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Evaluating the cost-effectiveness and the epidemiological effect of introducing rapid diagnostic tests (RDTs) within the Ugandan health system at varying levels of malaria endemicity
Although WHO recommends confirmatory diagnosis of all suspected malaria cases prior to treatment, in some areas of moderate/high malaria transmission children under 5 years of age with suspected malaria are still receiving antimalarial treatment. Adherence of health workers to RDT results has been poor in Uganda, due to insufficient evidence to recommend withholding treatment on the basis of negative parasitological results thus the perceived risks of a missed diagnosis outweigh all other risks.
The study aims to assess the risks of withholding antimalarials in children who have a negative RDT and to provide evidence for scale-up of RDT implementation in Uganda. The objectives are to: compare fever and parasite clearance in those receiving antimalarials and those who don’t; determine the rate of re-attendance; assess the safety of withholding antimalarials in children with a negative RDT result.
We conducted a prospective cohort study to assess the health outcomes of children that were managed according to RDT results. Eligible children aged 1-10 years were enrolled and followed up for two weeks. In addition, the sensitivity and specificity of RDT results was determined using expert microscopy as the gold standard.
A total of 163 children were recruited, 92 of whom tested RDT positive and 71 RDT negative. Of the RDT negative children who received no antimalarial treatment, none presented with fever within the two weeks follow-up period compared to 7% of RDT positive who came back with persistent fever one of whom developed complicated malaria. A total of 50 had complaints on subsequent visits ranging from URTI (26), Otitis (4), eye discharge (3), fever (2), abdominal pain (2), diarrhoea (7), dermatitis (4) helminthiasis (1), and complicated malaria (1). One hundred percent remained RDT/microscopy negative up to 2 weeks of follow-up. Fifty six percent of the patients were RDT positive initially and based on RDT result received an antimalarial. Of these, 60% were reported negative following quality control microscopy reading of the blood smears results and remained negative up to day 14. The RDT sensitivity and specificity were 100% and 53% respectively. The negative predictive value was 100% and the positive predictive value 59.8%.
We conclude that with the use of RDTs in an area of moderate malaria transmission, with holding antimalarials in RDT negative febrile children aged 1 to 10 years is safe.
Charles Karamagi (Makerere) & Pascal Magnussen (UoC)
Richard Ndyomugyeni (MoH, Uganda) & Kristian Hansen (LSHTM)