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. 2022 Sep 8;9(9):CD009527.
doi: 10.1002/14651858.CD009527.pub3.

Adding rapid diagnostic tests to community-based programmes for treating malaria

Elizabeth N Allen  1 , Alison Beriliy Wiyeh  2 , Michael McCaul  3
Affiliations

Adding rapid diagnostic tests to community-based programmes for treating malaria

Elizabeth N Allen et al. Cochrane Database Syst Rev. .

Abstract

Background: The World Health Organization (WHO) recommends parasitological testing of all suspected malaria cases using malaria rapid diagnostic tests (mRDTs) or microscopy prior to treatment. Some governments have extended this responsibility to community health workers (CHWs) to reduce malaria morbidity and mortality through prompt and appropriate treatment. This is an update of a Cochrane Review first published in 2013.

Objectives: To evaluate community-based management strategies for treating malaria or fever that incorporate both a definitive diagnosis with an mRDT and appropriate antimalarial treatment.

Search methods: We searched CENTRAL, MEDLINE, Embase, five other databases, and three trials registers up to 14 September 2021.

Selection criteria: We included individually randomized trials and cluster-randomized controlled trials (cRCTs), controlled before-after studies, and controlled interrupted time series studies in people living in malaria-endemic areas, comparing programmes that train CHWs and drug shop vendors to perform mRDTs and provide appropriate treatment versus similar programmes that do not use mRDTs, and versus routine health facility care.

Data collection and analysis: We used standard Cochrane methods. For each dichotomous outcome, we extracted the number of participants with the event and the total number of participants in each group, unless studies presented results at a population level only. Primary outcomes were all-cause mortality, hospitalizations, and number of people receiving an antimalarial within 24 hours. Secondary outcomes were malaria-specific mortality, severe malaria, outcomes related to antimalarial treatments, antibiotic prescribing to people with a negative microscopy or polymerase chain reaction (PCR) result, parasitaemia, anaemia, and all adverse events.

Main results: We included eight studies from several African countries, Afghanistan, and Myanmar. Staff included CHWs and drug shop vendors. Community use of malaria rapid diagnostic tests compared to clinical diagnosis Compared to clinical diagnosis, mRDT diagnosis results in reduced prescribing of antimalarials to people who are found to be malaria parasite-negative by microscopy or PCR testing (71 fewer per 100 people, 95% confidence interval (CI) 79 to 51 fewer; risk ratio (RR) 0.17, 95% CI 0.07 to 0.40; 3 cRCTs, 7877 participants; moderate-certainty evidence). This reduction may be greater among CHWs compared to drug shop vendors. People diagnosed by mRDT are more likely to receive appropriate treatment; that is, an antimalarial if they are microscopy- or PCR-positive and no antimalarial if they are microscopy- or PCR-negative (RR 3.04, 95% CI 2.46 to 3.74, 3 cRCTs, 9332 participants; high-certainty evidence). Three studies found that a small percentage of people with a negative mRDT result (as read by the CHW or drug shop vendors at the time of treatment) were nevertheless given an antimalarial: 38/1368 (2.8%), 44/724 (6.1%) and 124/950 (13.1%). Conversely, in two studies, a few mRDT-positive people did not receive an antimalarial (0.5% and 0.3%), and one small cross-over study found that 6/57 (10.5%) people classified as non-malaria in the clinical diagnosis arm received an antimalarial. Use of mRDTs probably increases antibiotic use compared to clinical diagnosis (13 more per 100 people, 95% CI 3 to 29 more; RR 2.02, 95% CI 1.21 to 3.37; 2 cRCTs, 5179 participants; moderate-certainty evidence). We were unable to demonstrate any effect on mortality. Community use of malaria rapid diagnostic tests compared to health facility care Results were insufficient to reach any conclusion.

Authors' conclusions: Use of mRDTs by CHWs and drug shop vendors compared to clinical diagnosis reduces prescribing of antimalarials to people without malaria. Deaths were uncommon in both groups. Antibiotic prescribing was higher in those with a negative mRDT than in those with a negative clinical diagnosis.

PubMed Disclaimer

Conflict of interest statement

EA: none AW: none MM: none

Figures

1
1
Conceptual framework for community‐based programmes for malaria.
2
2
Logic model for community‐based programmes for malaria.
mRDT: malaria rapid diagnostic test; ACT: artemisinin‐based combination therapy.
3
3
Study flow diagram.
4
4
Risk of bias summary: review authors' judgements about each risk of bias item for each included study. Different criteria were applied depending on the study design, and we performed no bias assessment where an outcome was not included for a particular study design.
5
5
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies. Different criteria were applied depending on the study design, and we performed no bias assessment where an outcome was not included for a particular study design.
1.1
1.1. Analysis
Comparison 1: Malaria rapid diagnostic test (mRDT) compared to clinical diagnosis for community‐based programmes for treating malaria, Outcome 1: Antimalarial prescribing to microscopy‐ or PCR‐negative people
1.2
1.2. Analysis
Comparison 1: Malaria rapid diagnostic test (mRDT) compared to clinical diagnosis for community‐based programmes for treating malaria, Outcome 2: Appropriate treatment
1.3
1.3. Analysis
Comparison 1: Malaria rapid diagnostic test (mRDT) compared to clinical diagnosis for community‐based programmes for treating malaria, Outcome 3: Number receiving antimalarials
1.4
1.4. Analysis
Comparison 1: Malaria rapid diagnostic test (mRDT) compared to clinical diagnosis for community‐based programmes for treating malaria, Outcome 4: Antibiotic prescribing to microscopy‐ or PCR‐negative people
See this image and copyright information in PMC

Update of

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Publication types