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MALARIA CLINICAL MANIFESTATIONS The classic symptoms of malaria are high fever with chills, rigor, sweats, a ! hea!

ache, which may "e paro#ysmal$ If appropriate treatme t is ot a!mi istere!, fever a ! paro#ysms may occ%r i a cyclic patter $ &epe !i g o the i fecti g species, fever classically appears every other or every thir! !ay$ Other ma ifestatio s ca i cl%!e a%sea, vomiti g, !iarrhea, co%gh, tachyp ea, arthralgia, myalgia, a ! a"!omi al a ! "ac' pai $ A emia a ! throm"ocytope ia are commo , a ! pallor a ! (a% !ice ca%se! "y hemolysis may occ%r$ )epatosple omegaly may "e prese t$ More severe !isease occ%rs i people witho%t previo%s e#pos%re, yo% g chil!re , a ! people who are preg a t or imm% ocompromise!$ I fectio with Plasmodium falciparum, o e of the * Plasmodium species that i fects h%ma s, pote tially is fatal a ! most commo ly ma ifests as a fe"rile o specific ill ess witho%t locali+i g sig s$ Severe P falciparum !isease may ma ifest as o e of the followi g cli ical sy !romes, all of which are me!ical emerge cies a ! may "e fatal % less treate!, Cerebral malaria, which may have varia"le e%rologic ma ifestatio s, i cl%!i g ge erali+e! sei+%res, sig s of i crease! i tracra ial press%re, co f%sio , a ! progressio to st%por, coma, a ! !eath Hypoglycemia, which may occ%r with meta"olic aci!osis a ! hypote sio associate! with hyperparasitemia or "e associate! with .%i i e treatme t Noncardiogenic pulmonary edema Renal failure ca%se! "y ac%te t%"%lar ecrosis /rare i chil!re yo% ger tha 0 years of age1 Respiratory failure and metabolic acidosis, witho%t p%lmo ary e!ema Severe anemia attri"%ta"le to high parasitemia se.%estratio a ! hemolysis associate! with hypersple ism- or Vascular collapse and shock associate! with hypothermia a ! a!re al i s%fficie cy 2eople with asple ia who "ecome i fecte! may "e at i crease! ris' of more severe ill ess a ! !eath$ Sy !romes primarily associate! with Plasmodium vivax a ! Plasmodium ovale i fectio are as follows, Anemia attri"%ta"le to ac%te parasitemia Hypersplenism with !a ger of late sple ic r%pt%re- a ! Relapse, for as lo g as 3 to 4 years after the primary i fectio , attri"%ta"le to late t hepatic stages$ Sy !romes associate! with Plasmodium malariae i fectio i cl%!e, Chronic asymptomatic parasitemia for as lo g as several years after the last e#pos%re- a ! Nephrotic syndrome from !epositio of imm% e comple#es i the 'i! ey$ Congenital malaria seco !ary to peri atal tra smissio rarely may occ%r$ Most co ge ital cases have "ee ca%se! "y P vivax a ! P falciparum; P malariae a ! P ovale acco% t for fewer tha 567 of s%ch cases$ Ma ifestatio s ca resem"le those of eo atal sepsis, i cl%!i g fever a ! o specific symptoms of poor appetite, irrita"ility, a ! lethargy$ ETIOLO89 The ge %s Plasmodium i cl%!es species of i traerythrocytic parasites that i fect a wi!e ra ge of mammals, "ir!s, a ! reptiles$ The * species that fre.%e tly i fect h%ma s are P falciparum, P vivax, P ovale, a ! P malariae. Plasmodium knowlesi, mis!iag ose! as P malariae, has "ee show to i fect h%ma s i Malaysia$ E2I&EMIOLO89 Malaria is e !emic thro%gho%t the tropical areas of the worl! a ! is ac.%ire! from the "ite of the female oct%r al:fee!i g Anopheles species of mos.%ito$ O e half of the worl!;s pop%latio lives i areas where tra smissio occ%rs$ <orl!wi!e, 366 to 466 millio cases a ! a estimate! = millio !eaths occ%r each year$ Most !eaths occ%r i yo% g chil!re $ Malarial i fectio poses s%"sta tial ris's to preg a t wome a ! their fet%ses a ! may res%lt i spo ta eo%s a"ortio a ! still"irth$ The ris' of malaria is highest, "%t

varia"le, for travelers to s%":Sahara Africa, 2ap%a New 8%i ea, the Solomo Isla !s, a ! >a %at%- the ris' is i terme!iate o the I !ia s%"co ti e t a ! is low i most of So%theast Asia a ! Lati America$ The pote tial for malaria tra smissio is o goi g i areas with previo%s elimi atio if i fecte! people ret%r a ! the mos.%ito vector is still prese t$ These co !itio s have res%lte! i rece t cases i travelers to areas s%ch as ?amaica, the &omi ica Rep%"lic, a ! the @ahamas$ )ealth care professio als sho%l! chec' a %p:to:!ate so%rce ( n!cdc!gov"travel# to !etermi e malaria ris' whe provi!i g pretravel malaria a!vice or eval%ati g a fe"rile ret%r e! traveler$ Tra smissio is possi"le i more temperate climates, i cl%!i g areas of the A ite! States where Anopheles species mos.%itoes are prese t$ Nearly all of the appro#imately =466 a %al reporte! cases i the A ite! States res%lt from i fectio ac.%ire! a"roa!$ =B3 Rarely, mos.%itoes i airpla es flyi g from tropical climates have "ee the so%rce of cases i people wor'i g or resi!i g ear i ter atio al airports$ A commo mo!es of malaria tra smissio are co ge ital, thro%gh tra sf%sio s, or thro%gh the %se of co tami ate! ee!les or syri ges$ P vivax a ! P falciparum are the most commo species worl!wi!e$ P vivax malaria is prevale t o the I !ia s%"co ti e t a ! i Ce tral America$ P falciparum malaria is prevale t i Africa a ! 2ap%a New 8%i ea$ P vivax a ! P falciparum species are the most commo malaria species i so%ther a ! So%theast Asia, Ocea ia, a ! So%th America$ P malariae, altho%gh m%ch less commo , has a wi!e !istri"%tio $ P ovale malaria occ%rs most ofte i <est Africa "%t has "ee reporte! i other areas$ Relapses may occ%r i P vivax a ! P ovale malaria "eca%se of a persiste t hepatic /hyp o+oite1 stage of i fectio $ Recr%!esce ce of P falciparum a ! P malariae i fectio occ%rs whe a persiste t low: co ce tratio parasitemia ca%ses rec%rre ce of symptoms of the !isease$ I areas of Africa a ! Asia with hypere !emic i fectio , rei fectio i people with partial imm% ity res%lts i a high prevale ce of asymptomatic parasitemia$ The sprea! of chloro.%i e:resista t P falciparum strai s thro%gho%t the worl! is of i creasi g importa ce$ Resista ce to other a timalarial !r%gs ow is occ%rri g i ma y areas where the !r%gs are %se! wi!ely$ Resista ce to s%lfa!o#i e:pyrimethami e is commo thro%gho%t Africa, a ! meflo.%i e resista ce has "ee !oc%me te! i Mya mar /@%rma1, Thaila !, Cam"o!ia, >iet am, a ! Chi a$ Chloro.%i e:resista t P vivax has "ee reporte! i I !o esia, 2ap%a New 8%i ea, the Solomo Isla !s, Mya mar, I !ia, a ! 8%ya a$ Malaria symptoms ca !evelop as soo as C !ays after e#pos%re i a area with e !emic malaria to as late as several mo ths after !epart%re$ More tha 067 of cases !iag ose! i the A ite! States have o set of symptoms after their ret%r to the A ite! States$ &IA8NOSTIC TESTS &efi itive !iag osis relies o i!e tificatio of the parasite microscopically o stai e! "loo! films$ @oth thic' a ! thi "loo! films sho%l! "e e#ami e!$ The thic' film allows for co ce tratio of the "loo! to fi ! parasites that may "e prese t i small %m"ers, whereas the thi film is most %sef%l for species i!e tificatio a ! !etermi atio of the !egree of parasitemia /the perce tage of erythrocytes har"ori g parasites1$ If i itial "loo! smears test egative for Plasmodium species "%t malaria remai s a possi"ility, the smear sho%l! "e repeate! every =5 to 5* ho%rs !%ri g a C5:ho%r perio!$ I areas with hypere !emic i fectio , the prese ce of malaria o a "loo! smear is ot co cl%sive evi!e ce of malaria as a ca%se of the ma ifesti g ill ess, "eca%se other i fectio s ofte are s%perimpose! o low:co ce tratio parasitemia i chil!re a ! a!%lts with partial imm% ity$ Co firmatio a ! i!e tificatio of the species of malaria parasites o the "loo! smear is importa t i g%i!i g therapy$ Serologic testi g ge erally is ot helpf%l, e#cept i epi!emiologic s%rveys$ 2olymerase chai reactio /2CR1 assay is availa"le i refere ce la"oratories a ! some state health !epartme ts$ &NA pro"es a ! malarial ri"osomal RNA testi g may provi!e rapi! a ! acc%rate !iag osis i the f%t%re "%t c%rre tly are %se! i e#perime tal st%!ies o ly$ A ew AS Foo! a ! &r%g A!mi istratio /F&A1: approve! test for a tige !etectio /a rapi! !iag ostic test1 is availa"le i the A ite! States$ It is the o ly a tige :!etectio 'it availa"le a ! is approve! for %se "y hospitals a ! commercial la"oratories$ All rapi! !iag ostic tests are recomme !e! to "e co !%cte! i parallel with ro%ti e microscopy to provi!e f%rther i formatio ee!e! for patie t treatme t, s%ch as the perce tage of erythrocytes har"ori g parasites$ A egative rapi! !iag ostic test res%lt sho%l! "e co firme! "y microscopic e#ami atio , "eca%se low:level

parasitemia may ot "e !etecte!$ Also, i formatio a"o%t the se sitivity of rapi! !iag ostic tests for the 5 less commo species of malaria, P ovale a ! P malariae, is limite!$ More i formatio a"o%t rapi! !iag ostic testi g for malaria is availa"le at !cdc!gov"malaria"diagnosis$treatment"diagnosis!htm $ TREATMENT The choice of malaria chemotherapy is "ase! o the i fecti g species, possi"le !r%g resista ce, a ! the severity of !isease /see &r%gs for 2arasitic I fectio s, p C031$ Severe malaria is !efi e! as a y o e or more of the followi g, parasitemia greater tha 47 of re! "loo! cells, sig s of ce tral ervo%s system or other e !:orga i volveme t, shoc', aci!osis, a !Dor hypoglycemia$ 2atie ts with severe malaria re.%ire i te sive care a ! pare teral treatme t % til the parasite !e sity !ecreases to less tha =7 a ! they are a"le to tolerate oral therapy$ E#cha ge tra sf%sio may "e warra te! whe parasitemia e#cee!s =67 or if there is evi!e ce of complicatio s /eg, cere"ral malaria or re al fail%re1 at lower parasite !e sities$ For patie ts with severe malaria i the A ite! States, i trave o%s artes% ate has "ecome availa"le thro%gh a (oi t F&A:Ce ters for &isease Co trol a ! 2reve tio /C&C1 i vestigatio al ew !r%g protocol$ Cli icia s may co tact the physicia o call thro%gh the C&C malaria hotli e /CC6:*00:CC00, Mo !ayE Fri!ay, 0,66 amE*,36 pm Easter Time- or CCC:*00:C=66 at all other times1 for a!!itio al i formatio a ! release of the !r%g$ =B* For patie ts with P falciparum malaria, se.%e tial "loo! smears to !etermi e perce tage of erythrocytes har"ori g parasites are i !icate! to mo itor treatme t$ Assista ce with ma ageme t of malaria is availa"le 5* ho%rs a !ay thro%gh the C&C Malaria )otli e /CC6:*00:CC001$ ISOLATION OF T)E )OS2ITALIFE& 2ATIENT Sta !ar! preca%tio s are recomme !e!$ CONTROL MEASARES Co trol of the Anopheles species mos.%ito pop%latio , protectio agai st mos.%ito "ites, treatme t of i fecte! people, a ! chemoprophyla#is of travelers to areas with e !emic i fectio are effective$ Meas%res to preve t co tact with mos.%itoes, especially from !%s' to !aw /"eca%se of the oct%r al "iti g ha"its of the female Anopheles mos.%ito1, thro%gh %se of "e! ets impreg ate! with i sectici!e, mos.%ito repelle ts co tai i g !iethyltol%ami!e /&EET1 /see 2reve tio of Mos.%ito"or e I fectio s, p =G31, a ! protective clothi g also are "e eficial a ! sho%l! "e optimi+e!$ The most c%rre t i formatio o co% try:specific ris's, !r%g resista ce, a ! res%lti g recomme !atio s for travelers ca "e o"tai e! "y co tacti g the C&C / !cdc!gov"malaria" or the Malaria )otli e at CC6:*00:CC001$ Chemoprophyla%is for &ravelers to Areas 'ith (ndemic Malaria )*+ More tha 067 of malaria: i fecte! patie ts reporte! i the A ite! States !i! ot follow a C&C:recomme !e! prophyla#is regime $ The appropriate chemoprophylactic regime is !etermi e! "y the traveler;s ris' of ac.%iri g malaria i the area/s1 to "e visite! a ! "y the ris' of e#pos%re to chloro.%i e: or meflo.%i e:resista t P falciparum or chloro.%i e:resista t P vivax$ I !icatio s for prophyla#is for chil!re are i!e tical to those for a!%lts$ 2e!iatric !osages sho%l! "e calc%late! o the "asis of the chil!;s c%rre t weight- chil!re ;s !osages ever sho%l! e#cee! a!%lt !osages$ The !r%gs %se! for malaria chemoprophyla#is ge erally are well tolerate!$ )owever, a!verse reactio s ca occ%r$ Mi or a!verse reactio s !o ot re.%ire stoppi g the !r%g$ Travelers with serio%s a!verse reactio s sho%l! "e a!vise! to co tact their health care professio al$ Chemoprophyla#is sho%l! "egi "efore arrival i the area with e !emic i fectio /starti g = wee' "efore for meflo.%i e a ! chloro.%i e a ! =E5 !ays "efore for !o#ycycli e a ! atova.%o e:prog%a il1, allowi g time to !evelop "loo! co ce tratio s of the !r%g$ If there is !esire to e s%re tolera ce of the a ti malarial !r%g to "e %se! for prophyla#is, the the !r%g sho%l! "e starte! earlier so that there is time to assess a y a!verse eve ts "efore !epart%re a ! time to cha ge to a other effective !r%g if ee!e!$ For e#ample, if there is co cer a"o%t i !ivi!%al tolera ce with meflo.%i e, the prophyla#is ca "e starte! 3 wee's "efore travel$ Most a!verse eve ts will occ%r !%ri g the first 3 !oses, a ! if the i !ivi!%al !oes ot tolerate meflo.%i e, the there is still time to prescri"e alter ative therapy "efore travel$ Travelers to areas where chloro.%i e:resista t malaria species have ot "ee reporte! sho%l! ta'e chloro.%i e, o ce wee'ly, starti g = wee' "efore e#pos%re for the !%ratio of e#pos%re a ! for * wee's

after !epart%re from the area with e !emic malaria$ A!verse reactio s that ca occ%r i cl%!e gastroi testi al tract !ist%r"a ce, hea!ache, !i++i ess, "l%rre! visio , i som ia, a ! pr%rit%s, "%t these ge erally are mil! a ! !o ot re.%ire !isco ti %atio of the !r%g$ Travelers to areas witho%t reporte! chloro.%i e:resista ce also may choose to ta'e o e of the 3 !r%g regime s !escri"e! "elow$ Three !r%gs with similar efficacy are availa"le i the A ite! States for preve tio of chloro.%i e:resista t malaria$ Travelers to areas where chloro.%i e:resista t P falciparum e#ists sho%l! ta'e atova.%o e: prog%a il, !o#ycycli e, or meflo.%i e$ A fi#e!:!ose com"i atio of atova.%o e:prog%a il is approve! for preve tio a ! treatme t of chloro.%i e:resista t P falciparum malaria$ Atova.%o e:prog%a il is ta'e !aily, starti g = !ay "efore e#pos%re a ! co ti %i g for the !%ratio of e#pos%re a ! for = wee' after !epart%re from the area with e !emic malaria$ A pe!iatric form%latio is availa"le i the A ite! States "%t is ot approve! for prophyla#is i chil!re weighi g less tha == 'g$ )owever, recomme !atio s of the C&C s%ggest that atova.%o e:prog%a il ca "e %se! i chil!re weighi g 4 'g or more, whe travel to areas where chloro.%i e:resista t P falciparum e#ists ca ot "e avoi!e!$ Atova.%o e: prog%a il is co trai !icate! for preg a t wome $ The rare a!verse effects reporte! "y people %si g atova.%o e:prog%a il for chemoprophyla#is are a"!omi al pai , a%sea, vomiti g, mo%th %lcers, a ! hea!ache$ &o#ycycli e is ta'e !aily, starti g = to 5 !ays "efore e#pos%re, for the !%ratio of e#pos%re a ! for * wee's after !epart%re from the area with e !emic malaria$ Travelers ta'i g !o#ycycli e sho%l! "e a!vise! of the ee! for strict a!here ce to !aily !osi g- the a!visa"ility of always ta'i g the !r%g o a f%ll stomach- a ! the possi"le a!verse effects, i cl%!i g !iarrhea, photose sitivity, a ! i crease! ris' of mo ilial vagi itis$ &o#ycycli e also ca !ecrease the effective ess of oral co traceptives i wome of chil!"eari g age$ Ase of !o#ycycli e sho%l! "e avoi!e! for preg a t wome a ! for chil!re yo% ger tha 0 years of age "eca%se of the ris' of !e tal stai i g /see A timicro"ial Age ts a ! Relate! Therapy, p C3C1$ Meflo.%i e is ta'e o ce wee'ly, starti g = wee' "efore travel, co ti %i g wee'ly !%ri g travel, a ! for * wee's after travel has co cl%!e! /see &r%gs for 2arasitic I fectio s, p C031$ Meflo.%i e is ot approve! "y the F&A for chil!re who weigh less tha 4 'g or are yo% ger tha B mo ths of age$ )owever, recomme !atio s of the C&C s%ggest that meflo.%i e "e co si!ere! for %se i chil!re , regar!less of weight or age restrictio s, whe travel to areas where chloro.%i e:resista t P falciparum e#ists a ! ca ot "e avoi!e!$ )owever, pare ts sho%l! "e a!vise! ot to travel to co% tries with e !emic malaria with chil!re weighi g less tha 4 'g or yo% ger tha B wee's of age "eca%se of the ris's associate! with i fectio /septicemia or malaria1 i yo% g i fa ts$ The most commo ce tral ervo%s system a" ormalities associate! with meflo.%i e are !i++i ess, hea!ache, i som ia, a ! !ist%r"i g !reams$ Meflo.%i e has "ee associate! with rare serio%s a!verse eve ts /i cl%!i g psychoses or sei+%res1 at prophylactic !oses- these reactio s are more commo with the higher !oses %se! for treatme t$ Other a!verse eve ts that occ%r with prophylactic !oses i cl%!e gastroi testi al tract !ist%r"a ces, hea!ache, !epressio , a ! a #iety !isor!ers$ Meflo.%i e is co trai !icate! for %se i travelers with a ' ow hyperse sitivity to meflo.%i e- people with active !epressio or a history of !epressio - people with ge eral a #iety !isor!ers, psychosis, schi+ophre ia, or other ma(or psychiatric !ist%r"a ces- people with a history of sei+%res / ot i cl%!i g fe"rile sei+%res1- a ! people with a history of car!iac co !%ctio a" ormalities$ Altho%gh a war i g a"o%t co c%rre t %se with "eta:"loc'ers is give i the pro!%ct la"eli g, a review of availa"le !ata s%ggests that meflo.%i e may "e %se! "y people co c%rre tly receivi g "eta:"loc'ers if they have o % !erlyi g arrhythmia$ Ca%tio sho%l! "e a!vise! for travelers i volve! i tas's re.%iri g fi e motor coor!i atio a ! spatial !iscrimi atio $ 2atie ts i whom meflo.%i e prophyla#is fails sho%l! "e mo itore! closely if they are treate! with .%i i!i e or .%i i e s%lfate, "eca%se either !r%g may e#acer"ate the ' ow a!verse effects of meflo.%i e$ Chil!re sho%l! avoi! travel to areas where chloro.%i e:resista t P falciparum e#ists % less they ca ta'e a highly effective !r%g, s%ch as atova.%o e:prog%a il, !o#ycycli e, or meflo.%i e$ If other a timalarial !r%gs ca ot "e %se!, in consultation ith local malaria e%perts or e%perts at the C,C (C,C Malaria

Hotline- ../01220..22#, prima.%i e may "e %se! to preve t malaria while the traveler is i the area with a ris' of malaria$ NOTE, Travelers m%st "e teste! for gl%cose:B:phosphate !ehy!roge ase /8B2&1 !eficie cy a ! have a !oc%me te! 8B2& i the ormal ra ge "efore prima.%i e %se$ 2rimary prima.%i e prophyla#is sho%l! "egi = to 5 !ays "efore !epart%re to the area with ris' of malaria a ! sho%l! "e co ti %e! o ce a !ay while i the area with ris' of malaria a ! !aily for C !ays after leavi g the area$ The !r%g sho%l! ot "e %se! !%ri g preg a cy$ 3rophyla%is ,uring 3regnancy and 4actation Malaria i preg a cy carries sig ifica t ris's of mor"i!ity a ! mortality for "oth the mother a ! fet%s$ Malaria may i crease the ris' of a!verse o%tcomes i preg a cy, i cl%!i g a"ortio , preterm "irth, a ! still"irth$ For these reaso s a ! "eca%se o chemoprophylactic regime is completely effective, wome who are preg a t or li'ely to "ecome preg a t sho%l! try to avoi! travel to areas where they co%l! co tract malaria$ <ome traveli g to areas where !r%g:resista t P falciparum has ot "ee reporte! may ta'e chloro.%i e prophyla#is$ )armf%l effects o the fet%s have ot "ee !emo strate! whe chloro.%i e is give i the recomme !e! !oses for malaria prophyla#is$ 2reg a cy a ! lactatio , therefore, are ot co trai !icatio s for malaria prophyla#is with chloro.%i e$ For preg a t wome who travel to areas where chloro.%i e:resista t P falciparum e#ists, meflo.%i e sho%l! "e recomme !e! for chemoprophyla#is !%ri g the seco ! a ! thir! trimesters$ For wome i their first trimester, most evi!e ce s%ggests that %se of meflo.%i e is ot associate! with a!verse fetal or preg a cy o%tcomes, s%ch as spo ta eo%s a"ortio s, still"irths, a ! "irth !efects, whe ta'e i prophylactic !oses, "%t more !ata are ecessary to ma'e co cl%sive stateme ts a"o%t its safety i early preg a cy$ Co se.%e tly, meflo.%i e is the !r%g of choice for prophylactic %se for wome who are preg a t or li'ely to "ecome preg a t whe e#pos%re to chloro.%i e:resista t P falciparum is % avoi!a"le$ Lactati g mothers of i fa ts weighi g more tha 4 'g may also %se atova.%o e:prog%a il for prophyla#is whe e#pos%re to chloro.%i e:resista t P falciparum is % avoi!a"le$ Self0&reatment of Malaria Malaria ca "e treate! effectively early i the co%rse of !isease, "%t !elay of appropriate treatme t ca have serio%s or eve fatal co se.%e ces$ Travelers who !o ot ta'e a a timalarial !r%g for prophyla#is or who are o a less:tha :effective regime or who may "e i very remote areas ca "e give a self:treatme t co%rse of atova.%o e:prog%a il$ Travelers sho%l! "e a!vise! that self:treatme t is ot co si!ere! a replaceme t for see'i g prompt me!ical help$ A self:treatme t regime sho%l! "e !isc%sse! with a physicia e#pert i travel me!ici e "efore !epart%re$ Travelers ta'i g atova.%o e:prog%a il as their a ti malarial !r%g regime sho%l! ot ta'e atova.%o e: prog%a il as their self:treatme t !r%g a ! sho%l! %se a alter ative treatme t regime - the C&C Malaria )otli e /CC6:*00:CC001 provi!es a!vice o ma ageme t of travelers who ca ot %se atova.%o e: prog%a il for self:treatme t$ Travelers sho%l! "e a!vise! that a y fever or i fl%e +a:li'e ill ess that !evelops withi 3 mo ths of !epart%re from a area with e !emic malaria re.%ires imme!iate me!ical eval%atio , i cl%!i g "loo! films to r%le o%t malaria$ 3revention of Relapses To preve t relapses of P vivax or P ovale i fectio after !epart%re from areas where these species are prima.%i e resista t or tolera t, %se of high:!ose prima.%i e sho%l! "e co si!ere!$ 2rima.%i e ca ca%se hemolysis i patie ts with 8B2& !eficie cy- th%s, all patie ts sho%l! "e scree e! for this co !itio "efore prima.%i e therapy is i itiate!$ 3ersonal 3rotective Measures All travelers to areas where malaria is e !emic sho%l! "e a!vise! to %se perso al protective meas%res, i cl%!i g the followi g, /=1 %si g i sectici!e:impreg ate! mos.%ito ets while sleepi g- /51 remai i g i well:scree e! areas- /31 weari g protective clothi g- a ! /*1 %si g mos.%ito repelle ts co tai i g &EET$ To "e effective, most repelle ts re.%ire fre.%e t reapplicatio s /see 2reve tio of Mos.%ito"or e I fectio s, p =G3, for recomme !atio s regar!i g preve tio of mos.%ito"or e i fectio s a ! %se of i sect repelle ts1

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