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EDITORIALS: Jane N Zuckerman Imported malaria in the UK BMJ 2008; 337: a135 [Full text]

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Imported malaria in the UK: Unde venis? & Quo vadis?

Felix ID Konotey-Ahulu   (16 July 2008)

Private Prescriptions and Malaria Prophylaxis

Jahura Hossain   (24 July 2008)

Imported malaria in the UK: Unde venis? & Quo vadis? 16 July 2008
Felix ID Konotey-Ahulu, Kwegyir Aggrey Distinguished Professor of Human Genetics, University of Cape Coast,, Ghana Consultant Physician Genetic Counsellor Haemoglobinopathies, 10 Harley St, London W1G 9PF Send response to journal: Re: Imported malaria in the UK: Unde venis? & Quo vadis?	Imported malaria in the UK: Unde venis? & Quo vadis? Professor Jane Zuckerman’s excellent editorial [1] mentions 2 things which are often missed in other articles on this subject: (a) “Improved vector” control in an overseas region leads to “a significant decrease in imported cases” of malaria from that region and (b) people who have not “lived in an endemic area for many years” but who visit relatives there “underestimate their risk of exposure to travel related illness, especially malaria” [1], which attitude Professor Zuckerman calls “a dangerous presumption”. And so it is, as the following report warning my fellow Ghanaians shows. CEREBRAL MALARIA PLUS RENAL FAILURE A Ghanaian allowed me to mention her name and that of her unfortunate relative in The Ghanaian Times “so that you may learn from her experience” [2]. She phoned me in London one midnight asking if I could recommend a psychiatrist. Her 57 year old relative “had just returned from Accra where he had visited for the first time in 25 years, and was very confused” [2]. He did not need a psychiatrist, I said “but rush him to the nearest hospital and tell them he has (write this down) Falciparum Malaria, and that he needs Quinine at once” [2]. Before I let her go off the phone, I said to her “Ask them to check his urine flow every hour, because he is likely to have acute kidney failure” [2]. Afraid to call an ambulance in case they took the patient to a psychiatric hospital, “her household bundled the patient into her car and sped to the nearest hospital” [2]. A blow by blow account of what happened next appears in The GhanaianTimes [2], but suffice it to say that the lady’s advice was totally ignored in the emergency room though the patient was admitted to hospital because of his deteriorating temperature. “When days later the staff realised that Mr S. R. indeed had both cerebral malaria and acute kidney failure, they rushed him with fanfare to a London Hospital. Too late, it was, and Mr S. R. died. He was buried in the UK”. [2] I concluded that article (one of seven weekly articles on Malaria in Ghanaian Times) thus: “Tell relatives visiting home from a long sojourn abroad that MALARIA KILLS! [2] VECTORS and MALARIA and POLITICAL DIMENSION In more than one of the other articles in the Ghanaian Times I underlined Professor Zuckerman’s other often forgotten point, namely, “Get rid of vectors and malaria tends to disappear”. But getting rid of vectors is a political matter which I can easily prove. First proof: There were much fewer mosquitoes in Accra during the Colonial Gold Coast than there were/are in self-governing Ghana. Why? Because, as I once pointed out “came Independence, and the Ghanaian African became independent of the Town Council man” [3] – the very man who hauled environmental polluters to Court for encouraging mosquito breeding. “The Colonial Days have so much to teach us” I bellowed to fellow Ghanaians [4]. My second proof is “Singapore and Trinidad” [5] – two tropical countries whose mosquito intolerance has been placed on a war footing. The cleanest countries I have had the privilege of visiting, I said, were “Zurich, Melbourne, and Singapore… I have mentioned Singapore as a tropical country that Ghana needed to emulate in the way they controlled the mosquito population” [5]. But how did they do this if not through political rigour? Another country, I told Ghanaians “not populated by Singaporeans, but by Black folk like Ghanaians, have also succeeded in eliminating malaria-carrying mosquitoes – Trinidad”. Yolande Agble had this to say “The frequent unannounced visits by sanitary inspectors and their teams, the strict penalties imposed on those citizens careless enough to leave drums and other receptacles of water lying uncovered etc. The result was that malaria was totally unknown to me until I got married and went to live in Ghana” [5] – enough to make a Ghanaian like me blush, if you could diagnose blushing in the black man [6] Another political discipline that Singapore and Trinidad have over sub-Saharan Africa is what I call “strictures on corruption”. I pointed out exactly how corruption militates against effective malaria control [7]. Work needs to be done about imported malaria not only “at home in the UK”, but also abroad where we need to go back to the “Colonial Days” in our approach to malaria control. Paradoxically, medicated bed nets whose importance has been over-hyped are given a wide berth in some African countries. “The usual un-medicated white nets were good enough in the Colonial Days, so why do we need these now?” is a common question being asked today [8], probably because of reported fears regarding safety [9]. “Ghanaian workers from the Noguchi Institute of Medical Research” I pointed out, “did some excellent research at Dodowa, and found that mosquito nets that had not been impregnated with any potion were as good at preventing malaria as anything else” [8]. The conventional nets were similarly effective in my boarding school days in preventing mosquito bites. ANTI-MALARIAL DRUGS I agree with Professor Zuckerman that Atovaquine plus Proguanine is to be preferred to Mefloquine if only because the latter (Mefloquine) has 51 side effects including psychosis and convulsions listed in the British National Formulary [10]. Moreover, from the African’s point of view, these drugs (including Malarone), although affordable by the British travelling overseas, are often too costly. As “cost is usually the major factor that determines the use of anti-malarial drugs” [11], we find in Ghana that “people are now growing anti-fever shrubs in their back gardens” [3] - shrubs like Artemisia annua and others. The Nigerians “prepare the leaves of the Neem tree (Azadirachta indica) into a ball called ‘Dongo Yarro’ and treat malaria with it” [8]. The neem saved me from cerebral malaria more than once when I was a child [3]. For some African chidren “Rectal artemether is effective and well tolerated and could be used as treatment for cerebral malaria” [12] The officially recommended imported Artemissin based compounded drugs (ACT) for malaria have caused alarming side effects in Ghana leading to public protests and the Director General of the Health Services with the Minister of Health had to appear together to answer furious questions [13]. And with the credit crunch dismantling economics in sub-Saharan Africa how long can we rely on imported drugs for our common diseases? As Mervin Willcox and Bodeker state in the BMJ “Traditional medicines have been used to treat malaria for thousands of years and are the source of the two main groups (artemissinin and quinine derivatives) of modern anti-malarial drugs” [14]. So why are we using our scarce foreign exchange importing drugs with 51 side effects? DEFECTIVE PHARMACOVIGILANCE? Could one reason be compromised pharmacovigilance? [15], coupled with the related “lap dogs to drug firms” mentality? [16]. All of which brings us back to public health measures with political rigour as the most effective way forward to tackling the malaria menace. Singapore and Trinidad did not (and do not) need vaccines for malaria, having both maintained the public health discipline of the Colonial Days [17 18 19]. As I said at the close of the 20th Century: “Vaccines have achieved much this century, but to ‘Wait for WHO to give us vaccines’ while we neglect ourselves and our environment is wholly irresponsible” [20]. UNDE VENIS? & QUO VADIS? As regards UK medical practice, I am clearly reminded as if it was yesterday of what that brilliant malariologist Professor Brian Maegraith, drummed into us 46 years ago at the Liverpool School of Tropical Medicne [21]. Whichever patient walked into your consulting room you asked two vital questions: “Unde venis? [Literally in Latin “From where have you come?”] and “Quo vadis?” [“To where are you going?”]. This way the British pilot who complained of yellow eyes and diarrhoea after an overseas duty was not mistaken for suffering from hepatitis when, in fact, he had serious malaria, and the non-immune Ghanaian adult in London with cerebral malaria was not required to see a psychiatrist. Felix I D Konotey-Ahulu MD(Lond) FRCP(Lond) DTMH(L’pool) – Kwegyir Aggrey Distinguished Professor of Human Genetics, University of Cape Coast, Ghana and Consultant Physician Genetic Counsellor in Haemoglobinopathies, London W1G 9PF felix@konotey-ahulu.com Competing interests: None declared 1 Zuckerman JN. Imported malaria in the UK. BMJ 2008; 337:a135 (12 July) 2 Konotey-Ahulu FID. Epidemiology of malaria (1). Ghanaian Times Jan 21 2006, page 6 3 Konotey-Ahulu FID. Averting a malaria disaster. Lancet 1999; 354: 258 (17 July) 4 Konotey-Ahulu FID. Epidemiology of malaria (2). Ghanaian Times Jan 28 2006, page 6 5 Konotey-Ahulu FID. Epidemiology of malaria (3). Ghanaian Times Feb 4 2006, page 6 6 Konotey-Ahulu FID. Black people’s red faces and AIDS prevention. Lancet 2000; 355: 1559 (29 April) 7 Konotey-Ahulu FID. Epidemiology of malaria (5). The Why? Question. Ghanaian Times Feb 18 2006, page 6. 8 Konotey-Ahulu FID. Ghanaian doctors in malaria research. Ghanaian Times 7 Jan 2006, page 6 9 The Globe and Mail Toronto. Tough flight for mosquito nets “If they are safe for babies and mothers in Africa, why are they not safe enough in Canada for a week?” 18 August 2006 10 British National Formulary (BNF) ‘46’, September 2003, pages 317 -318 11 White NJ, Nosten F, Looareesuwan S ET et al. Averting a malaria disaster. Lancet 1999; 353: 1965-67. 12 Aceng JR, Byarubaga JS, Tumwine J. Rectal artemether versus intravenous quinine for the treatment of cerebral malaria in Uganda: randomised clinical trial. BMJ 2005; 330: 334 13 Amofah G. Furore over Artesunate-Amodiaquine. Daily Graphic, Accra 15 May 2006, page 23. 14 Willcox ML, Bodeker G. Traditional herbal medicines for malaria. BMJ 2004; 329: 1156-59 (13 Nov) 15 Konotey-Ahulu FID. Who should best pharmacovigilate in developing countries? BMJ Rapid Response http://www.bmj.com/cgi/eletters/335/7618/462#176455 (14 Sep 2007) 16 Konotey-Ahulu FID. Doctors must not be lapdogs to drug firms: even more relevant to The Third World. BMJ Rapid Response. November 12 2006. http://www.bmj.com/cgi/eletters/333/7576/1027#149040 17 Konotey-Ahulu FID. Fever and WHO recommendation. Lancet 1997: 350: 1549 (Nov 22) 18 Konotey-Ahulu FID. Public health in less developed countries. Lancet 2000; 356: 1769-70 (Nov 18) 19 Konotey-Ahulu FID. A non-sense mutation and protection from severe malaria. Lancet 2001; 358: 927-28 (September 15) 20 Konotey-Ahulu FID. Supreme worth of clinical epidemiology in Africa: bancroftian filariasis as one case in point [Guest Editorial] African Journal of Health Sciences (AFHES Nairobi) 1999; 6: 1-2. 21 Professor Brian Maegraith 1907-1989 “Maegraith possessed ideas ahead of his time. In his classic paper ‘Unde venis?’ (meaning ‘where do you come from?’), published in The Lancet in 1963, he stressed the importance of taking a patient’s geographical history as he envisaged the escalation of air travel and the increasing likelihood of imported disease as people returned from tropical areas within the period of incubation of potential infection of many tropical diseases. Maegraith was famed for his pioneering approach in this area.” http://sca.lib.liv.ac.uk/collections/colldescs/lstm/maegraith.htm Accessed 15 July 2008. . Competing interests: None declared
Private Prescriptions and Malaria Prophylaxis 24 July 2008
Jahura Hossain, Locum GP London Send response to journal: Re: Private Prescriptions and Malaria Prophylaxis	Cost is an important factor when people decide whether to comply with malaria prophylaxis or not. I have had patients change their minds once they realised the high cost of purchasing malaria prophylaxis for an entire family. Other patients felt they could only afford prophylaxis for their children but not for themselves. Yet others have returned their private prescriptions and asked for something cheaper. While the Department of Health holds the notion that malaria prophylaxis should not be reimbursed under the NHS (National Health Service), GPs (General Practitioners) will continue to write private prescriptions for these drugs. Zuckerman's editorial (BMJ 2008;337:a135) asks what else can be done to prevent malaria in UK travellers. Given the expected increase in cases of imported malaria, it is surely time to rethink NHS policy on the reimbursement of malaria prophylaxis. Even the most carefully targeted communication about malaria prevention does little to convince a patient who is worried about cost. Competing interests: None declared