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doi: 10.1186/1475-2875-7-232.

Overuse of artemisinin-combination therapy in Mto wa Mbu (river of mosquitoes), an area misinterpreted as high endemic for malaria

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Overuse of artemisinin-combination therapy in Mto wa Mbu (river of mosquitoes), an area misinterpreted as high endemic for malaria

Charles Mwanziva et al. Malar J..

Abstract

Background: Adequate malaria diagnosis and treatment remain major difficulties in rural sub-Saharan Africa. These issues deserve renewed attention in the light of first-line treatment with expensive artemisinin-combination therapy (ACT) and changing patterns of transmission intensity. This study describes diagnostic and treatment practices in Mto wa Mbu, an area that used to be hyperendemic for malaria, but where no recent assessments of transmission intensity have been conducted.

Methods: Retrospective and prospective data were collected from the two major village health clinics. The diagnosis in prospectively collected data was confirmed by microscopy. The level of transmission intensity was determined by entomological assessment and by estimating sero-conversion rates using anti-malarial antibody responses.

Results: Malaria transmission intensity by serological assessment was equivalent to < 1 infectious bites per person per year. Despite low transmission intensity, > 40% of outpatients attending the clinics in 2006-2007 were diagnosed with malaria. Prospective data demonstrated a very high overdiagnosis of malaria. Microscopy was unreliable with < 1% of slides regarded as malaria parasite-positive by clinic microscopists being confirmed by trained research microscopists. In addition, many 'slide negatives' received anti-malarial treatment. As a result, 99.6% (248/249) of the individuals who were treated with ACT were in fact free of malaria parasites.

Conclusion: Transmission intensity has dropped considerably in the area of Mto wa Mbu. Despite this, most fevers are still regarded and treated as malaria, thereby ignoring true causes of febrile illness and over-prescribing ACT. The discrepancy between the perceived and actual level of transmission intensity may be present in many areas in sub-Saharan Africa and calls for greater efforts in defining levels of transmission on a local scale to help rational drug-prescribing behaviour.

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Figures

Figure 1
Figure 1
Rainfall distribution and number of outpatient visits diagnosed with malaria. Bars indicate the number of clinically diagnosed malaria patients younger than five years of age (closed bars) or ≥ 5 years of age (open bars) in the KKKT and RCHF clinics combined in the period January 2006 – November 2007. The dashed line indicates the total monthly rainfall in mm/month measured at the nearby Lake Manyara National Park.
Figure 2
Figure 2
Management of individuals with suspected malaria at the KKKT clinic. Clinic slide = slide stained and read by clinic microscopist; research slide = slide stained and read by trained research microscopist; RDT = rapid diagnostic test
Figure 3
Figure 3
Management of individuals with suspected malaria the RCHF clinic. Clinic slide = slide stained and read by clinic microscopist; research slide = slide stained and read by trained research microscopist; RDT = rapid diagnostic test
Figure 4
Figure 4
Age specific seroprevalence plot of anti-MSP-119antibodies. The vertical axis shows the proportion of seropositive individuals in each age group, the horizontal axis shows the midpoint age of each age group. Filled triangles represent the raw data; the lines represent the fitted equation with parameters λ = 0.026 and ρ = 0.026 and the 95% confidence interval.
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