Malaria Treatment & Prevention
Overdiagnosis and mistreatment of malaria among febrile patients at primary healthcare level in Afghanistan: observational study
New BMJ paper - Open Access
Abstract
Objective To assess the accuracy of malaria diagnosis and treatment at primary level clinics in Afghanistan.
Design Prospective observational study.
Setting 22 clinics in two Afghan provinces, one in the north (adjoining Tajikistan) and one in the east (adjoining Pakistan); areas with seasonal transmission of Plasmodium vivax and Plasmodium falciparum.
Participants 2357 patients of all ages enrolled if clinicians suspected malaria.
Interventions Established (>5 years) microscopy (12 clinics in east Afghanistan), newly established microscopy (five clinics in north Afghanistan), and no laboratory (five clinics in north Afghanistan). All clinics used the national malaria treatment guidelines.
Main outcome measures Proportion of patients positive and negative for malaria who received a malaria drug; sensitivity and specificity of clinic based diagnosis; prescriber’s response to the result of the clinic slide; and proportion of patients positive and negative for malaria who were prescribed antibiotics. Outcomes were measured against a double
read reference blood slide.
Results In health centres using clinical diagnosis, although 413 of 414 patients were negative by the reference slide, 412 (99%) received a malaria drug and 47 (11%) received an antibiotic. In clinics using new microscopy, 37% (75/202) of patients who were negative by the reference slide received a malaria drug and 60% (103/202) received an antibiotic. In clinics using established microscopy, 50.8% (645/1269) of patients who were negative by the reference slide received a malaria drug and 27.0% (342/1269) received an antibiotic. Among the patients who tested positive for malaria, 94% (443/472) correctly received a malaria drug but only 1 of 6 cases of falciparum malaria was detected and
appropriately treated. The specificity of established and new microscopy was 72.9% and 79.9%, respectively. In response to negative clinic slide results, malaria drugs were prescribed to 270/905 (28.8%) and 32/154 (21%) and antibiotics to 347/930 (37.3%) and 99/154 (64%) patients in established and new microscopy arms, respectively. Nurses were less likely to misprescribe than doctors.
Conclusions Despite a much lower incidence of malaria in Afghanistan than in Africa, fever was substantially misdiagnosed as malaria in this south Asian setting. Inaccuracy was attributable to false positive laboratory diagnoses of malaria and the clinicians’ disregard of negative slide results. Rare but potentially fatal cases of falciparum malaria were not detected, emphasising the potential role of rapid diagnostic tests. Microscopy increased the proportion of patients treated with antibiotics producing a trade-off between overtreatment with malaria drugs and probable overtreatment with antibiotics.
Attached resource:
-
BMJ Paper (external URL) Link leads to: http://www.bmj.com/highwire/filestream/595478/field_highwire_article_pdf/0/bmj.e4389.full.pdf
Sungano Mharakurwa
Does this not illustrate how instrumental RDTs have turned out to be? Would reorientation of nurses and doctors to trust the diagnostic test help, or does that have its own dangers if the test is wrong?
10:43 AM, 3 Sep 2012 | Permalink
Violet Chaka
Dear Sungano,
I totally agree with you on how important malaria RDT's have proven to be in low resource settings. However some doctors will only accept the result of an RDT in parallel to a peripheral blood smear microscopy result siting quantifiable results and accurate speciation of microscopy. In countries where validation of the RDT kits have been done by reference labs and where there is a comprehensive rollout program (including Quality Assurance programs) I think you are right: probably the re-orientation of clinicians to trust RDT results would be of great help.
Regards,
Violet
11:09 AM, 3 Sep 2012 | Permalink
Wellington Oyibo
The report on the overdiagnosis and overtreatment of malaria in Nigeria in children corroborates the Afghanistan's study.
expand commentSee attached publication.
Wellington Oyibo
________________________________
From: GHDonline (Violet Chaka) <>
To: Wellington Oyibo <>
Sent: Monday, September 3, 2012 4:10 PM
Subject: Re: [Malaria Treatment & Prevention] Overdiagnosis and mistreatment of malaria among febrile patients at primary healthcare level in Afghanistan: observational study
Violet Chaka replied to the discussion "Overdiagnosis and mistreatment of malaria among febrile patients at primary healthcare level in Afghanistan: observational study" in the Malaria Treatment & Prevention community.
Reply contents:
"Dear Sungano,
I totally agree with you on how important malaria RDT's have proven to be in low resource settings. However some doctors will only accept the result of an RDT in parallel to a peripheral blood smear microscopy result siting quantifiable results and accurate speciation of microscopy. In countries where validation of the RDT kits have been done by reference labs and where there is a comprehensive rollout program (including Quality Assurance programs) I think you are right: probably the re-orientation of clinicians to trust RDT results would be of great help.
Regards,
Violet"
--
View this post online:
<http://www.ghdonline.org ...
11:41 AM, 3 Sep 2012 | Permalink
Elhassan Elhassan
Thanks Sophie Beauvais for storming such important topic in (GHD), I agree with you that the issue is crucial and needs emphasis. It is a fact that sting blood film to diagnose malaria may be confusing especially in Sub- Saharan countries lie mine, the fact that shows the importance of RDT to be well tested and implemented, especially in pregnancy which is a vulnerable condition to malaria complications. I advocate this approach. We have published a similar article about the non malarial fever in pregnancy. You and decent colleagues can go through the abstract in (Asian Pacific Journal of Tropical Medicine, (2010)392-394), titled as (Non-malarial fever among pregnant women in Medani Hospital,Sudan: diagnostic uncertainty and over treatment with quinine) or follow the link:
expand commentjournal homepage:www.elsevier.com/locate/apjtm. The abstract is as follows:
Objectives:
To investigate the accuracy of malaria diagnosis among pregnant women admitted in Medani Maternity Hospital, Central Sudan during June-October 2009 and to investigate the antimalarials prescribed in this setting.
Methods:
Socio-demographic characteristics and obstetrics history were gathered using pre-tested questionnaires. The finger prick blood samples were collected from pregnant women who admitted as malaria case after an initial microscopic test done by ...
7:37 AM, 18 Oct 2012 | Permalink
Edit Comment Text