Malaria & Us

I had read about malaria as an undergraduate student while studying parasitology, pharmacology and clinical medicine. I thought I knew all about malaria. Things evolved a bit over years while I concentrated on Obstetrics & Gynecology, but it being such a common illness, I kept up with the advances because our patients developed malaria anyway, and I had to treat them even if I was an Obstetrician and Gynecologist. But there is something very funny going on. One would expect a consensus on the management of malaria. Unfortunately it is sadly lacking. Everybody knows (I suppose) the dosage of chloroquine for treatment of malaria. We have always treated adult patients with an initial dose of 1 g (= 600 mg base) followed by an additional 500 mg (= 300 mg base) after six to eight hours and a single dose of 500 mg (= 300 mg base) on each of two consecutive days. But some time ago the health department sent us a circular asking us to give it in a funny dosage that I could not find in any text book, recent or old. Perhaps the health department is in the process of publishing a book of its own that it expects all consultants to follow. If so, it has remained in press for too long. I blush mentally at the thought of that dose and cannot put it down here. Then there was the time when I developed resistant malaria. I had taken a full course of chloroquine and was on day 8 of primaquine therapy for vivax malaria, when my fever returned. So I saw an honorary physician in the hospital, who had been my teacher once. He casually looked at my report and told me equally casually to take quinine. I was aghast. With a number of modern drugs available for resistant malaria, I could not see why such a drug should be prescribed to anyone, especially to a professor in the institute. I sought opinion of another physician, who directed me to the ICMR cell which was doing research on malaria. They advised me to take chloroquine and primaquine again, this time from their stock, saying what I purchased in open market might have been substandard. I trusted them and complied with the prescription. I developed a recurrence of fever on day 8 of primaquine therapy. Then I was given mefloquine and artesunate and was cured. I lost a lot of weight, hemoglobin, strength and morale in the bargain. Now the city has so many patients of malaria that there are no beds available for patients in any of the private hospitals. My wife is a physician doing general practice. She told the waiting list for admission into a five-star hospital in town was 320 last week - as if illnesses can wait that long to be treated. In my institute some residents in medicine department follow standard therapy guidelines - chloroquine with doxycycline as primary therapy, and artesunate if it is resistant malaria. There are others who primarily treat patients with artesunate. Some treat ordinary patients with the former and very important persons with the latter. None of them prescribes primaquine for radical cure of vivax malaria. My wife tells me that private practitioners in town are also treating patients similarly, i.e. without primaquine. If we consider the city to be endemic for malaria, then primaquine tgherapy is to be substituted by chloroquine prophylaxis on weekly basis after cure of the febrile illness with one course of the drug. But the city has not yet been declared endemic, and even if it is so, even chloroquine prophylaxis is not being given. I think the reservoir of the parasite is being maintained in livers of patients, and they keep on getting recurrences, increasing their own morbidity as well as creating source of the parasites to be spread to others through mosquitoes. These new patient treated the same way as the older ones add to the city’s hepatic reservoir of malarial parasites. I came across a reference that states that a single dose of primaquine must be given to falciparum malaria patients, so that the gametocytes are killed and the patient does not transmit malaria to mosquitoes who then cannot spread it to other people. I wonder if the physicians will heed this advice in time. What I do to my obstetric patients and what my wife does in her practice is too small to make an impact on the city’s malaria problem.