Page 125 - Journal of Special Operations Medicine - Winter 2014

population who live in the areas with the highest ma- headache, myalgias, exhaustion, nausea, vomiting, and
laria transmission rates can be found in just 10 coun- diarrhea. Malaria must be considered in all febrile pa-
tries: Guinea, Togo, Mali, Mozambique, Burkina Faso, tients in a malarious area. Critically ill patients will have
Ghana, Côte d’Ivoire, Uganda, Nigeria, and Democratic a detectable parasitemia during their illness; however,
Republic of Congo (Figure 3). 4 symptoms can occur before parasites are detectable by
blood smear. Therefore, patients with suspected malaria
Figure 3 Malaria map showing number of reported malaria should be tested with a total of three blood smears or
deaths in 2012. 3 rapid diagnostic tests (RDT), one every 8 to 12 hours.
The BinaxNOW RDT (Alere Inc., Waltham, MA, USA;
®
www.alere.com) can detect plasmodium parasites using
whole blood from a finger stick and is the diagnostic
tool of choice when a skilled microscopist is not avail-
able. This RDT is suitable for point-of-care field use, is
7
disposable, and can be ordered through standard medi-
cal supply channels (NSN 6550-01-554-8536/box of 12
tests). Thick and thin blood smears should be obtained
simultaneously to confirm diagnosis and speciation and
should be forwarded to the closest medical treatment
facility (MTF) or the SOCAFRICA Surgeon’s office for
diagnosis. Many deployed providers have established
relationships with local health clinics that employ a
laboratory technician with extensive experience in ma-
Source: World Health Organization laria diagnosis. These relationships can be leveraged for
confirmation of the rapid test results and for refresher
The four primary species of malaria parasites that in- training on thick- and thin-smear testing, since malaria
fect humans are: Plasmodium falciparum, P. malariae, diagnosis by microscopy is an advanced and perishable
P. ovale, and P. vivax. P. falciparum is the predominant skill. Initial treatment for adult patients with uncom-
strain of malaria in Africa. It causes severe disease and plicated malaria is artemether/lumefantrine (Coartem ;
®
can be fatal without timely and proper treatment. To Novartis International AG, Basel, Switzerland; www.
prevent severe disease and death, SOF forces deployed novartis.com) 20/120mg per tablet: 4 tablets as a single
to Africa must adhere to all personal protective coun- dose, 4 tablets again after 8 hours, and then 4 tablets
termeasures, especially chemoprophylaxis, and unit twice daily for the following 2 days (total course is 24
protective measures. The primary means of contracting tablets). Alternatively, atovaquone/proguanil may be
malaria is via the Anopheles mosquito bite; Anopheles used to treat uncomplicated malaria; however, experts
mosquitos are active from dusk to dawn. Therefore, recommend using artemether/lumefantrine instead for
mosquito control and protection from mosquito bites those who have been using atovaquone/proguanil for
are the mainstay of reducing malaria transmission. prophylaxis. If applicable, this regimen consists of ato-
vaquone/proguanil (250mg/100mg per tablet) 4 tablets
While are several options for malaria chemoprevention by mouth per day for 3 days. The treatment of severe
8
exist, SOCAFRICA policy recommends atovaquone/ malaria for SOF forces in Africa is a challenging di-
proguanil (Malarone ; GlaxoSmithKline plc, Brentford, lemma since the only US Food and Drug Administra-
®
Middlesex, England; www.gsk.com) for SOF units de- tion (FDA)-approved drug is intravenous (IV) quinidine.
ploying to malarious areas where the risk of transmis- Quinidine carries the risk of fatal dysrhythmias and
sion is greater than 10%, according to the National should not be administered without adequate cardiac
Center of Medical Intelligence (NCMI). Malarone is a monitoring, limiting its use in austere settings. IV arte-
5
combination of atovaquone and proguanil in a single sunate is considered the drug of choice to treat severe
tablet. It is effective everywhere, including areas with malaria. While artesunate is widely available in Af-
7
multidrug resistant parasites. Atovaquone/proguanil rica, there is a real and valid concern on the continent
prophylaxis is safe and well tolerated, with the most for counterfeit drugs or drugs that do not meet West-
frequent adverse events reported as nausea, vomiting, ern quality control standards. Therefore, the best plan
abdominal pain, or diarrhea. Atovaquone/proguanil for treating severe malaria is rapid evacuation off the
6
should be taken 1 to 2 days prior to travel and for 7 continent to a USMTF where IV artesunate is available
days after returning from Africa. as an investigational new drug (IND) that can be ad-
ministered under controlled protocols (e.g. Landstuhl
The signs and symptoms of malaria at the outset of pre- Regional Medical Center in Germany). This scenario
sentation include: fever, rigors (shaking chills), sweats, may require emergency treatment during evacuation,

Clinical Considerations in African Operations 115