Combating malaria misdiagnosis

Health experts say the majority of malaria cases in Mali are misdiagnosed, which causes resistance to malaria drugs and leaves other illnesses untreated.

“When people are sick in Mali, the doctor will usually tell them they have malaria whether or not they test for it,” said Fatou Faye, an infectious diseases researcher and trainer at a privately funded medical laboratory, the Charles Merieux Centre in Bamako.

“The patients then buy anti-malarial drugs in the street and build up a resistance to treatment.”

As a result, according to research by Dr. Imelda Bates at the Malaria Knowledge Project (MKP), part of the Liverpool University School of Tropical Medicine, this means people miss other causes of feverish illness such as pneumonia and meningitis, which can cause further illness and even death.

Economic productivity is also affected, and misdiagnosis can deepen poverty due to prolonged illnesses and money being wasted on the wrong drugs.

Malaria is the most prevalent disease among Malian children under five years old according to George Dakono coordinator of the national project to fight against malaria.

“Shocking levels” of misdiagnosis

The discrepancy between real and assumed cases has reached “shocking” levels all over Africa according to the MKP.

Malaria diagnostics in Mali rely on expensive equipment which most health clinics, particularly in rural areas, cannot afford and do not have the trained staff to use, Michel Van Herp an epidemiologist with non-governmental organisation Médecins Sans Frontières (MSF) Belgium, told IRIN.

As a result most doctors “make assumptions based on suspicion,” he said, leading to over-treatment of malaria cases.

Further, according to Dakono and Faye, most people who develop a fever in Mali do not visit a health clinic at all, either because they live too far away or are unwilling to pay up to US$0.95 for a consultation. They self-diagnose and treat instead.

Up to 70 percent of cases of feverish illness in children are diagnosed and treated at home according to the MKP.


Photo: Nicholas Reader/IRIN
Child with malaria being treated at an MSF-funded government health centre.

Laboratories the ‘gold standard’ 

Mali needs more and better-equipped laboratories to combat mass misdiagnosis, according to Faye.

Valentina Buj, a health project officer with the World Health Organization (WHO) said “blood smear-tests in a laboratory are the gold-standard in malaria diagnostics.”

But the majority of the 82 government-run laboratories around the country lack the right equipment and trained technicians to diagnose malaria, Faye told IRIN.

The Charles Merieux Foundation has set up a laboratory in Bamako to diagnose malaria and other infectious diseases, train technicians from health clinics around the country in how to use diagnostic equipment and run a lab, and with European Union funding, to equip labs around the country. Its aim is to replicate standards found in French laboratories.

“We want to create a situation that for the majority of diseases they encounter, they can accurately diagnose them themselves,” Faye said.

Rapid diagnostic tests

But for MSF’s Van Herp, laboratories are not the answer to improving malaria diagnostics in rural Mali where clinics and laboratories are few and far-between.

“We need simple, low-technology malaria test kits, rather than buying more expensive equipment and carrying out in-depth trainings which is hard to do in rural areas,” he told IRIN.

For him the answer is to get rapid diagnosis tests or ‘RDT’s, which are small, easily transported and cost on average US$0.45, to community health workers throughout the country so they can test people village by village. 

“The test takes 15 minutes to produce results and it takes half a day to train a community health worker how it’s used,” said Van Herp, “they are the only options for diagnosis at the household level.”

The test is simple - if a person has malaria, chemicals in the test react to a product produced by the malarial parasite in their blood, causing a red strip to appear fifteen minutes later. And where MSF has distributed them, the number of patients seeking diagnosis for malaria has increased from one in four to 100 percent.

Taking the kits country-wide is a challenge in Mali -– they require a long shelf-life, sophisticated distribution systems, and their results are unreliable in temperatures of over 30 degrees Celsius, which is Mali’s average temperature. “The technology still needs to be finessed,” Buj said.

MSF nonetheless says it plans to expand its programme, which currently is diagnosing 80,000 people in malaria-prone regions, across the country alongside the government.

''...The Ministry of Health is already subsidising...health centres...so why shouldn't it start supporting diagnostics fees as well...''

Funding

With simple technology, improving diagnostics does not have to be expensive – it would take US$61 million to cover Mali’s diagnostic needs according to Van Herp - but it requires the government and donors to take it more seriously.

The first step, according to the MKP is cost-benefit analyses to map out malaria prevalence, resistance patterns, and clinics capacity to analyse which diagnostics approach is better – rapid tests or improving labs.

International donors have stepped in to improve Mali’s efforts to fight malaria with US$126 million from the George Bush foundation and the Global Fund to fight HIV/AIDS, malaria and tuberculosis committed over five years, but critics say not enough of this money targets diagnostics.

“The Ministry of Health is already subsidising medicines, staff salaries and building health centres, and international funds are coming in, so why shouldn’t it start supporting diagnostics fees as well?” asked Van Herp.

According to a health practitioner in a government clinic in Fana, a town north of Bamako, “if the government does not support diagnostics, its other efforts will fall flat.”

WHO’s Buj is positive Mali is going in the right direction. “When it comes to… diagnostics, the situation is definitely getting better in Mali,” she said.

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