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TIPS ON MALARIA

  • HOW CAN MOSQUITOES BE CONTROLLED?

    Mosquitoes around the home can be reduced significantly by minimizing the amount of standing water available for mosquito breeding. Residents are urged to reduce standing water around the home in a variety of ways.

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    The best way is to avoid being bitten by mosquitoes.This can be accomplished using personal protecting  while outdoors when mosquitoes are present. Treated bed nets should be used sleeping. Mosquito repellent should be used when outdoor.

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    Nearly half of the world’s population is at risk of getting malaria. Pregnant women are particularly at risk of malaria. Children under 5 years are at high risk of malaria.
     

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  • Volume 1

A bumpy ride for RDTs

By Eunice Menka - Ghana

A sachet of pure water is very cheap and common on the streets of Accra, costing less than the equivalent of 10 cents. In fact, it is about the cheapest item in the country. Some stakeholders believe that for rapid diagnostic test (RDTs) kits to gain patronage across the country, it essentially has to be cheaper than a sachet of filtered water.

The use of RDTs kits have become topical in policy discussions in reaction to the over- diagnosis and the blind treatment of malaria which led to fears that people will develop resistance to the most potent treatment, artemisinin–based combination therapies (ACTs).

A trend has been seen which is similar to what happened to chloroquine and older medicines when parasites became resistant to them.

The same fears led to the introduction of heavy subsidies under the Affordable Medicines Facility for Malaria (AMFm) by the Global Fund to improve access to quality ACT drugs.

Putting a stop to the blind treatment of malaria has therefore become criticalto avoid mismanagement in malaria treatment because of cheap access to ACTs.  

To that effect, the World Health Organization (WHO) released new guidelines for the treatment of malaria, and on procuring safe and efficacious anti-malarials.

The Guidelines for treatment now place heavy emphasis on testing before treatment, adding that “ACTs have transformed the treatment of malaria, but if not used properly the medicine could become ineffective.” 

The world body said the move towards universal diagnostic testing of malaria is a critical step forward in the fight against malaria as it will allow for the targeted use of ACTs for those who actually have malaria.

The aim is to help identify patients who have fever, but do not have malaria, so that alternative diagnoses can be made and appropriate treatment provided.

Quoting Dr Robert Newman, Director of the WHO Global Malaria Programme (GMP), the report said: "The world now has the means to rapidly diagnose malaria and treat it effectively.”

 "WHO now recommends diagnostic testing in all cases of suspected malaria. Treatment based on clinical symptoms alone should be reserved for settings where diagnostic tests are not available," he added.

The WHO said the recent development of quality-assured RDTs using a dip stick and a drop of blood means a policy change is possible. The tests can reliably demonstrate the presence or absence of malaria parasites in the blood.

Promoting the use of RDTs

Research on RDT kits have been carried out with a view to encouraging its use as a policy.

The Dodowa Health Research Centre in the Greater Accra region, researched into the impact of RDT kits. The research aimed at promoting the rational prescribing of anti-malaria drugs among 52 chemical sellers in the Dangme West District.

The trial among chemical sellers was a follow-up to trials earlier conducted at the health facility level, where RDT kits for malaria were introduced to study the prescription by medical practitioners, clinicians and the attitude of patients to reduce over prescription of anti-malarial drugs.

The research revealed that where no microscopes were available, the introduction of RDT reduced over-prescription by 36 per cent.

The Kintampo Health Research Centre recently began a research project titled: Rapid Diagnostic Tests and Artemisinin-based Combination Therapy Study.

It was aimed at looking at the effects of restricting the use of artesunate plus amodiaquine combination therapy to malaria cases confirmed by dipstick tests.

The centre evaluated how RDT could fit into the Integrated Management of Childhood Illnesses (IMCI) in health centres in Kintampo and five other districts of the Brong Ahafo region.

The study has expectations that its findings will guide national policy on how RDTs could be used in the management of childhood febrile illnesses.     

The National Malaria Control programme (NMCP) has also championed the use of RDT kits.

Over the last 2 years, the NMCP joined hands with the Pharmaceutical Society of Ghana (PSOG) to train some 1, 500 pharmacists across the nation on RDTs usage as part of Ghana’s programme on the AMFm.

Chemical sellers also benefitted from a similar training, all with the aim of making RDT kits part of the bigger picture of managing malaria. 

Challenges

RDTs kits do not seem to enjoy much visibility and you get the impression the product will take some time yet to become widely used.

It appears there are issues of costs, public awareness and education and public perceptions about bloodletting yet to be dealt with.  

Poor prescriber behaviour and patient attitude of “I feel the symptoms, just treat me for malaria whether or not I have it,” are still very much in place.

Many frontline health workers within the communities prefer symptomatic treatment and do not put much premium on RDTs.

The question is, are clinicians and patients ready for usage of RDT kit considering that behavioural change takes a long time, especially in the absence of sufficient public education.

INDEPTH’s Effectiveness and Safety Studies on anti-malarials (INESS) showed that some clinicians still carry out presumptive diagnosis and treating patients with ACTs even after laboratory diagnosis and RDTs confirm the absence of malaria parasites.

This sharply undermines the drive towards the deployment of RDT kits in malaria management and takes away from the heavy investments being made in terms of research and training.

The question remains as to whether people would be willing to bear the cost of RDT kits without heavy subsidies and whether clinicians are ready to stick to diagnosis confirmed by the RDT kits, especially when they are tried and tested and of good quality.

Experts feel that patients would prefer treatment based on symptomatic diagnosis rather than buy a kit for diagnosis seeing that the RDT kits cost nearly as much as the treatment with subsidized ACTs.

According to statistics 90 per cent of cases of malaria in Ghana are still diagnosed clinically, which is a normal practice.

Health workers should be trained as to what steps to take in the absence of malaria. Also, psychological issues involving a patient who feels he or she has malaria and the dilemma of a health worker as to what to tell a patient in such cases, need to be addressed.

Mr Asare Yeboah, is one of the pharmacists who benefitted from the training on usage of RDTs kits offered by the Pharmaceutical Society of Ghana.

“Any health worker may want to test his clients but the cost is a deterrent.  Literacy is also a challenge as there is also some misconception about blood-letting.”

“We need to offer regular training for health workers on RDTs as each year new pharmacists fresh from school get into the system,” he says.

Another area of concerns is that while policy makers are investing on RDT kits, they are not very visible on the market.

For instance, the Legon branch of Ernest Chemists, a leading drug dispensing outlet in the country, has no stock of RDTs.

Mr Yeboah who works there said it does not form part of their supplies from their warehouse. He said the thing to do in this situation is to treat malaria on symptomatic diagnosis.  

A few enquiries in some other chemists like DECCON Pharmacy at Sakumono in the Greater Accra region and Ghana’s tertiary health institution,  Korle Bu Teaching hospital, shows that RDTs kits are not part of the management of malaria. 

A case for RDTs

Given the resources that have been sunk into the promotion of RDTs it will be a waste if the low patronage and other concerns are not addressed quickly by policy makers, especially now that there are cheaper versions of ACTs under the AMFm facility and the need to prevent drug abuse and subsequent resistance.

Besides, there are very important reasons why RDTS are becoming very attractive and key elements in diagnosing malaria.

The clinical diagnosis of malaria has always remained challenging because malaria features mimic those of many other infectious diseases. Laboratory evidence remains the only accepted means of confirming infection in malaria-endemic countries, such as Ghana.

The use of the microscope is the standard method for malaria diagnosis at the laboratory and the instrument is only available in hospitals and some health centres and it takes days to get results. It has an accuracy of 70 per cent to 75 per cent depending on how well the equipment is maintained.

With RDT kits, apart from prescribers easily and quickly detecting the presence of malaria in a patient within minutes, the kits do not need electricity, laboratories, microscope or very specialized technicians to operate.

Among its appealing virtues is the fact that the device could be very useful in rural settings and poorly endowed areas, environments very common in Africa, where the bulk of malaria cases are found.

The aim of introducing RDTs is therefore to solve some of these problems as almost always every fever is suspected to be that of malaria leading invariably to treatment with anti-malarials.

Presumptive diagnosis could be eliminated and the over exposure of the population to the risk of drug toxicity would be reduced with its attendant spread of resistance.

The uninterrupted supply of good quality reagents, trained staff and good quality monitoring and supervisory methods are all that is essential for the RTD kits usage.

There is a case for RDT kits and there is every need therefore for policy makers to work out the fine details of making RDT kits usage attractive and pervasive.

Editions: 
Ninth Edition