Malaria Consortium Africa, Plot 2, Sturrock Road, PO Box 8045, Kampala, Uganda.
Malar J. 2010 Jul 12;9:200. doi: 10.1186/1475-2875-9-200.
Early and accurate diagnosis of malaria followed by prompt treatment reduces the risk of severe disease in malaria endemic regions. Presumptive treatment of malaria is widely practised where microscopy or rapid diagnostic tests (RDTs) are not readily available. With the introduction of artemisinin-based combination therapy (ACT) for treatment of malaria in many low-resource settings, there is need to target treatment to patients with parasitologically confirmed malaria in order to improve quality of care, reduce over consumption of anti-malarials, reduce drug pressure and in turn delay development and spread of drug resistance. This study evaluated the effect of malaria RDTs on health workers' anti-malarial drug (AMD) prescriptions among outpatients at low level health care facilities (LLHCF) within different malaria epidemiological settings in Uganda.
All health workers (HWs) in 21 selected intervention (where RDTs were deployed) LLHF were invited for training on the use RDTs. All HWs were trained to use RDTs for parasitological diagnosis of all suspected malaria cases irrespective of age. Five LLHCFs with clinical diagnosis (CD only) were included for comparison. Subsequently AMD prescriptions were compared using both a 'pre-post' and 'intervention-control' analysis designs. In-depth interviews of the HWs were conducted to explore any factors that influence AMD prescription practices.
A total of 166,131 out-patient attendances (OPD) were evaluated at 21 intervention LLHCFs. Overall use of RDTs resulted in a 38% point reduction in AMD prescriptions. There was a two-fold reduction (RR 0.62, 95% CI 0.55-0.70) in AMD prescription with the greatest reduction in the hypo-endemic setting (RR 0.46 95% CI 0.51-0.53) but no significant change in the urban setting (RR1.01, p-value=0.820). Over 90% of all eligible OPD patients were offered a test. An average of 30% (range 25%-35%) of the RDT-negative fever patients received AMD prescriptions. When the test result was negative, children under five years of age were two to three times more likely (OR 2.6 p-value<0.001) to receive anti-malarial prescriptions relative to older age group. Of the 63 HWs interviewed 92% believed that a positive RDT result confirmed malaria, while only 49% believed that a negative RDT result excluded malaria infection.
Use of RDTs resulted in a 2-fold reduction in anti-malarial drug prescription at LLHCFs. The study demonstrated that RDT use is feasible at LLHCFs, and can lead to better targetting of malaria treatment. Nationwide deployment of RDTs in a systematic manner should be prioritised in order to improve fever case management. The process should include plans to educate HWs about the utility of RDTs in order to maximize acceptance and uptake of the diagnostic tools and thereby leading to the benefits of parasitological diagnosis of malaria.
在疟疾流行地区，早期、准确的疟疾诊断以及及时治疗可以降低重症疟疾的风险。在显微镜检查或快速诊断检测（RDT）不可用的地方，广泛采用疟疾疑似病例的经验性治疗。随着青蒿素为基础的联合疗法（ACT）在许多资源匮乏地区被用于治疗疟疾，有必要针对寄生虫学确诊的疟疾患者进行治疗，以改善医疗质量，减少抗疟药物的过度使用，降低药物压力，从而延缓耐药性的发展和传播。本研究评估了在乌干达不同疟疾流行地区，疟疾 RDT 对基层卫生保健机构（LLHCF）门诊卫生工作者（HWs）抗疟药物（AMD）处方的影响。
所有 21 个干预（部署 RDT）LLHF 的卫生工作者（HWs）都被邀请参加 RDT 使用培训。所有 HWs 都接受了培训，无论年龄大小，都要对所有疑似疟疾病例进行寄生虫学诊断。选择了 5 个只有临床诊断（仅 CD）的 LLHCF 进行比较。随后，使用“前后”和“干预对照”分析设计比较 AMD 处方。对 HWs 进行了深入访谈，以探讨影响 AMD 处方实践的任何因素。
在 21 个干预 LLHCF 中，共评估了 166131 名门诊患者（OPD）。RDT 的总体使用导致 AMD 处方减少了 38%。AMD 处方减少了两倍（RR 0.62，95%CI 0.55-0.70），在低流行地区的降幅最大（RR 0.46，95%CI 0.51-0.53），但在城市环境中没有显著变化（RR 1.01，p 值=0.820）。所有符合条件的门诊患者中，超过 90%的患者都接受了检测。平均有 30%（25%-35%）的 RDT 阴性发热患者接受了 AMD 处方。当检测结果为阴性时，五岁以下儿童接受抗疟药物处方的可能性是年龄较大儿童的两到三倍（OR 2.6，p 值<0.001）。在接受访谈的 63 名 HWs 中，92%的人认为阳性 RDT 结果证实了疟疾，而只有 49%的人认为阴性 RDT 结果排除了疟疾感染。
在 LLHCF 中使用 RDT 可使抗疟药物处方减少两倍。该研究表明，RDT 在基层卫生保健机构中是可行的，可以更好地针对疟疾治疗。应优先在全国范围内系统地部署 RDT，以改善发热病例管理。该过程应包括计划教育 HWs 了解 RDT 的实用性，以最大限度地接受和采用诊断工具，从而带来寄生虫学诊断疟疾的好处。
