• In regions where malaria is a serious problem (malaria-endemic areas), many people cannot access the treatment they need.
• Rapid diagnostic tests for diagnosing malaria (mRDTs) are simple to use: they involve dropping a finger prick of blood onto a small cassette.
• In the context of community-based programmes in malaria-endemic areas, when people without professional healthcare qualifications use mRDTs rather than providing a diagnosis based on physical signs and symptoms (clinical diagnosis), the treatment of malaria improves.
• Further research is needed to understand the impact of mRDTs on how often antibiotics are prescribed.
How is malaria diagnosed and treated in community-based programmes?
There are effective and safe treatments for malaria (antimalarial medicines, also known as antimalarials), but many people still cannot access the medicines they need, especially if they live far from health facilities. To improve this situation, local people without formal healthcare qualifications have been trained to diagnose and treat malaria either by recognising malaria signs and symptoms or using an mRDT. These people can be community health workers or vendors in non-pharmacy medicine shops.
What did we want to find out?
We aimed to compare the effect of two different techniques for diagnosing malaria (mRDTs and clinical diagnosis) used by local people without formal healthcare qualifications, on the treatment given. We also wanted to compare the community use of mRDTs with the routine care provided in health facilities, such as hospitals, to find out which approach resulted in better treatment for people with suspected malaria.
What did we do?
This is an update of a published Cochrane Review. We searched online databases for studies that compared mRDT diagnosis to clinical diagnosis in the community, or mRDT diagnosis and treatment in the community to health facility care. We extracted information about the study designs, the people being treated, the type of non-medically qualified health worker, their training, the mRDTs and treatments used, and the results (including deaths, number of people with or without malaria treated with an antimalarial, and use of antibiotics). Where possible, we combined results using statistical software.
What did we find?
We found six studies from Africa, one from Myanmar, and one from Afghanistan. Five studies compared community use of mRDT to community clinical diagnosis of malaria, and three compared community use of mRDT to health facility care. Five studies used laboratory tests to double-check the community diagnosis of malaria (whether mRDT or clinical). All studies except one offered less than one week's training to the staff. The antimalarials used were mostly for taking by mouth, although two studies also trained staff to give medicine to very ill children by inserting it into their bottoms. Most studies also trained staff to send people who had a negative mRDT result, people who were very ill, young babies, and pregnant women to a health facility. The medicines were sometimes free to patients or customers. Customers who had to pay in medicine shops often paid a reduced price. The mRDTs were usually free.
When mRDTs were used in the community, far fewer people who did not actually have malaria received antimalarials (about 71 fewer per 100 people). Community health workers may be less likely than medicine shop vendors to give antimalarials to people without malaria.
Similarly, more people diagnosed by mRDT (about 45 more per 100) got the right treatment: an antimalarial if they definitely had malaria (proven by laboratory tests), no antimalarial if they did not. Some studies found that a few people with a negative mRDT result (as read by the community health worker or medicine shop vendor) received antimalarial anyway. One small study found that some people with a negative clinical diagnosis received an antimalarial. Conversely, other studies found that a few people with a positive mRDT result did not get an antimalarial.
We also found some increased antibiotic use in the mRDT group in people with a negative laboratory test result compared to the clinical diagnosis group (about 13 more uses of antibiotic per 100 people). We were unable to draw any conclusion about people's health or use of treatments when comparing use of mRDTs in the community with the usual health facility care.
There were very few deaths in the study population.
What are the limitations of the evidence?
We are moderately confident that fewer people without malaria receive antimalarials after an mRDT, and that more people diagnosed by mRDT get the right treatment, because the studies that provided these results included a large number of people, even if there were some differences in study methods.
How up to date is this evidence?
This evidence is up-to-date to 14 September 2021.
Use of mRDTs by CHWs and drug shop vendors compared to clinical diagnosis reduces prescribing of antimalarials to people without malaria. Deaths were uncommon in both groups. Antibiotic prescribing was higher in those with a negative mRDT than in those with a negative clinical diagnosis.
The World Health Organization (WHO) recommends parasitological testing of all suspected malaria cases using malaria rapid diagnostic tests (mRDTs) or microscopy prior to treatment. Some governments have extended this responsibility to community health workers (CHWs) to reduce malaria morbidity and mortality through prompt and appropriate treatment. This is an update of a Cochrane Review first published in 2013.
To evaluate community-based management strategies for treating malaria or fever that incorporate both a definitive diagnosis with an mRDT and appropriate antimalarial treatment.
We searched CENTRAL, MEDLINE, Embase, five other databases, and three trials registers up to 14 September 2021.
We included individually randomized trials and cluster-randomized controlled trials (cRCTs), controlled before-after studies, and controlled interrupted time series studies in people living in malaria-endemic areas, comparing programmes that train CHWs and drug shop vendors to perform mRDTs and provide appropriate treatment versus similar programmes that do not use mRDTs, and versus routine health facility care.
We used standard Cochrane methods. For each dichotomous outcome, we extracted the number of participants with the event and the total number of participants in each group, unless studies presented results at a population level only. Primary outcomes were all-cause mortality, hospitalizations, and number of people receiving an antimalarial within 24 hours. Secondary outcomes were malaria-specific mortality, severe malaria, outcomes related to antimalarial treatments, antibiotic prescribing to people with a negative microscopy or polymerase chain reaction (PCR) result, parasitaemia, anaemia, and all adverse events.
We included eight studies from several African countries, Afghanistan, and Myanmar. Staff included CHWs and drug shop vendors.
Community use of malaria rapid diagnostic tests compared to clinical diagnosis
Compared to clinical diagnosis, mRDT diagnosis results in reduced prescribing of antimalarials to people who are found to be malaria parasite-negative by microscopy or PCR testing (71 fewer per 100 people, 95% confidence interval (CI) 79 to 51 fewer; risk ratio (RR) 0.17, 95% CI 0.07 to 0.40; 3 cRCTs, 7877 participants; moderate-certainty evidence). This reduction may be greater among CHWs compared to drug shop vendors. People diagnosed by mRDT are more likely to receive appropriate treatment; that is, an antimalarial if they are microscopy- or PCR-positive and no antimalarial if they are microscopy- or PCR-negative (RR 3.04, 95% CI 2.46 to 3.74, 3 cRCTs, 9332 participants; high-certainty evidence). Three studies found that a small percentage of people with a negative mRDT result (as read by the CHW or drug shop vendors at the time of treatment) were nevertheless given an antimalarial: 38/1368 (2.8%), 44/724 (6.1%) and 124/950 (13.1%). Conversely, in two studies, a few mRDT-positive people did not receive an antimalarial (0.5% and 0.3%), and one small cross-over study found that 6/57 (10.5%) people classified as non-malaria in the clinical diagnosis arm received an antimalarial. Use of mRDTs probably increases antibiotic use compared to clinical diagnosis (13 more per 100 people, 95% CI 3 to 29 more; RR 2.02, 95% CI 1.21 to 3.37; 2 cRCTs, 5179 participants; moderate-certainty evidence). We were unable to demonstrate any effect on mortality.
Community use of malaria rapid diagnostic tests compared to health facility care
Results were insufficient to reach any conclusion.