title: Rapid diagnostic tests to improve treatment of malaria and other febrile illnesses: patient randomised effectiveness trial in primary care clinics in Afghanistan.
abstract: OBJECTIVE
  To assess the impact of rapid diagnostic tests on the diagnostic accuracy and treatment of malaria and non-severe fever in an Asian setting.
  
  
  METHODS
  Patient randomised trial in primary level clinics.
  
  
  METHODS
  Two areas of Afghanistan where Plasmodium vivax and Plasmodium falciparum are endemic; one area with moderate transmission (eastern region) and one with low transmission (northern region).
  
  
  METHODS
  5794 patients of all ages with suspected malaria enrolled by 80 clinicians in 22 clinics.
  
  
  METHODS
  Malaria rapid diagnostic tests were compared with clinical diagnosis where no parasite diagnostic test was available, longer established field microscopy, and recently introduced microscopy.
  
  
  METHODS
  Proportion of patients appropriately treated with an antimalarial, defined as patients with P vivax who received chloroquine, patients with P falciparum who received artemisinin based combination therapy, and patients with no malaria parasites who did not receive an antimalarial. Secondary outcomes included diagnostic test accuracy and the proportion of patients negative for malaria who received antibiotics and antimalarials.
  
  
  RESULTS
  In the low transmission area, comparing rapid diagnostic tests with clinical diagnosis, 65% (212/325) versus 12% (40/321) of febrile patients were appropriately treated for malaria (adjusted odds ratio 92.7, 95% confidence interval 12.4 to 694.1, P<0.001). The proportion of patients who were negative for malaria and received an antibiotic was 57% (185/325) in the rapid diagnostic test arm compared with 14% (46/321) in the clinical diagnosis arm (16.9, 3.8 to 75.4, P<0.001). In the comparison of rapid diagnostic test with microscopy in the moderate transmission area, 83.6% (1696/2028) versus 76.3% (1512/1983) of patients were appropriately treated for malaria (1.70, 1.30 to 2.23, P<0.001). A higher proportion of P falciparum cases received appropriate treatment with artemisinin based combination therapy when malaria was diagnosed by rapid diagnostic test (82%, 58/71 v 32%, 24/76; 9.2, 3.88 to 21.66, P<0.001).
  
  
  CONCLUSIONS
  In South and central Asian regions of low to moderate malaria transmission where clinics lack capacity for diagnosis with rapid diagnostic tests or microscopy, the introduction of the tests should be considered to improve clinical care, reduce the overuse of antimalarials, and improve disease surveillance.
authors.affiliation: London School of Hygiene and Tropical Medicine, London, UK Health Protection and Research Organisation, Kabul, Afghanistan toby.leslie@lshtm.ac.uk.
authors.forename: Toby
authors.initials: T
authors.lastname: Leslie
authors.affiliation: London School of Hygiene and Tropical Medicine, London, UK Health Protection and Research Organisation, Kabul, Afghanistan.
authors.forename: Amy
authors.initials: A
authors.lastname: Mikhail
authors.affiliation: Health Protection and Research Organisation, Kabul, Afghanistan.
authors.forename: Ismail
authors.initials: I
authors.lastname: Mayan
authors.affiliation: London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Bonnie
authors.initials: B
authors.lastname: Cundill
authors.affiliation: HealthNet-TPO, Kabul, Afghanistan.
authors.forename: Mohammed
authors.initials: M
authors.lastname: Anwar
authors.affiliation: Merlin, Kabul, Afghanistan.
authors.forename: Sayed Habib
authors.initials: SH
authors.lastname: Bakhtash
authors.affiliation: HealthNet-TPO, Kabul, Afghanistan.
authors.forename: Nader
authors.initials: N
authors.lastname: Mohammed
authors.affiliation: Health Protection and Research Organisation, Kabul, Afghanistan.
authors.forename: Habib
authors.initials: H
authors.lastname: Rahman
authors.affiliation: Health Protection and Research Organisation, Kabul, Afghanistan.
authors.forename: Rohullah
authors.initials: R
authors.lastname: Zekria
authors.affiliation: London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Christopher J M
authors.initials: CJ
authors.lastname: Whitty
authors.affiliation: London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Mark
authors.initials: M
authors.lastname: Rowland
mesh_terms: D000293:Adolescent; D000328:Adult; D000346:Afghanistan; D000368:Aged; D000553:Ambulatory Care; D000962:Antimalarials / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D042241:Early Diagnosis; D005260:Female; D005334:Fever / Q000188:drug therapy / Q000209:etiology; D006801:Humans; D007223:Infant; D016778:Malaria, Falciparum / Q000175:diagnosis* / Q000188:drug therapy; D016780:Malaria, Vivax / Q000175:diagnosis* / Q000188:drug therapy; D008297:Male; D008853:Microscopy / Q000379:methods; D008875:Middle Aged; D010274:Parasitology / Q000379:methods; D019095:Point-of-Care Systems; D018401:Sample Size; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000962:Antimalarials