Malaria Microscopy Research Articles

Characterizing microscopic and submicroscopic malaria parasitaemia at three sites with varied transmission intensity in Uganda.

BackgroundParasite prevalence is a key metric used to quantify the burden of malaria and assess the impact of control strategies. Most published estimates of parasite prevalence are based on microscopy and likely underestimate true prevalence.MethodsThick smear microscopy was performed in cohorts of children (aged 6 month to 10 years) and adults every 90 days over 2 years, at three sites of varying transmission intensity in Uganda. Microscopy-negative samples were tested for sub-microscopic parasitaemia using loop-mediated isothermal amplification (LAMP). Generalized estimating equation models were used to evaluate associations between age and parasitaemia, factors associated with sub-microscopic infection and associations between parasitaemia and haemoglobin.ResultsA total of 9260 samples were collected from 1245 participants. Parasite prevalence among children across the three sites was 7.4, 9.4 and 28.8 % by microscopy and 21.3, 31.8 and 69.0 % by microscopy plus LAMP. Parasite prevalence among adults across the three sites was 3.1, 3.0 and 5.2 % by microscopy and 18.8, 24.2 and 53.5 % by microscopy plus LAMP. Among those with parasitaemia, adults and persons recently treated with anti-malarial therapy had the highest prevalence of sub-microscopic infection. Children with sub-microscopic or microscopic parasitaemia had lower mean haemoglobin levels compared to children with no detectable parasites.ConclusionsAcross a range of transmission intensities in Uganda, microscopy vastly underestimated parasite prevalence, especially among adults.

In vivo efficacy of artemether-lumefantrine and artesunate-amodiaquine for uncomplicated Plasmodium falciparum malaria in Malawi, 2014.

BackgroundMalaria causes significant morbidity in Malawi, with an estimated 5 million cases in 2014. Artemether-lumefantrine (AL) and artesunate-amodiaquine (ASAQ) are the first- and second-line treatments for uncomplicated malaria, respectively, but emerging resistance threatens their efficacy. In order to understand whether AL and ASAQ remain efficacious for the treatment of uncomplicated Plasmodium falciparum malaria in Malawi, a therapeutic efficacy trial was conducted.MethodsDuring March–July 2014, febrile children aged 6–59 months with microscopy-confirmed uncomplicated P. falciparum malaria (1000–200,000 parasites/μL) were enrolled in a 28-day randomized in vivo efficacy trial at three sites: one each in northern (Karonga), central (Nkhotakota) and southern (Machinga) Malawi. The study was powered to estimate site-specific efficacy for AL and overall efficacy for ASAQ, with 3:1 randomization to AL or ASAQ. Blood was collected for malaria microscopy and molecular testing on days 0–3, 7, 14, 21, and 28. Recrudescence and reinfection were differentiated using polymerase chain reaction (PCR) genotyping of merozoite surface protein. The primary outcome was the PCR-corrected day 28 Kaplan–Meier cumulative success rate.ResultsA total of 452 children were enrolled; 303/338 (89 %) and 98/114 (86 %) reached a study endpoint in AL and ASAQ arms, respectively. All treatment failures occurred after day 3. The day 28 uncorrected cumulative success rate was 97.1 % (95 % confidence interval [CI]: 93.9–100 %) for ASAQ and 76.8 % (95 % CI 72.1–81.5 %) for AL, with 82.5 % (95 % CI 75.4–89.7 %), 69 % (95 % CI 59.9–78.1 %), and 78.2 % (95 % CI 70.2–86.3 %) success in the northern, central, and southern regions, respectively. The day 28 PCR-corrected cumulative success rate was 99 % (95 % CI 97.2–100 %) in the ASAQ arm and 99.3 % (95 % CI 98.3–100 %) in the AL arm, with 98–100 % efficacy in each site.ConclusionsAs evidenced by the day 28 PCR-corrected cumulative success rates, both AL and ASAQ remain efficacious treatments for uncomplicated malaria in Malawi. The lower uncorrected efficacy in the AL arm compared to ASAQ may be explained by the shorter half-life of lumefantrine (3–6 days) compared to amodiaquine (9–18 days). The high reinfection rate suggests that there is a continued need to scale-up effective malaria prevention interventions.

Performance evaluation of malaria microscopists working at malaria slides rechecking laboratories for external quality assessment in Ethiopia

Background: Microscopic diagnosis of Giemsa stained thick and thin blood films by skilled microscopists has remained the standard laboratory method for the diagnosis of malaria. The Performance of Malaria Microscopists in all health facilities have been raised concerns by many experts. Microscopists who are working at Malaria Rechecking Laboratories have to be competent to cross check blood film slides which are collected from testing sites. Methods & Materials: A cross-sectional study was conducted to assess the performance of 107 Malaria Microscopists who are working at 23 Malaria Rechecking Laboratories in Ethiopia. A set of 12 blood film slides containing known Negative and positive (different species, stage, and parasite density) results were distributed to each Malaria microscopists. Data was collected and entered into Microsoft Excel sheets and exported to software SPSS version 20 for analysis. Chi-square (for categorical data), sensitivity, specificity, percent agreement, and kappa score were calculated to assess laboratory professionals’ performance in detecting and identification of Plasmodium species. Association was taken as significant at P < 0.05. Results: A total of 107 study participants were involved in this study, the mean age of the participants was 30+/- 5.04 years. Overall, the sensitivity of participants in detection and species identification of malaria parasites were 96.8% and 56.7%, respectively. The overall agreement on detection and identification of malaria species was 96.8% (Kappa = 0.9) and 64.77% (kappa = 0.33), respectively. About 34(31.8%) participants were used unrecommended quantification (+) system. The least malaria species which were identified correctly by the participants were P. malariae(2.8%) followed by and P.ovale(32.7%). Malaria microscopists working at sub regional laboratory had a better Quantification performance (P=0.003). Study participants who were participated on malaria microscopy and quality assurance training had a better performance on parasite quantification (P<0.001). Conclusion: Agreement of the participants with expert microscopist in the identification of different malaria species and quantification were very low. Most participants did not identify P. malariae and P.ovale correctly. Therefore, policy backed regular competency assessment and training for malaria microscopists is essential and mandatory that can assure proper diagnosis and management of malaria in Ethiopia.

Sharp decline of malaria cases in the Burie Zuria, Dembia, and Mecha districts, Amhara Region, Ethiopia, 2012-2014: descriptive analysis of surveillance data.

BackgroundIn the Amhara Region of Ethiopia, a steep decline of malaria cases was seen in early 2014. This study verified the decrease of the malaria cases along with the positivity rates among acute febrile illness patients, from late 2012 through 2014 in selected districts of the Amhara Region of Federal Republic of Ethiopia.MethodsDescriptive epidemiological analysis was conducted on the routine malaria surveillance data from the World Health Organization epidemiological week 28 of 2012 to week 52 of 2014 in three districts: Burie Zuria, Dembia and Mecha, the Amhara Region in Ethiopia. The authors visited the three district health offices, and health centres, when necessary, and collected the surveillance data on malaria for that period.ResultsThe study found that the malaria cases, along with the positivity rates, decreased from late 2012 to early 2014 in all three districts. Though the situation had slightly reverted in late 2014, the numbers of cases were much smaller than in late 2012 in all three districts. Despite the different diagnostic techniques used at health centres (malaria microscopy) and health posts (rapid diagnostic tests), moderate to high correlations were found, suggesting that the trends were real and not caused by a defect in the reagent, differences in the technicians’ skills for microscopy, or a change of the health workers’ attitudes toward cases with acute febrile illness. The decrease in malaria cases in early 2014 may have resulted from successful implementation of the three pillars of malaria control—case management, indoor residual spraying and insecticide-treated nets—in the districts where a high percentage of households were protected by indoor residual spraying and/or insecticide-treated nets.ConclusionWhile the current efforts for malaria control should be strengthened and maintained, the review of malaria surveillance data should also be used to verify the malaria trend in the region.

Quality analysis of malaria blood smears of fever patients in Changzhou City in 2014

To understand the quality of blood smears for Plasmodium detection in Changzhou City, so as to provide the technical support for malaria surveillance in the post-elimination period. The blood smears of fever patients from each cities (districts) in Changzhou City in 2014, including more than 3% of the negatives and all the positives, were selected. The quality of the blood smear making, dyeing, cleanliness and results were reviewed by the experts from the municipal malaria microscopy station, and the data were analyzed statistically. Totally 996 negative blood smears were reviewed in 2014, with a review rate of 4.52%. The qualified rates of blood smear making, dyeing and cleanliness were 92.87%, 93.27% and 94.48%, respectively. A total of 34 positive blood smears were reviewed, and there were no false detections and leak detections. The qualified rates of blood smear making and dyeing were more than 90% in all the seven cities (districts). As for qualified rate of cleanliness, except the rate in Qishuyan District (81.36%), those in the other six cities (districts) were all above 90%. The qualified rates of blood smear making, dyeing and cleanliness were all more than 90% in first-class, second-class and third-class hospitals. The major quality defects of the blood smears were sediment, abnormal making and thick membrane shedding, and the proportions were 25.91%, 21.76% and 19.17%, respectively. The quality of blood smears for Plasmodium detection in Changzhou City is satisfying. In the future, the training and supervision still should be strengthened to guarantee the capacity of microscopic examinations for Plasmodium detection in the surveillance of post-elimination period.

An outbreak investigation of scrub typhus in Western Province, Solomon Islands, 2014.

ObjectiveTo identify the etiology and risk factors of undifferentiated fever in a cluster of patients in Western Province, Solomon Islands, May 2014.MethodsAn outbreak investigation with a case control study was conducted. A case was defined as an inpatient in one hospital in Western Province, Solomon Islands with high fever (> 38.5 °C) and a negative malaria microscopy test admitted between 1 and 31 May 2014. Asymptomatic controls matched with the cases residentially were recruited in a ratio of 1:2. Serum samples from the subjects were tested for rickettsial infections using indirect micro-immunofluorescence assay.ResultsNine cases met the outbreak case definition. All cases were male. An eschar was noted in five cases (55%), and one developed pneumonitis. We did not identify any environmental factors associated with illness. Serum samples of all five follow-up cases (100%) had strong-positive IgG responses to scrub typhus. Nine out of ten controls were negative for ST antibodies. Four controls had low levels of antibodies against spotted fever group rickettsia, and only one had a low-level response to typhus group rickettsia.DiscussionThis outbreak represents the first laboratory-confirmed outbreak of scrub typhus in the Western Province of Solomon Islands. The results suggest that rickettsial infections are more common than currently recognized as a cause of an acute febrile illness. A revised clinical case definition for rickettsial infections and treatment guidelines were developed and shared with provincial health staff for better surveillance and response to future outbreaks of a similar kind.

Malaria rapid diagnostic test evaluation at private retail pharmacies in Kumasi, Ghana.

Objective:Malaria rapid diagnostic test (MRDT) provides a good alternative to malaria microscopy diagnosis, particularly in resource-constrained settings. This study therefore evaluated MRDT in private retail pharmacies (PRPs) as a critical step in community case malaria management.Methods:In a prospective, cross-over, validation survey at six PRPs in the Ashanti Region of Ghana, 1200 patients presenting with fever in the preceding 48 h were sampled. Fingerstick blood samples were collected for preparation of thick and thin blood films for malaria microscopy. Categorized patients (600 each) went through the processes of MRDT or presumptive diagnosis (PD) of malaria. The malaria disease prevalence of the study area was established. Selectivity (Se), specificity (Sp), positive predictive value (PPV) along with false discovery rate (FDR), and negative predictive value (NPV) along with the false omission rate (FOR), and diagnostic odds ratio (DOR) of MRDT were then calculated.Findings:While 43.0% tested positive using the MRDT, 57.0% tested negative. However, 62.0% MRDT-negative patients in addition to all the MRDT positives were given artemether-lumefantrine. Of those diagnosed by PD, 98.2% were prescribed with an antimalarial (microscopy however confirmed only 70.3% as positive). Se and Sp of the MRDT were 90.68 ± 11.18% and 98.68 ± 1.19%, respectively. Malaria prevalence was estimated to be 43.3%. PPV was 98.0%, FDR was 2.0%, NPV was 98.0%, FOR was 2.0%, and DOR was 2366.43.Conclusion:Results highlighted good performance of MRDTs at PRPs which could inform decision toward its implementation.

The Validity of Rapid Malaria Test and Microscopy in Detecting Malaria in a Preelimination Region of Egypt.

Background. Malaria is a leading cause of morbidity and mortality worldwide. Rapid and accurate diagnosis of malaria would improve control measures and reduce morbidity and mortality. Objective. The aim of this study was to assess the prevalence of malaria in high risk foci in Egypt and the effectiveness of rapid diagnostic tests in diagnosis and subsequently control of malaria. Methodology. A total number of 600 cases of both sexes with different ages were included in the present study. Cases were included in 2 groups; first group (500 cases) were randomly selected from households in Fayoum Governorate and second group (100 cases) were admitted to Fayoum Fever Hospital with signs suggestive of malaria. Cases were subjected to detailed history taking, clinical examination, microscopic examination of thin and thick blood films, and immunological test to detect plasmodial antigens. Results. A total of 3 positive cases were detected by rapid diagnostic tests (RDTs). Out of these 3 cases, one case was positive for malaria parasite by microscopic examination of blood films. All positive cases in the study had history of travel to malaria endemic areas. Conclusion. RDTs are simple and effective for rapid diagnosis of malaria to help in implication of control measures in different localities.

Prevalence of Plasmodium falciparum Malaria among Pregnant Students in Dodoma Region, Tanzania: No Cases Have Been Detected.

Malaria in pregnancy, being often asymptomatic, is a major problem in endemic African countries. It is characterized by anemia and placental malaria leading to poor pregnancy outcomes. In 2001 Tanzania adopted an intermittent-preventive treatment of malaria in pregnancy (IPTp) policy, which recommends receiving doses of antimalarial drugs every planned visit to the antenatal care centre (ANC), starting from the second trimester. Currently the policy is valid across the whole country, regardless that there are regions with very low malaria endemicity in Tanzania, such as Dodoma region. The current study aimed to show the real prevalence of malaria among young pregnant women in Dodoma region, by measuring the prevalence of malaria among University of Dodoma (UDOM) students, and to describe the social health care features of student female community. Two methods of malaria diagnostic, microscopy, and rapid test, as well as retrospective inspection of ANC registry book, showed the very low prevalence of malaria disease among pregnant students, approximately 0.3%. Additionally, the sociodemographic data from the questionnaires showed that all students use different malaria preventive measures, and most of them have the regular sexual partner. This fact approves the correlation between illiteracy of woman and the risk of malaria infection transmission.

Field Evaluation of Malaria Microscopy, Rapid Malaria Tests and Loop-Mediated Isothermal Amplification in a Rural Hospital in South Western Ethiopia

BackgroundIn up to one third of the hospitals in some rural areas of Africa, laboratory services in malaria diagnosis are limited to microscopy by thin film, as no capability to perform thick film exists (gold standard in terms of sensitivity for malaria diagnosis). A new rapid molecular malaria diagnostic test called Loop-mediated isothermal DNA amplification (LAMP) has been recently validated in clinical trials showing exceptional sensitivity and specificity features. It could be a reliable diagnostic tool to be implemented without special equipment or training.ObjectiveThe objective of this proof of concept study was to confirm the feasibility of using LAMP technique for diagnosis of malaria in a rural Ethiopian hospital with limited resources.Methodology/Principal FindingsThis study was carried out in Gambo General Hospital, West Arsi Province (Ethiopia), from November 1st to December 31st 2013. A total of 162 patients with a non-focal febrile syndrome were investigated. The diagnostic capability (sensitivity, specificity, positive predictive and negative predictive values) of rapid malaria tests and microscopy by thin film was evaluated in comparison with LAMP. Eleven (6.79%) out of the 162 patients with fever and suspected malaria, tested positive for LAMP, 3 (1.85%) for rapid malaria tests and none of the eleven cases was detected by thin film microscopy.Conclusions/SignificanceLAMP can be performed in basic rural laboratories without the need for specialized infrastructure and it may set a reliable tool for malaria control to detect a low level parasitemia.

Surveillance, health promotion and control of Chagas disease in the Amazon Region--Medical attention in the Brazilian Amazon Region: a proposal.

We refer to Oswaldo Cruz's reports dating from 1913 about the necessities of a healthcare system for the Brazilian Amazon Region and about the journey of Carlos Chagas to 27 locations in this region and the measures that would need to be adopted. We discuss the risks of endemicity of Chagas disease in the Amazon Region. We recommend that epidemiological surveillance of Chagas disease in the Brazilian Amazon Region and Pan-Amazon region should be implemented through continuous monitoring of the human population that lives in the area, their housing, the environment and the presence of triatomines. The monitoring should be performed with periodic seroepidemiological surveys, semi-annual visits to homes by health agents and the training of malaria microscopists and healthcare technicians to identify Trypanosoma cruzi from patients' samples and T. cruzi infection rates among the triatomines caught. We recommend health promotion and control of Chagas disease through public health policies, especially through sanitary education regarding the risk factors for Chagas disease. Finally, we propose a healthcare system through base hospitals, intermediate-level units in the areas of the Brazilian Amazon Region and air transportation, considering the distances to be covered for medical care.

Brucellosis serology as an alternative diagnostic test for patients with malaria-like symptoms

Background: In a low transmission zone for malaria, we explored the presence of brucellosis as an alternative diagnosis in febrile patients. Specifically, the objective of our study was to determine the proportion of patients presenting to the hospital with malaria-like febrile symptoms that were concurrently brucellosis sero-positive, and assess related risk factors.Methods: The study was done at the rural hospital in Endulen, in the Ngorongoro Conservation Area (NCA), Tanzania. Hospital patients were enrolled showing malaria-like febrile symptoms and were tested for malaria (microscopy) as well as brucellosis (agglutination test, plus commercial ELISAs for IgM and for IgG). Patient demographic characteristics and risk factors for brucellosis were determined using a questionnaire interview.Results: A total of 159 patients were enrolled, of which 57 were positive for malaria and 58 were positive by ELISA for brucellosis, with 54 (93%) of these brucellosis-positives solely positive for isotype IgG, 1 (1.7%) solely for isotype IgM, and 3 (5.2%) positive for both IgM and IgG. However, the brucellosis agglutination test was only positive in 9 of 159 samples. Co-infections of malaria and brucellosis occurred, but malaria disease status was not significantly correlated with brucellosis status. Patients serologically positive for brucellosis were more likely to have had contact with aborted animal materials (p=0.002).Conclusions: Brucellosis is a potentially missed diagnosis amongst pastoralists in rural Tanzania with malaria-like symptoms. However, concurrent and isotope-specific serology is integral to ensure detection and appropriate clinical management.

Provider compliance to artemisinin-based combination therapy at primary health care facilities in the middle belt of Ghana.

BackgroundIn 2004, Ghana implemented the artemisinin-based combination therapy (ACT) policy. Health worker (HW) adherence to the national malaria guidelines on case-management with ACT for children below 5 years of age and older patients presenting at health facilities (HF) for primary illness consultations was evaluated 5 years post-ACT policy change.MethodsCross-sectional surveys were conducted from 2010 to 2011 at HFs that provide curative care as part of outpatient activities in two districts located in the middle belt of Ghana to coincide with the periods of low and high malaria transmission seasons. A review of patient medical records, HW interviews, HF inventories and finger-pricked blood obtained for independent malaria microscopy were used to assess HW practices on malaria case-management.ResultsData from 130 HW interviews, 769 patient medical records at 20 HFs over 75 survey days were individually linked and evaluated. The majority of consultations were performed at health centres/clinics (68.3 %) by medical assistants (28.6 %) and nurse aids (23.5 %). About 68.4 % of HWs had received ACT-specific training and 51.9 %, supervisory visits in the preceding 6 months. Despite the availability of malaria diagnostic test at most HFs (94 %), only 39.8 % (241) out of 605 (78.7 %) patients who reported fever were investigated for malaria. Treatment with ACT in line with the guidelines was 66.7 %; higher in <5 children compared to patients ≥5 years old. Judged against reference microscopy, only 44.8 % (107/239) of ACT prescriptions that conformed to the guidelines were “truly malaria”. Multivariate logistic regression analysis showed that HW were significantly more likely to comply with the guidelines if treatment were by low cadre of health staff, were for children below 5 years of age, and malaria test was performed.ConclusionAlthough the majority of patients presenting with malaria received treatment according to the national malaria guidelines, there were widespread inappropriate treatment with ACT. Compliance with the guidelines on ACT use was low, 5 years post-ACT policy change. The Ghana NMCP needs to strengthen HW capacity on malaria case-management through regular training supported by effective laboratory quality control measures.

Performance assessment employing slide sets: A tool for the classification of senior microscopists from Colombia´s Malaria Control Program

One of the most important activities for quality assurance of malaria diagnosis is performance assessment. In Colombia, performance assessment of malaria microscopists has been done through the external performance assessment and indirect external performance assessment programs. To assess the performance of malaria microscopists of public reference laboratories using slide sets, and to describe the methodology used for this purpose. This was a retrospective study to evaluate the concordance of senior microscopists regarding parasite detection, species identification and parasite count based on the results of the assessment of competences using two sets, one comprising 40 slides, and another one with 17 slides. The concordance for parasite detection was 96.9% (95% CI: 96.0-97.5) and 88.7% (95% CI: 86.6-90.5) for species identification. The average percentage of concordant slides in the group evaluated was 89.7% (95% CI: 87.5-91.6). Most of the senior microscopists in Colombia were classified in the two top categories in the performance assessment using slide sets. The most common difficulty encountered was the identification of parasite species. The use of this tool to assess individual performance of microscopists in the evaluation of samples with different degrees of difficulty allows for characterizing the members of the malaria diagnosis network and strengthening the abilities of those who require it.

Malaria, anaemia and nutritional status among schoolchildren in relation to ecosystems, livelihoods and health systems in Kilosa District in central Tanzania.

BackgroundMalaria prevalence and transmission intensity in Tanzania is heterogeneous with spatial and temporal variations between geographical areas and ecological systems. The objective of this study was to determine the prevalence of malaria, anaemia and nutritional status in relation to livelihoods, ecosystem and health systems in Kilosa District in central Tanzania.MethodsThis study was conducted in four villages, two characterised by rice irrigation ecosystem and the other two by dry savannah ecosystem and pastoral livelihoods. In each ecosystem, one of the villages had a healthcare facility. Schoolchildren were screened for malaria infection using malaria rapid diagnostic test (mRDT) and microscopy and they were assessed for their anaemia and nutritional statuses.ResultsA total of 1,019 school children (age = 4–16 years) were screened for malaria infection. The overall prevalence of Plasmodium falciparum infection was 10.6 % and 4.5 % by mRDT and microscopy, respectively. Children from pastoral villages had lower (2.9 %) prevalence of malaria than their counterparts (18.2 %) in the rice irrigation villages. A significantly high risk of malaria was observed among children in rice irrigation than in the pastoral ecosystem (OR: 0.13; 95%CI 0.07, 0.23). Children living in areas with health care facilities had a low odd of malaria infection by 45 % (OR: 0.55; 95 % CI = 0.35, 0.86). Overall, the prevalence of anaemia in the district was 43.4 % (n = 775); and 58.3 % of those with severe anaemia were among children from the pastoral villages. Anaemia was significantly higher among children not using mosquito nets (p = 0.049); and among those with malaria infection (p <0.001). The majority (96 %) of the children had Body Mass Index less than 18.5 kg/m2 which indicate high proportion of underweight.ConclusionThere are significant variations in the risk of acquiring malaria infection between different ecosystems and livelihoods. These findings suggest that malaria control programmes must take into account ecosystems and livelihoods of the targeted population through an integrated management of malaria and nutrition approach.

A comprehensive assessment of the malaria microscopy system of Aceh, Indonesia, in preparation for malaria elimination.

BackgroundThe Health Office of Aceh aims to eliminate malaria from Aceh Province, Indonesia by 2015. Malaria was formerly common in Aceh (population 4.5 million), but has declined dramatically in recent years consequent to post-tsunami control efforts. Successful elimination will depend upon rapid and accurate diagnosis and case follow-up at community level. A prerequisite to this is widespread coverage of high quality malaria diagnosis. This study describes the results of a comprehensive assessment of the malaria diagnostic capacity in Aceh as the province moves towards malaria elimination.MethodsThe study was conducted in 23 districts in Aceh from October 2010 to July 2011. Six types of questionnaires were used to collect data on competency of microscopists and laboratory capacity. Standardized slides were used to evaluate the proficiency of all microscopists. In addition, site visits to 17 primary health centres (PHC) assessed diagnostic practice and logistics capacity.ResultsFive hundred and seventy four malaria microscopists have been officially registered and assigned to duty in the 23 districts in Aceh Province. They work in 345 laboratories, predominantly in PHCs (69 %) and hospitals (25 %). Three laboratories were evaluated as adequate for all 30 elements, while 29 laboratories were adequate for less than five of 30 elements. Standardized proficiency tests showed that 413 microscopists were at basic (in training) level, with 10 advanced and 9 reference level. No microscopist achieved expert level. Neither the province nor any of Aceh’s districts has a standardized inventory and logistics database for malaria diagnostics, nor did any of the surveyed laboratories operate a quality assurance programme for either microscopy or rapid diagnostic tests.ConclusionsThe study highlights the importance of careful assessment of diagnostic capacity when embarking upon a large-scale malaria elimination programme. Aceh’s laboratories have minimal infrastructure with nearly all microscopists still in training. On the positive side, a large workforce of microscopists has been assigned to laboratories with the needed equipment. Aceh will need to embark on a large-scale comprehensive quality assurance scheme if it is to achieve malaria elimination.

C-reactive protein in children with malaria in Luanda, Angola: a prospective study.

C-reactive protein (CRP) is an acute phase reactant of which little is known in malaria, especially in central Africa. In this prospective study CRP was measured in children with suspected malaria. Of 346 children, 234 had positive and 112 negative malaria microscopy. Their median CRP was 140 mg/L (IQR 88) vs 69 mg/L (IQR 129; p<0.001) respectively. CRP was positively correlated with parasitemia (p<0.001), and length of hospital stay (p=0.01), and negatively with thrombocyte count (p=0.01), and hemoglobin level (p=0.01). C-reactive protein increases in malaria and correlates with parasitemia and some manifestations of complicated disease.

Evidence-based malaria control in Timor Leste from 2006 to 2012.

BackgroundMalaria has been a major public health problem in the newly established Democratic Republic of Timor Leste with over 200,000 cases being reported in 2006 and 2007. The National Malaria Control Programme (NMCP) was established in 2003. The progress made in malaria control in Timor Leste is reported.MethodsRecords maintained at the NMCP, the district health services, the Health Information and Management System, the National Laboratory on malaria diagnosis and entomological data of the NMCP were reviewed.ResultsThere has been a 97% decrease in the reported malaria incidence from 2006 (223,002 cases) to 2012 (6,202 cases). 185,106 clinical cases reported in 2006 decreased to 2,016 in 2012 with introduction and expansion of malaria microscopy services and introduction of monovalent RDTs in 2008 and bivalent RDTs in 2010 in all parts of the country. The National Treatment Guidelines using ACT as the first-line treatment for Plasmodium falciparum infections and introduction of monovalent RDTs, led to a 42% and a 33% decrease from 2007 to 2008 in reported clinical and total malaria cases, respectively. LLINs were distributed initially to pregnant females and children under five and later per every two persons living in high-risk areas (based on microstratification at sub-district level). IRS was carried out in three districts in 2010 and extended to six districts in 2012. Anopheles barbirostris and Anopheles subpictus have been incriminated as malaria vectors. A National Laboratory, which routinely cross checks blood smears for quality assurance of microscopy was established. Malaria focal points at regional, district and sub district level, entomology surveillance staff, monitoring and evaluation officers, and quality control technicians were appointed to strengthen malaria control activities at all levels in the country.ConclusionThe 97% decrease in the incidence of malaria in Timor Leste is due to application of evidence-based malaria control methods that included enhancing improved quality surveillance, early diagnosis and prompt treatment of cases with effective anti-malarials, targeted vector control, human resource development and deployment, commitment of staff, GFATM funding and technical assistance from WHO.

External Quality Assessment of Malaria Microscopy in Hawassa Health Facilities, Southern Ethiopia

Background: Misinterpretation of malaria microscopy results can lead to inappropriate case management of malaria. The objective of this study was to assess the quality of malaria microscopy among health facilities in Hawassa city. A cross - sectional study was conducted to assess the quality of malaria microscopy diagnosis in Hawassa city health facility laboratories from November 2012 to January 2013 in Sothern Ethiopia. Validated panel malaria slides were distributed to health facilities accompanied with a questionnaire that assessed factors related to malaria microscopy improvement. Operational definitions for correct result and major and minor errors were outlined. A total of 51 laboratory professionals in 10 health facilities were surveyed with a response rate of 85%. Results were collected and data was analyzed by SPSS, and Win Pepi software. Result: Of 306 malaria slides examined in Sample 1-Sample 6 [S1-S6] only 54% of the examinations reported correctly. Considering major errors in [S1-S4], the most common errors were reporting negative for positive slide 39/83(47%), species identification error 29/83(35%) and density 15/83 (18%). In mixed Plasmodium falciparum/Plasmodium vivax (Pf/Pv) sample, only 18% of participants made correct diagnosis in identifying both Pf/Pv species. In Plasmodium negative sample 45(88.2%) of participants scored (no parasites observed) correctly. Considering S1-S4, 29 of the 165 densities reported were different from the reference density established for each slide. 53% of participants had never participated in a formal training on malaria microscopy, and among those who did, more than half were trained earlier than 2008. All of the participants reported to use tap water in preparation of working Giemsa solution. Conclusion: The present assessment revealed a poor quality of malaria microscopy in Hawassa city administration health facilities. Therefore, responsible bodies are required to improve quality of malaria microscopy, and also provide regular refreshment training for laboratory professionals in malaria microscopy. Further similar study should be conducted in large scale.

Assessment of competence of participants before and after 7-day intensive malaria microscopy training courses in Nigeria.

The accuracy of malaria diagnosis by microscopy has been a challenge in health facilities in Nigeria due to poor competence of microscopists and inability to report on malaria species other than Plasmodium falciparum. Short microscopy courses were conducted to improve the skills of laboratory personnel to perform malaria microscopy in public health facilities in Nigeria. Seven-day malaria microscopy courses were conducted annually between 2011 and 2013 for microscopists in public health facilities. The training courses contained theoretical and practical sessions. Impact of the training was evaluated by practical and theoretical pre- and post-training assessments on malaria slide reading, parasite enumeration and basic malariology. The 102 participants who completed the training consisted of medical laboratory scientists (62; 60.8%), medical laboratory technicians (24; 23.5%) and other healthcare workers (16; 15.7%). The knowledge of basic malariology (theory) at pre- and post-tests were 34% (95% CI 31.7-36.3%) and 74.9% (95% CI 71.8-78.0%), respectively (P<0.001). The mean slide reading detection, species and counting agreements in pre-training assessment were 48.9%, 27.9% and 0%, respectively, and in post-training 56.8%, 39.2% and 25%, respectively. The mean species agreements in picture test pre- and post-training were 21.9% and 55.1%, respectively. There were significant differences (P<0.05) in the median pre-test scores in picture tests and basic malariology of the three categories of participants but not in malaria slide reading and parasite counting tests. However, post-training, a significant difference in test scores of the three categories of participants was recorded only for basic malariology (P=0.0003). The 7-day malaria microscopy courses significantly increased the knowledge and microscopy skills of the trainees and were sufficient to bridge the significant difference in baseline microscopy skills of the different categories of trainees that participated in the training courses.