Relapsing Malaria

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QUESTION

I’m constantly on malaria drugs, fall ill every 2 weeks and always diagnosed with malaria.I’m getting really fed up and need a permanent solution to all of this. I want to live a healthy life and I’m tired of being on malaria drugs. How do I overcome malaria permanently?

ANSWER

It is very unusual to be reinfected so constantly with malaria. First of all, how are you getting diagnosed? You should be getting a blood test, and not relying on symptoms only; the symptoms of malaria are very general and it could be that you are suffering from something else entirely.

The two main methods for accurate diagnosis are blood smear and rapid diagnostic test. The blood smear is used throughout the world, but can sometimes miss light infections (though if you feel sick, your infection is likely heavy enough to be detected by this method). The problem is that it requires a trained technician to take the sample, prepare it properly, and read it thoroughly and accurately. In my experience, many clinics, especially if they are rushed and busy, will not take the time to read a blood slide properly, and will just diagnose malaria without looking. This is really bad!

It is very important to be properly diagnosed, so you can get the correct treatment, and if you don’t have malaria, you can be diagnosed for something else. The second kind of diagnostic is a rapid diagnostic test, or RDT. This looks for antibodies to malaria in your blood, and is very sensitive and quick. In an ideal world, you should try to have both done, to cross-check the results.

The next thing is to check whether you are receiving the correct treatment for the type of malaria that you have (if you are positively diagnosed with malaria). In many parts of the world, malaria has become resistant to some of the main medications used against it. Notably, this is the case in many places with Plasmodium falciparum, the most dangerous kind of malaria, which has become resistant to chloroquine in many parts of the world, to sulfadoxine-pyrimethamine (sold as Fansidar in many places) and also to mefloquine (sold as Lariam) in some places. As such, the World Health Organisation NEVER recommends these treatments be given as first line drugs against P. falciparum malaria—instead, they recommend artemisinin-combination therapies (ACTs), such as Alu, Coartem or Duo-Cotecxin. If you have been diagnosed with P. falciparum, you must try to take these kinds of drugs first. No resistance to ACTs has been reported, so if you take the full dose correctly, as prescribed by your doctor (and check to make sure the drugs are not expired), then you should be cured of malaria.

However, treatment does not stop you from getting infected again, and this is where prevention comes it. Preventing malaria is a cornerstone of control efforts. Since malaria is transmitted by a mosquito, preventing mosquitoes from entering the house, and particularly stopping them from biting you at night, is crucial. Screening all doors and windows can help stop mosquitoes from getting in, and in high transmission areas, many people will also spray inside their houses every once in a while with insecticides to kill any lingering insects.

In addition, sleeping under a long-lasting insecticide treated bednet can drastically reduce the number of mosquitoes that are able to bite you at night. If you already have a net, it may be worth re-dipping it in insecticide (usually permethrin) to make sure it is still working effectively. The mosquitoes that transmit malaria feed at night, so if you are walking around outside in the evenings or at night, it is important to try to wear long-sleeved clothing, to prevent them from accessing your skin.

All of these efforts will help prevent you from getting malaria again in the future.

Malaria Vaccine

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QUESTION

Is there a vaccine for malaria?

ANSWER

No, as of yet there is not a vaccine available for malaria. The most promising vaccine candidate, RTS,S, which has been developed by GlaxoSmithKline, is currently undergoing Phase III trials in Africa. The trial is not due to finish until 2014, so we will have to wait until then to know how effective it is. Preliminary results, published last year, suggested that it may prevent up to 50% of malaria cases in young children, though the long term protection level is not known. Other age groups will also have to be analyzed, as well as the effect of the vaccine on malaria mortality levels.

Malaria Pills Taken with Other Drugs

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QUESTION

Can malaria pills be taken with other vaccines or medications?

ANSWER

Malaria pills can be taken with most other medications, though this may vary with the type of prophylaxis (medication to prevent malaria) that you take, and there may be some specific combinations which are not recommended, so be sure to consult with a doctor about specific drug interactions. For example, Malarone (atovaquone-proguanil) is known to interact with anticoagulant drugs such as warfarin and aspirin, though depending on the dose it may be possible to take both, as long as the patient is carefully monitored.

If you are planning to travel to a malarial area, you will likely need to get a prescription before being able to get prophylaxis, so you should take that opportunity to talk to the nurse or physician about your specific medications and whether they will interact.

Repeated Malaria Cases, New Guinea

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QUESTION

Hello, I live in Papua New Guinea. Myself, my wife and my 2 kids (both under 4 years old), get diagnosed with malaria approximately 3-4 times a year, usually vivax or falciparum. Our GP uses a prick of blood and examines under a microscope. Is it that easy/obvious to diagnose under this method and is it common to get this many attacks in a year? I also fear the affects of taking malaria tabs (eg Fansidar, Primaquin, Artemeter, Amodiaquine) this many times, especially for my young kids. Please help!

ANSWER

In high transmission areas, particularly in rural areas in sub-Saharan Africa, it certainly isn’t unusual for children to get as many a 5 or 6 malaria attacks in a year; adults tend to present with fewer clinical episodes, usually because they were heavily exposed as children and thus developed a significant level of immunity against malaria.

If you and your wife didn’t grow up in a malarial area, then you would not have that acquired immunity, and so you would be expected to get sick almost as often as your young children. Papua New Guinea certainly is a high transmission zone, and I think one thing which might help your family is to focus more on malaria prevention. Since malaria is transmitted by mosquitoes, the best way to avoid getting malaria is to avoid getting bitten by mosquitoes. You should all be sleeping under log-lasting insecticide-treated bednets, which kill and/or repel mosquitoes that try to bite you while you sleep (the mosquitoes that transmit malaria, of the genus Anopheles, are most active at dusk, at night, and at dawn—during the heat of the day they usually don’t feed, but may be found in cooler, heavily shaded areas).

You could also try spraying the walls of your house with a long-lasting insecticide like permethrin, which will also kill adult mosquitoes. Making sure your house is well-screened will also prevent mosquitoes from getting in and biting you at night and in the evenings, and if you are going out during these times, you and your family should wear long-sleeved clothing, and exposed skin should be covered with insect repellent. A DEET-based insect repellent is best, but you may not be comfortable using these regularly on young children, since it can have some potentially dangerous long-term effects, particularly on the liver.

In terms of your other questions, looking at your blood under the microscope is the normal way to diagnose malaria in many places, so it sounds like your GP is doing a good job. There is no indication of adverse effects from taking multiple, repeated doses of anti-malarials, but as I mention above, taking additional preventive measures may further help in reducing your family’s malaria incidence.

One thing you might want to talk to your doctor about is the fact that in some cases, Plasmodium vivax can cause relapses of infection weeks or even months after the initial infection. The reason is that P. vivax can form dormant life stages, which can hide out in the liver, and cannot be killed by the normal anti-malarial treatment. However, there is a medication, called primaquine, which can kill these liver forms, and prevent future relapse. People with a deficiency in a particular enzyme, called G6DP, may not be able to take this medication, as it may cause severe anaemia, so prior to taking the drug you might have to be tested for this deficiency. However, it is definitely something you should talk to your GP about.

Please take a moment to complete our Malaria Survey, as it will help us better understand the effects of malaria medications.

Persistent Antibodies to Malaria?

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QUESTION

I had malaria as child, more than 30 years ago. It was successfully treated with no relapse. I have since travelled to malaria- endemic countries, but the last time was over 3 years ago. No symptoms. I recently donated blood and routine screening has detected malaria antibodies. How long do the antibodies persist?

ANSWER

Based on your experience, I would say at least three years! While I doubt your antibodies would persist since your infection as a child, it is more likely that in your more recent trips to malarial areas you have been re-exposed to the parasite, but for whatever reason, the infection didn’t progress into a full-blown episode of malaria. This could well be due to some residual immunity from childhood, or you just received a light enough infection that your general immune system was able to fight off. Either way, this would have produced new antibodies against malaria, which were picked up by the blood screen.

The length of time antibodies persist is important information in the control of malaria, since serological tests (which detect antibodies) can be used for screening of populations in low-transmission environments, but their efficacy is reduced in locations where people have been treated for malaria but their antibodies persist. Also, understanding how antibodies are created and maintained in the body is necessary for gaining an appreciation of how preventive measures, such as bednets, might potentially leave populations more vulnerable to malaria later on, through lack of acquired immunity.

Malaria and Pregnancy

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QUESTION

Can your baby become immune if you’re pregnant and you have malaria?

ANSWER

Some of the protective antibodies that the mother produces when she has malaria can pass to her baby via the placenta. There is also evidence for immune system “priming” in foetuses when their mothers have been infected my malaria during pregnancy. However, these potentially protective effects are usually far outweighed by the negative effects of malaria during pregnancy.

Due to changes to the mother’s immune system and also perhaps due to the creation and physiology of the placenta, pregnant women are very vulnerable to malaria. For reasons which are not fully understood, women experiencing their first pregnancy (primagravidae) are most susceptible to malaria and their foetuses are most likely to have severe effects. These effects vary depending on the immune status of the mother and whether she is from an endemic or low transmission malaria environment, but typical results include low birth weight, anaemia and spontaneous abortion—abortion rates due to malaria can vary between 15-70%.

There is also the risk (up to 33% in some studies) that malaria will pass directly from the mother to the baby, either through the placenta or in blood during childbirth—this is called “congenital malaria,” and can manifest as early as 1 day after delivery but a late as months after. The symptoms are similar to that of adult malaria, with fever, anaemia, lethargy, etc.

Given these negative effects, it is very important to protect pregnant women against malaria, and bednet distribution schemes in many places target these women. In high transmission settings, women may also be offered intermittent preventive therapy (IPT) which consists of at least two doses of anti-malarial medication, usually once during the second and once during the third trimester.

Prevention of Malaria

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QUESTION

What is the prevention of malaria?

ANSWER

Malaria prevention consists of a combination of mosquito avoidance measures and chemoprophylaxis. Although very efficacious, none of the recommended interventions are 100% effective.

Mosquito Avoidance Measures

  • Because of the nocturnal feeding habits of Anopheles mosquitoes, malaria transmission occurs primarily between dusk and dawn.
  • Contact with mosquitoes can be reduced by remaining in well-screened areas, using mosquito bed nets (preferably insecticide-treated nets), using a pyrethroid-containing flying-insect spray in living and sleeping areas during evening and nighttime hours, and wearing clothes that cover most of the body.
  • All travelers should use an effective mosquito repellent.
  • The most effective repellent against a wide range of vectors is DEET (N,N-diethylmetatoluamide), an ingredient in many commercially available insect repellents. The actual concentration of DEET varies widely among repellents. DEET formulations as high as 50% are recommended for both adults and children older than 2 months of age (see the Protection Against Mosquitoes, Ticks, and Other Insects and Arthropods section later in this chapter). DEET should be applied to the exposed parts of the skin when mosquitoes are likely to be present.
  • In addition to using a topical insect repellent, a permethrin-containing product may be applied to bed nets and clothing for additional protection against mosquitoes.

Read the full article about Malaria Prevention.

Malaria while in Addis Ababa, Ethiopia?

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QUESTION

My husband and I recently adopted our second child from Ethiopia about 3 months ago. We did NOT take Malaria medication because we only stayed in Addis Ababa and did not travel outside the city—or very far from out hotel for that matter. I’ve recently started very odd symptoms—aches, chills but no fever, general feeling of malaise, runs, dry cough, hot flashes followed by sweats, and fatigue so severe I sometimes don’t have the energy to talk. The weird part is that the symptoms come and go. I feel fine for a few days, and then boom! Down for the count again, then fine the next day. I’m going to see my Dr. tomorrow, but could I have Malaria???

ANSWER

While the cyclical symptoms, occurring every few days, are similar to the cycles experienced by malaria sufferers, the lack of a fever is a good indication that you don’t have malaria. Moreover, as you clearly researched before your trip, Addis Ababa is not a transmission zone for malaria, so it is unlikely that you would have been infected during your trip. By now you will have probably seen your doctor, and I suspect s/he will have ruled out malaria. If you really want peace of mind, you can also ask for a blood test, just to check. I hope your condition is diagnosed and treated soon, and you recover quickly!

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.

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.