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Davidson H. Hamer, MD; Micky Ndhlovu, MBChB; Dejan Zurovac, MD, PhD; Matthew Fox, DSc, MPH; Kojo Yeboah-Antwi, MBChB, MPH; Pascalina Chanda, MPH; Naawa Sipilinyambe, MD; Jonathon L. Simon, DSc, MPH; Robert W. Snow, PhD, MSc

JAMA. 2007;297(20):2227-2231.

Context  Improving the accuracy of malaria diagnosis with rapid antigen-detection diagnostic tests (RDTs) has been proposed as an approach for reducing overtreatment of malaria in the current era of widespread implementation of artemisinin-based combination therapy in sub-Saharan Africa.

Objective  To assess the association between use of microscopy and RDT and the prescription of antimalarials.

Design, Setting, and Participants  Cross-sectional, cluster sample survey, carried out between March and May 2006, of all outpatients treated during 1 working day at government and mission health facilities in 4 sentinel districts in Zambia.

Main Outcome Measure  Proportions of patients undergoing malaria diagnostic procedures and receiving antimalarial treatment.

Results  Seventeen percent of the 104 health facilities surveyed had functional microscopy, 63% had RDTs available, and 73% had 1 or more diagnostics available. Of patients with fever (suspected malaria), 27.8% (95% confidence interval [CI], 13.1%-42.5%) treated in health facilities with malaria diagnostics were tested and 44.6% had positive test results. Of patients with negative blood smear results, 58.4% (95% CI, 36.7%-80.2%) were prescribed an antimalaria drug, as were 35.5% (95% CI, 16.0%-55.0%) of those with a negative RDT result. Of patients with fever who did not have diagnostic tests done, 65.9% were also prescribed antimalarials. In facilities with artemether-lumefantrine in stock, this antimalarial was prescribed to a large proportion of febrile patients with a positive diagnostic test result (blood smear, 75.0% [95% CI, 51.7%-98.3%]; RDT, 70.4% [95% CI, 39.3%-100.0%]), but also to some of those with a negative diagnostic test result (blood smear, 30.4% [95% CI, 8.0%-52. 9%]; RDT, 26.7% [95% CI, 5.7%-47.7%]).

Conclusions  Despite efforts to expand the provision of malaria diagnostics in Zambia, they continue to be underused and patients with negative test results frequently receive antimalarials. Provision of new tools to reduce inappropriate use of new expensive antimalarial treatments must be accompanied by a major change in clinical treatment of patients presenting with fever but lacking evidence of malaria infection.

Author Affiliations: Center for International Health and Development, Boston University School of Public Health, Boston, Mass (Drs Hamer, Fox, Yeboah-Antwi, and Simon); Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, Mass (Dr Hamer); Chainama Hills College Hospital of Health Sciences, Lusaka, Zambia (Dr Ndhlovu); Malaria Public Health and Epidemiology Group, Centre for Geographic Medicine, KEMRI/Wellcome Trust Collaborative Programme, Nairobi, Kenya (Drs Zurovac and Snow); Centre for Tropical Medicine, University of Oxford, John Radcliffe Hospital, Headington, Oxford, England (Drs Zurovac and Snow); and National Malaria Control Center, Ministry of Health, Lusaka, Zambia (Ms Chanda and Dr Sipilinyambe).

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