Beyond “test and treat” : Malaria diagnosis for improved pediatric fever management in sub-Saharan Africa

Abstract: This thesis examined malaria test use, adherence and integration into clinical practice for improved pediatric fever management in sub-Saharan African countries and explored Access, Facility Readiness and Clinical Practice bottlenecks to achieve this program goal.Study I examined diagnostic testing rates and its determinants for pediatric fevers across 13 countries in 2009-2012 including Access bottlenecks. Study II evaluated the effect of testing on treatment decisions at the population level in 12 countries in 2010-2012 and explored reasons for varying country results across Access, Facility Readiness and Clinical Practice bottlenecks. Study III explored Facility Readiness and Clinical Practice bottlenecks for using malaria diagnosis for improved pediatric fever management in Mbarara District Uganda. Study IV examined integrated pediatric fever management using RDT and IMCI in Malawi health facilities in 2013-2014 including Facility Readiness and Clinical Practice bottlenecks.Malaria testing of pediatric fevers was low (17%) and inequitable at the outset of new guidelines with febrile children in least poor household more often tested than in poorest (OR: 1.63, 95% CI: 1.39-1.91) (Study I). Significant variability was found in the effect of testing on ACT use across countries (e.g. Uganda OR: 0.84, 95% CI: 0.66-1.06; Mozambique OR: 3.54, 95% CI: 2.33-5.39). Four main themes explained varying results: available diagnostics and medicines; quality of care; care-seeking behavior; and malaria epidemiology (Study II). In Mbarara District Uganda malaria over-treatment for RDT-negative results reportedly occurred and was driven by RDT perceptions, system constraints and provider-client interactions (Study III). In Malawi health facilities, there was common compliance to malaria treatment guidelines in sick child consultations. 72% were tested or referred for malaria diagnosis and 85% with RDT-confirmed malaria were prescribed first-line anti-malarials. Yet integrated pediatric fever management was sub-optimal in terms of other assessments completed and antibiotic targeting. 28% with IMCI-pneumonia were not prescribed any antibiotic and 59% ‘without antibiotic need’ were prescribed any antibiotic. Few eligible clients had respiratory rates counted to identify antibiotic need for IMCI-pneumonia (18%). RDT-negative children had 16.8 (95% CI: 8.6-32.7) times higher antibiotic over-treatment odds compared to positive cases and this effect was conditioned by cough or difficult breathing complaints (Study IV).Thesis findings highlight Access, Facility Readiness and Clinical Practice bottlenecks that need to be addressed to use malaria diagnosis for improved pediatric fever management. Programs must move beyond malaria-focused ‘test and treat’ strategies towards ‘IMCI with testing’ in order to conceptualize RDT as one part of the established algorithm for managing sick children in an integrated manner. RDT should also be viewed as an important entry point for contributing to ongoing health system strengthening efforts.