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Use of RDTs to improve malaria diagnosis and fever case management at primary health care facilities in Uganda.

Kyabayinze DJ, Asiimwe C, Nakanjako D, Nabakooza J, Counihan H, Tibenderana JK - Malar. J. (2010)

Bottom Line: Overall use of RDTs resulted in a 38% point reduction in AMD prescriptions.There was a two-fold reduction (RR 0.62, 95% CI 0.55-0.70) in AMD prescription with the greatest reduction in the hypo-endemic setting (RR 0.46 95% CI 0.51-0.53) but no significant change in the urban setting (RR1.01, p-value=0.820).Use of RDTs resulted in a 2-fold reduction in anti-malarial drug prescription at LLHCFs.

View Article: PubMed Central - HTML - PubMed

Affiliation: Malaria Consortium Africa, Plot 2, Sturrock Road, PO Box 8045, Kampala, Uganda. d.kyabayinze@malariaconsortium.org

ABSTRACT

Background: Early and accurate diagnosis of malaria followed by prompt treatment reduces the risk of severe disease in malaria endemic regions. Presumptive treatment of malaria is widely practised where microscopy or rapid diagnostic tests (RDTs) are not readily available. With the introduction of artemisinin-based combination therapy (ACT) for treatment of malaria in many low-resource settings, there is need to target treatment to patients with parasitologically confirmed malaria in order to improve quality of care, reduce over consumption of anti-malarials, reduce drug pressure and in turn delay development and spread of drug resistance. This study evaluated the effect of malaria RDTs on health workers' anti-malarial drug (AMD) prescriptions among outpatients at low level health care facilities (LLHCF) within different malaria epidemiological settings in Uganda.

Methods: All health workers (HWs) in 21 selected intervention (where RDTs were deployed) LLHF were invited for training on the use RDTs. All HWs were trained to use RDTs for parasitological diagnosis of all suspected malaria cases irrespective of age. Five LLHCFs with clinical diagnosis (CD only) were included for comparison. Subsequently AMD prescriptions were compared using both a 'pre-post' and 'intervention-control' analysis designs. In-depth interviews of the HWs were conducted to explore any factors that influence AMD prescription practices.

Results: A total of 166,131 out-patient attendances (OPD) were evaluated at 21 intervention LLHCFs. Overall use of RDTs resulted in a 38% point reduction in AMD prescriptions. There was a two-fold reduction (RR 0.62, 95% CI 0.55-0.70) in AMD prescription with the greatest reduction in the hypo-endemic setting (RR 0.46 95% CI 0.51-0.53) but no significant change in the urban setting (RR1.01, p-value=0.820). Over 90% of all eligible OPD patients were offered a test. An average of 30% (range 25%-35%) of the RDT-negative fever patients received AMD prescriptions. When the test result was negative, children under five years of age were two to three times more likely (OR 2.6 p-value<0.001) to receive anti-malarial prescriptions relative to older age group. Of the 63 HWs interviewed 92% believed that a positive RDT result confirmed malaria, while only 49% believed that a negative RDT result excluded malaria infection.

Conclusion: Use of RDTs resulted in a 2-fold reduction in anti-malarial drug prescription at LLHCFs. The study demonstrated that RDT use is feasible at LLHCFs, and can lead to better targetting of malaria treatment. Nationwide deployment of RDTs in a systematic manner should be prioritised in order to improve fever case management. The process should include plans to educate HWs about the utility of RDTs in order to maximize acceptance and uptake of the diagnostic tools and thereby leading to the benefits of parasitological diagnosis of malaria.

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Anti-malarial prescriptions among outpatients at 26 lower-level health facilities (HCII and III) in Uganda between March and December, 2007. The trend of anti-malarial prescriptions comparing the health facilities where interventions with RDTs were deployed showing the "before" and "after" period. 21 Health facilities were provided RDTs in the month of June and these were compared to 5 health facilities where presumptive diagnosis was maintained until December.
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Figure 1: Anti-malarial prescriptions among outpatients at 26 lower-level health facilities (HCII and III) in Uganda between March and December, 2007. The trend of anti-malarial prescriptions comparing the health facilities where interventions with RDTs were deployed showing the "before" and "after" period. 21 Health facilities were provided RDTs in the month of June and these were compared to 5 health facilities where presumptive diagnosis was maintained until December.

Mentions: Comparative analysis based on the 'pre-and post' RDT deployment aspect of the evaluation, showed a 38% point reduction in anti-malarial prescriptions in all study health facilities when RDTs were introduced to support malaria clinical diagnosis. The highest drop was in the hypo-endemic malaria transmission settings with a two-fold reduction in the AMD prescriptions (see Table 1). During the pre-intervention period, more than half [54% 95% CI (53.9-54.7)] of all out-patient consultations (for all diseases) were presumptively treated as malaria based on clinical diagnosis. When RDTs were introduced to support diagnosis (post-intervention period), the proportion of AMD prescriptions significantly dropped to one third [33%, 95% CI (32.5%-33.2%)]. The percentage reduction in the anti-malarials dispensed varied in a linear trend for the different malaria transmission levels. Use of RDTs resulted in a 2-fold decrease (RR = 0.52 95% CI 0.51-0.54) in anti-malarial drug prescription of (59% drop) in the hypo-endemic district of Kapchorwa. There were minimal changes observed in hyper-endemic districts of Iganga. When comparison between HF with CD and HF with CD+RDT was performed, there was an overall 1.5-2 fold reduction (RR 0.68 95% CI 0.67-0.69) in anti-malarial drug prescription in the intervention group compared to the control group. The decrease in the prescriptions were more pronounced in the meso-endemic (RR = 0.47 95%CI 0.45-0.50) located facilities yet no significant difference was observed in Jinja (RR1.01, p-value = 0.820) when analysed as 'intervention -control' (see Table 2 and Figure 1).


Use of RDTs to improve malaria diagnosis and fever case management at primary health care facilities in Uganda.

Kyabayinze DJ, Asiimwe C, Nakanjako D, Nabakooza J, Counihan H, Tibenderana JK - Malar. J. (2010)

Anti-malarial prescriptions among outpatients at 26 lower-level health facilities (HCII and III) in Uganda between March and December, 2007. The trend of anti-malarial prescriptions comparing the health facilities where interventions with RDTs were deployed showing the "before" and "after" period. 21 Health facilities were provided RDTs in the month of June and these were compared to 5 health facilities where presumptive diagnosis was maintained until December.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2914063&req=5

Figure 1: Anti-malarial prescriptions among outpatients at 26 lower-level health facilities (HCII and III) in Uganda between March and December, 2007. The trend of anti-malarial prescriptions comparing the health facilities where interventions with RDTs were deployed showing the "before" and "after" period. 21 Health facilities were provided RDTs in the month of June and these were compared to 5 health facilities where presumptive diagnosis was maintained until December.
Mentions: Comparative analysis based on the 'pre-and post' RDT deployment aspect of the evaluation, showed a 38% point reduction in anti-malarial prescriptions in all study health facilities when RDTs were introduced to support malaria clinical diagnosis. The highest drop was in the hypo-endemic malaria transmission settings with a two-fold reduction in the AMD prescriptions (see Table 1). During the pre-intervention period, more than half [54% 95% CI (53.9-54.7)] of all out-patient consultations (for all diseases) were presumptively treated as malaria based on clinical diagnosis. When RDTs were introduced to support diagnosis (post-intervention period), the proportion of AMD prescriptions significantly dropped to one third [33%, 95% CI (32.5%-33.2%)]. The percentage reduction in the anti-malarials dispensed varied in a linear trend for the different malaria transmission levels. Use of RDTs resulted in a 2-fold decrease (RR = 0.52 95% CI 0.51-0.54) in anti-malarial drug prescription of (59% drop) in the hypo-endemic district of Kapchorwa. There were minimal changes observed in hyper-endemic districts of Iganga. When comparison between HF with CD and HF with CD+RDT was performed, there was an overall 1.5-2 fold reduction (RR 0.68 95% CI 0.67-0.69) in anti-malarial drug prescription in the intervention group compared to the control group. The decrease in the prescriptions were more pronounced in the meso-endemic (RR = 0.47 95%CI 0.45-0.50) located facilities yet no significant difference was observed in Jinja (RR1.01, p-value = 0.820) when analysed as 'intervention -control' (see Table 2 and Figure 1).

Bottom Line: Overall use of RDTs resulted in a 38% point reduction in AMD prescriptions.There was a two-fold reduction (RR 0.62, 95% CI 0.55-0.70) in AMD prescription with the greatest reduction in the hypo-endemic setting (RR 0.46 95% CI 0.51-0.53) but no significant change in the urban setting (RR1.01, p-value=0.820).Use of RDTs resulted in a 2-fold reduction in anti-malarial drug prescription at LLHCFs.

View Article: PubMed Central - HTML - PubMed

Affiliation: Malaria Consortium Africa, Plot 2, Sturrock Road, PO Box 8045, Kampala, Uganda. d.kyabayinze@malariaconsortium.org

ABSTRACT

Background: Early and accurate diagnosis of malaria followed by prompt treatment reduces the risk of severe disease in malaria endemic regions. Presumptive treatment of malaria is widely practised where microscopy or rapid diagnostic tests (RDTs) are not readily available. With the introduction of artemisinin-based combination therapy (ACT) for treatment of malaria in many low-resource settings, there is need to target treatment to patients with parasitologically confirmed malaria in order to improve quality of care, reduce over consumption of anti-malarials, reduce drug pressure and in turn delay development and spread of drug resistance. This study evaluated the effect of malaria RDTs on health workers' anti-malarial drug (AMD) prescriptions among outpatients at low level health care facilities (LLHCF) within different malaria epidemiological settings in Uganda.

Methods: All health workers (HWs) in 21 selected intervention (where RDTs were deployed) LLHF were invited for training on the use RDTs. All HWs were trained to use RDTs for parasitological diagnosis of all suspected malaria cases irrespective of age. Five LLHCFs with clinical diagnosis (CD only) were included for comparison. Subsequently AMD prescriptions were compared using both a 'pre-post' and 'intervention-control' analysis designs. In-depth interviews of the HWs were conducted to explore any factors that influence AMD prescription practices.

Results: A total of 166,131 out-patient attendances (OPD) were evaluated at 21 intervention LLHCFs. Overall use of RDTs resulted in a 38% point reduction in AMD prescriptions. There was a two-fold reduction (RR 0.62, 95% CI 0.55-0.70) in AMD prescription with the greatest reduction in the hypo-endemic setting (RR 0.46 95% CI 0.51-0.53) but no significant change in the urban setting (RR1.01, p-value=0.820). Over 90% of all eligible OPD patients were offered a test. An average of 30% (range 25%-35%) of the RDT-negative fever patients received AMD prescriptions. When the test result was negative, children under five years of age were two to three times more likely (OR 2.6 p-value<0.001) to receive anti-malarial prescriptions relative to older age group. Of the 63 HWs interviewed 92% believed that a positive RDT result confirmed malaria, while only 49% believed that a negative RDT result excluded malaria infection.

Conclusion: Use of RDTs resulted in a 2-fold reduction in anti-malarial drug prescription at LLHCFs. The study demonstrated that RDT use is feasible at LLHCFs, and can lead to better targetting of malaria treatment. Nationwide deployment of RDTs in a systematic manner should be prioritised in order to improve fever case management. The process should include plans to educate HWs about the utility of RDTs in order to maximize acceptance and uptake of the diagnostic tools and thereby leading to the benefits of parasitological diagnosis of malaria.

Show MeSH
Related in: MedlinePlus