title: Impact of training in clinical and microscopy diagnosis of childhood malaria on antimalarial drug prescription and health outcome at primary health care level in Tanzania: a randomized controlled trial.
abstract: BACKGROUND
  Prescribing antimalarial medicines based on parasite confirmed diagnosis of malaria is critical to rational drug use and optimal outcome of febrile illness. The impact of microscopy-based versus clinical-based diagnosis of childhood malaria was assessed at primary health care (PHC) facilities using a cluster randomized controlled training intervention trial.
  
  
  METHODS
  Sixteen PHC facilities in rural Tanzania were randomly allocated to training of health staff in clinical algorithm plus microscopy (Arm-I, n = 5) or clinical algorithm only (Arm-II, n = 5) or no training (Arm-III, n = 6). Febrile under-five children presenting at these facilities were assessed, treated and scheduled for follow up visit after 7 days. Blood smears on day 0 were only done in Arm-I but on Day 7 in all arms. Primary outcome was antimalarial drug prescription. Other outcomes included antibiotic prescription and health outcome. Multilevel regression models were applied with PHC as level of clustering to compare outcomes in the three study arms.
  
  
  RESULTS
  A total of 973, 1,058 and 1,100 children were enrolled in arms I, II and III, respectively, during the study period. Antimalarial prescriptions were significantly reduced in Arm-I (61.3%) compared to Arms-II (95.3%) and III (99.5%) (both P < 0.001), whereas antibiotic prescriptions did not vary significantly between the arms (49.9%, 54.8% and 34.2%, respectively). In Arm-I, 99.1% of children with positive blood smear readings received antimalarial prescriptions and so did 11.3% of children with negative readings. Those with positive readings were less likely to be prescribed antibiotics than those with negative (relative risk = 0.66, 95% confidence interval: 0.55, 0.72). On day 7 follow-up, more children reported symptoms in Arm-I compared to Arm-III, but fewer children had malaria parasitaemia (p = 0.049). The overall sensitivity of microscopy reading at PHC compared to reference level was 74.5% and the specificity was 59.0% but both varied widely between PHCs.
  
  
  CONCLUSIONS
  Microscopy based diagnosis of malaria at PHC facilities reduces prescription of antimalarial drugs, and appears to improve appropriate management of non-malaria fevers, but major variation in accuracy of the microscopy readings was found. Lack of qualified laboratory technicians at PHC facilities and the relatively short training period may have contributed to the shortcomings.
  
  
  BACKGROUND
  This study is registered at Clinicaltrials.gov with the identifier NCT00687895.
authors.affiliation: Infectious Diseases Unit, Department of Medicine, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden. bngasala70@yahoo.co.uk
authors.forename: Billy
authors.initials: B
authors.lastname: Ngasala
authors.forename: Marycelina
authors.initials: M
authors.lastname: Mubi
authors.forename: Marian
authors.initials: M
authors.lastname: Warsame
authors.forename: Max G
authors.initials: MG
authors.lastname: Petzold
authors.forename: Amos Y
authors.initials: AY
authors.lastname: Massele
authors.forename: Lars L
authors.initials: LL
authors.lastname: Gustafsson
authors.forename: Goran
authors.initials: G
authors.lastname: Tomson
authors.forename: Zul
authors.initials: Z
authors.lastname: Premji
authors.forename: Anders
authors.initials: A
authors.lastname: Bjorkman
mesh_terms: D000818:Animals; D000962:Antimalarials / Q000627:therapeutic use*; D002675:Child, Preschool; D011307:Drug Prescriptions / Q000706:statistics & numerical data; D004493:Education; D005260:Female; D006282:Health Personnel; D006302:Health Services Research; D006801:Humans; D007223:Infant; D016778:Malaria, Falciparum / Q000175:diagnosis* / Q000188:drug therapy* / Q000503:physiopathology; D008297:Male; D008853:Microscopy; D010963:Plasmodium falciparum / Q000302:isolation & purification*; D012424:Rural Population; D013636:Tanzania; D016896:Treatment Outcome
chemical_list: D000962:Antimalarials