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| Summer Series Part II - Other Infectious Diseases for the Caregiver and Lifesaver |
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by Bob Blumm, MA, PA-C, DFAAPA - July 25, 2011
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I have slight glimpses of memory as an 18 year old in the central highlands of Vietnam where I was stationed at a base near Dragon Mountain. I was doing temporary duty until my assignment came through. I was a medic; this was before PAs existed and, in this situation, I was responsible for a Quonset hut hospital unit of medical patients who were soldiers of the 4th Infantry Division. These soldiers were sick from the same disease, malaria. Some were running fevers, some needed alcohol bed baths along with IV hydration and medication. Some were very sick, some died and all were not able to be on full duty. I was a neophyte, a rube, totally without much understanding of the disease yet, as I was just in country. But my MOS (military occupational specialty) proscribed that I handle all things medical. It reminds me of today where regardless of the clinician, from doctor to nurse and all between, we assume he or she is able to function in all aspects of medicine, whereas some cannot even start an IV. Medicine has not changed; neither have assumptions. A wise King Solomon said that “there is nothing new under the sun.”
This was a good introduction for me in observing this disease because I spent some of my time with patients, some of my time in the laboratory. It was in the later place that I had the opportunity to see this disease on thin and thick blood smears under a microscope and I discovered that most of our patients had P. Falciparum type malaria. Today, almost 45% of the world’s population lives in areas where this disease is common and easily transmitted ---primarily in South and Central America, Southeast Asia and Africa. In 2010, there were over 300 million reported infections and 1.6 million deaths. The victims are inhabitants of the demographical zone, volunteer medical workers during and after severe storms, missionaries and their families, and military personnel from the country of origin and sometimes from those that are present to lend support, as the USA did in Haiti.
Malaria is transmitted by the bite of an infected Anopheles female mosquito; it is rarely transmitted through IV drug use, blood transfusions and organ transplantation as well as by prenatal transmission. This disease in humans is caused by four protozoan species of the genus Plasmodium. Many of my soldiers seemed to have the more deadly P. Falciparum, which is really endemic in the sub-Sahara, but in the mid 1960’s was rampant in Southeast Asia. Almost all of these soldiers had been in contact within the past month. This in spite of the plastic bottle of insect repellant that we wore in a band on our helmets and the mosquito netting that sometimes became too cumbersome to carry and was easily replaced by additional food or two ammo clips. Non-compliance definitely adds to the proliferation of medical illness.
Malaria in the United States has almost been eradicated, but the recent weather conditions along with humidity may possibly change a statistic that has been prevalent for the past few years. Although malaria had been eradicated since the 1950’s, seemingly, first and second generation immigrants who return to their endemic areas and then relocate in the US are the greatest of the number that has been reported (1500 patients.) Recent examinations of the literature reveal that 89% of the deaths from malaria are from Africa. Malaria is the fifth leading cause of death from infectious disease worldwide after respiratory infections, and HIV/AIDS, diarrheal illnesses and TB. Among the malaria species that infect humans, and are present in the United States and thought to have been eliminated, there are Anophles quadrimaculatus in the east, An. Freeborni in the west, and An. albimaus in the Caribbean and are still widely prevalent: thus there is a constant risk that malaria could be reintroduced to the United States which is why I initially wrote the article “Bugs Beyond Borders.”
The signs and symptoms of malaria are just as confusing as other illnesses, which is why our programs focus on differential diagnosis. You cannot diagnosis or treat a disease of which you are ignorant and are not considering in your differential. Malaria presents with a flu-like set of symptoms: fever, myalgia, headache, shaking, chills, malaise, cough, nausea and vomiting. The complications of P. Falciparum include cerebral edema and encephalopathy, as well as hypoglycemia in children.
Malaria has been known to exist for the past four thousand years and the word comes from the Italian for “bad air.”The CDC feels that it has had its effect on human civilization throughout the centuries just as the plague and other highly infectious diseases. The symptoms of malaria were described in early Chinese writings and in 2700 BC, several characteristic symptoms of what would later be called malaria were written in the Nei Ching, edited by Emperor Huang Ti. It was recognized by the Greeks in 4000BC, Hippocrates noted many of its symptoms and, by the age of Pericles, in the Sustra, a Sanskrit medical treatise, and the symptoms of malarial fever were described and attributed to the bites of certain insects. A number of Roman writers attributed it to the swamps.
There have been four Nobel prizes that have been awarded to men for their personal work in the epidemiology and treatment of this disease. There remain the few drugs that are responsible for treating this and, in many cases, malaria can be treated by oral quinine and, in some cases an antibiotic has been added for fourteen days. Quinine was discovered by the Jesuit missionaries living among the indigenous Indian tribes as early as the 17th century. With this bark, the Countess of Chinch’on, the wife of the Viceroy of Peru, was cured of her fever. The bark from the tree was then called Peruvian bark and the tree was named Cinchona after the Countess. The bark from the tree is now known as the antimalarial, quinine. Along with artemisinins, quinine is the most effective malarial drug available today.
Of great interest to us as a profession, it was the USPHS (U.S. Public Health Service) during the military occupation of Cuba and the construction of the Panama Canal in the early 20th century who made great strides on Malaria and Yellow Fever and their diligence enabled military trainees to function and train in malarious regions of the southern United States. It remains the responsibility of the United States to do all within its power to prepare all US citizens who are planning to travel to these areas and, who in the cases of emergency, oversee the preparations of those that volunteer and place themselves in harm’s way to help humanity abroad. I am proud that PAs and NPs, along with all of our nurses and volunteer physicians consider this a moral responsibility and make the necessary sacrifices.
Much of the information supplied has been made available by going to the CDC website on June 29, 2011 to gather current statistics and to gather history to reinforce this article.
Robert M. Blumm has received national recognition as a distinguished fellow of the American Academy of Physician Assistants (AAPA). He is the past president of the Association of Plastic Surgery Physician Assistants, and was past-president of the American Association of Surgical Physician Assistants, past president of the American College of Clinicians and NYSSPA, as well as Chairman of the Surgical Congress of the AAPA. In addition, Bob received the John Kirklin MD Award for Professional Excellence from the American Association of Surgical Physician Assistants. Along with his associate, Dr. Acker, Bob was the first recipient of the AAPA PAragon Physician-PA Partnership Award. He has been a contributing author of three textbooks, written 150 plus articles and is a sought out conference speaker throughout the United States.
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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