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Appendix

Microscopic Procedures for Diagnosing Malaria

To establish the diagnosis of malaria, a blood film must be prepared from fresh blood obtained by pricking the patient's finger (Figures A-1 and A-2).* The thin film is fixed in methanol before staining; the thick film is stained unfixed. Certain hospitals have a Wright-Giemsa stain available, which is acceptable; however, Wright stain alone will not reliably indicate Plasmodium parasites. For best results, the film should be stained with a 3% Giemsa solution (pH of 7.2) for 30--45 minutes. In P. falciparum infections, the parasite density should be estimated by counting the percentage of red blood cells infected --- not the number of parasites --- under an oil immersion lens on a thin film.

Thick blood films are more sensitive in detecting malaria parasites because the blood is concentrated, allowing a greater volume of blood to be examined. However, thick films are more difficult to read, and thin films might be preferred by laboratories that have limited experience. Plasmodium parasites are always intracellular, and they demonstrate, if stained correctly, blue cytoplasm with a red chromatin dot. Common errors in reading malaria films are caused by platelets overlying a red blood cell, concern regarding missing a positive slide, and misreading artifacts as parasites. Persons suspected of having malaria, but whose blood films do not indicate the presence of parasites, should have blood films repeated approximately every 12--24 hours for 3 consecutive days. If films remain negative, then the diagnosis of malaria is unlikely.

For rapid diagnosis, the thick and thin films should be made on separate slides. The thin film should be air-dried, fixed with methyl alcohol, and immediately stained. If no parasites are visible on the thin film, the laboratorian should wait until the thick film is dry, then examine it for organisms that might not have been detected on the thin preparation.

* In Figures A-1 and A-2, the hands are illustrated ungloved to better indicate their placement during the procedures. However, wearing gloves while processing blood specimens is recommended to prevent transmission of bloodborne pathogens (MMWR 1988;37:377--82, 387--8 and MMWR 1987;36[No. S2]).

Figure A-1
Figure 1
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Figure A-2
Figure 2
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