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. ---------------------------------------------------------------------------- To unsubscribe/subscribe or view archives of postings, go to the Gambia-L Web interface at: http://maelstrom.stjohns.edu/archives/gambia-l.html ----------------------------------------------------------------------------