Test or Treat: Parasitological Testing or Presumptive Treatment for Malaria in Rural Sierra Leone

Abstract

Malaria resulted in the death of 655,000 people in 2010, mostly children under the age of five in sub-Saharan Africa. Malaria is especially prevalent in Sierra Leone, its impact exacerbated by the recent civil war and deterioration of existing healthcare infrastructure. An integral aspect of malaria control is accurate diagnostic testing; however, availability of blood film microscopy, the gold standard of malaria diagnosis, is low in rural regions of Sierra Leone. Alternatively, one may diagnose by clinical symptoms, but this method has an extremely low specificity, leading to over-prescription of antimalarial medications and missed diagnoses of other febrile-causing illnesses. Another approach is the use of rapid diagnostic tests (RDTs), which accurately detect the presence of proteins created by Plasmodium species in the bloodstream. However, mandating RDT use in situations when diagnostic microscopy is unavailable is still a topic of fierce contention, one that can only be resolved with local epidemiological data concerning the distribution of febrile disease and the accuracy of clinical and syndromic diagnosis for malaria. This study examines the distribution of diagnoses of patients attending the Wellbody Alliance health clinic in Koidu, Sierra Leone. In addition, we compared the accuracy of each diagnostic method, hoping to identify setting-specific causes of reduced RDT accuracy. We conclude that the widespread use of clinical diagnosis in Sierra Leone leads to a large percentage of malaria-negative patients that are prescribed antimalarial medication, resulting in increased healthcare costs and potential health complications due to the untreated underlying cause of fever. In addition, the low sensitivity of RDTs used at Wellbody Hospital highlight the need to implement programs ensuring their timely and temperature-controlled delivery in order to maintain the integrity of the diagnostic test.