Malaria Deaths in the Tropics

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QUESTION

What’s the difference of malaria deaths between the subtropical and tropical regions and all the other regions?

ANSWER

I am assuming you are asking about the distribution of deaths caused by malaria between the tropics/sub-tropics and the rest of the world.

95% percent of all fatal malaria cases occur in sub-Saharan Africa, which lies entirely in the sub-tropics and tropics. Additionally, most of the deaths occur in Central, West and Eastern Africa (North Africa and South Africa have more advanced malaria prevention and control initiatives to the rest of the continent, and transmission is also less severe), and the other 5% of malaria deaths are mostly found in India and south-east Asia, so you could say that virtually all deaths due to malaria occur in tropical regions alone.

Indeed, there is almost no malaria in non-tropical or sub-tropical regions; the few cases each year in North America and Europe are usually due to imported cases from people who have traveled to tropical or sub-tropical regions.

Meaning of DDR

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QUESTION

what’s the meaning of DDR?

ANSWER

Within the context of malaria and health more generally, “DDR” often refers to “Drug Development Research,” meaning investigation of new anti-malarial compounds, both for malaria prevention (prophylaxis) and treatment.

However, in some health contexts (for example recreational drugs) it can also mean “Drug Demand Reduction,” which is very different. Therefore the specific program in question may determine the meaning of the acronym.

Injections for Malaria Treatment?

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QUESTION

I have a friend that just told me that she has Malaria. She said she has to go to the hospital every day for an injection for around the next 2 weeks. Is this a typical treatment. Why not just take pills? I`m just trying to wrap my head around this and understand the different treatments.

ANSWER

This is certainly not typical treatment for malaria. Uncomplicated malaria is usually treated with oral medication, and the type depends on the type of malaria you have. The most severe form of malaria, Plasmodium falciparum, is often resistant to chloroquine (still the first-line drug of choice for P. malariae, P. knowlesi and P. ovale infections, as well as for P. vivax in most parts of the world) and so first-line treatment is now usually an artemisinin-based combination therapy (ACT), such as Coartem.

As far as I am aware, it is only in cases of complicated, severe malaria that intravenous or intramuscular treatment is used (usually quinine), and in those cases, treatment would not be administered on an outpatient basis. It may be that your friend has a specific medical requirement for a non-oral form of medication, but it is definitely unusual!

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.

How to Control Malaria

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QUESTION

Suggestions to control malaria?

ANSWER

This answer is copied from an earlier question asking about strategies for controlling malaria in Africa. The methods below are being used by many health ministries, international agencies and non-governmental organisations to combat malaria all over the world (and not just in Africa).

Currently, malaria control is based on a combination of prevention, education, research and treatment. In more detail:

Prevention: This is arguably one of the keys to sustainably reducing malaria burdens and even eliminating infections. Central to this goal has been the distribution of long-lasting insecticide treated bednets, which prevent people from being bitten by infected mosquitoes while they sleep at night. Unfortunately, some recent research has just been published which suggests that bednets might be contributing to insecticide resistance in mosquitoes, as well as increased rates of malaria in adults due to decreasing natural immunity. As such, it may be that more research is needed in order to determine the most effective and efficient ways of using bednets to prevent malaria infection, particularly in high-risk groups like young children and pregnant women. Another arm of prevention is reducing the number of mosquitoes in an area (called vector control), and thus preventing transmission from occurring at all – this can be achieved through insecticide spraying but also filling in the stagnant pools of water that mosquitoes lay their eggs in. Vector control was highly successful in reducing malaria transmission in the United States and Mediterranean in the years after World War II.

Education: Through education, people living in at-risk areas for malaria transmission can learn about ways to prevent the disease, as well as what to do if they suspect they are infected. Similarly, education is important for travellers visiting malarial areas, so they know the best ways in which to avoid being infected.

Research: Understanding the distribution, factors affecting transmission and the development of new strategies for control and treatment is going to be crucial in the fight against malaria, and particularly in high-burden areas such as Africa. Similarly, scientists are busily looking for new compounds to treat malaria, as well as the ever-elusive malaria vaccine. If such a vaccine could be developed, it would be a huge step forward in the fight against malaria; recently, a study was published which reported the results of the first Phase 3 clinical trial of a malaria vaccine, in African children. The vaccine appeared to confer approximately a 50% level of protection against malaria; while this is a start, it perhaps did not live up to many people’s hopes of a new method for controlling malaria.

Treatment: Hand in hand with treatment comes diagnosis; if a person can have their infection easily, accurately and cheaply diagnosed, then they will be able to access effective treatment more rapidly, thus improving their chances of a swift recovery. As such, countries in Africa are working hard to provide health systems capable of local diagnosis and availability of treatment, so that people don’t have to travel far to have their infections cured.

Taken together, these four strategies are having some success even in the world’s poorest and most malaria-endemic regions, especially in decreasing the number of malaria deaths. Decreasing the overall number of infections will be yet a greater challenge, but one which the world, especially through commitment to the Millenium Development Goals, is dedicated to overcoming.

 

 

How is Malaria Cured?

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QUESTION

How is malaria cured?

ANSWER

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.

For more information, see the WHO recommendations for malaria treatment.

What is Malaria?

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QUESTION

What is it?

ANSWER

I have copied the below answer from an earlier question also asking what malaria is:

Malaria is a disease caused by parasites of the genus Plasmodium. Transmitted by mosquitoes, there are several different kinds of malaria distributed throughout the tropical and sub-tropical regions of the world, causing somewhere between 300-500 million cases of disease each year, and as many as 1 million deaths. In fact, malaria is one of the biggest killers of children under the age of five in sub-Saharan Africa, one of the regions of the world where the burden from malaria is the highest. Malaria is usually an acute disease, manifesting itself with severe fever, chills, headache and often nausea as well. Some types of malaria can have relapsing episodes over a time period of many years.

Having said this, malaria is easily preventable, through avoiding mosquito bites by wearing appropriate clothing and sleeping under insecticide-treated bednets, or through taking preventative medication (called prophylaxis). Malaria is also treatable once symptoms appear, through ingesting safe, effective and relatively cheap drugs. With such control measures at hand, you may ask why malaria is still such a huge problem in our world; the answer is that delivering control strategies and treatment to populations most at risk is difficult, and often countries with high malaria burdens don’t have efficient and effective health systems in place to coordinate control efforts.

International non-governmental organisations such as the World Health Organisation, as well as a multitude of non-profit organisations such as the Malaria Consortium and Malaria No More, work tirelessly to bring malaria control and treatment to the places that need it most, with the aim to eradicate malaria as a disease of public health importance.

Drugs for Malaria

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QUESTION

What drugs are used in the treatment of malaria?

ANSWER

There are a number of medicines used to treat malaria. Traditionally, chloroquine has been the first line drug of choice for uncomplicated, non-resistant malaria. However, several types of malaria, and most notably Plasmodium falciparum, the most severe and deadly kind, has become resistant to chloroquine in many places. In some parts of south-east Asia, Plasmodium vivax has also begun to show worrying signs of chloroquine resistance. In such settings, where resistance to chloroquine is suspected, the first line medications for uncomplicated cases are artemisinin-based combination therapies (ACTs), such as Coartem.

The World Health Organization has recommended that artemisinin only be given in combination with another drug to prevent malaria also becoming resistant to this therapy as well. Cases of malaria which have progressed beyond the grasp of that treatable with oral medication as described above (so-called “complicated” cases, most common with P. falciparum infection) are usually given intravenous quinine as a first-line response.

All of these treatments have been rigorously tested in strictly controlled clinical and field trials, and while they may have side effects, they are generally mild and in most cases, the patient will be given the dose without prior testing for reaction to the drug. One exception is with primaquine, which is sometimes used as a preventative medication against malaria and can also be used to treat the liver stages of P. vivax and P. ovale. Primaquine is known to cause severe haemolysis in people with G6DP deficiency, and so people with a high statistical probability of having this condition (for example due to family history or ethnicity) should be tested prior to being given primaquine.

 

ARCEVA for malaria

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QUESTION:

Is ARCEVA a good vaccine for malaria?

ANSWER:

ARCEVA isn’t a vaccine for malaria, but it is a brand name of one type of medication used to treat the disease. It belongs to the group of drugs called artemisinin-based combination therapies (ACTs), which are recommended by the World Health Organisation to treat uncomplicated malaria caused by Plasmodium falciparum, the most dangerous form of malaria. ARCEVA specifically contains artemether combined with lumefantrine. It is very important to know that there is no effective vaccine against malaria that is currently available; many scientists and researchers are vigorously hunting for such a vaccine, knowing that this would radically decrease the number of cases of malaria worldwide.

Diagnosed with Malaria in Nigeria

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QUESTION:

Hi my twin sister is in Nigeria on a 5 month missions trip. She has just been diagnosed with Malaria, they believe she got it a year ago in El Salvador and that it has been dormant in her system, she has week kidneys and has chronic high blood pressure due to childhood illnesses she has had her whole life. She is in the Northern part of Nigeria and the hospitals there are no real help, my questions is…. in your opinion should come home now to recover?? I am sure the type of Malaria she has, I have been doing lots of research and I am extremely concerned for her health. She has always had health issues and I am wondering if the malaria will be even worse for her given her pre-existing health conditions. It is very hard to reach her so I am not able to ask her many questions, I know she is in pain, can’t keep food down and currently is not being treated in a hospital. Any thoughts or recommendations would be appreciated!!! ASAP Please! Thank You! Tasha

ANSWER:

Hi Tasha, I answered your question directly in response to the comment you made on the Malaria Symptoms post, but here it is again:

Sorry for the slow reply, I’ve been travelling. It sounds like your sister really needs urgent medical attention, and is not receiving that where she is in northern Nigeria. If possible, I would try to encourage her to seek further medical help, either in the area she is in or, if she is able to travel, in one of the major cities. If they have accurately diagnosed the type of malaria she has (which is presumably how they suspected she was infected in El Salvador, since it is likely not a species of malaria that is commonly found in Africa), it will be straightforward to give her treatment, but any physicians she sees must be made aware of her existing health conditions. If she has Plasmodium vivax, which is often found in Central America, she should also look into taking a course of drugs (called primaquine) which will prevent further recurrence of the disease at a later date. Hope this has been of some help and that she is on the road to recovery already.

AND:

In addition to the above, I have just received some advice from a medical doctor who is involved with our website:

If she contracted it in El Salvador, then Plasmodium vivax most likely and not a particularly resistant strain (generally chloroquine sensitive west of Panama Canal). I think this could be easily treated in Nigeria so long as the diagnosis is clear and there are drugs available – almost any standard regimen would be effective. Did she have anything with her for prophylaxis or stand-by treatment? Chloroquine/mefloquine/Malarone shouldn’t need much adjustment for her kidneys, but it would help to know what her renal function is (GFR/Creatine). The pain and nausea/vomiting present a problem in keeping the medication down, however, even IV hydration is an option if she is becoming dehydrated from the illness. In general, more details are needed, as worsening kidney problems from hydration or gall bladder problems from not eating could complicate the picture, even if the malaria is treated. I don’t know where home is, but she should at least get to a town where basic blood work can be obtained, and anti-nausea medication/IV fluids are available.