How to tame your outbreak: 2, the fight against Malaria

In part 1 of How to tame your outbreak I have shared with you the three necessary steps to control an outbreak. These were: gather information, contain the spread and keep it safe. In theory it is as simple as opening a bag of crisps on a lonely and rainy Tuesday evening whilst sitting on the couch ready to watch Legally Blonde for the tenth time. Controlling an outbreak in practice is a whole different ballgame.

Now , I could share with you all the Outbreak control plans and actions about every Virus, Bacteria and what, but since I work closely with a Malaria Elimination Task Force (METF) at the Myanmar-Thailand border, let’s use Malaria as example.

So here we go: how to tame your Malaria Outbreak?

Step 1: gather information

Malaria is caused by a parasite and is transmitted via mosquito’s. They suck blood from a Malaria patient and inject that blood into a new patient, thus infecting them. We know what it is and also how it spreads. That was the easy part.

Step 2: contain the spread

To contain Malaria there are really three options we could take:

Option 1: eliminate the mosquito. In real life, super difficult, it is easier to erase the West African Black rhinoceros than these little biters.

Option 2: prevent it from biting you. DEET or bednets are helpful, but it’s not realistic for people living in remote areas to use DEET all the time.

Option 3: make sure everybody that gets infected is treated before a mosquito can bite them and spread it further. This means early detection and treatment with the anti malaria drugs that kill the parasite. With the upcoming resistance (here we go again) this option can also become very challenging.

So which option to choose? You could start with option 3: early treatment. Now this can be a tricky part. Especially in a rural area like right here on the border, there are many villages and people tend not to stay in just one place. They work in one place, live in a next and their family is somewhere else again. This means that in order to successfully contain the outbreak, you will have to map out all the villages that you need to target. In the case of METF this is over 1500 villages. Then you need:

  • Healthposts where people can go to get tested and treated.
  • Healthworkers, educated people to diagnose and treat patients
  • Medication, power supply, charts, needles, tests, alcohol (not to party into the night but to disinfect), etc.
  • Education of all people, including villagers. People need to understand what you’re doing and why they need to come as soon as they have fever.
  • A way of communication between the health posts and the hospitals in order to be able to send the severe patients in time for care

METF currently has over 1200 health posts with more than 1600 health workers. Can you imagine the work goes in to an operation like that?! And how much money, perseverance, guts (especially in the remote and unsafe areas) and love for the people? In the meantime, you can try option 1 and 2 (kill the mosquito and prevent the bites).

Step 3: keep it safe

The WHO grants a certificate that a country is “Malaria Free” (like Paraguay recently) when:

“a country has proven, beyond reasonable doubt, that the chain of local transmission of all human malaria parasites has been interrupted nationwide for at least the past 3 consecutive years; and that a fully functional surveillance and response system that can prevent re-establishment of indigenous transmission is in place.”

This means that, although my wonderful colleagues at METF have done a tremendous job already, saving thousands of lives in at least two countries, we’re not getting the certificate yet.

Containing an Outbreak is newsworthy and is a certain money collector. Keeping it safe is the part of the “outbreak” that funders are least interested in. It’s not news anymore. No extra figures to show. It’s just being there and staying there and not going anywhere until you’re sure. And that could take years and years. However, don’t get your guard down. Venezuela was declared malaria free in 1960 but had a big outbreak in 2016 with 240,613 patients and 280 deaths. As soon as you stop being prepared, it will come back.

So thank you METF and keep fighting the good fight.

 

Picture: Suphak Nosten: In the middle of the border, the one crossing for care, the one to provide care, across the border

 

Malaria: the search for a vaccine

After my previous blog, we all understand the basics of malaria. It is the parasite that kills, not the bad air from swamps or your armpits. And although we have some medicine to cure Malaria, humanity still didn’t find a vaccine to prevent catching one of the biggest infectious diseases out there. And that isn’t because nobody is looking for it or nobody is investing money in the research. On the contrary, finding a Malaria vaccine is like finding a needle in a haystack and then try to learn that needle to do a trapeze act. In short, it’s hard work.

Why and who needs a vaccine?

Well, a vaccine is not primarily for the people with a bit of money that want to see the Big Five. As nice as it seems that you can travel without taking these often expensive, sometime hallucinating medications, we need to take a wider perspective. A vaccine is needed to prevent children deaths. That’s what counts in these countries. Especially now that more and more Malaria parasites turn out to be resistant to our anti malaria pills.

How to train your dragon… uh, no, how to train your immune system step 1

In Nijmegen, the Netherlands, years ago, a research group found a couple of students to participate in their “can we train our immune system to recognize Malaria” study. They treated them with anti malaria pills and deliberately infected them with Malaria a couple of times. Then they stopped the medication. Now the real challenge began, without any prophylactic therapy all subjects were exposed to the Malaria once again. Just to see if the immune system had actually seen the parasite previously under treatment. Turns out: your immune system rocks! Even with the anti malaria pills it was able to get a good look at Malaria and remember what it looked like. The unfortunate thing was that this memory didn’t last very long. But it was a promising start.

How to train your immune system step 2

Now that we knew the immune system could be trained, researchers wanted to train it with a vaccine, a RTS,S vaccine. It took about 30 years to develop, but eventually they could test this vaccine in African children. They had really nice results, preventing serious Malaria in about 30% of the children. In a world where previously all malaria infected person died, this was good news! But, just like the Nijmegen group, they found that the immune systems memory weaned and the immune system needed to be exposed to the vaccine, and thus to malaria, in order to keep it working. Better than nothing, but not the holy grail humanity was looking for.

How to train your immune system step 3

Now the Dutch are hitting the news again. A new vaccine is made and is being tested in, amongst other countries, the Netherlands. The problem with the other vaccines appears to be that in the vaccine only some of the Malaria particles are used to train the immune system. But this is not good enough. The immune system needs more to ensure a long-lasting recognition. The new vaccine is supposed to be made from an inactivated whole parasite. Yes, you read it correctly, a whole Malaria parasite that has been modified to not go into hiding in your liver and not invade your blood cells. Pretty impressive right? Could work. Hopefully this vaccine wont take 30 years to get past all the safety and effectiveness tests!

So there you have it, the long long long search for a Malaria vaccine and the training of an immune system. Remaining questions that we want to get the answer to these coming years are: 1. Will this new vaccine give long lasting protection for the people that need it the most? 2. Will it help for all types of Malaria?

For now, don’t wait for this vaccine and do travel to Africa and see the animals, I can highly recommend it. Just take your prophylactic malaria pills.

Mal’aria? I don’t smell anything.

Some researchers state that humanity is on the verge to invent a vaccine against malaria. That would be great news, because Malaria is a notorious disease. In 2015 it infected roughly 121 million people with an estimated 429.000 death, most of which were children.

Time to shine a light on this disease in my blog. First some history and basics, next time we’ll learn about the search for that vaccine in a particular study in the Netherlands.

Although Malaria is a well-known disease, most Western people are only confronted with it when they travel to far away countries around the equator and they are going through their usual list of questions: 1. Do I need a special adapter to charge my phone? 2. Do I need a visa and by the way where is my passport? 3. Do I need to take a precautionary medicine for malaria or not?

But actually, not too long ago, this disease was also endemic (read my previous blog if you don’t know what that means) in Europe and in the USA. During World War II for example, approximately 500,000 men became infected with Malaria in Europe. Bet you didn’t know that.

Swamps and Miasma

Our very own granddad of medicine, Hippocrates, has described a disease with fever that would come after draining swamps and lakes. He was a believer of the “Miasma” theory, most people believed that you actually could get sick from bad air. In this case that the fumes from the swamps were the cause of the illness. Malaria even has its name derived from this Miasma theory; Mal Aria means Bad Air in Italian.

You might say: oh, stupid people, what were you thinking in 400 BC? Understand however that the Miasma theory has had an impact on the profession of medicine well into the 19th century.
But rest assured, you don’t need to shower, Malaria really has nothing to do with (your) bad air. It is all about the water where the mosquitos live. Without the mosquito: no Malaria! To be even more precise: malaria is caused by a parasite, Plasmodium, that specific mosquitos carry and inject humans with. At this moment there are 5 different Malaria species known of which P. Falciparum is the most famous one, but please don’t ask him for his signature.

Hide and Sick

Malaria can give you a lot of symptoms, but fever is for sure the numbero uno give-away. Unfortunately, the parasite can be a practical joker. It lives in different stages. Some of these stages are in your blood which are easily targeted by treatment, in other stages the parasite looks for a quiet place in the liver and can actually hide there for years before you get sick, resulting in a different treatment strategy.

Sometimes, natural medicine rocks

Now as a medical doctor, I’m not the biggest fan of traditional medicine. I’ve seen many times how the “traditional doctor” did not know the actual cause of the symptoms and just did some vague Magician Act. However, this does not mean that I don’t believe that nature has most of the answers to our problems. We’ve seen this for example with the discovery of Penicillin from a fungus, and yes, also in the treatment of Malaria, nature saved our asses again: the two most effective treatments for Malaria are both nature based.
The first effective treatment for malaria came from the bark of the cinchona tree, which contains quinine. The second drug is Artimisinine, which is a Chinese herb. It was used in China for many years to treat fever and hemorrhoids (love that combination).
Both of these drugs are used to make new variations to treat Malaria. But we need to go the extra mile. There is an actual danger for Resistance against these medicines. Here we go again. 

In summary: Bad air is difficult to breathe in, but does not actually cause Malaria … or hemorrhoids.

Next week: vaccination time

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