TITLE Challenges Facing the utility of pf specific malaria rapid Diagnostic tests(mrdts)-a case report at Webuye County Hospital-Bungoma County. By Maelo D.N Lab scientist, Rose Nasong’o MLT.

INTRODUCTION Malaria remains a public health problem in developing countries of Africa. In Kenya malaria caused by plasmodia species is endemic in western and coastal parts of Kenya and epidemic in Kenyan high altitude areas as highland malaria.Children under 5 yrs and pregnant women are at greater risk of malaria. 15-19% of hospital admission in Kenya are due to Malaria with 3-5% in patient deaths .12% of outpatient clinic visits in Kenya are due to malaria.Each family spends Kshs.1,400 or more annually for treating malaria.170 million working days are lost each year. Webuye County hospital which is located in Webuye town off Bungoma-Kitale Highway serves As Referral hospital for 26 Health facilities in Bungoma East, other sub-counties in Bungoma county and the better part of kakamega County with an estimated population close to 1.8 million People. The broad objective of the study was to establish challenges faced by usage of pf specific mrdts in malaria diagnosis in Webuye County Hospital.The specific objective is to establish the presence of other plasmodium species other than pf among patients declared malaria negative by pf specific mrdts , ii To determine the percentage positivity per plasmodium species by microscopic examination using Giemsa stain and iii, To determine the Drug of choice for each plasmodium species.

METHODOLOGY Examination of Giemsa stained BS from mrdt negative patients using a microscope. Study site-Webuye County hospital Laboratory Study period-Jan to April 2015 Study Design-Case control study Study participant-one Consent-Study participant and close family relatives Inclusion Criteria-Residents from remote areas Exclusion criteria-Residents from Urban Areas Lab diagnosis-Rapid Diagnostic tests, thick and thin blood smears for mps. Clinical Guide-Malaria out patient algorithm

Results 20 randomly selected patients were tested by both mrdts and Microscopy and results were compared one patient with critical results was sampled as a case study Patient name was Laban Nakuku, 60 years old, Lab no-20774, From Silungai Location, Manda Sub-location, and Lurare Village with family of 5 children and five Grandchildren who stays in Home bordering Water Points. MRdts-Negative Bs for mps- (10-20 parasites/hpf), species-p.malariae Treatment-Al resistant, responded to @ 2nd line quinine, artesunate, Chloroquine

RAW DATA Lad id no Test1 Results Test2 Result Remarks 19994 mrdts Negative Microscopy 1-5 para/100wbc pf 20004` negative 1-4 p/100wbc pm 20014 positive 10-20p/100wbc Pf,pm 20024 1-6p/100wbc po 20044 2-7p/100wbc 20565 20-30p/100wbc 20575 6-10p/wbc 20585 3-6p/100wbc 20603 2-4p/100wbc 20613 4-6p/100wbc 20724 10-15p/100wbc 20734 30-40p/100wbc 20744 postive 20754 Pf/po 20764 5-8 p/100wbc 20774 P m 20784 1-3p/100wbc 21017 4-10p/100wbc Pm/po 21027

KEY: Pm-plasmodium malariae, po-plasmodium ovale, Pf-plasmodium falciparum, PV-plasmodium vivax

PERCENTAGE POSITIVITY PER SPECIES MONTH TOTAL TEST DONE TOTAL TEST POSITIVE PLASMODIUM FALCIPARUM PLASMODIUM OVALE PLASMODIUM MALARIAE PLASMODIUM VIVAX JANUARY % 2732 1405 1399 99.6% 5 0.36% 1 0.07% FEBRUARY 2940 1189 1182 99.4% 4 0.34% 3 0.25% MARCH 3655 1028 1018 99.0% 9 0.87% 0.097% TOTAL 9327 3622 3599 99.36% 18 0.497% 0.138% 0%

% POSITIVITY

Discussion The above results shows that out of 20 randomly selected samples 14 were negative for mrdts and were all positive for malaria microscopy since mrdts failed to pick malaria parasites from low density samples.The remaining 6 samples were positive in both methods suggesting that mrdts are best in high parasite samples specific for pf species while for different species only microscopy detected the cases.

MAP

MALARIA OUT PATIENT ALGORITHM

Recommended Drugs and Dosages Treatment of uncomplicated malaria First Line Treatment: Artemether + Lumefantrine (AL) 6 doses given over 3 days Below 5 Kg Half a tablet of AL under supervision, Dispersible AL is now available and is the most convenient to administer Second Line Treatment Dihydroartemisinin+Piperaquine (DHAP) 3 doses given over 3 days

Recommended Drugs and Dosages In treatment of severe malaria Administer artesunate 2.4 mg/kg body weight at 12 and 24 hours from commencement of the initial dose Then once a day until patient is able to take medication orally(maximum 5 days) Thereafter administer a 3 day course of AL OR oral quinine adults 2 tablets 3 times daily at interval of 8 hours for a period of 3 days

Recommended Drugs and Dosages OR iv Quinine administered as a loading dose Of 20 mg/kg quinine in dextrose to run for 4 hours Give 10 mg/kg(max 600mg) 8 hours from commencement of the initial dose of parenteral quinine Repeat 10 mg/kg quinine infusion every 8 hours until the patient can take medication orally

REFERENCES 1.WHO.Basic malaria microscopy:Part I and II Learners Guide.Geneva,World Health Organisation 1991 2.WHO,Malaria microscopy Quality assurance manual.Manila,Western pacific Regional office 2009 3.Practical laboratory manual for tropical countries by Monica Cheesbrough 2nd edition

REFERENCES 4.Practical laboratory manual for centers in Eastern Africa by Jane Carter,Organes Lemma 5.Management of severe malaria. A practical handbook second edition. World Health Organisation,Geneva,2000 6.Piola etal, Supervised Vs Unsupervised intake of six dose Artemether Lumefantrine for treatment of acute uncomplicated plasmodium falciparum in Mbarara Uganda:A randomimised trial.Lancet 2005:365-1467-73 7.The British National Formulary 45 th March,2003

ACKNOWLEDGEMENT HUQAS scientific committee for review Webuye County Hospital Laboratory staff for their co operation DR Laktabai Moi University Malaria Research Co ordinator, For Availing mrdts For QA/QC SCLC bungoma East ,Mr. B Sirrengo for Encouraging and mentorship