For many years after the launching of the Roll Back Malaria Partnership, the malaria community had been putting the cart before the horse.Â As malaria drug policy changed to artemisinin-based combination therapy (ACT) rolled across the African continent in the wake of resistance to chloroquine and sulphadoxine-pyrimethamine, basic diagnostic criteria at the front line clinics still relied on clinical diagnosis, often through well accepted algorithms.
Health workers of all stripes from physicians to clinic aids trusted in their clinical judgement and prescribed ACTs in nearly all cases of febrile illness. This was justified to some extent by the deadly nature of malaria in small children.
Eventually two issues called into question the validity of algorithms and clinical judgement if malaria were to be eliminated.Â First, if we actually went to scale in providing malaria treatment for all suspected cases of malaria, we might never find adequate funding to buy all the needed ACTs, which cost upwards to 10 times that ofÂ the predecessors.
Secondly, if we were ever to gain a true picture of the malaria situation as interventions were scaled up and prevalence decreased, we could no longer base our health information systems on clinical or suspected cases.
Rapid diagnostic tests (RDTs) were a long time in coming and in many places have still not reached the front lines. Even when RDTs become available, they have not always been used correctly.Â Just last year we assessed RDT implementation in Burkina Faso, for example, and found most cases of paludism simple (uncomplicated malaria) were treated with ACTs without testing. The only encouraging note was that following the national sick child algorithm, cases with fever ANCDcough were treated as acute respiratory illness.
Cascade training had been rolled out to teach health workers in Burkina Faso to use RDTs, but nearly expired unused RDT stocks were found in their clinics.Â Not all RDTs were stored properly to protect against high tempaerature and humidity.
Even when RDTs were used, the existing clinic records systems did not provide a clear space to record RDT results. Some health workers were creative and addre red RDT+ and RDT- notations in their registers where space allowed.Â Findings of this assessment are being used to improve training.
Now comes an encouraging study from Tanzania that shows health workers not only can learn to use RDTs correctly. The researchers also foundÂ reductions of ACT use in lower transmission areas where previously clinical judgement had resulted in high proportions of febrile patients receiving ACTs.
The Tanzania experience shows the neet for both clear government policies supporting RDT use and well supervised dissemination of these policies out to the front line clinic. Both Rwanda and Mozambique have shown that RDTs can even be effectively used beyond the clinic walls by community health workers.Â Accurate diagnosis is a key step in th elimination of malaria.