Introducing malaria rapid diagnostic tests in private medicine retail outlets: A systematic literature review.

BACKGROUND: Many patients with malaria-like symptoms seek treatment in private medicine retail outlets (PMR) that distribute malaria medicines but do not traditionally provide diagnostic services, potentially leading to overtreatment with antimalarial drugs. To achieve universal access to prompt parasite-based diagnosis, many malaria-endemic countries are considering scaling up malaria rapid diagnostic tests (RDTs) in these outlets, an intervention that may require legislative changes and major investments in supporting programs and infrastructures. This review identifies studies that introduced malaria RDTs in PMRs and examines study outcomes and success factors to inform scale up decisions. METHODS: Published and unpublished studies that introduced malaria RDTs in PMRs were systematically identified and reviewed. Literature published before November 2016 was searched in six electronic databases, and unpublished studies were identified through personal contacts and stakeholder meetings. Outcomes were extracted from publications or provided by principal investigators. RESULTS: Six published and six unpublished studies were found. Most studies took place in sub-Saharan Africa and were small-scale pilots of RDT introduction in drug shops or pharmacies. None of the studies assessed large-scale implementation in PMRs. RDT uptake varied widely from 8%-100%. Provision of artemisinin-based combination therapy (ACT) for patients testing positive ranged from 30%-99%, and was more than 85% in five studies. Of those testing negative, provision of antimalarials varied from 2%-83% and was less than 20% in eight studies. Longer provider training, lower RDT retail prices and frequent supervision appeared to have a positive effect on RDT uptake and provider adherence to test results. Performance of RDTs by PMR vendors was generally good, but disposal of medical waste and referral of patients to public facilities were common challenges. CONCLUSIONS: Expanding services of PMRs to include malaria diagnostic services may hold great promise to improve malaria case management and curb overtreatment with antimalarials. However, doing so will require careful planning, investment and additional research to develop and sustain effective training, supervision, waste-management, referral and surveillance programs beyond the public sector.

Investigating a Non-Mesh Mosquito Net Among Outdoor Sleeping Nomadic Communities in Kenya.

Rising reports of exophagic malaria vectors make even more pressing the need for alternatives to traditional, mesh, long-lasting insecticidal nets (LLINs) designed for indoor sleeping and often inadequate in the protection of outdoor-sleeping populations. This study tests and evaluates the retention, utilization, and durability of novel, non-mesh nets designed for outdoor use. Longitudinal, cross-sectional surveys were conducted, the physical condition of nets was assessed, and bio-efficacy and insecticide content were tested. At 22 months, retention was 98.0%; 97.1% of nets fell within the World Health Organization (WHO) category of being in "good" condition; none were in the "torn" category. At 18 months post-distribution, 100% of nets had at least WHO Pesticide Evaluation Scheme (WHOPES)-acceptable levels of insecticide, this proportion was 66.7% at 22 months. This novel mosquito net has the potential to provide a durable and context-specific tool to prevent malaria among traditionally hard-to-protect and highly vulnerable populations.

Patient adherence to prescribed artemisinin-based combination therapy in Garissa County, Kenya, after three years of health care in a conflict setting.

BACKGROUND: Current day malaria cases and deaths are indicative of a lack of access to both methods of prevention, diagnosis, and treatment; an important determinant of treatment efficacy is adherence. This study is a follow up to the baseline study of adherence to artemether-lumefantrine (AL) carried out in Garissa District in 2010. The study presented evaluates any changes in adherence levels which may have occurred in the area during this period and after nearly three years of sustained use of ACT across the public health sector. METHODS: The study was carried out in Garissa County in the North Eastern Province of Kenya and included patients fitting the suspected malaria case definition and having been prescribed AL, regardless of confirmatory diagnosis. A questionnaire assessed the intake of AL via both self-reporting by the participant and observation of blister packs by the interviewer. On separate occasions exit interviews with patients and observations of prescribers were also carried out. RESULTS: Of the 218 participants enrolled, 195 were successfully followed up. 60% of participants were found to be adherent to the three-day AL regimen, this is 4.7% lower than the proportion of participants adherent in 2010; the result of a two-sided z-test was not significant (p = 0.23). The odds of the patient being adherent to AL increased by 65% with each additional correct statement regarding how to take AL that a patient could recall (between zero and four statements), this was the only variable significantly associated with patient adherence (p = 0.01). CONCLUSION: Sustaining the ACT adherence rates at the 2010 levels, through 2.5 years of insecurity in the study area is an achievement and suggests that if security can be improved barriers to improving health service quality and patient adherence to AL would be removed. This study, by looking specifically at anti-malarial adherence over a prolonged period and in a setting of severe conflict, provides a valuable and rare insight in to the challenges and barriers to ACT adherence in such settings.

Perceptions of malaria and acceptance of rapid diagnostic tests and related treatment practises among community members and health care providers in Greater Garissa, North Eastern Province, Kenya.

BACKGROUND: Conventional diagnosis of malaria has relied upon either clinical diagnosis or microscopic examination of peripheral blood smears. These methods, if not carried out exactly, easily result in the over- or under-diagnosis of malaria. The reliability and accuracy of malaria RDTs, even in extremely challenging health care settings, have made them a staple in malaria control programmes. Using the setting of a pilot introduction of malaria RDTs in Greater Garissa, North Eastern Province, Kenya, this study aims to identify and understand perceptions regarding malaria diagnosis, with a particular focus on RDTs, and treatment among community members and health care workers (HCWs). METHODS: The study was conducted in five districts of Garissa County. Focus group discussions (FGD) were performed with community members that were recruited from health facilities (HFs) supported by the MENTOR Initiative. In-depth interviews (IDIs) and FGDs with HCWs were also carried out. Interview transcripts were then coded and analysed for major themes. Two researchers reviewed all codes, first separately and then together, discussed the specific categories, and finally characterized, described, and agreed upon major important themes. RESULTS: Thirty-four FGDs were carried out with a range of two to eight participants (median of four). Of 157 community members, 103 (65.6%) were women. The majority of participants were illiterate and the highest level of education was secondary school. Some 76% of participants were of Somali ethnicity. Whilst community members and HCWs demonstrated knowledge of aspects of malaria transmission, prevention, diagnosis, and treatment, gaps and misconceptions were identified. Poor adherence to negative RDT results, unfamiliarity and distrust of RDTs, and an inconsistent RDT supply were the main challenges to become apparent in FGDs and IDIs. CONCLUSION: Gaps in knowledge or incorrect beliefs exist in Greater Garissa and have the potential to act as barriers to complete and correct malaria case management. Addressing these knowledge gaps requires comprehensive education campaigns and a reliable and constant RDT supply. The results of this study highlight education and supply chain as key factors to be addressed in order to make large scale roll out of RDTs as successful and effective as possible.