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

Abstract

Objective To assess the accuracy of malaria diagnosis and treatment at primary level clinics in Afghanistan.Design Prospective observational study.Setting 22 clinics in two Afghan provinces, one in the north (adjoining Tajikistan) and one in the east (adjoining Pakistan); areas with seasonal transmission of Plasmodium vivax and Plasmodium falciparum.Participants 2357 patients of all ages enrolled if clinicians suspected malaria.Interventions Established (>5 years) microscopy (12 clinics in east Afghanistan), newly established microscopy (five clinics in north Afghanistan), and no laboratory (five clinics in north Afghanistan). All clinics used the national malaria treatment guidelines.Main outcome measures Proportion of patients positive and negative for malaria who received a malaria drug; sensitivity and specificity of clinic based diagnosis; prescriber’s response to the result of the clinic slide; and proportion of patients positive and negative for malaria who were prescribed antibiotics. Outcomes were measured against a double read reference blood slide.Results In health centres using clinical diagnosis, although 413 of 414 patients were negative by the reference slide, 412 (99%) received a malaria drug and 47 (11%) received an antibiotic. In clinics using new microscopy, 37% (75/202) of patients who were negative by the reference slide received a malaria drug and 60% (103/202) received an antibiotic. In clinics using established microscopy, 50.8% (645/1269) of patients who were negative by the reference slide received a malaria drug and 27.0% (342/1269) received an antibiotic. Among the patients who tested positive for malaria, 94% (443/472) correctly received a malaria drug but only 1 of 6 cases of falciparum malaria was detected and appropriately treated. The specificity of established and new microscopy was 72.9% and 79.9%, respectively. In response to negative clinic slide results, malaria drugs were prescribed to 270/905 (28.8%) and 32/154 (21%) and antibiotics to 347/930 (37.3%) and 99/154 (64%) patients in established and new microscopy arms, respectively. Nurses were less likely to misprescribe than doctors.Conclusions Despite a much lower incidence of malaria in Afghanistan than in Africa, fever was substantially misdiagnosed as malaria in this south Asian setting. Inaccuracy was attributable to false positive laboratory diagnoses of malaria and the clinicians’ disregard of negative slide results. Rare but potentially fatal cases of falciparum malaria were not detected, emphasising the potential role of rapid diagnostic tests. Microscopy increased the proportion of patients treated with antibiotics producing a trade-off between overtreatment with malaria drugs and probable overtreatment with antibiotics.

Malaria “Diagnosis” and Diagnostics in Afghanistan

“…This occurred in a context in which, as indicated by recent observational data, overdiagnosis and overtreatment of malaria were widespread. This was particularly the case where no diagnostic technology was available, but also in locations where health workers had access to microscopy and/or RDTs (Leslie et al, 2012).…”

High prevalence of pfdhfr–pfdhps triple mutations associated with anti-malarial drugs resistance in Plasmodium falciparum isolates seven years after the adoption of sulfadoxine–pyrimethamine in combination with artesunate as first-line treatment in Iran

“…This surveillance is very important for early detection of resistance to anti-malarial drugs such as chloroquine (CQ) and sulfadoxinepyrimethamine (SP) and also for avoiding the further selection and extension of multidrug resistance (Maïga et al, 2007;Lynch et al, 2008;Certain et al, 2008;Harris et al, 2010). Such molecular study also provides a baseline data for the health authorities responsible for ensuring access to efficient anti-malarial drugs that could be fundamental to accelerate elimination program nationwide.…”

“Malaria And Typhoid Co-Infection In India: A Diagnostic Difficulty’’

“…Both typhoid and malaria share rather similar signs which lead to misdiagnosis and mismanagement resulting in either under treatment or over treatment. This predisposes to disease transmission from untreated patient to new host and further irrational use of antibiotics / anti malarial results increasing surge of drug resistance [7][8][9][10][11][12][13][14]. Hence this study was planned to determine the actual number of cases suffering from typhoid malaria co-infection in our set-up and also to evaluate the efficacy of various tests for diagnosis of typhoid malaria co-infection in febrile patients in New Delhi.…”