Bringing Malaria to the United States

QUESTION

I was recently diagnosed with Malaria still waiting to find out what strand, but either got it in Uganda or Rwanda. I have recently came back to the states and have been bit by mosquito. I have already started to take some medication for it, but I am concerned about spreading the virus to others in the states including my family. Is it possible that if I still have the infection to spread it to others or in the states? If so what should I do.

ANSWER

There actually used to be malaria in the United States, particularly in the southern areas, but concerted mosquito control efforts as well as public health initiatives eradicated it in the 1950s. I don’t think you need to worry too much about transmitting malaria—once you are on treatment, the number of parasites in your blood drops dramatically and it becomes more difficult to transmit the parasite to a mosquito. Also, there are lots of types of mosquitoes in the US, and only those of the genus Anopheles can transmit malaria. As such, if you are concerned about spreading malaria, you should take precautions to protect yourself from mosquitoes especially at night and at dusk and dawn, as this is when Anopheles mosquitoes are most active. The type of mosquitoes which bite during the day usually belong to the genus Aedes, and cannot transmit malaria. During these high risk times of day, you should take care to wear long-sleeved clothing, and also wear insect repellent, preferably containing DEET.

Do I need malaria tablets to live in Nigeria?

QUESTION

Do I need malaria tablets to live in Nigeria? I was born and bred in the UK and want to go back to live in Nigeria for about 2 years, do I need malaria tablets?

ANSWER

It is not usually recommended to take malaria tablets for long periods of time (i.e. more than a few months). People living for extended periods in areas with malaria should focus on other methods of prevention, such as sleeping under a long-lasting insecticide-treated bednet.

The mosquitoes that carry malaria, Anopheles, feed mostly in the evenings and at night, so it is particularly important to protect yourself during these times. Screening windows and doors tightly can help prevent mosquitoes form entering, as can air conditioning inside the house (it makes the climate less suitable for the mosquitoes).

In many parts of Africa, insecticide is sometimes sprayed indoors, again to prevent mosquitoes from being inside the house. Personal protection is also important; wearing long-sleeved clothing, particularly at dawn, dusk and at night, can prevent mosquitoes from biting you, as can wearing mosquito repellent, particularly kinds containing the chemical DEET.

Regarding tablets to prevent malaria, if you really want to pursue this option, the only medication which is recommended for long-term use is doxycycline, but you should consult with your doctor about its suitability for periods of longer than 6 months, and they should also explain to you the possible side effects associated with taking it.

While the above mentioned forms of prevention should be the mainstay of your efforts to avoid malaria, it is also important to know what the symptoms are and what to do if you suspect you might be infected.

Malaria is characterized by high fever, chills, aches and nausea most commonly, and if you think you may be infected, you should immediately go to a doctor or a clinic for diagnosis. The doctor/clinician should take a blood sample and either look at it under a microscope to look for malaria parasites or they will use a drop of blood in a rapid diagnostic test. In both cases, you should only take medication to treat malaria if you are positively diagnosed.

Repeated Malaria Cases, New Guinea

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.

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.

Malaria Prevention

QUESTION

what is the prevention of malaria?

ANSWER

There are many ways in which to prevent malaria. I’ll break them down into three categories: 1) medical prevention, 2) protection from getting mosquito bites and 3) vector control.

1) Medical prevention

Malaria can be prevented using certain medications. Taking drugs to prevent a disease is known as “chemoprophylaxis”, and so these drugs are often referred to as “malaria prophylactics”. There are several different types of malaria prophylactic: the most common ones are chloroquine, a mix of atovaquone and proguanil (marketed as Malarone), mefloquine (marketed as Lariam) and doxycycline. The mode of taking these medications vary (Lariam is taken once a week, for example, whereas the others are usually taken once every day), and they also have different restrictions and side effects. Chloroquine is not effective in areas where local forms of malaria have become resistant, for example, and Lariam is not recommended for people with a history of mental instability, as it is known to cause hallucinations and otherwise impair consciousness. Here on Malaria.com, we are actually currently running a survey on side effects of malaria prophylactic drugs, so if you have ever taken medication to prevent malaria, please take the survey: Malaria Medication Side-effects Survey: Treatment and Prophylaxis

It is worth noting that these drugs have not been tested for long term use, plus they can be expensive if taken for an extended period of time. As such, they may not be appropriate for people living in endemic areas for malaria. However, medication can be useful for preventing malaria in high risk groups, even when they are living in a malaria endemic area. One example is the use of intermittent preventive treatment (IPT) for preventing malaria infection in pregnant women, infants and young children. For more information on this, please see the review article written by Dr Felicia Lester for this website: http://www.malaria.com/research/malaria-pregnancy-preventive-treatment

2) Protection from getting mosquito bites

This section links in with the more general vector control strategies, which will be discussed below. Since malaria is transmitted through the bite of infected mosquitoes, preventing mosquito bites is a very effective way of reducing malaria incidence. One of the most popular methods for personal protection, especially in areas where malaria is endemic, is through sleeping under a mosquito bednet. The mesh prevents mosquitoes from being able to fly close to the person sleeping; however, if there are holes in the net, or the person skin is pressed directly against the mesh, the mosquito may still be able to bite them. This is where insecticide-treated bednets come in – they are impregnated with mosquito repellents to stop mosquitoes from biting through the mesh or passing through holes. Newly developed long-lasting insecticide treated bednets (LLINs) are even more effective, in that they don’t require “re-dipping” to maintain the level of repellent in the fibres, and so can protect a person for several years without losing efficacy. These LLINs have been instrumental in reducing cases of severe and fatal malaria, especially among pregnant women and young children, who are often targeted by bednet distributors.

Other methods for preventing mosquito bites include wearing long-sleeved clothing and personal application of mosquito repellent, particular those containing a percentage of DEET, which is a very effective insecticide. These measures should be especially taken in the evening, early morning and at night, which is when the Anopheles mosquitoes that carry malaria are most active.

3) Vector control

Finally, malaria can be prevented from reducing numbers of mosquitoes directly. Some methods target the adult mosquitoes; one such initiative is indoor residual spraying (IRS), whereby the inside of a house is sprayed with an insecticide to kill mosquitoes. Twelve different insecticides are approved by the World Health Organisation for this purpose, though pyrethroids are among the most popular, as they can be used on a variety of surfaces, do not leave a visible stain and can also protect against other insect pests, such as bedbugs.

Other methods for vector control focus on other parts of the mosquito lifecycle. Mosquito larvae require stagnant freshwater for their development, so some projects have worked to eliminate standing water sources, such as unnecessary ditches and puddles, which reduces the amount of habitat available for mosquitoes to lay their eggs and sustain larvae. Other programmes have spread insecticides directly in stagnant water to kill the larvae, or sought to introduce fish or other aquatic organisms, such as copepods, which consume mosquito eggs and larvae. This latter biological control approach is popular because it can also supply an area with fish for local consumption, and doesn’t contaminate water sources with chemicals.

Repellent for Malaria Mosquitos

QUESTION

My daughter is leaving for Africa for 5 weeks on a mission trip. Is there a repellent that can be used to ward off these infected mosquitos? Also what can she do to stay safe and protected?

ANSWER

There is no way of warding off only those mosquitoes that are infected with malaria. However, insect repellents which contain DEET (10% or higher) are the most effective against the species of Anopheles mosquito that carry malaria.

From personal experience, I can tell you that “natural” insect repellants that do not contain DEET are just not as effective against these mosquitoes. Your daughter can also spray her clothing with permethrin, which repells insects, and she should wear long-sleeved clothing in the evenings, early mornings and at night, when the malaria mosquitoes are most active. She should also try to sleep every night under a long-lasting insecticide treated bednet, which drastically reduces the number of bites.

In addition, your daughter should look into taking anti-malarial preventative medication, known as malaria prophylaxis. There are a number of different types; the two most commonly recommended for Africa are doxycycline (cheap, effective, but can cause sun sensitivity and so people taking it must be vigilant about using sun block! It also needs to be taken for four weeks after leaving the malarial area) and atovaquone-proguanil (sold as Malarone—this is effective, and has very few side effects, but is often very expensive. It only needs to be taken for a week after returning home), both of which are taken as a daily pill with food.

Malaria Symptoms, Cures, and Prevention

QUESTION

What is malaria cure, prevention, symptom and course?

ANSWER

I am not sure what you mean by “course” – however, links to information on malaria treatment, prevention and symptoms can be found on the main page of our website. For your convenience, I have provided them here:

As for malaria treatment, I have copied here an earlier answer in response to a question about malaria cures:

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.

 

Recurring Malaria Long Term Effects

QUESTION:

Hi, my husband is an expat working in Mozambique for the past 5 years. He has been diagnosed with malaria 9 times, what are the long term effects of this and is he just unlucky or do others also get infected often? thanks.

ANSWER:

If the proper precautions are not taken, then it is very easy to get infected with malaria multiple times; I have one Ugandan colleague who claims he gets sick at least once a year from malaria, usually sometime in the rainy season. However, there are means to protect oneself from regular infection, and it might be that your husband could be more vigilant about such methods of prevention. For example, he should make sure he sleeps under a long-lasting insecticide treated bednet, which drastically reduced the risk of being bitten by mosquitoes at night. Similarly, he should try to wear long trousers and long-sleeved shirts, preferably impregnated with a substance called permethrin (an insecticide which prevents mosquitoes from biting through clothing – it can be purchased at most camping stores and sprayed directly onto clothing only, not onto skin), especially at dawn, dusk and at night, when malaria-carrying mosquitoes are most active. When mosquito numbers are high, he could also use insecticide that contains DEET on any exposed skin as a further precaution against bites.

The good news is that if his previous bouts of malaria have been uncomplicated, and diagnosed and treated quickly, there should be no long term effects of having had the infection.

Researchers Discover Insect Repellent Thousands of Times More Effective than DEET

Imagine an insect repellent that not only is thousands of times more effective than DEET – the active ingredient in most commercial mosquito repellents – but also works against all types of insects, including flies, moths and ants.

That possibility has been created by the discovery of a new class of insect repellent made in the laboratory of Vanderbilt Professor of Biological Sciences and Pharmacology Laurence Zwiebel and reported this week in the online Early Edition of the Proceedings of the National Academy of Sciences.

“It wasn’t something we set out to find,” said David Rinker, a graduate student who performed the study in collaboration with graduate student Gregory Pask and post-doctoral fellow Patrick Jones. “It was an anomaly that we noticed in our tests.”

The tests were conducted as part of a major interdisciplinary research project to develop new ways to control the spread of malaria by disrupting a mosquito’s sense of smell supported by the Grand Challenges in Global Health Initiative funded by the Foundation for the NIH through a grant from the Bill & Melinda Gates Foundation.

“It’s too soon to determine whether this specific compound can act as the basis of a commercial product,” Zwiebel cautioned. “But it is the first of its kind and, as such, can be used to develop other similar compounds that have characteristics appropriate for commercialization.”

The discovery of this new class of repellent is based on insights that scientists have gained about the basic nature of the insect’s sense of smell in the last few years. Although the mosquito’s olfactory system is housed in its antennae, 10 years ago biologists thought that it worked in the same way at the molecular level as it does in mammals. A family of special proteins called odorant receptors, or ORs, sits on the surface of nerve cells in the nose of mammals and in the antennae of mosquitoes. When these receptors come into contact with smelly molecules, they trigger the nerves signaling the detection of specific odors.

In the last few years, however, scientists have been surprised to learn that the olfactory system of mosquitoes and other insects is fundamentally different. In the insect system, conventional ORs do not act autonomously. Instead, they form a complex with a unique co-receptor (called Orco) that is also required to detect odorant molecules. ORs are spread all over the antennae and each responds to a different odor. To function, however, each OR must be connected to an Orco.

“Think of an OR as a microphone that can detect a single frequency,” Zwiebel said. “On her antenna the mosquito has dozens of types of these microphones, each tuned to a specific frequency. Orco acts as the switch in each microphone that tells the brain when there is a signal. When a mosquito smells an odor, the microphone tuned to that smell will turn “on” its Orco switch. The other microphones remain off. However, by stimulating Orco directly we can turn them all on at once. This would effectively overload the mosquito’s sense of smell and shut down her ability to find blood.”

Because the researchers couldn’t predict what chemicals might modulate OR-Orco complexes, they decided to “throw the kitchen sink” at the problem. Through their affiliation with Vanderbilt’s Institute of Chemical Biology, they gained access to Vanderbilt’s high throughput screening facility, a technology intended for the drug discovery process, not for the screening of insect ORs.

Jones used genetic engineering techniques to insert mosquito odorant receptors into the human embryonic kidney cells used in the screening process. Rinker tested these cells against a commercial library of 118,000 small molecules normally used in drug development. They expected to find, and did find, a number of compounds that triggered a response in the conventional mosquito ORs they were screening, but they were surprised to find one compound that consistently triggered OR-Orco complexes, leading them to conclude that they had discovered the first molecule that directly stimulates the Orco co-receptor. They have named the compound VUAA1.

Although it is not an odorant molecule, the researchers determined that VUAA1 activates insect OR-Orco complexes in a manner similar to a typical odorant molecule. Jones also verified that mosquitoes respond to exposure to VUAA1, a crucial step in demonstrating that VUAA1 can affect a mosquito’s behavior.

“If a compound like VUAA1 can activate every mosquito OR at once, then it could overwhelm the insect’s sense of smell, creating a repellent effect akin to stepping onto an elevator with someone wearing too much perfume, except this would be far worse for the mosquito,” Jones said.

The researchers have just begun behavioral studies with the compound. In preliminary tests with mosquitoes, they have found that VUAA1 is thousands of times more effective than DEET.

They have also established that the compound stimulates the OR-Orco complexes of flies, moths and ants. As a result, “VUAA1 opens the door for the development of an entirely new class of agents, which could be used not only to disrupt disease vectors, but also the nuisance insects in your backyard or the agricultural pests in your crops,” Jones said.

Many questions must be answered before VUAA1 can be considered for commercial applications. Zwiebel’s team is currently working with researchers in Vanderbilt’s Drug Discovery Program to pare away the parts of VUAA1 that don’t contribute to its activity. Once that is done, they will begin testing its toxicity.

Vanderbilt University has filed for a patent on this class of compounds and is talking with potential corporate licensees interested in incorporating them into commercial products, with special focus on development of products to reduce the spread of malaria in the developing world.

Source: Proceedings of the National Academy of Sciences, Vanderbilt University

 

Malaria Prevention

Photo by Matthew Naythons, MD

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. [Read more…]