World Malaria Day 2014 – How Best to Invest in Malaria Prevention and Control

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Each year, April 25 provides an opportunity to reflect on the current status of the fight against malaria. We are in the middle year of the World Malaria Day theme of “Invest in the Future. Defeat Malaria,” which is set to last until 2015.

Funding for malaria control and prevention, as with all international public health endeavors, has always been perceived as a critical issue, but there is a refreshing diversity to the ways in which it is being discussed this World Malaria Day.  The U.S. Centers for Disease Control and Prevention (CDC), who spear-headed the successful eradication of malaria in the U.S. back in the 1950s, specifically mention their efforts to maximize effectiveness, and their strategies for using and evaluating new tools such that they can get the most impact per precious dollar spent.  The WHO has highlighted the importance of sustained political commitment, as a crucial factor related to ensuring continued financial support for malaria initiatives. The Global Fund to Fight AIDS, TB, and Malaria recently announced a new funding model, designed to enable “strategic investment for maximum impact.” [Read more…]

CDC Warns of Imported Malaria – U.S. Cases Reach 40 Year High

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Increase underscores importance of taking recommended medicines to prevent malaria when traveling

In 2011, 1,925 malaria cases were reported in the United States, according to data published in a supplement of the Morbidity and Mortality Weekly Report (MMWR) released today by the Centers for Disease Control and Prevention (CDC). This number is the highest since 1971, more than 40 years ago, and represents a 14% increase since 2010. Five people in the U.S. died from malaria or associated complications.

Almost all of the malaria cases reported in the U.S. were acquired overseas. More than two-thirds (69%) of the cases were imported from Africa, and nearly two-thirds (63%) of those were acquired in West Africa. For the first time, India was the country from which the most cases were imported. Cases showed seasonal peaks in January and August.

“Malaria isn’t something many doctors see frequently in the United States thanks to successful malaria elimination efforts in the 1940s,” said CDC Director Tom Frieden, M.D, M.P.H. “The increase in malaria cases reminds us that Americans remain vulnerable and must be vigilant against diseases like malaria because our world is so interconnected by travel.”

Malaria is caused by a parasite transmitted by the bite of an infective female Anopheles mosquito. In 2010, it caused an estimated 660,000 deaths and 219 million cases globally. The signs and symptoms of malaria illness are varied, but the majority of patients have fever. Other common symptoms include headache, back pain, chills, increased sweating, muscle pain, nausea, vomiting, diarrhea, and cough. Untreated infections can rapidly progress to coma, kidney failure, respiratory distress, and death.

“Malaria is preventable. In most cases, these illnesses and deaths could have been avoided by taking recommended precautions,” said Laurence Slutsker, M.D., M.P.H., director of CDC’s Division of Parasitic Diseases and Malaria. “We have made great strides in preventing and controlling malaria around the world. However, malaria persists in many areas and the use of appropriate prevention measures by travelers is still very important.”

Travelers to areas with malaria transmission can prevent the disease by taking steps such as use of antimalarial drugs, insect repellent, insecticide-treated bed nets, and protective clothing.

Travelers in the United States should consult a health-care provider prior to international travel to receive needed information, medications, and vaccines. CDC provides advice on malaria prevention recommendations on-line. If a traveler has symptoms of malaria, such as fever, headaches, and other flu-like symptoms, while abroad or on returning home, he or she should immediately seek diagnosis and treatment from a health-care provider.

Clinicians should consult the CDC Guidelines for Treatment of Malaria and contact CDC’s Malaria Hotline for case management advice, as needed. Malaria treatment recommendations can be obtained online or by calling the Malaria Hotline (770-488-7788 or toll-free at 855-856-4713).

Source: Centers for Disease Control (CDC)

Exchange Transfusion for Treatment of Severe Malaria No Longer Recommended

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The Centers for Disease Control (CDC) no longer recommends the use of exchange transfusion (ET) as an adjunct to antimalarial drugs for the treatment of severe malaria.

ET is a procedure in which a portion of blood from the infected patient is removed and replaced with uninfected blood. Previously, the rationale for the use of ET in severe malaria was that ET removed infected cells and toxic byproducts. ET has been used in countries like the United States to complement antimalarials when treating severe malaria. In fact, CDC used to recommend that ET could be considered as an adjunct to intravenous quinidine in patients with very high parasite loads (>10%), or if complications such as cerebral malaria, acute respiratory distress syndrome, or renal compromise occur. However, the use of ET has been based on limited evidence.

CDC examined the efficacy of ET as an adjunct treatment for severe malaria by analyzing data from the US National Malaria Surveillance System and reviewed the entirety of the published literature to update recommendations. Patients with severe malaria who were treated with ET were compared to those not treated with ET, and there was no significant association between ET and survival outcome. A review of the literature found that the evidence available was limited but overall showed no differences in outcome when ET was used. Adverse events due to ET were rarely reported but included acute respiratory distress syndrome, ventricular fibrillation, and hypotension. To date, this is the largest and most comprehensive study of exchange transfusion for treatment of severe malaria. Based on this evidence, adjunct ET cannot be recommended for the treatment of severe malaria.

Source: CDC

Malaria Life Cycle Illustration

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QUESTION
What is the life cycle of malaria?

ANSWER

The life cycle of malaria is complex, involving a definitive host, or vector, which for human malaria is a mosquito of the genus Anopheles, and also a human host. Inside both, the malaria parasite undergoes several different transformations and reproductive cycles, which are detailed in the schematic below.

You may also view a video of malaria life cycle.

Malaria life cycle

Schematic of malaria life cycle, courtesy of CDC (www.cdc.gov)

Malaria Symptoms Flash Back

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QUESTION

I got cerebral malaria in Uganda in 1988. Upon returning to the US I was part of an on-going study through the CDC for a couple years. During that time I had recurrence of what appeared to be an 8-10 hour relapse of the severe body aches, disorientation, fever, chills etc. The tropical doctor that was following me informed me that with something as severe as cerebral malaria the brain can record the experience and periodically and randomly play it back kind of like an LSD flashback. I was tested on multiple occasions and the parasite was dead. This has happened to me every several years since 1988.

I had a recurrence of these malaria-like symptoms last night and this morning and by 10 am I felt fine. I looked online but could not find anything relating to this information of the brain replaying the symptoms. Can you let me know if this is common or true?

Thank you in advance.

ANSWER

Hi, that is a very interesting story! I personally have not heard of other cases where a patient experienced regular “flashbacks” and I have consluted one of our medical advisers, and he has not personally heard of other cases of malaria “flashbacks” either.

It might be worth checking up directly with the CDC to see if any other patients they followed experienced similar after effects.

Malaria or Not?

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QUESTION

I went to Luanda, Angola and Port Hartcourt, Nigeria, Onne, Nigeria and Warri, Nigeria a few times. I suffer with voice problems, muscle control on my right side and some joint pains that have not been explained by my doctors.

I have been to doctors in Houston, Tx., New Orleans, La., New Iberia, La. and Franklin, La. and they all say the same thing. They don’t know what’s wrong with me. It maybe malaria that has laid dormant for nearly three years. I need to find out who can diagnose this for me and get me some help. My symptoms go back to 2009 with the balance being the first problem I noticed. The loss of my voice came later. I took off work for 5 months. Help me find someone close that might be able to help.

ANSWER

Although joint pains are associated sometimes with malaria infection, the most common symptoms are high fevers and chills—it would be unusual to suffer problems of with balance, the voice or muscle spasms.

A blood test is the only way to test for malaria for sure—this may be possible at a local travel clinic or any hospital which has a tropical medicine specialist.

I am not sure of any such exact clinics/hospitals in your area. However, I believe the CDC website has a list of local resources for tropical medicine. Otherwise, the CDC itself is located in Atlanta, GA, and they are certainly able to perform malaria testing, as well as give you advice as to whether you might be suffering from some other disease acquired internationally.

Malaria in the United States, Years Later

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QUESTION

For years, I have questioned what sickness I got years ago after a series of bug bites in a bayou in New Orleans. I’ve just read the symptoms described here and they fit everything I was suffering with. I even had problems with my liver, but I was never tested for Malaria because I had immediately left New Orleans for Italy. I never thought of mentioning it. This mysterious illness cropped up in different forms over the years and really I was never the same after it. It has been almost 12 years, and I still suffer from recurring illness which antibiotics help for a while, but it always comes back. Could it be that I have had Malaria in my system all this time?

ANSWER

While malaria was officially eradicated from the US in the 1950s, certainly the swamps and bayous of Louisiana and the rest of the Gulf were a key habitat and a major source of transmission prior to eradication. I just found a news report in the New York Times from October 1883 which reported 16 deaths due to “malarial fever” in the previous week alone!

While these days, virtually all of the 1,500 or so cases of malaria observed in the US every year are attributed to overseas travel, in 2002 a handful of cases of malaria in northern Virginia were believed to be due to local transmission. Prompt treatment, personal protective measures (such as screening houses) and vector control quickly quelled that mini-outbreak.

Given this history along with your symptoms, and particularly your recurrent episodes of fever, I would not rule out malaria, obtained in Louisiana, as a possibility! You should talk to your doctor about the possibility of a serological test for the antibodies against malaria—if positive, you should try to have a blood test done next time you have the recurrence of symptoms. If malaria is confirmed, you should report your case to the Centers for Disease Control (CDC) Domestic Malaria Unit, which monitors all malaria cases in the US.

Duo-Cotecxin and Fansidar as Treatment

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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.

Malaria, Hepatitis and Cholera Deaths

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QUESTION

Up to now how many people died of malaria?

Up to now how many people died of Hepatitis A?

Up to now how many people died of Cholera?

ANSWER

It is believed that malaria is singly responsible for the most deaths of humans in history. However, the exact number is impossible to know. Our modern concept of disease as caused by a particular organisms or pathogen is very new, having only really developed in the 19th century, though dating back to the work of Anton van Leeuwenhoek in the late 17th century (he has since been described as “the father of microbiology”).

As such, in the past, diseases were often mistaken for each other, and particularly since malaria has such general symptoms (fever, aches, chills—these are commonly seen in many other illnesses as well), it is hard to determine what people actually died from malaria and which died from other causes. Indeed, this difficulty remains today, making it hard to estimate accurately the number of people who die from malaria even now. The World Health Organisation currently estimates that approximately 700,000 people died last year of malaria, from close to 700 million cases – this actually represents a very low death rate, thanks is large part to global efforts to improve access to diagnosis and treatment.

Hepatitis A is far less common than malaria; there are an estimated 1.4 million cases per year. Most of these are asymptomatic or mild, with a low fatality rate (4 deaths per 1000 people infected in people under 50; that rises to 17.5 per 1000 for people over 50, as older people tend to have more severe manifestations of the disease and a greater risk of subsequent liver complications – note that these data are from the CDC back in 1991). There is a very safe and effective vaccine available against hepatitis A virus (HAV)—almost 100% of people given the vaccine develop antibodies against infection.

Cholera is slightly more common than HAV (3-5 million estimated cases each year, according to the World Health Organisation) but similarly, most cases are of mild severity. Less than 20% of patients develop “typical” cholera with severe, life-threatening dehydration. 100,000-120,000 people are estimated to die from cholera each year.

Paludrine/Avloclor Anti Malaria Travel Pack

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QUESTION

Is this anti malaria travel pack suitable for Borneo?

ANSWER

This kit is NOT appropriate for preventing malaria in Borneo. Avloclor contain chloroquine phosphate, and some types of malaria present in Borneo are resistant to chloroquine.

The CDC recommends that travelers to Malaysian or Indonesian Borneo should use atovaquone-proguanil (Paludrine contains proguanil, but the drug Malarone contains the combination of proguanil and atovaquone in one pill), mefloquine (sold under the brand name Lariam) or doxycycline.

Each of these different types of prophylaxis (preventative medication) has its advantages and disadvantages: Malarone is very expensive but many people consider it to have the fewest side effects; Lariam has been associated with severe side effects and is not recommended for people with a history of mental illness, but only needs to be taken once a week (the others require a daily pill); and doxycycline is cheap but may produce sun sensitivity.

When you return from your trip, please take a moment to share your experiences with anti-malarial medication by taking our malaria survey. We will compile all the results and post them on MALARIA.com, so visitors to the site can be informed about the preferences and side effects experienced by other members of the public who have used different forms of prophylaxis.