The protocol for Malaria:
Malaria
Let’s break it down!
Malaria is a mosquito-borne infectious disease caused by single-celled microorganisms from the plasmodium group. When an infected mosquito (particularly the Anopheles genus) bites the host, parasites travel from the saliva into the blood. From there, they circulate into the liver, mature, and reproduce where they then wreak havoc on the body; causing profound sickness. It is often confused with pneumonia and gastroenteritis.
Malaria is responsible for up to 435,000 deaths per year, 90% of which being in the African region. Most patients with malaria can expect a full recovery, but severe cases can have a mortality of up to 20%, even with intensive care and treatment. Although people in the US aren’t typically at risk for the disease, soldiers will often be deployed to regions that put them at a higher risk of contracting the disease. During some deployments, soldiers are asked to take Doxycycline daily as a prophylactic treatment for malaria. However, compliance with this has been notoriously low (35%-56%) and even successful compliance from a soldier cannot rule out a potential malaria infection.
The video below takes an even deeper look into Malaria:
The gold standard for diagnosing malaria is through microscopic examination, but it can also be diagnosed clinically. Since malaria can often be confused with other diseases, it’s helpful to be able to identify the risk factors:
- History of travel to malaria-endemic area: Far majority of cases are in African regions, but can really occur in any tropical or subtropical region; especially in South America or Asia.
- Non-Compliance with anti-malarial medications or PPE: Those that are asked to take such measures are certainly already in a high-risk area. Utilizing proper PPE is the cornerstone of prevention and prophylactic doxycycline is 84%-99% effective in preventing malaria infections. Those who are non-compliant with either of these are always going to be at a higher risk of contracting the disease.
Malaria patients do not typically show any unique symptoms initially, they just appear extremely unwell. Malaise (feeling of discomfort), fatigue, myalgia (body aches), and cyclic fevers and sweats are the most common symptoms. Severe cases of malaria will present with noticeable swelling in the liver (hepatomegaly) and spleen (splenomegaly) as the disease spreads throughout the body. This can also be a sign of recurrent malaria infections.
Below is a video from someone who has personally experienced what it’s like to have malaria (start at 9.31):
The primary treatment for malaria in the military setting is Malarone, which is a combination of atovaquone and proguanil that work together to inhibit the growth of parasites within the red blood cells in the body. Primaquine also helps treat malaria and prevents relapse by eliminating certain forms of plasmodium (P. vivax and P. ovale) from the liver and blood, although the exact mechanism is uncertain.
One thing the protocol makes a special note about is screening for G6PD deficiency before giving primaquine. A G6PD deficiency is a genetic abnormality that results in an inadequate amount of glucose-6-phosphate dehydrogenase (G6PD) in the blood. This is a very important enzyme (or protein) that regulates various biochemical reactions in the body, including keeping red blood cells healthy and preventing hemolytic anemia.
The problem with Primaquine is that even though it has the potential to radically cure people with malaria, it can cause serious harm to people with G6PD deficiencies. This deficiency is not particularly common among US soldiers, but it does affect over 400 million people worldwide, particularly in African, Asian, or Mediterranean regions. That is why everyone should ideally be screened for G6PD deficiency before being given primaquine. For a more in-depth review, check out the following osmosis video:
Lastly, Acetaminophen is recommended for malaria patients to help manage the body aches and fevers!
Most cases of uncomplicated malaria will clear up within 96 hours if treatment is provided. But regardless of how mild a particular case of malaria is in a patient, they will need a Routine evacuation for further observation and follow-up beyond your capabilities. In many cases, malaria can be lethal and should warrant an Urgent evacuation if the patient shows any altered mental status, respiratory distress, or unstable vital signs.
Good luck out there!
References
- PubMed: Compliance with Antimalaria Chemoprophylaxis in a Combat Zone
- EMRAP Corependium: Critical Parasitic Infections
- UpToDate: Malaria: Clinical manifestations and diagnosis in nonpregnant adults and children
- NCBI: Doxycycline for Malaria Chemoprophylaxis and Treatment: Report from the CDC Expert Meeting on Malaria Chemoprophylaxis
- Advanced Tactical Paramedic Protocols Handbook. 10th ed., Breakaway Media LLC, 2016.
- Why every medic should love Deployed Medicine - November 8, 2020
- 3 Areas Where Medics Fall Short - November 7, 2020