Parasite-based Diagnosis for Malaria in Uganda: Feasibility and Cost-Effectiveness

March 27, 2012 updated by: Institute of Public Health, Makerere University
The purpose of this study is to compare the cost-effectiveness of treating malaria based on three methods of diagnosis (rapid test, microscopy and presumptive diagnosis) among patients attending level three government health centres located in areas of low and high transmission intensities in Uganda. The study hypotheses are: in both low and high transmission areas, cost-effectiveness of malaria treatment with Artemether-Lumefantrine will be improved by the adoption of rapid diagnostic tests when compared with presumptive diagnosis or microscopy; and the difference between the cost-effectiveness of Artemether-Lumefantrine treatment following rapid diagnostic test or microscopy versus presumptive diagnosis will be greatest in low transmission areas.

Study Overview

Status

Unknown

Conditions

Intervention / Treatment

Detailed Description

The development of drug resistance in malaria parasites lead the Uganda Ministry of Health (MoH) to change the first-line anti-malarial treatment from the cheap Chloroquine/Sulfadoxine-Pyrimethamine combination to a more expensive Artemether-Lumefantrine. The MoH recommends treatment of all fever cases as malaria within 24 hours of illness with first-line drug. Under this policy, patients who do not have malaria but present with febrile illness will receive Coartem® resulting in significant drug wastage. With the increased cost of first-line drugs, this wastage places a substantial and potentially remediable burden on the health budget. As such, there is a need to gauge whether more accurate malaria diagnosis through microscopy and/or rapid diagnostic tests, might improve the cost-effectiveness of the new treatment regimes.

Specific objectives

  1. To assess the feasibility of rapid test and microscopy in diagnosis of malaria at health centre III.
  2. To compare the cost-effectiveness of treating malaria with Artemether- Lumefantrine based on microscopy, rapid test and presumptive diagnosis in different transmission intensities
  3. To assess whether introduction of malaria parasite-based diagnosis (rapid test or microscopy) at government Health Centre III improves the overall cost-effectiveness of outpatient management of febrile illness

Sample size determination The sample size was determined using standard formula. Estimating the sensitivity of either test to be 90%, Zα =1.96 and after stratifying for age (<5 years and ≥5 years), the calculated sample is 272 per health centre. Therefore, the total number of patients for 6 health centres in two districts = 6 x 272 = 1632.

Baseline: Baseline data was collected on the current malaria treatment practices; clinicians' view of malaria diagnosis; concerns towards the new treatment; and health centre staffing. Geographical locations of all visited government health centres was recorded using Germin etrex global positioning system (Germin International Inc., Olathe, USA). At six selected health centres, social and demographic data was collected from 613 patients.

Implementation of intervention: The main intervention is comprised of three malaria diagnostic approaches: presumptive diagnosis, field microscopy and rapid test (Paracheck Pf® device - Orchid Biomedical Systems, Goa, India). Each of these approaches was randomly allocated to a health centre. The first-line drug used is Artemether/Lumefantrine (20mg/120mg) (Novartis, Switzerland).

Consenting subjects are consecutively enrolled at the point when the attending clinician suspects that they have uncomplicated malaria. Where microscopy is the main diagnostic method, thick and thin blood smears are prepared per patient enrolled. Where rapid test is the main method, all patients are tested. One hundred patients per health centre are randomly selected to provide blood specimens for validation using expert microscopy and PCR as "gold standard." After enrolment, patients are systematically tracked until departure from the health centre. Patients are followed up on the seventh day of treatment to assess their clinical improvement. Those who fail to return on the scheduled date are traced from their homes on the eighth day.

Follow-up activities include: documentation of drugs prescribed and or dispensed; clinically assess the patient's status in comparison to Day 0; perform further tests including PCR if the patient does not show improvement; pill counting of drugs remaining - if the patient has not completed the dose; documentation of reasons for not completing dose; and documentation if the patient bought the prescribed drugs that were out of stock on Day 0.

Effectiveness is measured as the number of patients commencing treatment with Artemether/Lumefantrine. However, patients are followed up and effectiveness also measured on the 7th day of treatment indicated by their clinical improvement. The feasibility of the diagnostic methods is ongoing from the March 2010 to date.

Study Type

Interventional

Enrollment (Anticipated)

102087

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Uganda
      • Bushenyi and Iganga, Uganda
        • Recruiting
        • Bushenyi and Iganga districts - Government Health Cetres level III
        • Contact:
        • Contact:

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

3 months and older (Child, Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

  • Suspected uncomplicated malaria infection
  • Consent to participate

Exclusion Criteria:

  • Pregnancy (policy recommends quinine for treatment of malaria in pregnancy)

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Diagnostic
  • Allocation: Non-Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Other: Field microscopy
Field microscopy is the main method of malaria diagnosis
Device: Field microscopy and Paracheck Pf®
Malaria diagnosis based on microscopy and or Paracheck Pf®. Artemether/Lumefantrine (20mg/120mg) is first-line drug in all arms
Other: Paracheck Pf® device
Paracheck Pf® device (Rapid Diagnostic Test) is the main method for malaria diagnosis
Device: Field microscopy and Paracheck Pf®
Malaria diagnosis based on microscopy and or Paracheck Pf®. Artemether/Lumefantrine (20mg/120mg) is first-line drug in all arms
No Intervention: Presumptive diagnostic method

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Time Frame
diagnostic test validity; unit cost per malaria case diagnosed and treated with Artemether-Lumefantrine; total savings associated with treatment of confirmed malaria cases; compliance with directives for use of rapid test or microscopy
Time Frame: 18 months
18 months

Secondary Outcome Measures

Outcome Measure
Time Frame
unit cost of non-malaria febrile treatment; therapeutic behaviour in light of pressure to prescribe antimalarials
Time Frame: 18 months
18 months

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Makerere University

Collaborators

Department for International Development, United Kingdom

Investigators

  • Study Chair: Fred Nuwaha, MD, PhD, Department of Disease Control and Environmental Health, Makerere Universtiy School of Public Health

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start

October 1, 2006

Primary Completion (Anticipated)

March 1, 2012

Study Completion (Anticipated)

December 1, 2012

Study Registration Dates

First Submitted

November 28, 2007

First Submitted That Met QC Criteria

November 28, 2007

First Posted (Estimate)

November 29, 2007

Study Record Updates

Last Update Posted (Estimate)

March 28, 2012

Last Update Submitted That Met QC Criteria

March 27, 2012

Last Verified

March 1, 2012

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 2006/HD20/4758U

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

product manufactured in and exported from the U.S.

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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