The prospect has been fuelled by the state of (un) preparedness in Ghana and the inability to control the spread of the epidemic, should it occur. Reactions to the outbreak are reflected in psychological, social,

cultural, economic and above all health systems responses. There the need to design and implement appropriate information and communication approaches to address these concerns. A striking observation is the weakness in the health Ibrutinib in vivo systems of the three ‘index’ countries that have recent histories of social disablement through conflict. In this issue of the journal Professor Irene Agyepong presents a systems view and lessons from the ongoing outbreak in West Africa (page 168). We should learn from the history of cholera in the country and the failure to effectively control it after its first introduction as we draw our Ebola preparedness plans. The preparation for the exclusion of Ebola from our boundaries should also take into consideration the opportunities it offers to strengthen weak infection control and surveillance systems and general epidemic control plans. The public health attitude

should not only be Ebola control but institution of infection control and prevention, good surveillance and BIBF-1120 epidemic containment systems in general. David Ofori-Adjei and Kwadwo Koram Ghana Medical Journal gro.jdemanahg@rotidE hg.ude.gu.ihcugon@maroKK

Malaria causes an estimated 660 000 deaths annually and remains a major cause of morbidity and mortality in high-endemic countries.1 Traditionally, two approaches have been adopted in the

Ketanserin management of malaria: presumptive and test-based. The presumptive approach relies solely on clinical symptoms and signs to establish diagnosis and initiate treatment. In contrast, the test-based approach requires confirmation, either parasitological or antigen-antibody test, before the diagnosis of malaria can be made, and treatment initiated. For many years, the World Health Organisation (WHO) recommended the presumptive approach and this was implemented across countries in malaria-endemic, sub-Saharan Africa. In early 2010 however, WHO issued revised treatment guidelines that call for a shift from presumptive to test-based approach. This revision to the guidelines effectively brings to an end the practices of several decades. 2–4 This article reviews the evidence-base for the shift to the test-based approach, and examines implications of its implementation in Ghana. Justifications for the presumptive diagnosis of malaria The major justifications for the presumptive approach to managing malaria in high-endemic countries were: (1) The high levels of transmission and associated morbidity and mortality; (2) The availability of affordable, yet effective antimalarials; (3) The lack of appropriate diagnostic tools.