Killers without borders

By admin
02 September 2010

Extremely dangerous drug resistant malaria is on a relentless march to South Africa from the north. If you travel to malaria areas be aware that the danger is greater and deadlier than ever before

By Karena du Plessis

When Stephan Wolff got back to Cape Town after a diving holiday on an island off Mozambique, he was in top form.They'd enjoyed excellent diving, their accommodation had been the right combination of laid back and luxurious, and he was ready to tackle his stressful engineering job with renewed energy.

Three weeks later, however, he began to feel ill. His doctor diagnosed a bad bout of flu and suggested bed rest for a few days. But Stephan's fever, temperature and chills didn't go away and the crashing headaches left him groaning with pain. It was only after his girlfriend, Liesel Bredenkamp, developed the same symptoms that a family member who was a nurse, connected the dots and suggested malaria.

"We went back to the doctor, who did a blood test," says Stephan. "When the results came back positive for malaria, he couldn't apologise enough for not diagnosing the disease earlier.

I don't blame him, though, as I hadn't told him we'd been away. After a month back at home, any holiday seems like a distant memory and malaria was the last thing on my mind. Who gets malaria in Cape Town? We'd taken our tablets so we'd completely forgotten about it."

When Stephan Wolff got back to Cape Town after a diving holiday on an island off Mo- zambique, he was in top form.

They'd enjoyed excellent diving, their accommo- dation had been the right combination of laid back and luxurious, and he was ready to tackle his stressful engineering job with renewed energy.

Three weeks later, however, he began to feel ill. His doctor diagnosed a bad bout of flu and suggested bed rest for a few days. But Stephan's fever, temperature and chills didn't go away and the crashing headaches left him groaning with pain. It was only after his girlfriend, Liesel Bredenkamp, developed the same symptoms that a family member who was a nurse, connected the dots and suggested malaria.

"We went back to the doctor, who did a blood test," says Stephan. "When the results came back positive for malaria, he couldn't apologise enough for not diagnosing the disease earlier. I don't blame him, though, as I hadn't told him we'd been away.

After a month back at home, any holiday seems like a distant memory and malaria was the last thing on my mind. Who gets malaria in Cape Town? We'd taken our tablets so we'd completely forgotten about it."

Country hopping

Mosquitoes have little respect for country borders and crisscross in and out of South Africa on a daily basis. And the more people migrate to South Africa from Zimbabwe and Mozambique, the faster malaria – and especially drug-resistant malaria – has been found to spread.

Malarial areas: South Africa

Malarial areas: Africa

The northern and north-eastern areas of South Africa – specifi- cally Limpopo province, areas of Mpumalanga adjacent to and including the Kruger national Park and the northern areas of KwaZulu-natal – are regarded as malaria areas where drug-resistant malaria-carrying mosquitoes are now active.

Yet, while the number of cases of malaria in South Africa has dropped dramatically since 2001, for millions of people elsewhere in Africa (and the rest of the world) it's a disease that destroys lives and cripples developing economies.

Death by malaria is dreadful. Initially the patient experiences fever, headaches, vomiting and other flu-like symptoms; if not treated, life-threatening anaemia and coma follow.

Children suffer seizures and shock and then death as their underdeveloped immune systems try to fight the disease.

And the further bad news is most African countries now have drug-resistant strains of the disease. These strains have spilled over the Mozambican and Zimbabwean borders to Limpopo and Mpumalanga.

Compounding the problem is global warming. Mosquitoes are now able to breed far further south and north of the equator than ever before, placing more people at risk.

No-go for kids and pregnant women

Dr Jaco Folmer, the medical director of netcare Travel Clinics, is unequivocal in his advice about travelling with children to a malaria area. Netcare Travel Clinics advise parents not to take children under the age of five into malaria areas," he says.

"Malaria is one of the most serious, life-threatening diseases affecting paediatric travellers. The disease kills a child somewhere in the world every 30 seconds and accounts for one in five of all child deaths in Africa."

Children rapidly develop a high level of malaria parasites in their blood and severe complications including shock, seizures, coma and death. What makes it even worse is the initial symptoms of malaria in children may mimic many other common causes of paediatric fevers, delaying diagnosis and treatment.

Waiting just six hours for treatment could mean the difference between life and death for a child.

If you have to take a child into a malaria area, preventive prescription medication is available for children weighing more than 5 kg. Paediatric doses are calculated according to the weight of the child and the child's medical history must be taken into account to determine any contraindications.

As an overdose of antimalarials can be fatal, the medication should be stored out of reach of infants and children, Dr Fol- mer warns.

But it's not just children who are at increased risk. If you're pregnant, you should also avoid travelling to malaria areas. Dr Folmer explains: "Pregnant women are at an increased risk of contracting malaria as they have a higher body temperature and produce more carbon dioxide, both of which attract mosquitoes.

What's more, pregnant women who contract the disease tend to get a more serious strain. It could lead to a severely ill mom-to-be and end in miscarriage."

Good news from home

South Africans are benefiting from a well-managed malaria control programme and strides in combating the disease have been significant.

"The country has done remarkably well in managing malaria," says Dr Rajendra Maharaj, head of the Malaria Research Programme based at the Medical Research Council (MRC) in Durban, with understated pride.

Once-controversial pesticide to the rescue

"Spraying DDT inside homes has played a key role in managing malaria," Dr Maharaj confirms. He explains how the pesticide used to cause people to throw up their hands in horror because when used in large quantities this toxic compound accumulates in soil and groundwater and can poison humans and animals alike.

"DDT was banned from agricultural use in 1976 but it's never been banned for use in public health. In 2000 there was an alarming rise in malaria in KwaZulu-Natal and so spraying with DDT was reintroduced."

Mosquitoes enter people's homes, enjoy a blood meal and when the insects are full, they need to rest to digest the meal before flying away.

The thinking is while they're resting in houses sprayed with DDT they'll pick up a lethal dose of the insecticide and, one hopes, drop dead. This prevents the mosquito from breeding and going on to bite and infect others.

"The concern about DDT's effect on the environment also has to be seen in context," explains Dr Maharaj.

"When it was used in America to spray cotton crops, massive amounts were dumped onto the fields and would then seep into streams and groundwater. But the current spraying programme involves spraying only grams of DDT inside houses at a time.

And, traditionally, these huts are re-plastered with mud each year so the DDT doesn't end up in groundwater."

101 Everything you need to know

How big is the problem?

Malaria is endemic to parts of Africa, Asia and Central and South America. It's estimated to infect up to 500 million people worldwide every day and between 1,5 million and 2,7 million of them die of the disease.

Put another way, it affects 40 per cent of the world's population and is estimated to kill a child every 30 seconds – in spite of the disease being entirely preventable and curable.

What causes malaria?

It's caused by a single-celled parasite of the genus Plasmodium. When a female Anopheline mosquito bites a malaria-infected person, it sucks in the parasites that are present in the blood.

These plasmodia parasites then multiply in the mosquito and travel to the salivary glands from where they are transmitted to the next human whom the mosquito bites.

There's plenty to brag about. In 2001 alone, over 25 000 malaria cases were reported and 80 people died, while six years later some 2 000 cases were reported and 16 people died.

That's a significant drop by any standards. Malaria is a notifiable disease, which means it has to be reported to the health authorities so, unlike HIV/Aids for example, reported malaria figures are reliably accurate.

What happens inside the body explains the symptoms

Once bitten by an infected mosquito, the malaria parasites enter your bloodstream, go straight to their first breeding factory – the liver – and multiply.

After a period of about two weeks, hundreds of newly formed baby parasites burst from the liver. This is when you'll start feeling ill.

Unfortunately, malaria symptoms are very similar to flu symptoms and include headaches, fever, dizziness, lethargy and body pains, which often result in misdiagnosis.

The baby parasites now rush straight to their second breeding factory – the red blood cells – where they mature and reproduce again. Then, thousands erupt from the invaded red blood cells, each reduced and destroyed to a sticky mess, into the bloodstream and search for new unaffected red blood cells to invade.

Each time large numbers of new parasites break out from the red blood cells, the malaria patient will experience a fever spike. If huge numbers of the damaged and sticky red blood cells clump together, they can clog the renal tubes, causing kidney failure.

In extreme cases, they can infect the brain and cause cerebral malaria.

Malaria warriors

Kingsley Holgate, fear- less African explorer and famous philanthropist, has survived several bouts of malaria and rarely goes on a trip without doing some- thing to combat the disease.

On his most recent expedition more than 10 000 insecticide- treated nets were given to pregnant women and vulnerable children.

Bill Gates "For far too long malaria's been a forgotten epidemic," the tycoon said earlier this year when he donated around R2 billion for the development of a malaria vaccine, new antimalarials and new methods of preventing the disease.

Increasingly resistant

But for all the success of the Malaria Research Pro- gramme, drug resistance remains a huge problem. "Drug resistance starts when patients stop taking their medication as soon as they feel better," says Dr Jaishree Raman, a molecular biologist at the MRC.

"A small number of parasites are able to survive and multiply in the bloodstream.

These drug-tolerant parasites then undergo genetic changes that make them resistant to normal doses of the drug. It's ironic that taking anti- malarial medication in an area with a high incidence of drug-resistant malaria merely compounds the problem – the parasites become even more resistant to the drugs."

Researchers are engaged in a long, ongoing battle between finding new, effective antimalarial drugs and the malaria parasite's uncanny ability to beat them.

First there was chloroquine. Followed by chloroquine resistance. Then doctors turned to drugs known as SPs (safe for pregnant women and children and relatively cheap). Yet again, after five to 10 years, parasites developed a resistance to this drug.

Currently a combi- nation of two drugs known as ACT is one of the most effective ways of rapidly curing a patient as well as limiting the spread of the disease.

When the first reports of ACT-resistance arrived, the experts were extremely worried. The cause was mainly incorrect use of the drug or use of cheaper and less effective counterfeit drugs.

This drug resistance may soon spread from Asia to Africa, as has happened before. Surprisingly, given how many people it affects, malaria isn't regarded as a major disease by many governments and drug companies aren't investing large sums of money into developing new antimalarials.

Greater profits are to be found in developing other drugs.

Malaria will never be conquered in Africa, according to Dr Raman, unless ACTs are made more affordable for African countries, all sub-standard and counterfeit malaria drugs are removed from the market and countries conduct proper trials to ascertain which ACT is best suited to their scenario.

Hopes are now pinned on the responsible use of DDT and finding a malaria vaccine. A Swiss bio- technology company has announced it has successfully tested a malaria vaccine that could be marketed – but not before 2014.

How to prevent malaria

There are three types of tablets for the prevention of malaria currently available in South Africa. It's important to note not every drug suits everyone and each individual needs to be evaluated before leaving for a malaria-infested area.

  1. Malarone (known as Malanil) has very few side effects.

    You take it a day before entering a malaria area and use it for seven days after your return. The downside is cost: at about R38 per tablet, a two-week holi- day for a family of four can become very expensive!

  2. Mefloquine(Mefliam/Lariam) is the only option for pregnant travellers, who are strongly advised to take malaria prophylaxis.The World Health Organisation says prophylaxis is safe from the thirteenth week. Mefloquine should not be used by people with any psychiatric illness such as depression and anxiety, a heart condition or epilepsy as it can adversely affect them.For the right individual, however, it works very well. Side effects may include vivid dreams or insomnia, severe headaches and tinnitus (unbearable ringing in the ears).

    You need to take a tablet a week starting one week before you enter a malaria area, once a week while there and for four weeks after your return.

  3. Doxycyclineis a form of the antibiotic tetracycline, but only doxycycline is used in malaria prevention.You take one tablet daily, starting one day before you enter a malaria area, every day while there and daily for four weeks after your return.It's relatively cheap and works very well. It may cause sun sensitivity, sunstroke and heartburn in some people, but with proper precautions it can be used safely.

    Wear high factor sunscreen and a hat. It may reduce the effectiveness of oral contraceptives and some other drugs. Talk to your pharmacist about this. Dr Folmer of Netcare Travel Clinics explains all three available options are about 90 per cent effective.

    "Unfortunately, no prophylactic is 100 per cent effective, and you should always consider malaria if you become ill after or during a stay in a malaria risk area.

    "There is a common myth prophylaxis makes it difficult to detect malaria – but this is nonsense. Rather, people who take prophylactic medication tend not to get severe malaria. The reason is with fewer parasites in the blood and fewer symptoms, you have a better chance of survival!

    It is the symptoms that kill you and they are suppressed with prophylaxis," says Dr Folmer.

All three available options are about 90 per cent effective. Unfortunately, no prophylactic is 100 per cent effective.

Other important precautions

Take the following precautions when travelling to a malaria area and ensure your children are included in all these preventive measures:

  • Sleep under mosquito nets treated with insect repellent. Lower nets before dusk and make sure they are well tucked in on all sides.
  • Keep children indoors from dusk until dawn.
  • Wear long-sleeved clothing, trousers, socks and shoes when outdoors from dusk until dawn.
  • Use insect repellents on exposed skin. Take note of the manufacturer's recommendations, especially for young children.
  • Gauze screens in front of doors and windows help keep mosquitoes out.
  • Use a fan or air conditioner in the room.
  • Burn mosquito repellent coils and spray sleeping areas with mosquito repellent.

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