By Kemo Cham
In Waterloo, the Western Rural district some 18 miles from the capital Freetown, a young mother carrying a child hurriedly boarded a minibus, locally called ‘Poda Poda’. Hardly any of the other passengers might have noticed her until she drew their attention. Her son had been attacked by convulsion, a seizure that is common with babies, and she pleaded for the vehicle to depart immediately so that she could have him treated.
The driver, meanwhile, was busy honking for more passengers. Suddenly, everyone’s attention was now on the sick child. And as if to allay the general fear about Ebola, the visibly worried young mother had to quickly volunteer explanation. She had given him a dose of the malaria medication distributed by the Ministry of Health and Sanitation (MoHS). Apparently, the side effect had overwhelmed the seven year-old.
“If I go to the hospital they will think he has Ebola,” she said. She
was going to see a relative who was a nurse in Freetown. For the rest of the journey, the malaria medication, which was distributed between December 5 and 8, became the subject of discussion on the Poda Poda as other passengers shared their personal experiences with it.
Malaria is a parasitic disease caused by the plasmodium and infection
often occurs via a mosquito bite. Sierra Leone was ranked as the fifth most malaria endemic country in the 2013 World Malaria Report. According to the Sierra Leone government’s own Malaria Indicator Survey in 2013, the disease was leading cause of death among children.
Malaria, alongside HIV/AIDS and diseases like tuberculosis (TB), still account for the bulk of Sierra Leone’s major disease burden. Because of the impact of the Ebola outbreak, the governments of Sierra Leone, Guinea and Liberia, the hardest hit by the epidemic, face immense pressure to address these major healthcare issues.
Meanwhile, the World Health Organization (WHO), alongside partners like the Global Fund, the UN agency for children (UNICEF), the French medical charity MSF and the global campaign ‘Roll Back Malaria’, have all recommended the Mass Drug Administration (MDA) as the best approach at the moment.
Ebola Symptoms
The MDA was designed as a strategy to ease the burden of malaria with the goal of eliminating it, but seemingly it is also being used to ‘kill two birds with one stone’. The initial clinical symptoms of malaria and Ebola are similar - fever, headache, weakness, joint pains and vomiting. Because of this, clinicians have had trouble trying to deal with huge suspected cases of Ebola, at least some medicos have confirmed.
“We found out that about 85 percent of cases at the [Ebola] holding centres turn out to be malaria cases...,” said Dr Samuel Juana Smith, Manager at the National Malaria Control Program (NMCP) in Freetown.
He told Politico that because of these similarities in symptoms and the high prevalent rate of the parasitic disease in the country, the fight against Ebola had become complicated. In all three neighbouring Mano River Union (MRU) countries, malaria is the most common cause of fever and transmission occurs all year round and rises significantly in the rainy season - May to October. The three combined accounted for 6.6 million cases and 20,000 malaria deaths in 2013, according to WHO.
Therefore, says the UN health agency, the effectiveness of the Ebola response could be further optimised through the development of
targeted measures to reduce the number of fever cases. In Sierra Leone, the drug distribution is being carried out in two cycles. The next phase is expected to commence on 16 January. But amidst concerns about its side effect, which appears to produce the reverse effect of the intended objective, sending people like the mother in Waterloo away from hospitals, critics are calling for convincing explanation.
Malaria Hotspot
2.4 million people were targeted in the first phase, which saw health volunteers moved door-to-door in seven Malaria hot spot districts
across the country, handing out the drugs and, supposedly, providing guidance on how to administer them. However, reports of a mass lethargy towards the drug cast serious doubt about the effectiveness of the campaign. Many people reportedly abandoned their first round supply half way into the treatment. Many others did not even take the treatment.
At Malama, west of Freetown, Amie, a suckling young mother, terminated the treatment when she discovered her three months old child developed rashes after she took the first dose. Yet failure to complete treatment normally bears two major risks - It raises safety issues for the patient and, importantly, for the long term, helps the targeted parasites or disease causing organism to develop resistance to the drug.
The drug in question is an artimisinin-based combination therapies - Artisunate + Amodiaquine (AS+AQ). Experts say it serves both preventive and curative purposes. This seems to answer questions about why administering anti-malaria drug without testing for the parasite in the consumer’s blood. But one answer that appears to escape the authorities is the strong side effects of the drug, which include dizziness, headache and diarrhoea. But if other sources, including even mainstream media reports, are anything to go by, the effect may even be worse.
In Portee, in the far east of the capital, an elderly man reportedly died after taking an over-dose of the drug. In Kroobay, there were alleged reports of three deaths attributed to the drug. Many other unconfirmed reports have surfaced but, officially, the Ministry of Health denies any death was as a result of the drug.
As a first line treatment, Dr Juana Smith insisted to Politico that AS+AQ “is safe and effective” and that partly explained why the global health organisation recommended it. He also said that the drug was the first line of treatment of malaria in Sierra Leone, after it replaced Chloroquine in 2004 following a 2002 therapeutic study on the disease.
“AS+AQ has been here for a very long time and the people have been using it and they know that,” he said. In Sierra Leone, according to NMCP statistics, malaria accounts for 50 percent of outpatient morbidity and about 38 percent of hospital admissions, and it’s a leading cause of morbidity and mortality among children under the age of five.
Dr. Smith said out of every 10 Sierra Leoneans, four has the malaria parasite in their blood at every given time of the year. The national malaria prevalence rate is 43 percent, but in some mainly northern districts like Koinadugu and Kambia, it gets as high as over 60 percent, he added.
It was these “hotspots”, alongside the Western Area, which were targeted by the MDA. The other districts are Bombali, Moyamba, Port Loko, and Tonkolili, he said. Critics, however, blamed “poor” sensitisation for the conflicting report coming out of the field, even if the MoHS had insisted that the exercise came out well as planned.
In order for the exercise to be deemed successful, the MoHS needed to meet at least 80 percent coverage of the targeted communities. As far
as the malaria control program manager was concerned, that was achieved in the first round.
News about the mass drug distribution first came out to public domain barely a week before it was to be implemented. And the ministry of
health had promised that its trained volunteers would directly observe treatment for the first dose to ensure people abided by the guidelines. A related WHO guidance leaflet also stresses on effective communication between health authorities and communities about the expected benefits, but also on the potential to reduce malaria morbidity and mortality, to reduce febrile illnesses, which could be misdiagnosed as Ebola, and importantly to promote community participation and maximum uptake.
None of this was possible in light of the short term training the distributors were exposed to, observers say. Consequently, the drugs were handed out with little or no advice. And the results were that there were reports about overdose and deaths. With the next round of the distribution just at the corner, amidst this widespread weariness within the population, we can only wait and see how the drugs will be received.
© Politico 15/01/15
