topnaman | Malaria blog

PLOS Medicine (open access! – I enjoy supporting journals in this format) did it again. The journal has carried some great exchanges between scientific “clans” on contentious topics which tend to be both lively and informative. A previous debate included whether or not data from Demographic Surveillance Systems (DSS), a form of long term demographic and health data collection from the routine surveys of a defined population, should be openly accessible rather than only shared among researchers participating in a global DSS network.

The latest issue at hand is whether it is now appropriate to pursue a large scale expansion of laboratory confirmation of malaria through the use of rapid diagnostic tests (RDTs) and abandon the presumptive treatment of malaria based on clinical symptoms alone in sub-Saharan Africa. The geographic qualifier in this debate is important – in this region health systems are generally consider weak with little capacity for diagnosis. In addition, given the high burden of malaria, and health worker shortages the standard practice is to treat anyone with suspected malaria which is often simply the presence of fever and leads to a wastage of valuable drugs, promotion of drug resistance, and the under-treatment of other underlying causes of fever.

Of course, both sides support strengthening case management and the use of new tools like RDTs. The counterpoint is not so much a disagreement as it is a caution against rapid implementation. What we don’t know is how much attention scaling RDTs will take (i.e. do we have the capacity without losing focus on other interventions?), how many cases would be miss if presumptive treatment decreased, and when/what context such an effort should be executed. It is a complex scenario. To better understand how to interpret divergent opinions from the lens of program management and strategy, I asked a trusted malaria expert to share his views:

I agree with Blaise and others. However, the problem with the discussion is that Blaise et al. do not sufficiently think through how labour and time intensive the change process will be.  On the other hand, Mike et al. do not sufficiently understand that the process of introducing diagnostics – done properly with all thorough and full coverage of training and quality assurance of products and services – is in itself a health system strengthening activity.

Well, one way to succinctly summarize the debate. What are your thoughts?