To assess progress in the scale-up of rapid diagnostic tests and artemisinin-based combination therapies (ACTs) across Africa, malaria control programs have increasingly relied on standardized national household surveys to determine the proportion of children with a fever in the past 2 wk who received an effective antimalarial within 1–2 d of the onset of fever. Here, the validity of caregiver recall for measuring the primary coverage indicators for malaria diagnosis and treatment of children <5 y old is assessed.
Methods and Findings
A cross-sectional study was conducted in five public clinics in Kaoma District, Western Provence, Zambia, to estimate the sensitivity, specificity, and accuracy of caregivers' recall of malaria testing, diagnosis, and treatment, compared to a gold standard of direct observation at the health clinics. Compared to the gold standard of clinic observation, for recall for children with fever in the past 2 wk, the sensitivity for recalling that a finger/heel stick was done was 61.9%, with a specificity of 90.0%. The sensitivity and specificity of caregivers' recalling a positive malaria test result were 62.4% and 90.7%, respectively. The sensitivity and specificity of recalling that the child was given a malaria diagnosis, irrespective of whether a laboratory test was actually done, were 76.8% and 75.9%, respectively. The sensitivity and specificity for recalling that an ACT was given were 81.0% and 91.5%, respectively.
Based on these findings, results from household surveys should continue to be used for ascertaining the coverage of children with a fever in the past 2 wk that received an ACT. However, as recall of a malaria diagnosis remains suboptimal, its use in defining malaria treatment coverage is not recommended.
Please see later in the article for the Editors' Summary
The World Health Organization estimates that there are over 200 million cases of malaria each year, with nearly 1 million deaths. The majority of these deaths are among children living in sub-Saharan Africa, and Plasmodium falciparum is the parasite responsible. Malaria transmission can be prevented by insect control measures, and current treatment regimens use antimalarial drugs. Recently, the use of highly effective artemisinin-based combination treatments (ACTs) has significantly reduced the deaths and disability caused by malaria. To avoid drug overuse and the development of parasite resistance to ACTs, the World Health Organization recommends that before treatment with ACTs, a laboratory test to confirm malaria should be performed. Rapid diagnostic tests (RDTs) allow health workers to diagnose malaria in settings lacking laboratory facilities, thus providing a method for improving malaria diagnosis and reducing the overuse of ACTs.
Why Was This Study Done?
The success of RDTs and ACTs across Africa in combating malaria is measured by standardized national household surveys. These surveys assess the proportion of children with a fever in the past two weeks who have received an antimalarial treatment within 1–2 days of the onset of fever. The surveys do not distinguish between treatment of a suspected malaria case and one that was laboratory confirmed. Due to the availability and scale-up of RDTs in many African countries, caregivers and mothers are also now asked in national surveys if the child was tested for malaria, but are not usually asked for the result of any malaria diagnostic test given. Knowing whether a child has been diagnosed with malaria is necessary to construct a better indicator of what proportion of children receive an effective and appropriate antimalarial within the appropriate treatment time frame. This indicator is important because it provides more insight into the current diagnosis and treatment policies in most African countries.
Biased coverage estimates for diagnosis and treatment may result from these types of surveys because survey questions to caregivers of children concerning fever in the past two weeks, treatment-seeking behavior, and malaria diagnosis and treatment can be particularly subject to sources of error and bias. Despite this possibility, these indicators and surveys have not been checked against direct observation of the children to assess the validity of caregivers' recall and household surveys to gauge appropriate treatment of malaria in children.
What Did the Researchers Do and Find?
In this study, the authors investigated the validity of caregiver recall of malaria diagnosis and treatment in children under five years old. The authors did a cross-sectional study of five public clinics in Kaoma District, Western Provence, Zambia, to estimate the sensitivity, specificity, and accuracy of caregivers' recall of malaria testing, malaria diagnosis, and antimalarial treatment, and compared the surveys to direct observation at the health clinics. The results from this study demonstrate low sensitivity of caregiver recall of malaria diagnostic use, test results, and malaria diagnosis among children who had a fever in the past two weeks. However, the accuracy of caregiver recall that a child received an ACT was relatively high in this setting. This suggests that the current indicator for measuring the coverage of children with a fever in the past two weeks who received an ACT can be applied in similar settings, and may be useful for estimating infection and treatment over time.
What Do These Findings Mean?
These findings suggest that results from household surveys are accurate for obtaining information about the coverage of children with a fever in the past two weeks that receive an ACT. However, as caregiver recall of a malaria diagnosis is not highly sensitive, the authors suggest that malaria diagnosis from caregiver recall in household surveys is not recommended for defining malaria treatment coverage.
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001417.
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