Module 5: Rapid Diagnostic Tests By Community Health Workers

RDTs for Malaria

Increased use of artemisinin combination therapy (ACT) has generated greater interest in rapid diagnostic tests (RDTs), which test for the presence of malarial parasites, mostly Plasmodium falciparum, in blood samples.  The national health departments of countries with a high prevalence of malaria have increasingly adopted the usage of RDTs.  Laboratory tests such as those using microscopy already exist for detecting malaria.  However, due to the scarcity of health facilities and personnel in many of these countries, these laboratory tests cannot be performed widely and readily; many febrile patients are excluded from the benefits of this new technology.   The usage of community health workers as a means of distributing the RDTs, which require no lab work, could remedy this barrier.  However, in most countries in sub-Saharan Africa, CHWs are barred from handling blood because of concerns about the accidental transmission of HIV.  Little research has been conducted to determine the ability of CHWs to effectively and safely administer RDTs.(1)

RDTs are important because, while presumptive treatment of fever with malarial treatments has led to a decline of malaria in many areas in African countries, misdiagnosis of fever can prove extremely harmful.  According to Mukanga et al. (2010), “With policies that recommend presumptive treatment of fever, health workers and caretakers are less likely to look for other causes of fever, leading to delay in appropriate treatment and higher case fatality rates among non-malaria fevers than in malaria fevers.”  Moreover, presumptive diagnosis may lead to the unnecessary, excessive use of expensive drugs and the development of drug resistance.  As a result, RDTs are being used as an alternative to microscopy testing to improve diagnosis of febrile children in areas where malaria is prevalent.   In order to administer the RDTs, the CHWs need to be given practical training, accurate information, and standardized guidelines to ensure the safety of their patients.  By training more CHWs in malarial diagnosis and treatment, CHWs could expand the number of patients reached, encourage and provide early treatment, and gain additional skills for managing this epidemic.(2)

Problems with the Use of RDTs

While RDTs are relatively simple to administer, they can deliver incorrect diagnoses if not administered in the appropriate manner.(3)  A false negative test from a RDT could prove fatal for children. In fact, in a study in Sudan, health workers prescribed drugs despite negative test results; the same problems with presumptive diagnosis could exist with this new technology as well. Moreover, some researchers argue that insufficient research exists to terminate the use of presumptive treatment.

In addition, cultural misconceptions concerning the purpose of the tests can inhibit their uptake.  For example, a facility in Tanzania found that some caregivers believed that the tests were for HIV.  Furthermore, there is a stigma surrounding the drawing of blood, especially blood draws from children.  Community members in the Mukanga et al. (2010) study expressed the concern that children could be infected with HIV when blood was drawn.  Others feared that the blood would be transferred to someone who could use it to bewitch them. 

Lastly, community members expressed their doubt in the ability of the CHWs to administer the test and to prescribe drugs with no professional medical training. Despite this lack of trust, community members expressed confidence in the CHWs’ ability to administer the RDTs after receiving adequate training. Specifically, other health workers noted that those administering the RDT would need to be knowledgeable enough to explain to patients why they are taking blood. For the effective administration of RDTs, CHWs must be adequately educated, trained, supported, and monitored.(4)

Case Study: Evaluation of RDT Delivery by CHWs in Zambia

The Harvey et al. (2008) study examined whether CHWs could effectively and safely deliver RDTs.  The first group of CHWs was only given the manufacturer’s instructions and performed 57% of the test steps accurately. The group that received pictorial instructions performed 80% of the steps correctly, and the group that received both pictorial instructions and a three-hour training session scored the highest with 90% of the steps performed correctly. While those who had received the manufacturer’s instructions read 54% of tests correctly, those with training and pictorial representations read 93% of tests correctly.  This study concluded that allowing untrained CHWs to administer and read tests based only on written instructions could prove dangerous to the communities served.  However, with adequate training and clear instructions, Harvey et al. (2008) concluded that the “Use of malaria rapid diagnostic tests by community health workers is potentially an effective alternative for malaria case management in areas with limited functional microscopy and limited health care personnel or facilities.” 

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Footnotes

(1) Harvey, Steven A., Larissa Jennings, Masela Chinyama, Fred Masaninga, Kurt Mulholland, and David R Bell. “Improving community health worker use of malaria rapid diagnostic tests in Zambia: package instructions, job aid and job aid-plus-training.”  Malaria Journal 7(2008): 160.

(2) Mukanga, David, James K Tibenderana, Juliet Kiguli, George W Pariyo, Peter Waiswa, Francis Bajunirwe, Brian Mutamba, Helen Counihan, Godfrey Ojiambo, and Karin Kallander. “Community acceptability of use of rapid diagnostic tests for malaria by community health workers in Uganda.”  Malaria Journal 9(2010): 203.

(3) Harvey, Steven A., Larissa Jennings, Masela Chinyama, Fred Masaninga, Kurt Mulholland, and David R Bell. “Improving community health worker use of malaria rapid diagnostic tests in Zambia: package instructions, job aid and job aid-plus-training.”  Malaria Journal 7(2008): 160.

(4) Mukanga, David, James K Tibenderana, Juliet Kiguli, George W Pariyo, Peter Waiswa, Francis Bajunirwe, Brian Mutamba, Helen Counihan, Godfrey Ojiambo, and Karin Kallander. “Community acceptability of use of rapid diagnostic tests for malaria by community health workers in Uganda.”  Malaria Journal 9(2010): 203