Malaria: Should I See a Doctor?

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QUESTION

For the last couple of days I am suffering from all the symptoms that are mentioned on your website and I am taking tylenol for these symptoms thinking that it is flu but I am feeling better now. Should I still see a doctor or keep taking Tylenol?

ANSWER

Symptoms of malaria often include high fever, aches, chills, nausea, and headache.  When severe, malaria can lead to anemia, impaired consciousness and even coma or death.  The best course of action is to get a simple blood test to check if you have malaria, because if you do have it,  early treatment with the appropriate drug (for the type of malaria you have), is essential.

You should also know how to prevent getting 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.

Malaria Prophylaxis for Indonesia

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QUESTION

I have been working a 4-week rotation between the USA and East Kalimantan (Borneo) for about 2 years. While on Borneo, I am in the jungle much of the time. I have never contracted malaria. I am embarrassed to say I thought I had been inoculated for malaria when I first started working here. I just spent 10 days in a hospital last month fighting a blood degenerating viral infection not unlike hemophiliac dengue. Is there a preferred Rx I should take for malaria? I have no allergies to medicines that I am aware of. I am 57 year-old male.

ANSWER

Given the amount of time you spend in rural areas of Borneo, you probably should consider anti-malarial medication to prevent infection. There are three types of drug which are recommended against malaria in Indonesia: atovaquone-proguanil (sold as Malarone), mefloquine (sold as Lariam) and doxycycline. Each has pros and cons: Malarone and doxy have to be taken every day, while Lariam is only taken weekly, which might make it more convenient. However, both doxy and Lariam should be taken for a full 4 weeks after leaving the malarial area, while Malarone is only taken for a week after leaving.

In my opinion, Malarone has the fewest and mildest side effects (though some people complain of upset stomachs and disturbed sleep patterns), while doxycycline is sometimes a problem in the tropics since it can cause sun sensitivity. Lariam is not recommended for people with a history of mental illness, and has been reported to have psychiatric side effects, including nightmares, hallucinations and even altered behavior. Of the three, Malarone is the most expensive, and doxycycline usually the cheapest.

In terms of taking them long term, I don’t know of any studies that look at long term usage of Malarone (it is expensive enough that I doubt anyone takes it for very long trips!), while people do safely take doxycycline for periods of several months, and Peace Corps volunteers and American expats routinely take Lariam for periods of several years.

Of course, many people living long term in malarial areas do not find it convenient to take pills to prevent malaria, and focus on other preventative measures, mainly revolving around killing mosquitoes and avoiding being bitten. Sleeping under a long-lasting insecticide treated bednet is one such method, which is cheap, easy and very effective.

Incidentally, the area you are in is interesting from a malaria point of view since it is one of the few places where transmission of Plasmodium knowlesi occurs. This is a type of malaria which was thought to be only present in macaque monkeys, until human cases started becoming more prevalent a few years ago. Now it is considered a “human” type of malaria, and an emerging threat in south-east Asia. It’s important to be aware of it as the mosquitoes which transmit it tend to be forest-dwelling (since that is where the macaques live), and although very easily treated with chloroquine or other anti-malarials, an infection can progress rapidly into quite severe disease.

If you suspect you might have malaria at any point, therefore, it is crucial to get out and get tested at a clinic or hospital, where they can promptly treat you if you test positive. Be aware also that if tested via microscopy, P. knowlesi can often be confused with P. malariae or P. vivax; while the initial treatment is likely to be the same for all three, if you had P. vivax you might be told about taking an additional medication, called primaquine, to prevent future relapses, whereas relapses do not occur with P. knowlesi.

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.

Malaria Treatment and Prevention Methods

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QUESTION

I work in Central Africa republic.I was recently diagnosed with malaria (p.falciparum) after a blood test—my 4th attack in 15 months and given Co-Arinate. Two days after completing my dose I went for a 2nd blood test and the trophozoite count was 720/mm3.

The doctor prescribed co-artem and said if I don’t get better he shall transfuse quinine. Whats your comment on the treatment? Do these malaria medications/attacks have a long term effect on ones liver? What prophylaxis should I consider to prevent future attacks.

ANSWER

I will forward your question on to one of the medical professional who advises our website. However, normal procedure after treatment failure or incomplete treatment with one type of anti-malarial medication would be to try another type of medication first; Co-Arinate might not have been an ideal first choice given that many types of malaria around the world are showing signs of resistance to pyrimethamine, the combination drug in Co-Arinate.

Co-Artem would be a better first choice drug, given that there is no convincing evidence for resistance to its combination compound, lumefantrine. Quinine could be a potential next step though I would imagine Co-Artem will be successful—make sure the drugs have not expired and are in their original packaging, as counterfeit medication is a problem in many parts of the world.

Regarding prevention, a key method is to sleep under a long-lasting insecticide treated bednet; make sure it is re-dipped in insecticide every year or so to maintain its efficacy. The mosquitoes which transmit malaria tend to feed at night, and so protecting yourself and your home during the evening, night and early morning is crucial. Maintaining good screens on all windows and doors can be a very effective way of preventing mosquitoes from entering, and in many parts of the world, people spray inside with insecticides to reduce the number of mosquitoes yet further. Wearing long-sleeved clothing at night and in the evenings can also prevent bites.

More broadly speaking, you can try to make sure that stagnant water sources, such as empty containers or barrels, are removed, as mosquitoes require still water to breed. Reducing the presence of stagnant water will therefore reduce mosquito numbers; treating standing water with larvacides or adding fish that eat mosquito larvae can also help.

Malaria in Myanmar (Burma)

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QUESTION

Is Malaria an issue in Myanmar where I am going in June?

ANSWER from Malaria.com Editor

YES. Malaria is a risk in all rural areas of the country below 1,000 meters of altitude (anything below 3300 feet). Rangoon/Yangon and Mandalay do not have malaria.

You should take medication to prevent malaria (prophylaxis) throughout your stay, and also protect yourself from getting bitten by mosquitoes if you are travelling to risk areas for malaria. Personal protection measures including sleeping under an insecticide treated bednet, wearing insect repellent and wearing long-sleeved clothing, especially in the evenings, early morning and throughout the night, which is when the mosquitoes that transmit malaria are active and feeding.

Myanmar/Burma is known to have strains of malaria which are resistant to certain medications; specifically, chloroquine resistance is widespread, while some areas in addition have malaria which is resistant to mefloquine (sold as Lariam). As such, the CDC recommends atovaquone-proguanil (sold as Malarone) or doxycycline if you will be travelling in the provinces of Bago, Kachin, Kayah, Kayin, Shan, and Tanintharyi. In all other areas of the country, mefloquine should also be considered as an option.

Answer from Malaria.com medical advisor

For anyone planning a trip abroad its important to know the health risks in your destination. Malaria is an especially important concern for anyone traveling to tropical or subtropical regions. Here’s what I found on the CDC Travelers’ Health website. I find this is the best place to look for this information.

  • Areas of Burma with Malaria: Rural areas throughout the country at altitudes
  • If you will be visiting an area of Burma with malaria, you will need to discuss with your doctor the best ways for you to avoid getting sick with malaria. Ways to prevent malaria include the following:
  • Taking a prescription antimalarial drug.
  • Using insect repellent and wearing long pants and sleeves to prevent mosquito bites. Sleeping in air-conditioned or well-screened rooms or using bednets.
  • Some areas of Burma have resistance to certain antimalarial drugs.

See the malaria information for Burma to find out which antimalarial drug is appropriate for the area you plan to visit in Burma.

Malaria Socio-Economic Issues

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QUESTION

What are the socio-economic issues on the spread of malaria?

ANSWER

Malaria transmission requires the presence of Anopheles mosquitoes; as such, conditions which favor the growth and persistence of these mosquitoes will also be hotspots for malaria transmission, provided the climate is also sufficiently warm for the development of the parasite within the mosquito.

Rural areas without sophisticated water and sanitation systems often utilize streams or ponds for everyday water needs; if these produce stagnant patches of water, they can be an ideal location for the development of mosquito larvae.

Similarly, if rural farmers dig canals or ditches to irrigate their fields, these can become breeding areas. Urban areas tend to have less standing water, apart from cisterns, so in many cases transmission is less prevalent in urbanized locations.

As a further socio-economic factor, preventing mosquitoes from entering the house and biting people is  key way to prevent infection. Rich people in malarial areas may be more able to have fully screened houses, possibly even with air-conditioning, which will prevent mosquitoes from establishing in the house. They may also be more likely to have access to a long-lasting insecticide treated bednet, which further reduces mosquito bites, and also access to accurate diagnostic screening and treatment, if they do happen to get infected.

All of these factors contribute to making malaria burden highest in some of the world’s poorest areas, with the highest levels of mortality in sub-Saharan Africa.

Can’t Get Rid of Malaria

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QUESTION

Each and every month I am suffering from malaria ..Treatment is also going on but I am unable to get rid of it.

ANSWER

It is very unusual to be reinfected so constantly with malaria. First of all, how are you getting diagnosed? You should be getting a blood test, and not relying on symptoms only; the symptoms of malaria are very general and it could be that you are suffering from something else entirely. The two main methods for accurate diagnosis are blood smear and rapid diagnostic test. The blood smear is used throughout the world, but can sometimes miss light infections (though if you feel sick, your infection is likely heavy enough to be detected by this method). The problem is that it requires a trained technician to take the sample, prepare it properly, and read it thoroughly and accurately. In my experience, many clinics, especially if they are rushed and busy, will not take the time to read a blood slide properly, and will just diagnose malaria without looking. This is really bad! It is very important to be properly diagnosed, so you can get the correct treatment, and if you don’t have malaria, you can be diagnosed for something else. The second kind of diagnostic is a rapid diagnostic test, or RDT. This looks for antibodies to malaria in your blood, and is very sensitive and quick. In an ideal world, you should try to have both done, to cross-check the results.

The next thing is to check whether you are receiving the correct treatment for the type of malaria that you have (if you are positively diagnosed with malaria). In many parts of the world, malaria has become resistant to some of the main medications used against it. Notably, this is the case in many places with Plasmodium falciparum, the most dangerous kind of malaria, which has become resistant to chloroquine in many parts of the world, to sulfadoxine-pyrimethamine (sold as Fansidar in many places) and also to mefloquine (sold as Lariam) in some places. As such, the World Health Organisation NEVER recommends these treatments be given as first line drugs against P. falciparum malaria – instead, they recommend artemisinin-combination therapies (ACTs), such as Alu, Coartem or Duo-Cotecxin. If you have been diagnosed with P. falciparum, you must try to take these kinds of drugs first. No resistance to ACTs has been reported, so if you take the full dose correctly, as prescribed by your doctor (and check to make sure the drugs are not expired), then you should be cured of malaria.

However, treatment does not stop you from getting infected again, and this is where prevention comes it. Preventing malaria is a cornerstone of control efforts. Since malaria is transmitted by a mosquito, preventing mosquitoes from entering the house, and particularly stopping them from biting you at night, is crucial. Screening all doors and windows can help stop mosquitoes from getting in, and in high transmission areas, many people will also spray inside their houses every once in a while with insecticides to kill any lingering insects. In addition, sleeping under a long-lasting insecticide treated bednet can drastically reduce the number of mosquitoes that are able to bite you at night. If you already have a net, it may be worth re-dipping it in insecticide (usually permethrin) to make sure it is still working effectively. The mosquitoes that transmit malaria feed at night, so if you are walking around outside in the evenings or at night, it is important to try to wear long-sleeved clothing, to prevent them from accessing your skin. All of these efforts will help prevent you from getting malaria again in the future.

Other Causes of Malaria

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QUESTION

Apart from mosquitoe bites, is there any other thing that can cause malaria or if not from mosquitoes, is there any other way someone can get malaria?

ANSWER

Since the malaria parasites reside and reproduce in the blood, in some cases it is possible to transmit malaria from person to person through transfer of a large volume of blood, for example during a blood transfusion.

Some life stages of the parasite are also present in the liver, so cases of malaria transmission via organ donation (particularly of the liver) have also been noted. Finally, it is possible for a mother to transmit malaria to her unborn child via the placenta, or sometimes during childbirth, via the blood. The observation of malaria in newborn babies, who have not been bitten by mosquitoes, is known as congenital malaria. Despite the above possibilities, the vast majority of malaria transmission occurs via the bite of infected mosquitoes, so it is very important to protect yourself from these insects when in malarial areas.

Vaccine for Malaria

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QUESTION

Is there a vaccine to prevent malaria?

ANSWER

No, there is not currently a vaccine available to prevent malaria. The best current candidate, the RTS,S vaccine which was developed by GlaxoSmithKline, is currently undergoing Phase III clinical trials in Africa. Although preliminary results showed up to a 50% rate of protection against malaria in some age groups, the trials will not conclude until 2014 and so full results will not be known until after that date.

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.