Elsevier

The Lancet

Volume 364, Issue 9448, 20–26 November 2004, Pages 1896-1898
The Lancet

Rapid Review
Malaria misdiagnosis: effects on the poor and vulnerable

https://doi.org/10.1016/S0140-6736(04)17446-1Get rights and content

Summary

Context

Effective and affordable treatment is recommended for all cases of malaria within 24 h of the onset of illness. Most cases of “malaria” (ie, fever) are self-diagnosed and most treatments, and deaths, occur at home. The most ethical and cost-effective policy is to ensure that newer drug combinations are only used for true cases of malaria. Although it is cost effective to improve the accuracy of malaria diagnosis, simple, accurate, and inexpensive methods are not widely available, particularly in poor communities where they are most needed.

Starting point

In a recent study in Uganda, Karin Källander and colleagues emphasise the difficulty in making a presumptive diagnosis of malaria, and highlight the urgent need for improved diagnostic tools that can be used at community and primary-care level, especially in poorer populations (Acta Trop 2004; 90: 211–14).

Where next?

Health systems need strengthening at referral and community level, so that rapid accurate diagnosis and effective treatment is available for those who are least able to withstand the consequences of illness. Indirect evidence strongly suggests that misdiagnosis of malaria contributes to a vicious cycle of increasing ill-health and deepening poverty. Much better direct evidence is needed about why and how misdiagnosis affects the poor and vulnerable.

Section snippets

Misdiagnosis of malaria

In Africa over 70% of malaria cases do not present initially to health facilities but diagnose and manage their “malaria” (ie, fever) at home with traditional remedies or drugs bought from local shops. They only attend health centres after self-treatment fails, and even then they do not receive a good-quality diagnosis.6 At peripheral health facilities a diagnosis of malaria is based solely on clinical features such as fever. Although this approach can reduce morbidity,7 many infectious

Disproportionate effect on poor and vulnerable

The poor are less likely to seek western medical care for treatment of fevers than the more wealthy, leading to delays in diagnosis and treatment and more advanced disease (Worrall E, Basu S, Hanson K, London School of Hygiene and Tropical Medicine, personal communication). If this situation is compounded by inaccurate diagnoses, confidence in allopathic health services will be lost in favour of traditional healers. The belief that these providers can treat complicated malaria will be

Implications for public-health and health systems

Malaria-endemic countries have economic growth rates that are 1·3% lower than countries without malaria.13 The gap in prosperity between these groups of countries is widening every year and it is predicted that malaria cases will double over the next 20 years.17, 18 In many countries patients pay for health services, including consultations, laboratory tests, and drugs. These cost-recovery measures have driven the poorest away from allopathic health services and increased self-medication.19 To

Conclusion

With the introduction of antimalarial drugs that are more expensive and toxic than traditional, but failing, monotherapies, it will be unethical for health professionals to condone the current level of malaria misdiagnosis. The balance between the risk of wrong diagnosis and use of antimalarial drugs might be acceptable when drugs are safe and cheap, but with more expensive and less safe drug regimens it is more cost effective to improve the accuracy of malaria diagnosis.22 The effect of

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