Malaria Infections in Northern Sudan: Problems of Over- Diagnosis, Super Presumptive Treatment and Innovative Approaches For Parasite Detection

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Salwa Mohammed Elhassan, Abd-Elgayoum
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This study is composed of five main steps. In step one (chapter four) a cross-sectional descriptive study was carried out among people of El-Ezergab area. This area was chosen as a model to study Sudanese malaria knowledge, attitude and practices (KAP) in man-made malarious areas in Khartoum State. Ninety one percent of household heads reported malaria attack among household members in the previous year. Risk of malaria attack was significantly associated with family grade of education, occupation of household head, water and electrical supply, economic status of the family, number of rooms, expenses of treatment and treatment seeking behaviour. About 76.6% of household heads reported delayed treatment seeking behaviour for malaria. Knowledge attitude and practices have no association with malaria attacks except for a 2-fold increased risk of malaria in people obtaining water from irrigation canals. In the second step in chapter five, the retrospective study the reliability of microscopic diagnosis of malaria in Khartoum State was investigated. The results showed that the false positive diagnosis of malaria was 75.6%, the false negative was 0.01% and only 7.4% of the general practitioners (GPs) predictions came to be true malaria. The study disclosed poor clinical skills of GPs in malaria diagnosis, 0.43 of GPs rated 0% and only 3 GPs rated above 50%. Similarly 0.44 of the general microscopists (GMs) were rated 0%, but 0.23 were rated 100%. A prospective study was conducted; it confirmed the high frequency of malaria over- diagnosis and showed 100% concordance between the results of the expert malaria microscopist (MM) and the rapid diagnostic test (RDT). In step three (chapter six), 415 patients complained of repeated bouts of fever, including 322 patients with negative microscopic malaria diagnosis and 93 patients had true malaria infection were prescribed Artemisinin Combination Therapies. Blood samples were taken from all patients before treatment and revised for presence of malaria parasite by microscopy, RDT and PCR. Only one patient (0.03%) was found to be positive for malaria by RDT. In conclusion, this study disclosed the wide use of PMT, unsupported with the results of RDT and PCR, thus this was described as Super Presumptive Malaria Treatment (sPMT). As a fourth step (chapter seven),a non-invasive approach for malaria diagnosis was done, using PCR for detection of the parasite DNA in saliva, buccal mucosa and urine,from 93 patients with microscopically confirmed P. falciparum. Using species specific primers, the parasite DNA was not detected in the above mentioned samples other than blood, however it was detected with the surface Merozoite Surface Protein (MSP1 and MSP2) primers. In conclusion, the P. falciparum DNA was equally detected in saliva, buccal mucosa and urine of malaria patients, regardless of the patients' age, body temperature or parasite density. In the last step in chapter eight, 276 individuals from Kassala in eastern Sudan were recruited, including; 142 patients clinically diagnosed as Hyperactive Malaria Splenomegaly (HMS), and 134 apparently healthy individuals treated as control. The predominant presenting symptoms were repeated fever attacks (mostly intermittent) (100%), left hypochondrial mass (72%) and pain (47%), in addition to weight loss. Microscopy, RDT and PCR were used for malaria parasite detection in blood obtained from the above donors. 50% and 49% of the HMS patients were found to harbour malaria parasite detected by microscopy and RDT, respectively, the PCR had revealed 79.3% prevalence rate, the difference was significant, P = 0.00. In conclusion, higher parasite rate, higher prevalence of P. vivax and mixed infections were revealed by PCR, while RDT had no advantage over expert microscopy in parasite detection in HMS
Malaria Infections In Northern Sudan: Problems Of Over- Diagnosis Super Presumptive Treatment And Innovative Approaches For Parasite Detection