Malaria Options

[aussie]

I asked a Malaria expert working for the World Health Organisation as an advisor to the PNG Government on Malaria for some information on Malaria as I know, this is something you all worry about. His suggestion was that you print this out and keep it handy just in case so you need to pass it on your doctor back home in Australia.

I have lived in PNG since 1972 and have only been subjected to Malaria twice. Once in 1974 and again in 2010. Even here in PNG the doctors can get it wrong. When I became sick I immediately took a dose of Malaria tablets as everything was pointing to Malaria being the cause. When the course of tablets had run out I was still sick. I was then put into hospital and informed I had typhoid fever so was put on a treatment dose of 'Ciprofloxacin Tablets'. After two weeks and still not feeling well, I went back for a review.

Another blood test followed and another course of 'Ciprofloxacin Tablets'. However, I was not responding and began blacking out. I was soon on a flight to Cairns where they did a culture test of my blood. It was confirmed that I had Malaria, in fact the worst strain of Malaria. They put me on a course of Artemether - Lumefantrine (Riamet) 20mg-120mg. I noticed an immediate improvement in my health and for the first time in a month, started to feel like I wanted to get out of bed. Thats the thing about Malaria, if on the correct medication and course of tablets, it only lasts a few days. So if in doubt, ask for a culture test of your blood so you get the results quickly and ask for them to check for Malaria if you have been to PNG.

quote:

The Department of Health announces new combination treatment for all malaria in Papua New Guinea.

The following guidelines are to take effect immediately:

Fansidar must now be used in combination with chloroquine or camoquine for uncomplicated malaria.

Artemisinin drugs are now approved to replace quinine, as the second line drug of choice for severe/complicated and TFM cases. Artemisinin must be combined with Fansidar.

All health workers should familiarise themselves witha these new quidelines. All Standard Treatment manuals are being updated and should be available soon.

This message serves as a ready reference only. It is not intended to replace the Treatment Protocol, copies of which can be obtained by contacting the Malaria Control Program, Department of Health on telephone:

+675 301 3774 or +675 301 3736

Attached image(s)

 

[aussie]

SIMPLE / UNCOMPLICATED MALARIA

1. Chloroquine and Camoquine will continue to be used as the first line treatment. Dosages remain unchanged.

2. Fansidar must now be added to both Chloroquine and Camoquine. Fansidar is to be given as a single dose, on the first day of treatment.

Stat dose of Fansidar:

25 mg sulfadozine / kg - body weight (one 500 mg tablet per 20 kg body weight).

A clinical efficacy trial completed in Papua New Guinea has demonstrated the efficacy of the Chloroquine + Fansidar combination. It was 100% effective.

FACT: Malaria is the leading cause of death and morbidity in PNG. Rapid diagnosis and effective treatment are key strategies to reduce the incidence of malaria in PNG.

FACT: PNG's whole population is a risk of malaria. The Highlands region is increasingly becoming epidemic-prone. Indoor residual DDT spraying can reduce the malaria transmission risk in the Highlands.

FACT: Treated bednets are an effective public health intervention, but you must cover 80% of your target population to achieve an impact on malaria.

[aussie]

SEVERE MALARIA and TREATMENT FAILURE MALARIA:

Complicatedmalaria is indicated by the following danger signs:

• changes in behaviour (convulsions; consciousness; confusion; inability to walk; speak or recognise relatives);
• repeated vomiting; inability to retain oral medications; inability to eat or drink;
• passage of small quantities of urine or no urine; passage of dark urine;
• severe diarrhea;
• unexplained heavy bleeding from nose, gums or other sites;
• high fever (above 39 degrees celcius)
• severe dehydration (loose skin sunken eyes);
• anaemia
• yellow whites of eyes (jaundice)

1. Quinine is now replaced by Artemisinin derivatives (eg Artesunate, Artemether). The approved formulation for use are Artesunate 50 mg tablets and Artemether injection 80 mg/ml and 40 mg/ml ampoules.

2. Quinine is now reclassified as a category B drug. Its main use will be in the treatment of complicated malaria in the first Trimester of pregnancy. Artemisinin will be used for the treatment of complicated malaria in second/third trimesters of pregnancy.

3. Artesunate is given as a single daily dose for 7 days. The dose on day 1 is doubled as this is the loading dose. You would thus administer Artesunate as follows:

Day 1: 4mg / kg-bodyweight
Day 2-7: 2mg / kg-body weight

Give Fansidar on Day 3 (or sooner is patient able to swallow). Stat dose Fansidar: 25 mg sulfadoxine/kg body-weight.

4. Artemether is given IMI as a daily dose. You should change over to Artesunate tablets when the patient is able to take oral medication.

The first does of Artemether is doubled. Thus you would administer artemether as follows:

Day 1: 3.6 mg / kg-bodyweight
Day 2-7: 1.6 mg / kg-bodyweight

Give Fansidar on Day 3

Stat dose Fanisdar:

25 mg sulfadoxine / kg body-weight

Whenever possible, do a bloodslide in all cases of severe malaria and TFM's. REfer immediately to either health centre or hospital.

[aussie]

Treatment Failure Malaria (TFM)

If the plasmodium species is unknown, treat as for complicated malaria (Artesunate and Fansidar).

Diagnosis is made by bloodslide examination:

For Falciparum Malaria: irrespective of the patient's clinical status, the patient is treated as for complicated malaria, ie, Artemisinin derivative and Fansidar. For pregnant women in first trimester, use Quinine and Fansidar.

For Viavax Malaria: repeat treatment as for uncomplicated malaria (Chloroquine/Fansidar) followed by 14 day course of Primaquine. (to prevent later relapse from vivax parasites hidden in the liver).

For people from endemic areas (ie year round risk of frequent reinfection), may choose to omit primaquine. Treat or retreat vivax malaria as for uncomplicated malaria, then decide if primaquine makes sense.

Vivax relapse within 28 days of treatment: in any person irrespective of whether that person is from an endemic or non-endemic area, treat as for uncomplicated falciparum malaria followed by 14-day course of primaquine.

Primaquine is contraindicated in pregnancy: lactating mothers, G6-PD deficiency and young children less than 6 kg.

Pregnant women with bloodside positive vivax (confirmed) malaria should be treated as for uncomplicated malaria followed by regular chloroquine prophylaxis (no primaquine).

[aussie]

PROPHYLAXIS

Pregnancy: at booking, treat for uncomplicated malaria, followed by weekly chloroquine. Any breakthrough is treated with Artemisinin/Fansidar.

Prophylaxis for Adults: Partially immune nationals and long term foreign residents of PNG. Anyone in these group living in low transmission areas (Highlands or NCD), who travel to Holoendemic areas (high transmission areas) for work or holidays, should take chloroquine (300 mg weekly adult dosage) or mefloquine (5mg/kg weekly); or doxycycline (100 mg daily adult dosage); or chloroquine plus maloprim weekly.

Mefloquine is not to be taken by people with history of epilepsy, Phychosis or mental illness, or pregnant women.

Doxyclcline is not to be taken by children less than 15 years, or by pregnant women.

Fansidar (sulfadoxine-pyrimethamine) should not be used for prophylaxis (Fansidar for stat treatment only).

Children: (including those with thalassaemia, severe anaemia, malnutrition, big spleen/TSS) should take infant camoquine. Breakthrough is treated with Artemisinin/Fansidar.

Tropical Splenomegaly Syndrome: continue weekly chloroquine. Any breakthrough, positive bloodslide, severe anaemia (Hb less than 5g%), acute haemolysis is treated with Artemether/Fansidar. Pregnant women who develop TSS should be treated with quinine / Fansidar.

Post Splenectomy patients: for adults, weekly chloroquine for life. For children infant camoquine weekly.

Chloroquine Allergy: person who has had severe reations to chloroquine, skin reactions (excluding mild itchy skin, eye toxicity, thrombocytopaeria should be treated as for complicated malaria.

Transfusion malaria prophylaxis:

Use Artemisinin/Fansidar.