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Page 1 of 12
Research
RESEARCH
Rapid diagnostic tests to improve treatment of malaria
and other febrile illnesses: patient randomised
effectiveness trial in primary care clinics in Afghanistan
OPEN ACCESS
12
12
Toby Leslie lecturer and project manager , Amy Mikhail research fellow and project manager ,
2
1
Ismail Mayan field research coordinator , Bonnie Cundill lecturer and statistician , Mohammed
3
4
Anwar field research coordinator , Sayed Habib Bakhtash field research coordinator , Nader
3
2
Mohammed technical coordinator , Habib Rahman laboratory technologist , Rohullah Zekria
2
1
laboratory technologist , Christopher J M Whitty professor of international health , Mark Rowland
1
professor of entomology and malaria control and project leader
London School of Hygiene and Tropical Medicine, London, UK; 2Health Protection and Research Organisation, Kabul, Afghanistan; 3HealthNet-TPO,
Kabul, Afghanistan; 4Merlin, Kabul, Afghanistan
1
Abstract
Objective To assess the impact of rapid diagnostic tests on the
diagnostic accuracy and treatment of malaria and non-severe fever in
an Asian setting.
Design Patient randomised trial in primary level clinics.
Setting Two areas of Afghanistan where Plasmodium vivax and
Plasmodium falciparum are endemic; one area with moderate
transmission (eastern region) and one with low transmission (northern
region).
Participants 5794 patients of all ages with suspected malaria enrolled
by 80 clinicians in 22 clinics.
Interventions Malaria rapid diagnostic tests were compared with clinical
diagnosis where no parasite diagnostic test was available, longer
established field microscopy, and recently introduced microscopy.
Main outcome measures Proportion of patients appropriately treated
with an antimalarial, defined as patients with P vivax who received
chloroquine, patients with P falciparum who received artemisinin based
combination therapy, and patients with no malaria parasites who did not
receive an antimalarial. Secondary outcomes included diagnostic test
accuracy and the proportion of patients negative for malaria who received
antibiotics and antimalarials.
Results In the low transmission area, comparing rapid diagnostic tests
with clinical diagnosis, 65% (212/325) versus 12% (40/321) of febrile
patients were appropriately treated for malaria (adjusted odds ratio 92.7,
95% confidence interval 12.4 to 694.1, P<0.001). The proportion of
patients who were negative for malaria and received an antibiotic was
57% (185/325) in the rapid diagnostic test arm compared with 14%
(46/321) in the clinical diagnosis arm (16.9, 3.8 to 75.4, P<0.001). In the
comparison of rapid diagnostic test with microscopy in the moderate
transmission area, 83.6% (1696/2028) versus 76.3% (1512/1983) of
patients were appropriately treated for malaria (1.70, 1.30 to 2.23,
P<0.001). A higher proportion of P falciparum cases received appropriate
treatment with artemisinin based combination therapy when malaria was
diagnosed by rapid diagnostic test (82%, 58/71 v 32%, 24/76; 9.2, 3.88
to 21.66, P<0.001).
Conclusions In South and central Asian regions of low to moderate
malaria transmission where clinics lack capacity for diagnosis with rapid
diagnostic tests or microscopy, the introduction of the tests should be
considered to improve clinical care, reduce the overuse of antimalarials,
and improve disease surveillance.
Introduction
Malaria is a major public health problem throughout South and
central Asia, and approximately 2 billion people are at risk in
areas with endemic disease.1-3 Despite the population at risk,
compared with most of sub-Saharan Africa malaria in Asia is
a less common cause of acute illness than are viral or bacterial
infections, and most cases of malaria are due to Plasmodium
vivax, which is rarely fatal. Falciparum malaria is comparatively
rare in many areas, and thus fewer deaths from malaria occur
among febrile patients in Asia than among those in Africa.
Within the public health system, studies in India4 and
Afghanistan5 show a widespread perception that non-specific
febrile illness is largely due to malaria. As a result, substantial
overdiagnosis of malaria and consequent mistreatment of
Correspondence to: T Leslie Department of Disease Control, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical
Medicine, London, WC1E 7HT, UK toby.leslie@lshtm.ac.uk
No commercial reuse: See rights and reprints http://www.bmj.com/permissions
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Page 2 of 12
RESEARCH
Methods
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RESEARCH
Laboratory analysis
Study registrars prepared the reference blood slides in the clinics.
Thick and thin smears were prepared according to standard
operating procedures. Thin smears were fixed with methanol
and the slide was allowed to air dry before being stored in a
slide box. Within one week, two trained reference microscopists
who were blinded to each others results and the allocation of
the patient double read the slides using light microscopy. The
reference microscopists used standard solutions of 3% Giemsa
to stain the slides. They defined a slide as negative if no parasites
were seen after examining 100 fields. If the slide showed a
positive result, the microscopists counted and recorded the
asexual parasite counts against 200 white cells. A third
microscopist who was blinded to the original diagnoses read
the slides that were discordant for the presence or absence of
parasites or for Plasmodium species, and a best of three rule
applied.
The final reference diagnosis for malaria was blood slides with
concordant results between the two microscopists, and if the
slide results differed, the diagnosis was based on polymerase
chain reaction of filter paper blood samples.19 20 Polymerase
chain reaction was used to confirm all microscopy blood films
with a positive result and a random 10% of blood films with a
negative result.
Trial outcomes
The primary outcome was the proportion of patients
appropriately treated for suspected malaria measured against
the reference diagnosis. Appropriate treatment is a composite
outcome based on local treatment guidelines and defined as:
patients with P vivax receiving chloroquine, patients with P
falciparum or mixed infections receiving artemisinin based
combination therapy (sulfadoxine/pyrimethamine-artesunate),
and patients who are negative for malaria and not given an
antimalarial. To make it clearer for clinicians we changed the
way the primary outcome was presented in this paper from the
No commercial reuse: See rights and reprints http://www.bmj.com/permissions
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RESEARCH
Results
Figures 1-3 show the trial profile for each comparison. Of
62 005 patients seen in the outpatient departments of the clinics,
5749 were eligible and enrolled in the trial between 23
September 2009 and 22 September 2010.
Outcomes were available and analysed for a total of 5695
patients (99%). Data from 54 patients were not included in the
analysis owing to undefined reference results (unusable slides
or filter papers). Those excluded were equally distributed among
the clinics and between the study arms. Table 1 shows
enrolment characteristics at the patient and clinic level for each
arm and area. Within each region, patients in the two arms were
similar but in the low transmission setting the age of those
randomised to rapid diagnostic test was lower than those
randomised to the clinical diagnosis arm.
Table 2 shows the results of the reference malaria diagnosis.
The proportion of patients infected did not differ between arms
in any area, but, as expected, fewer cases occurred in the low
transmission area than in the moderate transmission area. Cases
of falciparum malaria were only seen in the moderate
transmission area.
Discussion
Overdiagnosis and over-treatment of malaria is a major problem
in South and central Asia where malaria is a minority cause of
febrile illness, and primary health centres often rely on clinical
symptoms for a diagnosis of malaria. Introducing rapid
diagnostic tests for malaria with a realistic, scalable training
package showed clear advantages over clinical diagnosis for
reducing overdiagnosis and improving the targeting of
antimalarials. Clinical diagnosis of malaria is unreliable and
clinicians are unable to distinguish malaria from other causes
of fever.23 Blanket treatment for suspected malaria with no
parasite confirmation is no longer supportable, and expansion
of effective diagnosis is needed.
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RESEARCH
Conclusions
With simple training, the introduction of rapid diagnostic tests
for malaria for use in patients with fever showed clear
advantages over clinical diagnosis and some advantages over
microscopy in primary level clinics in two epidemiological
settings, improving the accuracy of treatment of vivax and
falciparum malaria. However, the adoption of rapid diagnostic
tests also increased antibiotic treatment for non-malarial febrile
illness compared with microscopy or clinical diagnosis and did
not reduce over-prescription of antimalarials among patients
with a negative test result.
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RESEARCH
clinic staff, trial field staff, laboratory staff, and managers of HealthNet
TPO, Merlin, and the Health Protection and Research Organisation.
Funding Source: The study was funded by the Bill and Melinda Gates
Foundation though a grant to the ACT Consortium at the London School
of Hygiene & Tropical Medicine. The funding source played no role in
the design, conduct, analysis or interpretation of the results.
Competing interests: All authors have completed the ICMJE uniform
disclosure form at www.icmje.org/coi_disclosure.pdf and declare: the
research was funded by the Bill and Melinda Gates Foundation and
Sponsored by the London School of Hygiene and Tropical Medicine;
no financial relationships with any organisations that might have an
interest in the submitted work in the previous three years; no other
relationships or activities that could appear to have influenced the
submitted work.
Ethical approval: This trial was approved by the institutional review
board, Ministry of Public Health, Afghanistan and the ethics committee
of the London School of Hygiene and Tropical Medicine.
Data sharing: The full dataset is available from the corresponding author
at toby.leslie@lshtm.ac.uk.
Transparency: The lead author (TL) affirms that the manuscript is an
honest, accurate, and transparent account of the study being reported;
that no important aspects of the study have been omitted; and that any
discrepancies from the study as planned (and, if relevant, registered)
have been explained.
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RESEARCH
Tables
Table 1| Characteristics of clinics and patients enrolled in the trial, by area and study arm. Values are number (percentages) unless stated
otherwise
Microscopy arm
RDT arm
Microscopy arm
RDT arm
Clinical arm
22
20
1983
2027
515
523
321
325
Males
1116 (56.3)
1073 (52.9)
274 (53.2)
281 (53.7)
187 (58.3)
187 (57.5)
15.4 (12.6)
15.8 (12.9)
20.1 (14.9)
19.4 (15.1)
24.2 (16.6)
22.9 (15.8)
0-5
368 (18.6)
349 (17.2)
101 (19.6)
102 (19.5)
24 (7.5)
35 (10.8)
6-10
598 (30.2)
601 (29.6)
57 (11.1)
74 (14.2)
37 (11.5)
32 (9.9)
11-15
305 (15.4)
321 (15.8)
64 (12.4)
68 (13.0)
57 (17.8)
57 (17.5)
16-20
282 (14.2)
305 (15.0)
90 (17.5)
87 (16.6)
67 (20.9)
60 (18.5)
21-40
337 (17.0)
336 (16.6)
158 (30.7)
147 (28.1)
86 (26.8)
106 (32.6)
93 (4.7)
116 (5.7)
45 (8.7)
45 (8.6)
50 (15.6)
35 (10.8)
Summer
524 (26.4)
545 (26.9)
172 (33.4)
169 (32.2)
139 (43.3)
137 (42.2)
Autumn
671 (33.8)
672 (33.1)
107 (20.8)
114 (21.8)
39 (12.2)
43 (13.2)
Winter
323 (16.3)
334 (16.5)
76 (14.8)
80 (15.3)
40 (12.5)
38 (11.7)
Spring
465 (23.5)
477 (23.5)
160 (31.1)
160 (30.6)
103 (32.1)
107 (32.9)
Pf/Pv
1691 (83.5)
376 (72.3)
204 (62.8)
Pf/Pan
334 (16.5)
144 (27.7)
RDT arm
Age group:
>40
Patients by season:
No of clinics
121 (37.2)
12
0%
>0-3%
3-20%
21-25%
>25%
Clinic type
3 (2-8)
3 (2-7)
4 (1-6)
4 (1-6)
3 (1-3)
3 (1-4)
165 (120-229)
169 (127-231)
103 (77-136)
105 (76-134)
64 (32-116)
65 (28-122)
33 (1-170)
33 (1-175)
10 (1-136)
12 (1-134)
25 (1-98)
19 (1-95)
RDT=rapid diagnostic test; Pf/Pv=CareStart Pf (HRPII)/Pv (pLDH) (AccessBio, NJ); Pf/Pan=CareStart Pf (HRPII)/Pan (pLDH) (AccessBio, NJ).
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RESEARCH
Table 2| Number of patients with malaria diagnosis by double read reference blood smears and confirmed by polymerase chain reaction
among sample, by location and study arm. Values are number of patients (% of all cases) unless stated otherwise
Malaria reference diagnosis
and species
Microscopy arm
(n=515)
Clinical arm
(n=321)
RDT arm
(n=325)
510 (25.7)
466 (23.0)
5 (1.0)
2 (0.4)
Vivax malaria
434 (85.1)
395 (84.8)
5 (100)
2 (100)
Falciparum malaria
75 (14.7)
69 (14.8)
1 (0.2)
2 (0.4)
Microscopy arm
(n=1983)
Composition of slide:
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RESEARCH
Table 3| Number, proportion, and relative odds of patients being appropriately treated after diagnosis of malaria in two transmission areas
No with outcome/No in
group (%)
P value
<0.001
P value
<0.001
1512/1983 (76.3)
RDT
1696/2028 (83.6)
1095/1473 (74.3)
RDT
1270/1562 (81.3)
1
<0.001
<0.001
0.17
<0.001
0.022
393/434 (90.6)
RDT
368/395 (93.2)
1
0.12
24/76 (31.5)
RDT
58/71 (81.7)
<0.001
0.12
393/515 (76.3)
RDT
420/523 (80.3)
389/510 (76.3)
RDT
418/521 (80.2)
0.12
0.036
Microscopy
4/5 (80.0)
RDT
2/2 (100.0)
<0.001
<0.001
40/321 (12.5)
RDT
212/325 (65.2)
*Adjusted odds ratio using three level model, adjusted for fixed effect of patients age and clinic type (in east region) and random effects of clinician (within clinics)
and clinic (between clinics). Analysis for adjusted odds ratio is based on two level model of patients nested within clinicians and clinicians nested within clinics.
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RESEARCH
Table 4| Accuracy of field microscopy and rapid diagnostic tests (RDT) used in trial for diagnosis of falciparum and vivax malaria against
Diagnosis type
Performance measures by malaria type
Microscopy
Pf/Pv RDT
Pf/Pan RDT
33/76
60/64
6/7
1887/1906
1595/1626
325/327
382/434
281/304
86/91
1345/1548
1314/1386
233/243
4/5
0/2
447/459
373/374
138/141
100
38/321
0/204
119/120
Clinical diagnosis
Specificity % (95% CI):
No with diagnosis/No in group
Comparing microscopy with each type of RDT.
Pf/Pv=CareStart Pf (HRPII)/Pv (pLDH) (AccessBio, NJ); Pf/Pan=CareStart Pf (HRPII)/Pan (pLDH) (AccessBio, NJ).
*Fishers exact test, P=0.01-<0.001.
Fishers exact test, P=0.048.
2
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RESEARCH
Figures
Fig 1 Patient flow through trial in low transmission area (north region) in five clinics that lacked microscopy and used clinical
signs and symptoms to diagnose malaria
Fig 2 Patient flow through trial in moderate transmission area (east region) in 12 clinics that used microscopy to diagnose
malaria
Fig 3 Patient flow through trial in low transmission area (north region) in five clinics that used microscopy to diagnosis
malaria
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RESEARCH
Fig 4 Forest plot showing relative odds for appropriate malaria treatment in clinics in low transmission area using clinical
diagnosis versus rapid diagnostic test (RDT). Clinic 5 was excluded because of zero events (no patients appropriately
treated in control arm)
Fig 5 Forest plot showing relative odds for appropriate malaria treatment in clinics in low transmission area using microscopy
versus rapid diagnostic test (RDT)
Fig 6 Forest plot showing relative odds for appropriate malaria treatment in clinics in moderate transmission area using
microscopy versus rapid diagnostic test (RDT)
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