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TRANSCRIPT
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Diagnosis of Malaria:
Best practices, Issues
and way forward
Wellington A. Oyibo
ANDI CENTRE OF EXCELLENCE FOR MALARIA DIAGNOSIS
WHO/TDR Malaria Specimen Bank Site
College of Medicine,University of Lagos
Lagos – Nigeria
7/06/2013 1CME_LagMoH
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Overview
• Introduction
• Malaria diagnosis – background – Best practices
• Why parasitological diagnosis?
• Malaria Rapid Diagnostic Tests (RDTs)
implementation
• WHO/FIND’s framework for quality diagnostics
• Conclusions
• Acknowledgement
7/06/2013 2CME_LagMoH
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Introduction
• 216 million clinical cases annually worldwide (WHO,
2012)
• About 650,000 deaths, mostly in children less than 5
yrs old (WHO, 2012)
• Reduction in malaria rates … with massive
interventions ( 37% in children < 5yrs in facilities and 42% in communities nationally; lower prevalence in urban – rural areas/facilities in Lagos State)
• Over-diagnosis of malaria - fever = malaria
• Poor parasite confirmation compared with massive
deployment of ACTs (30 – 40% in Lagos State)
• Current malaria diagnostic realities, challenges and
opportunities7/06/2013 3CME_LagMoH
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7/06/2013 CME_LagMoH 4
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Objectives
• Highlight current best practices in malaria
diagnosis
• Describe opportunities in parasitological
confirmation of suspected malaria cases in
the context of service delivery and best
practices
• Elucidate misconceptions/beliefs in
performing malaria confirmatory tests
• Describe the Challenges and barriers to
effective malaria testing7/06/2013 CME_LagMoH 5
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Outcome
• Knowledge of current best practices in
malaria diagnosis at various levels of care
• Understanding of the opportunities in
malaria testing and how these can be
effectively employed in improving service
delivery
• Recognize misconception/beliefs and
barriers to enhance effective malaria case
management with diagnosis
• Re-orientated to scale-up malaria diagnosis
by providing access to malaria diagnosis
•
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Best practices in malaria
diagnosis
7/06/2013 CME_LagMoH 7
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Defining malaria
• Malaria is a disease caused by the obligate intracellular protozoa of the genus Plasmodium
• It is important to differentiate clinical malaria from Plasmodium infection
• Clinical malaria emphasizes the concomitant signs and symptoms +malaria parasite
• Plasmodium infection is the presence of the parasite in the blood without symptoms –asymptomatic- some level of immunity
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Etiology
• Plasmodium falciparum (>90% of infections and most dangerous)
• Plasmodium malariae (
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Invasion Receptors/Ligands
Species Host
Receptor Merozoite
Ligand
P. falciparum glycophorins (sialic acid)
EBA-175
P. vivax, P. knowlesi
Duffy Ag DBP
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7/06/2013 CME_LagMoH 12
Plasmodium falciparum
The Machine called Plasmodium
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Malaria Case Management Goal
Overall Public health goal: reduction of the infectious reservoir
Specifically
• Early detection and prompt effective treatment to cure the infection and prevent progression to severe disease
• Proper management of severe disease to prevent death
• Prevention of the unset of drug resistance
• Reduction of malaria transmission
7/06/2013 13CME_LagMoH
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Recognizing Malaria may no longer be as easy as “looking and touching”
Hot body and Cold
Hot body and irritabilityHot body, weakness and malaise
Cold and rigorsHot body Hot body, palor and unconsciousness
7/06/2013 14CME_LagMoH
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7/06/2013 CME_LagMoH 15
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Malaria Diagnosis
• Prompt, accurate diagnosis of malaria -
integral part of effective disease management
• Good quality tests improves management of
malaria, reduces unnecessary treatment with
antimalarial medicines, and improves
differential diagnosis of febrile illnesses
• Malaria diagnosis –clinical criteria – symptoms
detection of parasites in blood (parasitological or
confirmatory diagnosis – microscopy or RDT)7/06/2013 16CME_LagMoH
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WHO Recommendation
• “Prompt parasitologic confirmation by
microscopy or alternatively by rapid diagnostic
tests (RDTs) is recommended for all patients
suspected of malaria before treatment is
started. Treatment solely on the basis of
clinical suspicion should only be considered
when a parasitological diagnosis is not
accessible”
WHO (2010) Malaria Case Management Guide
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7/06/2013 CME_LagMoH 18
Test. Treat. Track
WHO, 2012
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National Policy Recommendation
National Policy on Diagnosis & Treatment
of Malaria
• Recommends universal parasite-based
confirmation of fevers
• Exemption: Severe malaria
7/06/2013 CME_LagMoH 19
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7/06/2013 CME_LagMoH 20
2011 Malaria diagnosis and treatment Guideline (FMoH, 2011)
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Rapid diagnosis tests
Avantages :
Rapid and simple,
even in remote areas.
Disadvantages :
Missing low parasites
Microscopy
Avantages :
Simple equipement,
rapid, low cost.
Disadvantages:
Subjective, Training of
microscopists, Difficult
Molecular methods
Avantages :
sensitive, better
species discrimination.
Disadvantages:
High cost,
not field-adapted
Parasite-based Diagnosis of malaria
7/06/2013 21CME_LagMoH
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Malaria Microscopy Quality
Assurance
Provides guidance for
National QA
programme
Development of
national slide banks
Criteria for
accreditation of
microscopists
25/04/2013 Doctors discuss malaria 22
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WHO manual on microscopy
QAHierarchical structure•Emphasis on re-training and accreditation standards•Sustainable cross-checking (less slides)•National slide banks
Competency
Selection
Training
Assessment
Equipment/ reagents
Support networkSlide /results delivery
Work environment
Performance
Supervisione.g. cross-checking??
25/04/2013 23Doctors discuss malaria
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Malaria Microscopy Quantification
Plus system:• 1-10 parasites per 100 HPF………….
+
• 11-100 parasites per 100 HPF………
++
• 1-10 parasites per
HPF……………….+++
• >10 parasites per
HPF………………..++++
Less accurate
Misinterpretations
• QuantitativeParasite count X est. WBC (8,000) = Parasite/ul
bld
WBC count
Gives approximate density of parasites
per ul of blood
Relies on a predetermined range of WBCs
(200 -500)
Can only be applied on thick films
7/06/2013 CME_LagMoH 24
Semi-quantitative Plus system protocol in semi-quantitative hardly followedQuantification allows accurate follow-up of parasite clearance
Training/re-training, good quality reagents and workload of the microscopists
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Highlights on Malaria Microscopy
• In current malaria epidemiological realities, MP
testing useful in patients with continued fever and
+ve malaria HRP-2 RDT – more referrals from
PHCs anticipated
• Permits demonstration (detection & speciation) and
quantification of parasites – esp. in-patients and
children
• High quality consumables, microscopes, and
competency of microscopists critical
• Low competency being addressed with capacity
building
• Quality Assurance frame-work being established7/06/2013 CME_LagMoH 25
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Appropriate Malaria Diagnosis for
Developing Countries
• Prompt & timely
• Sensitive & Specific
• Guide therapeutic intervention
• Cost – effective and affordable
• Accessible to rural & urban populations
• Less laboratory sophistication
• Independent of electricity
• Easy-to-perform & interpret
• Non-subjective
25/04/2013 26Doctors discuss malaria
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State-of-the-arts on Malaria Rapid
Diagnostic Tests
Antigen detected NOT parasites
• Three antigens utilized:
Histidine-Rich Protein 2 (HRPII)
Plasmodium lactate dehydrogenase (pLDH)
Aldolase
Most RDTs are HRP-2 and pLDH
• Immunochromatographic antigen-capture device
7/06/2013 27CME_LagMoH
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Mal. RDTs Contd…
• Antibody detection (IgG, IgM, IgA) specific to
Plasmodium falciparum, P. vivax, P. ovale &
P. malariae
• Recombinant P.f & P.v Merozoite surface
protein (MSP) antigen coated on test band
however not too useful
HRP-2 RDTs RECOMMENDED FOR
PROGRAMMATIC USE IN POLICY
7/06/2013 28CME_LagMoH
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Histidine-Rich Protein II (HRPII)
• Specific to P. falciparum
• Abundant in cytoplasm & membrane of
infected erythrocytes
• Soluble & heat-stable antigen
• Composed largely of histidine & Alanine
• Stable in plasma & circulate for weeks
after clearance of parasitaemia
25/04/2013 29Doctors discuss malaria
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pLDH & Aldolase
• Rapid antigen clearance from circulation
• P. falciparum specific & pan specific
• Conserved major enzymes in the glycolytic pathway of Plasmodium sp
• Abundant & soluble in parasite’s cytoplasm
• More vulnerable to heat & humidity extremes
• Exhibit little intra-specific polymorphism
• Inter-species antigen variation
• Significant quantities released at time of cell rupture & febrile episodes
25/04/2013 30Doctors discuss malaria
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Rapid Malaria Tests (RDTs) Use when malaria microscopy is not available:
Health Centers and clinics without microscopy and also at OPDs and off-working hours in hospitals
Health care providers
Community health workers
Private pharmacies
Advantages:
No equipment required
Simplicity, requires minimal training
Rapidity of result
Quality assured mal RDTs available
But: requires some training, follow-up and supervision, need to build confidence in test results
7/06/2013 31CME_LagMoH
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RDT Procedural Steps: Summary
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VI. Squeeze out a drop of blood
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TEST DESCRIPTION
CONTROL WINDOW
C
TEST WINDOWT
SAMPLE WELL (BLOOD)
A
BUFFER WELL
B
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ClinicalMicro-
scopyRDT Clinical
Micro-
scopyRDT
Referral Hospitals
District Hospitals
Health Centers
Private Clinics
Aid Posts/Volunteers
Private Pharmacies
Traditional Healers ?
Households ?
Past and FutureExpanding Parasite-based Diagnosis
The Paradigm Shift
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WHO/FIND Malaria specimen bank development: Laboratory Network
7/06/2013 37CME_LagMoH
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7/06/2013 CME_LagMoH 38
Global Malaria Specimen Bank
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WHO malaria RDT product testing
Round 1-3 results
P. falciparum
Rnd 1 (2008) 41 productsRnd 2 (2009) 29 productsRnd 3 (2010) 50 productsRnd 4 (2011) ~50 products
7/06/2013 39CME_LagMoH
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Positive Control Wells (PCWs) by FIND: Quality control for health workers
7/06/2013 40CME_LagMoH
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Opportunities in
parasitological confirmation of
suspected malaria cases
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Why parasitological diagnosis of
malaria is necessary? (1)
• Clinical presentation of malaria least specific
• Causes of fever: non-serious viral infections to serious, life
threatening conditions that require immediate, appropriate
treatment
• Malaria infection can co-exist with other life-threatening
conditions e.g pneumonia
• When managing patients, it is difficult to know if the condition
is due to malaria or another disease solely on the basis of
clinical presentation
• Accurate diagnosis essential for optimal treatment to save
lives
• Dx more vital with successful malaria control where the
likelihood that malaria is the cause of fever is reduced 427/06/2013 CME_LagMoH
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Why parasitological diagnosis of
malaria is necessary? (2)• Parasitological testing – only way to diagnose
malaria accurately in febrile patients
• Treatment based on diagnostic testing is good
clinical practice and has many advantages over
presumptive treatment of all fever episodes: Improved care of parasite +ve patients
Identification of parasite –ve patients in whom another diagnosis must be sought and
treated accordingly
Avoidance of antimalarial medicine use in parasite-ve patients, which reduces side
effects, drug interactions and selection pressure for drug resistance, potentially
resulting in financial savings
Better public trust in the efficacy of ACT when it is used only to treat confirmed
malaria cases
Better public trust in diagnosis and treatment of non-malaria causes of febrile illness
7/06/2013 CME_LagMoH 43
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Manufacturer Test Company web sites Useable Specimen
ACON Laboratories Malaria P.f. Rapid Test http://www.aconlabs.com/ Whole blood
AmeriTek, Inc. One Step Malaria Test http://www.ameritek.org/ Whole blood
Binax NOW Malaria P.f./P.v. http://www.binax.com/ Whole blood
Bio-Quant, Inc One Step Malaria Test http://www.bio-quant.com/ Whole blood
Core Diagnostics Ltd. CORE Malaria (Pf, Pf/Pv, Pan Pf) http://www.corediag.com/ Whole blood
Cortez Diagnostics, Inc. OneStep RapiCard InstaTest http://www.rapidtest.com/ Whole blood
DiaMed SA OptiMAL Rapid Malaria Test d i amed.com Whole blood
Flow Inc. OptiMAL Rapid Malaria Test http://www.malariatest.com/ Whole blood
Genix Technology Malaria (P. fal.) Ag http://www.genixtech.com/ Whole blood
Genelabls Diagnostics Ltd. ASSURE® Malaria P.f. Rapid Test http://www.genelabs.com.sg/ Whole blood
Global eMed, LLC Smart Strip Malaria Test http://www.globalemed.com/ Whole blood
International Immuno-Diagnostics One-Step Malaria (PF/PV) http://www.intlimmunodiagnostics.com/ Whole blood
Kat-Medical KAT-Quick Malaria test http://www.katmedical.com/ Whole blood
Mega Diagnostics, Inc. MegaKwik Malaria (Pf) Card Test http://www.mega-dx.com/ Whole blood
Orchid Biomedical Systems Paracheck Pf http://www.tulipgroup.com/Orchid/ Plasma, whole blood
Premier Medical Corporation First Response Malaria P.f / P.v Antigen
Strips
http://www.premiermedcorp.com/ Whole blood
Princeton BioMeditech Corporation BioSign Malaria http: //www.pb mc.com Whole blood
SPAN Diagnostics ParaHIT f http://www.span.co.in/ Whole blood
Standard Diagnostics Inc. Malaria P.f/P.v Antigen Test
Malaria P.f/P.v Antibody Test
http://www.standardia.com/eng_product/ Whole blood, serum
Trinity Biotech Rapid Uni-Gold™ Malaria (Pf.) http://www.trinitybiotech.com/ Whole blood
Vencor International Inc. DxStrip Malaria Combo http://www.vencorinternational.com/ Whole blood
7/06/2013 44CME_LagMoH
http://www.aconlabs.com/http://www.ameritek.org/http://www.binax.com/http://www.bio-quant.com/http://www.bio-quant.com/http://www.bio-quant.com/http://www.corediag.com/http://www.rapidtest.com/http://diamed.com/http://www.malariatest.com/http://www.genixtech.com/http://www.genelabs.com.sg/http://www.globalemed.com/http://www.intlimmunodiagnostics.com/http://www.katmedical.com/http://www.mega-dx.com/http://www.mega-dx.com/http://www.mega-dx.com/http://www.tulipgroup.com/Orchid/http://www.premiermedcorp.com/http://www.pbmc.com/http://www.span.co.in/http://www.standardia.com/eng_product/http://www.trinitybiotech.com/http://www.vencorinternational.com/
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Malaria Test and Service delivery
• Opportunity for improving service delivery –
for malaria RDTs and Microscopy
• Improvement of diagnostic system
• Overall health system strengthening
• Dedication to service required: How can I
make things work in my facility? Is RDT
testing additional and undoable work for
me? How do I address the concerns of my
clients and provide satisfactory services?7/06/2013 CME_LagMoH 45
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Misconceptions/beliefs and
Challenges in malaria testing
7/06/2013 CME_LagMoH 46
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Misconceptions /beliefs
• All fevers are malaria
• Diagnosis not necessary
• 1-2 drops of blood from a patient is not
helpful to do a test considering the total
volume of blood in a patient
• Microscopy for MP test only real tests
• Malaria RDTs are not good (cross-reacts highly with other conditions…)
• Cost of diagnosis/Assumption of patient’s
inability to pay for test7/06/2013 CME_LagMoH 47
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Misconception/beliefs
• Malaria RDTs used to test for HIV (among
patients)
• Malaria RDT testing not for Doctors,
Nurses, Chews, etc - ONLY for the Lab
(Healthcare providers says it is not their
job)
• Malaria RDTs not as good as Microscopy
• Too many negative tests – RDTs not good
7/06/2013 CME_LagMoH 48
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Challenges in Malaria Diagnosis
• Over diagnosis of malaria – high reliance on clinical diagnosis of febrile illness and poor microscopy skills
• Microscopy: Reliance on high skills, electricity, workload, waiting time for results, unavailable in remote rural areas, subjectivity, lack of QA etc
• Detection of low density parasitaemia: false negatives
• Poor malaria microscopy skills & reporting
• Resistance to change by health workers
• Lack of confidence in malaria tests
• Poor access to diagnosis
7/06/2013 CME_LagMoH 49
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Malaria Microscopy Quantification
Plus system:• 1-10 parasites per 100 HPF………….
+
• 11-100 parasites per 100 HPF………
++
• 1-10 parasites per
HPF……………….+++
• >10 parasites per
HPF………………..++++
Less accurate
Misinterpretations
• QuantitativeParasite count X est. WBC (8,000) = Parasite/ul
bld
WBC count
Gives approximate density of parasites
per ul of blood
Relies on a predetermined range of WBCs
(200 -500)
Can only be applied on thick films
7/06/2013 CME_LagMoH 50
Semi-quantitative Plus system protocol in semi-quantitative hardly followedQuantification allows accurate follow-up of parasite clearance
Training/re-training, good quality reagents and workload of the microscopists
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Some Issues with Malaria RDTs
• Persistence of HRP II in circulation after parasite
clearance – false positive
• Variation in field trials but high quality RDTs now
available
• HRP II variation: Type A, B, & C sequenced
• Type B is current standards of HRP II
• HRP II deletions in some countries
• Low pLDH stability (shelf life) and performance
• Inability of RDTs to monitor the outcome of
treatment7/06/2013 51CME_LagMoH
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Other Factors
a. Inability to read the bands by some health
workers
b. Co-morbidities e.g false +ve with rheumatoid
factor (very, very low and insignificant)
c. Poor knowledge of mechanism of action by
health workers
d. Aberrant use of expired RDTs
e. Poor or lack of illustrative pictorials on RDTs’
use
7/06/2013 52CME_LagMoH
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Field evaluation of Blood transfer devices:Blood transfer devices
– Challenges with blood transfer devices– Improvement of blood transfer devices (accuracy, safety,
and ease-of-use).
UgandaNigeriaPhilippines
Heidi Hopkins et al., (2011). Blood transfer devices for malaria rapid diagnostic tests: evaluation of accuracy, safety and ease of use. Malaria Journal 2011, 10:30 25/04/2013 53Doctors discuss malaria
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7/06/2013 CME_LagMoH 54
2011 Malaria diagnosis and treatment Guideline (FMoH, 2011)
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7/06/2013 CME_LagMoH 55
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Moving forward – Making
progress: Expectations and
deliverables
7/06/2013 CME_LagMoH 56
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Current Malaria Realities
Health Workers/Patients
• High malaria negative tests
• More follow-up required for
RDT –ve patients
• Counseling of Patients on
withholding antimalarials
• Low testing in facilities
• Behavioural
modification/reorientation/tr
aining
• Low patient education on
tests
Diagnostic Tools
• Growing improvement in
testing and provision of
tools/commodities
• Quality of tests and
reagents need to be
sustained
• Superior tests – case
management, monitoring
interventions, tracking
resurgence…
• Development of Quality
Assurance in-country at
all levels7/06/2013 CME_LagMoH 57
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Global picture
• WHO global policy of universal parasite-based diagnosis before treatment
– Long accepted in Asia and South America
– Now policy in nearly all endemic African countries
• Increased availability of operational funds
• Poor quality global data on malaria transmission
• ACT as first-line therapy: higher cost of treatment, and imperative to preserve efficacy
• Demonstration that RDT use can reduce ACT consumption safely in wide scale use
7/06/2013 58CME_LagMoH
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Picture from the field
• High performing malaria RDTs in field trials (90 -98%
sensitivity and specificity among good RDTs)
• Diagnosis before treatment still poor
• Most RDTs (and microscopy) results are parasite-negative
• Growing capacity of Microscopists to detect malaria
• Rapidly-declining prevalence in many areas: large regions
of low and patchy transmission, with risk of re-emergence
(need to sustain gains, and invest more)
• Drive to Elimination of malaria in low-transmission regions
• Diagnostic commodities yet to match antimalarial medicine
deployment
7/06/2013 59CME_LagMoH
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Diagnostic options in the pipeline
• Magneto-optical biosensors for malaria Test
(MOT) - targets haemozoin in vivo?
• Urine tests?
• Maliva: a malaria-detecting gum that could offer
cheap, new way to diagnose or monitor
diseases?
• Mobile microscopy (hand-held digital
microscopes/cameras)?
• LAMP: Loop mediated isothermal pcr (current
testing shows over 95% sensitivity)• Equivalent capacity with current best-performing RDTs will prove their
usefulness7/06/2013 61CME_LagMoH
http://news.discovery.com/animals/swine-flu-animal-trading.html
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62
Population screening and LAMP
Interspecies variability(GC-2) (GC-2) (GC-2) (GC-1) (GC-1) (GC-3)
Primers amplifying Plasmodium mitochondrial DNA
Development underway of Loop-mediated isothermal DNA amplification (LAMP) that detects 1-6 parasites /l with minimal sample processing that requires no sophisticated equipment and can be read with the naked eye (FIND, Eiken).2013 report shows over 98% sensitivity
(+)(-)
In areas with low-transmission, a large proportion of patients with malaria are likely to have less than the 100 p/ml detected by RDTs.
Moving to population screening tests
15/07/201110th NMCP Best Practices Sharing
Workshop 13 - 15 July, 2011
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Summary: Parasite-based diagnosis and ACT
If no parasite-based diagnosis:
– Most recipients of ACT will not have malaria
– Patients with non-malarial febrile illness will receive wrong or late treatment
– Malaria incidence rates will be unavailable• (Poor resource allocation, poor planning, no elimination)
However, delaying ACT raises malaria mortality:
– Improving access to ACT is essential, should not be delayed
Diagnosis needs to catch up to treatment.
7/06/2013 63CME_LagMoH
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What facilities should do
• Get acquainted with current guideline & Review
malaria case-management SOPs
• Scale-up prompt and quality assured diagnosis
• Provide access to Testing: Use quality-assured
Diagnosis & ACTs – AVOID STOCK-OUT!!!
• Re-orientation of health workers
• Test request should go beyond etiology given high
rates of non-malarial fevers
• Expand platform to conduct supplementary tests e.g
FBC/differentials in the context of fever diagnosis
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In facilities…
• Effectively communicate reasons for malaria testing to
patients at consultation and blood draw
• Organize seamless ways for prompt testing especially
with malaria RDTs at OPDs
• Shorten turn-around time and make results available –
engagement and planning critical
• Procure quality RDTs and consumables for MP testing
• Monitoring/evaluation and review outcomes of fever
management – creating own evidence
• Keep accurate data and frequently analyze for trends
7/06/2013 CME_LagMoH 65
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What institutions can do
• Research and innovation on malaria
diagnostics, drugs and vaccines
• Malaria surveillance
• Capacity building for health workers
• Other support for malaria control
7/06/2013 CME_LagMoH 66
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67
ClinicalMicro-
scopyRDT Clinical
Micro-
scopyRDT
Referral Hospitals
District Hospitals
Health Centers
Private Clinics
Aid Posts/Volunteers
Private Pharmacies
Traditional Healers ?
Households ?
Past and FutureExpanding Parasite-based Diagnosis
The Paradigm Shift
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Closing Messages
• Quality assured RDTs as good as expert microscopists
• RDTs supplied by Government in Nigeria are among the
very best available globally
• Malaria microscopists are being trained for improvement
• Trust your test results and use it to guide antimalarial
prescriptions
• Refer patients to facilities where lab tests can be done
• Malaria testing done in the overall fever context - don’t
close your eyes and insist that it must be malaria – many
other causes of fevers – life threatening ones can be
neglected in the process
• Testing for malaria and withholding antimalarials will
require follow up but do it
• Document evidence – keep accurate records and analyze7/06/2013 CME_LagMoH 68
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Conclusion
• Prompt and accurate malaria diagnosis is key to effective malaria case management – reorientation imperative
• High quality RDTs are available for prompt diagnosis
• Parasitological confirmation of malaria still low –scaling up diagnosis to meet national target of 80% is critical
• Dealing with misconceptions and barriers critical to effective and sustainable malaria diagnosis
• Routine monitoring of efficacy of antimalarial medicines dependent on the institutionalization of an effective and efficient malaria diagnostic system
• PCWs by FIND – a useful tool for RDT QA in the field7/06/2013 69CME_LagMoH
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Remember, without diagnosis,
medicine is blind!
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Malaria diagnostic activities at University of Lagos
Microscopy and RDT Training Certification of MicroscopistsSlide-Banking External QA QA of RDTs (in-country lot testing, field testing, post-purchaseMalaria Indicator Surveys in communities7/06/2013 71CME_LagMoH
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Acknowledgement
• WHO/TDR (Geneva)
• WHO/AFRO/Nigeria
• Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
• NMCP (Nigeria)
• Society for Family Health; SuNMAP
• NIMR
• LagMoH
• EQA programmes in South Africa & Oman
• WHO (Western Pacific) & Philippines MoH
• Dedicated staff
• College of Medicine University of Lagos/LUTH
• Malaria Consortium/DFID, UK
• USAID/MAPS7/06/2013 72CME_LagMoH
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Thanks for your attention!
7/06/2013 CME_LagMoH 73