The endless fight against malaria

Wednesday, April 25 will mark the World Malaria Day, an international observation commemorated every year in recognition of global efforts to control malaria, one of the biggest killer diseases in the world. It is a day when countries all over the world highlight the need for continued investment and sustained commitment for malaria prevention and control. The theme this year is “Ready to Beat Malaria” — a notion that encourages us to work together to find a solution for the illness. Dr Stephenson Musiime, a paediatrician at GLAMERC Polyclinic, Remera, says that malaria is transmitted through an infected female anopheles mosquito and that the bite of a mosquito can burst the red blood cells, which could also lead to anaemia. Dr Aimable Mbituyumuremyi, the Malaria and Other Parasitic Diseases Division manager, Rwanda Biomedical Centre, says that over the last five years, the cases of malaria have gone up in Rwanda in general, and in particular, Eastern and Southern provinces. Generally, Mbituyumuremyi says, the number of malaria cases grew between 2013 and 2017. He says that World Malaria Day is an opportunity for everyone to pay attention to the burden of malaria in the country, and combine efforts to respond accordingly, as the disease is a real threat to all age groups. DANGERS OF MALARIA A report released by World Health Organisation in January this year states that children under five years of age are one of the most vulnerable groups affected by malaria. In Africa, about 285,000 children died before their fifth birthdays in 2016. In high transmission areas, partial immunity to the disease is acquired during childhood. In such settings, the majority of malarial disease, and particularly severe disease with rapid progression to death, occurs in young children without acquired immunity. Severe anaemia, hypoglycaemia and cerebral malaria are features of severe malaria more commonly seen in children than in adults. Musiime says that children with malaria can have difficulty in breathing, and the kidneys may get infected, which could sabotage passing of urine. Dr George Ruzigana, a gynaecologist at University Teaching Hospital of Butare, says that malaria is a very dangerous disease for pregnant women because the parasite accumulates within the placenta and it can have far-reaching consequences for both the mother and the unborn baby – that is, it could lead to intrauterine foetal demise, if not treated on time. PREVENTION According to last year’s World Malaria Report by World Health Organisation (WHO), spraying the inside walls of homes with insecticides (indoor residual spraying, IRS) is a very important prevention measure; punctual diagnosis and treatment is the most effective means of preventing a gentle case of malaria from mounting to severity and or death. Ruzigana adds that prevention is better than cure, and suggests the draining of stagnant water because this is the habitat of mosquitoes. However, he warns that in the first three months of pregnancy, some medication should be used with caution due to the embryo’s development to avoid tragic consequences. Mbituyumuremyi says that malaria prevention is better than treatment and that the community should be the centre of prevention programmes. This can be through community work (Umuganda), religious meetings, and household visits by community health workers to educate family members on malaria control. Messages delivered through administrative meetings, education sessions before service provision at health facilities, among others, are great opportunities to enlighten people on malaria prevention, he says. Looking at the work of WHO in the African region, most people who seek treatment for malaria in the public health system receive an accurate diagnosis and effective prescriptions. Yet, access to the public health system remains far too low. National-level surveys prove that only about one third (34 per cent) of children with a fever are taken to a medical health centre. According to the WHO report, a minimum investment of US$ 6.5 billion will be needed annually by 2020 in order to meet the 2030 targets of the WHO Global Malaria Strategy. The Centre for Disease Control and Prevention Rwanda (CDC Rwanda) under the President’s Malaria Initiative (PMI) – a major U.S. foreign assistance effort – supports implementing malaria prevention and control interventions by providing long-lasting insecticide, mosquito nets and indoor residual spraying, preventing malaria in pregnant women, improving diagnostics and case management, surveillance, and monitoring and evaluation of malaria-related activities. Early this year, WHO launched a World Malaria Report mobile app that one can download and get data on the latest information on malaria policies, funding, and interventions. Through CDC, there is technical support and collaboration with a three-year bed net durability study to assess how long bed nets remain efficient in the field and when they should be replaced. However, the results so far indicate that over 50 per cent of bed nets become unproductive between 18 and 24 months due to holes, though the insecticide absorption remains moderately constant and effective. Through the National Malaria Control Programme, CDC has strengthened its monitoring capacity by ensuring timely and accurate collection of insecticide resistance data. CDC has also supported Rwanda’s transition in a new health management information system in health facilities, and a community information system to help track community health worker activities. Mbituyumuremyi says that key interventions for malaria prevention have been implemented, including distribution of bed nets through mass campaigns every two to three years, like the recent campaign in late 2016 to early 2017. “Also, there is distribution of bed nets to pregnant women through antenatal care services. Bed nets have also been distributed to public schools countrywide and indoor residual spraying in high malaria burdened districts like Nyagatare, Kirehe, Gatsibo, Bugesera, Gisagara, Huye and Nyanza is in place, there is also sensitisation of communities on malaria prevention countrywide,” he explains. Mbituyumuremyi says that the above prevention programmes have, and continue to make, great impact in malaria reduction. For example, Nyagatare and Kirehe are good examples where interventions contributed to a significant drop in malaria cases in 2016 to date. However, communities still need to be mobilised for instructions on proper use of the bed nets, outdoor control of mosquitoes and indoor residual spraying. He says that all communities should be sensitised on mosquito breeding sites and its control by removing bushes around their houses and closing windows and doors in the early evening. Early treatment is advisable to reduce the burden of severe malaria and mortality. Mbituyumuremyi says, “Mortality due to malaria constitutes a national burden, however, following the implementation of ‘Home Based Management of Malaria’ by skilled community health workers in all districts for all age groups since 2016, and free services to people in Ubudehe 1 and 2 since the end of 2016, the number of malaria deaths decreased by 48 per cent from 2016 -2017 and the number of severe malaria cases was at 35 per cent in the same period.” He says that today no one should die of malaria in Rwanda. He says that around 20 people die every month; and so communities should be sensitised on early diagnosis and treatment to get to a zero-death status with regard to malaria in Rwanda. TREATMENT Mbituyumuremyi says that the treatment of malaria in Rwanda consists of various anti-malarial drugs available at the community level and health facilities depending on the type or severity of malaria. It is always recommended and ideal to start treatment as soon as any clinical sign of malaria, such as fever or headache, appears. Malaria is confirmed by a rapid diagnostic test or microscopy to prevent any delay. Mbituyumuremyi cautions that medication should never be shared among family members with the same clinical signs, rather everyone should be tested and receive treatment per their age and weight to avoid any resistance to treatment. Like the theme suggests – “Ready to Beat Malaria” – Mbituyumuremyi advises Rwandans to fight harder to beat malaria. He believes that together, a Rwanda free from malaria is not just a dream. Experts share their views People with a weak immune system are easily attacked by malaria since the body cannot fight it. However, when one suffers from malaria, they need proper food depending on the dose of medication they are taking so that it speeds recovery. Since Coartem weakens one a lot, the patient needs to take fresh juice as it contains micro nutrients which increases the body’s metabolism. I also recommend foods rich in vitamin B, C and flavonoids to boost the body. For pregnant women, they should avoid foods rich in Vitamin A, because it has toxicity which can lead to a miscarriage or premature birth. Private Kamanzi, Dietician – Amazon Wellness centre, Remera ----- In pregnant women, malaria is more severe; there is a higher level of parasites in the blood. Malaria infection in pregnant women is associated with mortality and low birth weight. It also increases the risk of intrauterine growth complication. I advise pregnant women to always sleep under an insecticide treated net to reduce the chances of malaria, any holes in the nets should be sowed to hinder mosquitoes from entering the net. Dr Iba Mayele, Gynaecologist – Clinic Galien, Kimironko ----- Malaria can lead to complications like a coma (cerebral malaria), generalised convulsions (seizures), kidney failure, pulmonary oedema, hypoglycaemia, lactic acidosis, severe anaemia, disseminated intravascular coagulopathy, and haemoglobinuria, which can lead to mortality. Once malaria is confirmed by either a test or microscope, it is up to a trained health provider to prescribe anti-malarial drugs according to the severity, either on outpatient basis or admission. Dr Raymond Awazi, Paediatrician – Hospital La Croix Du Sud, Kigali editorial@newtimes.co.rw

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The endless fight against malaria