Acceptability of rapid diagnostic test-based management of Malaria among caregivers of under-five children in rural Ghana

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.

Accuracy of malaria diagnostic tests performed on non-invasively collected samples: a systematic review and meta-analysis

Background

During the last decade, many studies have assessed the performance of malaria tests on non-invasively collected specimens, but no systematic review has hitherto estimated the overall performance of these tests. We report here the first meta-analysis estimating the diagnostic performance of malaria diagnostic tests performed on saliva, urine, faeces, skin odour (‘sniff and tell’) and hair, using either microscopy or PCR on blood sample as reference test.

Methods

We searched on PubMed, EMBASE, African Journals Online and Cochrane Infectious Diseases from inception until 19 January 2021 for relevant primary studies. A random effects model was used to estimate the overall performance of various diagnostic methods on different types of specimen.

Results

Eighteen studies providing 30 data sets were included in the meta-analysis. The overall sensitivity, specificity and diagnostic OR (DOR) of PCR were 84.5% (95% CI 79.3% to 88.6%), 97.3% (95% CI 95.3% to 98.5%) and 184.9 (95% CI 95.8 to 356.9) in saliva, respectively; 57.4% (95% CI 41.4% to 72.1%), 98.6% (95% CI 97.3% to 99.3%) and 47.2 (95% CI 22.1 to 101.1) in urine, respectively. The overall sensitivity, specificity and DOR of rapid diagnostic test for malaria in urine was 59.8% (95% CI 40.0% to 76.9%), 96.9% (95% CI 91.0% to 99.0%) and 30.8 (95% CI:23.5 to 40.4).

Conclusion

In settings where PCR is available, saliva and urine samples should be considered for PCR-based malaria diagnosis only if blood samples cannot be collected. The performance of rapid diagnostic testing in the urine is limited, especially its sensitivity. Malaria testing on non-invasively collected specimen still needs substantial improvement.

Host-Based Prognostic Biomarkers to Improve Risk Stratification and Outcome of Febrile Children in Low- and Middle-Income Countries

Fever is one of the leading causes for pediatric medical consultation and the most common symptom at clinical presentation in low- and middle-income countries (LMICs). Most febrile episodes are due to self-limited infections, but a small proportion of children will develop life-threatening infections. The early recognition of children who have or are progressing to a critical illness among all febrile cases is challenging, and there are currently no objective and quantitative tools to do so. This results in increased morbidity and mortality among children with impending life-threatening infections, whilst contributing to the unnecessary prescription of antibiotics, overwhelming health care facilities, and harm to patients receiving avoidable antimicrobial treatment. Specific fever origin is difficult to ascertain and co-infections in LMICs are common. However, many severe infections share common pathways of host injury irrespective of etiology, including immune and endothelial activation that contribute to the pathobiology of sepsis (i.e., pathogen "agnostic" mechanisms of disease). Importantly, mediators of these pathways are independent markers of disease severity and outcome. We propose that measuring circulating levels of these factors can provide quantitative and objective evidence to: enable early recognition of severe infection; guide patient triage and management; enhance post-discharge risk stratification and follow up; and mitigate potential gender bias in clinical decisions. Here, we review the clinical and biological evidence supporting the clinical utility of host immune and endothelial activation biomarkers as components of novel rapid triage tests, and discuss the challenges and needs for developing and implementing such tools.

Potential Use of Community-Based Rapid Diagnostic Tests for Febrile Illnesses: Formative Research in Peru and Cambodia

In 2012, the U.S. Defense Threat Reduction Agency Joint Science and Technology Office initiated a program to develop novel point-of-need diagnostic devices for surveillance of emerging infectious diseases including dengue, malaria, plague, and melioidosis. Prior to distribution of devices to observe their correct use among community members in Iquitos, Peru, and Phnom Penh, Cambodia, research was conducted to: 1) assess acceptability of use, including the motivation to use a rapid diagnostic test (RDT) before or instead of seeking care at a health facility, 2) explore comprehension of RDT use instructions, and 3) examine possible strategies for large scale RDT distribution and use at each site. In February 2014, 9 focus group discussions (FGD) with community members and 5 FGD with health professionals were conducted in Iquitos, and 9 FGD with community members and 9 in-depth interviews with health professionals in Phnom Penh. In both places, participants agreed to use the device themselves (involving finger prick) or could identify someone who could do so in their home or neighborhood. The main incentive to RDT use in both sites was the ability for device results to be used for care facilitation (post confirmatory tests), specifically reduced wait times to be seen or obtain a diagnosis. Comprehension of RDT use instructions was assessed in Iquitos by asking some participants to apply the device to research team members; after watching a short video, most steps were done correctly. In Phnom Penh, participants were asked to describe each step after reading the instructions; they struggled with comprehension. Health professionals’ main concerns in both sites were their community’s ability to accurately use the test, handle complicated instructions, and safety (i.e., disposal of lancets). Health system structure and ability to use home diagnostic devices varied in the two disease endemic sites, with substantial challenges in each, suggesting the need for different strategies for RDT large scale community use, and illustrating the value of formative research before deployment of novel technologies.

Development and use of devices to diagnose infectious diseases outside of health facilities (i.e., at home or in remote areas) continues to increase, providing new options for the follow up and treatment options of individuals, depending on the diseases. In this qualitative study, researchers in Iquitos, Peru, and Phnom Penh, Cambodia explored what local people thought about the possible availability of such a device to diagnose dengue and malaria in their own houses, and what would motivate them to use such a device instead of going directly to a health facility for the diagnosis. Participants reported being willing to use device on themselves and were motivated by the possibility that, by using this diagnostic device and taking the result to their health facility, they might be able to obtain quicker and more optimized attention at the health facility; for example, by obtaining a positive result to dengue or malaria on the rapid diagnostic device, they are aware they might still need confirmatory tests, but they would be able to reduce the wait time for obtaining a definitive diagnosis and starting treatment by a full day. Questions regarding accuracy of tests, complicated instructions and safety of using these devices in the community were brought up by participants—individuals living in the communities and local health professionals. Also, in this study, it was clear that if these devices were to be made available in Peru and Cambodia, different strategies for disseminating and using these in the communities would be needed to accommodate for different health infrastructure in both sites.

Assessing Acceptability of a Diagnostic and Malaria Treatment Package Delivered by Community Health Workers in Malaria-Endemic Settings of Burkina Faso, Nigeria, and Uganda

Background. The efficacy of artemisinin-based combination therapy (ACT) and rectal artesunate for severe malaria in children is proven. However, acceptability of a package of interventions that included use of malaria rapid diagnostic tests (RDTs), ACTs, and rectal artesunate when provided by community health workers (CHWs) is uncertain. This study assessed acceptability of use of CHWs for case management of malaria using RDTs, ACTs, and rectal artesunate.

Methods. The study was carried out in Burkina Faso, Nigeria, and Uganda in 2015 toward the end of an intervention using CHWs to provide diagnosis and treatment. Focus group discussions (FGDs) and key informant interviews (KIIs) were conducted with parents of sick children, community leaders, and health workers to understand whether they accepted the package for case management of malaria using CHWs. Transcripts from FGDs and KII recordings were analyzed using content analysis. The findings were described, interpreted, and reported in the form of narratives.

Results. Treatment of malaria using the CHWs was acceptable to caregivers and communities. The CHWs were perceived to be accessible, diligent, and effective. There were no physical, social, or cultural barriers to accessing the CHWs’ services. Respondents were extremely positive about the intervention and were concerned that CHWs had limited financial and nonfinancial incentives that would reduce their motivation and willingness to continue.

Conclusions. Treatment of malaria using CHWs was fully accepted. CHWs should be compensated, trained, and well supervised.

Clinical Trials Registration. ISRCTN13858170.

Examining Intervention Design: Lessons from the Development of Eight Related Malaria Health Care Intervention Studies

Abstract—Rigorous evidence of “what works” to improve health care is in demand, but methods for the development of interventions have not been scrutinized in the same ways as methods for evaluation. This article presents and examines intervention development processes of eight malaria health care interventions in East and West Africa. A case study approach was used to draw out experiences and insights from multidisciplinary teams who undertook to design and evaluate these studies. Four steps appeared necessary for intervention design: (1) definition of scope, with reference to evaluation possibilities; (2) research to inform design, including evidence and theory reviews and empirical formative research; (3) intervention design, including consideration and selection of approaches and development of activities and materials; and (4) refining and finalizing the intervention, incorporating piloting and pretesting. Alongside these steps, projects produced theories, explicitly or implicitly, about (1) intended pathways of change and (2) how their intervention would be implemented.The work required to design interventions that meet and contribute to current standards of evidence should not be underestimated. Furthermore, the process should be recognized not only as technical but as the result of micro and macro social, political, and economic contexts, which should be acknowledged and documented in order to infer generalizability. Reporting of interventions should go beyond descriptions of final intervention components or techniques to encompass the development process. The role that evaluation possibilities play in intervention design should be brought to the fore in debates over health care improvement.

Appropriate targeting of artemisinin-based combination therapy by community health workers using malaria rapid diagnostic tests: findings from randomized trials in two contrasting areas of high and low malaria transmission in south-western Uganda

Objective

To compare the impact of malaria rapid diagnostic tests (mRDTs), used by community health workers (CHWs), on the proportion of children <5 years of age receiving appropriately targeted treatment with artemisinin‐based combination therapy (ACT), vs. presumptive treatment.

Methods

Cluster‐randomized trials were conducted in two contrasting areas of moderate‐to‐high and low malaria transmission in rural Uganda. Each trial examined the effectiveness of mRDTs in the management of malaria and targeting of ACTs by CHWs comparing two diagnostic approaches: (i) presumptive clinical diagnosis of malaria [control arm] and (ii) confirmatory diagnosis with mRDTs followed by ACT treatment for positive patients [intervention arm], with village as the unit of randomisation. Treatment decisions by CHWs were validated by microscopy on a reference blood slide collected at the time of consultation, to compare the proportion of children <5 years receiving appropriately targeted ACT treatment, defined as patients with microscopically‐confirmed presence of parasites in a peripheral blood smear receiving artemether‐lumefantrine or rectal artesunate, and patients with no malaria parasites not given ACT.

Results

In the moderate‐to‐high transmission area, ACT treatment was appropriately targeted in 79.3% (520/656) of children seen by CHWs using mRDTs to diagnose malaria, vs. 30.8% (215/699) of children seen by CHWs using presumptive diagnosis (P < 0.001). In the low transmission area, 90.1% (363/403) children seen by CHWs using mRDTs received appropriately targeted ACT treatment vs. 7.8% (64/817) seen by CHWs using presumptive diagnosis (P < 0.001). Low mRDT sensitivity in children with low‐density parasitaemia (<200 parasites/μl) was identified as a potential concern.

Conclusion

When equipped with mRDTs, ACT treatments delivered by CHWs are more accurately targeted to children with malaria parasites. mRDT use could play an important role in reducing overdiagnosis of malaria and improving fever case management within iCCM, in both moderate‐to‐high and low transmission areas. Nonetheless, missed treatments due to the low sensitivity of current mRDTs in patients with low parasite density are a concern. For community‐based treatment in areas of low transmission and/or non‐immune populations, presumptive treatment of all fevers as malaria may be advisable, until more sensitive diagnostic assays, suitable for routine use by CHWs in remote settings, become available.

How Do Patients and Health Workers Interact around Malaria Rapid Diagnostic Testing, and How Are the Tests Experienced by Patients in Practice? A Qualitative Study in Western Uganda

Background

Successful scale-up in the use of malaria rapid diagnostic tests (RDTs) requires that patients accept testing and treatment based on RDT results and that healthcare providers treat according to test results. Patient-provider communication is a key component of quality care, and leads to improved patient satisfaction, higher adherence to treatment and better health outcomes. Voiced or perceived patient expectations are also known to influence treatment decision-making among healthcare providers. While there has been a growth in literature on provider practices around rapid testing for malaria, there has been little analysis of inter-personal communication around the testing process. We investigated how healthcare providers and patients interact and engage throughout the diagnostic and treatment process, and how the testing service is experienced by patients in practice.

Methods

This research was conducted alongside a larger study which explored determinants of provider treatment decision-making following negative RDT results in a rural district (Kibaale) in mid-western Uganda, ten months after RDT introduction. Fifty-five patients presenting with fever were observed during routine outpatient visits at 12 low-level public health facilities. Observation captured communication practices relating to test purpose, results, diagnosis and treatment. All observed patients or caregivers were immediately followed up with in-depth interview. Analysis followed the ‘framework’ approach. A summative approach was also used to analyse observation data.

Results

Providers failed to consistently communicate the reasons for carrying out the test, and particularly to RDT-negative patients, a diagnostic outcome or the meaning of test results, also leading to confusion over what the test can detect. Patients appeared to value testing, but were frustrated by the lack of communication on outcomes. RDT-negative patients were dissatisfied by the absence of information on an alternative diagnosis and expressed uncertainty around adequacy of proposed treatment.

Conclusions

Poor provider communication practices around the testing process, as well as limited inter-personal exchange between providers and patients, impacted on patients’ perceptions of their proposed treatment. Patients have a right to health information and may be more likely to accept and adhere to treatment when they understand their diagnosis and treatment rationale in relation to their perceived health needs and visit expectations.

Effect of Test-Based versus Presumptive Treatment of Malaria in Under-Five Children in Rural Ghana--A Cluster-Randomised Trial

BACKGROUND

Malaria-endemic countries in sub-Saharan Africa are shifting from the presumptive approach that is based on clinical judgement (CJ) to the test-based approach that is based on confirmation through test with rapid diagnostic tests (RDT). It has been suggested that the loss of the prophylactic effect of presumptive-administered ACT in children who do not have malaria will result in increase in their risk of malaria and anaemia.

METHODS AND FINDINGS

We undertook a cluster-randomized controlled trial to compare the effects of the presumptive approach using clinical judgment (CJ-arm) and the test-based approach using RDTs (RDT-arm in a high-transmission setting in Ghana. A total of 3046 eligible children (1527 in the RDT arm and 1519 in the CJ- arm) living around 32 health centres were enrolled. Nearly half were female (48.7%) and 47.8% were below the age of 12 months as at enrolment. Over 24-months, the incidence of all episodes of malaria following the first febrile illness was 0.64 (95% CI 0.49-0.82) and 0.76 (0.63-0.93) per child per year in the RDT and CJ arms respectively (adjusted rate ratio 1.13 (0.82-1.55). After the first episode of febrile illness, the incidence of severe anaemia was the same in both arms (0.11 per child per year) and that of moderate anaemia was 0.16 (0.13-0.21) vs. 0.17 (0.14-0.21) per child year respectively. The incidence of severe febrile illness was 0.15 (0.09, 0.24) in the RDT arm compared to 0.17 (0.11, 0.28) per child per year respectively. The proportion of fever cases receiving ACT was lower in the RDT arm (72% vs 81%; p = 0.02).

CONCLUSION

The test-based approach to the management of malaria did not increase the incidence of malaria or anaemia among under-five children in this setting.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00832754.

Improving Access to Malaria Rapid Diagnostic Test in Niger State, Nigeria: An Assessment of Implementation up to 2013

Nigeria's 2009–2013 malaria strategic plan adopted WHO diagnosis and treatment guidelines, which include the use of rapid diagnostic tests (RDTs) prior to prescribing treatment with artemisinin combination therapies (ACTs). The current study explores accessibility barriers to the use of RDTs in Niger State and makes recommendations for improving the uptake of RDTs. The study employs literature review, review of data from the Niger State Health Management Information System for January–October 2013, and application of Peters' conceptual framework for assessing access to health services. Data showed that 27 percent of public health facilities (HFs) implemented RDTs, with the aid of donor funds. In these facilities, 77 percent of fever cases presented during the study period were tested with RDTs; 53 percent of fever cases were confirmed cases of malaria, while 60 percent of fever cases were treated. Stockouts of RDTs were a major constraint, and severe fever tended to trigger presumptive treatment. We conclude that although implementation of RDTs led to a reduction in the use of ACTs at HFs, more substantial reduction could be achieved if the state government directed more resources towards the acquisition of RDTs as well as raising the level of awareness of potential users.

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.

Exploring health practitioners' acceptability of a prospective semi-quantitative pfHRP2 device to define severe malaria in the Democratic Republic of Congo

BACKGROUND

A rapid diagnostic tool is being developed to discern severely ill children with severe malaria from children who are ill with alternative febrile diseases but have coincidental peripheral blood parasitaemia. The device semi-quantitatively measures plasma pfHRP2 and has the potential to reduce mortality in children with severe febrile illnesses by improving diagnosis. The aim of this study is to identify contributing and inhibiting factors that affect healthcare practitioners' acceptability of this prospective diagnostic device in a high malaria transmission setting in the Democratic Republic of Congo.

METHODS

Data were collected qualitatively by conducting semi-structured interviews with a purposeful sample of health professionals in Kinshasa, capital of Democratic Republic of Congo. In total, 11 interviews were held with professionals at four different institutes.

RESULTS

Four key findings emerged: (1) Congolese practitioners perceive the semi-quantitative pfHRP2 device as a welcome intervention as they recognize the limited reliability of their current diagnostic and therapeutic approaches to severe febrile illnesses; (2) compatibility of the semi-quantitative pfHRP2 device with clinical equipment and competences of Congolese health practitioners is considered to be limited, especially in rural settings; (3) a formal training programme is crucial for correct understanding and application of the semi-quantitative pfHRP2 device; and, (4) provision of evidence to practitioners, and support from health authorities would be important to establish confidence in the semi-quantitative pfHRP2 device.

CONCLUSIONS

Congolese practitioners perceive the prospective semi-quantitative pfHRP2 device as a welcome addition to their clinical equipment. The device could improve current diagnostic work-up of severe febrile illness, which might consequently improve treatment choices. However, despite this recognized potential, several hurdles and drivers need to be taken into account when implementing this device in DR Congo.

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.

Shifting from presumptive to test-based management of malaria - technical basis and implications for malaria control in Ghana

The presumptive approach was the World Health Organisation (WHO) recommended to the management of malaria for many years and this was incorporated into syndromic guidelines such as the Integrated Management of Childhood Illnesses (IMCI). In early 2010 however, WHO issued revised treatment guidelines that call for a shift from the presumptive to the test-based approach. Practically, this implies that in all suspected cases, the diagnosis of uncomplicated malaria should be confirmed using rapid test before treatment is initiated. This revision effectively brings to an end an era of clinical practice that span several years. Its implementation has important implications for the health systems in malaria-endemic countries. On the basis of research in Ghana and other countries, and evidence from program work, the Ghana National Malaria Control Program has issued revised national treatment guidelines that call for implementation of test-based management of malaria in all cases, and across all age groups. This article reviews the evidence and the technical basis for the shift to test-based management and examines the implications for malaria control in Ghana.

Addressing Barriers to the Development and Adoption of Rapid Diagnostic Tests in Global Health

Immunochromatographic rapid diagnostic tests (RDTs) have demonstrated significant potential for use as point-of-care diagnostic tests in resource-limited settings. Most notably, RDTs for malaria have reached an unparalleled level of technological maturity and market penetration, and are now considered an important complement to standard microscopic methods of malaria diagnosis. However, the technical development of RDTs for other infectious diseases, and their uptake within the global health community as a core diagnostic modality, has been hindered by a number of extant challenges. These range from technical and biological issues, such as the need for better affinity agents and biomarkers of disease, to social, infrastructural, regulatory and economic barriers, which have all served to slow their adoption and diminish their impact. In order for the immunochromatographic RDT format to be successfully adapted to other disease targets, to see widespread distribution, and to improve clinical outcomes for patients on a global scale, these challenges must be identified and addressed, and the global health community must be engaged in championing the broader use of RDTs.

Implementation of the integrated management of childhood illness with parasitological diagnosis of malaria in rural Ghana: health worker perceptions

BACKGROUND

Timely and appropriate management of febrile illness among children under five years of age will contribute to achieving Millennium Development Goal-4. The revised World Health Organization-Global Malaria Programme's policy on test-based management of malaria must integrate effectively into the Integrated Management of Childhood Illness (IMCI). This study reports on perceptions of health workers on the health system factors influencing effective delivery of test-based diagnosis of malaria with IMCI.

METHODS

A qualitative study was conducted among a range of health workers at different levels of the health system in the Brong Ahafo Region of Ghana. Interview transcripts were transferred into Nvivo 8 software for data management and analysis. A frame-work approach at two levels was used in the analysis, which included the processes required for implementation of test-based management of malaria and the health systems context.

RESULTS

Forty-nine in-depth interviews were conducted. The National Health Insurance Scheme (NHIS) was perceived to have led to an increase in health facility attendance, thereby increasing the workload of health workers. Workload was reported as the main reason that health workers were not able to complete all of the examinations included in the IMCI algorithm. The NHIS financing guidelines were seen to be determining diagnosis and treatment practices by health-care givers. Concern was expressed about the erratic supply of malaria rapid diagnostic test kits (RDTs), the quality of RDTs related to potential false negative results when clinical symptoms were consistent with malaria. IMCI was seen as important but practically impossible to fully implement due to workload.

CONCLUSIONS

Implementation of the WHO-revised IMCI guideline is confronted with a myriad of health systems challenges. The perceptions of front-line health workers on the accuracy and need for RDTs together with the capacity of health systems to support implementation plays a crucial role. The NHIS financing guidelines of diagnostics and treatments are influencing clinical decision-making in this setting. Further study is needed to understand the impact of the NHIS on the feasibility of integrating test-based management for malaria into the IMCI guidelines.

The impact of providing rapid diagnostic malaria tests on fever management in the private retail sector in Ghana: a cluster randomized trial

OBJECTIVE

To examine the impact of providing rapid diagnostic tests for malaria on fever management in private drug retail shops where most poor rural people with fever present, with the aim of reducing current massive overdiagnosis and overtreatment of malaria.

DESIGN

Cluster randomized trial of 24 clusters of shops.

SETTING

Dangme West, a poor rural district of Ghana.

PARTICIPANTS

Shops and their clients, both adults and children.

INTERVENTIONS

Providing rapid diagnostic tests with realistic training.

MAIN OUTCOME MEASURES

The primary outcome was the proportion of clients testing negative for malaria by a double-read research blood slide who received an artemisinin combination therapy or other antimalarial. Secondary outcomes were use of antibiotics and antipyretics, and safety.

RESULTS

Of 4603 clients, 3424 (74.4%) tested negative by double-read research slides. The proportion of slide-negative clients who received any antimalarial was 590/1854 (32%) in the intervention arm and 1378/1570 (88%) in the control arm (adjusted risk ratio 0.41 (95% CI 0.29 to 0.58), P<0.0001). Treatment was in high agreement with rapid diagnostic test result. Of those who were slide-positive, 690/787 (87.8%) in the intervention arm and 347/392 (88.5%) in the control arm received an artemisinin combination therapy (adjusted risk ratio 0.96 (0.84 to 1.09)). There was no evidence of antibiotics being substituted for antimalarials. Overall, 1954/2641 (74%) clients in the intervention arm and 539/1962 (27%) in the control arm received appropriate treatment (adjusted risk ratio 2.39 (1.69 to 3.39), P<0.0001). No safety concerns were identified.

CONCLUSIONS

Most patients with fever in Africa present to the private sector. In this trial, providing rapid diagnostic tests for malaria in the private drug retail sector significantly reduced dispensing of antimalarials to patients without malaria, did not reduce prescribing of antimalarials to true malaria cases, and appeared safe. Rapid diagnostic tests should be considered for the informal private drug retail sector.Registration Clinicaltrials.gov NCT01907672.

Determinants of malaria diagnostic uptake in the retail sector: qualitative analysis from focus groups in Uganda

BACKGROUND

In Uganda, as in most other malaria-endemic countries, presumptive treatment for malaria based on symptoms without a diagnostic blood test is still very common. While diagnostic testing in public sector facilities is increasing, many people in Uganda who suspect malaria visit private sector outlets to purchase medications. Increasing the availability and uptake of rapid diagnostic tests (RDTs) for malaria in private outlets could help increase diagnostic testing for malaria but raises questions about the patient demand for and valuation of testing that are less critical for public sector introduction.

METHODS

In preparation for a behaviour change campaign to encourage and sustain the demand for RDTs in drug shops, eight focus group discussions with a total of 84 community members were conducted in six districts across Uganda's Eastern Region in November-December 2011. Focus groups explored incentives and barriers to seeking diagnosis for malaria, how people react to test results and why, and what can be done to increase the willingness to pay for RDTs.

RESULTS

Overall, participants were very familiar with malaria diagnostic testing and understood its importance, yet when faced with limited financial resources, patients preferred to spend their money on medication and sought testing only when presumptive treatment proved ineffective. While side effects did seem to be a concern, participants did not mention other potential costs of taking unnecessary or ineffective medications, such as money wasted on excess drugs or delays in resolution of symptoms. Very few individuals were familiar with RDTs.

CONCLUSION

In order to boost demand, these results suggest that private sector RDTs will have to be made convenient and affordable and that targeted behaviour change campaigns should strive to increase the perceived value of diagnosis.

The acceptability of intermittent screening and treatment versus intermittent preventive treatment during pregnancy: results from a qualitative study in Northern Ghana

Background

Affecting mother and child, malaria during pregnancy (MiP) provokes a double morbidity and mortality burden. Within a package of interventions to prevent MiP in endemic areas, the WHO currently recommends intermittent preventive treatment (IPTp). Concerns about anti-malarial resistance have however prompted interest in intermittent screening and treating (IST) as an alternative approach to IPTp. IST involves screening for malaria infection at scheduled antenatal care (ANC) clinic visits and treating malaria cases. In light of the need to comprehensively evaluate new interventions prior to roll out, this article explores the acceptability of IST with artemether-lumefantrine (AL) compared to IPTp with sulphadoxine-pyrimethamine (SP) and in Upper East Region, northern Ghana.

Methods

Data were collected alongside an open-label, randomized, controlled trial of IST-AL and IPTp-SP in Kassena-Nankana District. Thirty pregnant women enrolled in the clinical trial participated in six focus group discussions. Ten in-depth interviews were carried out with clinical trial staff. Observations were also made at the health facilities where the clinical trial took place.

Results

Trial participants were generally willing to endure the discomfort of the finger prick necessary for a rapid diagnostic test for malaria and this reflected a wider demand for diagnostic techniques. Reports of side effects were however linked to both trial anti-malarials. Direct complaints about SP were particularly severe with regard to women’s experience of vomiting. Although the follow-up treatment doses of AL for IST were not supervised, based on blister inspection and questioning trial, staff were confident about participants’ adherence to the treatment course. One case of partial adherence to the AL treatment course was reported.

Conclusion

Despite the discomfort of the finger prick required to perform the intermittent malaria screening, trial participants generally expressed more positive sentiments towards IST-AL than IPTp-SP. Nonetheless, questions remain about adherence to a multiple dose anti-malarial regimen during pregnancy, particularly in endemic areas where MiP is often non-symptomatic. Any implementation of IST must be accompanied by appropriate health messages on adherence and the necessary training for health staff regarding case management.

The development of effective behaviour change interventions to support the use of malaria rapid diagnostic tests by Tanzanian clinicians

Background

Parasitological confirmation is now recommended for all cases of suspected malaria. The roll-out of rapid diagnostic tests (RDTs) is hoped to enable this goal in low resource settings through point of care testing. However, simply making RDTs available has not led to high uptake of the tests or adherence to results by clinicians, with malaria continuing to be overdiagnosed in many settings. We undertook to design an evidence-based intervention package that would be sufficient to support the introduction of RDTs at dispensaries in Tanzania, to be evaluated through the Targeting Artemisinin Combination Therapy (TACT) cluster randomised controlled trial.

Methods

We describe five steps in our intervention design: formative research, review of existing evidence and theory, a workshop to define the intervention approach and content and results of formative research, engagement with behaviour change theory and literature, detailed design of intervention materials and piloting and pretesting of intervention materials. This involved fieldwork with a total of 19 health workers and 212 community members in northeast Tanzania.

Results

The formative research suggested that RDTs were a potential source of conflict in the health worker-patient interaction, but that health workers used various techniques to resolve this, including provision of antimalarial drugs for RDT-negative patients. Our reviews showed that evidence was mixed regarding the effectiveness of different methods and theories to support change in prescribing practice. Our design process is presented, drawing from this collective evidence. We describe the final TACT intervention package (including interactive small group workshops, feedback text messages, motivational text messages and patient information leaflets and posters) in terms of its programme theory and implementation theory.

Conclusions

Our study suggests that evidence-based design of complex interventions is possible. The use of formative research to understand malaria overdiagnosis in context was central to the design of the intervention as well as empirical research to test materials and methods prior to implementation. The TACT interventions may be appropriate for other settings where clinicians face similar challenges with malaria diagnostics.

Trial registration

NCT01292707.

Cost-effectiveness analysis of introducing RDTs for malaria diagnosis as compared to microscopy and presumptive diagnosis in central and peripheral public health facilities in Ghana

Cost-effectiveness information on where malaria rapid diagnostic tests (RDTs) should be introduced is limited. We developed incremental cost-effectiveness analyses with data from rural health facilities in Ghana with and without microscopy. In the latter, where diagnosis had been presumptive, the introduction of RDTs increased the proportion of patients who were correctly treated in relation to treatment with antimalarials, from 42% to 65% at an incremental societal cost of Ghana cedis (GHS)12.2 (US$8.3) per additional correctly treated patients. In the "microscopy setting" there was no advantage to replacing microscopy by RDT as the cost and proportion of correctly treated patients were similar. Results were sensitive to a decrease in the cost of RDTs, which cost GHS1.72 (US$1.17) per test at the time of the study and to improvements in adherence to negative tests that was just above 50% for both RDTs and microscopy.

Getting antimalarials on target: impact of national roll-out of malaria rapid diagnostic tests on health facility treatment in three regions of Tanzania

Objectives

Parasitological confirmation of malaria prior to treatment is recommended for patients of all ages, with malaria rapid diagnostic tests (mRDTs) an important tool to target artemisinin-based combination therapies (ACTs) to patients with malaria. To evaluate the impact on case management practices of routine government implementation of mRDTs, we conducted large-scale health facility surveys in three regions of Tanzania before and after mRDT roll-out.

Methods

Febrile patients at randomly selected health facilities were interviewed about care received at the facility, and blood samples were collected for reference blood smears. Health facility staff were interviewed about their qualifications and availability of malaria diagnostics and drugs.

Results

The percentage of febrile patients tested for malaria at the facility increased from 15.8% in 2010 to 54.9% in 2012. ACTs were obtained by 65.8% of patients positive by reference blood smear in 2010 and by 50.2% in 2012 (P = 0.0675); no antimalarial was obtained by 57.8% of malaria-negative patients in 2010 and by 82.3% in 2012 (P < 0.0001). Overall, ACT use decreased (39.9–21.3%, P < 0.0001) and antibiotic use increased (31.2–48.5%, P < 0.0001).

Conclusion

Roll-out of mRDTs in Tanzania dramatically improved diagnostic testing for malaria and reduced overuse of ACTs for patients without parasitemia. However, post–roll-out almost 50% of febrile patients did not receive a diagnostic test, and almost 50% of patients testing positive did not receive ACTs. Stock-outs of ACTs and mRDTs were important problems. Further investigation is needed to determine reasons for not providing ACTs to patients with malaria and potential for inappropriate antibiotic use.

"Even if the test result is negative, they should be able to tell us what is wrong with us": a qualitative study of patient expectations of rapid diagnostic tests for malaria

Background

The debate on rapid diagnostic tests (RDTs) for malaria has begun to shift from whether RDTs should be used, to how and under what circumstances their use can be optimized. This has increased the need for a better understanding of the complexities surrounding the role of RDTs in appropriate treatment of fever. Studies have focused on clinician practices, but few have sought to understand patient perspectives, beyond notions of acceptability.

Methods

This qualitative study aimed to explore patient and caregiver perceptions and experiences of RDTs following a trial to assess the introduction of the tests into routine clinical care at four health facilities in one district in Ghana. Six focus group discussions and one in-depth interview were carried out with those who had received an RDT with a negative test result.

Results

Patients had high expectations of RDTs. They welcomed the tests as aiding clinical diagnoses and as tools that could communicate their problem better than they could, verbally. However, respondents also believed the tests could identify any cause of illness, beyond malaria. Experiences of patients suggested that RDTs were adopted into an existing system where patients are both physically and intellectually removed from diagnostic processes and where clinicians retain authority that supersedes tests and their results. In this situation, patients did not feel able to articulate a demand for test-driven diagnosis.

Conclusions

Improvements in communication between the health worker and patient, particularly to explain the capabilities of the test and management of RDT negative cases, may both manage patient expectations and promote patient demand for test-driven diagnoses.