Doctors scrutinise treatment of malaria

The World Health Organisation's guidelines for treating the deadly disease are causing more harm than good, Doctors Without Borders says.

JOHANNESBURG // It is one of the most popular causes in the world. Often fatal, frequently killing children, but both treatable and preventable, the fight against malaria is perceived as winnable and carries none of the moral issues some people associate with HIV/Aids. It is estimated that a quarter of a billion people develop the parasitic disease every year, with 881,000 deaths, most of them children under five and most of them in Africa. But malaria is coming under increasing fire from the world's billionaire philanthropists. Bill Gates has given US$168 million (Dh617m) to the search for a vaccine, a particular challenge given the fact that it is caused by a microscopic animal, rather than a virus or bacteria - and last week pledges totalling almost $3bn were announced for a plan to eliminate it. Nonetheless, according to one of the world's premier medical charities, the World Health Organisation's own malaria guidelines risk leaving children to receive the wrong medicines, cause their real illness go untreated and they are potentially dying as a result.

Under WHO recommendations, all children who seek treatment for fever - the main symptom of the disease - in areas where malaria is endemic should be given artemisin-based combination therapies (ACTs), the latest generation of anti-malarial medication. But Medecins Sans Frontieres (MSF - or Doctors Without Borders) believes that is misguided. Rather than universally distributing malaria medications, the charity uses rapid diagnostic test kits for patients with fevers in many of the areas in which it operates. It only gives out ACTs when there is a positive result. The medical organisation released a survey of its findings in Johannesburg this week. In Bo district in Sierra Leone, where malaria is common year-round, only 65 per cent of feverish patients proved to have it. In two other areas, Bongor in Chad and Kangaba in Mali, positive tests were recorded in about two-thirds of cases in the malarial high season, and only 43 per cent in low season. The percentages for children under five were slightly higher than the average, but still implied that at the best of times almost one-third of children are being given treatment for a disease they do not have, and at times nearly half. "The usual decision trees for fever management at the primary health care level were often inadequate," the group said in its report, Full Prescription; better malaria treatment for more people, MSF's experience. "Not using the tests - as recommended by WHO - means that many will receive treatment for the wrong disease and no further examination will be performed to check what actually causes the fever." Seco Gerard, a Brussels-based policy adviser for MSF, added: "Of course malaria is one of the major killers for children, unfortunately there are other diseases with the same symptoms, mainly fever, which are also killers. The consequence is there's a whole bunch of children who are not going to get the treatment they need." In such cases they often had to return to the clinic later for more treatment, or if their illness worsened had to go to hospital - often difficult in the vast swathes of rural Africa where health facilities are rare. "The worst-case scenario is they could die," added Ms Gerard. She could not estimate how many child fatalities there were annually as a result, but pointed out that the malaria test kits cost less than $1 each and their accuracy was improving all the time. A second factor in avoiding overuse of malaria medicines is to delay the development of resistance to the drugs. Over the years, the malaria parasite has evolved to become immune to each successive generation of anti-malaria medicine, rendering each of them largely ineffective in turn. Artemisin, the key ingredient of ACTs, has a half-life in the human body of less than a day, so that its levels drop rapidly, making resistance harder to develop. But other drugs that are used as part of the combination last much longer, and will be prone to it in time. "Resistance will develop much faster if you give it to all the cases of fever," said Ms Gerard. "We are saying this is too important an issue, we need to move faster and make sure children are receiving the treatment they need for malaria or something else." The WHO's current malaria treatment guidelines say that in high-incidence regions: "Malaria is usually the most common cause of fever in children under five years of age in these areas. "Anti-malarial treatment should therefore be given to children with fever or a history of fever and no other obvious cause." Kamini Mendis, a malaria specialist with the body, said: "Where it's feasible malaria treatment should be preceded by confirmation of the diagnosis, except in children under five in Africa, because the death rate is so high that we don't want a wrong negative diagnosis. But the guidelines are in the process of being revised, she said. "We are moving more and more towards the point that MSF takes." Nonetheless, the new version will still recommend that clinicians issue ACTs if they suspect malaria, whatever the test result. "The risk of not treating due to a bad test is just too high," she added. [e-mail]