Preventative measures are needed to reduce the high numbers of infected patients in the past 2 years in Limpopo, writes Dr Tendani Matoro
EVERY year, malaria catches us off guard as if it is our first battle (against it). The November to April high risk period seems to bring more challenges to the NorthEastern parts of South Africa.
Health professionals from Kwazulu-Natal, low altitude areas of Limpopo and Mpumalanga (especially those bordering Zimbabwe, Mozambique and Swaziland) know the struggle of high patient volumes and medication shortages during the high risk malaria season.
Perhaps preventative measures need to be strengthened, again, to decrease the recent high volumes of infected patients during the past 2 years in Limpopo province.
One would hope that the overall outcome still remains better in patient complications and malaria death toll.
The South African Malaria Treatment Guidelines advocate for malaria elimination through patient and health care worker alertness and vigilance:
encouraging early treatment seeking within 24 to 48 hours
maintaining a high index of suspicion to ensure prompt diagnostic testing of all patients with malaria symptoms who are resident in, or have recently travelled to, a malaria area;
in those who test malaria positive, assess disease severity and start effective treatment immediately depending on disease severity;
notify each and every case (including all imported cases in nonendemic areas) and
monitor adequacy of response to treatment.
Malaria signs and symptoms can be very broad and non-specific. Fever, feeling cold, sweating or shivering, seen in malaria, can also point to a viral or bacterial infection. Being generally ill, weak, tired, joint or muscle pains are also non-specific
Special Groups features.
Some may present with loss of appetite, abdominal pains, nausea or vomiting. Children may simply refuse to eat and sometimes have a flu-like illness.
A high index of suspicion and early presentation at a health facility leads to a relevant diagnosis.
In an ideal situation, all malaria patients can be treated in hospital or get high level daily monitoring at their local clinics. Besides our limited resources, insufficient medical staff and outlying rural settlements, we still make up for our shortcomings. The following patients are considered for hospital admission: with danger signs high risk groups severe malaria suspected treatment failure (malaria parasites seen again within 6 weeks of treatment)
Danger signs can safely be picked up at home. An adult or child presenting with these should be rushed to a health care centre:
unable to drink or breastfeed (children) repeated vomiting recent history of convulsions (fits) lethargy (extreme weakness or tiredness)
unable to sit or stand
Pregnant women, young children, older people and HIV positive people are considered high risk groups. These individuals are at risk of developing severe malaria compared to the general population.
Our greatest fear with malaria is its severe form.
The associated complications can rapidly lead to death if inappropriately managed.
Certain complications can sometimes result in neurological deficits and chronic disability. Cerebral malaria can mimic meningitis or a stroke.
Recurrent fits related to this complicated form of malaria can cause irreversible brain damage. Impaired consciousness or sustained decreased consciousness (coma) can also result from cerebral malaria.
Organ system failure involving the kidneys can cause fluid retention with pulmonary oedema (water in the lungs).
Decreased urine output is a bad prognostic sign of renal failure.
Fast breathing is sometimes related to the pH imbalance in the body without a lung infection or pulmonary oedema. Falling kidneys will also fail to maintain a normal blood pH range.
Liver damage or failure may present with yellow eyes (jaundice) as a complication of malaria.
With extensive liver damage, the body struggles with maintaining good blood sugar levels leading to recurrent hypoglycaemia.
Bleeding may be exaggerated with liver failure, as the clotting process is regulated by the liver.
Circulatory (cardiac and vascular system) failure is multifactorial, resulting in shock.
When one’s blood pressure and heart rate (pulse) are not adequate to sustain normal bodily functions, that’s the meaning of physiological shock.
Loss of fluids, from sweating, high fever or other factors, mixed with kidney damage and the malaria and other infections in the blood (sepsis) contribute to circulatory failure. Malaria also destroys red blood cells causing anaemia.
Anaemia also significantly impacts on the circulatory system, negatively.
These are some of the features of severe malaria.
Those who are assessed as uncomplicated malaria and discharged home should be aware of these complications. Uncomplicated malaria can rapidly progress to severe malaria if one does not take treatment well.
Key patient information for outpatient treatment should include the following (The South African Malaria Treatment Guidelines):
Take all doses as directed, even if feeling better before treatment is completed. Artemether-lumefantrine (standard treatment used for malaria at government facilities in South Africa, also known as Co-Artem®) should be taken with a fat-containing meal or drink
It is important that the patient drinks enough fluids and takes paracetamol to treat their fever. Anti-inflammatories (like brufen etc.) should be avoided.
To expect improvement of symptoms within 24-48 hours and to return to the health facility if they remain unwell or their temperature is not settling by day three
To return to the health facility immediately if vomiting, or if the patient deteriorates in any way (e.g. becomes sleepy, confused, jaundiced)