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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
Patients with
history of fever
Malaria (81%)
Proportion of patients treated for malaria
in Dar es Salaam 2006
Patients
without fever
Malaria (42%)
3
Malaria Attributable Fever Fractions in 4 African cities 2003-2004
0-1 year 1-5 years 5-15 years >15 years
Abidjan
(Yopougon) 0.12 0.22 0.27 0.13
Cotonou 0 0.04 0 0
Dar es Salaam 0 0.03 0.04 0.02
Ouagadougou 0 0.13 0.04 0
Source: Wang et al. 2005
Hence, the vast majority of malaria treatments are unnecessary!
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
5
9 health facilities in DSM
Oct 2007 to
Sept 2008
Kahama et al. submitted Malaria J.
6
0%
10%
20%
30%
40%
50%
60%
70%
80%
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Se
p
Oct
Nov
Dec
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Se
p
Oct
Nov
Dec
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Se
p
2006 2007 2008
Po
sit
ivit
y (
%)
Hospitals
Health Centers
Dispensaries
RDT implementation
Routine microscopy: 48% Routine RDT: 8%
2006 2007 2008
Malaria test positivity rate before and after RDT
implementation
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jan
Feb Mar A
pr
May Ju
nJu
lAug
Sep O
ctNov
Dec
Jan
Feb Mar A
pr
May Ju
nJu
lAug
Sep O
ctNov
Dec
Jan
Feb Mar A
pr
May Ju
nJu
lAug
Sep
Po
sit
ivit
y r
ate
Hospitals
Health centres
Dispensaries
Malaria test positivity rates
Kahama et al. submitted Malaria J.
7
0%
20%
40%
60%
80%
100%
120%Ja
n
Feb
Ma
r
Ap
r
Ma
y
Ju
n
Ju
l
Au
g
Se
p
Oct
Nov
Dec
Ja
n
Feb
Ma
r
Ap
r
Ma
y
Ju
n
Ju
l
Au
g
Se
p
Oct
Nov
Dec
Ja
n
Feb
Ma
r
Ap
r
Ma
y
Ju
n
Ju
l
Au
g
Se
p
2006 2007 2008
Po
sit
ivit
y (
%)
Intervention
Control
RDT implementation
Kahama et al. submitted Malaria J.
Malaria test positivity rates
8
0
5000
10000
15000
20000
25000Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
dispensary 3
dispensary 2
dispensary 1
health centre 3
health centre 2
health centre 1
hospital 3
hospital 2
hospital 1
mRDT
2007 2008
Artemether/lumefantrine (ALu)
D’Acremont et al. Malaria J 2011
Drug consumption 1
9
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
Jan
Mar
May
Jul
Sep
Nov
Jan
Mar
May
Jul
Sep
Nov
Jan
Mar
May
Jul
Sep
dispensary 3
dispensary 2
dispensary 1
health centre 3
health centre 2
health centre 1
hospital 3
hospital 2
hospital 1
mRDT
2007 2008 2006
Quinine vials
D’Acremont et al. Malaria J 2011
Drug consumption 2
10
0%
20%
40%
60%
80%
100%
120%
Before RDT use After RDT use
Hospital 1
Hospital 2
Hospital 3
Health centre 1
Health centre 2
Health center 3
Dispensary 1
Dispensary 2
Dispensary 3
Control 1
Control 2
Control 3
Median intervention
Median control
Intervention HF
74% reduction
Control HF
37% reduction
0%
20%
40%
60%
80%
100%
120%
Before RDT use After RDT use
Hospital 1
Hospital 2
Hospital 3
Health centre 1
Health centre 2
Health center 3
Dispensary 1
Dispensary 2
Dispensary 3
Control 1
Control 2
Control 3
Median intervention
Median control
Variability between health facilities
ALu
D’Acremont et al. Malaria J 2011
11
Antibiotic prescriptions in Dar es Salaam
Antibiotics
Antimalarials
Proportion of
febrile patients
receiving:
Before RDT
implementation
After RDT
implementation
49% 73%
81% 24%
D’Acremont et al. Malaria J 2011
+49%
-74%
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
13
Improvements
1. ALu consumption considerably reduced - by 74%
2. Febrile 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
– Febrile patients treated with antibiotics increased from
49 to 73%
14
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)
IMALDIA Team & Acknowledgements
16
0
20000
40000
60000
80000
100000
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
New consultations Blood slides performed RDT performed Patients with a diagnosis of malaria Positive tests
0
20000
40000
60000
80000
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
New consultations Blood slides performed
RDT performed Patients with a diagnosis of malaria
Positive tests
2006 2007 2008
0
20000
40000
60000
80000
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
New consultations Blood slides performed
RDT performed Patients with a diagnosis of malaria
Positive testsRDTm
17
All IRA
50%
4%
12%
1%
5%
3%
15%
1%
3%
10%
31%
All GE
9%
Acute resp. infect. (ARI)
Upper resp. tract inf.
Bronchiolitis
Non-doc. pneumonia.
Doc. pneumonia
Gastroenteritis (GE)
Amoeba
Rota/Adenovirus
Salmonella/Shigella
Unknown pathogen
Urine infection
Skin infection
Others*
Bacteriemia
Typhoid Malaria
Unknown
Etiologies of fever in 1005 children
5%
1%
Rickettsiosis
5% 3%
1%
D’Acremont et al. in preparation * meningitis, acute HHV6, acute EBV/CMV, toxoplasmosis, Q fever