Volume 93, Issue 1
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Malaria treatment policy has changed from presumptive treatment to targeted “test and treat” (T&T) with malaria rapid diagnostic tests (RDTs) and artemisinin combination therapy (ACT). This transition involves changing behavior among health providers, meaning delays between introduction and full implementation are recorded in almost every instance. We investigated factors affecting successful transition, and suggest approaches for accelerating uptake of T&T. Records from 2000 to 2011 from health clinics in Senegal where malaria is mesoendemic were examined (96,166 cases). The study period encompassed the implementation of national T&T policy in 2006. Analysis showed that adherence to test results is the first indicator of T&T adoption and is dependent on accumulation of experience with positive RDTs (odds ratio [OR]: 0.55 [ ≤ 0.001], 95% confidence interval [CI]: 0.53–0.58). Reliance on tests for malaria diagnosis (rather than presumptive diagnosis) followed after test adherence is achieved, and was also associated with increased experience with positive RDTs (OR: 0.60 [ ≤ 0.001], 95% CI: 0.58–0.62). Logistic models suggest that full adoption of T&T clinical practices can occur within 2 years, that monitoring these behavioral responses rather than RDT or ACT consumption will improve evaluation of T&T uptake, and that accelerating T&T uptake by focusing training on adherence to test results will reduce overdiagnosis and associated health and economic costs in mesoendemic regions.

[open-access] This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Article metrics loading...

The graphs shown below represent data from March 2017
Loading full text...

Full text loading...



  1. World Health Organization, 2010. Guidelines for the Treatment of Malaria, 2nd ed. Geneva, Switzerland: World Health Organization. [Google Scholar]
  2. Reyburn H, Mbatia R, Drakeley C, Carnerio I, Mwakasungula E, Mwerinde O, Saganda K, Shao J, Kitua A, Olomi R, Greenwood BM, Whitty CJM, , 2004. Overdiagnosis of malaria in patients with severe febrile illness in Tanzania: a prospective study. BMJ 329: 1212.[Crossref] [Google Scholar]
  3. D'Acremont V, Kilowoko M, Kyungu E, Philipina S, Sangu W, Kahama-Maro J, Lengeler C, Cherpillod P, Kaiser L, Genton B, , 2014. Beyond malaria—causes of fever in outpatient Tanzanian children. N Engl J Med 370: 809817.[Crossref] [Google Scholar]
  4. World Health Organization, 2012. World Malaria Report 2014. Geneva, Switzerland: World Health Organization. [Google Scholar]
  5. Barat L, Chipipa J, Kolczak M, Sukwa T, , 1999. Does the availability of blood slide microscopy for malaria at health centers improve the management of persons with fever in Zambia? Am J Trop Med Hyg 60: 10241030. [Google Scholar]
  6. Reyburn H, Mbakilwa H, Mwangi R, Mwerinde O, Olomi R, Drakeley C, Whitty CJ, , 2007. Rapid diagnostic tests compared with malaria microscopy for guiding outpatient treatment of febrile illness in Tanzania: a randomized trial. BMJ 334: 403.[Crossref] [Google Scholar]
  7. Zurovac D, Midia B, Ochola SA, English M, Snow RW, , 2006. Microscopy and outpatient malaria case management among older children and adults in Kenya. Trop Med Int Health 11: 432440.[Crossref] [Google Scholar]
  8. Bisoffi Z, Sirima BS, Angheben A, Lodesani C, Gobbi F, Tinto H, Van den Ende J, , 2009. Rapid malaria diagnostic tests vs. clinical management of malaria in rural Burkina Faso: safety and effect on clinical decisions. A randomized trial. Trop Med Int Health 14: 491498.[Crossref] [Google Scholar]
  9. Brasseur P, Vaillant MT, Olliaro PL, , 2012. Anti-malarial drug safety information obtained through routine monitoring in a rural district of south-western Senegal. Malar J 11: 402.[Crossref] [Google Scholar]
  10. Graz B, Wilcox M, Szeless T, Rougemont A, , 2011. “Test and treat” presumptive treatment of malaria in high transmission situations? A reflection on the latest WHO guidelines. Malar J 10: 136.[Crossref] [Google Scholar]
  11. Uzochukwu BS, Onwujekwe E, Ezuma NN, Ezeoke OP, Ajuba MO, Sibeudu FT, , 2011. Improving rational treatment of malaria: perceptions and influence of RDTs on prescribing behaviour of health workers in southeast Nigeria. PLoS ONE 6: e14627.[Crossref] [Google Scholar]
  12. Ansah EK, Narh–Bana S, Epokor M, Akanpigbiam S, Quartey AA, Gyapong J, Whitty CJ, , 2010. Rapid testing for malaria in settings where microscopy is available and peripheral clinics where only presumptive treatment is available: a randomised controlled trial in Ghana. BMJ 340: c930.[Crossref] [Google Scholar]
  13. Msellem MI, Martensson A, Rotllant G, Bhattarai A, Stromberg J, Kahigwa E, Garcia M, Petzold M, Olumese P, Ali A, Bjorkman A, , 2009. Influence of rapid malaria diagnostic tests on treatment and health outcome in fever patients. Zanzibar: a crossover validation study. PLoS Med 6: e1000070.[Crossref] [Google Scholar]
  14. Yeboah–Antwi K, Pilingana P, Macleod WB, Semrau K, Siazeele K, Kalesha P, Hamainza B, Seidenberg P, Mazimba A, Sabin L, Kamholz K, Thea DM, Hamer DH, , 2010. Community case management of fever due to malaria and pneumonia in children under five in Zambia: a cluster randomized controlled trial. PLoS Med 7: e10000340.[Crossref] [Google Scholar]
  15. Drakeley C, Reyburn H, , 2009. Out with the old, in with the new: the utility of rapid diagnostic tests for malaria diagnosis in Africa. Trans R Soc Trop Med Hyg 103: 333337.[Crossref] [Google Scholar]
  16. Lubell Y, Reyburn H, Mbakilwa H, Mwangi R, Chonya S, Whitty CJ, Mills A, , 2008. The impact of response to the results of diagnostic tests for malaria: cost-benefit analysis. BMJ 336: 202205.[Crossref] [Google Scholar]
  17. Bruxvoort K, Kalolella A, Nchimbi H, Festo C, Taylor M, Thomson R, Cairns M, Thwing J, Kleinschmidt I, Goodman C, Kachur SP, , 2013. Getting antimalarials on target: impact of national roll-out of malaria rapid diagnostic tests on health facility treatment in three regions of Tanzania. Trop Med Int Health 18: 12691282.[Crossref] [Google Scholar]
  18. Thiam S, Thior M, Faye B, Ndiop M, Diouf ML, Diouf MB, Diallo I, Fall FB, Ndiaye JL, Albertini A, Lee E, Jorgensen P, Gaye O, Bell D, , 2011. Major reduction in anti-malarial drug consumption in Senegal after nation-wide introduction of malaria rapid diagnostic tests. PLoS ONE 6: e18419.[Crossref] [Google Scholar]
  19. Williams HA, Causer L, Metta E, Malila A, O'Reilly T, Abdulla S, Kachur SP, Bloland PB, , 2008. Dispensary level pilot implementation of rapid diagnostic tests: an evaluation of RDT acceptance and usage by providers and patients: Tanzania, 2005. Malar J 7: 239.[Crossref] [Google Scholar]
  20. Yukich JO, Bennett A, Albertini A, Incardona S, Moonga H, Chisha Z, Hamainza B, Miller JM, Keating J, Eisele TP, Bell D, , 2012. Reductions in artemisinin-based combination therapy consumption after the nationwide scale up of routine malaria rapid diagnostic testing in Zambia. Am J Trop Med Hyg 87: 437446.[Crossref] [Google Scholar]
  21. Ntoumi F, Vouvoungui JC, Ibara R, Laundry M, Sidibé A, , 2013. Malaria burden and case management in the Republic of Congo: limited use and application of rapid diagnostic tests results. BMC Public Health 13: 135.[Crossref] [Google Scholar]
  22. Agnamey P, Brasseur P, Cisse M, Gaye O, Dumoulin J, Rigal J, Taylor WR, Olliaro P, , 2005. Economic evaluation of a policy change from single-agent treatment for suspected malaria to artesunate-amodiaquine for microscopically confirmed uncomplicated falciparum malaria in the Oussouye District of south-western Senegal. Trop Med Int Health 10: 926933.[Crossref] [Google Scholar]
  23. Brasseur P, Badiane M, Cisse M, Agnamey P, Vaillant MT, Olliaro PL, , 2011. Changing patterns of malaria during 1996–2010 in an area of moderate transmission in southern Senegal. Malar J 10: 203.[Crossref] [Google Scholar]
  24. Brasseur P, Agnamey P, Gaye O, Vaillant M, Taylor W, Olliaro P, , 2007. Efficacy and safety of artesunate plus amodiaquine in routine use for the treatment of uncomplicated malaria in Casamance, southern Senegal. Malar J 6: 150.[Crossref] [Google Scholar]
  25. Brasseur P, Agnamey P, Gaye O, Cisse M, Badiane M, Vaillant M, Taylor WR, Olliaro P, , 2009. Dosing accuracy of artesunate and amodiaquine as treatment for falciparum malaria in Casamance, Senegal. Trop Med Int Health 14: 7987.[Crossref] [Google Scholar]
  26. Patil A, Huard D, Fonnesbeck C, , 2010. PyMC 2.0: Bayesian stochastic modelling in Python. J Stat Softw 35: 181.[Crossref] [Google Scholar]
  27. R Core Team, 2013. R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing. Available at: http://www.R-project.org/. [Google Scholar]
  28. Burnham K, Anderson D, , 1998. Model Selection and Inference: A Practical Information—Theoretic Approach. New York, NY: Springer-Verlag.[Crossref] [Google Scholar]
  29. Bastiaens GJ, Bousema T, Leslie T, , 2014. Scale-up of malaria rapid diagnostic tests and artemisinin-based combination therapy: challenges and perspectives in sub-Saharan Africa. PLoS Med 11: e1001590.[Crossref] [Google Scholar]
  30. Zurovac D, Githinji S, Memusi D, Kigen S, Machini B, Muturi A, Otieno G, Snow RW, Nyandigisi A, , 2014. Major improvements in the quality of malaria case-management under the “Test and Treat” policy in Kenya. PLoS ONE 9: e92782.[Crossref] [Google Scholar]
  31. Nyandigisi A, Memusi D, Mbithi A, Ang'wa N, Shieshia M, Muturi A, Sidoi R, Githinjo S, Juma E, Zurovac D, , 2011. Malaria case-management following change of policy to universal parasitological diagnosis and targeted artemisinin-based combination therapy in Kenya. PLoS ONE 6: e24781.[Crossref] [Google Scholar]
  32. Van Boeckel TP, Gandra S, Ashok A, Caudron Q, Grenfell BT, Levin SA, Laxminarayan R, , 2014. Global antibiotic consumption 2000 to 2010: an analysis of national pharmaceutical sales data. Lancet Infect Dis 14: 742750.[Crossref] [Google Scholar]
  33. Masanja IM, Selemani M, Amuri B, Kajungu D, Khatib R, Kachur SP, Skarbinski J, , 2012. Increased use of malaria rapid diagnostic tests improves targeting of anti-malarial treatment in rural Tanzania: implications for nationwide rollout of malaria rapid diagnostic tests. Malar J 11: 221.[Crossref] [Google Scholar]
  34. Njogu J, Akhwale W, Hamer DH, Zurovac D, , 2008. Health facility and health worker readiness to deliver new national treatment policy for malaria in Kenya. East Afr Med J 85: 213221.[Crossref] [Google Scholar]
  35. Abba K, Deeks JJ, Olliaro P, Naing CM, Jackson SM, Takwoingi Y, Donegan S, Garner P, , 2011. Rapid diagnostic tests for diagnosing uncomplicated P. falciparum malaria in endemic countries. Cochrane Database Syst Rev 7: CD008122. [Google Scholar]
  36. Chandler CI, Chonya S, Boniface G, Juma K, Reyburn H, Whitty CJ, , 2008. The importance of context in malaria diagnosis and treatment decisions—a quantitative analysis of observed clinical encounters in Tanzania. Trop Med Int Health 13: 11311142.[Crossref] [Google Scholar]

Data & Media loading...

Supplementary PDF

  • Received : 19 Sep 2014
  • Accepted : 22 Jan 2015
  • Published online : 08 Jul 2015

Most Cited This Month

This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error