Experience of introducing RDTs and

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• Experience of introducing RDTs and
• Quality Assurance of Malaria Microscopy in
  Somalia
• SIXTH INTERCOUNTRY MEETING OF
• NATIONAL MALARIA PROGRAMME MANAGERES
• CAIRO, EGYPT
• 3-6 July 2006
• Dr. Waqar A. Butt
  
  
  
  RBM Coordinator
  
  
  
  WHO Somalia

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Malaria Control Programme in Somalia

• Introduction
• Malaria Microscopy Vs RDTs
• Malaria Case Diagnosis
• RBM progress
• Challenges
• Future plans

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Introduction

• Malaria Microscopy Vs RDTs
• Prompt and accurate Diagnosis Key to effective
  disease management, one of the main intervention
  of Global malaria control strategy
• Poor diagnosis continues to hinder
• a) Non-specific clinical presentation
• b) High prevalence of asymptomatic infection
• c) Lack of resources and insufficient
  access to trained health care providers and
  health facilities
• 2. Major contributing factor that laboratory
  diagnosis of malaria has relied on microscopy
  performed correctly but unreliable and wasteful-
  poorly executed.

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Malaria Microscopy Vs RDTs

• In Somalia Context.
• gt60 of population visits private sector
• gt 70 positive malaria diagnosis is based on
  fever cases
• Over diagnosis is very common in private sector
• Microscopes and reagents are not standardized
  (WHO standard)
• Community concepts on malaria (fever means
  malaria)
• Self medication very common and under dosage
  (developed resistance to CQ)
• Un- trained staff in malaria microscopy. (private
  )
• No Government regulation and control

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Malaria Microscopy Vs RDTs

• Malaria case Diagnosis
• Malaria Microscopy Gold standard if executed
  efficiently
• Rapid Diagnostic test (RDTs) New tool
• - a valid alternative or,
• - Complement to microscopy

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Malaria Microscopy Vs RDTs

• Advantages of Microscopy
• Sensitive detect densities as low as 5 10
  parasite per ul of blood
• Informative Characterize species (Pf, Pv, Pm,
  Po) and stages (trophozoites, schizonts and
  gametocytes)
• Parasite density quantified hyper-parasitaemia
• Parasitological response to chemotherapy
• Relatively inexpensive (cost in endemic
  countries range US 0.14 -0.40 per slide examined
• General diagnostic technique ---shared with other
  disease control programe (TB, HIV/AIDs)

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Malaria Microscopy Vs RDTs

• Disadvantages
• Labour-intensive and time consuming (Specimen to
  result 60 minutes)
• Depends absolutely on good technique, reagents,
  microscopes and well trained and well supervised
  technicians (peripheral level)
• Often long delays in result to clinician
  treatment often without benefit of the result

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Malaria Microscopy Vs RDTs

• Advantages of RDTs
• Simpler to perform and to interpret
• Not required special equipment and electriciry
• Peripheral health workers and volunteers trained
  in hours
• Can detect Pf infection even when the parasite
  sequestered in deep vascular compartment

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Malaria Microscopy Vs RDTs

• Disadvantages of RDTs
• HRP II can detect only Pf
• HRP II can give positive result 2 weeks and
  parasite clearance as confirmed by Microscopy
• RDTs are more expensive than microscopy
• RDTs are not quantitative- investigation of
  therapeutic efficacy of anti-malarial drug

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Malaria Microscopy Vs RDTs

• Special Situations RDTs
• Complex emergencies
• - Non-immune population migration to endemic
  areas, environmental changes, malnutrition.
• Malaria epidemics
• Malaria in returning travelers

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Malaria Microscopy Vs RDTs

• RBM progress
• With support of GFATM new interim anti-malarial
  treatment policy introduced in Somalia 2006
• ACTs (ASSP) first line treatment with
  RDTs/Microscopy positive cases.
• If RDTs ve ACTs will be given (1st dose at DOTS)
• Initial stage of interim policy RDTs and
  Microscopy (both in hospital)

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Malaria Microscopy Vs RDTs

• In Somalia
• RDTs procured by UNICEF with ACTs, distributed to
  partners implementing programe
• Difficulty in distributing (PCA to be signed b/w
  UNICEF and partners .
• Acceptance by the community especially in
  Hospital they prefer Microscopy than RDTs
• Community awareness on RDTs
• Training of health staff completed in all zones
  will be evaluated after 3months
• Recent focal out break all RDT positive cases not
  positive on Malaria microscopy (treatment taken)
• RDT tally sheet and ACT tally sheet to all H/F

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Malaria Microscopy Vs RDTs

• Quality assurance of Microscopy.
• Trained Hospital and health facility Lab
  technicians in malaria microscopy but Positive
  and negative slides are not kept for QC/QA
• Transportation of slides difficult from the
  periphery to centre. (Funding)
• Introduce in NWZ as a pilot programme of QA by
  visiting the HF by WHO Laboratory Focal point
• 60 laboratories with malaria microscopy
  established
• Three reference laboratories established

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Malaria Microscopy Vs RDTs

• Challeges
• Sustainability after GF ????
• Logistic difficulty due to un-certainty in
  security situation
• High temperature, transportation, storage,
  humidity
• Private sector involvement ????

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Malaria Microscopy Vs RDTs

• Challenges

• Poor/ lack of communication to the sentinel
  sites
• Lack of motivation in some SS in terms of
• payment of the staff (Intensive)
• Lack of standard register for recording the
  malaria
• microscopy results
• To maintain good quality of blood smears
  examination in
• recently established peripheral laboratories
  (60)
• Training of private sector technicians ??

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Malaria Microscopy Vs RDTs

• Future Plan
• Strengthen Quality control and quality assurance
  for Microscopy and RDTs.
• Supervision of peripheral laboratories and on
  job training
• Resource mobilization for sustainability
  (Funding)
• Operational research on RDTs /Microscopy

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Thank You