treatment. The diagnostic performance of RDTs, as compared to microscopy or PCR is well described but the actual analytical sensitivity of current best-in-class tests is poorly documented. This value is however a key performance indicator and a benchmark value needed to developed new RDTs of improved sensitivity.

METHODS

Thirteen RDTs detecting either the Plasmodium falciparum histidine rich protein 2 (HRP2) or the plasmodial lactate dehydrogenase (pLDH) antigens were selected from the best performing RDTs according to the WHO-FIND product testing programme. The analytical sensitivity of these products was evaluated using a range of reference materials including P. falciparum and Plasmodium vivax whole parasite samples as well as recombinant proteins.

RESULTS

The best performing HRP2-based RDTs could detect all P. falciparum cultured samples at concentrations as low as 0.8 ng/mL of HRP2. The limit of detection of the best performing pLDH-based RDT specifically detecting P. vivax was 25 ng/mL of pLDH.

CONCLUSION

The analytical sensitivity of P. vivax and Pan pLDH-based RDTs appears to vary considerably from product to product, and improvement of the limit-of-detection for P. vivax detecting RDTs is needed to match the performance of HRP2 and Pf pLDH-based RDTs for P. falciparum. Different assays using different reference materials produce different values for antigen concentration in a given specimen, highlighting the need to establish universal reference assays.

Antimalarial prescription in a public hospital outpatient setting in Kenya: A best practice implementation project

BACKGROUND

Important gaps still exist in malaria case management despite implementation of the World Health Organization parasitological diagnosis before treatment recommendation. This calls for evidence-based strategies to improve health providers' adherence to these guidelines.

OBJECTIVE

The goal of this project was to improve adherence of confirmed parasitological diagnosis prior to antimalarial prescription in the outpatient department.

METHODS

The Joanna Briggs Institute Practical Application of Clinical Evidence System program was used to facilitate collection of baseline and post-audit data. The Getting Research into Practice program was also utilized to analyze the potential barriers and for designing the intervention strategies. This study was done during a 7-month period in an outpatient department of public health facility in Kenya.

RESULTS

Baseline and post-implementation audit results comparison indicate that there was a clinically significant improvement in all three criteria. One hundred percent of health providers underwent training on malaria case management, an improvement from 24% at baseline. Almost all (98%) suspected cases for malaria were tested for malaria parasite, and 98% doses of antimalarial drug dispensed had documentation indicating that the malaria test result was positive, an increase of 74%.

CONCLUSION

This study successfully increased the adherence to malaria parasitological confirmation before the treatment recommendation. The interdepartmental collaboration facilitated improvements that led to a reduction in presumptive prescription of antimalarial drugs, antimalarial medication costs, and potentially the emergence of drug resistance.

Improving the Specificity of Plasmodium falciparum Malaria Diagnosis in High-Transmission Settings with a Two-Step Rapid Diagnostic Test and Microscopy Algorithm

Poor specificity may negatively impact rapid diagnostic test (RDT)-based diagnostic strategies for malaria. We performed real-time PCR on a subset of subjects who had undergone diagnostic testing with a multiple-antigen (histidine-rich protein 2 and pan-lactate dehydrogenase pLDH [HRP2/pLDH]) RDT and microscopy. We determined the sensitivity and specificity of the RDT in comparison to results of PCR for the detection of Plasmodium falciparum malaria. We developed and evaluated a two-step algorithm utilizing the multiple-antigen RDT to screen patients, followed by confirmatory microscopy for those individuals with HRP2-positive (HRP2⁺)/pLDH-negative (pLDH^-) results. In total, dried blood spots (DBS) were collected from 276 individuals. There were 124 (44.9%) individuals with an HRP2⁺/pLDH⁺ result, 94 (34.1%) with an HRP2⁺/pLDH^- result, and 58 (21%) with a negative RDT result. The sensitivity and specificity of the RDT compared to results with real-time PCR were 99.4% (95% confidence interval [CI], 95.9 to 100.0%) and 46.7% (95% CI, 37.7 to 55.9%), respectively. Of the 94 HRP2⁺/pLDH^- results, only 32 (34.0%) and 35 (37.2%) were positive by microscopy and PCR, respectively. The sensitivity and specificity of the two-step algorithm compared to results with real-time PCR were 95.5% (95% CI, 90.5 to 98.0%) and 91.0% (95% CI, 84.1 to 95.2), respectively. HRP2 antigen bands demonstrated poor specificity for the diagnosis of malaria compared to that of real-time PCR in a high-transmission setting. The most likely explanation for this finding is the persistence of HRP2 antigenemia following treatment of an acute infection. The two-step diagnostic algorithm utilizing microscopy as a confirmatory test for indeterminate HRP2⁺/pLDH^- results showed significantly improved specificity with little loss of sensitivity in a high-transmission setting.

Simulations Show Diagnostic Testing For Malaria In Young African Children Can Be Cost-Saving Or Cost-Effective

Malaria imposes a substantial global disease burden. It disproportionately affects sub-Saharan Africans, particularly young children. In an effort to improve disease management, the World Health Organization (WHO) recommended in 2010 that countries test children younger than age five who present with suspected malaria fever to confirm the diagnosis instead of treating them presumptively with antimalarial drugs. Costs and concerns about the overall health impact of such diagnostic testing for malaria in children remain barriers to full implementation. Using data from national Malaria Indicator Surveys, we estimated two-stage microsimulation models for Angola, Tanzania, and Uganda to assess the policy's cost-effectiveness. We found that diagnostic testing for malaria in children younger than five is cost-saving in Angola. In Tanzania and Uganda the cost per life-year gained is $5.54 and $94.28, respectively. The costs projected for Tanzania and Uganda are less than the WHO standard of $150 per life-year gained. Our results were robust under varying assumptions about cost, prevalence of malaria, and behavior, and they strongly suggest the pursuit of policies that facilitate full implementation of testing for malaria in children younger than five.

The Point-of-Care Laboratory in Clinical Microbiology

Point-of-care (POC) laboratories that deliver rapid diagnoses of infectious diseases were invented to balance the centralization of core laboratories. POC laboratories operate 24 h a day and 7 days a week to provide diagnoses within 2 h, largely based on immunochromatography and real-time PCR tests. In our experience, these tests are conveniently combined into syndrome-based kits that facilitate sampling, including self-sampling and test operations, as POC laboratories can be operated by trained operators who are not necessarily biologists. POC laboratories are a way of easily providing clinical microbiology testing for populations distant from laboratories in developing and developed countries and on ships. Modern Internet connections enable support from core laboratories. The cost-effectiveness of POC laboratories has been established for the rapid diagnosis of tuberculosis and sexually transmitted infections in both developed and developing countries.

Prioritizing health system and disease burden factors: an evaluation of the net benefit of transferring health technology interventions to different districts in Zimbabwe

INTRODUCTION

Health-care technologies (HCTs) play an important role in any country's health-care system. Zimbabwe's health-care system uses a lot of HCTs developed in other countries. However, a number of local factors have affected the absorption and use of these technologies. We therefore set out to test the hypothesis that the net benefit regression framework (NBRF) could be a helpful benefit testing model that enables assessment of intra-national variables in HCT transfer.

METHOD

We used an NBRF model to assess the benefits of transferring cost-effective technologies to different jurisdictions. We used the country's 57 administrative districts to proxy different jurisdictions. For the dependent variable, we combined the cost and effectiveness ratios with the districts' per capita health expenditure. The cost and effectiveness ratios were obtained from HIV/AIDS and malaria randomized controlled trials, which did either a prospective or retrospective cost-effectiveness analysis. The independent variables were district demographic and socioeconomic determinants of health.

RESULTS

The study showed that intra-national variation resulted in different net benefits of the same health technology intervention if implemented in different districts in Zimbabwe. The study showed that population data, health data, infrastructure, demographic and health-seeking behavior had significant effects on the net margin benefit for the different districts. The net benefits also differed in terms of magnitude as a result of the local factors.

CONCLUSION

Net benefit testing using local data is a very useful tool for assessing the transferability and further adoption of HCTs developed elsewhere. However, adopting interventions with a positive net benefit should also not be an end in itself. Information on positive or negative net benefit could also be used to ascertain either the level of future savings that a technology can realize or the level of investment needed for the particular technology to become beneficial.

Cost-Effectiveness Analysis of Test-Based versus Presumptive Treatment of Uncomplicated Malaria in Children under Five Years in an Area of High Transmission in Central Ghana

Background

The presumptive approach of confirming malaria in health facilities leads to over-diagnosis of malaria, over use of anti-malaria drugs and the risk of drug resistance development. WHO recommends parasitological confirmation before treatment with artemisinin-based combination therapy (ACT) in all suspected malaria patients. The use of malaria rapid diagnostic tests (mRDTs) would make it possible for prescribers to diagnose malaria at point-of-care and better target the use of antimalarials. Therefore, a cost-effectiveness analysis was performed on the introduction of mRDTs for management of malaria in under-five children in a high transmission area in Ghana where presumptive diagnosis was the norm in public health centres.

Methods

A cluster-randomised controlled trial where thirty-two health centres were randomised into test-based diagnosis of malaria using mRDTs (intervention) or clinical judgement (control) was used to measure the effect of mRDTs on appropriate treatment: ‘a child with a positive reference diagnosis prescribed a course of ACT or a child with a negative reference diagnosis not given an ACT’. Cost data was collected from five purposively selected health centres and used to estimate the health sector costs of performing an mRDT and treat children for malaria and other common febrile illnesses. Costs of training healthcare personnel and supervision in the study period were also collected. A sample of caregivers to children participating in the trial was interviewed about household cost incurred on transport, drugs, fees, and special food during a period of one week after the health centre visit as well as days unable to work. A decision model approach was used to calculate the incremental cost-effectiveness ratios (ICERs). Univariate and multivariate sensitivity analyses were applied to assess the robustness of ICERs.

Results

The availability of mRDTs for malaria diagnosis resulted in fewer ACT treatments compared to the clinical judgement approach (73% versus 81%) and more children appropriately treated (70% versus 57%). The introduction of mRDT-based diagnosis would cost the Ministry of Health US$18.6 per extra appropriately treated child under five compared to clinical judgement while the ICER from a societal perspective was lower at US$11.0 per appropriately treated child. ICERs were sensitive to a decrease in adherence to negative mRDTs, malaria positivity rate and specificity of the mRDT.

Conclusion

The introduction of mRDTs is likely to be considered cost-effective in this high transmission setting as this intervention increased the number of appropriately treated children at low cost.

Trial Registration

ClinicalTrials.gov NCT00832754

Multi-method assessment of patients with febrile illness reveals over-diagnosis of malaria in rural Uganda

Background

Health clinics in rural Africa are typically resource-limited. As a result, many patients presenting with fever are treated with anti-malarial drugs based only on clinical presentation. This is a considerable issue in Uganda, where malaria is routinely over-diagnosed and over-treated, constituting a wastage of resources and an elevated risk of mortality in wrongly diagnosed patients. However, rapid diagnostic tests (RDTs) for malaria are increasingly being used in health facilities. Being fast, easy and inexpensive, RDTs offer the opportunity for feasible diagnostic capacity in resource-limited areas. This study evaluated the rate of malaria misdiagnosis and the accuracy of RDTs in rural Uganda, where presumptive diagnosis still predominates. Specifically, the diagnostic accuracy of “gold standard” methods, microscopy and PCR, were compared to the most feasible method, RDTs.

Methods

Patients presenting with fever at one of two health clinics in the Kabarole District of Uganda were enrolled in this study. Blood was collected by finger prick and used to administer RDTs, make blood smears for microscopy, and blot Whatman FTA cards for DNA extraction, polymerase chain reaction (PCR) amplification, and sequencing. The accuracy of RDTs and microscopy were assessed relative to PCR, considered the new standard of malaria diagnosis.

Results

A total of 78 patients were enrolled, and 31 were diagnosed with Plasmodium infection by at least one method. Comparing diagnostic pairs determined that RDTs and microscopy performed similarly, being 92.6 and 92.0 % sensitive and 95.5 and 94.4 % specific, respectively. Combining both methods resulted in a sensitivity of 96.0 % and specificity of 100 %. However, both RDTs and microscopy missed one case of non-falciparum malaria (Plasmodium malariae) that was identified and characterized by PCR and sequencing. In total, based on PCR, 62.0 % of patients would have been misdiagnosed with malaria if symptomatic diagnosis was used.

Conclusions

Results suggest that diagnosis of malaria based on symptoms alone appears to be highly inaccurate in this setting. Furthermore, RDTs were very effective at diagnosing malaria, performing as well or better than microscopy. However, only PCR and DNA sequencing detected non-P. falciparum species, which highlights an important limitation of this test and a treatment concern for non-falciparum malaria patients. Nevertheless, RDTs appear the only feasible method in rural or resource-limited areas, and therefore offer the best way forward in malaria management in endemic countries.

Factors affecting adherence to national malaria treatment guidelines in management of malaria among public healthcare workers in Kamuli District, Uganda

Background

Malaria remains a major public health threat accounting for 30.4 % of disease morbidity in outpatient clinic visits across all age groups in Uganda. Consequently, malaria control remains a major public health priority in endemic countries such as Uganda. Experiences from other countries in Africa that revised their malaria case management suggest that health workers adherence may be problematic.

Methods

A descriptive, cross-sectional design was used and collected information on health system, health workers and patients. Using log-binomial regression model, adjusted prevalence risk ratios (PRRs) and their associated 95 % confidence intervals were determined in line with adherence to new treatment guidelines of parasitological diagnosis and prompt treatment with artemisinin combination therapy (ACT).

Results

Nine health centres, 24 health workers and 240 patient consultations were evaluated. Overall adherence to national malaria treatment guidelines (NMTG) was 50.6 % (122/241). It was significantly high at HC III [115 (53 %)] than at HC IV (29 %) [PRR = 0.28 (95 % CI 0.148 0.52), p = 0.000]. Compared to the nursing aide, the adherence level was 1.57 times higher among enrolled nurses (p = 0.004) and 1.68 times higher among nursing officers, p = 0.238, with statistical significance among the former. No attendance of facility malaria-specific continuing medical education (CME) sessions [PRR = 1.9 (95 % CI 1.29 2.78), p = 0.001] and no display of malaria treatment job aides in consultation rooms [PRR = 0.64 (95 % CI 0.4 1.03), p = 0.07] was associated with increased adherence to guidelines with the former showing a statistical significance and the association of the latter borderline statistical significance. The adherence was higher when the laboratory was functional [PRR = 0.47 (95 % CI 0.35 0.63)] when the laboratory was functional in previous 6 months. Age of health worker, duration of employment, supervision, educational level, and age of patient were found not associated with adherence to new treatment guidelines.

Conclusion

Adherence to malaria treatment guidelines in Uganda is sub-optimal. There is an urgent need for deliberate interventions to improve adherence to these guidelines. Possible interventions to be explored should include: provision of job aides and improved access to laboratory services. There is also a need for continuous medical educational sessions for health workers, especially those at higher-level facilities and higher cadres, on adherence to guidelines in management of fever, including management of other causes of fever.

Cost and Predictors of Care-Seeking Behaviors Among Caregivers of Febrile Children-Uganda, 2009

Fever is a major cause of morbidity and mortality among children under 5 years of age in resource-limited countries. Although prevention and treatment of febrile illnesses have improved, the costs--both financial and nonfinancial--remain barriers to care. Using data from the 2009 Uganda Malaria Indicator Survey, we describe the costs associated with the care of a febrile child and assess predictors of care-seeking behavior. Over 80% of caregivers sought care for their febrile child, however less than half did so on either the day of or the day after the development of fever. The odds of seeking care decreased with each additional month of the child's age. Caregivers living in rural areas were more likely to seek care, however were less likely to seek care promptly. Caregivers with at least a primary school education and those familiar with the protective effect of bed nets and the need to seek care promptly were more likely to seek care. Despite government assistance, the majority of caregivers did incur costs (mean 13,173 Ugandan shilling; $6.84 U.S. dollars) associated with medical care. Continued efforts targeting barriers to seeking care, including the economic burden, are necessary.

Incorporating Demand and Supply Constraints into Economic Evaluations in Low-Income and Middle-Income Countries

Global guidelines for new technologies are based on cost and efficacy data from a limited number of trial locations. Country-level decision makers need to consider whether cost-effectiveness analysis used to inform global guidelines are sufficient for their situation or whether to use models that adjust cost-effectiveness results taking into account setting-specific epidemiological and cost heterogeneity. However, demand and supply constraints will also impact cost-effectiveness by influencing the standard of care and the use and implementation of any new technology. These constraints may also vary substantially by setting. We present two case studies of economic evaluations of the introduction of new diagnostics for malaria and tuberculosis control. These case studies are used to analyse how the scope of economic evaluations of each technology expanded to account for and then address demand and supply constraints over time. We use these case studies to inform a conceptual framework that can be used to explore the characteristics of intervention complexity and the influence of demand and supply constraints. Finally, we describe a number of feasible steps that researchers who wish to apply our framework in cost-effectiveness analyses.

Malaria burden and anti-malarial drug efficacy in Owando, northern Congo

Background

In the Republic of Congo, previous epidemiological studies have only been conducted in the south of the country where it is most accessible. Nationally representative data on the efficacy of new anti-malarial tools are lacking in the country. As an initial step to close the gap, clinical efficacy of two artemisinin-based combinations, artesunate-amodiaquine (ASAQ) and artemether-lumefantrine (AL), was assessed in Owando, a city in equatorial flooded forest in northern Republic of Congo.

Methods

Under 12 years old febrile children attending public health facilities were screened for malaria parasites using lactate dehydrogenase (LDH)-based rapid diagnostic test (RDT) for malaria and microscopic examination of thick blood films. Patients with at least 1,000 asexual Plasmodium falciparum parasites/µl of blood were clinically examined, included after informed consent, and followed up for 28 days, according to the 2009 World Health Organization protocol. Patients were randomly assigned to co-formulated ASAQ (Coarsucam^®) or AL (Coartem^®) treatment groups. Plasmodium falciparum recrudescent isolates were compared to pre-treatment isolates by polymerase chain reaction (PCR) using msp1, msp2, and glurp genes to distinguish between re-infection and recrudescence.

Results

Between November 2012 and February 2013, 857 under 12 years old febrile children were screened, of whom 198 (23.1 %) had positive RDT and 167 (19.5 %) positive thick films. ASAQ and AL efficacies were 92.7 and 94.2 % before PCR correction, respectively. After genotyping, the overall efficacy was 100 % for ASAQ and 98.0 % for AL.

Conclusion

The data reported here represent partially the burden of malaria in 0–11 years old febrile children examined in public health centres of Owando city and serve as reference for further studies. Both artemisinin-based combinations were highly efficacious in patients under 12 years old with acute uncomplicated malaria. ASAQ was associated with more adverse events, which may reduce compliance in unsupervised treatment.

Trial registration: ACTRN12612000940875

Status of the use and compliance with malaria rapid diagnostic tests in formal private health facilities in Nigeria

Background

Nigeria has the largest number of malaria-related deaths, accounting for a third of global malaria deaths. It is important that the country attains universal coverage of key malaria interventions, one of which is the policy of universal testing before treatment, which the country has recently adopted. However, there is a dearth of data on its implementation in formal private health facilities, where close to a third of the population seek health care. This study identified the level of use of malaria rapid diagnostic testing (RDT), compliance with test results and associated challenges in the formal private health facilities in Nigeria.

Methods

A cross-sectional study that involved a multi-stage, random sampling of 240 formal private health facilities from the country’s six geo-political zones was conducted from July to August 2014. Data were collected using health facility records, healthcare workers’ interviews and an exit survey of febrile patients seen at the facilities, in order to determine fever prevalence, level of testing of febrile patience, compliance with test results, and health workers’ perceptions to RDT use.

Results

Data from the 201 health facilities analysed indicated a fever prevalence of 38.5 % (112,521/292,430). Of the 2077 exit interviews for febrile patients, malaria testing was ordered in 73.8 % (95 % CI 71.7–75.7 %). Among the 1270 tested, 61.8 % (719/1270) were tested with microscopy and 38.2 % (445/1270) with RDT. Compliance to malaria test result [administering arteminisin-based combination therapy (ACT) to positive patients and withholding ACT from negative patients] was 80.9 % (95 % CI 78.7–83 %). Compliance was not influenced by the age of patients or type of malaria test. The health facilities have various cadres of the health workers knowledgeable on RDT with 70 % knowing the meaning, while 84.5 % knew what it assesses. However, there was clearly a preference for microscopy as only 20 % reported performing only RDT.

Conclusion

In formal private health facilities in Nigeria there is a high rate of malaria testing for febrile patients, high level of compliance with test results but relatively low level of RDT utilization. This calls for improved engagement of the formal private health sector with a view to achieving universal coverage targets on malaria testing.

Prescription practices for malaria in Mozambique: poor adherence to the national protocols for malaria treatment in 22 public health facilities

Background

Current World Health Organization and national protocols recommend the ‘test and treat’ strategy for the management of uncomplicated malaria, to reduce over prescription of artemisinin-based combination treatment (ACT). Therefore, adherence to these protocols varies in different sub-Saharan African countries and no information is available for Mozambique. This study was conducted with the aim to evaluate the prescription practices of ACT in Mozambique.

Methods

Retrospective audit of medical records corresponding to the period between July and December 2011 was conducted in 22 health units across 11 provinces in Mozambique. Two health units were selected per province according to availability of laboratory data (performing microscopy and rapid diagnostics testing-RDT or RDT only) and geographic setting (rural versus urban). At each facility, demographic data, laboratory results (blood smear or RDT), and prescription of ACT were all collected from the existing records.

Results

Between July and December 2011, a total of 61,730 cases were tested for malaria, of which 42.7 % (26,369/61,730) were positive. A total of 35.361 patients were malaria negative, and ACT was prescribed to 72.0 % (25.448/35.361) of them. Prescription of ACT to malaria negative patients was higher in the central region of the country as compared to the northern and southern (81.1 % in the central region versus 72.4 and 63.7 % in the northern and southern, respectively, p = 0.000) and in urban settings (88.7 % in rural versus 58.0 % in urban settings, p = 0.000). Stock out of RDT was observed in six (27.3 %) of the health facilities. When no RDT was available, patients were empirically treated with ACT.

Conclusion

Findings from this study demonstrate that health care worker’s adherence to the new guidelines for malaria treatment is poor in Mozambique and prescription of ACT to malaria negative patients remains very high. Enhanced training and supervision activities, community education and external quality assurance might lead to significant improvements in the clinician’s adherence to the new guideline for malaria treatment in Mozambique.

Cost-effectiveness of malaria diagnosis using rapid diagnostic tests compared to microscopy or clinical symptoms alone in Afghanistan

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.

Is there a distinction between malaria treatment and intermittent preventive treatment? Insights from a cross-sectional study of anti-malarial drug use among Ugandan pregnant women

Background

In Uganda, treatment of clinical malaria and intermittent preventive treatment with sulphadoxine-pyrimethamine (SP) are common during pregnancy. As a result, both formal and informal reports from antenatal sources suggest possible misuse of SP for malaria treatment among pregnant women. The objective of this study was to investigate anti-malarial drug use patterns among women who had recently suffered malaria illness before and during pregnancy.

Methods

A cross-sectional study in which a structured questionnaire (interviewer-administered) was used to collect data from pregnant women attending an urban antenatal clinic. Details of medicines used to treat malaria episodes suffered before and during pregnancy were captured. A first order Markov probability model was used to estimate probabilities of transitioning between treatment choices made before and during pregnancy. Logistic regression was used to explore whether demographic and obstetric characteristics were associated with transition patterns.

Results

Seven hundred women were interviewed among whom 428 had suffered malaria in both instances. Three hundred thirty of these could recall the medicines used in both instances. Women who used ACT/QNN (correct choice) before pregnancy had higher probabilities of transitioning to SP than staying on ACT/QNN during pregnancy (0.463 versus 0.451). Access of medicines from private outlets (clinics and pharmacies) were more than nine times predictive of receiving correct medicines (p=0.035 and p=0.039 respectively). Access of medicines from clinics was 5.9 times protective against receiving SP for malaria treatment (p=0.033). Among those who used SP before pregnancy, there was a 0.75 probability of staying on it during pregnancy. None of the factors explored could explain this observation.

Conclusion

Use of SP for malaria treatment is common during pregnancy. This may be contributing to adverse pregnancy outcomes. Antenatal care providers should endeavour to emphasize the distinction between treatment and prevention of malaria during pregnancy.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-015-0702-7) contains supplementary material, which is available to authorized users.

Attitudes toward home-based malaria testing in rural and urban Sierra Leone

Background

The purpose of this study was to examine malaria testing practices and preferences in Bo, Sierra Leone, and to ascertain interest in and willingness to take a home-based rapid diagnostic test administered by a community health volunteer (CHV) or a trained family member rather than travelling to a clinical facility for laboratory-based testing.

Methods

A population-based, cross-sectional survey of 667 randomly-sampled rural households and 157 urban households was conducted in December 2013 and January 2014.

Results

Among rural residents, 69% preferred a self/family- or CHV-conducted home-based malaria test and 20% preferred a laboratory-based test (with others indicating no preference). Among urban residents, these numbers were 38% and 44%, respectively. If offered a home-based test, 28% of rural residents would prefer a self/family-conducted test and 68% would prefer a CHV-assisted test. For urban residents, these numbers were 21% and 77%. In total, 36% of rural and 63% of urban residents reported usually taking a diagnostic test to confirm suspected malaria. The most common reasons for not seeking malaria testing were the cost of testing, waiting to see if the fever resolved on its own, and not wanting to travel to a clinical facility for a test. In total, 32% of rural and 27% of urban participants were very confident they could perform a malaria test on themselves or a family member without assistance, 50% of rural and 62% of urban participants were very confident they could perform a test after training, and 56% of rural and 33% of urban participants said they would pay more for a home-based test than a laboratory-based test.

Conclusion

Expanding community case management of malaria to include home testing by CHVs and family members may increase the proportion of individuals with febrile illnesses who confirm a positive diagnosis prior to initiating treatment.

Accuracy of two malaria rapid diagnostic tests (RDTS) for initial diagnosis and treatment monitoring in a high transmission setting in Uganda

Malaria rapid diagnostic tests (RDTs) may improve fever management in areas without microscopy. We compared the accuracy of histidine-rich protein 2 (HRP2) and Plasmodium lactate dehydrogenase (pLDH)-based RDTs, using expert microscopy as a gold standard, for initial diagnosis, treatment monitoring, and diagnosis of recurrent malaria in a cohort of children followed longitudinally in a high-transmission area in Uganda. For 305 initial fever episodes, sensitivity was 98% for HRP2 and 87% for pLDH, whereas specificity was 55% and 96%, respectively. The HRP2 gave 51% false-positive results on Day 28, whereas pLDH gave no false positives after Day 7. For 59 recurrent fever episodes during follow-up, sensitivity was 100% for HRP2 and 91% for pLDH, whereas specificity was 33% and 100%, respectively. The HRP2-based RDTs are useful for initial diagnosis of malaria caused by superior sensitivity; however, as a result of superior specificity, pLDH-based RDTs are more appropriate to monitor treatment and diagnose recurrent malaria.

Rapid diagnostic tests for diagnosing uncomplicated non-falciparum or Plasmodium vivax malaria in endemic countries

BACKGROUND

In settings where both Plasmodium vivax and Plasmodium falciparum infection cause malaria, rapid diagnostic tests (RDTs) need to distinguish which species is causing the patients' symptoms, as different treatments are required. Older RDTs incorporated two test lines to distinguish malaria due to P. falciparum, from malaria due to any other Plasmodium species (non-falciparum). These RDTs can be classified according to which antibodies they use: Type 2 RDTs use HRP-2 (for P. falciparum) and aldolase (all species); Type 3 RDTs use HRP-2 (for P. falciparum) and pLDH (all species); Type 4 use pLDH (fromP. falciparum) and pLDH (all species).More recently, RDTs have been developed to distinguish P. vivax parasitaemia by utilizing a pLDH antibody specific to P. vivax.

OBJECTIVES

To assess the diagnostic accuracy of RDTs for detecting non-falciparum or P. vivax parasitaemia in people living in malaria-endemic areas who present to ambulatory healthcare facilities with symptoms suggestive of malaria, and to identify which types and brands of commercial test best detect non-falciparum and P. vivax malaria.

SEARCH METHODS

We undertook a comprehensive search of the following databases up to 31 December 2013: Cochrane Infectious Diseases Group Specialized Register; MEDLINE; EMBASE; MEDION; Science Citation Index; Web of Knowledge; African Index Medicus; LILACS; and IndMED.

SELECTION CRITERIA

Studies comparing RDTs with a reference standard (microscopy or polymerase chain reaction) in blood samples from a random or consecutive series of patients attending ambulatory health facilities with symptoms suggestive of malaria in non-falciparum endemic areas.

DATA COLLECTION AND ANALYSIS

For each study, two review authors independently extracted a standard set of data using a tailored data extraction form. We grouped comparisons by type of RDT (defined by the combinations of antibodies used), and combined in meta-analysis where appropriate. Average sensitivities and specificities are presented alongside 95% confidence intervals (95% CI).

MAIN RESULTS

We included 47 studies enrolling 22,862 participants. Patient characteristics, sampling methods and reference standard methods were poorly reported in most studies. RDTs detecting 'non-falciparum' parasitaemiaEleven studies evaluated Type 2 tests compared with microscopy, 25 evaluated Type 3 tests, and 11 evaluated Type 4 tests. In meta-analyses, average sensitivities and specificities were 78% (95% CI 73% to 82%) and 99% (95% CI 97% to 99%) for Type 2 tests, 78% (95% CI 69% to 84%) and 99% (95% CI 98% to 99%) for Type 3 tests, and 89% (95% CI 79% to 95%) and 98% (95% CI 97% to 99%) for Type 4 tests, respectively. Type 4 tests were more sensitive than both Type 2 (P = 0.01) and Type 3 tests (P = 0.03).Five studies compared Type 3 tests with PCR; in meta-analysis, the average sensitivity and specificity were 81% (95% CI 72% to 88%) and 99% (95% CI 97% to 99%) respectively. RDTs detecting P.vivax parasitaemiaEight studies compared pLDH tests to microscopy; the average sensitivity and specificity were 95% (95% CI 86% to 99%) and 99% (95% CI 99% to 100%), respectively.

AUTHORS' CONCLUSIONS

RDTs designed to detect P. vivax specifically, whether alone or as part of a mixed infection, appear to be more accurate than older tests designed to distinguish P. falciparum malaria from non-falciparum malaria. Compared to microscopy, these tests fail to detect around 5% ofP. vivax cases. This Cochrane Review, in combination with other published information about in vitro test performance and stability in the field, can assist policy-makers to choose between the available RDTs.

Harmonization of malaria rapid diagnostic tests: best practices in labelling including instructions for use

Background

Rapid diagnostic tests (RDTs) largely account for the scale-up of malaria diagnosis in endemic settings. However, diversity in labelling including the instructions for use (IFU) limits their interchangeability and user-friendliness. Uniform, easy to follow and consistent labelling, aligned with international standards and appropriate for the level of the end user’s education and training, is crucial but a consolidated resource of information regarding best practices for IFU and labelling of RDT devices, packaging and accessories is not available.

Methods

The Roll Back Malaria Partnership (RBM) commissioned the compilation of international standards and regulatory documents and published literature containing specifications and/or recommendations for RDT design, packaging and labelling of in vitro diagnostics (IVD) (which includes RDTs), complemented with a questionnaire based survey of RDT manufacturers and implementers. A summary of desirable RDT labelling characteristics was compiled, which was reviewed and discussed during a RBM Stakeholder consultation meeting and subsequently amended and refined by a dedicated task force consisting of country programme implementers, experts in RDT implementation, IVD regulatory experts and manufacturers.

Results

This process led to the development of consensus documents with a list of suggested terms and abbreviations as well as specifications for labelling of box, device packaging, cassettes, buffer bottle and accessories (lancets, alcohol swabs, transfer devices, desiccants). Emphasis was placed on durability (permanent printing or water-resistant labels), legibility (font size, letter type), comprehension (use of symbols) and ease of reference (e.g. place of labelling on the box or cassette packaging allowing quick oversight). A generic IFU template was developed, comprising background information, a template for procedure and reading/interpretation, a selection of appropriate references and a symbol key of internationally recognized symbols together with suggestions about appropriate lay-out, style and readability.

Conclusions

The present document together with its additional files compiled proposes best practices in labelling and IFU for malaria RDTs. It is expected that compliance with these best practices will increase harmonization among the different malaria RDT products available on the market and improve their user-friendliness.

Electronic supplementary material

The online version of this article (doi:10.1186/1475-2875-13-505) contains supplementary material, which is available to authorized users.

Performance and clinical usefulness of the Optimal-IT® test in the treatment of confirmed malaria cases in rural areas in Côte d'Ivoire

Background

In Africa, malaria care is mostly based on clinical presumption and the general application of antimalarial treatment to all febrile episodes over several years. Treatment limited to confirmed cases might curb the practice of equating fever with malaria, antimalarial drug abuse and the extension of Plasmodium resistance, provided that powerful and reliable rapid diagnostic tests are used. This study aimed at determining the performances of the Optimal-IT® test in the strategy for the exclusive treatment of uncomplicated malaria in rural areas.

Materials and Methods

A prospective study conducted in the forest region of San Pedro, Côte d'Ivoire, included patients exhibiting clinical signs of uncomplicated malaria who gave their consent and benefited from thick blood film (TBF), blood smear (BS) and Optimal-IT® (pLDH-based) test. Rapid diagnostic test (RDT) results were taken into consideration to decide on malaria treatment and then compared with TBF/BS results (reference) to assess the performances and clinical usefulness of the RDT.

Results

The mean age of the 384 patients included (209 men, 175 women) was 28 years and the mean temperature was 38.1°C. TBF/BS and Optimal-IT® were concordant in 92% of patients but discordant in 10 false negative (3%) and 19 false-positive patients (5%). The average parasite density of P. falciparum was 25,600 trophozoites/μl. The performances calculated were: sensitivity=95%, specificity=91%, positive predictive value=90%, negative predictive value=95%, positive likelihood ratio=10, negative likelihood ratio=0.06 and diagnostic odds ratio=166, indicating that Optimal-IT® is a powerful and credible diagnostic tool. The 193 RDT-positive patients treated were healed, despite three recurrence cases at day (D) D17, D25 and D27, respectively. RDT-negative patients received various treatments (antibiotics, paracetamol), but two patients among them presented with a bout of malaria on D7. None of the previously untreated patients returned with severe malaria.

Conclusions

The Optimal-IT® test, which is already used in the field, showed good performances to effectively detect patients with and without malaria. It is therefore adapted to the malaria treatment strategy limited to confirmed cases.