Scaling up diagnostic testing, treatment and surveillance for malaria. – T3: Test. Treat. Track.

The April 2012 WHO Global Malaria Programme initiative – T3: Test. Treat. Track; supports malaria-endemic countries in their efforts to achieve universal coverage with diagnostic testing and antimalarial treatment, as well as in strengthening their malaria surveillance systems.

The initiative seeks to focus the attention of policy-makers and donors on the importance of adopting WHO’s latest evidence-based recommendations on diagnostic testing, treatment and surveillance, and on updating existing malaria control and elimination strategies, as well as country-specific operational plans. Malaria-endemic countries should ensure that every suspected malaria case is tested, that every confirmed case is treated with a quality-assured antimalarial medicine, and that the disease is tracked through timely and accurate surveillance systems to guide policy and operational decisions.

By strengthening diagnostic testing, treatment and surveillance through the T3 Initiative, affected countries will substantially improve child and maternal health; provide the much-needed bridge between efforts to achieve universal coverage with prevention tools and the goal of eliminating malaria deaths, and eventually eradicating the disease. It will also lead to a better overall understanding of the disease burden and enable national malaria control programmes to better direct available resources to where they are most needed.

Test. Every suspected malaria case should be tested.

In the past, fever was equated with malaria in many endemic countries. However, recent control efforts have significantly reduced the malaria burden – even in high-transmission areas of Africa – and it has become clear that continued presumptive treatment of malaria would lead to both drug wastage and under-treatment of other febrile illnesses. In early 2010, WHO recommended that every suspected malaria case be confirmed by microscopy or a rapid diagnostic test (RDT) prior to treatment. Only in areas where diagnostic testing is not possible should malaria treatment be initiated solely on clinical suspicion.

 In recent years, the availability of high-quality, inexpensive RDTs has made it possible to significantly improve and expand diagnostic testing across all levels of the health system, from district hospitals to community-based programmes. As a result, the testing rate has been increasing in all malaria-endemic regions of the world. In the WHO African Region, the testing rate in the public sector rose from less than 5% in 2000 to 45% in 2010. However, most endemic countries in Africa are still far from achieving universal access to diagnostic testing and will need to substantially expand access to RDTs or microscopy. In half of all endemic countries in Africa, over 80% of cases are still being treated without diagnostic testing. Universal Access to Malaria Diagnostic Testing: an Operational Manual, released in 2011, provides a comprehensive roadmap for scaling up diagnostic testing and moving towards universal access.

Accurate diagnosis will substantially improve the quality of care and ensure that antimalarial medicines are used rationally and correctly. Investing in an increased supply of RDTs in malaria-endemic countries will bring down the supply requirements for artemisinin-based combination therapies, or ACTs – the most effective medicines for uncomplicated malaria caused by the Plasmodium falciparum parasite. Countries that have already scaled up diagnostic testing are saving hundreds of thousands of ACT courses every year.

Microscopy and RDTs have unique characteristics that make each useful in particular situations and settings. Therefore, the introduction or expansion of one should not replace, but rather complement, the other. To strengthen malaria diagnostic testing, the diagnostic tools must be accurate and of high-quality, and they must be properly used. This requires accurate quantification and forecasting of need; procurement of appropriate tests and supplies; quality assurance across all levels of the health system; effective supply chain management; health worker training and supervision; and consistent monitoring and evaluation of programmes. The scale-up of diagnostic testing presents an unprecedented opportunity to improve the accuracy of malaria surveillance data, and also rationalize antimalarial drug use, and improve public trust in health care workers and in the effectiveness of antimalarials. It is key that malaria diagnostic testing is deployed as an integral component of programmes aiming to improve management of all febrile patients, including those with illnesses other than malaria.

Treat. Every confirmed case should be treated with a quality-assured antimalarial medicine.

Malaria is an entirely preventable and treatable disease. Hundreds of thousands of lives are saved each year by prompt antimalarial treatment. Prompt and appropriate treatment of uncomplicated malaria is critical to preventing progression to severe disease, as well as to reducing the overall parasite reservoir in a community. WHO recommends ACTs as the first-line treatment for uncomplicated malaria cases caused by P. falciparum. Only medicine combinations whose efficacy has been demonstrated through routine monitoring should be used.

Track. Every malaria case should be tracked in a surveillance system.

WHO urges malaria-endemic countries to strengthen their disease surveillance, health information and vital registration systems, so that ministries of health can better identify public health priorities and design effective health interventions.

WHO KEY RECOMMENDATIONS.

• Every suspected malaria case should be confirmed by microscopy or RDT prior to treatment.
• All diagnostic tools must be quality-assured across all levels of the health system.
• Scale-up of malaria diagnostic testing should be integrated with efforts to improve the management of other febrile illnesses.
• After diagnostic confirmation, every uncomplicated case of P. falciparum malaria should be treated with a quality-assured ACT.
• Every severe case of P. falciparum malaria should be treated with intravenous or intramuscular artesunate, followed by a full course of an ACT.
• Antimalarials should be routinely monitored for therapeutic efficacy.

Sources: Malar J. 2016; 15: 351. Published online 2016 Jul 8. doi: 10.1186/s12936-016-1394-3 PMCID: PMC4938925 PMID: 27392040. https://www.who.int/malaria/publications/atoz/test_treat_track_brochure.pdf- April 2012