Malaria danger faces returning emigrants

THE BUMPS on Eric Yao’s skin didn’t bode well and he remembers thinking, “Oh boy, I’m in trouble.”

The Dublin-based community worker had awoken at his family home in Accra, Ghana, to a nasty surprise. Those bumps had been caused by bites from malaria-spreading mosquitoes, and symptoms of the potentially fatal illness arose within days. Yao had neglected his usual malaria-prevention measures, having rushed to Ghana due to a relative’s ill health.

“It’s like flu, but it’s worse,” shudders Yao, who is co-ordinator of the Africa Centre in Dublin. “Your joints are aching, you’re throwing up, you have no appetite, you just can’t taste any food . . .” He felt “feverish” in stifling heat, and promptly got treatment which resolved the illness.

Yao’s trips to Ghana are normally well planned and he adopts prevention methods such as starting on malaria prophylaxis before travel and continuing as prescribed. “If I don’t take them, I know I’m taking a risk myself,” says Yao. “My system is no longer used to things down there.”

This isn’t just his gut instinct talking. The partial immunity to malaria acquired by people raised in endemic regions declines after their emigration to non-endemic countries such as Ireland, while their offspring are generally as susceptible as white Irish children.

But, according to Yao, these facts are little known among immigrants from Africa, the continent where most of the annual 250 million malaria cases arise.

He says “malaria is malaria” to many of Ireland’s African population – which he estimates at 60,000 – and few know of the heightened risk since emigrating or the vulnerability of their children.

This assessment is borne out in statistics from the Health Protection Surveillance Centre (HPSC), a HSE body responsible for surveillance, research and information provision on infectious diseases.

A paper it published in September 2010, Burden of Imported Malaria in Ireland,found that from 2001 to the end of 2009 most malaria notifications concerned Africans who had travelled to native countries to visit family (the illness is contracted when visiting malarious regions and is not contagious).

The report noted a sharp rise in notifications, “such that now there are on average 77 cases notified per annum as opposed to 20 cases per annum in the early noughties”. About one-quarter of notifications involved children, while hospital discharge stats suggested that annual incidences outnumbered overall notifications

It remains a live issue. There were a provisional 82 cases last year (down from 90 in 2009) and the dangers for affected people are very real, as illustrated by a tragic case in March last year when a Nigerian woman died from severe malaria.

She had returned to Ireland after suffering a miscarriage while visiting Nigeria and reportedly had decided against taking malaria prophylaxis due to her pregnancy. A diagnosis came too late to save her life.

Yemisi Ojo of Integration of African Children in Ireland underlines Yao’s assessment: Africans are aware of the possibility of contracting malaria but not the level of that risk.

“The awareness, the understanding, is not there at all,” she says. Ojo says that in this context, some bigger African families may feel that medication costs – which vary according to product and length of holiday – are not worth it.

African immigrants who take preventative medication tend to be particularly cautious about health, such as social care practitioner Albert Odoemene from Nigeria. “If I see anyone going home, I always tell them, ‘Go and see your GP’,” says the Dublin father of four.

Dr Paul McKeown, specialist in public health medicine at the HPSC, says the two key messages for immigrant and Irish travellers are to take preventative medication as prescribed; and implement steps to prevent mosquito exposure, such as using insect repellent containing Deet, which a pharmacist can advise on, covering up after sunset and sleeping under a mosquito net treated with insecticide.

He says there is no way immigrants can assess their waning immunity, which drops sharply following emigration.

Pregnant women are especially vulnerable – as are young children – and should plan any visit to a malarious region “in conjunction with their doctor”. There are “very safe” medications which can be taken in pregnancy, he adds.

The HPSC has engaged with clinicians to increase awareness of malaria, and in late 2010 it published leaflets and posters aimed at immigrants attending GP clinics and hospitals.

“Visiting family in Africa? Malaria can kill”, is the poster’s stark message. These resources are available at hpsc.ie.

But community advocates believe that more direct engagement is also necessary. As Yao identifies, a major information gateway to the African communities is through their influential pastors, imams and community leaders, as was noted in the HPSC’s report.

Yao says the Africa Centre has established an African Health Initiative, and obtained a “small grant” from the HSE this year to organise seminars on health issues. He believes health authorities need to better utilise African organisations and religious centres to deliver key messages.

“Information getting out there is not that difficult, it’s just a matter of us linking in with the HSE properly and ending that divide of them being ‘here’ and other people being ‘there’,” says Yao.

“‘You send us your grant application and we’ll look at it’ – I think it’s about time people began to move beyond that because within the HSE there has to be a face to a name, and the have to be able to sit down and listen to us and say, ‘Okay, this is the way they think’.”

Malaria: Responsible for 800,000 deaths worldwise every year

Malaria is caused by plasmodium parasites spread to people through bites from infected anopheles mosquitoes known as “malaria vectors” which usually bite between dusk and dawn.

It is most prevalent in Africa, but can also be contracted in the Indian subcontinent, southeast Asia, Central and South America, Hispaniola (Haiti and the Dominican Republic), the Middle East and Pacific Islands.

There are four types of the disease, of which falciparum malaria is the most deadly. It is especially common in sub-Saharan Africa and is responsible for the majority of the approximate 800,000 annual global deaths, most of them children.

Symptoms of malaria can include fever, headache and vomiting, and usually appear between 10 and 15 days after being bitten, although it can stay inactive for months before surfacing. In the case of falciparum malaria, it can quickly become life-threatening, and prompt medical assistance is vital.

Significant gains have been made in the strategic global fight against malaria, and some 43 countries – including 11 in Africa – have halved deaths in the past decade. But key issues remain, including malaria parasite resistance to drug treatments and the lack of an effective vaccine.

Later this year, a vaccine study by the Royal College of Surgeons in Ireland (RCSI) and University of Oxford will commence at the RCSI Clinical Research Centre at Dublin’s Beaumont Hospital.

Funded by the European Vaccine Initiative, the trial is based on new “viral vector” technology and aims to generate broad immunity against a key surface molecule of the parasite, the circumsporozoite protein.

“An effective malaria vaccine would be one of the best ways to prevent the hundreds of thousands of childhood deaths from malaria,” says trial supervisor Prof Sam McConkey of the RCSI.