When Knowledge Is Not Enough: Applying a Behavioral Design Approach to Improve Fever Case Management in Nigeria

BACKGROUND

We sought to encourage health care providers to adhere to national malaria case management guidelines. This requires them to conduct malaria parasite tests for every patient presenting with a fever and provide malaria treatment only to those who test positive for malaria. Our goal was to make it easier for providers to follow guidelines by addressing drivers of nonadherence uncovered through facility observations and interviews with staff and clients.

IMPLEMENTATION AND MONITORING

The case management interventions were piloted in 12 public health facilities in Akwa Ibom, Kebbi, and Nasarawa states in Nigeria between October and December 2019. Participating facilities included 1 hospital and 3 primary health centers in each state. Relevant changes included the following: (1) providers at each facility participated in facilitated discussions to correct misconceptions about the reliability of malaria test kits; (2) testing procedures were integrated into existing triage systems; (3) treatment algorithms were integrated into medical record forms; (4) providers were issued pictorial brochures outlining danger signs to share with clients, together with instructions for when to seek further care; and (5) a process was created for facilities to monitor their own adherence to guidelines.

LESSONS LEARNED

The lessons learned include: (1) disentangling the drivers of behavior allows for more targeted solutions, (2) solutions that streamline processes for overburdened providers allow them to redirect their attention and efforts where they can be most impactful, and (3) changing staff perceptions of workplace norms can support a holistic and sustained approach to behavior change.

Most common reasons for primary care visits in low- and middle-income countries: A systematic review

With the Covid-19 pandemic and the introduction of the WHO's Essential Diagnostics List (EDL), increasing global attention is focused on the crucial role of diagnostics in achieving universal health coverage. To create national EDLs and to aid health system planning, it is vital to understand the most common conditions with which people present at primary care health facilities. We undertook a systematic review of the most common reasons for primary care visits in low- and middle-income countries. Six databases were searched for articles published between January 2009 and December 2019, with the search updated on MEDLINE to January 2021. Data on the most common patient reasons for encounter (RFEs) and provider diagnoses were collected. 17 of 22,279 screened articles were included. Most studies used unvalidated diagnostic classification systems or presented provider diagnosis data grouped by organ system, rather than presenting specific diagnoses. No studies included data from low-income countries. Only four studies (from Brazil, India, Nigeria and South Africa) using the ICPC-2 classification system contained RFE and provider diagnosis data and could be pooled. The top five RFEs from the four studies were headache, fever, back or low back symptom, cough and pain general/multiple sites. The top five diagnoses were uncomplicated hypertension, upper respiratory tract infection, type 2 diabetes, malaria and health maintenance/prevention. No psychological symptoms were among the top 10 pooled RFEs. There was more variation in top diagnoses between studies than top RFEs, showing the importance of creating location-specific lists of essential diagnostics for primary care. Future studies should aim to sample primary care facilities from across their country of study and use ICPC-3 to report both patient RFEs and provider diagnoses.

Rationalization of the Laboratory Diagnosis for Good Management of Malaria: Lessons from Transitional Methods

Introduction

Malaria is an endemic disease in sub-Saharan Africa. In clinical practice, the main concern is the overdiagnosis of malaria leading to inappropriate drug prescription without laboratory confirmation.

Objective

This study aimed to evaluate clinical examination reliability compared with translational laboratory methods of malaria diagnosis.

Methods

The study was conducted in Goundi Hospital among hospitalized patients over a seven-month period. Patients were interviewed, and malaria tests done included the Giemsa-stained thick and thin blood smears. Diagnostic accuracy was analysed by calculating sensitivity, specificity, and predictive values.

Results

Among 1,874 participants, 674 (35.96%) patients had positive Giemsa-stained thick blood films. The rate of positivity is higher for patients under 5 years of age. The parasite densities were between 160 and 84.000 parasites/μL. The threshold pyrogen of the parasitic density was around 10.000 parasites/μL for patients between 0 and 11 months of age, between 1 and 4 years of age, and between 5 and 14 years of age. This threshold was lower for patients over 15 years of age. The study reported some issues in the findings: 60.88% (607/997) cases of fever without positivity of the blood thick smear and 40.13% (284/674) cases of positivity of the thick drop without fever. The positive predictive value of malaria was between 80 and 85% for patients under 5 years of age. This value is lower for patients between 5 and 14 years of age and patients over 15 years of age.

Conclusion

A presumptive diagnosis of malaria should be confirmed by the laboratory in all suspected cases in all possible scenarios. Every parasitemia should be followed by the calculation of parasitic density. However, for the children under 5 years of age in areas of high transmission, the presumptive diagnosis of malaria in certain circumstances could be considered.

A digital mobile health platform increasing efficiency and transparency towards universal health coverage in low- and middle-income countries

In low-and middle-income countries, achieving universal health coverage remains challenging due to insufficient, temporary and fragmented funding as well as limited accessibility to quality healthcare. Leveraging a mobile health platform can be a powerful tool to address these problems. This paper demonstrates how analysing data collected from a mobile health platform helps optimize healthcare provider networks, monitor patient flows and assess the quality and equitability of access to care. The COVID-19 pandemic reinforces the importance of real-time data on health-seeking behaviour. Between 2018 and 2019, as a Kenyan universal health coverage pilot was being planned, Kisumu County, with support from PharmAccess Foundation, implemented household-level digital registration for healthcare and collected socio-economic and healthcare claims data using the M-TIBA platform. In total, 273,350 Kisumu households enrolled. The claims data showed many patients visit higher-level facilities for ailments, that can be treated at primary care levels, unnecessarily. High-level estimate of the disease burden at participating facilities revealed rampant overprescription of pertinent medicines for highly prevalent malaria and respiratory tract infections, exemplifying clinical management deficiencies. M-TIBA data allowed tracking of individual patient trajectories. Analyses of data are shown at the aggregate level. The paper shows how mobile health platforms can be used to generate valuable insights into access to and quality of care. Funding for healthcare can be united through mobile health platforms, limiting the fragmentation in funding. They can be useful for funders, health managers and policymakers to improve the implementation of universal health coverage programs in low-and middle-income countries.

Prevalence, Parasite Density and Determinants of Falciparum Malaria Among Febrile Children in Some Peri-Urban Communities in Southwestern Nigeria: A Cross-Sectional Study

Background

Malaria remains a serious public health problem worldwide, particularly in tropical and subtropical regions, including Nigeria. This study investigates the prevalence, parasite density and determinants of malaria among symptomatic children in some peri-urban communities in southwestern Nigeria.

Methods

This was a randomized cross-sectional and hospital-based study. The standard method of microscopy was employed. Thick and thin films were prepared and viewed under a light microscope to identify and quantify malaria parasites. A well-structured and pre-tested questionnaire was used to obtain the subject’s information on the demographic, socio-economic and environmental variables.

Results

A total of 380 (71.7%) participants were infected with Plasmodium falciparum with a mean parasite density of 1857.11 parasite/µL of blood. Malaria prevalence and mean parasite density were significantly higher among male compared to their female counterparts [80.3% vs 61.4% and 2026.46 vs 1619.63 parasite/µL of blood]. Similarly, age group ≤5 years had the highest malaria prevalence (92.2%) and mean parasite density (2031.66 parasite/µL of blood) than other age groups (AOR 2.281, 95% CI: 1.187–4.384, P < 0.05). The multivariate logistic analysis showed that malaria disease is significantly associated with having mother with no formal education (AOR 12.235, 95% CI: 3.253–46.021, P < 0.05), having well and river as a major source of household water supply (AOR 13.810, 95% CI: 3.012–63.314, P < 0.05 vs AOR 5.639, 95% CI: 1.455–21.853, P < 0.05) and presence of stagnant water around home (AOR 5.22, 95% CI: 2.921–9.332, P < 0.05). Furthermore, protective factors observed include ownership of mosquito bed net (AOR 0.474, 95% CI: 0.223–1.008, P < 0.05) and distance of home to hospital (AOR 0.279, 95% CI: 0.158–0.493, P < 0.05).

Conclusion

Malaria remains a serious public health problem in the study area. Adopting integrated malaria control measures including educating parents on malaria prevention and control strategies, distributing mosquito bed nets, and establishing larvae source management program is highly imperative.

Connected diagnostics to improve accurate diagnosis, treatment, and conditional payment of malaria services in Kenya

Background

In sub-Saharan Africa, the material and human capacity to diagnose patients reporting with fever to healthcare providers is largely insufficient. Febrile patients are typically treated presumptively with antimalarials and/or antibiotics. Such over-prescription can lead to drug resistance and involves unnecessary costs to the health system. International funding for malaria is currently not sufficient to control malaria. Transition to domestic funding is challenged by UHC efforts and recent COVID-19 outbreak. Herewith we present a digital approach to improve efficiencies in diagnosis and treatment of malaria in endemic Kisumu, Kenya: Connected Diagnostics. The objective of this study is to evaluate the feasibility, user experience and clinical performance of this approach in Kisumu.

Methods

Our intervention was performed Oct 2017–Dec 2018 across five private providers in Kisumu. Patients were enrolled on M-TIBA platform, diagnostic test results digitized, and only positive patients were digitally entitled to malaria treatment. Data on socio-demographics, healthcare transactions and medical outcomes were analysed using standard descriptive quantitative statistics. Provider perspectives were gathered by 19 semi-structured interviews.

Results

In total 11,689 febrile patients were digitally tested through five private providers. Malaria positivity ranged from 7.4 to 30.2% between providers, significantly more amongst the poor (p < 0.05). Prescription of antimalarials was substantially aberrant from National Guidelines, with 28% over-prescription (4.6–63.3% per provider) and prescription of branded versus generic antimalarials differing amongst facilities and correlating with the socioeconomic status of clients. Challenges were encountered transitioning from microscopy to RDT.

Conclusion

We provide full proof-of-concept of innovative Connected Diagnostics to use digitized malaria diagnostics to earmark digital entitlements for correct malaria treatment of patients. This approach has large cost-saving and quality improvement potential.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01600-z.

Diagnosis of Malaria Parasites Plasmodium spp. in Endemic Areas: Current Strategies for an Ancient Disease

Fast and effective detection of the causative agent of malaria in humans, protozoan Plasmodium parasites, is of crucial importance for increasing the effectiveness of treatment and to control a devastating disease that affects millions of people living in endemic areas. The microscopic examination of Giemsa-stained blood films still remains the gold-standard in Plasmodium detection today. However, there is a high demand for alternative diagnostic methods that are simple, fast, highly sensitive, ideally do not rely on blood-drawing and can potentially be conducted by the patients themselves. Here, the history of Plasmodium detection is discussed, and advantages and disadvantages of diagnostic methods that are currently being applied are assessed.

Rare mutations in Pfmdr1 gene of Plasmodium falciparum detected in clinical isolates from patients treated with anti-malarial drug in Nigeria

Background

Plasmodium falciparum, the deadliest causative agent of malaria, has high prevalence in Nigeria. Drug resistance causing failure of previously effective drugs has compromised anti-malarial treatment. On this basis, there is need for a proactive surveillance for resistance markers to the currently recommended artemisinin-based combination therapy (ACT), for early detection of resistance before it become widespread.

Methods

This study assessed anti-malarial resistance genes polymorphism in patients with uncomplicated P. falciparum malaria in Lagos, Nigeria. Sanger and Next Generation Sequencing (NGS) methods were used to screen for mutations in thirty-seven malaria positive blood samples targeting the P. falciparum chloroquine-resistance transporter (Pfcrt), P. falciparum multidrug-resistance 1 (Pfmdr1), and P. falciparum kelch 13 (Pfk13) genes, which have been previously associated with anti-malarial resistance.

Results

Expectedly, the NGS method was more proficient, detecting six Pfmdr1, seven Pfcrt and three Pfk13 mutations in the studied clinical isolates from Nigeria, a malaria endemic area. These mutations included rare Pfmdr1 mutations, N504K, N649D, F938Y and S967N, which were previously unreported. In addition, there was moderate prevalence of the K76T mutation (34.6%) associated with chloroquine and amodiaquine resistance, and high prevalence of the N86 wild type allele (92.3%) associated with lumefantrine resistance.

Conclusion

Widespread circulation of mutations associated with resistance to current anti-malarial drugs could potentially limit effective malaria therapy in endemic populations.

Portable bright-field, fluorescence, and cross-polarized microscope toward point-of-care imaging diagnostics

Emerging technologies are enabling the feasibility of new types of point-of-care diagnostic devices. A portable, multimodal microscopy platform intended for use in remote diagnostic applications is presented. Use of such a system could bring high-quality microscopy to field use for diseases such as malaria, allowing better diagnostic and surveillance information to be gathered. The microscope was designed using off-the-shelf components and a manual filter selection to generate bright-field, fluorescent, and cross-polarized images of samples mounted to microscopy slides. Design parameters for the system are discussed, and characterization is performed using standardized imaging targets, multimodal phantoms, and blood smears simulating those used in malaria diagnosis. The microscope is shown to be able to image below element 9-3 of a 1951 U.S. Air Force target, indicating that the system is capable of resolving features < 775  nm. Morphological indicators of Plasmodium falciparum can be visualized in images from each modality and combined into high-contrast composite images. To optimize parasitic feature contrast across all three imaging modes, several different staining techniques were compared, with results indicating that use of a single nucleic acid binding fluorophore is preferable.

Consequences of restricting antimalarial drugs to rapid diagnostic test-positive febrile children in south-west Nigeria

OBJECTIVES

To investigate the consequence of restricting antimalarial treatment to febrile children that test positive to a malaria rapid diagnostic test (MRDT) only in an area of intense malaria transmission.

METHODS

Febrile children aged 3-59 months were screened with an MRDT at health facilities in south-west Nigeria. MRDT-positive children received artesunate-amodiaquine (ASAQ), while MRDT-negative children were treated based on the clinical diagnosis of non-malaria febrile illness. The primary endpoint was the risk of developing microscopy-positive malaria within 28 days post-treatment.

RESULTS

309 (60.5%) of 511 children were MRDT-positive while 202 (39.5%) were MRDT-negative at enrolment. 18.5% (50/275) of MRDT-positive children and 7.6% (14/184) of MRDT-negative children developed microscopy-positive malaria by day 28 post-treatment (ρ = 0.001). The risk of developing clinical malaria by day 28 post-treatment was higher among the MRDT-positive group than the MRDT-negative group (adjusted OR 2.74; 95% CI, 1.4, 5.4). A higher proportion of children who were MRDT-positive at enrolment were anaemic on day 28 compared with the MRDT-negative group (12.6% vs. 3.1%; ρ = 0.001). Children in the MRDT-negative group made more unscheduled visits because of febrile illness than those in MRDT-positive group (23.2% vs. 12.0%; ρ = 0.001).

CONCLUSION

Restricting ACT treatment to MRDT-positive febrile children only did not result in significant adverse outcomes. However, the risk of re-infection within 28 days was significantly higher among MRDT-positive children despite ASAQ treatment. A longer-acting ACT may be needed as the first-line drug of choice for treating uncomplicated malaria in high-transmission settings to prevent frequent re-infections.

Presumptive Treatment of Malaria in Ghana: Was It Ever Useful? Evidence from the Kassena-Nankana District of Northern Ghana

Background

The WHO currently advocates parasitological confirmation of malaria before treatment is commenced. However, many arguments have emerged both for and against this new position. To contribute to the debate, this secondary data analysis was conducted to determine the likelihood of malaria parasitaemia in a child presenting with fever, vomiting, or cough in the Kassena-Nankana District.

Methods

The dataset for this analysis was generated during a study to assess the incidence and risk factors for paediatric rotavirus diarrhoea in the Kassena-Nankana District. Over a two-year period, trained field staff recruited 2086 subjects with episodes of diarrhoea aged 24 months or below into the study. A standard case report form was used to collect data on histories of illness, symptoms, vaccination, and anthropometry. Blood smears were tested for malaria parasites. The data set generated was obtained, cleaned, and analysed using Epi Info version 7.1.1.14 statistical software.

Results

Of the 2086 subjects recruited, 2078 had blood smears done and 54.0% had malaria parasites. Fever and vomiting appeared to be associated with parasitaemia with odds ratios of 1.9 (95% CI: 1.5586–2.2370) and 1.2 (95% CI: 1.0352–1.4697), respectively. Cough however appeared protective with an odds ratio of 0.8 (95% CI: 0.6910–0.9765). The odds of parasitaemia appeared to increase where a child presented with more than one symptom.

Conclusion

Nearly half (46%) of the subjects in this study presented with symptoms but had no malaria. Presumptive treatment of malaria may therefore be useful in situations where diagnostic tests are not readily available, its routine practice should however not be encouraged.

Misuse of Artemisinin Combination Therapies by Clients of Medicine Retailers Suspected to Have Malaria Without Prior Parasitological Confirmation in Nigeria

Background: Prompt and effective case detection and treatment are vital components of the malaria case management strategy as malaria-endemic countries implement the testing, treating and tracking policy. The implementation of this policy in public and formal private sectors continue to receive great attention while the informal private retail sector (mostly the patent and propriety medicine vendors [PPMVs]) where about 60% of patients with fever in Nigeria seek treatment is yet to be fully integrated. The PPMVs sell artemisinin combination therapies (ACTs) without prior testing and are highly patronized. Without prior testing, malaria is likely to be over-treated. The need to expand access to diagnosis in the huge informal private health sector among PPMVs is currently being explored to ensure that clients that patronize retail drug stores are tested before sales of ACTs.

Methods: A cross-sectional multistage study was conducted among 1279 adult clients, 20 years and above, who purchased malaria medicines from 119 selected PPMVs in five administrative areas (States) of Nigeria, namely: Adamawa, Cross River, Enugu, Lagos and Kaduna, as well as the Federal Capital Territory, Abuja. Exit interviews using a standard case report questionnaire was conducted after the purchase of the antimalarial medicine and thick/thin blood smears from the clients’ finger-prick were prepared to confirm malaria by expert microscopy.

Results: Of the 1279 clients who purchased malaria medicines from the PPMV outlets, 107 (8.4%) were confirmed to have malaria parasites. The malaria prevalence in the various study areas ranged from 3.5% to 16%. A high proportion of clients in the various study sites who had no need for malaria medicines (84%-96.5%) purchased and used antimalarial medicines from the PPMVs. This indicated a high level of over-treatment and misuse of antimalarials. Common symptoms that are widely used as indicators for malaria such as, fever, headache, and tiredness were not significantly associated with malaria. Nausea/vomiting, poor appetite, chills, bitter taste in the mouth and dark urine were symptoms that were significantly associated with malaria among the adult clients (P<.05) but not fever (P=.06).

Conclusion: Misuse of ACTs following overtreatment of malaria based on clinical diagnosis occurs when suspected cases of malaria are not prior confirmed with a test. Non-testing before sales of malaria medicines by PPMVs will perpetuate ACT misuse with the patients not benefiting due to poor treatment outcomes, waste of medicines and financial loss from out-of-pocket payment for unneeded medicines.

Private sector malaria RDT initiative in Nigeria: lessons from an end-of-project stakeholder engagement meeting

The malaria rapid diagnosis testing (RDT) landscape is rapidly evolving in health care delivery in Nigeria with many stakeholders playing or having potential for critical roles. A recent UNITAID grant supported a pilot project on the deployment of quality-assured RDTs among formal and informal private service outlets in three states in Nigeria. This paper describes findings from a series of stakeholder engagement meetings held at the conclusion of the project. The agreed meeting structure was a combination of plenary presentations, structured facilitated discussions, and nominal group techniques to achieve consensus. Rapporteurs recorded the meeting proceeding and summaries of the major areas of discussion and consensus points through a retrospective thematic analysis of the submitted meeting reports. Key findings indicate that private providers were confident in the use of RDTs for malaria diagnosis and believed it has improved the quality of their services. However, concerns were raised about continued access to quality-assured RDT kits. Going forward, stakeholders recommended increasing client-driven demand, and continuous training and supervision of providers through integration with existing monitoring and supervision mechanisms.

Diagnostic tools in childhood malaria

Every year, millions of people are burdened with malaria. An estimated 429,000 casualties were reported in 2015, with the majority made up of children under five years old. Early and accurate diagnosis of malaria is of paramount importance to ensure appropriate administration of treatment. This minimizes the risk of parasite resistance development, reduces drug wastage and unnecessary adverse reaction to antimalarial drugs. Malaria diagnostic tools have expanded beyond the conventional microscopic examination of Giemsa-stained blood films. Contemporary and innovative techniques have emerged, mainly the rapid diagnostic tests (RDT) and other molecular diagnostic methods such as PCR, qPCR and loop-mediated isothermal amplification (LAMP). Even microscopic diagnosis has gone through a paradigm shift with the development of new techniques such as the quantitative buffy coat (QBC) method and the Partec rapid malaria test. This review explores the different diagnostic tools available for childhood malaria, each with their characteristic strengths and limitations. These tools play an important role in making an accurate malaria diagnosis to ensure that the use of anti-malaria are rationalized and that presumptive diagnosis would only be a thing of the past.

Immediate assessment of performance of medical laboratory scientists following a 10-day malaria microscopy training programme in Nigeria

BACKGROUND

Rapid and precise diagnosis of malaria is an essential element in effective case management and control of malaria. Malaria microscopy is used as the gold standard for malaria diagnosis, however results remain poor as positivity rate in Nigeria is consistently over 90%. The United States President's Malaria Initiative (PMI) through the Malaria Action Program for States (MAPS) supported selected states in Nigeria to build capacity for malaria microscopy. This study demonstrates the effectiveness of in-service training on malaria microscopy amongst medical laboratory scientists.

METHOD

The training was based on the World Health Organization (WHO) basic microscopy training manual. The 10-day training utilized a series of didactic lectures and examination of teaching slides using a CX 21 Olympus binocular microscope. All 108 medical laboratory scientists trained from 2012 to 2015 across five states in Nigeria supported by PMI were included in the study. Evaluation of the training using a pre-and post-test method was based on written test questions; reading photographic slide images of malaria parasites; and prepared slides.

RESULT

There was a significant improvement in the mean written pre-and post-tests scores from 37.9% (95% CI 36.2-39.6%) to 70.7% (95% CI 68.4-73.1%) (p < 0.001). The mean counting post-test score improved significantly from 4.2% (95% CI 2.6-5.7%) to 27.9% (95% CI 25.3-30.5%) (p < 0.001). Mean post-test score for computer-based picture speciation test (63.0%) and picture detection test (89.2%) were significantly higher than the mean post-test score for slide reading speciation test (38.3%) and slide reading detection test (70.7%), p < 0.001 in both cases.

CONCLUSION

Parasite detection and speciation using enhanced visual imaging was significantly improved compared with using direct microscopy. Regular in-service training and provision of functional and high resolution microscopes are needed to ensure quality routine malaria microscopy.

Overdiagnosis and overtreatment of malaria in children in a secondary healthcare centre in Sekondi-Takoradi, Ghana

Overdiagnosis and overtreatment of malaria is a major problem in children in malaria-endemic countries. This retrospective study identified children who were admitted with fever and were treated with or without anti-malarial medications and discharged at the Paediatric Unit of the Effia-Nkwanta Regional Hospital. The medical records of all children were searched, retrieved and assessed. A total of 1160 records from children (age range, 0-12 years) were reviewed and evaluated. Of the total number, 21.3% had laboratory confirmed malaria, 38.4% were malaria negative, while 40.3% had no malaria tests performed. In addition, the results showed that 4.5% of the laboratory confirmed malaria positive cases were not given anti-malarial medication while 84.1% of the malaria negative cases were given these incorrectly. Furthermore, 78.2% of the children with no malaria tests were prescribed anti-malarial medication. The presumptive diagnosis of malaria should be abandoned and the installation of a functional laboratory services promoted.

Prevalence of dengue and chikungunya virus infections in north-eastern Tanzania: a cross sectional study among participants presenting with malaria-like symptoms

BACKGROUND

In spite of increasing reports of dengue and chikungunya activity in Tanzania, limited research has been done to document the general epidemiology of dengue and chikungunya in the country. This study aimed at determining the sero-prevalence and prevalence of acute infections of dengue and chikungunya virus among participants presenting with malaria-like symptoms (fever, headache, rash, vomit, and joint pain) in three communities with distinct ecologies of north-eastern Tanzania.

METHODS

Cross sectional studies were conducted among 1100 participants (aged 2-70 years) presenting with malaria-like symptoms at health facilities at Bondo dispensary (Bondo, Tanga), Hai hospital (Hai, Kilimanjaro) and TPC hospital (Lower Moshi). Participants who were malaria negative using rapid diagnostic tests (mRDT) were screened for sero-positivity towards dengue and chikungunya Immunoglobulin G and M (IgG and IgM) using ELISA-based kits. Participants with specific symptoms defined as probable dengue and/or chikungunya by WHO (fever and various combinations of symptoms such as headache, rash, nausea/vomit, and joint pain) were further screened for acute dengue and chikungunya infections by PCR.

RESULTS

Out of a total of 1100 participants recruited, 91.2 % (n = 1003) were malaria negative by mRDT. Out of these, few of the participants (<5 %) were dengue IgM or IgG positive. A total of 381 participants had fever out of which 8.7 % (33/381) met the defined criteria for probable dengue, though none (0 %) was confirmed to be acute cases. Chikungunya IgM positives among febrile participants were 12.9 % (49/381) while IgG positives were at 3.7 % (14/381). A total of 74.2 % (283/381) participants met the defined criteria for probable chikungunya and 4.2 % (11/263) were confirmed by PCR to be acute chikungunya cases. Further analyses revealed that headache and joint pain were significantly associated with chikungunya IgM seropositivity.

CONCLUSION

In north-eastern Tanzania, mainly chikungunya virus appears to be actively circulating in the population. Continuous surveillance is needed to determine the contribution of viral infections of fever cases. A possible establishment of arboviral vector preventive control measures and better diagnosis of pathogens to avoid over-treatment of other diseases should be considered.

Malaria rapid diagnostic test in children: The Zamfara, Nigeria experience

BACKGROUND

Malaria remains a major cause of under-five morbidity and mortality in Nigeria, and prompt diagnosis occupies a strategic position in its management. Malaria rapid diagnostic test (RDT), a nontechnical, easy to perform test promises to meet this need. It is important to locally document the usefulness of the use of RDT in making prompt malaria diagnosis in children.

OBJECTIVE

To determine the prevalence of malaria and evaluate the diagnostic performance of malaria RDT kit in febrile under-five children presenting to a Tertiary Health Facility in Gusau, North-Western Nigeria.

MATERIALS AND METHODS

A cross-sectional study of children aged 6-59 months, evaluated for malaria in a tertiary health facility from August 2012 to January 2013. Information was obtained from care providers of all subjects with fever and a presumptive diagnosis of malaria. All subjects were investigated using Giemsa stain microscopy and Carestart™ malaria RDT.

RESULTS

The prevalence of malaria in 250 febrile under-five children was 54%. Three-quarter (79%) of the children received inappropriate nonrecommended antimalaria prior to their presentation, including 20% who received chloroquine. The overall sensitivity of RDT was 40.3%. The specificity, positive and negative predictive values were 89.6%, 81.8%, and 56.5%, respectively.

CONCLUSION

Use of RDT should be encouraged for screening and diagnosis using a protocol such that febrile children with positive RDT results are confirmed as having malaria while those with negative results are further evaluated using microscopy.

Molecular Testing for Plasmodium falciparum by Use of Serum or Plasma and Comparison with Microscopy and Rapid Diagnostic Testing in Febrile Nigerian Patients

Plasmodium nucleic acids have been detected in serum and plasma, but there is little published data describing the diagnostic performance of malaria nucleic acid amplification tests (NAATs) using these specimen types. Previously, our group described a multiplex NAAT for the detection of dengue virus, Leptospira, and Plasmodium species with a callout for P. falciparum (the DLM assay) that demonstrated sensitive detection of P. falciparum from plasma samples during initial evaluation. In this study, we evaluated the sensitivity and specificity of P. falciparum detection in febrile Nigerian patients using the DLM assay, microscopy, and a rapid diagnostic test (BinaxNOW Malaria). Assay performances were compared using a composite reference, which was considered positive if malaria was detected by two or more methods. Serum (n = 182) or plasma (n = 148) from 317 patients was tested; the average sample volume was 70 μl (range, 5 to 300 μl). The sensitivity and specificity of the DLM assay were 97.1% and 93.5%, respectively. The sensitivity of the malaria rapid diagnostic test (98.1%) was similar to that of the DLM assay, and both proved significantly more sensitive than microscopy (79%; P < 0.0001). When analysis was limited to samples with ≥75 μl of serum or plasma, the sensitivity of the DLM assay improved to 99% and specificity was 97.5%. For P. falciparum cases, cycle threshold values in the DLM assay correlated with the parasite density detected by microscopy (Spearman's rank correlation coefficient, P < 0.0001). In conclusion, malaria detection using the DLM assay on serum or plasma is more sensitive than and equal in specificity to microscopy in patients with P. falciparum malaria.