General Malaria Info

8/13/2019 General Malaria Info

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Malaria Advice for southern

Mozambique, Swaziland and

South Africa

www.malaria.org.za


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PRODUCED BY THE MALARIA

RESEARCH PROGRAMME OF THE

MEDICAL RESEARCH COUNCIL

!!!!MEDICAL RESEARCH COUNCIL, 2001

FOR:THE REGIONAL MALARIA CONTROL COMMISSION

1. MINISTRY OF HEALTH SWAZILAND-SIMON KUNENE2. MINISTRY OF HEALTH MOZAMBIQUEDRAVERTINO BARETTO3. MINISTRY OF HEALTH SOUTHAFRICA-JOATHAM MTHEMBU4. MEDICAL RESEARCH COUNCIL, SOUTHAFRICA-DR BRIAN SHARP

Acknowledgements:

1. The following sources are acknowledged for the figuresused in this booklet:

Malaria - Topics in International Health CD-ROMpublished by the Wellcome Trust.

The Mapping Malaria Risk in Africa (MARA)Collaboration.

The Malaria Research Programme of the MedicalResearch Council

2. Document prepared by Marlies Craig, Brian Sharp and Davidle Sueur of the Medical Research Council, Malaria ResearchProgramme, Durban, with contributions by Lee Baker and Karen

Barnes.

3. Document production funded by the Business Trust


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Table of Contents

General Information on

Malaria...4Distribution ...................................................................... 5

Life cycle ......................................................................... 8

1. The liver stage ......................................................... 9

2. The blood cycle ...................................................... 10

3. The cycle in the mosquito........................................ 11

Immunity ....................................................................... 11

Symptoms ..................................................................... 11

Diagnosis ...................................................................... 13

Prevention ..................................................................... 14

Personal protection .................................................... 14

Chemical prophylaxis ................................................. 15

Treatment...................................................................... 17Common Myths.............................................................. 181. It is better not to take any prophylaxis, as it masks the

symptoms and makes diagnosis difficult ...................... 18

2. There is this new deadly strain of malaria ................. 19

3. Malaria cannot be cured.......................................... 194. Prophylaxis need only be taken while in a malaria area?

................................................................................. 19

5. I wasnt bitten, can I stop taking my prophylaxis? ..... 20

Websites and phone numbers offering advice.....19


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General Information on Malaria

Plasmodiumis a group of one-celled, animal parasites that liveson the red cells in the blood of many birds, reptiles andmammals. There are four human malaria species - P.

Falciparum, P. Ovale, P. Vivax and P. Malariae.P. Falciparumisby far the most dangerous. Unfortunately it is also the mostcommon in Africa! Certain Anopheles mosquitoes transmitmalaria. The parasite has to undergo a crucial developmentprocess in the mosquito, and this cannot happen in any othermosquito.

Malaria kills roughly 850 000 people each year, most of whomare children under 5, and 90% of whom live in Africa, south ofthe Sahara. Each year there are probably more than 300 millioncases of malaria. Malaria is responsible for one out of every 4childhood deaths in Africa. Women are four times more likely toget sick, and twice as likely to die from malaria if they are

pregnant.

Malaria causes loss of productivity and therefore causes povertyand economic decline. The direct and indirect costs of malaria inAfrica exceed $2 billion per year. The loss of productivity inAfrican economies is much greater however: malaria slowseconomic growth in Africa by up to 1.3% each year. Thisslowdown in economic growth due to malaria is over and abovethe more readily observed short run costs of the disease. Sincesub-Saharan Africa's GDP is around $300 billion, the short-termbenefits of malaria control can reasonably be estimated atbetween $3 and $12 billion per year (Roll Back Malariainformation booklet).

The cheapest and safest malaria drug - chloroquine - is rapidlylosing its effectiveness. In some parts of the world malaria isresistant to the four leading front-line drugs. Malaria quicklyrebounded from the mass insecticide spraying campaigns in the


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1950's and 60's. It then eluded mass treatment strategies basedon a single drugs, such as chloroquine. Malaria can quicklyadapt and rebound when efforts are fragmented anduncoordinated. Yet malaria deaths could be reduced withcoordinated intervention.

Distribution

1. Global RiskPlasmodium Falciparum: Africa (85-90% of cases), SE Asia, SAmericaP. Vivax: S Asia, C America, C/E AfricaP. Ovale: W/S Africa, W Pacific,P. Malariae: infrequent all over

Mixed infections are possible. P. Falciparum often overridesother species, which is why they are often overlooked, remainuntreated and can flare up once P. Falciparumis removed.

2. Risk in AfricaThe figure below indicates the risk in Africa in terms of thenumber of months of transmission. Generally speaking, areaswith 1-3 month risk are regarded as epidemic areas while thosewith 4-6 are areas where transmission is seasonal (normally


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limited to the summer months). In areas of 7 months or more therisk is generally regardedas all year round as lowlevels oftransmission may continue

in so called non-suitablemonths

The figure below shows theapproximate months inwhich malaria transmissionstarts and ends. Thus inthe LSDI study areatransmission starts inNovember/December and

ends in May. Peak transmission is in February-March.

3. Malaria Risk for South Eastern AfricaThe figure below represents the current situation of malaria riskin south-eastern Africa. This figure was revised at the end of


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2000 to take into account the recent increase in malariatransmission. The figure is based on current data and input fromthe Ministry of Health, Malaria Collaborative Forum and MedicalResearch Council.


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0 50

Kilometers

100

Towns

1.Tshipese 2. Hans Merensky (Eiland)

3. Groot-Letaba4. Klaserie5. Sharalumi6. Timbavati 7. Thornybush 8. Blyderivierpoort9. Manyeleli10. Sabie-Sand11. Kruger National Park12. Pilanesburg

Game Reserves:

Low Risk Areas

Malaria all year round: antimalarialdrugs* are recommended

Mozambique

No antimalarial drugs arerecommended

Swaziland

No Risk or no data

Travellers are advised totake antimalarial drugs fromOctober through May, particularly forhigh risk people**

Antimalarial drugs* are recommendedall year round

High Risk Areas

Intermediate Risk Areas

Travellers are advised totake antimalarial drugs fromOctober through May, particularly forhigh risk people**

* Mefloquine OR Doxycycline (ORChloroquine PLUS Proguanil)

** High risk people are children < 5 years,pregnant women & immunocompromisedpeople (e.g. WHO stage 3 or 4 HIV, a personwho has had a splenectomy, or who is onimmunosuppressant medication)

Take precautionary measuresagainst mosquito bites throughoutthe year in ALL RISK areas

13. Ndumu14. Tembe

15. Kosi Bay16. Itala17. Mkuze18. Sodwana 19. False Bay 20. Fanies Island 21. Hluhluwe22. Umfolozi

!


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Life cycle

In the human the parasite multiplies in two stages: first in theliver cells, then in the blood cells.

1. The liver stageParasite forms (sporozoites), injected into a human from aninfectious mosquito, first travel to the liver where they undergo atremendous initial multiplication phase. One parasite cell in theliver stage produces 10 000 (in P. Vivax) to 30 000 (in P.Falciparum)merozoites (divided creatures). These then enterthe blood system where they start multiplying further.

The liver stage of the parasite can become dormant, and re-

emerge after 1-18 months (in P. Vivax / P. Ovale). Recurrence inP. Falciparum (


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2. The blood cycleIn the blood stream the parasites invade red blood cells, feedingon them as they grow and divide, and finally break free, thereby

destroying the cells. Each parasite produces 12 - 32 (in P.Falciparum, slightly less in other species) new parasites. Eachnew parasite then invades another red blood cell and startsdividing. This multiplication can quickly result in severe diseaseand death.

Fever is caused by release of waste material when infected cellsrupture in the blood. Cerebral malaria is caused by clotting of redblood cells in the brain blood capillaries as a result of the malariainfection. Severe anaemia is caused by destruction of bothinfected and uninfected cells by the parasite or by the body itself.The failure of other organs, like kidneys, liver and spleen, iscaused by the flood of waste materials and the clotting of bloodcapillaries, to the point where the body can no longer cope.

The blood cycle in P. Falciparumoccurs in deep circulation, i.e.in the blood vessels of the inner organs. Only when the cellsrupture do parasites appear in peripheral blood (where they canbe picked up through a finger prick). That is why it is sometimesdifficult to pick up parasites with the microscope, unless theblood was taken during a fever spell.

The maximum parasite density achieved by P. Falciparum is 2000 000 parasites per micro litre (l), or 50 000 in P. Vivax, 30000 in P. Ovale and 20 000 in P. Malariae. On average there are5 000 000 red blood cells per l blood, so P. Falciparum can

infect 40% of all red blood cells before death.


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3. The cycle in the mosquitoSoon after infection of the human host, some parasites, insteadof dividing, start forming sexual cells, called gametocytes (sexcell). A feeding mosquito then ingests these male and femalecells. In the stomach of the mosquito the male cell forms several

sperm, which fertilize the eggs. The fertilized ookinete (movingegg) then forces its way through the stomach wall into the bodycavity of the mosquito, where it settles and starts dividing,forming 8-10 000 sporozoites (animal spores). The sporozoitesthen travel through the body fluids towards the mosquitoessalivary gland. From here they are injected into another humanwhen the mosquito next feeds. After a mosquito bites andinfected person, it takes about 10-20 days (depending on thetemperature), before the mosquito can infect another person.

Anopheles mosquitoes are not automatically carriers of malaria.Only after they have fed on a human with malaria and beeninfected themselves, and only after the parasite has completedits cycle inside the mosquito can the mosquito infect another

human.

Immunity

Immunity is only acquired under conditions of frequent infectionfrom a young age. The more frequently a person is infected, thegreater the immunity becomes. Immunity does not preventinfection, but decreases disease and death, and increases rateof recovery. It can be lost when a person leaves the malariaarea. Immunity is also specific to a particular species and stageof the parasite. It is transferred from the mother to the infant butremains active only for 3-6 months. Foetal haemoglobin alsopartially protects babies during the first few months.

Symptoms

From infection to first symptoms (incubation period) is usually 7-14 days.


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In Adults In Children

First symptoms Feel weak, lethargic, uncomfortable, dizzinessChills, sweats, feverMuscular / abdominal painVomiting, watery diarrhoea

Additional symptomscan occur: Cough,Rapid shallowbreathingFeverish convulsions

UncomplicatedFalciparummalaria

Fever, vomiting, diarrhoea, anaemia.In non-immune people this rapidly becomes severe,life-threatening if it remains untreated.

Rapid shallowbreathing, cough,fever convulsions

Severe malaria(alwaysFalciparum)

Cerebral: unrousable coma, convulsions, musclespasm causing backward arching of body, facialgrimaceKidney failure: low urine output (


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Testing for malaria with amicroscope takes time, electricityand a good microscopist. Over thelast few years several malaria rapid

tests have been developed, whichmake a rapid diagnosis possible.They require a drop of blood from afinger prick, and involve a papertest strip that is dipped into theblood and other solution(s). After afew minutes, during which theliquids are absorbed into the strip,

a reading is obtained by the presence or absence of a colouredtest line on a white background. There are several differentproducts on the market now, and are roughly, equally effective.Most only detect P. Falciparum but a few can detect thepresence of one of the other malaria species.

Prevention

Personal protection

Malaria mosquitoes only bite after dark. The best prevention ispersonal protection against the malaria mosquito: Wear longsleeves and trousers in the late afternoon and night, stay in-doors if possible. The latter advice is however often difficult to

follow when on holidayin the tropics. Effectiveprotection may beobtained by using arepellent on exposed

skin. Additionalprotection may beobtained by applyingrepellent to clothes, asmosquitoes will often


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bite through clothes. Aerosol repellents can be used on clothesand often also give more effective coverage of exposed skinthan a stick or roll on. Sticks and roll-ons are useful forapplication to areas such as the face, where an aerosol mayaffect sensitive areas (e.g.eyes). Sleep under an insecticide-

impregnated bed net or in a netted tent or hut or in a house orcaravan with screens. Close windows and doors at night. Sprayinsecticide aerosol and/or burn mosquito coil at night. Syntheticpyrethroids (e.g. Deltamethrin) are usually used to impregnatenets (and clothes) as these have very low toxicity to man. Adosage for a single net can usually be purchased as a tablet orsmall sachet. Re-treatment should be carried out at 6 monthlyintervals or after washing.

Chemical prophylaxis

Drugs available for prophylaxis of malaria act on the parasites inthe red blood cells and prevent disease from developing andtypical symptoms from presenting. It is most important to takethe recommended drugs exactly as prescribed and to completethe course. Failing to complete the course results in inadequatedrug levels in the blood, allowing the parasites to multiply andmalaria to develop. It is important to continue prophylaxis for 4weeks after return from a malaria area.

Even if the drug is only partially effective (e.g. in the case ofpartial drug resistance), parasite development is still inhibited,symptoms may take longer to appear, and may be less severe atfirst, than if no prophylaxis was taken.

Malaria symptoms may only develop quite a while after leavingthe malaria area. This may reduce suspicion of malaria to the

detriment of the patient, especially as many people believe thatprophylaxis is a guarantee against malaria. It is therefore veryimportant that anyone experiencing any malaria or flu-likesymptoms after having been in a malaria area seeks helpimmediately and informs their physician that they have been in a


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malaria area.

Appropriate prophylaxis will considerably reduce the chances ofbeing infected with malaria and therefore of unnecessary illnessand death. However, no drug is guaranteed to protect everyone

every time.

Choices of prophylaxis:

1.MefloquineMefloquine (Lariam")( Meflium") is highly effective and has asimple weekly dosage. Start a week or two before, to check forpossible side effects. Complete the course. Continue while in thearea and for 4 weeks after leaving the area.

Mefloquine has been taken up to 12 months without side effects.However, it has a number of contra-indications and requires adoctors prescription. It also has rare but severe neurologicalside effects.

2. DoxycyclineThis drug is highly effective in SE Asia, and resistance is rare.However, it is for short-term use only and can cause lightsensitivity (Use a sunblock). Must be taken daily, starting 2 daysbefore, during and for 4 weeks after leaving the area. It cancause failure of the birth control pill and an alternative form ofcontraception should be used.

3. Proguanil/Chloroquine combinationProguanil (Paludrine") every day; Chloroquine (Daramal" /Nivaquine"/ Promal") once a week. This combination can betaken safely up to 3 months, very cautiously for 6. Start a day

before you leave. Not recommended for high-risk chloroquineresistance areas. Complete the course. Continue use for 4weeks after leaving the area.


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Treatment

Oral treatment is used for uncomplicated malaria, intravenous orintramuscular treatment for severe malaria. Symptomatictreatment is given for fever and other symptoms.

Pyrimethamine-Sulphadoxine (Fansidar"): to treat chloroquineresistant uncomplicated malaria. Cheap. Convenient single-dosetreatment. Sometimes causes vomiting and skin rashes.Resistance is developing in parts of Africa (Including KwaZulu-Natal, South Africa), so medical advice should be sought ifsymptoms persist despite treatment.

Quinine: to treat severe malaria and uncomplicated malariaresistant to chloroquine, Fansidar"and Mefloquine". Severeside effects, extremely bitter, therefore not often used as oraltreatment. Intravenous treatment suitable for treating pregnantwomen and children.

Chloroquine: cheapest, rapid action, symptomatic relief, butresistance to chloroquine is common, and it cannot clear theparasite. It is sometimes used in conjunction with Fansidar"because of rapid initial action. Not effective in non-immunepatients in the southern, eastern and central African areas.

Other treatments: fever-reducing drugs, antibiotics, physicalcooling, rehydration

Drug resistance should not be confused with: lack of compliance,inadequate dose, reinfection.

Multi drug resistance is most common in SE Asia, especially

borders of Thailand.


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Rapid malaria tests

ICT (can detect all types of

Plasmodium)Scientific GroupJohannesburg toll free:0800002639Durban: 031 - 579 4701

Cape BiotechMacMed consumablesFranco Zorzi for directpurchaseTel: 011-6538556

Kat QuickKat MedicalTel: 011 - 475 73 60/1Fax: 011 - 475 73 62Shawn Duke - 082 577 20 99

Makro-MalMakro Medical (Pty) ltd.JohannesburgLouis Roux / Colin Kramer -011 - 624 33 00Durban: Debbie Craig -0832691507

Common Myths

1. It is better not to take any prophylaxis, as it masks thesymptoms and makes diagnosis difficult

This is incorrect. Not to take prophylaxis when visiting a malariaarea puts travellers at risk of contracting a dangerous andlife-threatening disease.

Prophylactic drugs suppress parasite development, andtherefore, even if not totally effective (due to partial drugresistance or non-compliance), symptoms tend to take longer toappear, may be less severe at first and development ofcomplications is retarded. In the complete absence of drugs,

parasites are able to multiply at phenomenal rates, and malariacan quickly get out of hand, and lead to severe complicationsand death, within 24 hours.

Malaria is sometimes difficult to diagnose the standard way (by


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microscope) because malaria parasites are present in theperipheral blood only during a fever spell. If a finger prick istaken between fever spells, it is possible that the parasites arenot picked up. As prophylaxis retards the parasite multiplication,it may indeed make diagnosis more difficult initially, but repeated

blood smears or new and very sensitive rapid type tests willusually confirm malaria well before the patient is dangerously ill.

Remember, even if malaria is diagnosed and treated in goodtime, it is still an extremely unpleasant and dangerous illness.

2. There is this new deadly strain of malaria

Cerebral malaria is not a new strain; it is a complication ofuntreated Falciparummalaria. Early diagnosis and appropriatetreatment should ensure that no one ever gets cerebral malaria.

3. Malaria cannot be cured

Malaria can indeed be cured with the appropriate drugs. Due todrug resistance to certain drugs, it may take several attemptswith different (combinations of) drugs to effect a complete cure.Also, because most common drugs only kill the blood and notthe liver stages, the two malaria species that have dormant liverstages (Vivaxand Ovale) often do not get removed initially. If theparasite species is not identified correctly, or if there were twospecies present in the blood, of which one was missed, malariacan flare up again, sometimes months and years later. However,once the species has been correctly identified, the liver stagecan be successfully removed with Primaquine.

4. Prophylaxis need only be taken while in a malaria area

The drugs that we have to prevent malaria are known as bloodschizontocides, which means that they work on the parasite onceit enters the red blood cells. This does not occur until 10-14 days


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after being bitten by an infected mosquito. If the drug is stoppedbefore the parasites reach the blood cells, there will not beenough drug in the blood to kill the parasites and the prophylaxiswill fail. It is therefore most important to continue takingprophylaxis for 4 weeks after leaving a malaria area.

5. I wasnt bitten; can I stop taking my prophylaxis?

The female anopheles mosquito is not known as the silent killerfor nothing. She does not buzz around your head at night,irritating you. You may not be aware of her presence at all. Thereaction to her bite may also not be as pronounced as it is withother bloodsucking insects and you may be unaware of havingbeen bitten.

Phone numbers offering advice

Dept. Health, Communicable diseases: (012) 3120000

Medicine Information Centre: (021) 448302

TPS Drug Information Centre: (011) 3394811

Travel Clinic SAIMR: (011) 4899000

Glaxo Wellcome Malaria Hotline: (011) 4033586

Travel Clinic Durban ICC: Tel: (031) 3601122, Fax:(031) 3601121, Email: [email protected]

British Airways Travel Clinic: (011) 8073132 /(021) 4193172 / (031) w-3032423 ah-3013737

www.malaria.co.za

Malaria Research Programme, Medical Research Councilwww.malaria.org.za


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The Business Trust is an initiative of South African companies,working in partnership with government, to undertake targetedjob creation and capacity building programmes.

Its strategy focuses on Tourism for job creation, schooling forcapacity building and is underpinned by support for a reduction incrime. The trust is committed to enhancing trust and buildingcooperative relations between business and government.

Carefully selected strategic partners implement the BusinessTrust programmes, which aim to benefit the disadvantagedwhile the economy is put on a growth path that will provide

sustained improvements in the lives of the majority of SouthAfricans

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