瘧疾預(yù)防與控制手冊(cè)Malaria Prevention and Control

BPInternational

Malaria

Prevention&Control

Program

November2006

BPMP&CProgram

TableofContents

Chapter1:MalariaPolicy3

Chapter2:PreventionandControlofMalariaforBPInternational4

2.1The"ABC"ofMalariaprevention4

2.2TertiaryPrevention9

2.2TreatmentofMalaria10

Chapter3:ListofCountryMalariaOccurrence&Recommendations..…14

Table.1Coutries&RegionsofBPOpeartionwithMalariaRisk15

Chapter4:MalariaPersonalProtectiveEquipmentList19

Tab.1PersonalAntiMosquitoBiteItemsCheckList20

Tab.2ProphylaxisRegimens21

Tab.3MalariaSurvivalKit22

Tab.4EmergencyStandbyTreatmentKitforMalaria23

Appendix1:InformationCardsInsideMalariaSurvivalKit24

Appendix2:ReferenceInformationforMalariaPPEUsers25

Chapter5:TrackingandFollowUp29

5.1LettertoDoctor/Nurse

5.2MalariaInformationSheet

5.3LettertofamilyforMalariaPrevention

Appendix1:SpecificMedications32

Appendix2:TableofReferences34

GlossaryofMedicalTerms35

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MALARIAPOLICY

ItisBP'sPolicytostrivetoreducetheimpactofMalariaon

employeesandthesurroundingcommunityinareaswhereBP

operates.

Thiswillbedoneby:

?EducatingemployeesabouthowMalariaistransmitted;

?Ensuringthattheoperatingandaccommodationfacilitiesare

keptasfreefrommosquitoinfestationaspossibleby

responsibleEnvironmentalmethods;

?Thatassistanceisgiventothelocalindigentcommunitiesin

reducingtheloadofmalariaintheircommunities;

?Thatuptodatechemoprophylaxisandtreatmentisgivento

employees,bothwhilstintheMalariaareaaswellasafter

leavingit.

ThisPolicyshouldbereadinconjunctionwith:HSE,Community

Relations,PPE&C,MedicalandEnvironmentalPolicies.

ZengQingping

President

BPInternational

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Chapter2:

PreventionandControlofMalariaforBPInternational

PleasefindenclosedanoutlineoftheapproachthatwouldbeadoptedforBP,toreducethe

riskofMalariaoccurringtoanyofitsemployeesandcontractorsworkinginmalariariskarea.

TheObjectiveoftheprogramistoreducetheriskofanyEmployeesdevelopingmalariato

zero.

TherehavebeenmanysuccessesandfailuresoflargeMiningandExplorationprojectswhere

itcomestomanagingMalariaintropicalcountries.MalariaandYellowFever,bothMosquito

borndiseases,delayedtheconstructionofthePanamaCanal.Successeshavebeen

obtainedinlargeOil/GaspipelineprojectsinChadandcopperminingactivitiesinZambia.

WhenevertheEcosysteminAfrica,SouthoftheSahara,ischangedbyIndustrialactivities,it

bringstheriskofMalariatoEmployees.

2,1The“ABC”ofMalariaPrevention

A:Awarenessofmalariarisk

B:AvoidanceofMosquitoBites

C:CompliancewithChemoprophylaxis

D:EarlyDetection

E:Effectivetreatment

AnotherwayoflookingatIhiswouldbetoconsider3levelsofcontrol:

Primary-controlthevectors

Secondary-limittheabilityofthevectortointeractwithhtmans

Tertiary-intheeventofapersonbecominginfected,treatrapidlyandeffectively

Awareness

TheriskofacquiringMalariainAfricaandthedeathsassociatedwithmalariahaverisensince

the1970's,largelyasaresultofresistanceoftheParasitetomedicationsaswellas

resistanceoftheMosquitotostandardinsecticides.

Inaddition,Malariaisamovingtargetwithgeneticchangesoccurringinboththeparasiteand

themosquitoonaregularbasis.Thesechangesoftenleadtoresistancetostandard

medicationsandinsecticides.

TherehasalsobeenanupsurgeinpopulationmovementswithinAfrica,bothasaresultof

economicdevelopment,tourismandpoliticalupheavalsandwars.

MalariainAfricaiscausedin90%ofcasesbyPlasmodiumfalciparum,whichisthemost

deadlyofallthemalarialparasites.

Plasmodiumisagroupofone-celledanimalparasitesthatlivesontheredcellsintheblood

ofmanybirds,reptilesandmammals.Therearefour

humanmalariaspecies-P.falciparum,P.ovale,P.

vivaxandP.malaria.P.falciparumisbyfarthemost

dangerous.Unfortunately,itisalsothemost

commoninAfrica.Malariaistransmittedbycertain

Anophelesmosquitoes.Theparasitehastoundergo

acrucialdevelopmentprocessinthemosquito,and

thiscanonlyhappenincertainmosquito.

Malariakillsoveronemillionpeopleeachyear,most

ofwhomarechildrenunder5,andalmost90%of

whomliveinAfrica,southoftheSahara.Eachyear

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thereareover300millionclinicalcasesofmalaria,whichisfivetimesasmanyascombined

casesofTB,AIDS,measlesandleprosy.Malariaisresponsibleforoneoutofeveryfour

childhooddeathsinAfrica.

Womenarefourtimesmorelikelytogetsick,andtwiceaslikelytodiefrommalariaiftheyare

pregnant.Malaria-afflictedfamiliesareabletoharvestonly40%oftheircrops,comparedwith

healthyfamilies,suggestingalinkbetweenmalariaandpoverty.Thedirectandindirectcosts

ofmalariainAfricaareestimatedtoexceed$2billionperyear.Itisbelievedthatitcouldbe

controlledwithabudgetamountingtoone-tenthofthisamount.Malariaslowseconomic

growthinAfricancountriesbyanestimated1.3%eachyear.

Thecheapestandsafestmalariadrug-chloroquine-israpidlylosingitseffectiveness.In

somepartsoftheworld,malariaisresistanttothefourleadingfront-linedrugs.Malaria

quicklyreboundedfromthemassinsecticidesprayingcampaignsinthe1950'sand1960's.It

theneludedmasstreatmentstrategiesbasedonasingledrug,suchaschloroquine.Malaria

canquicklyadaptandreboundwheneffortsarefragmentedanduncoordinated.Yetithas

beenshownthatmalariadeathscouldbereducedwithco-coordinatedintervention.

Themalariaparasiteentersthehumanhostwhen

aninfectedAnophelesmosquitotakesablood

meal.Insidethehumanhost,theparasite

undergoesaseriesofchangesaspartofits

complexlife-cycle.Itsvariousstagesallow

plasmodiatoevadetheimmunesystem,infectthe

liverandredbloodcells,sndfinallydevelopintoa

formthatisabletoinfectamosquitoagainwhenit

bitesaninfectedperson,nsidethemosquito,the

parasitematuresuntilitreachesthesexualstage

whereitcanagaininfectahumanhostwhenthe

mosquitotakeshernextbloodmeal,10to14or

moredayslater.

AvoidanceofMosquitoBites

Thebestpreventionispersonalprotectionagainstthemosquito.Malariamosqcitoes

generallybiteafterdark.Wearlongsleevesandtrousersintheafternoonandevening;stay

in-doorsifpossible.Useinsectrepellentonexposedskin.Sleepunderabednetorina

nettedtentorhutorinahouseorcaravanwithscreens.Closewindowsanddoorsatnight.

Sprayinsecticideaerosoland/orburnmosquitocoilatnight.

DependingonwhereinAtrica,theEmployeesofBPwillbeworking,willdeterminetheirrisk

ofbeingbittenbyaninfectedmosquito.Thedeterminationoftheburdenofmalariais

extremelyimportantasinsomeareastheriskofthediseaseisyearlongandunrerritting

whereasinothersitisseasonalanddependantontherainfall.Knowledgeofthevecto",the

mosquito,anditscontrolisOGGontialindeterminingthebeststrategytoreducetheriskof

beingbitten.Forexampleinareaswherethereareclearlydefinedseasonalperiodsof

mosquitoactivity,sprayingaccommodationsatthoseperiodswithaspraywouldgivebest

protection.Inareaswhere,thediseaseisyear-long,sleepingunderinsecticideimpregnated

netswillprovidebetterprotection.

InsomeareasinAfrica,theaverageyearlynumberofbites/person/yearapproaches500,

whereasinmoreseasonalmalarialareasofWestAfricathenumberis<100.

Mosquito'sthatcarryMalariaarescientificallycalledAnopheline.Somefeaturesofthese

mosquito'sare:

?Theadultsareabout8mminlength

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?Theposturewhenfeedingisdistinctive,headdownandtail-up.(seepictureonpage

1)

?Theyflyquietly-hencetheyareoftencalledsilentkillers

?Theygenerallyprefercleanwaterfordevelopment-e.g.smallpoolsthatmightform

fromhoofprints,sandypoolsetc

?Theyrestbothindoorsandoutdoorsunderleavesortreeroots-eachspeciesof

mosquitohasitsownparticularpreferences

?Theycanbecarriedbywindandcanalsobecarriedlargedistancesinsidevehicles

andplanes.

?Anophelesliketofeedneargroundlevel,soadequatecoverageofthefeetandlegs

isessentialeitherwithclothingorspray.

Avoidingmosquitobitesismoreimportantthantakingchemoprophylaxis:thisappliesequally

toresidentsintheareaaswellasvisitors.PersonalProtectionMeasures:

?Buildhousesawayfrommarshyareaswherethemosquitoesbreed

?Ensureadequatedrainagefromhouses

?Installgauzescreensinfrontofoutsidedoorsandwindows

?Applyeffectivenon-toxiclongactinginsecticidesontotheinteriorwalls.Thechoice

ofsprayneedstobeinformedbyvectorstudies.DDTonlyneedstobesprayed

everyyearwhereasCarbonatesandParathyroidneedtobesprayed4timesayear

?Wearlongtrousersandlongsleevedshirts

?Applyinsectrepellanttoexposedskin

?Ceilingfansandairconsareveryeffective

?Useamosquitoproofnet,preferablyonesprayedwithaparathyroid

?Usemosquitomatsorcoils.

Chemoprophylaxis

Drugsavailableforprophylaxisofmalariaactontheparasitesintheredbloodcellsand

preventdiseasefromdevelopingandtypicalsymptomsfrompresenting.Itismostimportant

totaketherecommendeddrugsexactlyasprescribedardtocompletethecourse.Failingto

completethecourseresultsininadequatedruglevelsintheblood,allowingtheparasitesto

multiplyandmalariatodevelop.Itisimportanttocontinueprophylaxisfor4weeksafterreturn

fromamalariaarea.

Evenifthedrugisonlypartiallyeffective(e.g.inthecaseofdrugpartialresistance),parasite

developmentisstillinhibited,symptomsmaytakelongertoappear,andmaybelesssevere

atfirst,thanifnoprophylaxiswastaken.

Malariasymptomsmayonlydevelopquiteawhileafterleavingthemalariaarea.Thiscan

reducesuspicionofmalariatothedetrimentofthepatient,especiallyasmanypeoplebelieve

thatprophylaxisisaguaranteeagainstmalaria.Itisthereforeveryimportantthatanyone

experiencinganymalariaorflu-likesymptomsafterhavingbeeninamalariaareaseekshelp

immediately.

Appropriateprophylaxiswillconsiderablyreducethechancesofbeinginfectedwithmalaria.

However,nodrugisguaranteedtoprotecteveryoneeverytime.

Pre-deploymentMedicalexaminationsareessentialinorderthatthecorrect

chemoprophylaxisisgiventotheindividualemployee:

Thefollowingareabrieflistoftheissuesthataffectthechoiceofthemedication:

?Pregnancy

?Ago

?Pre-existingmedicalorpsychiatricconditions

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?WhatactivitiesareinvolvedintheEmployee'sjob-e.g.someanti-malarialinterfere

withfineco-ordination

?Thelengthofstayinamalariaarea.

Somecommonlyusedanti-malarialforprophylaxisare:

Mefloquine(Lariam/Mefliam)-{a^enasaweeklydoseandhasbeensafelyusedfor2years

whentakencontinuously.Themostsignificantside-effectsareassociatedwithinsomnia,

disturbancesofmoodandstrangedreams.Therearemereseriouspsychiatricsideeffectsas

wellbuttheseonlyoccurin1:10,000people.Theincidenceofsideeffectsdoesnotincrease

withthelengthoftakingthsdrug,sopeopleshouldstartthismedication4weeksbeforegoing

toamalarialarea,totestfortolerance.Mustbecontinuedfor4weeksafterleavingthearea

Doxycycline-Xa^eneverydayandcannotbeusedbypregnantwomenorchildren,alsocan

notbeusedforlongerthan4months.Manypeopledevelopsevereskinsensitivitywhen

takingthisdrug,sotheyneedtopreventthemselvesfromsunexposurewithsunscreenand

appropriateclothing.Mustbecontinuedfor4weeksafterleavingthearea

ChloroquineplusProguanil-ih'\sdrugisnotaseffectiveasMefloquineandsomeofthe

parasitesareresistanttoit.However,ithastheadvantageofbeingwell-toleratedandcanbe

usedforlongperiodsoftime.Thismedicationneedstobetakendaily.Mustbecontinuedfor

4weeksafterleavingthearea

AtovaquoneplusProguanil(Malarone)-r\eedstobestartedonly1daybeforeenteringthe

malariaareaandcontinuedfor7daysafterleavingit.Ingeneralitiswell-toleratedbutcannot

beusedbypregnantmothersandsmallchildren.

DetectionofMalaria-

Promptandaccuratediagnosisofmalariaispartofeffectivediseasemanagementandwill,if

implementedeffectively,helpreduceunnecessaryuseofanti-malarialmedicines.Thetwo

diagnosticapproachescurrentlyusedarebasedon:

1.thesymptomsandsignsofthedisease-i.e.aclinicaldiagnosisand

2.Detectionofthecausativeparasiteoritsproduct(s).

Themostcommonlyusedbeingmicroscopicdiagnosis,andmorerecentlyrapiddiagnostic

testsbasedonimmunochromatographictechnique

Thesymptoms/signsofmalariadevelopabout14daysafterthebiteofthemosquito.This

periodhowevermaybeveryprolonged,especiallyifthepatienthasbeentaking

chemoprophylaxis.Henceanyonepresentingwithoneof:hesymptomsmentionedbelow,

whohasbeeninamalariaareaupto3monthspreviouslymusthavemalariaexcluded:

?fever

?headache

?sweating

?fatigue

?muscleaches

?abdominalpain

?diarrheaandnausea

(RDTs)assistinthediagnosisofmalariabydetectingevidenceofmalariaparasitesin

humanblood.

Malariaoccursalmostexclusivelyinthetropicsandsub-tropics,andisassociatedinmany

areaswithpovertyandpoorhealthinfrastructure.MalariaRDTs,alsoknownas,Dipsticks^^

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or"MalariaRapidDiagnosticDevices(MRDDs)",havepo:entialtogreatlyimprovethequality

ofmanagementofmalariainfectionsintheseareaswhenthemainalternativeformof

diagnosis,highqualitymicroscopy,isnotreadilyavailable.

However,greatcareneedstobeexercisedinchoosingtheparticularkitastherearemany

drawbackswiththeiruseanditisessentialthattrainingisprovidedintheuseoftheparticular

RDTused.Inparticularitisrecommendedthatpeoplewhowillbeusingthisequipmentare

observedperformingthetestpriortodeployment.

Effectivetreatment

Asaresponsetoincreasinglevelsofresistancetoanti-malarialmedicines,WHO

recommendsthatallcountriesexperiencingresistancetoconventionalmonotherapies,such

aschloroquine,amodiaquineorsulfadoxine-pyrimethamine,shouldusecombination

therapies,preferablythosecontainingartemisininderivatives(ACTs-artemisinin-based

combinationtherapies)forfalciparummalaria.

AsyetanothersteptowardscombatingdrugresistanceinAfrica,WHOcurrently

recommendsthefollowingcombinationtherapies(inalphabeticalorder):

1.Artemether/lumefan:rine

2.Artesunateplusamodiaquine(Inareaswherethecurerateofamodiaquine

monotherapyisgreaterthan80%)

3.Artesunateplusmefloquine(InsufficientsafetydatatorecommenditsuseinAfrica)

4.Artesunateplussulfadoxine/pyrimethamine(Inareaswherethecurerateof

sulfadoxine/pyrimethamineisgreaterthan80%)

Itisessentialthattreatmentisstartedassoonaspossible,certainlywithin24hours.Hercein

theeventthatapersonhasanyofthesymptomsmentionedaboveanddoesnothaveaccess

toadoctororhealthser/ice,heshouldstartontheartemether-lumefantrinestarterpack

medication(Coartem)thatshouldbeprovidedtoallEmployees.

ThisdrugcombinationisconsideredtheFirstlinetreatmentinmanyAfricancountries,itis

nowreadilyavailablee.g.InAfrica:Burundi,Comoros,Ethiopia,Liberia,Mozambique,Sao

TomeandPrincipe,SierraLeone,SouthAfrica,Sudan,Zambia,Zanzibarandalthough

supplywasproblematicinthepast,itisnowmuchimproved.(Therawmaterialisderived

fromaplantcalled,Artemisiaannua,whichwasonlygrowninChinainthepastbutcultivation

isnowmuchmorewidespread).

Asmanydoctorswhoworkoutsidemalarialareas,willhavelimitedexposuretoknowledgeof

thetreatmentofMalaria,itisthoroughlyrecommendedthattheycarrywiththemthephone

numberoftheSOSAlarrrcentresinBeijingandJohannesburg.Atthesealarmcentresare

expertsinMalariawhocanadvisetreatingDr'sonthebesttherapy.ThisiscalledtheMalaria

HotlineServiceandthecontactdetailswillbefoundontheReferralletterdocument.

Thereisoftentheviewthatpeoplebecomeimmunetomalariaandhencedonotneedto

takepreventativemeasures.Althoughitistruethatlocalinhabitantsdodevelopadegreeof

immunity,theyarestillatrisk.PRCresidents,unlesstheyhavelivedinaMalariaarea,are

verysusceptibletocatchingthisdiseaseandbecomingseriouslyill.

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Summary

AwarenessofMalariaRisk

■location-moreriskinruralareas,lessincities

■accommodation-noreriskintents/huts,lessinhotels

■timeofyear-transmissionislessincolddrymonths

■timeoftheday-mosquitobitemainlyatnight

?lengthofstay-lorgerthestay,thehighertherisk

Bites

?wearlongsleevedclothingandlongtrousers

?applyaninsectrepellantlikeDEETtoallexposedareasexcepteyelidsandlips

■protectdoorsandwindowswithscreens

?overheadfansandairconsinhibitmosquito'sfromlanding

■useapyrethroidimpregnatedbednet

■usemosquitomats/coils

Chemoprophylaxis

?takethepillsatthesametimeeverydayoreveryweekdependingonthemedication

■takethepillsfor4weeksafterleavingthearea

Diagnosis

■earlydiagnosisiscritical

?useyourRDTYourself,iftherearenolaboratoryfacilitiesavailable

■MakesureyouaretrainedintheuseoftheRDTbeforeyouleavethePRC.

■Anyunexplainedillnessupto3/12afterleavingtheareamaybemalaria-haveyour

MlettertotheDr"wthyouatalltimes

Effectivetreatment-MalariaisaMedicalEmergency

2.2TertiaryPrevention

Tertiarypreventionisaimedatrapiddiagnosisandprompttreatment.

Diagnosis

Diagnosiscanbemadebasedontheclinicalsignsandsymptomsbutthisisonly

recommendedifthereisnoabilitytoperformmicroscopyoranRDTwithin2hours.

ThereasonpresumptivediagnosisisnotrecommendedisthatitoverdiagnosesMalariaand

thereisthepossibilityofmissingimportantotherdiagnoses.Inadditiontheproblemof

resistancetoMalariamedicationsisincreasediftheyareusedindiscriminately.

Microscopy

Thisis100%specificbutthesensitivitywilldependontheskillsoftheMicroscopist.The

advantageofMicroscopyisthatitgivesbothaqualitativeandquantitativeresultandthus

enablesthenaturalhistoryofthediseasetobefollowed.ThestaintobeusedIstheGiemsa

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stain.Itisrecommendedthataselectionofslidesbesenteachyeartoaresearchinstitution

inthecountryoforiginforqualitypurposes

RapidDiaanosticTesting(RDT)

TheRDTthatisrecommendedtoBPisaHRP2test,asthesearestableandcostless.A

disadvantageisthattheyonlytestforFalciparumMalaria.Itisrecommendedthatall

EmployeeswhorotatetoBPsitesfromthePRCareprovidedwiththesetests.

ThechoiceinthecampastowhethertouseMicroscopyorKatswilldependontheskilled

staffavailable.Itwouldbepreferabletohavebothtests.

GeneralPrinciplesofTreatmentofMalaria

Presumptivetreatmentisgenerallynotrecommended.Exceptionstothisarechildren<5years

oldandinsituationswherediagnosisislikelytobedelayedfor>2hours.

Inanon-immunepatientwithclinicalsigns/symptomsofMalaria,2NEGATIVEsmearscanbe

consideredtobedefinitive

ItisrecommendedthatBPfacilitiessupportacommunitydiagnosisandtreatment

programmed.Bydoingthis,MalariatransmissionisreducedbothforBPEmployeesand

locallyemployedstaffandasortofbufferzoneissetup.Itisstronglyrecommendedthatthis

treatmentincludesACT.

TreatmentprotocolsneedtobeunderstoodbyMedicalstaff

Emergencyresponseplans,includingcriteriafortransferringpatientswithMalariatoahigher

levelofcare,needtobesetupandchecked.

Recommendations

UncomplicatedMalaria-objectiveistocurethepatientandthusreducethelikelihoodof

transmissionbyreducingtheloadofparasites.Thetreatmentofchoiceisan

Artemisinin-basedcombinationtherapy(ACT).TherecommendeddrugisCoartem.

2.3TreatmentofMalaria

Thepatientcommonlycomplainsoffever,headache,andachesandpainselsewhereinthe

body,andoccasionallyofabdominalpainanddiarrhea.Inayoungchildtheremaybe

irritability,refusaltoeatandvomiting.Onphysicalexaminationfevermaybetheonlysign.In

somepatientstheliverandspleenarepalpable.Thiscliricalpresentationinnon-endemicor

low-endemicareasmaybemisdiagnosedasinfluenza.Unlesstheconditionisdiagnosed

andtreatedpromptlytheclinicalpicturemaydeteriorateatanalarmingrateandoftenwith

catastrophicconsequences

Apatientwithseverefalciparummalariamaypresentwithconfusionordrowsinesswith

extremeweakness(prostration).Inaddition,thefollowingmaydevelop:

>Cerebralmalaria,definedasunrousablecomanotat-attributabletoanyothercause

inapatientwithfalciparummalaria.

>Generalizedconvulsions.

>Severenormocyticanemia.

>Hypoglycaemia.

>Metabolicacidosiswithrespiratorydistress.

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>Fluidandelectrolytedisturbances.

>Acuterenalfailure.

>Acutepulmonaryedemaandadultrespiratorydistresssyndrome(ARDS).

>Circulatorycollapse,shock,septicemia("algidrralaria").

>Abnormalbleeding.

>Jaundice.

>Haemoglobinuria.

>Highfever.

>Hyperparasitaerria.>4%innon-immuneand>8%insemi-immune

Important:Theseseveremanifestationscanoccursinglyor,morecommonly,incombination

inthesamepatient.

Whoisatrisk?Childrenlessthan5yearsold,pregnantwomenandtravelerswith

low/noimmunity.Failuretoconsider,diagnoseandtreatmalariainthesegroupsleads

tohighmortality

GeneralGuidelineofMalariaTreatment

ManufacturedbyNovelties.Coartemconsistsof2components,Artemetherand

Lumefantrine.

Coartemiseffectivein95%ofcasesofMalariaandnoresistancehassofarbeenfound.

Thedosedependsonbodyweightbutforadultsitis4tabletstwicedailyfor3days.

AllBPEmployeeswholeavetheirsiteofworktoreturnhomewillbeprovidedwitha

StandbyTreatmentkitofCoartem.Thisistobeusedforthetreatmentandnot

prophylaxisofMalaria,forpeoplewhobecomeilloncebackhome.(Pleasesee

Emergencystandbytreatmentprotocol).

CoartemcanalsobeusedforuncomplicatedMalariainChildrenandPregnantfemalesin

thesecondandthirdtrimesters.Malariaisparticularlysevereinchildrenastheycanbe

considerednon-immune.

Fortreatmentinthewidercommunity,localgovernmentprotocolsneedtobetakeninto

consideration.Whateverthecase,monotherapyshouldnolongerbeused.

Otheracceptable1stlinetreatmentsofmalariaareSulfadoxine-Pyrimethamine,

AmodaquineandMefloquine.

Secondlinetreatmentswouldincludetetracyclines,doxycyclineandclindamycin,which

isthefirstchoiceinpregnantpatients.

SeveremalariaiscausedbyPlasmodiumfalciparuminfectionandusuallyoccursasa

resultofdelayintreatinganuncomplicatedattackoffalciparummalaria.Sometimes,

however,especiallyinchildren,severemalariamaydevelopveryrapidly.Recognizing

andpromptlytreatinguncomplicatedP.falciparummalariaisthereforeofvitalimportance.

Treatment

ArtusenateIVisthedrugofchoiceatadosageof2.4mgms/kgbodyweightat0,12and24

hoursandthendailyuntilthepatientcantakeoralmedications.Artesunatesolutionisdiluted

in5mlsof5%dextroseandthengivenintoeithertheIVlineorbyIntramuscularinjectioninto

theanteriorthigh.

QuinineIVisonlyusedinthe1sttrimesterofpregnancy.

MeticulousnursingcareisOGGontial,includingregularturningofthopatient,suctioning,

monitoringofintake-outputandawarenessofcomplications.Thisqualityofnursingisunlikely

tobeavailableonremotesites

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Clinicalmanagement

?Reducedconsciousness-thenecessityformonitoringtheGlasgowComaScore

(GCS,specificationpleaserefertoGlossaryinpage36))isevident.Early

maintenanceofadefinitiveairwayisessential.However,itisnecessarytoexclude

othercausesofcom