Christopher Whitty

• Professor (Full) at London School of Hygiene and Tropical Medicine

Background There has been a successful push towards parasitological diagnosis of malaria in Africa, mainly with rapid diagnostic tests (mRDTs), which has reduced over-prescribing of artemisinin-based combination therapies (ACT) to malaria test-negative patients. The effect on prescribing for test-positive patients has received much less attention....

Eosinophilia in those returning or recently migrated from the tropics is a common presentation in symptomatic and asymptomatic patients. Helminths are the cause in a substantial proportion of these cases. Investigation should begin with consideration of the geographic area arrived from or visited and clinical manifestations, if any. Strongyloides s...

This study describes the clinical features of a cohort of imported cases of strongyloidiasis and the performance of standard diagnostic techniques for this condition. A total of 413 cases were identified, of whom 86 had microscopically proven infection. In proven cases, 23% had normal eosinophil counts, 19% had negative Strongyloides-specific serol...

Background Plasmodium ovale spp. and P. malariae cause illness in endemic regions and returning travellers. Far less is known about these species than P. falciparum and P. vivax. Methods The UK national surveillance data, collected 1987 to 2015, were collated with the International Passenger Survey and climatic data to determine geographical, temp...

Background Most people with febrile illness are treated in the private drug retail sector. Ghana was among nine countries piloting the Global Fund Affordable Medicines Facility – malaria (AMFm). AMFm aimed to: increase artemisinin combination therapy (ACT) affordability; increase ACT availability; increase ACT use; and ‘crowd out’ artemisinin monot...

Background Several public health interventions to improve management of patients with fever are largely focused on the public sector yet a high proportion of patients seek care outside the formal healthcare sector. Few studies have provided information on the determinants of utilization of the private sector as against formal public sector. Underst...

Rigorous evidence of ‘what works’ to improve health care is in demand, but methods for the development of interventions have not been scrutinized in the same ways as methods for evaluation. This paper presents and examines intervention development processes of eight malaria health care interventions in East and West Africa. A case study approach wa...

Background: The West African Ebola crisis of 2013-15 is the largest outbreak since Ebola was first identified; Ebola has high case fatality. Sources of data: Pubmed with terms 'Ebola' and 'EVD' from January 1976 to June 2015. Public domain material. Areas of agreement: The emergence of Ebola virus, virology, clinical features and the major ele...

1. Malaria is the tropical disease most commonly imported into the UK, with 1300 to 1800 cases reported each year, and 2-11 deaths. 2. Approximately three quarters of reported malaria cases in the UK are caused by Plasmodium falciparum, which is capable of invading a high proportion of red blood cells and rapidly leading to severe or life-threateni...

Ebola causes severe illness in humans and has epidemic potential. How to deploy vaccines most effectively is a central policy question since different strategies have implications for ideal vaccine profile. More than one vaccine may be needed. A vaccine optimised for prophylactic vaccination in high-risk areas but when the virus is not actively cir...

Evidence-based policy ensures that the best interventions are effectively implemented. Integrating rigorous, relevant science into policy is therefore essential. Barriers include the evidence not being there; lack of demand by policymakers; academics not producing rigorous, relevant papers within the timeframe of the policy cycle. This piece addres...

The magnitude of the 2014-2015 West African Ebola virus disease outbreak was unforeseen at its onset and the initial international response was slow. The high mortality and the panic that this outbreak induced had a major effect on health systems. In this article we discuss some of the key public health and clinical lessons from this Ebola outbreak...

Eradication of a disease is one of the greatest gifts any generation can give to subsequent ones, but most attempts have failed. The biggest challenges occur in the final stages of eradication and elimination campaigns. These include falling public support as a disease becomes less common; the emergence of groups who do not support eradication; spi...

Although global efforts in the past decade have halved the number of deaths due to malaria, there are still an estimated 219 million cases of malaria a year, causing more than half a million deaths. In this forum article, we asked experts working in malaria research and control to discuss the ways in which malaria might eventually be eradicated. Th...

Improving access to parasitological diagnosis of malaria is a central strategy for control and elimination of the disease. Malaria rapid diagnostic tests (RDTs) are relatively easy to perform and could be used in primary level clinics to increase coverage of diagnostics and improve treatment of malaria. A cost-effectiveness analysis was undertaken...

The increasing investment in malaria rapid diagnostic tests (RDTs) to differentiate malarial and non-malarial fevers, and an awareness of the need to improve case management of non-malarial fever, indicates an urgent need for high quality evidence on how best to improve prescribers' practices. A three-arm stratified cluster-randomised trial was con...

To examine temporal and geographical trends, risk factors, and seasonality of imported vivax malaria in the United Kingdom to inform clinical advice and policy. Observational study. National surveillance data from the UK Public Health England Malaria Reference Laboratory, data from the International Passenger Survey, and international climactic dat...

To examine the impact of providing rapid diagnostic tests for malaria on fever management in private drug retail shops where most poor rural people with fever present, with the aim of reducing current massive overdiagnosis and overtreatment of malaria. Cluster randomized trial of 24 clusters of shops. Dangme West, a poor rural district of Ghana. Sh...

Schistosomiasis is one of the major parasitic diseases of the tropics, causing acute and long-term clinical syndromes. Almost all schistosomiasis is now imported from sub-Saharan Africa. This article summarises the aetiology, clinical presentation, diagnosis and management of schistosomiaisis for clinicians in non-endemic countries. © 2015 Royal Co...

Schistosomiasis in returning travellers is one of the most common imported tropical infections with potentially serious complications, which are preventable if diagnosed early. A review was undertaken of consecutive cases of schistosomiasis presenting at the Hospital for Tropical Diseases, London, UK from 1997 to 2012. All 1020 schistosomiasis case...

Christopher J. M. Whitty and colleagues explain why the United Kingdom is funding many small community centres to isolate suspected cases in Sierra Leone.

The possibility for one generation to eradicate a disease is very motivating. It is also very difficult. The many failed eradication attempts outnumber the one current success (smallpox), although two eradication campaigns for polio and Guinea worm are tantalisingly close to their goals. The early stages of a well-planned eradication campaign gener...

This Column features a Cochrane Review pertinent to health in countries with high disease burdens. We choose reviews with interesting methodological features, or with challenges related to interpretation and applicability. Now the Cochrane Library has optional Open Access, so we will preferentially choose these reviews that are thus freely availabl...

Objective To assess the impact of rapid diagnostic tests on the diagnostic accuracy and treatment of malaria and non-severe fever in an Asian setting. Design Patient randomised trial in primary level clinics. Setting Two areas of Afghanistan where Plasmodium vivax and Plasmodium falciparum are endemic; one area with moderate transmission (eastern r...

Active screening by mobile teams is considered the most effective method for detecting gambiense-type human African trypanosomiasis (HAT) but constrained funding in many post-conflict countries limits this approach. Non-specialist health care workers (HCWs) in peripheral health facilities could be trained to identify potential cases for testing bas...

Malaria remains a leading cause of mortality worldwide and a cause of morbidity in returning travellers in the UK. The management of malaria, recent advances in diagnosis and current areas of controversy are summarized, primarily for clinicians in non-endemic countries who do not routinely encounter it. The most important message is that malaria is...

Cost-effectiveness information on where malaria rapid diagnostic tests (RDTs) should be introduced is limited. We developed incremental cost-effectiveness analyses with data from rural health facilities in Ghana with and without microscopy. In the latter, where diagnosis had been presumptive, the introduction of RDTs increased the proportion of pat...

The debate on rapid diagnostic tests (RDTs) for malaria has begun to shift from whether RDTs should be used, to how and under what circumstances their use can be optimized. This has increased the need for a better understanding of the complexities surrounding the role of RDTs in appropriate treatment of fever. Studies have focused on clinician prac...

Background: The Malaria Reference Laboratory (MRL) provides a specialist advisory service for complex queries from healthcare professionals. This study was conducted to examine the types of queries that general practitioners and nurses ask around malaria prophylaxis, to identify issues which are not obvious from existing easily available sources....

#### Summary points Every year, several thousand people with malaria arrive in non-endemic countries, and about 1600 arrive in the United Kingdom alone. Case fatality in the UK, as elsewhere, is around 1% overall but varies by age and previous exposure to malaria.1 2 3 This rate is similar to that seen in endemic countries, but the age profile of...

Policy-makers in developing countries should not be swayed by the politicized arguments dominant in Europe, say Christopher J. M. Whitty and colleagues.

Malaria is the commonest imported infection in the UK. Malaria requiring ICU admission has a reported mortality of up to 25%. The relationship between ethnicity, immunity, and risk of malaria is complex. The Malaria Score for Adults (MSA) and Coma Acidosis Malaria (CAM) score have recently been proposed to risk stratify patients with malaria. Retro...

Active screening by mobile teams is considered the best method for detecting human African trypanosomiasis (HAT) caused by Trypanosoma brucei gambiense but the current funding context in many post-conflict countries limits this approach. As an alternative, non-specialist health care workers (HCWs) in peripheral health facilities could be trained to...

Principles of Medicine in Africa combines classical clinical medicine with a rich understanding of the major environmental and cultural influences on health and disease, providing comprehensive guidance for anyone intending to practise medicine in Africa. Disease is presented in the context of family and culture, and the effects of inequality and p...

We examine the impact of removing user fees for healthcare in rural Ghana using data from a randomized experiment that includes rich information on objective measures of child health status. We find that free care increased use of formal healthcare shifting care seeking away from informal providers, with particularly strong effects for children who...

To quantify geographical concentration of falciparum malaria cases in the UK at a hospital level. To assess potential delay-to-treatment associated with hub-and-spoke distribution of artesunate in severe cases. Observational study using national and hospital data. 3520 patients notified to the Malaria Reference Laboratory 2008-2010, 34 patients tre...

Severe febrile illness is a major cause of adult hospital admission in Africa. Studies of non-malarial fever come largely from children or from high HIV prevalence settings. This prospective study of adult admissions with severe febrile illness in a malaria-endemic area with moderate/low HIV prevalence investigated admission diagnosis as well as fi...

To assess the accuracy of malaria diagnosis and treatment at primary level clinics in Afghanistan. Prospective observational study. 22 clinics in two Afghan provinces, one in the north (adjoining Tajikistan) and one in the east (adjoining Pakistan); areas with seasonal transmission of Plasmodium vivax and Plasmodium falciparum. 2357 patients of all...

An observational study of patients presenting with diarrhoea to a walk-in service for returning travellers was conducted with the aim of identifying features that would help predict whether pathogens were bacterial or parasitic. In total, 509 cases were included, of which a bacterial aetiology was found in 55/440 (12.5%) and a parasitic cause in 51...

To determine which travellers with malaria are at greatest risk of dying, highlighting factors which can be used to target health messages to travellers. Observational study based on 20 years of UK national data. SETTING : National register of malaria cases. 25,054 patients notified with Plasmodium falciparum malaria, of whom 184 died, between 1987...

The extent to which removing user fees for health care in developing countries improves population health rests, in part, on how behavioural responses vary across individuals with different health needs. Using data from a randomised experiment of free care in Ghana and a measure of baseline health that is both objective and broad-based, we examined...

WHO guidelines for the treatment of young children with suspected malaria have recently changed from presumptive treatment to anti-malarial treatment guided by a blood slide or malaria rapid diagnostic test (RDT). However, there is limited evidence of the safety of this policy in routine outpatient settings in Africa. Children 3-59 months of age wi...

Accurate parasitological diagnosis of malaria is essential for targeting treatment where more than one species coexist. In this study, three rapid diagnostic tests (RDTs) (AccessBio CareStart (CSPfPan), CareStart PfPv (CSPfPv) and Standard Diagnostics Bioline (SDBPfPv)) were evaluated for their ability to detect natural Plasmodium vivax infections...

Foreword The UK Department for International Development (DFID) is committed to investing in research to combat poverty, reduce high mortality and morbidity in resource poor contexts and support progress towards meeting the Millennium Development Goals. Research helps us to identify what works, what does not work and how to understand the local con...

#### Summary points As travel increases,1 the number of pregnant women who travel will probably rise. Women often ask if travel is safe in pregnancy and seek advice from a range of healthcare professionals. Travel related maternal and fetal morbidity and mortality can be completely avoided only by postponing travel until after delivery, but travel...

A summary of the responses to the quantitative questions in the first round of the Delphi survey. (PDF)

A summary of the responses to the quantitative questions in the second round of the Delphi survey. (PDF)

Modelling is widely used to inform decisions about management of malaria and acute febrile illnesses. Most models depend on estimates of the probability that untreated patients with malaria or bacterial illnesses will progress to severe disease or death. However, data on these key parameters are lacking and assumptions are frequently made based on...

Southern Africa has a high incidence of bacterial meningitis in adults, often associated with HIV co-infection. Mortality exceeds 50%, even with appropriate antibiotic therapy, and is not improved with corticosteroids. Glycerol adjuvant therapy reduces long-term morbidity in bacterial meningitis in children, and its use is being promoted. We aimed...

This study describes 977 children with imported malaria in England and Wales between 2004 and 2008, focusing on 29 (3.0%) patients admitted to intensive care, of whom 10 had cerebral malaria, 4 required inotropes, and 1 had concurrent septicemia. The remaining 14 were admitted for monitoring only. None died, but 1 child developed cerebellar infarct...

Interactive model for the evaluation of HMM strategies. The model is a Microsoft Excel file and requires that macros are allowed to run. (0.57 MB XLS)

Home management of malaria (HMM), promoting presumptive treatment of febrile children in the community, is advocated to improve prompt appropriate treatment of malaria in Africa. The cost-effectiveness of HMM is likely to vary widely in different settings and with the antimalarial drugs used. However, no data on the cost-effectiveness of HMM progra...

Assessment of physical access to health services is extremely important for planning. Complex methods that incorporate data inputs from road networks and transport systems are used to assess physical access to healthcare in industrialised countries. However, such data inputs hardly exist in many developing countries. Straight-line distances between...

The Millennium Development Goal target for tuberculosis control is to halt the spread of tuberculosis by 2015, and begin to reverse the worldwide incidence. After the introduction of standard control practices in 1995, 36 million people were cured and about 6 million deaths were averted. However, substantial scientific advances and innovative solut...

Current knowledge of clinical features of imported childhood malaria is largely limited to small, retrospective, and/or single-center case series. This prospective, population-based study describes the epidemiology and clinical features of imported childhood malaria in children <16 years in the United Kingdom and Republic of Ireland. Active prospec...

Background: The most common form of malaria outside Africa, Plasmodium vivax, is more difficult to control than P. falciparum because of the latent liver hypnozoite stage, which causes multiple relapses and provides an infectious reservoir. The African (A-) G6PD (glucose-6-phosphate dehydrogenase) deficiency confers partial protection against seve...

Rapid diagnostic tests (RDTs) for malaria are at the early stages of introduction across malaria endemic countries. This is central to efforts to decrease malaria overdiagnosis and the consequent overuse of valuable anti-malarials and underdiagnosis of alternative causes of fever. Evidence of the effect of introducing RDTs on the overprescription o...

To assess the performance of WHO's "Guidelines for care at the first-referral level in developing countries" in an area of intense malaria transmission and identify bacterial infections in children with and without malaria. Prospective study. District hospital in Muheza, northeast Tanzania. Children aged 2 months to 13 years admitted to hospital fo...

Delays to treatment cost lives and quick fixes are not the answer

To test in West Africa the impact of rapid diagnostic tests on the prescription of antimalarials and antibiotics both where microscopy is used for the diagnosis of malaria and in clinical (peripheral) settings that rely on clinical diagnosis. Randomised, controlled, open label clinical trial. Four clinics in the rural Dangme West district of southe...

The current interest in malaria elimination has led to a renewed interest in drugs that can be used for mass administration to minimize malaria transmission. Primaquine (PQ) is the only generally available drug with a strong activity against mature Plasmodium falciparum gametocytes, the parasite stage responsible for transmission. Despite concerns...

A large number of tropical infections can cause neurological syndromes but the returning traveller is more likely to have a condition that is well known to a UK physician. Malaria is the most commonly imported life-threatening tropical infection and should be excluded urgently in all patients. It is also important not to miss herpes encephalitis, b...

A capture-recapture study was undertaken to estimate the incidence and likely total burden of malaria cases in England. Cases diagnosed by the national Malaria Reference Laboratory (MRL) between July 2003 and December 2004 were matched with cases reported to Hospital Episode Statistics using demographic, geographical, parasitological, and temporal...

Eosinophilia is a common finding in returning travellers and migrants, and in this group it often indicates an underlying helminth infection. Infections are frequently either asymptomatic or associated with non-specific symptoms, but some can cause severe disease. Here the British Infection Society guidelines group reviews common and serious infect...

In Yemen, morbidity and mortality due to malaria is high. We explored malaria-related treatment seeking, prevention practices and knowledge of transmission amongst parents in order to inform health education strategies. Yemen is culturally very distinct from most malaria-endemic countries. We aimed to identify beliefs which may be barriers to malar...

International travel is increasing. Most physicians and general practitioners will encounter returned travellers with fever and the majority of travel-related infection is associated with travel to the tropics. In those returning from the tropics malaria must always be excluded, and HIV considered, from all settings. Common causes of non-malarial f...

Over-diagnosis of malaria has previously been described, especially in East Africa. Abuja is the capital of the most populous country in Africa. Over-prescription of artemisinin-based combination therapy (ACT) antimalarials in Nigeria on the scale reported from other countries will result in substantial unnecessary use of this class of drug. In a s...

Trial Protocol (0.16 MB PDF)

CONSORT Checklist (0.06 MB DOC)

Paul Newton and colleagues propose guidelines for conducting and reporting field surveys of the quality of medicines.

Poor quality of care is a major concern in low-income countries, and is in part attributed to low motivation of healthcare workers. Non-physician clinicians (mid-level cadre healthworkers) are central to healthcare delivery in half of the countries in Africa, but while much is expected from these clinicians, little is known about their expectations...

Home management of malaria-the presumptive treatment of febrile children with antimalarial drugs-is advocated to ensure prompt effective treatment of the disease. We assessed the effect of home delivery of artemether-lumefantrine on the incidence of antimalarial treatment and on clinical outcomes in children from an urban setting with fairly low ma...

Longer version of the article (190 KB PDF).

Malaria in pregnancy is serious, and drug resistance in Africa is spreading. Drugs have greater risks in pregnancy and determining the safety and efficacy of drugs in pregnancy is therefore a priority. This study set out to determine the efficacy and safety of several antimalarial drugs and combinations in pregnant women with uncomplicated malaria....

Is well known at a biological and health systems level, but often ignored

Delays in accessing care for malaria and other diseases can lead to disease progression, and user fees are a known barrier to accessing health care. Governments are introducing free health care to improve health outcomes. Free health care affects treatment seeking, and it is therefore assumed to lead to improved health outcomes, but there is no dir...

Original Protocol (332 KB PDF)

CONSORT Statement (61 KB DOC)

Respiratory infections cause significant mortality in developing countries but are frequently undiagnosed. Reasons for this are unclear. We observed 1,081 outpatient consultations with patients less than five years of age in Tanzania. In 554 patients with cough or difficulty breathing, the absolute percentages examined were 5% for respiratory rate...

Following a long period when the effectiveness of existing mono-therapies for antimalarials was steadily declining with no clear alternative, most malaria-endemic countries in Africa and Asia have adopted artemisinin combination therapy (ACT) as antimalarial drug policy. Several ACT drugs exist and others are in the pipeline. If properly targeted,...

Artemisinin derivatives used in recently introduced combination therapies (ACTs) for Plasmodium falciparum malaria significantly lower patient infectiousness and have the potential to reduce population-level transmission of the parasite. With the increased interest in malaria elimination, understanding the impact on transmission of ACT and other an...

Little is known about the relative importance of environmental and socioeconomic factors for acquiring malaria in Yemen. A case-control study was conducted to determine the importance of these factors for acquiring malaria among children in Yemen. Cases of non-severe malaria were recruited from health centres; community controls were from the neigh...

To gain a better understanding of the decision-making context in the diagnosis of malaria in order to inform behaviour change strategies, using quantitative methods. We observed hospital outpatient and inpatient consultations in northeast Tanzania where malaria testing was routinely available, recording potential influences on testing and prescribi...