title: Diagnostic testing of pediatric fevers: meta-analysis of 13 national surveys assessing influences of malaria endemicity and source of care on test uptake for febrile children under five years.
abstract: BACKGROUND
  In 2010, the World Health Organization revised guidelines to recommend diagnosis of all suspected malaria cases prior to treatment. There has been no systematic assessment of malaria test uptake for pediatric fevers at the population level as countries start implementing guidelines. We examined test use for pediatric fevers in relation to malaria endemicity and treatment-seeking behavior in multiple sub-Saharan African countries in initial years of implementation.
  
  
  RESULTS
  We compiled data from national population-based surveys reporting fever prevalence, care-seeking and diagnostic use for children under five years in 13 sub-Saharan African countries in 2009-2011/12 (n = 105,791). Mixed-effects logistic regression models quantified the influence of source of care and malaria endemicity on test use after adjusting for socioeconomic covariates. Results were stratified by malaria endemicity categories: low (PfPR2-10<5%), moderate (PfPR2-10 5-40%), high (PfPR2-10>40%). Among febrile under-fives surveyed, 16.9% (95% CI: 11.8%-21.9%) were tested. Compared to hospitals, febrile children attending non-hospital sources (OR: 0.62, 95% CI: 0.56-0.69) and community health workers (OR: 0.31, 95% CI: 0.23-0.43) were less often tested. Febrile children in high-risk areas had reduced odds of testing compared to low-risk settings (OR: 0.51, 95% CI: 0.42-0.62). Febrile children in least poor households were more often tested than in poorest (OR: 1.63, 95% CI: 1.39-1.91), as were children with better-educated mothers compared to least educated (OR: 1.33, 95% CI: 1.16-1.54).
  
  
  CONCLUSIONS
  Diagnostic testing of pediatric fevers was low and inequitable at the outset of new guidelines. Greater testing is needed at lower or less formal sources where pediatric fevers are commonly managed, particularly to reach the poorest. Lower test uptake in high-risk settings merits further investigation given potential implications for diagnostic scale-up in these areas. Findings could inform continued implementation of new guidelines to improve access to and equity in point-of-care diagnostics use for pediatric fevers.
authors.affiliation: International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
authors.forename: Emily White
authors.initials: EW
authors.lastname: Johansson
authors.affiliation: Spatial Ecology and Epidemiology Group, Department of Zoology, University of Oxford, Oxford, United Kingdom.
authors.forename: Peter W
authors.initials: PW
authors.lastname: Gething
authors.affiliation: Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Helena
authors.initials: H
authors.lastname: Hildenwall
authors.affiliation: Spatial Ecology and Epidemiology Group, Department of Zoology, University of Oxford, Oxford, United Kingdom.
authors.forename: Bonnie
authors.initials: B
authors.lastname: Mappin
authors.affiliation: Center for Applied Biostatistics, University of Gothenburg, Gothenburg, Sweden.
authors.forename: Max
authors.initials: M
authors.lastname: Petzold
authors.affiliation: International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden; Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda.
authors.forename: Stefan Swartling
authors.initials: SS
authors.lastname: Peterson
authors.affiliation: International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
authors.forename: Katarina Ekholm
authors.initials: KE
authors.lastname: Selling
mesh_terms: D017954:Africa South of the Sahara / Q000453:epidemiology; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D003955:Diagnostic Tests, Routine; D005260:Female; D005334:Fever / Q000175:diagnosis* / Q000453:epidemiology* / Q000209:etiology; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008288:Malaria / Q000150:complications / Q000453:epidemiology; D008297:Male; D016017:Odds Ratio; D010372:Pediatrics; D011159:Population Surveillance; D012307:Risk Factors
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