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Diagnostic Testing of Pediatric Fevers: Meta-Analysis of 13 National Surveys Assessing Influences of Malaria Endemicity and Source of Care on Test Uptake for Febrile Children under Five Years
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). (Internationell barnhälsa och nutrition/Persson)
Spatial Ecology and Epidemiology Group, Department of Zoology, University of Oxford, Oxford, United Kingdom.
Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
Spatial Ecology and Epidemiology Group, Department of Zoology, University of Oxford, Oxford, United Kingdom.
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2014 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 9, no 4, e95483- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND:

In 2010, the World Health Organization revised guidelines to recommend diagnosis of all suspected malaria cases prior to treatment. There has been no systematic assessment of malaria test uptake for pediatric fevers at the population level as countries start implementing guidelines. We examined test use for pediatric fevers in relation to malaria endemicity and treatment-seeking behavior in multiple sub-Saharan African countries in initial years of implementation.

METHODS AND FINDINGS:

We compiled data from national population-based surveys reporting fever prevalence, care-seeking and diagnostic use for children under five years in 13 sub-Saharan African countries in 2009–2011/12 (n = 105,791). Mixed-effects logistic regression models quantified the influence of source of care and malaria endemicity on test use after adjusting for socioeconomic covariates. Results were stratified by malaria endemicity categories: low (PfPR2–10<5%), moderate (PfPR2–10 5–40%), high (PfPR2–10>40%). Among febrile under-fives surveyed, 16.9% (95% CI: 11.8%–21.9%) were tested. Compared to hospitals, febrile children attending non-hospital sources (OR: 0.62, 95% CI: 0.56–0.69) and community health workers (OR: 0.31, 95% CI: 0.23–0.43) were less often tested. Febrile children in high-risk areas had reduced odds of testing compared to low-risk settings (OR: 0.51, 95% CI: 0.42–0.62). Febrile children in least poor households were more often tested than in poorest (OR: 1.63, 95% CI: 1.39–1.91), as were children with better-educated mothers compared to least educated (OR: 1.33, 95% CI: 1.16–1.54).

CONCLUSIONS:

Diagnostic testing of pediatric fevers was low and inequitable at the outset of new guidelines. Greater testing is needed at lower or less formal sources where pediatric fevers are commonly managed, particularly to reach the poorest. Lower test uptake in high-risk settings merits further investigation given potential implications for diagnostic scale-up in these areas. Findings could inform continued implementation of new guidelines to improve access to and equity in point-of-care diagnostics use for pediatric fevers.

Place, publisher, year, edition, pages
2014. Vol. 9, no 4, e95483- p.
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:uu:diva-224057DOI: 10.1371/journal.pone.0095483ISI: 000335226500110PubMedID: 24748201OAI: oai:DiVA.org:uu-224057DiVA: diva2:715078
Available from: 2014-04-30 Created: 2014-04-30 Last updated: 2017-12-05Bibliographically approved
In thesis
1. Beyond “test and treat”: Malaria diagnosis for improved pediatric fever management in sub-Saharan Africa
Open this publication in new window or tab >>Beyond “test and treat”: Malaria diagnosis for improved pediatric fever management in sub-Saharan Africa
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

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.  

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2016. 88 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1173
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-273678 (URN)978-91-554-9455-1 (ISBN)
Public defence
2016-03-04, Rosénsalen, Akademiska sjukhuset, ing 95/96, Uppsala, 09:00 (English)
Opponent
Supervisors
Available from: 2016-02-12 Created: 2016-01-16 Last updated: 2016-02-19

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