The negatives of false positives: Misdiagnosing malaria leads to fevered complications

“When people are sick in Mali, the doctor will usually tell them they have malaria whether or not they test for it,” Fatou Faye, an infectious diseases researcher and trainer at a privately funded medical laboratory, the Charles Merieux Centre in Bamako recently told IRIN.

“The patients then buy anti-malarial drugs in the street and build up a resistance to treatment.”

Dr. Imelda Bates of the Malaria Knowledge Project says that when doctors misdiagnose malaria, patients may miss real treatments for other serious illnesses like pneumonia and meningitis. Most rural health clinics lack the proper equipment to make a full malaria diagnosis, leaving many patients uncertain what is causing their fevers. Because the potency of malaria strengthens after each fever cycle, many patients simply take anti-malarial drugs as a precaution.

The problem with most blood smears is that most patients already have a considerable amount of the malaria parasite in their bodies, which is picked up by the test, leading to a false-positive test and overdiagnosis.

Health professionals are calling for more funds going towards diagnosis, which would allow those health clinics away from population centers to purchase microscopy equipment that properly count the amount of parasites in blood, a more certain way of diagnosing the illness. This equipment, called rapid diagnosis tests, are inexpensive and can be used by untrained technicians.

Peace = lower malaria rates?

Peace in Cote d’Ivoire does not bring down malaria rates, says IRIN.

Statistics galore: At least 6-out-of-10 clinic treatments are for malaria, the story points out, and 20 percent of pregnant women have the mosquito-born disease, leading to low birth weights. Historical numbers were not available.

The question remains: Why do people get malaria in the first place? Never mind the how, we’ve covered that part here. We need to investigate the social aspects of the disease, and a post on Yahoo Answers (I couldn’t find anything better) claims that malaria thrives where people live in close quarters, in wet, “dirty places” (not my term) where mosquitoes thrive. Oftentimes these people lack the money – and/or will – to clean up the mosquito zone.

A different take. Environmentalists and international development agencies like USAID and the World Health Program have guilted African countries away from using DDT or other pesticides which will go after the mosquitoes that carry the disease, argues Paul Driessen in Spiked Online. Driessen, the author of Eco-Imperialism: Green Power, Black Death, claims that the most effective way to kill the mosquitoes in peoples’ homes (or at least where they sleep) is the combination of spraying DDT and using bed nets and screens, when necessary.

Yet, in a Reuters blog on the issue (which I must give a hat tip for the Driessen piece), a certain Ed Darnell contends DDT is an overrated (and dangerous) method of reducing mosquitoes in homes. A better solution would be better medical systems and education (and money) to drain those mosquito breeding areas.

Meningitis update...

Your Burkina Faso meningitis update, from the Times (of South Africa):

A meningitis epidemic has killed 441 people out of more than 4,000 cases reported in Burkina Faso since the start of January, the health ministry said today.

The outbreak is centred along the border with Ivory Coast, where 44 deaths had been reported by February 20, a day before the two countries announced a joint health programme to tackle the epidemic.

"Between January 1 and March 9, 2008, we have a total of 4,061 suspect cases of meningitis, including 441 deaths, a mortality rate of 10.85 percent," Ousmane Badolo, the ministry official in charge of epidemic disease surveillance told AFP.

Dr Badolo said that of 16 affected districts in Burkina Faso, the outbreak had reached epidemic levels in seven of them. The last official figures issued on March 2 reported 366 deaths out of 3,181 cases.

While cheap, cotton oil comes at a high cost in Mali

In Mali, cotton oil sells for half the price of imported cooking oils. However, there’s a stitch for one of West Africa’s largest cotton producers: It’s been found that local oil processors lack the equipment to remove a toxin gossypol from the oil. The BBC reported that government has temporarily shuttered 80 small-scale cotton pressers, leaving only 16 in business. They also launched a public information campaign on the present dangers of cotton oil.

The government has also been working on a new system to better track where and when locally produced oil is made.

From BBC:

"What we're working towards is that all producers in Mali will have a certain transparency, so you can see the date it was made, the factory it was made in, and with what sort of water they made it.

"With these rules I can give you a guarantee," says [Head of Ministry of Industry, Adama] Konate.

"So it's necessary that the consumer demands that the products they buy have a degree of transparency."

The real solution, Mr Konate feels, would be for Mali to start refining sunflower, sesame and groundnut seeds to make cheap cooking oil at home without the dangers of cotton seed oil.

The choice is yours
Gossypol, according to a paper by Matt Poore and Glenn M. Rogers at the North Carolina State University, is a natural toxin used to protect the cotton plants by slowing down reproduction rates of insects. Cattle, which can detoxify gossypol much more effectively than poultry, will develop heart damage and heart failure if they overeat cotton meal over a long period of time.

But we’re talking humans here. According to a story in MaleContraceptives.org, Chinese researchers have been on to the effects of cotton (really, gossypol) on male fertility since the 1920s. Five decades later, they conducted a ten-year study involving 8,000 men that found that those taking a daily gossypol pill had regular contraception along the lines of female contractive pills without a change in libido.

But side effects were found. Low levels of potassium, a disease called hypoklemia, were found between 1 and 10 percent of the subjects. This disease is mostly found with people with very poor functioning kidneys. (However, one Brazilian scientist argued that the Chinese diet is naturally poor in potassium.) Nonetheless, gossypol is a known toxin and its chances at becoming an “herbal” substitute for vasectomy are very slim.

It has also tumor inhibitors capabilities, making gossypol a candidate as a cancer drug. It also contains anti-malarial properties.

So, what needs to happen?
People have long heated cotton seeds to extremely high temperatures (about 230 – 260 Fahrenheit) and added hexane and two other solvents, which extracts the gossypol. The story doesn't say, but either the producers weren't bringing the cotton seed up to proper temperatures or they didn't have the proper chemicals to do the extraction.

Meningitis deaths creep upward in Burkina Faso

From Agence-France Presse:

A meningitis outbreak in Burkina Faso has infected thousands of people, killing hundreds, in the past two months, the health ministry told the AFP Thursday.

"We have identified 3,181 suspected cases of meningitis from January 1 until March 2, 2008, of whom 366 have died," said Doctor Ousmane Badolo, head of epidemiology surveillance at the ministry of health.

Fourteen districts are affected, of which five have declared a state of epidemic. Two have been downgraded following vaccination campaigns.

Badolo said Burkina Faso had enough vaccines to cover all infected districts although needs could change if the outbreak worsens.

So far, a (somewhat) quiet year in the Meningitis belt

From China View:

Africa is so far experiencing much lower levels of meningitis cases, compared with those of the same period last year, the World Health Organization (WHO) reported Friday.

Preliminary reports from 13 countries indicated 2,312 cases, including 324 deaths, during the first six weeks of this year in the belt, which stretches from Senegal to Ethiopia.

The number of cases dropped 29 percent from the figure last year, when 3,274 cases, including 413 deaths, had been reported.

However, major outbreaks have still been reported in Burkina Faso, the Central African Republic (CAR) and the Democratic Republic of the Congo (DRC), while Benin, Cote d'Ivoire, Ethiopia, Ghana, Mali, Niger, Nigeria and Togo have all reported cases of the highly contagious disease.

But it is not enough to reach epidemic levels. And there have been no cases so far in Cameroon or Chad, WHO said.

According to notes from the World Health Organization, Burkina Faso leads all other countries with 1,422 cases of meningitis and 204 deaths. This represents more than 60 percent of all cases on the continent.

Optimism follows malaria vaccine trials

Researchers remain optimistic after the results of an initial test of a new malaria vaccine showed a six-fold increase to the body’s defense system against the mosquito-born disease. The doctors supervising the study from the Malaria Research and Training Center at the University of Bamako point out that the initial survey only included 60 participants, one-third of whom received a full dose of the vaccine, another third taking a half dose and the final third took a control dose of a licensed rabies vaccine.

Each participant received three doses of their respective treatments, spaced one month apart. And all participants showed prior exposure to malaria parasites.

From Science News:

Those who received the candidate vaccine tolerated it very well and experienced a significant boost (up to a sixfold rise) in levels of vaccine-specific antibodies, while those who received the rabies vaccine had declining levels of antibodies as the rainy season receded.

Researchers will now increase the study to include 400 children in Mali, all between the ages of one years old and six.

How to get malaria
Malaria is a parasitic infection transferred through female Anopheles mosquitoes. (Males do not feed on blood.) These mosquitoes act as transmitters of the disease by receiving the malaria parasite by simply stinging an infected person. These females usually bite at night, but they transfer the disease through saliva, injecting a protozoan parasite called Plasmodium (or in some extreme cases Plasmodium falciparum) into the bloodstream of the host (you or your friends).

Once the human (you) becomes infected, malaria develops in two separate stages: Through the liver or directly to red blood cells. If the Plasmodium heads to the liver, it can lie dormant for up to two weeks where it begins attacking by asexually reproducing inside red blood cells. Once enough of the parasite is available to attack the red blood cells, it could break out to invade other cells. This is what creates fevers in the host body, which is attempting to fight back the attack on its red blood cells. By staying within the cells, malaria evades the body’s immune system and can continue its attack.

The parasite often attacks in stages, producing cyclical periods of hot and cold in the body. For the most part, malaria causes symptoms very similar to the flu: chills, headache, muscle ache, vomiting and malaise (whatever that means). However, the Center for Disease Control warns, if malaria is left untreated some people can develop complications like brain disease, anemia and kidney failure.

Economic affects
The CDC estimates that each year 500 million are treated for malaria at a hospital or clinic. At least six out of ten of those falling sick reside in sub-Saharan Africa. Malaria kills an estimated one million people per year, and sub-Saharan Africa makes up 80 percent of those victims. In Africa, children make up a large majority of malaria deaths.

For adults who fall ill from the disease, its effect on income is substantial. Lost hours due to sick time and money spent on treatment adds up to reducing sub-Saharan Africa’s economic growth by 1.3 percent each year, according to findings from a study conducted by the World Health Organization and the London School of Hygiene and Tropic Medicine.. Taken all together, Africa has lost an estimated $100 billion if malaria had been wiped out in Africa 35 years ago

There are also researchers who claim that countries with high malaria incidences (and mortality rates) lose investment opportunities. Also, tourism and travel to that country may by inhibited by high malaria rates.

Teenage pregnancy, unwanted babies and abortion in Burkina Faso

There’s a rise in teenage pregnancies in Burkina Faso, says IRIN, where as many as 500 unmarried teenage girls per year are becoming pregnant and often feel compelled to abandon their newborn babies.

The story paints a picture of niave girls moving with their families from the countryside to the big city, where sex norms are much more fluid. Shelters for pregnant single girls are full; and orphanages now overflow with abandoned babies.

The abortion issue
However, this information appears to be somewhat inconsistent with a 2003 study that estimated nearly 8,000 women undergo a clandestine abortion each year in Ouagadougou alone. The study, conducted by Demographic Research and Study Unit, or UERD, found that most of these women go to private clinics that perform abortion services after hours; others go to traditional healers and some purchase legal, yet dangerous drugs off the streets from unlicensed street venders.

I remember talking to these researchers a few years back, and Georges Guiella from UERD said that women with money can bribe their way into a clinic for an after-hours procedure. It is often common for a group of high school girls to gather up money to pay for a friend’s procedure, which cost (at least in 2004) between $50 and $100. For those who don’t have access to that kind of money, they often go to traditional healers who can make a concoction from leaves and tree bark that will kill the fertilized egg. For those who do not want to go this route, they can always purchase something off the street or a heavy dose of the anti-malarial medicine Nivaquine.

What is most worrisome to researchers and health workers is that teenage girls – most often between the ages of 15 and 19 – appear to make up the largest group of those looking for an abortion. These young girls are also the most likely to use the most dangerous methods to have the abortion.

The UERD study estimated that nearly 60 percent of women undergoing Ouagadougou’s clandestine abortions end up needed some form of medical care. Twenty years ago, the government set up a program to treat women needing healthcare from complications resulting from clandestine abortions. The problem, researchers and medical workers say, lies with women who relied on traditional healers and unlicensed vendors for their procedure. Dr. Blandine Thiéba from the country’s main hospital told me that these methods can often lead to infection, internal bleeding and other health complications. If left untreated, serious cases could lead to sterility, and as UERD found, sometimes death. (The UERD study estimated 28 deaths per year from clandestine abortions, which I found to be a little low.)

A worldwide phenomenon
In a report by the Alan Guttmacher Foundation, 210 million women throughout the world discover they are pregnant. Around 15 of every 100 of those women have a miscarriage. And, 22 percent of the world’s pregnant women terminate their pregnancy by a form of abortion. That adds up to 46 million women worldwide having an abortion each year, and nearly half of these procedures take place in countries where it is restricted or illegal. In Africa, more than 5 million women each year have an abortion, where it is oftentimes restricted throughout the continent. However, Africa is responsible for one-quarter of the world’s illegal abortions. Burkina Faso allows abortion for instances of rape and to protect the mother’s physical health.

The reasons for wanting abortion are universal: health issues of the child or the mother; economic concerns or any number of conflicts with the father. Also, for young unmarried teenagers everywhere, becoming pregnant bears a huge social burden.

In Africa, nearly 8 out of 10 sexually active women do not use a method of birth control. According to the Government of Burkina Faso, 22 percent of never-married Burkinabé women between the ages of 15 to 44 are sexually active. Of these women, 63 percent do not use contraception. For married women the same age, nearly 20 percent of those who “do not want a child soon” do not use contraception. All this adds up for the government of Burkina Faso to believe that almost one-quarter of all births are unplanned.

Sex workers flocking after soccer fans in Ghana. What will follow?

Think of the 20-day African Nations Cup as a public policy issues, especially in terms of health. With the arrival of thousands of football fans, footballers, their handlers and (let’s be honest) government officials, there is a fear of “sexual promiscuity and the spread of HIV/AIDS,” warns The Voice.

Other worries abound:

Frank Adu Poku, director general of the CID, said: “International sporting events have become fertile grounds for human trafficking and sexual exploitation of women and children.”

United Nations Fund for Population Activities will distribute 5,000 condoms at hotels. Will it be enough?

Sex workers are flocking to Ghana to cash in on the thousands of potential customers at the 2008 Africa Cup of Nations, which opened in Accra on Sunday.

Prostitutes, mainly from Nigeria, Cote d’Ivoire, Togo, Liberia and Benin have already joined their Ghanaian ‘sisters’ on the streets of the four venues — Accra, Sekondi-Takoradi, Kumasi and Tamale — to do business.

“Hundreds of Nigerian girls suspected to be prostitutes are reported to have come in and rented apartments in Accra, where they will stay and work during the tournament,” Nathaniel Attoh of The Graphic Sports said.

According to Attoh, the largest numbers of ‘call girls’ are from Cote d’Ivoire and Togo, which share borders with Ghana.

FGM in the marriage market

On August 15, 2004 Madam Adama Barry was arrested in Ouagadougou, Burkina Faso for performing female circumcision on 16 girls between the ages of 2 and 10. It wasn’t the first time Ms. Barry had seen the inside of a jail in Ouagadougou. In fact, this unrepentant female circumciser has already served four short jail terms for her part in these illegal coming-of-age rituals. To the government, the arrest of a 70-year-old woman proves how serious they are in tackling female genital mutilation.

Madam Barry’s arrest also shows just how far the country has to go in its fight against female excision. When Burkina Faso became the fifth African country to outlaw female circumcision in 1996, people hoped for a quick end to this social practice that had endured centuries. But today, nearly two-thirds of all women are still circumcised—down from 70 percent twenty years ago. Why are the government’s actions – and a large amount of Western aid money – taking so long to take hold in Burkina Faso?

It’s called by many names: Female Genital Mutilation. Excision. Female Circumcision. And it’s practice predates the introduction of Islam and Christianity in Africa, a continent where 130 million women have undergone the procedure and perhaps two million young girls continue to go through it each year.

By definition, excision is the removal of some or all of a woman’s genitalia. According to scientists, there are three different excision procedures. We’ll list them from least invasive to most invasive. The most medically limited procedure is the removal of part or the entire clitoris. The second procedure, and of higher intrusiveness, is additionally cutting away the inner labia; finally, the most invasive procedure includes cutting away the outer labia, which forces the vagina to be sewn shut.

This practice of female circumcision has become something of a cause célèbre among many people – Westerners, notably – who condemn it as an unhealthy attack on the human rights and sexual rights of unknowing young girls. They bring up the pain these young women go through; the dangers of using unclean utensils to carry out the operation; the build up of scar tissue that makes urination (or childbirth) difficult. Others rebut that excision is no different than expensive cosmetic surgery westerners have performed: they both address the need to be more attractive and desirable.

There are many theories on why it FGM takes place. Some claim the practice makes women complete, eliminating any resemblance to males. Others contest that an infant passing through the birth canal will die if it touches the mother’s clitoris. Other versions claim it is no different than foot binding in China: a practice of fidelity control to prevent women from straying. (Women who cannot have an orgasm will most likely not want to sleep with anyone other than their husband.)

The problem is that Burkina Faso outlawed the practice more than ten years ago – its eradication is a pet project of the first lady – but support for excision remains widespread. Side story: A gardener at an office I worked at in Ouagadougou was arrested for having it performed on one of his young girls. He spent a few nights in jail and then was forced to pay a fine. He returned to work unyielding in his belief that the custom should continue. One reason for his stubbornness, we later found out, was that he was reported to the authorities by his sister in law who didn’t like him. The feeling remains mutual, I was told.

The problem with circumcision is its social resilience. Traditions like dowries and scarification have largely been phased out. Why not FGM? Is it because the practice is wrapped up in sex roles, and in an agricultural society those roles are hard to change? Maybe.

Or, perhaps FGM's critics have been fighting the wrong battle.

Two researchers at the University of Auckland, Tatyana Chesnokova and Rhema Vaithianathan, take a different route and investigate excision as primarily an economic issue, claiming that families view the procedure as a premarital investment. Their have their young girls excised because the number of desirable men looking to marry circumcised women remains high. Getting circumcised increases the chances of marrying a successful man.

However, excision marks only an investment for the women, the researchers say in their paper Female Genital Cutting and Marital Outcomes. It is women alone who bore the great health risks and experience the possible side effects, including infection, possible sterilization, death.

The argument goes that if there would be no circumcised females, men would have no incentive to search for them. With more than three-quarters of Burkinabé women still practicing excision, that’s a long shot. However, if regulations against FGM could drive rates low enough, the professors argue, then perhaps these men will look for other aspects of female desire.

One way to do this is to take the economic advantage out of FGM. That means providing women with economic opportunities outside of marriage. A successful woman will attract successful men, the thinking goes. The researchers don’t go into details, but one could surmise beginning with increasing education for girls (which will augment employment potential) or at least increasing opportunities for training. Other possibilities include finding more jobs outside of the household for women or increasing the worth of female-exclusive occupations, like the production of shea butter.

It’s a long shot. For one, excision has been practiced – some say – since the second century. It’s hard to stamp something like that out. On the other hand, the possibility of a big treasure at the end of the day has spelt death for more than a few old traditions.

We interrupt this regularly scheduled program: Update on the fight against malaria

"If the US wants to win a war it ought to be the war on malaria," Senegalese singer Youssou N'dour, a Global Fund ambassador.

Here's a good update on how the fight against malaria is going.

It’s the dry season: Do you know where your meningitis vaccine is?

The International Red Cross/Red Crescent recently issued a warning that at least 14 African nations could face one of the worst meningitis epidemics since 250,000 people fell ill with the disease in 1996, in an outbreak that killed 25,000 people.

The affected countries stretch across the continent south of the Tropic of Cancer in what the World Health Organization deems the “meningitis belt,” including Burkina Faso, Benin, Chad, Democratic Republic of Congo, Ethiopia, Ghana, Ivory Coast, Kenya, Mali, Niger, Nigeria, Sudan, Togo and Uganda.

These countries are at risk because they are prone to extremely dusty winds during the dry season along with usually cold nights, decreasing the immunity of the pharynx at the back of the throat. The meningitis bacteria are most easily transmitted through close contact, especially through sneezing, coughing, sharing eating utensils or kissing. Throughout much of the region that makes up the so-called meningitis belt, people often live in crowded family quarters and sometimes travel to large markets, making transmission of the disease easier. (It can also spread quickly in dormitories.)

During last season in Burkina Faso meningitis infected more than 20,000 people, disabling 2,000 and killing more than 1,300. Across Africa, more than 1,600 died from the disease.

The first wave of the disease this season could hit as early as February, the IFRC warned. One problem is there are presently only seven million doses for meningitis vaccines to cover an estimated population of roughly 80 million spread throughout these 14 countries. The IFRC has initiated a €600,000 program that will train 25,000 volunteers in sensitization and community-based health training.

It even sounds dirty
According to WHO, “Meningitis is an infection of the meninges, the thin lining that surrounds the brain and the spinal cord,” which makes it a very serious disease. The two most common forms of meningitis are bacterial and viral. While still dangerous, viral meningitis is far less severe and can be treated with antibiotics.

For most victims, meningitis begins feeling like the flu and people often complain of stick neck, high fever, light sensitivity, confusion, headaches and vomiting. While vaccines only target bacterial meningitis, its symptoms progress much quicker than its viral cousin. This disease, which is fatal in five to 10 percent of all patients, and can cause degrees of brain damage and/or hearing loss in up to 20 percent of victims.

N. meningitidis A, C and W135 are the main strains that attack Africa. One strategy to fight the disease is to vaccinate a “critical percentage” of the population, which will extend protection to those who haven’t received the vaccine. On the international market, vaccines can run as much as $14 per dose, out of the reach of some Africans. Governments often try to purchase the vaccines from an international coordination group at roughly 66 cents per dose. However, these vaccines sometimes can arrive after an epidemic has picked up steam. Another problem is that vaccines do not exist for some serogroups of meningitis.