Supplement

Canadian Recommendations for the Prevention and Treatment of Malaria Among International Travellers

6. Self-treatment of Presumptive Malaria

Counsel regarding appropriate management of malaria is of value for all travellers in regions where malaria is highly endemic because reliable medical attention may not be available. However, travellers to high-risk regions should never rely exclusively on a self-treatment regimen. Under some circumstances, individuals at risk of malaria may be unable to seek medical care within 24 hours and may not have access to facilities that stock appropriate medications; therefore, they require access to medication for self-treatment of presumptive malaria.

All travellers should be advised that the signs and symptoms of malaria are non-specific, that there is a risk of other potentially serious illnesses mimicking malaria, and that there are potential adverse reactions to malaria therapy; thus self-treatment should never be undertaken lightly. Consultation with a tropical medicine expert is recommended before individuals are advised to embark on a self-treatment program.

Training long-term travellers and expatriates to become proficient in their practice of self-treatment is difficult, and efforts should focus on those living in areas where access to expert supervision and care of high quality is limited, and where the threat of malaria is significant. Ninety percent of global episodes of clinical malaria and deaths occur in subSaharan Africa; therefore, particular attention should be given to people travelling to that region.

Training should consist of the following steps:

Step 1 - Discuss Common Errors Concerning Malaria Recognition and Management

The consultant should discuss common errors that have compromised the value of self-treatment:

• Expatriates assume that they can recognize malaria from the symptoms.
• They do not consistently assume that fever is malaria until proven otherwise.
• They commonly mistake the anti-inflammatory and antipyretic effect of chloroquine to signify that they have successfully treated malaria.
• They do not always choose an appropriate regimen -
  • the drug administered for treatment is the same as that used for prevention;
  • single drug therapy is chosen over combination therapy;
  • the dose used is often that used in the community for "semi-immunes";
  • the drug used is often less effective than that used for prevention, e.g., mefloquine for prevention, chloroquine for treatment.

Step 2 - Advise that Malaria Presents in Various Ways

Travellers should be advised that the clinical presentation of malaria is variable and may mimic other diseases. An alternative diagnosis that requires treatment may be present, particularly in travellers who have been compliant with an appropriate chemoprophylaxis regimen. The most frequent symptoms of malaria are fever, headache, and generalized aches and pains. Fever, which may or may not be cyclical, is almost always present. Malaria can be misdiagnosed as influenza or another febrile illness, so that an early and accurate diagnosis is essential. Malaria is likely to be over-reported by laboratory technicians; nevertheless, if malaria is diagnosed there should be follow-up with medical management.

Step 3 - Indicate the Need to Seek Professional Medical Care as Soon as Possible

Travellers should be told that self-treatment is NOT considered definitive treatment but is a temporary, lifesaving measure while they seek medical attention. Self-treatment for malaria should be undertaken only if fever develops and professional medical care is not available within 24 hours. After self-treatment, medical attention should still be sought as soon as possible.

Step 4 - Select the Self-treatment Drug with Care

When choosing a drug regimen for self-treatment, safety, efficacy, and drug tolerance must be considered priorities. Individuals who are undergoing chemosuppression should never attempt treatment with the same drug, as there is the potential for additive toxicity and reduced efficacy.

Recommended Regimens
(NOTE: to be used only if fever develops and medical care is not available within 24 hours)

1. For individuals in chloroquine-sensitive regions who are not receiving chloroquine prophylaxis:
   1. Self-treatment with chloroquine should be initiated (see Table 4).
   2. SEEK MEDICAL HELP AS SOON AS POSSIBLE.
   3. Chloroquine prophylaxis should be started.
2. For individuals in chloroquine-sensitive regions who are already receiving chloroquine prophylaxis:
   1. Self-treatment with atovaquone/proguanil should be initiated (see Table 4).
   2. SEEK MEDICAL HELP AS SOON AS POSSIBLE.
   3. Chloroquine prophylaxis should be resumed.
3. For individuals in chloroquine- or chloroquine-and mefloquine-resistant P. falciparum regions who are not receiving atovaquone/proguanil chemoprophylaxis:
   1. Self-treatment with atovaquone/proguanil OR quinine plus doxycycline should be initiated.
   2. SEEK MEDICAL HELP AS SOON AS POSSIBLE.
   3. Atovaquone/proguanil, doxycycline, or mefloquine should be started or resumed.
4. For individuals in chloroquine- or chloroquine-and mefloquine-resistant P. falciparum regions who are receiving atovaquone/proguanil chemoprophylaxis:
   1. Self-treatment with quinine plus doxycycline should be initiated.
   2. SEEK MEDICAL HELP AS SOON AS POSSIBLE.
   3. Atovaquone/proguanil should be resumed.

Travellers may not have access to drugs approved by Health Canada when travelling in chloroquine- or chloroquine- and mefloquine-resistant regions. Conversely, they may have access to medication endorsed by the Roll Back Malaria Program that has not been formally approved for use in Canada. The Roll Back Malaria Program advocates the use of some fixed combination therapies because they improve compliance and efficacy while reducing errors and the emergence of drug resistance (see Table 4).

Step 5 - Educate About Drugs to Avoid

Warn the traveller about the following drug regimens, which are no longer recommended for self-treatment because of potential severe adverse effects and/or poor efficacy:

• Halofantrine (causes cardiac deaths)
• Mefloquine (unacceptably high rates of severe adverse events at treatment doses)
• Fansidar® alone (sulfadoxine plus pyrimethamine) (resistance)
• Fansimef® (mefloquine plus Fansidar®) (resistance)
• Chloroquine plus Fansidar® (resistance, ineffective)

Rapid detection of malaria using a simple dipstick test may be available to some travellers. The sensitivity and specificity of these tests vary, from 50% to 90%. Furthermore, there are limited data about their accuracy in the hands of non-experienced operators and under non-refrigerated conditions in the tropics. There are no rapid detection kits currently licensed in North America (see Section 7).

Table 4. Drugs for the self-treatment of malaria

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