Malaria misdiagnosis in Uganda – implications for policy change
Open accessAbstract
BACKGROUND: In Uganda, like in many other countries traditionally viewed as harbouring very high malaria transmission, the norm has been to recommend that febrile episodes are diagnosed as malaria. In this study, the policy implications of such recommendations are revisited. METHODS: A cross-sectional survey was undertaken at outpatient departments of all health facilities in four Ugandan districts. The routine diagnostic practices were assessed for all patients during exit interviews and a research slide was obtained for later reading. Primary outcome measures were the accuracy of national recommendations and routine malaria diagnosis in comparison with the study definition of malaria (any parasitaemia on expert slide examination in patient with fever) stratified by age and intensity of malaria transmission. Secondary outcome measures were the use, interpretation and accuracy of routine malaria microscopy. RESULTS: 1,763 consultations undertaken by 233 health workers at 188 facilities were evaluated. The prevalence of malaria was 24.2% and ranged between 13.9% in patients >or=5 years in medium-to-high transmission areas to 50.5% for children <5 years in very high transmission areas. Overall, the sensitivity and negative predictive value (NPV) of routine malaria diagnosis were high (89.7% and 91.6% respectively) while the specificity and positive predictive value (PPV) were low (35.6% and 30.8% respectively). However, malaria was under-diagnosed in 39.9% of children less than five years of age in the very high transmission area. At 48 facilities with functional microscopy, the use of malaria slide examination was low (34.5%) without significant differences between age groups, or between patients for whom microscopy is recommended or not. 96.2% of patients with a routine positive slide result were treated for malaria but also 47.6% with a negative result. CONCLUSION: Current recommendations and associated clinical practices result in massive malaria over-diagnosis across all age groups and transmission areas in Uganda. Yet, under-diagnosis is also common in children <5 years. The potential benefits of malaria microscopy are not realized. To address malaria misdiagnosis, Uganda's policy shift from presumptive to parasitological diagnosis should encompass introduction of malaria rapid diagnostic tests and substantial strengthening of malaria microscopy.
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Blood film microscopy is time-consuming and needs significant technical skills, good-quality reagents, and clean slides; its accuracy is of highly variable quality in sub-Saharan African hospitals.
“However, blood film microscopy is time-consuming and needs significant technical skills, good-quality reagents, and clean slides; thus, its accuracy is of highly variable quality in sub-Saharan African hospitals [7-10].”
From Reliability of rapid diagnostic test for diagnosing peripheral and placental malaria in an area of unstable malaria transmission in Eastern Sudan (2013) · cites this paper as [9]
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- Authors
- Nankabirwa, J., Zurovac, D., Njogu, J. N., Rwakimari, J. B., Counihan, H., Snow, R. W., & Tibenderana, J. K.
- Affiliations
- Malaria Consortium (UG)
- Boston University (US)
- Kenya Medical Research Institute (KE)
- Ministry of Health (UG)
- Malaria Consortium (GB)
- London School of Hygiene & Tropical Medicine (GB)
- Corresponding author
- Nankabirwa, Joan
- Zurovac, Dejan
- Venue
- Malaria Journal
- Published
- 2009-04-16
- Volume
- 8
- Issue
- 1
- Pages
- 66-66
- ISSN
- 1475-2875 (ISSN-L)
- PMC
- PMC2671516
- OpenAlex
- W1972686260
- Cited by
- 161
- References
- 27
- Citations by year
- 2026: 6 · 2025: 2 · 2024: 4 · 2023: 4 · 2022: 6 · 2021: 6 · 2020: 5 · 2019: 6 · 2018: 5 · 2017: 9 · 2016: 17 · 2015: 21 · 2014: 15 · 2013: 18 · 2012: 11
- FWCI
- 12.38
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Malaria Journal (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- OpenBU (Boston University) (submittedVersion, other-oa)
- Greater South Information System
- Funders
- Wellcome Trust (079080)
- Department for International Development, UK Government
- Department for International Development
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Malaria Research and Control
- Health Sciences › Medicine › Physiology › Clinical Laboratory Practices and Quality Control
- Health Sciences › Medicine › Genetics › Hemoglobinopathies and Related Disorders
- Keywords
- malaria misdiagnosis, malaria microscopy, malaria rapid diagnostic tests, diagnostic accuracy, malaria transmission intensity, children under five, febrile illness, malaria policy, Uganda
- MeSH terms
- Animals, Antimalarials, Child, Preschool, Cross-Sectional Studies, Diagnostic Errors, Diagnostic Tests, Routine, Female, Fever, Health Policy, Humans, Infant, Malaria, Male, Microscopy, Predictive Value of Tests, Sensitivity and Specificity, Uganda, Practice Guidelines as Topic, Parasitemia
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