Resurgence of Malaria: Impending Threat & Role of Medical Officers
Malaria is a potentially fatal disease causing severe epidemics. It is endemic in more than 100 countries worldwide causing disease and deaths for millions. According to the latest WHO estimates, released in December 2015, there were 214 million cases of malaria in 2015 and 438 000 deaths.
Malaria has been endemic in Sri Lanka for centuries and associated morbidity and mortality has incurred billions of rupees affecting the country’s development and economy. Sri Lanka has achieved a remarkable success by eliminating malaria from Sri Lanka. The last Indigenous case of malaria was reported in October 2012. Although indigenous transmission of malaria has been controlled, Sri Lanka still gets imported malaria cases mainly from India and African countries. At present Sri Lanka is challenged with maintaining the achieved success as the potential for malaria resurgence is high as in the past due to presence of vector and increased migration to and from malaria endemic countries. There were 36 imported malaria cases in 2015, which includes 17 cases each of Plasmodium vivax and Plasmodium falciparum and two cases of Plasmodium ovale. In 2016 there were 14 cases of imported malaria up to March 2016.
Clinical Vigilance
| Don’t forget to get the Travel History from all Fever Patients |
Vigilance of Medical community becomes the key determinant in Prevention of Reintroduction of malaria in the current context. Malaria Case Investigation analysis revealed that there were several occasions of delayed diagnosis, leading to development of severe malaria, while the patient is being in the health institutions. Missing a malaria diagnosis in a patient can have negative consequences in three ways. Firstly, it is likely to threaten the life of the patient. Secondly, it can hinder the credibility of our medical profession with regard to accurate diagnosis and delayed treatment and thereby failing to fulfill professional responsibilities towards individual patients. Thirdly as citizens, we have a corporate responsibility towards Prevention of reintroduction of Malaria in Sri Lanka.
| High risk groups for imported Malaria
· Armed Force personnel in UN peace-keeping missions /training in malaria endemic countries · Businessmen frequently travelling to India & other malaria endemic countries · Gem businessmen travelling to Mozambique & Madagascar · Travelers (local & foreign) to & from malaria-endemic countries · Sri Lankan Returnees from South India |
It is important to ask overseas travel history during the past one year, from all fever patients and exclude possibility of malaria. In addition, attention should be focused on risk groups mentioned.
Diagnosis
If you encounter any person from above mentioned risk groups, then immediately suspect and investigate for malaria. The gold standard diagnostic method is quality assured microscopy. However Rapid Diagnostic Test Kits which provide malaria species diagnosis within 20 minutes, are also available in selected government hospitals and in private sector.
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Once Malaria has been diagnosed, treatment should be started as early as possible to prevent development of severe malaria. Laboratory confirmation by microscopic examination of blood smears and/or Rapid Diagnostic Tests (RDT) is mandatory prior to initiation of anti-malarial treatment. Presumptive treatment with antimalarial drugs is no longer recommended. The treatment guideline has been revised in 2014 and is available in Anti Malaria Campaign web site http://www.malariacampaign.gov.lk/
Malaria treatment depends on the species of the malaria parasite; whether it is mono infection or mixed infection; severity of the dieses condition and the physiological state of patients.
For mono infection with Plasmodium vivax, the recommended drug is chloroquine followed by primaquine for 14 days to remove liver forms. For Plasmodium falciparum, Artemisinin based Combination Therapy (ACT) is recommended with single dose of primaquine. For severe malaria intravenous Artusunate is recommended as the first line therapy.
Inform All Suspected Malaria cases to AMC hot line immediately
0117 626 626
071 284 1767
Once a suspected case of imported malaria has been identified, the AMC conducts a series of activities to prevent onward transmission leading to resurgence. These activities include, confirming the diagnosis; providing information & necessary drugs; contact tracing & screening for asymptomatic carriers; entomological investigation to investigate possibility of onward transmission through vector mosquitoes, etc. Prompt notification to Anti Malaria Campaign (AMC) is vital as these activities need to be conducted within one-two weeks of identification of a case to prevent a possible outbreak. Please inform AMC via 24 hour hot line 0117-626 626 or 071-2841767
Prevention
| • Prevent mosquito biting when you are traveling in malaria endemic countries
• Get chemoprophylaxis from AMC |
Persons planning to visit a malaria endemic country, should be armed with necessary information on risk for malaria and malaria chemo-prophylactic drugs as necessary. These persons should be referred to AMC/ Reginal Malarial officers at least one week before leaving the country. Once referred, the risk is analyzed for contracting malaria during his/ her overseas stay, the necessary information and services will be delivered free of charge. Weekly doses of chloroquine or mefloquine is recommended as malaria prophylaxis depending on the country of visit. These prophylactic drugs should be started one week before leaving Sri Lanka and should be taken throughout the stay in the malaria endemic country and 4 weeks after returning to Sri Lanka.
Any fever up to one year after returning to Sri Lanka, from a malaria endemic country, should always be considered as malaria until proven otherwise.
Sri Lanka is applying for WHO certification as a malaria free country in 2016. Contribution of clinicians by early diagnosis, correct treatment and notifying malaria cases to Anti Malaria Campaign is crucial for this process.
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