I am getting malaria every 6 months

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QUESTION:

I am getting malaria every six months, after taken chloroquine medicine tablets. Is this  normal,when my resistance is low, or is it coming aging, is there any medicine to clear the malaria?

ANSWER:

While taking chloroquine can be used to treat malaria, it will not prevent re-infection, unfortunately. One thing to check though is whether you are living in an area where the local types of malaria might be resistant to chloroquine; if so, it will be worth seeing if you can be treated with artemisinin-based combination therapies (ACTs), such as Coartem or Lonart, instead.

Again, these will not prevent re-infection, however, so you need to also take other preventative actions, such as sleeping under a long-lasting insecticide treated bednet and wearing long-sleeved clothing in the evenings and at night to prevent mosquito bites.

It sounds from your question like you live in an area where malaria is common; however, if you are actually only travelling to malarial areas regularly, you could also ask your doctor about the possibility of taking preventative medicine against malaria for the time that you are travelling (these are called “prophylactics”).

You should also check which species of malaria parasite you are infected with – this can be determined when you are diagnosed with the infection, either through looking at your blood under a microscope or by using a rapid diagnostic test (RDT). If you Plasmodium ovale or Plasmodium vivax, there is a possibility that even though the initial acute phase of the infection is responding to treatment with chloroquine, the parasite is remaining dormant in your liver, and causing the recurrences every 6 months. In this case, you should ask your doctor about the possibility of taking a drug called primaquine, which kills these liver stages and prevents further relapse of the disease.

Diagnostic test for malaria?

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QUESTION:

What are the possible diagnoses tests?

ANSWER:

A blood test is usually required to diagnose malaria, although the blood can be used in a number of different ways. The most common, traditional form of diagnosis is a blood smear, observed under a microscope by a qualified technician. These can be “thick” or “thin”; the “thick” smear examines a whole drop of blood for the presence of the malaria parasites infecting the patient’s red blood cells. Because a relatively large volume of blood is examined in this way, the thick smear is useful for detecting low levels of parasites in the blood, and therefore is good for an initial “positive or negative” diagnosis. The thin smear allows for a closer look at the infected blood cells, and thus can be used to identify the species of malaria, which can be important for giving the patient appropriate treatment. The danger with blood smears is that very low intensity infections can sometimes be missed, given the a low number of parasites in the blood.

More recently, a number of antibody tests have been developed to test for malaria. These so-called “rapid diagnostic tests” (or RDTs) do not require the expertise of a blood smear and only need a tiny droplet of blood, and so can even be performed at home as part of a self-testing kit. Different tests have been developed to test between the various different species of malaria. While quick and easy, there are some concerns over the sensitivity and specificity of the various tests; trials in the field have gone some way to quantifying the effectiveness of these tests in different contexts. One potential advantage of RDTs is that in some cases they seem capable of positively diagnosing low intensity infections, that would be missed by traditional blood smear. A disadvantage for wide-spread use of these tests, especially in low resource settings, is that they are very expensive.

Finally, the advent of DNA-based techniques for identifying malaria parasites means that PCR (polymerase chain reaction) can be used on a patient’s blood for an almost fool-proof diagnosis, not only of species but also, to a certain extent, of intensity. However, this procedure takes time, is expensive and requires a fully equipped laboratory with trained personnel; as such, it is not usually used for every day diagnosis of malaria infections, and especially not in developing countries where the vast majority of malaria cases occur.

Malaria Blood Work

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QUESTION:

What means smear for malaria – value 1?

ANSWER:

In most cases, I would suggest this means a positive result, though the exact meaning of that depends to some extent to the type of blood test it was. You mention a smear; to me, that implies that the test used traditional microscopy to look for red blood cells infected with malaria parasites. In this case, a result of 1 would indicate that one infected red blood cell was observed, meaning the patient is positive for malaria, although with a light infection (at least at that point in time – especially if the patient had falciparum malaria, the intensity of the infection can increase very rapidly). Otherwise, blood can be used in malaria rapid diagnostic tests (RDTs), which look for antibodies to malaria in the patient’s blood. In this case, the test result can sometimes be denoted by a binary value: in other words, 0 indicates negative and 1 indicates positive.

It is very important to find out from your doctor or clinic exactly what kind of test they ran and what the results mean, to ensure that correct and effective treatment is administered as quickly as possible.

Simple Rapid Diagnostic Tests (RDTs) for Malaria Work Well

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When a person living in a malarial area gets a fever, health workers need to know the cause to make absolutely sure they give the right treatment. For many years in sub-Saharan Africa primary health workers have often assumed a fever is caused by malaria, and given antimalarial drugs. This approach means sometimes people receive the wrong treatment for their illness. It also wastes resources and, over time, can promote resistance to available drugs.

A new Cochrane Systematic Review examines the accuracy of Rapid Diagnostic Tests (RDTs), which are designed to detect malaria based on the presence of parasite antigens, using a quick and easy to use format. The World Health Organization (WHO), now strongly recommends health staff confirm a malaria diagnosis prior to treatment with artemisinin combination therapies (ACT’s), but in many settings, this demands a major shift in practice and is not as easy as it may seem to adopt.

Up until recently, confirming a diagnosis of malaria infection was done by detecting parasites in a blood sample using a microscope. This requires highly trained staff, reagents and equipment, all of which are in short supply in many areas where malaria is common. RDTs use carefully manufactured molecules (antibodies) that when in contact with an infected patient’s blood can bind with the malaria parasites and trigger a colour change on a test strip that can be easily seen with the naked eye. While these tests are technically difficult to manufacture, once built they are relatively simple to perform, require no specialised equipment and provide accurate results in many geographical settings.

“After reviewing available data in 74 different studies, we can say that the these antigen-detecting tests will identify at least 19 out of 20 cases, a success rate that would be very useful in clinical practice,” says Katharine Abba, who carried out this review at the Liverpool School of Tropical Medicine, UK.

“The use of Rapid Diagnostic Tests is another step towards reaching the goal of universal accuracy in the diagnosis of malaria and key to ensuring that the correct treatment is given to patients. Resources can be saved with the rational use of anti-malarial drugs and it will also reduce the pressure on drug resistance.”

There are various different RDTs designed to detect the malaria parasite. “All the tests performed reasonably well, but we do need more research to address issues such as how easy these tests are to use and what barriers there may be to adopting them,” says Abba.

Malaria is caused by the parasitic protozoan Plasmodium. It causes high fevers, headaches and aches and pains elsewhere in the body. If not treated early, malaria quickly evolves from an uncomplicated state into a severe disease where the brain is involved and the risk of death or brain damage is high. Malaria kills over 700,000 people a year worldwide, mostly children in Africa. In addition there are cases in Asia, Latin America, the Middle East and parts of Europe.

Source: Wiley

Treating Malaria by Health Extension Workers: A Case Study from Ethiopia

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For many years the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) have been promoting an Integrated Management of Childhood Illness (IMCI) training package to ensure that nurses and doctors are capable of treating sick children at health facilities.  Over the years, with the realization that many children did not have access to health facilities and therefore were not being ttreated, the two organizations published a Joint Statement on Managing Pneumonia in Community Settings (2004)[1].  This groundbreaking document calls on countries to bring treatment of childhood illness – pneumonia as well as malaria and diarrhea closer to communities that need it, by empowering trained community health workers to identify and manage these problems. Many countries have followed this advice with excellent results.  Here is a story from Ethiopia.

Aminata is a health extension worker (HEW) at the Tebisa health post, located in a rural, hilly area of East Amhara, some 400 kilometers away from Addis Ababa, the capital city of Ethiopia. Aminata received training on integrated community based management of common childhood illnesses (iCCM) in early 2011. After the training, she carried the essential materials and supplies with her back to the health post, and started treating children suffering from pneumonia, malaria, diarrhoea and/or severe acute malnutrition.  In the last two months, she has treated 35 children under five.

HEW Ethiopia
A Health Extension Worker (HEW) with Almaz and her family. Photo: Dr. L. Pearson

One of the children suffering from malaria is a five year old girl, Almaz (which means diamond in Amharic). She developed fever one night in April. Her mother took her to the health post and she was seen immediately. Aminata checked her temperature (39.0 OC), and respiratory rate (children sometimes have pneumonia and malaria at the same time) and pricked her finger to obtain a drop of blood to perform a Rapid Test for Malaria (RTM) to look for malaria parasites [Ed: Rapid Diagnostic Tests, or RDTs, are another, more general term for these tests].

Almaz did not have rapid breathing, an indication of pneumonia, but she did have falciparum malaria (the most severe and deadly of the types of malaria found in humans, and caused by the Plasmodium falciparum parasite).  She was given Coartem (Arthemeter-Lumefentrine) treatment by mouth for three days.  Aminata gave the first dose of medicine and gave the mother the rest of the tablets, explaining when to give them. Aminata made a point to discuss how important it is to feed a sick child so they do not lose weight, and to be alert to certain ‘danger signs’ in case the child is not getting better, in which case they should return immediately to the health post.

On the second day of treatment her mother brought her back to the health post for a follow up check.   Almaz’s mother expressed her gratitude. “If the HEWs are not providing treatment for sick children, I would have to carry Almaz to the health center some 4 hours away by foot. I would also have to pay for the treatment.  We were frustrated before iCCM started because we were not able to help children with malaria and pneumonia”.

malaria medicines at health post Ethiopia
Malaria medicine available, for free, at the Tebisa health post in Ethiopia. Photo: Dr L. Pearson

“The communities trust and support us even more now”, said Aminata. “Now the mothers are so happy, they even bring the children for immunization without us having to push them”.

In the next two years, about 20,000 HEWs will be trained and supported to provide iCCM in 10,000 rural villages. Hundreds and thousands of young children in Ethiopia will benefit from the iCCM programme jointly supported by the government of Ethiopia, Catalytic Initiative of Canada, UNICEF and other development partners. Program implementation will focus on remote and harder to reach villages and households, to ensure every child is covered, no matter where they are and who they are.

The iCCM is be an important opportunity to further improve quality of care provided at the health posts, and accelerate toward the achievement of Millennium Development Goal 4, to reduce deaths of children under 5 by two-thirds by 2015.

[1] Management of Pneumonia in Community Settings (PDF)

Treatment for malaria in Africa

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QUESTION:

What is the treatment for malaria in Africa?

ANSWER:

The appropriate form of treatment for malaria, regardless of where you are, depends on the type of malaria you have. This can be determined through diagnosis; each of the main malaria parasites that ordinarily infect humans (P. falciparum, P. vivax, P. malariae and P. ovale) looks slightly different under the microscope, although you have to be well trained to tell them apart! Rapid diagnostic tests (RDTs) can also sometimes distinguish between malaria species, although many RDTs only test for P. falciparum, he most acute, severe and deadly of the species.

In much of Africa, P. falciparum is the most common and dangerous form of the disease. In some places, it can be treated with chloroquine, though in many places the parasite has developed resistance to this drug, so other treatment is necessary.

The most common drugs given in areas with known chloroquine-resistant strains of P. falciparum are ACTs (artemisinin-based combined therapies). There are some parts of Africa where other forms of malaria, such as P. ovale and P. vivax, can also occur – it is important to know whether a patient is infected with these species as they require an additional form of treatment, the drug primequine, in order to kill dormant liver stages that characterise these species and can lead to a relapse of infection months or even years after the initial exposure.

Malaria Self-Diagnosis

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QUESTION:

I live in Nigeria and was wondering if there are ways to find out if I malaria without going to the doctor or a hospital?

ANSWER:

The current “gold-standard” for malaria diagnosis, at least of active infections, is through microscropy, where a trained technician looks at a droplet of your blood on a slide, and sees if any of your red blood cells are infected with the malaria parasite. Given the expertise required for this procedure, it is usually only available through a doctor or in a hospital setting. Moreover, this technique is not reliable for very low numbers of parasites, though most active malaria infections will be positively diagnosed.

However, in the last ten years, there has been a rise in the availability and effectiveness of so-called rapid diagnostic tests (RDTs) for malaria, which can be self-administered and so are able to be bought in a pharmacy and used at home. There are a wide variety of these tests, which work by using antibodies to detect the antigens produced by the malaria parasites. As such, the tests seem to be able to detect even low levels of parasitaemia, and in some cases can even tell you which kind of malaria you have. The tests usually come with all necessary materials, which include a lancet for pricking the fingertip for a drop of blood, although you should always check that everything is within the packaging (I have bought tests in Uganda which came without the buffer solution; this had to be purchased separately in this case). The WHO maintains a list of currently available RDTs (PDF).

Make sure the test you purchase is suitable for the type of malaria that is found in your region; many only test for P. falciparum, for example, which might not be appropriate for a region with high levels of P. vivax or other species.