The impact of the scale-up of malaria rapid diagnostic tests on the routine clinical diagnosis procedures for febrile illness: a series of repeated cross-sectional studies in Papua New Guinea

Abstract

BackgroundThis paper examines the impact of the scale-up of malaria rapid diagnostic tests (RDT) on routine clinical diagnosis procedures for febrile illness in primary healthcare settings in Papua New Guinea.MethodsRepeat, cross-sectional surveys in randomly selected primary healthcare services were conducted. Surveys included passive observation of consecutive febrile case management cases and were completed immediately prior to RDT scale-up (2011) and at 12- (2012) and 60-months (2016) post scale-up. The frequency with which specified diagnostic questions and procedures were observed to occur, with corresponding 95% CIs, was calculated for febrile patients prescribed anti-malarials pre- and post-RDT scale-up and between febrile patients who tested either negative or positive for malaria infection by RDT (post scale-up only).ResultsA total of 1809 observations from 120 health facilities were completed across the three survey periods of which 915 (51%) were prescribed an anti-malarial. The mean number of diagnostic questions and procedures asked or performed, leading to anti-malarial prescription, remained consistent pre- and post-RDT scale-up (range 7.4–7.7). However, alterations in diagnostic content were evident with the RDT replacing body temperature as the primary diagnostic procedure performed (observed in 5.3 and 84.4% of cases, respectively, in 2011 vs. 77.9 and 58.2% of cases in 2016). Verbal questioning, especially experience of fever, cough and duration of symptoms, remained the most common feature of a diagnostic examination leading to anti-malarial prescription irrespective of RDT use (observed in 96.1, 86.8 and 84.8% of cases, respectively, in 2011 vs. 97.5, 76.6 and 85.7% of cases in 2016). Diagnostic content did not vary substantially by RDT result.ConclusionsRapid diagnostic tests scale-up has led to a reduction in body temperature measurement. Investigations are very limited when malaria infection is ruled out as a cause of febrile illness by RDT.

Does test-based prescription of evidence-based treatment for malaria improve treatment seeking and satisfaction? Findings of repeated cross-sectional surveys in Papua New Guinea

“…Arguably, the difference in reported satisfaction may be related to the subsequent diagnosis and treatment of test confirmed non-malaria febrile illness patients. Previous studies in Papua New Guinea suggest that health workers rarely conduct further investigations once malaria has been ruled out as a cause of febrile illness30 and that antibiotics are widely overprescribed to this patient group 31. Coupled with the fact that diagnostic tools to assist in the accurate identification of fever aetiology (other than malaria) are scarce in resource-poor settings,32 then it is quite likely that many patients with non-malaria febrile illness, despite being appropriately managed according to test-based ACT prescription guidelines, may experience some degree of dissatisfaction with subsequent case management (which may be related to health worker behaviour and/or patient perceptions of the appropriateness of the diagnosis and treatment received).…”

A review of malaria epidemiology and control in Papua New Guinea 1900 to 2021: Progress made and future directions

“…Until 2002, diagnosis of malaria and treatment was administered on a presumptive basis ( 1 , 4 , 35 ) and fever cases were often treated as malaria ( 75 , 82 ). New malaria treatment guidelines introduced in 2009 required a parasitological diagnosis of fever cases with RDT or light microscopy and treatment only in the case of a positive diagnosis ( 63 , 83 ), a protocol which is now applied across the country ( 79 , 84 ).…”

“…Since the introduction of the new treatment protocol here has been an increase in the percentage of health centers stocking RDTs from 17.5% in 2010 to 90.2% in 2012 and in the use of RDTs for diagnosis of febrile illness ( 84 – 86 ). In 2014, 85% of health centers surveyed were able to provide first-line treatment for uncomplicated malaria, and 42% of health facilities had first-line treatment available for severe malaria ( 84 , 85 , 87 ).…”

“…Since the introduction of the new treatment protocol here has been an increase in the percentage of health centers stocking RDTs from 17.5% in 2010 to 90.2% in 2012 and in the use of RDTs for diagnosis of febrile illness ( 84 – 86 ). In 2014, 85% of health centers surveyed were able to provide first-line treatment for uncomplicated malaria, and 42% of health facilities had first-line treatment available for severe malaria ( 84 , 85 , 87 ). However, survey evidence in 2012 found that a high proportion of fever cases (96.4% of fever patients) were being treated for malaria on a presumptive basis, even with a negative RDT test, which may eventually contribute to parasite resistance to anti-malarial drugs ( 88 ).…”