Friday, 28 April 2017

When Malaria Hits Home


According to the World Health Organization’s (WHO) figures in 2012, the top five killers in Africa were HIV/Aids, lower respiratory tract infections, diarrheal diseases, strokes, and Malaria.  In my role as founder and president of Yeloto African Children’s Foundation, a non-profit organization named for my own children, I have made raising awareness of the ills and needs of children in Africa a central aspect of the mission of my efforts.  As I have shared before in both public and private arenas.   When I reflect on what I have seen and continue to see day to day during my vacation’s and annual charity sojourn to Nigeria, it generates great sadness in my heart to see how our country’s most valuable resource, its children, are not all provided for in a manner that ensures their optimum development and success.  What I find even more disheartening is reminiscent of a quote by entrepreneur, author, and motivational speaker Zig Ziglar, who is quoted as saying, “The world’s most deadly disease is “hardening of the attitudes.”  In too many arenas, from the average citizen to the highest echelons of government there is a sense of complacency about the needs of one of the most vulnerable populations in our midst. Our children need us and they need us now.  At the risk of sounding cliché, the truth remains; the children that we are passing by begging or hawking in the streets, or those that are dying as a result of preventable illnesses are our future.  I know that something as conceptually simple as paradigm shift in thinking as well as the synergism of individuals that choose to function as change agents hold the key to turning the tide and changing the present narrative for our African children. 
Aside from the fact that Malaria has taken the lives of approximately 627,000 lives (90 percent of the deaths belonging to Sub-Saharan Africa, and 77 percent were among children under age 5), I have chosen to write on Malaria because of my most recent personal experience.  In the never  ending struggle to raise our children to become well rounded, knowledgeable, scrupulous and upstanding citizens of the world my wife and I decided to avail our oldest son to some additional academic and cultural enrichment.  Despite all necessary preparations and what seemed like adequate precautions, approximately three weeks after he returned home from a four  week program he became significantly ill. In a matter of hours after his arrival to the emergency room he was transferred to the intensive care unit where he spent the next five days, my wife never left his side for his duration at the hospital. 

 Having experienced this has prompted consideration of not only the illness itself, but its impact.  Many questions came to mind. How could this have happened? What if he had not been in the US with both my wife and I (both of whom are healthcare professionals) watching him like hawks and with readily available and competent resources?  What if we had not taken him in time?  How unsettling it was for me to hear that my son had been transferred to the intensive care unit but how grateful I was that treatment was in fact available to him!  Then my thoughts turned to the WHO statistics and those children and families who are not as lucky and lose their lives (in significant numbers) to this illness.  Why is this the case?  Shouldn’t this scourge of an illness been eradicated already?  The health care community knows that Malaria is preventable and treatable, and history shows that it can be eliminated. Less than a century ago, it was prevalent across the world, including Europe and North America. Malaria was eliminated in most of Western Europe by the mid-1930s; the United States achieved elimination of the disease in 1951. 

Improving the delivery of existing interventions as well as the development of new tools and strategies provides us the opportunity to accelerate progress toward complete elimination in all countries.  By mobilizing the required commitment and resources, global eradication can be achieved and millions of lives saved.

While pondering the question why isn’t more being done? I was struck with the idea to pursue a public health approach.  In as far back as a 1920 publication, Winslow defines public health as "the science and art of preventing disease, prolonging life and promoting human health through organized efforts and informed choices of society, organizations, public and private, communities and individuals.  This is a key concept to keep in mind! The efforts of non-profit organizations both in the US and Nigeria are important long term strategies.  However, addressing the needs of those at risk of infection or currently afflicted is contingent on awareness and action NOW.  It is in this spirit I offer to you a consolidated review of Malaria, from its cause to treatment, and in my last few personal words before the review, implore you to take to heart the importance of each individual’s role in the most important aspect of Malaria….. Prevention!

Malaria Review:
Malaria is a mosquito-borne infectious disease that affects humans as well as animals caused by parasitic protozoans. It belongs to plasmodium type. The symptoms of malaria usually manifest itself within 10 to fifteen days after a person is bitten. Common symptoms of malaria include fever, fatigue, vomiting and headaches.  And in severe cases of malaria symptoms include yellow skin, seizures, coma, or death. It is advised that people be properly treated to prevent reinfection.
In those who have recently pulled through infection, re-infection commonly causes moderate symptoms. This partial resistance may be lost over months to years if a person has no continued exposure to malaria. It is usually transmitted by infected female anopheles mosquito. Parasites are passed to human’s blood from mosquitoes saliva.
There are 5 species of plasmodium, the most deadly specie is P. Falciparum. In poor countries, the best and most cost effective way to diagnose malaria is by microscopic examination of blood using blood films. A more expensive way is by Antigen-based rapid diagnostic tests (RDT).
In areas where these tests are unaffordable, it has become a common place for both physicians and patients alike to see a history of fever as the indication to treat for malaria. This is a dangerous practice as it leads to over diagnosis of malaria and also contributes to drug resistance. Misdiagnosis can erode confidence in an already trust challenged health care system.
PREVENTION.
This can be classified under 3 major categories-
1.    Medications
Medications can be used to prevent and treat malaria. Chloroquine, mefloquine (Lariam), doxycycline and combination medication like sulfadoxine/pyrimethamine also popularly known as fancidar. Fancidar is recommended in infants of greater than 2 months of age. Women after the first trimester of pregnancy can also take fancidar in a country with high rates of malaria like Nigeria. The recommended treatment for in most sub-saharan African countries is a combination of anti-malaria medications that include an artermisinin. The second medication maybe either mefloquine or sulfadoxine/ pyrimethamine (fancidar). Quinine along with doxycycline maybe used if an artemisinin is not available.

2.    Mosquito Elimination
Prevention of malaria has shown to be more cost effective than treatment of the disease. The initial cost to maintain low endemicity is too costly for poorer countries.

3.    Mosquito control
Refers to the different practice’s used to diminish malaria by reducing the levels of transmission by mosquitoes.
·      Insect repellants based on DEET or picaridin
·      Insecticide treated mosquito nets
·      Indoor residual spraying (IRS)
·      Prompt treatment reduces chance of transmission.
·      Decrease the availability of open water or add chemicals to decrease development of mosquito larva
·      Intermittent preventive therapy with Fancidar should also be considered
                 CATEGORIZATION
Malaria is classified into 2 major classes either severe or uncomplicated by World Health Organization. It is considered  severe when any of the subsequent criteria are present, otherwise  it is deemed uncomplicated.
·      Decrease consciousness
·      Significant weakness such as the person is unable to walk
·      Inability to feed
·      Two or more convulsions
·      Low blood pressure (less than 70mmHg in adults and 50mmHg in children)
·      Breathing problems
·      Circulatory shock
·      Kidney failure or hemoglobin in the urine
·      Bleeding problems, or hemoglobin less than 50g/L
·      Pulmonary oedema (excess of watery fluid collecting in tissues of the body)
·      Blood glucose less than 40mg/dL
·      Acidosis or lactate levels of greater than 5mmol/L
·      A parasite level in the blood of greater than 100,000 per microliter


                   TREATMENT
·      Simple or uncomplicated malaria may be treated with oral medications
·      The first vaccine, called RTS,S, WAS APPROVED BY European regulators in 2015, there is a pilot implementation of the vaccine  currently on going in Africa.
·      The most effective treatment for P. falciparum infection is a therapy that combine’s  artemisinin or its derivatives with some other antimalarial drug. These treatment are both effective and well tolerated in patients.
·      These additional antimalarials include : amodiaquine, lumefantrine, Lariam (mefloquine) or Fansidar (sulfadoxine/pyrimethamine), dihydroartemisinin and piperaquine
·      Artemisinin-combination therapy, or ACT is about 90% effective when used to treat uncomplicated malaria.
·      In pregnant women in first trimester use quinine plus clindamycin
·      Use ACT in the second and third trimesters of pregnancy.
·      The recommended treatment of severe malaria is the intravenous use of antimalarial drugs. It should be done in a critical care unit. Symptoms include but not limited to high fevers, seizures, poor breathing, low blood sugar, low blood pressure and low blood potassium.