Scaling lab diagnosis of malaria and the end of presumptive treatment in Africa?

PLOS Medicine (open access! – I enjoy supporting journals in this format) did it again. The journal has carried some great exchanges between scientific “clans” on contentious topics which tend to be both lively and informative. A previous debate included whether or not data from Demographic Surveillance Systems (DSS), a form of long term demographic and health data collection from the routine surveys of a defined population, should be openly accessible rather than only shared among researchers participating in a global DSS network.

The latest issue at hand is whether it is now appropriate to pursue a large scale expansion of laboratory confirmation of malaria through the use of rapid diagnostic tests (RDTs) and abandon the presumptive treatment of malaria based on clinical symptoms alone in sub-Saharan Africa. The geographic qualifier in this debate is important – in this region health systems are generally consider weak with little capacity for diagnosis. In addition, given the high burden of malaria, and health worker shortages the standard practice is to treat anyone with suspected malaria which is often simply the presence of fever and leads to a wastage of valuable drugs, promotion of drug resistance, and the under-treatment of other underlying causes of fever.

Of course, both sides support strengthening case management and the use of new tools like RDTs. The counterpoint is not so much a disagreement as it is a caution against rapid implementation. What we don’t know is how much attention scaling RDTs will take (i.e. do we have the capacity without losing focus on other interventions?), how many cases would be miss if presumptive treatment decreased, and when/what context such an effort should be executed. It is a complex scenario. To better understand how to interpret divergent opinions from the lens of program management and strategy, I asked a trusted malaria expert to share his views:

I agree with Blaise and others. However, the problem with the discussion is that Blaise et al. do not sufficiently think through how labour and time intensive the change process will be.  On the other hand, Mike et al. do not sufficiently understand that the process of introducing diagnostics – done properly with all thorough and full coverage of training and quality assurance of products and services – is in itself a health system strengthening activity.

Well, one way to succinctly summarize the debate. What are your thoughts?

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2 Responses to “Scaling lab diagnosis of malaria and the end of presumptive treatment in Africa?”


  1. 1 Gil M. dela Cruz February 4, 2009 at 8:25 am

    Presumptive treatment deserves a second thought. It is a blind treatment. Nobody knows after treatment whether the disease is malaria or not. If it is considered as malaria then the data of malaria incidence will bloat. If we are treating non malaria with anti malaria drug then we are exposing the patient to risk of adverse drug reaction and the risk of development of drug resistance. Our experience in the country with presumptive diagnosis is not very good because with these presumptions basis for control method then will be erroneous resulting to further wastage of resources. But if the situation warrants presumptive treatment then it is the best for the community but there is a need to develop local capacity even volunteers to do diagnostic microscopy. By the way I am from the Philipppines. We trained volunteer microscopist in areas hardly accessible to the regular health system. It is supported by the Global Fund. As a result access to quality diagnostic microscopy improved tremendously and presumptive treatment was abondoned.

    • 2 naman February 4, 2009 at 2:04 pm

      Gil,

      thanks for your comments. As you note some situations will warrant presumptive treatment where under treatment could lead to excess mortality in the community, but ultimately diagnostics need to be strengthened. You mention training volunteers in microscopy, but this can be difficult. What is your experience with rapid tests (RDTs) for malaria where you work in Phillipines? Have they been introduced, are they for both PF and PV, and do health workers trust their results?


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