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Scientific title: Introducing rapid diagnostic tests (RDTs) into the public and private health sectors in Uganda: a randomised trial to evaluate impact on antimalarial drug use
What did we know before this research?
Most malaria deaths occur within 48 hours after the first symptoms appear. In areas where access to health centres is poor, community-based management of malaria can reduce mortality caused by the disease by up to 50%. This approach provides training to members of the community who are then able to quickly give effective treatment near the patients’ home.
In order to maximise the coverage and impact of artemisinin-based combination therapies (ACT), these drugs should be available not only in health centres but also in programmes of community-based management of malaria. In fact, shops are very often the first source of treatment that patients visit, and up to 80% of malaria cases are not treated within the formal health sector.
It is therefore crucial that malaria programmes in Africa examine the role that shops play in community-based management of malaria and ensure that the treatments they sell comply with national policy guidance.
Currently there is a significant over-use of antimalarial drugs, including sales of drugs that are no longer recommended. This happens because many cases of fever are immediately treated as malaria even without a test or laboratory confirmation. Since ACTs are generally more expensive than other antimalarials and are in limited supply, it is important that their use is restricted to people who are formally diagnosed. At the same time, patients with malaria need to be encouraged to purchase an ACT, as this is the most effective treatment for malaria. This can be done by using rapid diagnostic tests (RDTs), which don’t require electricity or qualified health staff.
What does this study add?
This study examines whether it is feasible and cost-effective to introduce RDTs into drug shops in Uganda in order to promote a rational and correct use of ACT drugs when managing cases of malaria. The research team compared how ACTs were prescribed in drug shops that had been trained to use RDTs and drug shops that continued with the usual way of diagnosing malaria based on clinical signs and symptoms. The research team carried out microscopy to confirm the presence of malaria parasites in the blood, in order to validate the vendor’s decision whether to treat a patient with an ACT.
The research Team
Dr. Anthony K Mbonye, Director of Health Services, Ministry of Health, Kampala, Uganda
Dr Siân Clarke, London School of Hygiene & Tropical Medicine, UK
Dr Pascal Magnussen, Copenhagen University, Frederiksberg, Denmark.
Dr Kristian Schultz Hansen, London School of Hygiene & Tropical Medicine
We conducted a cluster-randomised trial to investigate the use of rapid diagnostic tests (RDTs) for malaria in 59 registered drug shops in central Uganda, collecting data on more than 15,000 patients with fever visiting a drug shop.
The vast majority of patients that visited a drug shop seeking treatment for a fever chose to buy a malaria test, when offered one by the vendors taking part in the trial. The test results showed that less than 60% of these patients actually had malaria. The vendors usually adhered to the results of rapid diagnostic tests, reducing overprescription of artemisinin-based combination therapies (ACTs) by 73%. As a consequence, ACTs were more accurately targeted to patients that had malaria and appropriate use of ACTs in drug shops trained to use rapid diagnostic tests increased by 36%.
These findings show that it is feasible to collaborate with the private sector and improve the treatment of malaria in drug shops. Nevertheless, interviews and focus group discussions conducted alongside the trial revealed that despite their popularity, malaria tests were not a simple fix and could give a false impression of vendors’ other skills and services. The researchers caution that malaria testing in drug shops should only be introduced as part of a wider program – to improve treatment of other illnesses as well as malaria, strengthen linkage to formal health facilities and regulation by national authorities.
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