title: Developing standards for malaria microscopy: external competency assessment for malaria microscopists in the Asia-Pacific.
abstract: BACKGROUND
  Malaria diagnosis has received renewed interest in recent years, associated with the increasing accessibility of accurate diagnosis through the introduction of rapid diagnostic tests and new World Health Organization guidelines recommending parasite-based diagnosis prior to anti-malarial therapy. However, light microscopy, established over 100 years ago and frequently considered the reference standard for clinical diagnosis, has been neglected in control programmes and in the malaria literature and evidence suggests field standards are commonly poor. Microscopy remains the most accessible method for parasite quantitation, for drug efficacy monitoring, and as a reference of assessing other diagnostic tools. This mismatch between quality and need highlights the importance of the establishment of reliable standards and procedures for assessing and assuring quality. This paper describes the development, function and impact of a multi-country microscopy external quality assurance network set up for this purpose in Asia.
  
  
  METHODS
  Surveys were used for key informants and past participants for feedback on the quality assurance programme. Competency scores for each country from 14 participating countries were compiled for analyses using paired sample t-tests. In-depth interviews were conducted with key informants including the programme facilitators and national level microscopists.
  
  
  RESULTS
  External assessments and limited retraining through a formalized programme based on a reference slide bank has demonstrated an increase in standards of competence of senior microscopists over a relatively short period of time, at a potentially sustainable cost. The network involved in the programme now exceeds 14 countries in the Asia-Pacific, and the methods are extended to other regions.
  
  
  CONCLUSIONS
  While the impact on national programmes varies, it has translated in some instances into a strengthening of national microscopy standards and offers a possibility both for supporting revival of national microcopy programmes, and for the development of globally recognized standards of competency needed both for patient management and field research.
authors.affiliation: Rollins School of Public Health, Emory University, Georgia, USA.
authors.forename: Sania
authors.initials: S
authors.lastname: Ashraf
authors.forename: Angie
authors.initials: A
authors.lastname: Kao
authors.forename: Cecilia
authors.initials: C
authors.lastname: Hugo
authors.forename: Eva M
authors.initials: EM
authors.lastname: Christophel
authors.forename: Bayo
authors.initials: B
authors.lastname: Fatunmbi
authors.forename: Jennifer
authors.initials: J
authors.lastname: Luchavez
authors.forename: Ken
authors.initials: K
authors.lastname: Lilley
authors.forename: David
authors.initials: D
authors.lastname: Bell
mesh_terms: D001208:Asia; D019411:Clinical Laboratory Techniques / Q000592:standards*; D016903:Drug Monitoring / Q000592:standards; D006801:Humans; D007391:International Cooperation; D059021:Laboratory Proficiency Testing; D008288:Malaria / Q000175:diagnosis*; D008853:Microscopy / Q000592:standards*; D011361:Professional Competence / Q000706:statistics & numerical data*; D011785:Quality Assurance, Health Care