Effect of malaria rapid diagnostic tests on the management of uncomplicated malaria with artemether-lumefantrine in Kenya: a cluster randomized trial

Shortly after Kenya introduced artemether-lumefantrine (AL) for first-line treatment of uncomplicated malaria, we conducted a pre-post cluster randomized controlled trial to assess the effect of providing malaria rapid diagnostic tests (RDTs) on recommended treatment (patients with malaria prescribed AL) and overtreatment (patients without malaria prescribed AL) in outpatients >/= 5 years old. Sixty health facilities were randomized to receive either RDTs plus training, guidelines, and supervision (TGS) or TGS alone. Of 1,540 patients included in the analysis, 7% had uncomplicated malaria. The provision of RDTs coupled with TGS emphasizing AL use only after laboratory confirmation of malaria reduced recommended treatment by 63%-points (P = 0.04), because diagnostic test use did not change (-2%-points), but health workers significantly reduced presumptive treatment with AL for patients with a clinical diagnosis of malaria who did not undergo testing (-36%-points; P = 0.03). Health workers generally adhered to RDT results when prescribing AL: 88% of RDT-positive and 9% of RDT-negative patients were treated with AL, respectively. Overtreatment was low in both arms and was not significantly reduced by the provision of RDTs (-12%-points, P = 0.30). RDTs could potentially improve malaria case management, but we urgently need to develop more effective strategies for implementing guidelines before large scale implementation.

Performance of malaria rapid diagnostic tests as part of routine malaria case management in Kenya

Data on malaria rapid diagnostic test (RDT) performance under routine program conditions are limited. We assessed the attributes of RDTs performed by study and health facility (HF) staffs as part of routine malaria case management of patients > or = 5 years of age in Kenya. Expert microscopy was used as our gold standard. A total of 1,827 patients were enrolled; 191 (11.6%) were parasitemic by expert microscopy. Sensitivity and specificity of RDTs performed by study staff were 86.6% (95% confidence interval [CI]: 79.8-93.5%) and 95.4% (95% CI: 93.9-96.9%), respectively. Among tests performed by HF staff, RDTs were 91.7% (95% CI: 80.8-100.0%) sensitive and 96.7% (95% CI: 92.8-100.0%) specific, whereas microscopy was 52.5% (95% CI: 33.2-71.9%) sensitive and 77.0% (95% CI: 67.9-86.2%) specific. Our findings suggest that RDTs perform better than microscopy under routine conditions. Further efforts are needed to maintain this high RDT performance over time.

The effect of health care worker training on the use of intermittent preventive treatment for malaria in pregnancy in rural western Kenya

BACKGROUND

In 1998, Kenya adopted intermittent preventive treatment (IPTp) with sulphadoxine-pyrimethamine (SP) for malaria prevention during pregnancy. We conducted a survey in 2002 among women who had recently delivered in the rural neighbouring areas Asembo and Gem and reported coverage of 19% of at least one dose and 7% of two or more doses of SP. Health care workers (HCW) in Asembo were retrained on IPTp in 2003.

OBJECTIVES

To evaluate if IPTp coverage increased and if the training in Asembo led to better coverage than in Gem, and to identify barriers to the effective implementation of IPTp.

METHODS

Community-based cross-sectional survey among a simple random sample of women who had recently delivered in April 2005, interviews with HCW of antenatal clinics (ANC) in Asembo and Gem.

RESULTS

Of the 724 women interviewed, 626 (86.5%) attended the ANC once and 516 (71.3%) attended two or more times. Overall IPTp coverage was 41% for at least one dose, and 21% for at least two doses of SP. In Asembo, coverage increased from 19% in 2002 to 61% in 2005 for at least one dose and from 7% to 17% for two doses of SP. In Gem, coverage increased from 17% to 28% and 7% to 11%, respectively. Interviews of HCW in both Asembo and Gem revealed confusion about appropriate timing, and lack of direct observation of IPTp.

CONCLUSION

Training of HCW and use of simplified IPTp messages may be a key strategy in achieving Roll Back Malaria targets for malaria prevention in pregnancy in Kenya.