title: Low referral completion of rapid diagnostic test-negative patients in community-based treatment of malaria in Sierra Leone.
abstract: BACKGROUND
  Malaria is hyper-endemic and a major public health problem in Sierra Leone. To provide malaria treatment closer to the community, Médecins Sans Frontières (MSF) launched a community-based project where Community Malaria Volunteers (CMVs) tested and treated febrile children and pregnant women for malaria using rapid diagnostic tests (RDTs). RDT-negative patients and severely ill patients were referred to health facilities. This study sought to determine the referral rate and compliance of patients referred by the CMVs.
  
  
  METHODS
  In MSF's operational area in Bo and Pujehun districts, Sierra Leone, a retrospective analysis of referral records was carried out for a period of three months. All referral records from CMVs and referral health structures were reviewed, compared and matched for personal data. The eligible study population included febrile children between three and 59 months and pregnant women in their second or third trimester with fever who were noted as having received a referral advice in the CMV recording form.
  
  
  RESULTS
  The study results showed a total referral rate of almost 15%. During the study period 36 out of 2,459 (1.5%) referred patients completed their referral. There was a significant difference in referral compliance between patients with fever but a negative RDT and patients with signs of severe malaria. Less than 1% (21/2,442) of the RDT-negative patients with fever completed their referral compared to 88.2% (15/17) of the patients with severe malaria (RR = 0.010 95% CI 0.006 - 0.015).
  
  
  CONCLUSIONS
  In this community-based malaria programme, RDT-negative patients with fever were referred to a health structure for further diagnosis and care with a disappointingly low rate of referral completion. This raises concerns whether use of CMVs, with referral as backup in RDT-negative cases, provides adequate care for febrile children and pregnant women. To improve the referral completion in MSF's community-based malaria programme in Sierra Leone, and in similar community-based programmes, a suitable strategy needs to be defined.
authors.affiliation: Division of Global Health, Karolinska Institutet, Stockholm, Sweden. anna.thomson@stockholm.msf.org
authors.forename: Anna
authors.initials: A
authors.lastname: Thomson
authors.forename: Mohammed
authors.initials: M
authors.lastname: Khogali
authors.forename: Martin
authors.initials: M
authors.lastname: de Smet
authors.forename: Tony
authors.initials: T
authors.lastname: Reid
authors.forename: Ahmed
authors.initials: A
authors.lastname: Mukhtar
authors.forename: Stefan
authors.initials: S
authors.lastname: Peterson
authors.forename: Johan
authors.initials: J
authors.lastname: von Schreeb
mesh_terms: D000293:Adolescent; D000328:Adult; D002675:Child, Preschool; D003955:Diagnostic Tests, Routine / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007223:Infant; D008288:Malaria / Q000175:diagnosis*; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000175:diagnosis; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012807:Sierra Leone; D055815:Young Adult