Improved diagnostic testing and malaria treatment practices in Zambia.
BACKGROUND
Improving the accuracy of malaria diagnosis with rapid antigen-detection diagnostic tests (RDTs) has been proposed as an approach for reducing overtreatment of malaria in the current era of widespread implementation of artemisinin-based combination therapy in sub-Saharan Africa.


OBJECTIVE
To assess the association between use of microscopy and RDT and the prescription of antimalarials.


METHODS
Cross-sectional, cluster sample survey, carried out between March and May 2006, of all outpatients treated during 1 working day at government and mission health facilities in 4 sentinel districts in Zambia.


METHODS
Proportions of patients undergoing malaria diagnostic procedures and receiving antimalarial treatment.


RESULTS
Seventeen percent of the 104 health facilities surveyed had functional microscopy, 63% had RDTs available, and 73% had 1 or more diagnostics available. Of patients with fever (suspected malaria), 27.8% (95% confidence interval [CI], 13.1%-42.5%) treated in health facilities with malaria diagnostics were tested and 44.6% had positive test results. Of patients with negative blood smear results, 58.4% (95% CI, 36.7%-80.2%) were prescribed an antimalaria drug, as were 35.5% (95% CI, 16.0%-55.0%) of those with a negative RDT result. Of patients with fever who did not have diagnostic tests done, 65.9% were also prescribed antimalarials. In facilities with artemether-lumefantrine in stock, this antimalarial was prescribed to a large proportion of febrile patients with a positive diagnostic test result (blood smear, 75.0% [95% CI, 51.7%-98.3%]; RDT, 70.4% [95% CI, 39.3%-100.0%]), but also to some of those with a negative diagnostic test result (blood smear, 30.4% [95% CI, 8.0%-52. 9%]; RDT, 26.7% [95% CI, 5.7%-47.7%]).


CONCLUSIONS
Despite efforts to expand the provision of malaria diagnostics in Zambia, they continue to be underused and patients with negative test results frequently receive antimalarials. Provision of new tools to reduce inappropriate use of new expensive antimalarial treatments must be accompanied by a major change in clinical treatment of patients presenting with fever but lacking evidence of malaria infection.
Hamer
Davidson H
DH
Center for International Health and Development, Boston University School of Public Health, Boston, Mass 02118, USA. dhamer@bu.edu
Ndhlovu
Micky
M
Zurovac
Dejan
D
Fox
Matthew
M
Yeboah-Antwi
Kojo
K
Chanda
Pascalina
P
Sipilinyambe
Naawa
N
Simon
Jonathon L
JL
Snow
Robert W
RW
D000818:Animals; D000953:Antigens, Protozoan / Q000032:analysis*; D000962:Antimalarials / Q000627:therapeutic use*; D000077611:Artemether, Lumefantrine Drug Combination; D037621:Artemisinins / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D016000:Cluster Analysis; D003430:Cross-Sectional Studies; D004338:Drug Combinations; D004363:Drug Utilization; D004983:Ethanolamines / Q000627:therapeutic use; D005449:Fluorenes / Q000627:therapeutic use; D006801:Humans; D008288:Malaria / Q000175:diagnosis* / Q000188:drug therapy*; D008853:Microscopy; D018512:Parasitemia / Q000175:diagnosis; D010963:Plasmodium falciparum / Q000302:isolation & purification*; D015800:Protozoan Proteins / Q000032:analysis; D011933:Reagent Kits, Diagnostic; D019564:Unnecessary Procedures; D015024:Zambia
D000953:Antigens, Protozoan; D000962:Antimalarials; D000077611:Artemether, Lumefantrine Drug Combination; D037621:Artemisinins; D004338:Drug Combinations; D004983:Ethanolamines; D005449:Fluorenes; C514457:HRP-2 antigen, Plasmodium falciparum; D015800:Protozoan Proteins; D011933:Reagent Kits, Diagnostic