10
Prophylaxis and Personal Protection for Relief Workers

Nonimmune personnel participating in humanitarian relief efforts need to protect themselves from malaria. The two principal strategies for doing so involve chemoprophylaxis and the use of personal protection measures. The choice of prophylaxis should be based on current knowledge of drug resistance patterns for the specific area. Because chloroquine resistance is widespread, chloroquine prophylaxis is useful only in Central America, Haiti, the Dominican Republic, and limited areas of the Middle East. One study of American Peace Corps volunteers exposed to chloroquine-resistant malaria demonstrated that prophylactic efficacy could be increased by combining chloroquine with proguanil, but the efficacy of this combination was still much below that obtainable with weekly mefloquine (Lobel et al., 1993). Among European travelers to East Africa, the prophylactic efficacy of chloroquine was 10 to 42 percent; for chloroquine combined with proguanil, 72 percent; and for weekly mefloquine, 91 percent (Steffen et al., 1993).

Use of amodiaquine and sulfadoxine/pyrimethamine for prophylaxis is not recommended due to a high incidence of serious, potentially fatal, adverse reactions. Currently, the only option for long-term chemoprophylaxis of nonimmune relief workers in most malarious areas of the world is mefloquine (in areas where mefloquine resistance is rare or does not exist). For shorter-term prophylaxis, doxycycline, or atovaquone/ proguanil (Malarone) could be considered (see Table 10-1).



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Malaria Control During Mass Population Movements and Natural Disasters 10 Prophylaxis and Personal Protection for Relief Workers Nonimmune personnel participating in humanitarian relief efforts need to protect themselves from malaria. The two principal strategies for doing so involve chemoprophylaxis and the use of personal protection measures. The choice of prophylaxis should be based on current knowledge of drug resistance patterns for the specific area. Because chloroquine resistance is widespread, chloroquine prophylaxis is useful only in Central America, Haiti, the Dominican Republic, and limited areas of the Middle East. One study of American Peace Corps volunteers exposed to chloroquine-resistant malaria demonstrated that prophylactic efficacy could be increased by combining chloroquine with proguanil, but the efficacy of this combination was still much below that obtainable with weekly mefloquine (Lobel et al., 1993). Among European travelers to East Africa, the prophylactic efficacy of chloroquine was 10 to 42 percent; for chloroquine combined with proguanil, 72 percent; and for weekly mefloquine, 91 percent (Steffen et al., 1993). Use of amodiaquine and sulfadoxine/pyrimethamine for prophylaxis is not recommended due to a high incidence of serious, potentially fatal, adverse reactions. Currently, the only option for long-term chemoprophylaxis of nonimmune relief workers in most malarious areas of the world is mefloquine (in areas where mefloquine resistance is rare or does not exist). For shorter-term prophylaxis, doxycycline, or atovaquone/ proguanil (Malarone) could be considered (see Table 10-1).

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Malaria Control During Mass Population Movements and Natural Disasters TABLE 10-1 Antimalarial Prophylaxis Regimens Drug Name Adult Dose Estimated Costa per Tablet Mefloquine 228-250 mg (base)c once per week, starting 2 weeks before and during and 4 wks after exposure $7.66 Malarone 1 tablet (250 mg atovaquone) per day, starting 2 days before and during and for 7 days after exposure $3.95 Doxycycline 100 mg (salt) daily, starting 2 days before and during and 4 weeks after exposure $0.39 Chloroquine 300 mg (base) once per week, starting 1 week before and during and 4 weeks after exposure $4.50 Chloroquine + proguanil Chloroquine as above plus proguanil 200 mg (salt) daily, continuing for 4 weeks after exposure $4.50 (chloroquine) $0.03 (proguanil) a Costs reflect average wholesale prices derived from the Drug Topics Redbook (Medical Economics Co., 1999) and the International Drug Price Indicator Guide (McFayden, 1999). Less expensive sources of some drugs exist internationally. These prices are intended for general comparative purposes only. b Estimated cost includes pre- and postexposure doses (see text for explanation). Personal protection measures are aimed at reducing human-mosquito contact during the evening and night. Personal protection measures include the use of insecticide-impregnated bed nets, insect repellents (especially those containing at least 30 percent DEET), protective clothing, and avoidance. Because no chemoprophylactic regimen is completely effective, a combination of preventive strategies is best. Up-to-date information regarding recommended chemoprophylaxis regimens and other prevention measures can be found on the following websites: Centers for Disease Control and Prevention recommendations (<http://www.cdc.gov/travel/>), World Health Organization recommendations (<http://www.who.int/ith/>); and Canadian recommendations (<http://www.hc-sc.gc.ca/hpb/lcdc/publicat/ccdr/00vol26/26s2/index.html>).

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Malaria Control During Mass Population Movements and Natural Disasters Estimated Costb for 6 Months’ Exposure Comments/Cautions $230 (30 tablets)   $700 (177 tablets)   $77 (198 tablets) Not for use by pregnant women. Typically only used for limited duration of exposure. $130 (29 tablets) Only for use in Central America, northwest of Panama Canal, and island of Hispaniola. Price is for name-brand chloroquine; generics far less expensive. $142 (29 tablets chloroquine + 396 tablets proguanil) Addition of proguanil only marginally improves prophylactic efficacy of chloroquine, therefore not an advisable regimen for most instances. Proguanil not available in the U.S. c Mefloquine marketed in the United States contains 228-mg base per tablet; mefloquine marketed in Europe contains a 250-mg base per tablet. RECOMMENDATIONS Obtain current information on local drug resistance patterns when determining the most appropriate prophylaxis drug to recommend for relief workers. Either provide or facilitate provision of effective prophylactic medicines for relief workers. Train relief workers in the use of additional personal protection measures. Provide or facilitate the provision of materials needed for personal protection (such as insecticide-treated nets).

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Malaria Control During Mass Population Movements and Natural Disasters Chemoprophylaxis: Key Point Chemoprophylaxis and use of personal protective measures are necessary for protection of nonimmune relief personnel from malaria.