Professor Catherine Falade, a clinician-researcher and malaria expert tells SADE OGUNTOLA that the elimination of malaria is still quite a distance but requires prevention and proper treatment, especially at home level, to reduce its prevalence and prevent complications.
WHY is treating malaria with chloroquine a death warrant?
THE malaria parasite has developed resistance to chloroquine with the result that chloroquine does not clear the infection. Instead, the parasite continues to multiply and the patient becomes much more severely ill, leading to severe forms of malaria such as anaemia of varying severity, cerebral malaria and other manifestations of severe and complicated malaria, including death.
Pregnant women, children under 5 and people living with HIV are among the group of people more vulnerable to malaria in malaria endemic areas. Of what significance is this to malaria elimination in Nigeria?
Basically, the reason they are more vulnerable to malaria is the same. These groups of people have lower immunity to the disease and many other infections. A regular adult living in a malaria-endemic country like Nigeria would have acquired some immunity to malaria. Even when they have malaria, they don’t run the risk of dying from its severe form. Immunity against malaria is acquired through having had the infection a few times.
The pregnant woman normally would have acquired some immunity before pregnancy, but the baby is a foreign body in the pregnant woman and without a toning down of immunity, no pregnant woman will deliver a live baby. This makes a pregnant woman more prone to the severe effects of malaria. Children under the age of 5 are yet to build up their immunity fully. In the HIV-positive patient, the virus destroys CD4 cells, the white blood cells that ensure immunity. As such, the HIV-positive person has a depressed immunity and becomes more prone to malaria and its complications as well as a lot of other infections. However, when patients living with HIV are under treatment, as they take the anti-retroviral(ARV) drug, their immunity rises. That is why we don’t see those under treatment dying from malaria often.
Is that why intermittent prevention of malaria in pregnancy is preached to improve the chances of having a live baby?
Yes. The pregnant woman is more prone to coming down with malaria and its complications like anaemia and threatened abortion. Her unborn baby also risks being born premature or small for gestational age. So, intermittent preventive treatment helps to improve the health of the pregnant woman and her unborn child.
Can you share some of your findings on the epidemiology of malaria among HIV-positive patients and of what significance are these to malaria control in the community?
Studies indicate that once the patients are compliant with ARV drugs, their immunity rises. Those who are not compliant have a higher incidence of malaria and have a higher parasite density but because we are reaching them, we treat them immediately to clear the infection from their bodies. We also counsel them about the need to take their ARV drugs and also give them drugs to prevent some other opportunistic infections. This underscores the need to get rid of the stigma associated with HIV infection, and provide access to ARV and other essential treatment so that people living with HIV can have good quality lives.
Of what significance are malaria diagnosis and therapy in putting an end to malaria in Nigeria?
It is important for the populace to know that malaria has no particular signs and symptoms. The signs and symptoms you get in malaria are the same as what you will get in any infection like pneumonia, hepatitis or some other viral infection. Even with a boil that is not in a very visible place, there could be a fever, headache as well as aches and pains. It thus becomes important that malaria diagnosis is confirmed by laboratory diagnosis using malaria rapid diagnostic test or quality assured microscopy.
Is that why some clinicians always interpret every fever case as malaria or typhoid fever?
Yes. This is called presumptive diagnosis; it is assuming that all fevers especially in children are due to malaria. This came up many years ago because the prevalence of malaria was exceptionally high; it was like 80 per cent. But it is not so anymore, there has been a lot of effort to control malaria and so the prevalence has dropped. Now it is tantamount to malpractice to treat malaria without having identified the parasite.
The World Health Organisation stipulates that every suspected case of malaria must be confirmed by laboratory diagnosis before treatment. Malaria rapid diagnostic test, microscopy and polymerase Chain Reaction (PCR) are the officially approved methods of diagnosis. But microscopy is considered the gold standard against which all other forms of diagnosis can be measured.
However, it is not just any microscopy. It is quality-assured microscopy. I say this because most microscopists in the public space will put malaria parasite 1 +; saying it is malaria, no one can go wrong. But malaria is no longer common malaria or common fever because we know the havoc it has wrecked and because we are all targeting its elimination.
Every case of malaria must be treated even if it is one parasite in 200 high-power fields. By the way, the system of classifying the amount of malaria parasite in a blood film in the 1 +, 2 +, and 3 + is outdated. The ranges covered by the 1 +, 2 +, and 3 +, are quite wide and people just write what they like. But the system now is to specify how many parasites are seen in a high-power field. It gives a clear picture of what the situation is since they have to count the parasites seen in the blood films.
But out there are people who still talk about malaria as 1+, it is 2+ and so on
Unfortunately, that is true. That is because they have not updated themselves and because those technologists or technicians are not malaria microscopists. For them, every dot on the slide is a malaria parasite. But having a correct result is so important. Imagine that a child has pneumonia and presents early before the chest signs are fully developed, and the laboratory report says that a blood film free of malaria parasite has 1+, the doctor will be busy treating malaria, whereas the pneumonia gets worse and becomes roaring. In a series of studies on pneumonia, a higher proportion of the children who had earlier been treated for malaria before the diagnosis of pneumonia was made died. It is not because the malaria medicine killed them, but because the diagnosis of pneumonia was delayed. A larger proportion of the lung would have been involved and the bacteria spread into the blood. So, it is so important to be able to differentiate what you are treating.
Within 15 to 20 minutes, the result of malaria rapid diagnostic test is out. But there are lots of people saying that it gives a lot of false negatives. I can tell you categorically false negatives are less than six percent.
In one of our studies, we looked at the consequences of treating only rapid diagnostic test-positive children with antimalarials and other causes of fever in children. We had a false negative rate of 2.5 percent and none of the children with false negative had any major issues. The false negative results often occurs when the parasite load is still quite low and if for any reason you have a concern that the case is still malaria, don’t treat it; let the child come the next day, the parasite count would have risen and would be positive.
There is this notion that what is common is common and if a child has a fever, it is malaria. That is not true in every case. For instance, a child and even an adult with a viral upper respiratory tract infection or pneumonia can run a fever, vomit and have joint pains. It is the same thing with viral hepatitis.
Even when the tooth is infected due to a hole in it, the child will have a fever, joint pains and headaches. The signs and symptoms of inflammation are the same, no matter what causes it. That is the reason doctors always insist on seeing the patient because the cause of fever in 10 patients may not be the same. So, malaria diagnosis is important and the malaria rapid diagnostic test is easy to use by anybody.
So, how best can the kit contribute to improving malaria management at all levels of the healthcare system?
Any patient that is positive for malaria on the rapid diagnostic test should be treated with an efficacious drug and that is Artemisinin-based Combination Therapy (ACT) and not chloroquine. Chloroquine has failed. Many adults will tell you chloroquine works for malaria. But that is because chloroquine has an anti-inflammatory effect and so the aches and pains will go. Chloroquine also has fever-lowering effects which also makes the patient feel better as the fever resolves at least for a while as he/she will not feel febrile but the parasites are still swimming in the blood and growing because the parasites have developed resistance to it.
A lot of the adults say chloroquine works because they had never had malaria to start with. They were probably stressed or tired from too much work or a hectic lifestyle. So, instead of resting, they conclude that they have malaria and then go ahead to take chloroquine before retiring to bed. By the time they have slept for a day or two, they feel fine and they assume that they had malaria that chloroquine cured.
Malaria is very deadly, so how best can it be eliminated in Nigeria?
Elimination of malaria should start with prevention; we should all take this very seriously. Every Nigerian should avoid stagnant water around their houses; gutters must run and be cleared. Two, if you can afford it, please have a mosquito screen on windows and doors to reduce the chances of transmission. Three, sleeping inside an insecticide-treated bed net is important. Likewise, pregnant women should book early for antenatal care as it would avail them of the opportunity of intermittent prevention of malaria during pregnancy.
On treatment, all cases of fever at the health facility, including at pharmacy outlets, should be tested using rapid diagnostic testing. If it says negative, the chances are that the patient does not have malaria even when very ill. The patient should see a doctor.
If the rapid diagnostic test is negative and the microscopy is negative, the chances are high it is not malaria that is the cause of that illness. Insisting on flogging that patient with antimalarials is like signing a death warrant because they are not looking for the exact problem.
From your studies in the community, are there sociocultural and economic conditions that influence the steps taken in the care for malaria?
In our study of over 1000 caregivers, we came out with key, cogent findings. One, it is the mother that usually realises that a child is febrile first, so the mother must be educated on malaria management. Usually, at least 40 percent of the time, the father has to approve the treatment. So, it is important to carry fathers along. They all need to be taughT home management of malaria.
Patent medicine sellers (PMS) are available to the community members 24 hours, seven days a week. the PMS will allow community members whom they know to have medicine on credit. So, we cannot leave patent medicine sellers out of the education. The nearer home a child with malaria is treated, the better the outcome of treatment. That is why we have what is called home management of malaria.
Also, when a child on treatment improves, many mothers and other caregivers don’t complete the full course of antimalarial medicine. You know that because malaria is an infection before the parasite clears off the bloodstream, the child is better. A full dosage of antimalarial must be used and if the ACT used is Coartem, Lonart or any other brand that contains artemether-lumefantrine, it must be taken with a fatty meal to increase its absorption by the body. Two pieces of fried plantain, fried bean cake or bean porridge contain enough fat to ensure this. Full cream milk is another readily available source of fat that can be used to take the medicine. Half a sachet of powdered milk will do the trick. I have spent close to 15 years looking at home management of malaria. The best way to catch malaria is not in the hospital, but the severe cases will go to the hospital.
But often, people do want to go to the hospital because the waiting time is always long.
But they can be taught home management of malaria. It is so important because, in the local setting, complications of malaria-like severe anaemia and cerebral malaria are not considered a complication of malaria and the community member often believes that cases like these should not go to the hospital but rather the traditional healers.
In one of our studies, we have had to liaise with the traditional healers and the hospital and get them to cooperate to ensure mothers brought in sick children to get appropriate care. In Oke Ogun where we ran the study, we built enough rapport to get the traditional healthcare giver to quickly take that child to the nearest hospital and say “we have been told this is what we should do.”
Do you see Nigeria in the next few years achieving malaria elimination? Are there things to do to ensure this?
Elimination of malaria is still quite some distance away in Nigeria because we Nigerians like doing things our way. We have made progress and the prevalence of malaria has dropped significantly but we can do better by making artemisinin-based combination therapy available, and continuing public health education of all citizens so that we can all see this as a joint responsibility and not the responsibility of the government alone. To say that malaria elimination is on course, every suspected case must be documented and tested so that we know that we don’t have malaria in the country. We are still some distance away from that point.