What to do while on malaria medication

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QUESTION

Good day, I’m a 27yr old male currently in Nigeria. I would like to know my do’s and don’ts while on malaria medication. I ask this so I know what to forego in my athletic lifestyle- I visit the gym 3-4 times a week and have recently started horse riding.

ANSWER

There isn’t any restriction on the kinds of activities you can enjoy while on malaria medication! You should be able to continue with your normal healthy lifestyle. However, be aware that the foods you eat may have some impact on your body’s ability to uptake the anti-malarials. For example, it is recommended to take Malarone (atovaquone-proguanil) together with some food containing fat, as this aids absorption and reduces side effects. Conversely, if you are taking doxycycline, you should NOT take it within a few hours (and certainly not at the same time) as dairy products, as the calcium in milk can inhibit uptake of the drug.

About Malaria Proteins

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QUESTION

Please tell about about malarial causitive proteins.

ANSWER

I’m not sure what your question is, as malaria is not caused by a protein, but rather by a single-celled parasite called Plasmodium, which contains many different types of proteins. Some of these are indeed used for entering host cells and thus causing disease. Many of these proteins, and particularly ones on the surface of the malaria parasite, induce the host’s immune system, and so are called antigens. One of the most well known malaria antigens is called the Duffy antigen, and it is found on two types of malaria (Plasmodium knowlesi and Plasmodium vivax). It is used by the parasite to invade host red blood cells, and it is interesting because many populations of people in Africa have genetic changes in the parts of the red blood cell which the Duffy antigen binds to. This means these people, called Duffy negative, are much less susceptible to these types of malaria than people who are so-called Duffy positive and have normal red blood cells.

Malaria Prophylaxis for Indonesia

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QUESTION

I have been working a 4-week rotation between the USA and East Kalimantan (Borneo) for about 2 years. While on Borneo, I am in the jungle much of the time. I have never contracted malaria. I am embarrassed to say I thought I had been inoculated for malaria when I first started working here. I just spent 10 days in a hospital last month fighting a blood degenerating viral infection not unlike hemophiliac dengue. Is there a preferred Rx I should take for malaria? I have no allergies to medicines that I am aware of. I am 57 year-old male.

ANSWER

Given the amount of time you spend in rural areas of Borneo, you probably should consider anti-malarial medication to prevent infection. There are three types of drug which are recommended against malaria in Indonesia: atovaquone-proguanil (sold as Malarone), mefloquine (sold as Lariam) and doxycycline. Each has pros and cons: Malarone and doxy have to be taken every day, while Lariam is only taken weekly, which might make it more convenient. However, both doxy and Lariam should be taken for a full 4 weeks after leaving the malarial area, while Malarone is only taken for a week after leaving.

In my opinion, Malarone has the fewest and mildest side effects (though some people complain of upset stomachs and disturbed sleep patterns), while doxycycline is sometimes a problem in the tropics since it can cause sun sensitivity. Lariam is not recommended for people with a history of mental illness, and has been reported to have psychiatric side effects, including nightmares, hallucinations and even altered behavior. Of the three, Malarone is the most expensive, and doxycycline usually the cheapest.

In terms of taking them long term, I don’t know of any studies that look at long term usage of Malarone (it is expensive enough that I doubt anyone takes it for very long trips!), while people do safely take doxycycline for periods of several months, and Peace Corps volunteers and American expats routinely take Lariam for periods of several years.

Of course, many people living long term in malarial areas do not find it convenient to take pills to prevent malaria, and focus on other preventative measures, mainly revolving around killing mosquitoes and avoiding being bitten. Sleeping under a long-lasting insecticide treated bednet is one such method, which is cheap, easy and very effective.

Incidentally, the area you are in is interesting from a malaria point of view since it is one of the few places where transmission of Plasmodium knowlesi occurs. This is a type of malaria which was thought to be only present in macaque monkeys, until human cases started becoming more prevalent a few years ago. Now it is considered a “human” type of malaria, and an emerging threat in south-east Asia. It’s important to be aware of it as the mosquitoes which transmit it tend to be forest-dwelling (since that is where the macaques live), and although very easily treated with chloroquine or other anti-malarials, an infection can progress rapidly into quite severe disease.

If you suspect you might have malaria at any point, therefore, it is crucial to get out and get tested at a clinic or hospital, where they can promptly treat you if you test positive. Be aware also that if tested via microscopy, P. knowlesi can often be confused with P. malariae or P. vivax; while the initial treatment is likely to be the same for all three, if you had P. vivax you might be told about taking an additional medication, called primaquine, to prevent future relapses, whereas relapses do not occur with P. knowlesi.

Recurrence of Malaria Symptoms

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QUESTION

If a person suffering from malaria is given the proper treatment and he gets well but he again develops the symptoms of malaria..? These symptoms would arise from liver or blood? Who’ll be responsible for the recurrence of the symptoms?

ANSWER

Malaria can come back in three ways: first of all, the person could have been successfully treated, but then re-infected again by being bitten by an infected mosquito. In these cases, the person should focus on improved malaria prevention, such as sleeping under a long-lasting insecticide treated bednet.

Secondly, the patient could have recrudescence: when the patient takes medication, the treatment kills most of the malaria parasites in the blood, and enough so the patient feels better again, but some parasites still remain. Then, after the treatment finished, the parasite is able to replicate again, they increase in number in the blood and the patient feels ill again. In this case, you would say the infection came back from the blood, and the patient should take another dose of anti-malarials, but of a different kind to that which they originally had, in order to kill all of the parasites.

Finally, there is what is called relapse, which only occurs with two types of malaria: Plasmodium vivax and Plasmodium ovale. These are able to form dormant stages in the liver, so even when all the parasites are killed in the blood by the malarial treatment, these dormant forms survive. Many weeks, months or even years later, these dormant liver stages can re-activate and enter the blood again, causing new malaria symptoms. In this case, the liver was the source of the parasites. Again, the active blood infection should be treated with anti-malarials, but the patient should also talk to their doctor about taking primaquine, a drug which can kill any remaining dormant liver forms and thus prevent future relapses.

ASAQ Sanofi-Aventis

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QUESTION

In the summer of 2010 I went to Uganda on a medical trip where we saw hundreds of people affected by malaria. Ever since, I have had a huge heart for these children that we saw at the orphanage. This past summer, I took a Microbiology class at the University of Tennessee where we learned about Sanofi-Aventis and the affordable malaria medication made in 2007. I am starting an annual 5k in honor of my father who passed away to raise money to buy this medication to give to children in Uganda (my church has a medical clinic over there). I was wondering how I would go about obtaining this medication or if you could help me in any way. Thank you so much for your time.

ANSWER

It’s great that you have become passionate about helping people fight malaria in Uganda. In terms of helping people with access to anti-malarial medicine, I can think of three ways you could go about it.

First of all, you could raise money to donate to an organization which already works on health issues in the area of Uganda in which your church operates. You would need to do some research on what organizations operate in the area, and also try to find out a bit about their reputation and overheads (it’s frustrating to see your donations whittled away on mundane, if important, bureaucratic costs rather than going directly into buying medication). Alternatively, but along the same lines, you could look into donating the money directly to the medical clinic that your church supports, and see if they can purchase the necessary medications locally or at least within Uganda. Both of these approaches have the advantage that you will be partnering with people who already work in the area, know the local landscape, and have relationships with local government health clinics and other local authorities, who may hear of your action and feel the need to be informed. The disadvantage is that you would be reliant on drug supplies available in the area; throughout Africa, there are recurrent problems of people buying counterfeit drugs, or being given expired pills.

Similarly, supplies are not always reliable, and you might have to settle for buying whatever drug is available, regardless of the formulation or brand (though I would strongly encourage you to ONLY buy artemisinin-based combination therapies, or ACTs, of which Coarsucam and ASAQ Winthrop, both fixed dose combinations of artesunate-amodiaquine created by Sanofi-Aventis, are included).

Your third option, which is probably the most logistically challenging but over which you would have the most control, would be to solicit pharmaceutical companies directly to see if they would be willing to sell you pills directly at whole sale price, based on the money you raise from your annual race. Many pharmaceutical companies already have programs to develop health care initiatives and improve public health in the world’s poorest companies, so you could try to include your project as one of these initiatives.

Sanofi-Aventis itself has a program called Impact Malaria which works with a variety of stakeholders to tackle malaria on the ground, and which includes distribution of the drugs mentioned above. You could also look into other pharmaceutical companies that develop anti-malarial drugs, such as Novartis (which produces Coartem), Lonart (Bliss Gvs Pharma), and many others. One thing to bear in mind is that there are often restrictions on importing and exporting drugs, and also many other things to consider when doing drug donations.

This paper outlines some of the issues you should be thinking about if you want to go down the direct donation path: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1121783/

Duration of Malaria Symptoms

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QUESTION

If untreated how long will a person suffer symptoms caused by Malaria?

ANSWER

The answer to that depends a lot on what type of malaria they have as well as their own immune status, and particularly if they have been infected with malaria before. So, for example, P. falciparum is the most severe and deadly kind of malaria, and without treatment, many people who do not have acquired immunity (from previous infections) are likely to die within just a few days. This is the type of malaria that causes the most deaths, and explains why most of the fatalities occur in young children, who have not had the chance to acquire immunity.

In contrast, other kinds of malaria are less severe, and so symptoms can persist before the malaria parasite is naturally cleared by the parasite, usually within 1-2 weeks. In extreme cases, this can last much longer; Plasmodium malariae is the slowest replicating form of malaria, and so frequently causes mild infections which can last weeks, if not months. In some cases, people are infected with low levels of P. malariae for years without even experiencing symptoms, since their own immune system is able to keep levels of the parasite low enough so that they don’t cause noticeable disease.

Mosquitoes Transmission via Feces

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QUESTION

Can a mosquito give you malaria after having being on an infected person’s feces?

ANSWER

No. Malaria can only be transmitted via blood. As such, transmission via mosquitoes occurs when a mosquito feeds on the blood of an infected person, then bites someone who is not infected, and transfers the malaria parasite in the bite (this cannot happen straight away – the malaria parasite has to undergo some changes in the mosquito first).

Ingestion of Malaria Blood

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QUESTION

If someone were to eat/ingest the blood of an infected individual would they become infected with malaria? If an infected person’s blood was on their hands and they handled food, would eating the food put others at risk for malaria?

ANSWER

No, you would not get infected with malaria, as the malaria parasites must be transmitted into a person’s blood directly in order for them to be infected. As such, most transmission only occurs via mosquitoes: when a mosquito bites a person infected with malaria, it may pick up some of the malaria parasites while it feeds on the person’s blood. When it then goes to bite another person, after the parasite has replicated and changed inside the mosquito, it can pass the malaria on to the next person, again when it bites them and drinks the person’s blood.

Additionally, in some cases malaria can be transmitted by blood transfusion or organ donation, or from a mother to her unborn baby via the placenta, or through blood passed in childbirth. If you ate/drank malaria-infected blood, the parasites would be broken down and destroyed by your stomach acid.

Malaria Pills Vietnam

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QUESTION

I am travelling from Hanoi to Ho Chi Minh city via Haalong Bay, Hue and Hoi An, all are Costal areas. Should I take Malarone? I would prefer not to as I am trying to get pregnant.

ANSWER

In Vietnam, costal areas north of Nha Trang are considered malaria-free, as are the cities of Hanoi and Ho Chi Minh city. As such, it is only rural and costal areas closer to Ho Chi Minh city where you might be at risk. One option you have is to take mefloquine (Lariam) – it is safe to take while pregnant (or trying to get pregnant), and is effective in most areas of Vietnam. There is resistance to mefloquine in the Mekong Delta region, but it doesn’t sound like you will be travelling there, so this shouldn’t be a problem.

Malaria and Nausea

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QUESTION

Can malaria cause vomiting when a smell of petrol is inhaled?

ANSWER

One of the symptoms of malaria is nausea, and vomiting can also occur, but it would not necessarily be linked to certain smells. The most characteristic symptom malaria is a high fever, often also accompanied by periods of chills. See more malaria symptoms here.