What a great day today. The day began with a great discussion of a case study I prepared –a conglomerate of many malaria patients I have seen since my arrival in Kenya. We had a lively discussion of the case, and everyone participated: nurses, lab, pharmacy, reception and even the Information Technologist. There were real differences in how people interpreted the facts of the case, and even differences of professional opinion. Everyone was respectful of each other, and everyone with patient contact contributed. I think we aired some very good issues, talked about best practices and how to best implement the guidelines, even down to some discussion of where to best treat the patient, when to ask the lab to come to the patient rather than sending the patient to the lab, and how to prepare tablets that get crushed and administered to children. (During regular hours we can ask the pharmacy to prepare, and when we are on-call, after hours, the nurse can crush and mix with drinking water right in the holding room.)
Next, I saw some patients with one of the nurses, and one was a child with a positive blood smear for malaria. It turns out that she had been to another facility and had been given oral anti-malarials just two weeks ago. The family decided that she had actually been bewitched, and so she did not complete the medications. Instead, they took her to the herbalist who gave her remedies, but of course the child stayed sick. The mom even told us the child had vomited, in an apparent attempt to get an injection. Turns out the child was eating okay and last threw up three days ago. The mom said the child was “afraid” of the oral medicine, so we asked why. Turns out, the whole family had the impression that an injection was better for malaria than oral medication. Since I had just reviewed the treatment of malaria, I was able to describe the actions of the oral medicine, how quickly it entered the blood stream (peaking within 2 hours), and the benefits of using the combination pill rather than the single drug injection.
I was also confident that we were treating recurrent malaria due to inadequate treatment, rather than treatment failure which would require other drugs. Two weeks is too soon for someone to have a positive blood smear (visible parasites in the blood cells) if they have been adequately treated. After the three day treatment is complete there is a period of time, 4 or 5 days, in which one is somewhat protected from re-infection by a new mosquito bite. Then, there is a period of time, 7 to 9 days, after the bite, when the malaria parasites are hiding in the human liver and not causing any problems. During this time they are not visible in the blood smear.
In the end, the mother agreed that the oral medication sounded good, and felt that she could explain it to the father in a way that would also convince him. They left happy even though we did not give her a shot, and I was fairly sure that this time the child would finish her medication and eradicate the parasites in the blood—at least temporarily!
This part of Africa is called “hyperendemic” for malaria, and we are even more prone to get it being in a lakeside area. This means that malaria is always present in the population, is present in high numbers, and is highly transmissible—lots of the mosquitoes are infected. The mosquitoes here prefer human blood, and they live a long time in the mild climate. This corner of Kenya, the lakeside west, near the border of Tanzania, must be the best kind of environment for the mosquitoes that carry the Plasmodium falciparum parasites. P. falciparum is responsible for the most serious and deadly form of malaria, and is the most common cause of malaria here.