The impact of providing rapid diagnostic malaria tests on fever management in the private retail sector in Ghana: a cluster randomized trial

Evelyn K Ansah, Solomon Narh-Bana, Harriet Affran-Bonful, Constance Bart-Plange, Bonnie Cundill, Margaret Gyapong, Christopher J M Whitty, Evelyn K Ansah, Solomon Narh-Bana, Harriet Affran-Bonful, Constance Bart-Plange, Bonnie Cundill, Margaret Gyapong, Christopher J M Whitty

Abstract

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.Registration Clinicaltrials.gov NCT01907672.

Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organization for the submitted work; no financial relationships with any organizations 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”

© Ansah et al 2015.

Figures

https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4793985/bin/anse022208.f1_default.jpg
Fig 1 Trial profile: rapid diagnostic test versus normal practice in Licensed Chemical shops
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4793985/bin/anse022208.f2_default.jpg
Fig 2 Medicines dispensed by chemical sellers with or without a rapid diagnostic test (RDT) for malaria, by the subsequent blood slide results (not available to chemical seller to guide dispensing)
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4793985/bin/anse022208.f3_default.jpg
Fig 3 Medicines dispensed by chemical sellers based on rapid diagnostic test (RDT) for malaria

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