Christmas passed in a blur of busy days, busy nights and flu with all its complications. We have never seen so many small children with croup, bronchiolitis and viral pneumonia. I have never given so many small children steroids. The waiting room became a social centre for mums coming in twice a day and meeting similar mums with similar little sufferers.

After Christmas we had the biggest malaria epidemic ever. Everyone and his dog went away for Christmas or New Year and most of you didn’t take antimalarials, did you? Result lots of people with malaria 10 days later. So far we have seen only 2 cases of malaria in someone who was in Kampala 10 to 14 days previously, both at the same party! Everyone else had been up country, mostly the classic areas for malaria, Murchison and Jinja. Lesson: In Kampala we hardly see malaria, the risk is minimal. Up country the risk is almost inevitable, so take the tabs. Even those who took the old much-maligned chloroquin and paludrine did not get malaria. So it is still better than nothing according to our experience.

Still on Malaria, we get a lot of enquiries on what is the best prophylactic. So here goes with a quick summary.

Boiling and filtering your water. Wrong disease. Doesn’t prevent pregnancies either.

Nothing. Cheap, tasteless, no side effects and you never forget to take it. Seems to work well in Kampala, I know lots of people who have taken it for 20 or more years and never had malaria. Until they go to Murchison.

Paludrine and Chloroquin. Better than nothing. Visitors to Murchison taking nothing about 30% will get malaria on a 3 day visit, unless you go fishing in which case it is 70%. Those taking P &C often last 2 or 3 months before getting it. We’ve also seen people from Sudan on P & C with malaria. So not bad, but some risk. Costs 28,000/= for a month. One advantage is you can take it when you arrive and stop when you get back.

Doxycyclin. Very cheap, only 60/= a tablet from us, so a dollar a month. Seems to be very effective, we have not yet seen a case of malaria in anyone taking Doxy properly. It is a post exposure prophylactic, so you can start 3 days after arrival, but must continue for 10 days after you get back. Also a good idea to take it for 10 to 14 days if you are leaving the country, and prevent the nightmare of coming down with malaria in Europe and having half a dozen medical students coming to stare at you in ITU on your quinine drip. Other advantages it clears up acne. Disadvantages, it makes your contraceptive pill less effective, so you have to boil and filter the water, and it can cause yeast infections in women. It gives you oesophagitis, but is OK if always taken with food. I always take it when I go to the coast: it does cause worse sunburn in some people, but on the whole a very safe and effective drug for short visits. It is deposited in growing bones, so not for children who have not yet got all their front teeth, and not for pregnant women, though it hardly matters really if the first baby teeth have a brown line on them.

Mephloquin (Lariam) 100% effective so far, not one case of mephloquin resistance has been reported to date in East Africa. If a clinic tells you that you have malaria while on mephloquin, be very skeptical, and go somewhere else. Main problem is side effects. In our experience and that of many of my colleagues all over Africa, about 10% of people will have some sort of psychological problem. Which means it is an excellent drug for 90% of people. It is now cheaper than paludrine, 10,000/= a month. Very convenient as only once a week. Watch out for bad dreams; paranoia (they are out to get you but you’re not supposed to know) getting over-emotional, and eventually wild mood swings, laughing and crying at the same time and even total psychosis. If you survive the first 7 tablets without a problem you are not going to have a problem. Not for pregnant women (though no problems yet reported), and not for people with heart disorders or psychiatric history. Wouldn’t touch it myself, but for many people a safe, effective and cheap option.

Malarone. The original resistance trials were done in Uganda in the 90’s and are still on going. So the company does not allow it to be sold in Uganda. This is likely to change soon. Massive marketing has resulted in it being the most prescribed antimalarial in Europe. At about a pound a tablet it is 50 times the cost of Doxycyclin and 5 times mephloquin. I do not see the use of such a highly expensive drug, so if you must use it at least buy shares in Smith Klein Beecham and wallow in the profits. It is 100% effective (by the time you’ve bought a months supply you can’t afford to go to Murchison!) and has plenty of side effects. Not for pregnant women.

Daraprim and maloprim. Doesn’t work.

Treatment

Easy. Artenam (or any other good quality arthemether product) and doxcycyclin, or for children and pregnant women Artenam for 7 days instead of 5. Effective, cheap, almost no side effects, and Artenam doesn’t even taste bad. There is therefore absolutely no need for quinine drips or malarone. In particular Halfan can be dangerous. The product literature advises it should only be used in inpatients after an ECG. It has been withdrawn by some countries as too dangerous to consider. So don’t even think about it.

Warning. Artenam for 5 days will result in complete cure, followed by a relapse in about 3 weeks! So always take it with Doxycyclin, or for 7 days if Doxy is contraindicated.

A new combination is Arthemether with lumafantrine. Very effective, already widely used in the far east, (no, I mean Burma and Thailand, not Tororo!) and undergoing trials in Uganda. For the moment I would be cautious: we now know Halofantrine ie Halfan is dangerous, but it took a few years and a few deaths before I stopped using it, and another 4 or 5 years before it was widely recognized. So I want to see more information about lumafantrine before I use it myself.

Malaria rapid Kits An absolute must for people traveling up country. This test kit is easy to use, and gives you a diagnosis of malaria in 10 minutes. It will detect malaria down to about 1 parasite in 25 to 30,000 red cells. It reacts to the “F protein” produced by Plasmodium falciparum, and gives a red line on the strip. (Oh NO! I’ve just used the F word again! ) Just like a pregnancy test. It will miss malaria in a few people in very early disease, when there are enough parasites to cause fever but not enough to trip the test, so a negative should be repeated the next day. They work. You can rely on it. If you have a fever and the malaria rapid test is negative then either 1) you do not have malaria, or 2) it is another type, not falciparum, or 3) it is too early to test. Other causes of fever are more common than malaria so obviously no 1) is far and away the most likely. Stomach infections are common and respiratory infections are common. One gives you diarhoea the other a cough or sore throat. Rocket science, this. Other malarias are rare, only 2% of cases and mostly from mountainous cooler areas. They are benign, so if not treated do not matter much. They are tricky to diagnose and need specific treatment. No 3) is also simple. Malaria in a non immune gets worse by a factor of 10 every 2 days. So if you have a negative malaria rapid then you wait and see how you are. If you do not get better, then repeat the next day. If it is malaria then the amount of F protein will have increased and the test will be positive.