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Thesis.Pdf (2.125Mb) Femteårsoppgave i Stadium IV, profesjonsstudiet i medisin Det helsevitenskapelige fakultet Universitetet i Tromsø 9019 Tromsø Malaria in Malawi The current status of diagnosis, prophylaxis and treatment of malaria in Malawi, how international and national guidelines can improve the situation, and how research can change these guidelines for the future The sun sets over Lake Malawi Authors Marte Langsrud Stine Haram Vetle Nilsen Malmberg [email protected] [email protected] [email protected] MK-08 MK-08 MK-08 Supervisors Dr Jon Øyvind Odland Dr Kamija Phiri [email protected] [email protected] Universitetet i Tromsø University of Malawi Tromsø, June 2013 Table of Contents 1 Abstract ........................................................................................................................................... 1 2 Abbreviations .................................................................................................................................. 2 3 Introduction ..................................................................................................................................... 3 4 Method ............................................................................................................................................ 5 5 Theory .............................................................................................................................................. 6 5.1 Malaria..................................................................................................................................... 6 5.1.1 Pathophysiology .............................................................................................................. 7 5.1.2 Clinical manifestation of malaria ..................................................................................... 8 5.1.3 Severe malaria and complications after infection ........................................................... 8 5.1.4 Age and its effect on malaria ......................................................................................... 10 5.1.5 Malaria in pregnancy ..................................................................................................... 11 5.1.6 Malaria and HIV ............................................................................................................. 12 5.2 Diagnostics ............................................................................................................................ 13 5.2.1 Peripheral blood film microscopy ................................................................................. 13 5.2.2 Rapid diagnostic tests .................................................................................................... 13 5.2.3 Other diagnostic methods ............................................................................................. 14 5.2.4 Diagnosing malaria in pregnancy .................................................................................. 14 5.3 Antimalarial medications ...................................................................................................... 15 5.3.1 Quinine and other amino-alcohols ................................................................................ 16 5.3.2 Chloroquine and other 4-aminoquinolines ................................................................... 17 5.3.3 Pyrimethamine and sulfadoxine .................................................................................... 17 5.3.4 Antibiotics ...................................................................................................................... 18 5.3.5 Artemisinin and its derivatives ...................................................................................... 18 5.3.6 Artemisinin-based combination therapies .................................................................... 19 5.3.7 Iron supplementation and malaria ................................................................................ 21 5.3.8 Resistance to antimalarial drugs ................................................................................... 22 5.4 Preventive measures ............................................................................................................. 24 5.4.1 Insecticide-treated bed nets ......................................................................................... 24 5.4.2 Indoor residual spraying ................................................................................................ 26 5.4.3 Insecticide resistance .................................................................................................... 27 5.4.4 Larviciding ...................................................................................................................... 28 5.4.5 Intermittent preventive treatment ............................................................................... 29 5.5 DDT ........................................................................................................................................ 34 5.5.1 How DDT enters the environment ................................................................................ 34 5.5.2 How DDT enters the body ............................................................................................. 34 5.5.3 The effect of DDT on insects ......................................................................................... 35 5.5.4 How DDT, DDE and DDD can affect human health ....................................................... 35 5.5.5 The history of DDT ......................................................................................................... 36 5.6 Malaria in the world .............................................................................................................. 39 5.7 The World Health Organization ............................................................................................. 40 5.7.1 The WHO Global Malaria Programme ........................................................................... 40 5.7.2 Roll Back Malaria partnership ....................................................................................... 40 5.8 The WHO malaria guidelines ................................................................................................. 40 5.8.1 Recommendations in diagnosing malaria ..................................................................... 41 5.8.2 Recommendations in treatment ................................................................................... 42 5.8.3 Recommendations for malaria prevention ................................................................... 45 5.8.4 Recommendations in the use of DDT ............................................................................ 49 5.9 Malawi ................................................................................................................................... 50 5.9.1 About Malawi ................................................................................................................ 51 5.9.2 Health and development challenges in Malawi ............................................................ 51 5.9.3 WHO in Malawi.............................................................................................................. 53 5.9.4 Malaria in Malawi and the national guidelines ............................................................. 54 5.9.5 On-going malaria research in Malawi ........................................................................... 58 6 Discussion ...................................................................................................................................... 62 6.1 Health care challenges in Malawi .......................................................................................... 62 6.1.1 The lack of human resources ......................................................................................... 62 6.1.2 The quality of the health care workers ......................................................................... 63 6.1.3 The challenges in diagnosing malaria ............................................................................ 64 6.1.4 Selecting the right treatment ........................................................................................ 65 6.1.5 Preventing malaria in Malawi ........................................................................................ 66 6.1.6 Resistance development in Malawi............................................................................... 69 6.1.7 Inequality of wealth and the burden of disease in Malawi ........................................... 70 6.2 The implementation of the WHO guidelines in Malawi ........................................................ 71 6.2.1 The relevance of guidelines ........................................................................................... 71 6.2.2 The applicability of international guidelines in Malawi ................................................ 72 6.2.3 Prioritizing the guidelines .............................................................................................. 73 6.2.4 Developing national guidelines ..................................................................................... 73 6.2.5 Partial implementations of guidelines .......................................................................... 74 6.2.6 Guidelines requiring strict adherence ..........................................................................
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