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MALARIA: HEALTH INFORMATION FOR DELEGATES

(dated 2005-01-21)

The Disease

Malaria is one of the most serious and complex health problems facing humanity in the 20th century. Approximately 300 million of the world’s people are infected by the disease and between one and 1.5 million people die from it every year. The situation has become even more complex over the last few years with an increase in resistance to the drugs normally used to combat the parasite that causes the disease.

Malaria is caused by protozoan parasites of the genus Plasmodium. There are four species of Plasmodium that can produce the disease in various forms. The most widespread and dangerous of the four is Plasmodium falciparum. If untreated, it can lead to cerebral malaria, kidney failure, coma and death.

Parasites are transmitted from one person to another by the bite of the female Anopheles mosquito. Typically these mosquitoes bite between the hours of dusk and dawn and their sensitivity to insecticides is highly variable.

Malaria is diagnosed by test strips (sc “dipsticks”), microscopic examination of the blood and the clinical symptoms.

Signs and Symptoms of a Malaria Attack

Malaria symptoms can develop as early as eight days after initial exposure in a malaria-endemic area and as late as several months after departure from a malarial area, after chemoprophylaxis has been completed.

The clinical symptoms of malaria vary from very mild to very severe, depending on several factors. The most important feature of malaria is fever and shivering. Each attack may last several hours and often begins with shivering, and then there is a period of fever and finally profuse sweating. Headache, pains in the back and joints and all over the body are often present from early stages. In some cases there might be vomiting and diarrhoea.

Malaria can be treated effectively early in the course of the disease, but delay of appropriate treatment can have serious or even fatal consequences. Individuals who have symptoms of malaria should seek prompt medical attention, have a test, including thick and thin blood smears to confirm the suspected diagnosis.

If there are no health facilities and you suspect you are suffering from a malaria attack you should start self-treatment for example Lariam, preferably after self testing with Malaria test strips. For dosages, see page 3.

Malaria Prevention

At this moment there is no 100% safe method available to prevent malaria. No vaccine is available. All measures are aimed at reducing exposure and taking chemoprophylaxis to minimise the risks of catching malaria. It is of utmost importance to remember that the most effective malaria prevention relies on both prevention of mosquito bites and chemoprophylaxis

a.) Prevention of Exposure

This means elimination or reduction of contact with the malaria carrying mosquitoes. These mosquitoes bite exclusively between dusk and sunrise. One cannot conclude about the absence of mosquitoes when they are not noticed the anopheles mosquito does not buzz!

A correct implementation of mechanic protective measures is of utmost importance:

Sleep under a mosquito net. Treated mosquito nets are efficient as they kill the insects resting on it. The mosquito net should be treated (impregnated) with insecticide such as permethrine, and the impregnation should be repeated every 4-6 months. Mosquito nets made of synthetic materials are preferred to those made of cotton, since they are more airy and offer a better protection (the chemicals stay on the surface, while cotton absorbs it). The mosquito net must be undamaged and its borders have to be tucked under the mattress.

Use adequate clothing in the evenings long sleeves, long pants

Use repellent on all exposed areas of skin after the end of the afternoon

Screen windows and use insecticides between dusk and dawn (net, spray, coils...)

b.) Anti malarial Drugs

The Federation follows the WHO malaria programme recommendations. You will find the basic list of recommended drugs for prophylaxis and treatment and their regimes listed below. The choice of the drug will depend on the country of assignment, previous experience with malaria chemoprophylaxis (experienced side effects or known allergies to a specific drug) and use of other medications prescribed by a doctor. Delegates undergoing any type of treatment (for high blood pressure, cardiac problems, allergy, etc.) should always check with their physician before starting the chemoprophylaxis.

b.1.) Preventive Protocols - i.e. Chemoprophylaxis

It is very important to remember that:

All anti malarial drugs to be taken at weekly intervals should be started 1 week before departure.

Anti malarial drugs to be taken daily should be started 1 day before departure

All drugs should be continued for 4 weeks after the last possible exposure to infection. Exception: Malorone to be continued 1 week after the last possible exposure to infection.

Independently from the different type of regimens the following rules apply to all regimes, as these will also help in reducing possible side effects:

Tablets should be taken on the same day each week (for the weekly doses) and/or at the same time of the day.

Tablets should be taken after meals and with a fair amount of fluids

Alcohol intake should be avoided/minimised on the day chemoprophylaxis is taken

5. Nearly all medicines have side effects. The seriousness of side effects and individual tolerance to malaria medicines decide the need for adjustment or change. Usually they are mild. However if you experience serious adverse reactions you should seek advice from a health professional and choose alternative regimens. The chemoprophylaxis as such should not be discontinued.

Prophylaxis with Mefloquine (Lariam)

|Adult: 250 mg per week (one tablet of 250 mg once weekly) |

|Children |3 months - 2 yrs |2-4 years |5-8 years |9 - 15 years |

| |5 mg/kg |¼ tablet |½ tablet |¾ tablet |

Note:

Ÿ Person weighing less than 60 kg could reduce the weekly prophylaxis to ¾ tablet per week.

Ÿ Lariam can be administered to children above 3 months of age

Ÿ Lariam is contra-indicated in case of history of epilepsy and psychiatric disorder, persons with cardiac conduction abnormalities or using beta-blockers or calcium channel blockers, and during the first three months of pregnancy

Ÿ Pregnancy should be avoided while using Lariam and for 3 months after the last dose

Prophylaxis with Chloroquine + Proguanil

|Adult: - Chloroquine: 300 mg once weekly (see page for chloroquine dosages) |

|- Proguanil: 200 mg per day ( 2 tablets of 100 mg once a day) |

|Children |< 1 year |1 - 4 years |5 - 8 years |9 - 15 years |

|Chloroquine |25 - 50 mg |50 - 100 mg |100 - 200 mg |200 - 300 mg |

|+ Proguanil |25 mg (1/4 tab) |50 mg (1/2 tab) |75 mg (3/4 tab) |100 mg (1 tab) |

Choroquine trade names: Aralen, Avloctor, Nivaquine, Resochine

Proguanil trade name: Paludrine

Prophylaxis with Chloroquine

|Adult: -300 mg once weekly (see page 5 for chloroquine dosages) |

|Children |< 1 year |1 - 4 years |5 - 8 years |9 - 15 years |

|Chloroquine |25 - 50 mg |50 - 100 mg |100 - 200 mg |200 - 300 mg |

Prophylaxis with Doxycycline

|Adult : 100 mg per day (one tablet of 100 mg once daily) |

|Children |1-7 years |8-10 years (25-35kgs) 50mg |> 13 years |

| |contra-indicated |11-13 years (36-50kgs) 75mg |(50 + kg) |

| | | |100 mg |

Note

Doxycycline is contra-indicated throughout pregnancy.

Prophylaxis with Atovaquone/proguanil (Malorone)

|Adult |250mg Atovaquine + 100mg Proquanil/day (one tablet one daily) |

|Children |Not recommended to children below 11 kg. |

| |11-20 kg: 62,5 mg atovaquone plus 25 mg proguanil ( 1 paediatric tablet ) daily |

| |21-30 kg : 2 paediatric tablets daily |

| |31-40 kg : 3 paediatric tablets daily |

| |> 40 kg : 1 adult tablet |

Recommended dose is one/day, starting one day before expected exposure, continued until seven days after leaving the area.

Note that experience with this drug for prophylaxis in non-immune visitors/delegates is still limited. Contra-indicated if hypersensitive to any of the two drugs and if hypersensitive to any of the two drugs and if severe renal failure. Until further notice, pregnant and nursing women as well as children < 11 kg must not use Malorone (safety not established).

N.B. There are other drugs used for prophylaxis (Camoquine/Flavoquine, Daraprim, and others). These are either less effective or carry considerable risks or serious side effects. Additionally there are drugs which should not be considered for prophylaxis at all. These are Halofantrine (Halfan, widely used in Francophone Africa), Fansidar and Artemisinine (Artemeter, Arsumax, Cotexin) which are to be used in treatment only and if there are signs of resistance to quinine

b.2.) Treatment Protocols

Concerning Signs and Symptoms of Malaria, see page 1.

In general, if you feel you have signs and symptoms of malaria you should promptly seek professional advice and undergo laboratory tests, including thick and thin blood smears.

If there are neither health facilities nor health professionals at hand, and you suspect you are suffering a malaria attack you should start self-treatment, preferably after self testing with Malaria test strips.

Self-testing for malaria

A number of Malaria self test strips are available (CTI, ParaSight-F B&D, etc.), distinguishing between various types of plasmodium, including Falciparum. They provide very good sensitivity and very high specificity (well above 90 % in both). Our experience in the field is that a negative test may occur in the very beginning of an attack, but turns positive within 12 hours - i.e. repeat test is needed occasionally. Also some strips remain positive for quite some time after a Malaria attack.

If you are undergoing self-treatment, remember:

No treatment will immediately relieve all symptoms. Drugs take hours to be effective. Even with correct treatment, it will take up to 6 hours before symptoms start improving.

Once you have started the treatment you must complete it - unless there is a suspicion of serious side effects.

Complete the self treatment course and resume antimalarial prophylaxis 1 week after the first treatment dose. Mefloquine prophylaxis, however, should be resumed 1 week after the last treatment dose of quinine.

You should also take some Paracetamol or Aspirin to reduce the fever and drink plenty of fluids

Seek medical advice if no improvement, to exclude other serious causes of fever.

Unless you are under close medical supervision, do not take different anti-malarial drugs at the same time. Certain combinations can be very toxic and/or trigger serious side effects, thus endangering your life.

Treatment with Mefloquine (Lariam)

Adults: tablet of 250 mg: 3 tablets at once - 2 tablets after 6 hours - 1 tablet after 12 hours

Children: 15 mg per Kg body weight divided into 3 doses to be administered at the same intervals as for adults

Treatment with Chloroquine

| | |Adults* | |

| | |Tablet of 100 mg base (Nivaquine) |Tablet of 150 mg base (Chloroquine) | |

| |day 1 |6 tablets at once |4 tablets at once | |

| | |3 tablets after 8 hours |2 tablets after 8 hours | |

| |day 2 |3 tablets |2 tablets | |

| |day 3 |3 tablets |2 tablets | |

Children: over dosage of chloroquine is very toxic, treatment dosage for children must be carefully based on the child’s body weight in reason of 10 mg base/kg day 1, 10 mg base/kg day 2, and 5 mg base / kg day 3.

|Note Not all packages of chloroquine indicate the dosage as “mg base”, in most cases dosages are indicated as “mg sulphate” or “mg |

|phosphate”, corresponding dosages of “mg base” are as follows: |

|chloroquine 130 mg sulphate = 150 mg phosphate or diphosphate = 100 mg base |

|chloroquine 200 mg sulphate = 250 mg phosphate or diphosphate = 150 mg base |

Persons weighing more than 80 kg should adjust the dosage of chloroquine to 25 mg base/kg body weight. The total dose will be divided over 3 days.

For example: the treatment dosage of chloroquine for a person weighting 90 Kg will be 2.250 mg chloroquine base; if each tablet contains 150 mg chloroquine base the person will need 15 tables, divided over 3 days, which will give 5 tablets a day.

Treatment with Artemether/Lumefantrine = Coartem 20/120

|1 tablet containing 20 mg of Artemether and 120 mg of Lumefantrine. |

|Adult |3 days course of 6 doses total taken: |

| |4 tablets at once then 4 tablets after 8 hours then |

| |4 tablets after 24 hours then 4 tablets after 36 hours then |

| |4 tablets after 48 hours and 4 tablets after 60 hours |

|Children |Not recommended under 10kg |

| |10-14 kg : 1 tablet ( 20mg artemether plus 120 mg lumefantrine) per dose |

| |15-24 kg : 2 tablets per dose |

| |25-34 kg 3 tablets per dose |

| |35 kg and over 4 tablets per dose. |

Note: Coartem is not recommended during pregnancy and breastfeeding.

IMPORTANT:

The following drugs must not be used for self treatment, either because they need to be administered together with other drugs or because of potentially dangerous side effects. Quinine injection and/or tablets must be reserved for complicated treatment, and most often in combination with other drugs.

Halfan must not be used since there are possible serious side effects, in particular if the person has been using Quinine or Lariam during the last four weeks prior to taking Halfan.

Artemisinine should not be self administered and not used as treatment unless supervised by a specialist. It has to be used in combination with other antimalarials, otherwise there is great risk of relapse within a month.

Possible side effects of the different regimens

Mefloquine (Lariam, Méphaquine) Side effects include gastrointestinal disturbances, dizziness, fainting, headache, vivid nightmares, fatigue, confusion, depression, difficulty in concentration, swift changes of mood. Lariam should never be used in persons with a history of epilepsy, psychiatric disorders or persons with cardiac conduction abnormalities or using beta-blockers or calcium channel blockers, nor during the first three months of pregnancy. Dosage for young children should be determined by the paediatrician. To reduce possible side effects it is recommended to take Lariam in the evening, possibly before the rest day and with plenty of fluid. Avoid alcohol and anxiolytic drugs the day you take Lariam.

Note: Female delegates and spouses using Lariam should take adequate precaution to avoid pregnancy while taking the prophylaxis and for three months after the last tablet.

Chloroquine (Nivaquine, Resochin, Quinercyl, Aralen) rarely causes serious adverse reaction when taken as chemoprophylaxis. Minor side effects that may occur include gastrointestinal disturbance, dizziness, and pruritus. In some persons chloroquine might also cause some complaints of slightly diminished visual acuity. These discomforts generally do not require discontinuation of the drug and cease after stopping the chemoprophylaxis.

Proguanil (Paludrine) is very safe. Minor side effects are stomach and intestinal discomfort, and these can be reduced by taking it soon after the meal.

Doxycycline is contra-indicated throughout the pregnancy and in children less than 8 years of age. It can cause gastro-intestinal upset, photosensitivity and vaginal yeast infections. It must be taken with plenty of fluids and never taken just prior to lying down.

Coartem 20/120: is contra-indicated throughout the pregnancy, during breastfeeding and to children below 10 kg. Side effects include rash, headache, trouble in sleeping, palpitation, loss of appetite, nausea, vomiting, diarrhoea, abdominal pain, fatigue and general weakness, aching joints and muscles, itching of the skin and cough. Coartem is better absorbed if taken with fatty food and plenty of fluid.

Recommendations to all delegates

You may be an experienced delegate who has never had malaria, and therefore consider prophylaxis unnecessary. Our experience is that many in this category suffer serious attacks sooner or later. You might be infected with a multi-drug resistant strain of plasmodium and develop a severe attack or die.

When entering a new area check with local health personnel, whether your prophylaxis/treatment is re-considered the most effective regimen.

When travelling on field trips always carry with you a full course of treatment.

If the prophylaxis has serious side effects, seek advice from the health delegate (if not available, seek advice from locally well known and well reputed professionals) and choose an alternative regimens.

If you are the Head of Delegation or Sub-delegation, please remember that you have the responsibility of informing all arriving delegates of the level of risk, the prophylaxis that must be taken and have it available at delegation/sub-delegation level. It is also your responsibility to make sure that all residences are properly screened and that all beds are provided with mosquito nets; that malaria prophylaxis and insecticide solution to impregnate mosquito nets (permethrine) are made available.

Recommendations to health delegates

As health delegate you must remember that consistency between words and your own action is critical to get adherence to agreed rules amongst those who do not have a clue of the seriousness of a malaria attack

Health Co-ordinators[1] must be aware of contra-indications to chemoprophylaxis and possible alternative regimens appropriate for the region.

Health Co-ordinators must be fully aware of the MoH standard chemoprophylaxis and treatment protocols in their country, as well as local availability of anti malarial drugs. Quality control is uneven from one country to another; therefore delegations should rely on drugs produced in countries with adequate quality control.

Health Co-ordinators are responsible for identifying referral hospitals and developing, in co-ordination with the HoD, a medical evacuation plan in line with the delegation security regulations.

Delegates should be reminded from time to time that they are living in endemic areas and that prophylaxis must be maintained. If side effects persist for more than 4 - 6 weeks, a second line prophylaxis drug regimen must replace the original one. It is your responsibility to advise on the second line regimen, if needed, after consultation with the Health Officer or the Health and Care Department

Remember protective measures taken against malaria will also reduce exposure to other illnesses transmitted by other insects.

| |

|Hannele Haggman, Health Officer, Tel +41-22-730 4417 e-mail: Hannele.Haggman@ |

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[1]Or health delegate depending on delegation structure

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