Protocol for treating malaria in MSF Missions (2004)
25 April 2004
However, we are observing that current anti-malarial treatments are inappropriate in many of our missions. In other countries where chloroquine is used, we know that this medication is very likely ineffective, but we do not have adequate data regarding a reliable alternative treatment. Finally, according to the teams, certain missions use an effective anti-malarial whose resistance level is acceptable, according to published reports. But we know that using these drugs in monotherapy and on a large scale risks a fairly rapid development of resistance. Procedures for putting ACTs in place as first-Line treatment of uncomplicated P. falciparum malaria: Where? In all missions where MSF is directly involved in patient care. This assumes that diagnosis and treatment can be monitored and overseen. How? All clinical suspicion of malaria must be confirmed by a positive thick smear or positive rapid test (paracheck) before initiating treatment. Expatriate and local MSF staff must understand the importance of this treatment and its prescription modalities (see protocols) and must explain clearly to the patient how treatment is taken and the importance of continuing treatment at home. The first treatment dose must be taken under a health workers' supervision. Who is it for? The drug combination including an artemisinin derivative is recommended as first-line treatment for all patients. This treatment is particularly necessary in regions where malaria is hypoendemic or of unstable transmission or when populations have migrated from a hypoendemic region to an endemic region where transmission is stable. In these situations all age brackets are at risk of developing severe malaria. Hypoendemic or unstable transmission regions are, in general, the high plateau regions (> 1,500 meters) and the Sahel-Saharan areas. Populations living in endemic regions generally acquire immunity at around 5 years of age (later if transmission is not intense). Immunity confers protection limiting malaria symptoms and severe bouts of the illness. In situations where such immunity is acquired, the drug combination with an artemisinin derivative should be recommended as first-line treatment, with priority given to children aged 5 years and below and to pregnant women. If possible, this recommendation should be expanded to all age groups (for practical reasons and also to reduce transmission and development of resistance). Exceptional situations EPIDEMICS Epidemics generally occur in regions where malaria is hypoendemic and/or transmission is unstable. All age brackets are symptomatic and at risk of developing severe malaria. Furthermore, in an epidemic, there is high gametocyte carriage, which increases the transmission of malaria. Gametocyte carriage must be reduced as quickly as possible through diagnosis and effective early treatment. A drug combination with an artemisinin derivative has the advantage of working quickly and acting on the gametocytes, thus reducing transmission. This property of artemisinin derivatives therefore renders its use particularly important in an epidemic. Artesunate will be combined with a second anti-malarial, chosen based on resistance level (SP, AQ or CQ). If that drug is unfamiliar in the epidemic region, CoartemÃ?® (a combination of artemether and lumefantrine) or the combination artesunate mefloquine (see utilization protocols) may be used. OPERATIONAL RESEARCH PROJECTS It would be worthwhile to evaluate implementation of this drug combination with studies that provide arguments supporting its use (compliance, cost savings, development of mutations, reduction in gametocyte carriage) in order to convince national and international health authorities of the appropriateness of these drug combinations. Furthermore, it is important for MSF to evaluate the real effectiveness of drug combinations in our intervention contexts (without DOTS). These studies should be proposed on a case-by-case basis by the field or headquarters and will be conducted in cooperation with Epicentre. LABORATORY TEST GUIDELINES What is Paracheck? Paracheck is a rapid test that detects the presence of Plasmodium Falciparum (P.f) in blood. It is an indirect method of detecting P.f as it detects the HRP-2 antigen secreted by the trophozoite and gametocyte the moment that they invade red blood cells. It is a qualitative (presence or absence of P.f) and not a quantitative measure (it cannot quantify the parasitemia). The result is obtained within 10 minutes using a very simple technique. This test has a very high sensitivity (95 percent), so it is as reliable as a skilled microscopist. Its greatest disadvantage is that it remains positive for seven to 14 days after treatment. There is thus no point in redoing the test during that period. Clinical criteria required to conduct a paracheck: All clinical suspicion of malaria must be confirmed by a paracheck: Fever >38Ã?°C or presence of fever in the previous two days MORE or less, one of the following criteria: - Anemia - Splenomegaly - Headache - Absence of other infections (otitis=0, pneumonia=0, angina=0) Suspicion of severe malaria Interpreting results and procedures: 1- The result is positive: "At the time of the test, the patient has P.f malaria: treat "The patient shows evidence of having been treated for P.f malaria: ask the patient when and which treatment s/he received. If you feel the treatment was inadequate (chloroquine or Fansidar although elevated resistance is known to exist in the area), give the optimal treatment (drug combination with an artemisinin derivative). If the patient received the optimal treatment within the last 15 days with a good compliance record: do not treat. Check for other causes of fever. 2 - The result is negative: "The patient is not infected by P.f malaria: check for other causes of fever via a new clinical exam. "The patient may be infected by P.Malariae, P.ovale or P Vivax : If prevalence is elevated for one of these three types of Plasmodium (PV in Southeast Asia, Sri Lanka and Central America), it may be useful to treat with chloroquine. However, because the prevalence of these forms is very low (as is the case in most African countries): do not give anti-malaria treatment seek another diagnosis. "The patient has signs of severe malaria: treat as severe malaria 3- The result is questionable or cannot be interpreted: Redo the test.