Should Malaria Treatment Be Guided by a Point of Care Rapid Test? A Threshold Approach to Malaria Management in Rural Burkina Faso

Abstract

BackgroundIn Burkina Faso, rapid diagnostic tests for malaria have been made recently available. Previously, malaria was managed clinically. This study aims at assessing which is the best management option of a febrile patient in a hyperendemic setting. Three alternatives are: treating presumptively, testing, or refraining from both test and treatment. The test threshold is the tradeoff between refraining and testing, the test-treatment threshold is the tradeoff between testing and treating. Only if the disease probability lies between the two should the test be used.Methods and FindingsData for this analysis was obtained from previous studies on malaria rapid tests, involving 5220 patients. The thresholds were calculated, based on disease risk, treatment risk and cost, test accuracy and cost. The thresholds were then matched against the disease probability. For a febrile child under 5 in the dry season, the pre-test probability of clinical malaria (3.2%), was just above the test/treatment threshold. In the rainy season, that probability was 63%, largely above the test/treatment threshold. For febrile children >5 years and adults in the dry season, the probability was 1.7%, below the test threshold, while in the rainy season it was higher (25.1%), and situated between the two thresholds (3% and 60.9%), only if costs were not considered. If they were, neither testing nor treating with artemisinin combination treatments (ACT) would be recommended.ConclusionsA febrile child under 5 should be treated presumptively. In the dry season, the probability of clinical malaria in adults is so low, that neither testing nor treating with any regimen should be recommended. In the rainy season, if costs are considered, a febrile adult should not be tested, nor treated with ACT, but a possible alternative would be a presumptive treatment with amodiaquine plus sulfadoxine-pyrimethamine. If costs were not considered, testing would be recommended.

Spatial heterogeneity can undermine the effectiveness of country-wide test and treat policy for malaria: a case study from Burkina Faso

“…Similar to the findings in [ 39 , 51 ], the analysis presented here suggests that a generalized test-based policy should not be used uniformly across all contexts. In particular, even with improved diagnostic methods (e.g., positive control wells; [ 66 ]), the ‘back-of-the-envelope’ calculation above reveals how the probability of false-negative results will still be relatively large when prevalence is high.…”

“…To avoid this, region-specific guidelines for malaria diagnosis and treatment might need to be developed, a process that can be potentially aided by the developed tool. Differently from past approaches that have relied on a threshold for the pre-test probability of clinical malaria [ 39 ], the proposed tool focuses on the probability of false-negative results to determine which areas a test and treat policy might be warranted. Obviously there are a number of other considerations that should be taken into account when determining policies for malaria diagnosis and treatment.…”

Performance of HRP2-based rapid test in children attending the health centre compared to asymptomatic children in the community

“…However, the debate for the abandonment of presumptive treatment in under-fives is still ongoing. Some still argue that a febrile child under five years of age should be treated presumptively since it is more cost-effective [ 8 ]. Moreover, it appears that health workers often do not always take microscopy or Rapid Diagnostic Test (RDT) results into account, resulting in a waste of resources [ 8 ].…”

Compliance with Malaria Rapid Diagnostic Test Results and Correlates among Clinicians in Uyo, Akwa Ibom State, Nigeria: 2018

“…Malaria accounts for 60% of out-patient attendance and 30% of hospital admissions in Nigeria. In malaria endemic countries in sub-Saharan Africa, clinicians still prescribe anti-malaria drug to clients with Malaria RDT negative results: 80% to 85% of RDT negative febrile patients seen by clinicians are treated for malaria [9]. Compliance with malaria RDT result was found to be generally poor, especially when the result is negative [10].…”