Academic journal article Bulletin of the World Health Organization

Introducing Rapid Diagnostic Tests for Malaria to Drug Shops in Uganda: A Cluster-Randomized Controlled trial/Introduction De Tests Diagnostiques Rapides Du Paludisme Dans Les Pharmacies En Ouganda: Un Essai Controle Randomise Par grappe/Introduccion De Pruebas De Diagnostico Rapido Para la Malaria En Farmacias En Uganda: Un Ensayo Controlado Aleatorio Por Grupos

Academic journal article Bulletin of the World Health Organization

Introducing Rapid Diagnostic Tests for Malaria to Drug Shops in Uganda: A Cluster-Randomized Controlled trial/Introduction De Tests Diagnostiques Rapides Du Paludisme Dans Les Pharmacies En Ouganda: Un Essai Controle Randomise Par grappe/Introduccion De Pruebas De Diagnostico Rapido Para la Malaria En Farmacias En Uganda: Un Ensayo Controlado Aleatorio Por Grupos

Article excerpt

Introduction

In areas where malaria is endemic, the appropriate management of febrile illness and the effective use of resources for malaria control rely on the availability and use of diagnostic tests. (1) In the absence of diagnostic tests, antimalarial drugs are often taken for illnesses that have similar symptoms to those of malaria. (2-5) Failure to diagnose malaria can lead to poor case management, a waste of scarce health resources and increased risk of antimalarial resistance. (1-6) The non-treatment or delayed treatment of malaria contribute substantially to malaria-attributable child mortality. (7,8) In Uganda, only a minority of febrile illnesses are treated with artemisinin combination therapy--i.e. the recommended first-line treatment for malaria--and many of such episodes go untreated. (9) Similar observations have been made in Kenya, the United Republic of Tanzania and other African countries. (10-13)

The World Health Organization (WHO) recommends parasitological confirmation of malaria before antimalarial drug use. (14) Although the current Global malaria action plan of the Roll Back Malaria Initiative calls for universal access to malaria testing, (15) such access remains a distant goal in most countries with endemic malaria. A study in six African countries found that only 4-31% of children with febrile illnesses were tested for malaria. (9) In many countries, patients and caregivers rely heavily on a loosely regulated private sector for malaria treatment. (16,17) In consequence, the engagement of the private sector has become an increasingly common strategy in malaria control programmes--as reflected, for example, in the pilot Affordable Medicines Facility-malaria (AMFm). (18)

The development of inexpensive and simple rapid diagnostic tests for malaria has opened the possibility of widespread access to malaria diagnosis. These antigen detection tests have been shown to be as effective as routine microscopy in malaria diagnosis (19) and can be safely performed by individuals with only basic training. (20) Although research from Cambodia, (21) Somalia (22) and Uganda (23) has shown that the distribution of rapid diagnostic tests by the private sector is feasible, we know very little of the impact of this approach on population-level rates of malaria diagnosis and purchase of antimalarial drugs. We therefore conducted a trial in eastern Uganda to investigate the impact--on malaria diagnosis and the purchase of antimalarial drugs - of training the vendors from licensed drug shops to test patients with a rapid diagnostic test for malaria. The trained vendors were also encouraged to buy the test, at a subsidized price, from local wholesale providers. The study took place in Uganda's eastern region, where the annual transmission rates for malaria exceed 100 infective bites per person (24) and presumptive symptom-based treatment remains common--especially when, as commonly occurs, treatment is sought outside the higher level public-health facilities. (25-27) Malaria is responsible for 30-50% of outpatient visits and 9-14% of inpatient deaths in Uganda. (28)

Methods

The study was designed as a cluster-randomized controlled trial, with extensive monitoring of the health behaviour of households before and after a rapid diagnostic test was made available in local drug shops. Since the study was designed to explore both cross-sectional and pre-post differences, 67 (85%) of the study villages were randomly selected to receive the intervention while the remaining 12 (15%) were used as a control group. The study was implemented between March 2011 and April 2012. Training in the use of the diagnostic test occurred between 21 June and 6 July, 2011. A simple random number draw--generated by Stata/SE version 11.0 (StataCorp. LP, College Station, United States of America)--was used for the selection of study villages and households and the assignment of villages to the intervention or control arm. …

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