Improving diagnosis and treatment of uncomplicated malaria
Authors: Neeru Singh, Ravendra K Sharma
Journal: The Lancet Global Health (2014)

Malaria is a major public health problem and a leading cause of mortality worldwide, especially in sub-Saharan Africa, where 90% of the world's 627 000 malaria deaths occur every year.1WHOWorld malaria report 2013. World Health Organization, Geneva2013www.who.int/iris/bitstream/10665/97008/1/9789241564694_eng.pdfGoogle Scholar However, the disease is usually curable if diagnosed quickly. Diagnosis is often made on the basis of clinical symptoms, but this method is alarmingly inaccurate. Presumptive treatment of malaria is often used for all patients with fever to reduce malaria morbidity and mortality, particularly in resource-poor health facilities. Microscopy is the gold standard for diagnosis of malaria, but its effectiveness is affected by several factors, including quality of sample preparation, level of parasitaemia, and the skill of the laboratory technician.2Kilian AH Metzger WG Mutschelknauss EJ et al.Reliability of malaria microscopy in epidemiological studies: results of quality control.Trop Med Int Health. 2000; 5: 3-8Crossref PubMed Scopus (104) Google Scholar Rapid diagnostic tests provide an alternative to microscopy and give results accurately and promptly.3Singh N Bharti PK Singh MP et al.Comparative evaluation of bivalent malaria rapid diagnostic tests versus traditional methods in field with special reference to heat stability testing in Central India.PLoS One. 2013; 8: e58080Crossref PubMed Scopus (17) Google Scholar, 4WHONew perspectives: malaria diagnosis. Report of a joint WHO/USAID informal consultation 25–27 October 1999. World Health Organization, Geneva2000http://whqlibdoc.who.int/hq/2000/WHO_CDS_RBM_2000.14.pdfGoogle Scholar With the introduction of artemisinin-based combination therapy, treatment should be provided only to patients with confirmed malaria infection to avoid overuse and reduce the cost of treatment, reduce drug wastage, and delay the emergence of resistance.5WHOAntimalarial drug combination therapy. Report of a WHO technical consultation. World Health Organization, Geneva2001http://whqlibdoc.who.int/hq/2001/WHO_CDS_RBM_2001.35.pdfGoogle Scholar However, for various reasons, clinicians and health providers rely more on their own clinical judgment than on the results of diagnostic tests,6Kyabayinze DJ Asiimwe C Nakanjako D Nabakooza J Counihan H Tibenderana JK Use of RDTs to improve malaria diagnosis and fever case management at primary health facilities in Uganda.Malar J. 2010; 9: 200Crossref PubMed Scopus (96) Google Scholar, 7Chandler CI Mwangi R Mbakilwa H Olomi R Whitty CJ Reyburn H Malaria overdiagnosis: is patient pressure the problem?.Health Policy Plann. 2008; 23: 170-178Crossref PubMed Scopus (59) Google Scholar and antimalarial treatment is often given to patients with negative results on rapid diagnostic tests.8Ndyomugyenyi R Magnussen P Clarke S Malaria treatment-seeking behaviour and drug prescription practices in an area of low transmission in Uganda: implications for prevention and control.Trans R Soc Trop Med Hyg. 2007; 101: 209-215Summary Full Text Full Text PDF PubMed Scopus (45) Google Scholar, 9Hamer DH Ndhlovu M Zurovac D et al.Improved diagnostic testing and malaria treatment practices in Zambia.JAMA. 2007; 297: 2227-2231Crossref PubMed Scopus (200) Google Scholar To improve the situation, various intervention programmes to encourage behavioural change by clinicians and health providers have been developed and tested in different African countries. In The Lancet Global Health, Wilfred Mbacham and colleagues10Mbacham WF Mangham-Jeffries L Cundill B et al.Basic or enhanced clinician training to improve adherence to malaria treatment guidelines: a cluster-randomised trial in two areas of Cameroon.Lancet Glob Health. 2014; (published online April 25.)http://dx.doi.org/10.1016/S2214-109X(14)70201-3Google Scholar report the results of a cluster-randomised trial to assess the introduction of rapid diagnostic tests when packaged with basic or enhanced clinician training interventions in two regions in Cameroon. Compared with control, neither the basic (1 day of training in malaria diagnosis, rapid diagnostic testing, and malaria treatment) nor the enhanced (3 days of training, including the basic modules plus three additional modules about adapting to change, professionalism, and effective communication) training programmes improved the proportion of patients treated in accordance with malaria treatment guidelines (the primary outcome; adjusted risk ratio 1·04 [95% CI 0·53–2·07; p=0·90] for basic and 1·17 [0·61–2·25; p=0·62] for enhanced training). However, the enhanced training programme was effective at reducing the proportion of patients with a negative test result receiving antimalarial drugs. This finding is encouraging and in line with those from similar studies done in other parts of the world. A study by Mbonye and colleagues done in Uganda11Mbonye MK Burnett SM Burua A et al.Effect of integrated capacity-building interventions on malaria case management by health professionals in Uganda: a mixed design study with pre/post and cluster randomized trial components.PLoS One. 2014; 9: e84945Crossref PubMed Scopus (21) Google Scholar similarly showed a significant reduction in the proportion of patients with a negative diagnostic test result for malaria who were prescribed antimalarial drugs after the training of health providers. However, in Mbacham and his colleagues' study,10Mbacham WF Mangham-Jeffries L Cundill B et al.Basic or enhanced clinician training to improve adherence to malaria treatment guidelines: a cluster-randomised trial in two areas of Cameroon.Lancet Glob Health. 2014; (published online April 25.)http://dx.doi.org/10.1016/S2214-109X(14)70201-3Google Scholar neither of the training programmes significantly affected the proportion of patients with suspected malaria being tested or the proportion of patients with positive test results receiving artemisinin-based combination therapy. Conversely, results from the study in Uganda11Mbonye MK Burnett SM Burua A et al.Effect of integrated capacity-building interventions on malaria case management by health professionals in Uganda: a mixed design study with pre/post and cluster randomized trial components.PLoS One. 2014; 9: e84945Crossref PubMed Scopus (21) Google Scholar showed a significant improvement in the proportion of patients who received an appropriate antimalarial drug among those prescribed any antimalarial treatment. Although the investigators of the present study used a stratified cluster-randomised design and appropriate statistical techniques to analyse the data, limitations exist with respect to the sample size and unequal clusters in different study groups. Furthermore, the post-intervention survey was done 3 months after the intervention; the changes in clinicians' behaviour with respect to the treatment of patients with negative test results might lose significance if measured again after 6 months or a year. Sustainability of behaviour change is crucial if such interventions are to provide any lasting benefits.12Smith LA Jones C Meek S Webster J Review: provider practice and user behavior interventions to improve prompt and effective treatment of malaria: do we know what works?.Am J Trop Med Hyg. 2009; 80: 326-335PubMed Google Scholar Mbacham and colleagues' findings answer many research questions, but some important issues remain unresolved. The investigators do not explore the reasons for the differences in outcomes between the basic-training and enhanced-training interventions, even though the comparison of these two different training programmes was a central feature of the study. Researchers have discussed the importance of rapid diagnostic tests in malaria diagnosis and have emphasised the possibility of saving millions of treatments of artemisinin-based combination therapy every year. Although malaria transmission varies widely across Africa, assessments of the implementation of rapid diagnostic tests have shown programme strengths, weaknesses, and lessons that might benefit other parts of the continent. Overall, Mbacham and colleagues have successfully shown that the introduction of rapid diagnostic tests for malaria diagnosis and control might not succeed unless accompanied by a vigorous programme to change the behaviour of clinicians and health providers to promote adherence to WHO malaria diagnosis and treatment guidelines.13WHOGuidelines for the treatment of malaria. second edition. World Health Organization, Geneva2010http://whqlibdoc.who.int/publications/2010/9789241547925_eng.pdf?ua=1Google Scholar Moreover, as suggested by Chandler and collegues,14Chandler CI Whitty CJM Ansah EK How can malaria rapid diagnostic tests achieve their potential? A qualitative study of a trial at health facilities in Ghana.Malar J. 2010; 9: 95Crossref PubMed Scopus (76) Google Scholar the introduction of rapid diagnostic tests should be accompanied by various strategies: clear guidelines and messages to providers; well-designed training to combat the long-standing use of presumptive treatment; establishment of a scheme to promote rapid diagnostic tests to patients and providers, with timely feedback of quality-control results for tests to providers14Chandler CI Whitty CJM Ansah EK How can malaria rapid diagnostic tests achieve their potential? A qualitative study of a trial at health facilities in Ghana.Malar J. 2010; 9: 95Crossref PubMed Scopus (76) Google Scholar on the basis of WHO product-testing guidelines;15WHOMalaria rapid diagnostic test performance. Results of WHO product testing of malaria RDTs: round 4. World Health Organization, Geneva2012http://www.finddiagnostics.org/export/sites/default/resource-centre/reports_brochures/docs/RDTMalariaRd4_Web3.pdfGoogle Scholar and preparation and support for the introduction of rapid diagnostic tests to local health facilities. Finally, strengthening of the capacity of clinicians and health providers should be a priority of malaria-control initiatives. According to WHO's 2013 World Malaria Report,1WHOWorld malaria report 2013. World Health Organization, Geneva2013www.who.int/iris/bitstream/10665/97008/1/9789241564694_eng.pdfGoogle Scholar malaria mortality rates fell by about 42% globally and 49% in the WHO African region between 2000 and 2012. Incidence declined by 25% worldwide and 31% in the African region in the same period.1WHOWorld malaria report 2013. World Health Organization, Geneva2013www.who.int/iris/bitstream/10665/97008/1/9789241564694_eng.pdfGoogle Scholar These decreases were possible mainly because of the introduction of artemisinin-based combination therapy as first-line treatment for uncomplicated malaria since 2000 in most African countries, and because of the scale-up of rapid diagnostic tests. The success of the implementation of these policies in resource-poor settings has been assessed in very few countries; the present study provides a basis for future studies to explore what kinds of intervention packages and delivery channels will be suitable for increasing adherence to rapid diagnostic tests. We declare that we have no competing interests. Basic or enhanced clinician training to improve adherence to malaria treatment guidelines: a cluster-randomised trial in two areas of CameroonEnhanced clinician training, designed to translate knowledge into prescribing practice and improve quality of care, has the potential to halve overtreatment in public and mission health facilities in Cameroon. Basic training is unlikely to be sufficient to support the behaviour change required for the introduction of RDTs. Full-Text PDF Open Access