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Malaria in pregnancyIn search of tools for improved preventionRuizendaal, E.

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Chapter 2.Success or failure of critical steps in community case management of malaria with rapid diagnostic tests: a systematic review

Esmée Ruizendaal, Susan Dierickx, Koen Grietens Peeters, Henk D F H Schallig, Franco Pagnoni, Petra F Mens

Malaria Journal 2014, 13:229


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AbstractBackground

Malaria still causes high morbidity and mortality around the world, mainly in sub-Saharan Africa (SSA). Community case management of malaria (CCMm) by community health workers (CHWs) is one of the strategies to combat the disease by increasing access to malaria treatment. Currently the World Health Organiza-tion (WHO) recommends to treat only confirmed malaria cases, rather than to give presumptive treatment.

Objectives

This systematic review aims to provide a comprehensive overview of the success or failure of critical steps in CCMm with rapid diagnostic tests (RDTs).

Methods

The databases of Medline, Embase, the Cochrane Library, the library of the ‘Ma-laria in Pregnancy’ consortium, and Web of Science were used to find studies on CCMm with RDTs in SSA. Studies were selected according to inclusion and exclu-sion criteria, subsequently risk of bias was assessed and data extracted.

Results

27 articles were included. CHWs were able to correctly perform RDTs, although specificity levels were variable. CHWs showed high adherence to test results, but in some studies a substantial group of RDT negatives received treatment. High risk of bias was found for morbidity and mortality studies, therefore, effects on morbidity and mortality could not be estimated. Uptake and acceptance by the community was high, however negative-tested patients did not always follow up referral advice. Drug or RDT stock-outs and limited information on CHW moti-vation are bottlenecks for sustainable implementation. RDT-based CCMm was found to be cost effective for the correct treatment of malaria in areas with low to medium malaria prevalence, but study designs were not optimal.

Discussion

Trained CHWs can deliver high quality care for malaria using RDTs. However, lower RDT specificity could lead to missed diagnoses of non-malarial causes of fever. Other threats for CCMm are non-adherence to negative test results and low referral completion. Integrated CCM may solve some of these issues. Unfortunately, mor-bidity and mortality are not adequately investigated. More information is needed about influencing sociocultural aspects, CHW motivation and stock supply.

Conclusion

CCMm is generally well executed by CHWs, but there are several barriers for its success. Integrated CCM may overcome some of these barriers.


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BackgroundMalaria affects over 300 million people every year, with around 90% of infections occurring in sub-Saharan Africa (SSA).1,2 Community case management of malar-ia (CCMm), formerly known as home based management of malaria, is a strategy recommended by the World Health Organization (WHO) which aims at reducing the malaria burden by improving early access to malaria directed healthcare.3 It is based on treatment of malaria cases, mainly children, by community health workers (CHWs), within the community. Different cadres exist for CHWs, but all these individuals have in common that they are part of the community, they are not professional healthcare workers but receive a short training and often work on a voluntary basis or for small compensation (although in some countries they are included in the salaried healthcare system). While fever cases were previously treated presumptively with anti-malarials, CCMm programmes are now expected to follow the WHO recommendation to treat only malaria patients with confirmed diagnosis, usually with rapid diagnostic tests (RDTs).4 It is expected that this will reduce unnecessary malaria treatment and increase correct diagnosis in patients suffering from other febrile illnesses. Three published reviews describe RDT use in CCMm, however, the issues discussed in these reviews are limited5,6 and not all of the important literature was included,6 or CHWs were not distinguished from professional healthcare providers.7 Systematically obtained information on the success or failure of critical steps in RDT-based CCMm is lacking, but is needed in order to show its value in malaria control programmes. Furthermore, the WHO currently advises to proceed to integrated community case management (iCCM),8 which focuses on the diagnosis and treatment of multiple diseases such as malar-ia, pneumonia and diarrhoea, and lessons from CCMm should be used during this transition. This systematic review aims to provide a comprehensive overview of the success or failure of critical steps in CCMm with rapid diagnostic tests (RDTs).

MethodsSearch methodology

A systematic search was performed in the databases of Medline, Embase, the Cochrane Library and the library of the ‘Malaria in Pregnancy’ consortium (MIP consortium). Web of Science was used to search for missed relevant studies in references and citing articles. The databases were last searched on October 12, 2013. Synonyms for ‘malaria’, ‘RDT’ and ‘CHW’ were combined to find all relevant studies. For the complete search syntax see Additional file 1.


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Selection of studies

After removal of duplicates, title and abstract of articles were screened for in- and exclusion criteria by two independent readers (ER and PFM). A second screening was performed on full text articles. Discrepant results were resolved by discus-sion until a unanimous decision was reached. Criteria for inclusion were: original studies on RDT-based CCMm performed by CHWs defined as non-professional healthcare workers working within a community, studies on Plasmodium falci-parum malaria, studies on one of the following critical steps: test performance by CHWs, execution of test, test interpretation, adherence to test results by CHWs, ef-fect on morbidity and mortality, adherence to test results by patients, referral com-pletion, social acceptance, community uptake, stock-outs, CHW incentives and motivation and cost-effectiveness. Exclusion criteria were: studies on integrated CMM in which the individual effect of RDT-based CCMm on the outcome cannot be identified and studies outside SSA. The focus on SSA was chosen because of the specific malaria epidemiology with a high burden of P. falciparum malaria and high morbidity and mortality rates.9 Authors of relevant conference abstracts were contacted for more detailed results and information on methodology; in case of no additional information, no response, or if full study details did not meet in- or exclusion criteria, these abstracts were excluded.

Data extraction

Data were extracted from included studies by two independent readers (ER and PFM) and additionally for social-behavioural themes by SD and KGP. Critical ap-praisal was done in Review Manager for intervention and diagnostic studies.10 Evers checklist was used for studies on cost-effectiveness according to Cochrane advice.11 For all other studies, criteria are not well defined in literature, so criteria were defined per outcome. No studies were discarded based on qualitative as-sessment. If possible, separate data for CCMm from studies on integrated CCM (iCCM) were extracted.

Analysis

A forest plot was created of the RDT test characteristics by the use of Review Man-ager. No meta-analysis was performed due to heterogeneity of study character-istics and specificity outcomes. The same heterogeneity accounts for adherence to test results. For the analysis of social-behavioural themes, NVivo Software for qualitative data analysis (QSR International Pty Ltd Cardigan, UK) was used.


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ResultsSearch results

In total, 295 articles were found, of which 293 were by database searching and two via other sources. The latter articles were found after e-mail contact with authors of two abstracts.12,13 Both referred to an article that could not be found in any of the databases.14,15 After removal of duplications and after the screening steps on inclusion and exclusion criteria 27 articles remained for data extraction (Figure 1). Exact reasons for exclusion of full text articles can be found in Additional file 2. One article16 provided the same outcome information as another17 (based on the same study) and is, therefore, not separately discussed.

In Additional file 3, an overview of the included studies is presented and for each of the critical steps the number of articles and relevant articles are indicated. Most of the articles were published between 2008 and 2013.

Figure 1. Flow chart of search strategy


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Risk of bias summary

Risk of bias was assessed for each study for every outcome (Figures 2 - 9). Nearly all studies on RDT performance showed low risks of bias. The same accounted for RDT execution, although Counihan et al.18 sometimes used non-febrile volun-teers instead of patients for RDT observations and Harvey et al.19 showed baseline differences in the groups of CHWs. Adherence to test results showed little bias, although it was often unclear how studies collected data. One study on adherence showed a possible patient selection bias because a large group of malaria-sus-pected patients was not tested at all.20 More variable quality was found in studies on interpretation, healthcare-seeking behaviour, stock-outs and cost-effective-ness. In all three cost-effectiveness studies, debatable assumptions were made: sensitivity and specificity used for calculations were derived from studies on pro-fessional healthcare workers instead of CHWs.21–23 Furthermore, in two cost-ef-fectiveness analyses adherence to test results was assumed to be 100%.21,22 High

Figure 2. Risk of bias summary for test performance

Risk of biasApplicability

concerns

Test performance Patie

nt s

elec

tion

Inde

x te

st

Ref

eren

ce s

tand

ard

Flow

and

tim

ing

Patie

nt s

elec

tion

Inde

x te

st

Ref

eren

ce s

tand

ard

Chinkhumba 2010 + + + + + + +

Ishengoma 2011 + + + + + + +

Lemma 2011 + + + + + + +

Mubi 2011 + + − + + + +

Premji 1994 + + + + ? + +

Ratsimbasoa 2012 + + ? ? + + +

Tiono 2013 + + + + + + +

+ low risk of bias, ? unclear, - high risk of bias


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risk of bias was seen for all studies concerning morbidity and mortality; none met the preferred intervention design of a double-blind, randomized, controlled trial (RCT). At the same time, blinding patients and CHWs is impossible for this type of intervention. It is therefore unfortunate that the one study that described a non-blinded cluster RCT used a subjective outcome measure (patients’ reporting of clinical recovery), potentially introducing bias.24 The other studies were either not randomized,25 or were single-armed, pre- and post-intervention studies.26,27 It should be noted that studies that showed high risk of bias for a certain outcome did not necessarily show high risk of bias for their main objective.

Figure 3. Risk of bias summary for direct interpretation of RDT

Interpretation RDT Sele

ctio

n pa

tient

s / t

ests

Sele

ctio

n CH

Ws

Inde

x te

st

Ref

eren

ce s

tand

ard

Tim

e bi

as

Mis

sing

dat

a

n observations

Counihan 2012 ? + + ? + + 63, 61 and 59 CHWs reading 1 RDT

Mukanga 2011 + + + ? + + 182 RDTs

Harvey 2008 ? − + ? + + 32, 21 and 26 RDTs (1 per CHW)

Hawkes 2009 ? + + ? + + 10 CHWs, number of RDT observations unclear

Mubi 2011 + + + − − + 722 RDT positives


Figure 4. Risk of bias summary for interpretation of photographs

Interpretation photographs Se

lect

ion

patie

nts

Sele

ctio

n CH

Ws

Inde

x te

st

Ref

eren

ce s

tand

ard

Tim

e bi

as

Mis

sing

dat

a

n observations

Counihan 2012 − + + + + + 630, 610 and 590 test results

Harvey 2008 − − + + + + 320, 210 and 260 test results



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Figure 5 Risk of bias summary for RDT execution

Execution Out

com

e as

sess

men

t

Sele

ctio

n pa

tient

s

Sele

ctio

n CH

Ws

Mis

sing

dat

a

Oth

er b

ias

n observations

Counihan 2012 + − + + + 63, 61 and 59 CHWs conducting 1 RDT

Mukanga 2011 + + + + + 182 RDTs

Harvey 2008 + ? − + + 32, 21 and 26 RDTs (1 per CHW)

Hawkes 2009 + ? + + + 10 CHWs, number of RDT observations unclear

Ndiaye 2013 + + ? + + 30 CHWs, number of RDTs unclear


Figure 6 Risk of summary for adherence

Adherence Out

com

e as

sess

men

t

Sele

ctio

n pa

tient

s

Sele

ctio

n CH

Ws

Mis

sing

dat

a

Oth

er b

ias

n observations

Chanda 2011 (2x) ? + ? + + 9847

Chinkhumba 2010 ? + + + ? 1317

Elmardi 2009 ? ? − ? + 30 CHWs

Hamer 2013 + + + + + 975

Ishengoma 2011 ? + ? + + 18213

Mubi 2011 ? + + + + 1457

Mukanga 2011 + + + ? + 182

Mukanga 2012 + + + + + 525 (BF), 591 (Gh), 975 (Ug)

Ndiaye 2013 + ? + + + 14554



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Figure 7 Risk of bias summary for intervention studies on morbidity and mortality

Morbidity/ mortality R

ando

m s

eque

nce

gene

ratio

n

Allo

catio

n co

ncea

lmen

t

Blin

ding

of p

artic

ipan

ts a

nd p

erso

nnel

Blin

ding

of o

utco

me

asse

ssm

ent

Inco

mpl

ete

outc

ome

data

Sele

ctiv

e re

port

ing

Oth

er b

ias

Elmardi 2009 − − − − ? + −

Mubi 2011 + + − − + + ?

Rutta 2012 − − − − ? + +

Thiam 2012 − − − ? ? ? ?


Figure 8 Risk of bias summary for cost-effectiveness studies

Cost-effectiveness Out

line

of s

tudy

set

up

Des

ign

Incl

uded

cos

ts

Incl

uded

out

com

es

ICER

Dis

coun

ting

Sens

itivi

ty a

naly

sis

Chanda 2011 + + + − + + −

Hawkes 2009 + + − − + ? −

Lemma 2011 + ? + − + ? +



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Figure 9 Risk of bias summary for healthcare-seeking behaviour

Health-care seeking behaviour O

utco

me

asse

ssm

ent

Sele

ctio

n pa

tient

s

Sele

ctio

n CH

Ws

Mis

sing

dat

a

Oth

er b

ias

n observations

Elmardi 2009 − + − ? + 48 households pre-, 17 post-study.

Lemma 2010 + + + ? + 16 RDT CHWs (5123 visits), 17 no RDT CHWs (10457 visits)

Tayler-Smith 2011 ? + ? ? + number of CHWs unclear, 13268 (2004) - 90294 (2005) patients


RDT performance when used by CHWs

Sensitivity and specificity of RDTs when performed by CHWs was assessed in seven studies (Figure 10 and Table 1). Studies differed in participants, malaria transmission and RDT type used. Sensitivities ranged between 83.2 and 97.9% if RDTs were compared with microscopy as reference standard. Ishengoma et al. found that the sensitivity was significantly higher for cases <five years of age and for fever cases.28 Sensitivity decreased with decreasing malaria transmission over the years in this study,28 but this was not confirmed in Tiono et al.14 Ratsimbasoa et al. additionally calculated RDT sensitivity with PCR as reference standard (RS) and found a sensitivity of 61.8%.29

The specificity of RDTs in the hands of CHWs was found to be more variable than the sensitivity, ranging from 39% in the study of Chinkhumba et al.30 to 95.1% in the study of Lemma et al.22. In Chinkhumba et al. patients who self-treated with anti-malarials (2-8% in previous two weeks) were not excluded and this was as-sociated with a lower specificity.30 Mubi et al. also showed low specificity, but it was mentioned that the microscopy slides were of poor quality, possibly impair-ing the detection of parasites in actual true positive samples.24 Slide quality was not mentioned in Tiono et al., who found a low specificity, especially in the high transmission season (25.4%).14 The conditions for RDT storage were appropriate and the authors mainly related the results to persistent circulating antigens.14 In Ishengoma et al. a higher specificity for children <five years of age was shown compared with older patients.28


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Figure 10 Forest plot of RDT performance when performed by CHWs (no subgroup analyses)

Lemma 2011a = Paracheck Pf, Lemma 2011b = Parascreen pan/pf

Table 1 RDT test performance by CHWs

StudyTarget population RDT type

Reference standard (RS)

RS positive* (%)

Sensitivity (%)

Specificity (%)

Ratsimba-soa 201229

>2 months (history of) fever

CareStart PCR 56.7% 61.8% 95%

Ratsimba-soa 201229

>2 months (history of) fever

CareStart Microscopy of thin and thick BS

37.2% 95.9% 87%

Chinkhum-ba 201030

>5 years (history of) fever

Bioline SD, First Response malaria, Paracheck PF

Microscopy of thick BS (expert)

38.5% 95% 43%

Chinkhum-ba 201030**


Bioline SD Microscopy of thick BS (expert).

41% 97% 39%

Chinkhum-ba 201030**


First response malaria

Microscopy of thick BS (expert).

40% 92% 42%

Ishengoma

201128

All ages, care seeking

Paracheck Pf, ParaHIT

Microscopy of thick and thin BS.

20.8% 88.6% 88.2%

Ishengoma

201128

< 5 years Paracheck Pf, ParaHIT

Microscopy of thick and thin BS

19.7% 90.1% 93.6%

Ishengoma

201128

≥5 years Paracheck Pf, ParaHIT


21% 88.3% 86.5%

Ishengoma

201128

No fever patients



14.5% 84.7% 90.1%

Ishengoma

201128

Fever patients



33.9% 92.2% 82.9%

Lemma

201122**

>3 months suspected of malaria

Paracheck Pf

Microscopy of thick BS.

18.7% 88.7% 94.2%


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StudyTarget population RDT type

Reference standard (RS)

RS positive* (%)

Sensitivity (%)

Specificity (%)

Lemma

201122**

>3 months suspected of malaria

Parascreen Microscopy of thick BS.

18.7% 83.2% 95.1%

Mubi

201124

>3 months (history of) fever.

Paracheck Pf

Microscopy of thick BS.

22.6% 85.3% 59.8%

Premji

199431

Children <42 months

Parasight

TM-F test

Microscopy of thin and thick BS.

66.6% 84% 81%

Tiono

201314

Children 6-59 months with (history of) fever.

FirstSign Malaria Pf


54.8% 97.9% 53.4%

Tiono

201314

Children 6-59 months with (history of) fever. (High transmis-sion)



76.1% 98% 25.4%

Tiono

201314

Children 6-59 months with (history of) fever. (Low transmis-sion)



31.8% 97.6% 63.7%

*P. falciparum, ** Two types of RDTs separately tested

RDT interpretation

RDT interpretation was assessed by either direct assessment of RDTs (five stud-ies) or by photographic assessment (two studies) (see Table 2). Correct interpre-tation was high for the direct assessment of RDTs; 96 to 100% of tests and 95.1 to 100% of CHWs, provided that CHWs were trained properly.18,19,21,32 In photographic assessments, which have the inherent risk of selection bias as the number of am-biguous tests is relatively high, well-trained CHWs also scored high numbers of correctly interpreted tests, although more mistakes were made in reading faint positive and invalid tests.18,19 The importance of training was shown for direct inter-pretation of RDTs as well as for photographic assessment in Harvey et al.19 In both

Table 1 RDT test performance by CHWs (continued)


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assessments correct interpretation was lowest for CHWs who used only manu-facturer’s instructions, better for CHWs who used a job aid and the best for CHWs who used a job aid and received three hours’ training. Unfortunately, a risk of se-lection bias was present because CHWs were not randomly selected and com-pletion of secondary education was 6, 19 and 35%, respectively. Some indications were also found for the beneficial effect of repetitive execution of RDTs. In Harvey et al. improvement was seen with each successive RDT, although these data were not presented.19 Improvement over time was also presented by Counihan et al.; the percentage of CHWs correctly interpreting RDT results from patients or volunteers at three, six and 12 months after training was 95.1, 98.3 and 98.3%, respectively.18 In contrast, this was not the case with the ten-item photographic assessment in which four CHWs consistently showed poor interpretation.

Execution of RDTs

Execution of RDTs was investigated in five studies that used non-uniform out-come variables (see Table 2). The way CHWs executed RDTs was judged on sever-al items, but differences in number and definition of items further impaired com-parison.18,19,21,32 Nevertheless CHWs were found to correctly conduct RDTs if prop-erly trained; 90 to 100% of steps were successfully executed in two studies that used the same WHO checklist, Hawkes et al.21 and Harvey et al.19 In contrast, un-trained CHWs that used only manufacturer’s instructions or a job aid were found to respectively conduct only 57 and 80% of steps correctly in Harvey et al.19 The assessment of each individual executed step in this study showed that problems were found in dispensing buffer drops, waiting correct amount of time, pricking side of finger, blood collection and recording result in register. Counihan et al., who assessed only the execution of eight RDT steps (see Additional file 4) that were considered critical for diagnosis or safety, showed improvement over time: 40.3, 61.7 and 79.7% of CHWs correctly performed critical steps at three, six and 12 months, respectively.18 Problematic steps were writing patient’s name on cassette, recording results in register, usage of the blood collection loop, reading the test result in the right time and disposing non-sharps in non-sharps container.18–20 Why these steps were problematic was not studied. No specific studies were done that looked at safety issues while performing RDTs but some included particular find-ings. Ndiaye et al. observed that 0% of CHWs used gloves, but this was partly due to stock problems.20 In contrast, high levels of glove use were reported in Couni-han et al.18 (100% of CHWs after 12 months) and Harvey et al.19 (96% in the group of trained CHWs). In Counihan et al. an observer had to intervene once because a CHW was about to re-use a lancet on a new patient.18


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Table 2 Interpretation and execution of RDTs by CHWs

Study CHW training Outcome interpretation Outcome execution

Counihan 201218

Half-day training. At 3 months CHWs received a poster-sized job aid and a photographic guide on RDT interpretation.

(I).RDT test results correctly read by 95.1, 98.3 and 98.3% of the CHWs at 3, 6 and 12 months after training respectively.

(II) Correct interpretation of positive RDT results was 96.5% at 3 months, 98.3% at 6 months and 90.5% at 12 months.

(II) Correct interpretation of negative RDT results was 94.3% at 3 months, 97.9% at 6 months and 94.7% at 12 months.

(II) Faint positive lines were correctly interpreted by 89.7% at 3 months, 96.7% at 6 months and declined to 76.7% at 12 months.

19-item checklist, interpretation included, 8 items were considered critical.

Median correctly performed critical steps were 87.5%, 100% and 100% at 3, 6 and 12 months respectively.

40.3, 61.7 and 79.7% of CHWs correctly performed critical RDT steps at 3, 6 and 12 months respectively.

Mukanga 201132

8-day training by experienced trainers. Job aid provided.

100% of the RDTs were correctly interpreted shortly after training (<2 weeks).

96.3% of RDTs were correctly performed shortly after training (<2 weeks) in a 14-item checklist, interpretation excluded.

Harvey 200819

Group 1: only use of manufacturers’ instructions. Group 2: only use of job aid. Group 3: 3-hour training on RDTs + job aid.

(I) 72, 86 and 96% of CHWs correctly interpreted RDT results for group 1, 2 and 3 respectively.

(II) 54, 82 and 93% of tests were correctly inter-preted for group 1, 2 and 3 respectively.

57% of steps, 80% of steps and 90% of steps were correctly performed by group 1, 2 and 3 respectively at the same day of receiving instructions, job aid or training in a 16-item checklist, interpretation included.

Hawkes 200921

One day training. Pictorial job aid was provided.

100% of CHWs correctly interpreted the RDT directly after training.

Median score on a WHO 16-item assessment of RDT performance was 100% (range of 94-100%) directly after training.


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Study CHW training Outcome interpretation Outcome execution

Ndiaye 201320

CHWs: one month theoretical training, one month practical training at health post. CMDs: 3-day theoretical training, 15 days practical training at health post.

- % CHWs and CMDs correctly performing the step, observed over two years.

(1) Surface clean and flat - 87%

(2) Test opened just before use - 100%

(3) Document patient name and date - 83%

(4) Use of gloves - 0%

(5) 5 μL finger prick blood specimen - 93%

(6) 4 drops of solution buffer in right well - 93%

(7) test rest on level surface - 97%

(8) waited maximum 15 minutes - 93%

Mubi 201124 One week training. 99.7% of positive tests were correctly interpreted throughout the 5-month study period.

-

(I) Based on assessment of RDTs. (II) Based on photographic assessment.

Adherence to test results and referral guidelines by CHWs

In general almost all patients (>90.0%) with positive RDTs were provided with an-ti-malarial drugs by CHWs (Table 3). The percentage of patients with negative RDTs who, contradictory to the guidelines, still received anti-malarial treatment was more variable, ranging from 0.2 to 58%. Six studies showed levels <10%, in-cluding all iCCM studies, while two studies showed outliers of 20.3%20 and 58%30 of negative-tested patients that were treated. One other study presented the per-centage of CHWs adhering to test results and showed that 30% of them treated negative-tested patients based on clinical judgment rather than RDT result; this was not related to previous experience in malaria management or educational background.27 Ndiaye et al. showed that the adherence was related to the type of care providers in their study.20 Community medicine distributors (CMDs) were only trained on RDT-based malaria management, while CHWs were attributed more health intervention tasks. CHWs gave artemisinin-combination therapy (ACT) to 24.8% of RDT negatives, while CMDs gave ACT to 10.4% of RDT negatives. Besides treating a high number of negative patients, CHWs also treated 22.3% of patients

Table 2 Interpretation and execution of RDTs by CHWs (continued)


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with ACT who were not tested at all, while for CMDs this was only 0.8%. Further-more, CHWs and CMDs did not comply with the referral policy; referral rates from patient groups that should have been referred ranged from 18.2 to 47.1% with the lowest referral rates found for babies <two months of age and patients with severe symptoms. The only other study reporting on referral by CHWs showed better re-sults, in the first year, 79.5% of RDT negatives were referred according to protocol and in the second year this had increased to 97.4%.25 No explanations were given in the studies on reasons for non-adherence regarding treatment of negatives and referral.

Table 3 Adherence to test results by CHWs

StudyTarget population Treatment Alternative

Adherence overall*

Positives treated

Negatives treated

CCMm studies

Chanda

201123,33

All ages, care seeking.

AL, SP <5 kg

Complicated malaria and non-malaria febrile cases were referred to HF.

99.9% 99.3% 0.2%

Chinkhumba 201030

>5 years, (history of) fever

NS Referral not mentioned.

86.9% 98% 58%

Elmardi

200927

NS AS/SP Complicated malaria and non-malaria febrile cases were referred to HF.

70%** NS NS

Ishengoma 201128

≥5 years with (histo-ry of) fever

AL Referral not specified.

95.8% 98.9% 5.4%

Mubi

201124

>3 months, (history of) fever. Exclu-sion: severe disease

AL Referral not specified.

96.8% 99.7% 6.1%

Ndiaye 201320***

Patients of all ages, care seeking.

NS CHW: referral of patients <2 months, RDT negatives, severe symptoms, suspected drug ad-verse events. CMD: referral of all cases excluding uncompli-cated malaria cases.

88.6% 92.0% 20.3%

Ndiaye 201320***


NS CHW: Referral of patients <2 months, RDT negatives, severe symptoms, suspected drug adverse events.

85.6% 90.1% 24.8%


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StudyTarget population Treatment Alternative

Adherence overall*

Positives treated

Negatives treated

Ndiaye 201320***


NS CMD: Referral of all cases excluding uncomplicated malaria cases.

93.9% 95.3% 10.4%

iCCM studies

Hamer 201217 & Yeboah-Antwi 201016

Children 6 months-5 years, fever.

AL Children with danger signs were referred to HF.

99.3% 98.5% 0.4%

Mukanga

201132

Children <5 (history of) fever no danger signs.

AL CHWs also diagnosed and treated pneumonia. No referral mentioned.

97.8% 98.6% 4.8%

Mukanga 201234****

BF: 6-59 months, (history of) fever

AL Referral for severe disease and for non-responders at day 3 after CHW visit.

99.0% 100% 4.8%

Mukanga 201234****

Gh: 6-59 months, (history of) fever

AA Referral for severe disease and for non-responders at day 3 after CHW visit.

99.5% 100% 3.3%

Mukanga 201234****

Ug: 4-59 months (history of) fever.

AL Referral for severe disease and for non-responders at day 3 after CHW visit.

99.0% 99.9% 7.6%

*=correct treatment, **=percentage of CHWs that relied on RDT results, ***=adherence percentages calculated from study data, ****=CHWs attended review meetings with study team each month discussing non-adherence to diagnostic and treatment algorithm with CHWs, HF=health facility, NS= not specified, AL= artemether – lumefantrine, SP= sulphadoxine-pyrimethamine, AS= artesunate, ACT= artemisinin-based combination therapy (not further specified), BF= Burkina Faso, Gh = Ghana, Ug = Uganda.

Morbidity and mortality

Four trials assessed outcomes related to morbidity, mortality or both (Table 4), but all showed low quality evidence (Figure 7) impairing firm conclusions. One study reported lower slide positivity rates during the RDT-based CCMm interven-tion period in comparison with presumptive CCMm in the pre-intervention period. However, besides changing to RDT-based diagnosis, the type of anti-malarial drug used changed from sulphadoxine-pyrimethamine to an ACT in this study.26 Two other studies showed beneficial effects of RDT-based CCMm but only compared it to areas with no CCMm.25,27 In contrast, the perception of patients on morbidi-ty did not improve with RDT-based CMMm. In a randomized, cross-over trial on RDT-based CCMm versus presumptive CCMm, a significant increased perception

Table 3 Adherence to test results by CHWs (continued)


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of disease recovery was found in the presumptively treated patients at day 7 com-pared with the intervention arm (97.3 versus 93.3%, p = 0.000). More patients were treated with anti-malarials in the control group; however, in both the intervention and control group the perceived unrecovered patients harboured only few malaria positives (repeated testing at day 7), thus suggesting a possible bias in the subjec-tive study outcome.24

Table 4 Morbidity and mortality outcomes of RDT based CCMm strategies

Study Design Intervention Control Outcome

Mubi 201124

RCT RDT-based CCMm

Presumptive CCMm Increased perception of recovery in control group (97.3%) versus interven-tion group (93.3%) at day 7. P = 0.000

Two malaria related deaths, one in each arm.

Thiam 201225

NRCT RDT-based CCMm

No CCMm Malaria related hospitalizations decreased by 43.1% in intervention areas and 40.9% in control areas. Malaria attributed deaths decreased by 62.5% in intervention areas (significant decrease) and 23.4% in control areas (no significant decrease).

Rutta 201226

Pre-post study

RDT-based CCMm (with AL)

Comparison with pre-intervention period (presumptive CCMm with SP)

A drop of >72.0% in malaria slide positivity rate to a persistent low level of <10% was observed in the study period.

Elmardi 200927

Pre-post study

RDT-based CCMm (with AS/SP).

Comparison with pre-intervention period (no CCMm, health centres treated with AS/SP)

24% fever cases in last two weeks pre-intervention and 8.5% fever cases post intervention (p=0.000).

61 deaths (all <5 years) in the last sea-son pre-implementation of intervention versus 1 death (>5 years) in the season post-implementation (p=0.000).

Community acceptance

Studies by Mukanga et al.35 in Uganda and Nsagha et al.36 in Cameroon assessed the opinion of community members before introducing an RDT-based CCMm in-tervention. In Mukanga et al. presumptive CCMm was already implemented and a positive attitude towards the CHWs was present, due to their voluntary services, accessibility and the effectiveness of provided drugs.35 The change to CHWs us-ing RDTs was therefore well received. In Nsagha et al. all participants would wel-come RDTs, but in this urban setting, where other healthcare providers are avail-able, CHWs were not always considered to be the appropriate persons to carry out RDTs.36 Participants in both studies stressed that proper training of CHWs on RDT use was considered essential.


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A few years later Mukanga et al. asked community members in Uganda for their opinion after introduction of RDT-based CCMm; 79.4% thought CHWs’ service was better after introduction of RDTs and 88.7% thought CHWs should continue to use RDTs.37 Support for a high acceptance was also found in Senegal, where commu-nity members mainly praised the increased access to malaria care.38 Furthermore, in several studies participants welcomed RDTs since it made correct diagnosis possible at the village level, which saved money on transport.36,38

Acceptability of diagnosis and treatment by CHWs was related to the outcome of the RDT. Only 5% of CHWs had problems persuading RDT-positive patients of a malaria diagnosis in Sudan.27 This is supported by Mubi et al., in which 97.4% of patients complied to prescribed treatment after a positive RDT.24 However, per-suading patients that they did not have malaria was problematic for 20% of CHWs in case of negative test results,27 an issue that was already predicted by Mukanga et al.35

Adherence to referral advice by patients was reported in only two studies.33,39 Chanda et al. used a system in which CHWs were notified by health centre staff if a referred patient visited the health centre.33 For 40 to 42% of the referrals feedback was received. In contrast, Thomson et al. found a very low referral completion of 1.5%.39 They surveyed children three to 59 months and pregnant women in their second and third trimester in Sierra Leone. A large variation in referral completion was found within the different communities (0 to 18.8%). Furthermore, if stratified for RDT results, referral completion was 88.2% for RDT positives (usually referred for signs of severe malaria) in contrast to 0.9% for RDT negatives. Barriers for adherence mentioned in focus group discussions were bad roads,38 difficulties in transport,38 distance to health centres33,38 and lack of staff at the health centre which may result in long waiting hours.33

Uptake of RDT based CCMm by members of the community

Three studies reported on the uptake by the community of RDT-based CCMm in comparison to baseline levels (pre-intervention period), presumptive CCMm or health centre-based care (Table 5). Two studies showed an increased use of RDT-based CCMm services over the study period.15,27 Additionally, one of the studies compared it to health centre-based care and showed a constant number of visits in these clinics. It was concluded that the overall access to malaria healthcare had thus increased by the intervention.15 These positive findings are not always sup-ported, as in a study of Lemma et al., the number of people visiting the random-ly selected CHWs who performed RDT-based CCMm was half of those visiting CHWs who used presumptive diagnosis.40 The reasons for this reduction were not further investigated. Obstacles for visiting the CHW mentioned by the commu-nity in three other studies were the unavailability of the CHW,16,37 dislike of CHW


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services,37 distrust of the skills of the CHWs,37 lack of drugs,37 fear of HIV/AIDs infection,35 a disease that is perceived to be too severe for CHW to handle,16 and the relative distance to the health centre versus to the CHW.16,37

Table 5 Healthcare-seeking behavior

Study Intervention Control Outcome

Elmardi 200927

RDT-based CCMm

Comparison with pre-intervention period (no CCMm)

Pre-intervention 25% of mothers of sick children <5years would seek care within the village, after the study 64.7% would seek care within the village (p value).

Lemma 201040

RDT-based CCMm

Presumptive CCMm Only half the number of patients (5,123 pa-tients) visited CHWs who performed RDT-based CCMm compared with presumptive CCMm (10,475 patients).

Tay-ler-Smith 201115

RDT-based CCMm free of charge

Health centre care, little payment was required for ACT.

In two years there was an increase in number of episodes of treated malaria per child per year from 0.4 to 1.2 for CHWs, whereas it remained stable at 0.2 for health centres.

Stock-outs

In the pre-intervention focus group discussions in the study of Mukanga et al., problems in lack of transport for replenishment of supplies were foreseen.35 Four studies mentioned stock-out problems.18,20,33,38 The only other study that men-tioned supply issues did not experience any stock-out problems.27 In all studies the CHW was instructed to replenish stocks at an affiliated health centre. Blanas et al. found in 2009 that 74% of villages did not have RDTs or the RDTs were expired.38 In 68% of villages no ACT was available. However, Ndiaye et al. found in the same study area in 2010 and 2011, that 90.2% of CHWs had RDTs in stock and 88% had sufficient ACT in stock.20 It seems that experience over time helped stock man-agement, although in the latter study only 11.8% of all stock management forms were completed. Stock-out problems were also found in the studies of Chanda et al.33 (stock-outs of RDTs for about two weeks) and Counihan et al.18 (stock-outs of drugs and RDTs). One of the biggest problems for CHWs in the latter study was the refusal of health centres to resupply the CHWs. Health centres were either not informed about the agreement on stock supply or they experienced stock-outs themselves.18


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Motivation and remuneration of CHWs

Ndiaye et al. showed that there was high seasonal variation in CHW participation in Senegal.20 This could be due to the difference in malaria burden but the authors also suspect that the little remuneration and the nearby gold mining activities had their impact on CHW participation. CHWs are mostly considered volunteers, but incentives such as small fees for their consultation,27 compensation in material form or services,16,17,23,29 or structured payments17,24,26,30 were mentioned in most studies. In Elmardi et al. only 35% of CHWs were satisfied with the financial out-come of their services which was 0.5 US$ per consultation.27 However, when these CHWs were asked about the most motivating aspect of their work, it was not the financial compensation but community respect and spiritual outcome. This was supported by Hamer et al. in which only four of 18 CHWs received some kind of payment, but almost all were satisfied or highly satisfied with their CHW job (37 and 61%, respectively).17 There was no information on the impact of incentives and motivation on the attrition of CHWs.

Cost-effectiveness

Two studies on cost-effectiveness compared RDT-based CCMm to presumptive CCMm21,22 and a third compared it with health centre-based malaria care23 (Table 6). All three studies did not have sufficient quality for cost-effectiveness analyses as described in risk of bias summary and all used a short-term outcome for health benefit, that is cost per correctly treated case,22,23 or related cost per case saved from unnecessary treatment.21 Compared to health centre-based care, costs for RDT-based CCMm were lower per correctly treated case, but the additional cost per change in case appropriately diagnosed and treated was 4.18 US$ for RDT-based CCMm in Zambia.23 RDT-based CCMm was also found to cost less compared with presumptive CCMm for areas with low to medium malaria trans-mission,22 but not in high transmission areas as was shown in the Democratic Republic of Congo.21 Furthermore, study region could be of importance as shown by Lemma et al. in Ethiopia.22 The study was situated in an area where Plasmodi-um vivax is also prevalent and consequently the RDT that differentiated between types of malaria species showed the lowest costs per appropriately treated case. However, for total costs, only differentiating between P. falciparum malaria and all other fever cases was the cheapest option.


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Table 6 Cost-effectiveness of RDT based CCMm strategies

Study Intervention Control Malaria prevalence Outcome

Hawkes 200921

RDT-based CCMm for ≥5-14 years, presumptive <5 years old.

Presumptive treatment up to 14 years old.

88% by microscopy, for calculations prevalence of 80% was considered.

8.79 US$ for each case saved from unnecessary treatment (total health budget per person per year is 15$). Total costs three times as high for RDT based CCMm.

Lemma 201122

RDT-based CCMm for P. falciparum with AL, other febrile cases treated with CQ.

Two comparisons.

1. RDT-based CCMm for P. falciparum (AL) and P. vivax (CQ) and referral of all others.

2. Presumptive treatment with AL for all fever patients.

Slide positivity rate 27.29%, of which 70% P. falciparum.

Intervention: 4.66 US$ per correctly treated case.

Control 1. 1.69 US$ per correctly treated case.

Control 2. 11.08 US$ per correctly treated case.

Total costs were lowest for intervention strategy.

Chanda 201123

RDT-based CCMm with AL for all age groups (free of charge)

Health centre-based care (free of charge)

Prevalence 24% in RDT-based CCMm and 26% in health centres, either by RDT or microscopy.

Cost per case appropriately diagnosed and treated 4.22 US$ in RDT based CCMm (mainly because of higher adherence) and 6.61 US$ in health centers. Additional cost per change in case appropriately diagnosed and treated was 4.18 US$.

DiscussionThis review showed that CHWs are able to provide qualitative health care for malaria if properly trained. This is substantiated by other reviews for shared out-comes.5–7 Nevertheless some barriers are present for the success of the interven-tion. The success and failure of each of the steps in CCMm is discussed below.

The high quality of care is reflected in the good sensitivity and specificity of RDTs used by CHWs compared with microscopy. A high sensitivity is needed because, as the new first line of health care, RDT-based CCMm cannot be inferior in detect-ing malaria cases to the existing practices in health centres in which microscopy is often used, especially because it seems that RDT negatives, including false nega-tives, may not always reach a health centre for additional care.33,39 When the RDTs performed by CHWs were compared to PCR the sensitivity lowered but many of these cases were also missed by microscopy.29 Furthermore, the clinical relevance


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of these low parasitaemia cases is being debated, because they are considered to be ubiquitous and usually asymptomatic, although it might cause anaemia.41 Re-cent indications of a decreased malaria transmission in regions in SSA could how-ever lead to lower levels of immunity in the population and might subsequently in-crease disease susceptibility, also for subjects with low parasitaemia levels.42 RDT performance in case of low parasitaemia levels will therefore become increasingly important, especially in elimination settings.

Specificity levels were more variable, which is also seen in RDT use by profession-al health-care workers.43 This is a potential threat to the success of CCMm as it could lead to overtreatment and missed diagnoses of other febrile illnesses. This could be a reason to promote the implementation of iCCM, as other serious caus-es of fever, such as pneumonia, will be detected with this intervention. Factors in-fluencing specificity could be microscopy slide quality24 and persistent circulating HRP2 antigens (the diagnostic target of P. falciparum RDTs) after clearance of the malaria infection.44 The latter might explain a lower specificity when a substantial part of individuals received previous anti-malarial treatment30 and the lower spec-ificity for individuals with a higher immunity against malaria, such as children >five years of age in Ishengoma et al.28 and in Chinkhumba et al.30 Another possibility for a low specificity, though controversial, could be that RDTs are more sensitive than microscopy, meaning that false positives were actually true positives.43 Sup-port for this conclusion may be found in Ratsimbasoa et al. who showed a higher specificity if RDTs were compared with PCR than if RDTs were compared with microscopy.29

The performance of RDTs did not seem to be much influenced by execution and interpretation of RDTs, as these showed generally good results. It should however be considered that all results were collected by (in)direct evaluation of the CHWs and this may have biased the outcome.45 Job aid and training were factors posi-tively associated with interpretation and execution of RDTs, however, this improve-ment could also be related to the selection bias in CHWs. That would imply CHWs perform better with higher educational background. Nevertheless progress may still be obtained by increased practice of RDTs during training,18,19 especially prac-tice of interpretation of faint positives and invalid test results and practice of the steps that were found to be frequently problematic; these were collecting blood in the right way and in the right amount, dispensing buffer drops in the right amount and in the right well, registering patient data and waiting the correct time before reading test results.18–20 It is unknown why these steps were more problematic. Only one study reported an event with high safety risk,18 but safety issues should always be well addressed during training. Furthermore, visual impairments may hamper the correct interpretation of RDTs and therefore screening for visual im-pairments should be done before appointing new CHWs.34


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RDT performance could also have been influenced by 1) storage conditions,46 which stresses the need of a cold chain, or 2) type of RDT, because of variable intrinsic diagnostic qualities and differences in ease of execution and interpreta-tion. Many types of RDTs are available and not enough evidence was found in this review to advise on a specific type of test. Guidance for RDT choice can be found in a published WHO report which shows an extended overview of all different ma-laria RDTs, although it should be noted that these were tested in regulated circum-stances by laboratory technicians, thus not informing on end-user impact.47

Adherence to test results and referral guidelines is important for safe and success-ful implementation of RDT-based CCMm and the reviewed literature highlighted that CHWs showed generally high levels of adherence to test results regarding treatment. This in contrast to professional healthcare workers, in whom adher-ence was found to be much more variable because they often rely on clinical judg-ment instead of RDT results48–52 and the fear of false-negative RDT results may tempt them to treat negative patients, especially in the case of subjects with no or little malaria immunity.53 It could be that these reasons also contributed to the few studies on CHWs who reported non-adherence to negative test results,20,27,30 espe-cially because CHWs were previously instructed to regard any fever case as malar-ia. This is however unknown since CHW reasons for not adhering to negative test results were not investigated, although several studies stressed the importance of training and monitoring in order for the CHWs to adhere to the study guidelines.17,18,23,24,26,28,30,32,33,40 Interestingly, all studies with an iCCM design showed good adherence to negative RDT results. The provided alternatives for malaria treat-ment in iCCM, such as antibiotic treatment for pneumonia after diagnosis with a respiratory rate timer, could have contributed positively to this adherence.

Unfortunately, despite the importance of referring patients with danger signs, ad-herence to referral policy is scarcely addressed, with one study reporting low20 and one reporting high adherence.25 Again, why CHWs did not refer patients was not studied. From the patient perspective, two studies investigated referral completion and showed that many patients did not follow up on referral, although the big dif-ference in magnitude between these studies is remarkable.33,39 Possible barriers for patients to complete referral were found to be mostly due to transportation difficulties; a problem that is even bigger for health centre-based care and one that is not easily solved, although iCCM could reduce the overall need for referral. Other barriers were not thoroughly investigated; however an interesting finding was that RDT result apparently influenced referral completion.39

Studies on morbidity and mortality lacked high quality evidence which impairs firm conclusions. CCMm should be beneficial compared with presumptive CCMm by decreasing overtreatment, and increasing diagnoses of other diseases. Howev-er, false negative RDT results could negate the beneficial effects. The low evidence


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is surprising, but may reflect the more challenging design needed, which should incorporate follow-up of all patients.

The effect on morbidity and mortality in the total population is dependent on acceptability and healthcare-seeking behaviour of the community, which was found to increase within the community after introduction of RDT-based CCMm. It should however be noted that the studies reporting on the uptake of CCMm with RDTs took place during a trial, which could influence the way people behave. This effect is better known as the Hawthorne effect.45 Several aspects were men-tioned as barriers of CCMm uptake in the reviewed studies. Even though CHWs are mostly selected by the community or community leaders and must often meet certain criteria of educational background, barriers related to distrust of the CHW are mentioned.37 How often distrust is a problem and what this is based upon is unknown. Better understanding of distrust might help in correctly sensitizing the community to increase acceptance and uptake of CCMm. Other barriers are lo-gistical factors such as distance and transport to CHW, unavailability of CHW and stock outs. As CCMm already brings malaria care closer to the patient’s home, problems of distance and transport are not specific for community based health-care and are difficult to solve. Unavailability of the CHW might be related to too lit-tle remuneration, limiting CHWs in their time because they must take care of their livelihood. CHW remuneration is shortly discussed below. The issue of stock-outs seems to be a frequent problem for RDTs and anti-malarial drugs18,20,33,38 Next to the failure to provide patients the care they need at these moments, even the ru-mour of stock-out could prevent people from visiting CHWs.37 The problem might be even bigger after trial termination because stock supply is usually more strictly regulated during study periods. Experience with stock management by CHWs may have a positive influence on the availability,20 but stock management by CHWs is not always the main barrier.33 CHWs usually rely on nearby health facilities for their stock supply but, due to financial, logistical, political, and other factors, drug supply through the government health systems is often unreliable and shortages of essential drugs are common in health centres as well, especially in the most remote areas.54

Another issue important for sustainability of RDT-based CCMm is CHWs’ moti-vation and remuneration. It is unfortunate that information is scarce and there is no evaluation of motivation and the remuneration alternatives on the subsequent retention of CHWs in RDT-based CCMm. However, respect by the community and spiritual outcomes seem to be important for motivation. This was also reported in a recent Cochrane review that informed on motivation for lay health workers involved in all types of healthcare interventions.55 Altruism, social recognition, knowledge gain, and career development were mentioned as motivations. Dis-crepancies were found in opinions on payment as incentive; supporters thought


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their time investment and obtained skills should be compensated, opponents thought working in a profit-oriented way can evoke negative reactions within the community.56 Non-monetary incentives, such as bicycles, uniforms, mobile phones, or health insurance were generally well appreciated.56,57

The last important item for long-term implementation, in particular for policy makers, is cost-effectiveness. Cost-effectiveness is highly dependent on malaria transmission, infrastructure and existing health systems. It can be concluded from the reviewed literature that the possible monetary beneficial effects of RDT-based CCMm versus presumptive CCMm are the biggest in areas with low to moderate malaria prevalence, at least for the costs per correctly treated case. With declining malaria prevalence in many SSA countries, RDT-based CCMm will probably be-come increasingly cost-effective.58 However, because of limitations in the study designs these cost-effectiveness analyses are not informative enough for policy makers. Most importantly not all health-related benefits were included, such as the effect on longer term morbidity and mortality. Also, the real-time information on malaria prevalence that can be obtained with RDT testing is of importance for malaria control programmes. Moreover, testing with RDTs enables CHWs to ad-equately treat other febrile diseases than malaria and is the first step in moving from CCMm to iCCM. Because of these additional benefits, cost-utility analyses on differences in disability or quality adjusted life years (DALYs or QALYs) would gain the most information on the actual effects for patients and the possible im-pact for society of RDT-based CCMm.

A number of limitations are present due to the scope of this review. First of all, for several outcomes only a few studies were found, limiting the amount of ev-idence. Moreover, the few studies found were sometimes of insufficient quality for the relevant outcome, such as for morbidity and mortality. In general, very few studies investigated the factors that could explain why some of the critical steps in CCMm are successful or not. Secondly, in contrast to outcomes of diagnostic quality, cost-effectiveness, or impact of intervention on morbidity or mortality, it was challenging to assess the risk of bias for the remaining outcomes, because criteria for quality assessment were not standardized. Thirdly, most outcomes were investigated in trial settings, in which logistics are frequently well arranged and motivation is high, but only until the end of the study period. The lack of im-plementation studies may therefore have caused a bias. Finally, the restriction of the review to CCMm prevented the use of studies on iCCM without distinguishable CCMm data, but this was the only way to establish the benefits and failures of the individual intervention for the fight against malaria. Nevertheless, integrated CCM is an important development that may lead to increased access to target-ed healthcare, without jeopardizing but potentially even improving malaria care. Although the data presented in this review give a wealth of information, several


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aspects warrant further studies. First of all, no firm conclusions can be made on the absolute impact of the test and treat policies on morbidity and mortality. Fur-ther studies appropriately designed to measure this effect are needed and should preferably include follow-up of all patients, including referred and RDT-negative patients to also estimate the change in detection of other febrile diseases. Proven effect on morbidity and mortality will help policy makers in their decision about implementation of the intervention.

Furthermore, this review has shown that social science contributions are scarce. This limits the understanding of the implementation of RDT-based CCMm in dif-ferent local contexts. Multidisciplinary approaches in which biomedical and social sciences asses the intervention, both by qualitative and quantitative methods, are needed. Factors influencing adherence to test results, referral completion, accep-tance and uptake of the intervention and CHW attrition need to be more thoroughly investigated. Moreover, research is required to assess the best and most sustain-able way of (re)training and supervising CHWs.

Little is published on logistic and structural elements, which would allow the de-sign of a sustainable programme. Therefore, the system of stock supply and stock management throughout the healthcare system should be outlined and analysed to detect the problem areas.

ConclusionsDespite limitations of the currently available evidence, several recommendations can be made for the design and implementation of CCMm. It is most important that CHWs receive a training in which they have enough opportunity to practice the difficult steps and interpretation of RDTs to ensure adequate execution and interpretation of the tests and consequently ensure the most optimal test perfor-mance. Furthermore, the risks derived from potentially lower specificity may be outweighed if iCCM is implemented. A job aid, repeated training and supervision can subsequently enhance the overall performance of CHWs, including adherence to test results. Again, further improvement in adherence can be obtained by imple-menting iCCM. Community sensitization is needed to ensure comprehension of the intervention and trust in the skills of the CHW. Furthermore, it might stimulate adherence to treatment and referral advice. The stock management system needs to be elucidated and stock management training should be an integrated part in the CHW and health centre staff training.

Finally, since factors influencing cost-effectiveness are abundant and variable in different malaria-endemic areas and because the scarce number of studies available lack the inclusion of important benefits, an individual cost-effectiveness


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analysis is still needed for each area preparing for RDT-based CCMm implemen-tation.58

The implications raised in this review can be used to draft RDT-based CCMm or iCCM programmes and research projects, even for risk groups not explicitly ad-dressed in most RDT-based CCMm studies, such as pregnant women. Howev-er, specific considerations would be in place depending on malaria pathogenesis, transmission dynamics, the existing healthcare structure and the local culture and social setting.

Abbreviations

ACT: artemisinin-combination therapy; CCMm: community case management of malaria; CHW: community health worker; CMD: community medicine distributor; iCCM: integrated community case management; RDT: rapid diagnostic test; SSA: sub-Saharan Africa; WHO: World Health Organization

Competing interests

The authors declare that they have no competing interests.

Acknowledgements

We would like to thank all authors who sent us additional information on their stud-ies. We would also like to thank I M Nagel (Medical Library, Academic Medical Centre, University of Amsterdam, Amsterdam) for her support with drafting the search strategies, K Vaughan (Royal Tropical Institute/Koninklijk Instituut voor de Tropen (KIT), Health Unit, Linnaeusstraat 35f, Amsterdam) for her assistance in critically assessing the cost-effectiveness studies, F Forland (Royal Tropical In-stitute/Koninklijk Instituut voor de Tropen (KIT), Biomedical Research, Meiberg-dreef 39, Amsterdam) for his suggestions for critical appraisal of unstandardized outcomes and P Klatser (Royal Tropical Institute/Koninklijk Instituut voor de Tro-pen (KIT), Biomedical Research, Meibergdreef 39, Amsterdam) for his comments on the manuscript. The preparation of this review has received funding from the European Community’s Seventh Framework Programme under grant agreement No.305662 (Project: Community-based scheduled screening and treatment of malaria in pregnancy for improved maternal and infant health: a cluster-random-ized trial ‘COSMIC’).


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17. Hamer DH, Brooks ET, Semrau K, Pilingana P, MacLeod WB, Siazeele K, Sabin LL, Thea DM, Yeboah-Antwi K. Quality and safety of integrated community case management of malaria us-ing rapid diagnostic tests and pneumonia by community health workers. Pathog Glob Health. 2012;106(1):32-39. doi:10.1179/1364859411Y.0000000042.

18. Counihan H, Harvey SA, Sekeseke-Chinyama M, Hamainza B, Banda R, Malambo T, Masani-nga F, Bell D. Community health workers use malaria rapid diagnostic tests (RDTs) safely and accurately: results of a longitudinal study in Zambia. Am J Trop Med Hyg. 2012;87(1):57-63. doi:10.4269/ajtmh.2012.11-0800.

19. Harvey SA, Jennings L, Chinyama M, Masaninga F, Mulholland K, Bell DR. Improving community health worker use of malaria rapid diagnostic tests in Zambia: package instructions, job aid and job aid-plus-training. Malar J. 2008;7:160. doi:10.1186/1475-2875-7-160.

20. Ndiaye Y, Ndiaye JL a, Cisse B, Blanas D, Bassene J, Manga I a, Ndiath M, Faye SL, Bocoum M, Ndiaye M, Thior PM, Sene D, Milligan P, Gaye O, Schellenberg D. Community case management in malaria: review and perspectives after four years of operational experience in Saraya district, south-east Senegal. Malar J. 2013;12(1):240. doi:10.1186/1475-2875-12-240.

21. Hawkes M, Katsuva JP, Masumbuko CK. Use and limitations of malaria rapid diagnostic testing by community health workers in war-torn Democratic Republic of Congo. Malar J. 2009;8:308. doi:10.1186/1475-2875-8-308.

22. Lemma H, San Sebastian M, Löfgren C, Barnabas G. Cost-effectiveness of three malaria treat-ment strategies in rural Tigray, Ethiopia where both Plasmodium falciparum and Plasmodium vivax co-dominate. Cost Eff Resour Alloc. 2011;9(1):2. doi:10.1186/1478-7547-9-2.

23. Chanda P, Hamainza B, Moonga HB, Chalwe V, Banda P, Pagnoni F. Relative costs and effec-tiveness of treating uncomplicated malaria in two rural districts in Zambia: implications for nationwide scale-up of home-based management. Malar J. 2011;10(1):159. doi:10.1186/1475-2875-10-159.

24. Mubi M, Janson A, Warsame M, Mårtensson A, Källander K, Petzold MG, Ngasala B, Maganga G, Gustafsson LL, Massele A, Tomson G, Premji Z, Björkman A. Malaria rapid testing by communi-ty health workers is effective and safe for targeting malaria treatment: randomised cross-over trial in Tanzania. PLoS One. 2011;6(7):e19753. doi:10.1371/journal.pone.0019753.

25. Thiam S, Thwing J, Diallo I, Fall FB, Diouf MB, Perry R, Diop M, Diouf ML, Cisse MM, Diaw MM, Thior M. Scale-up of home- based management of malaria based on rapid diagnostic tests and artemisininbased combination therapy in a resource-poor country: results in Senegal. Malar J. 2012;11(1):334. doi:10.1186/1475-2875-11-334.

26. Rutta ASM, Francis F, Mmbando BP, Ishengoma DS, Sembuche SH, Malecela EK, Sadi JY, Kamugisha ML, Lemnge MM. Using community-owned resource persons to provide early diag-nosis and treatment and estimate malaria burden at community level in north-eastern Tanza-nia. Malar J. 2012;11:152. doi:10.1186/1475-2875-11-152.

27. Elmardi KA, Malik EM, Abdelgadir T, Ali SH, Elsyed AH, Mudather MA, Elhassan AH, Adam I. Fea-sibility and acceptability of home-based management of malaria strategy adapted to Sudan’s conditions using artemisinin-based combination therapy and rapid diagnostic test. Malar J. 2009;8:39. doi:10.1186/1475-2875-8-39.


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28. Ishengoma DS, Francis F, Mmbando BP, Lusingu JP a, Magistrado P, Alifrangis M, Theander TG, Bygbjerg IC, Lemnge MM. Accuracy of malaria rapid diagnostic tests in community studies and their impact on treatment of malaria in an area with declining malaria burden in north-eastern Tanzania. Malar J. 2011;10(1):176. doi:10.1186/1475-2875-10-176.

29. Ratsimbasoa A, Ravony H, Vonimpaisomihanta J-A, Raherinjafy R, Jahevitra M, Rapelanoro R, Rakotomanga JDDM, Malvy D, Millet P, Ménard D. Management of uncomplicated malaria in febrile under five-year-old children by community health workers in Madagascar: reliability of malaria rapid diagnostic tests. Malar J. 2012;11:85. doi:10.1186/1475-2875-11-85.

30. Chinkhumba J, Skarbinski J, Chilima B, Campbell C, Ewing V, San Joaquin M, Sande J, Ali D, Mathanga D. Comparative field performance and adherence to test results of four malaria rapid diagnostic tests among febrile patients more than five years of age in Blantyre, Malawi. Malar J. 2010;9:209. doi:10.1186/1475-2875-9-209.

31. Premji Z, Minjas JN, Shiff CJ. Laboratory diagnosis of malaria by village health workers using the rapid manual ParaSightTM-F test. Trans R Soc Trop Med Hyg. 1994;88:418.

32. Mukanga D, Babirye R, Peterson S, Pariyo GW, Ojiambo G, Tibenderana JK, Nsubuga P, Kalland-er K. Can lay community health workers be trained to use diagnostics to distinguish and treat malaria and pneumonia in children? Lessons from rural Uganda. Trop Med Int Health. 2011;16(10):1234-1242. doi:10.1111/j.1365-3156.2011.02831.x.

33. Chanda P, Hamainza B, Moonga HB, Chalwe V, Pagnoni F. Community case management of malaria using ACT and RDT in two districts in Zambia: achieving high adherence to test results using community health workers. Malar J. 2011;10(1):158. doi:10.1186/1475-2875-10-158.

34. Mukanga D, Tiono AB, Anyorigiya T, Källander K, Konaté AT, Oduro AR, Tibenderana JK, Amen-ga-Etego L, Sirima SB, Cousens S, Barnish G, Pagnoni F. Integrated community case manage-ment of fever in children under five using rapid diagnostic tests and respiratory rate count-ing: a multi-country cluster randomized trial. Am J Trop Med Hyg. 2012;87(5 Suppl):21-29. doi:10.4269/ajtmh.2012.11-0816.

35. Mukanga D, Tibenderana JK, Kiguli J, Pariyo GW, Waiswa P, Bajunirwe F, Mutamba B, Counihan H, Ojiambo G, Kallander K. Community acceptability of use of rapid diagnostic tests for malaria by community health workers in Uganda. Malar J. 2010;9:203. doi:10.1186/1475-2875-9-203.

36. Nsagha DS, Elat J-BN, Ndong PA, Tata PN, Tayong M-NN, Pokem FF, Wankah CC. Feasibility of home management using ACT for childhood malaria episodes in an urban setting. Drug Healthc Patient Saf. 2012;4:1-18. doi:10.2147/DHPS.S25406.

37. Mukanga D, Tibenderana JK, Peterson S, Pariyo GW, Kiguli J, Waiswa P, Babirye R, Ojiambo G, Kasasa S, Pagnoni F, Kallander K. Access, acceptability and utilization of community health workers using diagnostics for case management of fever in Ugandan children: a cross-section-al study. Malar J. 2012;11:121. doi:10.1186/1475-2875-11-121.

38. Blanas DA, Ndiaye Y, Nichols K, Jensen A, Siddiqui A, Hennig N. Barriers to community case management of malaria in Saraya, Senegal : training , and supply-chains. Malar J. 2013;12(1):95. doi:10.1186/1475-2875-12-95.

39. Thomson A, Khogali M, de Smet M, Reid T, Mukhtar A, Peterson S, von Schreeb J. Low referral completion of rapid diagnostic test-negative patients in community-based treatment of malaria in Sierra Leone. Malar J. 2011;10:94. doi:10.1186/1475-2875-10-94.

40. Lemma H, Byass P, Desta A, Bosman A, Costanzo G, Toma L, Fottrell E, Marrast A-C, Ambachew Y, Getachew A, Mulure N, Morrone A, Bianchi A, Barnabas GA. Deploying artemether-lumefantrine with rapid testing in Ethiopian communities: impact on malaria morbidity, mortality and health-care resources. Trop Med Int Health. 2010;15(2):241-250. doi:10.1111/j.1365-3156.2009.02447.x.


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41. Samo Gudo E, Prista A, Jani I V. Impact of asymptomatic Plasmodium falciparum parasitemia on the imunohematological indices among school children and adolescents in a rural area high-ly endemic for Malaria in southern Mozambique. BMC Infect Dis. 2013;13:244. doi:10.1186/1471-2334-13-244.

42. Roucher C, Rogier C, Dieye-Ba F, Sokhna C, Tall A, Trape J-F. Changing malaria epidemiology and diagnostic criteria for Plasmodium falciparum clinical malaria. PLoS One. 2012;7(9):e46188. doi:10.1371/journal.pone.0046188.

43. Batwala V, Magnussen P, Nuwaha F. Are rapid diagnostic tests more accurate in diagnosis of Plasmodium falciparum malaria compared to microscopy at rural health centres? Malar J. 2010;9(1):349. doi:10.1186/1475-2875-9-349.

44. Swarthout TD, Counihan H, Senga RKK, Van den Broek I. Paracheck-Pf® accuracy and recently treated Plasmodium falciparum infections : is there a risk of over-diagnosis ? Malar J. 2007;6:1-6. doi:10.1186/1475-2875-6-58.

45. Landsberger HA. Hawthorne Revisited: Management and the Worker, Its Critics, and Develop-ments in Human Relations in Industry. Ithaca (N.Y.): Cornell university press; 1958.

46. Albertini A, Lee E, Coulibaly SO, Sleshi M, Faye B, Mationg ML, Ouedraogo K, Tsadik AG, Fe-leke SM, Diallo I, Gaye O, Luchavez J, Bennett J, Bell D. Malaria rapid diagnostic test trans-port and storage conditions in Burkina Faso, Senegal, Ethiopia and the Philippines. Malar J. 2012;11(1):406. doi:10.1186/1475-2875-11-406.

47. World Health Organization. Malaria Rapid Diagnostic Test Performance: Results of WHO Prod-uct Testing of Malaria RDTs: Round 4 (2012). Vol 4. Geneva; 2012.

48. Skarbinski J, Ouma PO, Causer LM, Kariuki SK, Barnwell JW, Alaii JA, Oliveira AM De, Zurovac D, Larson BA, Snow RW, Rowe AK, Laserson KF, Akhwale WS, Slutsker L, Hamel MJ. Effect of Malaria Rapid Diagnostic Tests on the Management of Uncomplicated Malaria with Artemether-Lume-fantrine in Kenya : A Cluster Randomized Trial. Am J Trop Med Hyg. 2009;80(6):919-926.

49. Kyabayinze DJ, Asiimwe C, Nakanjako D, Nabakooza J, Counihan H, Tibenderana JK. Use of RDTs to improve malaria diagnosis and fever case management at primary health care facilities in Uganda. Malar J. 2010;9(1):200.

50. Masanja IM, Selemani M, Amuri B, Kajungu D, Khatib R, Kachur SP, Skarbinski J. Increased use of malaria rapid diagnostic tests improves targeting of anti-malarial treatment in rural Tanza-nia : implications for nationwide rollout of malaria rapid diagnostic tests. Malar J. 2012;11(1):221. doi:10.1186/1475-2875-11-221.

51. D’Acremont VD, Kahama-Maro J, Swai N, Mtasiwa D, Genton B, Lengeler C. Reduction of an-ti-malarial consumption after rapid diagnostic tests implementation in Dar es Salaam: a be-fore-after and cluster randomized controlled study. Malar J. 2011;10(1):107. doi:10.1186/1475-2875-10-107.

52. Bruxvoort K, Kalolella A, Nchimbi H, Festo C, Taylor M, Thomson R, Cairns M, Thwing J, Klein-schmidt I, Goodman C, Kachur SP. Getting antimalarials on target: impact of national roll-out of malaria rapid diagnostic tests on health facility treatment in three regions of Tanzania. Trop Med Int Health. 2013;18(10):1269-1282. doi:10.1111/tmi.12168.

53. Björkman A, Mårtensson A. Risks and benefits of targeted malaria treatment based on rapid diagnostic test results. Clin Infect Dis. 2010;51(5):512-514. doi:10.1086/655689.

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55. Lewin S, Munabi-Babigumira S, Glenton C, Daniels K, Bosch-Capblanch X, van Wyk B, Odgaard-Jensen J, Johansen M, Aja G, Zwarenstein M, Scheel I. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases: a review synopsis. Cochrane Database Syst Rev. 2010;28(3):243-245. doi:10.1111/j.1525-1446.2011.00950.x.

56. Glenton C, Colvin C, Carlsen B, Swartz A, Lewin S, Noyes J, Rashidian A. Barriers and facilitators to the implementation of lay health worker programmes to improve access to maternal and child health : qualitative evidence synthesis (Review). Cochrane Libr. 2013;(10).

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58. Shillcutt S, Morel C, Goodman C, Coleman P, Bell D, Whitty JM, Mills A. Cost-effectiveness of malaria diagnostic methods in sub-Saharan Africa in an era of combination therapy. Bull World Health Organ. 2008;86(2):101-110. doi:10.2471/BLT.07.042259.


60

Additional file 1.‘Search syntax’. Latest update 12th October 2013.

Database Search syntax

Medline

http://www.ncbi.nlm.nih.gov/pubmed/

malaria[mesh] OR malaria[tiab] OR plasmodium falci-parum[tiab] OR p falciparum[tiab]

AND

mass screening[mesh] OR screen*[tiab] OR sst[tiab] OR rdt[tiab] OR rapid diagnos*[tiab] OR (rapid[tiab] AND test*[tiab]) OR (rapid antigen test*[tiab])

AND

home based[tiab] OR home management[tiab] OR com-munity case management[tiab] OR community man-agement[tiab] OR community based[tiab] OR hmm[tiab] OR community health[tiab] OR home health worker*[-tiab] OR health community worker*[tiab] OR home case management[tiab] OR community directed[tiab] OR village health worker*[tiab] OR Community Malaria Vol-unteer*[tiab] OR community owned resource person*[-tiab] OR village malaria worker*[tiab] OR health exten-sion worker*[tiab] OR malaria control assistant*[tiab] OR community malaria volunteer*[tiab] OR “Community Health Workers”[Mesh] OR “Home Health Aides”[Mesh]

Embase ‘malaria’/exp OR ‘plasmodium falciparum’/exp OR ma-laria:ab,ti OR (plasmodium:ab,ti AND falciparum:ab,ti) OR (p:ab,ti AND falciparum:ab,ti) AND [embase]/lim

AND

‘screening’/exp OR screen*:ab,ti OR sst:ab,ti OR rdt:ab,ti OR (rapid NEXT/1 diagnos*):ab,ti OR (rapid NEXT/4 test*):ab,ti OR (‘rapid antigen’ NEXT/1 test*):ab,ti AND [embase]/lim

AND

‘health auxiliary’/exp OR (home NEXT/1 based):ab,ti OR (home NEXT/1 management):ab,ti OR (‘commu-nity case’ NEXT/1 management):ab,ti OR (community NEXT/1 management):ab,ti OR (community NEXT/1 based):ab,ti OR hmm:ab,ti OR (community NEXT/1 health):ab,ti OR (‘home health’ NEXT/1 worker*):ab,-ti OR (‘health community’ NEXT/1 worker*):ab,ti OR (‘home case’ NEXT/1 management):ab,ti OR (commu-nity NEXT/1 directed):ab,ti OR (‘village health’ NEXT/1 worker*):ab,ti OR (‘community malaria’ NEXT/1 volun-teer*):ab,ti OR (‘community owned resource’ NEXT/1 person*):ab,ti OR (‘village malaria’ NEXT/1 worker*):ab,ti OR (‘health extension’ NEXT/1 worker*):ab,ti OR (‘malar-ia control’ NEXT/1 assistant*):ab,ti OR (‘malaria village’ NEXT/1 worker*):ab,ti AND [embase]/lim


61

02


Cochrane

http://www.thecochranelibrary.com

malaria or “plasmodium falciparum” or “p falci-parum”:ti,ab,kw in Cochrane Reviews (Reviews and Pro-tocols) and Trials (Word variations have been searched) OR [Malaria] explode all trees OR [Malaria, Falciparum] explode all trees OR [Plasmodium falciparum] explode all trees

AND

screen* or sst or rdt or (rapid next diagnos*) or (rapid next test*) or (“rapid antigen” next test*):ti,ab,kw (Word variations have been searched) OR [Mass Screening] explode all trees

AND

“home based” or “home management” or “community case management” or “community management” or “community based” or hmm or “community health” or (“home health” next worker*) or (“health community” next worker*) or “home case management” or “com-munity directed” or (“ village health” next worker*) or (“Community Malaria” next Volunteer*) or (“Community owned resource” next person*) or (“village malaria” next worker*) or (“health extension” next worker*) or (“ma-laria control” next assistant*):ti,ab,kw (Word variations have been searched) OR [Community Health Workers] explode all trees


62


MIP library

http://library.mip-consortium.org/

malaria:TI or malaria:AB or (plasmodium falciparum:TI) or (plasmodium falciparum:AB) or (p falciparum:TI) or (p falciparum:AB)

AND

screen*:TI or screen*:AB or sst:TI or sst:AB or rdt:TI or rdt:AB or ((rapid:TI) next diagnos*:TI) or ((rapid:AB) next diagnos*:AB) or ((rapid:TI) next test*:TI) or ((rapid:AB) next test*:AB) or ((rapid antigen:TI) next test*:TI) or ((rap-id antigen:AB) next test*:AB)

AND

(home based:TI) or (home based:AB) or (home man-agement:TI) or (home management:AB) or (community casemanagement:TI) or (community case manage-ment:AB) or (community management:TI) or (communi-ty management:AB) or (community based:TI) or (com-munity based:AB) or hmm:TI or hmm:AB or (community health:TI) or (community health:AB) or ((home health:TI) next worker*:TI) or ((home healh:AB) next worker*:AB) or ((health community:TI) next worker*:TI) or ((health community:AB) next worker*:AB) or (home case management:TI) or (home case management:AB) or (community directed:TI) or (community directed:AB) or ((village health:TI) next worker*:TI) or ((village health:AB) next worker*:AB) or ((community malaria:TI) next volun-teer:TI) or ((community malaria:AB) next volunteer:AB) or ((community owned resource:TI) next person*:TI) or ((community owned resource:AB) next person*:AB) or ((village malaria:TI) worker*:TI) or ((village malaria:AB) worker*:AB) or ((health extension:TI) next worker*:TI) or ((health extension:AB) next worker*:AB) or ((malaria control:TI) next assistant*:TI) or ((malaria control:AB) next assistant*:AB) or ((malaria village:TI) next worker*:-TI) or ((malaria village:AB) next worker*:AB)


63

02

Additional file 2‘Excluded articles with reasons’

Excluded article Reason for exclusion

Alfred Tiono 2010 et al. Abstract. Author referred to Tiono 2013 et al.

Ashton et al. Only opinion of CHWs on ease of handling of RDT.

Betson 2011 et al. Abstract.

Bjorkman 2011 et al. Abstract. Study described in Msellem 2009 PLoS Med et al: no use of CHWs.

Blanas et al. 2010 Abstract. Full study described in Blanas 2013

Brieger et al. 2011 Abstract.

Buwembo 2012 et al. Abstract.

De Smet et al. Abstract, author suggested Tayler-Smith 2011.

Diarra 2012 et al. Community clinic health workers. No response on question whether these met the definition of CHWs.

Diouf 2010 et al. Abstract. Not specific on RDT based home-management interven-tion.

Gerstl 2010 et al. No CHWs.

Gerstl 2009 et al. Abstract. Full text in Malaria J 2010 not about CHWs.

Hopkins 2011 et al. Only data available for all health workers combined, not separately for CHWs.

Iyer 2011 et al. Abstract. About integrated CCM.

Jean et al. 2011 Abstract, full study described in Tine 2011 et al. Malaria J

Landoh 2012 et al. Morbidity study not focused on RDT based CCMm

Luchavez et al. 2007 Not situated in SSA and not the right outcome.

Masanja et al. 2010 Only data available for all health workers combined, not separately for ‘volunteers’.

Muhindo et al. 2012 No CHWs performing RDTs.

Ndiaye et al. 2011 Abstract. Described in Ndiaye et al. 2013

Ndiaye et al. 2012 Abstract. Described in Ndiaye et al. 2013

Ndyomugyenyi et al. 2012 Abstract.

Ngasala 2011 et al. RDTs only used for first screening, treatment and follow-up based on subsequent microscopy result so no relevant outcomes.

Orji et al. 2012 Abstract.

Ouatarra et al. 2011 No CHWs.

Pagnoni et al. 2011 Abstract, full study described in Mukanga et al. 2012 (multi-country study)

Ponsar et al. 2009 Abstract.

Roger et al. 2011 Abstract, full study by Tine 2011 et al.

Rutta et al. 2009 Abstract, full study by Rutta et al. 2012.

Shekalaghe et al. 2013 No CHWs.


64

Excluded article Reason for exclusion

Silumbe et al. 2012 Abstract.

Thiam et al. 2012 (AMJT-MH)

Abstract.

Thiam et al. 2012 (AJTMH) Abstract. Full study in Thiam et al. 2012 (Malaria J)

Thiam et al. 2011 Abstract. Full study in Thiam et al. 2012 (Malaria J)

Tine 2011 et al. Intervention directed at IPT instead of RDT based CCMm.

Willcox et al. RDTs not performed by CHWs.

Yeboah-Antwi et al. 2009 Abstract. Full study described in Yeboah-Antwi et al. 2010.


65

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Lem

ma40

20

10Et

hiop

iaCa

re-s

eeki

ng

patie

nts

≥1 y

ear

Two-

year

stu

dy. Y

ear 1

all

inte

rven

tion

CHW

s pr

esum

ptiv

ely

trea

ted

mal

aria

. Con

trol

are

as h

ad n

o CC

Mm

. Yea

r 2 h

alf o

f in

terv

entio

n CH

Ws

perf

orm

ed R

DT-b

ased

CCM

m.

X

Lem

ma22

20

11Et

hiop

iaPa

tient

s w

ith

(his

tory

of)

fe

ver

Eval

uatio

n of

thre

e CC

Mm

app

roac

hes.

1) D

iagn

osis

of s

pe-

cies

-spe

cific

mal

aria

+ tr

eatm

ent;

2) D

iagn

osis

of o

nly

P.

falc

ipar

um +

trea

tmen

t; 3)

Pre

sum

ptiv

e di

agno

sis

+ tr

eatm

ent

XX

Ad

dit

ion

al

file

3 (

con

tin

ue

d)

‘Ove

rvie

w o

f inc

lude

d st

udie

s an

d re

port

ed o

utco

mes

’


67

02

Stud

yCo

untr

yPa

rtic

ipan

tsSt

udy

desi

gn

RDT performance

RDT interpretation

RDT execution




Uptake by community

Stock outs

CHW incentives


Mub

i24

2011

Tanz

ania

Patie

nts

≥3

mon

ths

with

(h

isto

ry o

f)

feve

r

Ran

dom

ized

cro

ssov

er tr

ial.

One

gro

up o

f CH

Ws

perf

orm

ed

RDT

-bas

ed C

CMm

, oth

er g

roup

trea

ted

mal

aria

pre

sum

ptiv

e-ly

. Gro

ups

alte

rnat

ed e

very

wee

k.X

XX

XX

Muk

anga

35

2010

Uga

nda

Care

give

rs o

f ch

ildre

n <5

ye

ars

Surv

ey a

mon

g co

mm

unity

mem

bers

prio

r to

impl

emen

tatio

n of

RDT

-bas

ed C

CMm

.X

X

Muk

anga

32

2011

Uga

nda

Patie

nts

<5

year

s w

ith (h

is-

tory

of)

feve

r

Stud

y on

com

pete

nce

of C

HW

s to

use

RDT

s. A

sses

smen

t 3

days

-2 w

eeks

aft

er tr

aini

ng. 1

3 co

nsul

tatio

ns o

bser

ved.

XX

X

Muk

anga

37

2012

d

Uga

nda

Care

give

rs o

f pa

tient

s <5

ye

ars

Cros

s-se

ctio

nal s

tudy

on

care

give

rs’ o

pini

on o

n in

terv

entio

n CH

Ws

perf

orm

ing

RDT

-bas

ed C

CMm

and

trea

ting

pneu

mon

ia

with

am

oxic

illin

.X

X

Muk

anga

34

2012

d

Burk

ina

Faso

, G

hana

, U

gand

a

Patie

nts

4 –

59

mon

ths

with

(h

isto

ry o

f)

feve

r

Clus

ter r

ando

miz

ed c

ontr

olle

d tr

ial.

Inte

rven

tion

CHW

s pe

r-fo

rmed

RDT

-bas

ed C

CMm

+ p

neum

onia

dia

gnos

is (r

espi

ra-

tory

rate

) and

trea

tmen

t. C

ontr

ol C

HW

s tr

eate

d m

alar

ia p

re-

sum

ptiv

ely,

in G

hana

they

als

o tr

eate

d pn

eum

onia

on

clin

ical

di

agno

sis.

X


68

Stud

yCo

untr

yPa

rtic

ipan

tsSt

udy

desi

gn

RDT performance

RDT interpretation

RDT execution




Uptake by community

Stock outs

CHW incentives


Ndi

aye20

20

13Se

nega

lAl

l car

e-se

ek-

ing

patie

nts

Eval

uatio

n of

two

type

s of

CH

Ws

on p

erfo

rman

ce o

f RDT

-ba

sed

CCM

m.

XX

X

Nsa

gha36

20

12Ca

mer

-oo

nPe

ople

from

di

ffer

ent s

ocio

-de

mog

raph

ic

back

grou

nds

Focu

s gr

oup

disc

ussi

ons

and

in-d

epth

inte

rvie

ws

on R

DT-

base

d CC

Mm

bef

ore

impl

emen

tatio

n.X

Prem

ji31

1994

Tanz

ania

Patie

nts

<42

mon

ths

who

ar

e re

gula

rly

test

ed fo

r ma-

laria

.

Stud

y on

RDT

per

form

ance

in h

ands

of C

HW

s.

X

Rat

sim

ba-

soa29

201

2M

ada-

gasc

arPa

tient

s 2-

59

mon

ths

with

(h

isto

ry o

f)

feve

r

Eval

uatio

n of

one

yea

r int

erve

ntio

n of

RDT

-bas

ed C

CMm

.

X

Rutt

a26

2012

c

Tanz

ania

All c

are-

seek

-in

g pa

tient

s.Pr

e- a

nd p

ost-i

nter

vent

ion

surv

ey (s

tudy

of 4

yea

rs) o

n R

DT-

base

d CC

Mm

for p

atie

nts

≥5 y

ears

and

pre

sum

ptiv

e tr

eat-

men

t for

pat

ient

s <5

yea

rs.

X

Ad

dit

ion

al

file

3 (

con

tin

ue

d)

‘Ove

rvie

w o

f inc

lude

d st

udie

s an

d re

port

ed o

utco

mes

’


69

02

Stud

yCo

untr

yPa

rtic

ipan

tsSt

udy

desi

gn

RDT performance

RDT interpretation

RDT execution




Uptake by community

Stock outs

CHW incentives


Tay-

ler-S

mith

15

2011

Chad

Chad

: pat

ient

s <1

5 ye

ars

Eval

uatio

n of

up

to 5

yea

rs o

f RDT

-bas

ed C

CMm

.X

Tion

o14

2013

d

Burk

ina

Faso

Child

ren

aged

6

– 5

9 m

onth

s w

ith (h

isto

ry

of) f

ever

Stud

y on

RDT

per

form

ance

if u

sed

by C

HW

s fr

om th

e in

ter-

vent

ion

arm

of a

clu

ster

-RCT

X

Thia

m25

20

12Se

nega

lPa

tient

s w

ith

susp

ecte

d m

alar

ia.

Non

-ran

dom

ized

con

trol

led

tria

l. 25

rura

l dis

tric

ts w

ith R

DT-

base

d CC

Mm

as

inte

rven

tion,

con

trol

are

as w

ith n

o CC

Mm

at

all.

XX

Thom

son39

Sier

ra

Leon

ePa

tient

s 3-

59

mon

ths

and

preg

nant

wom

-en

2nd

and

3rd

tr

imes

ter.

Surv

ey o

n re

ferr

al b

ased

on

reco

rd re

view

s ov

er th

ree

mon

ths

in a

n ar

ea w

ith re

cent

ly in

trod

uced

RDT

-bas

ed C

CMm

.X

Tota

l7

55

124

86

52

4

a-d A

rtic

les

with

the

sam

e le

tter

are

bas

ed o

n th

e sa

me

stud

y.


70

Additional file 4Counihan et al. : Community health workers use malaria rapid diagnostic tests (RDTs) safely and accurately: results of a longitudinal study in Zambia. Am J Trop Med Hyg 2012, 87:57-63

19 steps required to correctly and safely prepare a rapid diagnostic test (RDT) (critical steps noted in boldface type).

1. Assemble new test packet, swab, buffer, pipette, lancet and gloves.2. Put on new pair of gloves.3. Check expiry date on package.4. Check desiccant sachet is still dry (do not include answer in total score).5. Write patient’s name on cassette.6. Place cassette on a level surface.7. Clean finger with antiseptic/alcohol.8. Allow finger to dry before pricking it.9. Use a sterile lancet for finger prick.10. Puncture the side of the ball of the finger.11. Dispose of lancet in sharps bin immediately after pricking finger.12. Collect blood with the enclosed pipette making sure to fill close to the first

cross line.13. Using the pipette, blot blood onto the pad in the smaller well.14. Dispose of pipette in sharps container immediately.15. Dispense 5 drops of clearing buffer into the larger well.16. Wait 15 minuts before reading negative results.*17. Read test results correctly.18. Record results in CHW register.19. Dispose of non-sharps (gloves, wrappers, alcohol swab, and desiccant) safely.

*Positive results may be read before 15 minuts if control line has also appeared. Results should not be read after 30 minutes.

UvA-DARE (Digital Academic Repository) Malaria in ... · ia (CCMm), formerly known as home based...

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Transcript of UvA-DARE (Digital Academic Repository) Malaria in ... · ia (CCMm), formerly known as home based...