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Presentation Transcript

Malaria Prevention: 

Malaria Prevention Mary F. Vaeth, MD, MS Deployment Health Clinical Center

Malaria Prevention Objectives: 

Malaria Prevention Objectives Describe geographic distribution and risk factors for malaria Review classification and life cycle of malaria parasite Describe personal protective measures for malaria prevention Discuss malaria chemoprophylaxis

Epidemiology of Malaria: 

Epidemiology of Malaria Global malaria Incidence increased over 40 years 300-500 million infected annually (90% in Sub-Saharan Africa Over 1 million deaths annually (mostly infants and children Reasons malaria problem has worsened Development of resistance by parasite and mosquito vector Socioeconomic problems Movement of nonimmune populations into malarious areas (refugees and travelers)

Malaria Endemic Countries: 

Malaria Endemic Countries P. falciparum (most prevalent) and P. malariae in all shaded areas P.ovale predominant in Sub-Saharan Africa and P. vivax in the other areas Centers for Disease Control and Prevention

Countries and Territories With Malarious Areas: 

Countries and Territories With Malarious Areas * = P. vivax risk only World Health Organization

Cause of Malaria: 

Cause of Malaria Cause – protozoan parasite genus Plasmodium Vector – female Anopheles mosquito (about 60 of the 400 species) Host - man Species of malaria parasite - P. falciparum P.vivax P. ovale P. malariae

Transmission: 

Transmission Vector – Anopheles mosquito Blood transfusion Organ transplant Congenital

Malaria Risk: 

Malaria Risk Risk varies widely between and within countries Depends on travel itinerary (location, duration, type of travel) Transmission is highest in Africa Most urban areas are malaria-free except in Africa and India Risk highest at end of rainy season Usually restricted to altitudes below 1500 meters but can occur up to almost 3000 meters

Locations of P. falciparum Drug Resistance: 

Locations of P. falciparum Drug Resistance Resistance to Chloroquine has been confirmed in all areas with P. falciparum malaria except Dominican Republic Haiti Central America west of former Panama Canal Zone Egypt Some countries in the Middle East

Locations of P. falciparum Drug Resistance (cont.): 

Locations of P. falciparum Drug Resistance (cont.) Resistance to Fansidar Widespread in Amazon River Basin area of South America Much of Southeast Asia Other parts of Asia Large parts of Africa Resistant to Mefloquine Borders of Thailand with Myanmar (formerly Burma) and Cambodia Western provinces of Cambodia Eastern states of Myanmar

Locations of P. vivax Drug Resistance: 

Locations of P. vivax Drug Resistance Resistance to Chloroquine Indonesia Papua New Guinea Declining sensitivity to Chloroquine Brazil Columbia India Myanmar (formerly Burma) Republic of Korea Thailand

Locations of P. malariae Drug Resistance: 

Locations of P. malariae Drug Resistance Resistance to Chloroquine Indonesia

Three Stages of Malaria Parasite Life Cycle: 

Three Stages of Malaria Parasite Life Cycle Liver Red blood cells Mosquito

Life Cycle of Malaria Parasite: 

Life Cycle of Malaria Parasite Centers for Disease Control and Prevention Division of Parasitic Diseases

Malaria Incubation Period: 

Malaria Incubation Period Corresponds with liver stage of malaria parasite P. falciparum 12 Days P. vivax 14 Days* P. ovale 14 Days* P. malariae 30 Days * May be 8 - 10 months or longer for some strains

Life Cycle of Malaria Parasite (cont.): 

Life Cycle of Malaria Parasite (cont.) Infected mosquito takes blood meal and injects sporozoites into human host Sporozoites infect liver cells, multiply and mature into schizonts that rupture and release merozoites into the bloodstream In P. vivax and P. ovale, a dormant stage (hypnozoites) can persist in the liver and cause relapses by invading the bloodstream weeks, or even years, later Merozoites infect red blood cells

Slide17: 

Malaria Parasite in Red Blood Cells

Classic Clinical Symptoms of Malaria: 

Classic Clinical Symptoms of Malaria Blood stage parasites are responsible for clinical manifestations Classical cyclic paroxysms Cold stage: chills and shaking Hot stage: warm, headache, vomiting Sweating stage: weakness Feel well for period of time, then cycle repeats itself

Life Cycle of Malaria Parasite (cont.): 

Life Cycle of Malaria Parasite (cont.) Some merozoites mature into schizonts that rupture into the bloodstream releasing more merozoites Some merozoites differentiate into sexual cells (male and female gametocytes) Mosquito ingests gametocytes during blood meal Gametocytes mature and produce a fertilized egg that grows, ruptures and releases sporozoites Sporozoites migrate to mosquito’s salivary gland waiting to be injected into a new human.

Principles of Malaria Protection: 

Principles of Malaria Protection Be Aware of the risk, the incubation period, and the main symptoms Avoid Being bitten by mosquitoes, especially between dusk and dawn Take the (Chemoprophylaxis) antimalarial drugs to suppress infection when appropriate Seek immediate Diagnosis and treatment if a fever develops one week or more after entering an area where there is a malaria risk, and up to 1 year after departure

Personal Protective Measures (PPM): 

Personal Protective Measures (PPM) Avoid malarious areas Stay indoors from dusk to dawn in screened or air conditioned rooms Use insect spray inside rooms, bed nets Cover skin by wearing long sleeves, long pants Apply DEET lotion on exposed skin Use treated bed nets

DoD Insect Repellent System: 

DoD Insect Repellent System YOU NEED TO KNOW… Dry cleaning removes permethrin from the uniform + + = MAXIMUM PROTECTION Permethrin On Uniform DEET On Exposed Skin Properly Worn Uniform US Army Center for Health Promotion and Preventive Medicine

Insect Repellents For Skin And Clothing: 

DEET lotion NSN 6840-01-284-3982 Apply a thin coat to EXPOSED skin One application lasts up to 12 hours Insect Repellents For Skin And Clothing Individual Dynamic Absorption Kit (IDA) Treatment lasts for for over 50 launderings NSN 6840-01-345-0237 NSN 6840-01-278-1336 Aerosol spray can Treatment lasts through 5-6 washes Permethrin US Army Center for Health Promotion and Preventive Medicine

Use of Bed Net While Sleeping: 

Use of Bed Net While Sleeping Spray the outside of the net with permethrin Tuck edges under cot or sleeping bag Don’t let net touch your skin while you sleep US Army Center for Health Promotion and Preventive Medicine

Chemoprophylaxis: 

Chemoprophylaxis Broad term comprising multiple strategies for the prevention of disease using medications Primary prophylaxis Prior to, during, and after the exposure period to prevent the initial infection Terminal prophylaxis At the end of the exposure period (or immediately after) to prevent relapses or delayed-onset of clinical presentations

Action of Antimalarial Drugs: 

Action of Antimalarial Drugs Kills parasites during multiplication phase in red blood cells Suppresses symptoms by lowering the number of parasites in the blood; does not prevent infection Taken long enough, eventually eliminates P. falciparum and P. malariae infection Requires terminal prophylaxis to eliminate liver stage of P. vivax and P. ovale

Factors for Choosing Malaria Chemoprophylaxis: 

Factors for Choosing Malaria Chemoprophylaxis Type of malaria Drug resistance in specific locations History of allergic or other reaction to the anti-malarial drug of choice Restriction based on job (e.g., mefloquine not authorized for aviators and divers)

Drugs for Primary Malaria Chemoprophylaxis: 

Drugs for Primary Malaria Chemoprophylaxis Chloroquine Mefloquine (Lariam® and generic brands) Doxycycline Atovaquone-proguanil (Malarone®)

Schedule for Taking Primary Malaria Chemoprophylaxis: 

Schedule for Taking Primary Malaria Chemoprophylaxis Prior to travel, start malaria medication: Chloroquine and mefloquine - 1 to 2 weeks Doxycycline and atovaquone/proguanil - 1 to 2 days Can start earlier to allow any potential adverse effects to be identified prior to travel Most antimalarial drugs well tolerated (Minor side effects do not require stopping the drug) Continue drug during travel and after leaving malarious area: Chloroquine, mefloquine and doxycycline - 4 weeks Atovaquone/proguanil - 7 days

Antimalarial Medications: 

Antimalarial Medications Chloroquine Mefloquine (Lariam® and generic brands) Doxycycline Atovaquone-proguanil (Malarone®) Primaquine

Chloroquine: 

Chloroquine Adults: 500 mg per week (300 mg base) From 1-2 weeks before entry, during, and 4 weeks after exit from malarious area OK in all ages, including infants, pregnant and lactating women Overdose in children potentially fatal Side effects: GI upset, headache, dizziness, blurred vision, insomnia and pruritis Has been reported to exacerbate psoriasis Occasional GI upset, recommend take with food

Drugs of Choice in Chloroquine-Resistant Areas: 

Drugs of Choice in Chloroquine-Resistant Areas Mefloquine (Lariam ®) Doxycycline Atovaquone-proguanil (Malarone®)

Mefloquine (Lariam ®): 

Mefloquine (Lariam ®) Adults: 250mg per week From 1-2 weeks before entry, during, and 4 weeks after exit from malarious area Safe for use in 2nd and 3rd trimesters and inadvertent use in 1st trimester has not resulted in adverse effects Safe for use in breastfeeding women, but infants must take their own separate dose of mefloquine

Mefloquine Contraindications: 

Mefloquine Contraindications Known hypersensitivity to mefloquine or related compounds (e.g., quinine or quinidine) Active depression or recent history of depression Generalized anxiety disorder, psychosis, schizophrenia, or other major psychiatric disorders History of seizure disorder or epilepsy

Mefloquine Cautionary Warnings: 

Mefloquine Cautionary Warnings May cause psychiatric symptoms at rate of 1 per 2,000-13,000 persons Symptoms include: anxiety, paranoia, depression, hallucinations, psychotic behavior Rarely symptoms continue after drug is stopped Rare cases of suicidal ideation and suicide although no relationship has been confirmed Advise patients to discontinue medication if experience psychiatric symptoms such as excessive anxiety, depression, restlessness or confusion Substitute alternative antimalarial medication

Lariam Medication Guide: 

Lariam Medication Guide Developed by the Food and Drug Administration (FDA) in cooperation with the drug’s manufacturer, Roche Pharmaceuticals Designed to help ensure patients understand the risks of malaria, and the rare but potentially serious psychiatric adverse events associated with use of Lariam As of July 2003, required that a Guide be given to the traveler each time that Lariam is dispensed Copy available at http://www.fda.gov/medwatch/ SAFETY/2003/LariamMedGuide.pdf

Doxycycline: 

Doxycycline Adults: 100 mg per day From 1-2 days before entry, during, and 4 weeks after exit from malarious area GI upset, photosensitivity, vaginal yeast infections, esophageal ulceration possible Take with sufficient liquid to transport capsule into stomach; take with food Contraindicated in pregnancy, lactation, and in children 8 and under Effectiveness equivalent to mefloquine and chloroquine

Atovaquone-proguanil (Malarone®) : 

Atovaquone-proguanil (Malarone®) Adults: 1 tablet per day (atovaquone 250mg, proguanil 100mg) From 1-2 days before entry, during, and for 7 days after exit from malarious area Take with food or milky drink Adverse effects: abdominal pain, nausea, vomiting, headache Contraindicated in children <11kg, pregnant women, women breastfeeding infants <11kg, and patients with severe renal impairment

Pregnancy and Malaria: 

Pregnancy and Malaria Malaria infection more severe Increased risk for prematurity, abortion, stillbirth Advise women who are pregnant or likely to become pregnant to avoid travel to malarious areas if possible Chemoprophylaxis Chloroquine is safe Mefloquine is safe in 2nd and 3rd trimester and probably during the 1st Don’t use primaquine, doxycycline, and atovaquone/proguanil

Terminal Prophylaxis with Primaquine: 

Terminal Prophylaxis with Primaquine Decreases the risk of relapses by eradicating liver stage of P. vivax and P. ovale Taken for 14 days during last 2 weeks of 4 week post-exposure prophylaxis with chloroquine, mefloquine or doxycycline Taken during the final 7 days of post-exposure prophylaxis with atovaquone/proguanil and for an additional 7 days or for 14 days after atovaquone/proguanil has been completed Adults: CDC has recently increased the recommended dose from 15mg to 30 mg

Terminal Prophylaxis with Primaquine (cont.): 

Terminal Prophylaxis with Primaquine (cont.) Possible GI distress; take with food Contraindicated in pregnancy Breastfeeding OK if infant G6PD negative G6PD deficiency and primaquine Inherited sex linked trait, full expression in males More common in persons of African, Mediterranean and Asian ancestry Primaquine causes hemolysis, more severe in Mediterranean and Canton variants G6PD testing advisable before treatment with primaquine

Restrictions on Blood Donation: 

Restrictions on Blood Donation Persons who are residents of nonmalarious countries are not allowed to donate blood for 1 year after returning from a malarious area Persons who are residents of malarious countries are not allowed to donate blood for 3 years after leaving a malarious area (Residence is > 6 months in country) Persons who have had malaria are not allowed to donate blood for 3 years after completion of treatment for malaria

Information Sources Centers for Disease Control and Prevention: 

Information Sources Centers for Disease Control and Prevention Health Information for International Travel Malaria locations and prophylaxis guidelines http://www.cdc.gov/travel/yb National Center for Infectious Disease, Division of Parasitic Diseases Prophylaxis guidelines http://www.cdc.gov/ncidod/dpd/parasites/ malaria/default.htm

Information Sources (cont.) Other Sources: 

Information Sources (cont.) Other Sources World Health Organization http://www.who.int/health-topics/malaria.htm Navy Environmental Health Center Navy Medical Department Pocket Guide to Malaria Prevention and Control NEHC-TM PM 6250.1 (September 2000) www-nehc.med.navy.mil/downloads/prevmed/ Malaria2000.PDF

Information Sources (cont.) Other Sources (cont.): 

Information Sources (cont.) Other Sources (cont.) US Army Center for Health Promotion and Preventive Medicine http://chppm-www.apgea.army.mil Armed Forces Medical Intelligence Center Malaria locations http://mic.afmic.detrick.army.mil

Information Sources (cont.) Deployment Health Clinical Center: 

Information Sources (cont.) Deployment Health Clinical Center For Clinicians For Veterans & Families For Reserve Components Deployment Cycle Support Education and Training Emerging Health Concerns Items and Announcements Library Education and Training Risk Communication Research War on Terrorism New Users Contact DHCC Index & Site Map Help and FAQs http://www.PDHealth.mil

Slide47: 

DoD Deployment Health Clinical Center Walter Reed Army Medical Center Building 2, Room 3G04 6900 Georgia Ave, NW Washington, DC 20307-5001 E-mail: pdhealth@na.amedd.army.mil Website: www.PDHealth.mil Provider Helpline 1-866-559-1627 Questions, Information, Assistance Patient Helpline 1-800-796-9699 202-782-6563 DSN:662