Use and Limitations of Malaria Rapid Diagnostic Testing in Sub-Saharan Africa: a Systematic Review & Longitudinal Study in Western Kenya

The World Health Organization recommends parasitological confirmation of malaria prior to treatment. Malaria rapid diagnostic tests (RDTs) represent simple, mobile diagnostic technologies that are used in a variety of contexts to overcome limitations of other techniques. Malaria RDTs increase the availability and feasibility of accurate diagnoses and may result in improved quality of care. Though RDTs are used in a variety of contexts, no studies have compared how well or effectively RDTs are used across different contexts and types of care providers. This report is composed of two related works: a systematic review and a longitudinal study. The systematic review was conducted to describe the diagnostic use of RDTs in formal health facilities, the community, drug shops and schools. A comprehensive search of the Pubmed database was conducted to evaluate RDT execution, test accuracy, or adherence to test results in sub-Saharan Africa. Overall, RDTs were performed safely and effectively by community health workers provided they receive proper training, but analogous information was largely absent for formal health care workers. Tests were generally accurate across contexts, except for in drug shops where lower specificities were observed. Adherence treatment guidelines based on RDT results was higher among drug shop vendors and community health workers, while adherence was more variable among formal health care workers, most notably with negative test results. Malaria RDTs are generally used well, though compliance with recommended treatment based on test results is variable – especially in the formal health care sector. However, their use by community health workers (CHWs) remains in question due concerns about long-term trends relating to blood safety, the interpretation of test results, and adherence to treatment protocols. In addition to the systematic review, a longitudinal study was conducted to determine if CHWs maintained their competency at conducting RDTs over a 12-month timeframe, and if this competency varied with various socio-demographic measures. 103 CHWs in Kenya were recruited into longitudinal study to compare RDT execution at the time of training and 12 months post-training. Community health workers performed RDTs at acceptable levels, with at least 80% of CHWs completing 18 of the 22 steps correctly. Quality of performance did not decrease over the 12 months. Socio-demographic characteristics including being younger than 50 years of age, and previous experiences with malaria RDTs were correlated with better performance over time. Community health workers provided very accurate interpretation of RDT results, especially when considering only strong-positive and negative test results. Training in using Deki reader devices was associated with better performance in interpreting RDT results. In conclusion, CHWs perform RDTs sufficiently, maintain competency for at least 12 months, and better performance can be associated with certain characteristics. The results of both studies hold important implications for health policy and future multidisciplinary research.