Don't get malaria in the US!

If you have to get malaria, you might be better off getting it in Nigeria than in the US. I've been in North Carolina this week for the SIM International Workshop on Information Technology. A couple of my old friends, who now live here, told me about their niece (I'll call her Anita) who had recently been to Africa and now had been sick with malaria-like symptoms for some time. By the time they were telling me, Anita had been admitted to the ICU and the doctors were still puzzling over her condition. An infectious disease specialist had been called in but there was still no diagnosis. All the tests, including those for malaria, had been negative. We talked about the probability that Anita had malaria ... that's just what people get when they're in Africa. Sure, you can argue about how much malaria there is in a given setting, or how likely it is when someone has been on preventive drugs, or what other tropical diseases are possible, but malaria is still one of the biggest risks for travelers. Furthermore, it's often hard to diagnose by lab methods as the parasite can be hard to find in the blood. Malaria is a dangerous disease, particularly in those who are under five years old, pregnant, or not already "semi-immune." After repeated episodes of the illness, people get a degree of immunity so that they tend to be protected from the severe, potentially fatal forms such as cerebral involvement, severe anemia, and shock. Even that protection starts to be lost after a few months of being away from malaria zones. British medical journals reminder remind readers now and then of the seriousness of the risk of malaria in travelers. I don't remember seeing quite as much info in American journals, perhaps because there are fewer immigrants and travelers from Africa. Three days after my friends told me about Anita, I heard that her doctors had finally reached a diagnosis: malaria. The parasite was found in her bone marrow, which means she had to have at least a bone marrow aspiration if not a biopsy, painful procedures. Up to that point, according to my second- or third-hand information, she had been treated with antibiotics but not anti-malarial drugs. I don't know how complete the story was that I heard -- and certainly these medical stories tend to get muddled and distorted especially when passed along by non-medical people. Still, it does highlight a big difference in the way malaria is treated in Nigeria compared to the US. In the malarious parts of Africa, the general approach is to treat high-risk people when they get symptoms of malaria, until or unless the diagnosis can be excluded. Effective, cheap drugs are available and simple oral treatment with various two-drug combinations is usually successful. Two of those combinations in Nigeria are Co-artem (artesunate and lumefantrine) and and Artequin (artesunate plus mefloquine). The most common American approach, in contrast, seems to be to treat malaria as a highly exotic disease which only specialists can diagnosis and treat, and to insist on a clear laboratory diagnosis before treating it. I'm not sure why this is, though perhaps it's partly because the simple, effective drugs are not available. Partly, though, it's just a different philosophy of treatment. In Nigeria, if I am faced with a child who likely has giardia, it would take several days, inconvenience and maybe $12 to make the diagnosis. Meanwhile, the patient would remain ill and might be lost to follow up. On the other hand, for $4 I can treat the illness. Even though I may treat some patients who do not need it, nearly everyone ends up ahead. The result of all this is that I encourage family and friends, when returning from Africa, to take a box of malaria treatment home with them. Then, if they get sick with what seems like malaria, they can contact a doctor who is familiar with malaria, and consider starting treatment. I don't recommend simply treating oneself without contacting a medical professional, since other serious conditions could be missed, treatment of severe malaria might be delayed, and a doctor familiar with the drugs should prescribe them. It certainly doesn't hurt to have the simple, effective drugs available and ready to be used on a doctor's advice, though. Finally, the best treatment is prevention. When traveling to malaria areas, be sure to take effective an preventive drug and avoid mosquito bites. When you return to your home, be sure to continue the medicine for the recommended time, since the malaria parasites can stay in your body for some weeks and need to be suppressed until the last one is gone.