Malaria

Epidemiology & Prevention

Group Captain AD Green
Royal Centre for Defence Medicine
Dip Trav Med Course
21 September 2016
 OUTLINE

1. Malaria
2. House of Commons Defence
Select Committee Report
3. Medico-legal issues
NB: Additional
malaria deaths
Malaria life cycle
 Plasmodium species
infecting primates
Plasmodium billbrayi Plasmodium gorb
Plasmodium billcollinsi
•
Plasmodium inui
Plasmodium bouillize
•
Plasmodium jefferyi
Plasmodium brasilianum
•
Plasmodium joyeuxi
Plasmodium bucki
•
Plasmodium knowlesi
Plasmodium cercopitheci
•
Plasmodium lemuris
Plasmodium coatneyi
•
Plasmodium malariae
Plasmodium coulangesi
•
Plasmodium ovale
Plasmodium cynomolgi bastianelli
•
Plasmodium ovale wallikeri
Plasmodium cynomolgi ceylonensis
•
Plasmodium percygarnhami
Plasmodium cynomolgi cynomolgi
•
Plasmodium petersi
Plasmodium eylesi
•
Plasmodium reichenowi
Plasmodium falciparum
•
Plasmodium rodhaini
Plasmodium fieldi
•
Plasmodium sandoshami
Plasmodium foleyi
•
Plasmodium semnopitheci
Plasmodium fragile
•
Plasmodium schwetzi
Plasmodium girardi
•
Plasmodium silvaticum
Plasmodium georgesi
•
Plasmodium simiovale
Plasmodium gonderi
•
Plasmodium simium
Plasmodium gonderi
•
Plasmodium uilenbergi
Plasmodium gora
•
Plasmodium vivax
Plasmodium youngei
 An. leucosphyrus
+
long-tailed macaque
Malaria and Specific Advice
Detailed clinical management:
Seek advice

Detailed prevention:
National Guidelines

https://www.gov.uk/government/publications/ma
laria-prevention-guidelines-for-travellers-from-
the-uk

http://nathnac.net/

http://travelhealthpro.org.uk/
2014 Guideline Changes
 Malaria Prevention

• What is the malaria risk?

• How to prevent being infected
• Occupational exposure
• Chemoprophylaxis (pre-emptive
therapy)
• Diagnosis and treatment
 The vector
Anopheles species
Night biting
Attracted to humans
Repellents
Impregnation of material with
insecticides
Static locations
Breeding sites
How does this translate to risk to
travellers?

Geosentinel 2010
How does this translate to risk to
travellers?
Protecting the susceptible:
the ideal drug?

• 100% effective, all species

• No resistance
• No adverse events
• Single dose / infrequent doses
• No lead in / lead out times
• Cheap
• Global utility
 Currently available
prophylactic drugs UK
• chloroquine

• proguanil

• doxycycline

• mefloquine (Lariam)

• atovaquone-proguanil
(Malarone)
 mefloquine
• Effective antimalarial >90% efficacy
• Long half-life, once weekly dose
• Loading dose?
• Breakthroughs may be late
• Impact of publicity on compliance
• NOT AIRCREW
 mefloquine:
Adverse Events
• AEs more common in females

• AEs more common in therapy, and when loading doses

used

• AE rate depends on type of questioning in studies

• Participants knowledge of possible AE increases

reporting bias

• High frequency of neurological and psychiatric AE in

placebo groups
 Symptom A B
Bad dreams 8 3
Excessive sleepiness 23 23
Fatigue 41 37
Inability to concentrate 25 27
Irritability 20 17
Insomnia 7 10
Headaches 15 13

A = Hospital Doctors
B = Students
 CONSENSUS GLOBAL OPINION
(WHO REVIEW 2013)
• mefloquine remains an option for chemoprophylaxis

• AE occur, but probably at no greater rate than for other

drugs

• Severe AE are rare, and probably about 1:10,000

people

• AE more common in therapy, and with loading doses

• “more high quality double-blind RCTs required”

- drug been in use since mid-1980s
- over 34 million people used drug for chemoprophylaxis
 Malarone
• proguanil + atovaquone
• Oral only
• Licensed in UK
- Therapy uncomplicated P. falciparum since1997
- Prophylaxis P. falciparum since 2001 (35 days
only until 2013)
• Used for therapy on operations
 Malarone
• Prophylaxis issues
- Cost
- Resistance (Kenya, West Africa)
- Self-treatment (standby)
- Aircrew
• Suitable for selected military
groups/individuals
 doxycycline
• Effective antimalarial
• Estimated >85% protection
• Adverse events: Gastrointestinal,
photosensitivity, fungal infection
• Poor efficacy vs. P. vivax & P. ovale
• Short half-life: compliance essential
• Use in aircrew
 chloroquine & proguanil
• Efficacy data 15-20 years old
• Possibly still effective in Africa in 2013
- anecdotal failure common
- estimated <70% protection or less
• Adverse events
- Gastrointestinal, mouth ulceration
• Use in aircrew, pregnancy
• No evidence eye damage long term malaria
prophylaxis
 Other issues
• Standby therapy
- Co-artemether & lumifantrine (Riamet)
- Malarone
- dihydroartemisinin-piperaquine (Eurartesim)
• Rapid diagnostics
- Training, therapy
• tafenoquine (Etaquine)
- novel primaquine, prophylaxis, long half life
- G6PD deficiency
 SUMMARY OF
RECOMMENDATIONS
1. MQ becomes “drug of last resort”

2. ACMP to write military guidelines

3. Face-to-face risk assessment prior to every individual’s

deployment, and offer alternative drugs

4. Audit of all MQ prescribed since 2013

5. Monitor compliance/record keeping

6. MQ “Helpline” to be set up

7. “Do more research”

 CONCLUSION
1. While it is clear to us that there are significant risks attached to the use
of Lariam for military personnel, we accept that there are a very limited
number of occasions when its prescription may be necessary. However,
we conclude that the MoD should designate Lariam as a ‘drug of last
resort’ and that prescribing it should be restricted by the following
conditions:

a. Only to those who are unable to tolerate any of the available

alternatives;

b. Only after a face-to-face Individual Risk Assessment has been

conducted;

c. Only after the patient has been made aware of the alternatives and
has been given the choice between Lariam and another suitable
anti-malarial drug. (Paragraph 98)
 KEY POINTS AS APPLIED
TO TRAVEL MEDICINE
1. Does the patient know about the material risks of the
treatment I am proposing?

2. Does the patient know about reasonable alternatives

to this treatment?

3. Have I taken reasonable care to ensure that the

patient actually knows this?

4. Have I documented the consent process?