Roy Jobson
Roy Jobson

Tips on malaria prevention

I’ve recently become aware of two publications about malaria. The first is about preventing malaria in travelling children. The second, about malaria treatment. I’ve also become aware of a product on the market called “Nordman Artemisia Anti-Malaria“.

The article in the South African Family Practice Journal by Dr Sophie Mathijs has the title: “Malaria prevention in travelling children.” It highlights the potentially dire consequence (ie death) of an infection with plasmodium falciparum (the malaria-causing organism) in a child and gives excellent sensible advice on how to prevent this. The concerns are also applicable to adults.

The article from Malaria Journal focuses on malaria treatment in developing countries. The spectre of artemisinin resistance spreading globally is raised, with the possible loss of an effective first-line malaria treatment (as a combination therapy — ie artemisinin in combination with other anti-malarial medications). Although quinine is still used and is effective, it is not recommended for routine first-line treatment in uncomplicated malaria. Artemisinin-combination therapy is recommended. Artemisinin was originally obtained from a herb artemisia annua.

The announcement at UCT of a new single-dose antimalarial agent earlier in 2012, although an exciting discovery, was in some aspects premature. That agent has many years of research and testing ahead before it might become widely available as a treatment — if it indeed passes all the testing.

Artemisinin is not even mentioned in the first article about prevention. This is correct because it should not be used for prevention but reserved only for treatment. As the department of health’s South African guidelines for the prevention of malaria state “artemisinin derivatives are pivotal for the treatment of malaria and so should be strictly protected for this indication and never used (alone or in combination or as herbal or complementary medicines) for the prevention of malaria. This is strongly recommended by the World Health Organisation in order to delay the development of resistance” (emphases added). These guidelines also state “there is no scientific evidence to support use of complementary, alternative and homeopathic preparations for the prevention (or treatment) of malaria”.

Nordman Artemisia Anti-Malaria” contains artemisia afra. It is stated in advertisements in the South African Journal of Natural Medicine that: i) the product can be used for both the prophylaxis (prevention) and treatment of malaria ii) its active ingredient is artemisinin and iii) because it is a herbal remedy and not a “man-made” drug, resistance is unlikely to develop.

Of these claims: i) is not scientifically proven ii) is false iii) is false.

The first statement is based only on “traditional” use. This is not (yet) a criterion accepted in the Medicines Act (The Medicines and Related Substances Act, 1965 (Act 101 of 1965) ) as evidence. In any case, the traditional use mainly involved making a decoction or tea using the herb — not packing “capsules” with a herbal powder!

The second statement was disproven in a 2008 South African Journal of Botany article which reported on testing for the presence of artemisinin in artemisia afra plants as well as in the “Nordman Anti-Malaria Artemisia” capsules — and found none in either. The same tests done at the same time by the same investigators on artemisia annua plants — the usual source of artemisinin — confirmed the presence of artemisinin. (It is perhaps fortunate that, despite the claims made for it, the product does not contain artemisinin so that it does not potentially contribute to both artemisinin-resistance globally and the possible loss of an effective anti-malarial treatment.)

Although journalist Siyammukela Mahlangu does not identify the product or company, she bluntly states ” … the company has been lying and has put people’s lives at stake“. She does refer to the journal, the university department and one of the co-authors by name — and the journal article refers to the company (“Nordman Natural Therapies”) by name — and their “capsules”.

The third statement seems to have emanated from the imagination of the copy writer. It comes perhaps from a failure to understand that the active ingredients of herbal or natural remedies are “chemicals” — as are the active ingredients of “man-made” drugs.

If you’re travelling to some of the malaria-endemic parts of South Africa or to a neighbouring country where malaria is prevalent — make sure you and your children are protected from malaria. Avoid being bitten by mosquitoes through using bed nets, insecticides and insect-repellents, get the most appropriate anti-malaria prevention from your pharmacist and take it correctly and, if you (or your children) get sick with a flu-like illness (especially: high temperature, sweating, chills and muscle aches) after returning — see your health practitioner as soon as possible, and tell them that you were recently in a malaria area.

It is advisable NOT to use Nordman Artemisia Anti-Malaria. The product has not had any independent testing of its quality, safety or efficacy (ie if it works or not) — verified by the Medicines Control Council (MCC) whose responsibility this is. Registered anti-malarials are classified as Schedule 4 substances and would only be available with a prescription and may not be advertised directly to the public. It is astounding that the MCC has allowed the continued availability of Nordman Artemisia Anti-Malaria (and its misrepresentation) to South Africans. People taking it may have a false sense of security that they are protected. The product clearly constitutes a serious public health risk.

Disclaimer: I am writing in my personal capacity. My views are not necessarily a reflection of the views of my employer, Rhodes University, or necessarily the views of the Allied Health Professions Council of South Africa, of which I am a council member.

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    • Momma Cyndi

      Thank you for the information. It is always difficult to judge if products work or not.

      Giving a bit more information about the 4 main types of malaria may be a good idea. I have been told that, if people are going to areas where more than one type is prevalent (or travelling through areas of various types), it is arguably better to invest in a malaria test kit rather than taking the prophylaxis. There is so many contradictory information out there that it sometimes is hard to figure out what is fact and what is myth

    • http://none Lyndall Beddy

      Blacks of Africa had a resistance to malaria, which white Europeans did not have – which is why European explorers who tried to enter central Africa all died before treatment for malaria was found. BUT there were also apparently strong smelling herbs which repelled the mosquitoes used to protect people and cattle, which we still know little about. Like most herbalists they would have found out that the herbs worked but not WHY they worked.

      Even in European culture little was known about germs, viruses and bacteria until recent history. In the 19th century both Florence Nightingale and Dr James Barry had uphill battles trying to prevent infections with fresh air, cleanliness and good nutrition because they could not explain WHY they worked.

      But one of the funniest true stories I read was about an anti malaria campaign in Kenya – which included large posters of blow ups of mosquitoes in all Public Buildings. A few months later when the medical team came back they found that none of the preventative measures were being used. When they asked the locals why not, they replied “You Whites have such BIG mosquitoes, we don’t have your problem – our mosquitoes are VERY small.”

      AND they refused to dip their cattle for the same reason!

    • impedimenta

      Thanks for keeping us informed and for staying vigilant, Roy. Merry Christmas!

    • Roy

      @Momma Cyndi – thanks. My intention was to focus only on the most lethal form of malaria which would have been reflected in the original heading “Killer malaria prevention.” I would not recommend malaria testing kits – especially if you have no guarantee that the kits have been independently validated by a credible body.

      @Lyndall – an interesting story. I spent over a year in Minnesota USA, when an advertising campaign for a casino was on the go. Billboards featured a “giant” mosquito – labelled “African mosquito.” Several Minnesotans we spoke to believed it was true that African mosquitoes were enormous!
      It’s true that people living in an endemic malaria area may develop a partial immunity – which is usually lost when leaving the area. Sickle cell anaemia also has a protective or ameliorating effect.
      I object to people making claims for “traditional” herbs and medicines and repackaging them (or different parts than used traditionally) in modern formulations. The non-traditional reformulation of the herb “kava kava” led to cases of death and liver failure requiring liver transplants. This was one of the reasons why it was declared “undesirable” by the MCC in about 2003.

      @impedimenta – thank you.

    • Roy

      Just received: The World Health Organization’s World Malaria Report 2012. http://bit.ly/U8BXgv

    • Terry Higginson

      Hi Roy

      This is a timeous reminder regarding Malaria prophylaxis and the need to use a medically approved medicine only.

      There is an incredibly pervasive belief amongst the public that standard MCC approved prophylaxis merely masks the malaria instead of preventing it, leading to failed diagnostic blood tests and delays in treatment. Many people feel that the side effect profile of cheap MCC approved doxycyclin and/or mefloquin are severe impediments to taking them. The steep cost of malanil puts them off this safer prophylaxis

      Many going into malaria risk areas for extended periods therefore prefer to take a malaria test kit and Co-artemesan treatment. It’s Russian roulette, you will say, but today’s consumer is well informed and assert their right to choose

      Another puzzling fact, is that the standard mosquito repellents in South Africa contain 12.5% DEET, whereas the top selling Australian repellent brad “Bushman” contains 70% DEET. Surely we’re more at risk than the Aussies?

    • http://kwerekwere.blogspot.com mundundu

      you know, i take a LONG break from these things, and i come on and see some of the same people making the same half-cocked comments.

      [why yes, lyndall, i'm talking about you.]

      yet again, you only half-tell the story. while people in africa had one version of resistance to malaria, the peoples of the mediterranean had a different resistance. while, in sub-saharan africa, being double-recessive for this resistance led to sickle cell disease, in the mediterranean, it leads to thalassemia.

      the spanish explorers in the americas were not falling over dead from malaria — lots of other things, yes, but not from malaria.

      _____

      on a lighter note —

      terry: the reason that south african mosquito repellents can use weaker DEET is that south africa is not as mosquito-friendly as australia. basically the highveld is a mosquito-blocker; its average year-round temperature is not warm enough for malarial mosquitoes to thrive. and most mozzies can’t get break through.

      funnily enough, not having to fight malarial mosquitoes was a major factor in the development of south africa and does not get nearly the credit that it should.

      ____

      roy: it’s good that you say “tell the doctor” if you’ve been in a malarial area. i don’t think south african doctors are trained in tropical diseases [not being tropical, that would make sense]. i returned from brazil with dengue, and if i hadn’t told her i thought it was dengue, the test would have never happened.

    • http://kwerekwere.blogspot.com mundundu

      continuing….

      the portuguese really didn’t explore their bits of africa except to make slavery runs. but no, they weren’t dropping dead from malaria. yellow fever, however, was a different story.

      [and the europeans took yellow fever to the americas on slave ships. so much for "superiority".]

      ______________

      personally, i don’t know why people won’t DEET/DDT the f**k out of their houses for the short and intermediate term, which is the case in urban central america, which is malarial.

      i really wish that DDT usage had been permitted to continue for another decade or so in much of the developing world; its “banning” has been problematic for development.

    • nguni

      Artemisinin is great stuff, hard to get in SA but cheap in countries north of SA. Agree it shouldn’t be used as prophylaxis. I have family in the DRC, South Africans who moved there about 6 years ago. They have all had malaria numerous times and have indeed become more-or-less immune now, especially the kids. So it’s not just blacks that can become immune. I got malaria despite being on Malarone in the Kruger Park, so I’m fairly sceptical regarding conventional pills.

    • Piet Boerie

      Prevention is better than cure especially how strong and for how long you need to take anti-malerials.

      I took tablets, got Malaria. I now never take anti-malaria tablets but I always cover up at night, use nets and sprays, eat healty and not get drunk.

      Never ever again will I trust these makes of these pills.

    • Mack Nyati

      One Jim Humble also professes to heal malaria, and other afflictions, with what he calls ‘MMS’.

      Please go to http://genesis2church.org/mms-protocol-malaria.html for more information…

    • Terry Higginson

      @ mundundu: I dont know why you say we dont need high DEET %tage repellants just because you’re OK up on the high veld. We get considerable flows of tourists to Kruger/Low veld and Mozambique who are all vulnerable to malaria mozzie bites. Tourists to the wild coast area are often eaten alive by pepper ticks from undipped feral cattle. A 70% DEET would beat the only other agent available – Bayticol spray, on toxicity

      Limited DDT spraying under the eaves of huts/dwellings/compounds has been used in Northern KZN with considerable sucess – to the point where malaria is virtually under control there. But there is still the fear stigma attached to DDT

    • Dr Harris Steinman

      @Mack Nyati
      Thanks for reminding us of MMS that has no proof of having any efficacy at all, but furthermore is implausible from a physiological and chemical point of view. Furthermore a number of regulatory authorities have warned the public that adverse effects from MMS are of high risk. A number of relevant articles have been compiled at CamCheck.co.za: http://www.camcheck.co.za/tag/miracle-mineral-solution-mms/

    • Momma Cyndi

      Roy

      Most of the ‘bush pilots’ get their test kits from the Travel Clinic and they seem to be happy with them. The amount of time they are traveling in malaria areas and the large variety of malaria they encounter makes taking the tablets a bit problematic.

      I have also heard that taking a prophylaxis for one type of malaria and contracting a different form of malaria, makes diagnosis difficult – it would be interesting to have a doctor’s opinion on that

    • http://none Lyndall Beddy

      Tick bite fever can be as dangerous for both cattle and people – also called sleeping sickness. Which is why the boere wear heavy boots with socks even in the heat.

    • Noob

      @Lyndall

      ………*eish*
      where to begin?

      Tick bite fever is an imprecise lay term that means different things to different people, and is best avoided so as to avoid muddled confusion (of which your post is an excellent example):
      there are a multitude of tick bourne pathogens that may induce pyrexia

      Tick bite fever in dogs: caused by Babesia canis (ssp Rossi in Subsharan Africa). Sometimes confused with Ehrlichia canis, especially in cases with co-morbidity
      Tick bite fever in cattle: this is not a clinically used term so no idea which organism /disease to which you refer? Babesia bovis,Cowdria, Coxiella, Anaplasmosis, Theileriosis etc. etc.
      Tick bite people in people: Rickettsia conorii , Rickettsia africae

      Sleeping sickness in people: Trypanosoma brucei rhodesiense and T.brucei gambiense. Not tick bourne at all but transmitted by Tsetse flies.
      Boots with long socks (even with comb inserted) will not help :)

      Sleeping sickness in animals (cattle, dogs): various trypanosomes including T. vivax, T. brucei brucei and T. congolense

      ..and none of this has anything to do with malaria.

    • Roy

      @Noob – thanks for providing the correct information concerning sleeping sickness.

      @Momma Cyndi – I accessed the following about rapid tests: http://www.traveldoctor.co.za/downloads/malaria_pamphlet.pdf which clearly states that a *trained* travel companion should do the test; and you also have to carry emergency treatment with you. Also: “not all [tests] are of equal quality” – and in SA there’s really no sure way of knowing which are the best quality. I would still recommend appropriate prophylaxis.

      @Mack Nyati – with warnings from both Health Canada and the FDA not to use MMS, I wouldn’t risk my life. Remember that P. falciparum can be fatal. If MMS is available in South Africa, why haven’t the data for its efficacy been submitted to the MCC as part of an application for registration?

    • Geoff

      Well I wish I’d read this an hour ago, having just spent (and apparently wasted) R280 on a bottlle of Nordman Artemisia capsules.

      Surely something can be done about these bogus pills. Would a complaint to the Advertising Standards Authority help?

    • http://www.geofflouw.com Geoff

      I’ve had a rather interesting time.

      I got my money back & went & bought Coartem (purely as a treatment in case I do get malaria while traveling through Africa), and also complained to Nordman (their response included a charge that Roy Jobson “is joined at the hip to the pharmaceutical industry”, which sounded to me like an allegation that he gets paid to slander the herbal products industry, although having read some of his other articles, I find this hard to believe).

      I’ve been reading some stuff on the internet, and cannot find any info that Artemisia afra contains artemisinin (also some info that artemisinin can’t be used as a preventative measure because it only stays in the system for a short time). So unless Nordman has test results that prove otherwise, it would appear that the claim on their label that their product contains artemisinin is incorrect.

      The funny thing is that a few articles I read (which appeared to be credible) claim that Artemisia afra does in fact have anti-malarial properties…but not due to artemisinin. It contains a completely different substance (or combination of substances) that do the trick. So I might end up buying some of the stuff again.

      And if it doesn’t work, then there’s always the Coartem.

    • Roy Jobson

      It’s nearly a year since I first wrote this blog and the MCC has now declared Nordman Artemisia Anti-Malaria an undesirable medicine. (Government Notice 916, Government Gazette 37075, 27 November 2013.)

      It states, “[t]he Medicines Control Council . . . is of the opinion that it is not in the public interest that Nordman Artemisia Anti-Malaria Capsule . . . be made available to the public, and has declared this medicine undesirable.

      “The Council further directs any person who-has in his or her possession any quantity of Nordman Artemisia Anti-Malaria Capsule to return them to the manufacturer thereof or to the importer concerned.

      “In terms of the provision of Section 23(3) no person shall sell any medicines that have been declared undesirable.”

      What this means is that Nordman Artemisa Anti-Malaria has been “banned” by the MCC.

    • Pro African Remedies

      Rob your knowledge and understanding of the latest scientific malaria research is abysmally lacking despite being a professor of pharmacology!
      Nordman’s Anti-malarial Artemisia is a traditional African remedy. Bart Knol in Malaria World, October 22, 2012, the world’s scientific network for malaria professionals comes to the conclusion that ” Artemisia herbal remedy is polytherapy. Not only efficient in therapy but also in prevention and because of its multiple active constituents unlikely to lead to resistance.” Researchers of the University of Massachusetts showed that the artemisa plant was 40 times more effective than the synthetic drug which has usurped the name of the main ingredient Artesiminin” of the herbal remedy causing confusion even in scientific minds! The researchers reached the conclusion that,”the plant is clinically efficacious, well tolerated and compatible with the public health imperative of forestalling evolution of resistance.” Peter Odwang’s (Uganda) double blind trials over a period of 15 years support it. The Registrar of Medicine has acted ulta vires by making the sale of Nordman’s Anti-malarial undesirable both in terms of the Medicines and Related Substances Act 101 which gives her no legal authority over Traditional African Medicine; she has also contravened the South African Constitution sections 33(1) and (2) which requires her action to be reasonable, lawful and procedurally fair and to supply written reason for such action (not…

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