Professional Documents
Culture Documents
Acute Diarrhea
1. PURPOSE
This guideline addresses the diagnosis and management of acute diarrheal syndromes due to
infectious causes.
2. BACKGROUND
Acute diarrhea represents one of the most common complaints of Volunteers located in
developing countries. While diarrhea can be related to many factors, including change in
diet, it is often the result of an infection with one of a variety of organisms (viral, bacterial or
parasitic), contracted by ingesting food or water which has been contaminated with fecal
pathogens.
Most people will consider any increase in stool frequency or softening of the stool to be due
to diarrhea. Significant diarrhea is best defined as:
Commonly, diarrhea is self limiting, resolving in a few days with no specific treatment
required other than adequate fluid replacement. Sometimes, however, diarrhea can be
serious or even life threatening (usually because of dehydration.) It is important to be able to
recognize patients in whom the diarrhea is potentially serious and to be able to correctly
investigate when necessary and provide treatment.
There are three main mechanisms by which pathogens can cause diarrhea. They may:
Invade/destroy the mucosal lining of the bowel (e.g., shigella, non-typhoid salmonellae,
E. histolytica)
Produce toxins which cause fluid to move into the bowel. Also known as secretory
diarrhea. (e.g., Vibrio cholerae, enterotoxigenic E. coli)
Cause a malabsorption like syndrome (e.g., giardia)
3. PREVENTION
Avoidance of contaminated water and food is the primary strategy in preventing diarrhea
among Volunteers.
drinking, even under the most extreme field conditions. Other methods which may be used
but may be less effective in some situations are described in ATTACHMENT A. Of these, only
filtering through a 1-2 micron filter followed by iodine or chlorine treatment is as effective as
boiling. Iodine and chlorine are less effective against protozoal cysts (ameba and giardia)
and are not effective against cryptosporidium cysts. The true frequency of cryptosporidium
infections is not known and is probably underestimated. Diarrhea due to cryptosporidium
typically persists for 10-14 days and is self-limited in healthy persons. Whenever possible,
water should be completely disinfected using one of the first two methods.
Many types of water filters marketed for travelers and rural use are ineffective against one or
more common pathogens. Usually iodine or chlorine must be used in addition to a water
filter. At this time, the water filters which use both a 1-2 micron filter to remove parasites
and cysts and an iodine resin to inactivate bacteria and viruses appear to be effective.
Conclusive field testing of such filters is lacking.
The complete cooking of food inactivates pathogens. Food should be eaten immediately
after cooking as a delay can allow bacteria to multiply again, and cooked food should be
protected from flies and other sources of recontamination. Soaking vegetables in a chlorine
solution after scrubbing them to remove dirt and other particles appears to be effective but
cannot completely disinfect heavily contaminated foods. After washing, soak the items in a
solution of one tablespoon household bleach per gallon for 15 minutes and then rinse in
treated water.
4. PROPHYLAXIS
While antibiotics have been shown to reduce the risk and severity of travelers diarrhea for
short-term travelers, there is also a significant risk of an adverse reaction to the drugs
themselves. This is especially so for Volunteers who remain in an area for several years.
Volunteers should not be given prophylactic antibiotics. They should be instructed in food
and water precautions and self management of minor diarrhea, along with seeking medical
attention when necessary.
Taking a full history and performing a comprehensive examination will guide the practitioner
to the likely cause of an episode of diarrhea and its severity. Laboratory tests may be used to
confirm this clinical suspicion.
See Table 5.1 Clues to the Etiology of Infectious Diarrhea, Table 5.2 Evaluation of Acute
Diarrhea and Table 5.3 Management of Acute Diarrhea on the following pages.
Objective
Physical findings
Assessment
When assessing a patient with diarrhea, the following questions must be answered:
Plan
PATIENT WITH
ACUTE DIARRHEA
TREATMENT:
- Oral fluids
Fever, dysentery or NO - Observe
severe diarrhea - Symptomatic treatment
(see text)
- Further workup if prolonged
YES
NO
* Inflammatory diarrhea is
likely if the stool contains blood
or mucus or the patient has a Patient CONSULT
significant fever improves NO APCMO/OMS
YES
DIARRHEA
RESOLVED
6. SUPPORTIVE CARE
Avoidance of hypovolemia with adequate hydration is the most critical therapy for acute
diarrheal illnesses. The average adult with diarrhea should drink a minimum of 2-3 Liters
daily. Oral rehydration solutions can be easily mixed up by the PCV.
Two acceptable recipes are as follows:
Add to 1 Liter of clean water: tsp of salt, tsp of baking soda and 4 tbsps of
Sugar
Add to 1 Liter of clean water: tsp of salt and 8 tsps of Sugar
These solutions can be flavored with some fruit juice or other soft drink.
The benefits of dietary changes other than adequate oral hydration have not been established
in controlled studies. Diets similar to the BRAT (banana, rice, applesauce, and toast) diet
should not make the diarrhea worse and will provide some calories. With most diarrheal
illnesses, individuals develop some degree of lactose intolerance. Dairy products should be
avoided during the acute diarrhea episode and for several weeks after.
When acute diarrhea is severe, contains blood or mucus, or is associated with a significant
fever, an invasive bacterial pathogen is likely. In these cases, consideration should be given
to the use of antibiotics even before the laboratory results are available.
Bulking agents (Kaolin and Pectin) can improve the consistency of diarrheal stool but have
not been shown to decrease the symptoms of infectious diarrhea.
effective in shortening the course of infectious diarrhea in about 50% of cases. Do not
exceed this dosage.
Bacterial diarrhea is usually associated with the sudden onset of frequent watery
stools, crampy abdominal pain, and sometimes fever, nausea or vomiting. WBCs,
blood and mucus may be present in the stool.
Bacterial diarrhea usually resolves spontaneously in 3-5 days. Fluid replacement
with electrolyte solution is the most important part of the treatment.
The use of antibiotics may shorten the duration of an episode of bacterial diarrhea.
Pathogenic bacteria quickly develop antibiotic resistance, therefore antibiotics are
reserved for use in only the more severe cases.
It is important to determine if there is inflammation of the bowel wall, (blood or
mucus in the stool or fever) as this indicates a more severe illness which should be
investigated with stool culture and microscopy. Consideration should also be given
to the empiric use of antibiotics (see section 6.) Amebic dysentery can also produce
this clinical picture.
Ciprofloxacin 500mg two times daily for 3 days (other quinolones may be used)
or
Azithromycin, 1 gm in a single dose
Most people infected with giardia remain asymptomatic, especially those who have
been previously infected and have developed some immunity.
When symptoms do develop, patients may be ill for weeks or months with loose
foul-smelling stools, belching and flatus, abdominal cramps and weight loss.
The diagnosis is confirmed by finding giardia cysts on microscopic examination of
the stool. Recovery of cysts in the stool is often difficult, requiring repeated stool
examinations and/or presumptive therapy when the diagnosis is suspected.
A stool test to detect giardia antigen is available, however presumptive treatment
for suspected giardiasis remains a practical method of managing this condition.
Treatment of Giardia
Volunteers diagnosed and treated for giardiasis should have their stool
examinations repeated to assess the efficacy of the treatment.
Infrequently, giardiasis may persist despite standard treatment. Quinacrine 100mg
three times daily for 5 days can be used for suspected treatment-resistant giardiasis.
Other intestinal flagellated protozoans (Trichomonas hominis, Chilomastix mesnili,
Enteromonas hominis) are non-pathogenic and do not require treatment.
Infection occurs by the ingestion of viable cysts from fecally contaminated water,
food, or hands.
There are three main clinical presentations of amebiasis:
Asymptomatic Carriers
Most people infected with E. histolytica do not develop diarrhea but remain
asymptomatic and continue to pass cysts in their stool (which can infect others.)
These cysts may be found when the patient is being investigated for an episode
of acute diarrhea.
Asymptomatic carriers are treated with a luminal agent.
Amebic Colitis
When diarrhea does develop, it is often foul-smelling and associated with
flatulence. Bouts of diarrhea may alternate with periods of relatively normal
bowel function. This presentation may be difficult to distinguish from
giardiasis. Less common is acute amebic dysentery characterized by an acute
diarrheal episode associated with fever, severe cramping, and gross blood in the
stool.
Both cysts and trophozoites are found in the stool of persons with symptomatic
intestinal amebiasis. If only cysts are seen despite careful stool examination
another cause should be sought.
Other species of ameba (Entamoeba coli, Entamoeba hartmanni, Endolimax
nana, Iodamoeba buetschlii) are non-pathogenic and do not require treatment.
Volunteers diagnosed and treated for amebiasis should have their stool
examinations repeated to assess the efficacy of the treatment.
Extraintestinal Amebiasis
Amebic disease outside the intestinal tract is rare, however an amebic liver
abscess is the most likely cause of a liver abscess in a Volunteer.
Symptoms usually involve the insidious onset of fever, sweats, fatigue, and
weight loss. A more acute presentation involves high fever, right upper
quadrant pain, nausea and vomiting.
Diagnosis is confirmed by demonstrating a multi-loculated cyst in the liver on
ultrasound. Amebic serology is positive in 90% of cases and LFTs may be
elevated. Stool microscopy is frequently negative for cysts or trophozoites.
Initial treatment is medical and laparotomy or aspiration can usually be avoided.
Always consult OMS.
It is not unusual for patients being treated with antibiotics to develop diarrhea. This
is due to an alteration in the normal bowel flora. Usually antibiotic-induced
diarrhea resolves quickly when the antibiotics are stopped.
If the diarrhea persists after the antibiotics have been stopped, there may be an
overgrowth of Clostridium difficile in the bowel (present in 3% of healthy adults)
producing pseudomembranous colitis. Some laboratories are able to identify C.
difficile toxin in stool specimens.
Metronidazole/Tinidazole
Abdominal pain, metallic taste, severe vomiting if alcohol consumed within 48 hours
(antabuse-like reaction), stomatitis, glossitis. Contraindicated in first trimester of
pregnancy.
Paromomycin
GI disturbances.
Iodoquinol
Diloxanide
Quinacrine
Dizziness, headache, rash, yellow discoloration of the skin, toxic psychosis (rare) acute
hepatic necrosis (rare.)
REFERENCES
Centers for Disease Control and Prevention. Health Information for International Travel, 2003-
2004, Atlanta, Georgia, 2003
Adapted from the CDC Yellow Book 2014, Chapter 2: Water Disinfection for Travelers
______________________________________________________________________________
Office of Volunteer Support August 2015
Peace Corps
Technical Guideline 815
1. PURPOSE
To provide guidance in the techniques of stool examination and the interpretation of the
results.
2. BACKGROUND
Intestinal diseases are one of the most common types of illness among Volunteers. PCMOs
must have a good understanding of these diseases and be aware of the techniques used to
diagnose them. Bacterial cultures of the stool, when available, are appropriate for the
evaluation of acute, severe diarrhea. (See Technical Guideline 810 Acute Diarrhea, Table
5.2) Fecal white blood cells are also an important clue in acute cases. More often, stool
examination for ova and parasites is performed to evaluate chronic diarrhea or to screen for
the presence of pathogenic organisms.
Microscopic stool examination requires formal training and periodic competency testing.
PCMOs are not expected to be able to perform microscopic stool examinations (other than
for fecal white blood cells) but must be familiar with the techniques and quality control (if
any) used by their referral labs. Many laboratories in the U.S. and abroad are not able to
consistently and correctly identify pathogens. It is generally recommended that stool
specimens be periodically submitted to a reference lab in the U.S. or elsewhere to help assess
the reliability of in-country testing. See Technical Guideline 360 Use of U.S.
Laboratories.
Ova or parasites are found in less than 50% of specimens from infected persons.
Examination of three specimens collected on different days typically increases the detection
rate to 80-90%. Good lab technique and a skilled microscopist are critical in the correct
identification of pathogenic organisms.
Stool concentration procedures should be used before either test to increase the sensitivity of
the examination. The simplest concentration method is sedimentation of feces in a tube. The
sediment than can be examined. Other concentration methods may be used in the referral
laboratories.
Collection
Ask the Volunteer to pass stool into a large, clean container, then transfer several
tablespoons of stool into the smaller feces container.
Feces must not be contaminated with urine or water.
Usually three specimens, collected on sequential days, are required.
As specimens degenerate over time, the following time limits apply from passage of feces
until testing is performed:
For culture:
MIF kit or formalin can be used both by Volunteers on site (to forward specimens to
PCMOs) and Health Units (to forward specimens to laboratories).
Preserved (MIF or formalin treated) specimens cannot be used for bacterial culture.
The following substances can cause false negative results on O & P if used within three
days of the examination:
Protozoa
Helminths
2. NON-PATHOGENIC ORGANISMS
No treatment required
3. OTHER FINDINGS
PREVENTION OF MALARIA
1. PURPOSE
To provide Peace Corps Medical Officers (PCMOs) with guidance on malaria prevention for
Volunteers.
2. BACKGROUND
Malaria is a mosquito-borne parasitic disease endemic to many areas of the world served by
Peace Corps Volunteers. It is a serious and sometimes fatal disease. As such, the Office of
Medical Services (OMS) employs a comprehensive prevention program to prevent malaria in
Volunteers. Medical officers and Volunteers are required to rigorously adhere to the
components of the program. Components of the program include:
Primary prevention: the provision of personal protective equipment, i.e., mosquito nets,
insect repellent, and insect spray to all Volunteers serving in malaria endemic areas.
Screening on windows and doors of Volunteer living areas is strongly encouraged.
Secondary prevention: the provision of malaria chemoprophylaxis, including post-
departure prophylaxis and presumptive anti-relapse therapy (PART) when indicated, to
all Volunteers serving in malaria endemic areas.
Education: the provision of education to PCMOs and Volunteers on malaria prevention
measures, including mosquito avoidance strategies and the proper use of
chemoprophylactic medication.
Policy: OMS policy that requires all Volunteers serving in malaria endemic areas to
rigorously adhere to malaria prevention measures, i.e., use of personal protective
equipment and chemoprophylaxis, throughout their tour of duty.
The OHS Epidemiology and Surveillance Unit coordinates Peace Corps malaria case
surveillance.
Specific guidance on the diagnosis and treatment of malaria is addressed in Technical
Guideline 845 Treatment of Malaria.
3. GENERAL CONSIDERATIONS
Malaria is caused by one of five protozoan species of the genus Plasmodium: P. falciparum,
P. vivax, P. ovale, P. malariae, and P. knowlesi. All are transmitted by the bite of an
infected female Anopheles mosquito. P. falciparum is the most dangerous species among the
five. It poses the greatest risk of death to non-immune persons and is the species most likely
to develop resistance to antimalarial drugs. P. vivax and P. ovale have a dormant liver phase
Office of Health Services December 2014 Page 1
TG 840
Malaria Prevention
that may persist in the liver for up to four years and cause recurrences after routine
chemoprophylaxis is discontinued. PART is used to eradicate these species from the liver
and prevent late relapses of malaria. P. malariae is the least common species of malaria. It
has a dormant blood borne phase that can cause recurrences years after leaving an infected
area.
Malarial transmission occurs in large areas of Central and South America, Hispaniola,
Sub-Saharan Africa, the Indian subcontinent, Southeast Asia, the Middle East, and
Oceania. ATTACHMENT A provides a general illustration of the worldwide
distribution of malaria. P. falciparum and P. malariae are present in most malarial
areas. P. vivax and P. ovale are present in all malarial areas except Haiti and the
Dominican Republic.
The Plasmodium genus of protozoan parasites has a life cycle that is split between a
vertebrate host and an insect vector. In general, the host is man and the insect vector is
the Anopheles mosquito. Asexual development occurs in the human host, and sexual
development occurs in the mosquito. The basic life cycle of the parasite is illustrated in
ATTACHMENT B.
The Office of Medical Services requires all Volunteers serving in malaria endemic areas to
limit their exposure to infectious mosquitoes and to use personal protection measures to
prevent malaria. Anopheles mosquitoes bite at night, with peak biting between 10 p.m. and 4
a.m. Medical officers should advise Volunteers to limit their exposure to mosquitoes during
these hours.
Clothing: Wear light or bright clothing that covers most of the body, e.g., long sleeved
shirts, long pants, and socks. Mosquitoes are attracted to dark clothing after dusk.
Permethrin-sprayed clothing provides maximum protection.
Mosquito Nets: Sleep under mosquito netting. Netting should have small mesh and
should not be damaged. When used properly, nets over cots and beds provide excellent
protection against mosquitoes and crawling insects. Nets impregnated with permethrin
provide maximum protection. Permethrin- impregnated nets can be procured, at no
charge to post, through the Post Logistic Support in Administrative Services
(M/AS/PLS). See TG 240, 15.4 Mosquito Nets.
Insect Repellent: Apply insect repellent. Use preparations that contain 30-35% N, N
diethylmethylbenzamide (DEET). . Preparations containing Picaridin 20% have equal
efficacy with preparations containing DEET 35%. When applied properly, these
preparations are effective for several hours. In addition, Volunteers should: (1) avoid
applying repellants with high-concentrations of DEET (>35%) to their skin - high
concentration products have rarely been associated with toxic encephalopathy in children;
(2) avoid inhaling or ingesting repellents; (3) avoid getting repellents in their eyes, (4)
wash repellent-treated skin after coming indoors, and (5) if using both sunscreen and
insect repellent, apply sunscreen first, preferably about 20 minutes before the insect
repellent. Insect repellents can reduce the effectiveness of sunscreen by about one third.
PCVs are encouraged to reapply repellent after bathing or sweating, if they are still at risk
Insect Spray: When needed, use Pyrethroid-containing flying-insect spray in living and
sleeping areas during evening and nighttime hours. Sprays should be used for at least a
half-hour before retiring. Insect spray may be provided at the discretion of the post.
Pyrethroid-containing insect sprays can be procured locally or through PLS. Permethrin
may be sprayed on clothing for additional protection against mosquitoes.
Screens: Stay in well-screened areas during mosquito feeding times. In malaria endemic
areas, OMS strongly recommends window and door screening of Volunteer living areas.
Mosquitoes breed in stagnant or slow moving water found in places such as water barrels or
catchments, discarded tires or pottery, stumps of trees, large leaves, and flower beds.
Therefore, PCMOs should instruct Volunteers to cover all household water containers and,
when possible, make every effort to eliminate or properly drain standing water within 30
meters of their living areas. This may decrease the number of mosquitoes to which they are
exposed. In humid, forested areas, decreasing the mosquito population may not be a
practical consideration.
5. CHEMOPROPHYLAXIS
The Office of Medical Services requires PCMOs to provide all Volunteers serving in malaria
endemic areas with appropriate chemoprophylaxis during their service and following close of
service (COS). This includes the provision of sufficient medication for post-exposure and
PART and the provision of chemoprophylaxis during vacation, home leave, medical
evacuation, and other departures from country. Volunteers residing in non-malaria endemic
areas who travel to malaria endemic areas should also be provided with appropriate
chemoprophylaxis.
The Office of Medical Services also requires PCMOs to educate Volunteers about the
following: (1) the life cycle of the malaria parasite (see ATTACHMENT B); (2) the proper
use of chemoprophylactic medication; and (3) the importance of uninterrupted
chemoprophylaxis.
Peace Corps primarily uses two types of chemoprophylactics: suppressive and PART.
Suppressive chemoprophylactics, e.g., chloroquine, doxycycline, mefloquine, and Malarone
kill blood (asexual) stages of plasmodia, thereby suppressing clinically significant illness.
PART, e.g., primaquine, attacks liver stages of the parasite, thereby preventing disease.
PART is directed against the relapsing malarias, P. vivax and P. ovale (see Section 11
below). Therefore, prophylaxis prior to arriving in country (pre-exposure prophylaxis) or
immediately upon arrival in country (loading dose), and prophylaxis following departure
from country (PART), is required.
Optimal malarial prophylaxis takes into consideration the most effective antimalarial
agent, side effects and Volunteer adherence.
There is no first-line drug in Peace Corps. All antimalarial drugs are utilized, as
appropriate, in suppressing malaria. Drug options include chloroquine, mefloquine,
doxycycline and atovaquone-proguanil (Malarone). Medical officers should, therefore,
individualize their choice of chemoprophylactic agent for each Volunteer based on the
following considerations:
Consider:
Area-specific OMS recommendations (see Section 5.2 below).
Drug-resistance profile in country, i.e., the Volunteers risk of exposure to
chloroquine-resistant P. falciparum malaria.
Drug contraindications and precautions.
Other factors:
Tolerance; includes the likelihood of Volunteer adherence to a particular
chemoprophylactic regimen (see Sections 5.3 and 8 below).
Dosing schedules, i.e., weekly versus daily dosing. Regimens that
require daily dosing may increase the opportunity for non-compliance,
whether accidental, intentional, or associated with illness.
Book
Centers for Disease Control and Prevention (CDC). Health Information for International
Travel 2014. Oxford University Press, New York 10016. Atlanta: Department of Health and
Human Services, Public Health Service, Centers for Disease Control and Prevention,
National Center for Emerging and Zoonotic Infectious Diseases, Division of Global
Migration and Quarantine; available online at
http://wwwnc.cdc.gov/travel/yellowbook/2014/table -of-contents
Internet
Phone
The Office of Medical Services bases its recommendations for malaria chemoprophylaxis
on the most recent guidance from the CDC. In general, CDC chemoprophylaxis
recommendations are based on the overall rate of malaria transmission, i.e., malaria
risk, and the presence of chloroquine-resistant P. falciparum, in a given area. Malaria
risk estimates, i.e., the estimated risk of a traveler acquiring malaria, are primarily
derived from World Health Organization (WHO) surveillance data and can vary
markedly from area to area and year to year. The Office of Medical Services does not
endorse guidance for malaria prophylaxis that is not consistent with CDC guidelines.
Apart from its bitter taste, chloroquine is usually well tolerated. Minor side effects
include gastrointestinal disturbances, dizziness, blurred vision, and headache;
gastrointestinal problems may be alleviated by taking the drug with food. It has been
associated with triggering flares of psoriasis and pruritus, although serious side effects
are rare. Pruritus occurs in up to 25 percent of darked skinned individuals of African
descent due to concentration of the drug in skin; this is not an allergic reaction. Retinal
injury, which can occur when high doses of chloroquine are used to treat rheumatoid
arthritis, does not occur with the weekly dosages used for malaria prevention.
Chloroquine is safe for use in pregnancy. (See UpToDate for the latest information)
Doxycycline is administered daily beginning one to two days prior to exposure, daily
during exposure, and daily for four weeks following exposure. Noncompliance with
this daily regimen is an important reason for doxycycline prophylaxis failure.
Doxycycline is usually well tolerated, but has been associated with gastrointestinal
upset; less commonly, ultraviolet photosensitivity, Candida vaginitis, and rare cases of
esophageal ulceration may also occur. The drug should be taken with fluids and food; it
should not be administered immediately before lying down. Sunscreen should be
applied liberally for the duration of prophylaxis. It is advisable to offer women
antifungal self treatment for management of Candida vaginitis (eg, fluconazole).
Doxycycline is contraindicated in pregnant women and in children <8 years of age.
For pregnant patients who cannot avoid travel to areas with chloroquine-resistant P.
falciparum, mefloquine may be safely administered during all trimesters.
All Volunteers serving in malaria endemic areas are at high risk for infection with the
malaria parasite. To suppress clinical infection, OMS requires all Volunteers serving in
malaria endemic areas to rigorously adhere to a chemoprophylactic regimen throughout
their tour of duty and following COS. This includes the use of chemoprophylaxis during
vacation, home leave, medical evacuation, and other departures from country. Volunteer
failure to comply with OMS-recommended malaria prevention measures can result in
symptomatic malaria infections. These infections cause significant illness, impair
Volunteer effectiveness, result in unnecessary financial costs, and, tragically, occasionally
result in Volunteer death.
During pre-service training, Trainees will participate in group and individual discussions
with a medical officer to decide whether a weekly medication schedule or a daily
medication schedule and which agent would be best for the individual Trainee to assure
100% compliance for the entirety of his/her PC service.
Volunteers should not stop any chemoprophylactic regimen without consulting the
PCMO. Improper self-discontinuation of prophylaxis places a Volunteer at risk for
malaria. Volunteers who are unable to comply with malaria prevention strategies due to
willful misconduct or disregard for the Peace Corps Volunteer Health Program should be
referred to the Country Director for administrative action (see MS 262 Section 3.2).
The flow chart below is a guideline for dealing with PCVs who contract malaria. Every
case must be handled individually and discussions and medical recommendations must be
documented appropriately in the medical record. Do not forget to discuss mosquito bite
avoidance measures as well as chemoprophylactic use. For any given PCV, there is no
set number of documented cases of malaria that would necessarily lead to an action
to separate.
This policy is consistent with the July 2003 FDA-approved patient labeling and legal
requirement that a Mefloquine Medication Guide is supplied to patients when mefloquine
is dispensed. The purpose of the medication guide is to help ensure patients understand the
risks of malaria and the rare but potentially serious neuropsychiatric adverse events
associated with use of mefloquine. It also provides information on how they can recognize
these neuropsychiatric risks and take early action to prevent serious harm.
6. STARTING CHEMOPROPHYLAXIS
In general, the CDC recommends that travelers start chemoprophylaxis one to two weeks
prior to arrival in a malarial area. If this is not possible, the CDC advises travelers to start
antimalarials just prior to their departure or immediately upon their arrival in a malaria-
endemic area. Both strategies, when combined with mosquito avoidance and personal
protective measures, i.e., insect repellent, bed nets, and screens, are effective in preventing
acute malaria. Therefore, for Peace Corps Trainees, OMS recommends that malaria
prophylaxis be started either during staging or immediately upon arrival in country.
Loading Dose
In countries where Volunteers do not receive antimalarial medication prior to departure from
the U.S. and the PCMO suspects that Volunteers may be immediately and intensely exposed
to malaria upon their arrival in country, they should consult OMS for guidance. In such
cases, OMS will consider whether to recommend a loading dose of a chemoprophylactic
agent that can rapidly produce protective blood levels. In general, a loading dose is only
used for Volunteers taking mefloquine, but this is discouraged by OMS For those PCVs who
choose to use mefloquine, it is recommended that the PCV/T be placed on daily doxycycline
during the first two weeks of mefloquine treatment. A loading dose is not required for
Volunteers taking doxycycline and no data exists to support a loading dose in Volunteers
taking chloroquine or Malarone.
7. CHEMOPROPHYLACTIC AGENTS
CHEMOPROPHYLACTIC AGENTS
Discontinuation
duration (time
Tablet Dose and after last
Drug size Frequency exposure) Adverse Reactions Contraindications
Atovaquone- 250 mg One tablet 7 days Adverse reactions Contraindicated in persons with:
proguanil atovaquon daily include abdominal severe renal
(Malarone) e and 100 pain (17%), impairment (creatinine
mg nausea (12%), clearance < 30
proguanil vomiting (12%), ml/min).
headache (10%),
Should b e avoided in persons
diarrhea (8%),
who are taking:
weakness (8%),
loss of appetite tetracyclines.
(5%), and Tetracyclines cause a
dizziness. 40% decrease in
atovaquone
Mouth ulcers,
concentrations.
cough, pruritus,
urticaria, blood Metopramide and
disorders, and rifampin. Both drugs
hair loss have reduce the plasma
also been concentration of
reported atovaquone
Mefloquine, Malarone and doxycycline may also be used in chloroquine -sensitive areas as necessary.
The following chemoprophylactic agents are not listed as malaria prophylactic options
by the CDC and are not recommended by OMS.
Chloroquine/Proguanil (Paludrine)
Preventing acute malaria depends not only upon the effectiveness of specific antimalarial
agents, but also upon the Volunteers compliance with, and tolerance of, a recommended
chemoprophylactic regimen.
Medical officers are encouraged to consider antimalarial tolerance when determining optimal
chemoprophylactic therapy for Volunteers. Tolerance includes the Volunteers previous
experience with antimalarial medications the likelihood of Volunteer adherence to a
particular chemoprophylactic regimen.
When switching from one antimalarial to another, care is necessary to avoid a gap in
protective blood levels. This is especially important in Trainees as blood levels may be
low for several weeks after starting a weekly chemoprophylactic agent. It is also
important for Volunteers who have been in a malarial area for many weeks and are
likely to already be infected.
Daily Dose to a Daily Dose
When switching from a daily dose of doxycycline or Malarone to a daily dose of
doxycycline or Malarone, no overlap is necessary.
9. MISSED DOSES
Volunteers are more likely to forget drugs that are given daily and this may lead to
breakthrough cases of malaria. If this occurs, the PCMO should discuss the option of a
weekly drug (if clinically appropriate) with the Volunteer..
The Office of Medical Services requires all Volunteers who have been in a malaria
endemic area for more than four weeks1 , where P. ovale and P. vivax exist, to take
PART (terminal prophylaxis). At present, these areas include all malaria endemic
countries except Haiti and the Dominican Republic where these forms of malaria have
not been reported.
Primaquine phosphate is the drug of choice for malaria terminal prophylaxis (see
Section 11.2 below). Primaquine is effective against the liver stages (hypnozoites) of P.
vivax and P. ovale and decreases the risk of late relapses of malaria. Such relapses
typically occur 6-12 months after stopping chemoprophylaxis and can occur as long as
four years after prophylaxis is discontinued. Primaquine is the only drug that is
effective against the dormant liver stage of the parasite.
Presumptive Ant-relapse Therapy
1
As per CDC: No reasonable data exist to support the use of primaquine in individuals who are exposed to P.
vivax or P. ovale for less than 4 weeks.
Post Exposure Dose: Primaquine phosphate 30 mg base (52.6 mg salt) once daily
for 14 days. Primaquine should be started 2 weeks following final departure from
the malaria endemic area if the Volunteer is taking chloroquine, mefloquine, or
doxycycline; and 1 week following final departure if the Volunteer is taking
Malarone. Primaquine should be given concurrently with all antimalarials except
Malarone.
The enzyme G6PD is required for Primaquine metabolism. Because G6PD
deficiency is associated with severe hemolysis, all Volunteers must be tested
for G6PD deficiency prior to being given primaquine. Medical Officers
must clearly document G6PD test results in the Volunteer health record and
should not issue primaquine to Volunteers with any degree of G6PD
deficiency (see Section 12 below).
Regular Malaria Prophylaxis: Volunteers should continue to take their regular
malaria prophylaxis regimen (with the exception of Malarone) for four weeks after
leaving a malarial area. Volunteers taking Malarone should continue for one week
after leaving a malarial area.
Adverse Reactions: Minor side effects include headaches, abdominal cramps,
nausea, vomiting and pruritus. Methemoglobinemia is also common, but rarely
necessitates interruption of therapy. Leukopenia and agranulocytosis occur rarely.
Contraindications: Primaquine can cause hemolysis in persons with G6PD
deficiency. Hemolysis may be mild or severe. Medical Officers should not give
Volunteers with an abnormal or low G6PD test result primaquine (see section
11 below).
Pregnancy: Primaquine is contraindicated during pregnancy. Pregnant Volunteers
departing malaria endemic areas should be issued a PC-127C Authorization for
Payment of Medical/Dental Services for an OB/GYN prenatal consultation, to
include recommendations regarding terminal malaria prophylaxis (see TG 170
Pregnancy).
Medical Officers must provide all Volunteers leaving malaria endemic areas with the
following:
See also Malaria Prophylaxis in TG 330 under Section 4.4 Physical Exam.
Malaria prophylaxis according to the guidance outlined above. This should include:
(1) post-exposure prophylaxis as outlined above and in TG 330 Attachment G, and
(2) an additional 30 day supply of a malaria prophylaxis medication, e.g.,
mefloquine, doxycycline, or Malarone, if the Volunteer will be traveling in a
malaria endemic area prior to returning to the U.S If the Volunteer will be
traveling for more than 30 days, provide them with the website
(http://www.istm.org/AF_CstmClinicDirectory.asp)where they can find a travel
clinic in the country they will be visiting to obtain prophylaxis.
Medications for one course of interim self-treatment of malaria for use should the
Volunteer develop symptoms of acute malaria (see TG 845.5.1 Interim Self-
Treatment Regimens for medications and dosing schedules).
PART according to the guidance outlined in Section 11.1 Presumptive Anti-
Relapse Therapy above.
Handout titled Instructions for Volunteers: COS Guidelines for Preventing
Malaria (see TG 330, ATTACHMENT G), to include:
Education and instruction on post-departure malaria prophylaxis.
Education and instruction on PART.
Instructions to report their Peace Corps service and exposure to malaria to
their HOR physician. P. vivax and P. ovale may relapse despite compliance
with primaquine PART.
The Office of Medical Services requires that all Volunteers be tested for G6PD deficiency
prior to the administration of primaquine. Glucose-6-Phosphate Dehydrogenase (G6PD) is
an enzyme in red blood cells that is involved with glucose metabolism. Persons with G6PD
deficiency are at risk for hemolytic anemia when taking primaquine. Hemolysis may be
severe in some people.
All Trainees going to malaria endemic areas of Africa are tested for G6PD deficiency prior to
Peace corps service. If a Trainees G6PD status is unknown, and the Trainee is serving in a
malaria endemic area, testing should be done in country if a reliable laboratory exists in
country. Preferably, the test should be done during pre-service training (PST) so that if a
Trainee terminates service early, his/her G6PD status will be known prior to departure.
If a reliable laboratory is not available in country, PCMOs should provide Volunteers with a
PC-127C Authorization of Payment of Medical/Dental Services for G6PD deficiency
testing in the U.S. This may be done during service or at COS.
Medical officers may use Quest Diagnostics for G6PD level determination if post can
reliably ship blood to the U.S. in less than 48 hours. Blood should be sent anticoagulated in
a lavender-top tube. Samples received more than 48 hours after collection may be falsely
reported as having low G6PD activity due to sample deterioration (see TG 360 Use of U.S.
Laboratories).
Volunteers who have not been tested for G6PD deficiency prior to COS should not be issued
primaquine. These Volunteers should be issued a 127C authorization for, primary care
consultation for G6PD testing and terminal malaria prophylaxis as indicated.
In addition, Volunteers: (1) whose test results have not been received, (2) whose test results
are not clearly documented in the health record, or (3) whose test results report any degree of
G6PD deficiency should not be issued primaquine. Medical officers may contact OMS for
assistance obtaining results.
Test results must be obtained and clearly documented on the cover of the Volunteer health
record prior to the administration of primaquine. The laboratory report should be filed in the
health record under In-Service Diagnostics.
Normal: Normal or G6PD present test results done in country or at a U.S. lab are
acceptable. When indicated, these Volunteers may be given primaquine.
Abnormal: Medical officers should issue the Volunteer a 127C authorization for
primary care consultation for evaluation of G6PD deficiency and terminal malaria
prophylaxis as indicated. A copy of the lab report should be attached to the 127C.
PCMOs should instruct Volunteers with abnormal results to remain on their malaria
prophylaxis until their G6PD status is confirmed. Medical officers should not give
primaquine to a Volunteer with an abnormal or abnormally low G6PD result.
No result available at COS: Volunteers who have not been tested for G6PD deficiency
prior to COS should not be given primaquine.
In addition to the following guidance, PCMOs should refer to the current edition of Health
Information for International Travel published by the CDC for additional information on
antimalarial recommendations in pregnant women, nursing mothers, and children.
Pregnant Volunteers: Severe cases of malaria can occur during pregnancy. Pregnancy
alters the immune system and malaria may adversely affect the outcome of pregnancy.
Therefore, all pregnant Volunteers are required to take malaria chemoprophylaxis. The
CDC recommended drugs of choice in pregnancy are:
Chloroquine-sensitive areas: Chloroquine 300 mg (500 mg base) weekly.
Chloroquine-resistant areas: Mefloquine 250 mg weekly if the potential benefit
justifies the potential risk to the fetus.
Doxycycline and primaquine are contraindicated during pregnancy.
Malarone is not currently recommended by the CDC for use in pregnancy. Medical
officers should consult OMS in situations where a pregnant Volunteer is unable to
take mefloquine.
Pregnant Volunteers located in areas with chloroquine-resistant malaria should be placed
on mefloquine and evacuated or separated from the malarial area within one week of
pregnancy diagnosis (see TG 170.4.1 Pregnancy in Areas with Chloroquine-resistant
Malaria). Weekly mefloquine should be continued for 4 weeks after leaving the endemic
area.
REFERENCES
Arguin PM, Keystone, JS. Prevention of malaria infection in travelers. In: UpToDate, Basow,
DS (Ed), UpToDate, Waltham, MA, 2012.
Boudreau, Shuster, Sanchez et al. Tolerability of Prophylactic Lariam Regimens. Trop Med
Parasitol 1992, 44:257.
Cox-Singh J, Davis TM, Lee KS, et al. Plasmodium knowlesi malaria in humans is widely
distributed and potentially life threatening. Clin Infect Dis 2008; 46:165.
Freedman DO. Clinical practice. Malaria prevention in short-term travelers. N Engl J Med
2008; 359:603.
Hill DR, Ericsson CD, Pearson RD, et al. The practice of travel medicine: guidelines by the
Infectious Diseases Society of America. Clin Infect Dis 2006; 43:1499.
Kochar DK, Saxena V, Singh N, et al. Plasmodium vivax malaria. Emerg Infect Dis 2005;
11:132.
Lobel H. O. & Kozarsky P. E. Update on prevention of malaria for travelers. JAMA, 278,
1767-1771, 1997.
Lobel H. O., Miani, M., Eng T., et al. Long-term malaria prophylaxis with weekly
mefloquine. Lancet, 1993, 341: pp. 848-851.
Mali S, Steele S, Slutsker L, et al. Malaria surveillance - United States, 2008. MMWR
Surveill Summ 2010; 59:1.
Mali S, Kachur SP, Arguin PM, et al. Malaria surveillance--United States, 2010. MMWR
Surveill Summ 2012; 61:1.
Mandell, G. L., Douglas, R. G., and Bennett, J. E. Principals and Practice of Infectious
Diseases, 5th edition. Churchill Livingston, 2000.
Navy and Marine Corps Public Health Center. Pocket Guide to Malaria Prevention and
Control. Portsmouth, Virginia. 2011.
Steffen R., Fuchs E., Schildknecht J., et al. Mefloquine compared with other malaria
chemoprophylactic regimens in tourists visiting East Africa. Lancet, 1993, 341, pp. 1299-
1303.
Steffen, R., et al., Malaria chemoprophylaxis among European tourists in tropical Africa: use,
adverse reactions, and efficacy. Bull World Health Organ, 1990. 68(3): pp. 313-22.
Wilson ME, Weld LH, Boggild A, et al. Fever in returned travelers: results from the
GeoSentinel Surveillance Network. Clin Infect Dis 2007; 44:1560.
Worldwide Distribution
of Malaria
From
December 2014
TG 840 ATTACHMENT B
The malaria parasite life cycle involves two hosts. During a blood meal, a malaria-infected female Anopheles
mosquito inoculates sporozoites into the human host . Sporozoites infect liver cells and mature into
schizonts , which rupture and release merozoites . (Of note, in P. vivax and P. ovale a dormant stage
[hypnozoites] can persist in the liver and cause relapses by invading the bloodstream weeks, or even years
later.) After this initial replication in the liver (exo-erythrocytic schizogony ), the parasites undergo asexual
multiplication in the erythrocytes (erythrocytic schizogony ). Merozoites infect red blood cells . The ring
stage trophozoites mature into schizonts, which rupture releasing merozoites . Some parasites differentiate
into sexual erythrocytic stages (gametocytes) . Blood stage parasites are responsible for the clinical
manifestations of the disease.
The gametocytes, male (microgametocytes) and female (macrogametocytes), are ingested by an Anopheles
mosquito during a blood meal . The parasites multiplication in the mosquito is known as the sporogonic
cycle . While in the mosquito's stomach, the microgametes penetrate the macrogametes generating
zygotes . The zygotes in turn become motile and elongated (ookinetes) which invade the midgut wall of the
mosquito where they develop into oocysts . The oocysts grow, rupture, and release sporozoites , which
make their way to the mosquito's salivary glands. Inoculation of the sporozoites into a new human host
perpetuates the malaria life cycle .
TG 840 Attachment C
Antimalarial Chemoprophylaxis: Advantages and Disadvantages
Chloroquine is highly effective, but can be use only in those areas of the world where the malaria is sensitive to
the medication. The usual dosing one tablet weekly
Advantages Disadvantages
Highly effective preventive medication Possible stomach upset often made better if taken with
food
Once weekly dosing Possible problems with vision
Stays in the system for a long time providing some Possible problems with hearing or ringing in the ears
antimalarial activity if a dose is delayed
Should not be used during pregnancy
Mefloquine is highly effective. The usual dosing is one tablet weekly
Advantages Disadvantages
Highly effective preventive medication Should not be used by individuals with a history of most
mental health issues
Weekly dosing could be an advantage for those not Should not be used by individuals with a history of
used to taking daily meds seizures
Stays in the system for a long time providing some Should not be used by individuals with a history of
antimalarial activity if a dose is delayed disturbances of the electrical conduction of the heart
Only antimalarial medication approved for pregnancy Possible worsening or development of sleep
disturbance including nightmares; severe anxiety;
paranoia; hallucinations; depression; restlessness;
unusual behavior; confusion; suicidal thoughts [subject
of FDA boxed warning]
Possible development of dizziness, room spinning, ear
ringing, loss of balance which may persist or become
permanent [subject of FDA boxed warning]
Possible stomach upset
Possible headache
Atovaquone/Proguanil (Malarone) is highly effective. The usual dosing is one tablet daily
Advantages Disadvantages
Highly effective preventive medication Since atovaquone/proguanil is also used as a second-
line treatment for active malaria, it cannot be used for
treatment if used for daily suppression
Once daily dosing for those already taking daily meds Possible stomach upset
Should not be used during pregnancy
Doxycycline is highly effective. The usual dosing is one tablet/capsule daily
Advantages Disadvantages
Highly effective preventive medication Must be taken with at least 8 oz. of water and
preferably food
Once daily dosing for those already taking daily meds Does not stay in the system for a long time and must be
taken at roughly the same time every day
Only agent with no malaria resistance demonstrated Possible increased sun sensitivity in approximately 20%
of users. Must be compulsive with use of sun screen
Also effective in preventing or suppressing several other Possible heartburn and stomach upset which is
tropical infectious diseases (rickettsial disease and significantly less likely if taken with a full glass of water
leptospirosis) or food
Possibly improve acne Possible increased chance of developing yeast
infections (vaginal)
Cannot be used during pregnancy
** This is not intended to be an exhaustive list of side effects of these medications. Your PCMO can provide more detailed
information.
December, 2014
TG 840 ATTACHMENT D
Chloroquine Tablets
(Anti-Malarial Medication)
MEDICATION INFORMATION SHEET
What is chloroquine?
Chloroquine is one of several types of drugs used to prevent and treat malaria. The type of drug
prescribed for you will be based on the area of the world you are traveling to and your medical conditions.
Be sure your medical record shows that you received this medication.
Page 2
TG 840 ATTACHMENT D
Doxycycline
(Anti-Malarial Medication)
Medication Information Sheet
What is doxycycline?
Doxycycline is one of several types of drugs used to prevent and treat malaria. The
type of drug prescribed for you will be based on the area of the world you are
traveling to and your medical conditions.
Doxycycline is an antibiotic used to treat a wide variety of bacterial infections
(including the prevention and treatment of anthrax).
Page 3
TG 840 ATTACHMENT D
Be sure your medical record shows that you received this medication.
Page 4
TG 840 ATTACHMENT D
Mefloquine Tablets
(Anti-Malarial Medication)
Medication Information Sheet
What is mefloquine?
Mefloquine is one of several types of drugs used to prevent and treat malaria. The type of
drug prescribed for you will be based on the area of the world you are traveling to and your
medical conditions.
Page 5
TG 840 ATTACHMENT D
Be sure your medical record shows that you received this medication.
Page 6
TG 840 ATTACHMENT D
Atovaquone/Proguanil
R
(Malarone )
(Anti-Malarial Medication)
Medication Information Sheet
Page 7
TG 840 ATTACHMENT D
Be sure your medical record shows that you received this medication.
Page 8
TG 840 ATTACHMENT D
Primaquine Phosphate
(Anti-Malarial Medication)
Medication Information Sheet
TERMINAL PROPHYLAXIS
WHEN TO START PRIMAQUINE (30 MG)
POST-DEPARTURE PROPHYLAXIS (Following Departure from a Malarial
Endemic Area)
Mefloquine Start on Day 15 (2 weeks following
departure)
Chloroquine Start on Day 15 (2 weeks following
departure)
Doxycycline Start on Day 15 (2 weeks following
departure)
Malarone Start on Day 8 (1 week following
departure)
Page 9
TG 840 ATTACHMENT D
If your G6PD level is low or absent, you should NOT take primaquine
If your G6PD is low or absent, your PCMO will give you authorization
(PC-127C) for G6PD retest and consultation with your home of
record physician
Individuals with low or absent G6PD levels should only take
primaquine if recommended, and supervised, by a medical
professional
If you have arthritis, psoriasis, lupus, liver disease or allergies to
primaquine
If you are pregnant or breast-feeding. Discuss the risks and benefits
with your Peace Corps health provider.
If you miss one or more doses for any reason, take ONE dose as
soon as possible and then continue on your usual dosing schedule.
DO NOT double-up the dose to catch up unless instructed to by a
Peace Corps health care provider.
Page 10
Mefloquine Patient Information Guide
Date
If, at any time, I experience what I feel are possible side effects from Mefloquine, I
will promptly discuss the situation with my Medical Officer, and I may be placed on
alternative anti-malaria prophylactic medication.
Signature
10/5/2003
Peace Corps
Technical Guideline 845
1. PURPOSE
Provide guidance on malaria case diagnosis, treatment, monitoring and reporting procedures.
2. BACKGROUND
Malaria is one of the 10 most prevalent and deadly diseases in the world. Between 300-500
million clinical cases occur every year with over 1.2-2.7 million deaths. Ninety percent of
these occur in sub-Saharan Africa. Malaria is a parasitic disease spread by the bite of the
Anopheles mosquito. For additional information on the malaria parasite and for specific
guidance on malaria prevention, see Technical Guideline 840 Prevention of Malaria.
The Office of Medical Services (OMS) bases its recommendations for the presumptive
treatment of malaria on the most recent guidance from the Centers for Disease Control and
Prevention (CDC). Recommendations for the treatment of confirmed cases of malaria are
based on a review of current literature, expert consensus opinion, and evidence-based
guidelines where they exist.
For additional information regarding the diagnosis and treatment of malaria, Peace Corps
Medical Officers (PCMOs) should refer to additional information from CDC at the following
internet site: http://www.cdc.gov/malaria/diagnosis_treatment/tx_clinicians.htm
3. GENERAL CONSIDERATIONS
The incubation period for malarial parasites varies from 7 to 28 days, depending on the
species. The incubation period is the time that elapses between exposure, i.e., the bite of an
infected mosquito, and infection, i.e., the development of clinical symptoms of malaria. The
average incubation period for P. falciparum is 9-14 days.
Infection with the species P. falciparum can be life threatening. The parasite alters red blood
cells causing the cells to stick to the sides of blood vessels. When the level of parasitemia is
high, the cells sludge and clump together, eventually blocking capillaries throughout the
body. This is called microvascular sequestration. In the absence of medical treatment,
parasitemia of more than 5% is often fatal. Severe infection can also lead to coma, severe
anemia, cerebral malaria, hypoglycemia, renal failure, acidosis, convulsions, and death.
Infections with the species P. vivax, P. ovale, and P. malaria are rarely life-threatening,
however, symptoms may be severe. With these species, the percent of parasitized red blood
cells is rarely more than 1%; sludging usually does not occur, and complications are less
common.
Since few Volunteers serving in malarial areas can escape mosquito bites during their
service, and no preventative drugs are completely effective, PCMOs should assume that all
Volunteers are infected with the malaria parasite and that any Volunteer may develop the
clinical signs and symptoms of malaria infection.
The definitive diagnosis of malaria relies on the identification of parasites in the peripheral
blood (see Section 4.3 below). However, if a peripheral blood smear is not available or is
negative, PCMOs should always consider the diagnosis of malaria in any febrile Volunteer
who has been in a malarial area for more than one week and is experiencing any of the
symptoms outlined in the table below.
Malaria classically presents with nonspecific and irregular fever, chills, headache, and
malaise. Symptoms generally develop 10 days to 4 weeks after an infective bite. Often
there is a prodromal phase of the disease that is similar to a non-specific viral illness.
Initial symptoms may progress over 1-2 days to include any of the following:
In practice, presenting symptoms are variable. The disease may present with
nonspecific respiratory or gastrointestinal symptoms or, in more serious cases of P.
falciparum malaria, with shock, delirium, and coma. Vomiting occurs in
approximately 20% of patients, and mild diarrhea in less than 5%. Signs and symptoms
also depend on the malaria species, the Volunteers degree of immunity, and whether
the Volunteer has regularly taken chemoprophylaxis.
Fever Periodicity
A cyclical or periodic fever pattern may or may not be present. If present, fevers may
show an every-other-day (tertian / 48 hour) periodicity in P. vivax, P. ovale and P.
falciparum malaria, or an every-third-day (quartan / 72 hour) periodicity in P. malariae
malaria. Periodicity corresponds to the release of merozoites from the red blood cells
in the asexual cycle.
Most physical signs are nonspecific. The Volunteer may seem only slightly ill, or may
appear pale and sallow. There may be sweating, anxiety, and distress. Common
clinical findings on physical exam include the following (Mandell, et al., 2000):
Vital Signs:
Temperature: may range from normal to 105F (40.6C). Most Volunteers
will have a temperature of 102F or higher at some time in their illness.
Blood Pressure: orthostatic hypotension (90-100 mmHg systolic); caused
by a decrease in effective intravascular volume secondary to marked
peripheral vasodilation.
Respiratory Rate: tachypnea.
Pulse: tachycardia.
Skin:
May be cool and pale or warm and dry; mild jaundice may be present.
Palms and lips may appear pale or cyanotic.
Eyes:
Conjunctivae may be pale.
Sclerae may appear yellow due to hemolysis.
Chest:
Lungs: scattered rales; rarely, evidence of consolidation or pulmonary
edema.
Cardiac: normal except for tachycardia.
Abdomen:
Generalized tenderness to palpation.
Spleen: moderate splenomegaly. Usually appears when acute symptoms
have continued for 4 or more days or if there has been long-term infection
with malaria. Spleen may be extremely delicate due to the sudden
stretching of the capsule and is prone to rupture, especially in P. vivax
malaria. Vigorous palpation of the spleen is dangerous and should be
avoided.
Liver: tender hepatomegaly.
Lymphadenopathy: Does not occur in malaria and its presence in a Volunteer with
malaria should prompt a search for additional etiology.
Musculoskeletal: Despite complaints of myalgia and arthralgia, neither muscle
tenderness nor joint effusions are present. Peripheral edema is usually absent.
Neurologic: Normal with the exception of delirium and other minor behavioral
changes that may result from high fever.
The identification of parasites on thick and thin blood smears of peripheral blood is the
mainstay of malaria diagnosis. Symptoms may precede a detectable level of
parasitemia by a few days, so smears should be examined at least twice a day until
parasites are detected. Efforts should be made to quantify the level of parasitemia as it
is useful to determine a baseline parasitemia from which the response to therapy can be
monitored. Efforts to diagnosis the malaria species may also be made; however, most
laboratory technicians are not experienced in the morphologic differentiation of
Plasmodial species. Also, PCMOs should not base treatment on the type of species
reported on peripheral blood smear examination. Treatment should always be based on
the types of malaria species in country (see Section 6 below). Slides should be saved
and sent to the CDC for species confirmation (see Section 10 below).
Thick smears are more sensitive in detecting malaria parasites because the blood is
concentrated, allowing a greater volume of blood to be examined. Thick smears should
only be used for detecting the presence of parasites and quantifying parasitemia, not for
species diagnosis. Thick smears, however, are more difficult to read, and thin smears
may be preferred by some laboratories that have limited experience. Thin smears may
be used for detecting parasites and should be used for making species diagnosis.
Peripheral blood smears are prepared in all cases of suspected malaria infection. In the
Peace Corps setting, these peripheral blood smears are prepared by both Volunteers and
PCMOs. Medical Officers should supply all Volunteers serving in malaria-endemic
areas with Peace Corps Malaria Kits. These Kits contain all the materials needed for
smear preparation, i.e., slides, lancets, alcohol wipes and band-aids. The Kits can be
procured through the Overseas Support Division in Administrative Services
(M/AS/OSD). For ordering information see TG 240.15.2 MIF Kits and Malaria Kits.
Medical Officers are responsible for teaching Volunteers when and how to prepare
proper malaria blood smears. Training should occur during Pre-Service Training (PST)
and In-Service Training (IST). Illustrated instructions for preparing blood smears are
included in ATTACHMENT A of this TG and in Appendix B of the Pre-Service
Health Training Module on Malaria.
If malaria is suspected, Volunteers and PCMOs should prepare thick and thin smears
according to the following guidelines:
Complete Blood Count (CBC) to include peripheral smear; peripheral smear may
demonstrate hemolytic anemia, leukopenia, and thrombocytopenia.
Liver Function Tests (LFTs) to include ALT, AST, direct/indirect bilirubin, and
albumin; results may demonstrate elevated levels of ALT, AST due to hepatic
congestion, elevated indirect bilirubin levels from hemolysis and hypoalbuminemia
from impaired liver function.
Serum glucose level; may reveal hypoglycemia
Fluorescent stain (QBC method): This method, which requires special capillary
tubes, a centrifuge, and a fluorescent microscope, is reported to be as sensitive as a
thick smear examination for the detection of low levels of parasitemia. The test
requires expert technical skills, and overdiagnosis of malaria by those using this
method is common. It does not replace thin and thick smear examination.
Antigen test for P. falciparum: This test, a rapid and simply accomplished dipstick
antigen capture assay, appears promising for field diagnosis; however, it is
currently not available for widespread clinical use. Also, sensitivity decreases with
low parasite density.
ELISA for P.falciparum: Serologic tests are not useful in the diagnosis of acute
malaria attacks. Antibodies to malaria may persist for 10 or more years and the test
does not differentiate past from present infection.
Malaria may mimic numerous diseases, from influenza to mental illness. It can be
especially difficult to distinguish between acute malaria, typhoid fever, and dengue
fever. Symptoms of malaria are not specific and are often confused with:
The Office of Medical Services requires PCMOs to provide all Volunteers serving in
malarial areas with medication for the interim self-treatment of presumed malaria. Interim
self-treatment is recommended for non-immune individuals who are at risk of infection with
malaria and who may not have prompt access to medical care, e.g., Peace Corps Volunteers.
The intent of interim self-treatment is to reduce or control symptoms and to allow the
Volunteer time to obtain medical attention and follow-up. The appropriate medication (see
section 5.1 below) and ATTACHMENT B Instructions for Volunteer Emergency Self-
Treatment should be included in the Volunteer Health Kit.
Medical Officers are required to educate Volunteers on the proper management and treatment
of presumed malaria. This includes instruction on the preparation of peripheral blood smears
(see ATTACHMENT A and Section 4.3 above), medication use, and the need to seek
immediate medical attention when malaria infection is suspected. Education should occur
during PST and IST.
Note: Coartem should be taken with high fat food and drinks such as milk as this
markedly improves absorption of drugs.
Or
Medical Officers should not use mefloquine, Fansidar, or halofantrine, for the
interim self-treatment of malaria (see Section 6.3 below).
Note: For specific information see also Health Information for International Travel,
(Yellow Book), available from the CDC, or on the world wide web at
www.cdc.gov/travel/reference.htm
Oceania (Papua New Guinea, Solomon Islands, and Vanuatu): Volunteers who are
days away from medical care and are exposed to both drug resistant P. falciparum and
P. vivax, should be provided with, and instructed in the use of, two of the interim self-
treatment regimens in case of delays receiving medical attention.
6. TREATMENT OF UNCOMPLICATED MALARIA
The Office of Medical Services recommends the following treatment regimens for
uncomplicated malaria in Volunteers.
OR
OR
Note: Malarone should not be used for treatment in individuals who are taking
Malarone for malaria chemoprophylaxis
COARTEM 4 tablets orally at the time of initial diagnosis, again after 8 hours,
then twice daily for the following 2 days (4 tablets each time for total course of
24 tablets)
OR
6.2 Monitoring
Medical Officers should not use the following medications for the treatment of
presumed or confirmed uncomplicated malaria in Volunteers.
Volunteers with complicated malaria usually require hospitalization and medical evacuation
(medevac).
Complicated malaria is almost always due to P. falciparum and is associated with a mortality
of 15-20%. In severe P. falciparum infections, red blood cell parasitemia is often, though not
always, higher than 3-5%. The prognosis is poor when there are multiple complications or if
there are any mature parasites in the peripheral blood. Other species of malaria may produce
severe or complicated infection; however, the complications listed below are almost
exclusively due to the red blood cell sludging seen with P. falciparum.
Complications include:
Cerebral malaria - characterized by headache, mental disturbances, neurologic signs,
retinal hemorrhages, convulsions, delirium, and coma. Mortality is as high as 25%, even
with appropriate medical care.
Hyperpyrexia
Hemolytic anemia - may lead to severe anemia and hemoglobinuria which may cause
urine to turn black (blackwater fever).
Pulmonary edema - may be associated with cardiac failure.
Acute tubular necrosis and renal failure - secondary to renal microvascular damage or
hemoglobinuria; may lead to acute renal failure or severe anemia.
Lactic acidosis
Hypoglycemia
Cardiac dysrhythmias
Gastrointestinal syndromes - including secretory diarrhea and dysentery; results from
damage to the bowel.
* Published sources caution about the use of a loading dose when quinine, quinidine, or
treatment doses of mefloquine have been taken in the preceding 24 hours. Recognizing the
possibility of cardiac arrhythmias, adequate blood levels of quinine must be achieved as soon
as possible and may be life-saving.
** As hypoglycemia and hypovolemia are both frequently observed, D5/NS or D5/.5NS are the
preferred IV fluids.
7.3 Monitoring
Vital signs
Parasite concentration via peripheral smear examination.
Hematocrit/hemoglobin, and serum electrolytes.
Blood glucose: Administer IV or PO glucose as necessary to prevent
hypoglycemia.
Cardiac status (ECG required for quinidine treatment).
Fluid status: Use two IV lines if one is needed for fluid replacement.
Urinary output
Medication monitoring:
Regulate IV quinine carefully, as too rapid an infusion may cause seizures,
hypotension, cardiovascular collapse, heart block, ventricular fibrillation, or
death.
Do not use steroids or mannitol in the management of complicated or
cerebral malaria. They have been shown to worsen clinical outcome
(White, N., 1996).
Quinidine is more likely to produce cardiac conduction changes and should
always be monitored in an intensive care setting when possible. However, if
monitoring is not readily available, prompt administration of quinine or
quinidine is critical in the management of severe, life-threatening malaria
transfused with whole blood or the equivalent blood components. Medical Officers
should consult with OMS immediately if an exchange transfusion is being considered.
8.1 Chloroquine
Precautions:
Malarone should not be used for treatment of acute malaria in individuals
who are taking Malarone for malaria chemoprophylaxis due to possible
Malarone-resistant disease
Concomitant use of tetracyclines, metoclopramide or rifampin reduces the
plasma concentration of atovaquone and, therefore, should be avoided.
Malarone may not be adequate treatment for P. vivax malaria. In cases of
suspected of P. vivax malaria, additional therapy, e.g., Primaquine, may be
necessary. Medical Officers should contact their APCMO or OMS for
guidance in these cases.
Effectivenesss: Effective drug in the treatment of acute malaria and remains more
than 85% effective nearly everywhere (NEJM, 1996). Acts rapidly against the
asexual erthyrocyctic stages of all four Plasmodium species.
Adverse Reactions: Treatment is not well tolerated, and compliance with the 7 day
courses of treatment required for resistant P. falciparum infections is poor. Oral
compounds are extremely bitter. Adverse reactions often induce the complex of
cinchonism (nausea, vomiting, dysphoria, tinnitus, and high-tone deafness). These
reactions are dose related and reversible. Less common adverse reactions include
urticaria, angioedema of the face, itching, agranulocytosis, hepatitis, and
hypoglycemia in patients with high parasitemia. Serious toxic reactions are rare.
Contraindications: Hemolysis, with a potential for hemolytic anemia, may occur in
patients with G6PD deficiency.
Effectivenesss: Effective drug for the treatment of severe malaria. There are no
reports of resistance to quinidine in any strains of Plasmodia.
Adverse Reactions: Quinidine is toxic to the heart if given too quickly or in too high
a dose. ECG changes including prolonged QT intervals are common, but life-
threatening arrhythmias are rare with proper doses. Most adverse reactions are
gastrointestinal including nausea, vomiting, abdominal pain, diarrhea, and
esophagitis. Symptoms of mild to moderate cinchonism may appear in sensitive
patients after one dose of the drug. Less frequent adverse reactions include
urticaria, skin flushing with intense itching, and hypersensitivity reactions of
angioedema, acute asthmatic episode, and liver toxicity
Contraindications: Quinidine is contraindicated in patients who are known to be
allergic to it, or who have developed thrombocytopenic purpura during prior
therapy with quinidine or quinine. In the absence of a functioning artificial
pacemaker, quinidine is also contraindicated in any patient whose cardiac rhythm is
dependent upon a junctional or idioventricular pacemaker, including patients in
complete atrioventricular block. Quinidine is also contraindicated in patients who,
like those with myasthenia gravis, might be adversely affected by an anticholinergic
agent.
Precautions: Quinidine should always be administered with caution. Infusion
should be stopped temporarily if the ECG shows prolongation of the QRS interval
by >50%, or if the QT interval is prolonged >50% of the preceding R-R interval.
Hypotension may occur if infusion is too rapid.
Medical Officers are required to consult OMS immediately if a pregnant Volunteer develops
malaria. Medical Officers should also review TG 170 Pregnancy. Prompt treatment of
pregnant Volunteers with malaria is essential and should be initiated as outlined below. P.
falciparum malaria is associated with low birth weight, fetal distress, premature labor,
miscarriage, stillbirth, and hypoglycemia.
In pregnant Volunteers, the OMS preferred drug of choice in areas with chloroquine
sensitive P. falciparum malaria is chloroquine (see Section 6.1 for dosing
schedules). In areas with chloroquine-resistant P. falciparum malaria, the
recommended treatment is Quinine in combination with clindamycin. Quinine
treatment should continue for 7 days for infections acquired in Southeast Asia and
for 3 days for infections acquired in Africa or South America; clindamycin
treatment should continue for 7 days regardless of where the infection was
acquired. PCMOs should consult OMS in treatment planning for any pregnant
Volunteer in areas with chloroquine resistant P. falciparum malaria. Doxycycline
is contraindicated during pregnancy, and the CDC does not currently recommend
the use of Malarone in pregnant women unless the potential benefit outweighs the
potential risk to the fetus, e.g., a pregnant woman who has acquired P. falciparum
malaria in an area of multi-drug resistance and who could not tolerate other
treatment options. The safe use of the Coartem during pregnancy has not been
established.
For information on sending specimens to the CDC, see Technical Guideline 360 Use of U.S.
Laboratories.
REFERENCE
de Alencar, F.E., et al., Atovaquone and proguanil for the treatment of malaria in Brazil.
Journal of Infectious Disease, 1997. 175(6): pp. 1544-7.
Centers for Disease Control and Prevention (CDC). Health Information for International
Travel, 2003-2004, Atlanta, Georgia, 2003.
Centers for Disease Control and Prevention (CDC). Malarone for Malaria Treatment and
Prophylaxis, Atlanta, Georgia, 2000.
Mandell, G. L., Douglas, R. G., and Bennett, J. E. Principals and Practice of Infectious
Diseases, 5th edition. Churchill Livingston, 2000.
Navy Environmental Health Center. Navy Medical Department Guide to Malaria Prevention
and Control, Norfolk, Virginia, 1991.
White, N.J. The Treatment of Malaria. The New England Journal of Medicine, Vol. 335:
800-806, No. 11, September 12, 1996.
To establish the diagnosis of malaria, thick and thin blood smears from fresh peripheral blood
are required. Medical Officer and Volunteers should prepare smears anytime malaria is
suspected, regardless of fever spikes or time of day. All of the materials needed for smear
preparation are contained in the Peace Corps Malaria Kit.
Peripheral blood is obtained by pricking the finger (see Figure A-1). Thick and thin smears
should be made on separate slides, however, smears may be made on the same slide (see
Figure A-2).
* In Figures A-1 and A-2 hands are shown ungloved to better illustrate their placement during the procedures.
However, PCMOs should always wear gloves while processing blood specimens to prevent transmission of
bloodborne pathogens (see Technical Guideline 260 Infection Control).
Page 1
TG 845 ATTACHMENT A
Thin film: Air dry. Fix with methyl alcohol. Stain. If no parasites are found, wait until the
thick film is dry and examine it for organisms that might not have been detected on the thin
preparation.
Thick film: Air dry. Stain unfixed.
Slides may be stained using a Wright-Giemsa stain; however, Wright stain alone will not reliably
show Plasmodium parasites. For best results, smears should be stained with a 3% Giemsa
solution (pH of 7.2) for 30-45 minutes. On microscopic examination, Plasmodium parasites are
always intracellular, and they demonstrate, if stained correctly, blue cytoplasm with a red
chromatin dot.
In P. falciparum infections, the parasite density should be estimated by counting the percentage
of red blood cells infected - not the number of parasites - under an oil immersion lens on a thin
film.
Reference: Adapted from Holtz, T., Kachur, S. P., et al. Malaria Surveillance United States, 1998. In: CDC
Surveillance Summaries. MMWR, December 7, 2001, 50; (No. SS05): 1-18.
Page 2
TG 845 ATTACHMENT B
Dear Volunteer,
In your Peace Corps Health Kit, you have been issued antimalarial medication for the emergency
self-treatment of presumed malaria. The specific medication, i.e., Malarone, or
Quinine/Doxycycline, has been selected for you based on the type of malaria in your country, the
prophylactic antimalarial drug you are taking, and your personal medical history. You should
only take the medication provided to you, and you should only take the medication if you feel
your symptoms are due to acute malaria and you are unable to access medical care
immediately.
Understand that many of the signs and symptoms of malaria mimic other viral and bacterial
illnesses and, often, presumed malaria is not malaria. If you have regularly taken your
prophylactic anti-malarial medication, you should not develop acute malaria. However, if you
do experience some or all of the above symptoms, you should: (1) carefully consider the cause
of your symptoms, and (2) if you feel that these symptoms may be from malaria, follow the
directions for emergency self-treatment of malaria below.
Coartem and Malarone are the drugs of choice for emergency self-treatment of
malaria
COARTEM 4 tablets orally at the time of initial diagnosis, again after 8 hours,
then twice daily for the following 2 days (4 tablets each time for total course
of 24 tablets)
Note: Coartem should be taken with high fat food and drinks such as milk as
this markedly improves absorption of drugs.
Or
2. Make blood smears: Blood smears are required for your PCMO to make the diagnosis
of malaria. You were trained how to make these smears during Pre-Service Training
(PST). A Malaria Kit and a handout with instructions on slide preparation are in your
Health Kit. Using the supplies in the Malaria Kit, do the following:
Contact the PCMO immediately and arrange for travel to the Peace Corps Health Unit or
to a regional medical facility approved by the PCMO. This is necessary so that the
PCMO or an approved health care provider can confirm the diagnosis, provide adequate
treatment and manage any complications or associated conditions.
The purpose of emergency self-treatment is to control the signs and symptoms of malaria
and to allow you time to obtain medical attention and follow-up. Emergency self-
treatment medication may, or may not, be effective treatment for malaria. You must
seek immediate medical attention!
Send this form, the blood slides, and blood for drug testing to: Centers for Disease Control and Prevention,
Malaria Epidemiology Branch, 4770 Buford Highway, MS F22, Atlanta, GA 30341 Fax: (770) 488-7761
TG 845 ATTACHMENT D
PEACE CORPS
COARTEM MEDICATION GUIDE
What is Coartem?
Coartem is a medication to treat malaria. Coartem tablets contain a combination of artemether (20mg) and
lumefantrine (120mg). These two medications work to clear the body of malaria parasites, and, when combined, are
especially effective against multi-drug-resistant strains of P. falciparum malaria.
Coartem is in the class of medications known as ACT, or "Artemether Combination Therapies." The World
Health Organization has determined that ACT are the preferred course of treatment for uncomplicated P. falciparum
malaria.
I understand that malaria is a serious and potentially fatal disease and that proper use of anti-
mosquito measures as well as anti-malarial medications can prevent malaria. I also understand
that proper use of Coartem as directed by my Medical Officer can effectively treat the disease. I
understand that failure to use proper preventive or treatment measures may result in substantial
illness, injury, disability and/or death.
If, at any time, I experience what I feel are possible side effects from Coartem, I will promptly
discuss the situation with my Medical Officer, and I may be placed on alternative anti-malaria
treatment.
________________________________
Signature
_____________
Date
Peace Corps
Technical Guideline 850
SCHISTOSOMIASIS
1. PURPOSE
To provide PCMOs with guidance on COS treatment for Volunteers who serve in
schistosomiasis endemic areas
2. BACKGROUND
Schistosomiasis, also known as bilharzia, is a parasitic disease endemic to many areas of the
world served by Peace Corps Volunteers. Among human parasitic diseases, schistosomiasis
ranks second behind malaria in terms of socioeconomic and public health importance in
tropical and subtropical areas. The disease is endemic in 73 developing countries and infects
more than 200 million people. It is a serious disease that, if left undiagnosed and untreated,
can result in major morbidity or mortality.
As such, the Office of Health Services (OHS) attempts to: (1) prevent schistosomiasis
infections in Volunteers, (2) treat those Volunteers who become symptomatic during service
and (3) treat all PCVs living in endemic areas during service. Components of this prevention
and management strategy include:
3. EPIDEMIOLOGY/LIFE CYCLE
Schistosomiasis occurs when human skin comes in contact with contaminated fresh water in
which specific species of snails that carry schistosomes are living. Disease transmission occurs
only in fresh water and only in areas where the specific snail host is present. Medical Officers
and Volunteers should, however, assume that all rivers, streams, lakes, and other bodies of
fresh water in schistosomiasis endemic areas are contaminated.
The pathophysiology of schistosomal disease reflects the geographic distribution and the unique
life cycle of the parasite. Schistosomal disease results directly from schistosome eggs being
deposited in host tissue and from the granulomatous host response to them. It is the eggs, not
the worms that are responsible for most of the pathology associated with the disease.
The three major species that infect humans are S. haematobium endemic in Africa and the
Middle East, S. mansoni endemic in Africa, parts of South America, the Caribbean and the
Middle East; and S. japonicum endemic in China, Southeast Asia, and the Philippines.
Other species include S. mekongi located in the Mekong River area of Southeast Asia, and
S. intercalatum located in Central and West Africa (see table below).
The life cycle of the schistosome parasite requires the presence of human carriers, fresh
water, and a species-specific intermediate snail host. Transmission occurs when the
cercarial form of the parasite penetrates human skin. The basic life cycle is illustrated in
ATTACHMENT B.
The Schistosoma parasites can penetrate the skin of persons who are wading, swimming,
bathing, washing, or otherwise in contact with contaminated water. Therefore, to reduce or
eliminate potential schistosomiasis exposure, OHS requires PCMOs educate Volunteers on
disease specific prevention measures. Education should include personal behaviors and
strategies for avoiding exposure, country specific information that may assist Volunteers in
avoiding exposure and disease specific interventions to reduce the risk of infection when
exposure occurs.
The Office of Health Services also requires all Volunteers serving in schistosomiasis endemic
areas to observe schistosomiasis prevention measures. These include, but are not limited to,
the following precautions.
Avoid contact with, including swimming in, all freshwater bodies of water; this includes
lakes, ponds, rivers, streams, irrigation systems, dams, canals and other bodies of
freshwater. All freshwater bodies of water in endemic areas are potentially contaminated.
Swimming in the ocean or well-maintained, chlorinated pools is safe.
Do not bathe in any of the freshwater sources mentioned above. Bathe in water that is
made safe by the following methods: (1) allowing the water to stand for greater than 48
hours during which time the cercariae die; (2) heating the water for 5 minutes at 150 F; or
(3) filtering with a water filter or fine mesh filter.
Never drink untreated water from any of the freshwater sources mentioned above.
Infection can occur through the skin of the lips and mouth. Drink safe water. Drinking
water should be made safe using the water disinfection methods described in TG 810
ATTACHMENT A Water Disinfection Methods.
Though several prevention measures associated water contact have been examined (application
of DEET to the skin prior to freshwater exposure and vigorous towel drying after freshwater
exposure), these measures are not proven to provide significant protection against schistosomal
infection. The only measure that reliably prevents schistosomiasis is avoidance of contact with
freshwater in endemic countries.
5. CLINICAL FEATURES
All Volunteers with signs or symptoms suggestive of possible schistosomiasis infection must
be evaluated. The definitive diagnosis of schistosomiasis is made by identification of eggs in
urine (S. haematobium) or stool (all species); or a history of fresh water exposure in an
endemic area and a positive antibody titer.
Most Volunteers who become infected with schistosomiasis are asymptomatic, do not
recall symptoms of acute infection, and appear to have a light infection with few adult
worms present. If symptoms are present, they vary according to the stage of infection
and the worm location of the specific schistosome species.
Key symptoms and signs of acute and early chronic infection include the following:
Fever Urticaria
Cough Right Upper Quadrant pain
Malaise, Fatigue Hepatosplenomegaly
Arthralgias, Myalgias Eosinophilia
Abdominal pain Hematuria, dysuria (chronic)
Diarrhea (may be bloody)
Schistosomal dermatitis is a pruritic, papular or urticarial rash that occurs at the site of
cercarial penetration. The reaction may develop a few hours after infection or may appear
up to one week later, and may last a few hours to several days. At this early stage of
infection, most people have no complaints and no clinical symptoms. Some may
complain of burning or irritation of the skin followed, in some cases, by urticaria.
The differential diagnosis of schistosomal dermatitis includes allergy, insect bites, and
contact dermatitis.
Symptoms usually develop 2 8 weeks after exposure to contaminated water, but may
even develop months later. The onset of symptoms usually coincides with the onset of
egg deposition and often precedes the appearance of eggs in urine or feces. Eggs, if
found in urine or feces, typically appear 40-50 days after exposure but may take over 90
days to appear. By this time, the acute stage may be over, with symptoms having
resolved over a period of several weeks.
Often the patient becomes suddenly ill with presentations varying from mildly ill with to
extremely ill. Symptoms include fever (99-105 F), chills, nonproductive cough,
headache, anorexia, weight loss, generalized myalgias, right-upper quadrant pain, and
diarrhea (may be bloody). Lymphadenopathy and hepatosplenomegaly may be present.
When the acute infection is massive in a patient with no previous exposure to
schistosomes, the resulting illness can be serious and life threatening.
Symptoms of early chronic disease may be seen in Peace Corps Volunteers. These
symptoms usually appear 10-12 weeks after infection when some, of the many of
thousands, of eggs released each day by an adult worm, reach the lumen of the bowel or
bladder and cause inflammation of these organs. Symptoms of intestinal disease
typically include fatigue, abdominal pain, vague, nonspecific intestinal complaints and
diarrhea. The diarrhea may progress to dysenteric bloody diarrhea and subsequent iron
deficiency anemia. Symptoms of urinary tract disease include dysuria, frequency and
hematuria.
Rarely, schistosomiasis involves the central nervous system (CNS). Egg deposition in
the brain or around the spinal cord may produce seizures and/or a transverse myelitis-like
syndrome. Cerebral mass lesions may result from egg deposition in or around brain
tissue. Most reported cases of cerebral schistosomiasis are caused by S. japonicum, and
most cases of schistosomal tranverse myelitis by S. mansoni or S. haematobium.
Symptoms of both syndromes may include severe headache and neck stiffness, central
nervous system (CNS) changes, both generalized and focal, and paralysis. In severe
cases infection may result in death.
PCMOs should consider the possibility of neuroschistosomiasis in all patients who have a
history of freshwater exposure in schistosomiasis endemic areas and CNS abnormalities,
even in the absence of classic signs and symptoms of acute disease.
Neuroschistosomiasis can occur several months after exposure to infested water and in
low-intensity infections in which eggs may be undetectable or difficult to identify in
urine or stool.
Late chronic disease is responsible for most of the morbidity and mortality associated
with the disease. Chronic schistosomiasis occurs almost exclusively in lifetime residents
of endemic areas and is very rarely seen in expatriates or Peace Corps Volunteers.
During the late chronic stage of infection, schistosome eggs, and the antigens they
secrete, can accumulate in target organs, which eventually results in granuloma
formation, scarring and fibrosis. The intensity and duration of infection determine the
Physical exam is often unremarkable. Physical findings vary with the stage of the illness,
worm location, worm burden, and target-organ involvement.
Schistosomal Dermatitis
Vital Signs: Temperature may range from normal to 105F (40.6C); blood pressure,
respiratory rate and pulse may be elevated secondary to fever
Skin: Nonspecific, erythematous, macular or maculopapular rash; petechial rash or
urticaria may be present
Chest: Lungs normal or cough; Cardiac normal
Abdomen: Generalized tenderness to palpation may be present
Spleen: Moderate splenomegaly
Liver: RUQ tenderness with hepatomegaly
Extremities: Peripheral edema is usually absent; paralysis, if neurologic involvement
Lymphadenopathy: May be generalized and present
Musculoskeletal: Despite complaints of myalgia and arthralgia, neither muscle
tenderness nor joint effusions are present
Neurologic: Seizures and/or altered mental status if CNS involvement; paralysis
S. haematobium egg excretion peaks between 10 a.m. and 2 p.m., thus samples should
ideally be obtained around noon when excretion is maximal. Because eggs are not shed
at a steady rate during the day, egg identification may be improved with concentration
and examination of a 24-hour urine collection.
In individuals who are suspected to have schistosomiasis and in whom eggs cannot be
identified, serologic antibody testing may be a useful tool in the diagnosis of
schistosomiasis. However antibody testing cannot distinguish between past, current,
active or chronic disease so is not useful for individuals with a history of past disease and
treatment. It also may not become positive for at least 4 6 weeks after infection.
OHS does not recommend screening, via antibody testing, of Volunteers who are
asymptomatic, even with a history of fresh water exposure. The Office of Health
Services does support in-service diagnostic antibody testing when clinically indicated.
Schistosoma antibody testing can be done by the local lab, if available, or sent to Quest
Diagnostics. Samples should no longer be sent to the CDC for schistosomal antibody
testing.
Complete Blood Count (CBC): Peripheral eosinophilia is a common finding in most forms
of schistosomiasis and may reach between 15-50%, particularly in acute infection.
Eosinophilia, however, has a broad differential diagnosis and, in isolation, is not considered
diagnostic of shistosomiasis, nor is it required for the diagnosis of schistosomiasis.
Liver function tests (ALT, AST, GGT, alkaline phosphate, direct/indirect billirubin,
albumin): Alkaline phosphate and GGT may be increased with hepatic granulomatosis.
Transaminiases are generally not affected. Elevations may be caused by any coexisting
hepatocellular disease, e.g., hepatitis.
Imaging Studies
CXR, plain x-ray film of the abdomen, IVP, ultrasound, echocardiography, cystoscopy,
endoscopy, CT scan and MRI
Persistent or severe symptoms may require follow-up exams. CT scan and MRI may be
useful in the evaluation of CNS disease.
6. TREATMENT OF SCHISTOSOMIASIS
Praziquantel is the current drug of choice for treating acute and chronic schistosomiasis based
on its spectrum of activity, safety, and cost.
Cercarial Dermatitis
Acute Schistosomiasis
In general, immediate treatment is indicated and should be initiated when one or more of
the following findings are present:
When microscopic examination of stool and urine for eggs is negative or not
available, or when antibody titers are pending or indeterminate, PCMOs should
maintain a high index of suspicion of disease and consider treatment when the
following findings are present:
Positive history of exposure AND one or more of the following signs or symptoms of
disease:
1. History of dermatitis and/or fever-like syndrome.
2. Hematuria - isolated hematuria, i.e., in the absence of other signs or symptoms of
disease, is not considered diagnostic of schistosomiasis.
3. Eosinophillia - isolated eosinophilia, i.e., in the absence of other signs or symptoms
of disease, is not considered diagnostic of schistosomiasis.
4. Any evidence of chronic schistosomal disease (see Section 5.1).
In the acute stage eggs may not be present, still, the presumptive diagnosis of acute
schistosomiasis may be made on clinical suspicion reinforced by the presence of any of
the above mentioned signs or symptoms of disease.
When there is a high index of suspicion of disease and no laboratory confirmation of
infection, PCMOs should consider repeat testing and OHS consultation.
S. japonicum, S. mekongi
Oxamniquine (Vansil) had previously been an alternative drug for treating S. mansoni, but
is no longer readily available.
Steroids
Steroids have been used in the management of acute schistosomiasis; however, there
are no clinical trials to assess optimal therapy. Nevertheless, steroids may be useful
prior to treatment in heavily infected persons to control the heightened immunologic
reaction to worm antigens after Praziquantel is given. Treatment may exacerbate
symptoms as a result of increased antigen release.
Corticosteroids should be used only for persons who are extremely toxic appearing
and whose symptoms fail to respond or worsen with treatment. Use with CNS
involvement to prevent inflammation and edema around the eggs. Prednisolone 40
mg/day for 5 days is the recommended dosing.
At the time of diagnosis, PCMOs should strongly encourage the Volunteer to avoid
repeated exposure to contaminated water and should review the disease prevention
measures outlined in Section 4. In addition, PCMOs should insure the Volunteer
understands the following: (1) the presence of anti-schistosomal antibodies does not
reliably prevent re-infection; and (2) re-infection is possible and serious systemic
complications, while infrequent, do occur.
Volunteers who exhibit repeated high risk behavior through freshwater contact and do
not comply with schistosomiasis prevention strategies due to willful misconduct or
disregard for the Peace Corps Volunteer Health Program should be referred to the
Country Director for administrative action (see TG 155 Non-Compliance with Medical
Policies or Instructions).
The Office of Health Services requires PCMOs to monitor Volunteers post treatment for
symptom resolution and determination of cure. Medical Officers should:
Reevaluate the Volunteer for resolution of symptoms. Most symptoms will improve within
a few weeks of treatment with Praziquantel, although resolution of some may take several
months.
Persistent symptoms warrant follow-up exams as indicated, e.g., cystoscopy, ultrasound or
urologic evaluation for hematuria or other GU symptoms; endoscopy or GI referral for
blood in the stool or other GI symptoms, etc.
If eggs were identified in urine or stool prior to treatment, repeat urine or stool exams at 1-
2 months and 3-4 months to confirm the disappearance of eggs and to assess efficacy of
treatment. Praziquantel is not 100% effective; therefore, PCMOs should monitor urine or
stool for the disappearance of eggs.
Retreat if indicated. Eggs may be shed for months after successful therapy or natural death
of worms. Eggs may or may not be viable, but because the tests required to distinguish live
from dead eggs are not readily available, PCMOs should repeat treatment every few
months until eggs are no longer detectable. Treatment should arrest egg laying, granuloma
formation, and future complications.
In those with negative exams for eggs, if praziquantel does not relieve the symptoms that
are attributed to schistosomiasis, consider another etiology.
Do not repeat antibody testing. Repeated antibody testing following treatment is not
clinically indicated. Antibody levels are likely to persist for many years; the duration of
positive antibody test following treatment is not known.
Starting in March 2012, all Volunteers living in Schistosomasis endemic regions are to be
treated empirically with Praziquantel at COS for possible exposure.
Volunteers are adults considered to be at risk which is the rational for empiric treatment of
Schistosomiasis. See the WHO strategy for treatment at:
http://www.who.int/schistosomiasis/strategy/en/index.html
Treatment should be given within 72 hours of COS a labeled container with detailed
instructions
See Section 6.2 for appropriate treatment regimens
Provide TG 330, ATTACHMENT J Praziquantel Medication Information Sheet to all
Volunteers receiving praziquantel
REFERENCES
Centers for Disease Control and Prevention. Yellow Book (Health Information for
International Travel, 2014).
World Health Organization, Schistosomiasis. Fact Sheet No. 115, March 2013.
The map shows schistosomiasis-endemic areas worldwide, categorized by areas where hepatic/intestinal
schistosomiasis occurs, where urinary schistosomiasis occurs, and where both types occur.
Hepatic/intestinal schistosomiasis is endemic in most of the eastern half of South America. Both types
are endemic in most African countries and the Middle East. Hepatic/intestinal schistosomiasis is endemic
in China; Thailand; Laos; Cambodia; and most other countries in Southeast Asia. Urinary schistosomiasis
is endemic in Turkey; Syria; Jordan; Iraq; Iran; India.
Note:
Urinary Schistosomiasis = S. haematobium;
Hepatic/Intestinal Schistosomiasis = S. mansoni in Africa, Middle East, South America, and the
Caribbean; S. intercalatum in Africa; S. japonicum, S. mekongi, and S. malaynensis in Asia.
The map represents a general illustration of the worldwide distribution of schistosomiais. PCMOs should
follow the guidance for schistosomiais prevention and treatment outlined in the text of Technical Guideline
850 Schistosomiais.
Map adapted from Health Information for International Travel, 2014 (Yellow Book). Published by the
Centers for Disease Control and Prevention., http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-3-
infectious-diseases-related-to-travel/schistosomiasis
November 2013
TG 850 ATTACHMENT B
Eggs are eliminated with feces or urine . Under optimal conditions the eggs hatch and release miracidia
, which swim and penetrate specific snail intermediate hosts . The stages in the snail include 2
generations of sporocysts and the production of cercariae . Upon release from the snail, the infective
cercariae swim, penetrate the skin of the human host , and shed their forked tail, becoming
schistosomulae . The schistosomulae migrate through several tissues and stages to their residence in
the veins ( , ). Adult worms in humans reside in the mesenteric venules in various locations, which at
times seem to be specific for each species . For instance, S. japonicum is more frequently found in the
superior mesenteric veins draining the small intestine , and S. mansoni occurs more often in the superior
mesenteric veins draining the large intestine . However, both species can occupy either location, and
they are capable of moving between sites, so it is not possible to state unequivocally that one species only
occurs in one location. S. haematobium most often occurs in the venous plexus of bladder , but it can
also be found in the rectal venules. The females (size 7 to 20 mm; males slightly smaller) deposit eggs in
the small venules of the portal and perivesical systems. The eggs are moved progressively toward the
lumen of the intestine (S. mansoni and S. japonicum) and of the bladder and ureters (S. haematobium),
and are eliminated with feces or urine, respectively . Pathology of S. mansoni and S. japonicum
schistosomiasis includes: Katayama fever, hepatic perisinusoidal egg granulomas, Symmers pipe stem
periportal fibrosis, portal hypertension, and occasional embolic egg granulomas in brain or spi nal cord.
Pathology of S. haematobium schistosomiasis includes: hematuria, scarring, calcification, squamous cell
carcinoma, and occasional embolic egg granulomas in brain or spinal cord.
Dosage 40 mg/kg total divided into two oral doses in 1 day, 4-6 hours apart, with food
Pounds Kilograms Total Dose Divided Dose # of tablets for each of dose
100 45.5 1820 mg 910 mg 1 1/2
110 50.0 2000 mg 1000 mg 1 3/4
120 54.5 2180 mg 1090 mg 2
130 59.1 2364 mg 1182 mg 2
140 63.6 2544 mg 1272 mg 2 1/4
150 68.2 2728 mg 1364 mg 2
160 72.7 2908 mg 1454 mg 2 1/2
170 77.3 3092 mg 1546 mg 2 3/4
180 81.8 3272 mg 1636 mg 2 3/4
190 86.4 3456 mg 1728 mg 3
200 90.9 3636 mg 1818 mg 3
210 95.5 3820 mg 1910 mg 3 1/4
220 100.0 4000 mg 2000 mg 3 1/2
230 104.5 4180 mg 2090 mg 3 1/2
240 109.1 4364 mg 2182 mg 3 3/4
250 113.6 4544 mg 2272 mg 3 3/4
Dosage 60 mg/kg total divided into two oral doses in 1 day, 4-6 hours apart, with food
Pounds Kilograms Total Dose Divided Dose # of tablets for each dose
100 45.5 2730 mg 1365 mg 2 1/4
110 50.0 3000 mg 1500 mg 2 1/2
120 54.5 3270 mg 1635 mg 2 3/4
130 59.1 3546 mg 1773 mg 3
140 63.6 3816 mg 1908 mg 3 1/4
150 68.2 4092 mg 2046 mg 3 1/2
160 72.7 4362 mg 2181 mg 3 3/4
170 77.3 4638 mg 2319 mg 4
180 81.8 4908 mg 2454 mg 4 1/4
190 86.4 5184 mg 2592 mg 4 1/2
200 90.9 5454 mg 2727 mg 4 3/4
210 95.5 5730 mg 2865 mg 5
220 100.0 6000 mg 3000 mg 5
230 104.5 6270 mg 3135 mg 5 1/4
240 109.1 6546 mg 3273 mg 5 1/2
250 113.6 6816 mg 3408 mg 5 3/4
November 2013