Africa: Defeating a Major Killer – One Step at a Time

A to Z Textiles factory in Arusha produces insecticide-impregnated bed nets and employees some 2000 Tanzanians, mostly women, thanks to investments by Sumitomo and the Acumen Fund. Nets are among the anti-malaria interventions that have saved over a billion lives since 2000.
7 August 2017

Cape Town — Despite dramatic progress against it, malaria still kills over 420 thousand people a year – an estimated 92 percent of them in sub Saharan Africa. Most of those are children.

Rapid malaria tests make it easier to diagnose the mosquito-borne disease, and that's a good thing, right? Well, a new study shows that many people who test positive for malaria appear to go untreated. It also highlights that while using the rapid tests is linked to a decline in the overuse of malaria medication, testing negative has led to an increase in the prescription of antibiotics.

But if your analysis of the study results stops there, you miss the point. Every advance against malaria leads to less suffering for children and their parents and progress for their countries. Gains against malaria in Africa – a 60 percent drop in deaths due to malaria in the last 16 years – have already contributed to a rise in life expectancy, and the decline in mortality has saved billions of dollars, according to the latest malaria report of the World Health Organization (WHO).

Rapid test kits for malaria work and save lives 

"The headline of this study is that RDTs (Rapid Diagnostic Tests) are powerful and effective diagnostic tools that are aiding treatment decisions," says Bruno Moonen, Deputy Director, Malaria at the Bill & Melinda Gates Foundation. "It would be a dangerous conclusion to draw that RDTs are creating problems. Quite the opposite, in fact."

Here's why the study is important. Almost all malaria deaths could be avoided through prevention and treatment. The study published today in the American Journal of Tropical Medicine and Hygiene - an analysis by researchers at the London School of Hygiene and Tropical Medicine (LSHTM), a leading global research and education institution, and international collaborators - points towards one way to reduce the toll.

An analysis of more than 500,000 patient visits showed that while rapid-testing to distinguish malaria from other fever-producing illnesses is essential for effective treatment, it is only a first step. Importantly, the study suggests that education for health professionals and patients about how to respond to test results could lead to more lives being saved and to improved treatment for non-malaria illnesses.

Malaria tests can save even more lives: study shows need to educate drug dispensers and understand their treatment decisions 

Further research is needed to understand why many patients who tested positive are not treated with effective anti-malaria drugs – artesiminin-based combination therapy (ACTs) – as well as to devise ways to curb overuse of antibiotics for patients who test negative for malaria, says the study's lead author, Katia Bruxvoort. Over-prescribing of antibiotics contributes to antibiotic resistance, a growing threat to global health. The United Kingdom commissioned a recent study that estimated 700 thousand people a year are dying from 'super bugs' that are resistant to most or all known treatment.

Malaria experts warn against misinterpreting the study to mean that use of rapid testing kits should be limited.

Heidi Hopkins, another author, describes the study as the largest analysis of the impact of rapid testing as a diagnostic tool. "The desirable benefit is that we have improved targeting of anti-malarials", she says, meaning more patients who need treatment are identified and can be treated. "It's not perfect, but it's definitely a step in the right direction."

In an interview, Hopkins said it is not clear from the study why some patients who test positive are not treated with ACTs. "We don't have data to suggest that shortages – or 'stock-outs' – of the drug in the clinics studied were the explanation, so we have to start considering other reasons that might be a little more nuanced than just not having the drug available," she said.

"For example, we can speculate that people who are used to working in settings where stock-outs do happen with some frequency, might have a mind-set of 'conserving'." Hopkins points out that a clinician who knows the appropriate treatment for a patient, according to WHO recommendations, might worry that the next week the clinic could run out of the medication and decide to save it for a patient who might need it more. She warns that this is complete speculation, but it serves to suggest the importance of gathering more data.

She says more insights into the reasons for the failure-to-treat are needed. "Why does that happen in different contexts and what can we do to resolve that. We need better evidence for how to manage fever cases – and how strategies might differ in a major hospital from a private drug shop or a community health care setting."

Dr. Oladimeji Oladepo, a medical school professor at the University of Ibaden in Nigeria, is among the African researchers developing such strategies and gathering data. He told AllAfrica's media partner, Premium Times, that poverty drives many people to buy chloroquine for children with fever from a private medicine vendor (PMV) before seeing a doctor.

Chloroquine has become ineffective against malaria in Nigeria, the country with the world's largest malaria burden. But many people remember that it was once a common medicine that worked, and it is at least 15 times cheaper than ACTs.

Dr. Oladepo - operators of mini-pharmacy shops in rural areas want to - and can - be part of the solution

Oladepo has worked with the association of PMVs – which are the only source of medications in many poor and rural areas across Nigeria. He told AllAfrica's media partner Daily Trust that he found PMVs eager to be part of the solution. "Part of what we want to do is to combine government regulation with patent medicine vendors' own internal regulatory mechanism for drugs," he said. "It works better than that of government and with PMV members playing a leading role, their members will comply with agreed standards."

Heidi Hopkins agrees that rapid testing is an important of the anti-malaria arsenal. "Tens of millions of these kits are being purchased and used," she says, "and there's good evidence that they can be used, in a variety of settings, safely and effectively.

"Having the capacity to diagnose malaria at the point of care is a huge step forward. It's led to positive progress, both in individual patient treatment and also led to more data-gathering and more knowledge about malaria epidemiology. We just need to be aware of unintended consequences as we work."

Education of both health-care dispensers and patients and understanding the choices they make is an important part of minimizing unintended consequences. "Just the technology alone is never enough to address the health care challenges," Hopkins says.

The LSHTM analysts and other collaborators confirm a general trend observed when rapid-diagnostic tests (RDTs) are introduced and highlight known challenges with the transition from no diagnosis or microscopy to malaria RDTs, says Moonen. "The over prescribing of malaria medication and the over prescribing of antibiotics seen in this study  is linked to health provider behavior and has nothing to do with the test that is providing valuable clinical information about malaria infection status."

It's a reminder, he says, "that innovations are one aspect of improving outcomes. We have the tools. It's important that they are used in the correct combination and according to WHO guidance to get the results we all want – reducing the burden of malaria and eventually eradicating the disease entirely."

Malaria researchers and anti-malaria campaigners are united in the view that massive investment is urgently required for the fight against malaria – which has the potential to come surging back, if not defeated. Malaria strains resistant to ACTs – currently the only effective treatment in much of the world – are present already in parts of Asia.

Activists say policy makers in parts of the world where malaria once raged – such as Washington DC – will bear the blame if that happens. Climate change is currently increasing the range of malaria-carrying mosquitoes, and disease knows no boundaries in a global world.

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