Over-diagnosis Of Malaria Research Articles

Malaria and respiratory syncytial virus as causes of acute febrile illness in an urban paediatric population in Ghana.

The sub-Saharan region of Africa is endemic for malaria, and fever is often assumed to be malaria. In Ghana, about 3.7 million cases were reported in 2011, with 24.4% of these laboratory-confirmed. Other causes of febrile illness, including respiratory syncytial virus (RSV), are prevalent in developing countries like Ghana. There is very little data on the prevalence of this virus in the country. This study determined the proportion of acute febrile illness in an urban paediatric population that was due to malaria or RSV. A hospital based surveillance system recruited children below five years of age reporting with fever (axillary temperature ≥ 37.5°C) at the outpatient department of an urban hospital from February 2009 to February 2010. Consenting parents/guardians were interviewed, the medical history of the child was taken and the child clinically examined. Thick blood film from capillary blood taken through a finger prick, was Giemsa-stained and microscopically examined for malaria parasites to confirm malaria diagnosis. Nasopharyngeal aspirate was also examined for RSV by polymerase chain reaction. Out of 481 febrile children, 51(10.8%) were positive for malaria whilst 75 (15.4%) were positive for RSV. Seven of the 75 RSV-positive cases (9.3%) were co-infected with malaria. Based on judgement by clinicians, over 80% of the febrile children were diagnosed and treated as having malaria either alone or in combination with other diseases. Not all febrile episodes in malaria-endemic regions are due to malaria. The diagnosis and subsequent treatment of patients based solely on clinical diagnosis leads to an over diagnosis of malaria. Improvement in the guidelines and facilities for the diagnosis of non-malaria febrile illness leads to improved malaria diagnosis. Clinicians should be looking for other causes of fever rather than treating all fevers as malaria.

Contextualizing Child Malaria Diagnosis and Treatment Practices at an Outpatient Clinic in Southwest Nigeria: A Qualitative Study

Background. This study sought to explore contextual features of an outpatient clinic located in southwest Nigeria that enable and/or discourage effective diagnosis and treatment of child malaria. Methods. We conducted in-depth interviews with mothers of 135 febrile children attending a pediatric outpatient clinic in southwest Nigeria. Also, participant observations and informal discussions with physicians were conducted to examine the potential impact of context on effective child malaria diagnosis and treatment. Results. The findings indicate that availability of drugs and laboratory testing for malaria, affordability of antimalarial drugs, access to the clinic (particularly access to pediatricians), adequacy of the outpatient clinic, and acceptability of services provided at the clinic are key contextual factors that influence effective case management of malaria in children. Conclusion. If the Millennium Development Goal 6 of reversing malaria incidence by 2015 particularly among children is to be achieved, it is necessary to identify the contextual factors that may act as potential barriers to effective diagnosis and treatment practices at clinical settings. Understanding the context in which case management of child malaria occurs can provide insights into the factors that influence mis- and over-diagnosis of malaria in clinical settings.

Challenges in diagnosing paediatric malaria in Dar es Salaam, Tanzania

BackgroundMalaria is a major cause of paediatric morbidity and mortality. As no clinical features clearly differentiate malaria from other febrile illnesses, and malaria diagnosis is challenged by often lacking laboratory equipment and expertise, overdiagnosis and overtreatment is common.MethodsChildren admitted with fever at the general paediatric wards at Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania from January to June 2009 were recruited consecutively and prospectively. Demographic and clinical features were registered. Routine thick blood smear microscopy at MNH was compared to results of subsequent thin blood smear microscopy, and rapid diagnostics tests (RDTs). Genus-specific PCR of Plasmodium mitochondrial DNA was performed on DNA extracted from whole blood and species-specific PCR was done on positive samples.ResultsAmong 304 included children, 62.6% had received anti-malarials during the last four weeks prior to admission and 65.1% during the hospital stay. Routine thick blood smears, research blood smears, PCR and RDT detected malaria in 13.2%, 6.6%, 25.0% and 13.5%, respectively. Positive routine microscopy was confirmed in only 43% (17/40), 45% (18/40) and 53% (21/40), by research microscopy, RDTs and PCR, respectively. Eighteen percent (56/304) had positive PCR but negative research microscopy. Reported low parasitaemia on routine microscopy was associated with negative research blood slide and PCR. RDT-positive cases were associated with signs of severe malaria. Palmar pallor, low haemoglobin and low platelet count were significantly associated with positive PCR, research microscopy and RDT.ConclusionsThe true morbidity attributable to malaria in the study population remains uncertain due to the discrepancies in results among the diagnostic methods. The current routine microscopy appears to result in overdiagnosis of malaria and, consequently, overuse of anti-malarials. Conversely, children with a false positive malaria diagnosis may die because they do not receive treatment for the true cause of their illness. RDTs appear to have the potential to improve routine diagnostics, but the clinical implication of the many RDT-negative, PCR-positive samples needs to be elucidated.

Expanding Access to Malaria Diagnosis through Retail Shops in Western Kenya: What Do Shop Workers Think?

Background. The common symptoms of malaria reduce the specificity of clinical diagnosis. Presumptive treatment is conventional but can lead to overdiagnosis of malaria, delay of appropriate treatment, overprescription of antimalarials, and drug resistance. Routine use of diagnostic tests can address many of these concerns. Though treatment is often procured from retailers, there is low availability of rapid diagnostic tests for malaria (MRDTs), a simple, inexpensive, and accurate diagnostic solution. We know little about the challenges to expanding access to diagnostics through these outlets. Methods. To understand the perceptions of the benefits and challenges to selling rapid diagnostic tests for malaria, we conducted focus group discussions with antimalarial retailers who serve the residents of the Webuye Health and Demographic Surveillance Site in western Kenya. Results. Medicine retailers perceived MRDTs to be beneficial to their customers and businesses but also included cost, fear of the tests, risks of self-treatment, and regulatory concerns among the challenges to using and selling MRDTs. Conclusion. MRDTs represent a viable approach to increase access to malaria diagnostic testing. Medicine retailers are eager for MRDTs to be made available to them. However, certain challenges remain to implementation in retail outlets and should be addressed in advance.

Over-diagnosis of malaria by microscopy in the Kilombero Valley, Southern Tanzania: an evaluation of the utility and cost-effectiveness of rapid diagnostic tests

BackgroundEarly and accurate diagnosis of febrile patients is essential to treat uncomplicated malaria cases properly, prevent severe malaria, and avert unnecessary anti-malarial treatments. Improper use of anti-malarials increases the risk of adverse drug reaction and the evolution of drug/parasite resistance. While microscopy is the most common form of malaria diagnosis, concerns over its accuracy have prompted the incorporation of malaria rapid diagnostic tests (RDTs) into many national malaria control programmes.MethodsOver a three-month period, a direct comparison between microscopy and RDTs was made in a rural, private dispensary in the Kilombero Valley, Morogoro District, southern Tanzania, with the aim of estimating the extent of malaria over-diagnosis and over-treatment with anti-malarials. The study cohort was made up of patients referred by the dispensary’s clinician for malaria testing. One hundred percent of patients approached agreed to participate in this study and were then tested using both microscopy and RDTs. Using the results from the comparison of the two tests at this dispensary, the potential cost effectiveness of introducing RDTs to a neighbouring public health centre was estimated on the basis of this centre’s past malaria records spanning December 2007 to August 2011.ResultsAt the private dispensary, the apparent prevalence of malaria was 78% based on microscopy whereas the true prevalence, calculated using RDTs as the gold standard, was estimated at 14%. This discrepancy indicates that when using microscopy as the sole diagnostic test, malaria is being over-diagnosed by approximately a factor of five in this setting. At the public clinic, apparent malaria prevalence based on microscopy was 74%. If similar rates of over-diagnosis are assumed, 5,285 patients of the 6,769 patients positively diagnosed with malaria using microscopy were likely given unnecessary anti-malarials, and their true cause of illness was not addressed. The introduction of RDTs to the public clinic would be highly cost-efficient, with an estimated net saving of over 96 USD/month.ConclusionsCompared with RDTs, microscopy led to almost four out of five patients being over-diagnosed with malaria in this rural part of Tanzania. A policy that encompasses both the private and public sectors of health care is needed to ensure quality diagnostic testing for febrile patients. With estimated prevalence at 14%, RDT introduction is recommended given WHO findings that RDTs are predicted to be cost-effective in prevalence areas of less than 20%. The use of RDTs in malaria diagnosis would not only reduce government spending but would prove beneficial to ensuring appropriate care and treatment of febrile illness.

The Benefits or Otherwise of Managing Malaria Cases with or without Laboratory Diagnosis: The Experience in a District Hospital in Ghana

BackgroundThis study was conducted at the Kintampo Municipal Hospital in Ghana to determine whether there was any benefit (or otherwise) in basing the management of cases of suspected malaria solely on laboratory confirmation (microscopy or by RDT) as compared with presumptive diagnosis.MethodChildren under five years who reported at the Out-Patient Department of the Hospital with axillary temperature ≥37.5°C or with a 48 hr history of fever were enrolled and had malaria microscopy and RDT performed. The attending clinician was blinded from laboratory results unless a request for these tests had been made earlier. Diagnosis of malaria was based on three main methods: presumptive or microscopy and/or RDT. Cost implication for adopting laboratory diagnosis or not was determined to inform malaria control programmes.ResultsIn total, 936 children were enrolled in the study. Proportions of malaria diagnosed presumptively, by RDT and microscopy were 73.6% (689/936), 66.0% (618/936) and 43.2% (404/936) respectively. Over 50% (170/318) of the children who were RDT negative and 60% (321/532) who were microscopy negative were treated for malaria when presumptive diagnoses were used. Comparing the methods of diagnoses, the cost of malaria treatment could have been reduced by 24% and 46% in the RDT and microscopy groups respectively; the reduction was greater in the dry season (43% vs. 50%) compared with the wet season (20% vs. 45%) for the RDT and microscopy confirmed cases respectively.Discussion/ConclusionOver-diagnosis of malaria was prevalent in Kintampo during the period of the study. Though the use of RDT for diagnosis of malaria might have improved the quality of care for children, it appeared not to have a cost saving effect on the management of children with suspected malaria. Further research may be needed to confirm this.

Malaria “Diagnosis” and Diagnostics in Afghanistan

In many malaria-endemic areas, including Afghanistan, overdiagnosis of malaria is common. Even when using parasite-based diagnostic tests prior to treatment, clinicians commonly prescribe antimalarial treatment following negative test results. This practice neglects alternative causes of fever, uses drugs unnecessarily, and might contribute to antimalarial drug resistance. We undertook a qualitative study among health workers using different malaria diagnostic methods in Afghanistan to explore perceptions of malaria diagnosis. Health workers valued diagnostic tests for their ability to confirm clinical suspicions of malaria via a positive result, but a negative result was commonly interpreted as an absence of diagnosis, legitimizing clinical diagnosis of malaria and prescription of antimalarial drugs. Prescribing decisions reflected uncertainty around tests and diagnosis, and were influenced by social- and health-system factors. Study findings emphasize the need for nuanced and context-specific guidance to change prescriber behavior and improve treatment of malarial and nonmalarial febrile illnesses.

Overdiagnosis of malaria means other life-threatening infections are missed.

Substantial overdiagnosis and mistreatment of malaria is taking place, wasting resources and leaving people vulnerable to other serious non-malarial infections.

Predicting mortality for paediatric inpatients where malaria is uncommon

ObjectiveAs the proportion of children living low malaria transmission areas in sub-Saharan Africa increases, approaches for identifying non-malarial severe illness need to be evaluated to improve child outcomes.DesignAs a prospective...

Overdiagnosis and mistreatment of malaria among febrile patients at primary healthcare level in Afghanistan: observational study

Objective To assess the accuracy of malaria diagnosis and treatment at primary level clinics in Afghanistan.Design Prospective observational study.Setting 22 clinics in two Afghan provinces, one in the north (adjoining...

Overdiagnosis and Overtreatment of Malaria in Children That Presented with Fever in Lagos, Nigeria

Background. Malaria diagnosis has been largely done clinically. The implication is the likely overdiagnosis of malaria when diagnosis is done soley on the basis of symptoms. Methods. Parasitological diagnosis was done among 1211, 0–12 years old febrile children that attended a Primary Health Centre in Lagos, Nigeria, who were diagnosed clinically and treated based on symptoms. Results. A total of 251 of 1,211 (20.7%) children less than 12 years old and 174 of the 1,027 of children 0–≤5 yrs (16.9%) were slide positive while 853 (83.1%) of 0–≤5 yrs that were slide negative were treated with Artemisinin based combination therapies (ACTs) in line with the Integrated Management of Childhood Infectioins (IMCI) guidelines and standard practice of the Clinic. Chills, diarrhoea, convulsions, headache, cough, respiratory distress, inactivity, loss of apetite, and vomiting occured significantly in the 0–≤5 and >5–12 years old malaria negative children. Conclusions. Overdiagnosis and overtreatment of malaria in this study was high. Therefore, malaria medicines should be prescribed on the basis of parasitological confirmation of all suspected malaria cases. The availability of quality-assured malaria rapid diagnostic tests (RDTs) is a useful tool to confirm malaria cases while the cause of the non-malaria fevers can be followed up and managed appropriately.

A refined estimate of the malaria burden in Niger

BackgroundThe health authorities of Niger have implemented several malaria prevention and control programmes in recent years. These interventions broadly follow WHO guidelines and international recommendations and are based on interventions that have proved successful in other parts of Africa. Most performance indicators are satisfactory but, paradoxically, despite the mobilization of considerable human and financial resources, the malaria-fighting programme in Niger seems to have stalled, as it has not yet yielded the expected significant decrease in malaria burden. Indeed, the number of malaria cases reported by the National Health Information System has actually increased by a factor of five over the last decade, from about 600,000 in 2000 to about 3,000,000 in 2010. One of the weaknesses of the national reporting system is that the recording of malaria cases is still based on a presumptive diagnosis approach, which overestimates malaria incidence.MethodsAn extensive nationwide survey was carried out to determine by microscopy and RDT testing, the proportion of febrile patients consulting at health facilities for suspected malaria actually suffering from the disease, as a means of assessing the magnitude of this problem and obtaining a better estimate of malaria morbidity in Niger.ResultsIn total, 12,576 febrile patients were included in this study; 57% of the slides analysed were positive for the malaria parasite during the rainy season, when transmission rates are high, and 9% of the slides analysed were positive during the dry season, when transmission rates are lower. The replacement of microscopy methods by rapid diagnostic tests resulted in an even lower rate of confirmation, with only 42% of cases testing positive during the rainy season, and 4% during the dry season. Fever alone has a low predictive value, with a low specificity and sensitivity. These data highlight the absolute necessity of confirming all reported malaria cases by biological diagnosis methods, to increase the accuracy of the malaria indicators used in monitoring and evaluation processes and to improve patient care in the more remote areas of Niger. This country extends over a large range of latitudes, resulting in the existence of three major bioclimatic zones determining vector distribution and endemicity.ConclusionThis survey showed that the number of cases of presumed malaria reported in health centres in Niger is largely overestimated. The results highlight inadequacies in the description of the malaria situation and disease risk in Niger, due to the over-diagnosis of malaria in patients with simple febrile illness. They point out the necessity of confirming all cases of suspected malaria by biological diagnosis methods and the need to take geographic constraints into account more effectively, to improve malaria control and to adapt the choice of diagnostic method to the epidemiological situation in the area concerned. Case confirmation will thus also require a change in behaviour, through the training of healthcare staff, the introduction of quality control, greater supervision of the integrated health centres, the implementation of good clinical practice and a general optimization of the use of available diagnostic methods.

Malaria: Overdiagnosed and Inappropriately Treated in Afghanistan

Studies document overdiagnosis of malaria and misprescription of malaria treatment in Africa, but what about Asia? To explore this issue, investigators undertook an observational study to assess the accuracy of diagnosis and treatment at 22 healthcare clinics in Afghanistan, a country in which vivax malaria predominates and transmission is seasonal. The study involved 10 clinics (5 that used clinical diagnosis and 5 that had newly established laboratories with smear microscopy) in the …

Temporal Association of Acute Hepatitis A and Plasmodium falciparum Malaria in Children

BackgroundIn sub-Saharan Africa, Plasmodium falciparum and hepatitis A (HAV) infections are common, especially in children. Co-infections with these two pathogens may therefore occur, but it is unknown if temporal clustering exists.Materials and MethodsWe studied the pattern of co-infection of P. falciparum malaria and acute HAV in Kenyan children under the age of 5 years in a cohort of children presenting with uncomplicated P. falciparum malaria. HAV status was determined during a 3-month follow-up period.DiscussionAmong 222 cases of uncomplicated malaria, 10 patients were anti-HAV IgM positive. The incidence of HAV infections during P. falciparum malaria was 1.7 (95% CI 0.81–3.1) infections/person-year while the cumulative incidence of HAV over the 3-month follow-up period was 0.27 (95% CI 0.14–0.50) infections/person-year. Children with or without HAV co-infections had similar mean P. falciparum asexual parasite densities at presentation (31,000/µL vs. 34,000/µL, respectively), largely exceeding the pyrogenic threshold of 2,500 parasites/µL in this population and minimizing risk of over-diagnosis of malaria as an explanation.ConclusionThe observed temporal association between acute HAV and P. falciparum malaria suggests that co-infections of these two hepatotrophic human pathogens may result from changes in host susceptibility. Testing this hypothesis will require larger prospective studies.

Presumptive treatment for malaria is not justified in children receiving cancer chemotherapy

Predominant etiologies of febrile neutropenia (FN) during the course of cancer chemotherapy include infections with bacteria, fungi, and viruses. Infection with malarial parasite is a possibility in regions that are endemic for malaria. Over-diagnosis and over-treatment of malaria is increasingly being recognized as a serious concern in malaria endemic regions. Aim was to determine the incidence of malarial infection in episodes of FN in children receiving chemotherapy for malignant disorders. Children, with malignant disorders, on chemotherapy, who fulfilled the definition of FN were enrolled prospectively. Standard microscopy, quantitative buffy coat, and antigen detection (OptiMAL) were performed in each episode of FN. One hundred episodes of FN involving 82 children were investigated. The age ranged from 2 to 13 years (mean: 5.8 ± 2.8). Eighty-one episodes were in children with acute lymphoblastic leukemia, 15 in acute myeloid leukemia, and remaining 4 in other malignancies. Evidence for malaria was not found in any case by any of the three methods. Malaria was not found to be a causative agent for FN in children with various malignant disorders, in a region with low endemicity for malaria. Presumptive administration of antimalarials in children with FN is unjustified. Pediatric oncologists constantly face the challenge of managing febrile illnesses in immunocompromised patients. Those practicing in malaria endemic regions can effectively exploit diagnostic tools for malaria for a rational decision.

How can malaria rapid diagnostic tests achieve their potential? A qualitative study of a trial at health facilities in Ghana

BackgroundRapid diagnostic tests (RDTs) for malaria are at the early stages of introduction across malaria endemic countries. This is central to efforts to decrease malaria overdiagnosis and the consequent overuse of valuable anti-malarials and underdiagnosis of alternative causes of fever. Evidence of the effect of introducing RDTs on the overprescription of anti-malarials is mixed. A recent trial in rural health facilities in Ghana reduced overprescription of anti-malarials, but found that 45.5% patients who tested negative with RDTs were still prescribed an anti-malarial.MethodsA qualitative study of this trial was conducted, using in-depth interviews with a purposive sample of health workers involved in the trial, ranging from those who continued to prescribe anti-malarials to most patients with negative RDT results to those who largely restricted anti-malarials to patients with positive RDT results. Interviews explored the experiences of using RDTs and their results amongst trial participants.ResultsMeanings of RDTs were constructed by health workers through participation with the tests themselves as well as through interactions with colleagues, patients and the research team. These different modes of participation with the tests and their results led to a change in practice for some health workers, and reinforced existing practice for others. Many of the characteristics of RDTs were found to be inherently conducive to change, but the limited support from purveyors, lack of system antecedents for change and limited system readiness for change were apparent in the analysis.ConclusionsWhen introduced with a limited supporting package, RDTs were variously interpreted and used, reflecting how health workers had learnt how to use RDT results through participation. To build confidence of health workers in the face of negative RDT results, a supporting package should include local preparation for the innovation; unambiguous guidelines; training in alternative causes of disease; regular support for health workers to meet as communities of practice; interventions that address negotiation of health worker-patient relationships and encourage self-reflection of practice; feedback systems for results of quality control of RDTs; feedback systems of the results of their practice with RDTs; and RDT augmentation such as a technical and/or clinical troubleshooting resource.

Cerebral malaria: human versus mouse studies

In a recent Opinion article [1], White and colleagues discuss the value of the murine Plasmodium berghei ANKA model in identifying pathological processes and therapeutic interventions in human cerebral malaria (HCM). This model involves P. berghei ANKA infection of inbred CBA or C57BL/6 strain mice, which develop clinical symptoms of cerebral complications including paralysis, fitting and coma with death around Day 8 post-infection [2]. Resistant mouse strains such as BALB/c mice develop hyperparasitemia and severe anemia with death occurring about 3 weeks after infection.

Malaria misdiagnosis in Uganda – implications for policy change

BackgroundIn Uganda, like in many other countries traditionally viewed as harbouring very high malaria transmission, the norm has been to recommend that febrile episodes are diagnosed as malaria. In this study, the policy implications of such recommendations are revisited.MethodsA cross-sectional survey was undertaken at outpatient departments of all health facilities in four Ugandan districts. The routine diagnostic practices were assessed for all patients during exit interviews and a research slide was obtained for later reading. Primary outcome measures were the accuracy of national recommendations and routine malaria diagnosis in comparison with the study definition of malaria (any parasitaemia on expert slide examination in patient with fever) stratified by age and intensity of malaria transmission. Secondary outcome measures were the use, interpretation and accuracy of routine malaria microscopy.Results1,763 consultations undertaken by 233 health workers at 188 facilities were evaluated. The prevalence of malaria was 24.2% and ranged between 13.9% in patients ≥5 years in medium-to-high transmission areas to 50.5% for children <5 years in very high transmission areas. Overall, the sensitivity and negative predictive value (NPV) of routine malaria diagnosis were high (89.7% and 91.6% respectively) while the specificity and positive predictive value (PPV) were low (35.6% and 30.8% respectively). However, malaria was under-diagnosed in 39.9% of children less than five years of age in the very high transmission area. At 48 facilities with functional microscopy, the use of malaria slide examination was low (34.5%) without significant differences between age groups, or between patients for whom microscopy is recommended or not. 96.2% of patients with a routine positive slide result were treated for malaria but also 47.6% with a negative result.ConclusionCurrent recommendations and associated clinical practices result in massive laria over-diagnosis across all age groups and transmission areas in Uganda. Yet, under-diagnosis is also common in children <5 years. The potential benefits of malaria microscopy are not realized. To address malaria misdiagnosis, Uganda's policy shift from presumptive to parasitological diagnosis should encompass introduction of malaria rapid diagnostic tests and substantial strengthening of malaria microscopy.

Malaria overdiagnosis and burden of malaria misdiagnosis in the suburbs of central Sudan: special emphasis on artemisinin-based combination therapy era

Accuracy of diagnosis is central for malaria control. Although microscopy is gold standard in malaria diagnosis, its reliability is largely dependent on user skill. In this study, we evaluated practitioners' clinical and microscopists' technical skills in diagnosis of malaria in central Sudan. In a retrospective study, 3203 blood smears from 95 peripheral health facilities (each represented by a general practitioner [GP] and general microscopist [GM]) were reexamined by expert microscopist. Furthermore, in a prospective study, 410 patients had their malaria diagnosis rechecked by rapid diagnostic test for validation of the microscopic diagnosis. Results showed that the rate of false-positive diagnosis of malaria was 75.6% and false-negative diagnosis was 0.01%. The study disclosed poor skills of the GPs and GMs in malaria diagnosis because 43% of the GPs and 44% of the GMs failed to make a single true-positive malaria diagnosis. The false-positive malaria diagnosis showed bias toward adult females. Economically, the calculated cost of diagnosis and treatment of malaria in Sudan in year 2000 is US$100 million, whereas the calculated cost of true malaria is approximately US$14 million. In conclusion, malaria overdiagnosis was widely recognized in central Sudan, with high economic burden during the era of artemisinin-based combination therapy. Finally, different scenarios were suggested for improvement of malaria diagnosis.

Diagnosis of malaria in children's outpatient departments in Abuja, Nigeria

Over-diagnosis of malaria has previously been described, especially in East Africa. Abuja is the capital of the most populous country in Africa. Over-prescription of artemisinin-based combination therapy (ACT) antimalarials in Nigeria on the scale reported from other countries will result in substantial unnecessary use of this class of drug. In a study of 1000 children seen in the outpatient paediatric clinics of four district hospitals in Abuja, 669 had history of fever, of whom 616 (92%) were diagnosed with malaria. Only 24 (3.8%) where confirmed by positive malaria slides. Of 82 malaria tests requested, 32 (40%) were not available when clinicians wrote their prescriptions. Of 256 children prescribed an ACT, 11 (4.4%) were test negative, eight (3.1%) test positive, in 11 (4.3%) the test was not available and the test was not requested for 219 (86%). The proportion of available negative slides for patients treated with an antimalarial was 23/26 (88%), which was similar to the 22/24 (91%) treated with an antimalarial who were test positive. Testing for malaria made almost no impact on ACT prescription or on all other antimalarials and antibiotics. Based on these findings there is high possibility of massive over prescription of antimalarials.