Tropical Health Matters

Noella Umulisa, Veneranda Umubyeyi, Tharcisse Munyaneza, Ruzindana Emmanuel, Aline Uwimana, Stephen Mutwiwa, and Aimable Mbituyumuremyi presented “Assessment of Competence of Participants Before and After 6-day Intensive Malaria Microscopy Training in Rwanda” at the 68th Annual Meeting of the American Society of Tropical Medicines and Hygiene. (Affiliations: Maternal and Child Survival Program/Jhpiego, Malaria and Other Parasitic Diseases Division [Mal & OPDD], National Reference Laboratory, Rwanda Biomedical Centre [RBC]). Their findings are shared below.

WHO recommends prompt malaria diagnosis either by microscopy or malaria rapid diagnostic test (RDT) in all patients with suspected malaria before treatment is administered. Light Microscopy remains the mainstay of malaria diagnosis, allows the identification of different malaria-causing parasites (P. falciparum, P. vivax, P. malariae and P. ovale). It is estimated that a diagnostic test with 95% sensitivity and 95% specificity requiring minimal infrastructure would avert more than 100,000 deaths and about 400 million unnecessary treatments. Frequent delays occur since conventional microscopy methods are labour intensive, require skilled manpower and time

Sufficient training of laboratory staff is paramount for the correct microscopy diagnosis of malaria. In Rwanda, P. falciparum is by far the most common contributing 97-99% of the parasite population, followed by P. ovale with 0.5-2% and followed by P. malariae 0.5–1% as mono-infection.

Rwanda has 8 referral hospitals, 4 provincial hospitals, 36 district hospitals, 504 health centers, 818 health posts and 30,000 CHWs able to perform malaria diagnostics. Each of these health facilities has a laboratory able to perform malaria microscopy with at least 1 trained lab technician and 1 functioning microscope.

In May 2018, the Rwanda Biomedical Center and partners trained 1 lab technician per health center from 6 poor performing districts in malaria microscopy. The main objective was to evaluate the performance of laboratory technicians in detecting and quantifying malaria parasites from 75 health facilities within 6 districts in Rwanda. Information was collected at two points in time.

In Month 1 there were a Pre-Test for Theoretical and practical evaluation, a Practical session, Slides preparation practice, and detection of parasite’s density and species. This was followed by the Post-Test, again a Theoretical and practical evaluation

In Month 4 Post training follow up was conducted with 35 randomly selected trained lab technicians after 4 months. Observation of technicians’ Conduct visual inspection and maneuvers used in routine malaria diagnosis was done. Their ability to Detect parasites on a standardized pre-validated slide panel of five slides was determined. during this 4 Months Post-Training Species Detection Performance, P. Falciparum was identified correctly more often than P. ovale or P. malariae.

The attached charts show the results of training. During the training 75 technicians from 75 health centers in 6 districts were trained from May 28th–June 18th, 2018. 53% of the trained lab technicians were female and 47% male.

Correct Parasite Density was slightly higher just after training. Classic training improved the performance of lab technicians in parasite’s density from 53% to 87% immediately after training.

After 4 months of training, P. falciparum and P. ovalae were correctly detected by 93% and 79% of lab technicians, respectively. Also, after 4 months of training, P. malariae was detected only by 68% of evaluated lab technicians. Training: Sensitivity (99%) and specificity (85%) remain high. Performance of lab technicians assessed using standardized pre-validated slide panel as gold standard after >4 months

Trainings of lab technicians improves performance on malaria parasites density and species detection. P. falciparum is the most well detected species followed by P. ovale . The detection rate for P. malariae was the lowest, this can be explained by the fact is not often seen in Rwanda. Participants had high sensitivity and specificity in the detection of malaria parasites.

Continuous capacity building for lab staff is needed to ensure accurate malaria laboratory diagnosis for appropriate treatment. Malaria microscopy diagnosis quality control/assurance activities from central and district level to health center level should be strengthen for continuous capacity building of lab technicians

Acknowledgements: This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID or the United States Government.

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