One in 200 Million: My Infection with Malaria

In my short few months in Africa, I managed to become one of the more than 200 million people each year who will be infected with malaria (WHO, as of 2015). 89% of these cases, and 91% of the over 400,000 deaths annually, occur in Sub-Saharan Africa alone (WHO).

My own infection was, by many measures, an anomaly. Unlike locals in malaria-prone regions, my body has no immunity to the disease. However, to my benefit, I had wealth of funds and education well beyond the local averages, lending me greater access to knowledge and prevention. My diagnosis and treatment, perhaps, were unusual as well. I’ll let you make your own assessment as I go!

Prevention

The risks of malaria in Africa had been on our minds at least 9 months before we arrived to the region. Late in the Fall of last year, I went to a clinic in New York City that specializes in travel medicine. At that time the doctor reviewed my vaccination history and gave me the required updates for long-term travel through the Global South. There is no vaccine for malaria so I’d also asked the doctor at that time about malaria prophylaxis, which he advised against. He said the side effects of the medication were extreme– suicidal thoughts–and that everyone gets malaria in Africa, it’s not too bad and we could be easily treated.

This was the ill-informed advice we were operating under as we began our trip and were about half way through travels in South America, at which point we began to make preparations for our time in Africa. Reading more about the region, we learned about the life threatening nature of malaria and decided that we needed something to ward against it.

The CDC has an excellent page describing the types of prophylaxis (here). We were most concerned about efficacy and side effects. Chloroquine, one of the most common preventative malaria medications, doesn’t work in much of Africa, as the local strains have become resistant. Mefloquine, the medication the doctor in New York must have been thinking of, can have extreme psychological side effects. Doxycycline, a very popular and cheap prophylactic, can make some people sensitive to the sun; since we were going to be out on the beach and in open bush, we decided this too was a bad option for us. Thanks to Internet access, information literacy, and knowledge of sites like the CDC, we were ready to advocate for our options when it came time to meet the doctor.

Informed by the CDC and other public health sites, we heard our areas of greatest risk were on the coast and in the bush safari in East Africa. While Ethiopia is also malaria prevalent, Addis Ababa and high altitude areas, like Lalibela where we were traveling, were not indicated to be high risk. Reading this in Brazil and reflecting on the misinformation in New York we decided that it would likely be better to get malaria prophylactics in Africa, where there would be knowledge of local strains and immunities.

We’d purchased travel insurance beforehand so called our insurance help line while on the road in Ethiopia. Within the day they provided us a list of recommended hospitals in the cities we’d be visiting in Ethiopia and Kenya. We emailed and called a few before finally deciding on a very knowledgeable and responsive hospital in Mombasa, the second largest city in Kenya.

We went to the hospital directly from the Mombasa airport, bags and all–our first stop in Kenya. After consulting with the really excellent (emails! private attention! no visit fees! are you listening, America?) pharmacist and doctor in Mombasa we decided on Malarone (local name Malarin), a drug that combines atovaquone and proguanil. The physicians had recommended Doxy as the much more affordable option (less than a cent vs something like $2.50 per pill!) but being paler than the locals we were worried about blistering sunburn side effects so ponied up hundreds of dollars for the 3 months of pills we needed. This was a jarring cost for the medical staff (about a third the annual GNI per capita in Kenya, per World Bank) and even for us, given our $35/day backpacking budget goals. But, health comes first, we reasoned together! Of course, as with anything we buy while traveling and because medicines are unfortunately prone to counterfeit, we checked that the medicines were legit and in good condition–sealed, not expired, GSK stamped everywhere in and outside the box. We began taking the pills immediately and wore long pants and shirts, bug spray, and slept under mosquito nets.

We’d continue to take the pills every day and were lucky to have access to mosquito nets and screens everywhere we slept, and funds for plentiful bug spray. Like the pills, we also bought our bug spray locally, and it was pricy. In Mombasa and Nairobi, we could only find it in pharmacies at high end shopping malls, at about $10-15 a bottle.

Diagnosis

We spent about ten days on the gorgeous Kenyan coast (photos here) before flying to Nairobi for a few days of errands then a month long safari through Kenya, Uganda, Rwanda, and Tanzania.

What you can see on safari is remarkable– I highly recommend it! (Photos here)

It was about 20 days into our safari tour that I began to feel ill. As we crossed into Rwanda the temperatures climbed and I felt extremely hot. Well, so did everyone else! I took to checking the heat of others’ foreheads for a couple days to see if what I was feeling was abnormal. By the time we were about to cross into Tanzania, I sensed something more serious. I was boiling and flush and could not get cool. I’d also begun to have a pretty painful cough. As we waited for (two hours for) our visas to be processed at the border, I walked back and forth to the bathroom to put water on my head, the back of my neck, arms, stomach. Mind you, running water isn’t always easy to find in this part of the world, so that was a gift. I tried not to cough to avoid border crossing suspicions! I told our guide I thought I needed to stop at the nearest clinic.

North-Western Tanzania is largely rural. That night we were set to camp in Nyakanazi, the largest town before a full day’s drive to the more populous Mwanza, Tanzania’s second largest city. In Nyakanazi we saw a “clinic” from the side of the road. A little plywood-constructed room, it held shelves with maybe a dozen medicines and there were two people working there. I explained my symptoms to the man at the desk and he gave me a test for malaria. This testing kit- perhaps the most common outside of major hospitals- is a finger prick blood test with an indicator like a pregnancy test. I’m a layperson so my understanding of what occurred there was this: The blood is mixed with a solution (iodine?) on the bubble and the indicator strip dyes up to a certain point. There are three spots the dye can travel to, creating a line indicating three different outcomes- type I malaria, type II malaria, or no malaria. After a nervous few minutes of waiting, mine appeared at the no malaria line– I was safe! I bought some cough medicine from the place and paid for the test — $2.75 total, a small price for me but above Tanzania’s average daily per capita income (per World Bank).

That night I continued to feel hot and my cough worsened. I skipped the group’s night activities to head to bed. In the morning I skipped breakfast to get more rest and hopped onto our truck for a long day’s drive. It was a miserable day in my body. I lied down up front in the truck on a sleeping pad, something generally reserved for our driver as a bed at night. As we made our way through bumpy roads and even through a ferry crossing, I was nearly delirious with a feeling of whole-body boiling.

When we arrived in Mwanza I split from the group to go to another clinic, a small hospital. There I was given a full blood lab checking for any abnormalities. I was given another malaria test, a pinprick but a different process, one I didn’t see as it was whisked away to a lab tech and eventually to be read by the doctor. We consulted with the doctor and he reported the tests showed negative for blood abnormalities and malaria. He diagnosed me with an acute respiratory infection and gave me a stronger cough syrup, an antibiotic, and something for the flu. In total, the doctor’s introductory visit, labs, and medicine cost about $17 (later follow up visits were at no charge, only labs and meds). As a percent of the Tanzanian GNI per capita this would be a lot– the equivalent of something like $930 assuming an income of $50,000.

Around sunset we arrived to our camp at the banks of Lake Victoria, a place only days later would I be able to appreciate for its beauty. As the majority of our group went for a swim, I plopped down on my sleeping pad in the tent, exhausted.

The next morning we were set to leave for a few days drive to the Serengeti. With continued fever, a worsened cough, and drained from the night’s several trips to the bathroom, I tried my best to pull my strength together. I downed as much rehydration solution as I could and tried to swallow some bites of bread, but I was painfully nauseous, my whole body heavy and leaden. It took all my will–and my partner’s encouraging– to sit up and, eventually, to have the talk with our tour leader that we wouldn’t be able to continue with the trip. At this time all we knew was that I had a terrible flu, but the conditions were only going to get more remote from here.

The rest of the day I slept. My head spun all day. I was weak and sweating and coughing and feverish– and most of all exhausted. The doctor said the antibiotics sometimes had side effects. Whether from those or the underlying illness my night was filled with bizarre, almost hallucinogenic, dreams. I took more rehydration salts, drank lots of fluids, and tried to hold down food.

The next day I still felt sick, but significantly better, and we decided to go to the hospital again, particularly to wrap up my condition formally for insurance purposes. I told the doctor how I’d felt the day before and he said it sounded like malaria, we should test just in case. My partner and I looked at each other anxiously. Another round through the same process, finger prick, another wait, and the results: malaria positive, 2 parasites identified in the sample of blood taken . Three tests and two different facilities to arrive at the diagnosis!

Treatment

I was prescribed a three day, six pill, regimen. The drug was a combination of Artemether and Lumefantrine. The doctor explained that it was recommended by the WHO as the most up to date and advanced treatment, one that should also limit the chances of possible relapse. I was instructed to take the pills morning and night with meals, fatty foods best. If I could hold down the pills I could stay in our hotel to rest. Otherwise, I would need to be admitted and given the drug intravenously.

Luckily, with a lot of sleep and taking great care with my diet, I was able to stay in the hotel and not have to be admitted. After three days I returned to the same doctor for a final blood test, showing negative for malaria.

Thoughts

What kind of malaria did I have? I’d asked that last visit. The doctor said we couldn’t be sure without a full test, which could only happen at the University hospital. He said 90% of the cases they get in the area are P. falciparum (I’m unsure the reliability of that data given the aforementioned– but there it is) This is most fatal form of malaria, one that can develop into the brain, causing coma and even death.

Given the general incubation period of over a week it’s likely my mosquito was from outside Mwanza, probably another country. We’ll never where or how exactly it happened. What we do know is that the chances of me contracting it are extremely rare: Malarone has high reported efficacy (FDA) and with preventative measures like nets, bug spray, and covered clothing, I’d been bit maybe a dozen times in the last month.

Wider lens

Malaria is one of the biggest killers in the world. There are estimates that in Africa alone it shaves 1.3% off of GDP each year (UNICEF), not to mention affecting millions of persons, and as a result their families, in loss of income and life. The direct costs of the disease have been estimated at $12B annually, with additional indirect and opportunity costs (CDC).

It’s called a preventable disease, preventable because cases like mine are unusual. Increasing the use of insecticide-treated mosquito nets (ITNs as the folks in policy and distribution call them), for example, has helped along with other measures to decrease malaria mortality dramatically in the last 15 years. Mortality rates have gone down 60% since 2000 (WHO).

And yet, with climate change, malaria has a chance to spread to newly vulnerable populations, to people like me who have no resistance. Work by Andrew Githeko, Paul Epstein, and Andrew Ferber highlights how this has created epidemics in parts of Africa thought previously to be low-risk. (an excellent article highlighting Githeko’s on the ground work and a book by Epstein and Ferber– I’d recommend!)

The fight continues on all fronts. There are exciting innovations in diagnosis, possible expansions of local preventions such as wormwood tea, and community education programs looking to increase prevention behaviors (one of many lists here). Drug companies are also pouring big money into both prophylaxis and treatment. I hope as many advocates and generics come forward to make these and new solutions affordable to the people who need them.

For me, I was extremely lucky to be where I was, in a large city with a good hospital, a knowledgeable physician, up to date and stocked medication, money to afford any treatment needed, and with the persistence to get tested multiple times. I had the education and curiosity to have read up significantly on the disease beforehand. I had access to plentiful clean (bottled, mind you) water, rehydration sachets, and fatty foods to help my drugs absorb and my body repair. I had a nice place to comfortably rest. I made it.

The disease for me was a bad week, feeling miserably sick, frightened at my prospects, and missing out on some parts of a trip I was really looking forward to: “first world problems” as they say.

The experience gave me a first-hand appreciation, however, for this dangerous killer. My thoughts turn to the many hurdles families must face, especially poor families without reliable access to measures for prevention, diagnosis, and treatment. Imagine me instead as an average citizen in a highland environment where malaria is new. My fight very probably could have been met with confusion, medical debt, and/or death. As a 34 year old woman, I would statistically have multiple children to boot–what of them?

I’ll be getting more involved in the global fight. Do you have any advice on how? Great organizations or tips to share? Please share for all in the comments!