Published in FOROYAA of 24-27 May, 1999
INTERVIEW WITH DR JAWLA, HEAD OF MALARIA CONTROL, ON THE TREATMENT AND
PREVENTION OF MALARIA IN THE GAMBIA
FOROYAA: Dr Jawla, it is the opinion of a lot of people that malaria is a
major killer in The Gambia. What is your opinion?
DR JAWLA: Yes, it is true that malaria is a main killer disease of children
under 5 years in The Gambia, and that is why the control method is very
important for the Department of State for Health.
FOROYAA: Can you give an estimate of the number of people killed annually by
malaria?
DR JAWLA: Perhaps it is difficult to give you clear-cut figures but returns
from Royal Victoria Hospital, Bansang Hospital and the major health centres
indicate that of all the killer diseases under 5, malaria may take off
under 15+ACU- to 20+ACU-.
FOROYAA: Many opinions exist over the standard cure for the disease. So what
is the standard cure for malaria?
DR JAWLA: Yes, the government has come up with a standard treatment manual
which is there and it is for all the treatment points and we encourage even
the private practitioners to use this, and the village health workers have
been taught to use it. So there is, but here and there some people do their
own things and some mess themselves up but of course there is a standard
treatment.
FOROYAA: Can you briefly tell us what the standard is?
DR JAWLA: For simple or non-complicated malaria at the health facility
level, whether it is a hospital, health centre or at the village health
worker, chloroquine is the first line of treatment+ADs- and for adults, ten
tablets of chloroquine is the standard treatment. On the first day you take
four tablets and each day you take two for three days. That is the standard
normal treatment manual country wide. The village health workers also know
it.
At the village level, we told the village health worker to give full
treatment cost not individual doses. For example, some people come to the
village health worker and say: sell two chloroquine tablets to me and
sometimes it is given to them but that is not proper.
What is proper is that a treatment dose of 10 tablets costs 75 bututs at the
village level. If you go to the health facility level, whether it is a
dispensary, health centre or hospital, you pay five dalasis and they
prescribe for you. Four tablets on the first day, two tablets each day for
three days, with some pain killers, of course, such as paracetamol or
aspirin. That is the standard.
FOROYAA: Did you establish the basis for importation of the drug so that
there will be enough drugs available in the health centres, hospitals, etc.
because some people do say they go to the health centre, pay five dalasi and
then told to go to buy drugs. So they then go to the primary pharmacies and
whatever they can afford is what they buy which can be an under dose. So is
there any plan to make sure that there is enough drugs stocked for the
malaria disease?
DR JAWLA: The treatment at the health facilities in The Gambia is
consultation and prescription. When you pay five dalasis, you are not only
paying for medication, but also that of consultation+ADs- that means even if a
doctor sees you, examines you and establishes a diagnosis for malaria, they
can prescribe for you. It should be available but in the event that it is
not available, you are advised to go to a private sector and buy it there.
So you should pay exactly what has been prescribed for you.
The amount of drugs imported depends on the consumption pattern from the
previous years. What is the consumption pattern on monthly basis and for the
malaria season and when the drugs come they also supply the health
facilities. If there is none at the health facilities, they should be able
to requisite this from their regional stores. Here and there, there may not
be shortage at the central store, but it is the transportation from one
facility to another that causes problems. So that's what the people should
pay more particular attention to.
FOROYAA: Do you know the quantity and price of the malaria drug that is
imported into the country, and how it is sold in local pharmacies?
DR JAWLA: I can only speak for the Department of Health. I would start from
the village level. A village health worker in a particular village will go
to a CHN (Community Health Nurse). The CHN will do requisition for the
Village Health Worker (VHW) and the VHWs go to their respective divisional
health teams.
For those in URD, it is Basse+ADs- in CRD, it is Bansang+ADs- LRD, it is Mansakonko,
etc. When they go to the divisional health store, the village health worker
will buy one tin of chloroquine which contains 1000 tablets for D27.30 and
then goes and retails this at the village level.
If the VHW buys a tin of chloroquine for D27.30 containing 1000 tablets, he
or she is supposed to give tablets to adults and a dose for an adult is 10
tablets. So there are 100 doses ion 1000 tablets and he or she sells a dose
for 75 bututs which means he or she gets a profit of about 45 dalasis and
that goes to a village health coffer and it can be recycled for the
revolving loan.
At the health facility level, the health facilities have their consumption
pattern. They know how much chloroquine they use on monthly basis during the
peak period of malaria and also off the peak period, so that their
requisitioning would be based on the need of the health facility. As soon as
the stock level is getting low, they will have to go and requisition again.
So this cycle of requisitioning is every two months, but if their supply is
very low they also have the opportunity of making supplementary order and
they get it.
FOROYAA: What about places where there is this Bamako Initiative?
DR JAWLA: They operate on cash and carry. They buy what they need. So the
shortage at the divisional level may not be. It depends on how regular the
village health workers come to the health facilities and how regular the
health facilities come to the divisional stores and how regular the
divisional stores come to replenish at the main store in Banjul.
As to the amount of anti-malaria drugs that come into the country per year
and the cost of it all, the Chief Pharmacist is in a position to tell you
that. The accountant can also tell you in the previous years how much they
ordered, and how much money is allocated to them and how much is brought
into the country.
But as far as our control programme is concerned, the accountant has send it
a request in the million of dalasis to be able to address our needs. It is
left to the decision makers to review the request. The amount of drugs
needed to supplement what we already have in our stores is as follows:
1. Chloroquine tablets - 150 milligram base in a tin of 1000 tablets, we
need 18,000 tablets and that cost D159, 239.50
2. Chloroquine syrup: 1 litre containers, we need 27,600 litres which cost
D513,665.20.
3. Chloroquine injection, 40 mg, we need 660,000 viles which cost D401,415.
4. Quinine: 26,000 doses which cost D48,231.59.
5. Quinine tablets - 1000 tablets per tin, we need 1500 tins which cost
D578,224.35
6. Fansider - 1000 tablets per tin, we need 1600 tins which cost
D418,964.32.
Total cost is D3,630,650.06. These medications together with preventive
measures and community awareness will go a long way to combatting malaria in
The Gambia.
FOROYAA: Before we go further, let us clear one point first. For example,
you have said that the full dose for an adult is ten chloroquine tablets.
Let us assume that you have taken 10 tablets, but you still feel that you
are not well, you still feel feverish, etc. etc., what do you do next?
DR JAWLA: Okay, you go back and report to your doctor and tell him or her
that you still feel bad, but you had some anti-malaria 10 tablets but still
your symptoms persist. In this case, they may want to do some blood test to
confirm whether you really have malaria or not. If they still feel that you
have malaria and the ten tablets are not useful to you, they can now go to a
second line treatment+ADs- either may be you vomit the tablets and therefore the
tablets are not receptive+ADs- they can now put you on the chloroquine injection
or they can give you quinine when the need arises. That is the prerogative
of the doctor to decide what other treatment you now have to take, after
following thorough investigation, both clinically and at the lab. In this
case, some people will take fansider which is considered in The Gambia as a
second line treatment. Three tablets of fansider is the adult dose.
For the kids, you have to weigh them and give them fansider.
FOROYAA: What about prevention? Do you have any preventive measures for this
illness?
DR JAWLA: Yes, this is very important. We have been telling people what to
do to help themselves, to avoid being bitten by mosquitoes, not to expose
themselves, but apart from that we also have a programme called Bednet
Dipping. The bednet dipping helps the individual to be protected from
mosquito bites. They buy the insecticides called Parmitrine or Peritrine,
dip their nets into these insecticide solutions, first by washing their nets
then dip them and hang them, usually over their beds. This is supposed to
last for at least six months duration to be protected from mosquito bites.
But it does not mean that if you dip your nets, you should go and sit
outside for three hours chatting, because some people come and say we have
dipped our nets and yet we have malaria. Perhaps due to the heat some people
cannot sit inside their houses and they sit outside and get bitten by
mosquitoes.
One can also buy repellents and put on long sleeve shirts, use fan outside,
clear you environment to prevent oneself from being bitten by mosquitoes.
All these are control methods.
So what the Control Unit of the Department of State is trying to do is to
enlighten people. It is good that you come in time because all the
divisions countrywide, we are now trying to gather all the village health
workers in The Gambia to train them as to how to document properly incidence
of malaria and the cases so that they know fully well how this goes on.
FOROYAA: What about the side effects? Is there any side effect for these
insecticides because you know children are around and anything is possible?
What advice can you give to insecticide users?
DR JAWLA: As far as we know, scientifically the insecticide is very safe,
provided that they follow the instructions carefully that children do not
come near the insecticide, the adults dip their bednets, wash their hands
thoroughly, and it is very safe. If there is any left over solution that
should be kept away from the children.
Throughout my practice in the provinces, I only had one incidence when a
child had parmitrine and got sick, but since that I have not heard of any
incidence as such. Some people, due to the concentration, said the odour is
irritable, but if the right concentration is used, the right amount, I think
it is very safe.
FOROYAA: And what is the measurement?
DR JAWLA: We have a measure cup, which is 80 millilitres of the insecticide
to be put in one litre of water and put in a container and dip your bednet
in it and the bednet nearly soaks all the water. So you do not have to
squeeze the bednet+ADs- you just hang it and during this six months any
mosquito, any fly, cockroaches, lice, bedbugs, etc. will be killed. So it is
very useful really.
FOROYAA: Are there people who resist chloroquine in The Gambia?
DR JAWLA: We have done a recent study in The Gambia, in Basse and Mansakonko
and I was privileged to be one of the principal investigators myself and one
realised that chloroquine resistance is not a big problem in The Gambia.
Majority of the people when they are sick and they have malaria, chloroquine
can treat them if they take a proper dose. So the resistance is not a
problem in The Gambia. If you do not take a proper dose, you do not knock
all the parasites from your body and therefore you can have a recurrent
attack, or if you are bitten again by an infected mosquito.
FOROYAA: Is there any vaccine for it?
DR JAWLA: There are trials in other parts of the world and the success rate
is still a problem, but we are very close to getting a vaccine. For the time
being there is no effective vaccine against malaria.
FOROYAA: Finally, what advice would you give to the Gambian public
generally?
DR JAWLA: Well, we are fast approaching the malaria season, that is, the
rainy season, but of course we know that in some areas throughout the year
mosquitoes are around and so whether it is seasonal or not they should take
protective means to avoid being bitten by a mosquito. They should avoid
exposing themselves too much to mosquito bites. They can buy mosquito nets,
dip them in insecticides, use repellents in addition to the net. When this
is done, children and pregnant mothers, who are most vulnerable, would be
saved from most of these nausea caused by malaria.
So my advice is that the insecticide is available in all the divisions, the
divisional health teams country wide will have it. We have made a
distribution plan and by the end of June, all the divisional health stores
will have it. They will also pass it to all the health facilities in their
areas. The health facilities will also pass it to their primary health care
and non primary health care settlements and anyone who wishes to have
insecticide can be able to have it, and in villages where there is no
village health worker, one can get it from the alkalos. The treatment dose
from the VHM is 75 bututs. The chloroquine syrup for children's dose is also
available at the village health worker, but the most important thing is they
must clean their environment, get rid of the stagnant waters, the pots,
outer cover, tyres, etc. to stop the mosquito breeding in their
environments. That will help them a lot.
FOROYAA: Thank you very much, Dr Jawla.
DR JAWLA: It's a pleasure. Thank you.
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