A cluster-randomised trial of health worker and community interventions to improve adherence to national guidelines for the use of ACTs in Tanzania: The TACT trial: (Targeting ACT)

Tanga and Kilimanjaro Regions of N.E. Tanzania

Dr. Hugh Reyburn, LSHTM

I am a clinical epidemiologist working for LSHTM based in the Joint Malaria Programme in Tanzania. JMP is a 4-partner collaboration including local partners of the National Institute for Medical Research in Tanzania and Kilimanjaro Christian Medical Centre.

Over the last 9 years I have been conducting malaria-related research in Tanzania including epidemiological studies of non-severe and severe malaria at different transmission intensities, studies of malaria diagnosis using RDTs and clinical trials for both severe and non-severe malaria.  In 2003 we conducted a study of how prescribers use RDT results in their prescribing of antimalarials and this forms one of the background studies to the current TACT trial.

Our work is closely linked to the National Malaria Control Programme in Tanzania and I have continued involvement in the Malaria Diagnosis Working Group under MOH in Tanzania.

Renata Mandike, Deputy Director, National Malaria Control Programme,Tanzania.

Raimos Olomi, Professor of Paediatrics KCMC, Tanzania,

Steven Magesa, National Institute for Medical Research, Amani Centre, Tanga

Christopher Whitty, Professor of International Health, LSHTM

Overdiagnosis of malaria is widespread in health facilities throughout Africa, a situation that is unsustainable given the relatively high cost of artemisinin combination therapy (ACTs) compared to older antimalarials. In addition it often denies patients treatment for their actual illness and generates unreliable data for health planners. For these reasons the National Malaria Control Programme introduced revised guidelines for malaria diagnosis and treatment in 2006 restricting the recommendation for antimalarial treatment in patients over the age of 5 years to those with a positive blood slide or malaria rapid diagnostic tests (RDTs) result. To support this, RDTs will be introduced into primary care health facilities in Tanzania starting in 2009.

The high accuracy of current rapid diagnostic tests (RDTs) provides the potential for a cost-effective solution to the problem of malaria overdiagnosis. However, RDTs with revised guidelines to restrict malaria diagnoses to RDT-positive patients have been unsuccessful unless accompanied by unsustainable levels of supervision and training.

Several studies have now documented 2 primary problems with RDTs. Firstly, that healthworkers frequently prescribe antimalarial drugs for patients who have tested negative using RDTs and secondly that in spite of the availability of RDTs prescribers continue to prescribe presumptively for malaria. The reasons for these practices are complex and poorly understood. There is an urgent need to identify a sustainable and cost-effective way to improve ACT prescribing with RDTs.

The TACT trial aims to identify such an intervention that may be useful both in improving case management of patients with malaria and in improving treatment of non-malarial febrile illness.

We presented data from a number of studies including the C-FIT study under ACT consortium at the NMFI Symposium at the ASTMH annual meeting in Philadelphia in December 2011.  The meeting was well attended and demonstrated currently strong interest in how malaria RDTs are revealing patients whose diagnosis and treatment remain uncertain in many settings.  In addition it was clear from presentations and questions from the floor that the problem of how to improve prescriber use of RDTs remains a major public health challenge.

Similarly, the Joint Malaria Programme annual scientific meeting in November 2011 was well attended by senior staff from MOH and NMCP in Tanzania who showed great interest in the TACT trial and how its results could influence national policy in Tanzania.