Malaria Protocol - guidelines for health professionals in the Northern Territory - 1997

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Northern Territory Department of Health Library Services Historical Collection

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DL 616.9362

NOR

1997

OOc ' ~

MALARiA PROTOCOL

CuidELiNES FoR HEALTh PRofEssioNALs

iN TltE NoRTliERN TERRiToRy , }nd Ed

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3 0820 00004173 6

MALARiA PROTOCOL

CuidELiNES FoR HEALTli PRofEssioNALs iN TliE NoRTliERN TERRiToRy ~ }nd Ed

Territory Health Services Disease Control Centre Darwin January 1997

~ I S

44575

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Prepared by Disease Control Centre, Darwin and Infectious Diseases Unit, Royal Darwin Hospital

1st Edition 2nd Edition 3rd Edition

June 1991 March 1994 January 1997

Further copies available from Disease Control Centre Territory Health Services PO Box 4D596

Casuarina NT 0811

Comments are welcome and should be directed to the ProjecUResearch Officer at the above address.

Related publications available:

• Malaria and you: Information for overseas students or visitors from countries with malaria

• Malaria and you: Territorians travelling to countries with malaria

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The most recent prophylaxis recommendations are published in Health Information for International Travel (Commonwealth Department of Health, Housing and Community Services), latest edition. Treatment recommendations are published in Antibiotic Guidelines (Victorian Postgraduate Medical Foundation), latest edition.

The malaria control program in the Northern Territory is a responsibility shared among general practitioners, hospitals, laboratories, medical entomology, community care/health centres, diseases control units, and the general community.

I NTROd UCTiON

The Northern Territory has a comprehensive malaria surveillance and control program that includes:

• advice on prophylaxis for travel overseas;

• early detection and hospitalisation of cases;

• correct treatment of cases;

• follow up of cases after discharge from hospital;

• assessment of all cases for further entomological investigation;

• investigation and radical treatmenUcure for high risk groups, for example migrants, refugees and co-travellers of cases who have malaria.

Malaria is caused by the blood parasite Plasmodium. There are 4 species: P. falciparum, P. vivax, P. ovale, and P. malariae.

The parasite is transmitted to humans by the bite of an infected female Anopheles mosquito. The malarious areas across the world include:

• Africa, Middle East, Asia, China, South East Asia including Indonesia, Papua New Guinea, the Western Pacific Islands, and Central and South America.

Risks of RE,EsTAblisliiNG ENdEMic MALARiA iN Tl-IE NoRTliERN TERRiToRy

The World Health Organisation certified the eradication of malaria from Australia in 1981, but Northern Australia still remains susceptible to the re-

establishment of the disease. ·

The receptive area is considered to be north of the 19th parallel which is a line just north of Townsville in Queensland and just south of Broome in Western Australia. The area includes the northern third of the Northern Territory, (north ofTennant Creek) with:

• a history of endemic malaria until 1962;

• widespread breeding of suspected major vectors of malaria;

• breeding of Anopheles mosquitoes in urban areas;

• regular tourist traffic from malarious countries, particularly Indonesia and Papua New Guinea.

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2

DiAGNosis

The number of imported cases of malaria has been increasing over the last decade as a result of increasing travel and the deterioration of malaria control in many countries.

The re-establishment of malaria in the Northern Territory, and particularly the introduction of chloroquine resistant P. falciparum could result in extensive morbidity and mortality in our population.

Malaria is a notifiable disease.

The Haematology Laboratory at the Royal Darwin Hospital provides a service for confirmation of malarial parasites and species identification to all public and private laboratories.

All travellers from malarious areas are advised to have blood slides for malaria (and repeated) if they become ill or develop a fever.

The disease may mimic many other illnesses and should be suspected whenever there is a history of travel to malarious areas. It is possible to be infected with malarial parasites and develop malaria even when anti- malarials have been correctly taken.

The absence of parasites on a blood slide does not exclude malaria, particularly if a person has recently taken anti-malarials or antibiotics. If negative, a blood slide should be repeated after six hours or during the next febrile episode.

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Positive Plasmodium

Fever: Think Malaria!

Overseas travel to malaria area l

past two years

with or without malaria prohphylaxis and/or previous malaria infection

Full blood count + malaria parasites

Negative

Repeat in 6 hours and/or return of fever

Negative

Repeat as necessary

Negative

Consider radical treatment

3

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4

MANAGEMENT of MALARiA

If malaria is clinically suspected in a person attending a Community Care/Health Centre, it is advisable to arrange for an urgent blood sample (EDTA) or malaria slide to be taken either at the Centre or at the hospital in Accident & Emergency (A&E). If the person is discharged from A&E or a Community Care/Health Centre before the result is available, the attending Medical Officer or Community Health Nurse must take responsibility to ensure that the person can be contacted and immediately hospitalised if the slide is positive. The patient must be made aware of this possibility.

All cases with malaria are admitted to hospital to ensure that adequate treatment is administered, and to avoid any risk of transmission of the parasite to the mosquito vectors that are present in the Top End of the Northern Territory.

Mosquito nets are not necessary if the patient is nursed in an air-conditioned

ward, and does not leave the ward between 6pm and 8am.

A detailed history must be obtained from every patient (see Appendix 1) including an itinerary of overseas travel and movement following their return to Australia. This is used as a basis for further entomological assessment, and also for the identification of co-travellers.

Malaria should be treated according to the protocols in the Antibiotic Guidelines (see Appendix 2). Infections caused by P. falciparum can be fatal, particularly if the diagnosis and treatment is delayed. In addition, the attached article from the Australian Family Physician may be helpful in hospital management of cases (see Appendix 3).

One week after discharge from hospital, patients treated for P. falciparum should be reviewed, a blood slide taken for malaria parasites and radical treatment with primaquine for 14 days should be considered. This is given to eradicate any possible co-infection with P. vivax.

All patients should have a G6PD screen to exclude G6PD deficiency before primaquine therapy. The 14 day primaquine therapy for all malaria cases can be supervised as an outpatient, with second daily phone calls to encourage compliance.

Malaria may relapse or recrudesce if the full course of treatment is not completed.

Patients can be discharged from hospital when:

1. In P. vivax the chloroquine course has been completed; OR In P. falciparum either

(i) in the quinine regimen the stat dose of sulphadoxine/pyrimethamine (Fansidar) has been given (or 3 days doxycycline completed) or

(ii) the mefloquine regimen has been completed;

AND

2. at least one blood slide has been negative;

AND

3. they feel well and are afebrile for 24 hours.

If treatment has not been completed/supervised, blood slides for malaria should be repeated at least once and a medical review arranged.

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Management of Malaria

Laboratory notifies Disease Control

Patient interview

Co-travellers malaria screening

& G6PD activity

Co-traveller:

positive malaria slide

CASE WITH MALARIA

Co-traveller:

negative malaria slide

Afebrile

Entomological assessment

Intervention

measures No action

Repeat malaria slide

Consider radical treatment of co- traveller - if G6PD

activity is normal

Hospital admission

Treatment protocol

Refer chart:

Medical treatment of

malaria

Refer chart:

Discharge criteria

5

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6

ADMIT TO HOSPITAL

•

Nurse in air conditioning 6 pm - 8 am

P. falciparum - Uncomplicated

Treat with (i) Quinine and 2nd or 3rd day stat

Sulphadoxine/

Pyrimethamine (Fansidar) or daily Doxycycline

or (ii) Melfloquine

..J Daily parasite count

..J Daily blood glucose &

Full Blood Count -v Closely monitor BP &

urine output

-'1 Check G6PD activity

Review in Medical Outpatients 1 week after discharge

Consider 14 day course of Primaquine as an outpatient (if G6PD activity-normal) to eradicate concomitant

P. vivax

P. vivax IP. ovate

Treat with Chloroquine

-..J Daily Parasite Count

-..J Full Blood Count

..J Check G6PD activity

Primaquine for 14 days

Seek specialist advice

Treat with Chloroquine

-..J Daily Parasite Count

-..J Full Blood Count

No further treatment

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(i)

(ii)

Criteria for discharge

P. falciparum

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In the Quinine regimen Sulphadoxine/

Pyrimethamine dose given OR 3 days Doxycycline completed OR

Completion of Mefloquine regimen

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At least 1 slide negative

I

Afebrile for 24 hours

I

They feel well

( Discharge )

Review by Medical Officer after 1 week

Primaquine therapy, if given, supervised by referral to Community

Care/Health Staff

P. vivax P. ovate P. malariae

Chloroquine course completed

At least 1 ^slide negative

Afebrile for 24 hours

They feel well

(

^Discharge

t )

~

14 day primaquine therapy commenced

Primaquine therapy supervised by referral to Community

Care/Health Staff

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ScREENiNG of HiGli Risk Cnoups

Protocols for screening for malaria parasites in high risk groups on entry to the Northern Territory have been developed. Such groups include students from high risk areas such as Papua New Guinea and the Solomon Islands and boat people.

MANAGEMENT of Co,TRAVEllERS

If the patient had travelled overseas with a group, eg. family members, friends or group tours, all co-travellers should be tested for malaria through the hospital pathology laboratory or their general practitioner. This is arranged by Disease Control staff when the patient is interviewed.

The pathology request form should include the name of the index case with malaria, and whether the co-traveller has any symptoms suggestive of malaria. Co-travellers with positive smears are treated accordingly, and those with negative smears are offered radical therapy with chloroquine followed by 14 days of primaquine (see below).

RAdicAL TREATMENT/CURE foR PERSONS AT Risk

The aim of radical therapy is to eradicate the hidden liver phase of P. vivax which can lead to relapses of malaria after months or years.

Although radical treatment is not routinely offered to all people arriving from malarious areas it is strongly recommended for:

• migrants and refugees

• staff from missionary organisations

• co-travellers of a case of malaria (particularly from high risk areas such as PNG and parts of Indonesia including Timer, Lombok and surrounding islands); they may include family, school, sporting and tour groups.

Radical treatment consists of:

1. treatment with chloroquine, unless it had been taken as prophylaxis or treatment within the preceding two weeks. The dose is the same as that used for treating acute P. vivax malaria (refer to Antibiotic Guidelines;

and

2. treatment with primaquine to eliminate parasites of P. vivax and P.

ovale which may persist in the liver for several years and cause a relapse. The dose is the same as for acute P. ^vivax malaria, and is given for 14 days (refer to Antibiotic Guidelines).

Blood tests to exclude parasitaemia and G6PD deficiency should be performed before starting radical treatment ( 1 - 2 ml blood in an EDTA - tube). If parasitaemia is present the person must be treated accordingly. If the person has G6PD deficiency primaquine should be withheld and further management should be discussed with a specialist physician.

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9 Treatment must be supervised both to ensure compliance and to assess any side effects (eg haemolysis, methaemoglobinaemia, nausea, vomiting, anorexia, dizziness, epigastric distress and abdominal pains or cramps).

Supervision should include at least second daily phone calls by Community Care/ Health Staff. This can be arranged by Community Health Referral.

RoLE of DisEASE CoNTRol ANd TliE MEdicAL ENToMoloGy BRANCli

The Royal Darwin Hospital laboratory or private laboratory will notify Diseases Control whenever a case of malaria is diagnosed. A staff member from Disease Control will interview the patient as soon as possible and complete the questionnaire (attachment 1 ). The Medical Entomology Branch (MEB) will then be notified and will assess the need for further action. Of particular concern are cases with gametocytes in their blood, as gametocytes are the form of malaria parasite infective for mosquitoes. Assessment by MEB includes:

• risk of probable patient-vector contact and therefore of possible transmission to mosquitoes.

Action that may be recommended if there is a possibility of local transmission may include:

• fogging operations around the immediate residential area or the nearest mosquito breeding or harbouring area;

• limited screening for malaria in the neighbourhood;

• a malaria warning pamphlet being distributed to nearby residents;

• doctors and Community Care/ Health Centres in the area being advised to be on alert for patients with unexplained fevers or other suggestive symptoms.

The surveillance report which has been completed by a staff member from Disease Control is sent to the Medical Entomology Branch and the patient files.

A Territory wide register of all confirmed malaria cases is maintained at Disease Control, Darwin.

Currie B. The diagnosis and treatment of malaria in Australia. Australian Family Physician 1993: 22 ( 10): 1773-1779.

Commonwealth Department of Health, Housing and Community Services.

Health information for international travel. Canberra: AGPS, latest edition. Malaria. In: Antibiotic Guidelines. Victorian Medical Postgraduate Founuation 9th ed. 1996 -1997 87 - 91.

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- - ~ ~ -

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MALARIAL SUR\Z:EILLANCE

DATE DISEASE CONTROL NOTIFIED: ... ./ ... ./19 ... .

ATTACHMENT 1

~~ • NT DEPARTMENT OF HEAL TH

~ . AND COMMUNITY SERVICES

I

SURNAME ............. OTHER NAMES ................................. . AGE ......... DOB ... ./ ... ./19... HRN ... SEX MD FD

NATIONALITY............ BIRTHPLACE ................................. . OCCUPATION (Present) .... .............. ..... ................. MEMBER OF DEFENCE FORCES YES

D

NO D ADDRESS ON DATE OF DIAGNOSIS ............................................................. . .................................... POSTCODE ................. . ALTERNATIVE ADDRESS ............................................................. . ................................................... POSTCODE ............... . What date did you arrive back in Australia? ....... ./ ... ./19 ....... First town/city of arrival: .......................................... .

What date did you arrive in the NT? ... ./ ..... /19 ... .

ALLERGIES (specifically Sulphonamides eg Bactrim, Dapsone, Fansidar) ........................ .

RECENT OVERSEAS TRAVEL (Include reason for travel eg holiday, study, immigrant, business, work)

Did you live in mostly URBAN AREAS

D

RURAL AREAS

D

URBAN AREAS ONLY

D

Reason for travel: ................................................. .

Travel Dates Countries visited Towns/Cities Please tick

Rural Urban

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RECENT MALARIA PRECAUTIONS

Common antimalarial drugs include Chloroquine, Maloprim, Proguanil/Paludrine, Doxycyc/ine, Mefloquine/Lariam.

DATE DRUG NAME

Started Ceased

DOSES MISSED

COMMENT (include side affects)

Who told you malaria prophylaxis was necessary ? (Include advice before doctor's visit, eg travel agent etc).

What date did you first notice this fever? ........ / .... /19 ... ..

Other symptoms (after initial onset): ................................................. .

···

Have you recently had a similar fever? YES

D NOD

If 'YES', date of last fever: ....... / ..... /19 ...

Were you aware that your fever may have been malaria? (Include where this advice was obtained, eg airport etc)

Where were you when you first became ill?

STREET No. / NAME I SUBURB / TOWN COUNTRY

... f ···

...

~

^...^..^...^..^....^...^...^...... .

Where have you been since you first became ill? (Include all locations prior to treatment, dates, evening and overnight outings, screened and unscreened areas and recollection of mosquitoes or mosquito bites)

DATES TOWN/ADDRESS

SCREENED/UNSCREENED

EVENING/OVERNIGHT OUTINGS

I

MOSQUITO BITES YES/NO

. .... ... .. .. .. ... . ... . . . .... ... ... .. .. ... .. ... .. . .... ... .. ... .... . . . .. . ... .. . ... ... r ... ... ... ..

Have you been treated for malaria before this attack? Y..:S

D NOD

(Include all dates, treatment prescribed and completed, any adverse reactions and country of treatment.)

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CURRENT ADMISSION

Admission date .... ./. ... ./19 ... Discharge date ... / ..... 19... Hospital: ................... _. ............................ .

Attending Medical Officer (Specialist) : .................................................... ..

PRESENT TREATMENT DATE

COMMENCED

DRUG

LABO RA TORY INVESTIGATIONS

DOSE / DURATION

BLOOD FILM: Date taken: ... / ........ /19........ Date read: ..... ./ ... /19 ... ..

COMMENT ( include side affects)

NAME OF LABORATORY ....................................................................................... . If laboratory not Royal Darwin Hospital (ROH) has specimen been sent to RDH for Cross checking? YES

D

^NO

D

RESULT

SPECIES

ROH FINDINGS - (if same as above, write A/A)

SPECIES STAGES DENSITY

Date of first negative film: ....... / ... /19 ..... .

STAGES

GAMETOCYTES YES/NO

HB

GAMETOCYTES YES/NO

wee PLATE LETS

DISCHARGE DRUGS: .................................................................. . Please attach copy of discharge summary and treatment given.)

FOLLOW UP BY COMMUNITY CARE STAFF: YES

D

^NO

0 .. .. ... . ... . .. . . .. ... .. ... . .. . ... . . . .... . . ... .

DATE OF OUTPATIENT APPOINTMENT: ... / ....... ./19 ........

(NB Primaquine course in P. fa/ciparum cases commenced at this appointment) Primaquine Commenced: YES

! -

_NO

I

~ · Details: ...................................... . CO-TRAVELLERS

!Type of group (family, student, work, holiday, military, conference etc.): .......................... . ............................................................................ Total No. in group: ............ .

I

~

NAME _I DOB ADDRESS y ~ COMMENT

I

......... L ................................. .

!

: : :: ::: :: :: :: : :::::: :: ::: : ::: ::: :: : ::: : : : : : : : r: : : ::: . ·:: :::: :~:: ::: : : : ::: ::: : : : : : : : :: : :: ::::: : : : : : :: :::: :: :::::: ::::: : :: : : : : :: : :: ::: : : :: :: : :: ::: : :::: : ::::: ::: ::: : : :::: :: :::::: :::: : : : :::: : : : :: ::

: : ::: f i .· · . · . : ::: : ::: : ::::::::: : :

SIGNATURE:..................................................... DESIGNATION:.................... . ... ./ ... ./19 ... .

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Northern Territory Department of Health Library Services Historical Collection

These pages have been removed as they

contravene copyright legislation.

Pages 20 to 25 of 29

APPENDIX 2

Item: Malaria

Source: Antibiotic Guidelines

Victorian Medical Postgraduate Foundation.

9

^th

ed. 1996 - 1997

Pages 87 – 91

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Northern Territory Department of Health Library Services Historical Collection

These pages have been removed as they

contravene copyright legislation.

Pages 26 to 29 of 29

APPENDIX 3

Article: FEVERS

The diagnosis and treatment of malaria in Australia

Author: Bart Currie FRACP, FAFPHM, DTM&H Source: Australian Family Physician

Vol 22 No. 13 October 1993

Article pages 1773 - 1779

Malaria Protocol - guidelines for health professionals in the Northern Territory - 1997

Department of Health Library Services ePublications - Historical Collection

Please note: this document is part of the Historical Collection and the information contained within may be out of date.

iN TltE NoRTliERN TERRiToRy , }nd Ed

Comments are welcome and should be directed to the ProjecUResearch Officer at the above address.

CONTENTS

For assistance with possible malaria cases contact:

I NTROd UCTiON

Risks of RE,EsTAblisliiNG ENdEMic MALARiA iN Tl-IE NoRTliERN TERRiToRy

DiAGNosis

Positive Plasmodium

Negative

Management of Malaria

Patient interview

CASE WITH MALARIA

Treatment protocol

ADMIT TO HOSPITAL

Nurse in air conditioning 6 pm - 8 am

ScREENiNG of HiGli Risk Cnoups

RAdicAL TREATMENT/CURE foR PERSONS AT Risk

RoLE of DisEASE CoNTRol ANd TliE MEdicAL ENToMoloGy BRANCli

MALARIAL SUR\Z:EILLANCE

~~ • NT DEPARTMENT OF HEAL TH

Northern Territory Department of Health Library Services Historical Collection

contravene copyright legislation.