Skip to Navigation
London School of Hygiene & Tropical Medicine Malaria Centre

Featured Publication


Photograph courtesy of Harparkash Kaur

25 July 2012
Malaria Centre members contribute to paper in BMJ on overdiagnosis and mistreatment of malaria in Afghanistan

Overdiagnosis and mistreatment of malaria among febrile patients at primary healthcare level in Afghanistan: observational study

  1. Toby Leslie, lecturer and project manager12
  2. Amy Mikhail, research fellow and project manager12
  3. Ismail Mayan, field research coordinator2
  4. Mohammed Anwar, field research coordinator3
  5. Sayed Bakhtash, field research coordinator4,
  6. Mohammed Nader, technical coordinator3
  7. Clare Chandler, lecturer1
  8. Christopher J M Whitty, professor1
  9. Mark Rowland, reader and project leader1

Author Affiliations

  1. 1London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
  2. 2Health Protection and Research Organisation, Kabul, Afghanistan
  3. 3HealthNet TPO, Karte-Se, Kabul, Afghanistan
  4. 4Medical Emergency Relief International, Kabul, Afghanistan


Objective To assess the accuracy of malaria diagnosis and treatment at primary level clinics in Afghanistan.

Design Prospective observational study.

Setting 22 clinics in two Afghan provinces, one in the north (adjoining Tajikistan) and one in the east (adjoining Pakistan); areas with seasonal transmission ofPlasmodium vivax and Plasmodium falciparum.

Participants 2357 patients of all ages enrolled if clinicians suspected malaria.

Interventions Established (>5 years) microscopy (12 clinics in east Afghanistan), newly established microscopy (five clinics in north Afghanistan), and no laboratory (five clinics in north Afghanistan). All clinics used the national malaria treatment guidelines.

Main outcome measures Proportion of patients positive and negative for malaria who received a malaria drug; sensitivity and specificity of clinic based diagnosis; prescriber’s response to the result of the clinic slide; and proportion of patients positive and negative for malaria who were prescribed antibiotics. Outcomes were measured against a double read reference blood slide.

Results In health centres using clinical diagnosis, although 413 of 414 patients were negative by the reference slide, 412 (99%) received a malaria drug and 47 (11%) received an antibiotic. In clinics using new microscopy, 37% (75/202) of patients who were negative by the reference slide received a malaria drug and 60% (103/202) received an antibiotic. In clinics using established microscopy, 50.8% (645/1269) of patients who were negative by the reference slide received a malaria drug and 27.0% (342/1269) received an antibiotic. Among the patients who tested positive for malaria, 94% (443/472) correctly received a malaria drug but only 1 of 6 cases of falciparum malaria was detected and appropriately treated. The specificity of established and new microscopy was 72.9% and 79.9%, respectively. In response to negative clinic slide results, malaria drugs were prescribed to 270/905 (28.8%) and 32/154 (21%) and antibiotics to 347/930 (37.3%) and 99/154 (64%) patients in established and new microscopy arms, respectively. Nurses were less likely to misprescribe than doctors.

Conclusions Despite a much lower incidence of malaria in Afghanistan than in Africa, fever was substantially misdiagnosed as malaria in this south Asian setting. Inaccuracy was attributable to false positive laboratory diagnoses of malaria and the clinicians’ disregard of negative slide results. Rare but potentially fatal cases of falciparum malaria were not detected, emphasising the potential role of rapid diagnostic tests. Microscopy increased the proportion of patients treated with antibiotics producing a trade-off between overtreatment with malaria drugs and probable overtreatment with antibiotics.

Access the full publication here.