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Antimalarial treatment may not be required for all febrile children
Björkman A. Clin Infect Dis. 2010;51:512-514.
D’Acremont V. Clin Infect Dis. 2010;51:506-511.
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Rapid diagnostic tests for malaria may render the blanket policy of administering antimalarial treatment to all young, febrile children in highly endemic regions unnecessary, according to recent data.
To assess the safety of withholding antimalarials in febrile children with negative rapid diagnostic tests for malaria (RDTm), researchers from several institutions conducted a prospective, two-arm, longitudinal study. Study sites included the Buguruni Health Center of Ilala Municipality in moderately endemic Dar es Salaam, Tanzania, and a local health facility in the highly endemic village of Signal in Kilombero Valley, Tanzania.
Clinicians used an RDTm to evaluate febrile children presenting to the health center for malaria. They did not prescribe antimalarials to children with negative results but usually prescribed them antibiotics. Follow-up was conducted 7 days after a child’s initial visit to assess health status and record visits to other facilities. Children with positive tests received treatment with a first-line antimalarial, such as artemether-lumefantrine, and also underwent 7-day follow-up.
Three hundred children with a median age of 28 months presenting to the Buguruni health center were included in the analysis. All children had a history of fever, and the axillary temperature upon presentation was at least 37.5ºC in 39% of children.
Fourteen percent of these children had positive RDTm results and initiated antimalarial treatment with either artemether-lumefantrine or oral quinine, the researchers said. Thirty-two percent of those with positive tests also received an antibiotic.
In Signal, 700 children with a median age of 24 months who had a history of fever were included in the analysis. Fifty-one percent had positive RDTm results, according to the researchers, with 96% receiving artemisinin-lumefantrine therapy and 18% also receiving antibiotics. Most of those with negative tests were also prescribed antibiotics.
Results indicated that 8% of all children with negative RDTm tests visited the health center with persisting fever before the 7-day follow-up period concluded. Ninety-seven percent, however, were cured by day 7. Only 3% of children with positive RDTm results spontaneously returned to the facility before the end of the follow-up period, the researchers said, with 98% being cured by day 7.
Of the children with negative RDTm tests, 55 returned to the health center before day 7 or were not cured by day 7. Three had positive RDTm results upon retesting but did not experience complications related to disease onset. All cases occurred in Signal.
In an accompanying editorial, Anders Björkman, MD, PhD, of Karolinska University Hospital in Stockholm, Sweden, and Andreas Mårtensson, MD, PhD, of Karolinska Institutet in Stockholm, Sweden, commented on the study’s implications.
“The present study by d’Acremont et al provides evidence of safety and support of the new paradigm in management of febrile children at the peripheral health care level in Sub-Saharan Africa, namely improved targeting of antimalarial treatment based on parasitological diagnosis and, more specifically, based on the use of RDT in this context,” they wrote.
Björkman and Mårtensson, however, also noted the importance of larger studies in different epidemiological areas with different health care levels to confirm these study findings.
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