Diagnostic Blood Test: Malaria in Nepal and India

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QUESTION

My daughter has returned from a 6 week trip to Nepal and then India. About 20 minutes into the flight home she developed pains and aches in her hips and legs, fever, generally feeling dreadful but no nausea or diarrhea. When she arrived after the 10 hour flight her temperature was 100.5. We were concerned about malaria, but when she saw her primary care doctor the next morning she felt much better and her temperature was normal.

Blood taken at that visit showed no sign of malaria, but the doctor said that she could develop a recurrence in 3-4 weeks time when blood test should be repeated to confirm malaria if present.

I don’t doubt her doctor, but do these symptoms suggest malaria? How common is it for an initial episode of malaria to show up as negative on blood tests? She started taking tablets 3 days before entering a high risk area and took them for 3 weeks, but stopped during a brief diarrheal illness and did not restarted her anti malaria tablets.

ANSWER 1 – From Malaria.com Editor:

I think your GP might be mistaken about this – the only way to diagnose malaria is through a blood test which is positive for the disease! I have never heard of any cases where the initial blood test is negative, followed by a positive recurrence several weeks later. There are cases were the initial level of infection is quite low, in which case sometimes the parasites can be missed when looking at the blood film; however, when symptoms are present, this is rare. Moreover, there is no biological reason for a recurrence in several weeks; usually, reoccurrence occurs when treatment is given and for whatever reason is unsuccessful, allowing the malaria parasites to come back (and this assumes they are positively observed in the first place!).

Another diagnostic option, if you want to double check, is to see if you can find a rapid diagnostic test for malaria, which uses a drop of the patient’s blood to look for proteins produced by the malaria parasite. Similarly, there are tests which look for antibodies against malaria; this kind of test, known as serology, is not good for diagnosing active infections since antibodies can persist after the infection has been cleared, but may give you an indication of whether your daughter was exposed to malaria at all during her time in Nepal. Both of these are even more sensitive than blood smears, and although not as common as blood smears, are available in many places, particularly through hospitals which have tropical medicine departments or experts. All in all, if your GP is insisting on a second malaria test in a few weeks, by all means there is no harm in doing that, but in the meantime I would seek a second opinion since I think it is more likely your daughter has another infection (possibly a gastrointestinal bug, or a viral infection) which may risk going undiagnosed if your GP fixates on malaria as the answer.

Regarding the symptoms, unfortunately the symptoms of malaria are very general and it is almost impossible to accurately diagnose the disease on the basis of symptoms alone, hence why a blood test is so important. The blood test, with positive observation of the malaria parasites, is also crucial to determine which species of malaria the patient has, which may have implications for the appropriate treatment.

Answer 2: From Malaria.com Medical Advisor (MD)

The diagnosis of malaria should always be considered for patients with a fever who have traveled to malaria endemic areas. Your concerns that this may be malaria are well founded. Malaria symptoms in the first few days of infection are similar to the early stages of many other febrile illnesses, including viral and bacterial infections. In malaria, the fever also typically waxes and wanes in the manner you described. Confirming the diagnosis requires detecting parasites or their products in a blood sample. The most common test involves inspecting blood under a microscope for the presence of malaria parasites. Sometimes early in the disease there aren’t enough parasites for detection by this method. For this reason, several blood smears taken at 12-24 hour intervals are sometimes required to rule out a diagnosis of malaria in a symptomatic patient.

Additionally, your daughter was vulnerable to infection because she stopped taking antimalaria medicines while traveling in a region of malaria risk. To offer protection, these medicines must be taken for the duration of the stay, and depending on the medicine, up to 4 weeks after the last possible malaria exposure.

Unfortunately most medical doctors in regions where malaria is very rare, like the the United States and Europe, have little experience diagnosing and managing malaria. I would advise you to seek attention at a travel clinic or infectious disease specialist without delay, where it is likely further blood tests will be undertaken immediately to establish laboratory confirmation, and the prompt initiation of treatment for malaria if present.

Malarial Attack Recurring

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QUESTION

My Father aged 65 years was diagnosed with malaria 15 days back and was on medication. Fever was recurring frequently and he had developed a lung infection. Three days back fever stopped and did not occur for 2 days and malarial infection was reducing. Now the Fever has started coming but other parameters are normal. Can you please suggest what needs to be done?

ANSWER

If your father also developed a lung infection, was he treated with antibiotics? If not, his later fever could be caused by that infection, and could be unrelated to the malaria.

He should have another blood test, to look for the malaria parasites; if they are still present, then you should talk to his doctor about trying another type of anti-malarial medication—the World Health Organization recommends artemisinin-based combination therapies (ACTs), such as Coartem, Alu and Duo-Cotecxin, as the first-line treatment against uncomplicated malaria.

However, given that your father appears to have concurrent other medical conditions, it may be that other treatment is more appropriate, and as such it is very important that you check with your doctor before taking additional medication.

Traditional Methods for Malaria Treatment and Prevention

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QUESTION

What are the traditional methods on treating and preventing malaria?

ANSWER

Many different cultures have had their own traditional ways of treating malaria. Perhaps the two best known come from the native tribes in the Western Amazon basin and the ancient Chinese.

Tribes in the Amazon used the bark of a shrub called Cinchona to treat fevers and shivering; Spanish priests in this region observed traditional Quechua healers using this bark and started using it themselves to treat the fevers associated with malaria. Many centuries later, the active ingredient from this bark was isolated and called quinine, which is still used in the treatment of malaria today.

In ancient China, traditional healers would use the plant sweet wormwood (Artemisia annua, to give it its full Latin name), also to treat fevers and the symptoms of malaria. For many hundreds of years, this traditional cure was forgotten about, until the 1970s when a concerted effort led by Mao Tse-Tung began to search for new anti-malarial compounds as part of their Vietnam war effort. Their scientists, led by Dr Youyou, re-discovered sweet wormwood and extracted a potent anti-malarial compound from it, called artemisinin. This compound and and its many derivatives, in the form of artemisinin-based combination therapies (ACTs), are now the mainstay of the World Health Organization’s first-line recommended treatment against uncomplicated malaria.

Malaria Treatment with Fansidar

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QUESTION

My husband has Malaria following a trip to Kenya and has had a fever for three days. We are in Russia and the only drug available at the pharmacy was Fansidar (we also have some Doxcycyclin). He took three Fansidar tablets last night and feels better but the fever has still not completely gone. What should we do? Take more Fansidar? Thanks for your help.

ANSWER

A single dose of three tablets is the correct amount for an adult over 45kg in weight—do not take any more. Unfortunately, Fansidar is not recommended as the first-line drug against malaria any more since many strains of P. falciparum (the most dangerous type of malaria, and the most common type in Kenya) now have resistance to Fansidar. This could be one reason why the treatment is not fully successful, though it could also be that the treatment has worked, but it will take a day or two more before your husband fully recovers.

Make sure your husband takes in plenty of fluids, and anti-inflammatory drugs such as ibuprofen might help with the fever and any aches he could also be suffering from.

If your husband is still feeling sick after a few days, you should try to have another blood test to see if the malaria parasites are still present in his blood. If you, you should try to find an artemisinin-based combination therapy, such as Coartem, Duo-Cotecxin or Alu. These are the most effective medications against malaria that are currently available, and are recommended as first-line treatment by the World Health Organization (for uncomplicated malaria).

Malaria Treatment and Prevention Methods

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QUESTION

I work in Central Africa republic.I was recently diagnosed with malaria (p.falciparum) after a blood test—my 4th attack in 15 months and given Co-Arinate. Two days after completing my dose I went for a 2nd blood test and the trophozoite count was 720/mm3.

The doctor prescribed co-artem and said if I don’t get better he shall transfuse quinine. Whats your comment on the treatment? Do these malaria medications/attacks have a long term effect on ones liver? What prophylaxis should I consider to prevent future attacks.

ANSWER

I will forward your question on to one of the medical professional who advises our website. However, normal procedure after treatment failure or incomplete treatment with one type of anti-malarial medication would be to try another type of medication first; Co-Arinate might not have been an ideal first choice given that many types of malaria around the world are showing signs of resistance to pyrimethamine, the combination drug in Co-Arinate.

Co-Artem would be a better first choice drug, given that there is no convincing evidence for resistance to its combination compound, lumefantrine. Quinine could be a potential next step though I would imagine Co-Artem will be successful—make sure the drugs have not expired and are in their original packaging, as counterfeit medication is a problem in many parts of the world.

Regarding prevention, a key method is to sleep under a long-lasting insecticide treated bednet; make sure it is re-dipped in insecticide every year or so to maintain its efficacy. The mosquitoes which transmit malaria tend to feed at night, and so protecting yourself and your home during the evening, night and early morning is crucial. Maintaining good screens on all windows and doors can be a very effective way of preventing mosquitoes from entering, and in many parts of the world, people spray inside with insecticides to reduce the number of mosquitoes yet further. Wearing long-sleeved clothing at night and in the evenings can also prevent bites.

More broadly speaking, you can try to make sure that stagnant water sources, such as empty containers or barrels, are removed, as mosquitoes require still water to breed. Reducing the presence of stagnant water will therefore reduce mosquito numbers; treating standing water with larvacides or adding fish that eat mosquito larvae can also help.

Chewable Malaria Medication

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QUESTION

Can this drug be chewed by an older person who can not swallow drugs?

ANSWER

Some malaria medication can be administered via injection. In places where malaria is still resistant to chloroquine, a syrup formulation is sometimes given to children who are unable to swallow tablets, so this might be an effective solution. Otherwise, you can talk to your doctor about the efficacy of the tablets if chewed—I imagine they will probably be fine, though they won’t taste very good!

Malaria in Ivory Coast

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QUESTION

I am going to work in the Ivory Coast on an oil and gas platform out at sea I will be in the Ivory Coast for about 30 Days and home for 26 Days and back in the Ivory Coast for 30 Days this could go on for a couple of years. What would you suggest that I take for anti malaria? Would O need a prescription or can I get it from the chemist?

ANSWER
You usually need a prescription to get anti-malarials. None of the available anti-malarials are really recommended for long-term use, except possibly for doxycycline, and since that one requires you to take for four weeks after you have left the malarial area, you might find yourself taking a pill every day for several years! Some people on doxycycline experience sun sensitivity as a side effect, which means it might not be the best choice for people working outdoors in the tropics.

Likewise, Lariam must be taken for four weeks after leaving the malarial area, but is only taken weekly, so it might be more convenient. Lariam is unsuitable for people with certain psychiatric disorders, and many people report side effects such as anxiety and increased aggression. Moreover, I am not sure what the recommendations are regarding long term use.

Malarone (atovaquone-proguanil) is convenient in that it only has to be taken for one week after leaving a malarial area, but again it is a daily pill, and while it probably has the least number of side effects, it is also the most expensive, and could be prohibitively so for long term use.

So, as you can see, there are pros and cons with all the main forms of preventive anti-malarial medications! Since you will be working out at sea, I actually wonder how great the risk of malaria actually is—the mosquitoes which carry the malaria parasite require stagnant freshwater in order to breed, and so if the platform does not contain these areas of still freshwater and if you are sufficiently off-shore so that mosquitoes cannot fly readily from the mainland, you may actually find there is not very much malaria there, and you will only be at risk if and when you visit the mainland.

In those cases, you could look into taking Malarone or another type of medication to protect you when you are on the mainland. In addition, for peace of mind, while on the rig you could use other types of prevention against malaria, such as sleeping under a long-lasting insecticide treated bednet at night and taking care not to be bitten by any mosquitoes that might be around.

As such, I would advise you trying to find out how far the platform is from the mainland and whether there is known malarial risk there. If there is, then you should talk to your doctor about the above anti-malarial drugs and decide which one would be best for you, if any—like bednets, there are also measures you can take to protect yourself from mosquitoes which can also be very effective is used regularly and correctly.

Malaria in South Africa

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QUESTION

What are the high, low and no-risk areas for malaria in South Africa?

ANSWER

Malaria has been successfully controlled in many parts of South Africa, with the result that most of the country is not at risk for malaria transmission. However, some pockets of higher risk remain in the north-eastern corner of South Africa (north-eastern KwaZulu-Natal, with the southern-most limit of transmission corresponding with the Tugela River, Limpopo (Northern) Province, and Mpumalanga Province). Malaria is also transmitted in Kruger National Park.

How is Malaria Treated

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QUESTION

how is malaria treated?

ANSWER

Malaria can be a severe, potentially fatal disease (especially when caused by Plasmodium falciparum) and treatment should be initiated as soon as possible.

Patients who have severe P. falciparum malaria or who cannot take oral medications should be given the treatment by continuous intravenous infusion.

Most drugs used in treatment are active against the parasite forms in the blood (the form that causes disease) and include:

  • chloroquine
  • atovaquone-proguanil (Malarone®)
  • artemether-lumefantrine (Coartem®)
  • mefloquine (Lariam®)
  • quinine
  • quinidine
  • doxycycline (used in combination with quinine)
  • clindamycin (used in combination with quinine)
  • artesunate (not licensed for use in the United States, but available through the CDC malaria hotline)

In addition, primaquine is active against the dormant parasite liver forms (hypnozoites) and prevents relapses. Primaquine should not be taken by pregnant women or by people who are deficient in G6PD (glucose-6-phosphate dehydrogenase). Patients should not take primaquine until a screening test has excluded G6PD deficiency.

How to treat a patient with malaria depends on:

  • The type (species) of the infecting parasite
  • The area where the infection was acquired and its drug-resistance status
  • The clinical status of the patient
  • Any accompanying illness or condition
  • Pregnancy
  • Drug allergies, or other medications taken by the patient

If you have or suspect you have malaria, you should contact your doctor immediately.

Treatment Duration of Lumartem

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QUESTION

I am on the lumartem treatment. I started at 8am to 4 pm. then 4am. i forgot to take the drugs at 4pm, but took it at 8;30o. Should I start all over or continue at 4am or 8 am?

ANSWER

If you miss a tablet, you should take the next one as soon as you remember, then wait the required interval before taking the pill after that. So, since you took the missed pill at 8.30, you should take the following one at 8.30am (12 hours later). Then continue as you would normally until all 6 doses have been taken – it is very important to complete the full course of tablets.