Medical Research Council Centre for Outbreak Analysis & Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom.
PLoS One. 2013 Jul 29;8(7):e69654. doi: 10.1371/journal.pone.0069654. Print 2013.
As international funding for malaria programmes plateaus, limited resources must be rationally managed for malaria and non-malarial febrile illnesses (NMFI). Given widespread unnecessary treatment of NMFI with first-line antimalarial Artemisinin Combination Therapies (ACTs), our aim was to estimate the effect of health-systems factors on rates of appropriate treatment for fever and on use of ACTs.
A decision-tree tool was developed to investigate the impact of improving aspects of the fever care-pathway and also evaluate the impact in Tanzania of the revised WHO malaria guidelines advocating diagnostic-led management.
Model outputs using baseline parameters suggest 49% malaria cases attending a clinic would receive ACTs (95% Uncertainty Interval:40.6-59.2%) but that 44% (95% UI:35-54.8%) NMFI cases would also receive ACTs. Provision of 100% ACT stock predicted a 28.9% increase in malaria cases treated with ACT, but also an increase in overtreatment of NMFI, with 70% NMFI cases (95% UI:56.4-79.2%) projected to receive ACTs, and thus an overall 13% reduction (95% UI:5-21.6%) in correct management of febrile cases. Modelling increased availability or use of diagnostics had little effect on malaria management outputs, but may significantly reduce NMFI overtreatment. The model predicts the early rollout of revised WHO guidelines in Tanzania may have led to a 35% decrease (95% UI:31.2-39.8%) in NMFI overtreatment, but also a 19.5% reduction (95% UI:11-27.2%), in malaria cases receiving ACTs, due to a potential fourfold decrease in cases that were untested or tested false-negative (42.5% vs.8.9%) and so untreated.
Modelling multi-pronged intervention strategies proved most effective to improve malaria treatment without increasing NMFI overtreatment. As malaria transmission declines, health system interventions must be guided by whether the management priority is an increase in malaria cases receiving ACTs (reducing the treatment gap), reducing ACT waste through unnecessary treatment of NMFI or expanding appropriate treatment of all febrile illness.
随着国际疟疾规划资金趋于平稳，必须合理利用有限资源来应对疟疾和非疟疾发热性疾病（NMFI）。鉴于广泛存在对 NMFI 进行一线抗疟青蒿素联合疗法（ACT）不必要治疗的情况，我们旨在评估卫生系统因素对发热症治疗的适当性以及 ACT 使用的影响。
开发了一个决策树工具，用于调查改善发热护理途径方面的影响，还评估了世界卫生组织（WHO）修订的疟疾指南提倡诊断导向管理对坦桑尼亚的影响。
使用基线参数的模型输出表明，49%（95%不确定区间：40.6-59.2%）的就诊诊所疟疾患者将接受 ACT，但也有 44%（95%不确定区间：35-54.8%）的 NMFI 患者也将接受 ACT。如果提供 100%的 ACT 库存，预计会使接受 ACT 治疗的疟疾病例增加 28.9%，但也会导致 NMFI 的过度治疗，预计 70%（95%不确定区间：56.4-79.2%）的 NMFI 病例将接受 ACT，因此，发热病例的正确管理总体减少 13%（95%不确定区间：5-21.6%）。模型预测增加诊断的可用性或使用对疟疾管理结果影响不大，但可能会显著减少 NMFI 的过度治疗。该模型预测，坦桑尼亚早期推出世界卫生组织修订指南可能导致 NMFI 过度治疗减少 35%（95%不确定区间：31.2-39.8%），但接受 ACT 的疟疾病例也减少 19.5%（95%不确定区间：11-27.2%），原因是未经检测或检测呈假阴性的病例数量可能减少四倍（42.5%对 8.9%），因此未得到治疗。
证明针对多方面干预策略的建模最能有效改善疟疾治疗，而不会增加 NMFI 的过度治疗。随着疟疾传播的减少，卫生系统干预措施必须以管理重点是增加接受 ACT 治疗的疟疾病例（减少治疗差距）、减少不必要治疗 NMFI 造成的 ACT 浪费还是扩大所有发热性疾病的适当治疗为指导。
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