What are we to presume in the era of ACTs?

presumptive-or-diagnostic.jpgThe potential demise of presumptive treatment for malaria was the topic of a ‘Controversies’ session at the 5th MIM Pan-African Malaria Conference on Monday.  One view was expressed by Ambrose Talisuna from Uganda Ministry of Health that as we move into the phases of sustained control toward elimination, there will be a greater need for parasitological diagnosis of malaria and more rational provision of ACTs.  Since the process of policy formulation to full implementation may take 2-4 years, Ambrose Talisuna thought it would not hurt to get started on efforts to update malaria treatment guidelines to emphasize a parasitological diagnostic component as a requirement for prescribing ACTs

Another perspective expressed by Mike English from Kenya Medical Research Institute was that it may be very difficult to change case management norms away from presumptive treatment until we can increase the confidence of clinicians in parasitological diagnostic methods by guaranteeing quality. Also there is concern that at least half of children in endemic areas live in high burden countries where presumptive treatment is still be a rational choice.

An interesting viewpoint came from Franco Pagnoni from TDR who said all treatment is presumptive. Even with parasitological diagnosis there are presumptions based on perceived quality of the diagnostic procedures and their interpretation.

There was a general sense that some Rapid Diagnostic Tests are clearly effective under research conditions, but have not been thoroughly tested in real life clinical conditions.  Another RDT challenge includes the general procurement and supply management difficulties facing all malaria commodities. There are cost issues too – will AMFm or a similar effort guarantee affordable malaria tests?  Another challenge of malaria treatment is the private sector, especially the informal component, and the community/home – how far will RDTs be distributed, and how can quality be maintained under such conditions?

As with all our efforts to move toward elimination we must recognize that different countries and different regions within countries are at different epidemiological stages.  We need development of flexible and appropriate case management and diagnostic guidelines. These must be disseminated in a way that builds diagnostic capacity at all levels – from the research lab to the community – with back-up to ensure 1) RDT and microscopy quality and 2) training that builds clinicians’ and treatment providers’ confidence in the tests and their own ability to use the tests correctly.

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