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Strategies for expanding access to quality malaria diagnosis in south-central Asia where malaria incidence is low

Start date: 1 Oct 2008

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[Project summary in Français / Português]

Scientific title: An examination of ACT strategy in south-central Asia on P. falciparum malaria in a context where P. vivax is the major species.

Latest on this research

[Français / Português]

The patient-randomised trial involved 5,794 patients in 22 clinics. Malaria rapid diagnostic tests were compared to clinical diagnosis where no parasite diagnostic test was available, established field microscopy, and microscopy that had recently been introduced.

In the low transmission area, comparing rapid diagnostic tests to clinical diagnosis, 65.2% (212/325) vs. 12.5% (40/321) of febrile patients were appropriately treated for malaria, (p<0.001). The proportion of malaria negative patients receiving an antibiotic was 56.9% (185/325) in the rapid diagnostic test vs. 14.3% (46/321) in the clinical diagnosis arm, (p<0.001). In the comparison of rapid diagnostic test to microscopy in the moderate transmission area, 83.6% (1696/2028) vs. 76.3% (1512/1983) were appropriately treated for malaria (p<0.001). A higher proportion of P. falciparum cases received appropriate treatment with artemisinin combination therapy when diagnosed by rapid diagnostic test (81.7% vs. 31.5%, p<0.001).

We conclude that in South Asian regions of low to moderate malaria transmission where clinics lack capacity for diagnosis with rapid diagnostic tests or microscopy, the introduction of the tests should be considered to improve clinical care, reduce the overuse of antimalarials, and improve disease surveillance.

Scroll down for peer reviewed publications, news stories and other resources related to this story.

What did we know before this research?

With the exception of Sub-Saharan Africa, most areas that are endemic for malaria have a combination of two species: Plasmodium falciparum and P. vivax. P. vivax is often the dominant species, accounting for a greater proportion of malaria cases.

Each of these species has a different level of severity and reaction to common drugs, therefore it’s crucial to diagnose patients and treat them accordingly. For example, P. falciparum is often resistant to cheap malaria drugs (monotherapies like Chloroquine), whereas P. vivax is still sensitive to those drugs. Recommended drugs for P. falciparum (ACT) can be more than ten times as expensive as those that are effective against P.vivax. Therefore, if a case of falciparum is mistakenly diagnosed as vivax, there is a danger of prescribing ineffective drugs which puts the patient at risk, and if a case of vivax is mistakenly diagnosed as falciparum, expensive ACT drugs are wasted unnecessarily.

Moreover, malaria transmission levels are much lower in south-central Asia than in Africa. For this reason, most people who go to clinics with fever do not, in fact, have malaria. Consequently, without accurate diagnosis and treatment, many patients are treated with a malaria drug when they do not, in fact, have malaria. This wastes drugs and neglects the treatment of the true cause of fever.

What does this study add?

Diagnosis is unavailable in most places where fever is common. Community health workers are often the main source of healthcare and are able to provide malaria drugs. However, without diagnosis that is reliable, clinicians and community health workers cannot distinguish the symptoms of malaria from other causes of fever. This results in huge overtreatment of malaria.  Even when microscopy is available, many patients who are negative for malaria still receive an antimalarial drug.

One solution is the use of rapid diagnostic tests (RDT). The tests are seen as relatively cost-effective in diagnosing patients in areas where malaria transmission is low or mixed, but this only applies if health workers trust their result.

We conducted a series of studies to test how effective different diagnostic and treatment methods are under field conditions, and measured their impact in effectively treating malaria.

First, we tested the accuracy of a rapid test that can distinguish the two malaria species and accurately identify negative patients. We found that one brand was the most accurate, and this was subsequently introduced as the national standard in Afghanistan.

We then conducted two randomised trials, one in clinics and one amongst community health workers, comparing the use of rapid diagnostic tests and microscopy. These studies will provide robust evidence for the most effective diagnostic tool, and allow both clinicians and community health workers to apply malaria treatments according to diagnostic results.

The research team

Principal Investigators

  • Prof. Mark Rowland, London School of Hygiene & Tropical Medicine 


  • Dr Toby Leslie - The Global Fund (previous: London School of Hygiene & Tropical Medicine)



Other Investigators

  • Prof Chris Whitty - London School of Hygiene & Tropical Medicine
  • Dr. Ismail Mayan, Health Protection and Research Organization, Kabul, Afghanistan
  • Ms Amy Mikhail - London School of Hygiene & Tropical Medicine
  • Dr Ismail Mayan - Health Protection and Research Organization (HPRO), Kabul
  • Dr Nader Mohammed - HealthNet-TPO, Kabul
  • Dr Anwar Hasanzai – HealthNet-TPO, Jalalabad, Nangaher
  • Dr Sayed Habib Baktash  - Medical Emergency Relief International (Merlin), Kunduz

Related Publications

Malaria “diagnosis” and diagnostics in Afghanistan

Joanna Reynolds, Molly Wood, Amy Mikhail, Tamanna Ahmad, Karimullah Karimullah, Mohibullah Motahed, Anwar Hazansai, Sayed Habib Baktash, Nadia Anwari, James Kizito, Ismail Mayan, Mark Rowland, Clare Chandler, and Toby Leslie  |  Published
Qualitative Health Research

Overdiagnosis and mistreatment of malaria among febrile patients at primary healthcare level in Afghanistan: observational study

Toby Leslie, Amy Mikhail, Ismail Mayan, Mohammed Anwar, Sayed Bakhtash, Mohammed Nader, Clare Chandler, Christopher J M Whitty professor, Mark Rowland  |  Published
British Medical Journal

Field trial of three different Plasmodium vivaxdetecting rapid diagnostic tests with and without evaporative cool box storage in Afghanistan

Amy FW Mikhail, Toby J Leslie, Mohammad I Mayan, Rohullah Zekria, Nader Mohammad, Mohammad A Hasanzai, Najibullah Safi, Christopher JM Whitty and Mark Rowland  |  Published
Malaria Journal

The practice of 'doing' evaluation: lessons learned from nine complex intervention trials in action

Joanna R, Deborah D, Lindsay M, Evelyn A, Sham L, Hilda M, Katia B, Jayne W, Lasse V, Shunmay Y, Toby L, Eleanor H, Hugh R, David L, David S, Bonnie C, Sarah S, Virginia W, Catherine G, Clare C  |  Published
Implementation Science

Rapid diagnostic tests to improve treatment of malaria and other febrile illnesses: patient randomised effectiveness trial in primary care clinics in Afghanistan

Toby Leslie, Amy Mikhail, Ismail Mayan, Bonnie Cundill, Mohammed Anwar, Sayed Habib Bakhtash, Nader Mohammed, Habib Rahman, Rohullah Zekria, Christopher J M Whitty, Mark Rowland  |  Published
British Medical Journal

Cost-effectiveness of malaria diagnosis using rapid diagnostic tests compared to microscopy or clinical symptoms alone in Afghanistan

Hansen S Kristian, Grieve Eleanor, Mikhail Amy, Mayan Ismail, Mohammed Nader, Anwar Mohammed, Baktash H Sayed, Drake L Thomas, Whitty J M Christopher, Rowland W Mark, Leslie J Toby  |  Published
Malaria Journal

Examining intervention design: lessons from the development of eight related malaria health care intervention studies

Clare I.R. Chandler*, Helen Burchett, Louise Boyle, Olivia Achonduh, Anthony Mbonye, Deborah DiLiberto, Hugh Reyburn, Obinna Onwujekwe, Ane Haaland, Arantxa Roca-Feltrer, Frank Baiden, Wilfred F. Mbacham, Richard Ndyomugyenyi, Florence Nankya, Lindsay Man  |  Published
Health Systems and Reform

Afghanistan Entry & Exit Interview Study

Clare Chandler, Molly Wood, James Kizito, Miriam Kayendeke, Christine Nabirye, Tamanna Ahmad, Karimullah Karimullah, Mohibullah Motahed, Anwar Hazansai, Sayed Habib Baktash, Nadia Anwari5, Nader Mohammed, Ismail Mayan, Amy Mikhail, Mark Rowland  |  Published
Summary results from qualitative analysis

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