Malaria overdiagnosis and burden of malaria misdiagnosis in the suburbs of central Sudan: special emphasis on artemisinin-based combination therapy era

A-Elgayoum, Salwa M.E.; El-Feki, Abd El-Karim Ahmed; Mahgoub, Babiker Ahmed; El-Rayah, El-Amin; Giha, Hayder A.

doi:10.1016/j.diagmicrobio.2009.01.029

Cited by 33 publications

(15 citation statements)

References 15 publications

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“…This is one of the reasons for the non recognition of the decreasing malaria transmission observed in sub-Saharan Africa, particularly in East Africa [4], [5], by global estimates of disease burden [6], [7], national statistics [8]and some researchers [9]. Over diagnosis of malaria not only contributes to the “scandal of ignorance of disease burden” but also to improper treatment leading to drug wastage and resistance, inefficient use of scarce resources, and most importantly poor health outcomes.…”

Section: Introductionmentioning

confidence: 99%

Cost Implications of Improving Malaria Diagnosis: Findings from North-Eastern Tanzania

et al. 2010

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BackgroundOver diagnosis of malaria contributes to improper treatment, wastage of drugs and resistance to the few available drugs. This paper attempts to estimate the rates of over diagnosis of malaria among children attending dispensaries in rural Tanzania and examines the potential cost implications of improving the quality of diagnosis.Methodology/Principal FindingsThe magnitude of over diagnosis of malaria was estimated by comparing the proportion of outpatient attendees of all ages clinically diagnosed as malaria to the proportion of attendees having a positive malaria rapid diagnostic test over a two month period. Pattern of causes of illness observed in a <2 year old cohort of children over one year was compared to the pattern of causes of illness in <5 year old children recorded in the routine health care system during the same period. Drug and diagnostic costs were modelled using local and international prices. Over diagnosis of malaria by the routine outpatient care system compared to RDT confirmed cases of malaria was highest among <5 year old children in the low transmission site (RR 17.9, 95% CI 5.8–55.3) followed by the ≥5 year age group in the lower transmission site (RR 14.0 95%CI 8.2–24.2). In the low transmission site the proportion of morbidity attributable to malaria was substantially lower in <2 year old cohort compared to children seen at routine care system. (0.08% vs 28.2%; p<0.001). A higher proportion of children were diagnosed with ARI in the <2 year old cohort compared to children seen at the routine care system ( 42% vs 26%; p<0.001). Using a RDT reduced overall drug and diagnostic costs by 10% in the high transmission site and by 15% in the low transmission site compared to total diagnostic and drug costs of treatment based on clinical judgment in routine health care system.ImplicationsThe introduction of RDTs is likely to lead to financial savings. However, improving diagnosis to one disease may lead to over diagnosis of another illness. Quality improvement is complex but introducing RDTs for the diagnosis of malaria is a good start.

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Section: Introductionmentioning

confidence: 99%

Cost Implications of Improving Malaria Diagnosis: Findings from North-Eastern Tanzania

et al. 2010

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“…Simultaneously, at facilities with existent microcopy the strengthening of the quality of this service is the utmost priority. The quality assurance activities supporting both, RDTs and malaria microscopy, will be critical determinants to ensure routine accuracy of RDTs and overcome deficiencies in the quality of malaria microscopic services that have been previously reported in Sudan [28,29] as well as in the region [30,31]…”

Section: Discussionmentioning

confidence: 99%

Progress towards implementation of ACT malaria case-management in public health facilities in the Republic of Sudan: a cluster-sample survey

et al. 2012

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BackgroundEffective malaria case-management based on artemisinin-based combination therapy (ACT) and parasitological diagnosis is a major pillar within the 2007-2012 National Malaria Strategic Plan in the Sudan. Three years after the launch of the strategy a health facility survey was undertaken to evaluate case-management practices and readiness of the health facilities and health workers to implement a new malaria case-management strategy.MethodsA cross-sectional, cluster sample survey was undertaken at public health facilities in 15 states of Sudan. Data were collected using quality-of-care assessment methods. The main outcomes were the proportions of facilities with ACTs and malaria diagnostics; proportions of health workers exposed to malaria related health systems support activities; and composite and individual indicators of case-management practices for febrile outpatients stratified by age, availability of ACTs and diagnostics, use of malaria diagnostics, and test result.ResultsWe evaluated 244 facilities, 294 health workers and 1,643 consultations for febrile outpatients (425 < 5 years and 1,218 ≥ 5 years). Health facility and health worker readiness was variable: chloroquine was available at only 5% of facilities, 73% stocked recommended artesunate and sulfadoxine/pyrimethamine (AS+SP), 51% had the capacity to perform parasitological diagnosis, 53% of health workers had received in-service training on ACTs, 24% were trained in the use of malaria Rapid Diagnostic Tests, and 19% had received a supervisory visit including malaria case-management. At all health facilities 46% of febrile patients were parasitologically tested and 35% of patients were both, tested and treated according to test result. At facilities where AS+SP and malaria diagnostics were available 66% of febrile patients were tested and 51% were both, tested and treated according to test result. Among test positive patients 64% were treated with AS+SP but 24% were treated with artemether monotherapy. Among test negative patients only 17% of patients were treated for malaria. The majority of ACT dispensing and counseling practices were suboptimal.ConclusionsFive years following change of the policy from chloroquine to ACTs and 3 years before the end of the new malaria strategic plan chloroquine was successfully phased out from public facilities in Sudan, however, an important gap remained in the availability of ACTs, diagnostic capacities and coverage with malaria case-management activities. The national scale-up of diagnostics, using the findings of this survey as well as future qualitative research, should present an opportunity not only to expand existing testing capacities but also to implement effective support interventions to bridge the health systems gaps and support corrective case-management measures, including the discontinuation of artemether monotherapy treatment.

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“…Thorough examination of thick and thin blood slides (BS) by experienced technologists using light microscopy remains the gold standard (Bailey et al, 2013; CDC, 2015; WHO, 2011a, 2010). However, several studies from sub-Saharan Africa have shown the real time accuracy of microscopy in basic health facilities is poor (A-Elgayoum et al, 2009; Kahama-Maro et al, 2011; Mwanziva et al, 2008) and that even experienced laboratory technologists at referral centers often report inaccurate BS results (Kilonzo et al, 2014; Strøm et al, 2013). …”

Section: Introductionmentioning

confidence: 99%

Malaria and HIV among pediatric inpatients in two Tanzanian referral hospitals: A prospective study

et al. 2016

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Malaria remains common in sub-Saharan Africa, but it is frequently over-diagnosed and over-treated in hospitalized children. HIV is prevalent in many malaria endemic areas and may delay parasite clearance and increase mortality among children with malaria. This prospective cohort study enrolled children with suspected malaria between 3 months and 12 years of age hospitalized at two referral hospitals in Tanzania. Both a thick blood smear (BS) and a malaria rapid diagnostic test (mRDT) were performed. If discordant results were obtained, PCR was performed for P. falciparum. Malaria was confirmed if two out of three tests were positive. Malaria parasite densities were determined for two consecutive days after diagnosis and treatment of malaria. All participants were tested for HIV. Among 1492 hospitalized children, 400 (26.8%) were enrolled with suspected malaria infection. There were 196/400 (49.0%) males, and the median age was 18 [9–36] months. BS was positive in 95/400 (23.8%), and mRDT was positive in 70/400 (17.5%), with moderate agreement (Kappa = 0.598). Concordant results excluded malaria in 291/400 (72.8%) and confirmed malaria in 56/400 (14.0%). PCR performed on 53 discordant results confirmed malaria in 1/39 of the BS-positive/mRDT-negative cases, and 6/14 of the BS-negative/mRDT-positive cases. The prevalence of confirmed malaria was 63/400 (15.8%). In multivariable logistic regression, malaria was associated with HIV (OR 3.45 [1.65–7.20], p=0.001). Current breastfeeding (OR 0.25 [0.11–0.56], p=0.001) and higher hemoglobin (OR 0.70 [0.60–0.81], p<0.001 per 1g/dL) were associated with decreased odds of malaria. Malaria parasite clearance was delayed in HIV-infected participants (p<0.001). Malaria is over-diagnosed even at referral centers in high transmission areas. Hospitalized HIV-infected children are more likely to have malaria and exhibit delayed clearance of parasites. Hospitals should consider using mRDTs as a first step for malaria testing among hospitalized children in sub-Saharan Africa.

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Malaria overdiagnosis and burden of malaria misdiagnosis in the suburbs of central Sudan: special emphasis on artemisinin-based combination therapy era

Cited by 33 publications

References 15 publications

Cost Implications of Improving Malaria Diagnosis: Findings from North-Eastern Tanzania

Cost Implications of Improving Malaria Diagnosis: Findings from North-Eastern Tanzania

Progress towards implementation of ACT malaria case-management in public health facilities in the Republic of Sudan: a cluster-sample survey

Malaria and HIV among pediatric inpatients in two Tanzanian referral hospitals: A prospective study

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