Many studies have examined the ability of CHWs and hospital workers to interpret the rapid diagnostic testing results with options on how to treat, which remains imperative. However, if a patient presents with fever and does not fit into the category of the few potential fever-causing illnesses that they received
training about, both groups of workers may feel at a loss and prescribe malarial treatment. A methodology to combat this mistrust of negative results and
assuage feelings of helplessness is to teach hospital workers and CHWs about other causes of fever besides malaria such as respiratory illnesses. Therefore, if they receive a negative result they do not have to feel guilty about not giving an antimalarial treatment if/when they find another disease to treat. An example of a good algorithm flow chart for them to follow (see Figure 7) is from Thiam et al.
2012, which had excellent adherence. Hamer et. al (2012) is also an effective example of how training with alternate diagnoses algorithm flow charts helps to heighten adherence (see Figure 8).
A proposed method is to make RDTs more widely available and to
enhance quality control measures to raise confidence in the tests by health care providers. To increase use of CHWs in rural areas since they already adhere well and to increase their potential by designating health facilities in the area where CHWs can refer RDT negative patients. CHWs should be picked by people in their villages to ensure that they are of high quality.
Thiam et. al (2012) also suspects that maintenance of high adherence by Home Care Providers to RDTs stems from the gradual scale-up of RDT use in the region; this group also plans to train Home Care Providers to manage other fever producing illnesses such as pneumonia and diarrhea. One method is to make sure that in scale-up operations and clinical trials that everyone in a health facility should use RDT and not have, for example, the same physician use RDT on one patient but microscopy on another (D’Acremont et al., 2011).
Figure 7: Algorithm Flow Chart for Fever Management by Home Care Providers. Taken from Thiam et al. 2012.
Figure 8: Classification and Treatment Algorithm Flowchart for Children Aged 6 Months to 5 Years that Present with Fever and/or Cough/Difficult Breathing. Danger signs indicate immediate referral to the nearest healthcare facility. Taken from Hamer et al. 2012.
Malaria guidelines in the national and international scale need to become unambiguous and the new guidelines should be dispersed among the
community. A component of the new guidelines should include allowing denial of antimalarials to children when RDT negative. In regions where previous
guidelines have been ambiguous, there should be advertising campaigns arranged to show the new changes. The new changes include the fact that malaria is declining in many areas and that fever does not equate to malaria as it did in the past due to many efforts to reduce malaria such as insecticides, larval control, insecticide-treated nets, etc. This will be beneficial when seen by hospital workers and CHWs, but also when seen by laypersons since it will make them less likely to request antimalarial treatments and to request antimalarial tests as frequently as they do now.
Additionally, a push to move from microscopy confirmed diagnostics to rapid diagnostic testing in all facilities, not just facilities that do not have adequate microscopy techniques, needs to happen in order to diagnose malaria succinctly.
RDTs have a high sensitivity and high positive predictive value and prove useful.
CONCLUSION
There is a discrepancy, especially in low endemicity settings, of perceived and actual malaria cases. The use of RDTs is especially important in areas of Africa that have declining malaria prevalence so that the prescription of
antimalarials also declines with its reducing existence. The use of RDTs also seems like it could be most favorable in areas that have low endemicity ratings because the reduction in antimalarial prescriptions that they will have if they comply with RDTs will be massive. On the other hand, places that have a high malaria endemic rate will not see as much of a decline in malaria cases
diagnosed and therefore may not see RDTs as useful since they will be confirming what they already thought.
When different agencies first implemented the use of RDTs for malaria management, many assumed that providers would exactly follow the RDT result and treat patients accordingly but that simply was not the case. The groups must first deal with steadfast attitudes among many communities where fever equates to malaria even when presented with evidence to the contrary. Overall, effective implementation of RDTs requires an attitude change in health care providers on both the community and hospital level.
In general, health care providers give antimalarial with positive RDT results in essentially a 1:1 ratio, it is only when faced with a negative RDT result that adherence begins to falter. In order to improve this, cascade models seem to
be effective as well as gradually introducing RDTs into practice so as to maintain efficient use of RDTs. Good training helped to decrease antimalarial prescribing to negative result patients but never as much in hospital workers as CHWs prescribe.
Trained clinicians and health care workers are more reluctant to adopt the changed protocols that RDT brings because they feel that they already know a lot about the malaria subject. Part of the reason for high adherence in CHWs is that in their training they were more likely to be offered options to take if the RDT result was negative. Additionally, they adhere better than hospital workers do because hospital workers do not have anyone to refer the patients to, they are the referral, and that poses a lot of pressure to try to prove the symptoms of the patient. Overall, training was not that different between CHWs and hospital workers but with the hospital workers, a lot more prior knowledge needs overcoming before they adhere to RDT results. It is not so much that CHWs adhere to RDT results in spite of their lack of overall medical training but that they adhere to RDT results precisely because of this lack of overall medical training.
Perhaps the presence of multiple diagnostic tools at hand makes it more difficult to adhere to the RDT result. Of course, a solution to this would not be to limit the use of microscopy in order to boost RDT adherence, especially when it should be used in combination to confirm one another. It might be beneficial to give extra training to health care facilities that are fortunate to have both
diagnostic tools on the benefit of adhering to RDTs. This discrepancy could be because microscopy is expensive and health care facilities that have both options have more highly paid and well-trained physicians who have more medical training and may feel more reluctant to change their methodologies.
The future direction of malaria management needs to improve malaria treatment in Africa by limiting patients’ exposure to antimalarial side effects unnecessarily, reduce resistance to antimalarial drugs, find alternative febrile causing diseases to treat them, and to improve cost. The use of rapid diagnostic testing is an excellent way to accomplish that.
REFERENCES
Bastiaens, G. J., Schaftenaar, E., Ndaro, A., Keuter, M., Bousema, T., &
Shekalaghe, S. A. (2011). Malaria diagnostic testing and treatment
practices in three different Plasmodium falciparum transmission settings in Tanzania: before and after a government policy change. Malaria Journal, 10, 76. doi:10.1186/1475-2875-10-76
Bisoffi, Z., Sirima, B. S., Angheben, A., Lodesani, C., Gobbi, F., Tinto, H., & Van den Ende, J. (2009). Rapid malaria diagnostic tests vs. clinical
management of malaria in rural Burkina Faso: safety and effect on clinical decisions. A randomized trial. Tropical Medicine & International Health, 14(5), 491–498. doi:10.1111/j.1365-3156.2009.02246.x
CDC-Centers for Disease Control and Prevention. (2010a). CDC - Malaria - About Malaria - Where Malaria Occurs. Retrieved from
http://www.cdc.gov/malaria/about/distribution.html
CDC-Centers for Disease Control and Prevention. (2010b). CDC - Malaria - About Malaria - Biology. Retrieved from
http://www.cdc.gov/malaria/about/biology/
CDC-Centers for Disease Control and Prevention. (2010c). CDC - Malaria - Diagnosis & Treatment (United States) - Treatment (U.S.). Retrieved from http://www.cdc.gov/malaria/diagnosis_treatment/treatment.html
CDC-Centers for Disease Control and Prevention. (2012). CDC - Malaria - Diagnosis & Treatment (United States) - Diagnosis (U.S.). Retrieved from http://www.cdc.gov/malaria/diagnosis_treatment/diagnosis.html
Chanda, P., Hamainza, B., Moonga, H. B., Chalwe, V., & Pagnoni, F. (2011).
Community case management of malaria using ACT and RDT in two districts in Zambia: achieving high adherence to test results using community health workers. Malaria Journal, 10, 158. doi:10.1186/1475-2875-10-158
Chinkhumba, J., Skarbinski, J., Chilima, B., Campbell, C., Ewing, V., San
Joaquin, M., … Mathanga, D. (2010). Comparative field performance and adherence to test results of four malaria rapid diagnostic tests among febrile patients more than five years of age in Blantyre, Malawi. Malaria Journal, 9, 209. doi:10.1186/1475-2875-9-209
D’ Acremont, V., Malila, A., Swai, N., Tillya, R., Kahama-Maro, J., Lengeler, C., &
Genton, B. (2010). Withholding Antimalarials in Febrile Children Who Have a Negative Result for a Rapid Diagnostic Test. Clinical Infectious Diseases, 51(5), 506–511. doi:10.1086/655688
D’Acremont, V., Lengeler, C., & Genton, B. (2007). Stop ambiguous messages on malaria diagnosis. BMJ, 334(7592), 489–489.
doi:10.1136/bmj.39143.024838.1F
D’Acremont, Valérie, Kahama-Maro, J., Swai, N., Mtasiwa, D., Genton, B., &
Lengeler, C. (2011). Reduction of anti-malarial consumption after rapid
diagnostic tests implementation in Dar es Salaam: a before-after and cluster randomized controlled study. Malaria journal, 10, 107.
doi:10.1186/1475-2875-10-107
D’Acremont, Valérie, Lengeler, C., Mshinda, H., Mtasiwa, D., Tanner, M., &
Genton, B. (2009). Time To Move from Presumptive Malaria Treatment to Laboratory-Confirmed Diagnosis and Treatment in African Children with Fever. PLoS Med, 6(1), e252. doi:10.1371/journal.pmed.0050252
Elmardi, K. A., Malik, E. M., Abdelgadir, T., Ali, S. H., Elsyed, A. H., Mudather, M.
A., … Adam, I. (2009). Feasibility and acceptability of home-based management of malaria strategy adapted to Sudan’s conditions using artemisinin-based combination therapy and rapid diagnostic test. Malaria Journal, 8, 39. doi:10.1186/1475-2875-8-39
GR Coatney, WE Collins, M Warren, & PG Contacos. (1971). The Primate Malarias. Bethesda: U.S. Department of Health, Education and Welfare.
Retrieved from http://www.dpd.cdc.gov/dpdx/HTML/ImageLibrary/M-R/Malaria/falciparum/body_Malaria_falciparum_il1.htm
Hamer, D. H., Brooks, E. T., Semrau, K., Pilingana, P., MacLeod, W. B.,
Siazeele, K., … Yeboah-Antwi, K. (2012). Quality and safety of integrated community case management of malaria using rapid diagnostic tests and pneumonia by community health workers. Pathogens and Global Health, 106(1), 32–39.
Hamer, D. H., Ndhlovu, M., Zurovac, D., Fox, M., Yeboah-Antwi, K., Chanda, P.,
… Snow, R. W. (2007). Improved diagnostic testing and malaria treatment practices in Zambia. JAMA : the journal of the American Medical
Association, 297(20), 2227–2231. doi:10.1001/jama.297.20.2227
Ishengoma, D. S., Francis, F., Mmbando, B. P., Lusingu, J. P., Magistrado, P., Alifrangis, M., … Lemnge, M. M. (2011). Accuracy of malaria rapid diagnostic tests in community studies and their impact on treatment of malaria in an area with declining malaria burden in north-eastern Tanzania. Malaria Journal, 10, 176. doi:10.1186/1475-2875-10-176 Kahama-Maro, J., D’Acremont, V., Mtasiwa, D., Genton, B., & Lengeler, C.
(2011). Low quality of routine microscopy for malaria at different levels of the health system in Dar es Salaam. Malaria Journal, 10, 332.
doi:10.1186/1475-2875-10-332
Kyabayinze, D. J., Asiimwe, C., Nakanjako, D., Nabakooza, J., Counihan, H., &
Tibenderana, J. K. (2010). Use of RDTs to improve malaria diagnosis and fever case management at primary health care facilities in Uganda.
Malaria Journal, 9, 200. doi:10.1186/1475-2875-9-200
Liberati, A., Altman, D. G., Tetzlaff, J., Mulrow, C., Gøtzsche, P. C., Ioannidis, J.
P., … Moher, D. (2009). The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care
interventions: explanation and elaboration. PLoS Medicine, 6(7), e1000100.
Ly, A. B., Tall, A., Perry, R., Baril, L., Badiane, A., Faye, J., … Michel, R. (2010).
Use of HRP-2-based rapid diagnostic test for Plasmodium falciparum malaria: assessing accuracy and cost-effectiveness in the villages of Dielmo and Ndiop, Senegal. Malaria Journal, 9, 153. doi:10.1186/1475-2875-9-153
Masaninga, F., Sekeseke-Chinyama, M., Malambo, T., Moonga, H., Babaniyi, O., Counihan, H., & Bell, D. (2012). Finding parasites and finding challenges:
improved diagnostic access and trends in reported malaria and
anti-malarial drug use in Livingstone district, Zambia. Malaria Journal, 11, 341.
doi:10.1186/1475-2875-11-341
Masanja, M. I., McMorrow, M., Kahigwa, E., Kachur, S. P., & McElroy, P. D.
(2010). Health Workers’ Use of Malaria Rapid Diagnostic Tests (RDTs) to Guide Clinical Decision Making in Rural Dispensaries, Tanzania. The American Journal of Tropical Medicine and Hygiene, 83(6), 1238–1241.
doi:10.4269/ajtmh.2010.10-0194
Msellem, M. I., Martensson, A., Rotllant, G., Bhattarai, A., Stromberg, J., Kahigwa, E., … Bjorkman, A. (2009). Influence of Rapid Malaria
Diagnostic Tests on Treatment and Health Outcome in Fever Patients, Zanzibar--A Crossover Validation Study. PLoS Medicine, 6(4).
doi:10.1371/journal.pmed.1000070
Mtove, G., Hendriksen, I. C., Amos, B., Mrema, H., Mandia, V., Manjurano, A., … Reyburn, H. (2011). Treatment guided by rapid diagnostic tests for malaria
in Tanzanian children: safety and alternative bacterial diagnoses. Malaria Journal, 10, 290. doi:10.1186/1475-2875-10-290
Mtove, G., Nadjm, B., Amos, B., Hendriksen, I. C. E., Muro, F., & Reyburn, H.
(2011). Use of an HRP2-based rapid diagnostic test to guide treatment of children admitted to hospital in a malaria-endemic area of north-east Tanzania. Tropical Medicine & International Health, 16(5), 545–550.
doi:10.1111/j.1365-3156.2011.02737.x
Neptune, A. (2011). Mechanisms to control malaria epidemics in displaced person and refugee camps (Thesis). Boston University School of Medicine, Boston, MA.
Paracheck Pf Device Rapid Test for Malaria (Ver. 3) (30301025). (2012, March).
FIND Diagnostics. Retrieved from
http://www.finddiagnostics.org/programs/malaria-afs/malaria/rdt-job-aids/products/paracheck_pf_malaria.html
Reyburn, H., Mbakilwa, H., Mwangi, R., Mwerinde, O., Olomi, R., Drakeley, C., &
Whitty, C. J. M. (2007). Rapid diagnostic tests compared with malaria microscopy for guiding outpatient treatment of febrile illness in Tanzania:
randomised trial. BMJ : British Medical Journal, 334(7590), 403.
doi:10.1136/bmj.39073.496829.AE
Robert Herriman. (2010, January 10). Side Effects of Malaria Medication.
LIVESTRONG.COM. Retrieved from
http://www.livestrong.com/article/72115-side-effects-malaria-medication/
Sage Weld. (2010, June 12). Antimalarial’s Side Effects. LIVESTRONG.COM.
Retrieved from http://www.livestrong.com/article/146919-antimalarials-side-effects/
Skarbinski, J., Ouma, P. O., Causer, L. M., Kariuki, S. K., Barnwell, J. W., Alaii, J.
A., … Hamel, M. J. (2009). Effect of Malaria Rapid Diagnostic Tests on the Management of Uncomplicated Malaria with Artemether-Lumefantrine in Kenya: A Cluster Randomized Trial. The American Journal of Tropical Medicine and Hygiene, 80(6), 919–926.
Taylor, S. M., Molyneux, M. E., Simel, D. L., Meshnick, S. R., & Juliano, J. J.
(2010). Does this patient have malaria? JAMA: The Journal of the American Medical Association, 304(18), 2048–2056.
Thiam, S., Thwing, J., Diallo, I., Fall, F. B., Diouf, M. B., Perry, R., … Thior, M.
(2012). Scale-up of home-based management of malaria based on rapid diagnostic tests and artemisinin-based combination therapy in a resource-poor country: results in Senegal. Malaria Journal, 11, 334.
doi:10.1186/1475-2875-11-334
Tierney, J. (2011). Pharmacological approaches to the treatment of Plasmodium falciparum malaria (Thesis). Boston University School of Medicine,
Boston, MA.
Ukwaja, K. N., Aina, O. B., & Talabi, A. A. (2011). Clinical overlap between
malaria and pneumonia: can malaria rapid diagnostic test play a role? The
Journal of Infection in Developing Countries, 5(03), 199–203.
doi:10.3855/jidc.945
Wilson, M. L. (2012). Malaria Rapid Diagnostic Tests. Clinical Infectious Diseases, 54(11), 1637–1641. doi:10.1093/cid/cis228
World Health Organization. Global Malaria Programme. (2012). World malaria report 2012. Geneva: World Health Organization. Retrieved from
http://www.who.int/malaria/publications/world_malaria_report_2012/wmr20 12_full_report.pdf
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