title: Assessment of the utility of a symptom-based algorithm for identifying febrile patients for malaria diagnostic testing in Senegal.
abstract: Malaria rapid diagnostic tests (RDTs) enable point-of-care testing to be nearly as sensitive and specific as reference microscopy. The Senegal National Malaria Control Programme introduced RDTs in 2007, along with a case management algorithm for uncomplicated febrile illness, in which the first step stipulates that if a febrile patient of any age has symptoms indicative of febrile illness other than malaria (e.g., cough or rash), they would not be tested for malaria, but treated for the apparent illness and receive an RDT for malaria only if they returned in 48 h without improvement.
  
  
  
  A year-long study in 16 health posts was conducted to determine the algorithm's capacity to identify patients with Plasmodium falciparum infection identifiable by RDT. Health post personnel enrolled patients of all ages with fever (≥37.5 °C) or history of fever in the previous 2 days. After clinical assessment, a nurse staffing the health post determined whether a patient should receive an RDT according to the diagnostic algorithm, but performed an RDT for all enrolled patients.
  
  
  
  Over 1 year, 6039 patients were enrolled and 58% (3483) were determined to require an RDT according to the algorithm. Overall, 23% (1373/6039) had a positive RDT, 34% (1130/3376) during rainy season and 9% (243/2661) during dry season. The first step of the algorithm identified only 78% of patients with a positive RDT, varying by transmission season (rainy 80%, dry 70%), malaria transmission zone (high 75%, low 95%), and age group (under 5 years 68%, 5 years and older 84%).
  
  
  
  In all but the lowest malaria transmission zone, use of the algorithm excludes an unacceptably large proportion of patients with malaria from receiving an RDT at their first visit, denying them timely diagnosis and treatment. While the algorithm was adopted within a context of malaria control and scarce resources, with the goal of treating patients with symptomatic malaria, Senegal has now adopted a policy of universal diagnosis of patients with fever or history of fever. In addition, in the current context of malaria elimination, the paradigm of case management needs to shift towards the identification and treatment of all patients with malaria infection.
authors.affiliation: U.S. Centers for Disease Control and Prevention and President's Malaria Initiative, Atlanta, USA. fez3@cdc.gov.
authors.forename: Julie
authors.identifier: 0000-0002-0471-281X
authors.initials: J
authors.lastname: Thwing
authors.affiliation: Senegal National Malaria Control Programme, Dakar, Senegal.
authors.forename: Fatou
authors.initials: F
authors.lastname: Ba
authors.affiliation: Pediatrics Service Hôpital le Dantec, Dakar, Senegal.
authors.forename: Alou
authors.initials: A
authors.lastname: Diaby
authors.affiliation: Parasitology Service Hôpital le Dantec, Dakar, Senegal.
authors.forename: Younouss
authors.initials: Y
authors.lastname: Diedhiou
authors.affiliation: Pediatrics Service Hôpital le Dantec, Dakar, Senegal.
authors.forename: Assane
authors.initials: A
authors.lastname: Sylla
authors.affiliation: Pediatrics Service Hôpital le Dantec, Dakar, Senegal.
authors.forename: Guelaye
authors.initials: G
authors.lastname: Sall
authors.affiliation: United States Agency for International Development, Dakar, Senegal.
authors.forename: Mame Birame
authors.initials: MB
authors.lastname: Diouf
authors.affiliation: Senegal National Malaria Control Programme, Dakar, Senegal.
authors.forename: Alioune Badara
authors.initials: AB
authors.lastname: Gueye
authors.affiliation: Senegal National Malaria Control Programme, Dakar, Senegal.
authors.forename: Seynabou
authors.initials: S
authors.lastname: Gaye
authors.affiliation: Senegal National Malaria Control Programme, Dakar, Senegal.
authors.forename: Medoune
authors.initials: M
authors.lastname: Ndiop
authors.affiliation: Senegal National Malaria Control Programme, Dakar, Senegal.
authors.forename: Moustapha
authors.initials: M
authors.lastname: Cisse
authors.affiliation: Université Cheikh Anta Diop, Dakar, Senegal.
authors.forename: Daouda
authors.initials: D
authors.lastname: Ndiaye
authors.affiliation: Senegal National Malaria Control Programme, Dakar, Senegal.|WHO, Dakar, Senegal.
authors.forename: Mady
authors.initials: M
authors.lastname: Ba
mesh_terms: D000293:Adolescent; D000328:Adult; D000465:Algorithms; D019090:Case Management; D002648:Child; D002675:Child, Preschool; D003955:Diagnostic Tests, Routine / Q000706:statistics & numerical data*; D005260:Female; D005334:Fever; D006801:Humans; D007223:Infant; D016778:Malaria, Falciparum / Q000175:diagnosis*; D008297:Male; D008875:Middle Aged; D000067716:Point-of-Care Testing / Q000706:statistics & numerical data*; D011237:Predictive Value of Tests; D012016:Reference Values; D012675:Senegal; D012680:Sensitivity and Specificity; D055815:Young Adult
keywords: Algorithm; Case management; Diagnosis; Fever; Malaria; Rapid diagnostic test; Treatment