Child Healthcare addresses all the common and important clinical problems in children, including:immunisation history and examination growth and nutrition acute and chronic infections parasites skin conditions difficulties in the home and society.

1. 11
Parasites
Children with AIDS may be infected with
Objectives unusual parasites not normally seen in healthy
children (e.g. Toxoplasmosis).
When you have completed this unit you
should be able to: 11-2 Which are the common intestinal
• Diagnose and manage children with parasites?
intestinal worms. In Southern Africa the common intestinal
• Diagnose and treat giardiasis. parasites are:
• Diagnose and treat amoebiasis.
• Diagnose and treat bilharzia. • Roundworms
• Diagnose and manage children with • Whipworms
malaria. • Pinworms
• Hookworms
• Giardia
INTRODUCTION •
•
Tapeworms
Amoebae
11-1 What are parasites?
ROUNDWORMS
These are small creatures (animals) which
invade and infect (infest) the body. They may
be either: 11-3 What is a roundworm?
• External parasites which live on or in the Roundworms are the most common parasites
skin, e.g. scabies and sandworms. found in the gut of children. The worms are
• Internal parasites which live in the body. pink and smooth and measure about 25 cm
Many internal parasites live in the bowel long. They look like pale garden earth worms.
(i.e. intestinal parasites such as worms).
Other parasites live in the blood (e.g. Roundworms produce thousands of eggs a day
malaria) or other organs such as the which are passed in the child’s stool (faeces).
bladder wall (e.g. bilharzia). The eggs have a very characteristic shape and
can be easily recognised if a sample of stool is
examined under a microscope.

2. PARASITES 183
Roundworms are common in children (undernutrition). Roundworms also
between the ages of 1 and 5 years. decrease the child’s appetite.
• A large bunch (bolus) of worms can cause
colic (cramping abdominal pain) and even
Roundworms are the most common bowel total small bowel obstruction. The mass
parasite in many poor countries. of worms may be palpable on abdominal
examination.
NOTE The roundworm is Ascaris lumbricoides. • Migrating worms can get stuck in the bile
Infection with roundworms is called ascariasis. duct, resulting in acute, severe pain over
the liver (biliary colic).
11-4 How do children get roundworms?
NOTE Roundworms can also cause bowel
If human faeces are not disposed of in a perforation, volvulus, intussusception, colangitis
hygienic way, or if sewerage sludge is used as and pancreatic duct obstruction. With heavy
a garden fertiliser, children can swallow and infections, bunches of roundworms can be
get infected by roundworm eggs. Roundworm seen in a plain abdominal X-ray. Do not give
mebendazole or albendazole if acute abdominal
eggs can survive in soil for years. Playing or
pain is present as treatment increases the worms’
crawling in contaminated soil or eating raw tendency to migrate and may precipitate bowel
vegetables that have not been washed may obstruction. Surgery must be considered if there
result in infection. High prevalence rates are are signs of obstruction.
common in communities with poor sanitation.
This is a major public health problem in many 11-6 How can roundworms cause chest
parts of South Africa. problems?
Roundworm eggs hatch in the child’s small The larvae (which hatch out of the eggs in the
bowel, and the newly hatched larvae then pass gut) can causes respiratory symptoms and signs
through the bowel wall into the bloodstream during the time that they are migrating through
and are carried to the alveoli of the lungs. the lungs. Children with roundworm larvae in
From here they make their way up the bronchi the lungs present with a dry cough or wheeze.
and trachea then get swallowed. In the small
bowel the roundworm larvae mature into adult NOTE A high eosinophil count in the peripheral
blood (10% or more) is typical. Chest X-ray may
worms where they can live for 2 years.
show a pneumonitis.
11-5 Do roundworms in the gut cause
11-7 How are roundworms treated?
clinical problems?
Roundworm infection can be treated with
Many children with roundworms appear
either:
healthy and have no symptoms. Often the
only way the parents know that their children • Mebendazole orally 100 mg (i.e. 1 tablet)
have roundworms, is when worms are seen in twice a day for 3 days if below 5 years and
the stool. Sometimes worms can be vomited. 500 mg as a single dose if 5 years or older.
When the child is ill with a fever, roundworms • Albendazole as a single dose 200 mg (2
may make their way up the child’s oesophagus tablets) for children below 2 years and 400
and come out of the nose. mg for children of 2 years or more.
Large numbers of worms in the bowel can
cause problems: 11-8 How can infection with roundworms
be prevented?
• Vague abdominal pain or discomfort
• The amount of food they use • By safely disposing of human faeces
can contribute to malnutrition (adequate sanitation), e.g. water borne
sewerage or correctly built pit latrines

3. 184 PARASITES
• By washing raw vegetables before they are 11-11 What are the clinical features of
eaten whipworm infection?
• By washing hands before preparing or
Whipworms usually infect children over 5
eating meals
years of age. If the infection is light there are
• By preventing children from eating soil
usually no symptoms or signs. Heavy infection
• By routinely deworming children
can cause:
11-9 When is deworming recommended? • Loose stools containing blood.
Deworming every 6 months is recommended • Rectal prolapse may occur with very heavy
for children between the ages of 2 and 5 infections. With prolapse, the worms may
years in communities with poor hygiene and be seen attached to the rectal mucosa.
inadequate sanitation (poor toilet facilities). • Iron deficiency anaemia due to chronic
This should be done even if there is no history blood loss in the stool. This may be severe.
of roundworms in the stool. Medication is • Malnutrition
usually given at the local primary care clinic
or in schools. Deworming has been found to Whipworm infection can cause iron deficiency
improve the learning capacity and growth of
anaemia.
school children.
Mebendazole is the drug of choice. 11-12 What is the treatment of whipworm
Albendazole is more expensive. The dose infection?
for deworming is the same as for treating
roundworms. Both these drugs are highly 1. Prevention through good hand hygiene,
effective for roundworms. washing raw vegetables and the correct
disposal of human faeces (as with
prevention of roundworms)
Regular deworming of young children is 2. Mebendazole or albendazole, as given for
recommended in communities where roundworms roundworms
are common. 3. Treat iron deficiency anaemia with oral iron.
PINWORMS
WHIPWORMS
11-13 What are pinworms?
11-10 What are whipworms?
Pinworm infection is very common. They are
Whipworms commonly infect the bowel small, thin worms (about 4 cm long). Pinworms
of children in Southern Africa. They are are especially common where children sleep
short, thin worms (about 4 cm) that attach or play together in crowded conditions. Adult
themselves to the mucosa of the large bowel female worms pass out the anus at night to lay
where they cause bleeding. It is rare to see the eggs on the perineum. Eggs are swallowed from
worms in the stool. contaminated fingers, clothing or bed linen.
As with roundworms, eggs are ingested Pinworms are common even where hygiene
(swallowed) with soil. The eggs hatch in the and sanitation are of a high standard. They are
child’s gut and the larvae attach to the bowel also known as threadworms.
wall. Unlike roundworms, the larvae do not NOTE The pinworm is Enterobius vermicularis.
migrate through the lungs.
NOTE The whipworm is Trichuris trichura. The eggs
in the stool have a typical ‘tea tray’ appearance.

4. PARASITES 185
11-14 What are the clinical features of 11-18 What are the clinical features of
pinworm infection? hookworm infection?
Perianal itching and scratching at night. This Usually, there are no symptoms unless there
may cause loss of sleep. Secondary infection is heavy infection. The child may have an
of the scratched skin is common. In girls the unusually large appetite and want to eat sand.
worms may enter the vulva causing irritation In severe cases there may be signs of iron
and vaginal discharge (vaginitis). deficiency anaemia.
Pinworm infection presents with perianal itching 11-19 How is hookworm infection
diagnosed?
and scratching, especially at night.
Worms and their eggs may be found in the
stools.
11-15 How is pinworm infection
diagnosed?
11-20 What is the treatment of hookworm
The clinical diagnosis can be confirmed by the infection?
parent finding the small worms on the skin
around the anus at night. A piece of sticky tape Mebendazole or albendazole, as for
(Sellotape) should be placed against the anus roundworm infection.
and surrounding skin during the night and then NOTE Pyrantel (Combantrin) orally 10 mg/kg as a
immediately removed. In this way eggs can be single dose may also be used.
collected and identified under a microscope.
11-16 What is the treatment of pinworms? TAPEWORMS
Mebendazole or albendazole, as used for
roundworms 11-21 What are tapeworms?
The common tapeworms that infect the
HOOKWORMS human gut are the pork and, to a lesser degree,
the beef tapeworm. They are very long (up
to 5 metres) segmented worms that grow
11-17 What are hookworms? in the small bowel of humans after eating
uncooked or partially cooked meat, which is
Hookworms commonly occur in warm, contaminated with tapeworm cysts. Tapeworm
moist climates such as northern KwaZulu- segments filled with eggs are excreted in
Natal and the Mozambique coast. With human stools and later may be swallowed
poor sanitation, hookworm eggs in the stool by animals (pigs or cows). The eggs hatch
contaminate the soil and hatch rapidly. They in the animal’s gut and are carried in the
then infect the feet of barefoot children. Once bloodstream to the muscles of the animals
the skin is penetrated, hookworms behave like where they become tapeworm cysts. Eating
roundworms as they enter the bloodstream infected, uncooked meat of these animals
and travel via the lungs to get into the small completes the life cycle of the tapeworm when
bowel. The worms attach to the bowel mucosa the eggs hatch, resulting in adult worms living
and cause bleeding. in the human gut.
NOTE There are two types of hookworm,
Ancylostoma duodenale and Necator americanus.
Most tapeworms result from eating poorly cooked
pork which is infected with tapeworm cysts.

5. 186 PARASITES
NOTE The pork tapeworm is Taenia solium and the are a common cause of fits in children that live
beef tapeworm is Taenia saginata. in rural areas where toilets are not available.
Good sanitation, safe water, hand-washing
11-22 How is tapeworm infection and washed vegetables will reduce the risk of
diagnosed? neurocycticercosis.
Small segments of the worm are seen in the
stool or may be found in the bed. Often there Swallowed pork tapeworm eggs from human
are no other symptoms. However, tapeworms faeces result in tapeworm cysts in the brain.
can cause abdominal discomfort, failure to
thrive and loss of appetite. NOTE The tapeworm cysts (cysticerci) are best
identified in the brain by MRI or CT scanning.
11-23 What is the treatment of tapeworm With time they become calcified and can be
infection? seen on X-ray. Cysts may also occur in muscles.
Antibody tests are of little help. Treatment of
Mebendazole orally 100 mg twice daily for 7 neurocysticercosis in hospital is with steroids and
days. Praziquantel.
11-24 How can tapeworm infection be
prevented? HYDATID DISEASE
If possible, animals should be slaughtered in a
registered abattoir where all meat is inspected 11-26 What is hydatid disease?
to ensure that it is not infected by tapeworm
cysts. Cooking meat well kills the cysts. This is caused by the dog tapeworm which
Therefore, avoid eating raw or partially cooked can occur in the gut of dogs. Eggs, which are
meat. Meat lightly cooked on an open fire may passed in the dog’s stool, may be swallowed
still contain live tapeworm cysts. by sheep and goats, resulting in tapeworm
cysts in their muscles. Other dogs can then
Human stools must be disposed of safely be infected with tapeworms by eating the raw
so that it cannot be eaten by pigs. This will meat of these sheep or goats.
prevent the pigs from becoming infected
with tapeworm cysts. Parts of the Eastern If eggs of the dog tapeworm are swallowed by
Cape of South Africa are particularly heavily humans instead, the eggs hatch in the human
contaminated with tapeworm eggs. gut and are carried by the bloodstream to
the liver or lung where they form large cysts
(hydatid cysts). These large cysts may cause
In villages, pigs must be prevented from eating clinical problems (hydatid disease) and will
human faeces. have to be removed surgically.
Dogs should be dewormed regularly and
11-25 Can tapeworm cysts enter the brain? they should not be allowed to eat raw meat,
Yes. Sometimes the eggs of the pork tapeworm, especially mutton or goat meat which is
which have been passed in human faeces, are infected with the cysts of the dog tapeworm.
swallowed by other humans (instead of by pigs) Prevent children eating soil as it may be
in food or water contaminated by infected contaminated with dog tapeworm eggs.
human faeces. The eggs hatch in the child’s Always wash hands before eating. Also wash
gut and are then carried by the bloodstream vegetables well.
into all parts of the body including the brain.
In the brain they form many small tape worm Hydatid disease results when children swallow
cysts (neurocysticercosis) which cause fits
the eggs of the dog tapeworm.
(convulsions). Tapeworm cysts in the brain

6. PARASITES 187
Treatment is with mebendazole or albendazole 11-29 What is the treatment of giardia
daily for 6 weeks. infection?
NOTE The dog tapeworm is Echinococcus Metronidazole (Flagyl) 500 mg (under 4 years)
granulosus. or 800 mg (4 years or older) daily for 3 days.
The prevention, diagnosis and treatment of It is best to avoid infection with giardia by
sandworm infection is discussed in Unit 12. not drinking contaminated water or eating
unwashed vegetables or salad.
GIARDIASIS AMOEBIASIS
11-27 What is giardiasis?
11-30 What is amoebiasis?
Giardiasis is an infection with a single-celled
Amoebiasis is an infection caused by a single-
organism (protozoa) called giardia. The cysts
celled organism (protozoa) called an amoeba
of giardia are swallowed in contaminated food
which infects the large bowel. Amoebae
or water. Giardia lives in the small bowel and
are passed in the stool from where they can
cysts are passed in the stool. The cysts in human
contaminate food or water causing infection in
stools contaminate the soil and nearby water.
others. Therefore, the provision of toilets and
NOTE Giardia lamblia is the cause of giardiasis. a safe water supply are important to prevent
amoebiasis.
11-28 What are the clinical features of NOTE Entamoeba histolytica is the amoeba which
giardia infection? causes amoebiasis.
Giardiasis is usually asymptomatic. However,
with heavy infection the child develops loose, 11-31 What are the clinical features of
foul-smelling, watery stools. Abdominal amoebiasis?
cramps and vomiting are common. Usually Mild infection is asymptomatic. However,
the infection resolves in a few days but it may heavy infection causes abdominal discomfort
become chronic. Chronic giardiasis may cause and dysentery with blood and mucus in the
chronic diarrhoea with malabsorption leading stools. Amoebae can also cause abscesses in
to failure to thrive and malnutrition. the liver. This presents with an enlarged tender
It is difficult to confirm the diagnosis by liver. Severe bowel infection can result in
finding cysts in the stool. Therefore, diagnosis perforation and peritonitis.
is usually suspected from the clinical history Amoebae can be seen microscopically in
and confirmed when the symptoms and signs warm stool. A blood test for antibodies against
disappear after treatment. amoebae is useful in identifying patients with
amoebiasis.
Giardiasis can cause chronic diarrhoea and failure
to thrive. 11-32 What is the treatment of amoebiasis?
Metronidazole (Flagyl) 200 mg 3 times daily
NOTE Giardia is a common cause of ‘travellers’ for 5 days. All children with severe dysentery
diarrhoea’.
or suspected liver abscess must be referred
urgently. A large liver abscess may need to be
aspirated.

7. 188 PARASITES
Clean water, washing hands before eating, parasites in communities where they are
avoiding unwashed vegetables and salads, and common.
the safe disposal of human faeces prevents
It is important that parents are aware of the
amoebiasis.
clinical features of infection with intestinal
parasites and can recognise the worms if they
11-33 How can infection with many types are seen.
of intestinal parasite be prevented?
The same basic steps are needed to prevent
most intestinal parasites: BILHARZIA
1. The safe disposal of faeces is most
important, e.g. water flush toilets or 11-35 What is bilharzia?
correctly-made pit toilets (VIP toilets).
Never pass urine or stool near a stream or Bilharzia (schistosomiasis) is a disease caused
dam. by the bilharzia parasite. About 2 million people
2. Hands should always be washed before are infected with bilharzia in South Africa.
preparing and eating food. They should There are 2 forms of bilharzia. One affects
also be washed before eating. the bowel while the other affects the bladder.
3. Always use a clean, safe source of water for Bilharzia of the bladder is the most common
drinking and washing. form of bilharzia in children in South Africa.
4. Always wash raw vegetables or salads Eggs of the bladder parasite are passed in the
before eating. urine. If the urine reaches a source of water,
5. Avoid eating meat which has not been the parasite can infect and multiply in a special
thoroughly cooked. snail often found in pools, dams, reservoirs,
6. Prevent pigs from eating human faeces. canals or slow flowing streams. Parasites
7. Do not leave dog faeces lying around. released from the snail can penetrate the skin
Public awareness campaigns are an important of humans. From here the parasites enter the
method of reducing the number of infected bloodstream and are carried to the bladder.
children. Methods of preventing infection Sometimes they may also reach other organs.
with intestinal parasites should be taught and In the bladder wall the parasites cause
practised at schools. inflammation, bleeding and eventually
scarring. Damage can extend to the rest of the
Safe toilets and clean water will prevent infection urinary tract, resulting in urinary obstruction
with most intestinal parasites. with chronic renal failure.
NOTE Bilharzia (schistosomiasis) is caused by either
Schistosoma haemotobium (bladder parasite) or
11-34 What is the treatment of intestinal Schistosoma mansoni (bowel parasite).
parasites?
Most intestinal parasites can be effectively
Bilharzia of the bladder is common in South
treated with oral mebendazole or albendazole.
Some require a single dose (roundworms, Africa.
whipworms and pinworms) but others need a
daily dose for a number of days (tapeworms). 11-36 What are the clinical features of
Giardia and Amoeba infections should be bilharzia of the bladder?
treated with metronidazole (Flagyl).
At the time of infection an itchy, papular rash
Regular treatment of children (e.g. deworming may occur at the site where the parasites enter
for roundworms) is advised for some intestinal the skin (called ‘swimmers’ itch’). This may be
followed a few weeks later by a flu-like illness.

8. PARASITES 189
Mild bladder infection with bilharzia MALARIA
parasites is often asymptomatic. With more
severe infection, the classical sign is terminal
haematuria (blood seen in the urine towards 11-40 What is malaria?
the end of micturition).
Malaria is a serious illness caused by a malaria
parasite which is transmitted to humans by a
Bilharzia of the bladder usually presents with special type of mosquito. When a mosquito
terminal haematuria. bites an infected person, human blood
containing malaria parasites is taken in by the
NOTE Bilharzia of the bowel may cause dysentery. mosquito. The mosquito becomes infected
(but not ill) and can then bite and infect other
11-37 How is the diagnosis of bilharzia of humans. In the human, the malaria parasite
the bladder confirmed? infects both red cells and the liver. Infection
of the red cells causes haemolysis, resulting
By finding the typical bilharzia eggs in the in anaemia. It also causes the red cells to stick
urine under a microscope. It is best to collect together which obstructs small blood vessels.
urine around midday when most eggs are Malaria is a common cause of chronic illness
released. A blood test for antibodies to the and death in many low lying regions where
parasite is also available. malaria mosquitoes occur.
NOTE Eosiniphilia in the blood is usually present
with bilharzia.
Malaria is an important cause of death in many
parts of southern Africa.
11-38 What is the treatment of bilharzia?
Praziquantel 40 mg/kg orally as a single As falciparum malaria is by far the most
dose. This treatment can be given at a clinic. common form of malaria in South Africa, other
Unfortunately, children who live in a bilharzia rarer forms of malaria will not be considered.
region may have to be treated repeatedly for
NOTE Almost all malaria in Southern Africa is
bilharzia.
caused by Plasmodium falciparum which is
transmitted by female Anopheles mosquitoes
11-39 How can bilharzia be prevented? (the vector of malaria).
Every effort must be made to prevent bilharzia
infection. Never pass urine into a stream or 11-41 What are the clinical signs of
pool of water. Standing or slow-moving water malaria?
such as farm dams and irrigation furrows are The patient develops an acute illness with
the home of the bilharzias snail, especially fever, shivering rigors and flu-like symptoms
in the eastern areas of South Africa and in 1 to 2 weeks after being bitten by an infected
Zimbabwe. Fast-moving streams are usually mosquito. Headache, nausea and body pains
safe. Swimming or bathing in infected water are common in uncomplicated (mild) malaria.
must be avoided as this is the common way of The symptoms and signs of malaria are very
getting bilharzias. Efforts are being made to non-specific, making the clinical diagnosis
kill the snails in high risk areas. difficult to confirm or exclude.
Severe headache, repeated vomiting and
Do not swim in standing water where there are drowsiness suggest the development of severe
bilharzia snails. malaria. Mild malaria may become severe and
even fatal within hours.
NOTE Infection of other organs such as the liver
(jaundice), gut (diarrhoea), lungs (respiratory

9. 190 PARASITES
distress) and kidneys (oliguria with renal failure) • Is passing urine
may occur. Massive haemolysis (blackwater fever) • Is not vomiting repeatedly, and is able to
causes anaemia, with dark urine. take oral medication
Anyone who develops fever in a malaria • Has no signs of organ failure
area, or within 2 weeks of leaving a malaria NOTE In uncomplicated malaria the parasite count
area, must be suspected of having malaria. on a thin blood smear is less than 5%, i.e. less
Thinking of malaria is the most important than 5% of red cells containing malaria parasites.
step in the clinical diagnosis. As the clinical In severe malaria the patient may have any of
symptoms and signs of malaria are very varied, the following:
it is always important to confirm the clinical
suspicion. There are often no clinical signs at • Signs of cerebral malaria
presentation. • Breathing difficulty
• Hypoglycaemia, jaundice or severe
anaemia (Hb less than 5 g/dl)
Suspect malaria in anyone with a flu-like illness • Repeated vomiting, apparent dehydration
who lives in or has recently visited a malaria or little urine passed
region. • A shocked appearance
NOTE In severe malaria the parasite count is well
11-42 How is the diagnosis of malaria over 5% (hyperparasitaemia). The higher the
confirmed? count, the more severe the malaria. Metabolic
acidosis may occur.
1. Seeing the malaria parasites within red
cells in a stained thick blood smear is
11-44 What is cerebral malaria?
the traditional ways of confirming the
diagnosis. Repeated smears may be needed This is the most dangerous complication of
before malaria is excluded as the smear severe malaria as the brain is affected and can
may be negative early in the infection. lead to rapid death. Young children, pregnant
2. A blood test to detect malaria proteins women and people who are HIV infected are
(rapid antigen test) is also useful in making particularly susceptible to cerebral malaria.
a rapid diagnosis. It is very reliable and Each year many children die of cerebral
available at primary care facilities in malaria in Africa.
malarial areas of South Africa.
Signs of cerebral malaria must always be
3. It is very important to confirm the
viewed with great concern:
diagnosis of malaria as soon as possible.
• Depressed level of consciousness, i.e.
drowsy, unable to stand, confused or
Most deaths due to malaria are caused by delayed unconscious
diagnosis or late treatment. • Convulsions
Remember that many other serious conditions
may present with the same symptoms and signs Confusion is an important sign of potentially fatal
as malaria, e.g. bacterial meningitis. Children cerebral malaria.
may also have malaria plus another infection.
NOTE In cerebral malaria the large numbers of
parasites obstruct the normal blood flow to the
11-43 How can you tell whether malaria is brain.
uncomplicated or severe?
In uncomplicated malaria the patient:
• Has mild symptoms
• Is fully alert and able to stand and walk

10. PARASITES 191
11-45 How is uncomplicated malaria In future intravenous artesunate will probably
treated? replace quinine as it is safer. Rectal artesunate
is also an effective emergency treatment.
Early and accurate diagnosis with urgent
treatment using the correct drugs is the key NOTE A loading dose of quinine 20 mg/kg diluted
to successful management. It is important in 5% dextrose water (10 ml/kg) must always be
to differentiate uncomplicated from severe given as a slow infusion over 4 hours and never
as a bolus. This is followed by 10 mg/kg 8 hourly
malaria. If possible all patients with malaria are
intravenously. Change to oral quinine as soon as
referred to a hospital or clinic where the staff possible.
are experience in treating malaria. They must
be closely followed up for the first few days. Using a combination of drugs for both
Patients with confirmed malaria are usually uncomplicated and severe malaria is more
treated with coartemether (Coartem). Coartem effective and less likely to result in resistance in
is a combination of two potent, rapidly acting the community than monotherapy (one drug
anti-malarial drugs which are well tolerated. only). The patient should improve clinically
within 48 hours and the fever should settle
For uncomplicated malaria, one dose of within 5 days.
Coartem should be taken immediately, then
again after 8 hours, followed by a twice daily
11-47 How is malaria prevented?
dose for the next 2 days. Each dose is 1 tablet
if 10–14 kg, 2 tablets if 15–24 kg, 3 tablets if 1. Pregnant women and young children should
25–34 kg and 4 tablets if 35 kg or more. Best not enter a malaria areas if at all possible.
taken with food. 2. Mosquitoes usually bite in the early
evening and early morning. Therefore, stay
Drug resistance is a major problem with
indoors with screens over windows and
malarial treatment. Most strains of malaria
doors or wear light coloured clothes, long
are now resistant to chloroquine alone or in
sleeves and trousers with shoes and socks
combination with other drugs. Paracetamol
in the evenings and early mornings.
is best for reducing the fever. Make sure the
3. Use a bed net impregnated with insecticide
patient is taking enough fluids.
(pyrethroid) at night.
Uncomplicated malaria can also be treated with 4. Use insect repellent on the skin and clothes
oral quinine. However, there are some serious or burn repellent coils or pads or sprays at
side effects of quinine, e.g. myocardial toxicity. night.
NOTE The dose of oral quinine is 10 mg/kg 8 hourly
5. Antimalarial drug prophylaxis is
for 7 days PLUS clindamycin 5 mg/kg 8 hourly for 7 recommended for short visits to a malaria
days or doxycycline (if over 8 years of age) 4 mg/kg area.
immediately then 2 mg/kg daily for 7 days. 6. By reducing the number of mosquitoes.
The quinine tablets are very bitter but can be Preventing mosquito bites is more effective
crushed and taken with jam, or mashed banana. than prophylaxis. Usually both are needed.
11-46 How is severe malaria treated? Preventing mosquito bites is the most effective
Severe malaria is usually treated with way of avoiding malaria.
intravenous quinine PLUS oral doxycycline
(if over 8 years) or clindamycin (oral,
11-48 What malaria prophylaxis is
intramuscular or intravenous in younger
recommended?
children). Intravenous drugs must be
started immediately and the patient urgently Malaria prophylaxis is needed by all who enter
referred to hospital. Look for and manage a malaria area (a region where malaria occurs),
hypoglycaemia, shock or convulsions. even if it is only a one day visit. The risk of

11. 192 PARASITES
becoming infected by malaria is particularly CASE STUDY 1
high in the rainy season when mosquitoes are
common. Full compliance is very important.
A mother brings her 5-year-old son to the
However, prophylaxis is never 100% effective.
clinic because he has passed 2 roundworms
1. Malanil or malarone (atovaquone plus with his stool. He is generally well but the
proguanil) for children of 10 kg or more. It mother complains that he scratches his anus at
is well tolerated but expensive. night which keeps him awake.
2. Mefloquine (Larium) for children of 5 kg
or more. 1. How do children get roundworms?
3. Doxycycline for older children (over 8
years). They ingest the roundworm eggs after playing
in sand or soil. If human faeces are not
It is best for all children under 5 years, disposed of correctly they can contaminate
especially children under 5 kg, not to enter a soil in the village, garden or playground. Eggs
malaria area as they are at high risk for severe can survive for years in soil and may also
infection. Chloroquine alone, chloroquine contaminate pools of water or raw vegetables.
with proguanil, and Coartem should not be This is a common public health problem.
used for prophylaxis.
NOTE Malanil daily ¼ tablet if 5–20 kg, ½ tablet 2. Can roundworms cause clinical
if 21–30 kg, ¾ tablet if 31–45 kg and 1 tablet if problems?
over 45 kg starting one day before entering and
stopping one week after leaving a malaria area. Usually not. However, with heavy infections
Mefloquine weekly ¼ tablet if 5–20 kg, ½ tablet children may complain of abdominal
if 21–30 kg, ¾ tablet if 31–45 kg and 1 tablet if pain or discomfort and lose their appetite.
over 45 kg starting one week before entering and Roundworms can cause bowel obstruction or
stopping 4 weeks after leaving a malaria area. block a bile duct. The larvae of roundworms
Doxycycline 100 mg daily starting 1 day before pass through the lungs and can cause
entering and stopping 4 weeks after leaving a coughing and wheezing.
malaria area.
Seasonal Intermittent Treatment of children 3. How should this child be treated?
in malaria regions decreases the incidence of
clinical malaria. With a single oral dose of mebendazole or
albendazole. The mother should be told how
to avoid reinfection.
11-49 How can the number of mosquitoes
be reduced?
4. Is routine deworming recommended for
1. By reducing the mosquito population all children?
with the use of controlled spraying around
homes with insecticides. This is done by A deworming programme is recommended in
state-employed teams. regions where roundworms are common.
2. By reducing pools of water where
mosquitoes can breed. 5. What is a common cause of perianal itch
at night in children?
NOTE Malarial mosquitoes have become resistant
to many insecticides. The controlled use of DDT Pinworms. These are short worms that infect
is very effective but remains controversial due to the gut and leave the anus at night, causing
the risk of environmental pollution and dangers irritation to the skin around the anus. They
to other animals and possibly the newborn infant. can also cause a vaginal discharge in girls.

12. PARASITES 193
6. How can the diagnosis be confirmed? 5. Can tapeworms affect the brain?
A strip of Sellotape should be stuck onto the Yes. If eggs of the pork tapeworm are passed
child’s skin over and next to the anus and then in human faeces and then later get swallowed
immediately removed. Pinworm eggs will stick by another human rather than a pig, they
to the Sellotape. These can then be seen under can hatch in the gut of that person and then
a microscope. The treatment is the same as for travel in the bloodstream to the brain where
roundworms. they form many small cysts. This is called
neurocysticercosis and usually presents with
convulsions. Neurocysticercosis is common in
CASE STUDY 2 communities where there are pigs and human
faeces are not disposed of safely.
A malnourished child from a rural village
presents at the local clinic after passing a piece 6. What problems can be caused by the dog
of tapeworm in her stool. Pigs run free and eat tapeworm?
human faeces. There are also a number of dogs If eggs of the dog tapeworm are ingested
in the village. by humans they hatch in the gut, enter the
bloodstream and are carried to organs such as
1. What are the common types of the liver and lungs where they grow into large
tapeworms in children? (hydatid) cysts. Therefore it is important that
The pork or beef tapeworms. Pig tapeworms children do not play in areas where dog faeces
are more common. are left to mix with the soil or pools of water.
Hydatid disease can be treated with oral daily
2. What is the clinical presentation of mebendazole or albendazole for 6 weeks.
tapeworms? Large cysts may have to be removed surgically.
Infected children are often asymptomatic.
However, tapeworms can cause poor appetite,
abdominal discomfort and weight loss. This CASE STUDY 3
child’s malnutrition may be partly explained
by the tapeworm. A month after returning from holiday on a
farm in the Eastern Cape, a 14-year-old child
3. How did this child get infected with a presents with a 3-week story of loose stools,
tapeworm? and terminal haematuria for 2 days. While on
holiday he swam in a farm dam.
Probably by eating uncooked or partially
cooked pork. Tapeworm eggs get passed in the 1. What is the common cause of terminal
stool and then may be eaten by pigs if toilets haematuria?
are not available. The eggs hatch in the pig’s
gut and then travel in the bloodstream to the Blood in the urine towards the end of
muscles where they form cysts. If these cysts in micturition is typical of bilharzia. The bilharzia
the meat are eaten by humans, they hatch out parasite settles in the wall of the bladder where
in the gut to form a tapeworm. it causes inflammation and bleeding.
4. What is used to treat intestinal 2. When did the infection probably occur?
tapeworms? When he swam in the farm dam. The special
Oral mebendazole twice daily for 7 days. bilharzia snail is common in the eastern parts
of South Africa where it lives in standing or
slow-moving water such as farm dams or

13. 194 PARASITES
irrigation furrows. If someone with bilharzia indicates severe, probably cerebral malaria.
passes urine into the water the snails can Malaria can progress from uncomplicated to
become infected. The parasites released from severe within hours if not treated.
the snails can then penetrate the skin of
anyone walking or playing in the water. 3. How can the diagnosis be confirmed?
By examining a blood smear or performing a
3. Can bilharzia be treated?
malaria rapid antigen test.
Yes. It can be treated very effectively with
praziquantel. It is best to first confirm the 4. What is the correct treatment?
diagnosis by seeing bilharzia parasites in
a urine sample collected around midday. She must be admitted to hospital urgently as
Chronic bilharzia infection can lead to damage cerebral malaria can be fatal. She needs to be
of the urinary system causing renal failure. treated with intravenous quinine plus either
doxycycline or clindamycin. Uncomplicated
malaria can be adequately treated with oral
4. What is the probable cause of the
Coartem provided the clinical diagnosis has
diarrhoea for the past 3 weeks?
been confirmed.
The child may have a bowel infection with
giardia, which causes diarrhoea. Although it 5. How can malaria be prevented while on
is often acute it may last for weeks or months. holiday?
Giardia is common where a safe water supply
and adequate toilets are not present. The only way to confidently avoid malaria is
not to enter a malaria area. However, malaria
can usually be avoided by making efforts not
5. Which drug is used to treat giardiasis?
to be bitten by mosquitoes and by taking
Metronidazole (Flagyl). malaria prophylaxis. Insecticide impregnated
bed nets are very effective. Also keeping
indoors after sunset with mosquito screens on
CASE STUDY 4 the door and windows. Wear long trousers and
sleeves, and shoes and socks if going out in the
Two weeks after returning from a malaria area, evening or early morning, when mosquitoes
a 10-year-old child presents with headache, are most active.
shivering and vomiting. The mother gave her
some paracetamol for the fever. A few hours 6. What malaria prophylaxis should be
later the child becomes confused and cannot taken?
stand up. The family did not take malarial The choice is atovaquone and proguanil
prophylaxis because they planned to be in the (Malanil) for children of 10kg or more, or
area for 2 days only. mefloquine (Larium) for children of 5 kg
or more. Children over 8 years can also use
1. Do you think this child has malaria? doxycycline. The medication must be taken
Yes. Malaria has an incubation period of 1 to correctly, including for the correct period after
2 weeks and presents with fever and a flu-like leaving the malaria area. Prophylaxis must be
illness. taken even for a one day visit.
2. How severe is the infection?
At presentation it was uncomplicated, with
fever and vomiting. However, within hours
she was confused and could not stand. This