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…]

Malaria in Vietnam, Thailand, Bali

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QUESTION:

I am 5 months pregnant and I was thinking about going on holiday to Vietnam, Thailand, or Bali. What is the risk of malaria in this countries?

 

RESPONSE:

Malaria transmission occurs in all of the nations you mention, though certain areas within these nations are lower risk.

You can find out more about specific regions and local antimalarial resistance patterns at the CDC website.

You should certainly consult your prenatal doctor to discuss the variety of potential risks, in addition to malaria, associated with international travel in the developing world as you enter the third trimester of pregnancy. Malaria infection in pregnant women can be more severe than in nonpregnant women and can increase the risk for adverse pregnancy outcomes. For these reasons, and because no chemoprophylactic regimen is completely effective, women who are pregnant are usually advised to avoid travel to areas with malaria transmission if possible. If travel to a malarious area cannot be deferred, chemoprophylaxis is essential. Chloroquine containing medications are have not been found to have harmful effects on the fetus. For pregnant women travelling to areas where chloroquine resistance is present, mefloquine is usually recommended.

 

 

Malaria Fever and Recovery

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QUESTION

My 21 year old daughter spent 4 months on a study abroad program in Dakar. A week before returning home she started having night fevers and would complain of retrosternal pain and rib and neck and shoulder pain. The next day she would be fine.

The episodes came every other day and eventually it occurred to her that it might be malaria. It was evening so she went to a pharmacy for a rapid diagnostic test which they didn’t have but they felt she had malaria based on her symptoms and gave her a 3 day course of artesunate-mefloquine.

She returned to the United States and a day after taking her last dose, she was seen by a physician and tests were done which showed that she had contracted Plasmodium falciparum malaria. Other than the smears, all her lab tests and CXR were normal and there were no abnormal findings on physical exam, in fact she was the picture of health.

We were told that she was cured and that no follow up was necessary and that she could continue with her planned trip to Thailand the next day. About 6 hours before boarding the plane to Bangkok she developed fever of 100.9 but had absolutely no other symptoms or pain. About an hour later she had a bout of diarrhea. She had one more low grade fever on the flight (99.8). I spoke to another physician who seems more familiar with malaria and was told that she is not actually cured and may continue to have episodic fevers and symptoms for a while or it’s possible she was just suffering from an ordinary garden variety gastrointestinal bug.

I have many questions. I understand that her malaria is the most virulent type. How is it that all her lab work and physical exam is normal 1 day after completing treatment? Can we expect it to remain normal? What causes the episodic fevers if she is supposedly cured? She is on doxycycline again prophylactically (which she was on in Senegal) while in Thailand. Should she be on something else since she did contract malaria on doxycycline? (She took it religiously). Thanks for any advice. She will be seeing a physician in Bangkok ASAP, but since I won’t be there to ask questions, I am hoping you can give me some answers. Your site is the best information I have found on malaria.

ANSWER

Many thanks for the comprehensive information you have provided regarding your daughter’s condition. Even though your daughter did have the most virulent form of malaria, she was very smart to seek treatment relatively promptly, and lucky to receive appropriate medication (artemisinin-based combination therapies, such as artesunate-mefloquine, are recommended by the World Health Organization as first-line treatment against malaria). It is likely due to this prompt and effective action that her lab tests and blood parameters were all normal so soon after treatment; had she waited longer for treatment, the consequences could have been much more severe. No resistance to this medication has been detected in Africa as of yet, so she should be fully cured and thus her health should remain stable; a blood smear, where her blood is examined under a microscope, can determine this; this is a very standard procedure so could easily be carried out in Thailand if she wants.

Fever is a side effect of the body’s immune system responding to a disease threat, so it is not uncommon for some symptoms to carry on after treatment. In addition, mild side effects of anti-malarial medication can often mimic the symptoms of malaria itself, including fever and nausea.

Given also the (entirely reasonable) possibility of an additional, unrelated stomach bug, I suspect that your daughter has successfully beaten off this malaria attack, and while she should remain vigilant if similar symptoms arise again, her health in the future should not be adversely affected at all by this episode.

Also, as mentioned briefly above, medical professionals in Thailand should be well equipped to diagnose and treat malaria if she suspects she has been reinfected. It is worth noting that malaria in south-east Asia has shown signs of resistance to mefloquine (as well as other drugs, such as chloroquine and sulfadoxine-pyrimethamine), so if she does require treatment while there, she should make sure the medication they provide does not contain any of the afore-mentioned compounds.

Regarding doxycycline, it’s great that your daughter took it religiously—that is certainly the first step towards protection. Randomized placebo controlled trials have shown it is between 92-96% effective in preventing P. falciparum malaria, which is very good, but obviously not 100% perfect – even when taken perfectly, some infections do occur. In addition, there is some data which suggests that dairy products, taken together with doxycycline, may limit  the uptake of the drug. This is rarely communicated to patients, who are instead contrarily told sometimes that taking the pills together with dairy products can reduce side effects! As such, please let your daughter know that she should avoid dairy products for 2-3 hours around the time she takes her doxycycline.

Am I more susceptible to malaria?

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QUESTION

I contracted common malaria, vivax?, when i was 20 yrs old from long visit to Papua NewGuinea, 1970. Returned to USA and was treated with chloro, primaquine drugs and really no problems since treatment.

Now going to Thailand for week, Chiang Mai and region. If bitten by local malarial mosq. am i more likely to recur? And should I certainly choose prophylaxis? thnx

ANSWER

If you were treated successfully with chloroquine and primaquine then there is no reason for your malaria to reoccur. Since it has been a long time since you had malaria, you probably also don’t have any antibodies against the parasite in your system anymore; this just means you don’t have any extra immunity against P. vivax (which you might have done if you had returned to a malaria area, and particularly one with the same strain of P. vivax as that which infected you, within a few months or years of being infected the first time), but it doesn’t mean you will be any more susceptible than someone who never had malaria.

In terms of where you are going, the city of Chiang Mai itself is not considered to have malaria transmission, but the areas surrounding it are, particularly as you get closer to the Burmese border. As such, if you will be travelling in rural and/or forested areas, you might want to consider taking prophylactic medication (and other preventative measures, like sleeping under a long-lasting insecticide treated bednet).

Thailand unfortunately has seen the emergence of resistance to a couple widely used prophylactic measures, namely chloroquine and mefloquine (sold as Lariam), so these are not appropriate preventative medicine in this region. Instead, you should consider taking doxycycline or atovaquone-proguanil (sold as Malarone).

New Partners Join the Asia Pacific Malaria Elimination Network (APMEN)

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The Asia Pacific Malaria Elimination Network (APMEN) has announced two new Partner Institutions have joined the organization: The Mahidol Vivax Research Center and the Malaria Research Centre, Universiti Malaysia Sarawak.

The Mahidol Vivax Research Center (MVRC) established in March 2011 is dedicated to the study of Plasmodium vivax and non falciparum malaria. Its establishment at Mahidol University in Thailand is important to the region, as Mahidol has a long record in the field of tropical disease medicine and research. Mahidol Vivax Research Center was initiated by the Dean of the Faculty of Tropical Medicine, Mahidol University, Associate Professor Pratap Singhasivanon and is directed by Dr. Jetsumon Prachumsri, formerly the leader of malaria research at the Armed Forces Research Institutes of Medical Sciences (AFRIMS) and APMEN Partner Institution representative.

The Malaria Research Centre was established at the Universiti Malaysia Sarawak in 2006 in recognition of the major contribution to malaria research by Professor Balbir Singh, Professor Janet Cox-Singh, and co-researchers at the Malaria Research Laboratory in the Faculty of Medicine and Health Sciences. MRC-UNIMAS is known for its work on Plasmodium knowlesi that was recognised by the World Health Organization (WHO) in 2008 as the fifth species of Plasmodia parasite to infect humans in the wild.

MRC-UNIMAS found that many malaria infections in Sarawak, Malaysia, had been incorrectly diagnosed and a major cause of malaria was Plasmodium knowlesi that is transmitted via the bit of an Anopheline mosquito from long-tail and pig-tail macaques. P knowlesi has also been reported in other parts of Malaysia, Indonesia, and Philippines and may be endemic in more countries in Southeast Asia. The final elimination of malaria in the Asia Pacific region will depend on a greater understanding of P knowlesi and how we can target this zoonosis.

The Malaria Research Centre, Universiti Malaysia Sarawak and the Mahidol Vivax Research Center have already supported APMEN through their active participation at last year’s annual meeting in Kota Kinabalu, Malaysia.

The fourth annual APMEN Annual Meeting will be held in May 2012 in Seoul, Republic of Korea. This year’s meeting will focus on how to sustain the gains made in the elimination of malaria and the importance in the coming years of maintaining successful approaches and their support. The region has many challenges to face in malaria elimination, in particular P. vivax, a type of malaria that is more difficult to diagnose and treat than P falciparum, the type of malaria most often discussed at a global level. APMEN through its information exchange, capacity building, and evidence building and advocacy activities is committed to supporting and maintaining elimination efforts in the Asia Pacific Region.

About the Asia Pacific Malaria Elimination Network
The Asia Pacific Malaria Elimination Network (APMEN) was established in 2009 to bring attention and support to the under-appreciated and little-known work of malaria elimination in Asia Pacific, with a particular focus on Plasmodium vivax.

APMEN is composed of 12 Asia Pacific countries (Bhutan, Cambodia, China, Democratic People’s Republic of Korea, Indonesia, Malaysia, Philippines, Republic of Korea, the Solomon Islands, Sri Lanka, Thailand, and Vanuatu) that are pursuing malaria elimination, as well as leaders and experts from key multilateral and academic agencies. The mission of this diverse but cohesive Network is to collaboratively address the unique challenges of malaria elimination in the region through leadership, advocacy, capacity building, knowledge exchange, and building the evidence base.

Development of the Network took place in 2008 through the leadership of the UCSF Global Health Group (GHG) and the School of Population Health, University of Queensland (SPH/UQ). APMEN collaborates closely with the WHO and is supported by the Australian Government through its international aid agency AusAID with a commitment of nearly $7 million for ongoing support to the Network. This complements Australia’s overall support for malaria control and elimination in the Asia Pacific and globally.

Source: Asia Pacific Malaria Elimination Network (APMEN)

Malaria in Thailand: Phrae and Nan

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QUESTION

We are traveling in Phrae and Nan (in Thailand) in the period of December-Januar. Is there any risk for malaria. We are travelling with kids (9 months, 6 and 8 year) and want to avoid risky areas. Can we travel safely in that region? Thank you for your reply.

ANSWER

Thanks for your question. Phrae and Nan are two districts in northern Thailand—the latter shares a border with Laos. While most of the very touristy destinations in Thailand (i.e. Bangkok and the coastal regions) are considered to have very low levels of malaria, and perhaps no transmission at all, I’m afraid that the areas bordering Laos, Myanmar and Cambodia do have malaria and so if you visit, you should take appropriate preventative precautions.

It is worth noting that some parts of Thailand are known to have mefloquine (sold as Lariam) and chloroquine resistant strains of malaria, although I have just looked it up and it doesn’t appear that Phrae and Nan are within these regions. However, it would still be worth seeing a physician or visiting a travel clinic to get specific advice for your family, and particularly what anti-malarials are appropriate for your children—a lot of that will depend on personal preference, such as how frequently you are comfortable taking medication and also how much you are prepared to spend.

Some, such as Lariam, are also frequently associated with side effects, which may affect your decision. If you do take anti-malarials on your trip, please take the Malaria Medication Side-effects Survey: Treatment and Prophylaxis. We are trying to collect information from travellers to record people’s experiences with the different types available.

In addition to preventative anti-malaria medication (known as prophylaxis), there are other preventative measures you can take, such as sleeping under a long-lasting insecticide-treated bednet, wearing long-sleeved clothing (especially in the evenings and at night when malarial mosquitoes tend to bite) and using insect-repellent on any exposed skin. You can also spray clothing with permethrin, a chemical which repels insects and prevents them from biting through thin cloth.

Malaria in Thailand

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QUESTION:

I am going to Thailand. Do I need to take Malaria medication there?

ANSWER:

Like many other countries, that depends on where in Thailand you are planning to go. The country on the whole has been successful in containing malaria, mostly through successful mosquito control initiatives and a great initiative of government-sponsored “malaria clinics”  dotted around the country, which diagnosed and treated thousands of people.

Now, malaria is more or less constrained to the border regions with Myanmar, Laos and Cambodia, and if you plan to travel to these areas, prophylaxis is recommended (malarone or doxycycline are best since the area has chloroquine-resistant strains of Plasmodium falciparum, the most quick-acting and dangerous form of malaria). There are a few cases of malaria from coastal areas every year, but bite prevention is probably sufficient to reduce the risk of infection – make sure to wear insect repellant, especially at night and dusk/dawn, and if possible sleep under an insecticide-treated bednet.

Finally, remember if you do take prophylaxis, and as per the manufacturer’s instructions, there is only a tiny risk of contracting malaria. But if you do find yourself with symptoms when you get back (see the ‘What are the symptoms of malaria?’ question in this Q&A forum for a description of the more common signs of malarial infection), it’s definitely worth getting checked out!

Of Macaques and Men

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Plasmodium knowlesi —a new challenge in the Roll Back Malaria Program?

Deforestation oil palm Malaysia

Oil palm plantation in Malaysia: Such land-use change may be affecting malaria transmission. Photo courtesy of Yusmar Yahaya (http://www.flickr.com/photos/leafbug/4880638055/sizes/m/)

Mention of malaria often conjures images of infants hospitalized in Africa. Although most deaths from malaria are children under 5 in sub-Saharan Africa, there are many different types of malaria that put over half of the world’s population at risk in subtropical and tropical regions worldwide.

There have historically been four species of Plasmodium parasites that cause malaria humans.  P. falciparum is the most lethal species that infects humans, whereas P. vivax is the most widespread.  P. vivax and P. ovale also cause clinical symptoms and decreased economic potential in certain regions.

[Read more…]

Lariam Legacy

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In 1990, Lariam (mefloquine) became the drug of choice for malaria prevention.  It was endorsed by the Centers for Disease Control (CDC) and prescribed for travelers, government workers, and the U.S. military who were going to regions where malaria was present. It was even given to airline crews who flew to malaria regions.

Mefloquine has been responsible for psychotic breakdowns, suicides and a host of other side effects.  Many people taking it stopped on their own because they were able to realize it was the drug that was causing the problems.

Here is a vignette of my experience with the drug after it was first released in 1990.

I was in charge of the health unit for a film being made in northern Thailand.  I was aware that there was chloroquine resistant malaria in that region.  I contacted the CDC and talked to the head of the Malaria Prevention Department. He told me that the drug of choice was Lariam. I was unable to obtain it in the USA but was able to get a supply in Europe.

I wrote a letter to the crew instructing them to take the drug while in Thailand. I  think now it was fortunate that many stopped taking the drug because they recognized it was causing “ weird” feelings. I myself took the drug and noticed no effects from it.  However about 3 weeks into the “shoot” a camera-crane operator went suddenly berserk.  It took 5 people to hold him down and get him to the hospital, where eventually enough valium calmed him down. He was however still paranoid and irrational, and had to be evacuated back to England.

I had, at the time, no idea what the cause was for his breakdown.  It wasn’t until two years later when reports started appearing about the drug’s side effects that I realized what the cause was.  I shuddered to think about some of the airline pilots and U.S. military who were being given the drug.

I would be interested to hear if anyone has had personal experiences, or friends who have experienced side-effects from the drug.

Soil-Transmitted Helminths and Malaria in Pregnant Women on the Thai-Burmese Border

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Background: Deworming is recommended by the WHO in girls and pregnant and lactating women to reduce anaemia in areas where hookworm and anaemia are common. There is conflicting evidence on the harm and the benefits of intestinal geohelminth infections on the incidence and severity of malaria, and consequently on the risks and benefits of deworming in malaria affected populations. We examined the association between geohelminths and malaria in pregnancy on the Thai-Burmese border.

Methodology: Routine antenatal care (ANC) included active detection of malaria (weekly blood smear) and anaemia (second weekly haematocrit) and systematic reporting of birth outcomes. In 1996 stool samples were collected in cross sectional surveys from women attending the ANCs. This was repeated in 2007 when malaria incidence had reduced considerably. The relationship between geohelminth infection and the progress and outcome of pregnancy was assessed.

Principal Findings: Stool sample examination (339 in 1996, 490 in 2007) detected a high prevalence of geohelminths 70% (578/829), including hookworm (42.8% (355)), A. lumbricoides (34.4% (285)) and T.trichuria (31.4% (250)) alone or in combination. A lower proportion of women (829) had mild (21.8% (181)) or severe (0.2% (2)) anaemia, or malaria 22.4% (186) (P.vivax monoinfection 53.3% (101/186)). A. lumbricoides infection was associated with a significantly decreased risk of malaria (any species) (AOR: 0.43, 95% CI: 0.23–0.84) and P.vivax malaria (AOR: 0.29, 95% CI: 0.11–0.79) whereas hookworm infection was associated with an increased risk of malaria (any species) (AOR: 1.66, 95% CI: 1.06–2.60) and anaemia (AOR: 2.41, 95% CI: 1.18–4.93). Hookworm was also associated with low birth weight (AOR: 1.81, 95% CI: 1.02–3.23).

Conclusions / Significance: A. lumbricoides and hookworm appear to have contrary associations with malaria in pregnancy.

Author Summary: Intestinal worms, particularly hookworm and whipworm, can cause anaemia, which is harmful for pregnant women. The WHO recommends deworming in pregnancy in areas where hookworm infections are frequent. Some studies indicate that coinfection with worms and malaria adversely affects pregnancy whereas other studies have shown that coinfection with worms might reduce the severity of malaria. On the Thai-Burmese border malaria in pregnancy has been an important cause of maternal death. We examined the relationship between intestinal helminth infections in pregnant women and their malaria risk in our antenatal care units. In total 70% of pregnant women had worm infections, mostly hookworm, but also roundworm and whipworm; hookworm was associated with mild anaemia although ova counts were not high. Women infected with hookworm had more malaria and their babies had a lower birth weight than women without hookworm. In contrast women with roundworm infections had the lowest rates of malaria in pregnancy. Deworming eliminates all worms. In this area it is unclear whether mass deworming would be beneficial.

Citation: Boel M, Carrara VI, Rijken M, Proux S, Nacher M, et al. (2010) Complex Interactions between Soil-Transmitted Helminths and Malaria in Pregnant Women on the Thai-Burmese Border. PLoS Negl Trop Dis 4(11): e887. doi:10.1371/journal.pntd.0000887

Editor: Simon Brooker, London School of Hygiene & Tropical Medicine, United Kingdom

Copyright: © 2010 Boel et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: This study was part of the Wellcome Trust Mahidol University Oxford Tropical Medicine Research Programme funded by the Wellcome Trust of Great Britain. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

More information: Full text: Complex Interactions between Soil-Transmitted Helminths and Malaria in Pregnant Women on the Thai-Burmese Border (PDF)