A focal point for malaria should be added to the National COVID-19 task force

Dear Editor,

We write to follow up on the letter about COVID-19 published in the press on Saturday 9th May. Our intention then was to provide an additional source of information for the public at large. We commented on COVID-19 at the Palms Geriatric Home and the need, if not urgency, for testing of those asymptomatic persons in the atrisk population.

We also pointed out the urgent need to intensify contact tracing at the Palms and other institutions. This urgency is now immediate as we just learnt that there are 5 COVID-19 cases and one death at the Home. We should have trained persons to help the additional five cases recall with whom they have had close contact for the past few weeks. The porters, nurses, maids, doctors, and nurses who dealt with those patients should be encouraged to stay at home and maintain their distance from others for 14 days.

Visitors were not named in that group, as the assumption is that they were all truly banned as of April 2, last, and we hope that living in a society where most people know somebody, a ‘quick visit’ was very few and far between. The gatemen are not to be blamed but need to be educated, informed, and supported to understand their role, the risk to them, and the risk to which everyone else is placed.

To assist in this endeavour, we suggest the use of former, now treated psychiatric patients as gatemen. No one is to be allowed, not even politicians, to enter the home without a pass. At the same time, a list of names and addresses of all who enter the compound, will facilitate future (contact) tracing.

All residents and staff should wear masks and the residents, some of whom may be in the early stages of dementia, informed of the need to maintain a six foot distance from each other as well as the reasons why face cloths or masks are to be worn at all times.

There is without doubt a pressing need to organize social partners to assist in preventing the spread of the virus. Our elderly population deserve better from us.

Having dealt with the Palms Geriatric Home, we need to turn to the interior of the country, where most of our Amerindian population reside, gold mining is lucrative, and malaria is ever present. As they say in Suriname, ‘looking for gold, finding malaria’. We may have to adapt that to ‘looking for gold, finding Malaria and COVID-19’.

On May 12, news outlets carried a story from Lethem, Region 9, where a dual Guyana-Brazil citizen was feeling unwell, had a test for both malaria and COVID-19 and was found to be positive for COVID-19. He escaped from the Lethem hospital and was subsequently reached at his home in Bom Fim, just across the border separating Guyana and Brazil.

Detection of COVID-19, can be done in two ways, first by detection of the virus itself using a technique referred to as reverse transcription-polymerase chain reaction (RT-PCR), and by the detection of antibodies to the virus in the blood. To detect the virus, a swab (an extended cotton bud), is used to retrieve a sample of mucus from the nose or throat of the suspected case, depending on the amount of virus present, the sample may or may not have the virus.

The RT-PCR can detect exceedingly small amounts of virus in the body, even before symptoms appear. It is clear therefore, that the PCR test can detect the virus, if only the sample is properly collected. That is the reason why the test should be undertaken by someone trained in laboratory practices.

On the other hand, antibody tests are done on infected persons and can be detected in the persons’ blood. The antibodies become detectable about 7 days after being in contact with the virus and are detected as IgM (Immunoglobulin-M). After 14 days of initial contact with the virus, the body produces Immunoglobulin-G (IgG) which remains in the body and, (if COVID-19 behaves like most viruses), is expected to produce immunity to the disease for a long period afterwards. That is the logic behind asking people

who have been exposed to the virus to remain isolated from other people for 14 days, ensuring no further transmission or development of symptoms of the disease.

Conversely, there are some people who may have been exposed to exceedingly small amounts of the virus and can be asymptomatic. Hence the reason for isolation of those persons to reduce greater exposure to, and spread of, the virus.

Hopefully, we can now understand why we have been asked to stay at home, to use a mask when venturing out and to stay at least 6 feet away from strangers. Results of the Covid-19 test could be available in as few as a day or two.

Malaria can occur with many other infections, COVID-19 being one of them. A suspected or confirmed case of COVID19 should also receive a malaria test in areas where malaria is endemic.

The symptoms of COVID-19 are varied and include Fever, Cough, Shortness of Breath, Difficulty Breathing, Chills, Muscle pain, Headache, Sore throat, redeye, diarrhoea, recent loss of taste or smell, persistent pain or pressure in the chest, confusion or inability to wake up easily, bluish lips or face due to reduced oxygen. Based on that list, those who have had malaria would realize that the symptoms of COVID-19 and Malaria are remarkably similar.

Uncomplicated malaria is caused by one of five parasites worldwide and principally from two found in Guyana, Plasmodium vivax and Plasmodium falciparum. Either of these cause infected persons to become extremely sick with high fever, chills, and a flu-like illness.

Symptoms of the two diseases are similar but can vary to a different degree; patients may have a headache, sweats, nausea, vomiting, body aches and general malaise. When malaria becomes severe, as those who have worked in the gold mining areas of Guyana are aware, it is often caused by P. falciparum. It can result in what is known as severe malaria, with abnormal behaviour, impairment of consciousness, seizures or a coma and also an acute respiratory distress syndrome (ARDS) an inflammatory reaction in the lungs (very similar to COVID-19).

As the COVID-19 pandemic spread, there was lots of discussion about the use of Hydroxychloroquine and Chloroquine to treat cases of the disease but these drugs have not been proven scientifically for use in COVID-19 and are not recommended by the World Health Organization or the Centers for Diseases Control of the USA.

On the other hand, Chloroquine is an excellent antimalarial drug, in fact it is the first line of treatment for Plasmodium vivax malaria in combination with Primaquine. In Guyana, where Plasmodium falciparum has been shown to be resistant to Chloroquine, the first line of treatment is the Artemisinin-based Combination Therapy (ACT) known as Coartem (tablets containing Artemether and Lumefantrine) and a single dose of Primaquine.

The false belief that malaria cannot be cured is because relapses can occur if treatment is not taken completely. That is why we insist that a person with P. falciparum takes a complete 3-day treatment of ACT’s while someone with P. vivax must take the entire 14-day treatment of Chloroquine and Primaquine.

So, what, and how do we now deal with two similar diseases COVID-19, caused by a virus, and Malaria, caused by a parasite principally in the interior of the country; and as reported of the case in Lethem, among those who travel to and from the interior and can spread COVID-19?

We suggest, if not already in place, that a focal point for malaria be appointed on the National COVID-19 task force.

That person could help ensure a rapid response to patients with malaria prevention and management in areas affected by malaria and possibly COVID-19. The presence of someone with knowledge of malaria would be to identify endemic areas and ensure access to management of those suspected with the disease at health facilities and communities. Additionally, to estimate the number of diagnostic facilities needed and the population to be served (with Rapid Diagnostic Tests in preference to microscopy for those suspected of malaria), and to identify the logistical needs to ensure coverage on a very timely basis. The result of the malaria test is available in less than an hour.

The tests for malaria and COVID-19 are different. Malaria can be detected either by use of Rapid Diagnostic Tests (RDT’s) or by microscopy, through a finger prick for a blood sample. The tests for COVID-19 are a bit more complicated, with a carefully taken nose or throat swab for detection of the virus (RT-PCR) or a draw of blood for detection of antibodies.

Additionally, there should be an estimated number of tests and treatment needed, Chloroquine and Primaquine for confirmed P. vivax malaria cases and of Coartem (Artemether-Lumefantrine) and Primaquine for treatment of P. falciparum.

Clinicians and epidemiologists should work together to use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether that patient should be tested.

Asymptomatic infections with COVID19 have been reported and epidemiologic factors such as known exposure to an individual who has tested positive and occurrence of local community transmission can be used to provide guidelines for testing. We must ensure malaria testing in known malaria endemic areas as infections can result in death if tests and appropriate treatment are not readily available.

The recommendation from WHO and CDC is that priority for a COVID-19 test be given to older adults and people of any age group who have serious underlying medical conditions, inter alia, persons on treatment for cancer; those with chronic lung conditions; severe asthma; diabetes, chronic kidney and liver disease etc. We should not forget monitoring of prisons and other shelters for persons with symptoms of the disease.

Let us also not forget the extreme vulnerability of our (older) Amerindian population as we strive to contain and eliminate the spread of these two diseases.

Yours faithfully, Keith H. Carter, MD Bhiro Harry, MD Pedro Pons, MD

Raj. N. Mungol, MA