Potential for community based surveillance of febrile diseases: Feasibility of self-administered rapid diagnostic tests in Iquitos, Peru and Phnom Penh, Cambodia

Rapid diagnostic tests (RDTs) have the potential to identify infectious diseases quickly, minimize disease transmission, and could complement and improve surveillance and control of infectious and vector-borne diseases during outbreaks. The U.S. Defense Threat Reduction Agency's Joint Science and Technology Office (DTRA-JSTO) program set out to develop novel point-of-need RDTs for infectious diseases and deploy them for home use with no training. The aim of this formative study was to address two questions: 1) could community members in Iquitos, Peru and Phnom Penh, Cambodia competently use RDTs of different levels of complexity at home with visually based instructions provided, and 2) if an RDT were provided at no cost, would it be used at home if family members displayed febrile symptoms? Test kits with written and video (Peru only) instructions were provided to community members (Peru [n = 202]; Cambodia [n = 50]) or community health workers (Cambodia [n = 45]), and trained observers evaluated the competency level for each of the several steps required to successfully operate one of two multiplex RDTs on themselves or other consenting participant (i.e., family member). In Iquitos, >80% of residents were able to perform 11/12 steps and 7/15 steps for the two- and five-pathogen test, respectively. Competency in Phnom Penh never reached 80% for any of the 12 or 15 steps for either test; the percentage of participants able to perform a step ranged from 26-76% and 23-72%, for the two- and five-pathogen tests, respectively. Commercially available NS1 dengue rapid tests were distributed, at no cost, to households with confirmed exposure to dengue or Zika virus; of 14 febrile cases reported, six used the provided RDT. Our findings support the need for further implementation research on the appropriate level of instructions or training needed for diverse devices in different settings, as well as how to best integrate RDTs into existing local public health and disease surveillance programs at a large scale. Author summary Rapid diagnostic tests (RDTs) are becoming increasingly available and are useful during outbreaks of infectious and vector-borne diseases. This study set out to answer two questions regarding the use of RDTs in community settings. First, how well could community members at two diverse sites-Iquitos, Peru and Phnom Penh, Cambodia-perform an RDT on themselves and willing family members with only written and/or video instructions, and with two tests of different complexity? Second, and only in Iquitos, if RDTs were made widely available at no cost to households, would residents choose to use one for a family member showing febrile symptoms? In Peru, 202 community members were provided written and/or video instructions and a test kit, and then were observed operating the RDT on themselves or family members in their own homes. In Cambodia, 45 Community Health Workers and 50 community members were provided only written instructions at a local health center and asked to carry out the test. In both locations, trained observers scored each of the 12-15 steps necessary to conduct the test on a 3-point scale (1 being lowest proficiency level, 3 being highest), for one of the two RDTs in this study. In Iquitos, >80% of residents were able to perform 11/12 steps and 7/15 steps for the two- and five-pathogen test, respectively. Competency in Phnom Penh never reached 80% for any of the 12 or 15 steps for either test, with the percentage of participants demonstrating high competency ranging from 26-76% and 23-72%, for the two- and five-pathogen tests, respectively. Finally, in Iquitos, RDTs were distributed to households with earlier confirmed cases of dengue or Zika virus: about half of all household members that developed fevers were self-tested or tested by another family member. This study is consistent with our earlier findings from focus group discussions suggesting that implementation of simple home-based rapid diagnostic devices, could be used in different settings, but further research is needed to determine the best type and level of instructions to do this.

Automated summary

Rapid diagnostic tests (RDTs) have the potential to quickly identify infectious diseases, but the study found varied levels of competency in using RDTs between residents in Iquitos, Peru and Phnom Penh, Cambodia. When provided at no cost, only a portion of febrile cases opted to use the RDTs provided, indicating the need for further research on the appropriate level of instructions or training needed for different settings.