Do Clinicians in Areas of Declining Malaria Transmission Adhere to Malaria Diagnosis Guidelines? A Cross-sectional Study From Kampala, Uganda.

Abstract

Abstract; Background: Uganda clinical management guidelines recommend a malaria laboratory test in all patients presenting with fever, and only those with a positive test receive antimalarial treatment. However, the current practice in areas with declining malaria transmission remains unknown. We assessed the clinicians’ diagnostic practices, the factors associated with recommending a test, and the risk of missing a malaria case when a test is not recommended in patients presenting with fever in Kampala, an area of declining malaria transmission in Uganda. Methods: Between January and March 2020, 383 participants aged > 12 years and presenting to Kisenyi Health Centre IV with fever were enrolled in the study. A questionnaire was administered during exit interviews, routine diagnostic practices were recorded from participant clinical notes, and a research blood slide was obtained for later reading. Results: Of the enrolled participants, 356 (93%) had a malaria diagnostic test recommended by the managing clinician. Factors associated with increasing prevalence of having a test recommended included; history of overnight travel (adjusted prevalence ratio [aPR] 1.07, 95% confidence interval [CI] 1.02 – 1.13, p=0.011), being married (aPR=1.07, 95% CI 1.01 – 1.13, p=0.022), and having tertiary education (aPR=1.09 95% CI 1.01 – 1.17, p=0.031). Among the 27 participants where a malaria diagnostic test was not recommended, 4 (14.8%) had a positive study smear. Conclusion: Despite having significant declines in malaria transmission in Kampala in the last decade, clinicians at the study health facility highly adhered to the clinical management guidelines, recommending a malaria test in almost all patients presenting with fever. However, a significant proportion of malaria cases was missed when a test was not recommended. These results highlight the importance of laboratory testing for malaria in all patients who present with fevers and live in endemic setting even when transmission has significantly declined.