Diagnosis Randomised controlled trial
Improving malaria treatment by increasing access to accurate diagnostic tests: test results must guide treatment 10.1136/ebmed-2014-110069
Michael L Wilson Denver Health/University of Colorado, Denver, Colorado, USA Correspondence to: Professor Michael L Wilson, Medical Laboratories, Mail Code #0224, Denver Health Medical Center, 777 Bannock Street, Denver, CO 80204, USA; [email protected]
Commentary on: Leslie T, Mikhail A, Mayan I, et al. Rapid diagnostic tests to improve treatment of malaria and other febrile illnesses: patient randomised effectiveness trial in primary care clinics in Afghanistan. BMJ 2014;348:g3730.
Context Malaria control programmes focus on two things: reducing transmission by decreasing exposure to infected mosquitoes (via residual indoor spraying, use of insecticide-treated nets and prophylactic treatment) and improving diagnosis and treatment of infected persons. Treatment should be guided by an accurate diagnosis to avoid treating persons without malaria, so as to conserve resources and delay emergence of artemesinin resistance. Diagnosis is based on microscopy as the gold standard, with use of malaria rapid diagnostic tests (MRDT) as either an adjunct or alternative to microscopy when or where microscopy is unavailable. However, treatment is frequently not based on diagnostic test results, even when diagnostic tests are available.
Methods This was a randomised trial of MRDT in two areas of Afghanistan with endemic Plasmodium vivax and Plasmodium falciparum transmission. The eastern area has moderate transmission rates and the northern area low transmission rates. The study was conducted in 22 primary care clinics. Patients of all ages were eligible for inclusion in the trial. MRDT were evaluated as alternatives (in low-transmission areas where microscopy previously was not available) or adjuncts to microscopy (in low-transmission areas where microscopy was recently introduced and moderatetransmission areas where microscopy previously had been used). Patients were selected on the basis of a clinical suspicion of malaria. The primary outcome was defined as the proportion of patients treated appropriately according to the results of MRDT (eg, no treatment for a negative MRDT result; chloroquine for P. vivax infection; artemisinin-based combination therapies (ACT) for P. falciparum infection). Other outcomes measured included the proportion of patients who had negative tests for malaria but who were treated with antimicrobial or antimalarial agents.
Findings A total of 5794 patients with suspected malaria were evaluated. In the lowtransmission area, patients tested with MRDT were more often treated appropriately for malaria (212/325) when compared with patients who had only a clinical diagnosis (40/321; p
Improving malaria treatment by increasing access to accurate diagnostic tests: test results must guide treatment 10.1136/ebmed-2014-110069
Michael L Wilson Denver Health/University of Colorado, Denver, Colorado, USA Correspondence to: Professor Michael L Wilson, Medical Laboratories, Mail Code #0224, Denver Health Medical Center, 777 Bannock Street, Denver, CO 80204, USA; [email protected]
Commentary on: Leslie T, Mikhail A, Mayan I, et al. Rapid diagnostic tests to improve treatment of malaria and other febrile illnesses: patient randomised effectiveness trial in primary care clinics in Afghanistan. BMJ 2014;348:g3730.
Context Malaria control programmes focus on two things: reducing transmission by decreasing exposure to infected mosquitoes (via residual indoor spraying, use of insecticide-treated nets and prophylactic treatment) and improving diagnosis and treatment of infected persons. Treatment should be guided by an accurate diagnosis to avoid treating persons without malaria, so as to conserve resources and delay emergence of artemesinin resistance. Diagnosis is based on microscopy as the gold standard, with use of malaria rapid diagnostic tests (MRDT) as either an adjunct or alternative to microscopy when or where microscopy is unavailable. However, treatment is frequently not based on diagnostic test results, even when diagnostic tests are available.
Methods This was a randomised trial of MRDT in two areas of Afghanistan with endemic Plasmodium vivax and Plasmodium falciparum transmission. The eastern area has moderate transmission rates and the northern area low transmission rates. The study was conducted in 22 primary care clinics. Patients of all ages were eligible for inclusion in the trial. MRDT were evaluated as alternatives (in low-transmission areas where microscopy previously was not available) or adjuncts to microscopy (in low-transmission areas where microscopy was recently introduced and moderatetransmission areas where microscopy previously had been used). Patients were selected on the basis of a clinical suspicion of malaria. The primary outcome was defined as the proportion of patients treated appropriately according to the results of MRDT (eg, no treatment for a negative MRDT result; chloroquine for P. vivax infection; artemisinin-based combination therapies (ACT) for P. falciparum infection). Other outcomes measured included the proportion of patients who had negative tests for malaria but who were treated with antimicrobial or antimalarial agents.
Findings A total of 5794 patients with suspected malaria were evaluated. In the lowtransmission area, patients tested with MRDT were more often treated appropriately for malaria (212/325) when compared with patients who had only a clinical diagnosis (40/321; p
