A few weeks ago I had a message from a worried relative in the U.K. She had spoken to her doctor about my patient and had a list of tests that she wanted done. This was too great an opportunity to miss. I got her email address and with great glee sent this message. “I have received the list of tests you want done. Unfortunately I couldn’t understand them, so I put on my grass skirt, sat outside my hut, threw some bones in the air and then danced for 15 minutes. I think I got the dance wrong because it started raining instead.”

The fact is with the web there is no excuse for any doctor not to be absolutely up to date with anything in his field. When I look at Eye articles I wrote just 5 years ago I see how much things have changed just in the field of tropical medicine. So here goes with Updates on some of the common problems we see.

Malaria
New treatment
Some things have not changed. New Vision had an article recently showing that new drugs were going to be very expensive and wasted on people who do not have malaria as “every fever is treated as malaria”. Well at least the problem is being acknowledged and addressed. I have seen people this past week extremely ill because they were being treated for malaria when it wasn’t and the real diagnosis was delayed. One had amoebic dysentery, another hepatitis and another meningitis. The answer is very simple: the malaria rapid test. If it is negative then either there is no malaria and you need to think of another cause of the fever, or the number of parasites is too few to trip the test. In which case there are not enough to do any harm at all and the test will be positive tomorrow. Either way treating every fever as malaria is wrong and potentially dangerous.

The new recommended treatment in Uganda is arthemether derivatives combined with lumafantrine. Artenam and doxycyclin is also recognized as an effective alternative and at present much more readily available. However the MoH is bringing in a combination arthemether lumafantrine tablet (co-artem) for free distribution to health centres this year.

Chloroquin and Fansidar should no longer be used for treatment of malaria. Some people may still use quinine, but it must NEVER be given by intramuscular injection. It can cause horrible abscesses. If someone is unconscious there is the option of intramuscular Artenam, Artenam or co-artem by NG tube, or quinine IV. If someone wants to give you an injection when you are perfectly capable of swallowing then say thanks but no thanks and go somewhere else.

Prophylaxis. I am amazed how easily doctors are coerced by drug companies into prescribing the latest most expensive drugs. 2 Years ago many doctors in Europe and America were saying that Lariam was the only drug suitable for East Africa, and even saying that anyone who disagreed was irresponsible. I actually had one family inform me that they had to cancel their contract because Lariam was not safe in pregnancy and nothing else worked, so his wife could not come to Uganda in case she got pregnant. Er… quite. Now suddenly only Malarone works, nothing else is suitable and anyone who suggests otherwise is irresponsible etc.

Fact: The side effects of Lariam are exactly the same now as they were in 2002. It is also just as effective. All that has changed is the drug company propaganda.

So what’s new? Here is a quick update on prophylactics.

Nothing. Still a popular choice in Kampala, and still effective for most people. It is cheap, no side effects and you never forget to take it. Those going to Murchison will find at least 30% will get malaria and we also see a lot of cases from Entebbe and Jinja, so if you are traveling or just away for the weekend, choose another option.

Condoms. Wrong sort of prophylactic. Read on.
Paludrine or paludrine and chloroquin. Not recommended.
It is better than nothing and safe in pregnancy, but a significant number of users will get malaria. If you use P and C then have malaria rapid kits with you and a few doses of Artenam ready.

Doxycyclin. We started seeing cases of resistance for the first time in the past year, 2 definite cases so far. So it is still almost 100% effective but if you do get a fever while taking doxy you should still do a rapid test. Doxy should be taken with food but it forms an insoluble calcium salt if taken with milk. So if you have muesli for breakfast take your doxy with your supper. Still a good choice and only a dollar a month. It is also OK in early pregnancy, the insoluble calcium salt mentioned above means it stains developing teeth, which is hardly a big deal, but that does mean it is not a good choice for children with front teeth not yet through. And of course by the same logic it cannot be passed on by breast-feeding!

Lariam. No change. Still no resistance proven in Uganda, and still 100% effective in our experience. 10% will get psychological side effects, which start slowly and get worse each week. If you have taken 7 and had no problems yet, then it is going to be OK for you. Only 6$ a month and an excellent choice for 90% of people.

Malarone. A combi of paludrine and atovoquone, it is 100% effective, probably has more side effects than doxycyclin, but less than Lariam. It is 4$ a tablet in Uganda, so 120$ a month, more if you buy it in Europe or America. I think the reason it works is because by the time you have bought the Malarone you can’t afford to go to the game parks. An excellent choice for the rich, and probably my first choice in 5 years time. Not because I expect to be rich by then, but because GSK will have reduced the price.

Primaquin. An old drug making a comeback. Seems to be very effective as a “real” preventer, i.e. it kills the malaria in the liver. The only others that do that are Malarone and paludrine, the others all kill it once it has entered the blood stream 5 and a half days after being bitten.
So far it seems to be 100% effective, and recommended for children and pregnant women. Beware if you belong to a genetic group with G6PD deficiency. Should be impossible in Northern Europeans, but others should be tested or at least be careful when taking primaquin.

Bilharzia
Again some things don’t change. Most of the places advertised as “Bilharzia free” seem to mean you get it without paying. Bunyoni is genuinely Bilharzia free, and we seldom see it from Kaazi these days. Maybe our feet smell so bad when we launch our boats that the shistosomule refuses to come near us.
What is new is that Artenam apparently prevents Bilharzia. Best dosage is not yet confirmed by trials but it has been shown that Artenam 2 tabs a day for 2 weeks taken after exposure will prevent Bilharzia. I find this rather odd. For the first 4 weeks the schistosomes are supposed to be in the liver growing up, getting married and going on honeymoon, before swimming down a vein and setting up home in your pelvis for the next 10 years. Now if Artenam kills the immature, then it must do it in the liver. Yet it does not kill malaria in the liver, which is why it is useless as a prophylactic for malaria. Any biologist out there who has an answer? Medicine is not a logical science.

Treatment for bilharzia. Good news for anyone who has children who simply look at the tablets and they start to vomit. Praziquantal tablets work as suppositories. I suppose it is also good news for the French, Belgians and Germans. Personally faced by 7.5 tablets I would rather do it my way and swallow 4 now and 3.5 in 3 hours.

Vitamins
Some very disturbing trials have shown that swallowing vitamin tablets are bad for you. Some trials suggest some Vit B tabs increase the risk of cancer and a very large trial of postmenopausal women found that swallowing vitamin A C and E tabs doubled the risk of heart attack and stroke. Uganda has the most wonderful variety of fresh fruit and vegetables you could possibly find, so the only sensible advice is don’t take vitamin tablets, eat fruit and veg instead.

Antibiotics
Some newly published trials have shown yet again that antibiotics in people with fever, cough and “bronchitis”, are absolutely useless. Pneumonia is a rare disease causing noisy fast breathing, very ill, fever, chest pain, coughing pus and often rusty-looking blood. Most people will never see a genuine case of pneumonia in their entire lives. A child with a fever, a cough and a snotty nose does not have pneumonia and does not need antibiotics. They are even harmful, as they kill the nice safe bacteria that are supposed to live on us and replace them with potentially nastier ones.

If you are not sure if you need to see a doctor when your child has a fever and cough, then here is a good rule of thumb. Count the breaths per minute. If it is over 40 come on in. If it is over 60 and noisy come in immediately. If the child is obviously “ill” come in. If the child is quite well, playing and eating, wait and see.

Over use of antibiotics is nothing new and does not seem to be getting any better in many countries, but it is nice to see some serious trials being published that back up what has always been considered good practice.

Aids and STD’s
New trials show that post exposure prophylaxis works! However don’t get hung up on AIDS alone as if there were no other STD’s to worry about.
About 10 years ago I heard that in a trial somewhere in Uganda 50% of women had a treatable STD. I asked the doctor who did the trial about non-treatable STDs, and he told me about the high numbers with human papilloma virus. So I thought ”there is going to be an epidemic of cancer of the cervix in 10 years time”.

It has happened. Cervical cancer is not a nice way to die, and it is now shown to be due to one strain of human papilloma virus and it is pretty well undetectable. Certainly no one is testing for it in men before having sex. We get couples coming in for a HIV test before a relationship which is very wise, but not for Hep B, nor for that mater chlamydia, gonorrhoea, syphilis, chancroid, LGV or any of the other 26 potential STD’s.

But surely if we use condoms there is no risk?
In New Vision recently it was suggested that a condom fails in 15% of cases. That is a bit pessimistic, but no one even pretends it is 100% effective. I know 4 doctors with children conceived while using condoms, and a sperm is a lot bigger and more difficult to pass on than a virus.

We have a word for couples who use condoms for contraception. We call them parents. The best figures show it reduces risk of transmitting an STD by 10 times. That means 10 times with a condom equals once without. If no one even knows what the percentage of some of these diseases is, yet they know that according to the latest statistics over 9% of adults in Kampala has HIV, then surely the other diseases contracted the same way must also be as prevalent?

We also know the risk of transmission from men to women is a lot higher, up to 10 times higher, than from women to men. It is also obvious that the men most likely to be infected are non-monogamous, non-celibate, sexually active and young. In other words the very ones likely to be interested in you!

Another statistic is that in country A, if the rate of HIV in heterosexual men is 2,000 times higher than your country B, then it is safer to have sex with 200 men without a condom in your country than one man with a condom in country A. So the only sensible advice for short-term visitors especially the ladies is “don’t even think about it”. However if you can’t be that sensible, if you wake up in the morning realizing you have been stupid you must get post exposure prophylaxis as soon as possible.

It may work up to 72 hours later. Taken within 24 hours it is almost guaranteed to prevent HIV. Hep B immunization is also essential and a bunch of other invisible and predictable diseases can be prevented by a single dose of 2 tablets of an antibiotic, so don’t delay while you convince yourself that he is a lovely man with such beautiful eyes and couldn’t possibly ever tell lies about his past sexual history, wise up as they say in Ireland and get some PEP right away.

Summary
There are new drug recommendations for malaria.
Bilharzia can be prevented (and treated in a novel way).
Vitamin tablets may be dangerous.
Antibiotics are once again shown to be unnecessary in most people with coughs.
If you can’t keep your knickers on at least get post exposure prophylaxis for many of the prevalent diseases.
If you want to live a long and healthy life keep up to date!