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Malaria ChemoprophylaxisFrom: ATB28@aol.comSun Apr 21 06:40:55 1996
While exposure to, and infection with, malaria is uncommon in the USA we should remember that our patients often get around the world more than we'd like to! Our southern hemispheric colleagues are quite correct in stating that a mobile society and contemporary ease of travel makes awareness of this centuries-old disease an interesting topic of discussion for the listserve. The vector for transmission of malaria is via the bite of an infected female anopheline mosquito, most of which live in the wild below 8,000 ft ASL (most <3,000 ft ASL) and attack between dusk and dawn. The principal geographic distribution is between 45 degrees North and 40 degrees South latitude, in areas of at least 16 degrees C (~61 degrees F). The anopheles mosquito has a range of up to about a mile, vs the Ades (house) mosquito which is associated with other fun diseases such as dengue, urban yellow fever, and Japanese encephalitis. Stay upwind! The most effective repellent currently available is DEET (N,N,deithyl-m-touamide), which is best used impregnated in fabric mesh. The most common form of malaria, world wide is P. vivax (P. falciparum more in tropics and higher mortality). P. malariae and P. ovale are less common and currently none but PF show chloroquine resistance. P. vivax and P. ovale manifest persistent liver phases and require terminal prophylaxis. Current antimalarial drugs for prophylaxis: 1. Chloroquine 300 mg base ("Aralen") i tab weekly while exposed in endemic area 2. Chloroqiune 300 mg base/Primaquine 45 mg combination tab ("CP tablet") i tab weekly for 8 weeks after leaving area for terminal prophylaxis. 3. Pyrimethamine 25 mg sulfadoxine ("Fansidar") i tab weekly in addition to chloroquine when chloroquine-resistant PF has been reported, and continue i tab /week for 8 weeks for terminal prophylaxis. [N.b.: associated with severe (fatal in 4-9/100,000) Stevens-Johnson syndrome and toxic epidermal necrolysis ("I hate it when that happens.")] 4. Mefloquine (not available in US) - synthetic analog of quinine - 500 mg (ii tabs) loading dose and 250 mg (i tab) weekly. (Non-US readers...update on this please...now biweekly/monthly????) 5. Proguanil (not available in US) ("Paludrine") 200 mg is an OTC drug in most endemic areas. Must be taken daily. "Other regimens are available...consult your doctor for more information." If area is known to harbor ONLY PF you may omit the primaquine. Primaquine should not be used in pregnancy (see below) and should be used cautiously in G6PD deficient individuals (these individuals who can't take primaquine can have relapses, if infected, treated with chloroquine). PREGNANCY: Avoid travel to malarious areas! If not possible, use chloroquine alone and treat with primaquine after delivery. If chloroquine-resistant PF develops during chloroquine prophylaxis, treat with quinine or quinine plus pyrimethamine and folinic acid (but remember, pyrimethamine can result in folate deficiency). reference: Alfred K. Cheng, MD Consultant, Preventive Medicine Office of the Surgeon General Best up-to-date source for traveler information: CDC (404) 332-4559 (USA) Allan T. Bombard, MD "Laissez les bons temps roulez!" Reproductive Genetics Bronx, NY (and USAFR Flight Surgeon in training!)
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