The importance of correct malaria diagnostics
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Administrating "blind treatment" to patients with a fever, who are suspected of having malaria but often do not, could mean that a large proportion of them receive ACT unnecessarily. This has a number of serious implications, including the risk of development of drug resistance. ACT is a combination of an artemisinin derivate and a companion drug (another efficacious anti-malarial). This companion drug can remain in the bloodstream for several weeks. If a patient becomes infected with malaria soon after taking ACT, the parasites may be exposed to sub-therapeutic levels of the companion drug in the bloodstream, leading to the selection of resistant strains.
In addition, the use of ACT in the presence of a non-malarial infection may lead to left-over ACT pills, as a patient who does not get better may stop his treatment prematurely, and later take the remaining pills when he develops another fever, on another occasion. That leads to further risks of developing resistance.
The accurate diagnosis of malaria with RDTs not only avoids unnecessary use of ACTs, but also avoids the administration of repeated courses of treatment with only short intervals in between. Although ACTs are in principle very safe drugs, the repeated intake of certain ACTs at short intervals (especially artesunate-mefloquine) can lead to more side effects.
There are also concerns that the supply of artemisinin (the raw material needed to produce ACTs) may become insufficient over the next few years. Ensuring accurate diagnosis of malaria and the prescription of ACT only to patients that really need it is one way to reduce the risk of potential supply shortages.
Two recent developments support the call for the implementation of routine confirmation of malaria diagnosis: 1) WHO has issued new malaria treatment guidelines stating that all patients with suspected malaria should undergo biological confirmation before treatment is prescribed; 2) WHO, in collaboration with partner institutions, has conducted an in-depth evaluation of rapid diagnostic tests. This provided the technical basis for the WHO information note with interim recommendations on the supply of malaria RDT which offers guidance to ministries of health and other actors in making choices around the implementation of reliable tests.
For MSF, it is important that all actors opt for the routine confirmation of malaria diagnosis before prescribing treatment, so that patients in real need of ACT receive it and the implications of unnecessary prescription are avoided. MSF calls upon all donors who fund ACTs to compliment this with funds for appropriate quantities of RDTs.
The author is the Head of the Médecins Sans Frontières (MSF) Malaria Working Group.
