Colorado Travel Health

MALARIA IN INDIA

Written by Roxanne Royce from Colorado Travel Health www.coloradotravelhealth.com.
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Incidence

From Jan-April 2009, India reported .27 million cases of malaria and 180 deaths. In Mizoram India alone, an estimated 119 deaths were reported in an outbreak between January and October last year (2009).

Areas of India with Malaria:

It is present all throughout the country (including Delhi and Bombay/Mumbai) except in areas >2,000 m (>6,561 ft) in Himachal Pradesh, Jammu, Kashmir, and Sikkim.

Worldwide yearly incidence:

350–500 million infections worldwide and approximately 1 million deaths. Transmission is in large areas of Central and South America, parts of the Caribbean, Africa, Asia (including South Asia, Southeast Asia, and the Middle East), Eastern Europe, and the South Pacific. An interactive map at http://www.cdc.gov/malaria/map/index.html can be viewed for identifying areas around the world with malaria.

Infectious Agent

Malaria is caused by an organism called a protozoa from one of the four species of the genus Plasmodium: P. falciparum, P. vivax, P. ovale, or P. malariae. (Recently another parasite, P. knowlesi, from Old World monkeys has been linked to human infections and some fatalities in Southeast Asia. It is currently being investigated to determine its extent of transmission to humans). In India about 40% of the infections are due to P. falciparum which causes the most severe infection and without treatment is fatal. P. vivax accounts for about 40% of infections and although it can cause a reoccurring illness, is fatal only about 1% of the time. (P. ovale accounts for only 4-8% of infections and P. malariae less than 1%).

Mode of Transmission

Malaria is transmitted by the bite of an infected female Anopheles mosquito. Transmission can also occur with a blood transfusion, organ transplantation, contaminated needles, or congenitally (mother to fetus).

Clinical Presentation

The most typical signs & symptoms include the following:

Fever
Flu-like symptoms
Chills (sweating and shivering)
Aching muscles
Headache
Malaise
Tiredness and fatigue
Anemia
Jaundice (yellowing of the skin & whites of eyes)

One may, however, not have all of the above signs & symptoms and sometimes have just one. Symptom onset can develop as early as 7 days (usually at least 14 days) or it can be delayed significantly (many months) after the time of exposure. In severe disease (if left untreated or not treated early), mental confusion, seizures, kidney failure, acute respiratory distress syndrome (ARDS), coma and death can occur.

Diagnosis

Those with symptoms of malaria (even fever alone) should seek medical evaluation as soon as possible. Viewing a blood smear under a microscope (smear microscopy) remains the gold standard for malaria diagnosis. Correct identification of the species of malaria and the quantification of parasitemia is accomplished with microscopy which ensures the appropriate treatment. Rapid diagnostic test kits (RDTs) can detect antigens from malaria parasites in 2-15 minutes. However, only one such test is approved by the FDA (BinaxNOW), produced by a diagnostic company in Maine and is approved for use by hospital and commercial laboratories only.

Treatment

Prompt treatment ensures its effectiveness especially when a delay can result in serious or even fatal consequences. The specific treatment regimen will depend on the particular species of malaria, possible drug resistance, the degree of infectivity, pregnancy status and the age of the patient. Finding a provider who specializes in tropical medicine or infectious diseases is optimal. Recommendations for treatment: http://www.cdc.gov/malaria/diagnosis_treatment/treatment.html. Travelers, if possible, should be discerning with the treatment meds. Halofantrine (Halfan), for example, is not recommended due to its possible serious and sometimes fatal side effects. One should also be aware that in some places such as sub-Saharan, the rate of false-positive blood films for malaria may be very high. Patients are often diagnosed and treated for this illness at the expense of being treated for their actual infection.

Self-Treatment

Some travelers might be candidates for self-treatment whether they are or are not taking anti-malarial meds chemoprophylactically. Travelers may either refuse to take chemoprophylaxis or decide to take a questionable anti-malarial medicine. Some may be taking effective prophylaxis, but touring in remote areas. In both scenarios, they should be instructed to take their self-treatment if they have fever, chills or other influenza-like illness (and if 24 hours or more away from a clinician). Self-treatment, however, does not eliminate the need for follow up care with a provider as soon as possible. Atovaquone/proguanil (Malarone) can be used for presumptive self-treatment only if they aren’t already taking it prophylactically. The CDC Malaria Branch has a hotline (770-488-7788) to advise clinicians.

Preventive Measures for Travelers

Since chemoprophylaxis does not provide 100% protection, various mosquito avoidance measures are also recommended.

Mosquito Avoidance Measures

The mosquito which transmits malaria (Anopheles mosquito) feeds mostly from dusk to dawn so more precautions should be taken in this time frame. This can be achieved by wearing long-sleeved shirts and pants (treated with permethrine); using bed nets (preferably treated with permethrine); staying in accommodations with screened windows and air conditioning; and spraying one’s room with a pyrethroid-containing flying-insect spray. DEET or Picaridin can be used for one’s exposed skin. The DEET concentration should be between 20 and 35% and can be found in 20% extended release concentrations.

Chemoprophylaxis

All available medications are taken before during and after travel, but the duration and/or intervals of the various regimens vary with each medication. Determining which chemoprophylactic regimen before travel is not necessarily country specific, but rather region specific. Some areas might be hyper-endemic, others areas might have no risk and some areas might be resistant to a particular medicine. (And one's clinician will identify any possible contraindications). Sometimes travelers choose to obtain chemoprophylactic medications while abroad, but this should be h3ly discouraged. Medications might contain contaminants (and be dangerous); be counterfeit or be produced with substandard manufacturing practices.

References

CDC. Malaria. [Cited 2010 April 30]. Available from: http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/malaria.aspx

Written by Roxanne Royce from Colorado Travel Health www.coloradotravelhealth.com. You should follow me on twitter