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.

Repeated Malaria

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QUESTION

Since January 2011 I got three times malaria. Is it come regularly? Last week also I got maleria and I took medicine but still I have mild headache and sweating feeling tiredenes in between..

ANSWER

The timing of the repeated malaria episodes you have experienced means that it could be recrudescence (where treatment does not completely kill all the malaria parasites in your blood), relapse (where the malaria goes dormant in your liver, then comes back—this is only caused by Plasmodium vivax and Plasmodium ovale malaria) or even re-infection.

However, first of all, the most important thing is to make sure you are properly diagnosed with malaria and secondly, that you receive the right type of treatment for the kind of malaria that you have.

The symptoms of malaria are very general (fever, chills, nausea, tiredness, aches) and can also be caused by many other illnesses and diseases. As such, in order to confirm you actually have malaria, you should have a blood test (thick and thin blood smear, looked at under the microscope by a trained technician, or a rapid diagnostic test (RDT). In some places you can buy these RDTs from local pharmacies and do the test yourself at home).

Depending on where you live, there may be different types of malaria present; in this case, if you do have malaria, it is important to find out which one you have.

P. falciparum is the most common kind in sub-Saharan Africa and first-line treatment is an artemisinin-based combination therapy, such as Coartem – most areas have P. falciparum that is resistant to chloroquine, so this is not appropriate as treatment, nor are sulfadoxine and pyrimethamine combinations (such as Fansidar).

If you have P. vivax or P. ovale, chloroquine may be used, again depending on where you are and whether resistance is known from your area or not. In addition, you might also talk to your doctor about taking primaquine to prevent future relapse and recurrence of the infection.

Repeated re-infection can be prevented by protecting yourself more thoroughly against getting bitten by an infected mosquito. For example, you should sleep under a long-lasting insecticide treated bednet, screen your windows and doors and wear long-sleeved clothing at night and in the evenings. Indoor residual spraying, which coats your walls with insecticide, can also prevent mosquitoes from persisting inside your home.

Malaria in KwaZulu Natal

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QUESTION

How many people are infected by malaria in KZN?

ANSWER

By “KNZ” I assume you mean KwaZulu Natal (for the benefit of other readers, this is a region of South Africa, in the north-eastern portion of the country). KZN is one of the few parts of South Africa that experiences malaria transmission, though effective control measures have reduced its impact as a public health threat.

Up until 1996, South African policy had been to use DDT (even though it was a banned substance) to control mosquito populations, and malaria levels had correspondingly been low. However, after cessation of spraying with DDT, the number of malaria cases increased, to a high of over 40,000 cases in the 1999/2000 malaria season (in KZN, malaria is most commonly transmitted during the wet summer months, from November to May). Since then, the use of DDT as an insecticide has been reintroduced (along with other public health measures, such as switching to artemisinin-based combination therapies for first-line malaria treatment), and the burden of malaria has plummeted.

The most recent data I could find reported less than 3500 cases for the 2001/2002 malaria season, and zero cases in 2002/2003 (though the data I found were only up to February 2003). Efforts to coordinate malaria control between South Africa, Mozambique and Swaziland have also contributed to the success of reducing malaria transmission in the region.

P. Falciparum Malaria Treatment

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QUESTION

I dont have high fever yet have been diagnosed with P. falciparum malaria. How can this disease be treated and is it completely curable?

ANSWER

Don’t worry, if diagnosed early and given appropriate treatment, P. falciparum infection is very easily cured. You should be given a type of medication called artemisinin-based combination therapy (ACT). An example is Coartem, which is a combination of artemether and lumefantrine.

Other artemisinin derivatives that are commonly used include artesunate and dihydroartemisinin. You should start to feel better after just a few days and will make a complete recovery. Make sure you get the correct dose for your age and weight from the doctor, and take the medication for the full length of time the doctor tells you – this is very important to make sure the infection is completely cured, otherwise the infection may be able to come back.

Do malarial drugs engender joint pains?

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QUESTION

I am now over 50 and I lived all my life in Africa during which time I have had a considerable incidences of malarial attacks. Each time I took any anti-malarial drug I experienced some side-effects including blurred vision, fatigue and joint pains. The pains especially have since become a permanent part of me and even severe enough to hamper my mobility. Does my condition sound to have any relationship with the several quantity and varieties of anti malarial drugs that I took almost all my life?

ANSWER

There are no known long-term side effects to taking modern anti-malarial drugs. However it could be that you have had a reaction or allergy to the specific kind of anti-malarials you have used in the past. For example, quinine sulphate is associated with joint pain in rare cases. However, in Africa these days, the World Health Organisation recommends only the use of artemisinin-based combination therapies (ACTs, such as Coartem) as the first-line treatment for malaria. The side effects of ACTs tend to be mild, and limited to nausea, dizziness and vomiting. As far as I am aware, joint pain and blurred vision have not been reported as side effects.

We at Malaria.com are very interested in hearing people’s experiences with antimalarial medication, so we would be very grateful if you would take the time to complete a survey on malaria treatment which we are running on the website. Thank you!

“Test and Treat” Model Offers New Strategy for Eliminating Malaria

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As researchers work to eliminate malaria worldwide, new strategies are needed to find and treat individuals who have malaria, but show no signs of the disease. The prevalence of asymptomatic or minimally symptomatic malaria can be as high as 35 percent in populations with malaria and these asymptomatic individuals can serve as a reservoir for spreading malaria even in areas where disease transmission has declined.

In a new study, researchers at the Johns Hopkins Malaria Research Institute found that a strategy of actively identifying undiagnosed malaria and then treating those with the disease resulted in significantly lower prevalence of malaria cases compared to a control group. Their findings are published in the February 3, 2012 edition of the journal PLoS ONE.

“New strategies are needed, particularly in areas of declining transmission. One strategy is to screen people for malaria and treat those who are infected, even those who are not sick enough to go to the clinic,” said lead author, Catherine G. Sutcliffe, PhD, an assistant scientist with the Johns Hopkins Bloomberg School of Public Health’s Department of Epidemiology. “Using artemisinin combination therapy can enhance this strategy, as treatment can reduce transmission to mosquitoes. In regions of declining transmission, the burden of malaria could be reduced to such an extent that elimination is achievable.”

The study was conducted in southern Zambia, with colleagues from the Johns Hopkins Malaria Research Institute in Macha. Researchers analyzed data from surveys conducted in 2007 and between 2008 and 2009. In both surveys, households were screened for malaria using rapid diagnostic tests and treated with artemisinin combination therapy when malaria was detected.

According to the new study, a proactive test-and-treat case-detection strategy resulted in a sixfold reduction in prevalence in 2008 and 2009, with the initial parasite prevalence at 4 percent. Test and treat showed a twofold reduction in 2007, when community prevalence was higher at 24 percent.

“Proactive case detection with treatment using artemisinin-combination therapy can reduce transmission and provide indirect protection to household members. If resources permit, this strategy could be targeted to hot spots to achieve further reductions in malaria transmission,” said William J. Moss, MD, senior author of the study and associate professor with the Johns Hopkins Bloomberg School of Public Health.

Worldwide, malaria afflicts more than 225 million people. The disease kills between 800,000 and 1 million people each year, many of whom are children living in Africa.

Authors of “Reduced Risk of Malaria Parastemia Following Household Screening and Treatment: A Cross-Sectional and Longitudinal Cohort Study” include Catherine G. Sutcliffe, PhD; Tamaki Kobayashi, PhD; Harry Hamapumbu; Timothy Shields, MA; Sungano Mharakurwa, PhD; Philip E. Thuma, MD; Thomas A. Louis, PhD; Gregory Glass, PhD; and William J. Moss, MD.

The Johns Hopkins Malaria Research Institute is a state-of-the-art research facility at the Johns Hopkins Bloomberg School of Public Health. It focuses on a broad program of basic science research to treat and control malaria, develop a vaccine and find new drug targets to prevent and cure this deadly disease.

The research was funded by the Johns Hopkins Malaria Research Institute.

Source: Johns Hopkins Bloomberg School of Public Health

Lasting Headaches and Malaria

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QUESTION

I had malaria in July of 2011, returned to the U.S. in August, and had an occurrence of P. falciparum a little more than a month later. It was quickly treated, but I continue to get headaches. They occur about daily, and exercise induces a very severe headache. Is this a common lasting symptom of malaria?

ANSWER

Once successfully treated, malaria almost never has recurring or lasting side effects, nor are lasting headaches a known side effect of treatment with ACTs (artemisinin-based combination therapies, which is the recommended first-line treatment against P. falciparum). If your headaches are made worse through exertion, you should talk to your doctor about making sure they are not a symptom of a more serious condition.

Malaria in Burkina Faso

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QUESTION

(1)What drug is administered in the first 24 hours after malaria symptoms onset. What side effects have this/these drugs.

(2) I it is not possible to reach a treatment facility etc until 7 days after initial chills, fever etc and there are no symptoms remaining other than tiredness what is the drug of choice?. Local people say it is malaria but there is no diagnostic facility near the location until a week has passed.

The person in question is visiting in Burkina Faso where malaria is endemic. Standard anti malaria treatment was taken, but we are told that this is not always effective.

ANSWER

1) In most parts of sub-Saharan Africa, due to the spread of chloroquine-resistant strains of Plasmodium falciparum (the most widespread and deadly form of malaria), the first-line treatment for uncomplicated malaria infection are artemisinin-based combination therapy (ACTs) drugs, which combine artemisinin or a derivative (such as artemether) with another anti-malarial drug.

One very common combination is artemether with lumefantrine, which is often marketed as Coartem. ACTs have few common side effects, and very few severe ones, but mild side effects which are reported include nausea, dizziness, loss of appetite and vomiting. One severe side effect that has been reported is allergic reaction.

2) If a patient has had suspected malaria but seems to have recovered, they should probably present themselves to a clinic or physician for a blood test. This will determine whether the patient is still currently suffering from malaria; if so, they will probably still be treated with Coartem or another ACT as above. If there is no trace of the malaria parasites in the blood, the patient might want to try a rapid diagnostic test which looks for antibodies to the malaria parasite; this will tell them if they did in fact have malaria before. Some tests can also differentiate between Plasmodium falciparum and other forms of malaria.

This is important because if they test positive for P. vivax or P. ovale, there is a possibility that the malaria parasites are still present in the liver, in a dormant form, even once all the parasites are gone from the blood stream. In this case, the patient may want to consider talking to their doctor about taking primaquine, which kills the dormant liver stages of the parasites.

People with G6PD deficiency cannot take primaquine so in some cases a G6PD deficiency test may be required first. If the patient is found to have had Plasmodium falciparum, but no active infection appears in the blood, they should still monitor their health carefully for several weeks, and perhaps take malaria preventative medication such as doxycycline or Malarone; even after symptoms cease, in some cases a small number of P. falciparum parasites can remain in the blood, at concentrations too low to be seen under the microscope, but which can then flare up at a later date and cause symptoms to reappear. This is called recrudescence; once symptoms reappear, the patient should immediately seek a diagnosis from the doctor to confirm it is malaria, and then take treatment.

How is Malaria Treated

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QUESTION

How is malaria treated?

ANSWER

This answer is copied from an earlier question about the various available cures for malaria.

Malaria can be cured with a number of different medications, depending on then type of malaria and how far the disease has been progressed.

For standard, non-complicated Plasmodium falciparum malaria, the World Health Organisation recommends use of artemisinin-based combination therapies (ACTs), such as Coartem. This is due to increasing levels of resistance to chloroquine in many parts of the world. Indeed, even though chloroquine is still used in many places as first-line treatment against P. vivax, P. malariae, P. ovale and P. knowlesi uncomplicated malaria, there is some evidence that resistance to this treatment is also emerging, for example in P. vivax in parts of south-east Asia.

In cases where malaria infection has progressed to a stage where oral administration of medication is not possible, or where cerebral symptoms are suspected, the usual treatment option is intravenous quinine.

In addition, P. vivax and P. ovale malaria parasites are able to produce forms (called hypnozoites) which can become dormant in liver hepatocyte cells after the blood stages of the infection have been cleared. These dormant forms can become reactivated weeks or even months or years after the initial infection, which is called a “relapse” of the infection. One drug, called primaquine, is able to kill these liver stages, and so patients with either of these types of malaria should also discuss the possibility of taking primaquine.

Apart from these first-line treatments, there are other medications which are used against malaria, both prophylactically as well as for treatment. These include orally-administered quinine, pyrimethamine, mefloquine, proguanil, atovaquone and sulfonamides.

 

Recurrent Malaria; Coartem Side Effects

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QUESTION

I get recurrent malaria 2 to 3 times per year in Feb, March and Sept. I take Coartem which just about kills me.

I had it in early Sept this year and it was back 3 weeks later. Please can you advise how to stop it recurring. It has been a regular health problem since the 1980’s. I have had 3 Primaquine treatments to eradicate the liver parasites. The treatment did not work.

Your advice will be most appreciated.

ANSWER

Thanks for your question. First of all, is it of concern that you write that taking Coartem “nearly kills” you—do you mean you get very bad side effects? Side effects are rare with Coartem, and when they occur, they are usually mild and transient, such as headache, nausea, cough, or fever. Occasionally, patients report more significant side effects, such as tinnitus, back pain or itching. If you have more serious side effects than these, you should talk to your doctor about switching to a different formulation of malaria medication.

Given that you are based in sub-Saharan Africa, I would certainly recommend that you stick to artemisinin-based combination therapies (Coartem, for example, is a combination of artemether, which is an artemisinin-based compound, and lumefantrine), but there are different combinations, which may be more effective for you.

Second of all, in sub-Saharan Africa, Plasmodium falciparum is by far the most common form of malaria. Importantly, this parasite does NOT cause multiple episodes or recurrence, months after the initial infection, unlike Plasmodium ovale or Plasmodium vivax, both of which are found in Africa but are not nearly as common. Plasmodium falciparum infection can cause what is call “recrudescence,” which is where the number of parasites in the blood is reduced sufficiently so as not to be detectable, but then bounces back after treatment ceases, causing another bout of infection a few days or within a few weeks of the initial malarial episode—this might explain your most recent malaria experience.

Primaquine is only effective against recurring malaria when it is used to target the dormant liver stages of P. vivax and P. ovale. Therefore, in your case, it is extremely important that you are accurately diagnosed in terms of which malaria parasite you have, and each time you get infected as well. This will help determine whether you are continually being re-infected, for example with P. falciparum, or if you are indeed suffering from recurrences of P. vivax or P. ovale. If it is the latter, then primaquine is usually about 80% effective, based on global epidemiological analysis on P. vivax.

There is some evidence that strains of malaria from different regions, for example Thailand and Papua New Guinea, may be more resistant to primaquine than strains from other places. The good news about having P. vivax or P. ovale is that they are much more likely to respond to initial treatment with chloroquine, which you might tolerate better than Coartem.

So, in summary, if you have not done so already you should make sure your doctor diagnoses the species of malaria parasite that you have, either through microscopy (the different types of malaria look different under the microscope) or, preferably, through a serological blood test, which are even available as self-testing kits. At that point, alternative treatment options to Coartem can be discussed with your doctor, as well as whether it is appropriate to try primaquine again.