Malaria Prophylaxis – Travel Medicine

1. Malaria Prophylaxis – Travel Medicine Bryan S. Delage MD MC FS SAS North Dakota Air National Guard RSV Training for FS 2013

2. Malaria Prophylaxis • Objectives: • 1. Be able to access and search the CDC for recommendations for International Travel, and malaria prophylaxis. • 2. Learner should be able to choose appropriate malaria prophylaxis for travel to foreign countries • 3. Learner should be able to determine appropriate alternatives for Flyers and Non-Flyers for malaria prophylaxis • 4. Learner should be able to educate patients on appropriate ways to avoid contracting malaria while traveling, and the reasoning for prophylaxis.

3. Malaria Prophylaxis • Outline • A. Review of Malaria • B. Accessing the CDC web site for Travel Information • C. Appropriate antibiotics for prophylaxis • D. Alternatives for prophylaxis • D. Flyers vs. Non-flyers (Medication Guide) • E. Prevention of malaria ( An ounce of prevention is worth a pound of cure!)

4. Malaria Review • Malaria Review: • Infectious Agent : protozoan genus plasmodium; 4 species, falciparum, ovale, vivax, and malariae infect humans. (knowlesi – monkey, few human infections and deaths)

5. Malaria Review • All 4 species are transmitted by a bite from an infected anopheles female mosquito. Occasional transmission from blood transfusion, sharing needles or congenitally. • It accounts for 350-500 million infections yearly, and 1 million deaths

6. Malaria Review • Malaria transmission occurs in large areas of Africa, Central and South America, in the Caribbean, South and Southeast Asia, the South Pacific; as well as the Middle East and Eastern Europe

7. Malaria Review • Symptoms for malaria are fever, and influenza like symptoms: chills, headache, myalgias and malaise; and can occur at intervals, and uncomplicated disease can show anemia and jaundice; if severe, seizures, confusion, ARDS, coma and death can occur.

8. Malaria Review • Diagnosis by thick blood smears is the Gold Standard. • The CDC recommends only 2 treatments with reliable supply, for disease; atovaquone-proguanil, and artemether-lumefantrine

9. Malaria Prophylaxis • Preventing the transmission of malaria is best done by avoidance measures, and chemoprophylaxis • The need for chemoprophylaxis and what to recommend depends on the risk in the destination for travel.

10. Malaria Prophylaxis • There are a number of medications for malaria prophylaxis: • Atovaquone-Proguanil (Malarone) • Doxycycline • Mefloquine • Chloroquine and hydroxychloroquine • Primaquine

11. Malaria Prophylaxis • Historically the biggest problem with chemoprophylaxis is the resistance of some plasmodium falciparum strains to chloroquine. This has been found in all strains of falciparum in the world except for some in the Caribbean and Central America west of the Panama Canal and some countries in the Middle East.

12. Malaria Prophylaxis • Mefloquine resistance has been confirmed on the Borders of Thailand with Burma (Myanmar), and Cambodia, in the western provinces of Cambodia, and eastern States of Burma between Burma and China

13. Malaria Prophylaxis • So making a travel recommendation is based on good information of the risk in that country, the most reliable source for recommendations is the CDC, and accessing that information is easy. • http://www.cdc.gov/travel • Travelers' Health - CDC

14. Malaria Prophylaxis • Atovaquone-Proguanil • Doxycycline • Mefloquine • 1-2 days before, daily while in country and 7 days after • 1-2 days before, daily in country and 4 weeks afterwards • > = 2 weeks before, weekly in country and weekly for 4 weeks afterwards

15. Malaria Prophylaxis • Chloroquine and hydroxychloroquine • Primaquine • 1-2 weeks before travel, weekly while in country, and for 4 weeks afterwards • Only used for prophylaxis in areas with p. vivax, and for terminal prophylaxis

16. Prophylaxis Side Effects and Contraindications • Atovaquone-Proguanil • Doxycycline • Mefloquine • Abdominal pain, nausea, vomiting, headache, contraindicated in children less than 5kg, pregnant women, or patients with renal impairment • Photosensitivity, vaginal yeast infections, nausea/vomiting, contraindicated if allergic, during pregnancy, infants and children less than 8 • Rare psychoses or seizures, GI side effects, HA, insomnia, abnormal dreams, depression, anxiety, motor neuropathies; contraindicated in psychiatric patients and cardiac conduction problems

17. Prophylaxis Side Effects and Contraindications • Chloroquine and hydroxychloroquine • Primaquine • GI Disturbance, HA, dizziness, blurred vision, insomnia, pruritis, may exacerbate psoriasis, contraindicated where plasmodium falciparum is resistant • Contraindicated for those who have G6PD deficiency; GI upset. Primarily for P.vivax, not effective as prophylaxis for other strains

18. Flyers and Prophylaxis • Options • 1. Prophylaxis with Doxycycline • 2. DNIF and mefloquine • 3. Prophylaxis with Malarone (Atovaquone/proguanil) • Historically cheap, but supply may be issue, and contraindicated if allergic, no DNIF or GT • Not the best option, but if in a non-flying status is an option • According to Aircrew Med List – may be used after appropriate Ground Trial

19. Prophylaxis and Flyers • Aircrew Medication Guide does recommend that the last 2 weeks of prophylaxis for Doxycycline should be taken with Primaquine if not contraindicated • Aircrew medication guide does indicate in those taking malarone prophylaxis primaquine terminal prophylaxis for 2 weeks, for the last week with malarone, and for another week after malarone if not contraindicated

20. Prophylaxis and Flyers • Chloroquine can also be used for areas without mefloquine or chloroquine resistance – but also requires terminal prophylaxis with primaquine and ground testing prior to use. • So ground testing is required for use of malarone, primaquine, and chloroquine prior to use in Flyers,

21. Avoidance and Deterrence • Insect Repellent • Permethrin treatment of clothing • Lodging • DEET (30% or more) • Picaridin • Oil of Lemon Eucalyptus • IR 3535 • Buy treated clothing or treat long sleeve clothing • Stay inside in air conditioned rooms at night, use bed nets

22. Summary • Malaria Prophylaxis is easy, recommendations for meds are easily found at www.cdc.gov/travel • The short supply of doxycycline may affect choices, but for most including flyers after a ground trial, malarone is a good substitute • Avoidance measures and using insect repellent and treating clothing with permethrin are helpful adjuncts to malaria prophylaxis • Stress the risk for disease and the benefits of completing a full course, and if unable to complete due to side effects, switch to other meds for terminal prophylaxis