***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: In a cluster r and omized trial , Kojo Yeboah-Antwi and colleagues find that integrated management of malaria and pneumonia in children under five by community health workers is both feasible and effective Background In tropical Africa , where malaria is highly endemic , low grade infections are asymptomatic and the diagnosis of clinical malaria is usually based on parasite density . Here we investigate how changes in malaria control and endemicity modify diagnostic criteria of Plasmodium falciparum attacks . Methods and Findings Parasitological and clinical data from the population of Dielmo , Senegal , monitored during 20 years , are analyzed in a r and om-effect logistic regression model to investigate the relationship between the level of parasitemia and risk of fever . Between 1990 and 2010  , P. falciparum prevalence in asymptomatic persons declined from 85 % to 1 % in children 0–3 years and from 34 % to 2 % in adults ≥50 years . Thresholds levels of parasitemia for attributing fever episodes to malaria decreased by steps in relation to control policies . Using baseline threshold during following periods underestimated P. falciparum attacks by 9.8–20.2 % in children and 18.9–40.2 % in adults . Considering all fever episodes associated with malaria parasites as clinical attacks overestimated P. falciparum attacks by 42.2–68.5 % in children and 45.9–211.7 % in adults . Conclusions Malaria control modifies in all age-groups the threshold levels of parasitemia to be used for the assessment of malaria morbidity and to guide therapeutic decisions . Even under declining levels of malaria endemicity , the parasite density method must remain the reference method for distinguishing malaria from other causes of fever and assessing trends in the burden of malaria Objective In 2010 , the World Health Organization ( WHO ) published up date d guidelines emphasizing and exp and ing recommendations for a parasitological confirmation of malaria before treating with antimalarials . This study aim ed to assess differences in historic ( 2007–2008 ) ( cohort 1 ) and recent ( 2011–2012 ) ( cohort 2 ) hospital cohorts in the diagnosis and treatment of febrile illness in a low malaria prevalence area of northern Tanzania . Material s and Methods We analyzed data from two prospect i ve cohort studies that enrolled febrile adolescents and adults aged ≥13 years . All patients received quality -controlled aerobic blood cultures and malaria smears . We compared patients ' discharge diagnoses , treatments , and outcomes to assess changes in the treatment of malaria and bacterial infections . Results In total , 595 febrile in patients were enrolled from two referral hospitals in Moshi , Tanzania . Laboratory-confirmed malaria was detected in 13 ( 3.2 % ) of 402 patients in cohort 1 and 1 ( 0.5 % ) of 193 patients in cohort 2 ( p = 0.041 ) . Antimalarials  were prescribed to 201 ( 51.7 % ) of 389 smear-negative patients in cohort 1 and 97 ( 50.5 % ) of 192 smear-negative patients in cohort 2 ( p = 0.794 ) . Bacteremia was diagnosed from st and ard blood culture in 58 ( 14.5 % ) of 401 patients in cohort 1 compared to 18 ( 9.5 % ) of 190 patients in cohort 2 ( p = 0.091 ) . In cohort 1 , 40 ( 69.0 % ) of 58 patients with a positive blood culture received antibacterials  compared to 16 ( 88.9 % ) of 18 patients in cohort 2 ( p = 0.094 ) . In cohort 1 , 43 ( 10.8 % ) of the 399 patients with known outcomes died during hospitalization compared with 12 ( 6.2 % ) deaths among 193 patients in cohort 2 ( p = 0.073 ) . Discussion In a setting of low malaria transmission , a high proportion of smear-negative patients were diagnosed with malaria and treated with antimalarials despite up date d WHO guidelines on malaria treatment . Improved laboratory diagnostics for non-malaria febrile illness might help to curb this practice Background Early diagnosis and prompt , effective treatment of uncomplicated malaria is critical to prevent severe disease , death and malaria transmission . We assessed the impact of rapid malaria diagnostic tests ( RDTs ) by community health workers ( CHWs ) on provision of artemisinin-based combination therapy ( ACT ) and health outcome in fever patients . Methodology /Principal Findings Twenty-two CHWs from five villages in Kibaha District , a high-malaria transmission area in Coast Region , Tanzania , were trained to manage uncomplicated malaria using RDT aided diagnosis or clinical diagnosis ( CD ) only . Each CHW was r and omly assigned to use either RDT or CD the first week and thereafter alternating weekly . Primary outcome was provision of ACT and main secondary outcomes were referral rates and health status by days 3 and 7 . The CHWs enrolled 2930 fever patients during five months of whom 1988 ( 67.8 % ) presented within 24 hours of fever onset . ACT was provided to 775 of 1457 ( 53.2 % ) patients during RDT weeks and to 1422 of 1473 ( 96.5 % ) patients during CD weeks ( Odds Ratio ( OR ) 0.039 , 95 % CI 0.029–0.053 ) . The CHWs adhered to the RDT results in 1411 of 1457 ( 96.8 % , 95 % CI 95.8–97.6 ) patients . More patients were referred on inclusion day during RDT weeks ( 10.0 % ) compared to CD weeks ( 1.6 % ) . Referral during days 1–7 and perceived non-recovery on days 3 and 7 were also more common after RDT aided diagnosis . However , no fatal or severe malaria occurred among 682 patients in the RDT group who were not treated with ACT , supporting the safety of withholding ACT to RDT negative patients . Conclusions / Significance RDTs in the h and s of CHWs may safely improve early and well-targeted ACT treatment in malaria patients at community level in Africa . Trial registration Clinical Trials.gov Objectives Parasitological confirmation of malaria prior to treatment is recommended for patients of all ages , with malaria rapid diagnostic tests ( mRDTs ) an important tool to target artemisinin-based combination therapies ( ACTs ) to patients with malaria . To evaluate the impact on case management practice s of routine government implementation of mRDTs , we conducted large-scale health facility surveys in three regions of Tanzania before and after mRDT roll-out . Methods Febrile patients at r and omly selected health facilities were interviewed about care received at the facility , and blood sample s were collected for reference blood smears . Health facility staff were interviewed about their qualifications and availability of malaria diagnostics and drugs . Results The percentage of febrile patients tested for malaria at the facility increased from 15.8 % in 2010 to 54.9 % in 2012 . ACTs were obtained by 65.8 % of patients positive by reference blood smear in 2010 and by 50.2 % in 2012 ( P = 0.0675 ) ; no antimalarial was obtained by 57.8 % of malaria-negative patients in 2010 and by 82.3 % in 2012 ( P < 0.0001 ) . Overall , ACT use decreased ( 39.9–21.3 % , P < 0.0001 ) and antibiotic use increased ( 31.2–48.5 % , P < 0.0001 ) . Conclusion Roll-out of mRDTs in Tanzania dramatically improved diagnostic testing for malaria and reduced overuse of ACTs for patients without parasitemia . However , post – roll-out almost 50 % of febrile patients did not receive a diagnostic test , and almost 50 % of patients testing positive did not receive ACTs . Stock-outs of ACTs and mRDTs were important problems . Further investigation is needed to determine reasons for not providing ACTs to patients with malaria and potential for inappropriate antibiotic use Background Presumptive treatment of all febrile patients with anti-malarials leads to massive over-treatment . The aim was to assess the effect of implementing malaria rapid diagnostic tests ( m RDTs ) on prescription of anti-malarials in urban Tanzania . Methods The design was a prospect i ve collection of routine statistics from ledger books and cross-sectional surveys before and after intervention in r and omly selected health facilities ( HF ) in Dar es Salaam , Tanzania . The participants were all clinicians and their patients in the above health facilities . The intervention consisted of training and introduction of m RDTs in all three hospitals and in six HF . Three HF without m RDTs were selected as matched controls . The use of routine m RDT and treatment upon result was advised for all patients complaining of fever , including children under five years of age . The main outcome measures were : ( 1 ) anti-malarial consumption recorded from routine statistics in ledger books of all HF before and after intervention ; ( 2 ) anti-malarial prescription recorded during observed consultations in cross-sectional surveys conducted in all HF before and 18 months after m RDT implementation . Results Based on routine statistics , the amount of artemether-lumefantrine blisters used post-intervention was reduced by 68 % ( 95%CI 57 - 80 ) in intervention and 32 % ( 9 - 54 ) in control HF . For quinine vials , the reduction was 63 % ( 54 - 72 ) in intervention and an increase of 2.49 times ( 1.62 - 3.35 ) in control HF . Before- and -after cross-sectional surveys showed a similar decrease from 75 % to 20 % in the proportion of patients receiving anti-malarial treatment ( Risk ratio 0.23 , 95%CI 0.20 - 0.26 ) . The cluster r and omized analysis showed a considerable difference of anti-malarial prescription between intervention HF ( 22 % ) and control HF ( 60 % ) ( Risk ratio 0.30 , 95%CI 0.14 - 0.70 ) . Adherence to test result was excellent since only 7 % of negative patients received an anti-malarial . However , antibiotic prescription increased from 49 % before to 72 % after intervention ( Risk ratio 1.47 , 95%CI 1.37 - 1.59 ) . Conclusions Programmatic implementation of m RDTs in a moderately endemic area reduced drastically over-treatment with anti-malarials . Properly trained clinicians with adequate support complied with the recommendation of not treating patients with negative results . Implementation of m RDT should be integrated h and -in-h and with training on the management of other causes of fever to prevent irrational use of antibiotics Background Early diagnosis , as well as prompt and effective treatment of uncomplicated malaria , are essential components of the anti-malaria strategy in Madagascar to prevent severe malaria , reduce mortality and limit malaria transmission . The purpose of this study was to assess the performance of the malaria rapid diagnostic tests ( RDTs ) used by community health workers ( CHWs ) by comparing RDT results with two reference methods ( microscopy and Polymerase Chain Reaction , PCR ) . Methods Eight CHWs in two districts , each with a different level of endemic malaria transmission , were trained to use RDTs in the management of febrile children under five years of age .  RDTs were performed by CHWs in all febrile children who consulted for fever . In parallel , retrospective parasitological diagnoses were made by microscopy and PCR . The results of these different diagnostic methods were analysed to evaluate the diagnostic performance of the RDTs administered by the CHWs . The stability of the RDTs stored by CHWs was also evaluated . Results Among 190 febrile children with suspected malaria who visited CHWs between February 2009 and February 2010 , 89.5 % were found to be positive for malaria parasites by PCR , 51.6 % were positive by microscopy and 55.8 % were positive by RDT . The performance accuracy of the RDTs used by CHWs in terms of sensitivity , specificity , positive and negative predictive values was greater than 85 % . Concordance between microscopy and RDT , estimated by the Kappa value was 0.83 ( 95 % CI : 0.75 - 0.91 ) . RDTs stored by CHWs for 24 months were capable of detecting Plasmodium falciparum in blood at a level of 200 parasites/μl . Conclusion Introduction of easy-to-use diagnostic tools , such as RDTs , at the community level appears to be an effective strategy for improving febrile patient management and for reducing excessive use of anti-malarial drugs Background Accurate and practical malaria diagnostics , such as immunochromatographic rapid diagnostic tests ( RDTs ) , have the potential to avert unnecessary treatments and save lives . Volunteer community health workers ( CHWs ) represent a potentially valuable human re source for exp and ing this technology to where it is most needed , remote rural communities in sub-Saharan Africa with limited health facilities and personnel . This study reports on a training programme for CHWs to incorporate RDTs into their management strategy for febrile children in the Democratic Republic of Congo , a tropical African setting ravaged by human conflict . Methods Prospect i ve cohort 
    Output:
    
CHWs showed high adherence to test results , but in some studies a substantial group of RDT negatives received treatment .
High risk of bias was found for morbidity and mortality studies , therefore , effects on morbidity and mortality could not be estimated .
Uptake and acceptance by the community was high , however negative-tested patients did not always follow up referral advice .
RDT-based CCMm was found to be cost effective for the correct treatment of malaria in areas with low to medium malaria prevalence , but study design s were not optimal .
Discussion Trained CHWs can deliver high quality care for malaria using RDTs .
However , lower RDT specificity could lead to missed diagnoses of non-malarial causes of fever .
Integrated CCM may solve some of these issues .