Improving severe malaria outcomes: a doctor’s insight

Dr Fayulu (right) and Male ward team discuss the case of a severe malaria patient.

Dr David Fayulu, originally from the Democratic Republic of Congo (DRC), has been working as a doctor for the past 17 years across DRC, Zimbabwe, Chad, Central African Republic (CAR), Malawi and now Zambia. Malaria has been a common yet deadly disease he has been treating throughout his career not least in Zambia, where he is based today. Last month (December 2017) he saw over 400 malaria patients, including 15 severe malaria patients. In his experience, malaria is especially problematic in children under 5 and pregnant women.

You work in a referral hospital; however, many cases of severe malaria are often isolated in the community, which may be located far away from the hospital. What kind of support can be given to communities for improving the management and outcomes of severe malaria?

It’s important to train community health workers to identify malaria symptoms, so that they can act as a link between the hospital and the community and help to prevent disease progression to severe malaria. Communities should also be sensitized on severe malaria danger signs, so that they can act when needed, as soon as the symptoms appear. Preventative measures, such as mosquito nets and repellents, can also make a difference.

Children and pregnant women are more susceptible to malaria than adults and older children. How can these populations be better protected?

It is important to treat all cases of simple malaria, and particularly in these vulnerable groups, before it progresses to severe malaria, if possible. Ensuring children receive the recommended childhood immunization as well as proper nutrition will help support their immune system in case of infection. Lastly, pregnant women should attend antenatal visits to receive Intermittent Preventive Treatment in Pregnancy (IPTp) and screen for any possible malaria infections.

How is severe malaria managed in the countries where you have worked?

Artesunate is now the preferred drug for treating severe malaria due to the unwanted secondary effects of the previously recommended treatment, quinine. In my experience, few side effects have been reported and the drug is generally well tolerated by patients. In accordance with national guidelines, quinine is still used, but, as the alternative option and during the first trimester of pregnancy. In the second and third trimesters artesunate is generally used.

Artesunate is recommended for the treatment of severe malaria in pregnancy in all trimesters by the WHO. Why do you think this recommendation has not yet been adopted in certain countries and what is needed to increase this practice?

The adoption and use of artesunate in the first trimester of pregnancy, as recommended by WHO, is a sensitive issue as it involves the foetus and the mother. The final decision depends on a country’s own experience with the drug and studies conducted in this area, the risk-benefit to the mother and foetus and the resulting decision of the healthcare provider and mother. While no study or publication shows any threat to the foetus or mother with use of the drug, each country has its own guideline.

What is expected from various levels of the health system to ensure proper management of severe malaria is possible?

NMCP and MoH:

Provide hospital staff with the latest national treatment guidelines for malaria.

Provide them the necessary training to carry out recommendations for case management.

Ensure good and safe working conditions that provide the necessary equipment for case management including syringes, RDT kits, drugs, fluids, cannulas, etc.

International organizations:

Collaborate on local efforts to bring medical assistance to communities.

Engage in discussions with the local government to improve medical management and help them to achieve goals that were set in the interest of improving health in the community.

Participate in local capacity building by conducting training and workshops.