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Impact of ACTs and ITNs on Malaria Burden- Don’t forget Quality Assurance of Diagnosis

Posted by plosmedicine on 31 Mar 2009 at 00:16 GMT

Author: Roly D Gosling
Position: Clinical Lecturer
Institution: London School of Hygiene and Tropical Medicine
Submitted Date: November 28, 2007
Published Date: November 28, 2007
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

Bhattarai and colleagues present a very good picture of malaria control in Zanzibar[1]. I would like to raise one query to their paper.

In figure 1 the authors show the outpatient malaria diagnosis. This graph shows a plummeting of malaria diagnoses from approximately 1300 cases per month in early 2005 to less than 500 cases per month by the end of that year, more than a 60% reduction of reported cases of malaria. The authors fail to mention the third intervention that they employed, the intervention of Quality Assurance of malaria diagnosis.

In order to control malaria with effective strategies and measure their effect it is vital to know the true rates of malaria. Over diagnosis is common, especially in dispensaries where no laboratory diagnosis is available. These figures of outpatient malaria generated by clinical diagnoses and reported via the health management information system (HMIS) lead to a misleading picture of malaria. As can be seen, even in a high malaria transmission setting, it appears that over 60 per cent of diagnoses were incorrect.

There is no doubt that the combination of ACTs and ITNs work in reducing malaria transmission and clinical disease and this is clearly demonstrated in the results of the cross sectional surveys. However, any strategy to monitor the effects of these interventions must include Quality Assurance of malaria diagnosis, whether this be in the form of Rapid Diagnostic Tests or Quality Assurance of blood slides. Indeed, introducing these to peripheral dispensaries would also improve the quality of care given to patients as they would get the chance of getting a correct diagnosis and thus correct treatment.


[1] Bhattarai A, Ali AS, Kachur SP, Ma°rtensson A, Abbas AK, et al. (2007) Impact of artemisinin-based combination therapy and insecticidetreated nets on malaria burden in Zanzibar. PLoS Med 4(11): e309.doi:10.1371/journal.pmed.0040309

No competing interests declared.