MALARIA: PATIENTS, DOCTORS TELL TALES OF CONFUSION IN DIAGNOSIS AND TREATMENT

Malaria: Patients, doctors tell tales of confusion in diagnosis and treatment

The World Health Organisation's recent recommendation that emphasises evidence-based treatment of malaria brings to the fore confusion associated with the management of the disease in Nigeria, NIYI ODEBODE writes.

For two months, Olawale Idowu battled with an illness

he thought was malaria fever. Although he was treated for the ailment at a private clinic at Ipaja, a suburb of Lagos, where he lives, the illness kept recurring.

At a point, he thought he had contacted a more serious disease. When the illness persisted, Idowu went to the Lagos State University Teaching Hospital, Ikeja, where he was tested and was discovered to be suffering from typhoid.

Idowu said, 'I was treated in the private hospital based on my complaints. I actually told those who treated me that I had malaria because I felt feverish. The prescriptions I was given were based on my complaints. I was surprised when I was told at LASUTH that I had typhoid. I could not go to work for a month. I was receiving treatment in the hospital. '

According to the 35-year-old businessman, he rarely goes to hospital to treat malaria. 'What I do is to buy drugs near my house. I went to the private hospital after a malaria drug that I bought from a patent medicine vendor did not work,' he said.

Another Lagos resident, Elizabeth Kolawole, who resides in Mushin, said that although initially, he did not go to any hospital, a patent medicine vendor recommended a malaria drug for him when he was feeling feverish. 'It was later I learnt after I was suffering from typhoid after being tested in a private hospital,' she said.

Idowu and Kolawole are not the only people with this predicament. John Ike, also a resident of Lagos, bought a drug, which the patent medicine vendor, near his house claimed to be an antemisinin-based combination. Ike said that the malaria persisted despite using the drug.

He disclosed that he went to LASUTH, where he was given an antemisinin-combination therapy after testing positive for malaria. 'I was advised to adhere to the dosage of the ACT,' Idowu said.

Idowu and Ike's cases typify experiences of many people in Nigeria, where malaria is a common ailment. It accounts for 25 per cent of under-five mortality and 11 per cent of maternal deaths in the country. According to the Federal Ministry of Health, malaria is responsible for 60 per cent of outpatients' visits in the country. About N32bn is lost yearly to the treatment costs, prevention and loss of man's hours.

But in spite of the high prevalent rate of malaria, its diagnosis and treatment are still being trailed by confusion. This confusion was again brought to the fore by the new guidelines on the disease issued by the World Health Organisation last month.

The new guidelines placed emphasis on testing before treatment. They were also aimed at ensuring access to safe and efficacious anti-malaria medicines.

The WHO stated, 'The guidelines for the treatment of malaria (second edition) provide evidence-based and current recommendations for countries on malaria diagnosis and treatment. The main changes from the first edition of the guidelines (published in 2006) are the emphasis on testing before treating and the addition of a new artemisinin-based combination therapy to the list of recommended treatments.'

The Director of the WHO Global Malaria, Dr. Robert Newman, said, 'The world now has the means to rapidly diagnose malaria and treat it effectively.

'The WHO now recommends diagnostic testing in all cases of suspected malaria. Treatment based on clinical symptoms alone should be reserved for settings where diagnostic tests are not available.'

The world body explained that the development of quality-assured rapid diagnostic tests using a dip stick and a drop of blood necessitated a policy change. It noted that in 2008, only 28 per cent of suspected malaria cases were tested in 18 of 35 African countries.

According to the WHO, 'The move towards universal diagnostic testing of malaria is a critical step forward in the fight against malaria as it will allow for the targeted use of ACTs for those who actually have malaria.

'The aim is to reduce the emergence and spread of drug resistance and to help identify patients who have fever, but do not have malaria, so that alternative diagnoses can be made and appropriate treatment provided. Therefore, better management of malaria has a positive impact on management of other childhood illness and overall child survival.'

It said that it was supporting malaria endemic countries to improve the quality of their diagnostic services, using both microscopes. It also urged the manufacturers of RDTs to continue improving the accuracy and quality of these critically important diagnostic tests.

According to the WHO, 'Countries need to ensure that patients are diagnosed properly and take the full dose of ACTs to prevent the development of drug resistance,' it said.

The WHO explained that guidelines on procurement practices for artemisinin-based antimalarial medicines were based on the newest stringent internationally agreed production and procurement quality standards.

'Pharmaceutical markets in malaria endemic countries are often unregulated and national authorities need practical help to assess the quality of malaria medicines before they buy them,' said the Coordinator of the Medicines and Diagnostics Unit, Dr. Andrea Bosman.

He noted, 'Procurement channels are highly fragmented and so there are too many antimalarials of varying quality in the market.'

The WHO said that poor-quality medicines affected the health and lives of patients and damaged the credibility of health services. It added that by generating sub-therapeutic drug levels in malaria patients, poor medicines helped develop resistance.

The Malaria Programme Manager at the WHO Regional Office for Africa in Brazzaville, Dr George Ki-Zerbo, said, 'These guidelines will help countries select and procure effective medicines of good quality and save lives by improving the way patients are diagnosed and treated.'

The WHO's policies and recommendation of ACTs are not alien to Nigeria. In 2005, in line with the recommendation of the world body, the Federal Government banned the use of Chloroquine as first line drug in the treatment of malaria. The government recommended ACTs.

But in spite of this ban, some doctors still prescribe choloroquine for their patients. Besides, malaria is still characterised by blind treatment as many patients are not tested before prescriptions are given as shown in Idowu's experience.

Although some secondary and tertiary hospitals test suspected cases of malaria, such diagnoses are usually not rapid and doctors often commence treatment before results are out. The tool that is commonly used now are microscopes, which are used to detect plasmodium falciparaum in the blood of the patients.

The Secretary-General of the Nigerian Medical Association, Dr. Kenneth Okoro, said that before the WHO's guidelines, which emphasised evidence-based treatment were issued, doctors in Nigeria used to give palliative treatment before the laboratory results were ready.

He stated that such initial treatments were aimed at bringing the temperature of the patient down, before the laboratory results were obtained.

When banning Chloroquine in 2005, the former Minister of Health, Prof. Eyitayo Lambo, said, ''Evidences have shown that the first line drug, which is Chloroquine has lost its efficacy due to the emergence of chloroquine-resistant strains of Plasmodium falciparum. This trend was noticed in 1987 in the southeastern part of the country.'

But contrary to the recommendation of the WHO and the Federal Government, some doctors said that they still prescribed chloroquine and claimed that it was potent.

Okoro, the NMA secretary-general, said that many Nigerians were fond of taking sub-optimal dosage of ACTs. This, he said, might have resulted in the observation that the malaria parasite had developed resistance to even ACTs.

But the Vice-Chairman of the Lagos State branch of the NMA, Dr. Ibrahim Olaifa, doubted whether the ban was evidence-based.

He said, 'My personal experience as a physician is different from the picture that is being painted for the public. I have seen people that are parasite positive after taking ACT the way it should be taken. You give them Chloroquine, they get cured.

'The position of the WHO and the Federal Government is that ACT should be the first line drug for the treatment of malaria. That is not my experience. Chloroquine is still very relevant in the management of malaria in this country.

'The new position was borne out of politics and business. It was not evidence-based. I have not come across a study that shows that ACT is better than chloroquine. There is no point adopting something because other countries have adopted it. We are not putting enough efforts in research.'

Commenting on the rapid diagnostic test kits recommended by the WHO, Olaifa, said, 'It is a rational way of doing things. There are so many things that can cause fever - typhoid, pneumonia and urinary tract infections. It is good to test so that one will not be treating something else with an anti-malaria drug.

'But it is not all cases that you have the luxury of investigating before treatment, particularly in rural areas or urban areas where you have a large number of patients. The rapid diagnostic test kits are not yet available in the country.'

Also, the NMA national secretary-general agreed that the kits were not available in many hospitals. 'If you do a survey, you will see that even only a few tertiary hospitals have them. They are inadequate where they are available.'

Okoro stated that the use of the kits could develop problems because of the epileptic power supply in the country. 'Reagents are supposed to be stored at a temperature. In Nigeria, where power is not stable, the chemicals can lose their potency, thus leading to false positive results ( testing positive for people that do not have the parasite ) or false negative results (testing negative for people that have the parasite).'

He said that the country must guard against importation of expired test kits. 'Like we have fake drugs, Nigerians can cash in on the demand for the kits to bring in counterfeits,' he said.

The National President of the Pharmaceutical Society of Nigeria, Mr. Azubike Okwor, said that the confusion on the effectiveness of malaria drugs was not surprising.

He stated, 'We have problems with the use of drugs in this country. We also have problems with channels of drug distribution and storage. We have problems with power, which would have helped in storing drugs very well.'

Okwor explained that non-adherence to dosage could make the malaria parasite to develop resistance to ACTs. 'Many people cannot afford complete dosage. Even when they can afford it, they do not adhere to it. Once they get well, they think they do not need the drug again, but there is a difference between getting well and getting cured.'

The PSN president noted that many Nigerians got their malaria drugs from unprofessional sources, including unregistered patent medicine vendors, who were described as the largest sources of drugs in a study conducted by the Future Health System Research Consortium, Department of Health Promotion and Education, College of Medicine, University of Ibadan.

Commenting on the test kits, the immediate-past president of the PSN, Mr. Anthony Akhiemien, said, 'The evidence-based treatment is the ideal thing but in an environment where there is paucity of professionals, it is a challenge.'

Also, the incumbent Vice-President of the association, Mr. Olumide Akintayo, said that once the kits were available, people could go to recognised laboratories for tests.

Explaining government's policy, the Coordinator of the National Malaria Control Programme, Dr. Folake Ademola-Majekodunmi, said that the programme emphasised parasitological diagnosis of malaria particularly in children above five years of age and adults.

She assured Nigerians that the rapid diagnostic test kits would be provided through the assistance of two international partners, the Global Fund and the World Bank.

On the efforts of government to encourage evidence-based treatment, Majekodumi said, 'NMCP has planned massive printing and distribution of the national malaria treatment policy which emphasises case treatment and diagnosis. This is in addition to behavioural change. There is a plan to increase awareness on diagnosis before treatment.

'In the plan, microscopes distribution has been limited to both tertiary and secondary facilities while rapid diagnostic test kits have been planned for deployment through the primary facilities. Only 10 per cent of the kits go to secondary and tertiary facilities for minimal operation research and use.'

From the confusion associated with the treatment of malaria in Nigeria, it is clear that there is a need for more studies on the disease. Justifying the need for such studies, the PSN national president, said, 'Why it is important to align this country's treatment of malaria with that of the WHO, we need to do more studies. We need more studies about the effectiveness of chloroquine which the WHO is saying we should not use again. You should find out what is happening to ACTs because other countries are reporting effectiveness in the use of ACT. Why are we getting different results? '