Multiple Malaria Infections Each Year

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QUESTION

My name is Olumide and I live in Nigeria. I have had malaria too frequently and it’s giving me a lot of concern. I had one last August 2012 and am having another one this October as I am speaking with you. If I should count it, I’ll be having nothing less than 6 occurrences in a year. It’s always an headache induced malaria whereby after using the ACT combination recommended by WHO, two days after, am still having headache, am asthmatic though and can’t use more than Paracetamol. I am tired of all these and need your help.

ANSWER

One of the key things you should check is how you are being diagnosed with malaria—the symptoms of malaria are very general, such as headache, chills and fever. I have seen cases where people assume they have malaria and so take ACTs without getting properly diagnosed, and so they never actually go to the doctor to have their real illness diagnosed. Therefore, next time you feel sick, you should go to the doctor or to a clinic and make sure they do a proper malaria test. This will either be via taking your blood and looking at it on a slide under a microscope, or by using a drop of the blood in a rapid diagnostic test (RDT). I believe that in some parts of Nigeria, you can even buy the RDT in local pharmacies, and do the test yourself at home. Only if you test positive for malaria should you take ACTs; if the test is negative, you should go to a doctor and ask about other possible illnesses with similar symptoms (such as flu, pneumonia, etc).

At the same time, it could be that you are suffering from repeated malaria attacks, in which case you will need to improve your personal protection in order to prevent future attacks. Sleeping under a long-lasting insecticide treated bednet is crucial; you should also wear long-sleeved clothing at night and at the evening since this is when malarial mosquitoes in Africa are usually most active. You may also want to consider indoor residual spraying; this coats the inside walls of your house with insecticide, further reducing the number of mosquitoes that may bite you inside your home. For more information, please see our Malaria Prevention overview page: http://www.malaria.com/overview/malaria-prevention

URGENT HELP ON MALARIA

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QUESTION

I 25 yr old male from Lagos, Nigeria. I have been having frequent malaria since 2006 till present. My symptoms are always weakness of the body, feeling cold sometimes not always and also my mouth got better most cases. I have been to the hospital several times and the doctor told me my frequent malaria is because my blood genotype is AA and also am having a malaria parasites. I was given drugs and injection in most cases. It got to a stage I had to stop consulting the doctor and start making use of self description because the malaria goes and comes back and its cost me much money in going to the hospital every time.

The weakness is always my problem because will be restless and unable to study well even during my exams. I remember there was a period I sat down in front of my house and started crying cos I was fed up on getting weak during Xmas period while my mates were having fun. I also remember cases where I walked into one of the biggest pharmacy in my area and ask the guy which malaria drugs is the most expensive cos I was thinking the most expensive should be the most effective. He brought out some drugs which I paid some money.

I was free from malaria for the past 4 months not of recent I started having heavily symptoms mentioned above. I have taken several drugs like chloroquine 2-2-1 and Combisunate(arthmeter and lumefactrine),still yet no positive response.The Cold had stopped but my body is till getting weaker. I am just confuses don’t know what to do. I even thought of going for a HIV test soon cos I believe am not the only AA that stays in House. Others, I mean some of my family and neigbours do have often and it disappears immediately after taking some drugs.

I am fed up seriously and really don’t know what to do again.I hope you can help.

ANSWER

Thanks for your question. Getting infected with malaria doesn’t have anything to do with whether you are blood type A or O or anything else. Some people do have natural resistance to some types of malaria—for example a lot of people in sub-Saharan Africa are “Duffy negative” which means they are resistant to Plasmodium vivax malaria; other people carry the sickle cell gene, which also provides some protection.

However, it is not common to have so many repeated attacks of malaria. The first thing to do is to make sure you are protecting yourself sufficiently from mosquito bites. You can’t get malaria if you aren’t bitten by mosquitoes, and the type of mosquitoes that transmit malaria usually bite at night. As such, it is crucial to sleep every night under a long-lasting insecticide treated bednet. If you have one, it might need to be re-dipped in insecticide to make sure it keeps working effectively. Also, you should make sure all your windows and doors are properly screened to prevent mosquitoes from coming in; many people also do something called “indoor residual spraying” where they spray insecticide on the walls inside their house to kill any mosquitoes which might come in. If you live in an urban area, this might not be necessary if you can get good screens, or indeed if you have air conditioning (mosquitoes do not like cooler environments). Finally, you should try to wear long-sleeved clothing in the evenings and at night, again to stop mosquitoes from biting.

Finally, I think it is important to make sure that you are diagnosed properly. In many places I have been to, hospitals don’t do a proper check, but if someone has even a few of the symptoms of malaria, they just give them treatment. This is not good—you need a proper diagnosis, both to see what kind of malaria you have (so you can get appropriate treatment) and also to make sure you actually have malaria, and not something else which is being ignored because they think you have malaria!

In fact, your symptoms of fatigue, weakness and cold are not very typical of malaria, which is usually characterized by very high fever interspersed with chills, nausea and body aches. As such I think you might want to talk to a doctor about other possible explanations for your symptoms, especially since they are so persistent.

Finally, in Nigeria, you should NOT be given chloroquine to treat malaria, unless your case is confirmed as not being caused by Plasmodium falciparum. Virtually all the Plasmodium falciparum in Africa is resistant to chloroquine, and so it is no longer an effective treatment. Instead, first-line treatment for malaria is recommended as an artemisinin-based combination therapy, such as Combisunate which you mention above.

P. knowlesi versus P. falciparum: Treatment and Prevention

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QUESTION

I would like to know about the P. knowlesi – treatment compared to P. falciparum? preventive medicine?

ANSWER

At this point in time, P. knowlesi is completely susceptible to chloroquine, and so can be treated successfully using this drug. P. falciparum, on the other hand, is known to have widespread resistance to chloroquine, and so the World Health Organization recommends that chloroquine should not be used to treat P. falciparum malaria. Instead, for non-complicated malaria, the WHO recommends treatment with artemisinin-based combination therapies (ACTs). These drugs can also be used against other forms of malaria, including P. knowlesi, particularly if the hospital also treats cases of P. falciparum regularly and so has supplies of ACTs on hand. One study even showed that treatment with ACTs (specifically artemether-lumefantrine) was more effective than chloroquine in treating P. knowlesi. Severe cases of either infection should be treated with intravenous artesunate or quinine.

Prevention for both is roughly similar – chemoprophylaxis should be taken by people travelling to an area where transmission of these types of malaria occurs. However, given P. knowlesi‘s susceptibility to chloroquine, this drug is effective as a prophylactic for this malaria species, whereas it is not appropriate for P. falciparum, given high levels of resistance. In terms of prevention of mosquito bites, this differs due to the types of mosquito vectors each of these species of malaria uses. P. knowlesi is only found in south-east Asia, where the mosquitoes that transmit it tend to be forest dwelling. As such, people who spend time in the forest in the evening and at night are most at risk of contracting P. knowlesi. Wearing long-sleeved clothing and insecticide while in the forest may help prevention in this case. P. falciparum is found throughout the world, and uses many different species of mosquito vector. In Africa, the mosquitoes which transmit P. falciparum tend to rest indoors and thus bite people at night while they are sleeping. Therefore, in these settings, it is especially beneficial to sleep under a long-lasting insecticide treated bednet. Indoor residual spraying, which coats the inside walls of a house with insecticide to kill indoor-resting mosquitoes, can also be beneficial.

How is Malaria Prevented?

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QUESTION

What are the methods to prevent malaria?

ANSWER

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.
  • 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 (see the Malaria Risk Information and Prophylaxis, by Country, section later in this chapter) 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

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Community Based Management for Malaria

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QUESTION

what are the methods for community based management for malaria?

ANSWER

Community-based management of malaria revolves around three main principles: prevention, diagnosis and treatment.

Prevention mainly revolves around stopping mosquitoes from biting people. Methods for this include distribution of long-lasting insecticide treated bednets (and teaching people to use them properly!), indoor residual spraying to stop mosquitoes from living in houses, screening houses properly and removing sources of stagnant water from the community to stop mosquitoes from breeding. Collectively, these methods are considered “vector control”. They have benefit for the individuals who practice the methods, as well as collective benefit at the community level from reduced transmission. Within the community, pregnant women and young children, who are most at risk of severe infection, are often targeted for preventive measures. In addition, transmission of malaria from a pregnant mother to her unborn child can be prevented through chemoprophylaxis, administered usually twice during pregnancy, in a process known as intermittent preventive therapy (IPT).

Diagnosis and treatment involves educating people about the symptoms of malaria so that if they suspect they are infected, they know how and where to seek appropriate medical care. The community therefore has to provide a clinic or hospital that is sufficiently equipped to do accurate diagnosis, which requires blood testing. Clinicians should also be able to identify which type of malaria the patient is infected with, since this determines treatment. Identification of the type of malaria is usually done via looking at the blood of the patient under a microscope, a process which requires a significant amount of training. The type of treatment depends on the severity of infection as well as the type of parasite they are infected with.

All of the above interventions depend on sustained investment in community health care, training of local health workers and clinicians and education the community about the transmission of malaria and how this can be interrupted.

How to Prevent Malaria

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QUESTION

How to prevent malaria?

ANSWER

There are a number of ways to prevent malaria. These can be placed into two categories: medication and vector protection.

For medication, there are drugs you can take to prevent the malaria parasite from developing after someone is bitten by an infected mosquito. These drugs are known as “chemoprophylaxis.”

There are several different kinds, such as doxycycline, mefloquine (marketed as Lariam), atovaquone-proguanil (marketed as Malarone) and chloroquine—the type you use depends on the type of malaria present in the area. For example, in much of Africa and India, malaria is resistant to chloroquine, so this cannot be used as a prophylactic. In parts of Thailand, resistance to mefloquine has emerged. However, if the appropriate type of prophylaxis is used, it is very effective against malaria.

The problem is that these drugs have not been tested for long-term use, can be expensive and may have side-effects. Therefore they are of limited use for people who live in areas where malaria is endemic, and are more appropriate for travelers who are in malarial areas for short amounts of time. However, anti-malarial medication may be used in a very specific way for people at particularly high-risk for malaria, such as pregnant women and young children. In these cases, the high-risk individuals receive a dose or series of doses of malaria medication in order to prevent malaria. This form of prevention is known as intermittent preventive therapy (IPT).

Vector prevention involves protecting oneself against getting bitten by mosquitoes. This can involve wearing long-sleeved clothing in the evenings and at night, when malaria mosquitoes are most active, or wearing insect repellent on exposed skin. Indoor residual spraying, whereby repellent and insecticides are sprayed inside the house, can also be used to bring down the number of mosquitoes.

Another very effective technique for preventing malaria is to sleep under a long-lasting insecticide-treated bednet. The mesh acts as a barrier against the mosquitoes, and the insecticide impregnated in the mesh further repels the mosquitoes and prevents them from biting through the mesh.

Malaria Prevention

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QUESTION

What is malaria and the preventive measures?

ANSWER

Malaria is a disease caused by single-celled parasites of the genus Plasmodium. There are currently five species which cause disease in humans, and while each is slightly different, they all act in basically the same way, and cause similar symptoms. Of the five, the most dangerous is Plasmodium falciparum, which can lead to death in a matter of days if not treated promptly.

In terms of prevention, the same basic methods are used to prevent all types of malaria. These can be placed into two categories: medication and vector protection.

For medication, there are drugs you can take to prevent the malaria parasite from developing after someone is bitten by an infected mosquito. These drugs are known as “chemoprophylaxis.”

There are several different kinds, such as doxycycline, mefloquine (marketed as Lariam), atovaquone-proguanil (marketed as Malarone) and chloroquine—the type you use depends on the type of malaria present in the area. For example, in much of Africa and India, malaria is resistant to chloroquine, so this cannot be used as a prophylactic. In parts of Thailand, resistance to mefloquine has emerged. However, if the appropriate type of prophylaxis is used, it is very effective against malaria.

The problem is that these drugs have not been tested for long-term use, can be expensive and may have side-effects. Therefore they are of limited use for people who live in areas where malaria is endemic, and are more appropriate for travelers who are in malarial areas for short amounts of time. However, anti-malarial medication may be used in a very specific way for people at particularly high-risk for malaria, such as pregnant women and young children. In these cases, the high-risk individuals receive a dose or series of doses of malaria medication in order to prevent malaria. This form of prevention is known as intermittent preventive therapy (IPT).

Vector prevention involves protecting oneself against getting bitten by mosquitoes. This can involve wearing long-sleeved clothing in the evenings and at night, when malaria mosquitoes are most active, or wearing insect repellent on exposed skin. Indoor residual spraying, whereby repellent and insecticides are sprayed inside the house, can also be used to bring down the number of mosquitoes.

Another very effective technique for preventing malaria is to sleep under a long-lasting insecticide-treated bednet. The mesh acts as a barrier against the mosquitoes, and the insecticide impregnated in the mesh further repels the mosquitoes and prevents them from biting through the mesh.

Malaria Beliefs

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QUESTION

How do beliefs and attitude affect the spread, treatment and prevention of malaria?

ANSWER

Accurate information and knowledge about how malaria is transmitted, diagnosed and treated is crucial to controlling the disease, for the general public living in malarial areas, travelers to these areas and health professionals. For example, many travelers are unaware that their destination is in a malaria transmission zone, so they do not take appropriate preventive precautions. Similarly, many travelers I have met believe that if they have had malaria once, they are immune and cannot get reinfected, so don’t bother protecting themselves from mosquitoes – this is not true, and they are inadvertently putting themselves at great risk.

In terms of endemic areas, the focus is on educating people about day-to-day preventive measures, such as sleeping under long-lasting insecticide treated bednets and indoor residual spraying. Educational campaigns that focus on simple, straightforward ways to prevent malaria are more likely to influence people’s attitudes and lead to better malaria control. Similarly, teaching people to seek accurate diagnosis and then ensuring they have appropriate treatment is an important step.

In some places, people feel they cannot afford to visit a doctor or clinic, or would rather place their trust in a traditional healer or healing herbs; since the most effective medications against malaria are treatments such as artemisinin-based combination therapies, which are available through official health sources such as clinics, believing in traditional medicine can lead to the malaria infection becoming very severe, and even resulting in death. As such, another component to control is making sure that medical services such as clinics are easily accessible even for the poorest people, provide good health care and are affordable.

Repeated Malaria

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QUESTION

Since January 2011 I got three times malaria. Is it come regularly? Last week also I got maleria and I took medicine but still I have mild headache and sweating feeling tiredenes in between..

ANSWER

The timing of the repeated malaria episodes you have experienced means that it could be recrudescence (where treatment does not completely kill all the malaria parasites in your blood), relapse (where the malaria goes dormant in your liver, then comes back—this is only caused by Plasmodium vivax and Plasmodium ovale malaria) or even re-infection.

However, first of all, the most important thing is to make sure you are properly diagnosed with malaria and secondly, that you receive the right type of treatment for the kind of malaria that you have.

The symptoms of malaria are very general (fever, chills, nausea, tiredness, aches) and can also be caused by many other illnesses and diseases. As such, in order to confirm you actually have malaria, you should have a blood test (thick and thin blood smear, looked at under the microscope by a trained technician, or a rapid diagnostic test (RDT). In some places you can buy these RDTs from local pharmacies and do the test yourself at home).

Depending on where you live, there may be different types of malaria present; in this case, if you do have malaria, it is important to find out which one you have.

P. falciparum is the most common kind in sub-Saharan Africa and first-line treatment is an artemisinin-based combination therapy, such as Coartem – most areas have P. falciparum that is resistant to chloroquine, so this is not appropriate as treatment, nor are sulfadoxine and pyrimethamine combinations (such as Fansidar).

If you have P. vivax or P. ovale, chloroquine may be used, again depending on where you are and whether resistance is known from your area or not. In addition, you might also talk to your doctor about taking primaquine to prevent future relapse and recurrence of the infection.

Repeated re-infection can be prevented by protecting yourself more thoroughly against getting bitten by an infected mosquito. For example, you should sleep under a long-lasting insecticide treated bednet, screen your windows and doors and wear long-sleeved clothing at night and in the evenings. Indoor residual spraying, which coats your walls with insecticide, can also prevent mosquitoes from persisting inside your home.

Malaria In Africa

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QUESTION

What factors cause Africans to get this disease?

ANSWER

The highest number of malaria cases every year occur in Africa, not because of anything specifically due to the people living there (in fact, they may be better protected against malaria than most—I will come onto this later) but because malaria transmission is very high in many parts of sub-Saharan Africa and sufficient preventative measures are still lacking in some places.

Malaria transmission requires specific environmental criteria, such as sufficient temperature and rainfall. These conditions are met in many countries in Africa, and unlike some other parts of the world, temperatures are suitable year-round for the development of the Anopheles mosquitoes that act as the vector for mosquito, meaning that in some places, transmission can occur throughout the year. In addition, many people do not take appropriate preventative measures against malaria; in some cases, this is due to a lack of means to buy items such as insecticide-treated bednets, and in other cases people have not been educated about the dangers of malaria or how to prevent it, so they do not know what preventative measures they should be undertaking.

Organisations such as the World Health Organisation, the US Agency for International Development, the Global Fund, the Roll Back Malaria consortium and Malaria No More are working to improve both access to preventative measures, such as bednets and indoor residual spraying, while also educating people about the need for prevention and also what to do if they suspect themselves or a family member has malaria. These efforts have already reduced the burden of malaria in Africa; the number of deaths is dropping every year, and they hope to have eliminated deaths from malaria altogether by the year 2015.

I mentioned that Africans may be better protected against malaria naturally—scientists have noted that populations living in areas with high levels of malaria have some genetic protection against infection. One example of this is the Duffy antigen. People who are negative for this gene seem to be protected against Plasmodium vivax and P. knowlesi malaria (it was originally thought they were resistant to infection, but more recent evidence from Kenya suggests in fact they still get infected, but do not get as sick). Another is the gene for sickle cell anaemia; despite causing highly debilitating and even lethal anaemia if both copies of the gene are inherited, a single copy of the gene confers strong resistance against malaria. Both of these genetic traits are highly prevalent in African populations.

In addition, early exposure to malaria results in the acquisition of immunity to infection. This, over time, Africans who survive childhood malaria go on to be less susceptible as adults. The exception to this are pregnant women; in order to support the growing foetus, a pregnant women’s immune system becomes much weaker (otherwise there is a risk of the immune system rejecting the foetus). As such, even if she had high levels of acquired immunity to malaria prior to her pregnancy, once pregnant she becomes much more susceptible. This is particularly true for a woman’s first pregnancy.