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Preventing and treating malaria in children

 

Society has become increasingly mobile; families travel to visit extended families if they have migrated to the UK, and more and more people travel with work commitments and for leisure. Tropical diseases are now a global problem, and malaria in particular is a disease that often hits the headlines.

Malaria is an infectious disease caused by the Plasmodium parasites, carried by the Anopheles mosquitoe. There are five species of malarial parasite - P falciparum, P vivax, P malariae, P ovale and P knowlesi. 

This article considers the risks for children travelling to malarial areas. Anti-malarials are not free, and cost might deter parents from buying them. This article will consider the evidence and the risks involved.

Statistics

The World Health Organisation (WHO) estimates that in 2010 there were 216 million cases of malaria worldwide, resulting in approximately 655,000 deaths. The majority are children dying in sub- Saharan Africa.1 The Health Protection Agency2 (HPA) state that in 2011 there were 1,677 cases of imported malaria into the UK, and eight deaths. Six deaths were attributed to Plasmodium falciparum acquired in Africa and two from P vivax contracted in India.

Health promotion/Preventative measures for children 

Evidence showed that those who succumbed to malaria had not taken any prophylaxis, or had used it irregularly. There is also a lack of awareness that 90% of areas in Africa have preventative drug-resistant strains of the malarial parasite.

Prevention can be divided into stages A, B, C, D and E. (Advisory Committee on Malaria Prevention)3:

  • Awareness of risk.
  • Bite avoidance.
  • Chemoprophylaxis.
  • Diagnosis - with early treatment of infections.
  • Emergency treatment - in remote areas.

Awareness of Risk

It is important that we ensure clients are knowledgeable about the risks of malaria. Public health can map incidence and prevalence of disease and consider the ethnic breakdown of the area. Those regions with a high percentage of people from malarial areas should receive the necessary advice about preventive steps for themselves and their children.

According to the World Health Organisation (WHO) it is inadvisable to travel to malarial areas with small children and certainly not in pregnancy, due to the risk of stillbirth, prematurity or maternal death. Malarial transmission can be seasonal, so if possible trips should be planned in the dry season, when transmission is less common.4

Bite avoidance

Families should use pyrethroid- treated netting, which is widely available online, to protect young children. This should be used over cots and buggies as well as beds.

Impregnation lasts from six months to a year, depending on whether nets are washed or packed away in between uses. Mosquitoes particularly bite at twilight and during the night, so extra care is needed to cover the body at these times.

Rooms should be sprayed with an insecticide before entering, to kill any mosquitoes that have entered during the day. If possible, limbs should be covered to avoid the risks of bites, but this can be difficult in hot environments. Light-coloured clothes will reduce risk, as they are less attractive to mosquitoes.

Mosquitoe repellants containing diethyl toluamide (DEET) are recommended as being the most effective against bites. The safety profile is excellent, although if there are adverse reactions to DEET there are other less effective options on the market. DEET in any form is toxic if ingested and can irritate the eyes, so DEET should not be applied to the hands or faces of children.4

Chemoprophylaxis

All ages should take a prescribed antimalarial drug if they are travelling to a malaria risk area. Breast-fed babies might gain some medication from their mothers if they are complying with prophy- laxis, but the amount will be insufficient for their own protection.

Chloroquine (Avloclor or Nivaquine) remains the preferred choice in areas with chloroquine-sensitive malaria. It is available in a syrup form, which facilitates administration to children. It is usually taken once weekly.

Proguanil (Paludrine) is taken daily as an alternative to chloro- quine. 

Unfortunately resistance to this medication has also developed, so should be used only where the mosquito is still sensitive to the drug. Both chloroquine and proguanil should be taken a week before travel and continued for a further four weeks afterwards.

Doxycycline (such as vibramycin) is considered to be as effective as mefloquine or malarone. It is taken daily, starting one or two days prior to travel and continued for four weeks after leaving the malarial area. 

This is not suitable for children under twelve years of age, due to risks to bone health. Mefloquine is the favoured regime in chloroquine-resistant areas. Drug manufacturers recommend that mefloquine should not be administered to children less than 5kg in weight or under three months of age, but it should be considered for use for all others at a dose of 5mg base/kg once weekly. Fortunately young children are less likely to experience neuropsy- chiatric side effects. It should be taken weekly starting two to three weeks before travelling. It should again be taken for four weeks after departure from the malarial area. 

Malarone is of similar effectiveness to the other medications, with a combination of proguanil and atovaquone. Combined medication helps to reduce the likelihood of drug resistance. Malarone is contra-indicated for those less than 11kg in weight.

Chloroquine and proguanil are the only anti-malarials that can be bought from a pharmacist without a prescription. As many areas are now resistant to these drugs it is imperative that travellers visit their doctor or nurse for appropriate advice. Emergency treatment might include drugs such as Artemesin combined with Lumefan- trine.

No drug regime is 100% protective, so it is important to follow the other measures listed. Drug uses differ according to area visited, so travellers should seek specific advice before travelling.

Diagnosis

Early diagnosis is critical in young children because of the risk of complications and the rapidity of deterioration. Common symptoms in children include:

  • Drowsiness and irritability.
  • Poor appetite.
  • Rapid breathing and poor sleep pattern.
  • Nausea, pain, vomiting and diarrhoea.
  • Three to four day cycle of pyrexia and sweating.
  • Convulsions and loss of consciousness; possible death.

Cost Benefit Analysis

Research undertaken in 19915 considered the cost benefit ratio of immunisation versus treatment for malaria, typhoid and hepatitis A. Malarial prophylaxis was found to be significantly cost-effective due to the incidence of imported malaria. It was not found to be effective however for the other two infections. The authors recommend that public subsidy for vaccinations should be reviewed and targeted. Costs vary according to the particular prophylaxis purchased and vary continually. The medication is avail- able from pharmacists. Surgeries with a dispensing pharmacist can also supply medication.

Discussion 

The real hope for control of malaria is to find an effective vaccine. This eludes us still, despite pharmaceutical research over the last 25 years. Malaria is of greater concern to young children, particu- larly those under five, as they are at increased risk of severe complications. Malaria can be avoided if the above measures are taken; not just chemoprophylaxis, but also adapting behaviour to reduce the risks of bites. Medications differ in cost and suitability so it is important that parents gain advice from their GP, practice nurse, pharmacist or health visitor. It is clear that all those in primary care should collaborate in order to give consistent advice. It would be helpful for public health practitioners to use the same health promotional material in the community and deliver the same health messages.

Conclusion and Summary 

Public health practitioners must ensure that they keep themselves updated with regard to malarial chemoprophylaxis. They should ensure that there is information available to those travelling to malarial areas.

If English is not the first language then efforts should be made to translate into the relevant languages. Health promotion campaigns might be organised to reinforce the messages and infor- mation on malarial risk.

Evidence is conclusive that medication should be used alongside other measures, but who should pay for the prophylaxis? Should the Department of Health encourage the pharmaceutical industry to provide medication at a nominal price? This is a difficult issue, as companies need to recoup the costs of innovation and new medicines in the long term.

The new Health and Wellbeing Boards could look into this issue in their community at a local level to gather key evidence on what is the most cost effective way forward and how best to reduce health inequalities and improve health outcomes.

Resources

Fit for Travel

Foreign and Commonwealth Office

Health Protection agency

 

Malaria Hotspots

NatHNac

References

1. Umeed M. Statistical analysis of malaria cases in the UK. Practice Nursing 2012;23:7.

2. Guidelines for Malarial prevention in travellers from the UK. Health Protection Agency. 2007. 

3. Advisory Committee on Malarial Prevention.

4. Fischer P, Blalek R. Prevention of malaria in Children. Clin Infect Dis 2002;34(4):493-8.

5. Behrens R, Roberts J. Is travel prophylaxis worthwhile? Economicappraisal of prophylactic measures against malaria, hepatitis A and typhoid in travellers. BMJ 1994;309:918-22.