Many people have fevers, aches and diahorrea. Diagnose First, for peace of mind and better care

The following is an extract of a Concept Paper submitted to the Gates Foundation (but was too small in financaial terms) and was submitted to the Global Fund committee in Uganda. It was accepted by Uganda's CCM for Round 10.

Program Goal and Objectives
The Priority Areas to be contributed to in respect of Malaria are:
- Strengthened parasitological diagnosis of fevers (incl malaria) using RDTs and microscopy
- Strengthen programme management to ensure use of combination drugs, not pure Artemesia, and offer clinical alternatives to presumptive treatment with ACTs
- Support prompt diagnosis of fevers and mitigation of symptoms, especially among young and those with weakened immunity.

Studies in Uganda relating to the continued risk of malaria and the benefits of accurate diagnostic methods (RDT or blood slide microscopy) are numerous. Work by the Malaria Control Programme, Ministry of Health and their partners at the Infectious Disease Institute and the studies by the JMUP project and UCSF efficacy of RDTs all support the policy of Diagnose First.

Hope Clinic Lukuli wishes to support Diagnose First in Lukuli parish and the adjoining parishes of Makindye Division through the extensive stocking and distribution of approved RDTs at every health service point. Health service providers will offer the RDT as a necessary consultation tool towards diagnosis and it will be provided alongside rehydration and fever mitigation therapies.

Hope Clinic Lukuli has been accredited by the Ministry of Health as an NGO that is working in collaboration with national and district priorities. We have worked with the Malaria Consortium in a trial of ITN retreatment to become LLINs, we have been stockists of the Coartem brand since its introduction to Uganda and we continue to offer laboratory and RDT diagnosis of fever at the clinic.

Clinically-diagnosed malaria is the leading cause of morbidity and mortality, accounting for 25-40% of outpatient visits at health facilities, 15-20% of all hospital admissions, and 9-14% of all hospital deaths. Nearly half of in-patient deaths among children under five years of age are attributed to clinical malaria. The likelihood of death is hugely increased by delay in starting accurate drug medication of the disease and management of the symptoms, especially dehydration.

Our goal is to build on the work of the MU-UCSF Malaria Research Collaboration on RDT diagnostic protocols and training of health workers. The encouragement to guardians of children and to people who themselves feel they ‘have malaria’ to promptly seek and obtain accurate diagnosis as to the cause of the febrile state will reduce child and general malaria mortality. Whilst continuing IPT for pregnant women, the self diagnosing of ‘malaria’ and then using ACT or pure Artemesia as presumptive treatment is either a waste of centrally funded ACT stocks, a risk to premature resistance among the parasites to the effect of Artemesia and an unnecessary use of the household’s income by miss-treating the symptoms which were perhaps viral or bacterial in cause. We will safeguard the patient by managing the dehydration and febrile symptoms and promote microscopy at the nearest available health facility/ when it next opens for patients.

Hope Clinic Lukuli would map and then train every health service point in Lukuli (less than a dozen) that offer malaria treatment and also those in adjoining parishes of Makindye. In close consultation with the JUMP trainers and with Dr Timothy Musila, formerly of KCC, now Ministry of Health planning department, we have developed a protocol of diagnosis with RDT leading to ACT provision if positive else fever mitigation and rehydration if RDT-negative with referral to a laboratory test during clinic opening hours. We would request Dr M Mubiru to provide oversight.

Each health service point – whether clinic with microscope, dispensary or informal drug shop, would be provided with a stock of commodities for an initial month and monitored and restocked thereafter.

The restock and data collection allows supervision of correct stock usage:
• Approved brand of rapid diagnostic tests with buffers and blood sample extractors
• Printed guide (English and Luganda, with images) of the testing protocol and justification
• Pre-constituted cartons (200ml volume) of ORS formula to Uganda hygiene standards
• Preliminary stock of ACT drugs – Coartem or locally procured and approved brand
• Data collection forms to record use of RDT, dispensing of ORS and decision to prescribe course of ACT or refer to laboratory for microscopy

Each month a tally of tests and dispensing of ACT and fever mitigation drugs will be recorded and support provided through radio and loudspeaker to encourage prompt diagnosis of fevers (which results in free to client ORS) and reduced presumptive use of ACT and trust in diagnose first.