Parasite-based diagnosis for malaria in Uganda: feasibility and cost-effectiveness

Abstract

From 2006 the first-line treatment for uncomplicated malaria in Uganda was with artemisinin-based combination therapy (ACT). In 2010, Uganda adopted the universal parasite-based diagnosis for malaria before treatment with ACT. There is paucity of information regarding use of ACT and whether it is feasible to implement parasite-based diagnosis for malaria in the country. This study aimed at describing the challenges of using ACT for treatment of malaria and to assess whether it is feasible to implement parasite-based diagnosis for malaria. Methods: Semi-structured interviews were conducted with patients and health workers at 32 sub-County level health centres in Bushenyi (low transmission) and Iganga district (high transmission). Blood taken from 300 patients with febrile illness were tested for malaria using polymerase chain reaction, light microscopy and rapid diagnostic test (RDTs) to assess the accuracy of light microscopy and of RDT in identifying malaria infection. In a feasibility trial, 30 HCs were randomised to implement parasite-based diagnosis based on RDTs (n=10), blood microscopy (n=10) and presumptive diagnosis (n=10). Feasibility of implementing parasite-based diagnosis was assessed by comparing the cost-effectiveness of RDT and light microscopy; patient waiting time; the proportion of patients with febrile illness who received parasite-based diagnosis; and the type of treatment (either with antibiotics or anti-malarials). Results: The challenges identified were: stock-out of ACT, continued use of nonrecommended anti-malarials, understaffing and lack of parasitological diagnosis. RDT (91%) had a superior sensitivity compared to light microscopy (47.2%) in identifying malaria infection. Use of RDT for parasitological diagnosis was more cost-effective with an incremental cost-effectiveness ratio of US$ 5.0 compared to US$ 9.6 for microscopy per case correctly identified and treated. Patients were more likely to receive a parasitological diagnosis in RDT (96.6%) than with microscopy (60.9%). RDTs reduced patient waiting time compared to microscopy and were more convenient to health workers and patients. Parasite-based diagnosis was associated with a reduction in ACT prescription among patients testing negative. Prescription of anti-malarials was 100% in patients not receiving a parasitological diagnosis as it was in patients testing positive for malaria. Prescription of antibiotics was 41% among patients treated presumptively. Among patients who tested positive for malaria 23.2% were prescribed antibiotics compared to 52.1% in those who tested negative. Conclusion: RDTs are more attractive than microscopy if parasite-based diagnosis for malaria is to be rolled out in the country. Parasite-based diagnosis reduces the prescription of anti-malarials among patients who test negative but increases the prescription of antibiotics. Measures are needed to reduce the prescription of antimalarials among patients who test negative as well as for reducing the use of antibiotics among patients with febrile illness. Key words: Antibiotics, Artemisinin-based Combination Therapy, Diagnostics