African researchers, policy makers and other stakeholders are on the war path. They are firing from all cylinders and closing in on malaria through various interventions.

The latest eradication campaign is being spearheaded by the Bill and Melinda Gates Foundation. First, it was the malaria vaccine trials and now the INDEPTH Safety and Effectiveness Study of Anti-Malarials (INESS) project.

Various countries are also buying into the eradication agenda and are pushing for the use of malaria tests kits to deal a death blow to malaria.

The malaria vaccine research into the RTS,S candidate is on the front burner and barring any hitch, scientists in Africa are expected to announce a vaccine for inoculation against the disease for many of the continent's suffering children reeling under malaria.

The malaria eradication agenda is not ending there. It has been given a new lease of life with the introduction of a four-year study that would provide decision makers across Africa with independent and objective evidence on the safety and effectiveness of the new anti-malarial drugs, known as artemisinin-based combination therapies (ACTs).

Research sites at the Dodowa, Kintampo and the Navrongo Health Research Centres in Ghana together with others in Tanzania, Mozambique and Burkina Faso are carrying out the trial.

A 28-million dollar facility from the Bill and Melinda Gates Foundation is funding the trial in the four countries.

The INESS study is a phase four study and aims at providing evidence on the ACTs to find out if they are efficacious, safe, affordable and accessible among other factors.

ACTs have officially replaced chloroquine in treating malaria across Africa because malaria parasites have become resistant to the old malaria drug.
It is therefore expected that the phase four trial would provide national, regional and international decision-makers and governments across Africa with objective evidence on the real-life safety and effectiveness of ACTs as a basis for malaria treatment policy.

With the upsurge of the use of ACTs which are quite expensive for the ordinary man on the street and in a bid to avoid the misuse and abuse of the drugs, the use of rapid diagnostic tests (RDT) kits in the management of malaria is being moved from the back to the front burner in the diagnosis and management of malaria.

Tanzania is, for instance, stepping up the use of these kits under a government policy. The issue of drug efficacy and efficiency is assuming an important part in the management of malaria within the health system.

Dr Fustin Gabriel of the Ifakara Health Institute, in a recent interview during a tour of INESS project sites and some health facility by members of AMMREN in Tanzania, said the use of RDT kits is now a government policy and it is being implemented in phases in Tanzania. He said the first phase has begun in two regions, the Coastal and Morogoro regions of Tanzania.

Dr Fustin Gabriel interacting with AMMREN members

He said the Mchukwi Mission Hospital at Rufiji in the Coastal region is one such facility using the RDT kit as a confirmatory test although the use of the gold standard test for malaria microscopy is still in use. Presumptive diagnosis and treatment of malaria has been the standard practice in the management of malaria in many endemic countries.

It has been justified on the basis of high malaria transmission, inadequate laboratory services and the availability of cheap anti-malarial drugs.

It has however led to considerable over diagnosis of malaria an immediate consequence of which is the under diagnosis of other causes of febrile illnesses.

RDT kits are malaria-antigen based dipsticks that are fast and easy to use in the diagnosis of malaria and there are arguments that the kits are particularly suitable for use in peripheral health facilities where laboratory capacity is limited.

However, successful integration of RDT into for instance the Integrated Management of Childhood Illnesses (IMCI) programmes in various countries such as Ghana would depend on the sensitivity and specificity of the RDT kits that is used, the health system determinants and the impact of treatment outcomes.

It is in this direction that two of Ghana's lead research institutions at Kintampo and Dodowa are conducting various trials into RDT kits to enhance malaria treatment.

The Dodowa Health Research Centre in the Dangme West district is beginning a study to promote the rational prescription of anti-malarial drugs among chemical sellers through the introduction and use of RDT kits for testing malaria parasites within minutes.

The two-year study would be conducted among some 52 chemical shops in the Dangme West district to find out the impact of the introduction of RDTs on the dispensing behaviour of the chemical sellers, who are the main non-formal outlets in dispensing drugs at the community level.

Dr Evelyn Ansah, District Director of Health Services, speaking to journalists at Dodowa at a meeting organized by AMMREN-Ghana, says as part of the trials, ACTs would be made available at these chemical shops under an Affordable Medicines Facility-Malaria programme. The aim is to ensure that access to effective anti-malarial drugs improves especially in the private sector, which is not the case at present.

Dr Ansah talking to the Journalists

The trial among chemical sellers is a follow up to an earlier trial conducted at the health facility level where RDT kits for malaria were introduced to study the prescribing habits of doctors and clinicians at health facilities and patients' attitude to RDT. It was meant to reduce over prescription of anti-malarial drugs at the health facility level.

Malaria is endemic in most African countries but not all patients who present with a headache or fever would be suffering from malaria. Presumptive and mismanagement of malaria cases are not uncommon at these health facilities and the introduction of RDT kits is expected to help in proper diagnosis and management of malaria cases, if adopted as a policy.

The Kintampo Health Research Centre is also conducting a two-phase project to evaluate how RDT could be integrated into the Integrated Management of Childhood Illnesses (IMCI) in health centres in Kintampo and five other districts of the Brong-Ahafo region of Ghana.

The first phase of the project is examining the sensitivity and specificity of currently available RDTs and the factors of the health system likely to impact on the overall effectiveness of RDTs.
With all these studies being carried out there can be no hiding place for malaria. Researchers and policy makers in African can only wait and see as they close in on the disease.