Malaria: living with a killer
25 April 2007
Malaria kills over a million people around the world each year. Children in Africa suffer the heaviest - they account for 75% of all global deaths from malaria. Every thirty seconds a child dies of the disease. Mothers are also at risk: in endemic areas, malaria is responsible directly or indirectly for 30% of maternal mortality. But these deaths should not be happening, as malaria is largely a preventable, detectable and treatable disease. Every year, MSF treats over two million malaria patients around the world. In almost all our projects in tropical areas, we are faced with malaria, whether the programme focus be on HIV, basic health care or reproductive health. What is malaria? "I've only had malaria once. It was back in 2003. I was very, very sick. My fever started at midnight and by the morning I couldn't walk. There were no doctors here at that time, there were some volunteers but no real doctors. My brother and wife took me straight to hospital. My brother took me on the back of his bike to the hospital, which is 30 miles away. It took eight hours to get there and I drank five litres of water on the journey. When we arrived the doctor gave me an injection. I was passing a lot of urine and had a problem with my spinal cord. Then I fell unconscious." Martine Okeny, 40, Uganda The deadly malaria parasite - plasmodium falciparum - enters the human host when an infected Anopheles mosquito takes a blood meal. Malaria symptoms appear about 9 to 14 days after the infectious mosquito bite, although this varies with different plasmodium species. Typically, malaria produces fever, headache, vomiting and other flu-like symptoms. It is a major cause of illness and absenteeism from school and work. In severe cases children can suffer from convulsions, severe anaemia, and - provided they survive - can suffer from long-term neurological outcomes such as blindness or speech disorders affecting their ability to develop and benefit from education. Pregnant women too are particularly vulnerable. If drugs that are effective against the parasite are not available for treatment, the infection can progress rapidly to become life-threatening. Malaria is treatable: ACTs There is no secret about the best treatment for malaria in Africa today. Older drugs such as chloroquine or sulfadoxine-pyrimethamine (SP,often known as FansidarÃ?®) have grown increasingly ineffective when used alone in monotherapy, as the malarial parasite has become resistant to their action. Now newer combination treatments using artemisinin derivatives such as artesunate have stepped up to the challenge. "Before I worked for MSF I used chloroquine and Fansidar (SP) to treat malaria. About five out of ten of my patients wouldn't respond to these drugs and would come back so I would give them quinine and if they were severe cases I would give it to them intravenously. Now I'm working for MSF I often see patients who have taken chloroquine and fansidar. They come to the MSF clinic because they take these drugs and there is no improvement. Here we use the ACT, Coartem, it's a good drug without so many side effects, but it's very expensive." Robert Aniku (25) MSF Clinical Officer, Uganda The advantages to using these artemisinin-based combination therapies (ACTs) - low toxicity, few side-effects, easy patient-friendly treatment, rapid action against the parasite - are well known, and are widely validated scientifically. And ACTs have received the policy stamp of approval for 1st line treatment too: in 2001, the World Health Organisation (WHO) declared ACT the preferred method for treating malaria. In 2004, the Global Fund announced it would no longer fund treatments for malaria that were known to not work. Today, out of 54 African countries, 41 have officially changed their protocol to treat first-line malaria with artemisinin-based combination therapies. MSF uses ACT in all its programmes and has been advocating for ACTs since 2001 and by showing the high level resistance of older drugs through many studies conducted throughout Africa. Malaria is detectable: rapid diagnostic tests Diagnostic tools which are swift and accurate are also available. These are essential to ensure that only those that need treatment are actually prescribed the drugs. Not using diagnostic tools comes down to treating patients with what you think they might have, rather for what you know they have. Today, some of these tools, including blood pinprick tests such as ParacheckÃ?®, are adapted for use in remote areas - as they are reasonably solid, are easy to use, give fast results that are simple to interpret, and don't require much training or any heavy equipment or laboratory. MSF uses confirmed diagnosis, either through rapid tests or through microscope examination in laboratories, in all its malaria programmes. This is not the case in many places, though. "The majority of people who come to the clinic have malaria. We diagnose them clinically, if they have a fever or the chills, loss of appetite or vomiting then it's probably malaria. We don't do blood tests. We have just finished building a laboratory but at the moment we have no laboratory assistant. We don't use parachecks, I've seen them in the MSF clinic but we don't have them here. The Ministry of Health says they're too expensive." Irene, Ministry of Health nurse, Uganda Malaria is preventable Despite some promising developments, an effective vaccine is still years away. But there are other ways of battling this killer. Sleeping under insecticide-treated bed nets can save lives. Houses can be sprayed with insecticides. Unfortunately, many children, especially in Africa, continue to die from malaria as they do not sleep under these nets - mainly for reasons of cost. Most recent data on household use of insecticide-treated nets reveal low coverage rates of only around 5 per cent across Africa. There are however now signs of real progress in some African countries in their attempts to scale up the use of nets. And yet, malaria is resurgent In 1998, a global partnership was formed to combat the disease. The Roll Back Malaria (RBM) initiative set up by WHO, UNICEF, the World Bank and others, pledged in 2000 to cut malarial deaths by half before 2010. We are totally off target. In fact, things are actually getting worse. Nine years after the creation of RBM, the tide has not been turned on this global killer. Although it's hard to deliver a clear picture of the global scene following the arrival of ACT treatments, galloping resistance to existing treatments indicate that the spread of the disease continues unabated. "I brought my daughter here because she's not well. She has diarrhoea and a high fever. When we got here they weighed her and took her temperature. They did a blood test and told me she has malaria. Now I have some different tablets for her and I'm very happy because my baby will be cured." Betty Acayo (30) and her daughter Atimango Fioner Acayo (17 months), Uganda Crucially, though, the effects of this radically improved malaria diagnosis and treatment have yet to be felt in most places. In many places where MSF works, ACTs are hardly available outside our own projects. The global need for ACTs is estimated to be at 300 to 500 million treatment courses. Last year, however, drugs for less than 90 million treatments were bought worldwide. The problem extends to diagnostics: today, diagnosing malaria based on clinical symptoms alone and not by microscopy or rapid test, is still the norm in many places. This means mistakes are often made in diagnosis and people are given anti-malarial drugs even though they are not infected. An MSF study carried out in southern Sudan showed that seven out of ten cases could have been wrongly diagnosed as suffering from malaria. Treating these patients unnecessarily with anti-malarials means the real reasons for their fever is missed and left untreated. MSF ensured that of the more than two million treated for malaria in its projects in 2003, all were first properly diagnosed for the disease. Despite these promising tools, malaria statistics still make desperate reading. MSF is currently conducting research into why, despite the existence of treatments that work, millions of people are continuing to die needlessly of this curable disease.