Abstract
Recent WHO guidelines recommend a universal "test and treat" strategy for malaria, mainly by use of rapid diagnostic test (RDT) in all areas. The evidence for this approach is questioned here as there is a risk of over-reliance on parasitological diagnosis in high transmission situations, which still exist. In such areas, when a patient has fever or other malaria symptoms, the presence of Plasmodium spp neither reliably confirms malaria as the cause of the fever, nor excludes the possibility of other diseases. This is because the patient may be an asymptomatic carrier of malaria parasites and suffer from another disease.To allow clinicians to perform their work adequately, local epidemiologic data are necessary. One size does not fit all. If parasite prevalence in the population is low, a diagnostic test is relevant; if the prevalence is high, the test does not provide information of any clinical usefulness, as happens with any test in medicine when the prevalence of the tested characteristic is high in the healthy population. It should also be remembered that, if in some cases anti-malarials are prescribed to parasite-negative patients, this will not increase selection pressure for drug resistance, because the parasite is not there.In high transmission situations at least, other diagnoses should be sought in all patients, irrespective of the presence of malaria parasites. For this, clinical skills (but not necessarily physicians) are irreplaceable, in order to differentiate malaria from other causes of acute fever, such as benign viral infection or potentially dangerous conditions, which can all be present with the parasite co-existing only as a "commensal" or silent undesirable guest.
Highlights
The latest WHO guidelines on the treatment of malaria state that, whenever possible, “in all settings, clinical suspicion of malaria should be confirmed with a parasitological diagnosis“ [1,2]
This is a significant change from the previous guidelines [3], which recognized that parasitological diagnosis is not always necessary, in high transmission areas
This results in a high “false positive rate” and low specificity of rapid diagnostic test (RDT) compared to microscopy, in high transmission areas [6,36]
Summary
The latest WHO guidelines on the treatment of malaria state that, whenever possible, “in all settings, clinical suspicion of malaria should be confirmed with a parasitological diagnosis“ [1,2]. The sensitivity of clinical diagnosis varies as well, but in a high-transmission setting presumptive treatment of all febrile infants with anti-malarials is probably safer than relying on the result of an RDT[26]. Assumption 6: “Confirmation of treatment failures” Rapid diagnostic tests based on detection of the HRP-2 antigen often remain positive for over five weeks after the disappearance of live parasites, because they detect the HRP-2 antigen which is still present in debris from dead parasites for some time after total parasite clearance [35] This results in a high “false positive rate” and low specificity of RDTs compared to microscopy, in high transmission areas [6,36]. It is rarely possible to sustain such high quality microscopy outside the research setting, and poor quality microscopy is not clinically useful [37,38] for confirmation of treatment failures
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