• Evelyn K Ansah, Solomon Narh-Bana, Harriet Affran-Bonful, Constance Bart-Plange, Bonnie Cundill, Margaret Gyapong, and Christopher J M Whitty.
• Research and Development Division, Ghana Health Service, PO Box MB-190, Accra, Ghana Ansahekdr@yahoo.co.uk.
• BMJ. 2015 Jan 1;350:h1019.

ObjectiveTo examine the impact of providing rapid diagnostic tests for malaria on fever management in private drug retail shops where most poor rural people with fever present, with the aim of reducing current massive overdiagnosis and overtreatment of malaria.DesignCluster randomized trial of 24 clusters of shops.SettingDangme West, a poor rural district of Ghana.ParticipantsShops and their clients, both adults and children.InterventionsProviding rapid diagnostic tests with realistic training.Main Outcome MeasuresThe primary outcome was the proportion of clients testing negative for malaria by a double-read research blood slide who received an artemisinin combination therapy or other antimalarial. Secondary outcomes were use of antibiotics and antipyretics, and safety.ResultsOf 4603 clients, 3424 (74.4%) tested negative by double-read research slides. The proportion of slide-negative clients who received any antimalarial was 590/1854 (32%) in the intervention arm and 1378/1570 (88%) in the control arm (adjusted risk ratio 0.41 (95% CI 0.29 to 0.58), P<0.0001). Treatment was in high agreement with rapid diagnostic test result. Of those who were slide-positive, 690/787 (87.8%) in the intervention arm and 347/392 (88.5%) in the control arm received an artemisinin combination therapy (adjusted risk ratio 0.96 (0.84 to 1.09)). There was no evidence of antibiotics being substituted for antimalarials. Overall, 1954/2641 (74%) clients in the intervention arm and 539/1962 (27%) in the control arm received appropriate treatment (adjusted risk ratio 2.39 (1.69 to 3.39), P<0.0001). No safety concerns were identified.ConclusionsMost patients with fever in Africa present to the private sector. In this trial, providing rapid diagnostic tests for malaria in the private drug retail sector significantly reduced dispensing of antimalarials to patients without malaria, did not reduce prescribing of antimalarials to true malaria cases, and appeared safe. Rapid diagnostic tests should be considered for the informal private drug retail sector.Registration Clinicaltrials.gov NCT01907672.© Ansah et al 2015.

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