Super Malaria: What You Should Know

[Global Rescue]

Recent news reports about ‘super malaria’ are on the minds of many travelers. What exactly is ‘super malaria’ and to what extent should travelers be concerned about it?

Dr. Phil Seidenberg, who spent five years working in Zambia as Global Rescue’s African Regional Medical Director, has treated many malaria patients over the years. Below he responds to questions about ‘super malaria’ and shares advice regarding malaria prevention and treatment.

Q: What is ‘super malaria’?
A: ‘Super malaria’ is a term coined by the media that refers to resistance strains of malaria which have emerged in the Greater Mekong Sub-region (GMS): Laos, Myanmar, Cambodia, Thailand and Southern Vietnam. There is no medical or scientific term called ‘super malaria.’

Q: Is ‘super malaria’ new?
A: No, it is not new. The public health and scientific communities have known about it since 2008. However, based on recently published reports from the region, it is gaining a much larger footprint in Southeast Asia, which has everyone alarmed.

Q: What is malaria resistance?
A: Malaria resistance refers to strains of the parasite which seem resistant to the most commonly and effectively used treatments for malaria. For many years, the World Health Organization (WHO) has recommended a two-drug therapy for simple infections caused by malaria -- medications commonly referred to Artemisinin Combination Therapy (ACT). ‘Super malaria’ thus refers to cases in the GMS which are showing resistance to ACTs, something that seems to be more common and growing at an alarming rate.

Q: Is malaria resistance new?
A: No, malaria resistance is not new. In fact, malaria resistance has been around ever since we’ve figured out how to treat malaria, but we have always been able to develop newer medications or combinations of medicines to combat the resistant infections.

Q: Can ‘super malaria’ be treated?
A: Yes, ‘super malaria’ can be treated. Health facilities in the region have already begun using a different combination of ACTs, ones that include mefloquine. Mefloquine is a commonly prescribed malaria prophylactic for people traveling into malaria regions, particularly by US travelers prescribed by US physicians.

Q: What should I do if I plan on traveling to this region?
A: The simple answer is to continue to do all the things travelers should do when traveling into areas where there’s malaria:

• Use strong insect repellants
• Be sure to cover your arms and legs to prevent mosquito bites (particularly at sunrise and sunset)
• Sleep under mosquito nets when they’re available or bring them with you
• Try to keep windows and doors closed at night when sleeping to prevent mosquitoes from entering your room
• Check with your doctor to see if you should be taking preventive medications prior to traveling. They’re readily available.

Q: Is there anything else I should do?
A: Yes, you need to be aware of ‘super malaria’ if you’re traveling into a region where it’s known to occur: Laos, Cambodia, Thailand, Myanmar and Vietnam. For the best updated information, visit the Centers for Disease Control and Prevention (CDC) or WHO websites for country-specific information on places you plan to travel.

Also, Global Rescue always recommends that travelers going to malaria regions consider picking up Rapid Diagnostic Tests (RDTs) and treatment medications from the local pharmacies when you arrive in country. RDTs can be used by you to test yourself or a travel companion with a simple pin prick if you’re worried about malaria. They can also be used when returning home if you develop any symptoms for malaria: fever, headache, body aches, flu-like symptoms, nausea and vomiting. Remember, it usually takes some time between being bitten by a mosquito carrying malaria until you develop signs and symptoms of the infection. Picking up medications can also be helpful, as often times these treatment medications are not readily available in the United States.

Areas where there is resistant malaria present currently
Map image source: http://www.freeworldmaps.net/asia/southeastasia/physical.html.


For any further questions, please reach out to us at Global Rescue. We can always help you plan for a safe and healthy trip.

 

[CAustin]

Wonder how long it will take for this to reach Africa?

 

[sgt_zim]

Wonder how long it will take for this to reach Africa?

It wouldn't surprise me if there were already some form of it there now. In a previous life, I was a nurse. While taking my required microbiology class as a student, I ended up writing a paper on malaria, focusing on the Plasmodium falciparum specie. P. falciparum is endemic in sub-Saharan Africa as well as the parts of SE Asia described by this article, and it is by leaps and bounds the worst, most dangerous form of malaria. There are 4 others - P. ovale, P. malariae, P. vivax, and P. knowlesi. P. knowlesi was formerly known only in lesser primates, but seems to have jumped species to humans now. They're not certain of mode of transmission presently.

Some highlights so you understand the implications.
A healthy human has about 5 million red blood cells per cubic millimeter of blood. Gas exchange, delivering oxygen and picking up CO2, occurs in your capillaries, which are just large enough in diameter to allow one RBC to pass at a time.

P. falciparum is so aggressive that there can be as many as 2 million parasites per cubic millimeter of blood. Each parasite invades and destroys (by rupturing it) a single red blood cell. Those ruptured RBCs gum up the works in your capillaries, preventing other healthy RBCs from doing their job. Within a day or two of the onset of symptoms, you can lose 40% of your total quantity of RBCs. Your hematocrit could fall from a very healthy 48 to a very unhealthy 29 or 30 literally overnight.

RBCs live for about 90 days, so every day, your body replaces about 1% of your RBCs. Your spleen disposes of the dead RBCs. So not only are you now severely anemic, there is a fair chance of damage to your spleen since it is now having to dispose of 40% of your RBCs all at once. The 40% hemolysis (rupturing of RBCs) is a rough equivalent of losing 4 pints of blood.

If you go to malarial areas in Africa, take your mefloquine and/or doxycycline (an antibiotic that does double-duty as an anti-malarial) as prescribed, plus exercise the other precautions.

The other 4 species are far less dangerous, with anywhere from maybe 10,000 to 200,00 parasites per cmm of blood.

My African plans were already South Africa, Namibia, or Zim., so not much has changed for me.

 

[CAustin]

@sgt_zim this was a very informative response. I never understood exactly why malaria made you sick. But with your description on red blood cells being attacked and the spleen having the work overtime......no wonder people die from it.

 

[sgt_zim]

@sgt_zim this was a very informative response. I never understood exactly why malaria made you sick. But with your description on red blood cells being attacked and the spleen having the work overtime......no wonder people die from it.

You're welcome. World Health Organization estimates about 1 million deaths per year in sub-Saharan Africa due to P. Falciparum. That's roughly 10x more annual deaths in Africa than AIDS causes.

More malaria factoids.

• About 40,000 people died from malaria or yellow fever while constructing the Panama Canal.
• malaria (not P. falciparum strain) used to be endemic in the US, from the tidewater in Virginia all the way down the east coast and over to Brownsville, Texas. We wiped out malaria-carrying mosquitoes with DDT
• though we wiped out the malaria-carrying mosquitoes, there are still 3 species of mosquito (all in the genus Anopheles) in the US that can carry it (same species that used to carry it). That's why I'm such a border-security and immigration-control fanatic. Yellow fever is carried by another species that is very common in Texas and along the GoM coast.
• malarial life cycle is one of the most complex in the whole world. all 4 of the human-only species require a mosquito's gut to go through 2 stages of maturity. 2 species then undergo 6 more stages of life-cycle development in humans, and the other 2 species undergo 7 more stages of life-cycle development in humans.
• once in humans, the parasites go through boom-bust cycles. while they're in the "bust" cycles, they're maturing inside liver cells (they go straight to the liver when a mosquito delivers its payload). when they've reached critical mass in liver cells, they "boom" by rupturing liver cells and get released into the bloodstream where they do their real damage.
• "boom" cycles don't usually last more than a few days. "bust" cycles begin to stretch, from days to weeks to years, the longer you have them in your body.
• malaria is for life.
• anti-malarials are only efficacious for one stage of the life cycle.
• Bill Gates just dumped a boat-load of money into research on a vaccine for malaria. I hope they learn a lot more about malaria, but it is a complicated critter. It isn't a bacterium or a virus, it's a protozoan. I'm not hopeful that a vaccine will ever be discovered, but if they discover better treatments for it, especially treatments that will deal with the P. falciparum strain that is now resistant to mefloquin, that'll be a win.

 

[ArmyGrunt]

Sgt_zim, I appreciate all this extra info. I'm working on my BS in biology right now. All these extra tidbits made perfect sense! I've also shared this thread and that article with an instructor or two

 

[sgt_zim]

Sgt_zim, I appreciate all this extra info. I'm working on my BS in biology right now. All these extra tidbits made perfect sense! I've also shared this thread and that article with an instructor or two

there are loads of great scholarly articles on malaria life cycles. P. falciparum may be the most perfect killing machine on the planet.

If you end up having to do a research paper, malaria (and all of the politics around it) would be an interesting one to write. A great deal of the so-called research that Rachel Carson did when she was writing her book "Silent Spring" has turned out to be almost nothing but pure vapor-ware. DDT was, unfortunately, banned because of her "work." Pure transparency - DDT was losing efficacy in the war on malaria/malaria-carrying mosquitoes, but it had more to do with the way we were over-using it. DDT is a fine powder, and all that is required to protect most people from malaria is a light dusting of interior walls.

DDT is not human carcinogenic. The studies which declare it to be, of the handful that I've read, are equivocal at best, and pure bovine excrement at worst.

The rate of "fragile eggs" in falcon and pelican populations was only marginally higher due to DDT. It was so marginal as to be statistically insignificant.

DDT does undergo bio-magnification, meaning that it accumulates at each stage along the predator chain (insects die of it, fish consume the insect, the more insects they eat, the higher the concentration of DDT in the fish, the falcons and pelicans eat the fish, and so on).

What Rachel Carson did was monstrous. Her "research" ended up producing more human corpses (since DDT was banned because of her research) than Hitler did, and probably more than Stalin did.

Be warned, though: if you decide to undertake this as a project, you will probably be branded as a heretic.

 

[Hogpatrol]

Isn't this old news? I mean REALLY OLD news. Ok, I just re-read the global rescue article.
Yeah, it's old news, like 2008 news? Good Grief.

 

[CAustin]

Isn't this old news? I mean REALLY OLD news. Ok, I just re-read the global rescue article.
Yeah, it's old news, like 2008 news? Good Grief.

True but perhaps worthy of discussion given that not every hunter uses an anti malaria drug upon each visit to Africa. For instance I didn't last year because I'm reasonably informed the hunting area is free of malaria. However, I am rethinking that part of my trip now....why tempt the evil mosquito? The super strainwould concern me if traveling to know areas of existence.
I think the postings by sgt-Zim are very educational on many fronts not the least of which was his comment on the former use of DDT. That reviled chemical, now banned, did a lot of good. Just this past weekend I was telling a business associate of playing in the streets of Augusta GA in the early 1960s as the mosquito fog trucks went by. Really they were surpluss WW2 army vehicles mounted with........you guessed it DDT sprayers. Every night at dusk they came through theneighborhood spraying without regard to people out and about. My home at the time was about a mile from the Savanah river and most of the land between the river and our house was undeveloped and often wet. Great breeding grounds for the pests. So her I am over 50 years later and I think not really worse form the exposure that I know of. With the Zika Virous moving into the US we might want to think about bringing DDT back for a period to kill back the dam mosquito! The darn stuff works amazingly but must be used with a high degree of caution. I have seen it used in farm applications and every bug around dropping dead shortly after contact. Then fast forward a day or two and see birds dead from having eaten the dead bugs.

 

[Hogpatrol]

No criticism of the anyone's posts on the subject. Very informative and yes, I take my pills when in a known area. I just take issue with Global Rescue's, to me, hype. I lived in Panama for three years, working on the locks so I know about the malaria issue in that country. Waste oil and attention to standing water mitigated the problem during the construction years. As far as DDT, we could spray a thousand tons of it but as long as there are old tires laying around and untended swimming pools in Florida, there will be Zika.

 

[sgt_zim]

True but perhaps worthy of discussion given that not every hunter uses an anti malaria drug upon each visit to Africa. For instance I didn't last year because I'm reasonably informed the hunting area is free of malaria. However, I am rethinking that part of my trip now....why tempt the evil mosquito? The super strainwould concern me if traveling to know areas of existence.
I think the postings by sgt-Zim are very educational on many fronts not the least of which was his comment on the former use of DDT. That reviled chemical, now banned, did a lot of good. Just this past weekend I was telling a business associate of playing in the streets of Augusta GA in the early 1960s as the mosquito fog trucks went by. Really they were surpluss WW2 army vehicles mounted with........you guessed it DDT sprayers. Every night at dusk they came through theneighborhood spraying without regard to people out and about. My home at the time was about a mile from the Savanah river and most of the land between the river and our house was undeveloped and often wet. Great breeding grounds for the pests. So her I am over 50 years later and I think not really worse form the exposure that I know of. With the Zika Virous moving into the US we might want to think about bringing DDT back for a period to kill back the dam mosquito! The darn stuff works amazingly but must be used with a high degree of caution. I have seen it used in farm applications and every bug around dropping dead shortly after contact. Then fast forward a day or two and see birds dead from having eaten the dead bugs.

I would say that a southern hemisphere winter hunt in RSA, southern Namibia, southern Zim (check with CDC, don't take my word for it), and a couple other places are probably safe enough to not have to take mefloquin. There are vaccines you should probably take, but mefloquin is not without side effects, and I won't take it again unless I am going to a known malarial area. It gave me some really strange, vivid dreams when I took it for a trip down to Ecuador a number of years ago. There is some preliminary evidence linking mefloquin use with some of the mental challenges our vets are coming back to the states with - there's nothing definitive, but I think the research should be pursued. My sister did a mission trip to Uganda a year or two ago, and all she took was doxycycline (my only allergy to anything on earth is to doxycycline) for malaria prophylaxis.

Also keep in mind that if it is linked to their mental issues, those guys are taking it for 6 months and longer. If you did 10 days in Africa and need to take it, you'd start taking it at home about a week before you leave, and for about another week (I don't remember the exact before & after any more) after you get back. Take it exactly as labeled, down to the last jot and tittle in the instructions.

Always check with the CDC before you travel to places like that. Certain vaccinations, like Hep A, are a 2 shot series spread out over about a month. Hep B is a 3 shot series spread out over about 6 months. Then get a blood titer to ensure that the vaccination worked. That means medical-wise, you should start with your vaccinations probably a year before you head over there.

 

[sgt_zim]

No criticism of the anyone's posts on the subject. Very informative and yes, I take my pills when in a known area. I just take issue with Global Rescue's, to me, hype. I lived in Panama for three years, working on the locks so I know about the malaria issue in that country. Waste oil and attention to standing water mitigated the problem during the construction years. As far as DDT, we could spray a thousand tons of it but as long as there are old tires laying around and untended swimming pools in Florida, there will be Zika.

Given the old tires and untended swimming pools, sounds like Zika is here to stay. The nice thing about DDT is it makes it easy to deal with "house mosquitoes" - like the species that are known to carry malaria, yellow fever, and zika (same mosquito carries YFV and zika - Aedes egyptii). You dust the walls of your house twice a year, and you're pretty much good to go.

 

[Hogpatrol]

Before my first trip to Africa, I got Twinrix (hep a&B), yellow fever, pneumonia, current flu, and DPT boosters. Oddly enough back in the mid 70's, another smallpox vaccination was required for entry in to Panama.

 

[sgt_zim]

Before my first trip to Africa, I got Twinrix (hep a&B), yellow fever, pneumonia, current flu, and DPT boosters. Oddly enough back in the mid 70's, another smallpox vaccination was required for entry in to Panama.

that yellow fever injection...cripes, it felt like they were injecting hot lava in my butt. It has been more than 10 years since I got any of my exotic vaccinations, so I'll have to go through them all again before I got over there.

 

[sgt_zim]

We're thinking about maybe retiring to Panama, probably around David or Boquete.

 

[Hogpatrol]

We're thinking about maybe retiring to Panama, probably around David or Boquete.

Carnival in David! Boquete is in a class by itself but don't forget rainy season. Either one is a good pick although David is closer to Panama City if that's a consideration.

 

[sgt_zim]

they're both a fairly long trek to Panama City, so I'm not too concerned about that. I'm fine with Chiriqui in general, just the 2 big cities, or near them, would be more suitable for my wife.

3 or 4 hectares and 2000-2500 sf house is what I'm looking for.