Malaria or Kidney Infection?

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QUESTION

Two months ago my daughter was in Uganda working and when came back to the States she was hospitalized for 4 days with Malaria symptoms. Her tests came back negative they really didn’t act like they knew how to treat this. They kept telling her they didn’t know how to diagnosis Malaria. So they treated her for it. She now after 2 months is once again hospitalized with the same symptoms. They are telling her they think it is a kidney infection. Can malaria be misdiagnosed as a kidney infection. She once again has all the symptoms as malaria?

ANSWER

What tests did the doctors do to try to diagnose malaria in your daughter when she first got back to the States? Usually, malaria is diagnosed by a blood test, whereby a trained technician will look at the patient’s blood under a microscope. The technician looks for signs of the malaria parasite in the patient’s blood, and if seen, can determine the intensity of the infection as well as the species of malaria. This is important information for accurate treatment. Alternatively, rapid diagnostic tests, which utilize a droplet of blood in a device which looks similar to a pregnancy test, and can very quickly determine whether someone is infected with malaria. It is important to know that malaria cannot be diagnosed by looking at standard blood parameters. If you don’t think your doctors know what is afflicting your daughter, you should take her to a clinic which specializes in tropical or travel medicine. There, they will certainly know how to effectively diagnose your daughter.

Given that your daughter experienced a resurgence of symptoms two months after returning, if she did have malaria, then there are two kinds which she might have: Plasmodium ovale and Plasmodium vivax. The other types of malaria, including the most deadly kind, P. falciparum, are not able to come back and relapse once they are treated. However, in order to prevent future relapses, your daughter may also have to be treated with another form of medication called primaquine. I will emphasize again, however, that it is crucial to gain an accurate diagnosis before taking any form of treatment for malaria.

What does the goverment do to help malaria?

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QUESTION

Does the goverment help malaria?

ANSWER

Many governments around the world assist in controlling malaria. Some countries, like Australia and the United States, used to have malaria transmission occur within their own borders, but through dedicated control programs, have managed to eradicate the disease locally. In these cases, the government coordinated huge programs of draining standing water, spraying insecticides and ensuring that health clinics were equipped to diagnose and quickly treat any human cases.

Nowadays, the governments of the US and Australia, along with many other countries which do not have malaria, still assist in the fight against malaria by funding malaria control programs in other countries, either directly (for example, the US funds international health projects through the US Agency for International Development) or indirectly, through international organisations like the World Health Organisation and the Global Fund for HIV, TB and Malaria. They also provide training in technical expertise to scientists, doctors and clinicians from malaria-endemic countries.

The governments of countries which have malaria are also deeply engaged in fighting the disease, mostly through their respective Ministries of Health, which often have specific malaria departments. In India, for example, malaria control is carried out by the National Vector Borne Disease Control Programme (NVBDCP), which is part of the Directorate General of Health Services. The NVBDCP carries out a multi-pronged strategy to combat malaria, including early case detection and treatment, vector control (with spraying, biological control and personal protection), community participation, etc. In Uganda, the Malaria Control Programme also carries out the above activities, and also provides intermittent preventative treatment against malaria for young children and pregnant women and has in the past engaged in large-scale distribution of long-lasting insecticide treated bednets. Both countries also explicitly include monitoring and evaluation as part of their control strategies, to make sure that any interventions or control efforts they make are having a positive impact on reducing malaria morbidity and mortality.

Malaria Deaths by Country

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QUESTION

Where are the most deaths of malaria?

ANSWER

Over 90% of the deaths from malaria occur in sub-Saharan Africa, and in children under the age of five. According to the World Health Organisation’s 2011 World Malaria Report, the countries with the five highest numbers of reported malaria deaths for 2010 are (and number of reported deaths): Kenya (26,017 deaths), Democratic Republic of Congo (23,476), Tanzania (15,867), Burkina Faso (9,024) and Uganda (8,431).

However, it is important to note that this indicates the number of reported deaths that were confirmed as malaria; there are other countries in Africa which may have similar levels of malaria mortality but insufficient health infrastructure for accurate diagnosis of cause of death or reporting. Even in countries where reporting levels are high, causes of death are not always accurately determined.

HIV Antiretrovirals May Help Fight Malaria

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Bed nets and insecticides form the cornerstone of malaria prevention, with antimalarial drugs being used mainly to treat people who become ill with the disease. The drugs do have some protective effect, but it quickly wanes. Now a study in Uganda suggests that an antiretroviral drug given to HIV-infected children can boost the preventive power of a key malaria drug. [Read more…]

Where There is No Medicine, Let Alone a Doctor

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Remote or poorly accessible communities create special challenges for delivery of health care.

There were goats in my classroom this morning. Quite adorable kids, but unfortunately not the right species for my health survey. The school is located in Bunda District, sandwiched between Lake Victoria and the long western arm of Serengeti National Park, which stops only a few kilometers from the lake’s shoreline.

This zone of the Serengeti, the so-called Western Corridor, is a crucial stop-over point in the famous circular migration of wildebeest, zebra and other animals, following the rains around the vast grasslands. However, its relative remoteness means it doesn’t see quite the same surge of visitors as other parts of the park; still, every day fancy 4x4s and shiny tourist vans pull up to the Ndabaka Gate, full of foreigners paying $50 a day in park fees alone, for the unique experience of seeing Africa’s magnificent wildlife in one of the world’s most awe-inspiring natural landscapes.

goat tanzania

A kid goat sitting under a desk in a primary school in Tanzania. Photo: CJ Standley

There is little indication here in the village of the vast turnover of foreign currency occurring just a few kilometers to the east. The proximity to Lake Victoria, with its bounty of fish and permanent water supply, allowing year-round irrigation of crops, ensures that few children in this area are severely undernourished.

However, the lake is also a source of disease. The reedy fringes are the perfect habitat for certain species of freshwater snail, which transmit intestinal schistosomiasis; stagnant pools are also ideal nursery grounds for mosquito larvae.

Sanitation infrastructure is basic at best, with some houses possessing a pit latrine in a corner of the compound but many families simply doing their business in the tall papyrus groves right on the lakeshore. Most water for cooking, drinking and washing is collected directly from the lake, usually by children, and once their chores are done they play barefoot in the muddy alleys between huts: shoes are only worn for special occasions, sometimes not even for school. As a result, prevalence of schistosomiasis is high, malaria is an everyday burden and transmission of hookworm is rife.

What health care options exist for this community? The closest doctors are probably at the district hospital in Bunda, about a 20 minute drive north along the fast, tarmac road running between Mwanza and Musoma. However, to get to the main road, the villagers have to negotiate several kilometers of dirt track, rough and pitted, its ruts filled deep with water and mud during the rains. Closer by, there are shops which may stock basic medical items, such a few tablets of paracetemol or other generic painkillers, but sourcing malaria treatment requires again a trip to Bunda, or Lamadi, a town almost equidistant to the south.

The village does have a community health worker, but without funds or drugs, or indeed robust training, the help he can offer is limited. Tanzania has been trying to implement a national programme for the control of basic intestinal worms, and so about once a year, a team may sail through and distribute albendazole to all the children who happen to be attending school that day. Given that absenteeism rates run high, this is hardly providing blanket coverage. Moreover, the source of infection is not addressed; with high rates of transmission, re-infection is almost inevitable. What solutions can there be for remote, rural villages like this?

Kimi Island aerial Stothard

An aerial picture of Kimi Island in Lake Victoria, Uganda. Itinerant fishing communities can be seen at both ends of the island. Photo: JR Stothard

Perhaps some lessons can be learnt from Uganda. The Lake Victoria shoreline there consists of thousands of islands, each with one or more fishing shanty-towns, solely accessible by boat. Access difficulties here are even greater than in Tanzania, yet progress is being made. The Ugandan National Control Programme for Neglected Tropical Diseases has combined interventions for soil-transmitted helminthes (like hookworm) and schistosomiasis, training community medicine distributors in every possible village in the methods for administering treatment for both conditions. At the same time, educational workshops have been held to educate communities as to how to reduce transmission.

Over the last 8 years the programme has successfully reduced the burden of infection in many places, and the programme has expanded to include treatment for other neglected tropical diseases, such as lymphatic filariasis.

Yet, challenges remain. For example, as we see in Tanzania, rates of malaria prevalence are also high in Uganda, yet are not directly tackled by the neglected tropical disease teams; other branches of the Ministry of Health are responsible for the distribution of bednets and Coartem. However, the basic health infrastructure required is the same: mobilization of drugs/equipment, training of health personnel at the village level and education for the community themselves in order to change behaviours that may result in greater infection risk.

Last year I was lucky enough to participate in surveys of island communities in the Sesse Islands, as part of a much wider monitoring effort (funded by the Global Network of Neglected Tropical Diseases). Across the board, we observed villages where increased efficiency of health service delivery could make a huge difference.

Nyatwali children

The children who participated in our health survey, at their primary school in Tanzania. Photo: CJ Standley

It’s not hard for me to see parallels with my study village near the Serengeti. There are existing initiatives to de-worm school-age children; there is a community health worker; there is a basic need for prevention alongside treatment. All that is needed is for efforts to be more coordinated and packaged alongside education about the diseases.

Recognizing this need, the Bunda District Education Office has been incredibly supportive of our inquiries into designing a curriculum to teach the primary school children and their parents in the village about parasites and disease prevention. If all goes to plan, once we hold the workshop, the kids in attendance will be people, not goats!


Post Malaria Symptoms

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QUESTION

My girlfriend had malaria in Uganda. It was detected 2nd of October, it was mild form, she felt dizzy, temperature was little higher. She got Artefan, forth day she was in hospital for review, they told her from blood test that its not malaria anymore.

We came home (Slovakia) but week ago she had suddenly the same symptoms like she had had the first time—dizziness, pain in head, temperature. Rapid test showed her she has no malaria. But she is still feeling weak, once in five days she suddenly feels dizzy, sometimes temperature 37,3 Celsius (yesterday last time). Doctors found nothing. Could it be some post-malaria symptom or she might have some other infection? Is it normal?

ANSWER

Rapid tests for malaria are usually quite accurate, especially if the patient is experiencing symptoms. Moreover, the cycles of malaria infection are usually shorter, with patients experiencing fever and dizziness every other day (for Plasmodium falciparum, which is the most common kind in Uganda). I would recommend trying a second rapid test, preferably of a different brand, just to check—make sure it detects ALL kinds of malaria and not just Plasmodium falciparum, as while it is the most common and dangerous kind, there are other types in Uganda, such as P. ovale, which might not show up on a P. falciparum-only test.

If you have access to a travel clinic or hospital that has experience in tropical diseases, you could also see if they could do a blood slide and check for the presence of malaria parasites in your girlfriend’s red blood cells.

If a second rapid diagnostic test is negative, or there is no sign of visible malaria parasites in her blood, then I suspect she has some other infection, as continued symptoms are not usually a side effect of successful malaria treatment.

Illness from Uganda trip

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QUESTION:

I just came back from a visit to Uganda Africa. I was unable to take Malarone as I had bad side effects. Vomiting. I was only exposed once when we walked into a swampy rain forest. This of-course was the only day I did not have repellent. We were taking the kids on a nature walk and the German volunteer got a little lost. I ran as fast as could out of the area. Started to feel tired and weak 7 days later, getting severe headaches and going from hot to cold. 5 kids ended up with Malaria shortly after our walk. (I found this out after my return).

A missionary on the plain said I must likely had malaria and gave me Lumartem. By the time I got home I was having sever diarrhea and real bad body aches, low grade fever. The doctor here took my blood but reported my results would take 7 days. I started taking the Lumartem, & I felt better, the runs slowed down the boy aches lessened. Now I am finished with my 3 day prescription Feel pretty good compared to how I felt b4. Still have stomach cramps and small runs. What now? Should I go have a blood test to see if its gone or just wait and see???

ANSWER:

Considering you were in Uganda, it is not unlikely that you didn’t also pick up some sort of intestinal bug or parasite, which might be responsible for the residual runs and cramps. However, it is certainly important to take a blood test to ensure that you have completely cured the malaria infection; P. falciparum is common in Uganda, and causes a very severe form of malaria. While it can’t come back directly once it has been cured, if treatment is not entirely successful small numbers can remain in your blood stream and then start reproducing again once you have stopped taking medication, resulting in what is called “recrudescence” of the infection.

If possible, try to find out from the doctor that performs the blood test what type of malaria you had/have, as this will also determine whether you need additional medication (called primaquine) to prevent recurrence or relapse of the infection at a later date. Recurrence is due to a dormant phase of the malaria parasite hiding out in your liver; while P. falciparum cannot produce these dormant phases (and therefore can only relapse if the initial blood infection is not completely cured), two other malaria parasites, called P. vivax and P. ovale, can have liver stages, and so you may need to take primaquine if you are found to have been infected with either of these types.

Médecins Sans Frontières Calls for Switch from Quinine to Artesunate

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After the revision of World Health Organization (WHO) guidelines yesterday,  international medical humanitarian organization Médecins Sans Frontières (Doctors Without Borders) calls for a drug proven to reduce deaths in children suffering from severe malaria to be immediately rolled out in African countries.

In its new report, entitled “Making the Switch,” Médecins Sans Frontières (MSF) calls on African governments to follow new World Health Organization (WHO) guidelines, and switch from the far less effective quinine to artesunate, which could avert nearly 200,000 deaths each year. MSF also calls on WHO and donors to support governments so this urgent treatment change can happen quickly.

“When children arrive at the clinic with severe malaria, they often are having convulsions, vomiting or at risk of going into shock, and you just want to be able to give them effective treatment quickly,” said Veronique De Clerck, Medical Coordinator for MSF in Uganda. “For decades, quinine has been used in severe malaria, but it can be both difficult to use and dangerous, so it’s time to bid it farewell.  With artesunate, we now have a drug that saves more lives from severe malaria, and is safer, easier and more effective than quinine.”

Quinine has to be given three times a day in a slow intravenous drip that takes four hours, a treatment that is burdensome for both patients and health staff. Artesunate, in contrast, can be given in just four minutes, by giving a patient an intravenous or intramuscular injection.

A landmark clinical trial in late 2010 concluded that the use of artesunate to treat children with severe malaria reduces the risk of death by nearly a quarter.  The study, carried out in nine African countries, found that for every 41 children given artesunate over quinine, one extra life was saved.  Because of the complexities of administering quinine, children in the trial who were assigned to receive quinine were almost four times more likely to die before even receiving treatment.

MSF participated in the trial through its research affiliate Epicentre, with a research site in Uganda. MSF has since changed its own treatment protocols and now plans to work with national health authorities to roll out artesunate in its projects over the coming months.

The evidence is overwhelming, but MSF’s report stresses that change will not happen on its own. While WHO has now issued new guidelines recommending artesunate for treating severe malaria in children in Africa, it needs to also develop a plan to help countries make this switch.  African governments must urgently change their treatment protocols and donors must send a clear signal to countries that they will support the additional cost where needed.  Artesunate is three times more expensive, but the difference in cost of US$31 million each year for a global switch is very little for the nearly 200,000 lives that researchers say could be saved.

“We’ve been here before—when WHO changed its treatment recommendations for simple malaria in 2001 it took years for countries to actually make the switch, and shockingly, in some countries the far inferior drugs are still being used ten years on,” said Dr. Martin De Smet, who coordinates MSF’s malaria work.  “With severe malaria, WHO needs to make sure that the change is much less sluggish, so lives can be saved immediately.  There’s simply no excuse not to make the switch now.”

MSF provided malaria treatment to around one million people in 2010.  Severe malaria kills over 600,000 African children under the age of five annually.  Each year, around eight million simple malaria cases progress to severe malaria, where patients show clinical signs of organ damage, which may involve the brain, lungs, kidneys or blood vessels.

More information: Full MSF Report (PDF)

Source: MSF

Malaria Drug Tariff’s Hindering Malaria Relief

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The Malaria Taxes and Tariffs Advocacy Project (M-TAP), a two-year research and advocacy program recently released a report that shows the vast majority of the world’s malaria-endemic countries continue to maintain import tariffs on essential commodities used in the fight against malaria, including bednets, anti-malarial medicines, insecticides used in indoor residual spraying (IRS), IRS pumps, and rapid diagnostic tests.

Just six countries—Guinea, Kenya, Mauritius, Papua New Guinea, Tanzania, and Uganda—have taken action to remove all tariffs on ACs in the decade since the Abuja Declaration identified import tariffs and domestic taxes on ACs as a significant barrier to access. By contrast, 18 malaria-endemic countries currently maintain tariffs on all five AC categories reviewed by M-TAP, and 24 countries maintain tariffs on three or more ACs.

via M-TAP Releases New Tariff Data for 76 Countries.