Malaria chemoprophylaxis (6)
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Comments forwarded from colleague in Zimbabwe:
1. *Roll back malaria*
ACT is being used extensively in Zimbabwe, but only by the private sector. It is highly successful. Government Health Services are not able to use it, as there is no money to purchase it however comparatively cheap it may be! They do agree with its use however, wherever possible.
2. *Malaria prophylaxis*
a. *Use of Maloprim* (Deltaprin in Zimbabwe), Pyrimethamin/Dapsone.
Still being used in this part of Africa after 30 years continuously. No
resistance of any consequence, and virtually no side effects (only
occasional restlessness on day of taking and/or slight urticaria.) - not
enough to stop its use generally. Dose: one tablet every seven days.
Protection estimated at about 70%. [See note on its use in BNF paras on
malaria.]
b. *Mefloquine*
Psychotic side effects. Agree fully that mefloquin
should never be used as a prophylactic drug if patient shows any form of
untoward reaction it. Side effects are known to fade after about three
weeks of use. Original trials with US forces in Somalia did not document
side effects, which were seen, and those that did occur were not
reported. Being soldiers, they were simply told to "get on with the
job". In any event, most side effects faded after three weeks or so. I
feel that it is an over-rated prophylactic, although it is undoubtedly
highly effective if tolerated. Generic form is not known here.
3. *Doxycycline prophylaxis*
Generally accepted in Zimbabwe as a good prophylactic with two reservations. One is photosensitivity on pale skins, which is considerable. The other is unsuitability for children under 8 years. This age is considered here to be reasonable, rather than waiting until 11. Effects on bone and teeth seem to be minimal even if noticed at all. The dose of 100 mg. daily is the same as for adults, as we do not know of any paediatric dosage form. I rather think the BNF is a little conservative on such matters! Resistance to the drug as an antibiotic has not been recorded - it is rather similar I think to the use of oxytetracycline in a daily dose of acne vulgaris.
4. *Quinine loading dose*
Agreed that no loading dose is given if quinine and/or chloroquin has been used in curative dosage within previous 24 hours. Quinidine has not been used here at all.
5. *Mefloquin in certain jobs*
A time factor is involved here. If the drug is tried out in advance, and side effects can be tolerated for about four weeks, then, providing these effects have faded, there should be no reason why it should not be used from then on. Sleep disturbances are only associated with the psychotic effects, and again, should fade with time. For use in the Army, refer to Col.Regis Vaillancourt, Chief Pharmacist Canadian Armed Forces. (Also President Mlitary and Emergency section, FIP). An exercise in 2003 in urgent troop deployment, and an excellent screening process undertaken by duty pharmacists with reference to mefloquin, and with superb results. This should be a model for all Armed Services deployment in sensitive areas.
6. *Doxycycline resistance with malaria parasite*
Not recorded in Zimbabwe at all. Mefloquine resistance also not reported, but drug usually only used here for treatment and not prevention. World wide resistance in some cases in acknowledged, I hope these remarks may be helpful and of interest.
Peter V. Rollason, MPS, FRPhamS, MCPP.
Consultant Pharmacist specialisng in Malaria in South Central
Africa for past 30 Years.
9th. April 2005. Bulawayo, Zimbabwe.
e-mail: rolly@netconnect.co.zw