Fever is a common presenting complaint of ill children all over the world. Until recently in Sub-Saharan Africa, fever was synonymous with a presumed diagnosis of malaria. However, malaria is not the only common cause of fever or serious febrile illness (FI) in Sub-Saharan Africa, and the widespread success of malaria control has reduced the region’s share of the FI burden. In 2008, 16 percent of the 4.2 million deaths of children in this region were attributed to malaria, 18 percent to pneumonia, and 19 percent to diarrhea (Black and others 2010).
Historically, the response to fever in children in Sub-Saharan Africa was presumptive antimalarial treatment. Cheap, safe, and efficacious antimalarial medications were widely available, and the only method of diagnosis—microscopy—was scarce. The historically inexpensive medicines—chloroquine (CQ) and sulfadoxine/pyrimethamine (SP)—succumbed to the development of drug-resistant malaria parasites; since 2000, these drugs have been replaced as first-line treatment by the more expensive but highly efficacious artemisinin-based combination therapies (ACTs). Rapid diagnostic tests (RDTs) that do not require laboratory facilities or technical training have become available. In light of these two developments, in 2006 the World Health Organization (WHO) recommended that parasitological confirmation precede malaria treatment except in children in high-transmission settings (WHO 2006), and in 2010 the WHO made the recommendation universal, even for highly exposed children (WHO 2010). Most Sub-Saharan African countries have officially adopted this policy, although few have been able to implement it fully.
The major advantages claimed for pretreatment confirmation of malaria are the following:
Prevention of unnecessary ACT use, which can save money and reduce drug pressure that could lead to resistance
More appropriate treatment of nonmalaria fevers
Improved surveillance and better data for planning.
The appropriateness of the WHO test-and-treat policy is clear in low-endemicity settings; it is not so clear in many high-transmission settings, where all of the supposed advantages have been challenged (D’Acremont and others 2009; English and others 2009; Graz and others 2011).
Many economic evaluations have compared malaria RDTs to presumptive treatment and microscopy, using cost-effectiveness methods and measuring the following:
Cost per correctly diagnosed malaria case (Bualombai and others 2003; Chanda, Castillo-Riquelme, and Masiye 2009; de Oliveira, de Castro Gomes, and Toscano 2010; Fernando and others 2004; Rolland and others 2006)
Cost per correctly diagnosed and treated malaria case (Batwala and others 2011; Chanda and others 2011; Lubell and others 2007; Ly and others 2010; Rosas Aguirre, Llanos Zavalaga, and Trelles de Belaunde 2009; Willcox and others 2009; Zikusooka, McIntyre, and Barnes 2008)
Cost per disability-adjusted life year (DALY) averted (Shillcutt and others 2008).
Others have used cost-benefit analysis (Bisoffi and others 2011; Lubell, Hopkins, and others 2008; Lubell, Reyburn, and others 2008).
Most evaluations have found that an RDT test-and-treat approach performs better than a microscopy test-and-treat approach or presumptive treatment below a certain level of malaria endemicity (Batwala and others 2011; Bisoffi and others 2011; Bualombai and others 2003; Chanda, Castillo-Riquelme, and Masiye 2009; Hansen and others 2015; Ly and others 2010; Mosha and others 2010; Msellem and others 2009; Rolland and others 2006; Rosas Aguirre, Llanos Zavalaga, and Trelles de Belaunde 2009; Shillcutt and others 2008; Uzochukwu and others 2009; Zikusooka, McIntyre, and Barnes 2008; Zurovac and others 2008). Microscopy performed better than RDT in Brazil (de Oliveira, de Castro Gomes, and Toscano 2010), Sri Lanka for Plasmodium vivax (Fernando and others 2004), and one high-transmission setting (Willcox and others 2009) and about equivalent to RDT in Ghana (Ansah and others 2013).
The most influential factors affecting the results are malaria transmission intensity (Lubell, Hopkins, and others 2008; Zurovac and others 2008), cost and accuracy of the RDTs (Lubell, Hopkins, and others 2008), age (Zikusooka, McIntyre, and Barnes 2008), season (Bisoffi and others 2011), and response to negative test results (Bisoffi and others 2011; Lubell, Reyburn, and others 2008).
The analysis in this chapter assesses the potential cost-effectiveness of RDTs and their role in treatment strategies for overall FI management in children under age five years, taking into account transmission intensity, treatment setting, and relative availability of antibiotic treatment (or no drug treatment) for nonmalaria FI. It also examines the impact of the availability of different levels of diagnosis on optimal FI management strategy.
© 2017 International Bank for Reconstruction and Development / The World Bank.