G6PD anti-malaria regimen: Who should be screened?

G6PD anti-malaria regimen: Who should be screened?

By Foday Felix Sesay, Woodbridge, Virginia, USA*

A few years ago, a friend, who graduated with a Bachelor of Science in Nursing (with honors), was admitted at Inova Alexandria Hospital in Virginia, battling malaria. His admission came about, after a short visit to Freetown, Sierra Leone.

Two days after his arrival in Alexandria, Virginia, my friend (name withheld for confidentiality reasons), who was about to start a career in nursing, experienced symptoms that were consistent with malaria. Concerned about his health, my friend checked himself at Inova Alexandria. At the hospital, my friend gave a short history of his travel. A malaria smear was done, and the result was found to be consistent with Plasmodium (the malaria parasite). My friend was admitted, and started on quinine sulfate, along with doxycycline anti-malaria regimen. Two days during treatment with the above anti-malaria regimen, my friend developed an alarmingly high oral temperature. “Who would develop such an elevated temperature after two days of treatment with anti-malaria medication?” Dr. Imindra Rana (who was the Internal Medicine Doctor on call) asked. Laboratories were ordered, and the result came back with a presentation of severely destroyed (lysed) red blood cells.

Anticipating a medical emergency, wherein the realization of a definite action must not be delayed, Dr. Rana said his medical intuition translated into a laboratory test for G6PD, and my friend was found to be markedly deficient, (full blown G6PD), as Dr. Rana puts it. He immediately discontinued my friend’s medication regimen: quinine sulfate along with doxycycline. A G6PD receptive anti-malaria regimen, Mefloquine and Clindamycin, quickly replaced quinine sulfate and doxycycline. Following protocol, Dr. Rana also alerted the interdisciplinary treatment team about his findings on my friend. In fact, the first person to break the news about G6PD to my friend was a dietician, who told my friend not to eat fava beans and ingest sulfur medication.

A university of Ghana student at Legon (my alma mater), Verma Marie Anan (photo), was not so lucky. Her G6PD deficient status was not known or detected prior to and during her anti-malaria treatment in Ghana. Unfortunately, she died from the complications of G6PD deficiency. According to Hon Daniel Dugan, Medical Negligence or Fate (2015), the 23-years-old graduate was allegedly given an injection of a yet to be disclosed anti-malaria drug. She was then put on Cotem, a very powerful anti-malaria tablet. Allegations are being leveled against two prominent hospitals; Bob Freeman Clinic and Korle Bu Teaching Hospital for being negligent which resulted in her death (Dugan).

G6PD can also rear its menace when exposed to certain foods. A highly educated Sierra Leonean couple flew from Atlanta, Georgia, with their six-year old son, their only child, on vacation to Hawaii. The visit was uneventful until they ate at a well-known Chinese restaurant for lunch. According to the mother, they ate Chinese food with lots of beans, legumes and soy sauce. About 30 minutes after the feast, their energetic son presented with weakness that was progressing by the hour; as the weakness was accompanied with elevated oral temperature, the distraught couple rushed their son to the nearest urgent care center, where he was stabilized, the mother says. A medical investigation ruled out food poisoning and they took their son to a children’s hospital the next day, where the mother (who at the time was suspecting Chinese food as the cause of the son’s sudden illness) painstakingly enumerated the condiment that was in the Chinese food. The mention of soy sauce drew the attention of a female doctor of Somalian descent who suspected the elusive G6PD, ordered laboratory tests, which came out positive. The couple’s son was G6PD positive. The diagnosis of G6PD finally put to rest the mother’s concern of her son’s yellowing of eyes (a G6PD presentation), as batteries of lab test had ruled out jaundice, malaria and compromised liver, etc. This goes to buttress Dr. Rana’s statement that G6PD is an under-reported genetic condition. The couple is now educated about selective diet and medication for their son as a result of his G6PD status.

Dr. Imindra Rana

What Is G6PD?

Glucose 6–Phosphate Dehydrogenase Deficiency is a genetic condition in which a person’s red blood cells easily succumb to destruction when exposed to certain foods, medication or stress of infection. It is a hereditary condition which manifests in families. The red blood cells destruction can be ignited by infections, severe stress, certain foods such as fava beans, soy sauce, and certain drugs like standard anti-malaria, aspirin, nitrofurantoin, none-steroidal anti-inflammatory drugs (NSAID), quinidine and sulfa sulfur drugs (Hon Daniel Hagan, Medical Negligence or Fate, 2015). G6PD is common in blacks and it is speculated that 20% of Ghanaians have the condition. Symptoms may include dark urine, enlarged spleen, fatigue, pallor, rapid heart rate, shortness of breath and yellow skin color (jaundice).

G6PD is mainly found in areas where malaria is or has been endemic and can cause great problems especially in malaria treatment (G6PD and Malaria, Peters & Van Noorden, 2009). For example, Dapsone, used in amalgamation therapy for the treatment of Plasmodium Falciparum (World Health Organization 2006), and primaquine, used to eliminate the hymozoite reservoir of Plasmodium vivax and Plasmodium ovale, can induce serious hemolytic events (World Health Organization, 2006, 2008; Fanello et al 2008). Treatment for one of these drugs should be preceded by screening for G6PD deficiency to prevent hemolytic anemia. Therefore, an inexpensive test should be made available in countries where malaria is endemic to determine the deficiency reliably, including its heterozygous form. However, such a test is not yet available (Peter & Van Noorden, 2009). Cognizance about the cost of screening or genetic testing for G6PD, this writer placed a call to a sunrise laboratory office in Virginia, USA, where a spokesman revealed that the cost of a G6PD lab test, with health insurance, is 57.00 US dollars per person, and without health insurance, is 40.00 US dollars.

In recognition of the World Health Organization’s universal goal of health for all in the 21st century, I am appealing to WHO and the United Nations to make available G6PD screening to all individuals seeking malaria treatment in heavily malaria-infected countries. As Wickramansinghe and Abdalla (2000) put it: When severe G6PD deficiency complicates malaria infections, treatment with primaquine or dapsone can lead to life-threatening acute intravascular hemolysis followed by anemia and acute renal failure. However, an antidote to unscreened G6PD individuals seeking malaria treatment, in my opinion, is to provide awareness of G6PD to medical providers, and flood hospitals (if it is cost effective) with G6PD receptive or friendly anti-malaria drugs like mefloquine and clindamycin, that cured my G6PD deficient friend in Virginia, United States. Although the ideal situation is to screen for G6PD that will provide the advantage of knowing selective anti-malaria meds and diet, mefloquine has the advantage of curing malaria, to deficient G69D individuals who may not know they have the condition; this will help save lives. Thanks to Dr. Rana’s quick medical thinking to screen for G6PD to my friend, who was experiencing a life-threatening acute intravascular hemolysis due to the complication of G6PD and anti-malaria regimen. The late Verma Marie Anan was never screened until after her demise. May her soul rest in peace.

Conclusion
In 2017 Malaria deaths worldwide reached 430,000; and according to the latest WHO data, malaria deaths in Sierra Leone reached 7,134 or 8.73 percentage of total deaths (WHO, 2017). This writer did not see any data on malaria deaths due to G6PD complication. That 20% of Ghanaians are G6PD deficient is telling on a West African belt that has a high incidence of malaria infection.

Dr. Brima Kargbo

This writer is not aware of any mutation on the biological material of the malaria parasite that renders it more virulent and lethal. Compatriots that are unaware of being G6PD deficient and are seeking malaria treatment in hospitals should not die or suffer from the complication of G6PD. Had my friend and Verma Marie Anan knew they were G6PD deficient, they would not have suffered or died from the complication of G6PD respectively. I am therefore making a moral appeal to the World Health Organization and United Nation, to disseminate education on G6PD, provide screening for G6PD before an anti-malaria treatment, and ensure the availability of G6PD receptive anti-malaria drugs like mefloquine and clindamycin in heavily malaria infested countries.

End Notes
This article is dedicated to Sierra Leone’s Chief Medical Officer, Dr. Brima Kargbo for dedicated service to his country; Dr. Kargbo’s consistent leadership during the unprecedented lethal and virulent Ebola virus in 2014 is now for the history books.

*The author, Felix Foday Sesay, is a board-certified Registered Nurse (Psychiatry) and holds a master’s degree in Public Health from American Public University (USA).