Scientific title: A cluster-randomised trial of health worker and community interventions to improve adherence to national guidelines for the use of ACTs in Tanzania
What did we know before this research?
It is common practice in Africa to overdiagnose malaria, meaning that very often patients are given ACT drugs simply because they present fever. Given the high price of this type of medication, this approach becomes unsustainable. At the same time, it means that patients don’t receive treatment for their actual illness.
Faced with this problem, the World Health Organization introduced revised guidelines for malaria diagnosis and treatment in 2010. Antimalarial treatment should be restricted to patients whose malaria diagnostic result was positive (either through a blood slide or rapid diagnostic test). The National Malaria Control Programme in Tanzania has adopted these recommendations alongside the national scale-up of rapid diagnostic test distribution.
Several studies have now documented two primary problems with rapid diagnostic tests. Firstly, health workers frequently prescribe malaria drugs to patients whose test came negative. Secondly, although tests are available, staff continue to diagnose patients based on their symptoms only.
Because of their accuracy, rapid diagnostic tests are a potential cost-effective solution for malaria overdiagnosis. However, this method only works if health professionals are trained and supervised.
What does this study add?
There is an urgent need to improve the prescription of ACT drugs based on the results of rapid diagnostic tests.
The TACT trial is an intervention in 36 health facilities that may be useful in improving both the management of malaria cases and the treatment of other diseases that also cause fever. The control group of facilities received rapid diagnostic tests and basic training in how to use them. A second arm provided healthworkers with training at the workplace, messages from senior staff and monthy supervision sessions. A third arm provided both healthworkers and community members with the same package as well as a community-based intervention to modify the expectations of patients. Data is collected through exit surveys of patients.
The research team
Dr. Hugh Reyburn, London School of Hygiene & Tropical Medicine
Dr Renata Mandike, Deputy Director, National Malaria Control Programme, Tanzania
Ms Hilda Mbakilwa, Joint Malaria Programme, Moshi, Tanzania
Prof Raimos Olomi, Professor of Paediatrics KCMC, Tanzania
Dr Steven Magesa, National Institute for Medical Research, Amani Centre, Tanga
Prof Christopher Whitty, Professor of International Health, London School of Hygiene & Tropical Medicine
Dr Clare Chandler, Lecturer in Social Science, London School of Hygiene & Tropical Medicine
Latest on this research
The TACT trial demonstrated that training health workers for two days decreased the number of ACT prescriptions by approximately 75%. This was a much better effect then was expected and suggests that the tendency of overprescribing malaria drugs is reducing over time. Our analysis has shown that training and motivational SMS had a positive effect on prescribing practices. Also, giving leaflets to patients seemed to improve the way health staff used rapid diagnostic tests.
At the district where I work, MRDT is available at Accredited Drug Dispensing Outlet (ADDO) and this to some extent has improved diagnosis of malaria before the purchase of ACT.What I have observed is how to strike a balance when someone does not have money for the test but is presenting symptoms suggestive of malaria (financial position of the patient).The second problem is on negative MRDT test at the drug shop.Ideally, these are supposed to be referred to the nearest health facility for more investigation but this is not happening as most those seen were reluctant to go the health facility and insisted on getting the drugs for malaria (economic gain versus instructions).The third thing is mushrooming laboratory units who mostly report blood slides with 3parasite per 200wbc and advice their clients to obtain ACT on basis of the results.The above study gave us the importance of training but we need to more down to lower levels that include other ACT outlets such as ADDO.