Posts or Comments 28 September 2021

Monthly Archive for "February 2018"



Case Management &Severe Malaria Bill Brieger | 27 Feb 2018

The Heart of the Malaria Problem

February is Heart Month in some countries. This is a good time to explore how malaria affects the heart and cardiovascular health.

In 1946 Howard Sprague observed that although “malaria is a disease from which no organ or tissue is exempt, this paper is concerned with its influence upon the circulation, and more particularly upon the heart itself.” He then outlined four ways by which this influence happens:

  1. its chronic and recurrent nature
  2. the systemic toxemia of the paroxysm
  3. the profound anemia produced by hemolysis and suppression of hemopoiesis
  4. the occlusion of capillaries and arterioles of the myocardium

Since that time other researchers have elaborated on malaria and the cardiovascular system.

Mishra et al. raise a concern that, “The role of the heart in severe malaria has not received due attention.” They point out the following:

  • hypotension, shock and circulatory collapse observed in severe malaria patients
  • raised cardiac enzymes in complicated malaria
  • compromised microcirculation and lactic acidosis as well as excessive production of pro-inflammatory cytokines
  • Intravascular fluid depletion associated with severe malaria leading to impaired microcirculation … among others

They conclude that “Sudden cardiac deaths can also occur due to cardiac involvement,” but worry that, “It is not feasible to assess the cardiac indices in resource poor settings.”

A study by Ray and co-researchers indicated “involvement of cardiovascular system in severe malaria as evidenced from ECG and echocardiography. The study also revealed that cardiovascular instabilities are common in falciparum malaria, but can also be observed in vivax malaria.” A fatal case of imported malaria where the sole finding revealed at the postmortem evaluation was an acute lymphocytic myocarditis with myocardiolysis was described by Costenaro and colleagues.

In another example, Onwuamaegbu, Henein, and Coats reviewed the potential role of malaria in chronic and severe malaria and the connection to chronic heart failure. They concluded that, “Our review of the literature suggests that there are significant similarities in the cachexia seen in CHF and that of malaria, especially as related to the effects of muscle mass and immunology.” Clinical manifestations in P. falciparum malaria also include reduced cardiac output as was reported in an imported case of malaria by Johanna Herr and co-workers.

Marrelli and Brotto note that, “Sequestration of red blood cells, increased levels of serum creatine kinase and reduced muscle content of essential contractile proteins are some of the potential biomarkers of the damage levels of skeletal and cardiac muscles.” They explain that, “These biomarkers might be useful for prevention of complications and determining the effectiveness of interventions designed to protect cardiac and skeletal muscles from malaria-induced damage.”

Not just malaria as a disease is involved, but also the medicines used to treat it. Ngouesse and colleagues draw attention to antimalarial drugs with cardiovascular side effects. They draw particular attention to the dangers of halofantrine, quinine and quinidine, but also note mild and/or transient effects of other antimalarials.

Guidelines exist for proper and prompt malaria case management, especially protocols for caring for patients with severe malaria. These and the medicines required must be more readily available to front line health staff. And of course is we are more diligent in preventing malaria through long lasting insecticide-treated nets and other measures, our worries about severe malaria and CVD complications will reduce.

Eradication &Migration &Surveillance Bill Brieger | 06 Feb 2018

Malaria Should Lead to Compassion, Not Hate

In August 2017 the ‘Almost Impossible’ happened decades after the last of local malaria transmission stopped in Italy. NPR shared news from the Italian newspaper Corriere della Sera that, “A 4-year-old girl has died of malaria in Italy, where the disease is thought to have been wiped out. Troubled health officials are looking for answers.” By coincidence, two children from an African nation were being treated for malaria in the same hospital where the deceased was being treated for diabetes. No epidemiological link could be found.

World Malaria Report: http://www.who.int/malaria/publications/world-malaria-report-2017/en/

Unfortunately that has not stopped anti-immigrant politicians from using the incident to foster hatred.  The political party of a “far-right extremist who wounded 6 African immigrants in a racially motivated shooting rampage in central Italy,” blamed the death of the child mentioned above “from malaria on migrants who ‘bring back to Europe’ once, eradicated illnesses.”

A new article in Malaria Journal reports that even though, “Malaria is no longer endemic in Italy since 1970 when the World Health Organization declared Italy malaria-free, … it is now the most commonly imported disease.”  The study from Parma, Italy reports that, “Of the 288 patients with suspected malaria, 87 were positive by microscopy: 73 P. falciparum, 2 P. vivax, 8 P. ovale, 1 P. vivax/P. ovale, 1 P. malariae and 2 Plasmodium sp. All samples were positive by ICT except 6. ”

Malaria can travel with anyone who has been in an endemic area, whether migrant,  tourist or business person. The likelihood of malaria re-establishing itself in currently non-endemic areas is low, but there is of course value in maintaining epidemiological and entomological surveillance world-wide in the current drive to eradicate the disease.

The identification of malaria anywhere in the world should be cause for concern and compassion, not hate and exclusion.

Advocacy &Borders &Children &Conflict &Costs &Epidemiology &Funding &Human Resources &Leadership &Monitoring &Mortality &NTDs &Partnership &Surveillance Bill Brieger | 03 Feb 2018

African Leaders Malaria Alliance Recognizes Country Achievements, Adds NTDs to its Scorecard

The 30th African Union (AU) Heads of State Summit at its headquarters in Addis Ababa, Ethiopia provided an important opportunity to bring the challenges of infectious diseases on the continent to the forefront. Led by the African Leaders Malaria Alliance (ALMA), two major activities occurred, raising greater awareness and commitment to fighting neglected tropical diseases (NTDs) and recognizing the contributions countries have made in the fight against malaria.

For many years ALMA has maintained Scorecard for Accountability and Action by monitoring country progress on key malaria interventions. It later added key maternal and child health indicators.  At the AU Summit ALMA announced that NTD indicators would be added to the scorecards which are reported by country and in summary.

The scorecard will now “report progress for the 47 NTD-affected countries in sub-Saharan Africa in their strategies to treat and prevent the five most common NTDs: lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminths and trachoma. By adding NTDs to the scorecard, African leaders are making a public commitment to hold themselves accountable for progress on these diseases.”

In the press release Joy Phumaphi, Executive Secretary ofALMA, explained that, “Malaria and NTDs both lay their heaviest burden on the poor, rural and marginalised. They also share solutions, from vector control to community-based treatment. Adding NTDs to our scorecard will help give leaders the information they need to end the cycle of poverty and reach everyone, everywhere with needed health care.” This will be an opportunity to demonstrate, for example, that, “In 2016, 40 million more people were reached with preventive treatment for at least one NTD than the year before.”

The combination is based on the logic that NTDs and malaria are both diseases of poverty. Malaria and several NTDs are also vector-borne. Also community platforms are a foundation for delivering needed drugs and supplies to tackle these diseases. Ultimately the decision shows that Heads of State are holding themselves accountable for progress in eliminating these diseases.

At a malaria-focused side meeting of the AU Summit Dr. Kebede Worku (Ethiopia’s State Minister of Health) shared that his government has been mobilizing large amount of resources to the fight against malaria which has led to the shrinking of morbidity and mortality since 2005. He also stressed that Africans should be committed to eliminate malaria by the year 2030. “Failing to do so is to repeat the great failure of 1960s faced at the global malaria fighting.”

The highlight for the malaria community at the Summit was the recognition of six countries that have made exemplary progress in the past year. The 6 countries that are leading the way to a Malaria-Free Africa by 2030 are Algeria, Comoros, Madagascar, the Gambia, Senegal, and Zimbabwe, recognized by ALMA for their sharp decline in malaria cases. Madagascar, the Gambia, Senegal and Zimbabwe Reduced malaria cases by more than 20 percent from 2015 to 2016. Algeria and Comoros are on track to achieve a more than 40 percent drop in cases by 2020.

H.E . Dr. Barnabas Sibusiso Dlamini, the Prime Minister of the Kingdom of Swaziland, whose King and Head of State is the current chair of ALMA, warned all endemic countries that, “When we take our eyes off malaria, the cost for our countries is huge. Yet if we increase our efforts to control and eventually eliminate malaria, the yield we get from it is tremendous. It is time that we dig deep into our pockets and provide malaria programmes with the needed resources.”

Mentioning the need for resources raises a flag that calls on us to be a bit more circumspect about progress. IRINNews notes that this is a critical time in the fight against malaria, when threatened funding cuts could tip the balance in an already precarious struggle. IRIN takes the example of Zambia to raise caution. They report that the results of malaria control and the government efforts have been uneven. While parasite prevalence among small children is down almost by half in some areas, many parts of the country have seen increases in prevalence

IRIN concludes that, “For now, the biggest challenge for Zambia will be closing the gap in its malaria elimination strategy, which will cost around $160 million a year and is currently only about 50 percent funded – two thirds from international donors and one third from the Zambian government. Privately, international donors say the government must spend more money on its malaria programme if it is to succeed.” Cross-border transmission adds to the problem.

Internal strife is another challenge to malaria success. “The recent nurses’ strike which lasted for five months may have cost Kenya a continental award in reducing the prevalence of malaria during the 30th African Union Summit in Ethiopia on Sunday.” John Muchangi in the Star also noted that, “However, Kenya lost momentum last year and a major malaria outbreak during the prolonged nurses’ strike killed more than 30 people within two weeks in October.”

Finally changes in epidemiology threaten efforts to eliminate malaria in Africa. Nkumana, et al. explain that, “Although the burden of Plasmodium falciparum malaria is gradually declining in many parts of Africa, it is characterized by spatial and temporal variability that presents new and evolving challenges for malaria control programs. Reductions in the malaria burden need to be sustained in the face of changing epidemiology whilst simultaneously tackling significant pockets of sustained or increasing transmission. Many countries like Zambia thus face both a financial and an epidemiological challenge.

Fortunately ALMA is equipped with the monitoring and advocacy tools to ensure that its members recognize and respond to such challenges. The Scorecards will keep the fight against the infectious diseases of poverty on track.