Randomised primary health center based interventions to improve the diagnosis and treatment of undifferentiated fever and dengue in Vietnam

ABSTRACT: BACKGROUND: Fever is a common reason for attending primary health facilities in Vietnam. Response of health care providers to patients with fever commonly consists of making a presumptive diagnosis and proposing corresponding treatment. In Vietnam, where malaria was brought under control, viral infections, notably dengue, are the main causes of undifferentiated fever but they are often misdiagnosed and inappropriately treated with antibiotics. The objectives were to investigate if educating primary health center (PHC) staff or introducing rapid diagnostic tests (RDTs) improve diagnostic resolution and accuracy for acute undifferentiated fever (AUF) and reduce prescription of antibiotics and costs for patients. METHODS: A cluster, primary health center based, randomised trial, four years follow up in 12 primary health centers and one clinic of the Provincial Malaria Control Center in Binh Thuan province, southern Vietnam. The participants included primary health center staff and their patients who came with any febrile illness of duration less than 14 days, without any indication of either severe systemic or organ specific disease. Malaria was excluded by a thick smear. Four intervention arms: training on infectious diseases (A), provision of RDTs (B), combination (AB) and control (C). Frequencies of presumptive diagnoses that refer to an etiologic diagnosis, frequencies of correct presumptive diagnosis "dengue", prescription and use of antibiotics and health expenses were measured. RESULTS: The frequency of the non-etiologic diagnosis "undifferentiated fever" decreased in group AB, and - with some delay- also in group B. The diagnosis "dengue" increased in group AB, but only temporarily, although dengue was the most common cause of fever. A correct diagnosis for dengue initially increased in groups AB and B but only for AB this was sustained. Antibiotics prescriptions increased in group C. During intervention it initially declined in AB with a tendency to increase afterwards; in B it gradually declined. There was a substantial increase of patients' costs in B. CONCLUSIONS: The introduction of RDTs for infectious diseases such as dengue, through free market principles, does improve the quality of the diagnosis and decreases the prescription of antibiotics at the PHC level. However, the effect is more sustainable in combination with training; without it RDTs lead to an excess of costs