The impact of providing rapid diagnostic malaria tests on fever management in the private retail sector in Ghana: A cluster randomized trial
Research and Development Division, Ghana Health Service, PO Box MB-190, Accra, Ghana; Dodowa Health Research Center, Ghana Health Service, Ghana; Dangme West District Health Directorate, Ghana Health Service, Ghana; National Malaria Control Programme, Ghana Health Service, Ghana; London School of Hygiene and Tropical Medicine, London, United Kingdom
Objective To examine the impact of providing rapid diagnostic tests for malaria on fever management in private drug retail shops where most poor rural people with fever present, with the aim of reducing current massive overdiagnosis and overtreatment of malaria. Design Cluster randomized trial of 24 clusters of shops. Setting Dangme West, a poor rural district of Ghana. Participants Shops and their clients, both adults and children. Interventions Providing rapid diagnostic tests with realistic training. Main outcome measures The primary outcome was the proportion of clients testing negative for malaria by a double-read research blood slide who received an artemisinin combination therapy or other antimalarial. Secondary outcomes were use of antibiotics and antipyretics, and safety. Results Of 4603 clients, 3424 (74.4%) tested negative by double-read research slides. The proportion of slide-negative clients who received any antimalarial was 590/1854 (32%) in the intervention arm and 1378/1570 (88%) in the control arm (adjusted risk ratio 0.41 (95% CI 0.29 to 0.58), P<0.0001). Treatment was in high agreement with rapid diagnostic test result. Of those who were slide-positive, 690/787 (87.8%) in the intervention arm and 347/392 (88.5%) in the control arm received an artemisinin combination therapy (adjusted risk ratio 0.96 (0.84 to 1.09)). There was no evidence of antibiotics being substituted for antimalarials. Overall, 1954/2641 (74%) clients in the intervention arm and 539/1962 (27%) in the control arm received appropriate treatment (adjusted risk ratio 2.39 (1.69 to 3.39), P<0.0001). No safety concerns were identified. Conclusions Most patients with fever in Africa present to the private sector. In this trial, providing rapid diagnostic tests for malaria in the private drug retail sector significantly reduced dispensing of antimalarials to patients without malaria, did not reduce prescribing of antimalarials to true malaria cases, and appeared safe. Rapid diagnostic tests should be considered for the informal private drug retail sector.
antibiotic agent; antimalarial agent; antipyretic agent; artemisinin; antibiotic therapy; Article; blood smear; combination chemotherapy; controlled study; diagnostic error; diagnostic test accuracy study; drug use; fever; Ghana; health care quality; human; malaria; malaria control; malaria rapid test; outcome assessment; patient safety; pharmacy; poverty; prescription; priority journal; randomized controlled trial; rural area