Measuring Coverage in MNCH: Accuracy of Measuring Diagnosis and Treatment of Childhood Malaria from Household Surveys in Zambia

Abstract

BackgroundTo assess progress in the scale-up of rapid diagnostic tests and artemisinin-based combination therapies (ACTs) across Africa, malaria control programs have increasingly relied on standardized national household surveys to determine the proportion of children with a fever in the past 2 wk who received an effective antimalarial within 1–2 d of the onset of fever. Here, the validity of caregiver recall for measuring the primary coverage indicators for malaria diagnosis and treatment of children <5 y old is assessed.Methods and FindingsA cross-sectional study was conducted in five public clinics in Kaoma District, Western Provence, Zambia, to estimate the sensitivity, specificity, and accuracy of caregivers' recall of malaria testing, diagnosis, and treatment, compared to a gold standard of direct observation at the health clinics. Compared to the gold standard of clinic observation, for recall for children with fever in the past 2 wk, the sensitivity for recalling that a finger/heel stick was done was 61.9%, with a specificity of 90.0%. The sensitivity and specificity of caregivers' recalling a positive malaria test result were 62.4% and 90.7%, respectively. The sensitivity and specificity of recalling that the child was given a malaria diagnosis, irrespective of whether a laboratory test was actually done, were 76.8% and 75.9%, respectively. The sensitivity and specificity for recalling that an ACT was given were 81.0% and 91.5%, respectively.ConclusionsBased on these findings, results from household surveys should continue to be used for ascertaining the coverage of children with a fever in the past 2 wk that received an ACT. However, as recall of a malaria diagnosis remains suboptimal, its use in defining malaria treatment coverage is not recommended. Please see later in the article for the Editors' Summary

Nationwide implementation of integrated community case management of childhood illness in Rwanda

“…Prior research has shown that vital registry data underestimate under-5 mortality compared with data obtained from household surveys, 18 and in our study the HMIS data likely capture only about half of all child deaths. While national household-based birth history data are available from the 2010 Rwanda DHS, this survey provides only a 5-year average of national under-5 mortality, not district-level, monthly totals of under-5 deaths, which are needed to examine the impact of iCCM in the first year of implementation in each district 38 . Although our community-based HMIS data likely underestimate under-5 deaths, we expect them to underestimate deaths similarly in both the baseline and implementation periods.…”

Child Gender and Parental Reporting of Illness Symptoms in Sub-Saharan Africa

“…From a measurement perspective, estimates of gender imbalances in child illness and treatment based on parental reports may be inaccurate. Previous studies have already documented that parents do a poor job at distinguishing diseases in their children, 34 and also that recall periods have a biasing effect on illness reporting. 35 Parental reports collected as part of the DHS are a primary means for estimating illness prevalence among children in developing countries, but alternative or supplementary methods should perhaps be considered.…”

Diagnostic approaches to malaria in Zambia, 2009-2014

“…Positive RDT rates were the highest among febrile cases reporting to CHWs for treatment (Hamainza et al, 2014). Introduction of RDT and ACT consumption led to a large decline in reported malaria cases in parts of Zambia Eisele et al, 2013). Rapid diagnostic test was used to diagnose malaria for 98.3% cases in some clinics (Eisele et al, 2013).…”

“…Introduction of RDT and ACT consumption led to a large decline in reported malaria cases in parts of Zambia Eisele et al, 2013). Rapid diagnostic test was used to diagnose malaria for 98.3% cases in some clinics (Eisele et al, 2013). A higher proportion of laboratory tests confirmed by microscopy (67.4%), as opposed to clinically diagnosed malaria, was reported in one district in Zambia (Eisele et al, 2013) and it is felt that the use of RDTs in the diagnosis of malaria will affect national (and global) malaria control strategies.…”

“…Rapid diagnostic test was used to diagnose malaria for 98.3% cases in some clinics (Eisele et al, 2013). A higher proportion of laboratory tests confirmed by microscopy (67.4%), as opposed to clinically diagnosed malaria, was reported in one district in Zambia (Eisele et al, 2013) and it is felt that the use of RDTs in the diagnosis of malaria will affect national (and global) malaria control strategies. Geospatial technologies have created new opportunities for public health administrators to enhance planning, monitoring, analysis and management of health system.…”