The right way to administer quinine

At least 100 children in the Eastern district of Bukedea are currently deformed as a result of poorly administered quinine; an antimalarial drug. According to a story that was published in this newspaper on July 18, earlier this month, the children who were supposed to get better with quinine instead got permanent deformities as the drug paralysed their muscles and legs.
The children have deformities ranging from paralysis of their legs and foot drop [where a child can hardly lift the leg at the ankle) and require cushioned chairs and foam sheets to sit upright. The story, other than causing concern on how devastating quinine can be, led many people to share on the different social media platforms past experiences and side effects suffered such as temporary blurred vision, and ringing in the ears.
Like the cases in Bukedea district, similar cases have happened across the country where children die after being injected wrongly with quinine by inexperienced health workers. In 2016, a five-year-old boy at Gulu Regional Referral Hospital collapsed and died shortly after a student nurse reportedly injected him with undiluted quinine. This usually comes with convulsions, organ dysfunction, severe headaches and vomiting, among others.

Second line regimen
The World Health Organisation 2015 malaria treatment guidelines recommend the use of quinine, an antimalarial drug in the treatment of severe plasmodium caused malaria fever. It is, therefore, given orally or administered directly to the veins (intravenously) when first line drugs such as coartem and chloroquine fail but is also given as first line regimen when the condition is severe, according to WHO.
In Uganda the malaria control guidelines also recommend quinine as a second line regimen in the treatment of the disease that is prescribed after the failure of the first line drugs such as coartem and chloroquine. Malaria, caused by parasites that typically enter the body through the bite of a plasmodium infected mosquito also remains the number one killer in the country with a prevalence rate of 19 per cent.

Doctors explain
Experts have explained circumstances under which the drug known for its efficacy in the treatment of malaria can cause adverse effects such as deformities besides the temporary side effects.
Dr Vincent Karuhanga, a general practitioner at Friends Polyclinic, attributes the problem to ignorance among health workers who use wrong routes to administer the drug, causing effects such as muscle paralysis, sometimes leading to permanent deformities. “We no longer administer quinine on the bum but intravenously [through the veins] and use a sugar not salt drip because quinine removes sugar from the body,” Dr Karuhanga explains.
The risk associated with injecting quinine under the skin (on the bum) is that a nerve can be injected causing paralysis when an internal scar is created and infects the muscle, according to Dr Karuhanga. He also warns that even intramuscular admission of quinine through the muscle by an expert can still damage the nerve by accident.
This, Dr Karuhanga says, makes admission of quinine orally and intravenously safer than injecting directly through the muscles. “But quinine tablets are not commonly used because they cause vomiting and take very long to work so we use the drip,” he adds.

Resistance
Despite the likely side effects, quinine continues to be used globally, especially in countries where parasites that cause malaria have become resistant to cloroquine, a commonly used first line antimalarial drug.
For example, in 2015, the ministry of Health issued new guidelines for malaria treatment amid concerns that the parasites were becoming resistant to chloroquin. Statistics then indicated that 70 per cent of malaria cases in Kampala and Moroto could not be cured by chloroquine. The ministry revealed that resistance to quinine had not yet developed in Uganda, making the drug a better alternative treatment.
Dr Samuel Opio, a pharmacist and secretary Pharmaceutical Society of Uganda (PSU) also explains that nurses should, at worst, administer quinine intramuscularly (on the thighs and not bum) if they fail to trace the patient’s veins. He also warns that patients and caretakers have to always first inquire from the health worker about the side effects of the drug that they have been prescribed.
“What is causing the deformities is that health workers are giving intramuscularly (on the bum) instead of using intravenous (IV) and the drug goes under the skin to be absorbed by nerves and damage the muscles,” Dr Opio notes.
PSU, which regulates pharmacy practice in the country, Dr Opio says, emphasises the need for every hospital to have a pharmacist who can advise nurses on how to administer the prescribed medicine.
What should be done?
Dr Anthony Nuwa, the country technical officer of Malaria Consortium-Uganda; an NGO specialising in the prevention, control and treatment of malaria, recommends oral quinine before the health worker thinks of the intravenous route.
“But if the patient cannot swallow, then the intramuscular route would work. Half a dose of quinine should be given on the right thigh and the other half on the left thigh,” Dr Nuwa says. He warns patients against seeking treatment from quack health workers who are fond of giving quinine just because they have it in stock.
Controlling the effects
A big number of both children and adults prescribed quinine have complained of diarrhoea, headaches, stomach upsets and vomiting, among others. Other side effects include change in vision, skin rash, difficulty in breathing and ringing in the ears.
Responding to the common temporary side effects of the drug, Dr Nuwa notes: “Someone will get these side effects if they are dehydrated and have not eaten before taking the medicine. So, the health practitioner must always ask the patient whether they have eaten and if not, provide something to eat before administering the medicine.
Dr Nuwa also asks patients to see a health worker immediately such side effects strike, regardless of how minor they are.