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Opinions of Sunday, 16 May 2010

Columnist: Adjei, Eunice Achiaa

Is It Really Malaria ……, Have You Confirmed It?

Malaria has long been the number one cause of fever and the leading cause of child mortality in sub-Sahara Africa. As a result, the World Health Organization (WHO) recommended treating any fever episode in African children with antimalarial drugs to save lives. Currently the situation has changed; we now have new reliable rapid diagnostic tests (RDTs) to allow for laboratory confirmation of malaria at all levels of the health system.

According to WHO’s 10 facts on malaria (March 2009), about 3.3 billion people are at risk of malaria. Every year, about 250 million malaria cases and nearly one million deaths are recorded globally. But the argument is; is it really malaria? I believe some of these people die of other severe diseases and not malaria. I’m saying this because we tend to assume all headaches, all feverishness and body weaknesses to be malaria since we remember being bitten by some stubborn mosquitoes when we slept or sat outside late the other day.

Is malaria the only disease that presents with headache, cold, fever or general weakness? NO. Other diseases like typhoid fever, urinary tract infection, meningitis, influenza, viral infections, HIV/AIDS, appendicitis and even early pregnancy may present with similar symptoms. These are reasons why it should be confirmed by laboratory test before we can conclude categorically that it’s malaria or not. Confirmation could be done either by microscopy or use of RDT.

I have been following discussions on malaria and taken note of the statistics that are churned out annually and I hope you have noticed that too. Almost always the disease seems to place first among the top ten ailments. It is believed to afflict about 40% of out-patients in public health institutions.

The Programme Manager of National Malaria Control Programme, Dr. (Mrs.) Constance Bart- Plange in one of her presentations indicated that there are stories of various activities undertaken to combat malaria. She said distribution of insecticide treated bed nets, use of effective anti-malaria drugs, indoor residual spraying and personal protection among others can be mentioned as some major interventions that have recently engaged the attention of our Public Health experts, yet the situation appears to stay the same. “The question I want us to ask ourselves is this, what really is missing in the malaria control equation?” The answer is not far fetched; a lot have changed except one key practice, presumptive diagnosis and treatment of almost all febrile illnesses as malaria. There is one issue that contributes to the almost constant 40% of cases all the time. Perhaps it is about time we changed the way we diagnose malaria so that the real burden could be measured, she said.

It is now time to move from presumptive/clinical diagnosis to laboratory confirmation of cases. The shift from symptom-based diagnosis to parasite-based diagnosis of malaria will require in addition to microscopes, an easy to use tool or test device that will compliment microscopy and help cut down the work load that is likely to pile up on both laboratory staff and prescribers.

Malaria rapid diagnostic test devices (RDTs) assists in the diagnosis of malaria by providing evidence of the presence of malaria parasites in human blood. The use of this device will enable clinicians to make a more accurate diagnosis prior to treatment. Rapid diagnostic test requires minimal training on its use and can be used by the average health worker with minimal or no supervision. At present risk levels, the risk of missing a malaria case due to a false-negative test is substantially smaller than the risk of the patient dying due to another severe disease because of the focus on malaria. I remember visiting a clinic and after reporting about what was wrong with me, the doctor just wrote on my folder malaria and prescribed antimalaria for me. How did he know its malaria? He most likely relied on past experience but that is not a preferred option if technologically and practically feasible tools exist. It is very important for clinicians to refer patients to the laboratory to be tested before they can conclude he or she has malaria or not. That is currently the direction for malaria diagnosis strongly supported by the WHO and adopted by malaria endemic countries of which Ghana is inclusive. On the other hand, inaccurate malaria test results can lead to inappropriate patient management, misconceptions about anti-malaria drug resistance and public health misinformation. It will be helpful for all laboratories to demonstrate that their results are accurate and reliable. Samples of RDT tests could be crosschecked with microscopy for consistency as a quality assurance mechanism.

Presumptive treatment of fever cases as malaria is a hindrance to the control of malaria in Ghana. Many people are dying of other severe diseases, so let’s all join hands to reduce wastage of drugs and save lives too.

“Let’s all come together and drive malaria away.”

Eunice Achiaa Adjei (National Service Personnel) National Malaria Control Programme