Interactive training programmes for health workers could reduce overdiagnosis of malaria by half and help prevent valuable drugs from being wasted on patients who don't have the disease, according to new research published on World Malaria Day in The Lancet Global Health. The study shows that the roll-out of malaria rapid diagnostic tests (RDTs) in endemic countries should run alongside these new training programmes.
The study in Cameroon, carried out by the Artemisinin-based Combination Therapy (ACT) Consortium based at the London School of Hygiene & Tropical Medicine, compared the use of RDTs when packaged with either a basic or a comprehensive training programme for clinicians. Their results showed that those undertaking the comprehensive programme were much less likely to overuse antimalarials. Only 31% of patients in this group received a malaria drug that they didn't need, compared to 52% in the group undertaking the basic programme and 84% in the control group which represented the standard practice.
The more effective training package lasted three days and was designed to change prescribing practices. In addition to the content of the basic package, which only provided conventional training on RDTs, malaria diagnosis and treatment, the comprehensive package had smaller groups and longer discussions about clinical guidelines, real-life scenarios and effective communication with patients. It was also more interactive, using card games, drama and problem solving exercises.
This research was carried out in response to calls from governments to provide evidence that helps to change the behaviour of clinicians, who often treat patients based on their signs and symptoms without testing their blood for the presence of malaria parasites. This often results in patients with fever being overdiagnosed with malaria and receiving expensive malaria treatment that they don't need.
The study's lead author, Dr Virginia Wiseman from the London School of Hygiene & Tropical Medicine, said: "If we are serious about improving the targeting of malaria medicines by using RDTs, then there needs to be a far greater focus on behaviour change. This study, the first of its kind in Cameroon, highlights that health workers not only need training to diagnose and treat malaria, but most of all need the confidence to put what they learn into practice and to communicate more effectively with patients about why they are tested and that fever is not always caused by malaria. Our results suggest that a good training programme designed to translate knowledge into practice could dramatically reduce overdiagnosis of malaria in Cameroon and prevent the wastage of valuable medicines."
The World Health Organization recommends that health workers test patients for malaria before prescribing antimalarial treatment, but for decades malaria has been diagnosed based on symptoms alone. Microscopy is a method that requires laboratory equipment and qualified staff, while rapid diagnostic tests are alternative, simple tools to diagnose malaria accurately which can help health workers in remote locations to prescribe the correct treatment.
Professor David Schellenberg, director of the ACT Consortium at the London School of Hygiene & Tropical Medicine, said: "This study shows that rapid diagnostic tests can take the guesswork out of diagnosis, which can improve the targeting of malaria treatment to those who really need it. We recognise that this is one study carried out in one setting, in one country, but it helps us to maximise the value of RDTs in different contexts such as the private sector or other countries. It also draws attention to the importance of understanding the non-malarial causes of fever. For example, meningitis or pneumonia are life-saving infections and require referral and additional treatment."
Prof Wilfred Mbacham from the University of Yaoundé, who co-led the study in Cameroon, said: "Rapid diagnostic tests are new technologies that can greatly assist nurses and doctors in making life-saving decisions at the point-of-care. Rather than do passive training in the use of RDTs, building confidence and providing communication training are key to accept a negative test for a patient with fever and to use other treatment options. We reached this result through repeated consultations with the National Malaria Control Programme. Governments need to minimally invest in building up the critical mass of health workers who prescribe appropriately, which requires a curriculum change in medical schools."
The ACT Consortium is funded by the Bill & Melinda Gates Foundation.
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Notes to Editors
1. Basic or enhanced clinician training to improve adherence to malaria treatment guidelines: a cluster-randomised trial in two areas of Cameroon, Mbacham et al, Lancet Global Health 2014, Published Online April 25, 2014, http://dx.doi.org/10.1016/S2214-109X(14)70201-3
2. Collaborating institutions: University of Yaoundé, Cameroon; University of Nigeria
3. The cluster randomized trial was conducted in 46 public and mission facilities in urban and rural settings in Cameroon. The effect of the intervention on the treatment prescribed was determined by surveying 3982 patients who left facilities and reported they had sought treatment for a fever. In all three arms of the trial, almost 80% of adults and children presenting with a fever were tested for malaria, and the majority of patients who tested positive for malaria were prescribed an ACT. The main difference between the arms was in the patients who tested negative for malaria: 84% of test-negative patients in the control arm received an antimalarial, compared to 52% in the basic arm and 31% in the comprehensive arm. There is a 53% point difference between the control arm and the comprehensive arm, hence the comprehensive training halves the number of test-negative cases that were prescribed an antimalarial they did not need.
4. Overdiagnosis can happen when diagnostic tools are not available or health workers are not trained to use them, when clinicians are unable to diagnose or treat other infections that are causing fever, or when patients expect to obtain antimalarial drugs. Malaria overdiagnosis can lead to inappropriate treatment of patients with fever and wastes valuable medicines.
5. Virginia Wiseman (PhD in Health Economics) is based in Sydney, Australia. She is Senior Lecturer at the London School of Hygiene & Tropical Medicine and Associate Professor at the School of Public Health & Community Medicine, University of New South Wales.
6. David Schellenberg is the director of the ACT Consortium, Professor of Malaria & International Health at the London School of Hygiene & Tropical Medicine and policy adviser of Malaria No More UK.
7. Wilfred Mbacham is Professor of Public Health Biotechnology at the University of Yaoundé, Cameroon.
About the ACT Consortium
The ACT Consortium is an international research collaboration working on 25 projects in 10 countries to answer key questions on malaria drug delivery. Since initiating activities in 2008, the Consortium has been working to optimise the use of Artemisinin-based Combination Therapy (ACT), the first-line treatment for the most dangerous form of malaria recommended by the World Health Organization. The projects investigate ways to improve the access and targeting of ACTs, as well as to assess their safety and quality. The ACT Consortium is based at the London School of Hygiene & Tropical Medicine and a member of the School's Malaria Centre. Watch a video and learn more about the study in Cameroon at http://www.actconsortium.org/REACTCameroon and download the training manuals at http://www.actconsortium.org/REACTCameroonmanuals
About the London School of Hygiene & Tropical Medicine
The London School of Hygiene & Tropical Medicine is a world-leading centre for research and postgraduate education in public and global health, with 3,900 students and more than 1,000 staff working in over 100 countries. The School is one of the highest-rated research institutions in the UK, and was recently cited as the world's leading research-focused graduate school. Our mission is to improve health and health equity in the UK and worldwide; working in partnership to achieve excellence in public and global health research, education and translation of knowledge into policy and practice. http://www.lshtm.ac.uk
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