Malaria while in Addis Ababa, Ethiopia?

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QUESTION

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

ANSWER

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

Use of Fish for Malaria Eradication

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QUESTION

Why is very little research being done on the possibility of mosquito fish being used as a means of controlling the hatching of new eggs?

ANSWER

Actually there is a lot of scientific literature on the use of fish as a biological control of mosquitoes, usually through consumption of the mosquito larvae or pupae while they are in freshwater. The most common species used for this purpose are the guppy (Poecilia reticulata) and the appropriately named mosquito fish (Gambusia affinis). Other fish groups, like cyprinodontids (i.e. Aphanius species), tilapia and minnows will also eat mosquito larvae.

In addition, other freshwater predators, such as copepods, have been shown to be highly effective in  killing mosquito in laboratory and field experiments, though results are sometimes inconsistent (see Lardeaux, 2008 “Biological control of Culicidae with the copepod Mesocyclops aspericornis and larvivorous fish (Poeciliidae) in a village of French Polynesia,” in Medical and Veterinary Entomology, vol 6, issue 1, pages 9-15, for a comparison of the anti-mosquito effect of these different groups).

The Lardeaux paper also describes the failure of the program: despite introduction of larvivorous animals, biting rates of mosquitoes did not significantly reduce, indicating some of the complications that can be associated with biological control programs.

However, in Vietnam, field studies have shown significant reductions of local Aedes mosquitoes associated with the presence of copepods in standing water sources, which shows the potential positive effects of incorporating natural biological control agents within part of an integrated vector control strategy (Nam et al., 2000 “National progress in dengue vector control in Vietnam: Survey for Mesocyclops (Copepoda), Micronexa (Corixidae) and fish as biological control agents,” in the American Journal of Tropical Medicine and Hygiene, vol 62, issue 1, pages 5-10).

Another example of successful introduction of fish as biological control agent comes from Ethiopia (Fletcher et al., 1992 “Control of mosquito larvae in the port city of Assab by an indigenous larvivorous fish, Aphanius dispar,” in Acta Tropica, vol 52, issue 2-3, pages 155-166).

Treating Malaria by Health Extension Workers: A Case Study from Ethiopia

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For many years the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) have been promoting an Integrated Management of Childhood Illness (IMCI) training package to ensure that nurses and doctors are capable of treating sick children at health facilities.  Over the years, with the realization that many children did not have access to health facilities and therefore were not being ttreated, the two organizations published a Joint Statement on Managing Pneumonia in Community Settings (2004)[1].  This groundbreaking document calls on countries to bring treatment of childhood illness – pneumonia as well as malaria and diarrhea closer to communities that need it, by empowering trained community health workers to identify and manage these problems. Many countries have followed this advice with excellent results.  Here is a story from Ethiopia.

Aminata is a health extension worker (HEW) at the Tebisa health post, located in a rural, hilly area of East Amhara, some 400 kilometers away from Addis Ababa, the capital city of Ethiopia. Aminata received training on integrated community based management of common childhood illnesses (iCCM) in early 2011. After the training, she carried the essential materials and supplies with her back to the health post, and started treating children suffering from pneumonia, malaria, diarrhoea and/or severe acute malnutrition.  In the last two months, she has treated 35 children under five.

HEW Ethiopia
A Health Extension Worker (HEW) with Almaz and her family. Photo: Dr. L. Pearson

One of the children suffering from malaria is a five year old girl, Almaz (which means diamond in Amharic). She developed fever one night in April. Her mother took her to the health post and she was seen immediately. Aminata checked her temperature (39.0 OC), and respiratory rate (children sometimes have pneumonia and malaria at the same time) and pricked her finger to obtain a drop of blood to perform a Rapid Test for Malaria (RTM) to look for malaria parasites [Ed: Rapid Diagnostic Tests, or RDTs, are another, more general term for these tests].

Almaz did not have rapid breathing, an indication of pneumonia, but she did have falciparum malaria (the most severe and deadly of the types of malaria found in humans, and caused by the Plasmodium falciparum parasite).  She was given Coartem (Arthemeter-Lumefentrine) treatment by mouth for three days.  Aminata gave the first dose of medicine and gave the mother the rest of the tablets, explaining when to give them. Aminata made a point to discuss how important it is to feed a sick child so they do not lose weight, and to be alert to certain ‘danger signs’ in case the child is not getting better, in which case they should return immediately to the health post.

On the second day of treatment her mother brought her back to the health post for a follow up check.   Almaz’s mother expressed her gratitude. “If the HEWs are not providing treatment for sick children, I would have to carry Almaz to the health center some 4 hours away by foot. I would also have to pay for the treatment.  We were frustrated before iCCM started because we were not able to help children with malaria and pneumonia”.

malaria medicines at health post Ethiopia
Malaria medicine available, for free, at the Tebisa health post in Ethiopia. Photo: Dr L. Pearson

“The communities trust and support us even more now”, said Aminata. “Now the mothers are so happy, they even bring the children for immunization without us having to push them”.

In the next two years, about 20,000 HEWs will be trained and supported to provide iCCM in 10,000 rural villages. Hundreds and thousands of young children in Ethiopia will benefit from the iCCM programme jointly supported by the government of Ethiopia, Catalytic Initiative of Canada, UNICEF and other development partners. Program implementation will focus on remote and harder to reach villages and households, to ensure every child is covered, no matter where they are and who they are.

The iCCM is be an important opportunity to further improve quality of care provided at the health posts, and accelerate toward the achievement of Millennium Development Goal 4, to reduce deaths of children under 5 by two-thirds by 2015.

[1] Management of Pneumonia in Community Settings (PDF)