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MALARIA Prevention etc

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					              MALARIA
           Prevention, etc.

           CDR Mark Malakooti, MC, USN
Navy Environmental And Preventive Medicine Unit #2
                   Norfolk, VA
                 (757) 444-7671
                  Basics
A  mosquito-borne infectious disease
 Protozoan parasites of the genus Plasmodium
 Transmitted only by Anopheles mosquitoes
 Four species:
      P falciparum

      P vivax

      P ovale

      P malariae
              Why The Concern?
   Most prevalent disease in the world
     – 2.1 billion live in malarious areas
     – 100-300 million new cases annually
     – 1-3 million deaths annually
   4685 cases imported malaria in U.S. travelers ’92-’01
     – 19% inappropriate chemoprophylaxis
     – 56% took no chemoprophylaxis
     – 7 malaria-related deaths U.S. civilians given
       inappropriate chemoprophylaxis, CDC 1992-2001
   Potentially lethal disease
 Serious    threat to military ops
   Recent Military Experience
 Navy/Marines   – 62 cases worldwide 1997-2000
 Somalia – 1993 – 106 cases in Marines
                  – 127 cases U.S. Army
 Sierra Leone –1996 – 6 cases in Marines
                      – 91 cases British Army
 Nigeria - 2001 – 7 cases with 2 deaths, USA SF
 JTF Liberia outbreak - 80 cases treated:
   – 69/157 (44%) 26th MEU spending nights ashore
   – 80/290 (28%) JTF members any time ashore.
               Susceptibility

 Universal   susceptibility, EO

 No   absolute immunity
  – Partial immunity in areas of high endemicity
        Plasmodium Species
 P.   falciparum
  – Most severe and prevalent
  – 40-60% of cases
  – Widespread chloroquine resistance
  – Infects RBCs of all ages—Heavy parasitemia
             Presentation
 Fever                     96%
 Chills                    96%
 Headache                  79%
 Muscle Pain               60%
 Palpable liver            33%
 Palpable Spleen           28%
 Nausea or vomiting        23%
 Abdominal pain/diarrhea    6%
       Signs In Acute Infection

 Slightly   ill, Alert

 In   distress, Unconscious

 Fever
          Complicated Malaria
   Hyperparisitemia: (>3%)
   Hypoglycemia: (<60 mg/dl)
   Severe anemia (hct < 21% or rapidly falling hct)
   Renal failure
   Hyponatremia
   Cerebral malaria
   Prolonged hypothermia
   High output vomiting or diarrhea
   Pregnancy
    DIAGNOSIS
   Gold standard:
    Multiple thick and thin
    smears
   RDTs - dip stick tests




   CBC
   Examples of RDTs:




                         OptiMal Assay
     Para Sight F test                   OptiMal assay Result
                              Kit




•Require minimal training
•2 to 6 steps, take 5 to 30 minutes
•US $1.20 to $13.50 per test.
•None approved by FDA for diagnosis of malaria in US
               Treatment
 Chloroquine-sensitive   infections:

  – CHLOROQUINE 600 mg (2 tabs) po initially
  – 300 mg (1 tab) in 6 hrs
  – 300 mg (1 tab) QD for 2 days
               Treatment
 Uncomplicated     chloroquine-resistant
 infections:
  – Quinine 650 mg po tid x 3 days and
    doxycycline 100 mg po bid x 7 days,
        OR
  – Mefloquine 4-6 tabs po once
        OR
  – Malarone® 4 tabs po x 3 days

 Complicated    or severe infections
  – I.V. quinidine or quinine
  – ICU Care
                 Treatment
 Vivaxand ovale therapy should include
  PRIMAQUINE 30mg PO QD x 14 days
 Always check G6PD status
  – Risk of hemolysis




     N-(6-methoxyquinolin-8-yl)pentane-1,4-diamine
          Optimal Treatment
              Approach

 Rapid case identification
 Rapid parasitological classification
 Rapid initiation of therapy
 Rapid initiation of supportive care
                   Prevention
 Chemoprophylaxis
  – Check with PMO or ID
  – Based on current drug resistance patterns
 MEFLOQUINE
  –   Mefloquine 250mg. po q week, 2 wks prior to 4
      wks after
  OR
 DOXYCYCLINE
  –   Doxy 100mg. po qd, 2 days prior to 4 wks after
  PLUS
 PRIMAQUINE
  – 30mg. po qd x 14 days terminal prophylaxis
      Newest Antimalarial:
Atovaquone/Proguanil (Malarone®)

 Licensed 2000 in USA for treatment and
 prophylaxis of P. falciparum
  – Atovaquone is a blood schizonticide
  – Proguanil is metabolized to cycloguanil, a tissue
    schizonticide

 Combinationvery effective for prevention
 and treatment of multi-drug resistant P.
 falciparum
  – Generally well tolerated with >95% efficacy vs.
    placebo
        Dosage of              Malarone ®

 Prophylaxis  dose: one tablet per day
 Start 1-2 days prior to entering endemic
  area
 Continue for one week after leaving
    – (causal prophylaxis, kills parasites in liver)

 Adult    formulation:
    –   250 / 100 mg atovaquone / proguanil in single
        combination tablet
   Pediatric formulation:
    – 62.5 / 25 mg single tablet
  Cost of Malaria Chemoprophylaxis

 US$        3 day      1 wk        2 wk         4 wk      12 wk 24 wk

Meflo-         21         24          27         34          62         103
quine
Mala-          35         47          67         108        272         517
rone
Doxy-           1        1.18        1.40       1.85        3.65       6.34
cycline
Primaquine 2 week course: $3.22

doxycycline ($0.032); mefloquine ($3.42); primaquine ($0.115); Malarone ($2.92).
                          Other Drugs
 Artemesinin-derivative              combinations   (not avail in US)
    – Herb Artemisia annua, rapid blood schizonticide, IM/PO/PR
    – Coartem, Riamet artemether/lumefantrine
            3-day treatment 4 pills twice daily
    – Artesunate
   Tafenoquine
    –   synthetic primaquine analogue, half-life 14 days
    –   currently in advanced field testing, 1 tablet per week
    –   causal prophylactic for both P. falciparum and P. vivax
    –   radical cure for P. vivax/ovale single dose
    –   treatment for multidrug-resistant P. falciparum and
        chloroquine-resistant P. vivax
 Primaquine          for causal prophylaxis
    – 2 tabs daily, 2 days before through 7 days after exposure
       Most Important- Reduce Contact
              with Mosquitoes
 Personal   protective measures
  –   Proper wearing of uniform
  –   DEET
  –   PERMETHRIN
  –   Bed nets
        July 20, 2001 / 50(28);597-9


Malaria Deaths Following Inappropriate
Malaria Chemoprophylaxis ---United
States, 2001

•January--March 2001
•Two deaths in U.S. citizens

      •CASE 1 - 12-year-old
      •CASE 2 - 47-year-old
  Recent Military Experience

 Somalia, Restore Hope, ’92-’93
  – 106 cases in Marines
  – 127 cases U.S. Army
 JTF Liberia   outbreak - 80 cases treated:
  – 69/157 (44%) 26th MEU spending nights ashore
  – 80/290 (28%) JTF members any time ashore.
                 Somalia and Liberia
   Issues
     – Command responsibility
     – Compliance
            switching to mefloquine
    –   Location of camps
    –   Weather  poor usage of DEET
    –   Non-use of bed nets
    –   primaquine terminal prophylaxis
            USA had not recommended

 Cases resulted from failure to
    implement proper prophylaxis and
    personal protection
                 Current Issues
   DTG: 1/6/2005 Subject: MOD 7 TO USCENTCOM INDIVIDUAL
    PROTECTION AND INDIVIDUAL/UNIT
    DEPLOYMENT POLICY
     – COMPONENT/CJTF POLICIES WILL BE STORED ON THE
       COMMAND SURGEON HOME PAGE
       (HTTP://RECLUSE.CENTCOM.SMIL.MIL/CCSG/) UNDER
       THE FORCE HEALTH PROTECTION LINK
 AFGHANISTAN (March-November-year round)
 Iraq (MNC-I) Policy Malaria Prevention Dec04
 CJTF-HOA
 USS Comfort SOUTHCOM cruise
 Gulf of Guinea ops
             Conclusions
Education and aggressive monitoring of
compliance is needed for chemoprophylaxis
and personal protective measures to work
Remember:
            Flu-like Symptoms
                 +
            ‘Recent’ Travel
            To Malarious Area
                 =
            Think Malaria

				
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posted:4/26/2008
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