MAN­AG­ING MALARIA

Pre­ven­ta­tive mea­sures are needed to re­duce the high num­bers of in­fected pa­tients in the past 2 years in Lim­popo, writes Dr Ten­dani Ma­toro

African Times - - Perspectives - Dr Ten­dani Ma­toro is a Med­i­cal Doc­tor (MBChB, UCT), Gen­eral Prac­ti­tioner (Polok­wane), Clin­i­cal Ad­vi­sor (Ad­vanced Clin­i­cal Care HIV/Aids and TB), So­cial Com­men­ta­tor (News24 and Word­Press Blog) and Med­i­cal Colum­nist (African Times news­pa­per)

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.

Elim­i­na­tion

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.

Pre­sen­ta­tion

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.

Se­vere Malaria

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)

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