London School of Hygiene and Tropical Medicine, London, UK.
Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, USA.
BMC Med. 2020 Jan 30;18(1):17. doi: 10.1186/s12916-019-1483-6.
There has been a successful push towards parasitological diagnosis of malaria in Africa, mainly with rapid diagnostic tests (mRDTs), which has reduced over-prescribing of artemisinin-based combination therapies (ACT) to malaria test-negative patients. The effect on prescribing for test-positive patients has received much less attention. Malaria infection in endemic Africa is often most dangerous for young children and those in low-transmission settings. This study examined non-prescription of antimalarials for patients with malaria infection demonstrated by positive mRDT results, and in particular these groups who are most vulnerable to poor outcomes if antimalarials are not given.
Analysis of data from 562,762 patients in 8 studies co-designed as part of the ACT Consortium, conducted 2007-2013 in children and adults, in Cameroon, Ghana, Nigeria, Tanzania, and Uganda, in a variety of public and private health care sector settings, and across a range of malaria endemic zones.
Of 106,039 patients with positive mRDT results (median age 6 years), 7426 (7.0%) were not prescribed an ACT antimalarial. The proportion of mRDT-positive patients not prescribed ACT ranged across sites from 1.3 to 37.1%. For patients under age 5 years, 3473/44,539 (7.8%) were not prescribed an ACT, compared with 3833/60,043 (6.4%) of those aged ≥ 5 years. The proportion of < 5-year-olds not prescribed ACT ranged up to 41.8% across sites. The odds of not being prescribed an ACT were 2-32 times higher for patients in settings with lower-transmission intensity (using test positivity as a proxy) compared to areas of higher transmission. mRDT-positive children in low-transmission settings were especially likely not to be prescribed ACT, with proportions untreated up to 70%. Of the 7426 mRDT-positive patients not prescribed an ACT, 4121 (55.5%) were prescribed other, non-recommended non-ACT antimalarial medications, and the remainder (44.5%) were prescribed no antimalarial.
In eight studies of mRDT implementation in five African countries, substantial proportions of patients testing mRDT-positive were not prescribed an ACT antimalarial, and many were not prescribed an antimalarial at all. Patients most vulnerable to serious outcomes, children < 5 years and those in low-transmission settings, were most likely to not be prescribed antimalarials, and young children in low-transmission settings were least likely to be treated for malaria. This major public health risk must be addressed in training and practice.
Reported in individual primary studies.
在非洲，寄生虫学诊断疟疾的工作取得了成功，主要采用快速诊断检测（mRDT），这减少了对无疟疾检测结果的患者使用青蒿素为基础的联合疗法（ACT）的过度处方。然而，对于检测阳性患者的处方问题却关注甚少。在疟疾流行的非洲，疟疾感染对幼儿和低传播地区的人群最为危险。本研究调查了 mRDT 检测结果阳性的疟疾感染患者未开具抗疟药物的情况，特别是这些最容易因未开具抗疟药物而导致不良后果的人群。
对来自非洲五个国家的 8 项研究中的 562762 名患者的数据进行了分析，这些研究是作为 ACT 联盟的一部分共同设计的，于 2007 年至 2013 年期间在儿童和成人中开展，涉及各种公共和私人医疗保健部门，并跨越了一系列疟疾流行地区。
在 106039 名 mRDT 检测阳性的患者（中位年龄 6 岁）中，有 7426 名（7.0%）未开具 ACT 抗疟药物。mRDT 检测阳性患者未开具 ACT 的比例在不同地点从 1.3%到 37.1%不等。在年龄<5 岁的患者中，有 3473/44539（7.8%）未开具 ACT，而年龄≥5 岁的患者中这一比例为 3833/60043（6.4%）。在不同地点，<5 岁儿童未开具 ACT 的比例高达 41.8%。在低传播强度地区（以检测阳性作为指标），未开具 ACT 的患者的几率是高传播地区的 2-32 倍。在低传播地区的 mRDT 检测阳性儿童中，尤其可能未开具 ACT，未治疗的比例高达 70%。在未开具 ACT 的 7426 名 mRDT 检测阳性患者中，有 4121 名（55.5%）被开具了其他非推荐的非 ACT 抗疟药物，其余 44.5%（3111 名）未开具任何抗疟药物。
在五个非洲国家的八项 mRDT 实施研究中，大量 mRDT 检测阳性的患者未开具 ACT 抗疟药物，许多患者甚至未开具抗疟药物。最容易出现严重后果的患者，即年龄<5 岁的儿童和低传播地区的患者，最有可能未开具抗疟药物，而低传播地区的幼儿最不可能接受疟疾治疗。这是一个重大的公共卫生风险，必须在培训和实践中加以解决。
在各原始研究中报告。
