New WHO Guidelines for Malaria
The WHO appears to be altering its strategy somewhat,
to reach its chimerical goal of malaria elimination in Africa and Asia. In
the recent guidelines released, the first emphasis is on confirming
diagnosis before treatment. A mere 22% of those treated in Africa in 2008
were tested. Confirming diagnosis before treatment obviously has several
gains including prevention of drug resistance and adverse events, a habit
of looking for alternative diagnosis and confirmation of drug failures.
Earlier microscopy was the only cheap diagnostic tool available. However
costs of rapid diagnostic tests (RDT’s) using a dipstick and a drop of
blood have recently fallen, making it easier to ensure testing at
grassroot level. WHO has made a strong case for universal diagnostic
testing and is encouraging countries and kit manufacturers to
strengthen their testing capabilities.
Falciparum malaria is now resistant to most drugs
except artemesin based derivatives and more than 80 countries have now
adopted artemesin based combination therapy (ACT) as first line drug.
These drugs are expensive and should be used after confirmation of
diagnosis. After the distressing news of emergence of artemesin resistance
at the Thai-Cambodia border, alarm bells have started ringing. WHO
recommends oral artemisinin-based monotherapy should be removed from the
market because their use will hasten the development of parasite
resistance.
The WHO currently recommends duration of follow-up as
³
28 days in areas of
high as well as low to moderate transmission. Assessment over only 14
days, the period previously recommended in areas of high transmission, is
no longer considered sufficient.
This is because a significant proportion of treatment failures appear
after day 14.
There has been a recent increase in the number of RCT’s
in malaria and the current guidelines are strongly evidence based.
The following ACTs are
currently recommended by the WHO for falciparum malaria:
artemether-lumefantrine, artesunate + amodiaquine, artesunate + mefloquine,
artesunate + sulfadoxine–pyrimethamine.
WHO has now added a fifth ACT -
dihydroartemisinin plus piperaquine - to the previous list of recommended
medicines (www.who.int/en/).
A fourth year neurology resident’s observation in two
patients is now published in the March issue of Archives of Internal
Medicine as a new syndrome. The paper describes 2 patients in whom
high-protein dietary supplements were started in hospital. They had a
period of anorexia before hospital admission but no
history of liver disease. Subsequently altered mental status with ataxia
developed in both patients. After excluding other causes, hyperammonemia
was noted, while liver function test results remained normal. Removal of
the high-protein dietary supplements led to reversal of symptoms and
normalization of the ammonia level. It is estimated that with the ubiquity
of nutrition supplement use outside of liver failure, SHAKE
(supplement-associated hyperammonemia after c[k]achetic episode) syndrome
may be very common in modern hospitals (Arch Intern Med 2010;170:
486-488).