Malaria strikes capital Dhaka Bangladesh


  • 1.Introduction
  • 2.History of Malaria
  • 3.Economic costs of malaria
  • 4. Malaria in Bangladesh:Labs find up to 50pc tests positive
  • 5. Transmission of the Disease
  • 6. Malaria Prophylaxis
  • 7. Malaria Treatment
  • 8. Treatment with artemisinin
  • 9.Overflow Irrigation to combat Malaria
  • 9. References
  • 1. Introduction

    Malaria has been known since time immemorial, but it was centuries before the true causes were understood. Previously, it was thought that "miasma" (bad air or gas from swamps - "mal air ia") caused the disease. Surprisingly in view of this, some ancient treatments were remarkably effective. An infusion of qinghao (Artemesia annua ) has been used for at least the last 2000 years in China, its active ingredient (artemisinin) having only recently been scientifically identified. The antifebrile properties of the bitter bark of (Cinchona ledgeriana ) were known in Peru before the 15th century. Quinine, the active ingredient of this potion was first isolated in 1820 by the pharmacists.

    Although people were unaware of the origin of malaria and the mode of transmission, protective measures against the mosquito have been used for many hundreds of years. The inhabitants of swampy regions in Egypt were recorded as sleeping in tower-like structures out of the reach of mosquitoes, whereas others slept under nets as early as 450 B.C.

    Approximately 300 million people worldwide are affected by malaria and between 1 and 1.5 million people die from it every year. Previously extremely widespread, the malaria is now mainly confined to Africa, Asia and Latin America. The problems of controlling malaria in these countries are aggravated by inadequate health structures and poor socioeconomic conditions. The situation has become even more complex over the last few years with the increase in resistance to the drugs normally used to combat the parasite that causes the disease. Malaria is caused by protozoan parasites of the genus Plasmodium. Four species of Plasmodium can produce the disease in its various forms:

  • Plasmodium falciparum
  • Plasmodium vivax
  • Plasmodium ovale
  • Plasmodium malaria
  • P. falciparum is the most widespread and dangerous of the four: untreated it can lead to fatal cerebral malaria. Approximately 300 million people worldwide are affected by malaria and between 1 and 1.5 million people die from it every year. Previously extremely widespread, the malaria is now mainly confined to Africa, Asia and Latin America. The problems of controlling malaria in these countries are aggravated by inadequate health structures and poor socioeconomic conditions. The situation has become even more complex over the last few years with the increase in resistance to the drugs normally used to combat the parasite that causes the disease. Malaria is caused by protozoan parasites of the genus Plasmodium. Four species of Plasmodium can produce the disease in its various forms: Plasmodium falciparum Plasmodium vivax Plasmodium ovale Plasmodium malaria P. falciparum is the most widespread and dangerous of the four: untreated it can lead to fatal cerebral malaria.

    Like all other mosquitos, the anophelines breed in water, each species having its preferred breeding grounds, feeding patterns and resting place. Their sensitivity to insecticides is also highly variable. Plasmodium develops in the gut of the mosquito and is passed on in the saliva of an infected insect each time it takes a new blood meal. The parasites are then carried by the blood in the victim's liver where they invade the cells and multiply.

    After 9-16 days they return to the blood and penetrate the red cells, where they multiply again, progressively breaking down the red cells. This induces bouts of fever and anaemia in the infected individual. In cerebral malaria, the infected red cells obstruct the blood vessels in the brain. Other vital organs can also be damaged often leading to the death of the patient.

    The significance of malaria as a health problem is increasing in many parts of the world. Epidemics are even occurring around traditionally endemic zones in areas where transmission had been eliminated. These outbreaks are generally associated with deteriorating social and economic conditions, and main victims are underprivileged rural populations.

    In many areas conflict, economic crises and administrative disorganization can result in the disruption of health services. The absence of adequate health services frequently results in a recourse to self-administration of drugs often with incomplete treatment. This is a major factor in the increase in resistance of the parasites to previously effective drugs.

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    2. History of Malaria

    Malaria is a protozoal disease transmitted by the Anopheles mosquito, caused by minute parasitic protozoa of the genus Plasmodium, which infect human and insect hosts alternatively. It is a very old disease and prehistoric man is thought to have suffered from malaria. It probably originated in Africa and accompanied human migration to the Mediterranean shores, India and South East Asia. In the past it used to be common in the marshy areas around Rome and the name is derived from the Italian, (mal-aria) or "bad air"; it was also known as Roman fever.

    Today some 500 hundred million people in Africa, India, South East Asia and South America are exposed to endemic malaria and it is estimated to cause two and a half million deaths annually, one million of which are children.

    Malaria kills over one million people each year, about 3,000 a day: the majority of victims are children under five years of age.

    malariaThe Tanzanian malaria researcher Wen Kilama offers a sobering analogy, famous in the malaria research community: If seven Boeing 747s full of children crashed into a mountain every day, would the world take measures to prevent it?

    Greenwood (WHO-UNICEF- report) argues that the nearly U.S. $2 billion a year needed to "get everyone under a net and ensure access to artemisin is a small amount of money when compared to, say, the costs of the war in Iraq."

  • Malaria occurs in over a hundred countries and territories. More than 40 percent of the people in the world are at risk.
  • Malaria kills a child every 40 seconds.
  • Over 700,000 children under five will die needlessly from malaria this year.
  • At least 300 million people suffer from acute malaria each year.
  • The cheapest anti-malaria drug—chloroquine—is rapidly losing its effectiveness in almost all endemic countries.
  • Population movements, such as seasonal workers and refugees into malaria-endemic regions and countries, are causing major disease outbreaks and economic impacts.
  • Malaria is a major killer of refugees and displaced persons
  • Malaria-endemic countries are among the world's most impoverished.
  • Malaria causes death, reduces the productivity of agriculture, and affects tourism and external investment.
    Source: UNICEF
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    3.Economic costs of malaria

    Malaria affects the health and wealth of nations and individuals alike. In Africa today, malaria is understood to be both a disease of poverty and a cause of poverty. Malaria has significant measurable direct and indirect costs, and has been shown to be a major constraint to economic development. For developing economies this has meant that the gap in prosperity between countries with malaria and countries without malaria has become wider every single year.

    Annual economic growth in countries with high malaria transmission has historically been lower than in countries without malaria. Economists believe that malaria is responsible for a growth penalty of up to 1.3%% per year in some African countries. When compounded over the years, this penalty leads to substantial differences in GDP between countries with and without malaria and severely restrains the economic growth of the entire region.

    The direct costs of malaria include a combination of personal and public expenditures on both prevention and treatment of the disease. The indirect costs of malaria include lost productivity or income associated with illness or death. This might be expressed as the cost of lost workdays or absenteeism from formal employment and the value of unpaid work done in the home by both men and women. In the case of death, the indirect cost includes the discounted future lifetime earnings of those who die.

    The simple presence of malaria in a community or country also hampers individual and national prosperity due to its influence on social and economic decisions. The risk of contracting malaria in endemic areas can deter investment, both internal and external, and affect individual and household decision making in many ways that have a negative impact on economic productivity and growth.

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    4. Malaria in Bangladesh:Labs find up to 50pc tests positive

    Malaria has broken out in the capital and a large number of people are already infected with 'deadly malaria parasites', experts said. Diagnostic centres Medinova, Padma, Popular and Lab Aid, some private hospitals and the ICDDRB told The Daily Star they found malaria positive cases ranging from 5 to 50 percent of the number of tests for malaria they conducted in the last one year.

    patientExperts studying blood samples of hundreds of patients infected with malaria parasites said many of the 'malaria positive cases' have either been misdiagnosed or do not have any symptoms, which could endanger their lives. Investigations showed many doctors mistakenly diagnosed malaria as dengue, typhoid, and influenza and in some cases as jaundice because of their symptoms are similar to that of malaria --- high fever, headache and joint pains.

    The deadly disease is caused by plasmodium parasite transmitted to humans through the bite of infected female anopheles mosquito, usually found in forests. Dr Sheikh Md Abdur Razzak, chief of microbiology department at Sikder Women's Medical College in Dhaka, said, "I have evidence of thousands of blood slides which show presence of malaria parasite, amazingly most of the parasites are not readily detected under microscope."

    Explaining this, he said, " The parasite in the red blood cells appears very light rose-colored, so it is not easily distinguishable. One has to carefully look for the light pink circle or often half circle-shaped parasite, but majority of malaria cases are mistaken for other diseases having almost identical symptoms." "The problem is that since malaria is not commonly found in the city, when doctors suggest malaria test, technicians, often without appropriate knowledge, report a negative result," he pointed out.

    Citing examples, the expert said, "A government employee aged over 50 had extreme pains in his limb joints for about a decade without a cure due to wrong diagnosis. Finally, we detected he had malaria." Narrating his long suffering, the patient, Alamgir Noori, said he had given all up hopes for recovery. But now he is alright after taking drugs for malaria.

    Another microbiologist, Prof Shamir Saha of Dhaka Shishu Hospital, also admitted detecting malaria parasites in many patients. "We found 15 malaria positive cases out of 72 last month and three out of 42 in June." Dr Benazir Ahmed, a microbiologist at the Institute of Epidemiology, Disease Control and Research (IEDCR), said, "Studies show the mosquito that transmits malaria exists in the city but I cannot comment on finding malaria positive cases since we do not conduct the relevant test at the IEDCR."

    One expert said, "It is indeed mysterious that most of the patients tested positive for malaria parasite had no record of visiting areas like the Chittagong Hill Tracts forests, where mosquitoes that transmit malaria are found."

    Entomologist (scientist who studies insects) Touhid Uddin Ahmed, who carried out a study last year to find if anopheles mosquitoes exist in the capital, said, "Finding mosquitoes that transmit malaria in a place like Dhaka city is quite an unusual affair. But we must remember epidemics of malaria in Araihazar and Raigonj

    Experts mentioned malaria parasite enters the bloodstream and travels straight to the liver, where it replicates it replicates itself thousands of times while staying safe from any attack by the body's own defence mechanisms. Then they are released back into the bloodstream in a form that invade red blood cells. Once inside the red blood cell, they mature into a form that develops a tricky defence against the body's immune system.

    In the red blood cell, the parasites feed on haemoglobin and multiply. After every 48 hours, the cell ruptures and new parasites invade more red blood cells and repeat the cycle.

    Malaria claims 519 in Khagrachhari, Bangladesh

    Malaria claimed 519 lives in eight upazilas of the district in last three and half years, hospital sources said. Of them, 154 people died in 2001, 181 in 2002, 129 in 2003 and 55 in last six months. During the period 3,31,216 people were affected by the disease. District Civil Surgeon officials said the highest 14 people died of the disease in Sadar Hospital in last six months. Besides, 12 people died in Ramgarh, eight in Matiranga, six in Manikchhari, five each in Panchhari and Mahalchhari, four in Dighinala and one in Laxmichhari health complexes.

    Unofficial sources said the death in the district would be much higher than the official figure as most of the cases in remote areas remained unreported. Sources said the situation has deteriorated in recent times due to the lack of medicine and shortage of doctors in local health complexes. District Civil Surgeon Dr Sivash Das said though the number of malaria patients is on rise in the district (UNB, Khagrachhari, August 30, 2004).

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    5. Transmission of the Disease

    Anopheles mosquito bites a human and injects material from her salivary glands, which contains primitive malarial parasites called sporozoites, before feeding. These sporozoites circulate in the blood for a short time and then settle in the liver where they enter the parenchymal cells and multiply; this stage is known as pre-erythrocytic schizogony. After about 12 days there may be many thousands of young parasites known as merozoites in one liver cell. The blood stages of the four species of malaria can be seen in the section on diagnosis.

    In the red blood cells the parasites develop into two forms, a sexual and an asexual cycle. The sexual cycle produces male and female gametocytes, which circulate in the blood and are taken up by a female mosquito when taking a blood meal. The male and female gametocytes fuse in the mosquito's stomach and form oöcysts in the wall of the stomach. These oöcysts develop over a period of days and contain large numbers of sporozoites, which move to the salivary glands and are ready to be injected into man when the mosquito next takes a meal. In the asexual cycle the developing parasites form schizonts in the red blood cells which contain many merozoites, the infected red cells rupture and release a batch of young parasites, merozoites, which invade new red cells. In P.vivax, P.ovale and probably P.malariae, all stages of development subsequent to the liver cycle can be observed in the peripheral blood.

    However, in the case of P.falciparum only ring forms and gametocytes are usually present in the peripheral blood. Developing forms appear to stick in the blood vessels of the large organs such as the brain and restrict the blood flow with serious consequences (RPH Laboratory Medicine, 2002)

    Malaria kills about 3,000 children a day globally and the parasite that causes the disease is becoming harder to treat as it develops resistance to more and more drugs, a WHO study said Naimul Haq, August 2004

    The U.N.-backed “Roll Back Malaria Campaign” is likely to fall far short of its goal of halving the number of malaria deaths worldwide by 2010 due to the oldest scourge - a lack of donations. But the problem is that the number of malaria deaths has not dropped since 1998, when health activists, governments and international agencies including UNICEF, the World Health Organisation, the U.N. Development Programme and the World Bank launched the campaign.

    Not so long ago the British Medical Journal called the “Roll Back Malaria Campaign” a failing health initiative and questioned whether or not the campaign could be saved. The authors of another article published in a January issue of The Lancet went even further and accused the World Health Organisation and the Global Fund to Fight AIDS, Tuberculosis and Malaria of "institutional inadequacies" that created a "crisis" leading to increased child malaria deaths that will contribute to the failure of WHO's 1998 "Roll Back Malaria Campaign” to halve malaria deaths by 2010.

    Laboratory Diagnosis

    There are four species of the genus plasmodium responsible for the malarial parasite infections that commonly infect man, P.falciparum, P.vivax, P.malariae and P.ovale. The most important of these is P.falciparum because it can be rapidly fatal and is responsible for the majority of malaria related deaths.

    In recent years a number of new techniques based on the "dipstick" format, have become available for the diagnosis of malaria. These include the ICT-Malaria Pf, OptiMALr and the Kat-Quick kits. The methods are based on the principle of the detection of plasmodial histidine rich protein-2 (HRP-2) or parasite-specific lactate dehydrogenase (pLDH) which is present in P.falciparum infections.

    Dipstick tests have the potential of enhancing the speed and also the accuracy of diagnosing P. falciparum, particularly in non specialised laboratories where inexperienced or junior staff may be involved, since very little training is required for these techniques.

    Antibodies to malaria can be detected using enzymatic immunoassays or immunofluorescence techniques.

    Another relatively new method is the polymerase chain reaction (PCR) which uses a non-isotopically labelled probe following PCR amplification.

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    6.Malaria Prophylaxis

    Alpha-terphinel - Fight Against Malaria

    During the 1970s many countries suffered a huge increase in the number of malaria cases and for some this amounted to up to 30 times the low figures achieved during the 1960s. In India today more than half the nation's health budget is spent on anti-malaria campaigns. Its record of cases over the last three decades makes alarming reading; from 100 million in 1952, down 60,000 in 1962 and up again in 1978 to 50 million.

    Alpha-terphienyl, a compound derived from Tagetes marigolds, seems to be as effective as DDT in controlling mosquito larve.

    Antimalarial drug prophylaxis is a difficult area with a number of drug resistant strains of P. falciparum now common, particularly in South East Asia and increasingly in Africa. Resistance to Fansidar, Chloroquine, Maloprim, Lariam and Halofantrine, Malarone and quinine have all been reported. Resistance is important because falciparum malaria can be rapidly fatal.

    At present the following is recommended:

    Travellers should take active measures to protect themselves against mosquito bites. This is the best and most effective means of avoiding malaria. Generally mosquitoes start feeding at dusk. Therefore, there need be no restrictions on dress during the day but, from just before dusk, clothing should be worn that covers the arms and legs. In addition, a mosquito repellent should be applied on other exposed parts. Knock-down sprays, mosquito coils and pyrethrin-impregnated mosquito nets can also be effective at minimizing vector contact.

  • Chloroquine can still be used in some regions but is of limited value in many parts of the world. Treatment should be started one week before travelling to, and continued for four weeks after leaving, a malaria endemic area. (Adult dose 300mg weekly taken with a meal, at the same time and on the same day each week). It will suppress but not cure an infection with P. vivax and symptoms may not appear for weeks or months after the traveller has returned home. For children the dose is 5mg/kg base given once a week on the same day each week. Since liquid suspensions for children are no longer available, a tablet has to be divided to provide the appropriate dose.
  • Doxycycline is a suitable prophylactic anti-malarial agent to use in high risk areas such as South East Asia. It must not be used in children under 8 years of age nor in pregnant or breast-feeding women. Doxycycline may cause contraceptive pills to be less effective so additional precautions should be taken.
  • Mefloquine (Lariam) is still a widely used prophylactic. It has a long half life and the convenience of a once weekly dose. For adults (more than 45 kg bodyweight) the dose is 250mg base weekly, starting one week before arrival in a malarious area. >MalaroneTM. This is a combination of atovaquone and proguanil and recent studies have found it a safe and effective prophylactic agent with few side affects. Unfortunately it is expensive (~US$42 for 12 tablets) and has to be taken daily.

    If living "rough" always sleep under a mosquito net. Make sure that it is free of holes, is well tucked in and ideally impregnated with Permethrin*. Alternatively, one of several new and more effective, recently introduced synthetic pyrethroids (e.g. deltamethrin), may be used which has been shown to be effective even after 20 washings of the impregnated net.

    There are now test kits for malaria* designed for those travelling in remote areas. These antigen detection kits allow a diagnosis of falciparum malaria (and other species in some cases) to be made quickly without other equipment and treatment can be started without delay.

    With the increasing spread and intensity of malarial resistance to drugs worldwide, prophylaxis can never be considered completely reliable.
    (Professor T.M.E. Davis, University Department of Medicine, Fremantle Hospital, Western Australia. January, 2004)

    History of Treatment and Prophylaxis

    Key among the factors contributing to the increasing malaria mortality and morbidity is the widespread resistance of Plasmodium falciparum to conventional antimalarial drugs, such as chloroquine, sulfadoxine–pyrimethamine (SP) and amodiaquine. Multidrug-resistant P.falciparum malaria is widely prevalent in south-east Asia and South America. Now Africa, the continent with highest burden of malaria, is also being affected. Resistance to inexpensive monotherapies such as chloroquine and SP has developed or is developing rapidly, with increased mortality as a result.

    Antimalarial drugs fall into several chemical groups and it is useful to have some knowledge of their chemistry. a number of drugs which are no longer used. A number of drugs are no longer used.

    Quinine has been used for more than three centuries and until the 1930's it was the only effective agent for the treatment of malaria. It is one of the four main alkaloids found in the bark of the Cinchona tree and is the only drug which over a long period of time has remained largely effective for treating the disease. It is now only used for treating severe falciparum malaria partly because of undesirable side effects.

    Atebrin (mepacrine)
    This drug is a 9-amino-acridine developed in the early 1930's. It was used as a prophylactic on a large scale during the second world war (1939-45) and was then considered a safe drug. It had a major influence in reducing the incidence of malaria in troops serving in South East Asia. It is now considered to have too many undesirable side effects and is no longer used .

    A very effective 4-amino-quinoline both for treatment and prophylaxis. It was first used in the 1940s shortly after the Second World War and was effective in curing all forms of malaria, with few side effects when taken in the dose prescribed for malaria and it was low in cost. Unfortunately most strains of falciparum malaria are now resistant to chloroquine and more recently chloroquine resistant vivax malaria has also been reported

    This drug falls into the biguanide class of antimalarials and was first synthesised in 1946. It has a biguanide chain attached at one end to a chlorophenyl ring and it is very close in structure to pyrimethamine. The drug is a folate antagonist and destroys the malarial parasite by binding to the enzyme dihydrofolate reductase in much the same way as pyrimethamine. It is still used as a prophylactic in some countries

    In 1998 a new drug combination was released in Australia called Malarone. This is a combination of proguanil and atovaquone. Atovaquone became available 1992 and was used with success for the treatment of Pneumocystis carrinii. At present it is a very expensive drug.

    >Mefloquine (Lariam)
    First introduced in 1971, this quinoline methanol derivative is related structurally to quinine. The compound was effective against malaria, resistant to other forms of treatment when first introduced and because of its long half life was a good prophylactic, but widespread resistance has now developed and this together with undesirable side effects have resulted in a decline in its use.

    This is derived from a Chinese herbal remedy and covers a group of products. The two most widely used are artesunate and artemether. While they are widely used in Southeast Asia they are not licensed in much of the so called "Western World" including Australia. A high rate of treatment failures has been reported and it is now being combined with mefloquine for the treatment of falciparum malaria.

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    7. Malaria Treatment

    This species was originally sensitive to chloroquine. However, strains resistant to this and other antimalarial drugs are now commonplace. Because the parasite is able to multiply very rapidly and sequester within the microvasculature, a life threatening illness may develop in a very short space of time.

    Uncomplicated malaria (where patients can take oral therapy) can usually be treated effectively with one of three regimens:

    Quinine sulphate 10 mg salt/kg 8 hourly for seven days plus doxycycline 100 mg daily for 7 days. Patients will usually develop 'cinchonism' (tinnitus, high-tone hearing loss, nausea, dysphoria) after 2-3 days but should be encouraged to complete the full course to avoid recrudescence. Tetracycline (4mg/kg daily for seven days) or the combination drug FansidarTM (25mg/kg sulfadoxine plus 1.25mg/kg pyrimethamine as a single dose) can be given as less expensive alternatives to doxycycline.

    Malarone (atovaquone 250 mg plus proguanil 100 mg) 4 tablets daily for three consecutive days. This combination therapy is relatively new and appears to be very effective but it is also very expensive. Resistance to this drug combination has already been reported in a patient from Nigeria (Malaria J. 2002; 1:1).

    Mefloquine (LariumTM) given as 15 mg/kg in a divided dose followed by 10 mg/kg the following day. Antipyretic and antiemetic agents may need to be given prior to mefloquine administration to reduce the risk of vomiting.

    With the advent of widespread chloroquine resistance, this drug (dose 25mg base/kg in divided doses over 2-3 days; see P. vivax treatment regimen below) can be combined with others such as FansidarTM (25mg/kg sulfadoxine plus 1.25mg/kg pyrimethamine as a single dose) in areas where background immunity to malaria contributes to parasite clearance and alternative regimens are too expensive.

    Lapdap (chlorproguanil 2mg/kg plus dapsone 2.5mg/kg) daily for three days is an inexpensive combination of well established compounds being assessed in African trials.

    Severe malaria (where patients have coma, jaundice, renal failure, hypoglycaemia, lactic acidosis, severe anaemia, high parasite count, hyperpyrexia) is ideally treated in an intensive care or high dependency unit where patients can be monitored closely both clinically and biochemically. Intravenous quinine is the treatment of choice but rapid injection can lead to hypotension, dysrhythmias and death.

    In patients who have not received quinine in the previous 48 hours, one of two regimens can be used:

    1. Quinine dihydrochloride 20 mg salt/kg base given i.v. in 5% w/v dextrose or normal saline as a once-only 4 hour infusion followed, 4 hours later, by quinine dihydrochloride 10 mg salt/kg base 4-hour infusions, 8 hourly.
    2. Where a syringe pump or other accurate infusion device is available, quinine dihydrochloride 7 mg salt/kg base over 30 minutes followed immediately by quinine dihydrochloride 10 mg salt/kg base over 4 hours then, starting 4 hours later, quinine dihydrochloride 10 mg salt/kg base as 4 hour infusions, 8 hourly.

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    8. Treatment with artemisinin

    Artemisinin has been used for many years by the Chinese as a traditional treatment for fever and malaria. It is a sesquiterpene lactone derived from the wormwood plant Artemisia annua. Semi-synthetic derivatives including artemether and artesunate are now widely available in the tropics. These compounds are being increasingly used in a number of countries and are both cheap and effective. They are starting to be licensed in Western countries.

    They are particularly valuable in the treatment of multidrug-resistant falciparum malaria. Unless used with a second antimalarial as described below there is likely to be a high recrudescent rate. Side-effects have been reported but these are comparartively rare and seldom severe. Artemisinin derivatives are recommended for treatment but not for prophylaxis. If an artemisinin drug is used to treat vivax malaria, it should be accompanied by a course of primaquine.

    Artemisinin (500mg tablets) give 10-20 mg/kg on day 1 (500-1,000 mg) orally then 500mg for 4 days. Then give mefloquine 15mg base/kg or split dose 25mg base/kg. Artemisinin (200mg suppositories): for severe malaria 600-1200mg stat, 400-600mg after 4 hours then 400-800mg twice daily for 3 days. Give mefloquine as above.
    Artesunate (50 & 60 mg vials for intravenous use): for severe malaria 120mg I.V. stat. 60 mg at 4, 24 and 48 hours, 50-60 mg on days 3-5. Give mefloquine as above.
    Dihydroartemisinin (20 mg tablets): First dose 120mg then 60mg daily for 4-6 days then give mefloquine as above.
    Artemeter (vials for intramuscular use): For severe malaria 3.2 mg/kg intramuscularly stat then 1.6mg twice daily for 3-7 days, Give mefloquine as above.

    A recent report on the sale of artesunate in South East Asia found that 38% of the artesunate purchased was fake (Lancet 2001; 357:1948-49). Fake artesunate can be identified by a dye test (J Pharm Biomed Anal 2000;24: 65-70) Other fake drugs including mefloquine can also be found in South East Asian markets.

    (Professor T.M.E. Davis, University Department of Medicine, Fremantle Hospital, Western Australia. January, 2004)

    International health scholar, Amir Attaran of the Royal Institute of International Affairs and other authors accuse WHO of violating its own policy on malaria by acquiescing to pressures to cut costs on malaria treatment. The authors allege that, instead of promoting a new, highly effective treatment for malaria called artemisinin-class combination therapy, which is especially promising where drug resistance to conventional malaria treatments has emerged, WHO has approved the Global Fund's plans for cheap but ineffective chloroquine or sulfadoxine-pyrimethamine to treat malaria. They call the policy "indefensible" and say it amounts to "medical malpractice."

    Considering the increase in child malaria deaths due to drug resistance and extrapolating that to populations in which the Global Fund is financing the use of chloroquine or sulfadoxine-pyrimethamine, they do have a point as the continued use of older drugs like chloroquine and sulphadoxine-pyrimethamine is indefensible because they have become useless in the treatment of malaria because the parasite has built up a resistance to them. But treatment with artemisinin-class combination therapy (ACT) costs $2 a dose, between 10 and 20 times that of the outdated drugs.

    Artemisinin, which has no significant side effects, quickly reduces fevers and rapidly lowers blood-parasite levels, which can keep small outbreaks in mosquito-infested areas from becoming epidemics. The price of artemisinin cocktails has fallen from $2 per treatment to 90 cents or less as more companies in China, India and Vietnam have begun making them. Novartis, the Swiss drug giant, sells its artemisinin-lumefantrine mix, Coartem, to poor countries for 10 cents less than it costs to make.

    As a response to increasing levels of antimalarial resistance, WHO recommends that all countries experiencing resistance to conventional monotherapies, such as chloroquine, amodiaquine or sulfadoxine–pyrimethamine, should use combination therapies, preferably those containing artemisinin derivatives (ACTs – artemisinin-based combination therapies) for falciparum malaria.

    WHO currently recommends the following therapeutic options:

  • artemether/lumefantrine,
  • artesunate plus amodiaquine,
  • artesunate plus sulfadoxine/pyrimethamine (in areas where SP efficacy remains high),
  • artesunate plus mefloquine (in areas with low to moderate transmission), and
  • amodiaquine plus sulfadoxine–pyrimethamine, in areas where efficacy of both amodiaquine and SP remains high (mainly the countries of west Africa). This non-artemisinin-based combination therapy is reserved as an interim option for countries that, for whatever reason, are unable immediately to move to ACT.

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    9. Overflow Irrigation to combat Malaria

    traditional irrigationHuman communities have always generated, refined and passed on knowledge from generation to generation. Such “traditional” knowledge” is often an important part of their cultural identities. Traditional knowledge has played, and still plays, a vital role in the daily lives of the vast majority of people. Traditional knowledge is essential to the food security and health of millions of people in the developing world.

    In Bangladesh traditional agricultural practice that the farmers inherited since thousands of years replaced by agrochemical and so called modern “irrigation. system”. H. M. Khan, North West Hydraulic Consultant Ltd, Dhaka (1987) reveals that in planning or studies to find out the requirements of the farmers are totally neglected, mainly engineer’s decisions and designs are imposed on them although farmers posses the best source of hydrological and agricultural information. With the birth of “Green Revolution” flood embankments are constructed along either or both banks of the rivers which never protect severe floods but shallow normal floodwater. Farmer welcomes shallow flood that not only improves soil quality by depositing organic-rich silty-clayey sediments but also improves ground water condition during dry season. Flood embankments stop natural runoff monsoon rains and causes flooding.

    Sir William Willcocks, an irrigation expert was extremely impressed by Bengal’s ancient system of flood (or overflow) irrigation, which eventually disappeared. In a series of lecture delivered in the 1920s, Wilcocks strongly argued that the ancient system should be revived in Bengal as it best suited the region and the needs of the people. The ancient irrigation system based on floodwater entered the fields through the inundation of canals, carrying not only organic rich silty sediments but also fish which swam through these canals (Khal) into the lakes (bil) and tanks (pukur) to feed on the larva of mosquitoes (Agarwal and Narian, 1997).

    According to Wilcocks, the ancient system of overflow irrigation has lasted for thousands of years. Unfortunately, during Afgan-Maratha war in the 18th century and subsequent British conquest of India, this irrigation system was neglected, and was never revived (Wilcocks, 1930). As Wilcocks reveals:

    The delta of the Ganges is not a rainless area. It enjoys a rainfall of about 50 to 60 inches, when all rivers are in flood, and to make full use of the rich waters of the Ganges and Damodar floods and the abundant but nutritionally poor water of the monsoon rainfall that some early Bengal king put in practice the system of ‘overflow irrigation’ of the Ganges and Damodar deltas which insured health and wealth to Bengal hundreds of years. This system is perfectly suited to meet the special needs of Bengal

    Wilcocks observed “river water in the early months of the flood is gold” and made the following remarks when he spent sometime with the peasantry:

    I have learnt from these men why they long for the old days when rice fields, tanks and pools were full of fish, which Bernier (an early English traveller) said, were in abundance. The peasantry craves for fish, which were the food for the poor in old days, which they seldom see today... Bernier saw in the 17th century that the overflow irrigation combated Malaria, provided an abundant harvest of fish, enriched the soil and made congestion of the river impossible.

    In Bangladesh the government-constructed embankments that prohibit silt-laden flood water and monsoon rain does not drain the low pockets by gravity and caused return of mosquitoes and Malaria. In many areas farmers protests and cuts the embankments but the small rivers and canals (khals) are so heavily silted that the old system can not be reintroduced. We notice that after each severe flood when the rice fields are heavily flooded a bumper crop is yielded in following harvest season.

    Now arsenic rich ground water is no more alternative to irrigation and more stagnant water through ill-planned constructions increasing many water-borne diseases. We demand for surface water irrigation and traditional agriculture.

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    10. References

    1. The Africa malaria report. Geneva, World Health Organization, 2003 (WHO/CDS/MAL/2003.1093).
    2. The use of antimalarial drugs. Report of a WHO Informal Consultation. Geneva, World Health Organization, 2001 (WHO/CDS/RBM/2001.33).
    3. Antimalarial drug combination therapy: Report of WHO technical consultation, 4-5 April 2001. Geneva, World Health Organization (WHO/CDS/RBM/2001.35).
    4. Meeting on goal of malaria treatment policy in the Africa Region, 14-15 August 2003, Harare, Zimbabwe. Harare, World Health Organization (in preparation).
    5. Position of WHO's Roll Back Malaria Department on malaria treatment policy. Geneva, World Health Organization.
    6. Assessment and monitoring of antimalarial drug efficacy for the treatment of uncomplicated falciparum malaria. Geneva, World Health Organization, 2003 (WHO/HTM/RBM/2003.50).
    7. Framework for developing, implementing and updating antimalarial treatment policy in Africa: a guide for country malaria control programmes. Harare, World Health Organization .
    8. Procurement, quality and sourcing project: access to artemisinin-based combination antimalarial drugs of acceptable quality. Geneva, World Health Organization.
    9. Procurement of artemether/lumefantrine (Coartem®) through WHO. Geneva, World Health Organization.
    10. Report of the Expert Consultation on the Procurement & Financing of Antimalarial Drugs, 15-16 September 2003. Washington DC, World Bank.

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