Impact of Rapid Diagnostic Tests for malaria on case management in Dar es Salaam IMALDIA Project

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1 Impact of Rapid Diagnostic Tests for malaria on case management in Dar es Salaam IMALDIA Project Judith Kahama, Valerie D Acremont, Christian Lengeler Dar es Salaam City Council, United republic of Tanzania Swiss Tropical and Public Health Institute Basel, Switzerland

2 Proportion of patients treated for malaria in Dar es Salaam 2006 Malaria (81%) Malaria (42%) Patients with history of fever Patients without fever 2

3 Malaria Attributable Fever Fractions in 4 African cities year 1-5 years 5-15 years >15 years Abidjan (Yopougon) Cotonou Dar es Salaam Ouagadougou Hence, the vast majority of malaria treatments are unnecessary! Source: Wang et al

4 Objectives of the IMALDIA study: Improve laboratory diagnosis for malaria in routine management of fever cases at outpatient departments in Dar es Salaam Pilot implementation of Rapid Diagnostic Tests for malaria (RDTm) in Dar es Salaam - 3 District hospitals, - 3 Health Centers - 3 Dispensaries - 3 Matched control health facilities 4

5 9 health facilities in DSM 2007 to t 2008 Kahama et al. submitted Malaria J. 5

6 Malaria test positivity rates Malaria test positivity rate before and after RDT implementation 80% Routine microscopy: 48% Routine RDT: 8% 70% 60% 50% RDT implementation Hospitals Hospitals Health Centers centres Dispensaries Positivity (%) 40% 30% 20% 10% 0% Kahama et al. submitted Malaria J. 6

7 Positivity (%) Malaria test positivity rates 120% 100% RDT implementation Intervention Control 80% 60% 40% 20% 0% Kahama et al. submitted Malaria J. 7

8 Drug consumption mrdt Artemether/lumefantrine (ALu) dispensary 3 dispensary 2 dispensary 1 health centre 3 health centre 2 health centre 1 hospital 3 hospital 2 hospital D Acremont et al. Malaria J

9 Drug consumption mrdt Quinine vials dispensary 3 dispensary 2 dispensary 1 health centre 3 health centre 2 health centre 1 hospital 3 hospital 2 hospital D Acremont et al. Malaria J

10 Variability between health facilities 120% 100% 80% 60% 40% 20% 0% ALu Before RDT use 120% 100% 80% 60% 40% 20% 0% Before RDT use After RDT use Hospital 1 Hospital 2 Hospital 3 Control HF 37% reduction Intervention HF 74% reduction After RDT use Health centre 1 Health centre 2 Health center 3 Dispensary 1 Dispensary 2 Dispensary 3 Control 1 Control 2 Control 3 Hospital 1 Hospital 2 Hospital 3 Health centre 1 Health centre 2 Health center 3 Median intervention Median control Dispensary 1 Dispensary 2 Dispensary 3 Control 1 Control 2 Control 3 Median intervention Median control D Acremont et al. Malaria J

11 Antibiotic prescriptions in Dar es Salaam Proportion of febrile patients receiving: Antimalarials Before RDT implementation After RDT implementation 81% 24% -74% Antibiotics +49% 49% 73% D Acremont et al. Malaria J

12 Translation of research findings into policy Close collaboration with National Malaria Control Program Tanzanian Guidelines for RDT use Award of Round 7 Global Fund grant to implement RDT at national scale 12

13 Improvements 1. ALu consumption considerably reduced - by 74% 2. rile patients treated with antimalarials dropped from 81 to 24% 3. Only 7% of negative patients received an antimalarial To be improved: Poor accountability for ALu and RDTs in some health facilites 58% of patients WITHOUT fever are tested with RDT rile patients treated with antibiotics increased from 49 to 73% 13

14 IMALDIA Team & Acknowledgements Ministry of Health and Social Welfare Deo Mtasiwa (Chief Medical Officer) Dar es Salaam City Medical Office of Health Judith Kahama (City Medical Officer) Ndeniria Swai (Research Assistant) Swiss Tropical and Public Health Institute Valerie D Acremont (Clinical Epidemiologist) Christian Lengeler (Epidemiologist) Blaise Genton (Tropical Diseases Specialist) Amana hospital Willy Sangu (Medical Director) Financial support from the Swiss National Science Foundation RDTs provided in part by the US President s Malaria initiative (PMI) 14

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16 New consultations New consultations Blood slides Blood performed slides performed RDT performed RDT performed Patients with Patients a diagnosis with a of diagnosis malaria of New consultations Blood slides performed RDT performed Patients with a diagnosis of malaria Positive tests Positive tests Positive tests RDTm

17 Etiologies of fever in 1005 children Rickettsiosis Unknown Others* Typhoid 1% 3% 15% 5% Skin infection 1% 5% Urine infection 1% Bacteriemia * meningitis, acute HHV6, acute EBV/CMV, toxoplasmosis, Q fever Malaria 10% 5% 3% 1% All GE 9% 3% 12% 31% 4% Acute resp. infect. (ARI) Upper resp. tract inf. Bronchiolitis Non-doc. pneumonia. Doc. pneumonia All IRA 50% Gastroenteritis (GE) Amoeba Rota/Adenovirus Salmonella/Shigella Unknown pathogen 17 D Acremont et al. in preparation