Major Reduction in Anti-Malarial Drug Consumption in Senegal after Nation-Wide Introduction of Malaria Rapid Diagnostic Tests

et al. (2011) Major Reduction in Anti-Malarial Drug Consumption in Senegal after Nation-Wide Introduction of Malaria Rapid Diagnostic Tests. PLoS ONE 6(4): e18419. doi:10.1371/journal.pone.0018419 Major Reduction in Anti-Malarial Drug Consumption in Senegal after Nation-Wide Introduction of Malaria Rapid Diagnostic Tests Sylla Thiam 0 Moussa Thior 0 Babacar Faye 0 Me doune Ndiop 0 Mamadou Lamine Diouf 0 Mame Birame 0 Diouf 0 Ibrahima Diallo 0 Fatou Ba Fall 0 Jean Louis Ndiaye 0 Audrey Albertini 0 Evan Lee 0 Pernille Jorgensen 0 Oumar Gaye 0 David Bell 0 Sylviane Pied, Lile 2 University, France 0 1 Programme National de lutte contre le Paludisme, Ministe`re de la Sante , Dakar Fann, Senegal, 2 Faculte de Me decine , Universite Cheikh Anta Diop de Dakar , Fann Dakar, Se ne gal, 3 Foundation for Innovative New Diagnostics (FIND), Geneva , Switzerland , 4 Global Malaria Programme, World Health Organization , Geneva , Switzerland Background: While WHO recently recommended universal parasitological confirmation of suspected malaria prior to treatment, debate has continued as to whether wide-scale use of rapid diagnostic tests (RDTs) can achieve this goal. Adherence of health service personnel to RDT results has been poor in some settings, with little impact on anti-malarial drug consumption. The Senegal national malaria control programme introduced universal parasite-based diagnosis using malaria RDTs from late 2007 in all public health facilities. This paper assesses the impact of this programme on anti-malarial drug consumption and disease reporting. Methods and Findings: Nationally-collated programme data from 2007 to 2009 including malaria diagnostic outcomes, prescription of artemisinin-based combination therapy (ACT) and consumption of RDTs in public health facilities, were reviewed and compared. Against a marked seasonal variation in all-cause out-patient visits, non-malarial fever and confirmed malaria, parasite-based diagnosis increased nationally from 3.9% of reported malaria-like febrile illness to 86.0% over a 3 year period. The prescription of ACT dropped throughout this period from 72.9% of malaria-like febrile illness to 31.5%, reaching close equivalence to confirmed malaria (29.9% of 584873 suspect fever cases). An estimated 516576 courses of inappropriate ACT prescription were averted. Conclusions: The data indicate high adherence of anti-malarial prescribing practice to RDT results after an initial run-in period. The large reduction in ACT consumption enabled by the move from symptom-based to parasite-based diagnosis demonstrates that effective roll-out and use of malaria RDTs is achievable on a national scale through well planned and structured implementation. While more detailed information on management of parasite-negative cases is required at point of care level to assess overall cost-benefits to the health sector, considerable cost-savings were achieved in ACT procurement. Programmes need to be allowed flexibility in management of these funds to address increases in other programmatic costs that may accrue from improved diagnosis of febrile disease. - Funding: This study was funded through pre-existing grants to the Senegal Programme National de lutte contre le Paludisme from the Global Fund to fight AIDS, Tuberculosis and Malaria and the United States Presidents Malaria Initiative, and by the Foundation for Innovative New Diagnostics (FIND) through a grant from the Bill and Melinda Gates Foundation. The funding agencies had no role in the decision to undertake the study, study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. The World Health Organization recently strengthened its recommendation for parasite-based diagnosis of malaria, extending it to all cases of suspected malaria prior to treatment with antimalarial medicines [1] Accurate diagnosis enables targeting of anti-malarial drugs to those who will benefit, early identification of non-malarial fever requiring alternative management, and accurate and complete surveillance for confirmed malaria cases. Reducing drug wastage, in addition to saving money and conserving stocks of artemisinin-based combination therapies (ACT), may prolong the usefulness of ACTs globally by reducing pressure towards resistance. Clinical (symptom-based) diagnosis of malaria has a very poor specificity [2,3,4], and microscopy is predominantly limited to larger health facilities where the quality of the result can be assured [5]. Provision of universal access to parasite-based diagnosis for populations at risk of malaria will therefore depend on the wide use of malaria rapid diagnostic tests (RDTs); point-of care tests first introduced in 1993 (with the ParaSight-F test) and with a proliferation of products now coming into wide use [6,7,8,9]. Rapid point-of-care tests are routinely used for several diseases including HIV and syphilis, replacing centralized laboratory testing, as the requirement for a positive diagnostic result has long been accepted as a basis for treatment. , However, due to the historical anomaly of wide use of poorly-targeted anti-malarial treatment based on symptoms, particularly in sub-Saharan Africa, the introduction of malaria point-of-care tests will lead to a restriction in availability of treatment, rather than a widening of access as is intended through the introduction of HIV and syphilis test. Health care providers (and the communities they serve) must now not only re-learn malaria diagnosis, but develop and implement new management strategies for the majority of febrile patients whose malaria test results will be negative. This poses a dilemma for resource-limited health services, as diagnostics for non-malarial febrile illness are often unavailable and management strategies limited. Further, difficulties in ensuring malaria RDT quality promoted doubt as to whether the RDT was sufficiently accurate as a basis for with-holding a potentially life-saving antimalarial drug. The establishment of a product testing programme [9], methods for laboratory-based RDT lot-testing [10], and evidence of safe withholding of treatment in the field [11,12], have addressed many of these concerns. Although modeling suggests that malaria RDTs will be costeffective, and the potential public health advantages of enabling early appropriate management for other causes of fever are clear, these outcomes depend heavily on adherence to test results by providers and patients and in access to effective management of non-malarial fever [13,14]. Reported adherence to results has varied in reported studies; some studies questioned whether RDT use on a large scale can have a significant impact on the management of febrile disease [15,16]. Successful implementation will depend on a number of factors including good training of health workers and modification of long-standing community a (...truncated)