Impact of training in clinical and microscopy diagnosis of childhood malaria on antimalarial drug prescription and health outcome at primary health care level in Tanzania: a randomized controlled trial.
Impact of training in clinical and microscopy diagnosis of childhood malaria on antimalarial drug prescription and health outcome at primary health care level in Tanzania: a randomized controlled trial.
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坦桑尼亚初级卫生保健水平上，儿童疟疾临床和显微镜诊断培训对抗疟疾药物处方和健康结果的影响：一项随机对照试验。
DOI：
10.1186/1475-2875-7-199
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发表时间：
2008-10-02
期刊：
影响因子：
3
通讯作者：
Bjorkman A
中科院分区：
文献类型：
--
作者：
Ngasala B;Mubi M;Warsame M;Petzold MG;Massele AY;Gustafsson LL;Tomson G;Premji Z;Bjorkman A
根据寄生虫确诊的疟疾诊断开具抗疟药物对合理用药和发热性疾病的最佳结局至关重要。在初级卫生保健（PHC）机构中，采用聚类随机对照培训干预试验，评估了基于显微镜和基于临床的儿童疟疾诊断的影响。坦桑尼亚农村的16个初级保健设施被随机分配给对卫生工作人员进行临床算法加显微镜（第1组，n = 5）或仅临床算法（第2组，n = 5）或不进行培训（第3组，n = 6）的培训。在这些设施就诊的发热五岁以下儿童在7天后接受评估、治疗并安排随访。第0天仅在第1臂进行血液涂片，第7天在所有臂进行。主要结局是抗疟药物处方。其他结果包括抗生素处方和健康结果。采用PHC作为聚类水平的多水平回归模型来比较三个研究组的结果。在研究期间，分别有973、1 058和1 100名儿童参加了第一、第二和第三兵种。与ii组（95.3%）和III组（99.5%）相比，i组的抗疟药处方显著减少（61.3%）（P均< 0.001），而抗生素处方在两组之间无显著差异（分别为49.9%、54.8%和34.2%）。在第一阶段，99.1%的血液涂片读数呈阳性的儿童获得了抗疟疾处方，11.3%的血液涂片读数呈阴性的儿童也获得了抗疟疾处方。阳性读数的患者比阴性读数的患者更不可能得到处方抗生素（相对风险= 0.66,95%置信区间：0.55,0.72）。在第7天的随访中，与第3组相比，第1组报告症状的儿童较多，但出现疟疾寄生虫病的儿童较少（p = 0.049）。与参考水平相比，PHC显微镜读数的总体灵敏度为74.5%，特异性为59.0%，但两者在PHC之间差异很大。在初级保健设施中，基于显微镜的疟疾诊断减少了抗疟疾药物的处方，并似乎改善了对非疟疾发烧的适当管理，但发现显微镜读数的准确性存在重大差异。初级保健设施缺乏合格的实验室技术人员，培训时间相对较短，可能是造成这些缺陷的原因。本研究在Clinicaltrials.gov注册，标识符为NCT00687895。
Prescribing antimalarial medicines based on parasite confirmed diagnosis of malaria is critical to rational drug use and optimal outcome of febrile illness. The impact of microscopy-based versus clinical-based diagnosis of childhood malaria was assessed at primary health care (PHC) facilities using a cluster randomized controlled training intervention trial. Sixteen PHC facilities in rural Tanzania were randomly allocated to training of health staff in clinical algorithm plus microscopy (Arm-I, n = 5) or clinical algorithm only (Arm-II, n = 5) or no training (Arm-III, n = 6). Febrile under-five children presenting at these facilities were assessed, treated and scheduled for follow up visit after 7 days. Blood smears on day 0 were only done in Arm-I but on Day 7 in all arms. Primary outcome was antimalarial drug prescription. Other outcomes included antibiotic prescription and health outcome. Multilevel regression models were applied with PHC as level of clustering to compare outcomes in the three study arms. A total of 973, 1,058 and 1,100 children were enrolled in arms I, II and III, respectively, during the study period. Antimalarial prescriptions were significantly reduced in Arm-I (61.3%) compared to Arms-II (95.3%) and III (99.5%) (both P < 0.001), whereas antibiotic prescriptions did not vary significantly between the arms (49.9%, 54.8% and 34.2%, respectively). In Arm-I, 99.1% of children with positive blood smear readings received antimalarial prescriptions and so did 11.3% of children with negative readings. Those with positive readings were less likely to be prescribed antibiotics than those with negative (relative risk = 0.66, 95% confidence interval: 0.55, 0.72). On day 7 follow-up, more children reported symptoms in Arm-I compared to Arm-III, but fewer children had malaria parasitaemia (p = 0.049). The overall sensitivity of microscopy reading at PHC compared to reference level was 74.5% and the specificity was 59.0% but both varied widely between PHCs. Microscopy based diagnosis of malaria at PHC facilities reduces prescription of antimalarial drugs, and appears to improve appropriate management of non-malaria fevers, but major variation in accuracy of the microscopy readings was found. Lack of qualified laboratory technicians at PHC facilities and the relatively short training period may have contributed to the shortcomings. This study is registered at Clinicaltrials.gov with the identifier NCT00687895.