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Malaria Diagnosis, Treatment, Prevention

Malaria Diagnosis, Treatment, Prevention. Welcome to Malaria World. Statistics . 300-500 million people infected worldwide 1-2 million deaths annually Kills over 3,000 children DAILY 40% of the world’s population lives in malarious areas Major military importance for deployed US forces

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Malaria Diagnosis, Treatment, Prevention

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  1. Malaria Diagnosis, Treatment, Prevention

  2. Welcome to Malaria World

  3. Statistics • 300-500 million people infected worldwide • 1-2 million deaths annually • Kills over 3,000 children DAILY • 40% of the world’s population lives in malarious areas • Major military importance for deployed US forces • 1993, Operation Restore Hope, Somalia, Marines fell ill due to non-compliance and bad med intel as to plasmodium species in the area • 2003, Liberia, Marines and AF Ravens

  4. Infectious Parasitic Agent • Plasmodium ssp. • P. falciparum • most lethal, infects all ages of RBC’s • may cause hemolysis of 30% of RBC’s at a time • P. malariae • infects mature RBC’s • P. vivax and P. ovale • relapsing stage in liver • infect immature RBC’s

  5. Transmission: • Dusk to Dawn transmission • Transfer of sporozoites from mosquito saliva to human blood • Migrate to liver, infect cells and mulitiply • Liver cells rupture and release merozoites, which infect and cause rupture of RBC’s

  6. Clinical Signs • High fever, headache, chills • Anemia, splenomegaly, icterus • GI symptoms: nausea, vomiting, diarrhea • Periodicity of fever depends on species; almost continuous with P. falciparum

  7. Clinically severe signs with P. falciparum • Cerebral malaria: headache progressing to seizures, impaired consciousness, death • Renal tubular necrosis • Pulmonary edema due to tissue necrosis factor release

  8. Patient History • Travel to endemic area: Check the CDC “yellow book” for quick reference • “Airport malaria” is rare but possible; patient has not been to malarious area • Not on prophlyaxis or not compliant • Flu like symptoms may start in country, or weeks, months, or years after leaving area with relapsing forms ( P.vivax and ovale )

  9. Diagnosis • Gold Standard: Examine multiple blood smears, thick and thin, taken when fever is rising • Speciation is possible this way • “Dipstick” methods based on detecting P. falciparum proteins are used for field screening or confirmatory tests but do not replace the smears. • Expensive; malarious countries can rarely afford

  10. P. falciparum Delicate rings, multiples, marginalized, double chromatin

  11. P. malariae “Broad band” gametocyte form present, RBC’s not enlarged

  12. P. vivax Thick signet rings, enlarged RBC’s, developing forms

  13. P. ovale “Comet” shaped cells, enlarged RBC’s

  14. Prophylaxis • Chloroquine (non-resistant strains) • 300 mg base once weekly, begun 2 weeks before travel and continued until 4 weeks after leaving malarious area • Safe for pregnant women; however pregnant women are discouraged from travel to malarious areas! Mosquitoes prefer pregnant women due to skin temp and increased CO2 production.

  15. Prophylaxis • Mefloquine (non-resistant strains) • 250 mg weekly, 2 weeks prior, during, and 4 weeks after leaving malarious area • Can be given on days 1,2,3, and 7, then weekly, if time does not permit patient to start regimen 2 weeks prior. • Cannot be given to flyers • Side effects: nausea, dizziness, sleep disturbances

  16. Prophylaxis • Doxycycline • 100 mg SID, 1-2 days prior continuing through 4 weeks after. • OK for flyers with ground test • GI upset and sun sensitivity; yeast infections in women

  17. Terminal prophylaxis: • Primaquine is only drug that kills the relapsing stage (hypnozoite) of P. vivax and P. ovale in the liver • 23 mg daily for 14 days, upon leaving malarious area. • Not necessary to take it exactly upon leaving area; if it is missed, make sure it is taken at some point after deployment

  18. Prophylaxis • Flyers need ground test of doxycycline • All personnel should have known G6PD status before being given Primaquine. G6PD deficiency can lead to hemolysis. • If primaquine use is needed for treatment of malaria infection in G6PD deficiency, use once weekly, 30-45 mg for 8 weeks

  19. Malaria Treatment • Drug regimen depends on species of Plasmodium and severity of infection • Quinine (sulfate or dihydrochloride) • Malarone (atovaquone plus proguanil) • Mefloquine • Artemisinins (Chinese traditional tx) • Primaquine for relapsing species

  20. PREVENTION • DEET used on skin • Permethrin treated bednets and uniforms • Avoid activity dusk to dawn (showering, etc.) • Malaria control depends on direct discipline by those in command

  21. Good references: • Centers for Disease Control and Prevention (CDC) • Control of Communicable Disease Manual • Located with Public Health • National Center for Medical Intelligence (NCMI) • https://www.intelink.gov/ncmi/index.php • Air Force Reporting Instructions Tool (AFRIT) • https://aef.afpc.randolph.af.mil/AFRIT/Afrit.aspx

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