Download GLOBAL MALARIA PROGRAMME

Moving forward in the diagnosis of infectious diseases in developing
countries: a focus on malaria
Forum organized by Fondation Mérieux & the Roll Back Malaria Partnership
22 June 2009
Dr Sergio Spinaci
Global Malaria Programme
Estimated number of cases and deaths
Approximately 250 million cases per year: 85% in Africa, 9% in South-East Asia
Approximately 900 000 deaths: 91% in Africa, 85% in children under 5 years of age
Source: World Malaria Report, 2008
Cases
(millions)
Deaths
(thousands)
% deaths
under 5
Africa
Americas
Eastern Mediterranean
Europe
South-East Asia
Western Pacific
212
3
8
0
21
2
801
3
38
0
36
4
88%
29%
76%
0%
35%
40%
World
247
881
85%
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GLOBAL
MALARIA PROGRAMME
Laboratory-confirmed diagnosis of malaria
100 Malaria patients with confirmed diagnosis (%)
80
60
40
20
0
Africa
3 |
Western
Pacific
Eastern
Mediterranean
South-East
Asia
Americas
GLOBAL
MALARIA PROGRAMME
Europe
District health system in Ghana
District level
District hospital
District health
management teams
(DHMT)
patient referral
supervision
patient referral
Sub-district level
Sub-district health
management teams
(SDHMT)
...
Health centres
in sub-district
Health centres
in sub-district
patient referral
supervision
patient referral
supervision
...
patient referral
supervision
Community level
Community health
committees
CHPS zones
with community
support systems
...
4 |
CHPS zones
with community
support systems
CHPS zones
with community
support systems
GLOBAL
MALARIA PROGRAMME
CHPS zones
with community
support systems
...
Trend of malaria cases compared to total OPD
in Sene District, 2005–2008
60 000 Number of malaria cases
Malaria cases
Total OPD cases
40 000
20 000
0
2005
5 |
2006
2007
2008
GLOBAL
MALARIA PROGRAMME
Trend of laboratory-confirmed malaria cases
in the Sene District, 2005–2008
6000 Number of laboratory-confirmed malaria cases
5463
5000
4183
4000
3000
2000
1484
1000
0
6 |
2005
2006
2007
GLOBAL
MALARIA PROGRAMME
2008
Reduction in prescription of antimalarials
after RDT implementation
 A mean of 6-fold decrease in ALu consumption was observed
(range: 2–26) in intervention facilities and 1.7-fold decrease in
control health facilities
 Proportion of patients tested negative who were still prescribed
antimalarials decreased from 67% to 7%
 Fever patients tested for malaria increased from 73% to 90%
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GLOBAL
MALARIA PROGRAMME
Mean test positivity rates
in intervention and control health facilities
 Routine microscopy: 41% in hospitals; 49% in health centres; 65% in dispensaries
(range: 13–90%)
 Routine RDTs:
7% in hospitals; 10% in health centres; 9% in dispensaries
(range: 6–12%)
Malaria test positivity rate before and after RDT implementation
2006
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2007
GLOBAL
MALARIA PROGRAMME
2008
New development in 2007–2009
Malaria decrease due to effective control
Systematic review:
24 studies
conducted between 1989 and 2005
in 15 different African countries
including 15 331 patients
Proportion of malaria among fevers highly variable: 2% to 81%
Median parasite rate = 26%
D'Acrémont et. al. (2009). PLoS Med, 6 (1): e252
Median PfPR 1985-19992-10 = 37%
Median PfPR 2000-20072-10 = 17%
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GLOBAL
MALARIA PROGRAMME
New development in 2007–2009
Evidence of benefits of health outcomes
 1887 patients studied in Zanzibar in non randommized four-centre clinical trial with
weekly cross-over validation comparing RDT-aided malaria diagnosis with
symptom-based clinical diagnosis (CD)
 RDT was associated with lower prescription rates of antimalarial treatment than
CD alone, 361/1005 (36%) compared with 752/882 (85%).
Prescriptions of antibiotics were higher after RDT than CD alone, i.e., 372/1005
(37%) and 235/882 (27%); re-attendance due to perceived unsuccessful clinical
cure was lower after RDT 25/1005 (2.5%), than CD alone 43/882 (4.9%).
Total average cost per patient was similar: US$ 2.47 and 2.37 after RDT and CD
alone, respectively
Msellem et. al. (2009). PLoS Med, 6 (4): e1000070
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GLOBAL
MALARIA PROGRAMME
Debate on abandoning presumptive antimalarial treatment
for febrile African children
Time to move to laboratory
confirmed diagnosis
 Proportion of fevers due to malaria
has become significantly lower
 We now have reliable RDTs
(comparable to expert microscopy)
 Risk of false negative test is smaller
than risk of patient dying due to
another severe disease because of
the focus on malaria
D'Acrémont V et. al. (2009). PLoS Med, 6 (1): e252
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Against rapid abandoning of
presumptive treatment
 Health systems and health workers
not ready for this change
– Prescription of antimalarial to negative
– Problematic drug supply system
– No resources for treating other causes
of non-malaria fevers
 Pre-requirements
– More data on local epidemiology
– Improved implementation in > 5 years
– Evidence of safety of new policy
English M et. al. (2009). PLoS Med, 6 (1): e1000015
GLOBAL
MALARIA PROGRAMME
New diagnostics
at different levels of the health system
Drug
resistance
surveillance
Reference
labs
Regional
labs
District
level
Sub-district
level
Community
level
Specimen
bank
Recombinant
panel
LAMP
iLED
PCWs
TB
Malaria
HAT
Malaria
RTD lot
testing
RDT lot
testing
Malaria
LAMP
Improved
RDTs
Infant HIV Dx
Malaria
HAT
TB
TB
Malaria
HAT
FIND: Foundation for innovative new diagnostics
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GLOBAL
MALARIA PROGRAMME
Conclusions
 The quality of routine microscopy was as poor in hospitals and health centres as in
dispensaries
 Routine RDT implementation minimized over-diagnosis and significantly reduced ALu
consumption
 Without appropriate diagnosis the true burden of disease cannot be estimated
 Well-trained clinicians with adequate supportive supervision comply with RDT results
and improve on practice
 RDTs should be used as first-line diagnostic tool for malaria in all settings and all health
facility levels, including hospitals where the potential for saving lives is the greatest
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GLOBAL
MALARIA PROGRAMME