title: Accuracy of clinical diagnosis and malaria rapid diagnostic test and its influence on the management of children with fever under reduced malaria burden in Misungwi district, Mwanza Tanzania.
abstract: BACKGROUND
  Malaria diagnosis is known to be non-specific because of the overlap of symptoms of malaria with other infectious diseases that is made worse with declining malaria burden. Though the use of malaria rapid diagnostic test (mRDT) for malaria confirmation has universally been adopted, malaria decline may alter performance of mRDT. This study examined accuracy of clinical diagnosis and mRDT and its influence on prescription for febrile underfives.
  
  
  METHODS
  A cross-sectional study of 600 underfives was carried out in 6 randomly selected health facilities in Misungwi district, Mwanza; from November - December 2014. Consecutive underfives with a fever consultation were recruited: for each fever and the clinical diagnosis entertained were recorded. Parasitological confirmation of malaria was done by mRDT and microscopic examination of finger prick blood samples. Treatment was based on mRDT results, drugs prescribed recorded. Accuracy of clinical diagnosis and mRDT in predicting malaria was assessed by performance indices against microscopy. Antimalarial and antibiotics prescriptions were assessed against parasitological findings.
  
  
  RESULTS
  Clinically, 37.2% had malaria; 32.8% were mRDTpositive and 17.0% microscopically positive. Sensitivity of clinical diagnosis was very high (97.0% [95%CI: 91.0-99.2]); specificity 66.7% [95%CI: 62.3-70.8], and positive predictive value 37.4% (95%CI: 31.6-43.5). Sensitivity of mRDTwas very high (99.0% [95%CI: 93.9-99.9]), specificity (80.7% [95%CI: 76.9-84.0]), positive predictive value 51.3% [95% CI: 44.1-58.4]) and negative predictive 99.75% [95%CI: 99.4-100.0]. Those receiving antimalarial prescription, 75.0% were mRDT positive; 39.4% microscopically positive. Those receiving antibiotic, 78.8% were mRDT negative; 90.1% microscopically negative.
  
  
  CONCLUSIONS
  Decline in malaria lowered specificity of mRDT to < 95% against WHO recommendation. Though adherence to mRDT results was high, there was over prescription of antibiotics.
authors.affiliation: Tanzania Field Epidemiology and Laboratory Training Program.
authors.forename: Daniel Ndaki
authors.initials: DN
authors.lastname: Nkonya
authors.affiliation: Department of Parasitology, School of Public Health & Social Sciences, Muhimbili University of Health & Allied Sciences, Dar es Salaam, Tanzania.
authors.forename: Donath Samuel
authors.initials: DS
authors.lastname: Tarimo
authors.affiliation: Tanzania Field Epidemiology and Laboratory Training Program; Tanzania Ministry of Health, Community Development, Gender, Elderly and Children.
authors.forename: Rogath Saika
authors.initials: RS
authors.lastname: Kishimba
mesh_terms: D000962:Antimalarials / Q000008:administration & dosage / Q000627:therapeutic use*; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D003955:Diagnostic Tests, Routine / Q000379:methods*; D005260:Female; D005334:Fever / Q000175:diagnosis* / Q000469:parasitology; D006801:Humans; D007223:Infant; D008288:Malaria / Q000175:diagnosis* / Q000188:drug therapy; D008297:Male; D010818:Practice Patterns, Physicians'; D011237:Predictive Value of Tests; D012680:Sensitivity and Specificity; D013636:Tanzania
chemical_list: D000962:Antimalarials
keywords: Tanzania; Underfives; case management; clinical diagnosis; diagnostic accuracy; mRDT; malaria