Search

Malaria and anemia are common conditions in patients presenting to outpatient clinics in Kenya. Anemia is usually due to malaria infection with underlying micronutrient deficiency. Iron therapy has been shown to enhance recovery from anemia in children with malaria, without affecting malaria treatment. Iron and folic acid are often prescribed together for anemic individuals. Until recently in Kenya, the drug of first choice for non-severe malaria was sulfadoxine-pyrimethamine (SP), an antifolate antimalarial drug. In this study, 303 patients of all ages with anemia and uncomplicated Plasmodium falciparum malaria attending an outpatient clinic in an area of seasonal malaria were treated with SP and iron, and were randomized to receive folic acid. Parasite clearance rates were measured using a survival analysis plot for both parasitologic and clinical failure. There was a significant reduction in the efficacy of SP in patients taking standard therapeutic doses of folic acid using the survival curve for parasitologic failure (P < 0.0001), but no difference for clinical failure (P = 0.7008). Folic acid supplementation did not enhance recovery from anemia.

In eastern Africa where 90% of the malaria is due to Plasmodium falciparum, the accuracy of malaria diagnosis at the outpatient level is becoming increasingly important due to problems of drug resistance and use of alternative, costly antimalarial drugs. The quantitative buffy coat (QBC) technique, acridine orange staining with an interference filter system, and the ParaSight-F test have been introduced as alternative methods to conventional microscopy for the diagnosis of malaria. Two hundred thirteen outpatients were tested using these alternative methods and conventional microscopy by five experienced technologists; two were randomly allocated to read the results of each test. Paired results showed the highest level of agreement with the ParaSight-F test (99%), followed by Field stain (92%). The results of the QBC technique showed the least agreement (73%). Using conventional microscopy as the reference standard, the ParaSight-F test had a sensitivity range of 90-92% and a specificity of 99%, staining with acridine orange had a sensitivity range of 77-96% and a specificity range of 81-98% and the QBC technique had a sensitivity range of 88-98% and a specificity range of 58-90%. All microscopic tests showed lower sensitivities (as low as 20% using staining with acridine orange) in detecting low parasitemias (< or = 320/microl) than the ParaSight-F test (70%). Due to the high cost of the ParaSight-F test, Field-stained blood films remain the most appropriate method for diagnosis of P. falciparum in eastern Africa. The ParaSight-F test may be used in situations where no trained microscopists are available, or where malaria is strongly suspected and the results of microscopy are negative.

Objective: To determine if use of basic laboratory tests improves diagnosis and treatment outcomes in outpatients attending rural primary health care facilities. Setting: Six rural health centres in Kenya. Design: Cross-sectional study to observe change in diagnosis and treatment made by clinical officers after laboratory testing in outpatients attending six rural health centres in Kenya. Subject: The diagnosis and treatment of 1134 patients attending outpatient services in six rural health centres were compared before and after basic laboratory testing. Essential clinical diagnostic equipment and laboratory tests were established at each health centre. Clinical officers and laboratory technicians received on-site refresher training in good diagnostic practices and laboratory procedures before the study began. Results: Laboratory tests were ordered on 704 (62.1%) patients. Diagnosis and treatment were changed in 45% of tested patients who returned with laboratory results (21% of all patients attending the clinics). 166 (23.5%) patients did not return to the clinician for a final diagnosis and management decision after laboratory testing. Blood slide examination for malaria parasites, wet preparations, urine microscopy and stool microscopy resulted in most changes to diagnosis. There was no significant change in drug costs after laboratory testing. The greatest changes in numbers of recorded diseases following laboratory testing was for intestinal worms (53%) and malaria (21%). Conclusion: Effective use of basic laboratory tests at primary health care level significantly improves diagnosis and patient treatment. Use of laboratory testing can be readily incorporated into routine clinical practice. On-site refresher training is an effective means of improving the quality of patient care and communication between clinical and laboratory staff.