title: Should malaria treatment be guided by a point of care rapid test? A threshold approach to malaria management in rural Burkina Faso.
abstract: BACKGROUND
  In Burkina Faso, rapid diagnostic tests for malaria have been made recently available. Previously, malaria was managed clinically. This study aims at assessing which is the best management option of a febrile patient in a hyperendemic setting. Three alternatives are: treating presumptively, testing, or refraining from both test and treatment. The test threshold is the tradeoff between refraining and testing, the test-treatment threshold is the tradeoff between testing and treating. Only if the disease probability lies between the two should the test be used.
  
  
  RESULTS
  Data for this analysis was obtained from previous studies on malaria rapid tests, involving 5220 patients. The thresholds were calculated, based on disease risk, treatment risk and cost, test accuracy and cost. The thresholds were then matched against the disease probability. For a febrile child under 5 in the dry season, the pre-test probability of clinical malaria (3.2%), was just above the test/treatment threshold. In the rainy season, that probability was 63%, largely above the test/treatment threshold. For febrile children >5 years and adults in the dry season, the probability was 1.7%, below the test threshold, while in the rainy season it was higher (25.1%), and situated between the two thresholds (3% and 60.9%), only if costs were not considered. If they were, neither testing nor treating with artemisinin combination treatments (ACT) would be recommended.
  
  
  CONCLUSIONS
  A febrile child under 5 should be treated presumptively. In the dry season, the probability of clinical malaria in adults is so low, that neither testing nor treating with any regimen should be recommended. In the rainy season, if costs are considered, a febrile adult should not be tested, nor treated with ACT, but a possible alternative would be a presumptive treatment with amodiaquine plus sulfadoxine-pyrimethamine. If costs were not considered, testing would be recommended.
authors.affiliation: Centre for Tropical Diseases, S. Cuore Hospital, Negrar, Verona, Italy. zeno.bisoffi@sacrocuore.it
authors.forename: Zeno
authors.initials: Z
authors.lastname: Bisoffi
authors.forename: Halidou
authors.initials: H
authors.lastname: Tinto
authors.forename: Bienvenu Sodiomon
authors.initials: BS
authors.lastname: Sirima
authors.forename: Federico
authors.initials: F
authors.lastname: Gobbi
authors.forename: Andrea
authors.initials: A
authors.lastname: Angheben
authors.forename: Dora
authors.initials: D
authors.lastname: Buonfrate
authors.forename: Jef
authors.initials: J
authors.lastname: Van den Ende
mesh_terms: D000328:Adult; D000655:Amodiaquine / Q000627:therapeutic use; D000962:Antimalarials / Q000627:therapeutic use; D002050:Burkina Faso; D002675:Child, Preschool; D003657:Decision Making; D004338:Drug Combinations; D005334:Fever; D006801:Humans; D008288:Malaria / Q000175:diagnosis* / Q000188:drug therapy*; D019095:Point-of-Care Systems; D011336:Probability; D011739:Pyrimethamine / Q000627:therapeutic use; D019035:Rural Health Services; D012424:Rural Population; D012621:Seasons; D013413:Sulfadoxine / Q000627:therapeutic use
chemical_list: D000962:Antimalarials; D004338:Drug Combinations; D000655:Amodiaquine; C001205:fanasil, pyrimethamine drug combination; D013413:Sulfadoxine; D011739:Pyrimethamine