Minimising human error in malaria rapid diagnosis: clarity of written instructions and health worker performance.

The usefulness of rapid diagnostic tests (RDT) in malaria case management depends on the accuracy of the diagnoses they provide. Despite their apparent simplicity, previous studies indicate that RDT accuracy is highly user-dependent. As malaria RDTs will frequently be used in remote areas with little supervision or support, minimising mistakes is crucial. This paper describes the development of new instructions (job aids) to improve health worker performance, based on observations of common errors made by remote health workers and villagers in preparing and interpreting RDTs, in the Philippines and Laos. Initial preparation using the instructions provided by the manufacturer was poor, but improved significantly with the job aids (e.g. correct use both of the dipstick and cassette increased in the Philippines by 17%). However, mistakes in preparation remained commonplace, especially for dipstick RDTs, as did mistakes in interpretation of results. A short orientation on correct use and interpretation further improved accuracy, from 70% to 80%. The results indicate that apparently simple diagnostic tests can be poorly performed and interpreted, but provision of clear, simple instructions can reduce these errors. Preparation of appropriate instructions and training as well as monitoring of user behaviour are an essential part of rapid test implementation.

Feasibility of using flash-heated breastmilk as an infant feeding option for HIV-exposed, uninfected infants after 6 months of age in urban Tanzania.

OBJECTIVE: Heat-treating expressed breastmilk is recommended as an interim feeding strategy for HIV-exposed infants in resource-poor countries, but data on its feasibility are minimal. Flash-heating (FH) is a simple in-home technique for heating breastmilk that inactivates HIV although preserving its nutritional and anti-infective properties. Our primary objective was to determine, among HIV-infected mothers, the feasibility and protocol adherence of FH expressed breastmilk after 6 months of exclusive breastfeeding. DESIGN: Prospective longitudinal. PARTICIPANTS: One hundred one HIV-infected breastfeeding mothers. SETTING: Dar es Salaam, Tanzania. INTERVENTION: Peer counselors provided in-home counseling and support on infant feeding from 2 to 9 months postpartum. Mothers were encouraged to exclusively breastfeed for 6 months followed by FH expressed breastmilk if her infant was HIV negative. Clinic-based staff measured infant growth and morbidity monthly, and mothers kept daily logs of infant morbidity. FH behavior was tracked until 9 months postpartum using daily logs, in-home observations, and clinic-based and home-based surveys. Bacterial cultures of unheated and heated milk samples were performed. RESULTS: Thirty-seven of 72 eligible mothers (51.4%) chose to flash-heat. Median (range) frequency of milk expression was 3 (1-6) times daily and duration of method use on-study was 9.7 (0.1-15.6) weeks. Mean (SD) daily milk volume was 322 (201) mL (range 25-1120). No heated and 32 (30.5%) unheated samples contained bacterial pathogens. CONCLUSIONS: FH is a simple technology that many HIV-positive women can successfully use after exclusive breastfeeding to continue to provide the benefits of breastmilk while avoiding maternal-to-child transmission associated with nonexclusive breastfeeding. Based on these feasibility data, a clinical trial of the effects of FH breastmilk on infant health outcomes is warranted.