Malaria diagnostic testing and treatment practices in three different Plasmodium falciparum transmission settings in Tanzania: before and after a government policy change

Abstract

BackgroundPatterns of decreasing malaria transmission intensity make presumptive treatment of malaria an unjustifiable approach in many African settings. The controlled use of anti-malarials after laboratory confirmed diagnosis is preferable in low endemic areas. Diagnosis may be facilitated by malaria rapid diagnostic tests (RDTs). In this study, the impact of a government policy change, comprising the provision of RDTs and advice to restrict anti-malarial treatment to RDT-positive individuals, was assessed by describing diagnostic behaviour and treatment decision-making in febrile outpatients <10 years of age in three hospitals in the Kagera and Mwanza Region in northern Tanzania.MethodsProspective data from Biharamulo and Rubya Designated District Hospital (DDH) were collected before and after policy change, in Sumve DDH no new policy was implemented. Diagnosis of malaria was confirmed by RDT; transmission intensity was evaluated by a serological marker of malaria exposure in hospital attendees.ResultsPrior to policy change, there was no evident association between the actual level of transmission intensity and drug-prescribing behaviour. After policy change, there was a substantial decrease in anti-malarial prescription and an increase in prescription of antibiotics. The proportion of parasite-negative individuals who received anti-malarials decreased from 89.1% (244/274) to 38.7% (46/119) in Biharamulo and from 76.9% (190/247) to 10.0% (48/479) in Rubya after policy change.ConclusionThis study shows that an official policy change, where RDTs were provided and healthcare providers were advised to adhere to RDT results in prescribing drugs can be followed by more rational drug-prescribing behaviour. The current findings are promising for improving treatment policy in Tanzanian hospitals.

‘As a clinician, you are not managing lab results, you are managing the patient’: How the enactment of malaria at health facilities in Cameroon compares with new WHO guidelines for the use of malaria tests

“…Even when tests are carried out, findings are accumulating from studies in different countries that show between 35 and 85% of RDT negative patients have been prescribed antimalarials Bisoffi et al, 2009;Chinkhumba et al, 2010;Elmardi et al, 2009;Hamer et al, 2007;Kyabayinze et al, 2010;Reyburn et al, 2007;Skarbinski et al, 2009). By contrast, other studies have found a reduction in overdiagnosis, down to between 4% and 16% RDT negative patients receiving antimalarials after the introduction of RDTs with various supporting interventions (Bastiaens et al, 2011;D'Acremont et al, 2009;Hopkins, 2008;Masanja et al, 2010;Mawili-Mboumba et al, 2009;Msellem et al, 2009;Thiam et al, 2011;Williams et al, 2008). In spite of this mixed evidence over the effect of introducing RDTs, and in the absence of good information about the best way to support their introduction for effective adoption, scale-up of the tests is being promoted (World Health Organisation, 2010), and many countries including Cameroon have included the tests in their Global Fund grant applications (Ministry of Public Health, 2009).…”

The assessment of fever in under-five children in the Ekounou Health Area of Yaounde, Cameroon: Usefulness of rapid diagnostic tests

“…With reports of the decline in the incidence of malaria in many African countries (Bouyou-Akotet et al, 2009;Delacollette et al, 2009;Satoguina et al, 2009), it is imperative that parasite confirmation of malaria be scaled up in all age groups. Rapid diagnostic tests (RDTs) are cheap and practical for improving on the diagnosis and treatment of malaria and have been adopted as a public health policy in several African countries (Reyburn et al, 2007;Bisoffi et al, 2009;Bastiaens et al, 2011). The causes of nonmalarial fevers can then be followed up and managed appropriately (Oladipo and Wellington, 2013).…”

Antibiotic resistance—the need for global solutions

“…Evidence from the scientifi c record on the eff ect of diagnostic testing on prescription behaviour is mixed. 204,205 The increased prescription of antibiotics in the setting of a negative rapid diagnostic test fi nding for malaria might lead to improved rational use, or it could just result in overprescription of antibiotics as compensatory behaviour to mollify patients' expectations of treatment. 206 In the health-care delivery system, antibiotic steward ship might be through integrated community case management.…”