title: Comparative feasibility of implementing rapid diagnostic test and microscopy for parasitological diagnosis of malaria in Uganda.
abstract: BACKGROUND
  In Uganda, parasite-based diagnosis is recommended for every patient suspected to have malaria before prescribing anti-malarials. However, the majority of patients are still treated presumptively especially in low-level health units. The feasibility of implementing parasite-based diagnosis for uncomplicated malaria in rural health centres (HCs) was investigated with a view to recommending measures for scaling up the policy.
  
  
  METHODS
  Thirty HCs were randomized to implement parasite-based diagnosis based on rapid diagnostic tests [RDTs] (n = 10), blood microscopy (n = 10) and presumptive diagnosis (control arm) (n = 10). Feasibility was assessed by comparing the proportion of patients who received parasite-based diagnosis; with a positive malaria parasite-based diagnosis who received artemether-lumefantrine (AL); with a negative malaria parasite-based diagnosis who received AL; and patient waiting time. Clinicaltrials.gov: NCT00565071.
  
  
  RESULTS
  102, 087 outpatients were enrolled. Patients were more likely to be tested in the RDT 44, 565 (96.6%) than in microscopy arm 19, 545 (60.9%) [RR: 1.59]. RDTs reduced patient waiting time compared to microscopy and were more convenient to health workers and patients. Majority 23, 804 (99.7%) in presumptive arm were prescribed AL. All (100%) of patients who tested positive for malaria in RDT and microscopy arms were prescribed anti-malarials. Parasitological-based diagnosis significantly reduced AL prescription in RDT arm [RR: 0.62] and microscopy arm [RR: 0.72] compared to presumptive treatment. Among patients not tested in the two intervention arms, 12, 044 (96.1%) in microscopy and 965 (61.6%) in RDT arm were treated with AL [RR: 1.56]. Overall 10, 558 (29.4%) with negative results [5, 110 (23.4%) in RDT and 5, 448 (39.0%) in microscopy arms] were prescribed AL.
  
  
  CONCLUSIONS
  It was more feasible to implement parasite-based diagnosis for malaria using RDT than with microscopy. A high proportion of patients with negative malaria results are still prescribed anti-malarials. There is need to increase access to parasite-based diagnosis where microscopy is used. In order to fully harness the benefits of parasitological confirmation of malaria, it is necessary to reduce the prescription of anti-malarials in negative patients.
authors.affiliation: Department of Community Health, Mbarara University of Science & Technology, P.O. Box 1410, Mbarara, Uganda. vkbatwala@gmail.com
authors.forename: Vincent
authors.initials: V
authors.lastname: Batwala
authors.forename: Pascal
authors.initials: P
authors.lastname: Magnussen
authors.forename: Fred
authors.initials: F
authors.lastname: Nuwaha
mesh_terms: D000293:Adolescent; D000328:Adult; D000077611:Artemether, Lumefantrine Drug Combination; D037621:Artemisinins / Q000008:administration & dosage / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D003695:Delivery of Health Care / Q000592:standards; D003955:Diagnostic Tests, Routine / Q000379:methods*; D004338:Drug Combinations; D004983:Ethanolamines / Q000008:administration & dosage / Q000627:therapeutic use; D005240:Feasibility Studies; D005260:Female; D005334:Fever / Q000469:parasitology; D005449:Fluorenes / Q000008:administration & dosage / Q000627:therapeutic use; D006282:Health Personnel / Q000592:standards; D006801:Humans; D057970:Inappropriate Prescribing / Q000706:statistics & numerical data; D007223:Infant; D016778:Malaria, Falciparum / Q000175:diagnosis* / Q000453:epidemiology; D008297:Male; D008853:Microscopy; D010963:Plasmodium falciparum / Q000302:isolation & purification* / Q000472:pathogenicity; D010818:Practice Patterns, Physicians' / Q000592:standards / Q000706:statistics & numerical data; D019035:Rural Health Services / Q000592:standards*; D013997:Time Factors; D014454:Uganda / Q000453:epidemiology; D055815:Young Adult
chemical_list: D000077611:Artemether, Lumefantrine Drug Combination; D037621:Artemisinins; D004338:Drug Combinations; D004983:Ethanolamines; D005449:Fluorenes