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Thanks so much for your comment – it is always great hearing from people working in the field and facing the challenges of malaria prevention and treatment every day!

Certainly your story sounds like a familiar one – as you read in the article, my student Kelly also found extraordinarily (and suspiciously) high diagnosis of malaria at the local clinics. It’s great that you are double checking diagnosis from Dar, but I can understand your concerns that your patients are nevertheless in the meantime being pumped full of antimalarial drugs, regardless of whether they need them or not. RDTs are certainly a good way around this, but they do vary significantly in terms of specificity as well as sensitivity. Which brand/type are you using? The World Health Organisation has a great fact sheet about commercially available RDTs, which gives figures for detection probability of both Pf and Pv malaria (unfortunately they don’t seem to have compiled the same data for Pm or Po). So, for example, the ICT combo cassette that Kelly was using in Mang’ula has a decent (85%) probability of detecting 200 parasites per microlitre of blood for P. falciparum infections, but a much much lower probability (<10%) for detecting the same concentration of P. vivax. In Uganda, I worked with the SD combo tests, which have 90% accuracy for both parasites. So, it is worth checking the technical specs of the tests you have, as well as through the literature for studies which have used your test in field settings. The sensitivity and specificity measures should give you a good indication of how much to trust your RDT results (provided you are keeping the buffers at the appropriate temperature, using them correctly, and all those other usual caveats!). One thing specifically to bear in mind is that if you have an RDT that only tests for Pf but you have noticeable levels of Pv/other types of malaria in your area, the RDT won’t pick it up but a blood film should. Given that more and more evidence is accumulating to show the importance of non-Pf malaria in sub-Saharan (and particularly East) Africa, it might be worth trying to get your hands on some Pf/non-Pf combo tests to see if that might explain some of the disparity between negative RDT results and clinical suggestions of malaria.

Overall, you are completely right that overtreating can lead to an increase in resistance to malaria drugs; also of concern is that many people with general fever/chills/nausea symptoms are getting treated for malaria when in reality they might have another condition, requiring separate treatment. In particular, I am worried about the outbreaks of dengue which have been on the rise in Tanzania, and that particularly first time infections (i.e. in expats) will be mistaken for malaria. It will be very hard to change the clinics’ attitudes toward diagnosis, but something does have to be done. On a short-term scale, one option for you might be to remove the incentive for the clinics to diagnose your workers with malaria, for example by telling them you will be purchasing the drugs elsewhere, and not through the clinic or its local pharmacy. Longer term, the government is going to have to make efforts to ensure its clinic personnel are properly trained in microscopy and aware of the importance of accurately diagnosing malaria. Introducing RDTs alongside blood films has started in some places, which may go some way towards addressing the diagnostic balance.

- C

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Rgds
Colin

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Thank you SO much for your post. I hear a lot of stories about people who struggled for years with mysterious symptoms before finally being diagnosed with Lyme’s disease or other blood-borne parasites. As you say, diagnosis is notoriously inaccurate and treatment regimes can be tough – in developing countries in particular, where health infrastructure isn’t good, it can be very easy for clinics and hospitals to assume someone has malaria, give them treatment, and send them on their way, whereas in fact the person is suffering from something else.

In terms of the specifics of your case, were you tested for malaria in India and not found positive, or never tested? There are some very interesting possibilities for research into the dynamics and effects of co-infections of diseases like malaria and Babesia, since, as you say, they are related and both utilise blood as a habitat. I don’t know how much is known about the symptoms of such co-infections, or what the implications for treatment efficacy might be, but it could be worth talking to your doc about this. Another thing to discuss could be possibility of residual malaria infection from your time in India (such as Plasmodium vivax or Plasmodium ovale, which have dormant liver forms) being implicated in your liver’s failure to tolerate your current drug regimen. Since you are G6DP negative, you could be a candidate for primaquine, which is the drug used to kill those dormant liver stages.

Hope that helps, and thank you so much for sharing your story on http://www.malaria.com. I really believe that comments like yours are crucial in raising awareness about rarer blood-borne diseases like Lyme’s and Babesia to people who are suffering from symptoms that are proving difficult to diagnose.

- Claire

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Thanks for your question. Your diagnosis is indicative of a low level malaria infection – what is slightly confusing is that the count is given per number of WBC, which usually stands for white blood cells. If anything, the count should be presented as per number of red blood cells, since these are the cells that are infected by the malaria parasite. More usually, the count is given per microlitre of blood examined. Artequin is a combination therapy consisting of mefloquine and artemisinin, and so is suitable for treatment of all types of malaria. The full course of medication should completely cure the infection, as there is no evidence yet for resistance against this drug in Africa. However, if you want, you could revisit the clinic for another blood test to be sure that there is no trace of the malaria parasite left in your blood (i.e. you are completely cured). If you continue to experience fever and other symptoms, you should ask your doctor for advice on other infections – my experience in some parts of Tanzania is that diagnosis of malaria is sometimes given even when it is not accurate, and other methods of diagnosis show that the patient does not have malaria. I suspect this has happened to your friend, since it is rare to be positive for malaria using microscopy and not experience symptoms (unless your friend grew up in a highly malarial area and experienced many malaria infections in childhood – in this case he might be able to tolerate low levels of malaria without symptoms). Another method of diagnosis you might want to try are self-testing rapid diagnostic kits (RDT), which you should be able to buy either from the clinic or a pharmacy. Using this RDT, you can test yourself at home for malaria, and the test is more sensitive and accurate than the blood microscopy done in most clinics.

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