Federal Democratic Republic of Ethiopia

Ministry of Health

Malaria Laboratory Diagnosis

and Clinical Case Management
Quality Assurance Manual for
Malaria Elimination in Ethiopia

MAY 2017
Addis Ababa
Malaria Laboratory
Diagnosis and Clinical
Case Management Quality
Assurance Manual for Malaria
Elimination in Ethiopia

MAY 2017
Addis Ababa
 Foreword
Ethiopia has launched sub-national malaria elimination in March 2017. To
effectively implement the elimination efforts, it was necessary to develop
and use guidelines to inform and guide implementers and health care
workers. The availability of these documents will also standardize the work
on malaria elimination across the country in both private and public sectors.

The effort of developing standardized guidelines is a significant input to the

elimination efforts. Therefore, all partner organizations and all health care
facilities at all levels and places are expected to use this manual. We should
note that as this is the first of such efforts, this manual is updatable and can
be revised at any time given that there are significant developments in the
field.

Once more, the Ministry of Health appreciates the contribution of its

partners to the development of this manual and urges all those who are
involved in malaria elimination efforts to use this manual for ensuring the
right diagnostic procedures are followed.

II
Acknowledgements
The Federal Ministry of Health would like to thank the National Malaria Control
Program for overall coordination of the process, and WHO/AFRO for sponsoring
the workshop that developed this manual.

The Ministry also would like to acknowledge the contributions made by

Malaria Control and Elimination Partnership in Africa (MACEPA) at Program for
Appropriate Technology in Health (PATH), WHO, Columbia University - ICAP in
Ethiopia, and the Ethiopian Public Health Institute (EPHI).

The following individuals are acknowledged for their contributions in the

preparation of the manual:

Name Organization
Abnet Abebe EPHI
Adugna Abera EPHI
Anderson Chinorumba WHO/AFRO
Berhane Tesfaye PATH/MACEPA
Degu Mehari FMOH
Dereje Dillu FMOH
Desalegn Nega EPHI
Gezahegn Tesfaye PATH/MACEPA
Gudisa Asefa FMOH
Hailemariam Lemma CHAI
Hiwot Solomon FMOH
Hiwot Teka PMI/USAID
Kebede Etana FMOH
Mekonnen Tadesse ICAP in Ethiopia
Samuel Girma PMI/USAID
Worku Bekele WHO-Ethiopia
Yonas Petros ICAP in Ethiopia

III
Contents
Foreword ii
Acknowledgements iii
Contents iv
List of Tables vi
List of Figures vi
List of Abbreviations vii
Definition of Terms VIII
1. INTRODUCTION _________________________________________________________1

1.1. Malaria Epidemiology in Ethiopia ______________________________________1

1.2. Structure of Malaria Diagnostic Services in Ethiopia_______________________ 1
1.3. Laboratory Quality Management Systems_______________________________2
2. DIAGNOSTIC TOOLS FOR ELIMINATION_____________________________________2

2.1. Microscopy________________________________________________________3
2.2. Rapid Diagnostic Test ________________________________________________3
2.3. Glucose 6- Phosphate Dehydrogenase Rapid Test_________________________4
2.4. Advanced molecular tests____________________________________________4
3. THE QUALITY ASSURANCE PROGRAM______________________________________6

3.1. Roles and responsibilities of national bodies_____________________________7

3.2. Roles and responsibilities of regional bodies_____________________________8
3.3. National Documents________________________________________________9
3.4. Malaria Microscopy_________________________________________________9
3.5. Malaria and Glucose 6-Phosphate Dehydrogenase Rapid Tests_____________13
3.6. Advanced Molecular Malaria Tests____________________________________13
4. TRAINING____________________________________________________________14

4.1. Curriculums______________________________________________________14
4.2. Training of Trainers________________________________________________14
4.3. Basic Malaria Microscopy Training____________________________________14
4.4. Basic Malaria RDT Training __________________________________________15
4.5. Trainers__________________________________________________________15

IV
 5. EQUIPMENT AND SUPPLIES MANAGEMENT_______________________________15
5.1. Procurement________________________________________________________15
5.2. Specification________________________________________________________16
6. QUALITY ASSURANCE PROGRAM MONITORING _______________________________17

7. QUALITY ASSURANCE OF CLINICAL MALARIA CASE MANAGEMENT________________18

8. REFERENCE_____________________________________________________________21

9. ANNEXES________________________________________________________________22

Annex 9.1. Light microscope preventive maintenance form______________________22

Annex 9.2. Weighing balance equipment preventive maintenance form____________23
Annex 9.3. Giemsa working solution preparation log sheet_______________________24
Annex 9.4. Giemsa Stain Internal Quality Control Result Recording Form____________24
Annex 9.5. Supervisory Checklist for Malaria Microscopy Laboratory Service_________25
Annex 9.6. RDT Lot Testing Procedure________________________________________32
Annex 9.7. RDT on Site Support Supervision Checklist___________________________32
Annex 9.8. Microscope Minimum Requirements _______________________________35
Annex 9.9. Stock Giemsa Reagent Minimum Requirements_______________________36
Annex 9.10. Form 2.02: Malaria RDT Lot-Test Request Form (17-7-2011)_____________36
Annex 9.11. Protocol for Primaquine radical cure for P. vivax at Health Post Level_____38
Annex 9.12. Protocol for Primaquine radical cure for P. vivax at Health Center
and Hospital Levels____________________________________________40

V
 List of Tables
Table 1. Minimum specifications for the procurement of RDTs____________ 28

Table 2. List of indicators for monitoring quality assurance program_______ 29

List of Figures
Figure 1. Ethiopia laboratory structure_________________________________ 2

Figure 2. Malaria testing algorithm____________________________________ 4

Figure 3. The Structure of the Quality Assurance Program_________________ 10

Figure 4. Structure of panel testing___________________________________ 17

Figure 5. Structure of blinded rechecking______________________________ 18

Figure 6. Structure of on-site supportive supervision_________________________ 20

Figure 7. Flow of Pharmaceuticals & Information in the

Integrated Pharmaceutical Logistics System ____________________________ 26

VI
List of Abbreviations
AFRO African Regional Office
API Annual Parasite Incidence
CHAI Clinton Health Access Initiative
DBS Dried Blood Spot
DNA  Deoxyribo-Nucleic Acid
EDTA Ethylene Diamine Tetra -acetic Acid
EHNRI Ethiopian Health and Nutrition Research Institute
ELISA Enzyme-Linked Immunosorbent Assay
EPHI Ethiopian Public Health Institute
EQA External Quality Assurance
FMHACA Food, Medicines and Health Care Administration and Control Authority
FMOH Federal Ministry of Health
FIND Foundation for Innovative New Diagnostics
G6PD Glucose 6 Phosphate Dehydrogenase
ICAP Institute for AIDS Care and Treatment at Columbia University
IQC Internal Quality Control
IPLS Integrated Pharmaceuticals Logistics System
ISO International Organization for Standardization
LAMP Loop-mediated isothermal Amplification
LLIN Long Lasting Insecticidal Net
MACEPA Malaria Control and Elimination Partnership in Africa
MRDT Malaria Rapid Diagnostic Test
NMCP National Malaria Control Program
PATH Partnership for Appropriate Technology in Health
PCR Polymerase Chain Reaction
PFSA Pharmaceuticals Fund and Supply Agency
PMI President’s Malaria Initiative
PT Proficiency Testing
QA Quality Assurance
QC Quality Control
RDT Rapid Diagnostic Test
RRL Regional Referral Laboratory
SLMTA Strengthening Laboratory Management Towards Accreditation
SOP Standard Operating System
TDR Tropical Disease Research
TOT Training of Trainers
USAID U.S. Agency for International Development
WBC White Blood Cell
WHO World Health Organization

VII
Definition of Terms
Terms Definitions
Quality Control Refers to measures that must be included or carried out during each
assay run to verify or ensure that the test is working properly.

External Quality A system by which a laboratory’s performance is checked objectively by

Assessment an external agency or facility or a reference laboratory.
Malaria Elimination The interruption of local mosquito-borne malaria transmission in a
defined geographical area, i.e. zero incidence of locally contracted cases.
Corrective Action Action taken to eliminate the cause(s) of an existing nonconformity,
defect, or other undesirable situation in order to prevent recurrence.
Preventative Action Action taken to eliminate the cause(s) of a potential nonconformity,
defect, or other undesirable situation in order to prevent occurrence.
Accreditation Procedure by which an authoritative body gives formal recognition that
a body or person is competent to carry out specific tasks.
False Positive Rate Is the proportion of test results that indicates the presence of malaria
parasites, when actually there are no malaria parasites.
Invalid Rate The proportion of particular test devices that do not show the control
line after the recommended incubation time during testing.
Lot Testing Quality control testing of a product lot (batch) after release from the
manufacturing site.
Microscopist A person who uses a microscope to read blood films to confirm the
diagnosis of malaria and reports the findings.
Panel Detection A score between 0 and 100, calculated as the proportion of times
Score malaria RDT gives a positive result on all tests from both lots tested
against samples of parasite panels at a specific parasite density.
Parasite Density Number of parasites per microliter of blood detected by microscopic
examination of peripheral blood films.
Proficiency Testing Evaluation of participant’s performance against pre-established criteria.
Quality Assurance A planned and systematic set of activities focused on providing
confidence that quality requirements are being met.
Quality Control A set of activities or techniques for continuously assessing laboratory
work and the emergent results to ensure that all quality requirements
are being met.
Quality Management Management system to direct and control an organization with regards
System to quality.
Sensitivity A measure of the probability for correctly identifying a person with
malaria parasites.
Specificity A measure of the probability for correctly identifying a person with no
malaria parasites.

VIII
1. INTRODUCTION 1.2 Structure of Malaria Diagnostic
Services in Ethiopia
1.1 Malaria Epidemiology in Ethiopia The laboratory services in Ethiopia are divided into
Malaria is one of the main public health problems 4 levels:
in Ethiopia. Plasmodium falciparum and P. vivax are
• Level IV– Ethiopian Public Health Institute
the two most dominant malaria parasite species in
(EPHI), National reference laboratory,
Ethiopia and are prevalent in all malaria endemic
technical research arm of the FMOH
areas with their relative frequency varying in time
and space within a given geographical range. • Level III- Regional reference laboratories,
Approximately 60% of the total population lives Federal specialized referral hospital
in areas at risk of malaria. According to Ethiopia’s laboratories, and Uniformed Forces
Federal Ministry of Health (FMOH), out of the total hospital laboratories and Central Blood
2,627,182 malaria cases reported in 2014/2015, Bank Laboratory
2,210,298 (84.1%) were confirmed by either
microscopy or rapid diagnostic tests (RDT), and • Level II - Regional referral, zonal and
out of which, 1,415,150 (64.0%) were P. falciparum district hospital laboratories
and 795,148 (36.0%) were P. vivax. The other two
species (P. malariae and P. ovale) are very rare and • Level I - Health center laboratories and
are presumed to account for <1% of all confirmed health posts. These are illustrated in the
malaria cases. figure below.

Figure 1. Ethiopia laboratory structure

1
1.3 Laboratory Quality Management mandatory in all health facilities. Other sensitive
Systems tests may be introduced as they become endorsed
for use by the WHO and available in the country.
The MOH/EPHI has recognized the importance and
need to establish quality management systems In Phase II (pre-elimination phase) a national
in all laboratories based on ISO 15189 standards, laboratory quality management system will be
which sets the requirement for quality and put in place and all health facility laboratories in
competency of medical laboratories. In this view, elimination targeted areas will be part of external
many public and private laboratories have already quality assessment scheme. The national and
been ISO15189 assessed by different accrediting regional referral laboratories will take the lead in
bodies and partners supporting accreditation. implementing the external quality assessment
The remaining laboratories are working towards system per the guideline. In Phase III and IV
accreditation through initiatives such as (elimination and prevention of reintroduction
strengthening laboratory management towards phase) all available routine and advanced
accreditation (SLMTA). There is a high degree of (molecular) techniques will be used.
awareness among laboratory personnel on the ISO
15189 standard, with many laboratory personnel It is important for all the diagnostic steps for
trained on ‘Understanding ISO15189 standard’. the different methods (pre-analytical, analytical
and post analytical) to be performed accurately.
Therefore, standard operating procedures (SOPs)
2. DIAGNOSTIC TOOLS FOR will be available in all testing facilities for all the tests
ELIMINATION performed. SOPs on performing diagnostic tests
and job aids have been described in the manual for
Prompt and accurate diagnosis will be performed the laboratory diagnosis of malaria version 1.
for all suspected malaria cases using microscopy
To detect and treat asymptomatic cases during
or RDTs. Microscopy is performed in health centers
malaria elimination, RDT will be performed and
and hospitals where as RDTs are performed at
dried blood spot specimen will be collected and
health posts. In addition, specialized tests will be
transferred to regional or national reference
available for molecular diagnosis of cases, drug
laboratories for molecular testing. If the patient
efficacy studies and contact screening.
is positive for malaria by RDT at health posts
During Phase I (optimization phase) of malaria after treatment within the past 28 days, s/he will
elimination diagnosis with either RDT (health post) be referred to higher health facilities for better
or microscopy (health center and hospitals) will be evaluation by microscopy.

Suspected Malaria Case

No Microscopy (Health Posts) Microscopy Available (Hospitals & Health centres)

Perform RDT Perform Microscopy

Manage Patient as per Results

Figure 2. Malaria testing algorithm

2
2.1 Microscopy • Performing Internal Quality Control (IQC)
Microscopy remains the gold standard for routine • Participating in external quality assessment
malaria diagnosis. Its advantages include: (EQA) programs.
• Accurate, regular and complete reporting
• allows differentiation of malaria species and
parasite stages
2.2 Rapid Diagnostic Test
• allows quantification of parasite density
In Ethiopia, the prevalent plasmodium species
• allows assessment of drug efficacy are P. falciparum and P. vivax. As a result, the
• can be used to diagnose other diseases recommended RDTs are those that can pick both
falciparum and vivax. RDTs have several advantages
However, the quality of the microscopy remains
that include:
unsatisfactory in the absence of essential quality
supplies and competent personnel. Hence, a • RDTs can diagnose malaria using finger prick
robust and regular training and quality assurance blood and are easy to use
program will be implemented
• RDTs do not need specialised buildings or
equipment.
2.1.1 Use of Microscopy
• RDTs give results within a short time, usually
• Initial diagnosis of suspected malaria cases around 20 minutes
• Follow up of patients on malaria treatment Unlike other diagnostic tests that are performed in
• Drug efficacy studies the laboratory setting, malaria RDTs present special
challenges, including:
2.1.2 Specimen Type • Rapid malaria testing is conducted by
• Thick and thin blood films healthcare professionals who do not have
specific laboratory experience.
2.1.3 Reporting • IQC samples for RDTs are not available in the
• No haemo-parasites seen market

• If malaria parasites seen, report : • Proficiency testing for RDTs is not available

- Plasmodia species • Estimation of parasite density cannot be

performed
- Stage of malaria parasites with particular
emphasis on presence of gametocytes • Stage of the parasite cannot be determined

- Count parasites/µl of blood • Histidine-rich protein-2/3 gene deletion in

some of P. facliparum detecting RDTs
2.1.4 Responsibilities of testing
personnel
As a result of these challenges, there is a need for
Laboratory personnel performing microscopy are a robust training program of these non-laboratory
responsible for: staff members to provide them with all the needed
laboratory skills, including specimen collection
• Staining, examination and reporting of blood
and safety and emphasis on procuring quality
film results
products, pre-and post-shipment lot testing and
• Submitting monthly consumption data to ensuring the recommended transportation and
supplies department storage conditions.
• Ensuring proper storage of laboratory supplies
and equipment

3
2.2.1 Use of RDTs primaquine for vivax treatment, then G6PD testing
will be done on samples collected from a given
• Diagnosis of suspected malaria cases at health
focus with reports of suggestive hemolysis.
posts
• Screening of contacts
2.3.1 Specimen Type
N.B: RDTs should not be used for follow up of patients
• Capillary Blood
for treatment outcome since RDTs remain positive for
several days after successful treatment. • EDTA Blood

2.2.2 Specimen Type 2.3.2 Reporting

• Capillary Blood • Report as per manufacturer’s instruction.

• EDTA Blood
2.3.3 Responsibilities of testing
personnel
2.2.3 Reporting
Health workers performing G6PD rapid tests are
• Report as per manufacturer’s instruction
responsible for:

2.2.4 Responsibilities of testing • Performing G6PD RDT as per manufacturer’s

personnel instructions
Health workers performing RDTs are responsible • Submitting monthly usage data to the supplies
for: department
• Ensure proper storage of G6PD RDTs
• Performing malaria RDT as per manufacturer’s
instructions • Accurate, regular and complete reporting
• Submitting monthly usage data to the supplies
department 2.4 Advanced molecular tests
• Ensure proper storage of RDTs
2.4.1 Malaria PCR
• Making a blood smear and DBS during follow
National and regional referral laboratories are
up of patients on treatment
responsible for performing PCR using available
• Sending all blood films and DBS to the nearest PCR platforms.
laboratory
• Accurate, regular and complete reporting 2.4.1.1 Use of PCR
• Participate in EQA (onsite evaluation) of RDT • For differentiating recrudescence and
• Take part in RDT Competency Assessment new infections on suspected treatment
failure cases.
2.3 Glucose 6- Phosphate • To investigate parasite epidemiology
Dehydrogenase Rapid Test from surveys.

Radical treatment of P. vivax involves the use • To assess common drug resistance
of primaquine, which can cause hemolytic genes of plasmodium parasites
anemia in patients with glucose-6-phosphate such as K13 gene for ACT and
dehydrogenase (G6PD) deficiency. Primaquine Pvmdr1 and Pvcrt-o for Chloroquine).
can be given to vivax patients without testing for • To assess the presence of plasmodium
G6PD enzyme with strict and close follow up. This sporozoites in mosquitoes gut and
approach may change through time. If there are salivary gland.
reports of hemolysis problem in patients who take
• Contact screening.

4
 2.4.1.2 Specimen type 2.4.21 Use of LAMP
• DBS • Screening of contacts
• EDTA whole blood • Surveys

2.4.1.3 Reporting 2.4.2.2 Specimen type

• Positive/Negative • EDTA whole Blood
• Plasmodia species • Heparinized Blood
• Presence of drug resistance genes • DBS

2.4.1.4 Responsibilities of testing 2.4.2.3 Reporting

personnel • Positive/Negative
Laboratory personnel performing PCR are • Parasite species
responsible for:
• Presence of drug resistance genes
• Processing samples as per PCR SOP/
manufacturer’s instructions 2.4.2.4 Responsibilities of testing
personnel
• Ordering laboratory supplies and
equipment from the supplies Laboratory personnel performing LAMP are
department responsible for:
• Submitting monthly consumption • Sample analysis as per LAMP SOPs/
data to supplies department manufacturer’s instructions
• Ensuring proper storage of laboratory • Ordering laboratory supplies and
supplies and equipment equipment from the supplies
• Performing IQC department
• Accurate, regular and complete • Submitting monthly consumption
reporting data to the supplies department
• Ensuring proper storage of laboratory
2.4.2 Loop-mediated Isothermal supplies and equipment.
Amplification • Performing IQC
Loop-mediated isothermal amplification (LAMP) • Accurate, regular and complete
of DNA is a molecular technology platform. The reporting
Pan (genus) specific primers detect target DNA
sequence well conserved in all plasmodia species
while the P. falciparum and P. vivax specific primers
are specific for P. falciparum and P. vivax respectively.
While having almost similar sensitivity and
specificity to PCR, LAMP is superior in sensitivity
and specificity to microscopy. The advantage is
that it can be used in fieldwork.

5
3. THE QUALITY ASSURANCE Organizational Structure of Quality
PROGRAM Assurance Program
A hierarchical organizational structure of the
In order to support and facilitate quality assurance quality assurance program based on the structure
of microscopy and RDT in the context of malaria of the laboratory services and functions of the
elimination, a comprehensive quality assurance different levels will be used to coordinate all the QA
(QA) program which comprises all the processes activities. This is described in figure 3 below.
necessary to ensure that the results are accurate,
from blood collection to the delivery of the results
will be implemented.

Figure 3. The Structure of the Quality Assurance Program

6
3.1 Roles and responsibilities of 3.1.2 National Malaria Laboratory
national bodies Diagnosis and Quality Assurance
Coordinator
3.1.1 National Reference Laboratory The National Malaria Laboratory Diagnosis
The national reference laboratory is located in and Quality Assurance Coordinator is a senior
the premises of the EPHI, an autonomous federal laboratory personnel with extensive knowledge
government office accountable to the FMOH. It is of the national malaria control program (NMCP)
responsible for coordinating medical laboratory and proven skills in malaria microscopy and RDT
diagnostic services in Ethiopia. In addition, the diagnosis. He/ she is appointed at national level and
institute undertakes research, based on national is a member of the WHO Certified Expert Malaria
public health research agenda, on priority health Microscopists Reference Group and reports to EPHI
and nutrition problems, and generates, absorbs head and NMCP. His/her responsibilities include:
and disseminates scientific and technological
knowledge to improve the health of the public. • Acting as a communication link between the
EPHI’s responsibilities include the following: NMCP and the Laboratory Services
• Working closely with national reference
• Provide training of trainers on malaria laboratory in coordinating EQA activities
microscopy among the different laboratories and different
• Develop national guidelines and manuals programs.
• Maintain national malaria slide bank • Monitoring and evaluation of laboratory plan
for malaria diagnostic activities.
• Provide proficiency testing to regional
laboratories, uniformed forces and federal • Organizing microscopy training workshops for
hospitals medical laboratory personnel
• Compile and present summary reports on
the EQA program implementation to the 3.1.3 National Malaria Laboratory
stakeholders Diagnosis and Quality Assurance
• Set supervision standards; develop/review Coordinating Committee
checklists The National Malaria Laboratory Coordinating
• Conduct on-site evaluation to all regional Committee is made of senior laboratory
reference laboratories (RRLs) and federal personnel from national laboratory, private sector,
hospitals representatives of WHO Certified Expert Malaria
Microscopists Reference Group, and Pharmaceutical
• Perform lot testing for malaria RDT Fund and Supply Agency (PFSA) and is chaired by
• Perform advanced tests such as PCR, sensitive the Technical Supervisor of national laboratory. Its
ELISA, Serology responsibilities include:
• Conduct community and health facility based • Coordinating the activities of multiple partners
malaria operational researches such as regular
antimalarial drug resistance monitoring, • Resource mobilization, partner coordination
malaria indicator surveys, and monitoring the and budget preparations
of efficacy of chemicals used for IRS and LLINs • Develop and review laboratory policies on
• Malaria monitoring and evaluation through malaria diagnosis
Public Health Emergency Management (PHEM) • Preparing and overseeing implementation
system plans
• Monitoring and Evaluation

10
7
3.1.4 WHO Certified Expert Malaria 3.2 Roles and responsibilities of
Microscopists Reference Group regional bodies
These are laboratory personnel who have been
trained and certified by WHO as expert Malaria 3.2.1 Regional Reference Laboratory
Microscopists. Their roles include:
The regional reference laboratories are mandated
• Training laboratory personnel on malaria by regional health bureaus to support and strengthen
microscopy the laboratory services of respective regions. With
• Rechecking of blood smears regard to malaria elimination, regional reference
• Onsite supervisory visits on malaria microscopy laboratories are responsible to:
• Assist in surveys where examination of blood
• Provide basic training on malaria microscopy
smears is required
and RDT for health facilities under their
• Develop and review the RDT and microscopy catchment
training packages, job aids and Standard
• Establish and maintain regional malaria slide
Operating Procedures (SOPs)
bank
• Conduct competency assessment on malaria
• Provide proficiency testing to peripheral
microscopy
laboratories

3.1.5 Food, Medicine and Health Care • Conduct blinded rechecking of slides of their
catchment facilities
Administration and Control
Authority • Conduct their own internal quality control on
malaria microscopy
The Food, Medicine and Health Care Administration
and Control Authority (FMHACA) regulates the • Compile and present summary reports on the
registration and licensing of in-vitro diagnostics EQA program implementation to the national
among other products. These include laboratory reference laboratory
equipment, reagents and RDTs. The authority is • Conduct on-site evaluation, supportive
also mandated to approve and regulate In-vivo supervision and mentoring at peripheral health
studies including clinical trials on new and already facilities
existing antimalarial drugs and also to register and
• Prepare Giemsa stock solutions, check the
provide license for laboratory professionals.
quality and distribute to peripheral facilities
• Conduct advanced test such as PCR and ELISA
3.1.6 Pharmaceutical Fund and Supply
• Adopt SOPs developed at national level
Agency
PFSA is the national procurement body for medical 3.2.2 Regional Malaria Laboratory
commodities. Its responsibilities include:
Diagnosis and Quality Assurance
• Quantifying, procuring, storage and distribution Quality Officer
of laboratory commodities including RDTs.
The regional laboratory quality officer is senior
• Monitoring the quality of laboratory laboratory personnel with extensive knowledge of
commodities during storage and transportation the NMCP and proven skills in malaria microscopy
and RDT diagnosis. His/her responsibilities include:
• Acting as a communication link between
the regional malaria laboratory services and
regional malaria control program as well as the
link between regional laboratory service and
national reference laboratory

8
• Coordinating EQA activities among the 3.4 Malaria Microscopy
different health facilities in the region
• Organizing microscopy training workshops for 3.4.1 Quality Control
laboratory personnel
All laboratories shall comply with the requirements
• Checks laboratory documents and modifies of ISO 15189 for their internal quality control. This
based on new updates includes daily control and monitoring of each stage
of testing by laboratory personnel to ensure that
3.2.3 Sub Regional and EQA sites all tests are performed accurately and precisely.
Laboratories
The national reference laboratory will strengthen 3.4.2 Equipment Maintenance
certain health facility laboratories with satisfactory Each laboratory will perform daily equipment
performance in EQA to act as centers of excellence maintenance on microscopes, pH meters and
within the region. Where available, these “EQA weighing balances. This should include cleaning of
sites” will perform the following responsibilities. equipment after use and performing manufacturer’s
• Perform EQA to peripheral laboratories recommended scheduled maintenance. This
information shall be recorded on equipment
• Assist peripheral laboratories in carrying out maintenance log sheets and reviewed on a regular
corrective and preventative actions basis. See annex 8.1 and 8.2
• Mentoring of peripheral laboratories in quality
management system development and 3.4.3 Staining Reagent Preparation
implementation
Stock Giemsa stain should be diluted with buffered
• Report to regional laboratories distilled water to obtain a pH of 7.0 to 7.4, with the
optimum being 7.2. It should be prepared when
3.2.4 Health center and health post needed and should be discarded within 8 hours of
Health center and health post level diagnostic tests preparation. Both the stock and working solution
include malaria microscopy at health center and should be stored at room temperature (18°C to
malaria RDT at health post level. The diagnostic 26°C) taking into consideration manufacturer’s
tests at this level provide confirmatory diagnosis for recommendations. The stock solution should be
malaria, in accordance with the national guidelines kept in the original dark glass bottle in a cool, dry,
shady place, away from direct sunlight. The pH of
Health centers and health posts are responsible the buffers and the working solution should be
for performing malaria testing as per set national checked by a pH meter and recorded in the reagent
guidelines and standard operating procedures. This preparation log sheets which will be reviewed on a
include following manufacturer’s instructions and regular basis. See annex 8.3.
performing the tests under the right infrastructural
and environmental requirements. In addition,
health centers and health posts are responsible for 3.4.4 Staining
reporting malaria data to the district health office. Each new Giemsa working solution should be
checked for quality by using known positive and
negative malaria control slides. Malaria-positive
3.3 National Documents blood will be used to prepare positive control thick
EPHI develops and regularly reviews all documents and thin films, which can be stored (for up to 2
(guidelines, manuals, SOPs) for all activities. These weeks in a cool, dark, dry area) and stained at the
address the pre-analytic, analytic and post analytic same time for each batch of patient slides each
processes of all laboratory tests. All laboratories day. Before examining the stained patient slides,
and laboratory personnel should adhere to these the quality control (QC) slides are checked for the
documents. quality of red-cell staining to control the buffer
quality, and white blood cells (WBCs) are examined
for staining of nuclei and granules and of parasite

9
chromatin and red cell inclusions, if present. If the perform malaria microscopy on a set of prepared
QC slides are satisfactory, the patient slides can be slides received from the national and/or regional
examined with confidence. This information will be reference laboratory. This exercise will be used
recorded on the staining internal quality control to check the laboratories’ blood film preparation
reporting sheet. See annex 8.4 and staining process as well as the competency of
the technicians to recognize and identify malaria
parasites present.
3.4.5 Review and corrective action
All IQC data will be reviewed on a regular basis and The national reference laboratory will have well
preventative and/or corrective actions carried out characterized and validated blood film slides and
when necessary. This will involve a detailed root will provide PT to RRLs. The national reference
cause analysis where nonconformance is detected. laboratory will prepare feedback and communicate
results to RRLs. The national reference laboratory
will review PT results of regional reference
3.4.6 External Quality Assessment laboratories and their catchment health facilities
EQA is a process by which a laboratory’s and prepare summary reports for dissemination to
performance is checked objectively by an external stakeholders.
agency or facility or a reference laboratory. This
Regional reference laboratories will use well
can be achieved through panel testing or blinded
characterized and validated blood film slides
rechecking of slides for microscopy; and review
from regional or national slide bank to provide
of laboratory performance by on-site supervision.
PT to sub-regional laboratories and health facility
Both public and private health facility laboratories
laboratories. PT is conducted three times a year for
are expected to participate in the regional EQA
all laboratories. They prepare and communicate
program.
feedback to participant laboratories. The regional
reference laboratories will also prepare summary
3.4.6.1 Proficiency Testing report and share with regional stakeholders and
Proficiency testing (PT) refers to the process by the national reference laboratory.
which laboratories (known as the“test laboratories”)

Figure 4. Structure of panel testing

10
The national reference laboratory shall monitor of laboratories offering routine diagnostic services
the competency of its entire expert microscopists at health facility level. It also detects major
involved in the slide rechecking program, by deficiencies in laboratory performance due to
individually enrolling them in a regular PT incompetence, poor equipment, poor reagents,
scheme three times a year. The national reference poor infrastructure or poor work practices.
laboratory shall keep a database of PT performance
reports and share PT reports with National Malaria The national reference laboratory shall coordinate
Laboratory coordinator and NMCP. the implementation of blinded rechecking program
in the country including blinded rechecking of
The PT schemes will be conducted as per the malaria blood slides for federal hospitals. The
Malaria Laboratory Diagnosis External Quality regional reference laboratories coordinate the
Assessment Scheme Guidelines. implementation of blinded rechecking program in
their respective region. Blinded rechecking of blood
3.4.6.2 Blinded Rechecking of Blood Films films is conducted quarterly for all laboratories. All
summary reports on the performance of peripheral
Blinded rechecking is an important component laboratories shall be shared with regional
of Ethiopian malaria laboratory diagnosis quality stakeholders and the national reference laboratory.
assurance program. It will be used to assess blood Blinded rechecking is performed as per the Malaria
film preparation, quality of staining, and accuracy of Laboratory Diagnosis External Quality Assessment
the result. Rechecking reflects the true performance Scheme Guidelines.

Figure 5. Structure of blinded rechecking

11
 3.4.6.3 On-site supportive supervision personnel and examining a few stained positive and
negative films by supervisors to observe the quality
On-site supportive supervision will be performed
of film. This will be followed by giving feedback
with a standardized supervisory checklist that
to the site coupled with intensive coaching/
provides an overview of malaria microscopy
mentoring to correct all identified deficiencies.
diagnostic services at the site (see Annex 8.5).
The aim of the on-site supportive supervision is The national reference laboratory shall perform on-
to identify and correct deficiencies in laboratory site supportive supervision to regional laboratories
supplies storage and inventory, basic procedures, at least biannually. The regional reference
equipment, quality of reagents, training status of laboratory shall perform on-site evaluation and
the laboratory staff, review of laboratory practical support supervision to peripheral laboratories at
skills, work load, safety and waste disposal system, least biannually. Summary reports of onsite visits
performance of internal QC and result record should be forwarded to the national reference
keeping practice. laboratory. On-site supportive supervision will be
performed as per the Malaria Laboratory Diagnosis
Sufficient time must be allotted for the visit to
External Quality Assessment Scheme Guidelines.
include observation of all the work associated with
malaria microscopy, including preparing blood
films, staining, reading of films by the laboratory

Figure 6. Structure of on-site supportive supervision

12
3.5 Malaria and Glucose 6-Phosphate 3.5.3 Onsite Evaluation and Supportive
Dehydrogenase Rapid Tests Supervision for mRDTs and G6PD
The malaria rapid diagnostic test (mRDT) and tests
glucose-6-phosphate dehydrogenase (G6PD) rapid On-site evaluation will be performed on all testing
tests are fairly easy to perform but errors can arise if facilities performing malaria rapid tests and G6PD
the test kits are not stored properly, test procedure rapid test using standardized supervisory checklists
not performed correctly or results not interpreted (see annex 8.7). The aim of the onsite supportive
correctly. In addition, the infrastructure of the supervision is to identify and correct deficiencies in:
testing facility plays a key role, e.g.
• Storage facilities of rapid tests
• Room size/testing area
• Availability of supplies and equipment (e.g.
• Ambient temperature timers, thermometers, etc.)
• Direct sun light
• Testing infrastructure at facility
• Work surface
• Safety and waste disposal system
• Availability of a timing device
All these parameters will be assessed to ensure • Usage of the testing procedures
quality rapid test results. • Interpretation and recording of results
Pre-and post-shipment lot testing of malaria RDTs All deficiencies identified will be discussed with
will be performed on all procured batches and the facility and intensive coaching and mentoring
will be coordinated by EPHI. See annex 8.6 for lot will be given to correct the identified deficiencies.
testing procedure and form. Where applicable, the necessary recommendations
will be made which might include retraining of
personnel.
3.5.1 Quality Control for mRDTs and
G6PD tests The peripheral laboratories shall conduct on site
supportive supervision to all health posts within
All testing facilities shall store testing kits and
their catchment area at least biannually. All reports
reagents at manufacturer’s recommended
should be forwarded to the regional reference
environmental conditions. This shall include, but
laboratory and a copy retained in the facility.
not limited to, monitoring storage and testing/
assay temperatures for the test kits. The test device
pouch should be checked for any damage before 3.6 Advanced Molecular Malaria Tests
testing. The color of the desiccant pouch should
be checked each time a test device is opened 3.6.1 Quality Control
and it should conform to the manufacturer’s
IQC of PCR, LAMP and other advanced tests shall
recommendations. The test should be considered
be performed as per the requirements of ISO15189
invalid if the control band does not appear for the
in line with the manufacturer’s recommendations.
malaria RDT and if there is no or incomplete blood
All IQC data shall be recorded and reviewed on a
migration for the G6PD rapid test, and in such cases
regular basis.
the test should be repeated with a new test device.
Invalid results, poorly performing kit devices and
damaged kits should be recorded in the mRDT or 3.6.2 External Quality Assessment
G6PD rapid test quality control sheet.
EQA of the national and regional reference
laboratory performing advanced tests shall be
3.5.2 External Quality Assessment for part of the national and broader international EQA
mRDTs and G6PD tests schemes. It is important to note that the laboratories
are working towards ISO15189 accreditation and
Currently the only available external quality hence participate in national and international on
assessment activity for mRDTs and G6PD rapid site assessments and PT.
tests is on-site supportive supervision.

13
4. TRAINING - Malaria RDTs

One of the most important factors in ensuring • Overview

accurate and reliable malaria test results is the • How to perform RDTs
availability of appropriately trained staff to perform
microscopy, RDT testing, advanced molecular tests • Types: Multi-/single species identifying
and the various quality assurance activities. Training RDTs
sessions will be performed using appropriate
trainers and curriculums at the different testing • Other information related to RDTs
levels. Trainings will be conducted for both public
- Recording and reporting
and private sector personnel.
- Quality assurance of malaria laboratory
4.1 Curriculums diagnosis

Several training curriculums are available in - Managing supplies required for malaria
Ethiopia to cater for training of trainers, microscopy laboratory diagnosis
and the rapid tests. Microscopy curriculums are
developed at national level and reviewed regularly - Practical session
for updates. New training curriculums will be
developed as needed upon introduction of new 4.3 Basic Malaria Microscopy Training
diagnostic tools.
The basic malaria microscopy has been conducted
in Ethiopia for several years. The curriculum
4.2 Training of Trainers is designed at national level and used to train
This curriculum is meant for microscopy national laboratory technologists at various levels.
training of trainers (TOT) and is designed to equip
This curriculum is meant as refresher training
them with knowledge on how to facilitate trainings
for all laboratory personnel. It is designed to
in addition to microscopy and RDT knowledge. It is
equip laboratory personnel with knowledge on
a 5-day training. The curriculum has the following
parasite identification, species differentiation and
modules:
quantification. In addition, it is also an opportunity
- Training Basics to equip them with the latest national policy
changes and guidelines. It is a 4-day training and
• How to facilitate an interactive lecture has the following modules:

• How to facilitate activities and discussion - Microscopy

• How to facilitate laboratory skills session • Overview of malaria epidemiology

- Microscopy • Microscope parts, care and handling

• Overview of malaria • Laboratory safety and precaution

• Microscope parts, care and handling • Specimen collection and preparation of

blood films, preparation of stains and blood
• Laboratory safety and precaution film staining
• Specimen collection and preparation of • Malaria microscopy: Examination and
blood films, preparation of stains and blood species identification
film staining
- Recording and reporting
• Malaria microscopy: Examination and
species identification - QA of malaria laboratory diagnosis

14
 - Managing supplies required for malaria 5. EQUIPMENT AND SUPPLIES
laboratory diagnosis
MANAGEMENT
- Practical session
Equipment and supplies for diagnosis of malaria
can vary considerably by type, specifications and
4.4 Basic Malaria RDT Training manufacturers. They are directly related to the
Training of laboratory technologists is carried out final test results, hence choosing quality products
based on the curriculum prepared at national level. is essential. EPHI will come up with specifications
RDT training is part of the practical guide: Malaria for equipment and supplies for PFSA to procure.
prevention and control training module developed Equipment, supplies and testing procedures
by the ministry of health in 2013. shall be standardized to facilitate sustainable
procurement, maintenance and training programs.

4.5 Trainers
5.1 Procurement
4.5.1 National Trainers Below is the flow of procurement processes in
National trainers are trained by WHO certified Ethiopia for public facilities. Private facilities are
expert microscopists. They are responsible for expected to do their own procurement. Fig 7
training regional trainers. below shows the procurement process for public
sector facilities.

4.5.2 Regional Trainers

Regional trainers are trained by national trainers
and are responsible for training within their
regions. Regional trainers will be supported by
WHO certified expert microscopists.

Figure 7. Flow of Pharmaceuticals & Information in the Integrated Pharmaceutical Logistics System

15
5.2 Specification considered to be the most reliable stain in routine
practice due to its applicability to both thick and
5.2.1 Microscopes thin smears, its stability and its consistency and
reproducible staining results over a range of
All facilities performing microscopy are equipped
temperatures. The specifications of the Giemsa
with high quality microscopes purchased from
stain are listed in Annex 8.9.
reputable dealers. These should be well serviced
and maintained for accurate malaria diagnosis. 5.2.4 pH meters
Minimum standards for microscopes are listed in
Annex 8.8. Quality pH meters that read to 2 decimal places
will be used to check the pH of buffers and staining
solutions. All pH meters will be calibrated routinely
5.2.2 Slides or as per manufacturer’s directions.
Plain glass slides with a 20 mm frosted end area and
ground edges are recommended for making blood 5.2.5 Thermometer
films for malaria microscopy. Each slide measures A thermometer should be available in all
76X26X1mm. Slides should be scrupulously free laboratories to continuously measure the
from grease, dust, moisture and fungus. The temperature of the refrigerator, laboratory and
slide box should always be kept closed with the storage room of laboratory supplies.
desiccant pouch inside. Slide boxes should always
be kept away from moisture and dust. Slides 5.2.6 RDTs
should be washed, dried and wrapped if oily, dusty
or suspected to be contaminated with fungus. The procurement of RDTs will be based on WHO/
FIND/TDR panel detection scores- sensitivity,
5.2.3 Stains specificity, false positive rate and invalid rate. The
following minimum specifications (Table 1) will
The recommended stain in Ethiopia for malaria
be used:
microscopy is Giemsa stain. Giemsa stain is

Table 1. Minimum specifications for the procurement of RDTs

CHARACTERISTIC REQUIRED SPECIFICATION

Target species Pf, Pv and other (P. ovale & malariae)
Test format Cassette
Test type Pf, Pv and pan (P. ovale & malariae)
Minimum Panel Detection Score for Pf at 200 75%
parasites/μL
Minimum Panel Detection Score for PV at 200 75%
parasites/μL
Maximum False Positive rate 10%
Maximum Invalid Rate 5%
Temperature Stability Up to 45°C

16
 5.2.7 Dry blood spot card 5.2.10 Stock management
Filter paper for collection of dry blood spots will be Stock management at all levels is through use of
available bin cards and stock cards.

5.2.8 Timers 6. QUALITY ASSURANCE PROGRAM

Timers will be used for timing the staining and MONITORING
procedure for performing malaria RDTs. Cellphones
are not recommended for safety reasons. The performance of the QA program will be
monitored at all levels of implementation. The
5.2.9 Safe waste management system national level and the individual regions should set
achievable targets in each financial year depending
All Laboratories should have waste containers for on their resources, malaria epidemiological picture
infectious and non- infectious solid waste, and and work load and monitor progress of their
sharp containers which will be used for disposal of activities accordingly. The following indicators
lancets and others including needles. (Table 2) will be used.

Table 2. List of indicators for monitoring quality assurance program

Frequency of
Indicator Target Level
Measuring
Number of WHO certified expert malaria 12 Every three National
microscopists (level 1&2) years

Proportion of RDT batches pre and post 100% Annually National

shipment lot tested

Proportion of RDT batches tested post 100% Annually National

distribution

Proportion of laboratories participating in 75 % Three times a National &

Proficiency Testing year Regional
Proportion of laboratories participating in 100% Quarterly National &
blinded rechecking of blood films Regional
Proportion of laboratories visited for 100% Biannually National &
onsite support supervision Regional
Proportion of health posts visited for 100% Biannually National &
malaria RDT onsite support supervision Regional
Number of laboratory personnel trained 100% Biennial National &
in malaria microscopy Regional
Proportion of laboratories participating in 100% three times a National &
Proficiency Testing scoring ≥80% year Regional

Proportion of laboratories participating in 100% Quarterly National &

blinded rechecking scoring ≥80% Regional

Number of personnel trained in RDT 100% Biennial National &

Regional
Proportion of RDT performing sites scoring 100% Biannually National &
>80% in onsite support supervision Regional

17
7. QUALITY ASSURANCE OF to PQ. AL is contraindicated in first
trimester pregnancy and such patients are
CLINICAL MALARIA CASE treated with quinine tablets
MANAGEMENT
• Uncomplicated P. vivax cases will be
Quality assurance of clinical case management treated with chloroquine (CQ) and radical
refers to regular assessment of malaria diagnosis cure PQ unless contraindicated. For
and treatment practices tied with improvement implementation purpose, radical cure will
plans so that malaria case management practice is be started at elimination targeted districts
as per the recommendation of the national malaria and will be scaled up nationwide when
guidelines. Quality assured laboratory test result feasible. PQ is recommended to be started
is one of the inputs for quality assured clinical at the time of CQ initiation. See the annex
case management, and clinicians need additional for protocol and register of radical cure PQ
inputs like appropriate training and desktop
references. Audits are important tools to assess • Uncomplicated mixed P. falciparum and
and continuously improve the quality of malaria P. vivax infection is treated with AL and
case management. single dose PQ if the diagnosis is with
RDT and AL plus radical cure PQ if the
Recommendations of the national malaria diagnosis is with microscopy. AL and PQ
guidelines are contraindicated during first trimester
pregnancy and such patients will be
• All malaria suspected patients should be treated with quinine tablets
tested for malaria with recommended testing
methods: malaria suspect is a patient who has • Complicated and severe malaria is treated
fever and lives in malaria endemic area or has with IV/IM Artesunate followed by full
history of travel to malaria endemic area in the course AL
past 30 days. In pre-elimination and elimination
phases malaria suspect includes people living • All patients with malaria should be given the
within 100 m radius of a confirmed malaria following key messages
case. Clinicians should ask all febrile patients
• He/she has got malaria
for malaria risk (living in malaria endemic area
or travel to malaria endemic area). All patients • The medication has to be taken as
who are suspected to have malaria should be prescribed completely (full dose)
tested with RDT if they are seen in health post
or microscopy if they are seen at health center • Early treatment is important to prevent
or hospital level severe illness and death due to malaria

• All patients with confirmed malaria should • Take/give enough food and fluid (especially
be treated with the recommended specific fatty meal to enhance drug absorption
antimalarial drug and supportive care: and to avoid risk of hypoglycemia).

• Uncomplicated P. falciparum cases should • To return to the health facility if fever

be treated with Artemether-lumefantrine persists or patient is still sick after 72 hours
(AL) and single dose primaquine (PQ) to or any time before 72 hours if condition
clear the gametocytes and reduce onward worsens
transmission. G6PD testing is not required.
Primaqine is contraindicated in pregnancy, • Malaria is transmitted by mosquitoes
infants less than six months old, women • Malaria can be prevented by using
breast feeding infants less than six months insecticide treated nets, eliminating
and in people with known hypersensitivity

18
 mosquito breeding places, and protecting Audit tool
sprayed houses from re plastering

• All patients with malaria (clinical or confirmed) Health post level

should be recorded on tally sheets or registers Review malaria (or relevant) register

• All patients with negative test result should be • Number of patients seen in the previous month
evaluated for other causes of fever
• Number of malaria suspected patients that are
• All pregnant women with malaria should be tested for malaria with RDT
treated according to the national guideline
• Number of patients with confirmed malaria
• Uncomplicated P. falciparum that are treated according to the national
guideline
• First trimester: Quinine tablets
• Number of patients with negative test result
• Second and third trimesters: AL that are treated with antimalarial drugs
• Severe malaria • Number of pregnant women with malaria that
• First trimester: parenteral Artesunate are treated according to the national guideline
followed by quinine tablets • Observe febrile patient HEW interaction
• Second and third trimesters: Parenteral • Number of interactions observed
Artesunate followed by AL
• Number of patients with malaria that are
• All health care providers of malaria should be given key messages
trained on malaria case management
• Number of patients with malaria (clinical
• Patients with severe malaria should get first or confirmed) that are recorded on
dose in the OPD (with in the first 2 hours) registers
• Referred severe malaria cases should get pre- Review the ICCM register, if available (previous one
referral treatment month) and document the following
Clinical audit is a preferred way of ensuring that • Number of children seen in the previous month
these recommendations are implemented as per
the guideline. Chart review will be conducted • Number of children with fever
to assess diagnosis and treatment of malaria
cases. Clinician-patient interaction will be • Number of febrile children that are tested for
observed to assess the degree to which key malaria with RDT
messages are delivered and important job aids
• Number of children diagnosed with malaria
are available. Pharmacist-patient interaction will
also be observed to assess adherence support. • Number of children treated according to the
A standardized audit tool shall be used to audit national guideline
malaria case management services. The assessment
will be followed by quality improvement plan • Number of tested children without malaria
with responsible bodies and time line. The who are treated with antimalarial drugs
quality assessment cycle will be conducted every
quarter for each facility and the quality unit of the Summary of findings
health facility will be responsible to conduct the Strengths
assessments Weaknesses
Recommendations with responsible person and
timeline

19 22
Health center and hospital level • Observe febrile patient clinician interaction
Review 5 charts of severe malaria cases (since last • Number of interactions observed
quality assessment) and identify 20 consecutive
• Number of patients with malaria that are
patients with fever from adult OPD register, 20
given key messages
from pediatric OPD register and determine the
following: • Number of patients with malaria (clinical
or confirmed) that are recorded on tally
• For severe malaria charts sheets or registers
• Number of severe malaria charts reviewed • Review the IMNCI register (previous one
month) and document the following
• Number of patients who were given IV/IM
Artesunate • Number of children seen in the previous month

• Number of patients who were shifted to • Number of children with fever

AL after at least 24 hours of treatment
• Number of febrile children that are tested for
• Number of patients with severe malaria malaria with microscopy
who got first dose of IM/IV Artesunate in
the OPD (with in the first 2 hours) • Number of febrile children that are tested for
malaria with RDT
• Number of referred severe malaria cases
who were given pre-referral treatment • Number of children diagnosed with malaria

• Number of severe malaria cases that die in • Number of children treated according to the
the hospital national guideline

• Charts of identified febrile cases • Number of tested children without malaria

who are treated with antimalarial drugs
• Number of malaria suspected patients
that are tested for malaria with microscopy Summary of findings
• Number of malaria suspected patients Strengths
that are tested for malaria with RDT
Weaknesses
• Number of patients with confirmed
malaria that are treated according to the Recommendations with responsible person and
national guideline timeline
• Number of patients with negative test
result that are treated with antimalarial
drugs
• Number of pregnant women with malaria
that are treated according to the national
guideline

20
8. REFERENCE
Federal Ministry of Health. National Malaria Strategic Plan 2014 – 2020. June 2014, FMOH, Addis Ababa.

Ethiopian Health and Nutrition Institute. Malaria Laboratory Diagnosis External Quality

Assessment Scheme Guidelines, 2009. EHNRI, Addis Ababa, Ethiopia

National Department of Health. National Malaria Diagnosis Quality Assurance Guidelines.

2011. Department of Health, Pretoria.

World Health Organization. Malaria Microscopy Quality Assurance Manual. WHO, 2015

Ministry of Health. Malaria Microscopy Quality Assurance Guideline. 2007. Draft. Zanzibar.

Ministry of Health. Malaria QA/QC Laboratory Manual, Botswana Laboratory Services.

Ethiopian Public Health Institute. Malaria Laboratory Diagnosis External Quality Assessment

Scheme Guidelines, 2015, EPHI, Addis Ababa, Ethiopia (Under Printing).

Federal Ministry of Health of Ethiopia. HSDP IV Annual Performance Report EFY 2006

(2013/2014). FMOH, 2014. Report No.: Version 1.

PFSA. Standard Operating Procedures Manual For The Integrated Pharmaceuticals Logistics

System In Health Facilities Of Ethiopia, Second Edition, Addis Ababa, Ethiopia, November, 2015

WHO. A Framework For Malaria Elimination, World Health Organization 2017.

EHNRI. Manual For The Laboratory Diagnosis Of Malaria, First Edition, Ethiopian Health

and Nutrition Research Institute, Ministry of Health September, 2012, Addis Ababa

EPHI. Master plan for the Public Health Laboratory System in Ehiopia, second edition, 2009,

Addis Ababa.

21
9. ANNEXES
Annex 9.1. Light microscope preventive maintenance form
Month/Year: Equipment #: Serial #: Location:
DAILY MAINTENANCE (ü) Supervisor
Date Operator’s MONTHLY MAINTENANCE (ü)
Review
Name
Remove Clean Clean Turn off Cover Clean body of Clean eyepieces, Remove & clean Initials Date
oil from stage condenser light microscope microscope objectives & slide holder
objectives condenser
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

22
Annex 9.2. Weighing balance equipment preventive maintenance form
Clean balance on each day of use

Equipment #: Serial #: Location:

Month/Year: Month/Year:

Date Operator’s Cleaned? Supervisor review Date Operator’s Cleaned? Supervisor review
name (ü) Initials Date name (ü) Initials Date

1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 25
26 26
27 27
28 28
29 29
30 30
31 31

In order to carry out maintenance, review instructions described in the SOP and the equipment user’s
manual. Any problem or malfunction detected must be reported to the supervisor. Record any equipment
failure or problem on Equipment Problem Summary Form.

23
Annex 9.3. Giemsa working solution preparation log sheet
Preparation date Buffered Distilled Giemsa stock pH of working Tech Initials Supervisor
Water solution & Date Initials &
(7.2±0.2) Date
Lot # Expiry date Lot # Expiry date

Frequency: Perform QC on each batch of working Giemsa stain prepared

Materials: Use known positive and negative malaria slides

Annex 9.4. Giemsa Stain Internal Quality Control Result Recording Form
Region: __________________________ Zone__________________________ Woreda:
__________________ Facility: ___________________________

Sr. Date QC Storage Date of Date IQC IQC IQC Blood IQC Corrective Name & Remark
No. Blood Temp. of opening of Performed Blood Film Film Type Result Action Signature
film QC Blood Giemsa Stock ID (Positive or (Passed Taken (who
Prepared Film solution Negative or Failed) (if it is performed
Control) failed) IQC)
Neg Pos.

24
IQC will be performed NOTE:

• For every new batch of Giemsa stain • Frequency: Perform QC on each batch of
solution. working Giemsa stain prepared

• Regularly • Materials: Use known positive and negative

malaria slides
• When unexpected staining result observed
while examining blood film.
Annex 9.5. Supervisory Checklist for
QC Passed Means Malaria Microscopy Laboratory Service
• The background should be clean and free Region______________
from debris
Zone_____________ Woreda______________
• The color of erythrocytes is a pale green
Name of health facility _______________________
pink.
Name of laboratory department head___________
• Leukocytes nuclei are a deep rich purple. ___________________
• Malaria parasites are well defined with Tel. No_________________
deep-red chromatin and pale purplish, blue
cytoplasm Fax_________________________________

Storage temp. of QC blood film Date of onsite supervision conduct

ed_______________________________
• Below zero ˚c (Recommended) or

• Room temp.

Comments: ________________________________
___________________________________

Reviewed by: _______________________

Sign.____________________

Date: __________________

1. Training

No Questions Responses

Total No. Of lab staff___ Name of When was s/ How long was Who provided Comments
Number of laboratory trained staff he trained? the training? (# the training?
personnel trained on in the fiscal (mm/yyyy of Days) (Organization)
malaria microscopy___ year EC)

Comments

25
2. Malaria microscopy laboratory format and supplies

Are the following Items 1. = Available and being used

malaria microscopy 2. = Available, but not used
formats and other 3. = Not Available
materials available?
Malaria microscopy guideline
SOP for malaria microscopy
Laboratory result log book
Job aids
Weakly /monthly report form for malaria
Are the following Item 1 = Available and being Enough
reagents and other used for the
Laboratory 2 = Available, but not used coming 4
commodities 3= Not Available Months
1= Yes
available? 4= Not Applicable
2=No
Absolute methanol
Absorbent cotton wool
Beaker/volumetric flask
Binocular microscope with electric source of light
Brown bottle
Distilled water
Drying rack
Funnel
Giemsa powder/Giemsa stain stock solution
Glass beads
Glycerol
Immersion oil
Timer
Lens cleaning solution
Lens paper
Measuring cylinder
Microscope slides
Glass-writing pen/lead pencil
Slide boxes
Staining rack
Staining jar
Tally counter
Tissue paper
Reagents labeled with its name, date of preparation and expiry date 1-Yes
(observation) 2- No

I.

26
3. Equipment
How many Brand name # # Non Specific problem Remar
electric (for the first EQA cycle but for Functional Functional (examine stained blood
binocular other cycle fill this column if film slide to fill this
microscopes there is New arrival) column)
do you have?

Total

4. Malaria microscopy skill assessment

Who is responsible for 1. Laboratory personnel o
sample collection? 2. Non laboratory personnel
o
3. If non laboratory personnel, specify

Which type of blood film 1. Always thin smear o

do you use for malaria 2. Always thick smear
o
diagnosis? 3. As necessary
4. Always both (in the same slide or separate slide) o

Quality of thick and thin 1. Excellent o

films? 2. Good
o
(observation) 3. Poor

How do you dry the film? 1. Air dry o

2. Heat dry

Which part of the film (thin 1. Thin o

or thick) do you fix? 2. Thick
o
3. Both

How many fields do you 1. <25 o

examine to report a negative 2. 50 o
result (no parasites)? 3. 100 o
4. 200
o
5. ____________

Do you report positive 1. Species only o

results by identifying species 2. Stages only o
and parasite stages? 3. Both o
4. None

Do you quantify positive • Yes o

results (parasite density)? • No
• If yes, which method specify
__________________________
27
 When using WBC method, 1. 50 WBC o
how many WBC do you 2. 100 WBC o
count to quantify a parasite o
3. 200 WBC
load?
4. 500 WBC o
5. Not applicable
Do you clean the microscope 1. Yes o
or objective lenses prior to 2. No
starting microscope reading
and at the end of the day?
What do you use for 1. Cotton o
microscope lens cleaning? 2. Lens paper o
3. Tissue paper o
4. Other ____________________

Which reagent do you use 1. Giemsa o

for blood film staining? 2. Wright
o
3. If other, specify_____________?

For Giemsa stain

Do you prepare the stock 1. Preparing reagent o
reagent or use ready-made 2. Readymade reagent
reagent?
How often do you prepare 1. Every 24 hrs o
the working reagent? 2. Prior to staining
o
3. Other specify_____________

What is the commonly used 1. Brown bottle o

reagent container to store 2. Any transparent bottle
the stock stain? o
3. If other, specify ________________

Where do you store the stock 1. Away from direct sunlight and moisture in lockable o
reagent? 2. cabinet
Other, specify_________________

Have you ever interrupted 1. Yes o

malaria laboratory services 2. No
due to shortages of reagents, o
If yes,
supplies and microscope
1. Cause of interruption____________
problem?
2. For how long ______________ o
3. How many times in the last 4 months ________
o

28
Have you experienced 1= Yes o
some difficulties with your 2= No o
microscope during the last 4
If yes,
months?
1. with the Stage o
2. with the objective o
3. other specify,________________

Do you have an inventory list 1. Yes o

of supplies and stains? 2. No
How often do you receive 1. Monthly o
supplies like stains and 2. Every 6 months o
others?
3. Once a year

Do you have difficulties 1. Yes o

receiving your supplies? 2. No o
3. If yes, why _____________________________

Do you store patient blood 1. Yes o

(with EDTA) known to have 2. No
parasites
Do you keep slides for 1. Yes o
rechecking? 2. No o
3. If no, why? _____________________________
Have you been supervised in 1. Yes o
the past 6 months? 2. No o
3. If yes, specify the supervisor _______________
Is a standard laboratory 1. Yes o
register book in use? 2. No o
3. If not, why? ________________
Is a standard laboratory 1. Yes o
request form in use? 2. No o
3. If not, why? ________________________

29
5. Quality Assurance

Internal Quality Control (QC) Practiced

Do you prepare positive and negative 1. Yes o

slides for reagent quality control 2. No, if no why? __________________
purposes?
When do you conduct internal quality 1. Weekly o
control for malaria microscopy? 2 Monthly
3. Upon opening of new batch_
4. During unusual staining results
5. Others, Specify _________

Are stained slides ever rechecked by a o

person in the laboratory? 1. Yes
2. No, if no why? __________________

EQA practiced

Are stained slides validated regularly, o

and feedback obtained? 1. Yes
2. No, if no why? __________________

Do you participate in an EQA scheme, o

and is feedback obtained 1. Yes
2. No, if no why? ____________________

6. Safety and waste Disposal

Are gloves and gowns worn while 1. Yes o
performing the procedure?
2. No, if no why? _______________
Are a safety box/sharp container and non- 1. Yes o
sharp container available and placed in the 2. No, if no why?______________
right position?
Is the working area clean and 1. Yes o
decontaminated before/after procedures? 2. No, if no why? __________________

Is waste disposed of in the appropriate 1. Yes o

container (sharp material to sharp container 2. No, if no why? ___________________
and non-sharps to non-sharp container)?

30
2. How many blood film slides have been examined during the last four months?

Year Positive Negative Total

Malaria Other
Pf Pv Mixed Others Hemoparasite
Pf and Pv (specify)

3. SUPERVISORS’ COMMENTS (best practices, major problems identified, suggested solutions) on

MALARIA MICROSCOPY

BEST PRACTICES: _______________________________________________________________________

______________________________________________________________________________________
______________________________________________________________________________________
_________________________

MAJOR PROBLEM IDENTIFIED: _____________________________________________________________

______________________________________________________________________________________
______________________________________________________________________________________
_________________________

SUGGESTED SOLUTIONS: _________________________________________________________________

______________________________________________________________________________________
______________________________________________________________________________________
_________________________

SUPERVISORS
NAMESIGNATURE
1._____________________________ ______________________
2._____________________________ ______________________
3._____________________________ ______________________

31
Annex 9.6. RDT Lot Testing Procedure 4. A form and instructions will be sent to you,
complete with details regarding the volume
Materials
of RDTs required and the instructions for
1. WHO/FIND Form 2.02: Malaria RDT lot test shipment.
Request form
5. Return the completed request form to the lot
2. 100 RDT kits testing coordinator.

3. Shipment boxes 6. Upon arrival of test kits, select 100 RDT kits
(number requested by coordinator), preferably
4. Ice packs from different boxes in different shipment
pellets.
5. Temperature monitoring devices
7. Monitor storage temperature if RDTs are to be
Procedure kept prior to shipment.
1. Complete form 2.02 at least 2 weeks prior to 8. Pack RDT kits in boxes and insert a temperature
date of shipment arrival. monitoring device. Include a copy of the hard
2. Email completed form to Malaria_rdt@who.int copy of form 2.02 and temperature monitoring
and copy to the Lot testing coordinator, nora. chart.
champouillon@finddiagnostics.org. 9. Complete airway bill and ship to the address
3. File the hard copy of completed form 2.02 provided by the lot testing coordinator.

Annex 9.7. RDT on Site Support Supervision Checklist

MALARIA RDT ON-SITE SUPPORTIVE SUPERVISION CHECKLIST

GENERAL INFORMATION
NAME OF FACILITY:

NAME OF HEALTH DISTRICT:

NAME OF TESTING PERSONNEL:

PROFFESSION OF TESTING
PERSONNEL:
NAME OF ASSESSOR (S):

DATE OF ASSESSMENT:

TESTS KITS IN USE

32
1. INFORMATION ON TESTING PERSONNEL

For each step below, tick Yes, No or Cannot determine

Yes No Cannot
Determine
1.1 Was the testing personnel trained in Malaria Rapid
Diagnostic Testing?
1.2 Is the testing personnel confident in the results of the
Malaria RDT?
1.3 When was the last on site assessment for malaria RDT
done?
1.4 How many years have the testing personnel been
performing malaria RDT?
1.5 How many tests does the testing personnel perform per
month on average?

2. DEMONSTRATION/OBSERVATION OF MALARIA RDT PROCEDURE

Was this test done on a real patient?

Circle the correct answer: 1=Yes 1 Y 2 N Comments
2=No.
For each step below, circle 1 if the Health worker performed the step correctly, circle
2 if the Health Worker performed the step incorrectly, circle 3 if the Health worker
skipped the step, circle 4 if not evaluated
2.1 Assemble all the required accessories
(kits, 70% alcohol swab, dry cotton
1 2 3 4
swab, buffer, pipette, sharps container,
lancet & gloves)?
2.2 Use clean testing basin/ surface for the
1 2 3 4
pipette and dry cotton swab?
2.3 Put on new pair of gloves? 1 2 3 4
2.4 Check expiry date on test kits and
1 2 3 4
buffer?

2.5 Write patient’s name/ ID on test kits? 1 2 3 4

2.6 Place testing cassette on a level surface? 1 2 3 4

2.7 Clean finger with antiseptic / alcohol? 1 2 3 4
2.8 Allow finger to dry before pricking it? 1 2 3 4
2.9 Use a sterile lancet for finger prick? 1 2 3 4
2.10 Puncture off center on the fingertip? 1 2 3 4
For each step below, circle 1 if the Health worker performed the step correctly, circle
2 if the Health Worker performed the step incorrectly, circle 3 if the Health worker
skipped the step, circle 4 if not evaluated
2.11 Dispose lancet in sharps bin
1 2 3 4
immediately after pricking finger?
2.12 Avoided air bubble during sample
1 2 3 4
collection?
2.13 Collect enough blood with the
1 2 3 4
collection device for testing?

33
2.14 Dispense blood with device correctly? 1 2 3 4
2.15 Put correct volume of blood on testing
1 2 3 4
device?
2.16 Dispose blood collection device in a
1 2 3 4
biohazard bag immediately?
2.17 Dispense buffer with bottle in an
1 2 3 4
upright position?
2.18 Dispense the correct number of drops
1 2 3 4
of buffer?
2.19 Incubated the test for the right
1 2 3 4
amount of time?
2.20 Read Test results correctly? 1 2 3 4
2.21 Interpret the results correctly? 1 2 3 4
2.22 Record results in register? 1 2 3 4
2.23 Dispose gloves, wrappers, alcohol
1 2 3 4
swabs and desiccant safely?

Yes No Comment
Testing Facility Is there consistent testing temperature
monitoring?
Is there consistent storage temperature
monitoring?
Is lighting sufficiently available in all testing
rooms?
Are all Kits in use within the stated shelf life?
Are SOPs available where testing is
performed?
Purchasing
and Inventory
Are functional timers available for use where
testing is performed?
Are buffers available?
Are kits and reagents stored under
appropriate environmental conditions?
Is space adequate for storage of kits and
accessories?
Are personnel following “first expiry, first out”
method when managing stock?
Where there any stock outs in the past 6
months?
Is there a procedure for re-ordering kits and
accessories?
Records Are results interpreted and recorded
according to protocols?
Are records kept in a safe and secure place?

3. CHALLENGES
3.1 What are the challenges that the health care worker faces in the process of doing his/her duties?

34
Annex 9.8. Microscope Minimum Requirements
• Microscope must be completely UL*, CSA* and CE* tested, listed, and approved to ensure fire and/or
shock safety.

• Must have10x/18mm eyepieces.

• Must have auto compensating Siedentopf style binocular with diopter scale for interpupillary distance
(must have visible diopter scales).

• Must have 4-position reversed nosepiece of metal construction with internal ball bearing stops.
External clip system not acceptable.

• Must have 4x HI-Plan, 10x HI-plan, 40x HI-plan, and 100x oil HI-plan par focal and par centered infinity
corrected objectives.

• Mechanical stage must be of built-in design with metal rack and pinion X-Y drives. No polymer belts,
metal cables, timing belt systems or non-metallic components are acceptable in the drive mechanism.
Coaxial controls must be low mounted for ease of use.

• Pre-aligned Abbe condenser with graduated iris diaphragm wheel with markings to show where iris
aperture should be set for each objective magnification.

• Focus drive must be a self-tensioning, three ball design of all metal construction. Fine focus must
have graduations of 100 divisions and 3 microns per division. Focusing knobs on both sides must
have these markings.

• All gears throughout the microscope: mechanical stage, focus, condenser rack and pinion must be
made of metal, brass, stainless steel or aluminum – no plastic components.

• Illumination system must be designed for 12v/35w tungsten halogen 2,000 hour average life bulbs.

• Microscope must have hinged lamp door that is angled to help prevent breakage. Sliding “drawer”
type bulb covers not acceptable for safety reasons.

• Must have blue filter fixed into its mount, not loose. In Koehler kits, lollipop filters have “locking slots”
to prevent them from falling out when tilted.

• Microscope base temperature must not exceed 37 degrees centigrade using a 12v/20w halogen lamp
at full voltage for 6 hours.

• Power supply must be voltage sensing 85-265 volts with surge suppression and soft start lamp control.

• Lamp intensity must be conveniently located in stand armrest and controlled via an illuminated
rotating wheel.

• Stage finger assembly is to be slide friendly that does not damage or break slides.

• Microscope must have ergonomic design.

*UL: Underwriters Laboratories Inc.

*CSA: Canadian Standards Association
*CE: Conformance European

35
Annex 9.9. Stock Giemsa Reagent Minimum Requirements
Aspect Specification
Container Brown glass bottle
Appearance Color Dark Green to Very Dark Green and Black and Green-Black

Appearance Form Powder or Crystals

Concentration 0.67M
Formulation (When not commercially prepared) Glass beads, 3.0 mm
30.0 ml Absolute methanol,
acetone-free 270.0 ml
Giemsa stain powder (certified)
3.0 g Glycerol 140.0 ml

Wavelength 647 - 653 nm Absorbance ≥ 0.6

Wavelength 520 - 526 nm Absorbance ≥ 0.3
Wavelength 288 - 294 nm Absorbance ≥ 0.3
Wavelength 243 - 249 nm Absorbance ≥ 0.2

Annex 9.10. Form 2.02: Malaria RDT Lot-Test Request Form (17-7-2011)
TRANSPORT DETAILS

REQUESTING INSTITUTION
(Institution/Organization requesting for testing)
SENDING INSTITUTION
(if different from the Requesting Institution)
DATE SENT (dd/mm/yyyy)

RDT DETAILS
QUANTITY PROVIDED
RDT PRODUCT NAME CATALOGUE EXPIRY DATE
MANUFACTURER LOT NO. NO. OF NO. OF TESTS/
(as in product insert) NUMBER dd/mm/yyyy
BOXES BOX
(Delete/extend rows as
necessary.)
Temperature monitor included in the shipment: Yes No (Not routinely included)
If “yes” send the monitor together with RDTs to the testing institution (RDT QC laboratory)

36
TESTING DETAILS: Sending institution should insert the number of RDTs sent and an explanatory
note in blank cells below if the number of RDTs sent varies from the specified number through prior
agreement.

The number of RDTs sent may be varied for non-routine testing.

Minimum number of RDTs required per lot
Discuss with lot-testing coordinator and insert details below
Pf-only RDTs: 100 tests

Combination RDTs: 150 tests

Additional comments from the requestor

CONTACT DETAILS FOR RECEIPT OF RESULTS:

(Delete/extend columns as necessary.)

CONTACT PERSONS NAME

POSITION
INSTITUTION/ADDRESS
TEL. /FAX NO.
EMAIL ADDRESS

NOTE: This form should be sent by email prior to sending the RDTs to Malaria_rdt@who.int and the
lot-testing coordinator (at June 2010, nora.champouillon@finddiagnostics.org) or the email contact
specified on the WHO RDT website www.wpro.who.int/sites/rdt ). Include also a hard copy with the RDTs.
A summary of results report will be published regularly and this will include the product name but the
procurer agency name will be excluded

37
Annex 9.11. Protocol for Primaquine radical Mg
Number of 15mg
tablets
cure for P. vivax at Health Post Level Body weight (kg)
based on PER DAY FOR 14
Plasmodium vivax accounts for 33% of malaria 0.25mg/kg DAYS
cases in Ethiopia (MIS, 2011). It is characterized 5-14 1.25 to 3.5 ¼
by frequent relapses and the administration of 15-24 3.75 to 6 ½
primaquine radical cure reduced relapses by 40% 25-34 6.25 to 8.5 ½
during 15 months of follow up (WHO). The FMOH is 35 -60 and more 8.75 to 15 1
planning to introduce primaquine for plasmodium
vivax as radical cure. It will be a phased approach Adverse Events
where selected districts will implement initially Primaquine is generally well tolerated.
followed by all elimination targeted districts and
finally all over the country. The safety of primaquine • Dose-related gastrointestinal discomfort,
is not yet fully established and this approach will including abdominal pain, nausea and
help to scale up this important intervention. This vomiting (Administration with food improves
document outlines the standard protocol to be tolerability).
used at health post level.
• The most important adverse effect is
Mode of implementation hemolysis in some patients. This adverse
It will be implemented in selected districts from event may be seen occasionally in Ethiopian
malaria elimination districts. The experience will patients. Fortunately, primaquine is
be systematically documented. This will help us to eliminated from the body rapidly, so that
learn from limited sites before going to scale. hemolysis stops once the drug is stopped.
Contraindications
Dose and administration of primaquine
Primaquine is given for patients with plasmodium • Known hypersensitivity to primaquine
vivax. It may be repeatedly administered if the • Women breast feeding infants less than six
patient has repeated attacks of plasmodium vivax months old
malaria. Primaquine will be given at a dose of 0.25
mg/kg body weight per day for fourteen days. It • Infants less than six months
should be administered with food to prevent the • Pregnancy
gastrointestinal side effects
• Use the following checklist to reasonably rule out pregnancy
No Questions Yes No
1 Did your last menstrual period start within the past 7 days?
2 Have you abstained from sexual intercourse since your last
menstrual period or delivery?
3 Have you been using a reliable contraceptive method
consistently and correctly since your last menstrual period
or delivery?
4 Have you had a baby in the last 4 weeks?
5 Did you have a baby less than 6 months ago, are you fully or
nearly fully breast feeding, and have you had no menstrual
period since then?
6 Have you had a miscarriage or abortion in the past 7 days?

Interpretation:
If the client answered YES to at least one of the questions and she is free of signs or symptoms of pregnancy (see below),
you can be reasonably sure she is not pregnant.
If the client answered NO to all of the questions, pregnancy cannot be ruled out using the checklist. Refer her to health
center for pregnancy test or wait until the next menstrual cycle to start primaquine.

38
Signs and symptoms of pregnancy • Additionally ask for the symptoms of malaria
(fever) at each visit
• Increased frequency of urination
• Observe the urine of the patient with the
• Increased sensitivity to odors Hillmen colour chart
• Mood changes • Hillmen urine color estimation for
• Weight gain haemoglobinuria: urine should be placed
• Nausea and/or vomiting in a clear glass container and held up
• Breast tenderness against a white piece of paper, in a well
illuminated area, before estimating the
• Fatigue
colour compared to the Hillmen Colour
Procedure Chart. Urine colour estimation should
be carried out as soon after voiding
• The health extension worker will assist
as possible. A score of 5 or above is
the patient to select treatment supporter
considered evidence of haemoglobinuria.
from the household or neighborhood. The
treatment supporter will assist the patient in
taking all courses of the primaquine.
• The health extension worker will provide
health education and client education
material for patients and treatment
supporters
• The patient will come to the health post for
follow up at prescheduled days. The day of
initial treatment is designated as day zero.
The patient will be seen at the health post
at days 3, 7 and 13 to check symptoms of
anemia and urine color. When to stop PQ (Refer patient to health center)
• The symptoms of anemia are fatigue, • Symptomatic anemia
palpitation or dyspnea (shortness of • Urine color: a score of 5 or above on the Hillmen
breathing) on exertion urine colour chart

Documentation and follow up

39
Annex 9.12. Protocol for Primaquine Adverse Events
radical cure for P. vivax at Health Center Primaquine is generally well tolerated.
and Hospital Levels
• Dose-related gastrointestinal discomfort,
Plasmodium vivax accounts for 33% of malaria
including abdominal pain, nausea and
cases in Ethiopia (MIS, 2011). It is characterized
vomiting (Administration with food improves
by frequent relapses and the administration of
tolerability).
primaquine radical cure reduced relapses by 40%
during 15 months of follow up (WHO). The FMOH is • The most important adverse effect is hemolysis
planning to introduce primaquine for plasmodium in patients with glucose-6-phosphate
vivax as radical cure. It will be a phased approach dehydrogenase (G6PD) deficiency. The degree
where selected districts will implement initially of hemolysis is proportional to the dose,
followed by all elimination targeted districts and duration of exposure, and degree of G6PD
finally all over the country. The safety of primaquine deficiency. A study conducted by EPHI showed
is not yet fully established and this approach will the nonexistence of African and Mediterranean
help to scale up this important intervention. This variants of G6PD which are expected to be
document outlines the standard protocol to be present in Ethiopia. Fortunately, primaquine
used at health post level. is eliminated rapidly, so that hemolysis stops
once the drug is stopped.
Mode of implementation
Contraindications
It will be implemented in selected districts from
• Known hypersensitivity to primaquine
malaria elimination districts. The experience will
be systematically documented. This will help us to • Women breast feeding infants less than six
learn from limited sites before going to scale. months old
• Infants less than six months
Indications for PQ
• Pregnancy: do pregnancy test to rule out
Primaquine is to be used at selected elimination pregnancy
targeted areas for all patients diagnosed with Procedure
Plasmodium vivax malaria. It should also be given
for patients diagnosed with mixed infection using • The health worker will assist the patient to
microscopy select treatment supporter from the household
or neighborhood. The treatment supporter will
Dose and administration assist the patient in taking all courses of the
primaquine.
Primaquine is given for patients with plasmodium
vivax. It may be repeatedly administered if the • The health worker will provide health education
patient has repeated attacks of plasmodium vivax and client education material for patients and
malaria. Primaquine will be given at a dose of 0.25 treatment supporters
mg/kg body weight per day for fourteen days. It • The patient will come to the health center/
should be administered with food to prevent the hospital for follow up at prescheduled days.
gastrointestinal side effects The day of initial treatment is designated as
day zero. The patient will be seen at the health
Number of facility at days 3, 7 and 13 to check symptoms
mg
15mg tablets of anemia, urine color and hemoglobin
Body weight (kg)
based on PER DAY FOR measurement.
0.25mg/kg 14 DAYS
• Ask for anemia symptoms at each visit. The
5-14 1.25 to 3.5 ¼
symptoms of anemia are fatigue, palpitation or
15-24 3.75 to 6 ½ dyspnea (shortness of breathing) on exertion
25-34 6.25 to 8.5 ½
• Measure hemoglobin on days 0, 3, 7 and 13
35 -60 and more 8.75 to 15 1

40
• Ask for the symptoms of malaria (fever) at each When to stop PQ (refer patient to hospital)
visit
• Hemoglobin < 5 g/dL
• At each visit observe the urine of the patient
• Hemoglobin drop of >50% of the baseline
with the Hillmen colour chart
• Hemoglobin < 7 g/dL AND Hemoglobin drop
• Hillmen urine color estimation for from baseline of >25%
haemoglobinuria: urine should be placed
in a clear glass container and held up • Symptomatic anemia
against a white piece of paper, in a well
illuminated area, before estimating the • Urine color: a score of 5 or above on the Hillmen
colour compared to the Hillmen Colour urine colour chart
Chart. Urine colour estimation should
be carried out as soon after voiding
as possible. A score of 5 or above is
considered evidence of haemoglobinuria.

Documentation and follow up

41
52