Department of Global Health and Population, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts.
Swiss Tropical and Public Health Institute, Allschwil, Switzerland.
JAMA. 2024 Oct 15;332(15):1270-1281. doi: 10.1001/jama.2024.12589.
A prompt malaria diagnosis is crucial for the management of children with febrile illness in sub-Saharan African countries, where malaria remains a leading cause of mortality among children younger than 5 years of age. The development and distribution of point-of-care rapid diagnostic tests (RDTs) for malaria has transformed practice, but limited systematic evidence exists on how malaria RDTs have affected the management of febrile illness and mortality for children younger than 5 years of age across sub-Saharan Africa countries.
To evaluate the association between the distribution of malaria RDTs and the management of febrile illness and mortality among children younger than 5 years of age in sub-Saharan African countries.
DESIGN, SETTING, AND PARTICIPANTS: This quasi-experimental study used a novel dataset linking malaria RDT distribution to 165 nationally representative household surveys across 35 sub-Saharan African countries with mortality data. The sample comprised approximately 3.9 million child-year observations and approximately 260 000 febrile illness episodes in children younger than 5 years of age between 2000 and 2019.
Fixed-effects linear probability models were used to analyze the association between variation in malaria RDTs distributed per child younger than 5 years of age (by country per year) and blood testing, antimalarial drug use, antibiotic use, use of symptomatic treatments, and mortality rates. Variation in the effects of testing and treatment was also assessed across the sub-Saharan African countries that had varying prevalence of malaria.
The mortality sample included 1 317 866 children and the fever sample included 256 292 children. The mean age of the children with febrile illness was 2.4 years (SD, 1.3 years) and 49% were female. Each additional malaria RDT distributed per child younger than 5 years of age was associated with an increase of 3.5 percentage points (95% CI, 3.2-3.8 percentage points) in blood testing, an increase of 1.5 percentage points (95% CI, 1.2-1.8 percentage points) in the use of antimalarial drugs, an increase of 0.4 percentage points (95% CI, 0.1-0.6 percentage points) in antibiotic use, and a decrease of 0.4 percentage points (95% CI, 0.1-0.8 percentage points) in the use of treatments for symptoms. Each additional malaria RDT distributed per child younger than 5 years of age was associated with a reduction in child mortality of 0.34 deaths per 1000 child-years (95% CI, 0.15-0.52 deaths per 1000 child-years). The effects of malaria RDT distribution on medication use and child mortality varied across prevalence settings (low vs high) for malaria; there were survival improvements only in areas that had a high prevalence of malaria.
Increasing distribution of malaria RDTs was associated with increased blood testing, increased use of antimalarial drugs, and modestly improved survival in children younger than 5 years of age in sub-Saharan African countries. However, malaria RDTs were associated with increases in the rates of antibiotic use that were already high, suggesting that more comprehensive approaches to case management of febrile illness are needed.
重要性：在撒哈拉以南非洲国家，疟疾仍然是 5 岁以下儿童死亡的主要原因，因此对发热儿童进行快速、准确的疟疾诊断对于儿童管理至关重要。即时检验（point-of-care）快速诊断检测（RDT）的开发和推广改变了这一现状，但关于疟疾 RDT 如何影响撒哈拉以南非洲国家发热儿童的管理和死亡率，目前还缺乏系统的证据。
目的：评估疟疾 RDT 的分布与撒哈拉以南非洲国家 5 岁以下儿童发热的管理和死亡率之间的关系。
设计、地点和参与者：本准实验研究使用了一个新的数据集，该数据集将疟疾 RDT 的分布与撒哈拉以南非洲 35 个国家的 165 项具有代表性的家庭调查以及死亡率数据联系起来。样本包括 2000 年至 2019 年间约 390 万儿童年观察值和约 260000 例 5 岁以下发热儿童的发热发作。
主要结局和措施：采用固定效应线性概率模型分析了每 5 岁以下儿童（按国别和年份计算）分发的疟疾 RDT 数量的变化与血液检测、抗疟药物使用、抗生素使用、症状治疗使用以及死亡率之间的关联。还评估了在疟疾流行率不同的撒哈拉以南非洲国家，检测和治疗效果的变化。
结果：死亡样本包括 1317866 名儿童，发热样本包括 256292 名儿童。发热儿童的平均年龄为 2.4 岁（标准差为 1.3 岁），其中 49%为女性。每增加一个 5 岁以下儿童的疟疾 RDT，进行血液检测的比例增加 3.5 个百分点（95%置信区间，3.2-3.8 个百分点），使用抗疟药物的比例增加 1.5 个百分点（95%置信区间，1.2-1.8 个百分点），抗生素使用的比例增加 0.4 个百分点（95%置信区间，0.1-0.6 个百分点），症状治疗的比例减少 0.4 个百分点（95%置信区间，0.1-0.8 个百分点）。每增加一个 5 岁以下儿童的疟疾 RDT，儿童死亡率降低 0.34 例/1000 儿童年（95%置信区间，0.15-0.52 例/1000 儿童年）。疟疾 RDT 分布对药物使用和儿童死亡率的影响因疟疾流行率（低 vs 高）而有所不同；只有在疟疾流行率较高的地区，生存状况才有所改善。
结论和相关性：在撒哈拉以南非洲国家，增加疟疾 RDT 的分发与增加血液检测、增加抗疟药物使用以及 5 岁以下儿童死亡率适度降低有关。然而，疟疾 RDT 的使用与已经很高的抗生素使用率的增加有关，这表明需要更全面的方法来管理发热疾病。
