More than half the paediatric fevers treated in public health clinics in Africa are caused by diseases other than malaria, according to a study by Oxford University and other research groups, whose authors caution against the "continued indiscriminate use of anti-malarials for all fevers across Africa."
Of the 183 million children with malaria symptoms treated by public health clinics in 2007, only 43 percent were diagnosed with malaria, but many more most likely received anti-malarial medication.
"Malaria is still routinely made as the diagnosis of convenience in response to paediatric fever," the study's lead researcher, Peter Gething, told IRIN. "This in part stems from official guidelines that have only recently been updated, and in part because often the only treatments available in front-line clinics are anti-malarials."
In 2006 the World Health Organization (WHO) recommended that health workers in countries with a high number of suspected cases of malaria treat children with fevers – the main clinical symptom of malaria – for the disease, even without a diagnosis.
There was little else to do at the time, said WHO expert Peter Olumese. "The probability was high that the fevers were from malaria, the disease could turn fatal quickly and there was no time to lose, and there were no proven diagnostic tools," he told IRIN.
Since then, rapid diagnostic testing for malaria has become available, making it possible to confirm diagnoses without health workers, a microscope or a laboratory. In 2008, 11.5 million of these tests were distributed in Africa; in 2009, the Global Fund to Fight AIDS, Tuberculosis and Malaria financed 74 million tests, and another 105 million in 2010, according to the Roll Back Malaria Partnership.
People in communities have been trained to test one another for malaria. In Senegal, people of all ages are treated for malaria in government-funded health centres only once there is a positive result from a laboratory or rapid test.
In sub-Saharan Africa 31 countries have a policy of "universal diagnostic testing", while another 15 countries in the region have set a goal of testing before treatment in children aged five and older, judging it too risky to delay treatment in younger patients.
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Yet it can be equally risky to treat someone for malaria based only on the assumption that they have the disease, the director of WHO's global malaria programme, Robert Newman, told IRIN.
"You might be wasting ACT [anti-malarial artemisinin-based Combination Therapy], while increasing the risk for drug resistance; also, you are not treating the underlying febrile disease and the drug delay can be fatal. If you treat bacterial pneumonia with anti-malarials, you still have a problem."
On Kinaserom, one of the islands in Lake Chad, health workers recently started using rapid tests to check patients suspected of having malaria. Mahamat Boukar Moussa, the head nurse at a clinic on the island, told IRIN he gave patients malaria medication even when test results were negative. "The tests are not accurate and we cannot risk inaction."
Raoul Ngarhounoum, the regional health director overseeing the rollout of malaria rapid testing, told IRIN he agreed with the health workers' scepticism. "These are malaria-endemic areas, and just because a test says it is not malaria does not mean it is not."
Gething said that besides quality control, "Simply supplying RDT [rapid diagnostic testing] universally is likely to be less effective if it is not accompanied by sufficient training for front-line health workers."
The Foundation for Innovative New Diagnostics, which works with WHO to create quality control standards for rapid tests, recommends spot checking in each batch of tests ordered to ensure the tests were not poorly manufactured, or had been damaged in transit or storage.
Malaria treatment would not change overnight, said Gething. "In an ideal world, all fevers reaching clinics in Africa would be tested for malaria, using a reliable diagnostic test ... As always, the reality on the ground is more complex. For years the advice has been to treat all fevers as malaria, and changing that dogma is likely to take time."