Mentorship on malaria microscopy diagnostic

service in Ethiopia: Baseline competency of

microscopists and performance of health facilities
Bokretsion Gidey  (  [email protected] )
Ethiopian Public Health Institute
Desalegn Nega 
Ethiopia Public Health Institute
Adugna Abera 
Ethiopian Public Health Institute
Abnet Abebe 
Ethiopian Public Health Institute
Sindew Mekasha 
Ethiopian Public Health Institute
Geremew Tasew 
Ethiopian Public Health Institute
Mebrahtom Haile 
Federal Ministry of Health
Dereje Dillu 
Federal Ministry of Health
Degu Mehari 
Federal Ministry of Health
Ashena Assefa 
Ethiopian Public Health Institute
Wondimeneh Liknew 
Ethiopian Public Health Institute
Abeba G/tsadik 
Ethiopian Public Health Institute
Hussien Mohammed 
Ethiopian Public Health Institute
Ermias Woldie 
Ethiopian Public Health Institute
Tsegaye Getachew 
Ethiopian Public Health Institute
Desaelegn Ararso 

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 Ethiopian Public Health Institute
Dereje Yenealem 
Ethiopian Public Health Institute
Adisu Kebede 
Ethiopian Public Health Institute
Kebede Etana 
Federal Ministry of Health
Gizachew Kedida 
EMA: Ethiopian Medical Association
Hiwot Solomon 
Federal Ministry of Health
Getachew Tollera 
Ethiopian Public Health Institute
Adugna Woyessa 
Ethiopian Public Health Institute
Ebba Abate 
Ethiopian Public Health Institute

Research

Keywords: External Quality Assurance, Mentorship, Malaria Microscopy, Re-checking, Competency

DOI: https://doi.org/10.21203/rs.3.rs-87991/v2

License:   This work is licensed under a Creative Commons Attribution 4.0 International License.  
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Abstract
Background: In Ethiopia, malaria cases are declining as a result of proven interventions and in 2017, the
country launched a malaria elimination strategy in targeted settings. Accurate malaria diagnosis and
prompt treatment are the key components of the strategy to prevent morbidity and stop the continuation
of transmission. However, the quality of microscopic diagnosis in general is deteriorating as malaria
burden declines. Therefore, this study was carried out to evaluate the competency of microscopists and
the performance of health facilities on malaria microscopic diagnosis.

Methods: A cross-sectional study was conducted from August 1st to September 30th, 2019 in nine
regional states and one city administration. A standard checklist was used for on-site evaluation,
archived patient slides were re-checked, and pro ciency of microscopists was tested using WHO certi ed
slides from the national slide bank at the Ethiopian Public Health Institute (EPHI). The strength of
agreement, the sensitivity, the speci city, and the positive and negative predictive values were calculated.

Results: In this study, 102 health facilities (84 health centers and 18 hospitals) were included; from which,
202 laboratory professionals participated. In slide re-checking, moderate agreement (Agreement: 76.0%;
Kappa: 0.41) was observed between experts and microscopists on malaria detection in all health
facilities. The sensitivity and speci city of routine slide reading and the re-checking results were 78.1%
and 80.7%, respectively. Likewise, positive predictive value of 65.1% and negative predictive value of
88.8% were scored in the routine diagnosis. By panel testing, a substantial overall agreement (A: 91.8%; K:
0.79) was observed between microscopists and experts in detecting malaria parasites. The sensitivity
and speci city in the detection of malaria parasites was 92.7% and 89.1%, respectively. Furthermore, in
identifying species, a slight agreement (A: 57%; K: 0.18) was observed between microscopists and
experts.

Conclusion: The study found signi cant false positive and false negative results in routine microscopy on
slide re-checking of Plasmodium parasites. Moreover, reduced grade in parasite species identi cation
was reported on the panel tests. Therefore, implementing comprehensive malaria microscopy mentorship,
in-service training, and supportive supervision are the key strategies to improve the overall performance
of health facilities in malaria microscopy.

Background
Malaria remains a major public health challenge. In 2019, an estimated 229 million cases of malaria and
409,000 deaths were reported [1] compared with 238 million cases and 736,000 deaths in 2000 which
shows a signi cant decline. In Ethiopia, around 52% of the country’s population is at risk of the disease.
Generally, areas that lay below 2000 meters above sea level are considered malarious. Plasmodium
falciparum accounts for nearly 70% of all malaria cases while the remaining cases are due to P. vivax but
malaria prevalence is collectively declining from 2011(4.5%) to 2015 (1.2%) onwards [2- 3].

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The malaria elimination program in Ethiopia planned to eliminate malaria through a step-wise and sub-
national approach targeting speci c adjacent areas in order to shrink the country’s malaria map by 2030
[2]. Accurate diagnosis and prompt treatment are core strategies in the elimination of malaria [4]. The
diagnosis of malaria is carried out by detecting evidence of parasites or parts of parasites. Microscopic
examination of Giemsa-stained blood lm is still the gold standard for malaria diagnosis [5]. Due to a
lack of sustainable quality assurance program and trained laboratory technicians, this method has many
setbacks in detecting and identifying malaria species correctly in Ethiopia [6-9]. Additionally, inaccuracies
in diagnostic testing can lead to potentially devastating outcomes for the patient and public health,
compromising the quality of surveillance data at national level, and ultimately affecting public health
policy [10].

An effective malaria diagnosis practice has to be put in place to implement a quality management
system that is in line with international quality standards [11]. Strong laboratory capacity with full
equipment, reagents, and competent professionals ensures better curative interventions and in uences
treatment-seeking behavior [9] by attracting a higher patient ow than facilities with a weak laboratory
service. Therefore, incorporating a mentoring approach into supervision can transform the traditional
supervision   into a more effective intervention to improve the quality and delivery of patient care [16].
Mentoring typically includes a continued relationship and a broad skills transfer from an individual with
more experience in an area to a less experienced mentee to improve the performance of laboratory
personnel in a health facility [12-15]. An acceptable malaria microscopy service should provide results
that are consistently accurate and timely enough to have a direct impact on treatment [14]. This requires
a comprehensive mentorship and active quality assurance scheme. Therefore, this study aimed to
evaluate the competency of microscopists and the performance of health facilities on malaria
microscopy in Ethiopia. A comprehensive mentorship was provided based on the identi ed gaps.

Methods
Study area, design and period

A health facility based cross-sectional study was conducted from August 1st, 2019 to September 30th,
2019, at 102 health facility laboratories in nine regional states and one city administration in Ethiopia.

The distribution of study sites in Ethiopia

The spatial distribution of study sites is depicted in gure 1.

Sample size and selection procedure

In this study, about 102 Woredas (district) were selected according to the malaria reporting health
facilities proportionally from each region based on Annual Parasite Incidences (national malaria program
report, 2017). The mentors’ team in coordination with the Woreda health o ces selected one health

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facility per Woreda based on their malaria burden report, the presence of medical laboratory
professionals and active malaria microscopy diagnostic service.

Expert selection

Twenty-six experts, two from each respective regional Public Health Institutes were selected. Experts were
selected based on their experience on malaria microscopy, training on malaria diagnosis and quality
assurance, demonstration ability to transfer knowledge, commitment and willingness to mentor a facility
for three days. Five days standardization training was provided on malaria microscopy and mentorship.

Data collection process

Thirteen malaria microscopy expert teams, each team with two laboratory experts were formed. The
experts conducted interviews using a standardized questionnaire using the Open Data Kit (ODK) software
programmed on a Smartphone. Panel slides were distributed for pro ciency testing. Blindly re-checking
slides were checked at the health facilities level and the discordant slides were referred to the national
laboratory for con rmation. Real time data were sent to the EPHI data server immediately after data
collection completion at each health facility.

On-site evaluation

A standard supervisory checklist was used to assess the status of availability of documents and records
of quality indicators, quality of smear slides, microscopy diagnosis methods and safety practice,
equipment and supply management, capacity building issue and training related to malaria microscopy
in each health facility.

Pro ciency testing

A set of four standard reference slides from the national malaria slide bank at EPHI (one slide Pf, one Pv,
one mixed (Pf+Pv) and one negative) were used to test the pro ciency of microscopists for parasite
detection and species identi cation.

Slide re-checking

Expert microscopists (the mentors) selected ten stained slides randomly and systematically from the
archived of each participant laboratory ( ve negative and ve positive stained slides) as per the national
EQA guideline [9] and assessed the performance of health facilities in malaria microscopy diagnosis. The
slides were read by experts independently at health facility level and the results were compared
immediately.

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Data management and statistical analysis

The real time data were downloaded from the server, cleaned in Microsoft Excel, and imported to SPSS
V20 for analysis. Descriptive statistics were used to determine quality monitoring indicators, training, the
performance of health facilities in malaria microscopy, and competence of the laboratory professional.
Sensitivity, speci city, percent agreement, and kappa values were used to determine the competency of
laboratory personnel against the expert reader in routine diagnosis. Kappa value was calculated to see
the strength of agreement. Strength of agreement was classi ed as: Kappa of<0.20 is slight agreement,
0.21–0.40 is fair agreements, 0.41–0.60 is moderate agreement, 0.61–0.80 is substantial agreement, and
0.81–0.99 is almost perfect agreement [17].

Ethical consideration

Ethical approval was obtained from the Ethiopian Public Health Institute (EPHI) Institutional Review
Board (IRB) (Protocol number: EPHI-IRB-197-2019). An o cial cooperation letter was written to the health
facilities. Administrative approvals were obtained from the directors of the participating health facilities. 

Results
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Demographic characteristics

A total of 102 health facilities were enrolled; eighteen (17.6%) hospitals and 84 (82.4%) health centers
from the nine regional states and one city administration, in Ethiopia.

Of 202 laboratory professionals were included as participants in the competence assessment. The
median age of the study participants was 29 years (range: 20 – 55 years). Most of the participants
(68.5%) were male and about three in four participants 154(76.2%) reported that they had a diploma in
laboratory. Out of the 202 laboratory personnel, 158 (78.2%) were working at health centers. More than
half 107 (53.0%) of the laboratory personnel had ve years or more work experience in malaria
microscopy (Table 1).

Pro ciency Testing: Detection of malaria parasites and Species Identi cation

Overall performance on detection of parasites

A substantial percent agreement (91.8%; Kappa 0.79) was observed between study participants and
expert references in detecting malaria parasites. The overall sensitivity of malaria parasites detection by
the participants’ microscopy was 92.7% while the speci city was 89.1%. In the study, 92.7% positive
predictive value and 89.1% negative predictive values were observed.

Almost perfect agreement (92.87%; Kappa: 0.81) was observed at the health centers and substantial
agreement (88.1%; Kappa: 0.71) was observed at hospitals in detecting malaria parasites. The overall
score for sensitivity of malaria detection in health centers was 94.5% which was higher than in hospitals
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(86.4%). On the other hand, the speci city of participants in detecting malaria parasites was higher in
hospitals (93.2%) than in health centers (87.9%) (Table 2).

Species identi cation

Overall percent agreement on species identi cation

Slight agreement (57%; Kappa=0.18) was observed between participants and expert readers in identifying
Pf from non-Pf parasites. The overall percent agreement in identifying Pf and non-Pf was 49%
(Kappa=0.04) at hospital level and 59% (Kappa= 0.22) at the health center level. The percent agreement
in species identi cation at health centers was slightly higher than the agreement at the hospitals despite
low overall agreement at all facilities (Table 3).

Performance of health facilities in malaria microscopy diagnosis 

Slide Re-checking 

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In 102 assessed health facilities, 750 blood lm slides (maximum 10 blood lm slides) from each health
facility of routine activities were re-checked by experts. Comparing with expert readers, percent agreement
of the experts and facilities result in malaria parasite detection was 76.0% (K: 0.41) which was at the
base boundary of moderate agreement. The sensitivity and speci city were 78.1% and 80.7%,
respectively. Similarly, the positive and negative predictive values were 65.1% and 88.8%, respectively
(Table 4).

On-site evaluation

Only 72(70.5%) health facilities were performing thick and thin smears on a single slide for every patient.
Three in ten health facilities did not use thin smear for species identi cation. Less than half of health
facilities 46(45.1%) monitor the quality of prepared blood lm slides regularly. Only one in three health
facilities 38(37.3%) perform regular internal quality control (IQC) to check the quality of Giemsa solution
and more than two in three health facilities 65(64.7%) did not store or archive examined slides properly.
As part of quality assurance, one of the observed major challenges in most facilities was failure to
archive and store examined slides properly except in only 37(37.3%) of health facilities and only half of
51(50%) health facilities were participating regularly in any method of external quality assurance (Table
5). Sixty-one (59.8%) health facilities were supervised by national and/or regional health o ces in the
preceding year. Regular training on malaria diagnosis and quality assurance was reported on one-fourths
of 26(25.5%) health facilities. However, about 32(31.4%) health facilities diagnosed malaria using both
RDTs and microscope (Table 5).

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Discussion
In the routine microscopic diagnosis, moderate performance agreement (A: 76.0%; K: 0.41%) was
observed between study facilities and expert microscopists in parasite detection in all health facilities.
This study showed lower performance agreement as compared to study reported from the West Amhara
Region of Ethiopia [22], [23] and Hawassa, Southern of Ethiopia [24]. The discrepancy may be due to the
big number of health facilities used in the current study and may be because of the capacity of experts.
The sensitivity and speci city at detecting malaria in the peripheral blood stained slides were 78.1% and
80.7%, respectively. Similarly, the positive and negative predictive values were 65.1% and 88.8%,
respectively. Therefore, high false positive and false negative results were found on the assessed health
facilities which showed poor performance of the health facilities service in the routine diagnosis of
malaria at large. This result was lower than the ndings reported from other parts of Ethiopia [22], [23][25]
and, similar ndings were also reported in Pakistan [26]. However, our nding was in line with a study
performed in the Democratic Republic of Congo which showed the performance of routine malaria
microscopy remains inaccurate with large variations among different health centers [27]. Accurate

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microscopy results depend on the availability of a competent microscopist using good-quality reagents
for examining well-prepared slides and with a low-to-moderate workload [21]. In this nding, in slide re-
checking, almost half of the assessed health facility laboratories did not prepare both thick and thin
blood lms as per the standards.  Consequently, a low sensitivity in the detection of malaria parasite
indicated that there were many false-negative results, i.e. missed diagnosis of true infection. This can
lead to the delayed treatment, the development of serious complications, and the death or exposure to
unnecessary treatment with other drugs due to suspecting other fever-like diseases.

Regarding the pro ciency testing of the current nding, the overall percent agreement of the malaria
microscopists in the current study was 91.8% (K: 0.79) in parasite detection which is relatively higher
when compared with similar ndings at elimination targeted districts of Ethiopia where performance
agreement was 84.6% (K: 0.6) [28]. A study conducted in Hawassa town, Ethiopia, reported an agreement
of 88% (k: 0.67) [24] and similar ndings was reported from a study conducted in Bahirdar, Ethiopia
where the agreement was 88.5% (k: 0.78) [29]. Another study conducted in Tigray, Ethiopia, reported an
agreement of 79% (k: 0.62) [30]. A concordant result  reported from Addis Ababa public health facilities
showed a performance agreement of 91.7%  [19]. But the agreement of the current study was relatively
lower when compared with ndings of similar studies conducted in Ethiopia where the agreement was
96.8% (k: 0.9) [30]. The reason for this deviation may be because of the difference in malaria prevalence
which can affect microscopists’ ability to detect, but also the lack of mentorship, training, consistent
supervision, and capacity building used to develop detecting skills and standardizing malaria parasite
detection. Overall, sensitivity and speci city of laboratory personnel in detecting malaria parasites were
92.7% and 89.1%, respectively. Again, these results overlapped with positive predictive value (92.7%) and
negative predictive value (89.1%). These ndings were almost in agreement with  a sensitivity 88% and
speci city 91% from a study conducted in Zambia [31]. The sensitivity but not the speci city of this study
was higher than the sensitivity 83.2% and speci city 90.1% in a study conducted elsewhere in Ethiopia
[28], and sensitivity 63% and speci city 97% in a study reported in Tigray, Ethiopia [30]. The sensitivity
and speci city of this study was lower than the sensitivity 96.8% and speci city 96.7% of malaria
detection in a study conducted in another place in Ethiopia [30]. The relative lower speci city than
sensitivity in the current study at detecting malaria parasites showed that high rate of false positive
results of malaria were reported which led to the misdiagnosis of malaria when there was no true
infection of malaria parasite in the provided slides to the mentee.

Overall, the performance agreement on the identi cation of malaria species was 57% (K: 0.18) which
showed a slight agreement between participants and malaria microscopy experts. This result was higher
than in a similar study conducted in elimination targeted districts in Ethiopia with an agreement of 43.8%
(k: 0.11) [28] while it was lower than in a study conducted in Tigray, Ethiopia with an agreement of 76%
(k: 0.61) [30] and a study reported from Bahirdar, Ethiopia where the agreement was 72% (k: 047) [29].
The reason for the low identi cation of species by the microscopists in the current study may be due to
the fact that the microscopists prepared only a thick lm and were unable to differentiate the morphology
of the parasites. It may also due to the lack of training on how to differentiate the species, in addition to
the poor staining of reagents found on the on-site evaluation.
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In the on-site evaluation, we identi ed that only 72(70.5%) health facilities were performing thick and thin
smears on a single slide for every patient but the recommended blood lm preparation for diagnosis of
malaria parasite is doing both thin and thick lms on the same slide using 2µL and 6µL of whole blood,
respectively [18]. Three in ten health facilities were not using thin smears which can be used for species
identi cation. The result of the current study is greater than a study conducted in Addis public health
facilities [19]. Moreover, blood lms performed in 43 (42.2%) health facilities did not meet the quality of a
good blood lm for malaria microscopy diagnosis in this study. Internal quality control, used to check the
quality of Giemsa stains, was performed only by 38(37.3%) health facilities. In addition, only 37(37.3%)
of health facilities stored and archived slides properly. Moreover, in the previous year, the study identi ed
in 41 (40.2%) and 76 (74.5%) health facilities with no supervision and refresher training, respectively. This
study was in line with a study conducted in Addis Ababa public health facilities [19] and other study
conducted in the Asia-Paci c [20]. This result showed that less attention is given to the quality of malaria
diagnosis in the health facility level. It may be due to the lack of re-fresher trainings and regular
supervisions provided to laboratory professionals at the health facility level.

Limitation of the study: There were some limitations where the study health facilities were incorporated
purposely based on their high malaria load and presence of microscopic service; and hence, the nding
may not be inferred to all health facility performance in the country. The health facilities with no or lower
malaria reporting were not included. In addition, a low numbers of slides (three malaria positive slides &
one negative slide) were used in the panel testing which is below the WHO standard of ten slides.

Conclusion
Most of the malaria microscopists in the current study achieved a good grade agreement in parasite
detection. However, a poor grade was obtained in parasite species identi cation by the panel tests.
Moreover, high false positive and false negative results were seen on slide re-checking which showed the
poor performance of the health facilities in routine malaria microscopy. Poor quality control indicators
and follow up gaps were reported by a signi cant number of health facilities in this study. Consequently,
an improvement in the quality and accuracy of microscopic diagnosis of malaria is urgently needed.
Therefore, a strong commitment from the National Malaria Elimination Program (NMEP) and a
commitment from stakeholders are a vital step to accomplish the mentoring approach at all level of the
health facilities.

Abbreviations
EPHI: Ethiopian public health institute; EQA: external quality assurance; EQAS: External quality
assessment; NMEP: National Malaria Elimination Program; GPS: global positioning system; IQC: internal
quality control; IRB: institutional review board; ODK: open data kit; PT: pro ciency/panel testing; RDTs:
rapid diagnostic tests; SERO: scienti c and ethical review o ce; PPV: positive predictive value; NPV:
negative predictive value.

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Declarations
Author contribution

All authors contributed in conceptualization, study design, protocol development, training, and eld data
collection.BG, DN, AdA, AbA, MH, DD, DM, AW, EW analyzed the data and wrote the result, BG drafted the
manuscript and all authors read, commented and approved the nal manuscript.

Author details

1
Ethiopian Public health Institute (EPHI), POBox 1242, Patriot Street, Gulele Subcity, Addis Ababa,
Ethiopia. 2Federal Ministry of Health (FMoH), POBox 80002, Sudan street, Addis Ababa,Ethiopia.
3
Ethiopian Medical Laboratory Associations (EMLA), POBox: 4866, Tewodros Square, Addis Ababa,
Ethiopia.

Acknowledgments

The authors would like to acknowledge the Ministry of Health for nancial support of the eld work. We
also thank microscopic experts (mentors) from nine regional states and one city administration for
providing technical support. Our indisputable appreciation goes to all the malaria microscopists for their
willingness to join us for the competence assessment. And more, our especial gratitude goes to Ahlam
Awad for English proofreading. Finally, yet importantly, we express our gratitude to the supportive staff of
the Ethiopian Public Health Institute who helped in preparing the panels and supplies, facilitated eld
activities in addressing the logistics and handling nancial issues.

Competing interests

The authors declare that they have no competing interests.

Availability of data and materials

The dataset and materials used for the study are kept in a safe place on the EPHI server.

Consent for publication

All authors have read and agreed to publish this article.

Ethical approval and consent to participants

The study protocol was reviewed and approved by the Ethiopian Public Health Institute -IRB O ce, Addis
Ababa, Ethiopia.

Funding

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Funding for eld data collection and mentoring program was provided by the Ethiopian Federal Ministry
of Health.

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