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Appropriate targeting of artemisinin‐based combination therapy by community health workers using malaria rapid diagnostic tests: findings from randomized trials in two contrasting areas of high and low malaria transmission in south‐western Uganda
Author(s) -
Ndyomugyenyi Richard,
Magnussen Pascal,
Lal Sham,
Hansen Kristian,
Clarke Siân E.
Publication year - 2016
Publication title -
tropical medicine and international health
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.056
H-Index - 114
eISSN - 1365-3156
pISSN - 1360-2276
DOI - 10.1111/tmi.12748
Subject(s) - malaria , medicine , artesunate , artemisinin , rapid diagnostic test , artemether/lumefantrine , transmission (telecommunications) , plasmodium falciparum , randomized controlled trial , artemether , tropical medicine , immunology , pathology , electrical engineering , engineering
Objective To compare the impact of malaria rapid diagnostic tests ( mRDT s), used by community health workers ( CHW s), on the proportion of children <5 years of age receiving appropriately targeted treatment with artemisinin‐based combination therapy (ACT), vs. presumptive treatment. Methods Cluster‐randomized trials were conducted in two contrasting areas of moderate‐to‐high and low malaria transmission in rural Uganda. Each trial examined the effectiveness of mRDT s in the management of malaria and targeting of ACT s by CHW s comparing two diagnostic approaches: (i) presumptive clinical diagnosis of malaria [control arm] and (ii) confirmatory diagnosis with mRDT s followed by ACT treatment for positive patients [intervention arm], with village as the unit of randomisation. Treatment decisions by CHW s were validated by microscopy on a reference blood slide collected at the time of consultation, to compare the proportion of children <5 years receiving appropriately targeted ACT treatment, defined as patients with microscopically‐confirmed presence of parasites in a peripheral blood smear receiving artemether‐lumefantrine or rectal artesunate, and patients with no malaria parasites not given ACT. Results In the moderate‐to‐high transmission area, ACT treatment was appropriately targeted in 79.3% (520/656) of children seen by CHW s using mRDT s to diagnose malaria, vs . 30.8% (215/699) of children seen by CHW s using presumptive diagnosis ( P < 0.001). In the low transmission area, 90.1% (363/403) children seen by CHW s using mRDT s received appropriately targeted ACT treatment vs . 7.8% (64/817) seen by CHW s using presumptive diagnosis ( P < 0.001). Low mRDT sensitivity in children with low‐density parasitaemia (<200 parasites/ μ l) was identified as a potential concern. Conclusion When equipped with mRDT s, ACT treatments delivered by CHW s are more accurately targeted to children with malaria parasites. mRDT use could play an important role in reducing overdiagnosis of malaria and improving fever case management within iCCM , in both moderate‐to‐high and low transmission areas. Nonetheless, missed treatments due to the low sensitivity of current mRDT s in patients with low parasite density are a concern. For community‐based treatment in areas of low transmission and/or non‐immune populations, presumptive treatment of all fevers as malaria may be advisable, until more sensitive diagnostic assays, suitable for routine use by CHW s in remote settings, become available.