New Insights into the Diagnosis of Malaria Professor Bill Gilmore School of Healthcare Science, MMU

Malaria A parasitic disease caused by protists of the genus Plasmodium – Plasmodium falciparum – Plasmodium vivax – Plasmodium ovale – Plasmodium malariae

Malaria Parasite Life Cycle Female Anopheles mosquito Human blood and liver – resources/Teaching-and- education/Animations/Protozoans/index.htm

10 Facts about malaria Malaria is a disease that can be transmitted to people of all ages caused by parasites of the plasmodium species and spread by the bites of mosquitoes. 3.3 billion people are at risk – 250 million cases each year – One million deaths – People living the the poorest countries most vulnerable

10 facts about malaria One in five of al childhood deaths in Africa are due to malaria. An Africian child has between 1.6 and 5.4 episodes of malaria each year. – Every 30 seconds a child dies from malaria in Africa

10 facts about malaria (WHO) Early diagnosis and treatment are the two basic elements of malaria control Inappropriate use of anti malarial drugs in the 20 th century contributed to widespread resistance in the malaria parasite to drugs such as chloroquine. – Recent introduction of a new type of drug, artemisinin-based combination therapies has brought new hope.

10 facts about malaria (WHO) Malaria vector control aims to reduce the malaria bearing mosquito thereby reducing or interrupting transmission Insecticidal nets can protect more than 80% of a community sleeping inside them Indoor spraying id the most effective way of reducing mosquito density (DDT is effective for up to 12 months, other insecticides less so)

10 facts about malaria (WHO) Pregnant women are at high risk – Spontaneous abortion – Premature delivery – Stillbirth – Severe maternal anaemia – Low birth weight babies Malaria causes an annual loss of 1.3% economic growth.

Diagnosis Presumptive diagnosis – based on clinical symptoms 32%-93% Negative blood films (Amexo et al Lancet ) Rapid Diagnostic Tests (RDTs) Blood film examination – Thick films – concentrates parasites – Thin films – allows added value

Scoping exercise for WHO on Malaria Diagnosis Tanzania 2009

Scoping Exercise University University Hospital General Hospital Rural District Hospital Health Centre

Muhimbili University of Health and Allied Sciences/University Hospital

University Hospital

Ilala District Hospital

Kisarawe District Hospital

Mlandizi Health Centre

PILOT ASSESSMENT OF MALARIA DIAGNOSIS AND EDUCATION USING VIRTUAL MICROSCOPY FOR LABORATORIES IN AFRICA AND DEVELOPING NATIONS Laura Tatum PhD student, Manchester Metropolitan University UK NEQAS Honorary Research Fellow

Project overview Intervention (External QA and training) study to improve malaria microscopic diagnosis Online assessment of current malaria diagnosis Online training intervention aiming to improve diagnosis Post- training online assessment to determine if training has improved diagnosis Project is supported by the World Health Organization, UK NEQAS (H) and the Liverpool School of Tropical Medicine

Participants and locations Chile Colombia Hong Kong India Lebanon Nigeria Kenya

Initial assessment 40 stitched images “virtual slides” Images include – Different species – Varying parasite densities – Artefacts – Thick and thin films – Different staining methods

First assessment stage

Training programme Provided over a 6 month period Annotated images Photo gallery website – Background information about malaria – Methods involved in diagnosis – Stages of the parasite life cycle – Comparison of appearances of parasites in different blood films and between species – Quizzes for immediate feedback

An Example quiz

Final assessment 40 virtual slides delivered in same way as the initial assessment Images chosen to reflect those in the initial assessment Criteria used to ensure that the final images are of the same difficulty as those in the initial assessment

Initial assessment stage results There was not one case in which all participants gave the correct diagnosis The correct diagnosis was made in 74.5% of cases The correct species was determined in 53.4% of cases There were 8 cases in which all participants correctly identified the presence of parasites There were 24 P. falciparum cases, the correct diagnosis was made in 74.5% of these cases with the correct species determined in 53.2%. Variation was considerable between species

Species comparison

Experience

Conclusion Initial assessment results show that speciation can be a problem Results seem to reflect what participants are used to looking at- i.e. thick and thin films, species present Training stage is now complete Participants completed final assessment – blinding to be broken Problems with internet access – mobile phones ???

Thanks MMU – Laura Tatum – Len Seal – Bill Gilmore Manchester Royal Infirmary – John Burthem – Michelle Brereton UKNEQAS (H) – Barbara De La Salle – Mary West – Keith Hyde WHO – Gaby Vercauteren Liverpool School of Tropical Medicine – Imelda Bates