Malaria case studies - Burundi

Case studies - Burundi Saturday afternoon in Makamba, Burundi Alfred, a consultant nurse, works for MSF at the Nyantakara mobile clinic in the Makamba province in Burundi. He conscientiously carries out rapid diagnostic tests on the numerous patients who come in with symptoms of malaria. He's diagnosed and treated many cases of malaria in Makamba. One Friday, during his work day, Alfred feels weak and feverish. He asks another nurse to test him for malaria - the result is positive. But Alfred doesn't mention it to the MSF doctor - he knows that he can't take artemether or artesunate with amodiaquine, the combination treatment that could cure him , because the national authorities have strictly forbidden MSF doctors to use these drugs. So he keeps quiet and continues to work. That evening, greatly weakened, Alfred decides to take oral quinine - he knows that Fansidar, the antimalarial prescribed according to national protocol, isn't effective. He hopes that the quinine will cure him so that he can go back to work on Monday. But on Saturday morning, Alfred doesn't feel any better. The previous day, he already felt very weak and couldn't eat. He takes his second dose of quinine on an empty stomach, and promptly falls into a coma. A consultant nurse alerts Laura, the MSF doctor, as she returns from her consultations at the hospital. She rushes to Alfred's bedside and starts a 10% glucose drip with the necessary quinine dose, then quickly administers 50% dextrose. Alfred wakes up and Laura stops the quinine treatment. As she is not allowed to prescribe an artemisinin-containing combination, a friend of Alfred's goes to a pharmacy and buys the treatment for him. "Quinine is reputed to be particularly effective, but it didn't act fast enough for Alfred," Laura explains. "That's why his symptoms got worse. It's also possible that Alfred had hypoglycaemia, which is a common side-effect of quinine when it is taken orally - it is usually injected, so the nurse can check the patient for side-effects. If Alfred had taken an artemisinin-containing combination, his symptoms probably wouldn't have got worse: artemisinin derivatives act very fast and have a very strong effect on the parasites. They are also easily tolerated and don't cause hypoglycaemia." Alfred still works for MSF. He didn't suffer any after-effects from his bout of malaria. Cécile, a little one-year old girl, is brought in by her mother to the health centre supported by MSF. Her temperature is over 39°. She is very tired, has a cough and has stopped eating. The MSF team carry out a rapid diagnostic check - it's positive: Cécile has malaria. That day, the child is kept in medical care, but no matter how much we insist, her mother refuses to allow us to admit Cécile into hospital. She decides to take the child home with her during the afternoon, taking with her some quinine, paracetamol and antibiotics. Cécile and her mother return the following day for a check-up. Cécile is well, but as a precaution, we again advise to take her into medical care. But Cécile's mother refuses again, explaining that she has other small children whom she cannot leave at home alone. Cécile will have to continue her treatment at home. A week later, the mother brings Cécile back - she has fever again. When we question her mother, we realize that Cécile wasn't taking the treatment correctly. Although she ate well, she would vomit immediately after taking the medicines. Once again, her mother insists on taking Cécile back home with her. We decide to try again with oral quinine tablets. But a few days later, Cécile and her mother are back for the third time. We carry out a full blood test which confirms the presence of the Plasmodium falciparum parasite. This time, Cécile's mother has allowed her to be taken into medical care. She will go to a private health center where she will be treated with artemisinin derivatives under medical supervision. Cécile is now well. Théodore is a nurse in an MSF health centre. One day, he develops all the symptoms of malaria. A rapid test confirms the diagnosis, and oral quinine is prescribed. But the next day, Théodore is so dizzy he has to keep steadying himself against the wall as he works. He explains that he doesn't want to continue taking his treatment, because he is unable to work. But without treatment, he will get worse. The medical team advises him to take an artemisinin-containing treatment, which he goes and buys for himself. The next day, he is already a lot better. He is able to go back to work and continue his daily routine as usual.