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Malaria and children: the risks, precautions, and the nurse's role

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Carole Tracey MSc, DipHE, RGN, RM.

Practice Nurse, The Health Centre, University of East Anglia, Norwich

Malaria kills, yet decades ago doctors were confident that it could be beaten and control measures were beginning to be very effective, with medicines working well. Now the picture is very different and malaria is re-emerging as a very serious disease.

Malaria kills, yet decades ago doctors were confident that it could be beaten and control measures were beginning to be very effective, with medicines working well. Now the picture is very different and malaria is re-emerging as a very serious disease.



Cerebral malaria, caused by the Plasmodium falciparum parasite, remains a major global health threat to children. Along with tuberculosis, measles and malnutrition, malaria is one of the leading killers of children, and increasing drug resistance only exacerbates this (Cohen, 2002).



Children are particularly at risk because they become seriously ill in a very short period of time and, if their condition is left untreated, it may progress rapidly to convulsions, coma and death (World Health Organization, 2002).



The WHO advises avoiding, if possible, travel to areas of substantial malaria transmission, particularly with young children and infants (CATMAT, 2000). However, sometimes a cheap holiday to The Gambia or Kenya is just too tempting, and parents should be made aware of the potential consequences of not heeding this advice.



Malaria is one of the most common and serious of the tropical diseases. About 40% of the world’s population live in areas where there is a risk of contracting the disease. There are about 300 million clinical cases diagnosed a year and about 1.5-2.7 million deaths a year; most are children in Africa (Zucker and Carnevale, 1997). A child dies every 30 seconds of malaria.



In addition, each year in the developed world, travellers returning from malarial regions die from the disease. The UK is one of the world’s biggest importers of malaria, with more cases than in the USA or any European countries (Muentener et al, 1999).



The prevalence of malaria among children in the UK has risen by a third over the past two decades. (Williams et al, 2002). Yet a UK study showed that many of these deaths were preventable, as two- thirds of children who had acquired malaria could have taken prophylaxis (Williams et al, 2002), and it is a preventable and curable disease provided it is diagnosed and treated promptly.



For the 30 million or more travellers who visit malaria-endemic countries each year from non-tropical countries, malaria is the infection most likely to cause life-threatening illness or death. In the UK, about 2000 cases of malaria are reported each year with at least nine deaths (Public Health Laboratory Service, 2003); this, however, is considered to be an underestimate of the true figure (Warrell, 2002).



More than 75% of cases are of the severe ‘malignant’ form of the disease caused by the P. falciparum parasite. Over a third of all UK cases relate to immigrants who have settled in the UK and travelled back home to visit family and friends, and nearly 10% of the cases are found in children (PHLS, 2003).



Immigrants visiting family and friends in their home country tend to underestimate the risk of getting malaria and are therefore inclined to take fewer protective measures such as bite avoidance and chemoprophylaxis. Some also believe that they have lifetime immunity and are unaware that they will have lost any immunity that they once had (Warrell, 2002).



In the UK, immigrants who return to visit their friends and relatives in Africa have an incidence rate of malaria three times higher than that of tourists; for those going to Asia, it is eight times higher (Phillips-Howard et al, 1990). This may reflect their longer visits but could also be because they may be exposed to increased risk as they travel to more remote or rural locations, living in simple conditions without bed nets.



What is malaria?
Malaria is a protozoal disease transmitted by the female anopheline mosquito; it is caused by parasitic protozoa of the genus Plasmodium, which infects human and insect hosts alternately. There are about 420 different species of anopheline mosquito, of which 70 are able to transmit the parasite (Stürchler, 2000).



Four identified species cause human malaria:



- Plasmodium falciparum (mean incubation 12 days)



- Plasmodium vivax (mean incubation 13 days)



- Plasmodium ovale (mean incubation 17 days)



- Plasmodium malariae (mean incubation 28 days).



P. falciparum is the parasite that causes ‘malignant’ disease and poses substantial risk of life-threatening illness or death. Unfortunately it is also the main species that has become resistant in many countries to chloroquine, previously the mainstay of treatment. It has a short development phase within the human host and illness usually begins within two weeks of the infected bite. This period may be prolonged if partially effective or irregular chemoprophylaxis has been used.



P. vivax and P. ovale can cause illness within two to four weeks; however, these species also have a dormant phase where it may persist in the liver and may not cause any clinical symptoms for many months.



P. malarie is the mildest and most chronic of the four types; however, in areas where it is prevalent, there is epidemiological evidence that P. malariae infection can lead to nephrotic syndrome. (Kakkilaya, 2003).



When advising parents on malaria prevention it is important to have some understanding of the basic natural history and epidemiology of the disease, including the life cycle of the parasite within the mosquito and human. This goes some way to helping convince people of the life-threatening nature of this disease and to make clear why bite avoidance measures and compliance with appropriate chemoprophylaxis is so vital.



Clinical presentation
The classic symptoms of malaria are fever, malaise, headache and myalgia, but malaria may mimic other diseases such as typhoid - the symptoms of P. falciparum malaria are notoriously atypical and therefore difficult to diagnose.



Young children, especially, may have fevers from a variety of other causes. Initially, children with malaria may be lethargic, listless, drowsy, irritable or anorexic. Older children may have headaches and nausea. They may vomit, cough, have abdominal pain, anaemia or convulsions (Reitveld, 2001).



Children surviving acute attacks develop partial immunity and reinfection produces a less severe illness. This immunity is specific to the species. Severe childhood malnutrition is relatively protective against malaria since the parasites require iron, folic acid and glucose for multiplication (Cowan and Heap, 1993).



Malaria fevers occur at the time of rupture of the red blood cells. If this process becomes synchronised, episodes of fever occur every second day with P. vivax and P. ovale and every third day with P. malariae. In P. falciparum, multiplication and invasion of the cells occurs so rapidly that no synchronised pattern develops and fevers persist erratically.



Typically, the fever follows a classical sequence of three stages:



- The cold stage is characterised by marked shivering and chills



- The hot stage follows abruptly: the patient’s temperature rises rapidly up to 41°C and the person may be delirious



- The sweating stage occurs when the temperature drops. The patient’s clothing and bedclothes are drenched in sweat. The patient is exhausted but feels better (Kumar and Clarke, 1998).



The whole process takes about 10 hours.



Malaria should be suspected in anyone with a fever who has been exposed to mosquitoes in a malaria-endemic area.



Diagnosis is by microscopic examination of blood on thick and thin slides. Blood should be taken when the patient has a fever if possible and it is important to realise that a single negative test is not diagnostic and further sets should be taken at four- to six-hourly intervals. Patients with a strong suspicion of malaria, particularly P. falciparum should start treatment with quinine, even if the blood films are negative (CATMAT, 2000).



Malaria prevention
The latest UK guidelines issued in 2001 (Bradley and Bannister, 2001) identify four principles of malaria prevention that should receive attention from travel advisers, travellers and parents (Box 1).



Awareness of risk All travellers to malaria-endemic areas must be made aware of the risk of malaria in the areas to be visited. Activities such as camping increase the risk of contracting malaria and travellers must take action to reduce the risk. They must seek medical advice urgently if they develop a fever or flu-like illness while away or after return and tell any attending doctor about possible exposure to malaria mosquitoes, giving a clear travel history.



Bite avoidance: special precautions in children Bite prevention measures are as important as compliance with chemoprophylaxis and, as a travel adviser, I always stress to travellers that ‘if you don’t get bitten then you don’t get malaria or dengue fever or any other disease spread by mosquito’.



Safe protection from mosquito bites is particularly important for infants and small children and it is clear from the malaria parasite life cycle that, apart from the rare instance of transmission by blood transfusion (CATMAT, 2000), most malaria is spread by a bite from an infected mosquito. Preventing or minimising the bites will, therefore, have a significant effect on transmission of the disease (Chiodini, 2000).



Mosquitoes use visual, thermal and olfactory stimuli to locate the human host required for their blood meal, and bite predominantly between dusk and dawn, which is when transmission of malaria occurs.



Personal protection measures Sources of advice on malaria are listed in Box 2. For all children travelling to malarial regions, particular attention should be paid to personal protection measures to reduce contact with mosquitoes. These include:



- Sleeping in a well-screened, preferably air-conditioned, room. Rooms should be sprayed with a knock-down spray before evening to kill any mosquitoes that may have entered in the day



- Clothing should be light-coloured, long-sleeved and loose and cover most of the body - not easy in the heat of the tropics



- Heavily perfumed soaps and shampoos should be avoided as these attract mosquitoes



- Using insecticide-impregnated mosquito nets available for cots and small beds. Nets need to be retreated every six months and any tears need to be promptly repaired



- Using an insect repellent on exposed skin. The most effective insect repellents contain diethyltoluamide (DEET). Concentrations can vary but it is advised to use a product with no greater than 30% DEET for children and avoid putting it on hands to prevent accidental ingestion.



Repellents are lost from the skin through evaporation and absorption and are easily washed off by sweating or swimming and therefore need to be reapplied regularly.



What does not work
Knowing what does not work is as important as knowing what does. Acoustic devices that produce ultrasound waves have been shown to be ineffective in repelling mosquitoes (Mark et al, 2002), as have light traps, which are successful at electrocuting flies and other insects, but not mosquitoes.



Taking oral thiamine (B1) or garlic does not protect against mosquito bites (Mark et al, 2002). Ultimately, the traveller should stick to well tried and tested personal protection measures instead of wasting money on useless and usually expensive devices (Stürchler, 2000).



Travel advisers should always recommend against taking small children and infants to areas of substantial transmission of chloroquine-resistant P. falciparum (Box 3), such as certain regions of Africa, South America, Oceania and Asia (CATMAT, 2000).



Young children are at increased risk of malaria because the choices of safe and effective drugs for prevention and treatment are limited. None of the available antimalarial medications is 100% effective and they always have to be taken alongside taking strict bite avoidance measures (CATMAT, 2000). Any malaria chemoprophylaxis involves a risk-benefit analysis to weigh up the possible side-effects against the risk of acquiring malaria, in particular P. falciparum malaria.



The choice of chemoprophylaxis and dosage needs to be carefully considered. Very few antimalarial medications are available in paediatric formulations and it can be difficult to make a child swallow oral medications, most of which are bitter and foul tasting.



Malarone Paediatric tablets (GlaxoSmithKline) These are a combination of atovaquone and proguanil. The manufacturer claims that studies have found them to be a safe and effective prophylactic against P. falciparum with a low side-effect profile. The paediatric formulation is a quarter of the strength of the adult tablet (Box 4).



Malarone Paediatric is not recommended for children weighing less than 11kg, as there is not enough data for this patient group. Tablets have to be taken every day and should be administered with food or a milky drink to increase absorption and help minimise the risk of any gastrointestinal problems such as vomiting and diarrhoea. Tablets need to be started one or two days before travel into a high-risk area and need to be continued only for seven days after travel (for a maximum of 28 days), which should aid compliance.



Unlike mefloquine and chloroquine, Malarone Paediatric tablets are not contraindicated in children with epilepsy and who are too young for doxycycline. But they should not be used in those with severe renal impairment. Although they are more expensive compared with other antimalarials, their increased efficacy in preventing P. falciparum malaria and a side-effect profile similar to placebo has shown them to be a favourable choice with many GPs, practice nurses and parents.



Dosage for malaria prophylaxis is always calculated according to the child’s weight.



Mefloquine (Lariam, Roche) This has been widely used since the 1990s and, with the convenience of a once-weekly dose, it is an effective antimalarial. It needs to be started three weeks before travel to build up effective therapeutic levels and to assess for side-effects, and be continued for four weeks after return from a malaria-endemic area.



Mefloquine can be prescribed for babies and children weighing more than 5kg (Box 5). Data are not available on babies less than 5kg in weight and accurate dosing for prophylaxis becomes increasingly difficult in small children, due to the large size of the 250mg tablet which needs to be broken for children weighing less than 45kg. Side-effects can include sleep disturbances, nausea and vomiting and dizziness, and in rare instances neuropsychosis (CATMAT, 2000).



Over 20 million travellers have used mefloquine and, while there is controversy regarding tolerability, several studies and a meta analysis have shown that it does not have a significantly higher side-effect profile than other regimens (Schlagenhauf, 2001). However, issues relating to the tolerability of mefloquine are still current, as suicides have been reported among people who were taking mefloquine, an issue that is still under investigation worldwide (Benjamin and Olmsted, 2003).



Doxycycline (Vibramycin, Pfizer) This drug is contraindicated in children under 12 years in the UK because it may produce transient depression of bone growth and permanent discoloration of the teeth. Dosage for those aged over 14 years or weighing more than 50kg is the same as the adult dose: 100mg daily, the first dose two days before travel to a malaria area, and continued for four weeks afterwards (CATMAT, 2000).



Doxycycline side-effects include nausea, heartburn and diarrhoea, which can cause compliance problems. These effects can be avoided by giving it with a meal. Other side-effects can include candida infection and photosensitivity manifested by a severe sunburn reaction, which can be prevented by using a high-factor sunscreen and avoiding prolonged exposure to sun (CATMAT, 2000).



Chloroquine (Nivaquine, Beacon) This is a cheap, well-tolerated antimalarial that has been in continuous use for over 50 years. Its usefulness is now limited because of increasing P. falciparum resistance, and it should no longer be used as a first-line chemoprophylaxis (Global Fund, 2003). Chloroquine plus proguanil retains some effectiveness in multidrug-resistant areas. Chloroquine is safe for children of all ages and is the only antimalarial available in a paediatric elixir.



Dosage is based on weight; the first dose is given one week before travel and must continue for four weeks after return (Box 6). Chloroquine should be given on the same day each week with food to prevent nausea. Other side-effects can include headache, dizziness, blurred vision and itching. Caution is recommended in those with epilepsy and psoriasis may be exacerbated by it (CATMAT, 2000).



The WHO advises that parents do not take babies and small children to areas with chloroquine-resistant P. falciparum. If travel is unavoidable, the child must be carefully protected against mosquito bites and given appropriate chemoprophylaxis.



P. falciparum malaria in a small child is a medical emergency - children can die rapidly from malaria, early symptoms can be atypical and difficult to recognise; life-threatening complications can occur within hours of initial symptoms.



The possibility of malaria therefore should always be considered whenever a child gets a fever within a year of travel to a malaria-endemic area. Children of immigrant families may be at special risk and any fever in these children should be investigated.




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