Comparison of Molecular Tests for the Diagnosis of Malaria in Honduras

Honduras is a tropical country with more than 70% of its population living at risk of being infected with either Plasmodium vivax or Plasmodium falciparum. Laboratory diagnosis is a very important factor for adequate treatment and management of malaria. In Honduras, malaria is diagnosed by both, microscopy and rapid diagnostic tests and to date, no molecular methods have been implemented for routine diagnosis. However, since mixed infections, and asymptomatic and low-parasitaemic cases are difficult to detect by light microscopy alone, identifying appropriate molecular tools for diagnostic applications in Honduras deserves further study. The present study investigated the utility of different molecular tests for the diagnosis of malaria in Honduras. [Read more…]

Malaria Prophylaxis in Ghana, Africa

QUESTION

My husband will be traveling to Ghana soon. We have Mefloquine and Primaquine. Which one do you think is best for prophylaxis in Ghana? He also has Fansidar, but we understand it’s best not to use this for prophylaxis. Thank you for your help!

ANSWER

There are positives and negatives associated with both of these medications. Mefloquine is recommended for travelers in Ghana (whereas the Centers for Disease Control does not explicitly recommend primaquine for this area, since primaquine is particularly effective against Plasmodium vivax malaria, which is almost completely absent from West Africa), and only has to be taken once a week (primaquine must be taken daily).

A disadvantage with mefloquine is that you must start taking it 2 weeks before your trip, whereas primaquine can be started as little as 1-2 days before travel; mefloquine is also not recommended for people with a history of psychiatric or mental problems, as it can cause severe side effects. Even healthy individuals often report disturbing dreams or increased agression/anxiety while taking mefloquine. However, one major disadvantage to primaquine is that you must be tested for G6DP deficiency prior to taking it – your husband may have already done this, prior to being prescribed the drug. People with G6DP deficiency should not take primaquine.

Overall, the decision comes down to personal preference, though from a disease perspective, mefloquine would probably be the better choice for travel to Ghana, given the higher prevalence of P. falciparum malaria in this region, as opposed to P. vivax. Other options to consider would be atovaquone-proguanil (Malarone – expensive, taken daily, but very effective and very well tolerated by most people, with very low side effects) or doxycycline (very cheap, taken daily, is an antibiotic so can prevent some other infections but often results in sun sensitivity, which can be a problem in the tropics). Both of these can be started 1-2 days before arriving in the malarial area.

After you come back, I would be very grateful if you could take our malaria medication side effects survey, as we are very interested in hearing from our readers what their experiences with malaria prophylaxis and treatment have been.

As American as…Plasmodium vivax?

While its evolutionary history is disputed, there’s no doubt malaria was a key factor in the history of the Americas

I am in the midst of a fascinating book about the way the world changed after Columbus “discovered” America in 14921. Called, appropriately, 1493: Uncovering the World Columbus Created, it is author Charles C. Mann’s follow-up to an earlier, equally engaging book on pre-Colombian America (no prizes for guessing the title, which is 1491: New Revelations of the Americas Before Columbus2).

In both works, Mann devotes significant attention to the role that disease played in re-shaping the Americas in the immediate aftermath of European arrival. However, it is only in 1493 that he turns to malaria, and here he presents several startling examples of how malaria may have influenced key events in the history of the Americas, with subsequent knock-on effects on Europe as well. It is worth noting early on that Mann is very open about the uncertainty in his theories – not only were many other factors clearly involved, but malaria never acted alone, and was commonly accompanied by other introduced diseases, such as yellow fever. Yet even with these disclaimers, Mann’s stories are thought-provoking and illuminating.

For example, he describes how malaria contributed to the establishment of the enormously successful and unarguably brutal slave plantations of the American South. In its early years, the colony of Carolina was a net exporter of slaves, as captured Indians (Mann’s terminology) were sent elsewhere in colonies as forced labour. Additional work in the fields was provided by indentured servants, who were contracted for set periods of time; at first, slaves from Africa were relatively rare.

Anopheles quadrimaculatus Florida

Mosquitoes which were capable of transmitting malaria, such as this Anopheles quadrimaculatus, were already present in the Americas when Europeans and Africans arrived, carrying different forms of malaria. Photo courtesy of smccann on Flickr (http://www.flickr.com/photos/deadmike/)

This all changed as European and African diseases intermingled and became established in the New World; new agricultural practices, also imported by the Europeans, created habitats favourable for a native mosquito species which was able to transmit both Plasmodium vivax and Plasmodium falciparum malaria. Mann attributes the introduction of the former to Europeans, as P. vivax tolerates relatively low temperatures and was rife throughout southern England during the 1600s; P. falciparum was likely brought by African slaves.

Since, according to Mann, no human malaria had been present in the Americas prior to Columbus’ arrival, native Indian people were highly susceptible to these diseases, and either died or were incapacitated and unable to work while infected. Similarly, while some of the contracted servants brought from Europe may have been exposed to P. vivax in their home regions, and thus had some measure of acquired immunity, they fell like flies before the highly pathogenic P. falciparum species.

Africans, conversely, were exposed to P. falciparum as children in Africa and if they survived, were awarded a level of protection. Moreover, a high proportion of people from West and Central Africa possess one or more of a group of genetic mutations, the best-known of which is the Duffy negative phenotype, which makes the carrier almost completely resistant to P. vivax malaria.

As a result, in the newly-malarial fields and marshlands of what is now the American south, plantation owners rapidly ran out of native Indian slaves and indentured European labourers became financially unviable. The solution? Bring in a group of people resistant to the diseases decimating your other workers. And thus, in part, was borne the horrifying trans-Atlantic slave trade, bringing malaria-resistant West and Central Africans to live and die on the plantations in the American South, in a divided society that would persist for over three centuries.

Another quick example: Mann describes how malaria, in part, was responsible for the formation of Great Britain as a nation in the early 18th century. It turns out that in the late 1600s, Scotland, not wanting to miss out on the spoils of colonization, decided to establish a trading post in Panama. As with the plantations of the north, Mann explains that malaria (along with yellow fever) was brought to the isthmus of Central America by Europeans and Africans post-Colombus. Ravaged by disease, and unable to trade with any local tribes (presumably they too had been decimated by imported infections), the first Scottish colony was an abject failure. So, too, was a relief expedition a few years later. Both had been “joint-stakes” ventures, whereby thousands of merchants had contributed a small investment, with a hope of rich returns. Unfortunately, all of these investors lost everything. England had for a century shared a monarch with her neighbour to the north but was consistently denied full union by Scots understandably wary of domination by the larger country. Now, her leaders saw an opening. The English offered to repay the lost funds of all those who had invested in the ill-fated Panama scheme; in return, all they asked for was unification. In the end, England got her wish, and the Union Act of 1707 combined the two countries into the modern nation of Great Britain, a move, perhaps, that was partially defined by malaria.

While these are without doubt beautifully written and captivating tales of dramatic changes occurring throughout the first few centuries post-Columbus, particularly the idea of African slaves being brought in to replace Indian workers relies heavily on the supposition that Plasmodium vivax was introduced to the Americas by Europeans in the late 16th and early 17th centuries. Unfortunately, this is not strictly true.

Modern analysis of the origins of malaria usually relies on genetic evidence – that is, comparison between sequences of DNA between malaria from different regions and even different species, which can give clues as to how the parasite has changed and evolved over time. However, genetic traces of the path of malaria can also be uncovered from looking at malaria’s hosts, including human populations. For example, the Duffy negative group of mutations, mentioned earlier, provides almost or even complete protection against P. vivax. Given the high prevalence of these mutations in West and Central African populations (95-99% in some places!), some scientists have considered this evidence that P. vivax has co-evolved with humans in these regions for thousands of years, and that therefore the parasite might have evolved here3.

However, more recently, this suggestion has been refuted by looking at genetic patterns present within different strains of the Plasmodium vivax parasite itself, and comparing it to other species of malaria throughout the world. It turns out that genetically, P. vivax is actually very closely related to a group of malaria species that infect macaque monkeys in south-east Asia4,5. Estimates of the age of different strains of P. vivax also places the most ancient lineages in Asia, consistent with an “out of Asia” hypothesis. While this view has now approached consensus in the literature, the scientific jury is still out to explain the high occurrence of Duffy negative populations in Africa.

howler monkey

South American monkeys, such as this howler, are infected with forms of malaria which are closely related to that which infects humans. This has been used as evidence to show that Plasmodium vivax arrived in the Americas prior to Europeans in the 15th century. Photo courtesy of Rainbirder on Flickr (http://www.flickr.com/photos/rainbirder/)

Similar molecular tools have also been used to try to figure out when Plasmodium vivax first reached the Americas. In this, scientists have been assisted by the discovery of a species of malaria that infects monkeys, called P. simium. Genetically very similar to P. vivax, scientists have dated its evolutionary origins to show that P. vivax probably first entered the Americas via Melanesia and the Pacific several thousand years ago5. After this time, it managed to switch hosts into monkeys, producing modern variants of P. simium over time. As such, some native Indian populations may have encountered P. vivax long before Europeans ever arrived. However, what is also clear from analysis of modern P. vivax strains that are present in the Americas is that they are largely of European origins. It may even have been that native populations of pre-Columbian America found ways to manage P. vivax, perhaps through controlling its mosquito vector, thus reducing the parasite’s impact. Once Europeans arrived, however, not only were Indians unable to continue managing the land as they had done for generations, but they were suddenly faced with a huge new influx of P. vivax, and of strains they had not yet encountered3.

As such, having thus dashed a drop of water on Charles C. Mann’s parade, I concede that Europeans probably were responsible for the bulk of P. vivax in the early years of the Columbian Exchange, and particularly in the south-eastern United States where he argues it had such a big impact on the nascent trade in African slaves. Moreover, P. falciparum, by far the more deadly of malaria species, was also clearly introduced by these forced labourers from Africa, leading to greater mortality and perhaps, ironically, an even greater dependence on more African slaves. While perhaps hardly a game-changing disease like malaria, Mann might also be interested to learn that another wide-spread parasitic disease, intestinal schistosomiasis, was also likely transported to the Americas by the slave trade, and still remains a public health threat in parts of Latin America today.

In our highly globalized world, we are well aware of the risks of transporting diseases between continents and societies. However, as the theories regarding the origin of malaria in the Americas show, humans (and other animals) have in fact been disseminating disease-causing organisms to new places since the very dawn of our evolutionary history. In fact, Mann argues, very successfully, that while we attribute globalization to 20th century, transport and communications technology, we should instead look half a millennium back, and appreciate how the conquest of the Americas created the first global trade network spanning the Pacific, Atlantic and Indian Oceans, and therefore sowed the seeds of our own modern inter-connected age. And, within those early origins of globalization, even diseases themselves, such as malaria, may have played a role in shaping history.

 

Cited literature

1. Mann, CC (2005) 1491: New Revelations of the Americas Before Columbus. Knopf: New York, 480 pp.

2. Mann, CC (2011) 1493: Uncovering the New World Columbus Created. Knopf: New York, 560 pp.

3. Carter, R (2003) Speculations on the origins of Plasmodium vivax malaria, TRENDS in Parasitology, 19 (5): 214-219.

4. Escalante AA et al. (2005) A monkey’s tale: The origin of Plasmodium vivax as a human malaria parasite, PNAS, 102 (6): 1980-1985.

5. Cornejo OE & Escalante AA (2006) The origin and age of Plasmodium vivax, TRENDS in Parasitology, 22 (12): 558-563.

Malaria Effects on the Body

QUESTION

What are the effects of malaria on the body?

ANSWER

Malaria has a number of effects on the body. The parasite passes from the blood (where it enters via the bite of an infected mosquito) into the liver, where it reproduces and changes form. After a period of 1-4 weeks (usually – it can be longer) in the liver, the malaria parasite re-enters the blood and begins to infect red blood cells, undoing more reproduction inside the cells and then, in synchrony, bursting out once the cycle is complete. This process of reproduction and destroying red blood cells results in a build-up of toxins and debris in the blood; the resultant immune reaction produces side effects which are the common observable symptoms of malaria, such as fever, chills, nausea and aches.

One particular type of malaria, Plasmodium falciparum, is also able to modify the surface of red blood cells it infects. It causes these cells to become “sticky”, so they lodge in the small blood vessels leading up to major organs. This build-up is called sequestration, and results in reduced blood flow and oxygen deprivation in the organs. When sequestration occurs in the blood vessels in the brain, the patient may experience impaired consciousness, psychological disruption, coma and even death – this manifestation is called “cerebral malaria”.

If diagnosed and treated promptly, the malaria parasites in the blood can usually be killed rapidly and the patient will soon enjoy a complete recovery. With two forms of malaria, P. vivax and P. ovale, the parasite can remain dormant in the liver for months or even years, resulting in relapse of disease at a later date. To prevent this from occurring, patients with these types of malaria can sometimes take primaquine, a drug which kills the liver stages of the malaria parasite as well.

Reoccurring Malaria

QUESTION

Can malaria reoccur year after year from a single infection? I have been told that it comes back every year by many people. I have had malaria once and it never came back after successful treatment. My thinking is that once the parasite has been eliminated from the system it is gone unless you get bitten again.

ANSWER

There are several different types of malaria that infect humans, and two of these species (Plasmodium ovale and Plasmodium vivax) can recur from year to year after a single infection.

The way it happens is that these types of malaria are able to form dormant life stages which hide in the liver. Most malaria medication only targets the blood stage form of malaria, and so these liver stages escape being killed by the medication, and can survive for long periods of time without the patient knowing about them. Then, at some point later (no one knows exactly what triggers the relapse—there is evidence that infection with other forms of malaria can instigate relapse, or being bitten by mosquitoes, or even just the climate), the liver stages activate again and re-enter the blood stream, which causes a renewal of symptoms.

It is possible to prevent these relapses—there is one type of medication, called primaquine, which is able to kill the dormant liver stages and thus completely clear the patient of malaria. However, it is important to talk to your doctor before taking primaquine, as it is not suitable for some people (especially those with G6DP deficiency).

Apart from these two types of malaria, the other three forms that infect people (P. falciparum, P. malariae and P. knowlesi) cannot reoccur in the same way as described above – if you have been infected with one of these, and then been successfully treated, you cannot get the disease again unless you are bitten by another infected mosquito.

Malaria Prevention

QUESTION

What are the ways in which you can prevent yourself from being infected with malaria?

ANSWER

Malaria prevention consists of a combination of mosquito avoidance measures (since malaria is transmitted by infected mosquitoes) and chemoprophylaxis (medication to prevent the establishment of malaria in your body, if you do get bitten). 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.

Chemoprophylaxis

      • All currently recommended primary chemoprophylaxis regimens involve taking a medicine before travel, during travel, and for a period of time after leaving the malaria endemic area. Beginning the drug before travel allows the antimalarial agent to be in the blood before the traveler is exposed to malaria parasites.
      • Presumptive antirelapse therapy (also known as terminal prophylaxis) uses a medication towards the end of the exposure period (or immediately thereafter) to prevent relapses or delayed-onset clinical presentations of malaria caused by hypnozoites (dormant liver stages) of P. vivax or P. ovale. Because most malarious areas of the world (except the Caribbean) have at least one species of relapsing malaria, travelers to these areas have some risk for acquiring either P. vivax or P. ovale, although the actual risk for an individual traveler is difficult to define. Presumptive anti-relapse therapy is generally indicated only for persons who have had prolonged exposure in malaria-endemic areas (e.g., missionaries, volunteers).
      • In choosing an appropriate chemoprophylactic regimen before travel, the traveler and the health-care provider should consider several factors. The travel itinerary should be reviewed in detail and compared with the information on where malaria transmission occurs within a given country to determine whether the traveler will actually be traveling in a part of the country where malaria occurs and if significant antimalarial drug resistance has been reported in that location.
      • The resistance of P. falciparum to chloroquine has been confirmed in all areas with P. falciparum malaria except the Caribbean, Central America west of the Panama Canal, and some countries in the Middle East. In addition, resistance to sulfadoxine–pyrimethamine (e.g., Fansidar) is widespread in the Amazon River Basin area of South America, much of Southeast Asia, other parts of Asia, and in large parts of Africa. Resistance to mefloquine has been confirmed on the borders of Thailand with Burma (Myanmar) and Cambodia, in the western provinces of Cambodia, in the eastern states of Burma (Myanmar), on the border between Burma and China, along the borders of Laos and Burma, and the adjacent parts of the Thailand–Cambodia border, as well as in southern Vietnam.
      • Additional factors to consider are the patient’s other medical conditions, medications being taken (to assess potential drug–drug interactions), the cost of the medicines, and the potential side effects.

The medications recommended for chemoprophylaxis of malaria may also be available at overseas destinations. However, combinations of these medications and additional drugs that are not recommended may be commonly prescribed and used in other countries. Travelers should be strongly discouraged from obtaining chemoprophylactic medications while abroad. The quality of these products is not known, and they may not be protective and may be dangerous. These medications may have been produced by substandard manufacturing practices, may be counterfeit, or may contain contaminants. Additional information on this topic can be found in an FDA document

Purchasing Medications Outside the United States.

Treatment of Chronic Vivax Malaria

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.

Malaria Symptoms

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

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!

Duo-Cotecxin and Fansidar as Treatment

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.