Page 97 - Journal of Special Operations Medicine - Fall 2017

Table 1 Malaria Prevention
Avoidance of Anopheles Chemoprophylaxis for P. vivax
Mosquito Bites 12pp1274-1275 Chemoprophylaxis for All Plasmodium Species 21 or P. ovale Hypnozoites 21
Cover exposed skin and apply mosquito Begin 1 day before arrival. Begin 1 day before arrival.
repellant when venturing outside in the
evening and at night. Atovaquone-proguanil (Malarone): 250/100mg Primaquine 30mg base orally once a
orally once a day; take with food and a milky day; beware G6PD contraindications
Sleep inside insecticide-treated bednets. drink to improve absorption; expensive. and CYP2D6 nonresponders or poor
responders to the drug. Primaquine is also
Spray insecticides. OR contraindicated in pregnant women and
young infants. Continue for 1 week after
Eliminate Anopheles egg-laying sites Doxycycline (Doxy): 100mg PO once a day; departure.
(standing water). side-effects include nausea, diarrhea, and
photosensitivity; take with food or copious fluids
Apply larvacidal chemicals to Anopheles to avoid esophagitis; beware tetracycline allergy
egg-laying sites. and/or expiration toxicity.
Continue for 1 week after departure (Malarone),
or 4 weeks after departure (Doxy).

Table 2 Malaria Treatment
Prevention of Relapsing Malaria in
Patients With Suspected or Confirmed
P. vivax or P. ovale 20p60 Uncomplicated (Benign) Malaria 20p35,63 Complicated (Severe) Malaria 21
Primaquine 0.25–0.5mg/kg orally once a Artemisinin-based combination therapy (ACT) In any case of severe malaria, parenteral
day for 14 days. is the current best practice treatment for benign artesunate or artemether should begin
malaria. Artemether plus lumefantrine (Coartem) immediately. This should continue until the
is the premier drug in this class. patient is well enough to swallow, at which
point he or she may begin an oral ACT
Coartem given orally in six doses over 3 days (such as Coartem) regimen in lieu of the
(dosed twice a day). parenteral drug.
Coartem target dose range: 5–24mg/kg Artesunate (drug of choice): 2.4mg/kg
artemether and 29–144mg/kg lumefantrine. intravenously or intramuscularly at 0, 12,
and 24 hours, then once a day.
Coartem tablets are available in the following
strengths: 20/120 and 40/240mg. Artemether (next best drug if artesunate
is unavailable): 3.2mg/kg injected
intramuscularly into the rectus femoris
(anterior thigh), then 1.6mg/kg per day;
beware of erratic absorption in very ill
patients.

Primaquine is also administered for patients with no G6PD- interpret Plasmodium blood samples. Finally, continuing med-
related contraindications. 17p46 ical education must be vigorously pursued, and medical refer-
ence literature used should reflect the current best practices.
Part 4: Summary Disclosure
There are many reasons why P. vivax can be a problematic The author’s for-profit training company (Convergent Medi-
pathogen for the deployed SOF Medic. These reasons revolve cine) includes a course on malaria.
mainly around the pitfalls of treating the latent liver stage
and the relative difficulty in diagnosing P. vivax carriers. As References
with any facet of medicine, Medics can mitigate these chal- 1. World Health Organization (WHO). Control and elimination of
lenges by way of thorough preparation. Medical intelligence plasmodium vivax malaria: a technical brief. Geneva, Switzerland:
WHO. 2015. http://www.who.int/malaria/publications/atoz/97892
surveys of the deployment region must include a detailed anal- 41509244/en/. Accessed 21 February 2017.
ysis of the types of malaria likely to be encountered. Team- 2. Diakite M, Miura K, Diouf A, et al. Hematological indices in Malian
mates should be screened for G6PD deficiency (and CYP2D6 children change significantly during a malaria season and with in-
status, if available) before deploying to malaria-endemic re- creasing age: implications for malaria epidemiological studies. Am
gions. Ample quantities of mosquito nets, mosquito repellant, J Trop Med Hyg. 2016;95: 368-372. doi: 10.4269ajtm.16-0125.
chemoprophylaxis drugs, and treatment drugs are essential 3. Dye C. After 2015: infectious diseases in a new era of health and de-
tropical deployment items (a field G6PD detection device may velopment. Philos Trans R Soc Lond B Biol Sci. 2014; 369(1645):
20130426. doi: 10.1098/rstb.2013.0426.
be included if large numbers of indigenous patients are an- 4. WHO. World Malaria Report. Geneva, World Health Organiza-
ticipated). While no prophylaxis measures are 100% effective, tion (WHO). 2016:xvi.
team members’ compliance with malaria chemoprophylaxis 5. Howes R, Battle K, Mendis K, et al. Global epidemiology of plas-
must be strictly upheld. Medics must maintain a high level of modium vivax. Am J Trop Med Hyg. 2016; 16-0141. doi: 10.4269/
suspicion of malaria for all febrile patients in the tropics—to ajtmh.16-0141.
that end, species-appropriate RDTs should be kept close at 6. Warrell D. Clinical features of malaria. In: Warrell D, Gilles, H.
Essential Malariology. 4th ed. London, UK: Arnold; 2002:202.
hand, along with a complete microscope kit. In addition to 7. Taylor T, Agbenyega T. Malaria. In: Magill A, Hill D, Solomon T,
proficiency in the use of RDTs, SOF Medics should maintain Ryan E. Hunter’s Tropical Medicine. 9th ed. New York, NY: Else-
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