African Journals Online
Malawi Medical Journal

The Journal of the College of Medicine
and  Medical Association of Malawi

Volume 14, No 1, 2002

Editorial

Malaria control in Malawi

[Introduction]

Like the rest of Sub-Saharan Africa, malaria in Malawi continues to be one of the most important public health problems that our population faces; accounting for between 30 to 40% of hospital visits and 20 to 30% of hospital deaths, especially among children under the age of five years. Pregnant women are also susceptible to the devastating effects of malaria infection, although the major impact of malaria infection in pregnancy is not on the woman herself but on her unborn child, whose growth may be impaired as a consequence of the accumulation of parasites in the placenta. About 20% of Malawian babies are born with low birth weight (LBW), the most important predictor of neonatal and infant mortality, and malaria is the most important preventable cause of LBW.

The malaria vectors of the Lower Shire valley, Malawi.

A A Spiers, T Mzilahowa, D Atkinson & P J McCall

Abstract

The aim of this study was to characterise breeding sites and climatic factors that influence the abundance of malaria vectors in the Lower Shire valley, Malawi. We regularly sampled adult and larval mosquitoes over the transition periods between the wet and dry seasons during 2000 and 2001. Three potential malaria vectors, An. arabiensis, An. gambiae sensu stricto and An. funestus, and a fourth non-vector species An. quadriannulatus, were identified. (This is the first record of An. quadriannulatus in Malawi). These four species bred predominately in larger water bodies, particularly rice paddies, and to a lesser extent in boreholes and puddles. Smaller temporary pools and puddles evaporated too quickly to permit the completion of larval development. Abundance of An. gambiae s.l. was closely associated with minimum temperatures. We discuss the relevance of the findings to malaria vector control in Malawi.

Know your enemy

Some facts about the natural history of Malawi's Anopheles mosquitoes and implications for malaria control

D Chavasse

In this article I examine the relevance of environmental control techniques in Malawi in the context of what we know about breeding, resting and feeding habits of the common Anopheles species. I hope that this article may help to put to rest some common misconceptions concerning Anopheles control as a malaria prevention strategy.

Availability and use of sulphadoxine-pyrimethamine (SP) in pregnancy in Blantyre District

A Safe Motherhood and BIMI Joint Survey

Hannah Ashwood-Smith, Yolande Coombes, Nyokase Kaimila, Martha Bokosi and Kingsley Lungu

[Introduction] In Africa over 24 million pregnancies every year are affected by malaria, with less than 5% of pregnant women able to access treatment or effective interventions (USAID). The Malawi National Malaria Control Programme established by the Ministry of Health and Population (MOHP) implemented a policy that all pregnant women should receive two doses of sulphadoxine-pyrimethamine (SP). This has become known as the intermittent presumptive treatment with SP (IPT-SP) policy. According to the guidelines, the first dose should be given “during the first antenatal visit occurring after the first trimester of pregnancy is complete”, and the second dose “at the beginning of the third trimester (between 28 and 34 weeks)” (MOHP, 1997).

The pattern of bacteraemia in children with severe malaria

S M Graham, J Mwenechanya, M Tembo, M Kabudula, E M Molyneux, A L Walsh, M E Molyneux, T E Taylor

Abstract

Bacteraemia is a recognised complication of severe malaria and may increase mortality. We determined 1) the rate and pattern of bacteraemia in children with severe malaria; 2) the impact of bacteraemia on case-fatality rate; and 3) the rate and pattern of bacteraemia in following blood transfusion for severe malarial anaemia. For the first two objectives, a prospective study was undertaken involving children admitted consecutively to the Malaria Research Project ward between February 1996 and June 1999. Blood culture was performed on admission. Independent associations with bacteraemia and mortality were determined by logistic regression. Of 701 children with a final diagnosis of severe malaria, 36 (5.1%) had bacteraemia. A wide range of bacteria was isolated and the commonest was non-typhoidal Salmonella (NTS: n=18 or 50% of all isolates). The rate of bacteraemia was significantly higher in children with severe malarial anaemia without coma (11.2%) than in children with cerebral malaria without anaemia (3.2%) and this was due to the significant association of NTS bacteraemia with severe malarial anaemia (p<0.001). The overall case-fatality rate was 15% and was higher in children with bacteraemia (22%) but this difference was not significant. For the third objective, data were collected retrospectively of all children who received a blood transfusion in the paediatric department from March 1996 until May 1997 inclusive. A total of 1712 children received a blood transfusion. Of these, 243 (14.2%) had a blood culture taken for the investigation of fever following transfusion; a pathogen was grown from 60 (24.7%). NTS bacteraemia accounted for 76.3% of all bacteraemia cases. NTS bacteraemia is a common complication of severe malarial anaemia.

An audit of urine culture results at Queen Elizabeth Central Hospital (QECH) in 1994-95 and 1999-2001.

J J Kumwenda, R Mwenda

Abstract

We conducted a retrospective audit of urine cultures at the Queen Elizabeth Central Hospital (QECH), Blantyre. The aims of the audit were to determine the common organisms cultured from urine, in 1994-5 and in 1999-2001, and the sensitivity of these organisms to the first and second line drugs used in the management of urinary tract infection (UTI) in Malawi. A total of 401 samples were studied. One hundred and thirty- six of these grew isolates that were considered pathogenic. E. coli was isolated in 50% of the cultures. Isolates were sensitive to cotrimoxazole and nitrofurantoin (the recommended first-line treatments in Malawi) in only 13% and 48% of cultures, and sensitive to gentamicin in 40% and augmentin in 20% of cases. Levels of drug resistance did not differ between 1994 and 2001. Antibiotic policies for the management of UTI need to be reviewed in the light of the high isolate resistance to the two first line drugs used in the treatment of UTI in Malawi.

High incidence of tuberculosis in prison officers in Zomba, Malawi

Grey S, Kachisi, Anthony D Harries, Julia R Kemp, Felix M Salaniponi

Summary

We conducted a study in 4 prisons in Zomba district, Malawi, to determine the tuberculosis case notification rate in prison officers during the year 2000. Of 201 prison staff, 9 (4.5%) were diagnosed with TB: 2 with smear-positive pulmonary tuberculosis (PTB), 4 with smear-negative PTB and 3 with extrapulmonary TB (EPTB). This incidence in prison officers (9/201) was significantly greater than the incidence in primary school teachers in a separate (unpublished) study in Malawi the previous year (78/4,289) (OR 2.58, [95%CI, 2.44 – 2.73], p <0.015). Expressed as annual TB case notification rates, the data for prison officers in these 4 prisons was 4,478 per 100,000, compared to 1,786 per 100,000 in teachers. There may be a high incidence of TB in prison officers. Further research needs to be carried out in this group to confirm these findings and to develop an occupational health service to reduce the risk of TB for these workers.

The Eyes Have It: findings in the optic fundus correspond to cerebral pathology in fatal malaria

Blantyre Malaria Project and Malawi-Liverpool-Wellcome Trust Research Programme, College of Medicine, University of Malawi.

[A series of photographs of optic fundus findings in severe falciparum malaria]

Malaria Training Centre

G Malenga

[Introduction]: The Malaria Training Centre is part of a collaborative effort in malaria research and training between the College of Medicine and Liverpool School of Tropical Medicine (LSTM). Funding for a period of 5 years has been secured through the Gates Malaria Programme (GMP) of the London School of Hygiene and Tropical Medicine (LSHTM) which also covers three other African colleges and research institutions in Ghana, Tanzania and The Gambia. Other funding sources will be sought to ensure sustainability beyond the five year period.

The Blantyre Integrated Malaria Initiative:

a model for effective malaria control

Mary J Hamel, Christopher Mkandala, Nyson Chizani, Nyokase Kaimilla, Jim Kublin, Richard Steketee.

[Introduction]: The Blantyre Integrated Malaria Initiative (BIMI) is a district-wide malaria-control effort, supported jointly by the Government of Malawi and the United States Agency for International Development (USAID). BIMI was established in Blantyre District, Malawi in 1998 to promote sustainable and effective strategies to manage and prevent malaria-related morbidity and mortality. The goal of BIMI is to reduce malaria-related deaths among children under five-years of age by 30%.

Recent publications on Malaria Research in Malawi

A series of abstracts of articles on malaria that have appeared in international journals:

Beeson JG, Rogerson SJ. Cooke BM, Reeder JC, Chai W, Lawson AM, Molyneux ME, Brown GV. Adhesion of plasmodium falciparum-infected erythrocytes to hyaluronic acid in placental malaria. Nature Medicine 2000; 6(1):86-90.

Timothy Holtz, Lawrence Marum, Christopher Mkandala, Nyson Chizani, Jacquelin Roberts, Allan Macheso, Monica Parise and Patrick Kachur. Insecticide-treated bednet use, anaemia and malaria parasitaemia in Blantyre District, Malawi. Tropical Medicine and International Health 2002; 7:220-230

J G Kublin, F K Dzinjalamala, D D Kamwendo, E M Malkin, J F Cortese, L M Martino, R A G Mukadam, S J Rogerson, A G Lescano, M E Molyneux, P A Winstanley, P A Chimpeni, T E Taylor and C V Plowe. Molecular markers for treatment failure of sulfadoxine-pyrimethamine and chlorproguanil-dapsone for falciparum malaria and a model for practical application in Africa. Journal of Infectious Diseases 185:380-388 2002.

Heidi Brown, Stephen Rogerson, Terrie Taylor, Madalitso Tembo, James

Mwenechanya, Malcolm Molyneux, and Gareth Turner. Blood-brain barrier function in cerebral malaria in Malawian children. American Journal of Tropical Medicine and Hygiene 2001;64:207-213

Limangeni Mankhambo, Maxwell Kanjala, Sarah Rudman, Valentino Lema and Stephen Rogerson. Evaluation of the OptiMAL rapid antigen test and species-specific pcr to detect placental Plasmodium falciparum infection at delivery. Journal of Clinical Microbiology 2002;40:155-158.

Ian Clark, Richard Whitten, Malcolm Molyneux, Terrie Taylor

Hypothesis: Salicylates, nitric oxide, malaria and Reye's syndrome. The Lancet 2001;357:625-627

The Artemether-Quinine Meta-Analysis Study Group

A meta-analysis using individual patient data of trials comparing artemether with quinine in the treatment of severe falciparum malaria

[The seven trials included in the analysis took place in Malawi, Viet Nam, Thailand, Kenya, Papua New Guinea, The Gambia, and `West Africa'].

Transactions of the Royal Society of Tropical Medicine and Hygiene 2001;95:637-650

A Richardson, F Sisay-Joof, H Ackerman, S Usen, P Katundu, T Taylor, M Molyneux, M Pinder and D Kwiatkowski. Nucleotide diversity of the TNF gene region in an African village. Genes and Immunity 2001; 2:343-348

J Sulo, P Chimpeni, J Hatcher, J Kublin, C Plowe, M Molyneux, K Marsh, T Taylor, W Watkins & P Winstanley. Randomised clinical trial of chlorproguanil-dapsone (Lapdap) versus sulfadoxine-pyrimethamine (SP) for sequential episodes of uncomplicated falciparum malaria in Kenya and Malawi. Lancet 2002; in press.