DoH Guidelines: Prophylaxis

[Introduction] [Drugs] [Factors] [Comments] [Standby] [References] [Table1] [Table2] [Table3]

 


STANDBY EMERGENCY TREATMENT OF MALARIA

Standby treatment describes the use of antimalarial drugs carried for self administration when malaria is suspected and prompt  medical attention is not available. It is usually recommended if a traveller is going to  stay for an extended period of time in an area with no medical care. It is only an option in clearly defined situations when being given with clear oral and written guidelines.

Advice on standby treatment should be obtained before entering the area. The drugs for self administration are used when fever and flu-like symptoms occur,  and malaria is the probable cause. The treatment course should be completed and antimalarial prophylaxis should be resumed 7 days after the first treatment dose. Medical  advice should still be sought at the earliest opportunity after self treatment.

Two rapid identification tests for malaria are now available and can be  helpful in diagnosing malaria before standby treatment is administrated.

Both the plasma reagent dipstick13 (Parasite-F®) and the rapid immunochromatographic test (ICT Malaria P.f.®) are only suitable for P. falciparum diagnosis.

Most places in South Africa have adequate medical facilities thus  obviating the need for standby emergency treatment.

DRUGS FOR  STANDBY TREATMENT

The following drugs may be recommended as standby emergency treatment:

Sulfadoxine-Pyrimethamine (Fansidar®)

This drug is relatively safe if taken for (single dose) standby  treatment, without medical supervision. There is a limited risk of severe cutaneous  adverse effects if used as a single dose therapy. Since sulfadoxine is a sulphonamide, it  is contraindicated in patients exhibiting sulphonamide hypersensitivity.

Quinine

Quinine is only recommended for standby treatment if a person cannot take sulfadoxine-pyrimethamine. Since major adverse effects can occur, it should not  readily be used without a medical practitioner's supervision. It may cause minor adverse effects such as:

  • mild hearing impairment (notably high tone deafness)
  • tinnitus
  • headache
  • nausea
  • slight visual disturbances (occurring in up to 70% of patients)

Major side effects include:

  • arrhythmia
  • hypersensitivity
  • hypoglycaemia (most serious frequent adverse side-effect) especially during pregnancy

Quinine toxicity presents with CNS disturbances (visual and auditory most common manifestations) and cardiovascular abnormalities (hypotension, heart block,  ventricular arrhythmias), which can be confused with severe (complicated) malaria.

Halofantrine 13

Halofantrine should be administered on an empty stomach to prevent toxicity, since its administration with a fatty meal has been shown to increase  the rate of absorption six-fold. A significant breakthrough rate after the recommended  three dose regimen necessitates an additional course one week after the initial therapy, especially in non-immune patients.

  • * Halofantrine should not be administered after mefloquine has been  taken for chemoprophylaxis or treatment due to the additive cardiotoxicity.
  • * Halofantrine should not be used in patients with a known family  history of congenital QTC prolongation. Therefore, halofantrine should only be used as emergency self-treatment in patients known to have normal QTC intervals. These patients  must be carefully counselled on the dosing and method of administration since prolongation of the QTC interval may result in heart block.

DIAGNOSIS AND TREATMENT OF MALARIA

Since no precautionary measures are 100% effective, malaria can still be contracted in spite of taking preventive measures.  Any person resident in, or returning from, a malaria risk area who develops fever and flu-like symptoms should immediately consult their medical practitioner and mention that they have been in a malaria area. Symptoms can occur up to six months after leaving a  malaria area.

Some of the following symptoms usually occur: fever, rigors, headache, sweating, tiredness, myalgia (back and limbs), abdominal pain, diarrhoea, lost of appetite, orthostatic hypotension, nausea, slight jaundice, cough, enlarged liver and  spleen (sometimes not palpable). The patients should be tested for malaria. In the  majority of cases, examination of blood smears will reveal malaria parasites. If not found  initially, further specimens should be examined by an experienced laboratory before the infection is excluded, as false negatives may be found on initial examination.

Treatment should be given immediately according to the recommendations in the booklet: Guidelines for the Treatment of Malaria, published by the Department of Health, 1996.

 

The  guidelines are endorsed by the Medical Association of South Africa

Compiled by the Department of Health in  collaboration with the Subcommittee for Chemoprophylaxis and Therapy of the National Malaria Advisory Group.

October 1996

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