University of Zürich, WHO Collaborating Centre for Travellers' Health, Travel Clinic and Department of Public & Global Health, MilMedBiol Competence Centre, Epidemiology, Biostatistics and Prevention Institute, Switzerland.
University of Zürich, Biostatistics Department at Epidemiology, Biostatistics and Prevention Institute, Switzerland.
Travel Med Infect Dis. 2020 Nov-Dec;38:101902. doi: 10.1016/j.tmaid.2020.101902. Epub 2020 Oct 23.
Standby emergency self-treatment (SBET) is often recommended as an anti-malaria strategy for travellers to low-risk endemic areas. This self-treatment enables competent malaria therapy, if medical assistance is unavailable. The World Health Organization (WHO) recommends performing reliable diagnostic tests before starting antimalarial treatment. For the self-diagnosis of malaria in travellers, rapid diagnostic tests (RDT) can be used to confirm the infection before SBET is used. The aim of this research is to assess the use of RDT and/or SBET in travellers.
We searched the databases (PubMed, Scopus, Embase, CINAHL) using terms and synonyms for 'self-diagnosis' and 'self-treatment' combined with 'malaria' and 'travel'. Articles in English, French and German were included. Potential articles were screened and extracted by two authors (KU and PS). Only original articles and case reports documenting the self-use of RDT and/or SBET in travellers were included. Data were extracted using a standardised approach. We defined 'correct use' of RDT and SBET. Data on number and performance of RDT and SBET use, as well as malaria verification were collected in an Excel table. Five meta-analyses were performed using a random effects model and calculating pooled proportions. This systematic review was conducted according to the PRISMA guidelines and registered in PROSPERO (CRD42018108874).
The research resulted in 867 articles of possible relevance on RDT and 955 articles on SBET. After screening, a total of 4 articles on RDT use and 17 articles for SBET use in travellers were included in the systematic review. Most of the RDT were performed and interpreted properly by the travellers (pooled proportion 88%, 95% confidence interval (CI) from 64% to 97%), whereby the proportion of correct performance was increased after a pre-travel test run (97%). Major problems in the implementation such as pricking finger, placing blood drop, identifying lines and interpreting results could be discovered. We found data on 1025 SBET uses in studies of travellers to high-risk African countries. In these studies, the pooled proportion of SBET uses was 6% (95% CI from 2% to 13%). We found 545 SBET uses in studies of travellers to countries of mixed malaria risk. In these studies, the pooled proportion of SBET uses was 2% (95% CI from 1% to 7%). Furthermore, the evaluation showed a high proportion of correct SBET use (pooled proportion 69%, 95% CI from 35% to 90%). As a cause for incorrect use, errors in dosage (under- or overdose), disregard of minimal incubation period (< 7 days since first possible malaria exposure) and absence of fever were identified. Four cases of post-SBET severe adverse events were documented. In a third of travellers who used SBET, a Plasmodium spp. infection could be detected (pooled proportion 31%, 95% CI from 16% to 51%).
This systematic review and meta-analysis showed that the majority of travellers were able to use RDT and SBET correctly. Standardised pre-travel instructions and specific training are indicated to increase the proportions of correct RDT and SBET use. With improved and user-friendly technology, RDT may become an integral part of SBET malaria recommendations for travellers. Combined use of RDT and SBET could be an appropriate strategy for selected subgroups of travellers to low-risk, remote malaria areas. Future research should focus on combined RDT and SBET strategies.
备用紧急自我治疗（SBET）常被推荐作为旅行者前往低风险流行地区的抗疟策略。这种自我治疗可在无法获得医疗援助的情况下进行有效的疟疾治疗。世界卫生组织（WHO）建议在开始抗疟治疗之前进行可靠的诊断测试。对于旅行者的疟疾自我诊断，可以使用快速诊断测试（RDT）在使用 SBET 之前确认感染。本研究的目的是评估旅行者中 RDT 和/或 SBET 的使用情况。
我们使用“自我诊断”和“自我治疗”以及“疟疾”和“旅行”的术语和同义词在数据库（PubMed、Scopus、Embase、CINAHL）中进行搜索。纳入英文、法文和德文的文章。由两名作者（KU 和 PS）筛选和提取潜在文章。仅纳入记录旅行者自行使用 RDT 和/或 SBET 的原始文章和病例报告。使用标准化方法提取数据。我们定义了 RDT 和 SBET 的“正确使用”。使用 Excel 表格收集 RDT 和 SBET 使用的数量和性能以及疟疾验证的数据。使用随机效应模型进行了五项荟萃分析，并计算了合并比例。本系统评价按照 PRISMA 指南进行，并在 PROSPERO（CRD42018108874）中进行了注册。
关于 RDT 的研究产生了 867 篇可能相关的文章，关于 SBET 的研究产生了 955 篇文章。经过筛选，共有 4 篇关于 RDT 使用的文章和 17 篇关于旅行者 SBET 使用的文章纳入系统评价。大多数旅行者正确地进行和解释了 RDT（合并比例为 88%，95%置信区间（CI）为 64%至 97%），经过旅行前测试运行后，正确执行的比例增加（97%）。在实施过程中发现了一些主要问题，例如刺破手指、放置血滴、识别线和解释结果。我们在研究前往高风险非洲国家的旅行者的研究中发现了 1025 例 SBET 使用的数据。在这些研究中，SBET 使用的合并比例为 6%（95%CI 为 2%至 13%）。我们在研究前往疟疾混合风险国家的旅行者的研究中发现了 545 例 SBET 使用。在这些研究中，SBET 使用的合并比例为 2%（95%CI 为 1%至 7%）。此外，评估显示 SBET 的正确使用比例较高（合并比例为 69%，95%CI 为 35%至 90%）。不正确使用的原因包括剂量错误（用药不足或过量）、忽略最小潜伏期（首次可能发生疟疾暴露后<7 天）和无发热。记录了 4 例 SBET 后严重不良事件。在使用 SBET 的旅行者中，有三分之一（31%，95%CI 为 16%至 51%）检测到疟原虫感染。
本系统评价和荟萃分析表明，大多数旅行者能够正确使用 RDT 和 SBET。需要进行标准化的旅行前指导和专门培训，以提高正确使用 RDT 和 SBET 的比例。随着技术的改进和用户友好性的提高，RDT 可能成为旅行者 SBET 疟疾推荐的重要组成部分。RDT 和 SBET 的联合使用可能是针对低风险、偏远疟疾地区的选定旅行者亚组的一种合适策略。未来的研究应重点关注 RDT 和 SBET 的联合策略。
