Community Health Workers Use Malaria Rapid Diagnostic Tests (RDTs) Safely and Accurately: Results of a Longitudinal Study in Zambia

Malaria Consortium, Maputo, Mozambique; Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Malaria Consortium, Lusaka, Zambia; Zambia National Malaria Control Center, Lusaka, Zambia; Livingstone District Health Management Team, Livingstone, Zambia; World Health Organization, Lusaka, Zambia; Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
The American journal of tropical medicine and hygiene (Impact Factor: 2.7). 07/2012; 87(1):57-63. DOI: 10.4269/ajtmh.2012.11-0800
Source: PubMed


Malaria rapid diagnostic tests (RDTs) could radically improve febrile illness management in remote and low-resource populations. However, reliance upon community health workers (CHWs) remains controversial because of concerns about blood safety and appropriate use of artemisinin combination therapy. This study assessed CHW ability to use RDTs safely and accurately up to 12 months post-training. We trained 65 Zambian CHWs, and then provided RDTs, job-aids, and other necessary supplies for village use. Observers assessed CHW performance at 3, 6, and 12 months post-training. Critical steps performed correctly increased from 87.5% at 3 months to 100% subsequently. However, a few CHWs incorrectly read faint positive or invalid results as negative. Although most indicators improved or remained stable over time, interpretation of faint positives fell to 76.7% correct at 12 months. We conclude that appropriately trained and supervised CHWs can use RDTs safely and accurately in community practice for up to 12 months post-training.

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Available from: Busiku Hamainza, Oct 08, 2015
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    • "It is not clear why these districts still have more than 90% clinically diagnosed cases after extended use of RDTs was rolled out in 2005-2006. A study has shown that appropriately trained and supervised CHWs can use RDTs, both safely and accurately, in community practice in Zambia (Counihan et al., 2012). "
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    ABSTRACT: Malaria is an important health burden in Zambia with proper diagnosis remaining as one of the biggest challenges. The need for reliable diagnostics is being addressed through the introduction of rapid diagnostic tests (RDTs). However, without sufficient laboratory amenities in many parts of the country, diagnosis often still relies on non-specific, clinical symptoms. In this study, geographical information systems were used to both visualize and analyze the spatial distribution and the risk factors related to the diagnosis of malaria. The monthly reported, district-level number of malaria cases from January 2009 to December 2014 were collected from the National Malaria Control Center (NMCC). Spatial statistics were used to reveal cluster tendencies that were subsequently linked to possible risk factors, using a non-spatial regression model. Significant, spatio-temporal clusters of malaria were spotted while the introduction of RDTs made the number of clinically diagnosed malaria cases decrease by 33% from 2009 to 2014. The limited access to road network(s) was found to be associated with higher levels of malaria, which can be traced by the expansion of health promotion interventions by the NMCC, indicating enhanced diagnostic capability. The capacity of health facilities has been strengthened with the increased availability of proper diagnostic tools and through retraining of community health workers. To further enhance spatial decision support systems, a multifaceted approach is required to ensure mobilization and availability of human, infrastructural and technological resources. Surveillance based on standardized geospatial or other analytical methods should be used by program managers to design, target, monitor and assess the spatio-temporal dynamics of malaria diagnostic resources country-wide.
    Geospatial health 05/2015; 10(1):330. DOI:10.4081/gh.2015.330 · 1.19 Impact Factor
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    • "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 [34] and therefore screening for visual impairments should be done before appointing new CHWs. "
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    ABSTRACT: Malaria still causes high morbidity and mortality around the world, mainly in sub-Saharan Africa. 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 Organization 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).
    Malaria Journal 06/2014; 13(1):229. DOI:10.1186/1475-2875-13-229 · 3.11 Impact Factor
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    • "The concept of community-based management of malaria stems from the recognition that human resource deficits amongst clinically-trained professional cadres are commonplace, so extending service delivery beyond centralized health facilities, by mobilizing through community health workers (CHW) will be required to improve access to appropriate management of uncomplicated malaria [43,44]. CHWs have demonstrated the capacity to effectively diagnose malaria with RDTs and provide treatment according to the locally relevant policy and guidelines [41,42,45,46]. The community-based diagnosis and treatment approach has also been shown to be cost-effective [47,48], improve delivery of malaria case management overall [49-51], is well accepted by communities [52-54] and also provides a potentially valuable population–wide platform for monitoring trends in human parasitaemia [55]. "
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    ABSTRACT: Active, population-wide mass screening and treatment (MSAT) for chronic Plasmodium falciparum carriage to eliminate infectious reservoirs of malaria transmission have proven difficult to apply on large national scales through trained clinicians from central health authorities.Methodology: Fourteen population clusters of approximately 1,000 residents centred around health facilities (HF) in two rural Zambian districts were each provided with three modestly remunerated community health workers (CHWs) conducting active monthly household visits to screen and treat all consenting residents for malaria infection with rapid diagnostic tests (RDT). Both CHWs and HFs also conducted passive case detection among residents who self-reported for screening and treatment. Diagnostic positivity was higher among symptomatic patients self-reporting to CHWs (42.5%) and HFs (24%) than actively screened residents (20.3%), but spatial and temporal variations of diagnostic positivity were highly consistent across all three systems. However, most malaria infections (55.6%) were identified through active home visits by CHWs rather than self-reporting to CHWs or HFs. Most (62%) malaria infections detected actively by CHWs reported one or more symptoms of illness. Most reports of fever and vomiting, plus more than a quarter of history of fever, headache and diarrhoea, were attributable to malaria infection. The minority of residents who participated >12 times had lower rates of malaria infection and associated symptoms in later contacts but most residents were tested <4 times and high malaria diagnostic positivity (32%), as well as incidence (1.46 detected infections per person per year) persisted in the population. Per capita cost for active service delivery by CHWs was US$5.14 but this would rise to US$10.68 with full community compliance with monthly testing at current levels of transmission, and US$6.25 if pre-elimination transmission levels and negligible treatment costs were achieved. While monthly active home visits by CHWs equipped with RDTs were insufficient to eliminate the human infection reservoir in this typical African setting, despite reasonably high LLIN/IRS coverage. However, dramatic impact upon infection and morbidity burden might be attainable and cost-effective if community participation in regular testing can be improved and the substantial, but not necessarily prohibitive, costs are affordable to national programmes.
    Malaria Journal 03/2014; 13(1):128. DOI:10.1186/1475-2875-13-128 · 3.11 Impact Factor
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