Successful Integration of Community-Based Rapid Antigen Testing for COVID-19 and Malaria in Mali

In Mali, access to health care facilities (HCFs) is limited due to distance and transportation costs, and this limitation may have led to an under detection of COVID-19 cases. This prospective randomized study compared a community-based, integrated COVID-19 and malaria testing strategy (intervention arm) to the national standard-of-care strategy (SOC arm). Four health areas were randomly assigned. All people seeking care who accepted the study were enrolled by community health workers (CHWs) and screened for COVID-19 symptoms. In the intervention arm, CHWs performed COVID-19 and/or malaria antigen rapid diagnostic tests (Ag-RDTs) for patients who met clinical criteria for possible COVID-19, including fever. In the SOC arm, CHWs referred patients who met clinical criteria for possible COVID-19, including fever, to the nearest health care facility (HCF) where COVID-19 and/or malaria Ag-RDTs were performed. Febrile patients refusing referral were tested for malaria by CHWs. Among 1,164 patients enrolled, 73% had fever and 72% meet clinical criteria for possible COVID-19. Malaria Ag-RDTs were performed in 79% and 3% COVID-19 suspected patients in intervention and SOC arms, respectively (P <0.001). Only three patients tested positive for COVID-19. Among 449 patients referred to HCFs, 248 refused to go to the HCFs, and only 10 of 201 who agreed to the referral actually reached one. Among febrile patients, 75% and 34% received malaria treatment in intervention and SOC arms, respectively (P <0.001). Integration of community-based testing for COVID-19 and malaria Ag-RDTs was found to be feasible. However, limited access to HCFs in rural areas highlights the need for treatment services to be available at the community level.