Examination of Malaria Parasite

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QUESTION

How can you examine malaria parasites?

ANSWER

Malaria parasites are usually examined under a microscope using a peripheral blood smear method (also called a blood film). Thick blood smears, which use a large unsmeared drop of blood, are sensitive since a large number of red blood cells can be examined, though the parasites, if present, are difficult to distinguish morphologically.

For species-level identification of malaria parasites, a thin blood film is more commonly used, whereby a small volume of blood is smeared thinly across the slide and then stained, usually with Romanowsky stain, in order to see the detailed structures which differentiate the different species of malaria. It is crucial to make the blood films soon after the blood sample has been taken, and to store the blood in an appropriate anti-coagulate.

Characters to look out for include the presence of Maurer’s dots on the surface of red blood cells infected with Plasmodium falciparum. You may also see multi-infected red blood cells with this species, and it is rare to see mature trophozoites or schizonts with this parasite since when this stage is reached the red blood cells are usually sequestered deep within major organs and so are not readily present in the peripheral blood.

These parasites have crescent-shaped gametocytes. Plasmodium vivax, on the other hand, enlarges red blood cells that it infects and seems to show a preference for immature red blood cells. The presence of Schüffner’s dots is also characteristic – these looks like specks or granules on the cell surface of the infected red blood cell. P. ovale is very similar to P. vivax, in that it also enlarges the red blood cells and can have Schüffner’s dots, but fewer merozoites tend to be present per cell and infected red blood cells tend to look elongated. P. malariae does not alter the size or shape of the red blood cell it infects and tends to form rosette-like patterns of 8-10 merozoites. Later on in maturation, its trophozoites may form characteristic band-like patterns across the cell.

Anti-Malarial Tablets for Kenya

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QUESTION

Which are the best tablets to take against malaria in Kenya?
Is there a malaria vaccination?

ANSWER

I’ll answer your second question first—no, there does not yet exist a commercially available malaria vaccine. Currently, one promising vaccine candidate is undergoing Phase 3 clinical trials in children in sub-Saharan Africa; recently published preliminary findings suggest that it provides roughly 50% protection against malaria.

As for which tablets you should take, there are a number of options, and choosing between them is basically a matter of personal preference. The three main kinds recommended for sub-Saharan Africa are doxycycline, atovaquone/proguanil combination (sold under the brand name Malarone) and mefloquine (sold as Lariam). These three differ in how you take them (usually once a day for doxycycline and Malarone and once a week for Lariam), how expensive they are (doxycycline is the cheapest, Malarone the most expensive) and the side effects you might experience (sun sensitivity is a big problem for some people on doxycycline, some people report hallucinations on Lariam, whereas Malarone usually has the fewest severe side effects).

If you’re not sure what’s best for you, you can always talk it over with your doctor when asking for the prescription, and they might have recommendations, based on their knowledge of your health and specific requirements.

It is worth noting that levels of chloroquine resistance are very high in sub-Saharan Africa, and so chloroquine is not recommended as a prophylactic when travelling to this region.

Years of ill health – could it be malaria-related?

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QUESTION

I wonder if I have a long term relapsing form of malaria and would really appreciate your advice.

I have worked coming and going between the UK and Kenya, Ethiopia and Eritrea for about 17 years in aid/international development (rural and urban areas). I stopped travelling to the region about 2 years ago. One of the reasons to stop this work was my poor health.

Since about 15 years I started developing a number of chronic somewhat overlapping problems that have made work difficult and year after year just won’t go away, even now that my life is purely Europe-based. One of these may be unassociated with working specifically in such tropical areas but rather a result of general stress.

This first condition (or group of ailments) is always with me to some extent or another and is something like repetitive strain injury from too much computer use under stress, which especially affected my hands neck and back. Now it is more like generalised chronic pain (bone and muscle aches and weakness, numbness or inability to use at all in bad phases). This pain is kind of background noise with intense flare-ups by now, but I do sometimes wonder if it IS related to other symptoms which seem to present as two distinct cyclical conditions.

What i wonder if either of these two could be directly related to malaria or malaria pill use—or the result of another parasite (i.e. I developed a lump in my ankle which the doctor thought was related to sulphonamide allergy from anti-malarials, but later a lot of egg-white like substance burst from several spots on my feet when in a hot bath—parasite eggs? and ?the parent got digested by my body?).

The symptoms of the two recurring problems are: (1) often hungry and weak with nausea and fuzzy brain/poor focus/concentration, and very occasionally flashing lights in my eyes for a short period and inability to express myself clearly, feel better immediately on eating

(2) about every two to three months I have several weeks of quite bad flu-like/viral-type symptoms: general aches (distinct from the chronic pain), sore throat and slight nasal congestion that doesn’t turn into a cold, bad headache, pronounced fatigue, slight nausea, general feeling of ill health. This often seems accompanied by general but not so acute loose bowel movements.

I seem to have experienced the first group of symptoms for years, perhaps before travelling for work as I have always been the type to need a lot of food and I burn it quickly. But the symptoms are getting more pronounced and constant as I get older (I’m now 46).

The second group of symptoms I have in cyclical patches both in the UK and while travelling. However when travelling in East Africa the symptoms became much more pronounced e.g. the fatigue much greater, the cold symptoms turned into something more acute and I sometimes lost my voice even and had intense pain on the roof of my mouth as though someone had grated it with a cheese-grater, the diarrhoea became very bad and acute.

I used to think I had eaten bad food, was affected by the high altitude, developed a weakness to the prevalent upper respiratory infections so many rural people had, got over run-down from too much work travel and heat etc. etc. I felt I had to carry out my work trips on adrenilin each time.

But actually I realised I got a reduced version of the same things back home months after travelling.

I also wondered if I was badly affected by too many vaccines over the years, and also the fact that I had become allergic to anti-malarial pills. In recent years I took the antibiotic instead of straight anti-malarials as I had developed problems with each kind (e.g. Larium I got severely depressed and otherwise had symptoms of sulphonamide allergy.).

But in wracking my brain as to what is wrong with me year after year I of course think of malaria as well as other options. I wonder if I DID contract malaria but was never properly treated for it (rather the anti-malarials will have kept it in a weaker version?). And if so could ALL my symptoms (e.g. all 3 chronic conditions I can identify, or maybe the second two only) be those of malaria lodged in my system and recurring and recurring?

My apologies for the long-winded explanation, hope it makes sense. But as you can imagine I am getting very worn down by all this and no UK doctor seems to find a solution. I have seen different specialists over the years including tropical medicine people but again, no final diagnosis.

I really hope for your help or advice. If not a mosquito do you think the worm is something to try and find out more about. They never tested that because the (? adult parasite?) lump in my leg went away and as regards the egg white in the bath (about 8 months later) I didn’t know what it was and only afterwards thought it had to be eggs!

Everyone in my work team apart from me contracted malaria of some kind in the region over the years. And I appeared to be the only person not to, but my health problems go on and on.

I look forward to your thoughts or ideas from others in this forum.

With thanks and best wishes, PM

ANSWER

Thanks for writing in, PM. I passed your message on to two medical doctors that serve as advisors to malaria.com. I have summarised their responses below, though both agree your symptoms do not sound like they are due to recurring malaria, at least not by itself.

Persistent anaemia (a common cause of fatigue and general malaise) post-malaria treatment would have been identified and treated long ago by most physicians.  Signs of malaria, acute or relapsing, are much more distinctive and lacking in this person’s description of  his/her symptoms.

Something that has gone on this long without killing the patient, without producing some unusual finding on exam, or showing some hint of itself in standard labwork is likely constitutional or the result of repeat assault on the immune system.  Drug allergies, especially to sulfonamide-based drugs, are more apparent or pronounced in persons with chronic viral illnesses—for example this is often seen with HIV—up to 30% of HIV patients develop rash or fever to sulfonamide prescriptions, a much greater proportion than the general population.  The mechanism for this reaction is thought to be some type of immune priming by the virus causing the system to overreact when presented with  new antigens.  In the long term, this “chronic immune stimulation” eventually results in immune dysregulation, and the many symptoms described by this person (fatigue/aches/gastrointestinal disturbance/mental fog…) can result.  So many factors can contribute—repeated bouts of malaria, medications used as treatment, intercurrent viral infections (for which there are no commercial diagnostic tests nor specific treatment), other parasitic disease—strongyloidiasis/filariasis/Toxocara, the immeasurable immune stresses of frequent travel.  The most common discoverable and TREATABLE entity in this case might be gut parasites, but it might also be assumed that these have been caught by doctors by now.

Minimum evaluation (assuming that basic blood work and chemistries are normal) should include thyroid and hormone evaluation, glucose tolerance, gluten tolerance, HIV and EBV studies and at least a screen for Borrelia/treponemes/Bartonella etc.  It is unlikely that a hormone-secreting tumor would go undiagnosed this long, rather, the “hunger” is perhaps due to CHO sensitivity/insulin sensitivity (hypoglycemia).  A re-exam for gut parasites using antigen stool studies and endoscopy if indicated.  The aches are non-specific, but could be related to waning hormone levels (androgens OR oestrogens), vitamin D deficiency, immune dysregulation as discussed, or even autoimmune disease.

As such, the spectrum of possibilities is wide, but hopefully the above might give you some ideas to discuss with your doctor at a future visit. Also, since you are UK-based, if you haven’t already I would suggest you try to get an appointment with the Hospital for Tropical Diseases on Warren Street in London. They have wonderful diagnosticians with expertise in rare tropical infections, and so might be able to pick up the more unusual parasites/bacteria mentioned above.

Good luck!

What are mosquito larvae?

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QUESTION

What are mosquito larvae?

ANSWER

Larvae are one of the life stages of mosquitoes; they are baby mosquitoes, if you will. Adult mosquitoes lay eggs as a “raft” on the surface of a body of fresh water—they prefer still and stagnant pools. These eggs then hatch into the mosquito larvae, which live in the freshwater pool until they form a pupa, just under the surface. These pupae then hatch into adults again, completing the life cycle.

Mosquito larvae are omnivorous, eating algae and small organisms also living in the water. Despite living immersed in water, they require oxygen to breathe, which they inhale using two different methods: Aedes and Culex mosquitoes (the vectors of a number of diseases, including West Nile disease, dengue fever, yellow fever, encephalitis and filarisasis) have a specialised breathing organ, a bit like a snorkel, called a siphon, which they use to suck in air, whereas Anopheles mosquitoes (the main vectors of malaria) lack this organ and so have to lie next to the surface to take in air. The larvae moult four times while they live in water; after the fourth time, they are ready to pupate and become adults. The entire larval stage of a mosquito’s life usually take between one and two weeks, depending on the ambient temperature.

Schizont

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QUESTION

What is a schizont?

ANSWER

A schizont is a malaria parasite which has matured and contains many merozoites, which are the parasite stage that infects red blood cells.

Schizonts can be produces during two separate phases of the life cycle within the human host: first in the hepatocytic cells in the liver (when sporozoites mature) during the exo-erythrocytic cycle and then within the red blood cells during the erythrocytic cycle (when trophozoites mature and divide).

When malaria parasites do not immediately mature into schizonts in the liver (as can be the case with Plasmodium vivax and P. ovale infections), the parasite instead becomes a hypnozoite, which can lay dormant in the liver for many weeks or even months (or, in rare case, years), and produce relapse of infection at a much later date.

How to Prevent Malaria

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QUESTION

How to prevent malaria?

ANSWER

Despite its wide geographic range and potentially severe consequences, there are actually several effective strategies for controlling malaria, many of which have been successful of reducing the burden of the disease, and especially the number of deaths, in various regions.

The first step towards control is prevention. This has largely been achieved through the distribution of long-lasting insecticide treated bednets, which prevent people from being bitten by infected mosquitoes as they sleep at night. While this has drastically reduced the number of cases of malaria in some settings, and particularly in certain high risk groups such as children under five and pregnant women, some worrying new data just was published which suggested that in high transmission zones, bednets may actually exacerbate re-infection rates for older children and adults, and lead to insecticide resistance in mosquitoes. As such, while bednets clearly are still a key prevention strategy, their effect should be closely monitored.

Secondly, there is diagnosis and treatment. These go hand in hand, as they usually require the availability of health services or health professionals. If malaria infections are rapidly and accurately diagnosed, appropriate treatment can be swiftly given, preventing the progression of the disease and allowing the patient to recover. Appropriate administration of medication, as well as adherence to the full course of the drugs, can also help to prevent drug-resistance from emerging.

Finally, there are on-going research initiatives looking to find new ways to tackle malaria. For example, many scientists are involved in the search for a malaria vaccine, which, if safe, effective, and sufficiently cheap, could transform the way we think about fighting malaria. Similarly, due to the unfortunate circumstance of ever-increasing drug-resistance, particularly in Plasmodium falciparum, new types of medication are constantly being tested and trialled. The combination of all these efforts has managed to reduce the mortality of malaria greatly over the past few years; the aim now, espoused by organisations such as Malaria No More, is to get to a point where deaths from malaria are eliminated by the year 2015.

 

Paludisme Depuis 5 Mois (Malaria for 5 Months)

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QUESTION:

En fait je souffre d’un palu que le médécin a mal traité après une analyse sanguine. J’aimerais savoir comment faire pour m’en débarrasser car je traine ce palu maitenant depuis 5 mois.

ENGLISH TRANSLATION:

In fact I suffer from malaria which the doctor has treated poorly after a blood test. I would like to know how to clear myself of this because I have been carrying this malaria now for 5 months.

ANSWER:

C’est rare de souffre telle longtemps que 5 mois continuellement avec palu; plus commun c’est de observer plusieurs episodes d’infection en serie, si la traitement n’est-ce pas un succes. Mais tout ca depend un peu du type du palu. Vous devrez tenir un autre test sanguine pour determiner ce type du palu, de preference au hôpital ou dans un clinique de santé. Avec celle information, le médécin peut vous recommender un traitement approprié. Par example, si vous avez un infection de Plasmodium vivax ou P. ovale, le parasite peut rester en repos dans le foie pendant plusieurs semaines ou bien plusieurs mois. Des médicaments qui traitent l’infection dans le sang, comme chloroquine ou ACTs, ne touchent pas cette stages de vie dans le foie. Dans ce cas, vous devez parler avec votre médécin sur un autre médicament, qui s’appelle primaquine, qui tue a les parasites dans le foie et previent encore plus de rechutes.

ENGLISH TRANSLATION: It’s rare to suffer from malaria continuously for five months; it is more common to see multiple infections over and over in series, if the disease is not treated appropriately. But all of this depends on the type of malaria that you have. You need to have another blood test to determine the type of malaria, and based on this information, the doctor can give you appropriate treatment. For example, if you have Plasmodium vivax or P. ovale, the parasite can rest dormant in the liver for several weeks or even months. The drugs which treat the initial infection in the blood, such as chloroquine or ACTs, don’t affect these liver stages. In this case, you must talk to your doctor about taking another medication, called primaquine, which kills the liver stages of the malaria parasite and prevents further relapses of the disease.

History of Fighting Malaria

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QUESTION

What are some examples of attempts of fighting this disease that happened in the past?

ANSWER

The battle against malaria has been going on, in one form or another, for literally thousands of years. The ancient Chinese mention the symptoms of the disease in a medical scroll as early as 2700 BCE – even more remarkably, a herb called Artemesia has been used in traditional Chinese medicine for more than 2000 years to treat malaria, and compounds extracted from that same herb are the basis for some of the most effective modern medications, known as artemisinin-based combination therapies (ACTs). Indigenous tribes in the Americas also had traditional medicines to treat malaria; having conquered the New World, the Spanish learned of a bark, from the Cinchona tree, which could cure malaria. Quinine, extracted from this same tree bark, is still used today to treat malaria.

However, back then the causes of malaria were not known—it wasn’t until the late 19th century that a more complete understanding of malaria would emerge. The first key development in this process was the observation of the parasites that cause malaria in a patient’s blood, which was first done by Charles Louis Alphonse Laveran in 1880.

A few years later, in 1897, a British army doctor called Ronald Ross discovered that the parasite was transmitted via the bite of infected mosquitoes, of the genus Anopheles. This latter finding allowed for the emergence of the first programmes for malaria control, which focused on vector control, through insecticide use and elimination of water bodies used by the mosquito larvae. An early example of the success of this approach came in the building of the Panama Canal; started in 1906, progress was initially slow, due to the enormous proportion of workers who fell ill from yellow fever and malaria. With vector control, the number of cases plummeted, and the canal was finally opened in 1914.

While prophylactic quinine had also been part of the control strategy during the building of the Panama Canal, it played a much more secondary role to vector control. Using similar strategies, focusing primarily on killing adult mosquitoes through insecticide spraying (mainly DDT), the United States of America successfully eliminated malaria from its shores in the early 1950s. Prior to this, transmission had occurred across most of the south-east of the country.

In the last 50 years, access to early diagnosis and effective treatment have gained a more prominent role among many malaria control strategies, although prevention is still seen as crucial. Many developing countries, where malaria is still rife, have set up national control programmes, which seek to ensure that all communities have access to adequate care and information about malaria prevention.

A key tool in the prevention arsenal has been the long-lasting insecticide treated bednet; sleeping underneath one prevents bites from the mosquitoes that carry malaria, which are most active in the evenings and at night, especially in children and pregnant women, who are among the people most at risk from infection. Bednet distribution has been a major focus of many malaria campaigns, and very successful in many places; in 2008, for example, bednet coverage was estimated at over 80% of the at-risk population in Djibouti, Mali, Ethiopia and Sao Tome and Principe.

Does malaria kill?

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QUESTION

Is malaria a killer disease?

ANSWER

Yes. Malaria causes somewhere between 700,000 to 1 million deaths worldwide, mostly in children under five, and mostly in sub-Saharan Africa. As such, it is actually one of the leading causes of death in young children in developing countries.

Given this high mortality, many initiatives working to control malaria are dedicated to reducing the number of deaths as a key way of lowering the overall burden of this disease; groups such as Malaria No More and the Roll Back Malaria Partnership have committed to bringing the number of deaths from malaria to zero or near zero by 2015.

Where does malaria come from?

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QUESTION

Where does malaria normally come from?

ANSWER

Malaria is caused by single-celled parasites of the genus Plasmodium; the parasites enter the human body via the bite of an infected mosquito. However, the mosquito has to pick up the infection in the first place from another infected human; so in a sense, you could say that malaria both comes from mosquitoes, as well as from other people, although only indirectly!

More generally, your question could be read as asking where does malaria come from geographically—malaria is actually distributed over most of the world, and at some point or another has been found on all continents except Antarctica. In modern times, it tends to be restricted to the tropics and sub-tropical regions of the world, since temperature is a key factor pertaining to its survival. However, seasonal transmission (especially in the summer, hotter months) still persists even in some temperate regions. Moreover, with global climate change, it is feared that the distribution of malaria will continue to spread, and even more people will be affected.