Impact of Rapid Diagnostic Tests for malaria

on case management in Dar es Salaam

IMALDIA Project

Judith Kahama, Valerie D’Acremont, Christian Lengeler

Dar es Salaam City Council, United republic of Tanzania

Swiss Tropical and Public Health Institute Basel, Switzerland

2

Patients with

history of fever

Malaria (81%)

Proportion of patients treated for malaria

in Dar es Salaam 2006

Patients

without fever

Malaria (42%)

3

Malaria Attributable Fever Fractions in 4 African cities 2003-2004

0-1 year 1-5 years 5-15 years >15 years

Abidjan

(Yopougon) 0.12 0.22 0.27 0.13

Cotonou 0 0.04 0 0

Dar es Salaam 0 0.03 0.04 0.02

Ouagadougou 0 0.13 0.04 0

Source: Wang et al. 2005

Hence, the vast majority of malaria treatments are unnecessary!

4

Objectives of the IMALDIA study: Improve laboratory

diagnosis for malaria in routine management of fever cases

at outpatient departments in Dar es Salaam

Pilot implementation of Rapid Diagnostic Tests for malaria

(RDTm) in Dar es Salaam

- 3 District hospitals,

- 3 Health Centers

- 3 Dispensaries

- 3 Matched control health facilities

5

9 health facilities in DSM

Oct 2007 to

Sept 2008

Kahama et al. submitted Malaria J.

6

0%

10%

20%

30%

40%

50%

60%

70%

80%

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

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Au

g

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p

Oct

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Jan

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Ma

r

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r

Ma

y

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Au

g

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Ma

r

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r

Ma

y

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Au

g

Se

p

2006 2007 2008

Po

sit

ivit

y (

%)

Hospitals

Health Centers

Dispensaries

RDT implementation

Routine microscopy: 48% Routine RDT: 8%

2006 2007 2008

Malaria test positivity rate before and after RDT

implementation

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jan

Feb Mar A

pr

May Ju

nJu

lAug

Sep O

ctNov

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Jan

Feb Mar A

pr

May Ju

nJu

lAug

Sep O

ctNov

Dec

Jan

Feb Mar A

pr

May Ju

nJu

lAug

Sep

Po

sit

ivit

y r

ate

Hospitals

Health centres

Dispensaries

Malaria test positivity rates

Kahama et al. submitted Malaria J.

7

0%

20%

40%

60%

80%

100%

120%Ja

n

Feb

Ma

r

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r

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n

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g

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Oct

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Au

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p

2006 2007 2008

Po

sit

ivit

y (

%)

Intervention

Control

RDT implementation

Kahama et al. submitted Malaria J.

Malaria test positivity rates

8

0

5000

10000

15000

20000

25000Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

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May

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dispensary 3

dispensary 2

dispensary 1

health centre 3

health centre 2

health centre 1

hospital 3

hospital 2

hospital 1

mRDT

2007 2008

Artemether/lumefantrine (ALu)

D’Acremont et al. Malaria J 2011

Drug consumption 1

9

0

2000

4000

6000

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10000

12000

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16000

18000

Jan

Mar

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Jan

Mar

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Jan

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Sep

dispensary 3

dispensary 2

dispensary 1

health centre 3

health centre 2

health centre 1

hospital 3

hospital 2

hospital 1

mRDT

2007 2008 2006

Quinine vials

D’Acremont et al. Malaria J 2011

Drug consumption 2

10

0%

20%

40%

60%

80%

100%

120%

Before RDT use After RDT use

Hospital 1

Hospital 2

Hospital 3

Health centre 1

Health centre 2

Health center 3

Dispensary 1

Dispensary 2

Dispensary 3

Control 1

Control 2

Control 3

Median intervention

Median control

Intervention HF

74% reduction

Control HF

37% reduction

0%

20%

40%

60%

80%

100%

120%

Before RDT use After RDT use

Hospital 1

Hospital 2

Hospital 3

Health centre 1

Health centre 2

Health center 3

Dispensary 1

Dispensary 2

Dispensary 3

Control 1

Control 2

Control 3

Median intervention

Median control

Variability between health facilities

ALu

D’Acremont et al. Malaria J 2011

11

Antibiotic prescriptions in Dar es Salaam

Antibiotics

Antimalarials

Proportion of

febrile patients

receiving:

Before RDT

implementation

After RDT

implementation

49% 73%

81% 24%

D’Acremont et al. Malaria J 2011

+49%

-74%

12

Translation of research

findings into policy

Close collaboration with

National Malaria Control Program

Tanzanian

Guidelines

for RDT use

Award of Round 7

Global Fund grant

to implement RDT

at national scale

13

Improvements

1. ALu consumption considerably reduced - by 74%

2. Febrile patients treated with antimalarials dropped from 81 to 24%

3. Only 7% of negative patients received an antimalarial

To be improved:

– Poor accountability for ALu and RDTs in some health

facilites

– 58% of patients WITHOUT fever are tested with RDT

– Febrile patients treated with antibiotics increased from

49 to 73%

14

Ministry of Health and Social Welfare

Deo Mtasiwa (Chief Medical Officer)

Dar es Salaam City Medical Office of Health

Judith Kahama (City Medical Officer)

Ndeniria Swai (Research Assistant)

Swiss Tropical and Public Health Institute

Valerie D’Acremont (Clinical Epidemiologist)

Christian Lengeler (Epidemiologist)

Blaise Genton (Tropical Diseases Specialist)

Amana hospital

Willy Sangu (Medical Director)

Financial support from the Swiss National Science Foundation

RDTs provided in part by the US President’s Malaria initiative (PMI)

IMALDIA Team & Acknowledgements

16

0

20000

40000

60000

80000

100000

Jan

Feb

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New consultations Blood slides performed RDT performed Patients with a diagnosis of malaria Positive tests

0

20000

40000

60000

80000

Jan

Feb

Mar

Apr

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Aug

Sep

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Jan

Feb

Mar

Apr

May

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Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

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New consultations Blood slides performed

RDT performed Patients with a diagnosis of malaria

Positive tests

2006 2007 2008

0

20000

40000

60000

80000

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

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Dec

Jan

Feb

Mar

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Jun

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Sep

New consultations Blood slides performed

RDT performed Patients with a diagnosis of malaria

Positive testsRDTm

17

All IRA

50%

4%

12%

1%

5%

3%

15%

1%

3%

10%

31%

All GE

9%

Acute resp. infect. (ARI)

Upper resp. tract inf.

Bronchiolitis

Non-doc. pneumonia.

Doc. pneumonia

Gastroenteritis (GE)

Amoeba

Rota/Adenovirus

Salmonella/Shigella

Unknown pathogen

Urine infection

Skin infection

Others*

Bacteriemia

Typhoid Malaria

Unknown

Etiologies of fever in 1005 children

5%

1%

Rickettsiosis

5% 3%

1%

D’Acremont et al. in preparation * meningitis, acute HHV6, acute EBV/CMV, toxoplasmosis, Q fever