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Nov 8, 2011   |   Blog Post

Changing the Nature of Diagnosis in Last Mile Communities

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To date, malaria treatment in most endemic countries has been based on presumptive treatment. This means that any febrile child under five years of age is immediately prescribed antimalarial medication, based on the assumption that they are likely to have malaria. When lab tests were costly and rarely available, this policy undoubtedly saved countless lives. But times have changed.

The availability of rapid diagnostic tests (RDTs) ā€“ in conjunction with decreasing rates of transmission and fewer fevers due to malaria ā€“ has instigated a policy revision. Trending toward parasitic diagnosis based on positive laboratory tests, researchers and policy makers are reviewing the criteria for treatment based on the availability of this new technology, which makes testing feasible in previously unfeasible settings.

Long considered the ā€˜gold standardā€™ of malaria diagnosis, microscopy is a highly sensitive and low cost technique if performed under quality controlled conditions. Unfortunately it is labor intensive, has a lag time between test completion and diagnosis, and requires both laboratory technicians and expensive equipment in order to complete.

Many clinics that cannot support this technology prescribe malaria treatment based on presumptive diagnosis. While presumptive treatment based on febrile presentation is still considered appropriate for children under-five and other high-risk individuals, it is no longer considered cost-effecĀ¬tive or best practice. Antiquated antimalarial medications such as chloroquine may cost less per unit, but the recent reliance on expensive artemisinin-based combination therapies (ACT) demands more careful distribution. Decreasing the rate of prescription for non-malarial cases is vital to keeping costs down and keeping subsidies high ā€“ a combination that ultimately increases the drugsā€™ availability for the most impoverished populations. Over-prescription this regimen based on the presumptive treatment protocol commonly employed in remote clinics not only wastes mediĀ¬cation and costs more money than antibiotic alterĀ¬natives that would otherwise be appropriate for non-malarial febrile illnesses, but also increases the risk of ACT resistance developing in the community.

In an effort to minimize these consequences of presumptive treatment, RDTsĀ  have been designed as new laboratory-confirmed diagnostic technique. Alternatives to microscopy, RDTs are now em-ployed around the world by countries adhering to the World Health Organizationā€™s recommendation of parasite-based malaria diagnosis. Requiring no formal laboratory equipment and able to be adminĀ¬istered by any trained community health worker, RDTs are presenting changing the face of malaria diagnosis in rural clinics where microscopy is not feasible.

Immediate advantages of RDTs include lack of deĀ¬pendency on laboratory equipment, electricity, and personnel, as well as lower levels of training required for implementation. With rural health centers in endemic areas seeing hundreds of cases of fever every day, a more conservative prescription of antimalarials will not only decrease the rate of parasitic resilience, but will also conserve limited medical resources. Whatā€™s more, RDTs now exist for many diseases including HIV and syphilis! To this end, they have become a game-changer for accurate diagnosis and resource conservation in underserved communities.

Excited to be engaged in this international shift and acutely aware of the benefits it has for health service provision, VillageReach has been actively involved in the distribution of RDTs in Mozambique since 2010. Taking this one step further, we have proposed a collaborative RDT consumption study with our partners in Mozambique to refine our understanding of the challenges to stocking and utilizing these incredible products. By estimating stock shortages and overages, and identifying factors of supply and demand that are associated with these we hope to be more effective in eliminating barriers and improving access to this awesome technology. While the research is still in its infancy, the insight it will afford into RDT consumption and distribution will provide a wealth of data with which to refine programs and improve service delivery in last mile communities.

Kassia Binkowski

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