Abdulla, S.

Bruxvoort, K.

Cairns, M.

Festo, C.

Goodman, C.

Kachur, S.P.

Kalolella, A.

Nchimbi, H.

Poirot, E.

Taylor, M.

Thomson, R.

Thwing, J.

English

Digital Library of the Tanzania Health Community

Over-and under diagnosis of malaria at health facilities in Tanzania:  
Implications for developing composite indicators of appropriate treatment based on malaria parasitemia status 
Background 
• Artemisinin based combination therapy (ACT) is the first line drug for malaria in most endemic 
countries, but there are concerns that quality of care remains poor.  Patients needing ACT do not 
receive it, but there is also considerable over treatment due to the lack of accurate diagnosis and 
inappropriate management.   
• Given the importance of treating patients according to their parasitemia status, there is a need to 
develop composite indicators of appropriateness of antimalarial treatment that take this into 
account. 
• We conducted surveys in government health facilities in three regions of Tanzania to assess 
appropriateness of treatment prior to national scale-up of rapid diagnostic tests (RDTs) and to 
assess the usefulness of a range of composite indicators of appropriate treatment. 
K. Bruxvoort1,2, C. Festo2, H. Nchimbi2 , J. Thwing3, R. Thomson1,2, A. Kalolella2, M. Cairns1, M. Taylor1,2, E. Poirot2, S. Abdulla2, C. Goodman1, S.P. Kachur3 
1London School of Hygiene and Tropical Medicine, London, United Kingdom, 2Ifakara Health Institute, Dar es Salaam, Tanzania, 3Centers for Disease Control and Prevention, Atlanta, GA, United States  
Discussion 
• Over- and under-treatment of malaria is still common in Tanzania, even among patients that are tested for malaria.  While national scale-
up of RDTs may address this to some degree, high prevalence of ACT stock-outs and inappropriate health worker practices remain 
significant problems. 
• Our base composite indicator for appropriate antimalarial treatment reveals that 58.5% of patients were treated appropriately for malaria 
based on their true parasitemia status.  This indicator varies only slightly when adjusted for previous ACT treatment or correct dose for 
weight, but drops to 47.3% when restricted to only those facilities with Alu in stock. 
• Performance according to the base case composite indicator appeared relatively good in Mwanza compared to the other two regions. However, this 
may be misleading as Mwanza's stronger performance mainly reflected the high ALu  stock-out rates in this region, which meant that antimalarials 
were more rarely given to patients without parasitemia. 
• There is a need to develop more robust indicators of appropriate treatment with ACTs given patients’ parasitemia status. Options may 
include weighting the indicator to give greater weight to correct antimalarial treatment of those with parasitemia or the use of an 
alternative “balanced scorecard” approach. 
Methods 
 140 health facilities (11 hospitals, 24 health centres, and 105 dispensaries) were randomly selected 
with population proportional to malaria outpatient utilization rate in Mwanza, Mbeya, and Mtwara 
regions. 
 Between May and October 2010, 1746 patients presenting with fever in the previous 48 hours were 
enrolled on arrival to the health facility. 
 Following their consultations, patients were interviewed about demographic information, previous 
treatment for fever, and care received at the facility.  Finger prick blood samples were taken by 
study staff to test for malaria parasitemia. 
Table 2: Potential composite indicators of appropriate antimalarial treatment  [Percent (95% CI)] 
Mwanza  Mbeya  Mtwara   <5  ≥5  Total 
Patients with interview data and study blood 
smear results (N) 
604     553  492  984  665  1649 
Base case: Appropriate antimalarial treatment 
given study blood smear result1 
74.3  
(66.1, 81.2) 
48.6 
 (39.2, 58.2) 
50.2  
(43.5, 56.9) 
55.4  
(49.8, 60.8) 
63.2 
 (56.5, 69.4) 
58.5  
(53.6, 63.3) 
Variant 1: With compliance of provider to 
correct dose for weight2 
74.0 
 (65.6, 80.9) 
48.3 
 (38.8, 57.9) 
47.8 
 (41.3, 54.3) 
54.3  
(48.8, 59.7) 
62.4 
 (55.8, 68.6) 
57.6  
(52.7, 62.3) 
Variant 2: Adjusting for previous antimalarial 
treatment3 
74.3 
 (66.1, 81.2) 
48.6 
 (39.2, 58.2) 
50.0 
 (43.2, 56.8) 
55.3  
(49.7, 60.7) 
63.2  
(56.5, 69.4) 
58.5  
(53.6, 63.2) 
Patients with interview data and study blood 
smear results at facilities with ALu in stock (N) 
269  432  462  696  467  1163 
Variant 3: Base case restricted to facilities with 
ALu in stock4 
59.1  
(47.5, 69.8) 
37.5 
(28.7, 47.2) 
49.6  
(42.5, 56.7) 
43.1 
(37.7, 48.7) 
53.3  
(45.4, 61.5) 
47.3  
(42.1, 52.6) 
1[pos study BS +ALu at facility] + [neg study BS + no AM at facility] / N with study BS & interview data 
2[pos study BS +ALu at facility + correct dose for weight] + [neg study BS + no AM at facility] / N with study BS & interview data 
3[pos study BS +ALu at facility + no ALu previously] + [pos study BS + ALu previously + quinine at facility] + [neg study BS + no AM] / N with study BS 
& interview data 
4 [pos study BS +ALu at facility] + [neg study BS + no AM at facility] / N with study BS & interview data at facilities with ALu in stock 
This work was conducted as part of IMPACT2: Monitoring Interventions to Improve ACT Access and Targeting, a collaboration between London School of Hygiene and Tropical 
Medicine (LSHTM), the U.S. Centers for Disease Control and Prevention (CDC), and the Ifakara Health Institute (IHI).  The project is funded by the Bill and Melinda Gates 
Foundation, through  the ACT Consortium (www..actconsortium.org). 
0 
20 
40 
60 
80 
100 
RDTs  Microscopy  All four weight-specific 
packs of Alu 
Any Alu 
P
e
r
c
e
n
t
 
Availability of diagnostics and ACTs at health facilities  
Mwanza (N=40) 
Mbeya (N=56) 
Mtwara (N=44) 
Total (N=140) 
84.18 
14.79 
1.03 
Percent receiving diagnostic test at 
health facility by type 
No diagnostic test  Blood smear  RDT 
Results 
• Of 1746 patients interviewed, 1033 were under five years old, while 713 were age five or above.  
18.8% had previously sought care at a another source, and 1.3% had obtained an ACT at another 
source. 
• 77.8% of health facilities had any artemether-lumefantrine (ALu), the government-recommended 
ACT, in stock, and 41.1% had all four weight-appropriate doses in stock.   Stock-outs were most 
frequent in Mwanza (Figure 1).   
• Of 1651 patients tested by study blood smear, 6.6% tested positive in Mwanza,1.6% in Mbeya, and 
20.9% in Mtwara.  Overall, 12.3% of  patients under five years old and 9.2% of all patients had a 
positive study blood smear. 
• Only 15.9% of patients were tested for malaria by health workers at the facility.  Sensitivity and 
specificity of facility-based diagnostic tests compared to study blood smears were 86.1% and 
52.7%, respectively. 
• ACTs were obtained by 67.1% of all patients with a positive facility test (73.7% if restricted to sub-
set of facilities with ALu in stock).  An antimalarial was obtained by 25.2% of all patients with a 
negative facility test  and 42.1% of all untested patients. 
• Based on study blood smears, 65.8% of patients testing positive, 39.0% of patients testing 
negative, and 41.1% of patients overall obtained an ACT. 91.1% of patients obtaining ALu received 
the correct dose by weight. 
0 
20 
40 
60 
80 
100 
Tested 
positive 
(n=146) 
Tested 
positive* 
(n=133) 
Tested 
negative 
(n=131) 
Tested 
negative* 
(n=109) 
Not tested 
(n=1469) 
Not tested* 
(n=967) 
P
e
r
c
e
n
t
 
Treatment received at health facilities 
Obtained ACT 
Obtained any AM 
* Restricted to 
facilities with ALu 
in stock 

Over-and Under Diagnosis of Malaria at Health Facilities in Tanzania: Implications for Developing Composite Indicators of Appropriate Treatment Based on Malaria Parasitemia Status

http://ihi.eprints.org/1103/2/IHIPost_(7).pdf

Over-and Under Diagnosis of Malaria at Health Facilities in Tanzania: Implications for Developing Composite Indicators of Appropriate Treatment Based on Malaria Parasitemia Status

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