Rapid diagnostic tests versus clinical diagnosis for managing people with fever in malaria endemic settings

Abstract

Background In 2010, the World Health Organization recommended that all patients with suspected malaria are tested for malaria before treatment. In rural African settings light microscopy is often unavailable. Diagnosis has relied on detecting fever, and most people were given antimalarial drugs presumptively. Rapid diagnostic tests (RDTs) provide a point‐of‐care test that may improve management, particularly of people for whom the RDT excludes the diagnosis of malaria. Objectives To evaluate whether introducing RDTs into algorithms for diagnosing and treating people with fever improves health outcomes, reduces antimalarial prescribing, and is safe, compared to algorithms using clinical diagnosis. Search methods We searched the Cochrane Infectious Disease Group Specialized Register; CENTRAL (The Cochrane Library); MEDLINE; EMBASE; CINAHL; LILACS; and the metaRegister of Controlled Trials for eligible trials up to 10 January 2014. We contacted researchers in the field and reviewed the reference lists of all included trials to identify any additional trials. Selection criteria Individual or cluster randomized trials (RCTs) comparing RDT‐supported algorithms and algorithms using clinical diagnosis alone for diagnosing and treating people with fever living in malaria‐endemic settings. Data collection and analysis Two authors independently applied the inclusion criteria and extracted data. We combined data from individually and cluster RCTs using the generic inverse variance method. We presented all outcomes as risk ratios (RR) with 95% confidence intervals (CIs), and assessed the quality of evidence using the GRADE approach. Main results We included seven trials, enrolling 17,505 people with fever or reported history of fever in this review; two individually randomized trials and five cluster randomized trials. All trials were conducted in rural African settings. In most trials the health workers diagnosing and treating malaria were nurses or clinical officers with less than one week of training in RDT supported diagnosis. Health worker prescribing adherence to RDT results was highly variable: the number of participants with a negative RDT result who received antimalarials ranged from 0% to 81%. Overall, RDT supported diagnosis had little or no effect on the number of participants remaining unwell at four to seven days after treatment (6990 participants, five trials, low quality evidence ); but using RDTs reduced prescribing of antimalarials by up to three‐quarters (17,287 participants, seven trials, moderate quality evidence ). As would be expected, the reduction in antimalarial prescriptions was highest where health workers adherence to the RDT result was high, and where the true prevalence of malaria was lower. Using RDTs to support diagnosis did not have a consiste...

Enhancing the Capacity of Policy-Makers to Develop Evidence-Informed Policy Brief on Infectious Diseases of Poverty in Nigeria

“…Of the 13 policy options recommended by the malaria policy brief group, 5 options were eventually accepted after the "evidence synthesis" (ie, synthesising evidence largely from systematic reviews). [40][41][42][43][44][45][46][47] These included the following: (i) Distribution of insecticide treated bednets (ITNs) to be more effective, proper orientation on the usage; (ii) Laboratory diagnosis of malaria to be considered along clinical assessment before treatment of malaria; (iii) artemisinin combination therapies (ACTs) recommended but quality control must be ensured; (iv) More funding for research on indigenous malaria drugs; and (v) Vector control using indoor residual spraying and larval source management. The option on restriction of antimalarial prescription as an over the counter (OTC) drug, was replaced with option that chemists to perform rapid diagnostic test for malaria (RDT) before giving antimalarials (Table 5).…”

Rapid diagnostic tests for malaria

“…4 All the trials were conducted in Africa, indicating that in general, but not in all settings, RDT substantially reduced the over-prescription of antimalarials while not showing a consistent effect on the prescription of antibiotics or the short term outcome for patients.…”

Can Rapid Diagnostic Testing for Malaria Increase Adherence to Artemether–Lumefantrine?: A Randomized Controlled Trial in Uganda

“…The fact that most people who tested negative on the RDT decided to still take AL also suggests that patients may have lacked confidence in the RDT result. Though our study design is likely to have biased RDT-negative patients toward taking the medicines, several other studies, across different contexts, have also found high prescription and purchase rates of ACTs despite a negative test result, 28,[48][49][50] likely because there is a tendency in malariaendemic areas for both health workers and patients to treat all fever episodes as malaria. [51][52][53] It may be that over time, as patients learn about the accuracy of the test, RDTs will have a greater impact on adherence.…”