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Are there any implications? There is likely to be an increased use of RDT in improving clinical decision making and treatment in malarious settings. While this can be justifiably correct in an era where malaria transmission is reducing, this reduction in transmission is not uniform, and therefore presumptive treatment based on sound clinical judgment can still be of some benefit in high transmission areas. Generally, in rural Africa, clinical care is often critically compromised by the lack of regulatory controls on the quality of diagnostics. Physicians can also be faced with having to select tests based only on information provided in the product insert or on published data that often originate from inadequate or flawed study designs. Furthermore, robust algorithms for negative RDTs rarely exist, thus adherence to diagnosis results is likely to be compromised. It will be important therefore, to consider local realities to decide how to treat fever patients with different parasitological outcome and to base selection of RDTs to be used in appropriate settings from sound scientific evidence. Secondly, presumptive treatment of malaria in an era of artemisinin based combination therapy should continue in resource limited settings. This will mean that the use of antibiotics is encouraged in such settings for malaria, despite the unavailability of diagnostic facility for other infections (bacterial or viral). Whether this is justified or not depends on local factors and physician judgment usually coloured by previous dramatic clinical experience and belief in point-of-care diagnostics. What effects would the one-size-fits-all recent WHO guidelines have on health care provider behaviour? what is likely to change? Is this change in support of the malaria elimination agenda? Many questions need to be investigated.
Thank you Innocent for your comment. There has been various schools of thought in response to the recent WHO guideline. However, I think guidelines are guidelines not 'laws cut in stone' For areas of low or moderate malaria transmissions, this guideline may be more applicable since a negative test result of RDT is likely to be predictive of absence of malaria and need to search for other causes. In areas of high transmission however, the situation is complex. High risk groups including under five children with negative RDT results may still have malaria even though other causes of fever should be ruled out. Delay in treating such children may be rapidly fatal. Also, in practice such children are treated for malaria irrespective of the test result. I think there is a need for a multicenter study in areas of high malaria transmission to investigate the risk/benefit of test and treat versus presumptive treatment for malaria. Does anybody know if such study has been done?
A study to assess the benefit/risk of test and treat versus IPTp strategy would currently being implemented by a team of the London School. I have not heard about a trial to compare the efficiency of test and treat versus presumptive treatment
Hi Oluwagbenga, applicability of the guidelines in a high transmission area. A commentary on the guidelines by Graz et al.(http://www.malariajournal.com/content/10/1/136) puts this in context. I personally think that this guyideline as it is will become more and more applicable in the future and malaria transmission drops, but presently, it is doubtful especially in areas of high transmission. Many clinicians treating malaria in high transmission areas may likely rely on bedside reasoning as against using or depending on the results of RDT for clinical decisions.
Hi SOME, I would like to follow this study. It addresses another important area in malaria management. Is there a link?