Malaria ======= þ Drugs for prevention: - Malarone (atovaquone/proguanil) 250mg/100 mg i tab daily - Mefloquin (Lariam): - Doxycycline 100 mg daily - Chloroquine phosphate (e.g., Aralen) 500mg (300 mg of base) weekly - pyrimethamine sulfadoxine (Fansidar): 3 doses PO stat for treatment - primaquin 30 mg base daily þ Incubation period - 5.5-15 days for intrahepatic phase, depending on species þ Prophylaxis: - Africa, e.g., Kilimanjaro: The current thought up here in Canada is that the non medical traveller should not begin a self treatment for malaria unless they are unable to seek medical care within 24 hours from the time of onset (fever). Due to the fact that malaria symptoms are so non-specific there is a real risk of treating another disease, and or running into problems with the toxicity of malaria therapy. I have heard that there is a rapid detection (of malaria) product sold outside of Canada that uses a simple dipstick test. The sensitivity and specificity of these tests in research laboratories is > 90%. There is however limited (if any) data about their accuracy in the hands of non-experienced operators and under non-refrigerated (read: real world) conditions. I am not sure if they are ready to be used yet by the wilderness traveller for the self diagnosis of malaria. Before recommending that a traveller undertakes self diagnosis and treatment I think it is important for us (the medical worker) to sit down and educate them on the signs and symptoms of malaria, other diseases that it can mimic and the risk / benefits of starting treatment on their own. It is also as important for the person to realize that they must get to a physician as soon as possible and that self treatment does not negate this obligation. I tell them that it is a "life saving measure like a AnaKit" and that self treatment is only temporary. Quinine alone to carry for self treatment is not good enough. For self treatment (prior to getting to a medical clinic): If in a chloroquine sensitive regions and not receiving chloroquine prophylaxis, self-treatment with chloroquine should be taken. Chloroquine is supplied in a 150 mg base (Aralen or in some parts of the world Nivaquine) and the self treatment is 1.5 gm (base) over 3 days. It is recommended that: Day 1 - 2 tabs BID Day 2 - 2 tabs BID Day 3 - 2 tabs for a total of 10 tabs. Chloroquine prophylaxis should then be started. If in a chloroquine sensitive regions and already receiving chloroquine prophylaxis, self treatment with atovaquone 250 mg / proguanil 100 mg (Marlarone) should be taken. Take 4 tabs once a day for 3 days. Once again chloroquine prophylaxis should be resumed. If in a chloroquine or chloroquine and mefloquine resistant P. falciparum regions, treatment recommendations for un-complicated P. falciparum involve taken oral Marlarone (as above) and resuming Mefloquine or other another appropriate prophylaxis. OR Oral Quinine 250 mg, two tabs TID for 3 to 7 days (7 in SE Asia) and doxycycline 100 mg, one tab BID for 7 days. You need both the Doxy and the Quinine to be effective. Once again Mefloquine or other appropriate prophylaxis should be resumed. OR If in Sub-Saharan Africa or the Indian Subcontinent you can begin oral Quinine (as above) plus three tabs of Pyrimethamine 25 mg with Sulfadoxine 500 mg (Fansidar). Once again Mefloquine or other appropriate prophylaxis should be resumed. It is worth noting that Fansidar is not the same drug as Fansimef (which is marketed in some areas. Fansimef is a combination of Mefloquine and Fansidar as is NOT recommended for the prevention or treatment of malaria. There is a risk of additive toxicity and reduced efficacy if used. Oral Quinine is not enough. Hope that helps, don't prescribe off this email (look it up incase I made a typo). Steven ---------------------------------------------------------- Lt. Steven D. Pirie, RN, BScN, UE General Duty Ward Officer - Military In-Patient Unit Canadian Forces Support Unit Ottawa - Civic Hospital Site 2 Health Support Operational Training Unit ----------------------------------------------------------