Treatment of Chronic Vivax Malaria

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QUESTION

What is the treatment of chronic Vivax malaria?

ANSWER

Blood stage infection with Plasmodium vivax can usually be treated successfully with chloroquine, though resistance is spreading in some areas (notably the Pacific Islands, Papua New Guinea, parts of south-east Asia and especially Indonesia, and Peru). P. vivax is also sensitive to artemisinin-based combination therapies (ACTs) and as no resistance to artemisinin has been reported, these are widely recommended (though combinations which include sulfadoxine-pyrimethamine should be avoided as many strains of P. vivax appear to be resistant to pyrimethamine).

Liver stage (i.e. relapsing) P. vivax can only be treated with one drug: primaquine. Instances of liver stage treatment failure are relatively commonplace, and may be strain or dosage dependent. Primaquine is not recommended for people with G6DP deficiency, so potential patients, and particularly those from locations or ethnic groups known to have high levels of G6DP deficiency, should be tested prior to treatment.

What does the goverment do to help malaria?

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QUESTION

Does the goverment help malaria?

ANSWER

Many governments around the world assist in controlling malaria. Some countries, like Australia and the United States, used to have malaria transmission occur within their own borders, but through dedicated control programs, have managed to eradicate the disease locally. In these cases, the government coordinated huge programs of draining standing water, spraying insecticides and ensuring that health clinics were equipped to diagnose and quickly treat any human cases.

Nowadays, the governments of the US and Australia, along with many other countries which do not have malaria, still assist in the fight against malaria by funding malaria control programs in other countries, either directly (for example, the US funds international health projects through the US Agency for International Development) or indirectly, through international organisations like the World Health Organisation and the Global Fund for HIV, TB and Malaria. They also provide training in technical expertise to scientists, doctors and clinicians from malaria-endemic countries.

The governments of countries which have malaria are also deeply engaged in fighting the disease, mostly through their respective Ministries of Health, which often have specific malaria departments. In India, for example, malaria control is carried out by the National Vector Borne Disease Control Programme (NVBDCP), which is part of the Directorate General of Health Services. The NVBDCP carries out a multi-pronged strategy to combat malaria, including early case detection and treatment, vector control (with spraying, biological control and personal protection), community participation, etc. In Uganda, the Malaria Control Programme also carries out the above activities, and also provides intermittent preventative treatment against malaria for young children and pregnant women and has in the past engaged in large-scale distribution of long-lasting insecticide treated bednets. Both countries also explicitly include monitoring and evaluation as part of their control strategies, to make sure that any interventions or control efforts they make are having a positive impact on reducing malaria morbidity and mortality.

What is Malaria?

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QUESTION

What is malaria?

ANSWER

Malaria is a serious and sometimes fatal disease caused by a parasite that commonly infects a certain type of mosquito which feeds on humans. People who get malaria are typically very sick with high fevers, shaking chills, and flu-like illness. Four kinds of malaria parasites can infect humans: Plasmodium falciparum, P. vivax, P. ovale, and P. malariae. Infection with P. falciparum, if not promptly treated, may lead to death. Although malaria can be a deadly disease, illness and death from malaria can usually be prevented.

Headaches, Sweats, Nausea, Fatigue

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QUESTION

Since visiting Gambia I have been off food, suffering from headaches, sweats, nausea, tiredness and diarrhea after every meal, when I can eat that is. Do you think I should go to the doctor for a test for malaria?

ANSWER

Yes—whenever you have symptoms that include fever and sweats after visiting an area of high malaria transmission, it is always worthwhile getting a malaria test. With a positive diagnosis, the doctor can find out what type of malaria you have and then give you the most appropriate treatment. If the test is negative, the doctor is then able to look for other possible causes of your symptoms, such as an intestinal parasitic infection or some other illness.

How Many Malaria Deaths in Africa?

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QUESTION

What is the estimated number of deaths in Africa caused by malaria each year?

ANSWER

The exact numbers of deaths caused by malaria every year is very difficult to measure accurately, due to difficulties in diagnosis and also failure to report cases. However, the Roll Back Malaria partnership, coordinated by a host of international organisations including the World Health Organisation, estimates that last year approximately 801,000 people died of malaria in Africa, which represents over 90% of the total annual worldwide deaths. Of those, the vast majority of victims were children under the age of five.

Malaria Symptoms

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QUESTION

How does the virus cause the symptoms?

ANSWER

Malaria is actually not caused by a virus—it is caused by a microscopic single-celled parasite called Plasmodium. Several different species cause malaria in humans, the most common of which are P. vivax and P. falciparum.

To describe the process in a very oversimplified way, the malaria parasites cause disease by infecting red blood cells, multiplying inside them, then simultaneously bursting out again, destroying then red blood cell in the process. The sudden destruction of lots of red blood cells, plus the debris and waste products left behind by the malaria parasites, stimulate a rapid immune reaction, which itself causes the rapid spike of fever. The characteristic cycles of fever sometimes seen with malaria sufferers occurs because the malaria parasites synchronise their emergence from the red blood cells. The destruction of red blood cells, together with concurrent physiological changes associated with immune response and inflammation, can also lead to decreased haemoglobin levels and anaemia.

More severe clinical symptoms are often seen with P. falciparum malaria infection, particularly if not promptly diagnosed and treated. This is because the P. falciparum parasite infects a red blood cell, it changes the surface of the cell and makes it “sticky”; when the red blood cell then tries to pass through the small blood vessels that lead into the body’s organs, it becomes stuck. This process is known as “sequestration”. If enough red blood cells become sequestered in the organs, it can reduce blood flow to the organ, resulting in oxygen deprivation. When this happens in the blood vessels in the brain, the patient may experience impaired consciousness, confusion and even coma and death—this manifestation is known as “cerebral malaria.”

Malaria Testing

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QUESTION

My daughter is in Kigoma, Tanzania and has the symptoms of Malaria. She was given Duo Cotecxin and it seems to have started making her feel better. But after reading up on all the different types of Malaria parasites I am wondering if a blood test reading at a clinic would be recommended or is it too late for an accurate reading now that she is on meds?

ANSWER

I am always very nervous about people given malaria medication without a proper blood test-based diagnosis. The symptoms of malaria can sometimes be very general, and I have recently seen some data from elsewhere in Tanzania whereby clinics are giving virtually everyone who comes in with a fever malaria medication, even if the blood tests are negative! This is a sure way to develop resistance to malaria drugs, plus exposes people to the potential side effects of medication that they may not need, while also failing to diagnose or treat them for whatever other condition they may also have.

In your daughter’s case, since she is feeling better, it may be that she did indeed have malaria. Regardless, now that she is taking the treatment, she should make sure to finish the full dose of pills. It still could also be worth going in for a blood test. In any case it will put your mind at rest, and if there are still traces of the parasite in her blood, then you will know for sure that she had malaria. Moreover, it might tell you which type of malaria she had. While P. falciparum is the most common form of malaria in sub-Saharan Africa, cases of other types, such as P. vivax and P. ovale, are being reported more and more frequently.

These two types can form liver stages (called hypnozoites) which can stay dormant for weeks, months or even years after the initial infection. During this period, the patient will experience no symptoms; then, when the hypnozoites activate and re-enter the blood again, the patient will get a “relapse” of the malaria symptoms. The only drug available to kill these liver stages is primaquine; as such, if your daughter is positively diagnosed with P. vivax or P. ovale malaria, she should be aware of the possibility of a relapse, and perhaps discuss with a doctor the possibility of taking primaquine.

I hope she recovers fully and enjoys her stay in Kigoma—I spent almost a month out there last year!

What is the Meaning of the Word “Malaria”?

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QUESTION

The word malaria comes from two medievial Italian words meaning?

ANSWER

Malaria comes from “mal” and “aria,” which means “bad air.” Before the parasite that caused malaria was discovered, people thought the disease was caused by foul air, and associated it with marshes and low-lying swamps. They were not 100% wrong—those areas are perfect breeding grounds for the mosquitoes which transmit malaria, and so infection often occurs in and around these areas.

Duo-Cotecxin and Fansidar as Treatment

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QUESTION

My husband weighs and has malaria. He was told by the pharmacist to take 2 tablets stat, then 1 daily for five days followed by 3 Fansidar tablets. We live in Papua New Guinea. I see on the Duo-Cotecxin web site the dose is three tabs daily. Which is correct?

ANSWER

Fansidar is a very different drug to Duo-Cotecxin—it is made of a combination of sulfadoxine and pyrimethamine, whereas Duo-Cotecxin is an artemisisin-based combination therapy (ACT), consisting of dihydroartemisinin together with piperaquine. As such, the dosages and time courses of therapy are likely to be different. However, Fansidar is not usually recommended as treatment anymore—it appears to have low efficacy against Plasmodium vivax and in the 1980s and 1990s, the World Health Organisation and Center for Disease Control (CDC in the US) only recommended it for use against chloroquine-resistant P. falciparum.

However, nowadays, both organisations recommend ACTs (like Duo-Cotexcin) to treat all uncomplicated P. falciparum infection as well. Therefore, unless your husband has been diagnosed with P. ovale or P. malariae malaria (both of which are sometimes found in PNG), Fansidar probably should not have been the first-line treatment given to him. Keep a close watch over his recovery, and if there is any sign of reccurrence of the symptoms, go back to the doctor for another malaria test.

How can I get malaria pills?

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QUESTION

I do have symptoms of severe malaria. How can I get malarial pills in Holland? I went to the hospital the doctors said nothing is wrong with me which is not true.

ANSWER

If you have the symptoms of severe malaria (high fever, chills, nausea, body aches) then you should go to an emergency room at a hospital immediately.

Malaria infection can be very serious if not treated promptly and with appropriate medicine. You must inform the doctors of your travel and medical history. Malaria is not transmitted in Holland so you must have been infected elsewhere.

Tell the doctors in particular if you have recently (in the past month) travelled to an area where malaria is transmitted (sub-Saharan Africa, South America, some parts of Central America, Haiti, Central Asia, South-East Asia, many of the Pacific Islands). I am certain that if you truly have the symptoms of severe malaria they will not turn you away from the hospital, and especially not if you make it clear that you may have been at risk for malaria.

However, if you have not travelled to malarial areas recently, then it is much less likely you have malaria. However, some forms of malaria can “relapse” after a long dormant period. If you have had malaria previously, and have suffered these relapses, then this is also very important information to tell your doctors.

It is important to take anti-malarial medication only if you have had a blood test to confirm that you have malaria. The symptoms are general enough that they are often mistaken for malaria when they are in fact caused by another disease. Moreover, in most parts of Europe, it is difficult to get malaria medication without a prescription.

It is very important that you visit an emergency room, hospital or your doctor as soon as possible to get tested for malaria and given the appropriate treatment if indeed you test positive for malaria.