Doctors relying on guesswork to treat Malaria

One million doses of medication are wasted in Cameroon ever year on patients who do not need them simply because doctors assume every fever is due to malaria

Millions of patients are being put on medication they do not need because the vast majority of doctors are assigning malaria to patients who do not have it, according to a leading public health researcher. The widespread practice is leaving patients with poorly treated fevers, wasting billions worth of badly needed doses of medicines and increasing the risk of malaria drug resistance, said Wilfred Mbacham, associate professor of public health biotechnology at the University of Yaounde I, on Monday.

Malaria is a leading cause of death in the country.

Children under five are among the most likely to die from malaria Children under five are among the most likely to die from malaria More than eight in ten licensed physicians around the country are guilty of the phenomenon known as malaria over-diagnosis. Less than three in ten people who came to hospital with a fever actually have malaria; the rest do not but are often treated for malaria, Mbacham said.

Doctors are getting things wrong because they systematically rely on guesswork in spite of the availability of reliable testing equipment and kits, Mbacham said.

“[All] facilities we diagnosed had functional microscopy, which means they could have done the diagnosis but they did not,” Mbacham said.

Doctors are also ignoring rapid diagnostics tests (RDTs), which can allow them properly confirm malaria from behind their desk in the absence of complex laboratory investigations.

Part of the problem is poor training – doctors are stuck with an old WHO prescription that required fevers in developing countries to be presumed malarial before anything else.

Up to one million doses of malarial treatment – worth about CFA5 billion – would be saved annually if doctors gave malarial drugs only to people suffering from malaria, Mbacham said.

View or download visualization of Malaria in Cameroon

Mbacham led a study that tried to assess the difference the use of rapid diagnostic tests can make when combined with basic and enhanced clinical training.

In a paper published in The Lancet Global Health, Mbacham and his team showed that training could significantly reduce the problem and cut back on the waste.

The study compared patients leaving three groups of physicians – those that had received basic training, those that had received a more robust training and those conducting business as usual.

Fully trained physicians were less likely to give patients malaria treatment they did not need, followed by those with basic training and then those with no training at all. Overall, the study concluded that comprehensive training halved the number of patients getting malaria treatment that they did not need.

“Rapid diagnostics tests are new technologies that can greatly assist nurses and doctors in making life-saving decisions at point of care,” Mbacham said.

“Rather than do passive training in the use of RDTs, building confidence and providing communication training are key to accept a negative test for a patient with fever and to use other treatment options.

“We reached this result through repeated consultations with the National Malaria Control Programme.

“Governments need to minimally invest in building up the critical mass of health workers who prescribe appropriately, which requires a curriculum change in medical schools.”

The study was conducted for the Artemisinin-based Cambination Therepy Consortium based at the London School of Hygiene and Tropical Medicine.

“If we are serious about improving the targeting of malaria medicines by using RDTs, then there needs to be a far greater focus on behaviour change,” said Dr Virginia Wiseman of the London School of Hygiene & Tropical Medicine.

“This study, the first of its kind in Cameroon, highlights that health workers not only need training to diagnose and treat malaria, but most of all need the confidence to put what they learn into practice and to communicate more effectively with patients about why they are tested and that fever is not always caused by malaria.

“Our results suggest that a good training programme designed to translate knowledge into practice could dramatically reduce overdiagnosis of malaria in Cameroon and prevent the wastage of valuable medicines.”

“This study shows that rapid diagnostic tests can take the guesswork out of diagnosis, which can improve the targeting of malaria treatment to those who really need it,” said

“We recognise that this is one study carried out in one setting, in one country, but it helps us to maximise the value of RDTs in different contexts such as the private sector or other countries.

“It also draws attention to the importance of understanding the non-malarial causes of fever. For example, meningitis or pneumonia are life-threatening infections and require referral and additional treatment.”

By Eugene N Nforngwa