Improving Malaria Diagnostic Capacity in sub-Saharan Africa


Malaria kills over 1 million children below five years of age in sub-Saharan Africa annually, with control hampered by drug resistance, widespread overtreatment, and unreliable diagnostics1. The vast majority of health resources to low income countries are focused on preventive programs and access to needed medications, two paramount needs. This can leave essential laboratory services overlooked, with non-specific clinical algorithms used instead. Misdiagnosis rates for malaria and many other infections are thus high, leading to inadequate treatment, increased morbidity and mortality, and waste of limited drugs2,3. Amongst Tanzanian patients with a clinical diagnosis of severe malaria, according to World Health Organization (WHO) criteria, less than 50% had a blood smear confirming presence of Plasmodium falciparum4. In Ghana, 40% of children meting WHO criteria for malaria instead had bacterial sepsis5. Improving laboratory functioning has the real capacity to reduce misdiagnosis. Perhaps the most critical barrier to expanding diagnostic capacity is the shortage of personnel, as current efforts in education and training are grossly inadequate6. A survey of Ghana laboratory workers found only 26% to be professionally qualified7. Supervisors, able to educate and monitor accuracy, are even scarcer. Inaccurate testing also erodes confidence in lab results. In areas where laboratory testing is available, physicians often perceive it to be unreliable, rejecting negative lab reports in favour of their clinical judgment8. Major steps must be taken to restore faith in laboratory accuracy in order to change perceptions of clinicians and governments9.


Improving health care in low income countries will only come through partnership with institutions in high income countries. Development of effective training and education resources, drawing on successful educational strategies, is an important way to enhance laboratory capacity and meet an urgent need. The internet allows widespread dissemination of training materials and is an ideal medium to reach low-income countries as internet access grows.

 

Goal 1: Evaluation and Needs Analysis of Malaria Diagnostic Capacity
Strengthening relationships established during a trip to Africa in 2006, three central and regional hospitals will be visited in Rwanda – Centre Hospitalier Universitaire de Kigali, Hôpital de Gahini, and Kibogora Hospital. One week will be spent at each site. Detailed notes will be made of malarial disease burden, lab infrastructure, supplies, personnel numbers and training, quality assurance, protocols, and testing rates and results. Specific educational needs will be identified, and effective means of meeting them will be discussed. In particular, currently used teaching tools will be evaluated. Time will also be spent on wards to gain clinical exposure.

 

Goal 2: Development of Educational Resources for Malaria Diagnosis
Following return to Halifax, and by consulting existing resources,10,11,12 time will be spent in the IWK lab developing effective teaching tools for malaria diagnosis in areas with limited resources. Close attention will be paid to ensure information is understandable and accessible. Extensive use of instructive photographs and videos, and images of blood smears, will be included. Narrative will be culturally focussed and provided in English, French, and if possible, Swahili. Resources will be assembled into an online site and shared with staff in Africa, with feedback being incorporated.  IWK contact information will be given to provide support.

 

Timeline

weeks 1-4: observation of lab infrastructure, personnel, and protocols in Rwanda
weeks 5-6: protocol development in IWK microbiology lab
weeks 7-9: documentation and editing of educational resources
weeks 10-12: translation and compilation into web site

The process of resource development proposed here will be documented as a model for future projects. The IWK’s role in sharing its laboratory expertise will help fill the critical gap of diagnostic capacity in low-income countries and expand the IWK’s position as a partner in global health.

 

References

    • Rowe AK et al. Estimates of the Burden of Mortality Directly Attributable to Malaria for Children under 5 Years of Age in Africa for the Year 2000: Final Report for the Child Health Epidemiology Reference Group (CHERG) (WHO, Geneva, 2004).
    • Petti CA, Polage CR, Quinn TC, Ronald AR, Sande MA. Laboratory medicine in Africa: a barrier to effective health care. Clinical Infectious Diseases 2006; 42:377.
    • Njama-Meya D, Clark TD, Nzarubara B, Staedke S, Kamya MR, Dorsey G. Treatment of malaria restricted to laboratory-confirmed cases: prospective cohort study in Ugandan children. Malar J 2007;6:7.
    • Reyburn H, Mbatia R, Drakeley C, et al. Overdiagnosis of malaria in patients with severe febrile illness in Tanzania: a prospective study. BMJ 2004; 329:1212.
    • Evans JA, Adusei A, Timmann C, et al. High mortality of infant bacteraemia clinically indistinguishable from severe malaria. QJM 2004; 97:591.
    • Narasimhan V, Brown H, Pablos-Mendez A, et al. Responding to the global human resources crisis. Lancet 2004; 363:1469.
    • Bates I, Bekoe V, Asamoa-Adu A. Improving the accuracy of malaria-related laboratory tests in Ghana. Malar J 2004; 3:3.
    • Hamer DH, Ndhlovu M, Zurovac D, Fox M, Yeboah-Antwi K, Chanda P, et al. Improved diagnostic testing and malaria treatment practices in Zambia. JAMA 2007;297:2227.
    • Bissofi Z and Van den Ende J. Costs of treating malaria according to test results. BMJ 2008; 336:7637.
    • Rafael ME, Taylor T, Magill A, Lim YW, Girosi F, Allan R. Reducing the burden of childhood malaria in Africa: the role of improved diagnostics. Nature 2006;444:39.
    • Reyburn H, Mbakilwa H, Mwangi R, Mwerinde O, Olomi R, Drakeley C, et al. Rapid diagnostic tests compared with malaria microscopy for guiding outpatient treatment of febrile illness in Tanzania: randomised trial. BMJ 2007;334:403.
    • Bates I, Bekoe V, Asamoa-Adu A. Improving the accuracy of malaria-related laboratory tests in Ghana. Malar J 2004; 3:38.