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Research

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

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h1019 (Published 04 March 2015) Cite this as: BMJ 2015;350:h1019
  1. Evelyn K Ansah, deputy director1,
  2. Solomon Narh-Bana, field epidemiologist2,
  3. Harriet Affran-Bonful, pharmacist3,
  4. Constance Bart-Plange, programme manager4,
  5. Bonnie Cundill, lecturer in statistics5,
  6. Margaret Gyapong, director2,
  7. Christopher J M Whitty, professor of public and international health5
  1. 1Research and Development Division, Ghana Health Service, PO Box MB-190, Accra, Ghana
  2. 2Dodowa Health Research Center, Ghana Health Service
  3. 3Dangme West District Health Directorate, Ghana Health Service
  4. 4National Malaria Control Programme, Ghana Health Service
  5. 5London School of Hygiene & Tropical Medicine, London, UK
  1. Correspondence to: E K Ansah Ansahekdr{at}yahoo.co.uk
  • Accepted 26 January 2015

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

Footnotes

  • We thank the chemical sellers in the Dangme West District and their clients for their participation in this trial, and the fieldworkers especially our field supervisors Michael Epokor and Samson Akanpigbiam. We also acknowledge the immense support provided by the Brian Greenwood, David Schellenberg, and the secretariat of the Malaria Capacity Development Consortium of the London School of Hygiene & Tropical Medicine.

  • Contributors: EKA and CJMW designed the study, with input from SN-B and MG. EKA, SN-B, MG, HB, and CB-P performed the study with input from BC. EKA, BC, CJMW, and SN-B analyzed and interpreted the data. EKA, BC, and CJMW wrote the first draft of the manuscript. SN-B, MG, HB, and CB-P contributed to the revision and finalization of the manuscript. All authors approved the final version of the manuscript. EKA is the study guarantor.

  • Funding: The study was sponsored by the Malaria Capacity Development Consortium of the London School of Hygiene & Tropical Medicine with funding from the Welcome Trust and the Bill and Melinda Gates Foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

  • 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”

  • Ethical approval: The study received ethical approval from the Ethics Committee of the London School of Hygiene & Tropical Medicine and the Ethical Review Committee of the Ghana Health Service.

  • Transparency declaration: The lead author (the manuscript’s guarantor) 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.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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