Professional Documents
Culture Documents
Acute Diarrhea
1. PURPOSE
This guideline addresses the diagnosis and management of acute diarrheal syndromes due to
infectious causes.
2. BACKGROUND
Acute diarrhea represents one of the most common complaints of Volunteers located in
developing countries. While diarrhea can be related to many factors, including change in
diet, it is often the result of an infection with one of a variety of organisms (viral, bacterial or
parasitic), contracted by ingesting food or water which has been contaminated with fecal
pathogens.
Most people will consider any increase in stool frequency or softening of the stool to be due
to diarrhea. Significant diarrhea is best defined as:
Diarrhea:
Dysentery:
Acute:
Chronic:
Commonly, diarrhea is self limiting, resolving in a few days with no specific treatment
required other than adequate fluid replacement. Sometimes, however, diarrhea can be
serious or even life threatening (usually because of dehydration.) It is important to be able to
recognize patients in whom the diarrhea is potentially serious and to be able to correctly
investigate when necessary and provide treatment.
There are three main mechanisms by which pathogens can cause diarrhea. They may:
Invade/destroy the mucosal lining of the bowel (e.g., shigella, non-typhoid salmonellae,
E. histolytica)
Produce toxins which cause fluid to move into the bowel. Also known as secretory
diarrhea. (e.g., Vibrio cholerae, enterotoxigenic E. coli)
Cause a malabsorption like syndrome (e.g., giardia)
3. PREVENTION
Avoidance of contaminated water and food is the primary strategy in preventing diarrhea
among Volunteers.
Water must be assumed to be contaminated unless it is known to be safe; i.e., potential
pathogens are removed or inactivated. Boiling remains the simplest and most effective
method of water disinfection. Water that has been boiled for three minutes is safe for
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Acute Diarrhea
TG 810
drinking, even under the most extreme field conditions. Other methods which may be used
but may be less effective in some situations are described in ATTACHMENT A. Of these, only
filtering through a 1-2 micron filter followed by iodine or chlorine treatment is as effective as
boiling. Iodine and chlorine are less effective against protozoal cysts (ameba and giardia)
and are not effective against cryptosporidium cysts. The true frequency of cryptosporidium
infections is not known and is probably underestimated. Diarrhea due to cryptosporidium
typically persists for 10-14 days and is self-limited in healthy persons. Whenever possible,
water should be completely disinfected using one of the first two methods.
Many types of water filters marketed for travelers and rural use are ineffective against one or
more common pathogens. Usually iodine or chlorine must be used in addition to a water
filter. At this time, the water filters which use both a 1-2 micron filter to remove parasites
and cysts and an iodine resin to inactivate bacteria and viruses appear to be effective.
Conclusive field testing of such filters is lacking.
The complete cooking of food inactivates pathogens. Food should be eaten immediately
after cooking as a delay can allow bacteria to multiply again, and cooked food should be
protected from flies and other sources of recontamination. Soaking vegetables in a chlorine
solution after scrubbing them to remove dirt and other particles appears to be effective but
cannot completely disinfect heavily contaminated foods. After washing, soak the items in a
solution of one tablespoon household bleach per gallon for 15 minutes and then rinse in
treated water.
4. PROPHYLAXIS
While antibiotics have been shown to reduce the risk and severity of travelers diarrhea for
short-term travelers, there is also a significant risk of an adverse reaction to the drugs
themselves. This is especially so for Volunteers who remain in an area for several years.
Volunteers should not be given prophylactic antibiotics. They should be instructed in food
and water precautions and self management of minor diarrhea, along with seeking medical
attention when necessary.
5. HISTORY, EXAMINATION, AND LABORATORY TESTS
Taking a full history and performing a comprehensive examination will guide the practitioner
to the likely cause of an episode of diarrhea and its severity. Laboratory tests may be used to
confirm this clinical suspicion.
See Table 5.1 Clues to the Etiology of Infectious Diarrhea, Table 5.2 Evaluation of Acute
Diarrhea and Table 5.3 Management of Acute Diarrhea on the following pages.
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5.1
CLUE
ANATOMIC LOCATION
Giardiasis, enterotoxigenic
E. coli, early shigellosis or
cholera
Amebiasis, shigellosis,
salmonellosis,
campylobacter
Tenesmus, fecal
urgency, dysentery
Colitis
same as above
Prominent fever
Mucosal invasion
Prominent vomiting
Gastroenteritis
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Objective
Physical findings
Vital signs:
Inspection:
Palpation:
Auscultation:
Assessment
When assessing a patient with diarrhea, the following questions must be answered:
1.
2.
3.
4.
5.
6.
Plan
See Table 5.3 MANAGEMENT OF ACUTE DIARRHEA
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Acute Diarrhea
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PATIENT WITH
ACUTE DIARRHEA
TREATMENT:
Fever, dysentery or
severe diarrhea
NO
- Oral fluids
- Observe
- Symptomatic treatment
(see text)
- Further workup if prolonged
YES
MORE SEVERE ILLNESS; EVALUATE
:
- Fecal RBC/WBC
- Stool O & P
- Stool culture
- Malaria smear (if appropriate)
- CBC
Inflammatory
diarrhea* or
fever
Give empiric
antibiotic therapy,
consider IV fluids
YES
NO
Patient
improves
NO
CONSULT
APCMO/OMS
YES
DIARRHEA
RESOLVED
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6. SUPPORTIVE CARE
Avoidance of hypovolemia with adequate hydration is the most critical therapy for acute
diarrheal illnesses. The average adult with diarrhea should drink a minimum of 2-3 Liters
daily. Oral rehydration solutions can be easily mixed up by the PCV.
Two acceptable recipes are as follows:
Add to 1 Liter of clean water: tsp of salt, tsp of baking soda and 4 tbsps of
Sugar
Add to 1 Liter of clean water: tsp of salt and 8 tsps of Sugar
These solutions can be flavored with some fruit juice or other soft drink.
The benefits of dietary changes other than adequate oral hydration have not been established
in controlled studies. Diets similar to the BRAT (banana, rice, applesauce, and toast) diet
should not make the diarrhea worse and will provide some calories. With most diarrheal
illnesses, individuals develop some degree of lactose intolerance. Dairy products should be
avoided during the acute diarrhea episode and for several weeks after.
7. EMPERIC ANTIBIOTIC THERAPY AND USE OF ANTIDIARRHEAL
MEDICATION
When acute diarrhea is severe, contains blood or mucus, or is associated with a significant
fever, an invasive bacterial pathogen is likely. In these cases, consideration should be given
to the use of antibiotics even before the laboratory results are available.
Antibiotics for use in severe or invasive bacterial diarrhea
Ciprofloxacin 500mg two times daily for 3 days
or
Azithromycin, 1 gm in a single dose
* Azithromycin is preferred in southeast Asia due to development of quinolone-resistant
Campylobacter jejuni
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effective in shortening the course of infectious diarrhea in about 50% of cases. Do not
exceed this dosage.
8. MANAGEMENT OF SPECIFIC PATHOGENS
8.1
Bacterial diarrhea is usually associated with the sudden onset of frequent watery
stools, crampy abdominal pain, and sometimes fever, nausea or vomiting. WBCs,
blood and mucus may be present in the stool.
The use of antibiotics may shorten the duration of an episode of bacterial diarrhea.
Pathogenic bacteria quickly develop antibiotic resistance, therefore antibiotics are
reserved for use in only the more severe cases.
8.2
Viral diarrhea
8.3
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Most people infected with giardia remain asymptomatic, especially those who have
been previously infected and have developed some immunity.
When symptoms do develop, patients may be ill for weeks or months with loose
foul-smelling stools, belching and flatus, abdominal cramps and weight loss.
8.4
Volunteers diagnosed and treated for giardiasis should have their stool
examinations repeated to assess the efficacy of the treatment.
Infection occurs by the ingestion of viable cysts from fecally contaminated water,
food, or hands.
Most people infected with E. histolytica do not develop diarrhea but remain
asymptomatic and continue to pass cysts in their stool (which can infect others.)
These cysts may be found when the patient is being investigated for an episode
of acute diarrhea.
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Amebic Colitis
Both cysts and trophozoites are found in the stool of persons with symptomatic
intestinal amebiasis. If only cysts are seen despite careful stool examination
another cause should be sought.
Volunteers diagnosed and treated for amebiasis should have their stool
examinations repeated to assess the efficacy of the treatment.
Extraintestinal Amebiasis
Amebic disease outside the intestinal tract is rare, however an amebic liver
abscess is the most likely cause of a liver abscess in a Volunteer.
Symptoms usually involve the insidious onset of fever, sweats, fatigue, and
weight loss. A more acute presentation involves high fever, right upper
quadrant pain, nausea and vomiting.
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8.5
It is not unusual for patients being treated with antibiotics to develop diarrhea. This
is due to an alteration in the normal bowel flora. Usually antibiotic-induced
diarrhea resolves quickly when the antibiotics are stopped.
If the diarrhea persists after the antibiotics have been stopped, there may be an
overgrowth of Clostridium difficile in the bowel (present in 3% of healthy adults)
producing pseudomembranous colitis. Some laboratories are able to identify C.
difficile toxin in stool specimens.
Treatment of Antibiotic Induced Diarrhea
Mild:
Severe:
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REFERENCES
Drugs for Parasitic Infections, The Medical Letter, August 2004
Centers for Disease Control and Prevention. Health Information for International Travel, 20032004, Atlanta, Georgia, 2003
March 2010
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TG 810, Attachment A
Adapted from the CDC Yellow Book 2014, Chapter 2: Water Disinfection for Travelers
______________________________________________________________________________
Office of Volunteer Support
August 2015
Peace Corps
Technical Guideline 815
1. PURPOSE
To provide guidance in the techniques of stool examination and the interpretation of the
results.
2. BACKGROUND
Intestinal diseases are one of the most common types of illness among Volunteers. PCMOs
must have a good understanding of these diseases and be aware of the techniques used to
diagnose them. Bacterial cultures of the stool, when available, are appropriate for the
evaluation of acute, severe diarrhea. (See Technical Guideline 810 Acute Diarrhea, Table
5.2) Fecal white blood cells are also an important clue in acute cases. More often, stool
examination for ova and parasites is performed to evaluate chronic diarrhea or to screen for
the presence of pathogenic organisms.
3. EXAMINATION OF STOOL FOR OVA & PARASITES (O & P)
Microscopic stool examination requires formal training and periodic competency testing.
PCMOs are not expected to be able to perform microscopic stool examinations (other than
for fecal white blood cells) but must be familiar with the techniques and quality control (if
any) used by their referral labs. Many laboratories in the U.S. and abroad are not able to
consistently and correctly identify pathogens. It is generally recommended that stool
specimens be periodically submitted to a reference lab in the U.S. or elsewhere to help assess
the reliability of in-country testing. See Technical Guideline 360 Use of U.S.
Laboratories.
Ova or parasites are found in less than 50% of specimens from infected persons.
Examination of three specimens collected on different days typically increases the detection
rate to 80-90%. Good lab technique and a skilled microscopist are critical in the correct
identification of pathogenic organisms.
Two different O & P examinations can be performed:
(1)
(2)
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Stool Examination
TG 815
Ask the Volunteer to pass stool into a large, clean container, then transfer several
tablespoons of stool into the smaller feces container.
Diarrheal stool
Formed stool
Diarrheal stool
Formed stool
For culture:
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MIF kit or formalin can be used both by Volunteers on site (to forward specimens to
PCMOs) and Health Units (to forward specimens to laboratories).
Preserved (MIF or formalin treated) specimens cannot be used for bacterial culture.
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TG 815 ATTACHMENT A
GUIDE TO O&P RESULTS
1. POTENTIALLY PATHOGENIC INTESTINAL PARASITES
Treatment may be required.
Protozoa
Helminths
2. NON-PATHOGENIC ORGANISMS
No treatment required
3. OTHER FINDINGS
RBC (red blood cells)
Indicates gastrointestinal tract bleeding
WBC (white blood cells)
Indicates inflammation of the bowel. Investigation and treatment may be required (see TG 810
Acute Diarrhea.)
Charcot-Leyden crystals, starch granules, fat or oil, and budding yeasts
Relatively common and not in themselves significant in the absence of symptoms.
Peace Corps
Technical Guideline 840
PREVENTION OF MALARIA
1. PURPOSE
To provide Peace Corps Medical Officers (PCMOs) with guidance on malaria prevention for
Volunteers.
2. BACKGROUND
Malaria is a mosquito-borne parasitic disease endemic to many areas of the world served by
Peace Corps Volunteers. It is a serious and sometimes fatal disease. As such, the Office of
Medical Services (OMS) employs a comprehensive prevention program to prevent malaria in
Volunteers. Medical officers and Volunteers are required to rigorously adhere to the
components of the program. Components of the program include:
Primary prevention: the provision of personal protective equipment, i.e., mosquito nets,
insect repellent, and insect spray to all Volunteers serving in malaria endemic areas.
Screening on windows and doors of Volunteer living areas is strongly encouraged.
Secondary prevention: the provision of malaria chemoprophylaxis, including postdeparture prophylaxis and presumptive anti-relapse therapy (PART) when indicated, to
all Volunteers serving in malaria endemic areas.
Policy: OMS policy that requires all Volunteers serving in malaria endemic areas to
rigorously adhere to malaria prevention measures, i.e., use of personal protective
equipment and chemoprophylaxis, throughout their tour of duty.
The OHS Epidemiology and Surveillance Unit coordinates Peace Corps malaria case
surveillance.
Specific guidance on the diagnosis and treatment of malaria is addressed in Technical
Guideline 845 Treatment of Malaria.
3. GENERAL CONSIDERATIONS
Malaria is caused by one of five protozoan species of the genus Plasmodium: P. falciparum,
P. vivax, P. ovale, P. malariae, and P. knowlesi. All are transmitted by the bite of an
infected female Anopheles mosquito. P. falciparum is the most dangerous species among the
five. It poses the greatest risk of death to non-immune persons and is the species most likely
to develop resistance to antimalarial drugs. P. vivax and P. ovale have a dormant liver phase
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that may persist in the liver for up to four years and cause recurrences after routine
chemoprophylaxis is discontinued. PART is used to eradicate these species from the liver
and prevent late relapses of malaria. P. malariae is the least common species of malaria. It
has a dormant blood borne phase that can cause recurrences years after leaving an infected
area.
3.1
3.2
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Clothing: Wear light or bright clothing that covers most of the body, e.g., long sleeved
shirts, long pants, and socks. Mosquitoes are attracted to dark clothing after dusk.
Permethrin-sprayed clothing provides maximum protection.
Mosquito Nets: Sleep under mosquito netting. Netting should have small mesh and
should not be damaged. When used properly, nets over cots and beds provide excellent
protection against mosquitoes and crawling insects. Nets impregnated with permethrin
provide maximum protection. Permethrin- impregnated nets can be procured, at no
charge to post, through the Post Logistic Support in Administrative Services
(M/AS/PLS). See TG 240, 15.4 Mosquito Nets.
Insect Repellent: Apply insect repellent. Use preparations that contain 30-35% N, N
diethylmethylbenzamide (DEET). . Preparations containing Picaridin 20% have equal
efficacy with preparations containing DEET 35%. When applied properly, these
preparations are effective for several hours. In addition, Volunteers should: (1) avoid
applying repellants with high-concentrations of DEET (>35%) to their skin - high
concentration products have rarely been associated with toxic encephalopathy in children;
(2) avoid inhaling or ingesting repellents; (3) avoid getting repellents in their eyes, (4)
wash repellent-treated skin after coming indoors, and (5) if using both sunscreen and
insect repellent, apply sunscreen first, preferably about 20 minutes before the insect
repellent. Insect repellents can reduce the effectiveness of sunscreen by about one third.
PCVs are encouraged to reapply repellent after bathing or sweating, if they are still at risk
Insect Spray: When needed, use Pyrethroid-containing flying-insect spray in living and
sleeping areas during evening and nighttime hours. Sprays should be used for at least a
half-hour before retiring. Insect spray may be provided at the discretion of the post.
Pyrethroid-containing insect sprays can be procured locally or through PLS. Permethrin
may be sprayed on clothing for additional protection against mosquitoes.
Screens: Stay in well-screened areas during mosquito feeding times. In malaria endemic
areas, OMS strongly recommends window and door screening of Volunteer living areas.
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5. CHEMOPROPHYLAXIS
The Office of Medical Services requires PCMOs to provide all Volunteers serving in malaria
endemic areas with appropriate chemoprophylaxis during their service and following close of
service (COS). This includes the provision of sufficient medication for post-exposure and
PART and the provision of chemoprophylaxis during vacation, home leave, medical
evacuation, and other departures from country. Volunteers residing in non-malaria endemic
areas who travel to malaria endemic areas should also be provided with appropriate
chemoprophylaxis.
The Office of Medical Services also requires PCMOs to educate Volunteers about the
following: (1) the life cycle of the malaria parasite (see ATTACHMENT B); (2) the proper
use of chemoprophylactic medication; and (3) the importance of uninterrupted
chemoprophylaxis.
Chemoprophylaxis is the use of antimalarial medication to suppress clinically significant
disease. Antimalarial medications do not prevent infection with the malaria parasite; rather,
they suppress clinical disease by attacking the parasites at different stages of its life cycle.
There are no antimalarials that are 100% effective or without side effects.
Peace Corps primarily uses two types of chemoprophylactics: suppressive and PART.
Suppressive chemoprophylactics, e.g., chloroquine, doxycycline, mefloquine, and Malarone
kill blood (asexual) stages of plasmodia, thereby suppressing clinically significant illness.
PART, e.g., primaquine, attacks liver stages of the parasite, thereby preventing disease.
PART is directed against the relapsing malarias, P. vivax and P. ovale (see Section 11
below). Therefore, prophylaxis prior to arriving in country (pre-exposure prophylaxis) or
immediately upon arrival in country (loading dose), and prophylaxis following departure
from country (PART), is required.
5.1
Choice of Chemoprophylaxis
Optimal malarial prophylaxis takes into consideration the most effective antimalarial
agent, side effects and Volunteer adherence.
There is no first-line drug in Peace Corps. All antimalarial drugs are utilized, as
appropriate, in suppressing malaria. Drug options include chloroquine, mefloquine,
doxycycline and atovaquone-proguanil (Malarone). Medical officers should, therefore,
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individualize their choice of chemoprophylactic agent for each Volunteer based on the
following considerations:
Other factors:
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Phone
CDC (800) CDC-INFO
CDC Malaria Hotline (treatment): (770) 488-7788 (M-F 9 a.m.- 5 p.m. EST); (after hours
request to speak with the Malaria Branch Clinician).
International Society of Travel Medicine: 1-(770)-736-7060
5.2
There is no first-line drug in Peace Corps. All antimalarial drugs are utilized, as
appropriate, in suppressing malaria. Drug options include atovaquone-proguanil
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Volunteer Adherence
All Volunteers serving in malaria endemic areas are at high risk for infection with the
malaria parasite. To suppress clinical infection, OMS requires all Volunteers serving in
malaria endemic areas to rigorously adhere to a chemoprophylactic regimen throughout
their tour of duty and following COS. This includes the use of chemoprophylaxis during
vacation, home leave, medical evacuation, and other departures from country. Volunteer
failure to comply with OMS-recommended malaria prevention measures can result in
symptomatic malaria infections. These infections cause significant illness, impair
Volunteer effectiveness, result in unnecessary financial costs, and, tragically, occasionally
result in Volunteer death.
To encourage Volunteer adherence, PCMOs should: (1) educate Volunteers on the
importance of primary and secondary malaria prevention strategies; (2) provide
Volunteers information on the various chemoprophylactic regimens (see
ATTACHMENT C Antimalarial Chemoprophylaxis, Advantages and
Disadvantages, and ATTACHMENT D Antimalarial Medication Information
Sheets); (3) instruct Volunteers to consult the PCMO if adverse reactions to
chemoprophylaxis occur; and (4) counsel Volunteers who state they are unwilling or
unable to follow OMS-required malaria prevention strategies and, when appropriate,
offer alternative prophylactic antimalarial medication (see Section 8 below).
During pre-service training, Trainees will participate in group and individual discussions
with a medical officer to decide whether a weekly medication schedule or a daily
medication schedule and which agent would be best for the individual Trainee to assure
100% compliance for the entirety of his/her PC service.
Volunteers should not stop any chemoprophylactic regimen without consulting the
PCMO. Improper self-discontinuation of prophylaxis places a Volunteer at risk for
malaria. Volunteers who are unable to comply with malaria prevention strategies due to
willful misconduct or disregard for the Peace Corps Volunteer Health Program should be
referred to the Country Director for administrative action (see MS 262 Section 3.2).
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The flow chart below is a guideline for dealing with PCVs who contract malaria. Every
case must be handled individually and discussions and medical recommendations must be
documented appropriately in the medical record. Do not forget to discuss mosquito bite
avoidance measures as well as chemoprophylactic use. For any given PCV, there is no
set number of documented cases of malaria that would necessarily lead to an action
to separate.
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6. STARTING CHEMOPROPHYLAXIS
In general, the CDC recommends that travelers start chemoprophylaxis one to two weeks
prior to arrival in a malarial area. If this is not possible, the CDC advises travelers to start
antimalarials just prior to their departure or immediately upon their arrival in a malariaendemic area. Both strategies, when combined with mosquito avoidance and personal
protective measures, i.e., insect repellent, bed nets, and screens, are effective in preventing
acute malaria. Therefore, for Peace Corps Trainees, OMS recommends that malaria
prophylaxis be started either during staging or immediately upon arrival in country.
Loading Dose
In countries where Volunteers do not receive antimalarial medication prior to departure from
the U.S. and the PCMO suspects that Volunteers may be immediately and intensely exposed
to malaria upon their arrival in country, they should consult OMS for guidance. In such
cases, OMS will consider whether to recommend a loading dose of a chemoprophylactic
agent that can rapidly produce protective blood levels. In general, a loading dose is only
used for Volunteers taking mefloquine, but this is discouraged by OMS For those PCVs who
choose to use mefloquine, it is recommended that the PCV/T be placed on daily doxycycline
during the first two weeks of mefloquine treatment. A loading dose is not required for
Volunteers taking doxycycline and no data exists to support a loading dose in Volunteers
taking chloroquine or Malarone.
7. CHEMOPROPHYLACTIC AGENTS
This following table is a summary of dosing schedules, adverse reactions, and
contraindications of common chemoprophylactic agents used by Peace Corps. Additional
information is also available in the Antimalarial Medication Information Sheets (see
ATTACHMENT D.
CHEMOPROPHYLACTIC AGENTS
Drug
Atovaquoneproguanil
(Malarone)
Tablet
size
Dose and
Frequency
250 mg
atovaquon
e and 100
mg
proguanil
One tablet
daily
Discontinuation
duration (time
after last
exposure)
7 days
Adverse Reactions
Adverse reactions
include abdominal
pain (17%),
nausea (12%),
vomiting (12%),
headache (10%),
diarrhea (8%),
weakness (8%),
loss of appetite
(5%), and
dizziness.
Mouth ulcers,
cough, pruritus,
urticaria, blood
disorders, and
hair loss have
also been
reported
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Contraindications
Contraindicated in persons with:
severe renal
impairment (creatinine
clearance < 30
ml/min).
Should b e avoided in persons
who are taking:
tetracyclines.
Tetracyclines cause a
40% decrease in
atovaquone
concentrations.
Metopramide and
rifampin. Both drugs
reduce the plasma
concentration of
atovaquone
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Chloroquine
phosphate
(Aralen and
generic agents)
500 mg
salt (300
mg base)
One tablet
weekly
4 weeks
Reports of sleep
disturbance and
unusual dreams;
reactions tend to
be no more
frequent than for
mefloquine users.
May cause
depression,
blurred vision,
nausea, pruritus,
headache, or
paresthesias.
Persons with
porphyria.
May interfere with
antibody response to
human diploid cell
rabies intradermal
vaccines.
Reports of rare,
severe, adverse
reactions
including
neuropsychiatric,
e.g., extrapyramidal
symptoms,
neuropathies,
agitation, and
psychosis
(1/13,600 people)
May worsen
symptoms of
psoriasis.
[Retinopathy in
persons with a
history of longterm, high dose,
chloroquine use,
i.e., a total
cumulative
exposure > 60
gms (approx. 4
years of weekly
medication).
Routine eye
exams q6 months
are indicated in
these individuals.]
Doxycycline
hyclate
(Vibramycin,
Vibra-Tabs,
other brands,
and generic
agents);
doxycycline
monohydrate
(Monodox,
Adoxa, and
generic agents)
100 mg
One tablet
daily
4 weeks
Minor adverse
reactions include
photosensitivity,
increased
incidence of
monilial vaginitis,
and
gastrointestinal
disturbance. May
cause
esophagitis,
especially if taken
at night.
Mefloquine
hydrochloride
(Lariam and
generic agents)
250 mg
salt (228
mg base)
One tablet
weekly
4 weeks
Minor adverse
reactions include
GI disturbance
and dizziness;
reactions tend to
be transient and
December 2014
Pregnancy
Persons allergic to
tetracycline or other
macrolide antibiotics.
a known
hypersensitivity to
mefloquine or related
compounds, e.g.,
quinine.
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self-limited.
Infrequent reports
of chest pain,
edema and
dyspepsia.
Reports of sleep
disturbances and
unusual dreams;
reactions tend to
be no more
frequent than for
chloroquine users.
May cause
psychiatric
symptoms ranging
from anxiety,
paranoia, and
depression to
hallucinations and
psychotic
behavior. On
occasion, these
symptoms have
been reported to
continue long after
mefloquine has
been stopped
Reports of rare,
severe, adverse
reactions, the
most common
being
neuropsychiatric ,
e.g. tremor,
ataxia, mood
changes, and
panic attacks
(1/10,000-13,000
people).
active depression, a
recent history of
depression,
generalized anxiety
disorder, psychosis,
schizophrenia or other
major psychiatric
disorders.
History of convulsions
or seizures.
Not recommended in persons
with:
cardiac conduction
defects, e.g., A-V
block, bundle branch
block, or a prolonged
QT interval.
atrial or ventricular
arrhythmias.
are on beta-blockers
for the cardiac
conduction defects and
arrhythmias listed
above.
Use with caution in persons
with:
a previous history of
depression.
Rare cases of
suicidal ideation
and suicide,
though no
relationship to
drug
administration has
been confirmed
Mefloquine, Malarone and doxycycline may also be used in chloroquine -sensitive areas as necessary.
7.5
Chloroquine/Proguanil (Paludrine)
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Pyrimethamine (Daraprim)
Pyrimethamine-dapsone (Maloprim)
Amodiaquine
Halofantrine (Halfan)
If the request for an alternative agent is not climically appropriate, assess the Volunteers
reasons for requesting an alternative agent and consider switching to an alternative agent
to improve adherence.
8.1
Switching Antimalarials
When switching from one antimalarial to another, care is necessary to avoid a gap in
protective blood levels. This is especially important in Trainees as blood levels may be
low for several weeks after starting a weekly chemoprophylactic agent. It is also
important for Volunteers who have been in a malarial area for many weeks and are
likely to already be infected.
Daily Dose to a Daily Dose
When switching from a daily dose of doxycycline or Malarone to a daily dose of
doxycycline or Malarone, no overlap is necessary.
December 2014
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TG 840
Malaria Prevention
It is unusual to switch from weekly chloroquine to weekly mefloquine but in these rare
instances, a three-day loading dose of mefloquine should be provided. Medical officers
should contact OMS for guidance prior to starting mefloquine therapy in these cases.
9. MISSED DOSES
If a dose of a weekly chemoprophylactic agent is missed, the Volunteer should take that
missed dose as soon as they remember it, and continue on their regular schedule.
If a dose of a daily chemoprophylactic agent is missed, the Volunteer should resume daily
dosing immediately. No loading dose is necessary when resuming chemoprophylaxis with
these agents. Volunteers should be advised against doubling up on their antimalarial when
resuming chemoprophylaxis after missing a dose of their medication.
Volunteers are more likely to forget drugs that are given daily and this may lead to
breakthrough cases of malaria. If this occurs, the PCMO should discuss the option of a
weekly drug (if clinically appropriate) with the Volunteer..
December 2014
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TG 840
Malaria Prevention
Dose
Adverse Reactions
Post Exposure:
30 mg base (52.6)
mg salt) once
daily for 14 days.
Start 2 weeks
following final
departure from the
malaria endemic
area if the
Volunteer is taking
chloroquine,
mefloquine, or
doxycycline.
Start 1 week
following final
departure from the
malaria endemic
area if the
Volunteer is taking
Malarone.
Minor adverse
reactions include
headaches,
abdominal cramps,
nausea, vomiting
and pruritus.
Methemoglobinemia
is common but
rarely necessitates
discontinuation of
therapy.
Contraindications
Leukopenia and
agranulocytosis
occur rarely.
As per CDC: No reasonable data exist to support the use of primaquine in individuals who are exposed to P.
December 2014
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TG 840
Malaria Prevention
Post Exposure Dose: Primaquine phosphate 30 mg base (52.6 mg salt) once daily
for 14 days. Primaquine should be started 2 weeks following final departure from
the malaria endemic area if the Volunteer is taking chloroquine, mefloquine, or
doxycycline; and 1 week following final departure if the Volunteer is taking
Malarone. Primaquine should be given concurrently with all antimalarials except
Malarone.
See also Malaria Prophylaxis in TG 330 under Section 4.4 Physical Exam.
Malaria prophylaxis according to the guidance outlined above. This should include:
(1) post-exposure prophylaxis as outlined above and in TG 330 Attachment G, and
(2) an additional 30 day supply of a malaria prophylaxis medication, e.g.,
mefloquine, doxycycline, or Malarone, if the Volunteer will be traveling in a
malaria endemic area prior to returning to the U.S If the Volunteer will be
traveling for more than 30 days, provide them with the website
(http://www.istm.org/AF_CstmClinicDirectory.asp)where they can find a travel
clinic in the country they will be visiting to obtain prophylaxis.
December 2014
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TG 840
Malaria Prevention
Medications for one course of interim self-treatment of malaria for use should the
Volunteer develop symptoms of acute malaria (see TG 845.5.1 Interim SelfTreatment Regimens for medications and dosing schedules).
PART according to the guidance outlined in Section 11.1 Presumptive AntiRelapse Therapy above.
December 2014
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TG 840
Malaria Prevention
Normal: Normal or G6PD present test results done in country or at a U.S. lab are
acceptable. When indicated, these Volunteers may be given primaquine.
Abnormal: Medical officers should issue the Volunteer a 127C authorization for
primary care consultation for evaluation of G6PD deficiency and terminal malaria
prophylaxis as indicated. A copy of the lab report should be attached to the 127C.
PCMOs should instruct Volunteers with abnormal results to remain on their malaria
prophylaxis until their G6PD status is confirmed. Medical officers should not give
primaquine to a Volunteer with an abnormal or abnormally low G6PD result.
No result available at COS: Volunteers who have not been tested for G6PD deficiency
prior to COS should not be given primaquine.
Pregnant Volunteers: Severe cases of malaria can occur during pregnancy. Pregnancy
alters the immune system and malaria may adversely affect the outcome of pregnancy.
Therefore, all pregnant Volunteers are required to take malaria chemoprophylaxis. The
CDC recommended drugs of choice in pregnancy are:
Malarone is not currently recommended by the CDC for use in pregnancy. Medical
officers should consult OMS in situations where a pregnant Volunteer is unable to
take mefloquine.
December 2014
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TG 840
Malaria Prevention
December 2014
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TG 840
Malaria Prevention
REFERENCES
Arguin PM, Keystone, JS. Prevention of malaria infection in travelers. In: UpToDate, Basow,
DS (Ed), UpToDate, Waltham, MA, 2012.
Boudreau, Shuster, Sanchez et al. Tolerability of Prophylactic Lariam Regimens. Trop Med
Parasitol 1992, 44:257.
Cox-Singh J, Davis TM, Lee KS, et al. Plasmodium knowlesi malaria in humans is widely
distributed and potentially life threatening. Clin Infect Dis 2008; 46:165.
Freedman DO. Clinical practice. Malaria prevention in short-term travelers. N Engl J Med
2008; 359:603.
Goldsmith R. & Heynemann D. Tropical Medicine and Parasitology. Norwalk, CT:
Appleton & Lange, 1989.
Hill DR, Ericsson CD, Pearson RD, et al. The practice of travel medicine: guidelines by the
Infectious Diseases Society of America. Clin Infect Dis 2006; 43:1499.
http://www.cdc.gov/malaria/travelers/drugs.html (Accessed on November 23, 2012).
Kochar DK, Saxena V, Singh N, et al. Plasmodium vivax malaria. Emerg Infect Dis 2005;
11:132.
Krause G, Schneberg I, Altmann D, Stark K. Chemoprophylaxis and malaria death rates.
Emerg Infect Dis 2006; 12:447.
Leder K, Black J, O'Brien D, et al. Malaria in travelers: a review of the GeoSentinel
surveillance network. Clin Infect Dis 2004; 39:1104.
Lobel H. O. & Kozarsky P. E. Update on prevention of malaria for travelers. JAMA, 278,
1767-1771, 1997.
Lobel H. O., Miani, M., Eng T., et al. Long-term malaria prophylaxis with weekly
mefloquine. Lancet, 1993, 341: pp. 848-851.
Mali S, Steele S, Slutsker L, et al. Malaria surveillance - United States, 2008. MMWR
Surveill Summ 2010; 59:1.
Mali S, Kachur SP, Arguin PM, et al. Malaria surveillance--United States, 2010. MMWR
Surveill Summ 2012; 61:1.
Mandell, G. L., Douglas, R. G., and Bennett, J. E. Principals and Practice of Infectious
Diseases, 5th edition. Churchill Livingston, 2000.
Navy and Marine Corps Public Health Center. Pocket Guide to Malaria Prevention and
Control. Portsmouth, Virginia. 2011.
December 2014
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TG 840
Malaria Prevention
December 2014
Page 21
TG 840 Attachment A
Worldwide Distribution
of Malaria
From
December 2014
TG 840 ATTACHMENT B
The malaria parasite life cycle involves two hosts. During a blood meal, a malaria-infected female Anopheles
mosquito inoculates sporozoites into the human host
. Sporozoites infect liver cells
and mature into
schizonts
, which rupture and release merozoites
. (Of note, in P. vivax and P. ovale a dormant stage
[hypnozoites] can persist in the liver and cause relapses by invading the bloodstream weeks, or even years
later.) After this initial replication in the liver (exo-erythrocytic schizogony
), the parasites undergo asexual
multiplication in the erythrocytes (erythrocytic schizogony
). Merozoites infect red blood cells
. The ring
stage trophozoites mature into schizonts, which rupture releasing merozoites
. Some parasites differentiate
into sexual erythrocytic stages (gametocytes)
. Blood stage parasites are responsible for the clinical
manifestations of the disease.
The gametocytes, male (microgametocytes) and female (macrogametocytes), are ingested by an Anopheles
mosquito during a blood meal
. The parasites multiplication in the mosquito is known as the sporogonic
cycle
. While in the mosquito's stomach, the microgametes penetrate the macrogametes generating
zygotes
. The zygotes in turn become motile and elongated (ookinetes)
which invade the midgut wall of the
mosquito where they develop into oocysts
. The oocysts grow, rupture, and release sporozoites
, which
make their way to the mosquito's salivary glands. Inoculation of the sporozoites into a new human host
perpetuates the malaria life cycle
.
TG 840 Attachment C
Antimalarial Chemoprophylaxis: Advantages and Disadvantages
Chloroquine is highly effective, but can be use only in those areas of the world where the malaria is sensitive to
the medication. The usual dosing one tablet weekly
Advantages
Disadvantages
Highly effective preventive medication
Possible stomach upset often made better if taken with
food
Once weekly dosing
Possible problems with vision
Stays in the system for a long time providing some
Possible problems with hearing or ringing in the ears
antimalarial activity if a dose is delayed
Should not be used during pregnancy
Mefloquine is highly effective. The usual dosing is one tablet weekly
Advantages
Disadvantages
Highly effective preventive medication
Should not be used by individuals with a history of most
mental health issues
Weekly dosing could be an advantage for those not
Should not be used by individuals with a history of
used to taking daily meds
seizures
Stays in the system for a long time providing some
Should not be used by individuals with a history of
antimalarial activity if a dose is delayed
disturbances of the electrical conduction of the heart
Only antimalarial medication approved for pregnancy
Possible worsening or development of sleep
disturbance including nightmares; severe anxiety;
paranoia; hallucinations; depression; restlessness;
unusual behavior; confusion; suicidal thoughts [subject
of FDA boxed warning]
Possible development of dizziness, room spinning, ear
ringing, loss of balance which may persist or become
permanent [subject of FDA boxed warning]
Possible stomach upset
Possible headache
Atovaquone/Proguanil (Malarone) is highly effective. The usual dosing is one tablet daily
Advantages
Disadvantages
Highly effective preventive medication
Since atovaquone/proguanil is also used as a secondline treatment for active malaria, it cannot be used for
treatment if used for daily suppression
Once daily dosing for those already taking daily meds
Possible stomach upset
Should not be used during pregnancy
Doxycycline is highly effective. The usual dosing is one tablet/capsule daily
Advantages
Disadvantages
Highly effective preventive medication
Must be taken with at least 8 oz. of water and
preferably food
Once daily dosing for those already taking daily meds
Does not stay in the system for a long time and must be
taken at roughly the same time every day
Only agent with no malaria resistance demonstrated
Possible increased sun sensitivity in approximately 20%
of users. Must be compulsive with use of sun screen
Also effective in preventing or suppressing several other Possible heartburn and stomach upset which is
tropical infectious diseases (rickettsial disease and
significantly less likely if taken with a full glass of water
leptospirosis)
or food
Possibly improve acne
Possible increased chance of developing yeast
infections (vaginal)
Cannot be used during pregnancy
** This is not intended to be an exhaustive list of side effects of these medications. Your PCMO can provide more detailed
information.
December, 2014
TG 840 ATTACHMENT D
Chloroquine Tablets
(Anti-Malarial Medication)
MEDICATION INFORMATION SHEET
What is chloroquine?
Chloroquine is one of several types of drugs used to prevent and treat malaria. The type of drug
prescribed for you will be based on the area of the world you are traveling to and your medical conditions.
How do I take the tablets?
This medication may cause nausea, vomiting, stomach upset, cramps, loss of
appetite, diarrhea, tiredness, weakness, or headache. These effects should subside
as your body adjusts to the medication. If these symptoms persist or become
severe, inform your Peace Corps health provider.
Contact your Peace Corps health provider if any of the following side effects
occur: changes in your sight, blurred vision, trouble seeing at night, problems
focusing clearly, difficulty hearing, or ringing in the ears.
An allergic reaction to this drug is unlikely, but seek immediate medical attention
if any of these symptoms occur: rash, itching, swelling, dizziness, or trouble
breathing.
If you notice other effects not listed above, contact your Peace Corps health
provider.
Tell your Peace Corps health provider if you have pre-existing liver disease,
blood disorders, or psoriasis.
Tell your Peace Corps health provider of all prescription and nonprescription
R
R
drugs you may use, especially cimetidine (Tagamet ), kaolin (Kaopectate ), or
R
magnesium trisilicate (Gaviscon ).
Do not start or stop any medicine without Peace Corps health care provider
approval.
Page 1
TG 840 ATTACHMENT D
This medication should be used only when clearly needed during pregnancy. Discuss
the risks and benefits with your Peace Corps health provider.
Small amounts of this medication are found in breast milk. Consult with your Peace
Corps health provider before breast-feeding.
What should I do if I miss a dose?
If you miss a dose, take the missed dose as soon as you remember and then continue
the usual dosing schedule. DO NOT double-up the dose to catch up unless
instructed to by a Peace Corps health care provider.
What should I do if I overdose?
Page 2
TG 840 ATTACHMENT D
Doxycycline
(Anti-Malarial Medication)
Medication Information Sheet
What is doxycycline?
Doxycycline is one of several types of drugs used to prevent and treat malaria. The
type of drug prescribed for you will be based on the area of the world you are
traveling to and your medical conditions.
Take each dose with a full glass of water (4 oz or 120 ml) or more.
Take with food or milk if stomach upset occurs unless your Peace Corps health
provider directs you otherwise.
Antibiotics work best when the amount of medicine in your body is kept at a constant
level. Do this by taking the medicine at evenly spaced intervals, such as at the same
hour each day or night.
Take this medication as prescribed. It is important that you not miss any doses and
that you take the drug on a regularly scheduled basis.
This medication may cause stomach upset, diarrhea, nausea, headache or vomiting. If
these symptoms persist or worsen, notify your Peace Corps health provider.
These symptoms are unlikely, but report to your Peace Corps health provider if they
occur: stomach pain, yellowing of the eyes or skin, vision changes, mental changes.
Use of this medication for prolonged or repeated periods may result in a secondary
infection (e.g., oral, bladder or vaginal yeast infection).
In the unlikely event that you have an allergic reaction to this drug, seek immediate
medical attention. Symptoms of an allergic reaction include: rash, itching, swelling,
dizziness, or trouble breathing.
If you notice other effects not listed above, contact your Peace Corps health provider.
Page 3
TG 840 ATTACHMENT D
Tell your Peace Corps health provider your complete medical history, especially liver
problems, kidney problems, allergies, especially drug allergies, trouble swallowing,
esophagus problems (e.g., hiatal hernia, GERD [gastro-esophageal reflux disease]).
Doxycycline may make you more prone to sunburn. Wear protective clothing, use a
sunscreen if needed, and limit your sun exposure.
This drug should not be used by children up to 8 years of age because its use may
permanently discolor their teeth or cause other problems. Caution is advised in older
children also.
Tell your Peace Corps health provider of all prescription and nonprescription drugs
you may use, especially other antibiotics, live vaccines, sucralfate, antacids, vitamins,
warfarin, or iron.
This medicine may decrease the effectiveness of oral contraceptives. Consult your
Peace Corps health provider about other types of birth control.
Do not start or stop any medicine without Peace Corps health care provider approval.
What if Im pregnant or breast-feeding?
This medication is not recommended for use during pregnancy. Consult your Peace
Corps health provider before using this medication.
This drug passes into breast milk and has had undesirable effects on nursing infants.
Therefore, its use is not recommended while breast-feeding. Consult your Peace
Corps health provider before breast-feeding.
What should I do if I miss a dose?
If you should miss a dose, take the missed dose as soon as you remember and then
continue the usual dosing schedule. DO NOT double-up the dose to catch up.
What should I do if I overdose?
Page 4
TG 840 ATTACHMENT D
Mefloquine Tablets
(Anti-Malarial Medication)
Medication Information Sheet
What is mefloquine?
Mefloquine is one of several types of drugs used to prevent and treat malaria. The type of
drug prescribed for you will be based on the area of the world you are traveling to and your
medical conditions.
How do I take the tablets?
It is important that you not miss any doses and that you take the drug on a regularly
scheduled basis.
This medication may cause stomach upset, stomach pain, nausea, vomiting, diarrhea,
headache, insomnia, vivid dreams, or lightheadedness. These effects should subside
as your body adjusts to the medication. If these symptoms persist or become severe,
inform your Peace Corps health provider.
This medication may cause dizziness or restlessness. Use caution when driving or
engaging in activities requiring alertness.
Contact your Peace Corps health provider immediately if any of the following side
effects occur; an alternative antimalarial will be substituted: unexplained anxiety,
mood changes, depression, hallucinations, restlessness, or confusion.
An allergic reaction to this drug is unlikely, but seek immediate medical attention if
any of these symptoms occur: rash, itching, swelling, dizziness, or trouble breathing.
If you experience an irregular heartbeat or notice other effects not listed above,
contact your Peace Corps health provider.
Is there any reason I should not take mefloquine?
Tell your Peace Corps health provider your complete medical history, especially
psychiatric problems, heart problems, seizure disorders, and allergies, especially
drug allergies.
Page 5
TG 840 ATTACHMENT D
This medication should be use only when clearly needed during pregnancy. Discuss
the risks and benefits with your Peace Corps health provider.
This drug is excreted into breast milk. Consult with your Peace Corps health
provider before breast-feeding.
What should I do if I miss a dose?
If you miss a dose, take the missed dose as soon as you remember and then continue
the usual dosing schedule. DO NOT double-up the dose to catch up unless
instructed to by a Peace Corps health care provider.
What should I do if I overdose?
Wear light or bright clothing that covers most of your body (long
sleeved shirts, long pants, socks). Permethrin treated clothing provides
maximum protection.
Use mosquito nets over cots, beds, and tents. Permethrin treated nets
provide maximum protection.
Be sure your medical record shows that you received this medication.
Page 6
TG 840 ATTACHMENT D
Atovaquone/Proguanil
R
(Malarone )
(Anti-Malarial Medication)
Medication Information Sheet
What is atovaquone/proguanil (Malarone)?
Atovaquone/proguanil (Malarone) is a combination drug, one of several drugs used to
prevent and treat malaria. The type of drug prescribed for you will be based on the area of
the world you are traveling to and your medical conditions.
How do I take the mediation?
Your dosage and how long you will take this medication will depend on the reason
for its use (prevention or active infection).
Dosage for children is based on the childs weight and the reasons for its use
(prevention or active infection).
If you vomit within 1 hour of taking this medication, repeat the dose.
It is important that you not miss any doses and that you take the drug on a regularly
scheduled basis.
This medication may cause nausea, vomiting, stomach pain, headache, or diarrhea. If
these symptoms persist or worsen, contact your Peace Corps health provider
promptly.
Contact your Peace Corps health provider immediately if any of these serious side
effects occur: loss of appetite, weight loss, unusual fatigue, or dizziness.
Contact your Peace Corps health provider immediately if any of these unlikely but
serious side effects occur: severe vomiting or diarrhea, fever, muscle or back pain.
An allergic reaction to this drug is unlikely, but seek immediate medical attention if
any of these symptoms occur: rash, itching, swelling, dizziness, or trouble breathing.
If you notice other effects not listed above, contact your Peace Corps health provider.
Is there any reason I should not take Malarone?
Tell your Peace Corps health provider your complete medical history, especially
kidney problems, previous treatments with this medication, recent severe vomiting or
Page 7
TG 840 ATTACHMENT D
This medication should be used only when clearly needed during pregnancy. Also
use protective clothing, insect repellents, and bed nets if you are pregnant and
traveling to an area at high risk for malaria. Discuss risks and benefits with your
Peace Corps health provider.
One of the drugs (proguanil) in this product passes into breast milk. Consult your
Peace Corps health provider before breast-feeding.
What should I do if I miss a dose?
If you miss a dose, take the missed dose as soon as you remember and then continue
the usual dosing schedule. DO NOT double the dose to catch up.
What should I do if I overdose?
Be sure your medical record shows that you received this medication.
Page 8
TG 840 ATTACHMENT D
Primaquine Phosphate
(Anti-Malarial Medication)
Medication Information Sheet
TERMINAL PROPHYLAXIS
WHEN TO START PRIMAQUINE (30 MG)
POST-DEPARTURE PROPHYLAXIS
(Following Departure from a Malarial
Endemic Area)
Mefloquine
Start on Day 15 (2 weeks following
departure)
Chloroquine
Start on Day 15 (2 weeks following
departure)
Doxycycline
Start on Day 15 (2 weeks following
departure)
Malarone
Start on Day 8 (1 week following
departure)
Page 9
TG 840 ATTACHMENT D
If your G6PD level is low or absent, you should NOT take primaquine
If your G6PD is low or absent, your PCMO will give you authorization
(PC-127C) for G6PD retest and consultation with your home of
record physician
Individuals with low or absent G6PD levels should only take
primaquine if recommended, and supervised, by a medical
professional
If you have arthritis, psoriasis, lupus, liver disease or allergies to
primaquine
If you are pregnant or breast-feeding. Discuss the risks and benefits
with your Peace Corps health provider.
If you miss one or more doses for any reason, take ONE dose as
soon as possible and then continue on your usual dosing schedule.
DO NOT double-up the dose to catch up unless instructed to by a
Peace Corps health care provider.
Page 10
Mefloquine guide
Page 1
Mefloquine guide
Page 2
Mefloquine guide
Page 3
TG 840 ATTACHMENT F
Date
I,
___, have received and read the June 2013,
Mefloquine (mefloquine hydrochloride) Medication Guide.
If, at any time, I experience what I feel are possible side effects from Mefloquine, I
will promptly discuss the situation with my Medical Officer, and I may be placed on
alternative anti-malaria prophylactic medication.
Signature
10/5/2003
Peace Corps
Technical Guideline 845
2. BACKGROUND
Malaria is one of the 10 most prevalent and deadly diseases in the world. Between 300-500
million clinical cases occur every year with over 1.2-2.7 million deaths. Ninety percent of
these occur in sub-Saharan Africa. Malaria is a parasitic disease spread by the bite of the
Anopheles mosquito. For additional information on the malaria parasite and for specific
guidance on malaria prevention, see Technical Guideline 840 Prevention of Malaria.
The Office of Medical Services (OMS) bases its recommendations for the presumptive
treatment of malaria on the most recent guidance from the Centers for Disease Control and
Prevention (CDC). Recommendations for the treatment of confirmed cases of malaria are
based on a review of current literature, expert consensus opinion, and evidence-based
guidelines where they exist.
For additional information regarding the diagnosis and treatment of malaria, Peace Corps
Medical Officers (PCMOs) should refer to additional information from CDC at the following
internet site: http://www.cdc.gov/malaria/diagnosis_treatment/tx_clinicians.htm
3. GENERAL CONSIDERATIONS
The incubation period for malarial parasites varies from 7 to 28 days, depending on the
species. The incubation period is the time that elapses between exposure, i.e., the bite of an
infected mosquito, and infection, i.e., the development of clinical symptoms of malaria. The
average incubation period for P. falciparum is 9-14 days.
Infection with the species P. falciparum can be life threatening. The parasite alters red blood
cells causing the cells to stick to the sides of blood vessels. When the level of parasitemia is
high, the cells sludge and clump together, eventually blocking capillaries throughout the
body. This is called microvascular sequestration. In the absence of medical treatment,
parasitemia of more than 5% is often fatal. Severe infection can also lead to coma, severe
anemia, cerebral malaria, hypoglycemia, renal failure, acidosis, convulsions, and death.
Infections with the species P. vivax, P. ovale, and P. malaria are rarely life-threatening,
however, symptoms may be severe. With these species, the percent of parasitized red blood
cells is rarely more than 1%; sludging usually does not occur, and complications are less
common.
November 2006
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TG 845
Malaria Diagnosis and Treatment
KEY SYMPTOMS
KEY SIGNS
Periodic fever
Jaundice
Liver tenderness
Splenomegaly
Pulmonary edema (severe)
Renal failure (severe)
Malaria classically presents with nonspecific and irregular fever, chills, headache, and
malaise. Symptoms generally develop 10 days to 4 weeks after an infective bite. Often
there is a prodromal phase of the disease that is similar to a non-specific viral illness.
Initial symptoms may progress over 1-2 days to include any of the following:
In practice, presenting symptoms are variable. The disease may present with
nonspecific respiratory or gastrointestinal symptoms or, in more serious cases of P.
falciparum malaria, with shock, delirium, and coma. Vomiting occurs in
approximately 20% of patients, and mild diarrhea in less than 5%. Signs and symptoms
also depend on the malaria species, the Volunteers degree of immunity, and whether
the Volunteer has regularly taken chemoprophylaxis.
November 2006
Page 2
TG 845
Malaria Diagnosis and Treatment
Fever Periodicity
A cyclical or periodic fever pattern may or may not be present. If present, fevers may
show an every-other-day (tertian / 48 hour) periodicity in P. vivax, P. ovale and P.
falciparum malaria, or an every-third-day (quartan / 72 hour) periodicity in P. malariae
malaria. Periodicity corresponds to the release of merozoites from the red blood cells
in the asexual cycle.
4.2
Physical Exam
Most physical signs are nonspecific. The Volunteer may seem only slightly ill, or may
appear pale and sallow. There may be sweating, anxiety, and distress. Common
clinical findings on physical exam include the following (Mandell, et al., 2000):
Vital Signs:
Pulse: tachycardia.
Skin:
May be cool and pale or warm and dry; mild jaundice may be present.
Eyes:
Chest:
Abdomen:
November 2006
Page 3
TG 845
Malaria Diagnosis and Treatment
Lymphadenopathy: Does not occur in malaria and its presence in a Volunteer with
malaria should prompt a search for additional etiology.
Neurologic: Normal with the exception of delirium and other minor behavioral
changes that may result from high fever.
November 2006
Page 4
TG 845
Malaria Diagnosis and Treatment
smear preparation, i.e., slides, lancets, alcohol wipes and band-aids. The Kits can be
procured through the Overseas Support Division in Administrative Services
(M/AS/OSD). For ordering information see TG 240.15.2 MIF Kits and Malaria Kits.
Medical Officers are responsible for teaching Volunteers when and how to prepare
proper malaria blood smears. Training should occur during Pre-Service Training (PST)
and In-Service Training (IST). Illustrated instructions for preparing blood smears are
included in ATTACHMENT A of this TG and in Appendix B of the Pre-Service
Health Training Module on Malaria.
If malaria is suspected, Volunteers and PCMOs should prepare thick and thin smears
according to the following guidelines:
Prepare smears every 6 to 8 hours for several days. Numerous blood smears may
be required to identify parasites.
Because the level of parasitemia varies from hour to hour especially for P.
falciparum infections in which parasites may be difficult to find obtain and
examine blood at 6-8 hour intervals for a minimum of 3 days, during and between
fever spikes.
Send smears to a reliable local laboratory for staining and examination. Smears
may be stained and examined in the Peace Corps Health Unit if facilities and
trained personnel exist.
Send all smears to the CDC according the instructions outlined in Section 10 Case
Reporting.
Complete Blood Count (CBC) to include peripheral smear; peripheral smear may
demonstrate hemolytic anemia, leukopenia, and thrombocytopenia.
Liver Function Tests (LFTs) to include ALT, AST, direct/indirect bilirubin, and
albumin; results may demonstrate elevated levels of ALT, AST due to hepatic
congestion, elevated indirect bilirubin levels from hemolysis and hypoalbuminemia
from impaired liver function.
Fluorescent stain (QBC method): This method, which requires special capillary
tubes, a centrifuge, and a fluorescent microscope, is reported to be as sensitive as a
thick smear examination for the detection of low levels of parasitemia. The test
November 2006
Page 5
TG 845
Malaria Diagnosis and Treatment
requires expert technical skills, and overdiagnosis of malaria by those using this
method is common. It does not replace thin and thick smear examination.
Antigen test for P. falciparum: This test, a rapid and simply accomplished dipstick
antigen capture assay, appears promising for field diagnosis; however, it is
currently not available for widespread clinical use. Also, sensitivity decreases with
low parasite density.
ELISA for P.falciparum: Serologic tests are not useful in the diagnosis of acute
malaria attacks. Antibodies to malaria may persist for 10 or more years and the test
does not differentiate past from present infection.
Amebiasis
Dengue Fever
Relapsing fever
Hypoperfusion/shock
Meningococcemia
Influenza
Viral encephalitis
Typhoid
Tuberculosis
Acute gastroenteritis
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Malaria Diagnosis and Treatment
Medical Officers should not use mefloquine, Fansidar, or halofantrine, for the
interim self-treatment of malaria (see Section 6.3 below).
Note: For specific information see also Health Information for International Travel,
(Yellow Book), available from the CDC, or on the world wide web at
www.cdc.gov/travel/reference.htm
5.2
Special Circumstances
Oceania (Papua New Guinea, Solomon Islands, and Vanuatu): Volunteers who are
days away from medical care and are exposed to both drug resistant P. falciparum and
P. vivax, should be provided with, and instructed in the use of, two of the interim selftreatment regimens in case of delays receiving medical attention.
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6.2
Monitoring
To confirm response to treatment, PCMOs should monitor the Volunteers clinical
response to treatment and the level of parasitemia on peripheral blood smears. Blood
smears should be examined 2-3 times a day to determine whether the parasitemia is
decreasing. Failure to reduce parasitemia in the first 24-48 hours of treatment should
raise the possibility of drug failure. Also, no significant clinical response to treatment
in 24-48 hours, or the persistence of parasites after the fifth day, implies treatment
failure and PCMOs should start an alternative treatment regimen. Monitoring should
continue until the parasite level is zero.
6.3
Fansidar: Treatment with Fansidar has been associated with fatal reactions
including Stevens Johnson Syndrome and Toxic Epidermal Necrolysis.
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Volunteers with complicated malaria usually require hospitalization and medical evacuation
(medevac).
Complicated malaria is almost always due to P. falciparum and is associated with a mortality
of 15-20%. In severe P. falciparum infections, red blood cell parasitemia is often, though not
always, higher than 3-5%. The prognosis is poor when there are multiple complications or if
there are any mature parasites in the peripheral blood. Other species of malaria may produce
severe or complicated infection; however, the complications listed below are almost
exclusively due to the red blood cell sludging seen with P. falciparum.
Complications include:
Hyperpyrexia
Hemolytic anemia - may lead to severe anemia and hemoglobinuria which may cause
urine to turn black (blackwater fever).
Acute tubular necrosis and renal failure - secondary to renal microvascular damage or
hemoglobinuria; may lead to acute renal failure or severe anemia.
Lactic acidosis
Hypoglycemia
Cardiac dysrhythmias
7.1
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Published sources caution about the use of a loading dose when quinine, quinidine, or
treatment doses of mefloquine have been taken in the preceding 24 hours. Recognizing the
possibility of cardiac arrhythmias, adequate blood levels of quinine must be achieved as soon
as possible and may be life-saving.
As hypoglycemia and hypovolemia are both frequently observed, D5/NS or D5/.5NS are the
preferred IV fluids.
**
7.2
Alternate Regimen
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7.3
Monitoring
Monitoring of complicated malaria should include the following:
7.4
Vital signs
Fluid status: Use two IV lines if one is needed for fluid replacement.
Urinary output
Medication monitoring:
Exchange Transfusion
Exchange transfusion is recommended for cerebral malaria and should be strongly
considered for parasitemia >10% or for progressive pulmonary or renal failure. One or
two total body exchanges may be necessary. Patients requiring this therapy are
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Malaria Diagnosis and Treatment
transfused with whole blood or the equivalent blood components. Medical Officers
should consult with OMS immediately if an exchange transfusion is being considered.
8.2
Chloroquine
Adverse Reactions: Treatment limiting adverse drug reactions occur in less than
1% of patients receiving treatment doses, and serious drug reactions attributable to
treatment doses are rare. The most commonly reported adverse reactions include
abdominal pain (17%), nausea (12%), vomiting (12%), headache (10%), diarrhea
(8%), weakness (8%), loss of appetite (5%), and dizziness.
Elevated ALTs and ASTs occur in patients treated with Malarone and at a greater
frequency than patients treated with mefloquine; however the differences were not
significant and values returned to normal by day 28 in most patients. Although the
clinical significance of these elevations is unknown, studies have not shown liver
enzyme elevations to be treatment limiting (Looareesuwan, S., et al., 1999).
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Malaria Diagnosis and Treatment
8.3
8.4
Precautions:
Adverse Reactions: Treatment is generally well tolerated. Common side effects are
sleep disorder, headache, dizziness, palpitation, abdominal pain, anorexia, diarrhea,
vomiting, rash, pruritis, cough, arthralgia, myalgia, asthenia and fatigue. On ECG
monitoring, QT prolongation without clinical symptoms has been observed in
patients treated with Coartem.
Effectivenesss: Effective drug in the treatment of acute malaria and remains more
than 85% effective nearly everywhere (NEJM, 1996). Acts rapidly against the
asexual erthyrocyctic stages of all four Plasmodium species.
Adverse Reactions: Treatment is not well tolerated, and compliance with the 7 day
courses of treatment required for resistant P. falciparum infections is poor. Oral
compounds are extremely bitter. Adverse reactions often induce the complex of
cinchonism (nausea, vomiting, dysphoria, tinnitus, and high-tone deafness). These
reactions are dose related and reversible. Less common adverse reactions include
urticaria, angioedema of the face, itching, agranulocytosis, hepatitis, and
hypoglycemia in patients with high parasitemia. Serious toxic reactions are rare.
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8.5
Effectivenesss: Effective drug for the treatment of severe malaria. There are no
reports of resistance to quinidine in any strains of Plasmodia.
Adverse Reactions: Quinidine is toxic to the heart if given too quickly or in too high
a dose. ECG changes including prolonged QT intervals are common, but lifethreatening arrhythmias are rare with proper doses. Most adverse reactions are
gastrointestinal including nausea, vomiting, abdominal pain, diarrhea, and
esophagitis. Symptoms of mild to moderate cinchonism may appear in sensitive
patients after one dose of the drug. Less frequent adverse reactions include
urticaria, skin flushing with intense itching, and hypersensitivity reactions of
angioedema, acute asthmatic episode, and liver toxicity
In pregnant Volunteers, the OMS preferred drug of choice in areas with chloroquine
sensitive P. falciparum malaria is chloroquine (see Section 6.1 for dosing
schedules). In areas with chloroquine-resistant P. falciparum malaria, the
recommended treatment is Quinine in combination with clindamycin. Quinine
treatment should continue for 7 days for infections acquired in Southeast Asia and
for 3 days for infections acquired in Africa or South America; clindamycin
treatment should continue for 7 days regardless of where the infection was
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Malaria Diagnosis and Treatment
acquired. PCMOs should consult OMS in treatment planning for any pregnant
Volunteer in areas with chloroquine resistant P. falciparum malaria. Doxycycline
is contraindicated during pregnancy, and the CDC does not currently recommend
the use of Malarone in pregnant women unless the potential benefit outweighs the
potential risk to the fetus, e.g., a pregnant woman who has acquired P. falciparum
malaria in an area of multi-drug resistance and who could not tolerate other
treatment options. The safe use of the Coartem during pregnancy has not been
established.
Blood or serum for drug testing, i.e., Mefloquine or Malarone levels. Chloroquine and
doxycycline levels may be requested on a case by case basis.
REFERENCE
de Alencar, F.E., et al., Atovaquone and proguanil for the treatment of malaria in Brazil.
Journal of Infectious Disease, 1997. 175(6): pp. 1544-7.
Centers for Disease Control and Prevention (CDC). Health Information for International
Travel, 2003-2004, Atlanta, Georgia, 2003.
Centers for Disease Control and Prevention (CDC). Malarone for Malaria Treatment and
Prophylaxis, Atlanta, Georgia, 2000.
Goldsmith R. & Heynemann D. Tropical Medicine and Parasitology. Norwalk, CT:
Appleton & Lange, 1989.
Looareesuwan, S., et al., Efficacy and safety of atovaquone/proguanil compared with
mefloquine for treatment of acute Plasmodium falciparum malaria in Thailand. American
Journal of Tropical Medicine and Hygiene, 1999. 60(4): pp. 526-32.
November 2006
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Malaria Diagnosis and Treatment
Mandell, G. L., Douglas, R. G., and Bennett, J. E. Principals and Practice of Infectious
Diseases, 5th edition. Churchill Livingston, 2000.
Navy Environmental Health Center. Navy Medical Department Guide to Malaria Prevention
and Control, Norfolk, Virginia, 1991.
White, N.J. The Treatment of Malaria. The New England Journal of Medicine, Vol. 335:
800-806, No. 11, September 12, 1996.
November 2006
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TG 845 ATTACHMENT A
To establish the diagnosis of malaria, thick and thin blood smears from fresh peripheral blood
are required. Medical Officer and Volunteers should prepare smears anytime malaria is
suspected, regardless of fever spikes or time of day. All of the materials needed for smear
preparation are contained in the Peace Corps Malaria Kit.
Peripheral blood is obtained by pricking the finger (see Figure A-1). Thick and thin smears
should be made on separate slides, however, smears may be made on the same slide (see
Figure A-2).
* In Figures A-1 and A-2 hands are shown ungloved to better illustrate their placement during the procedures.
However, PCMOs should always wear gloves while processing blood specimens to prevent transmission of
bloodborne pathogens (see Technical Guideline 260 Infection Control).
Page 1
TG 845 ATTACHMENT A
Thin film: Air dry. Fix with methyl alcohol. Stain. If no parasites are found, wait until the
thick film is dry and examine it for organisms that might not have been detected on the thin
preparation.
Slides may be stained using a Wright-Giemsa stain; however, Wright stain alone will not reliably
show Plasmodium parasites. For best results, smears should be stained with a 3% Giemsa
solution (pH of 7.2) for 30-45 minutes. On microscopic examination, Plasmodium parasites are
always intracellular, and they demonstrate, if stained correctly, blue cytoplasm with a red
chromatin dot.
In P. falciparum infections, the parasite density should be estimated by counting the percentage
of red blood cells infected - not the number of parasites - under an oil immersion lens on a thin
film.
Reference: Adapted from Holtz, T., Kachur, S. P., et al. Malaria Surveillance United States, 1998. In: CDC
Surveillance Summaries. MMWR, December 7, 2001, 50; (No. SS05): 1-18.
Page 2
TG 845 ATTACHMENT B
Headache
Nausea (occasionally)
Vomiting (occasionally)
Diarrhea (rarely)
Understand that many of the signs and symptoms of malaria mimic other viral and bacterial
illnesses and, often, presumed malaria is not malaria. If you have regularly taken your
prophylactic anti-malarial medication, you should not develop acute malaria. However, if you
do experience some or all of the above symptoms, you should: (1) carefully consider the cause
of your symptoms, and (2) if you feel that these symptoms may be from malaria, follow the
directions for emergency self-treatment of malaria below.
DIRECTIONS FOR EMERGENCY SELF-TREATMENT
1. Take the anti-malarial drug in your Health Kit.
Coartem and Malarone are the drugs of choice for emergency self-treatment of
malaria
COARTEM 4 tablets orally at the time of initial diagnosis, again after 8 hours,
then twice daily for the following 2 days (4 tablets each time for total course
of 24 tablets)
Note: Coartem should be taken with high fat food and drinks such as milk as
this markedly improves absorption of drugs.
Or
MALARONE 4 tablets orally as a single dose daily for 3 days
Note: Do not take Malarone for emergency self-treatment
if you taking Malarone for antimalarial prophylaxis.
TG 845 ATTACHMENT B
2. Make blood smears: Blood smears are required for your PCMO to make the diagnosis
of malaria. You were trained how to make these smears during Pre-Service Training
(PST). A Malaria Kit and a handout with instructions on slide preparation are in your
Health Kit. Using the supplies in the Malaria Kit, do the following:
Make at least one thin blood smear. Thin smears may be more accurate for malaria
diagnosis.
Make the first slide when you start your self-treatment medication.
TG 845 ATTACHMENT C
Send this form, the blood slides, and blood for drug testing to: Centers for Disease Control and Prevention,
Malaria Epidemiology Branch, 4770 Buford Highway, MS F22, Atlanta, GA 30341 Fax: (770) 488-7761
TG 845 ATTACHMENT D
PEACE CORPS
COARTEM MEDICATION GUIDE
What is Coartem?
Coartem is a medication to treat malaria. Coartem tablets contain a combination of artemether (20mg) and
lumefantrine (120mg). These two medications work to clear the body of malaria parasites, and, when combined, are
especially effective against multi-drug-resistant strains of P. falciparum malaria.
Coartem is in the class of medications known as ACT, or "Artemether Combination Therapies." The World
Health Organization has determined that ACT are the preferred course of treatment for uncomplicated P. falciparum
malaria.
What are the risks of malaria?
Malaria is a parasitic disease that is transmitted by mosquito bites. The malaria parasite enters your blood cells
and destroys them.
Symptoms of malaria include shaking chills, headache, muscle aches, and tiredness, and sometimes even
nausea, vomiting, and diarrhea. Malaria may cause anemia and jaundice (yellow coloring of the skin and eyes)
because of the loss of red blood cells.
Infection with one type of malaria, Plasmodium falciparum, if not promptly treated, may cause kidney failure,
seizures, mental confusion, coma, and death. Malaria is a leading cause of death around the world. More than 1
million people die of malaria each year.
Why do I need Coartem?
You can prevent malaria by taking personal protective measures such as mosquito nets over your bed when you
sleep, anti-mosquito insect repellant that contains DEET, wearing long pants and long-sleeve shirts with collars.
Anti-malarial medications such as Lariam (mefloquine), doxycycline, and Malarone (atovaquone/proguanil) also
protect against malaria if taken properly.
If you do contract malaria, you can treat it with proper medications like Coartem if symptoms are identified
quickly and treatment is begun appropriately. Failure to adequately prevent or treat malaria can result in illness,
permanent injury or disability, and even death.
Who should NOT take Coartem?
Pregnant women in their first trimester should NOT take Coartem if you feel that you might be pregnant,
notify your health care provider immediately, before you take Coartem. Those with hypersensitivity reactions to
either artemether or lumefantrine, the two components of Coartem, should not take Coartem if you have had
allergic reactions to either artemether or lumefantrine in the past, notify your health care provider.
How do I take Coartem?
Coartem is taken as FOUR tablets, two times a day, for three days. You should take each dose of four tablet
with a meal to increase the absorption of the medication from your stomach. Recommended foods include milk,
cheese, and meat.
What are the risks of Coartem?
Every medication has possible side effects. Side effects from Coartem may include dizziness, fatigue,
decreased or absent appetite, nausea, vomiting, abdominal pain, heart palpitations, muscle aches, sleep disorders,
joint pains, headache, and rash. Many of these symptoms may be caused by malaria itself and may not be due to
Coartem. In addition, many of these side effects have been reported as mild or moderate; studies have found no
serious or persistent neurological side effects from use of Coartem. If you feel you may be experiencing side effects
from Coartem, contact your medical officer immediately.
Is Coartem approved by the U.S. Food and Drug Administration (FDA)?
Coartem was approved for use since 1999. Although Coartem is eligible for approval by the FDA, its manufacturers
have not yet submitted the drug for FDA approval. However, Coartem has been identified as a drug of choice by the
World Health Organization (WHO) for treatment of malaria. The Peace Corps is permitted to use Coartem because
it is an effective treatment for malaria and complies with Peace Corps guidelines.
PEACE CORPS
COARTEM MEDICATION GUIDE
ACKNOWLEDGEMENT
________________________________
Signature
_____________
Date
Peace Corps
Technical Guideline 850
SCHISTOSOMIASIS
1. PURPOSE
To provide PCMOs with guidance on COS treatment for Volunteers who serve in
schistosomiasis endemic areas
2. BACKGROUND
Schistosomiasis, also known as bilharzia, is a parasitic disease endemic to many areas of the
world served by Peace Corps Volunteers. Among human parasitic diseases, schistosomiasis
ranks second behind malaria in terms of socioeconomic and public health importance in
tropical and subtropical areas. The disease is endemic in 73 developing countries and infects
more than 200 million people. It is a serious disease that, if left undiagnosed and untreated,
can result in major morbidity or mortality.
As such, the Office of Health Services (OHS) attempts to: (1) prevent schistosomiasis
infections in Volunteers, (2) treat those Volunteers who become symptomatic during service
and (3) treat all PCVs living in endemic areas during service. Components of this prevention
and management strategy include:
Policy: OHS policy that requires all Volunteers serving in schistosomiasis endemic areas
to adhere to schistosomiasis infection prevention measures, i.e., avoidance of known risk
areas and employment of risk reduction strategies throughout their Volunteer service.
COS Treatment: all PCVs living in endemic areas are treated with Praziquantel at COS.
3. EPIDEMIOLOGY/LIFE CYCLE
Schistosomiasis occurs when human skin comes in contact with contaminated fresh water in
which specific species of snails that carry schistosomes are living. Disease transmission occurs
only in fresh water and only in areas where the specific snail host is present. Medical Officers
and Volunteers should, however, assume that all rivers, streams, lakes, and other bodies of
fresh water in schistosomiasis endemic areas are contaminated.
Office of Health Services
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Schistosomiasis
The pathophysiology of schistosomal disease reflects the geographic distribution and the unique
life cycle of the parasite. Schistosomal disease results directly from schistosome eggs being
deposited in host tissue and from the granulomatous host response to them. It is the eggs, not
the worms that are responsible for most of the pathology associated with the disease.
Site
Species
Urinary
S. haematobium
Geographic Distribution 1, 2
Africa southern Africa, sub-Saharan Africa, Lake Malawi, the Nile River
valley in Egypt.
Middle East Iran, Iraq, Saudi Arabia, Syria, Yemen
Intestinal
S. mansoni
Africa - southern Africa, sub-Saharan Africa, Lake Malawi, the Nile River
valley in Egypt.
Middle East - Iran, Iraq, Saudi Arabia, Syria, Yemen
South America including Brazil, Venezuela, Surinam
Caribbean Antigua, Dominican Republic, Guadeloupe, Martinique,
Montserrat, St. Lucia (low risk).
S. intercalatum
S. japonicum
S. mak ongi
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Avoid contact with, including swimming in, all freshwater bodies of water; this includes
lakes, ponds, rivers, streams, irrigation systems, dams, canals and other bodies of
freshwater. All freshwater bodies of water in endemic areas are potentially contaminated.
Swimming in the ocean or well-maintained, chlorinated pools is safe.
Do not bathe in any of the freshwater sources mentioned above. Bathe in water that is
made safe by the following methods: (1) allowing the water to stand for greater than 48
hours during which time the cercariae die; (2) heating the water for 5 minutes at 150 F; or
(3) filtering with a water filter or fine mesh filter.
Never drink untreated water from any of the freshwater sources mentioned above.
Infection can occur through the skin of the lips and mouth. Drink safe water. Drinking
water should be made safe using the water disinfection methods described in TG 810
ATTACHMENT A Water Disinfection Methods.
Though several prevention measures associated water contact have been examined (application
of DEET to the skin prior to freshwater exposure and vigorous towel drying after freshwater
exposure), these measures are not proven to provide significant protection against schistosomal
infection. The only measure that reliably prevents schistosomiasis is avoidance of contact with
freshwater in endemic countries.
5. CLINICAL FEATURES
All Volunteers with signs or symptoms suggestive of possible schistosomiasis infection must
be evaluated. The definitive diagnosis of schistosomiasis is made by identification of eggs in
urine (S. haematobium) or stool (all species); or a history of fresh water exposure in an
endemic area and a positive antibody titer.
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Schistosomiasis
Fever
Cough
Malaise, Fatigue
Arthralgias, Myalgias
Abdominal pain
Diarrhea (may be bloody)
Urticaria
Right Upper Quadrant pain
Hepatosplenomegaly
Eosinophilia
Hematuria, dysuria (chronic)
Stage 2: Acute
Stage 3: Chronic
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days to appear. By this time, the acute stage may be over, with symptoms having
resolved over a period of several weeks.
Often the patient becomes suddenly ill with presentations varying from mildly ill with to
extremely ill. Symptoms include fever (99-105 F), chills, nonproductive cough,
headache, anorexia, weight loss, generalized myalgias, right-upper quadrant pain, and
diarrhea (may be bloody). Lymphadenopathy and hepatosplenomegaly may be present.
When the acute infection is massive in a patient with no previous exposure to
schistosomes, the resulting illness can be serious and life threatening.
Early Chronic Schistosomiasis
Symptoms of early chronic disease may be seen in Peace Corps Volunteers. These
symptoms usually appear 10-12 weeks after infection when some, of the many of
thousands, of eggs released each day by an adult worm, reach the lumen of the bowel or
bladder and cause inflammation of these organs. Symptoms of intestinal disease
typically include fatigue, abdominal pain, vague, nonspecific intestinal complaints and
diarrhea. The diarrhea may progress to dysenteric bloody diarrhea and subsequent iron
deficiency anemia. Symptoms of urinary tract disease include dysuria, frequency and
hematuria.
Early Neurologic Manifestations
Rarely, schistosomiasis involves the central nervous system (CNS). Egg deposition in
the brain or around the spinal cord may produce seizures and/or a transverse myelitis-like
syndrome. Cerebral mass lesions may result from egg deposition in or around brain
tissue. Most reported cases of cerebral schistosomiasis are caused by S. japonicum, and
most cases of schistosomal tranverse myelitis by S. mansoni or S. haematobium.
Symptoms of both syndromes may include severe headache and neck stiffness, central
nervous system (CNS) changes, both generalized and focal, and paralysis. In severe
cases infection may result in death.
PCMOs should consider the possibility of neuroschistosomiasis in all patients who have a
history of freshwater exposure in schistosomiasis endemic areas and CNS abnormalities,
even in the absence of classic signs and symptoms of acute disease.
Neuroschistosomiasis can occur several months after exposure to infested water and in
low-intensity infections in which eggs may be undetectable or difficult to identify in
urine or stool.
Late Chronic Schistosomiasis
Late chronic disease is responsible for most of the morbidity and mortality associated
with the disease. Chronic schistosomiasis occurs almost exclusively in lifetime residents
of endemic areas and is very rarely seen in expatriates or Peace Corps Volunteers.
During the late chronic stage of infection, schistosome eggs, and the antigens they
secrete, can accumulate in target organs, which eventually results in granuloma
formation, scarring and fibrosis. The intensity and duration of infection determine the
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Schistosomiasis
Vital Signs: Temperature may range from normal to 105F (40.6C); blood pressure,
respiratory rate and pulse may be elevated secondary to fever
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Complete Blood Count (CBC): Peripheral eosinophilia is a common finding in most forms
of schistosomiasis and may reach between 15-50%, particularly in acute infection.
Eosinophilia, however, has a broad differential diagnosis and, in isolation, is not considered
diagnostic of shistosomiasis, nor is it required for the diagnosis of schistosomiasis.
Liver function tests (ALT, AST, GGT, alkaline phosphate, direct/indirect billirubin,
albumin): Alkaline phosphate and GGT may be increased with hepatic granulomatosis.
Transaminiases are generally not affected. Elevations may be caused by any coexisting
hepatocellular disease, e.g., hepatitis.
Imaging Studies
Radiography is an important diagnostic tool in the evaluation of sequelae and
complications of chronic schistosomiasis, however, radiographic findings are extremely
rare in the usually, lightly infected, Volunteer population. Thus, the following exams
should not routinely be performed.
CXR, plain x-ray film of the abdomen, IVP, ultrasound, echocardiography, cystoscopy,
endoscopy, CT scan and MRI
Persistent or severe symptoms may require follow-up exams. CT scan and MRI may be
useful in the evaluation of CNS disease.
Malaria
Viral illness
6. TREATMENT OF SCHISTOSOMIASIS
Praziquantel is the current drug of choice for treating acute and chronic schistosomiasis based
on its spectrum of activity, safety, and cost.
Cercarial Dermatitis
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Schistosomiasis
Acute Schistosomiasis
In general, immediate treatment is indicated and should be initiated when one or more of
the following findings are present:
2.
3.
Positive history of exposure, AND signs and symptoms of acute disease (see
Section 5.2), AND a strong clinical suspicion of schistosomiasis infection.
When microscopic examination of stool and urine for eggs is negative or not
available, or when antibody titers are pending or indeterminate, PCMOs should
maintain a high index of suspicion of disease and consider treatment when the
following findings are present:
2.
3.
4.
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In the acute stage eggs may not be present, still, the presumptive diagnosis of acute
schistosomiasis may be made on clinical suspicion reinforced by the presence of any of
the above mentioned signs or symptoms of disease.
6.1
Monitor for acute complications, i.e., volume depletion and gastrointestinal (GI)
bleeding, CNS.
Be aware that treatment will not immediately relieve the symptoms of acute
schistosomiasis as symptoms are due to an immunological reaction. Symptoms may
transiently worsen as the killed worms release antigen increasing the strength of the
immunological reaction.
6.2
S. japonicum, S. mekongi
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Schistosomiasis
Oxamniquine (Vansil) had previously been an alternative drug for treating S. mansoni, but
is no longer readily available.
Steroids
Steroids have been used in the management of acute schistosomiasis; however, there
are no clinical trials to assess optimal therapy. Nevertheless, steroids may be useful
prior to treatment in heavily infected persons to control the heightened immunologic
reaction to worm antigens after Praziquantel is given. Treatment may exacerbate
symptoms as a result of increased antigen release.
Corticosteroids should be used only for persons who are extremely toxic appearing
and whose symptoms fail to respond or worsen with treatment. Use with CNS
involvement to prevent inflammation and edema around the eggs. Prednisolone 40
mg/day for 5 days is the recommended dosing.
For persons with mild symptoms, non-steroidal anti-inflammatory agents should be
used.
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Reevaluate the Volunteer for resolution of symptoms. Most symptoms will improve within
a few weeks of treatment with Praziquantel, although resolution of some may take several
months.
Persistent symptoms warrant follow-up exams as indicated, e.g., cystoscopy, ultrasound or
urologic evaluation for hematuria or other GU symptoms; endoscopy or GI referral for
blood in the stool or other GI symptoms, etc.
If eggs were identified in urine or stool prior to treatment, repeat urine or stool exams at 12 months and 3-4 months to confirm the disappearance of eggs and to assess efficacy of
treatment. Praziquantel is not 100% effective; therefore, PCMOs should monitor urine or
stool for the disappearance of eggs.
Retreat if indicated. Eggs may be shed for months after successful therapy or natural death
of worms. Eggs may or may not be viable, but because the tests required to distinguish live
from dead eggs are not readily available, PCMOs should repeat treatment every few
months until eggs are no longer detectable. Treatment should arrest egg laying, granuloma
formation, and future complications.
In those with negative exams for eggs, if praziquantel does not relieve the symptoms that
are attributed to schistosomiasis, consider another etiology.
Do not repeat antibody testing. Repeated antibody testing following treatment is not
clinically indicated. Antibody levels are likely to persist for many years; the duration of
positive antibody test following treatment is not known.
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Schistosomiasis
Starting in March 2012, all Volunteers living in Schistosomasis endemic regions are to be
treated empirically with Praziquantel at COS for possible exposure.
Volunteers are adults considered to be at risk which is the rational for empiric treatment of
Schistosomiasis. See the WHO strategy for treatment at:
http://www.who.int/schistosomiasis/strategy/en/index.html
Treatment should be given within 72 hours of COS a labeled container with detailed
instructions
See Section 6.2 for appropriate treatment regimens
Provide TG 330, ATTACHMENT J Praziquantel Medication Information Sheet to all
Volunteers receiving praziquantel
REFERENCES
UpToDate, Treatment and Prevention of Schistosomiasis, July 2013,
http://www.uptodate.com/contents/treatment-and-prevention-ofschistosomiasis?detectedLanguage=en&source=search_result&search=schistosomiasis&select
edTitle=3%7E65&provider=noProvider
UpToDate, Diagnosis of Schistosomiasis, July 2013,
http://www.uptodate.com/contents/diagnosis-ofschistosomiasis?detectedLanguage=en&source=search_result&search=schistosomiasis&select
edTitle=2%7E65&provider=noProvider
UpToDate, Treatment and Prevention of Schistosomiasis, July 2013,
http://www.uptodate.com/contents/treatment-and-prevention-ofschistosomiasis?detectedLanguage=en&source=search_result&search=schistosomiasis&select
edTitle=3%7E65&provider=noProvider
Center for Disease Control and Prevention, Division of Parasitic Disease,
www.dpd.cdc.gov/dpdx
Centers for Disease Control and Prevention. Yellow Book (Health Information for
International Travel, 2014).
Medscape, Schistosomiasis, March 1, 2013, http://emedicine.medscape.com/article/228392overview
Uniformed Services University of the Health Sciences, Schistosomiasis, Tropical Medicine
Central Resource, Chapter 2. http://tmcr.usuhs.edu/tmcr/chapter2/intro.htm
World Health Organization, Schistosomiasis. Fact Sheet No. 115, March 2013.
World Health Organization, Preventive Chemotherapy in Human Helminthiasis, 2006,
http://whqlibdoc.who.int/publications/2006/9241547103_eng.pdf
Office of Health Services
November 2013
Page 13
TG 850 ATTACHMENT A
The map shows schistosomiasis-endemic areas worldwide, categorized by areas where hepatic/intestinal
schistosomiasis occurs, where urinary schistosomiasis occurs, and where both types occur.
Hepatic/intestinal schistosomiasis is endemic in most of the eastern half of South America. Both types
are endemic in most African countries and the Middle East. Hepatic/intestinal schistosomiasis is endemic
in China; Thailand; Laos; Cambodia; and most other countries in Southeast Asia. Urinary schistosomiasis
is endemic in Turkey; Syria; Jordan; Iraq; Iran; India.
Note:
Urinary Schistosomiasis = S. haematobium;
Hepatic/Intestinal Schistosomiasis = S. mansoni in Africa, Middle East, South America, and the
Caribbean; S. intercalatum in Africa; S. japonicum, S. mekongi, and S. malaynensis in Asia.
The map represents a general illustration of the worldwide distribution of schistosomiais. PCMOs should
follow the guidance for schistosomiais prevention and treatment outlined in the text of Technical Guideline
850 Schistosomiais.
Map adapted from Health Information for International Travel, 2014 (Yellow Book). Published by the
Centers for Disease Control and Prevention., http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-3infectious-diseases-related-to-travel/schistosomiasis
November 2013
TG 850 ATTACHMENT B
TG 850 Attachment C
Kilograms
45.5
50.0
54.5
59.1
63.6
68.2
72.7
77.3
81.8
86.4
90.9
95.5
100.0
104.5
109.1
113.6
Total Dose
1820 mg
2000 mg
2180 mg
2364 mg
2544 mg
2728 mg
2908 mg
3092 mg
3272 mg
3456 mg
3636 mg
3820 mg
4000 mg
4180 mg
4364 mg
4544 mg
Divided Dose
910 mg
1000 mg
1090 mg
1182 mg
1272 mg
1364 mg
1454 mg
1546 mg
1636 mg
1728 mg
1818 mg
1910 mg
2000 mg
2090 mg
2182 mg
2272 mg
Kilograms
45.5
50.0
54.5
59.1
63.6
68.2
72.7
77.3
81.8
86.4
90.9
95.5
100.0
104.5
109.1
113.6
Total Dose
2730 mg
3000 mg
3270 mg
3546 mg
3816 mg
4092 mg
4362 mg
4638 mg
4908 mg
5184 mg
5454 mg
5730 mg
6000 mg
6270 mg
6546 mg
6816 mg
Divided Dose
1365 mg
1500 mg
1635 mg
1773 mg
1908 mg
2046 mg
2181 mg
2319 mg
2454 mg
2592 mg
2727 mg
2865 mg
3000 mg
3135 mg
3273 mg
3408 mg