title: Malaria Rapid Diagnostic Tests and Malaria Microscopy for Guiding Malaria Treatment of Uncomplicated Fevers in Nigeria and Prereferral Cases in 3 African Countries.
abstract: BACKGROUND
  The World Health Organization recommends that malaria treatment be based on demonstration of the infecting Plasmodium parasite specie. Malaria rapid diagnostic tests (RDTs) are recommended at community points of care because they are accurate and rapid. We report on parasitological results in a malaria study in selected rural communities in 3 African countries.
  
  
  METHODS
  In Nigeria, community health workers (CHWs) performed RDTs (SD-Bioline) and thick blood smears on all children suspected to have malaria. Malaria RDT-positive children able to swallow received artemisinin-based combination therapy (Coartem). In all countries, children unable to take oral drugs received prereferral rectal artesunate irrespective of RDT result and were referred to the nearest health facility. Thick blood smears and RDTs were usually taken at hospital admission. In Nigeria and Burkina Faso, RDT cassettes and blood smears were re-read by an experienced investigator at study end.
  
  
  RESULTS
  Trained CHWs enrolled 2148 children in Nigeria. Complete parasitological data of 1860 (86.6%) enrollees were analyzed. The mean age of enrollees was 30.4 ± 15.7 months. The prevalence of malaria parasitemia in the study population was 77.8% (1447/1860), 77.6% (1439/1855), and 54.1% (862/1593) by RDT performed by CHWs vs an expert clinical research assistant vs microscopy (gold standard), respectively. Geometric mean parasite density was 6946/µL (range, 40-436 450/µL). There were 49 cases of RDT false-negative results with a parasite density range of 40-54 059/µL. False-negative RDT results with high parasitemia could be due to non-falciparum infection or result from a prozone effect. Sensitivity and specificity of SD-Bioline RDT results as read by CHWs were 94.3% and 41.6%, respectively, while the negative and positive predictive values were 86.1% and 65.6%, respectively. The level of agreement in RDT reading by the CHWs and experienced research staff was 86.04% and κ statistic of 0.60. The malaria parasite positivity rate by RDT and microscopy among children with danger signs in the 3 countries was 67.9% and 41.8%, respectively.
  
  
  CONCLUSIONS
  RDTs are useful in guiding malaria management and were successfully used for diagnosis by trained CHWs. However, false-negative RDT results were identified and can undermine confidence in results and control efforts.
authors.affiliation: Department of Pharmacology and Therapeutics.
authors.forename: Catherine O
authors.initials: CO
authors.lastname: Falade
authors.affiliation: Department of Epidemiology and Medical Statistics, College of Medicine, University of Ibadan, Nigeria.
authors.forename: IkeOluwapo O
authors.initials: IO
authors.lastname: Ajayi
authors.affiliation: Child Health Division, Ministry of Health, Kampala, Uganda.
authors.forename: Jesca
authors.initials: J
authors.lastname: Nsungwa-Sabiiti
authors.affiliation: Groupe de Recherche Action en Santé, Ouagadougou, Burkina Faso.
authors.forename: Mohamadou
authors.initials: M
authors.lastname: Siribié
authors.affiliation: Groupe de Recherche Action en Santé, Ouagadougou, Burkina Faso.
authors.forename: Amidou
authors.initials: A
authors.lastname: Diarra
authors.affiliation: Groupe de Recherche Action en Santé, Ouagadougou, Burkina Faso.
authors.forename: Luc
authors.initials: L
authors.lastname: Sermé
authors.affiliation: Epidemiology and Biostatistics Research Unit, Institute of Advanced Medical Research and Training, College of Medicine.
authors.forename: Chinenye
authors.initials: C
authors.lastname: Afonne
authors.affiliation: Department of Epidemiology and Medical Statistics, College of Medicine, University of Ibadan, Nigeria.
authors.forename: Oyindamola B
authors.initials: OB
authors.lastname: Yusuf
authors.affiliation: Groupe de Recherche Action en Santé, Ouagadougou, Burkina Faso.
authors.forename: Zakaria
authors.initials: Z
authors.lastname: Gansane
authors.affiliation: Department of Sociology, Faculty of Social Sciences, University of Ibadan, Nigeria.
authors.forename: Ayodele S
authors.initials: AS
authors.lastname: Jegede
authors.affiliation: UNICEF/UNDP/World Bank/WHO/Special Programme for Research & Training in Tropical Diseases, World Health Organization, Geneva, Switzerland.
authors.forename: Jan
authors.initials: J
authors.lastname: Singlovic
authors.affiliation: UNICEF/UNDP/World Bank/WHO/Special Programme for Research & Training in Tropical Diseases, World Health Organization, Geneva, Switzerland.
authors.forename: Melba
authors.initials: M
authors.lastname: Gomes
mesh_terms: D037621:Artemisinins / Q000008:administration & dosage / Q000627:therapeutic use; D002050:Burkina Faso / Q000453:epidemiology; D002648:Child; D002675:Child, Preschool; D003150:Community Health Workers / Q000706:statistics & numerical data; D003955:Diagnostic Tests, Routine / Q000379:methods*; D004359:Drug Therapy, Combination; D005260:Female; D005334:Fever / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology; D006801:Humans; D007223:Infant; D008288:Malaria / Q000175:diagnosis* / Q000188:drug therapy / Q000453:epidemiology; D008297:Male; D008853:Microscopy / Q000379:methods*; D009549:Nigeria / Q000453:epidemiology; D018512:Parasitemia / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology; D014454:Uganda / Q000453:epidemiology
chemical_list: D037621:Artemisinins; C031327:artemisinin
keywords: ACT; RDT; malaria; microscopy; parasitemia