Download Malaria A Public Health Threat 4-20-13

Running Head: MALARIA: A PUBLIC HEALTH THREAT
Malaria: A Public Health Threat
Stefanie Varno
Concordia University
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Running Head: MALARIA: A PUBLIC HEALTH THREAT
Abstract
This paper explores the epidemiology, biostatistics, pathophysiology and
psychosocial/behavioral health issues of malaria. Malaria affects millions of people worldwide
and is responsible for thousands of deaths each year with a vast majority occurring in children
under the age of five. Malaria is not a huge threat in the United States, but due to travel and
military personnel it is still a risk and must be cautioned against so not to re-introduce the
epidemic. Prevention is the best method and has been very successful when the resources are
available. Unfortunately many third world countries do not have the resources and continue to
have fatalities. The key to preventing and curing diseases such as malaria is to understand the
cause, composition and methods of transmission. Many organizations have done a great deal of
research in order to collect this information and biostatistics to create a world eradication plan.
At this time malaria still impacts many underdeveloped countries, but a worldwide eradication
plan is being revisited. It is a heartbreaking disease because it is so preventable yet takes the
lives of so many due to lack of resources.
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Introduction
There are several key components that determine whether someone becomes ill. Public
Health has the goal of preventing illness whenever possible. There are many factors involved in
determining the possibility of prevention; epidemiology which concerns the location, distribution
and ease of contamination; pathophysiology which accounts for the composition of the infecting
agent; and psychosocial and behavioral factors of the infected which largely influences the
outcome. Biostatics are collected regularly on any endemic diseases and the information
gathered is used to find out about cause and effect, health risks and disease cures (Schneider,
2011). Malaria is a disease that has been studied for decades; due to the research and
biostatistics collected there are viable preventative measures and treatment options available.
Unfortunately many of the areas where malaria is endemic do not have the resources available to
inhibit or cure those that become infected.
Basics of Malaria
About Malaria Malaria is an infectious disease acquired from the bite of an infected female
Anopheles mosquito, which transmits a Plasmodium parasite (Arguin, P. M., Kachur, S. P. &
Mali, S., 2012). Anyone can contract malaria if bit by an infected mosquito. No one is
completely immune to malaria and the majority of those infected live where the Anopheles
mosquitoes are abundant. Once an infected mosquito bites someone the symptoms usually
emerge within ten to fifteen days (World Health Organization, 2013). Generally symptoms are
very similar to those of the flu and include fever, headache and vomiting. In some severe cases
symptoms can be life threatening and lead to jaundice, kidney failure, anemia, coma and even
death (Info Please Database, 2007). According to Arguin, et al.; “Malaria infections can be fatal
if not diagnosed and treated promptly with antimalarial medications appropriate for the patient’s
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age and medical history, the likely country of malaria acquisition, and previous use of
antimalarial chemoprophylaxis” (2012). It is sad that malaria is such a problem in today’s world
because it is very preventable and curable. According to the World Health Organization (WHO)
there has been an increase in control measures, which is reducing the likelihood of the illness in
many areas (2013). Yet because malaria causes illness and mortality when untreated it exhausts
the economy and because it is so prevalent in underprivileged countries that have no funds to
treat/prevent the disease, it becomes a vicious cycle of sickness and destitution (Center for
Disease Control and Prevention- Malaria, 2012). The WHO statistics shows that malaria was
responsible for approximately 660,000 deaths in 2010, the majority of those being African
children (2013).
Symptoms “Malaria is a group of parasitic diseases that causes clinical illness with pathologic
changes in many body organs when parasites successfully invade and multiply in circulating red
blood cells” (Conrad, 1969). This clinical illness includes flu-like symptoms such as fever,
shaking, chills, headache, muscle aches, nausea, vomiting and diarrhea. Jaundice and anemia
may also occur due to the loss of red blood cells (Malaria Symptoms and Causes, 2011).
According to Stephen Rogerson (2006) “over half of malaria-related deaths are attributed to
severe malaria anemia.” The mechanism that causes anemia in malaria victims is not
completely understood, but the destruction and loss of red blood cells is definitely a
contributing factor (Brousse, et al., 2011). Rogerson (2006) says that for each infected red
blood cell, ten or more uninfected red blood cells can be lost, possibly because malaria can
alter even the uninfected cells.
Types of Plasmodium Malaria, a global problem effecting 70-80 million people (Angel, et al.,
2010), is caused by four species of protozoan parasites of the genus Plasmodium: P. vivax, P.
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flaciparium, P. malariae and P. ovale (Baldy, Bigler, Conti and Wiersma, 2001). Of the
different types of malaria, only one is known to come with life threatening complications; P.
falciparum (Malaria Symptoms and Causes, 2011). If this particular type is not promptly
treated blood supply can be disrupted and lead to kidney failure, seizures, confusion, coma
and death. Of the remaining types, two; .P vivax and P. ovale, can reoccur. The reoccurrence
or relapse happens when the parasite, which goes dormant in the liver for months to years
comes out of hibernation and begins invading the red blood cells. (Malaria Symptoms and
Causes, 2011). Generally malaria is a very curable disease if diagnosed and treated properly.
How Plasmodium Infects the Host Members of the Plasmodium genus are eukaryotic
microbes (Wiser, 2013). A distinctive trait of the malarial parasite is it intracellular existence;
because of this relationship the parasite is able to alter the host cell (Wiser, 2013). The cell of
choice for malarial parasites is the erythrocyte, or red blood cells. The parasite enters the
erythrocyte and modifies the cell by exporting proteins into its new host. One particular job of
these proteins is to prohibit the cell from circulating through the spleen. Bypassing the spleen is
a problem because that is where the blood is filtered; the spleen identifies and eliminates old,
malformed or damaged red blood cells(Children's Hospital of Pittsburgh, 2013). The spleen is
the body’s quality control checkpoint; it can pick out the uninvited cells and create antibodies to
get rid of them. But in the case of malaria those unwanted cells never encounter the spleen and
therefore are never removed from circulation. Another task of the newly introduced protein is to
modify the antigens or antibodies manufactured by the erythrocyte. Since the infected cells never
pass through the spleen, they are not recognized as trespassers and the formation of antibodies is
not initiated. The intricacies of malaria are still being studied as the disease is not
completely understood, the cause and effect are known, but the details of pathology need
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continued research. The implications malaria has on public health is not a major cause for
concern in the United States, but they are significant globally.
Where Malaria is Found
“Since the Anopheles mosquito that carries the malaria parasite still exists in the United States,
there is a constant risk that malaria could be re-introduced”(CDC Data and Statistics, 2009). Yet
right now the majority of malaria cases reported in the United States are acquired during travel
outside of the country. According to the CDC only 1 out of 1,505 cases reported in 2007 was
acquired in the U.S. and that one case was due to a blood transfusion (CDC Data and Statistics,
2009). When someone is diagnosed with malaria in the U.S. quite a bit of data is gathered on that
person. This is considered qualitative data and it is gathered in order to help understand what
some of the risk factors are. Some examples of qualitative data include location of recent travel
and reason for travel. This data allows public health professions to learn who the target audience
should be (regular travelers going to endemic countries) which allows them to then work on a
method of informing and teaching prevention.
Reporting In the United States all malaria cases are supposed to be reported to the CDC for
tracking and information purposes. There are a few possible ways to submit these reports;
through the National Malaria Surveillance System (NMSS), the National Notifiable Diseases
Surveillance System (NNDSS) or directly to the CDC. “A substantial difference between the
data collected in the two systems (NMSS and NNDSS) is that NMSS receives more detailed
clinical and epidemiologic data regarding each case (e.g., information concerning the area to
which the infected person has traveled)”(Mali, Kachur, & Arguin, 2012). The Armed Forces
Health Surveillance Center (AFSHC) also reports malaria cases that were not reported by state
health departments to the CDC.
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Accuracy One issue faced in reporting malaria cases is accuracy of reporting. The above
mentioned systems rely on passive reporting. In the United States there are few cases and there is
a reliable health care system in place, which allows for fairly accurate reporting. According to
the World Health Organization (WHO) (2012) the accuracy of the data collected is highly
dependent on many factors; “(i) the extent to which malaria patients seek treatment; (ii) whether
or not patients use health facilities covered by a country’s surveillance system; (iii) the
proportion of patients who receive a reliable diagnostic test; and (iv) the completeness of
recording and reporting” (p.47). Somewhere like Africa where thousands of cases occur daily,
tracking and treating each individual case with the available resources is unfeasible. “In 2010
WHO estimated that there were 220 million malaria cases worldwide and received reports of 23
million confirmed cases from endemic countries, representing a case detection rate of 10%
globally”(World Malaria Report 2012, 2012).
Importance “Imported infections, including malaria, are becoming a more common problem
worldwide due to the growth of international travel, shifts in immigrant and refugee population
movements, and military/peace-keeping deployments” (Lederman, et al., 2006). As mentioned
previously malaria was eradicated from the United States in 1951, but due to the fact that the
Anopheles mosquito still exists in the States, so does the threat. Tracking and collecting data on
malaria is an important step in preventing re-introduction into the United States as well as
working on prevention techniques and elimination plans for endemically infected countries.
There are many factors that need to be considered for successful elimination; financial
constraints, political support, neighboring countries, environment/entomologic situation and the
program capacity (World Malaria Report 2012, 2012). Another huge factor is resistance. Due to
the fact that malaria has been around a while, many of the treatments have been rendered
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ineffective due to a built up resistance. “The future of global malaria control and elimination
therefore depends on the ability of research and development to deliver a steady output of tools
to replace those which become ineffective because of resistance, and to devise new tools to make
elimination of malaria possible in high transmission situations” (World Malaria Report 2012,
2012). Dr. Margaret Chan, Director of the WHO even says “while our current tools remain
remarkably effective in most settings, resistance … has been detected in four countries of SouthEast Asia, while mosquito resistance to insecticides has been found in 64 countries around the
world. While such resistance has not yet led to operational failure of malaria control programs,
urgent and intensified efforts are required to prevent a future public health disaster” (World
Malaria Report 2012, 2012). Regrettably some of these tools will not even be employed in
countries such as Africa before they become ineffective due to resistance.
Socioeconomics and Malaria
African children are the highest risk population due to their environment and
socioeconomic status. “In theory, genes, biology, and health behaviors together account for
about 25% of population health. Social determinants of health represent the remaining three
categories; social environment, physical environment/total ecology, and health services/medical
care” (Center for Disease Control and Prevention, 2013). In the third world countries of Africa
the environment harbors mosquitoes and the medical care is inadequate. The most common
factors for malaria contraction are the environment and proactive measures utilized. If malaria is
endemic in an area are those individuals utilizing preventative measures such as anti-malarial
medication, mosquito nets, repellent, etc? In a study done by Boyle, Georgiades, Kyu and
Shannon (2013) conducted in Nigeria, a malaria endemic area, they stated “Compared with
children living in communities with no campaigns, those in the campaign areas were less likely
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to test positive for malaria after adjusting for geographic locations, community and individuallevel characteristics including child-level use of insecticide-treated nets (ITNs).” They show that
education and ITNs were a positive method of prevention of malaria. The problem is that the
majority of endemically infected areas are unable to afford ITNs or any other method of
prevention. The socioeconomics of an area greatly affect the health of that population. Schneider
(2011) says “Groups with the lowest SES (socioeconomic status) have the highest mortality
rates, a fact that is true in many different countries and has been true for centuries…” (p 226).
The SES is not something that is easily changed, it is important to work on this aspect, but focus
on what can be improved until a change in SES can be made.
Genetics and Malaria
Although environment plays a significant role in the risks of malaria contraction,
individual’s genes also play a part. The genetic make-up can factor into the likelihood of
contraction as well as the severity, specifically in an individual with Sickle Cell Disease (SDC)
or Sickle Cell Trait. Sickle cell disorder is the most significant hereditary blood disease infecting
people of black African descent (Arinola and Olaniyi, 2009). According to information published
by Harvard University individuals with sickle cell trait, meaning they are carriers of the disease
(one must be homozygous to have the disease), were infected with malaria less often than
individuals who did not carry the gene for sickle cell disease (Information Center for Sickle Cell
and Thalassemic Disorders, 2002). Harvard also claimed that children with Sickle Cell Diseases
had a higher fatality rate with malaria infections being a leading cause (Information Center for
Sickle Cell and Thalassemic Disorders, 2002). Arinola and Olaniyi (2009) state that the crescent
shape of the red blood cells, a key component of sickle cell disease, increased an individual’s
vulnerability to malaria, which could be due in part to a defective immune system. Akoto et al.
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(2010) point out that malaria encourages the red blood cells to adhere to the endothelium to
avoid circulation, which could ultimately cause destruction. Therefore good red blood cells are
being destroyed due to the malaria while the infected cells and sickle cells, which also have a
sticky quality enabling them to avoid destruction, are taking over. So if an individual is a carrier
their risk for malaria is decreased where as someone who has SCD can have much more severe
symptoms due to complications from SCD.
Individual Responsibility
Unfortunately genes are not something that can be controlled. The environment can be
controlled to an extent but the amount of resources and cooperation necessary to make those
changes in most communities is unrealistic. For public health professionals the most effective
way to make a change would be to make a change to the social environment (Schneider, 2011),
but when that is not possible it is necessary to affect each person individually. The most effective
way to accomplish this would be to use the Health Belief Model. For malaria the first step would
be to make people aware of where the threat is, i.e.; what areas are endemic to malaria. The CDC
and the World Health Organization (WHO) have done a great job researching and advertising
those specific areas. The next step is to inform people of the severity of the threat. The WHO
statistics shows that malaria was responsible for approximately 660,000 deaths in 2010. .
“Approximately half of all deaths caused by infectious diseases each year can be attributed to
just three diseases: tuberculosis, malaria, and AIDS. Together, these diseases cause over 300
million illnesses and more than 5 million deaths each year” (Information Please Database, 2007).
The data and statistics reported on malaria are significant. The severity of this problem is well
tracked and well advertised. The third step is where the problem comes in, perceived barriers to
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taking action to reduce the risk. The primary action would be to eliminate the infected population
of Anopheles mosquitoes. Secondary actions would include prevention methods such as
medication, mosquito nets, mosquito repellant, insecticides, etc. The tertiary action would be
treatment once infected. The problem is that most nations that are endemically affected do not
have the resources to enact any one of these actions effectively. The last step is perceived
effectiveness of taking action to prevent or minimize the problem. Many studies have been done
to prove the effectiveness of preventative measures such as mosquito nets or anti-malarial
medication, but again the issue is obtaining those resources for the endemically effected
countries.
Conclusion
It is important to realize that no one is invincible from disease and illness. In the case of
malaria the best option would be to remove the infecting agent, the Anopheles mosquito, from
the environment. In many communities that is not a feasible option so they must resort to
secondary actions of prevention. Often times the resources for prevention are not available
therefore, many people become infected. The last action is to treat those infected, but again
resources are generally not available to the communities that need them most. Public health
professionals need to continue to encourage individuals to affect whatever factors they can to
provide the healthiest lifestyle possible while health professionals continue to find better ways
and resources to treat the community as a whole. It is critical for public health professionals and
researchers to continue to study and gather data as malaria and several other diseases are
becoming increasingly resistant to the currently used treatment and/or prevention methods.
Progress is being made on eradicating malaria globally, but much work is still to be done. During
the last ten years approximately 1.1 million deaths were prevented as a result of increased
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interventions, but malaria is still taking the life of an African child every minute (World Malaria
Report 2012, 2012). It is necessary to continue to teach and educate about precautions and
prophylactic measures in order to protect as many people as possible. The CDC is a great
resource to learn what diseases are prevalent in what areas, and find out how to prepare to
decrease the risk of infection.
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