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Medicine for the Outdoors

Dr. Paul Auerbach is the world's leading outdoor health expert. His blog offers tips on outdoor safety and advice on how to handle wilderness emergencies.

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Overdiagnosis and Mistreatment of Malaria


At a medical meeting where I was recently lecturing about the intersection between wilderness medicine and disaster medicine, a wise person from the audience reminded the listeners that if they really wanted to be prepared to participate in global humanitarian efforts, they should consider concentrating on studying the diagnosis and treatment of the diseases prevalent in the regions in which they would they would be deployed.

For most of us who practice in the U.S., the practical application of this advice means studying “tropical” infectious diseases. These include diseases like dengue fever, malaria, leishmaniasis, and so forth. We know how difficult it is to stay current on medical problems we seldom see, so this advice is hugely important.

The fact is that even in countries where diseases are prevalent, proper diagnosis and management may be sketchy.  In a recent article entitled “Overdiagnosis and mistreatment of malaria among febrile patients at primary healthcare level in Afghanistan: observational study,” Toby Leslie and colleagues from the London School of Hygiene and Tropical Medicine assessed the accuracy of malaria diagnosis and treatment at primary level clinics in Afghanistan (BMJ2012;345:e4389 doi: 10.1136/bmj.e4389). These clinics were in two Afghan province areas with seasonal transmission of Plasmodium vivax and P. falciparum. The assumption would be that  there resides a certain degree of expertise in these locations of diagnosing malaria.  These study locations had a mixture of diagnostic possibilities available, including experience with interpreting microscope slides of blood samples (for malarial parasites), little experience with interpreting similar slides, or no capability for looking at slides.

What the study showed is that in health centers using clinical (history and physical examination) diagnosis, fever was substantially misdiagnosed as malaria, which led to overdiagnosis and overtreatment. The inaccuracy was attributed to falsely positive interpretation of slides or to simply ignoring slides that were deemed to be negative for malaria. Rare but potentially fatal cases of falciparum malaria were not detected.

What can we glean from this study?

It is probably safe to say that better education and diagnostic techniques are needed in these locations. It is probably reasonable to conclude that this problem is not confined solely to this location. So, a more reliable diagnostic test(s), rapid or otherwise, would likely be beneficial, and some attempt to make current methods more reliable. Otherwise, “overcalling” malaria will lead to unnecessary treatment with the possibilities of adverse drug reactions, and missing other diseases that should be treated (such as typhoid or other severe bacterial diseases).

In looking at a situation such as this, we should not leap to criticism, but take this situation as an educational and diagnostic challenge to be conquered.








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About the Author

Dr. Paul S. Auerbach is the world’s leading authority on wilderness medicine.