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

BMJ 2012; 345 doi: (Published 24 July 2012) Cite this as: BMJ 2012;345:e4389
  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
  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
  1. Correspondence to: T Leslie toby.leslie{at}
  • Accepted 30 May 2012


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 of Plasmodium 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.


  • Contributors: TL, AM, MR, CC, and CJMW designed the study. IM, MA, SB, and NM assisted in design, trained the field workers, managed the study in the field, and contributed to data analysis and interpretation. TL analysed the data, wrote the initial draft, and is the guarantor of the study. All authors contributed to the final manuscript and approved the submitted version. All authors had full access to all of the data and take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Funding: The study was funded by a grant from the Bill and Melinda Gates Foundation as part of the ACT Consortium ( and sponsored by the London School of Hygiene and Tropical Medicine. Neither the funder nor sponsor had any role in the design or conduct of the study, analysis or interpretation of the data, or in the decision to publish.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: The study protocol was approved by the Institutional Review Board of the Ministry of Public Health, Islamic Republic of Afghanistan (No 112453) and by the ethics review board of the London School of Hygiene and Tropical Medicine (No 5386).

  • Data sharing: No additional data available at this time but queries regarding sharing of data, protocols, etc should be addressed to the corresponding author (toby.leslie{at}

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