Consequences of restricting antimalarial drugs to rapid diagnostic test‐positive febrile children in southwest Nigeria

Objectives: To investigate the consequence of restricting antimalarial treatment to febrile children that test positive to a malaria rapid diagnostic test (MRDT) only in an area of intense malaria transmission. Methods: Febrile children aged 3‐59 months were screened with an MRDT at health facilities in south‐west Nigeria. MRDT‐positive children received artesunate‐amodiaquine (ASAQ), while MRDT‐negative children were treated based on the clinical diagnosis of non‐malaria febrile illness. The primary endpoint was the risk of developing microscopy‐positive malaria within 28 days post treatment. Results: 309 (60.5%) of 511 children were MRDT‐positive while 202(39.5%) were MRDT‐negative at enrolment. 18.5% (50/275) of MRDT‐positive children and 7.6% (14/184) of MRDT‐negative children developed microscopy positive malaria by day 28 post treatment (ρ=0.001). The risk of developing clinical malaria by Day 28 post‐treatment was higher among the MRDT‐positive group than the MRDT‐negative group (adjusted OR 2.74; 95% CI, 1.4, 5.4). A higher proportion of children who were MRDT‐positive at enrolment were anaemic on day 28 compared with the MRDT‐negative group (12.6% versus 3.1%; ρ = 0.001). Children in the MRDT‐negative group made more unscheduled visits because of febrile illness than those in MRDT‐positive group (23.2% vs 12.0%; ρ = 0.001).Conclusion: Restricting ACT treatment to MRDT‐positive febrile children only did not result in significant adverse outcomes. However, the risk of re‐infection within 28 days was significantly higher among MRDT‐positive children despite ASAQ treatment. A longer‐acting ACT may be needed as the first line drug of choice for treating uncomplicated malaria in high transmission settings to prevent frequent reinfections.