Recommended malaria prophylaxis and stand-by treatment
for international staff travelling to East Timor[1]
Rationale for choice of drugs: Under normal circumstances, chloroquine plus proguanil would be the recommended malaria prophylaxis. However, at present there are large-scale population movements and a destruction of services, including malaria control interventions, combined with an influx of non-immune foreigners in East Timor. These circumstances favour the spread and increase of both malaria transmission and antimalarial drug resistance. P.falciparum highly resistant to chloroquine and resistant to sulfadoxine/pyrimethamine has already been reported in East Timor. Under these circumstances, chemoprophylaxis with mefloquine or doxycycline is preferable to regimens containing chloroquine.
Recommended prophylaxis: mefloquine OR doxycycline
Dosing: mefloquine prophylaxis 5 mg/kg in a single weekly dose
doxycycline prophylaxis 1.5 mg salt/kg daily
Emergency stand-by treatment: quinine
Alternative stand-by treatment when on doxycycline prophylaxis: mefloquine
Dosing: quinine treatment 8 mg base/kg orally 3 times daily for 7 days
mefloquine treatment 15 mg/kg in a single dose
General comments:
Mefloquine prophylaxis should be started at least one week before entering the endemic area, but preferably 2-3 weeks before, so that side-effects can be detected before travel and, if necessary, prophylaxis can be changed to doxycycline. Doxycycline prophylaxis should be started the day before entering the endemic area. Chemoprophylaxis should be continued with unfailing regularity throughout the stay in Timor, and for 4 weeks after leaving the endemic area. Normal precautions and contra-indications to either of these drugs should be observed.
Chemoprophylaxis does not offer 100 % protection, and staff should be alert to the possibility of a clinical attack of malaria, which may appear as early as 7 days after entering the endemic area. Falciparum malaria, which can be fatal, must always be suspected if fever, with or without other symptoms, develops at any time between one week after the first possible exposure and 2 months (or even later in rare cases) after the last possible exposure. Staff should be informed that malaria can kill if treatment is delayed beyond 24 hours, and that medical help must be sought promptly if a febrile illness occurs. A blood sample should be taken and examined for malaria parasites on one or more occasions.
Staff should be informed on how to protect themselves against mosquito bites.
Most international staff will be able to obtain prompt medical attention when malaria is suspected. However, some may be unable to seek such care within 24 hours of the onset of symptoms, particularly if they are in an isolated location far from medical services. In such cases, it is advised that prescribers issue antimalarial drugs to be carried by the staff for self-administration (“stand-by emergency treatment”). Staff prescribed stand-by emergency medication should be given precise instructions on the recognition of symptoms, the treatment regimen, possible side-effects, and the action to be taken in the event of drug failure. Self-treatment is a first-aid measure, and they should seek medical advice as soon as possible. Mefloquine prophylaxis should only be resumed 7 days after the last self-treatment dose of quinine. Doxycycline prophylaxis can be resumed immediately.
[1] For more information on malaria chemoprophylaxis, stand-by treatment and prevention against mosquito bites: International Travel and Health - vaccination requirements and health advice, WHO, Geneva, 1999. ISBN 92 4 158024 0