Malaria guidelines 2012.pdf

2012

www.nt.gov.au/health

Guidelines for Malaria

Prepared by the Centre for Disease Control, Darwin and Infectious Diseases Unit, Royal Darwin Hospital.

1st Edition June 19912nd Edition March 19943rd Edition January 19974th Edition June 20045th Edition April 20076th Edition September 2012

The Malaria Treatment Guidelines pages 15-20 are reproduced with permission from the Antibiotic Expert Group - Malaria. In: Therapeutic Guidelines: Antibiotic. Version 14. Melbourne: Therapeutic Guidelines Limited; 2010. pp.163–70.

For assistance with possible malaria cases contact the following urgently:

Working hours Infectious Diseases Registrar Royal Darwin Hospital Ph: 8922 8888

After hours Infectious Diseases Physician on call Royal Darwin Hospital Ph: 8922 8888

Centre for Disease ControlDepartment of Health, Northern Territory 2012This publication is copyright. The information in this report may be freely copied and distributed forQRQ�SUR¿W�SXUSRVHV�VXFK�DV�VWXG\��UHVHDUFK��KHDOWK�VHUYLFH�PDQDJHPHQW�DQG�SXEOLF�LQIRUPDWLRQsubject to the inclusion of an acknowledgement of the source. Reproduction for other purposesUHTXLUHV�WKH�ZULWWHQ�SHUPLVVLRQ�RI�WKH�&KLHI�([HFXWLYH�RI�WKH�'HSDUWPHQW�RI�+HDOWK��1RUWKHUQ�7HUULWRU\�

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General enquiries are welcome and should be directed to:Senior Branch ManagerCentre for Disease ControlDepartment of HealthPO Box 40596Casuarina NT 0811Phone: 08 8922 8089Facsimile: 08 8922 8310

For further information contact your regional Centre for Disease ControlDarwin: Disease Control ph 8922 8044Katherine: Disease Control ph 8973 9049East Arnhem: Disease Control ph 8987 0359Tennant Creek: Disease Control ph 8962 4259

Contents

Introduction ...................................................................................................................................................1

Risks of re-establishing endemic malaria in the Northern Territory .......................................................1

Prevention and prophylaxis ........................................................................................................................2

Diagnosis ......................................................................................................................................................2

17�&DVH�GH¿QLWLRQ� .......................................................................................................................................3

Initial management of malaria .....................................................................................................................4

Ward monitoring and discharge plan ........................................................................................................5

Management of malaria................................................................................................................................6

Principles of management .............................................................................................................................6Place of treatment ..........................................................................................................................................6Initial management .........................................................................................................................................7Indications for intensive care unit or high dependency unit admission for parenteral therapy .......................7Discharge to HITH ..........................................................................................................................................8Referral to and management of patients with malaria via Hospital in the Home (HITH) ................................8Eradication treatment for P. vivax and P. ovale dormant stages .....................................................................9Follow-up ........................................................................................................................................................9Public health response ................................................................................................................................10

Background ....................................................................................................................................................10Screening of high risk groups .........................................................................................................................10Refugee migrant screening ............................................................................................................................10Management of co-travellers ..........................................................................................................................105ROH�RI�&'&�0DODULD�6XUYHLOODQFH�2I¿FHU��062� ...........................................................................................11Medical Entomology ......................................................................................................................................12Malaria public health response ...................................................................................................................13

APPENDIX 1 ..................................................................................................................................................14

Therapeutic guidelines: antibiotic. Malaria 2010 .......................................................................................14

Treatment ......................................................................................................................................................14

Uncomplicated Plasmodium falciparum malaria.............................................................................................14Severe malaria ...............................................................................................................................................15Other forms of malaria ....................................................................................................................................16Prophylaxis ...................................................................................................................................................17

Vector avoidance ............................................................................................................................................18Chemoprophylaxis ..........................................................................................................................................18Areas with chloroquine-susceptible malaria ...................................................................................................18Areas with chloroquine-resistant malaria........................................................................................................19$UHDV�ZLWK�PHÀRTXLQH�UHVLVWDQW�PDODULD.........................................................................................................19Stand-by emergency treatment ...................................................................................................................19

APPENDIX 2. Malaria Surveillance Case Questionnaire ..........................................................................20

APPENDIX 3. Use of IV artesunate for severe and complicated malaria ...............................................23

APPENDIX 4. Primaquine: patient information .........................................................................................25

$33(1',;��*XLGHOLQHV�IRU�DVVHVVLQJ�XQDXWKRULVHG�,QGRQHVLDQ�¿VKHUSHUVRQV�IRU�PDODULD.............26

APPENDIX 6. Advise to parents of students arriving in the NT from malaria endemic areas ............28

APPENDIX 7. Medical Entomology investigation .....................................................................................31

APPENDIX 8. Malaria factsheet ..................................................................................................................32

APPENDIX 9. Malaria factsheet (Indonesian)............................................................................................34

1

Malaria Guidelines for Health Professionals in the Northern Territory

7KLV�GRFXPHQW�RXWOLQHV�VRPH�VHOHFWHG�DQG�XQLTXH�DVSHFWV�RI�PDODULD�VXUYHLOODQFH�DQG�FRQWURO�LQ�WKH�1RUWKHUQ�7HUULWRU\��17��,W�GHVFULEHV�WKH�LQWHQVLYH�PHDVXUHV�WKDW�DUH�HVVHQWLDO�LI�ZH�DUH�WR�SUHYHQW�WKH�re-establishment of malaria in the NT.

The malaria control program in the NT is a responsibility shared among general practitioners, KRVSLWDOV�� ODERUDWRULHV��PHGLFDO� HQWRPRORJ\�� FRPPXQLW\� FDUH�KHDOWK� FHQWUHV�� GLVHDVH� FRQWURO� XQLWV�and the general community.

Introduction

7KH�17�KDV�D�FRPSUHKHQVLYH�PDODULD�VXUYHLOODQFH�DQG�FRQWURO�SURJUDP�WKDW�LQFOXGHV�a. Early detection and hospitalisation of cases;b. Correct treatment of cases;c. Follow up of cases after discharge from hospital;d. Centre for Disease Control (CDC) assessment of all cases to establish appropriate entomological

LQYHVWLJDWLRQ�e. $GYLFH� RQ� SURSK\OD[LV� IRU� WUDYHO� RYHUVHDV� YLD� H�J�� +HDOWK� 6HUYLFHV�$XVWUDOLD� �+6$�� 7UDYHO�

Doctor and certain General Practitioners; andf. 6FUHHQLQJ� DQG� WUHDWPHQW�FXUH� IRU� KLJK� ULVN� JURXSV�� IRU� H[DPSOH� UHIXJHHV��PLJUDQWV�� LOOHJDO�

¿VKHUSHUVRQV�DQG�FR�WUDYHOOHUV�RI�FDVHV�ZKR�KDYH�PDODULD�

Malaria is caused by the blood parasite Plasmodium. There are 5 species that infect humans: P. falciparum, P. vivax, P. ovale, P. malariae and in South East Asia only, P. knowlesi.

The parasite is transmitted to humans by the bite of an infected mosquito. The female mosquitoes of the genus Anopheles are the only mosquitoes that can transmit malaria. The malarious areas across the world include:

� Africa, Middle East, Asia, China, South East Asia including Indonesia, East Timor, Papua New *XLQHD��WKH�:HVWHUQ�3DFL¿F�,VODQGV��DQG�&HQWUDO�DQG�6RXWK�$PHULFD�

Risks of re-establishing endemic malaria in the Northern Territory

7KH�:RUOG�+HDOWK�2UJDQL]DWLRQ��:+2��FHUWL¿HG�WKH�HUDGLFDWLRQ�RI�PDODULD�IURP�$XVWUDOLD�LQ��EXW�Northern Australia still remains susceptible to the re-establishment of the disease.

7KH�UHFHSWLYH�DUHD�LV�FRQVLGHUHG�WR�EH�QRUWK�RI�WKH��WK�SDUDOOHO�ZKLFK�LV�D�OLQH�MXVW�QRUWK�RI�7RZQVYLOOH�in Queensland and just south of Broome in Western Australia. The area includes the northern third of the NT, (north of Tennant Creek) and is considered at risk because of:

a. A history of endemic malaria until 1962;b. Widespread breeding of the Anopheles mosquito;c. Breeding of Anopheles mosquitoes in urban areas; andd. 5HJXODU�WRXULVW�WUDI¿F�IURP�PDODULRXV�FRXQWULHV��SDUWLFXODUO\�,QGRQHVLD��(DVW�7LPRU�DQG�3DSXD�

New Guinea.

2 3

DEPARTMENT OF HEALTH Malaria Guidelines for Health Professionals in the Northern Territory

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Malaria

Reporting

5HSRUWLQJ�LV�PDGH�WR�WKH�1RUWKHUQ�7HUULWRU\�1RWL¿DEOH�'LVHDVHV�6\VWHP��171'6��&RQ¿UPHG�FDVHV�DUH�VHQW�IURP�WKH�171'6�WR�WKH�1DWLRQDO�1RWL¿DEOH�'LVHDVHV�6XUYHLOODQFH�6\VWHP��11'66��Probable cases are reported to the NTNDS only.

&RQ¿UPHG�FDVH

$�FRQ¿UPHG�FDVH�UHTXLUHV�ODERUDWRU\�GH¿QLWLYH�HYLGHQFH�

Probable case

$�SUREDEOH�FDVH�UHTXLUHV�ODERUDWRU\�VXJJHVWLYH�HYLGHQFH�

/DERUDWRU\�GH¿QLWLYH�HYLGHQFH

1. 'HWHFWLRQ�DQG�VSHFL¿F� LGHQWL¿FDWLRQ�RI�PDODULD�SDUDVLWHV�E\�PLFURVFRS\�RQ�EORRG�¿OPV�ZLWK�FRQ¿UPDWLRQ�RI�VSHFLHV�LQ�D�ODERUDWRU\�ZLWK�DSSURSULDWH�H[SHUWLVH

OR2. Detection of Plasmodium species by nucleic acid testing.

Laboratory suggestive evidence

The detection of Plasmodium antigen in blood in the absence of recent appropriate treatment (and WKH�FDVH�LV�QRW�D�FRQ¿UPHG�FDVH��

7KH�DYHUDJH�QXPEHU�RI�LPSRUWHG�FDVHV�RI�PDODULD�WR�WKH�1RUWKHUQ�7HUULWRU\�HDFK�\HDU�RYHU�WKH�ODVW��\HDUV�LV��UDQJH��±��7KH�1RUWKHUQ�7HUULWRU\�KDV��QRWL¿FDWLRQV�SHU��SRSXODWLRQ�ZKLFK�LV�WKH�KLJKHVW�SHU�FDSLWD�QRWL¿FDWLRQ�UDWH�ZKHQ�FRPSDUHG�WR�RWKHU�$XVWUDOLDQ�MXULVGLFWLRQV�

7KH� UH�HVWDEOLVKPHQW�RI�PDODULD� LQ� WKH�17�FRXOG� UHVXOW� LQ�H[WHQVLYH�PRUELGLW\�DQG�PRUWDOLW\� LQ�RXU�SRSXODWLRQ��(YHU\�HIIRUW� LV� WKHUHIRUH�PDGH� WR�NHHS� WKH�17�PDODULD� IUHH�DQG� WR�PDLQWDLQ�$XVWUDOLD¶V�malaria free status.

Prevention and prophylaxis

:LWK�7HUULWRULDQV�WUDYHOOLQJ�PRUH�WR�HQGHPLF�PDODULD�DUHDV��LQFOXGLQJ�$ERULJLQDO�$XVWUDOLDQV�ZKR��UHWXUQ�WR�KLJKO\�PDODULD�UHFHSWLYH� UHPRWH�DUHDV�RI� WKH�7RS�(QG��KHDOWK�SURIHVVLRQDOV�QHHG� WR�XQGHUVWDQG�DQG�JLYH�H[SHUW�DQG�FXUUHQW�WUDYHO�PHGLFLQH�DGYLFH��6XFK�H[SHUW�DGYLFH�RQ�PDODULD�SUHYHQWLRQ�DQG�SURSK\OD[LV� FDQ�EH�JDLQHG� WKURXJK� WUDYHO�PHGLFLQH�FOLQLFV�� WKH�:+2� �ZZZ�ZKR�LQW�LWK�HQ��RU�&'&�$WODQWD�*XLGHOLQHV� �KWWS��ZZZ�FGF�JRY�WUDYHO�� $GYLFH� LV� DOVR� LQFOXGHG� LQ�7KHUDSHXWLF� JXLGHOLQHV��antibiotic. Version 14, 2010 (see Appendix 1).

Diagnosis

0DODULD�LV�GLDJQRVHG�E\�GHWHFWLRQ�RI�WKH�SDUDVLWH�WKURXJK�PLFURVFRS\�RI�WKLFN�DQG�WKLQ�EORRG�¿OPV��$V�LGHQWL¿FDWLRQ�RI�PDODULD�SDUDVLWHV�LV�QRW�D�FRPPRQ�ODERUDWRU\�HYHQW�LQ�$XVWUDOLD��WKH�+DHPDWRORJ\�Laboratory at the Royal Darwin Hospital (RDH) and the Institute of Medical and Veterinary Science �,096�� SURYLGH� D� VHUYLFH� IRU� FRQ¿UPDWLRQ� RI� PDODULDO� SDUDVLWHV� DQG� VSHFLHV� LGHQWL¿FDWLRQ� IRU� DOO�SXEOLF� DQG�SULYDWH� ODERUDWRULHV� VHUYLFLQJ� WKH�17��0DODULD�PLFURVFRS\� LV� WKH� µJROG� VWDQGDUG¶� IRU� WKH�FXUUHQW�17�FRQ¿UPHG�FDVH�GH¿QLWLRQ�DQG�UHPDLQV�PDQGDWRU\�IRU�WKH�GLDJQRVLV�RI�PDODULD�DQG�VSHFLHV�LGHQWL¿FDWLRQ��0DODULD�DQWLJHQ�WHVWLQJ�VKRZV�WKH�SUHVHQFH�RI�SODVPRGLDO�DQWLJHQV�DQG�FDQ�EH�XVHIXO�LQ�VXSSRUWLQJ�PLFURVFRS\�IRU�GLDJQRVLV��+RZHYHU�D�QHJDWLYH�DQWLJHQ�WHVW�GRHV�QRW�H[FOXGH�PDODULD�LQIHFWLRQ��HJ��ORZ�SDUDVLWH�QXPEHUV��DQG�DQ�DQWLJHQ�WHVW�FDQ�UHPDLQ�SRVLWLYH�IRU�XS�WR��ZHHNV�DIWHU�appropriate treatment. Polymerase chain reaction (PCR) is not routine and is not the gold standard. 0DODULD�LV�D�OHJLVODWHG�QRWL¿DEOH�GLVHDVH�LQ�WKH�17��

$Q\�WUDYHOOHU�ZKR�KDV�UHWXUQHG�IURP�D�PDODULRXV�UHJLRQ�LQ�WKH�SDVW��\HDUV�DQG�ZKR�KDV�D�IHYHU�RU�KLVWRU\�RI�IHYHU�VKRXOG�XQGHUJR�WHVWLQJ�IRU�PDODULD�SDUDVLWHV�DQG�DQWLJHQ��7KH�GHFLVLRQ�WR�KDYH�EORRG�¿OPV�WDNHQ�VKRXOG�QRW�EH�LQÀXHQFHG�E\�FRPSOLDQFH�ZLWK�SURSK\OD[LV�UHJLPHQV�DV�LW�LV�SRVVLEOH�WR�EH�LQIHFWHG�ZLWK�PDODULDO�SDUDVLWHV�DQG�GHYHORS�PDODULD�HYHQ�ZKHQ�DQWL�PDODULDOV�KDYH�EHHQ�FRUUHFWO\�taken.

The absence of parasites on a blood slide does not exclude malaria, particularly if a person has UHFHQWO\�WDNHQ�DQWL�PDODULDOV�RU�DQWLELRWLFV��,I�QHJDWLYH��D�EORRG�VOLGH�VKRXOG�EH�UHSHDWHG��KRXUV�ODWHU�DQG�DW�OHDVW�GDLO\�WKHUHDIWHU�LI�IHYHU�SHUVLVWV�

4 5


Initial management of malaria

Complicated

* *LYH�ZLWK�D�VPDOO�JODVV�RI�PLON�RU�D�VRIW�ELVFXLW�DV�IDW�LQFUHDVHV�WKH�DEVRUSWLRQ�† If unable to tolerate quinine discuss with Infectious Diseases Physician.‡ P. knowlesi malaria is indestinguishable from P. malariae on microscopy. All P. malariae FDVHV�ZLWK�D�KLVWRU\�RI�WUDYHO�WR�

South East Asia should be treated as P. knowlesi.§ 3DWLHQWV�FDQ�QRW�EH�GLVFKDUJHG�WR�+RVSLWDO�LQ�WKH�+RPH��+,7+��DIWHU��SP�DQG�VKRXOG�EH�DGPLWWHG�DW�OHDVW�RYHUQLJKW�

Ward monitoring and discharge plan

Ward discharge planP. falciparum P. malariaeP. knowlesi

Ward/ED discharge planP. vivaxP. ovale

i. Ongoing oral treatment being tolerated

ii. &OLQLFDOO\�LPSURYLQJiii. Parasitaemia falling

Treatment being tolerated

'H¿FLHQW

*�3'�DFWLYLW\

Normal

Stat dose of primaquine on full stomach (45mg for adults)��PJ�NJ�IRU�FKLOGUHQ��PD[��PJ��

to sterilise gametocytes

Seek specialist DGYLFH

Transfer to HITH

Complete a total of 3 days malaria WUHDWPHQW�REVHUYHG�WZLFH�D�GD\�E\�+,7+��'DLO\�EORRG�¿OPV�XQWLO�QR�

parasites seen

5HYLHZ�DQG�UHSHDW�PDODULD�¿OP�LQ��ZHHN�LQ�,QIHFWLRXV�'LVHDVHV�

Paediatric outpatient clinic, Refugee Clinic* or in Detention Centre

,Q�YHU\�VHOHFWHG�FDVHV��HJ��UHVLGHQWV�IURP�HQGHPLF�countries), Infectious Diseases Physician to consider ��GD\�SULPDTXLQH�WKHUDS\��LI�*�3'�DFWLYLW\�LV�QRUPDO��in P. falciparum FDVHV�LQ�YLHZ�RI�possible co-infection

with P. ovale and or P. vivax (primaquine to be taken on a full stomach).

Parasitaemia falling

14-day primaquine therapy commenced to eradicate

hypnozoites (to be taken on a full

stomach)

5HYLHZ�ZLWK�EORRG�¿OP�1 week after discharge LQ�,QIHFWLRXV�'LVHDVHV�

Paediatric outpatient clinic

� 'DLO\�SDUDVLWH�FRXQW�XQWLO�QHJDWLYH � Daily blood glucose and full blood count � Closely monitored BP and urine output

* 5HIXJHH�&OLQLF�LV�RIIHUHG�E\�9DQGHUOLQ�'ULYH�VXUJHU\��WUDQVSRUW�IRU�UHIXJHHV�LV�DYDLODEOH�WKURXJK�0HODOHXFD�5HIXJHH�Centre

Case must be discussed with Infectious Diseases Physician (all hours)

Uncomplicated

TreatmentAdults (excluding pregnant women in 1st trimester) and children >5kg��VW�OLQH��DUWHPHWKHU�OXPHIDQWULQH�

(Riamet)*

Pregnant women (1st trimester) and children <5kg- quinine sulfate† and clindamycin

Treat as complicated malaria if one or more of the following:

� Unable to tolerate oral medication

� Parasitaemia >2% � $Q\�VLJQV�RI�VHYHUH�PDODULD�

�altered mental state � jaundice � renal impairment �oliguria �unable to sit unaided � respiratory distress �VHYHUH�DQDHPLD �hypoglycaemia �acidosis

$GPLW�WR�+'8�,&8�LI�VHYHUH�PDODULD - 1st Line - IV Artesunate (Appendix 2) - 2nd line - IV Quinine�6HH�$SSHQGL[��protocol in ICU)

� All P. falciparum � All P. knowlesi‡ � All P. malariae

� P. vivax � P. ovale

�ODERUDWRU\�FRQ¿UPDWLRQ�WKDW�there is no co-infection with P. falciparum)

Criteria for hospital admission � Parasitaemia >1%? � Child <12 months old? � 6LJL¿FDQW� FR�PRUELGLW\"� HJ�� LVFKDHPLF�heart disease

� Pregnant (urine test for all women of child bearing age)?

� Unable to tolerate oral medication � Accommodation requirements are not met (see HITH p 6, 7)

Admit to ward Adults under Infectious Diseases team

Children (Paediatric team)see ward monitoring p 5

Admit to HITH§ see ward monitoring p 5

NO to ALLYES to ANY

Normal

*�3'�DFWLYLW\

'H¿FLHQW

Transfer to HITH

Complete a total of 3 days malaria WUHDWPHQW�REVHUYHG�WZLFH�D�GD\�E\�+,7+��'DLO\�EORRG�¿OPV�XQWLO�QR�

parasites seen

6 7


Management of malaria

Principles of management

%HFDXVH�RI�WKH�SXEOLF�KHDOWK�UDPL¿FDWLRQV�RI�PDODULD�DQG�WKH�FRPSOH[LW\�RI�WKH�SDUDVLWH¶V�OLIH�F\FOH��WKH�SULQFLSOHV�RI�WUHDWPHQW�DUH�WR�FXUH�WKH�LQGLYLGXDO�DQG�SUHYHQW�UHODSVHV�EXW�DOVR�LQFOXGH�UHGXFLQJ�DQG�eliminating transmission. The aims of treatment are as follows:

a. (UDGLFDWLRQ�RI�WKH�PDODULD�SDUDVLWHV�ZLWK�VSHFL¿F�DQWLPDODULDO�PHGLFDWLRQ�b. 6WHULOLVDWLRQ�RI�WKH�VH[XDO�IRUPV��JDPHWRF\WHV��ZLWK�D�VSHFL¿F�JDPHWRFLGDO�GUXJ��SULPDTXLQH��

WR�SUHYHQW�WUDQVPLVVLRQ�RI�WKH�SDUDVLWH�WR�PRVTXLWRHV�c. (UDGLFDWLRQ�RI� WKH�GRUPDQW� OLYHU� IRUPV��K\SQR]RLWHV��RI�P. vivax and P. ovale with a 2-week

course of primaquine; andd. 3UHYHQWLRQ�RI�WUDQVPLVVLRQ�WR�ORFDO�PRVTXLWRHV�E\�SK\VLFDOO\�VHSDUDWLQJ�WKH�SDUDVLWLVHG�SDWLHQW�

IURP�WKH�PRVTXLWR�HQYLURQPHQW�XQWLO�QR�ORQJHU�DEOH�WR�WUDQVPLW�WKH�SDUDVLWH�

$� GHWDLOHG� KLVWRU\�PXVW� EH� REWDLQHG� IURP�HYHU\� SDWLHQW� �VHH�$SSHQGL[� �� LQFOXGLQJ� DQ� LWLQHUDU\� RI�RYHUVHDV�WUDYHO�DQG�PRYHPHQW�IROORZLQJ�WKHLU�UHWXUQ�WR�$XVWUDOLD��7KH�KLVWRU\�ZLOO�KHOS�LQ�DVVHVVLQJ�WKH�ULVN�RI�SDUDVLWH�GUXJ�UHVLVWDQFH��LQIRUP�IXUWKHU�HQWRPRORJLFDO�DVVHVVPHQW�DQG�DOORZ�IRU�LGHQWL¿FDWLRQ�RI�FR�WUDYHOOHUV�

Place of treatment

Hospital

All cases of P. falciparum, P. malariae and P. knowlesi malaria and any malaria cases where the VSHFLHV�FDQQRW�EH�FRQ¿UPHG�ZLWKLQ��KRXUV�UHTXLUH�DVVHVVPHQW�LQ�KRVSLWDO��

� 7KLV�LV�WKH�SUHIHUUHG�SUDFWLFH�LQ�WKH�17�WR�SUHYHQW�OLIH�WKUHDWHQLQJ�FRPSOLFDWLRQV�RI�P. falciparum. � ,W�LV�DOVR�LPSRUWDQW�WR�DYRLG�DQ\�ULVN�RI�WUDQVPLVVLRQ�RI�WKH�SDUDVLWH�WR�WKH�PRVTXLWR�YHFWRUV�WKDW�

are present in the Top End of the NT. � 3DWLHQWV�DUH�LQLWLDOO\�QXUVHG�LQ�DQ�DLU�FRQGLWLRQHG�ZDUG��DQG�PXVW�QRW�OHDYH�WKH�ZDUG�EHWZHHQ�

6pm and 8am. � Asymptomatic patients with low parasitaemia eg. refugees may be treated through Hospital in

WKH�+RPH��+,7+��DIWHU�UHYLHZ�E\�WKH�,QIHFWLRXV�'LVHDVHV�UHJLVWUDU�RU�FRQVXOWDQW�DW�5'+�

Hospital in the home (HITH)

&RQ¿UPHG�P. vivax, or P. ovale�FDQ�EH�WUHDWHG�E\�+,7+�SURYLGHG�a. Parasitaemia is <1%;b. The child is >12 months of age;c. 7KHUH�DUH�QR�VLJQL¿FDQW�FR�PRUELGLWLHV�HJ��LVFKDHPLF�KHDUW�GLVHDVH�d. Pregnancy is excluded;e. 7KHUH�LV�QR�HYLGHQFH�RI�FR�LQIHFWLRQ�ZLWK�P. falciparum malaria. This requires blood microscopy

FRQ¿UPDWLRQ�RI�VSHFLHV�E\�DQ�DFFUHGLWHG�VSHFLDOLVW�PLFURVFRSLVW�

f. :KHUH� WKH�SDWLHQW� LV�JDPHWRF\WH�SRVLWLYH� WKDW� WKH�¿UVW�GRVH�RI�DUWHPHWKHU�OXPHIDQWULQH�KDV�EHHQ�JLYHQ�

g. 7KH�SDWLHQW�LV�DIIHFWHG�PLOGO\�E\�PDODULD�LH��WROHUDWLQJ�RUDO�ÀXLGV�DQG�GLHW�DQG�KDV�WROHUDWHG�WKH�¿UVW�WUHDWPHQW�GRVH�

h. The patient agrees to remain indoors in screened or air conditioned accommodation between GXVN�DQG�GDZQ�XQWLO�DUWHPHWKHU�OXPHIDQWULQH�WKHUDS\�LV�FRPSOHWHG�

i. Another household member has a phone and is able to use it if the patient becomes unwell or there is an emergency*;

j. 7KH�SDWLHQW�VSHDNV�D�ODQJXDJH�IRU�ZKLFK�D�WHOHSKRQH�LQWHUSUHWHU�RU�IULHQG�IDPLO\�PHPEHU�FDQ�interpret eg. Swahili, French, Dinka, Arabic, Kirundi. If it is a rare language and no lingua IUDQFD�FDQ�EH�IRXQG��WKH�SDWLHQW�ZLOO�KDYH�WR�EH�DGPLWWHG�

k. 7KH�SDWLHQW�LV�QRWL¿HG�WR�&'&�VR�WKDW�&'&�RI¿FHUV�FDQ�DVFHUWDLQ�WKDW�SDWLHQWV�WUHDWHG�DV�+,7+�RXWSDWLHQWV�GR�QRW�SRVH�D�SXEOLF�KHDOWK�ULVN��$�SKRQH�PHVVDJH�PD\�EH�OHIW�ZLWK�&'&�after hours; and

l. 7KH�FDVH�KDV�EHHQ�GLVFXVVHG�ZLWK�DQ�,QIHFWLRXV�'LVHDVHV��,'��3K\VLFLDQ�DW�5'+��DYDLODEOH�24 hours per day) to check:

� �7KH�DERYH�SRLQWV�D�WR�O � Clinical condition � Follow-up arrangements � �6SOHHQ�VL]H�DQG�RIIHU�DGYLFH�DERXW�VSRUWLQJ�UHVWULFWLRQV�

Initial management

Uncomplicated malaria should be treated as per protocols outlined in Therapeutic guidelines: antibiotic. 9HUVLRQ� �� VHH� $SSHQGL[� �� %HFDXVH� RI� GLI¿FXOWLHV� DFFHVVLQJ� FKORURTXLQH�� DUWHPHWKHU�lumefantrine is the preferred oral treatment for P. vivax from any malaria region.

Indications for intensive care unit or high dependency unit admission for parenteral therapy

� $Q\�GHJUHH�RI�DOWHUHG�FRQVFLRXVQHVV��MDXQGLFH��ROLJXULD��VHYHUH�DQDHPLD�RU�K\SRJO\FDHPLD � $�SDUDVLWH�FRXQW�DERYH��PP��!��RI�UHG�EORRG�FHOOV�SDUDVLWLVHG� � 7KH�SDWLHQW�LV�YRPLWLQJ�RU�FOLQLFDOO\�DFLGRWLF�

6HYHUH� falciparum and knowlesi malaria can be fatal, particularly if the diagnosis and treatment is GHOD\HG�� 7KH�:RUOG�+HDOWK�2UJDQL]DWLRQ�KDV�D�KDQGERRN�RQ� WKH�PDQDJHPHQW�RI� VHYHUH�PDODULD��KWWS��ZZZ�ZKR�LQW�PDODULD�HQ��,QWHQVLYH�FDUH�XQLWV�KDYH�SURWRFROV�IRU�WKH�PDQDJHPHQW�RI�VHYHUH�malaria.

)LUVW�OLQH�SDUHQWHUDO�WKHUDS\�RI�VHYHUH�falciparum malaria is artesunate (see Appendix 3).

*Please note: There is a HITH nurse on call 24hours (they only speak English).Unless the patient or a household member speaks English, there should be another contact person (Melaleuca Refugee &HQWUH�RU�IULHQG�QHLJKERXU��ZKR�LV�DYDLODEOH�WR�LPPHGLDWHO\�DWWHQG�WKH�KRXVH�LI�FDOOHG�

8 9


Discharge to HITH

Patients with P. falciparum, P. malariae, and P. knowlesi can be discharged to HITH when:1. The oral course of anti-malarial medication is being toleratedAND2. 7KH\�DUH�FOLQLFDOO\�LPSURYLQJ�AND3. Parasitaemia is fallingAND4. For cases of P. falciparum, P. malariae and P. knowlesi a stat* gametocidal dose of primaquine

��PJ�IRU�DGXOWV��PJ�NJ�IRU�FKLOGUHQ��LV�JLYHQ�DW�GLVFKDUJH�LI�*�3'�DFWLYLW\�LV�QRUPDO��

The discharge algorithm is on p 5.

Referral to and management of patients with malaria via Hospital in the Home (HITH)

6HH�ÀRZ�FKDUW�Ward monitoring and discharge plan p 5.

In working hoursa. 5HIHU�WR�WKH�,QIHFWLRXV�'LVHDVHV�+,7+�UHJLVWUDU�$6$3�b. ,'�+,7+�UHJLVWUDU��DORQJ�ZLWK�D�+,7+�QXUVH��ZLOO�DVVHVV�WKH�SDWLHQW¶V�VXLWDELOLW\�IRU�GLVFKDUJH�

home (see ward monitoring and discharge plan p 5).c. 7KH�¿UVW�GRVH�RI�DUWHPHWKHU�OXPHIDQWULQH�>DQG�IRU�P. falciparum the stat dose of primaquine

��PJ�IRU�DQ�DGXOW�ZKR�LV�QRW�*�3'�GH¿FLHQW�@��VKRXOG�EH�JLYHQ�DQG�REVHUYHG�SULRU�WR�WUDQVIHU�WR�+,7+��7KH�SDWLHQW�VKRXOG�EH�REVHUYHG�IRU�DQ�KRXU�IROORZLQJ�WKLV�WR�HQVXUH�QR�YRPLWLQJ��*LYH�with a small glass of milk or a soft biscuit as fat increases the absorption.

d. ,I�WKH�SDWLHQW�LV��\HDUV�RI�DJH��WKH�SDHGLDWULFLDQ�RQ�FDOO�VKRXOG�EH�LQYROYHG��

Out of working hours (after 9pm)a. Patients can not be discharged to HITH after 9pm and should be admitted to hospital at least

RYHUQLJKW��b. 7KH�QH[W�PRUQLQJ� WKH�+,7+�QXUVHV�UHJLVWUDU�FDQ�DVVHVV� WKH�SDWLHQW�DQG�GLVFKDUJH� WR�+,7+�

LI� DSSURSULDWH��+,7+�QXUVHV�DUH�DYDLODEOH�RQ�ZHHNHQGV�GXULQJ�ZRUNLQJ�KRXUV�DQG�PXVW�EH�consulted if a discharge is planned on a weekend, as must be the ID consultant on call.

Management at HITH

a. *LYH�HDFK�DUWHPHWKHU�OXPHIDQWULQH�GRVH�%'�DW��DQG��ZLWK�D�VPDOO�JODVV�RI�PLON�RU�D�VRIW�ELVFXLW��GLUHFWO\�REVHUYHG�WKHUDS\�E\�+,7+�QXUVH��IRU�D�WRWDO�RI��GRVHV��QRWH�WKH�VHFRQG�GRVH�LV�WR�EH�JLYHQ��KRXUV�DIWHU�WKH�LQLWLDO�GRVH��

b. 'R�GDLO\�PDODULD�¿OPV�XQWLO�QR�SDUDVLWHV�DUH�VHHQ�c. There is no need to repeat malaria antigen test during treatment.

d. If the patient or a household member speaks no English, use the Telephone Interpreter 6HUYLFH�GXULQJ�YLVLWV�>7,6��&OLHQW�QXPEHU��\RXU�DOORFDWHG�QXPEHU�@�

e. Once treatment has been completed for a refugee, liaise with the Refugee Clinic Vanderlin 'ULYH�6XUJHU\��UHJDUGLQJ�IROORZ�XS��,Q�PRVW�FDVHV�WKLV�ZLOO�LQYROYH�EORRG�¿OPV�DQG�)%&�DQG�FOLQLFDO�UHYLHZ�DW�GD\��SRVW�WUHDWPHQW�

Eradication treatment for P. vivax and P. ovale dormant stages

7KH�DLP�RI�WKLV�WUHDWPHQW�LV�WR�HUDGLFDWH�WKH�KLGGHQ�OLYHU�SKDVH�RI�P. vivax or P. ovale (hypnozoites) which can lead to relapses of malaria after months or years.

,W�LV�JLYHQ�IRU�� Those diagnosed with P. vivax or P. ovale�LQIHFWLRQ�ZKR�KDYH�D�QRUPDO�*�3'�UHVXOW� � Those with P. falciparum who are at high risk of co-infection with P. vivax hypnozoites;

$OWKRXJK��GD\�SULPDTXLQH�HUDGLFDWLRQ�WUHDWPHQW�LV�QRW�URXWLQHO\�RIIHUHG�WR�DOO�SHRSOH�DUULYLQJ�from malarious areas due to possible co-infection with P. vivax it is strongly recommended for:

a. 0LJUDQWV� DQG� UHIXJHHV� IURP� UHJLRQV�ZLWK� KLJK� HQGHPLFLW\� IRU� YLYD[�PDODULD� �HJ�� 31*��Solomon Islands, eastern Indonesia). This does not include refugees from Africa.

b. ([SDWULDWH�ZRUNHUV�UHVLGHQW�IRU�SURORQJHG�SHULRGV�LQ�UHJLRQV�ZLWK�KLJK�HQGHPLFLW\�IRU�YLYD[�malaria.

Radical treatment consists of treatment with primaquine for 14 days (refer to Therapeutic guidelines: antibiotic��9HUVLRQ��1RWH� WKH�QHHG� IRU� WKH�KLJKHU�GRVH�RI��PJ�NJ�GD\�GRVH� LQ�P. vivax infections.

%ORRG� WHVWV� WR� H[FOXGH� SDUDVLWDHPLD� DQG� *�3'� GH¿FLHQF\� VKRXOG� EH� SHUIRUPHG� EHIRUH� VWDUWLQJ�eradication treatment (1-2mL blood in an EDTA tube). If parasitaemia is present the person must be WUHDWHG�DFFRUGLQJO\�� ,I� WKH�SHUVRQ�KDV�*�3'�GH¿FLHQF\�SULPDTXLQH�VKRXOG�EH�ZLWKKHOG�DQG�IXUWKHU�management should be discussed with an Infectious Diseases Physician.

7UHDWPHQW�PXVW�EH�UHYLHZHG�ERWK�WR�HQVXUH�FRPSOLDQFH�DQG�WR�DVVHVV�DQ\�VLGH�HIIHFWV��HJ��KDHPRO\VLV��PHWKDHPRJORELQDHPLD�� QDXVHD�� YRPLWLQJ�� DQRUH[LD�� GL]]LQHVV�� HSLJDVWULF� GLVWUHVV� DQG� DEGRPLQDO�SDLQV�RU�FUDPSV��7UHDWPHQW�PXVW�EH�WDNHQ�ZLWK�IRRG�WR�DYRLG�JDVWURLQWHVWLQDO�VLGH�HIIHFWV�

3DWLHQWV� ZLOO� EH� JLYHQ� DQ� LQIRUPDWLRQ� VKHHW� RXWOLQLQJ� WKH� SRVVLEOH� VLGH� HIIHFWV� IURP� SULPDTXLQH�(Appendix 4).

Follow-up

3DWLHQWV�VKRXOG�EH�UHYLHZHG�ZLWK�D�EORRG�¿OP�E\�WKH�DGPLWWLQJ�,QIHFWLRXV�'LVHDVHV�3DHGLDWULF�WHDP�7 days after treatment is commenced (including a check that primaquine (where necessary) is being WROHUDWHG��7KH� FOLQLFDO� UHYLHZ�DOVR�QRWHV� WKH� UHFRYHU\�RI� WKH�SDWLHQW� DQG� UHVROXWLRQ�RI� V\PSWRPV��3DWLHQWV�VKRXOG�EH�DGYLVHG�WKDW�LI�WKHUH�LV�UHFXUUHQFH�RI�IHYHU�LQ�WKH�QH[W��PRQWKV�WKH\�VKRXOG�VHHN�PHGLFDO�DGYLFH�DQG�UHSHDW��EORRG�¿OP�

10 11


Public health response

Background

7KH�H[LVWHQFH�RI� FRPSHWHQW�PDODULD� YHFWRUV� VXFK�DV�Anopheles farauti s.l. in the Top End of the Northern Territory means that each case of malaria diagnosed in the Top End is a potential risk for the rest of the population. The NT has remained malaria free for many decades due to the strict isolation of cases and prompt public health response by CDC and Medical Entomology.

0DODULD�LV�VFKHGXOHG�DV�D�QRWL¿DEOH�GLVHDVH�XQGHU�WKH�1RWL¿DEOH�'LVHDVH�$FW�DQG�LV�XUJHQWO\�QRWL¿DEOH�E\�ERWK�GRFWRUV�DQG�ODERUDWRULHV��1RWL¿FDWLRQ�RI�D�FDVH�RI�PDODULD�LV�XVXDOO\�UHFHLYHG�IURP�ODERUDWRULHV�E\�SKRQH�EXW�LV�VRPHWLPHV�UHFHLYHG�E\�ID[��&'&�PD\�VHHN�IXUWKHU�LQIRUPDWLRQ�IURP�FOLQLFLDQV��2QFH�diagnosed, the responsibility for initiating the public health response lies with the local CDC Malaria 6XUYHLOODQFH�2I¿FHU��062��ZKR�WKHQ�LQIRUPV�0HGLFDO�(QWRPRORJ\��ZKR�PD\�RU�PD\�QRW�LQVWLJDWH�D�response in the community.

Screening of high risk groups

3URWRFROV�KDYH�EHHQ�GHYHORSHG� IRU�VFUHHQLQJ� IRU�PDODULD�SDUDVLWHV� LQ�KLJK�ULVN�JURXSV�RQ�HQWU\� WR�WKH�17��6XFK�JURXSV�LQFOXGH�UHIXJHH�PLJUDQWV��LOOHJDO�¿VKHUSHUVRQV��VHH�$SSHQGL[��VWXGHQWV�IURP�high-risk areas such as Papua New Guinea (see Appendix 6), West Papua and the Solomon Islands. 2YHU�WKH�ODVW��\HDUV�WR��RI�DOO�PDODULD�LQIHFWLRQV�LQ�WKH�17�ZHUH�GLDJQRVHG�E\�VFUHHQLQJ��Contact NT CDC for further information on 8922 8804.

Refugee migrant screening

'XH�WR�WKH�ULVN�RI�DV\PSWRPDWLF�FDUULDJH�RI�PDODULD�DQG�SRWHQWLDO�ORFDO�WUDQVPLVVLRQ��DOO�QHZO\�DUULYHG�UHIXJHHV�IURP�$IULFD�DUH�VFUHHQHG�SUHIHUDEO\�ZLWKLQ��KRXUV�RI�DUULYDO�LQ�'DUZLQ��

CDC staff work in consultation with the Department of Immigration and Multicultural Affairs and Melaleuca Refugee Centre to arrange transport and testing at Royal Darwin Hospital (weekdays). All UHIXJHH�PLJUDQWV�DUH�WHVWHG�ZLWK�D�WKLFN�DQG�WKLQ�EORRG�¿OP�DQG�PDODULD�DQWLJHQ�

$OO� SRVLWLYH�PDODULD� UHVXOWV� �LQFOXGLQJ�SRVLWLYH�DQWLJHQ�QHJDWLYH�EORRG�¿OP��DUH� WKHQ�SKRQHG� WR� WKH�Infectious Diseases Registrar on call who then contacts the Melaleuca Refugee Centre to arrange immediate transport of the patient to the Emergency Department for assessment and treatment (see ÀRZVKHHW�S��

5HIXJHH�PLJUDQWV�ZKR�KDYH�D�SRVLWLYH�DQWLJHQ�DQG�QHJDWLYH�¿OP�DUH�DVVHVVHG� LQGLYLGXDOO\�E\� WKH�,QIHFWLRXV�'LVHDVHV�5HJLVWUDU�DQG�WUHDWHG�IRU�PDODULD��HYHQ�LQ�WKH�DEVHQFH�RI�SDUDVLWHV��

Management of co-travellers

$OO�FR�WUDYHOOHUV�RI�D�PDODULD�FDVH�ZLWK�VLPLODU�KLJK�ULVN�PDODULD�H[SRVXUH�VKRXOG�EH�WHVWHG�IRU�PDODULD�through the NT Centre for Disease Control (CDC). This is arranged by the MSO when the patient is LQWHUYLHZHG�

7KH�SDWKRORJ\�UHTXHVW� IRUP�VKRXOG� LQFOXGH�WKH�WHUP�µFR�WUDYHOOHU�RI�PDODULD�FDVH¶�� WKH�UHJLRQ�PRVW�OLNHO\�WKDW�PDODULD�ZDV�DFTXLUHG�DQG�ZKHWKHU�WKH�FR�WUDYHOOHU�KDV�DQ\�V\PSWRPV�VXJJHVWLYH�RI�PDODULD��&R�WUDYHOOHUV�ZLWK�SRVLWLYH�VPHDUV�DUH�WUHDWHG�DFFRUGLQJO\��

5ROH�RI�&'&�0DODULD�6XUYHLOODQFH�2I¿FHU��062�

1. &RQ¿UP�WKDW�WKH�FDVH�IXO¿OV�WKH�FDVH�GH¿QLWLRQ�IRU�D�FRQ¿UPHG�RU�SUREDEOH�FDVH1 (see p 3). 2. ,QWHUYLHZ�WKH�FDVH�XVLQJ�WKH�Malaria Surveillance Case Questionnaire (Appendix 2). This is

usually done face-to-face if the patient is in hospital but can be done by phone.3. 0DNH�DQ�DVVHVVPHQW�EDVHG�RQ�WKH�RQVHW�RI�WKH�LOOQHVV�DQG�WKH�WUDYHO�KLVWRU\�DERXW�WKH�OLNHO\�

VRXUFH�RI�LQIHFWLRQ��7KHUH�LV�VSDFH�LQ�WKH�HQKDQFHG�GDWD�IRU��SODFHV�RI�DFTXLVLWLRQ��µFRXQWU\�RI�LQIHFWLRQ¶��VWDUWLQJ�ZLWK�WKH�PRVW�OLNHO\��,I�WKH�FRXQWU\�LV�31*��,QGRQHVLD�RU�(DVW�7LPRU��WKH�region of infection should also be ascertained and documented.2

4. $V�SDUW�RI�WKH�LQWHUYLHZ�DVFHUWDLQ�LQ�GHWDLO�WKH�ORFDWLRQ�RI�WKH�FDVH�LQ�WKH�17�DIWHU�WKH\�EHFDPH�XQZHOO��¿UVW�IHYHU��,QFOXGH�ORFDWLRQ�RI�UHVLGHQFH�EXW�DOVR�DVN�DERXW�DQ\�WUDYHO��LQFOXGLQJ�GDWHV��ZLWKLQ�WKH�17�GXULQJ�WKDW�WLPH��'RFXPHQW�GDWH�RI�RQVHW�RI�IHYHU��

5. ,I�WKH�FDVH�KDV�EHHQ�GLDJQRVHG�E\�VFUHHQLQJ�WKH\�PD\�QRW�KDYH�D�KLVWRU\�RI�IHYHU��DVN�DERXW�GHWDLOV�RI�ORFDWLRQ�LQ�WKH�17�VLQFH�DUULYDO�

6. 1RWH�ZKHWKHU�JDPHWRF\WHV�DUH�SUHVHQW�LQ�WKH�EORRG�¿OP�7. Following collection of the enhanced data, inform Medical Entomology about the case. If there

DUH�JDPHWRF\WHV�SUHVHQW��0HGLFDO�(QWRPRORJ\�VKRXOG�EH�QRWL¿HG�E\�SKRQH�DQG�WKH�FRPSOHWHG�questionnaire forwarded.

8. $UUDQJH�IRU�VFUHHQLQJ�RI�FR�WUDYHOOHUV�3 This may be through General Practitioners but can be arranged through CDC.

9. Core data entry from the Malaria Surveillance Case Questionnaire is entered into the NTNDS by the MSO.

10. 7ZR�ZHHNV�DIWHU�LQWHUYLHZ��FKHFN�FDVH�UHFRUG�WR�DVFHUWDLQ�WKH�ZKHWKHU�SULPDTXLQH�ZDV�XVHG�(1 day or 14 day course). It might be necessary to contact the case for this information.

11. Enhanced data is then entered into the NTNDS by the MSO.

See algorithm p 13.

1 Note that there is an NT-only probable category for malaria2 See the NTNDS data dictionary for lists of regions3�7KH�GH¿QLWLRQ�RI�FR�WUDYHOOHU�LV�QRW�DOZD\V�VWUDLJKWIRUZDUG�EXW�FRXOG�EH�GH¿QHG�DV�DQ\RQH�ZKR�ZDV�WUDYHOOLQJ�ZLWK�WKH�

case at the likely time of acquisition and can be contacted.

12 13


Malaria public health response

Case of malaria

/DERUDWRU\�QRWL¿HV�&'&�DQG�FOLQLFLDQV�RI�malaria, type and gametocyte status

,QWHUYHQWLRQ�measures

No action

� &'&�062 �LQWHUYLHZV�patient and completes HQKDQFHG�QRWL¿FDWLRQ�IRUP

� MSO organises screening RI�FR�WUDYHOOHUV

After 2 weeks CDC MSO SKRQHV�FDVH�DQG�LQWHUYLHZV�WR�YHULI\�FRPSOLDQFH�ZLWK�primaquine treatment if

prescribed

&R�WUDYHOOHU�PDODULD�screening

� symptoms � PDODULD�WKLFN�DQG�WKLQ�¿OP � malaria antigen � check for G6PD

&R�WUDYHOOHUSRVLWLYH�PDODULD�VOLGH�

DQG�RU�DQWLJHQ

'LVFKDUJH�IURP�IROORZXS�IURP�&'&�DIWHU�SURYLGLQJ� � education on malaria (factsheet†) � IXWXUH�WUDYHO�DQG�PDODULD�SURSK\OD[LV�DGYLFH � DGYLFH�RQ�SUHYHQWLRQ�RI�PRVTXLWR�ELWHV

Entomological assessment

�0DODULD�6XUYHLOODQFH�2I¿FHU† Appendix 8 and 9

Medical Entomology

0HGLFDO� (QWRPRORJ\� VKRXOG� EH� QRWL¿HG� RI� DOO� PDODULD� FDVHV� DQG� ZLOO� DVVHVV� WKH� QHHG� IRU� IXUWKHU�DFWLRQ�� 7KH�0DODULD� 6XUYHLOODQFH�2I¿FHU� IURP�&'&�ZLOO� LQWHUYLHZ� WKH� SDWLHQW� DV� VRRQ� DV� SRVVLEOH�(within working hours), complete the NT Malaria Surveillance Case Questionnaire (Appendix 2), fax LW� WR�0HGLFDO� (QWRPRORJ\� DQG� ¿OH� WKH� RULJLQDO� DW� &'&� DIWHU� QRWL¿FDWLRQ��2I� SDUWLFXODU� FRQFHUQ� DUH�FDVHV�ZLWK�JDPHWRF\WHV�LQ�WKHLU�EORRG��DV�JDPHWRF\WHV�DUH�WKH�IRUP�RI�PDODULD�SDUDVLWH�LQIHFWLYH�WR�PRVTXLWRHV��WKHVH�SDWLHQWV�VKRXOG�KDYH�UHFHLYHG�WKH�¿UVW�GRVH�RI�DUWHPHWKHU�OXPHIDQWULQH�RU�D�VWDW�dose of primaquine as an inpatient or in the Emergency Department before transfer to HITH).

It is important to establish with the malaria case: � Where and when the patient was most likely infected; � :KHUH�WKH\�KDYH�EHHQ�VWD\LQJ�LQ�WKH�17�VLQFH�WKH\�EHFDPH�V\PSWRPDWLF��LQFOXGLQJ�FRQWDFW�

details of the property owner); � +RZ�ORQJ�WKH\�KDYH�EHHQ�DW�WKDW�ORFDWLRQ��DQG � Whether they were bitten by mosquitoes between dusk and dawn at that location.

Medical Entomology investigation

7KH�0HGLFDO� (QWRPRORJ\� LQYHVWLJDWLRQ� GHWHUPLQHV� WKH� ULVN� RI� SUREDEOH� SDWLHQW�YHFWRU� FRQWDFW� DQG�therefore of possible transmission to mosquitoes.

7KH�GHFLVLRQ�IRU�IXUWKHU�DFWLRQ�LV�PDGH�RQ�ZKHWKHU�LQIHFWLYH�VWDJHV�RI�PDODULD�DUH�SUHVHQW�LQ�WKH�EORRG��WKH�ORFDWLRQ�RI�WKH�SDWLHQW�GXULQJ�¿UVW�IHYHU��WKH�OHQJWK�RI�WLPH�VLQFH�WKH�¿UVW�IHYHU�DQG�WKH�OLNHOLKRRG�RI�H[SRVXUH�WR�YHFWRU�PRVTXLWRHV��7KH�SUR[LPLW\�RI�WKH�SDWLHQW¶V�UHVLGHQFH�DQG�RWKHU�SODFHV�YLVLWHG�DW�QLJKW�WR�WKH�QHDUHVW�PRVTXLWR�EUHHGLQJ�VLWHV�DUH�GHWHUPLQHG�IURP�PDSV��3UHYLRXV�PRVTXLWR�WUDS�FDWFKHV�from these areas and the nearest routine mosquito monitoring site (if applicable) are assessed for the potential presence of Anopheles�VSHFLHV�YHFWRU�PRVTXLWRHV��VHH�0HGLFDO�(QWRPRORJ\�LQYHVWLJDWLRQ��Appendix 7).

,I� WKH�SODFH�RI�UHVLGHQFH�LV�D�UHJLRQDO�FHQWUH�RXWVLGH�RI�'DUZLQ�� WKH�UHOHYDQW�(QYLURQPHQWDO�+HDOWK�2I¿FHU��(+2��LV�DOHUWHG�WR�WKH�QHHG�WR�VHW�PRVTXLWR�WUDSV�DQG�WKH�SRVVLEOH�QHHG�WR�FRQGXFW�DQ�DGXOW�FRQWURO�RSHUDWLRQ�DQG�WR�HQVXUH�HTXLSPHQW�DQG�VWDII�DYDLODELOLW\��

Action that may be recommended if there is a possibility of local transmission may include: � Fogging operations around the immediate residential area or the nearest mosquito breeding

or harbouring area; � /LPLWHG�VXUYHLOODQFH�IRU�PDODULD�LQ�WKH�QHLJKERXUKRRG� � A malaria warning pamphlet being distributed to nearby residents; and � 'RFWRUV� DQG�&RPPXQLW\�&DUH�+HDOWK�&HQWUHV� LQ� WKH� DUHD� EHLQJ� DGYLVHG� WR� EH� RQ� DOHUW� IRU�

SDWLHQWV�ZLWK�XQH[SODLQHG�IHYHUV�RU�RWKHU�VXJJHVWLYH�V\PSWRPV�

5HFRUGV�RI�DOO�FRQ¿UPHG�PDODULD�FDVH�LQYHVWLJDWLRQV�DUH�PDLQWDLQHG�DW�&'&��'DUZLQ�

&R�WUDYHOOHUQHJDWLYH�PDODULD�VOLGH�

and antigen.

&R�WUDYHOOHUStill has symptoms?

Discuss with Infectious Diseases

Physician

14 15


APPENDIX 1

Therapeutic guidelines: antibiotic. Malaria 2010

0DODULD�PXVW�EH�FRQVLGHUHG�LQ�DQ\�SDWLHQW�ZKR�KDV�YLVLWHG�D�PDODULRXV�DUHD�DQG�SUHVHQWV�ZLWK�D�IHEULOH�illness. A blood sample collected into an EDTA tube should be sent to an appropriate laboratory for H[DPLQDWLRQ��LQFOXGLQJ�WKLFN�DQG�WKLQ�¿OPV�

$� VLQJOH� QHJDWLYH� EORRG� ¿OP� RU� QHJDWLYH� DQWLJHQ� WHVW� GRHV� QRW� H[FOXGH� WKH� GLDJQRVLV� RI� PDODULD��SDUWLFXODUO\�LI�DQWLPDODULDOV�RU�DQWLELRWLFV�KDYH�EHHQ�WDNHQ�UHFHQWO\��&HUWDLQ�DQWLELRWLFV�WKDW�DUH�FRPPRQO\�XVHG�E\�WUDYHOOHUV��VXFK�DV�WULPHWKRSULP�VXOIDPHWKR[D]ROH��WHWUDF\FOLQHV�DQG�WKH�ÀXRURTXLQRORQHV��KDYH�VRPH�DQWLPDODULDO�DFWLYLW\��7KLV�PD\�PRGLI\�RU�VXSSUHVV�PDODULD�V\PSWRPV�DQG�PDNH�GLDJQRVLV�E\�EORRG�¿OP�PRUH�GLI¿FXOW�

Of the 5 species that infect humans, Plasmodium falciparum is the most pathogenic and most resistant to standard antimalarials.

Treatment

Uncomplicated Plasmodium falciparum malaria

$UWHPHWKHU�OXPHIDQWULQH�LV�WKH�GUXJ�RI�¿UVW�FKRLFH�IRU�WKH�WUHDWPHQW�RI�XQFRPSOLFDWHG�Plasmodium falciparum malaria. Initial treatment in hospital is recommended. Use:

1. artemether+lumefantrine tablets 20+120 mg

adult and child more than 34 kg: 4 tablets (child 5 to 14 kg: 1 tablet; 15 to 24 kg: 2 tablets; 25 to 34 kg: 3 tablets) orally with fatty food or full-fat milk, at 0, 8, 24, 36, 48 and 60 hours, making a total adult dose of 24 tablets in 6 doses

OR

2. atovaquone+proguanil tablets 250+100 mg (adult formulation)

adult and child more than 40 kg: 4 tablets (child 11 to 20 kg: 1 tablet; 21 to 30 kg: 2 tablets; 31 to 40 kg: 3 tablets) orally with fatty food or full-fat milk, daily for 3 days

OR THE COMBINATION OF

3. quinine sulfate 600 mg (adult less than 50 kg: 450 mg) (child: 10 mg/kg up to 600 mg) orally, 8-hourly for 7 days*

%RWK�TXLQLQH�VXOIDWH�DQG�ELVXOIDWH�DUH�DYDLODEOH�LQ��PJ�WDEOHWV��4XLQLQH�VXOIDWH��PJ�LV�DSSUR[LPDWHO\�HTXLYDOHQW�WR�TXLQLQH�ELVXOIDWH��PJ��$OWKRXJK�OLVWHG�DV�&DWHJRU\�'��TXLQLQH�KDV�EHHQ�H[WHQVLYHO\�XVHG�IRU�WUHDWLQJ�P. falciparum malaria in pregnancy.

PLUS EITHER

doxycycline 100 mg (child more than 8 years: 2.5 mg/kg up to 100 mg) orally, 12-hourly for 7 days, which need not commence on day 1

OR (for pregnant females or children)

clindamycin 300 mg (child: 5 mg/kg up to 300 mg) orally, 8-hourly for 7 days.

$WRYDTXRQH�SURJXDQLO�VKRXOG�QRW�EH�XVHG�IRU�WUHDWPHQW�RI�PDODULD�LQ�SDWLHQWV�ZKR�WRRN�WKHVH�GUXJV�as prophylaxis.

Severe malaria

8UJHQW�WUHDWPHQW�RI�VHYHUH�PDODULD�LV�HVVHQWLDO�LI�WKH�SDWLHQW�KDV�DQ\�RI�WKH�IROORZLQJ�

� DQ\�GHJUHH�RI�DOWHUHG�FRQVFLRXVQHVV��MDXQGLFH��ROLJXULD��VHYHUH�DQDHPLD�RU�K\SRJO\FDHPLD � D�SDUDVLWH�FRXQW�DERYH��PP��JUHDWHU�WKDQ��RI�UHG�EORRG�FHOOV�SDUDVLWLVHG� � WKH�SDWLHQW�LV�YRPLWLQJ�RU�FOLQLFDOO\�DFLGRWLF�

Chloroquine-resistant Plasmodium falciparum� PXVW� EH� DVVXPHG� WR� EH� WKH� LQIHFWLYH� DJHQW�� 2QFH�PDQGDWRU\�,9�WKHUDS\�KDV�EHHQ�VWDUWHG��VHHN�H[SHUW�DGYLFH��$�ODUJH�PXOWLFHQWUH�UDQGRPLVHG�FRQWUROOHG�WULDO�KDV�VKRZQ�PRUWDOLW\�LQ�VHYHUH�P. falciparum malaria is lower when IV artesunate* is used rather than IV quinine†. Artesunate should be used in preference to IV quinine only if it is immediately DYDLODEOH��8VH�

1. artesunate (adult and child) 2.4 mg/kg IV, on admission and repeat at 12 hours and 24 hours, then once daily until oral therapy is possible. When patient is able to tolerate oral therapy, give a full course (6 doses) of artemether+lumefantrine, as for uncomplicated P. falciparum malaria

OR (if parenteral artesunate is not immediately available)

2. quinine dihydrochloride IV, as outlined below.

,I�TXLQLQH�LV�XVHG��DQ�LQLWLDO�ORDGLQJ�GRVH�VKRXOG�EH�JLYHQ�XQOHVV�WKH�SDWLHQW�KDV�UHFHLYHG��RU�PRUH�GRVHV�RI�TXLQLQH�RU�TXLQLGLQH� LQ� WKH�SUHYLRXV��KRXUV��RU�PHÀRTXLQH�SURSK\OD[LV� LQ� WKH�SUHYLRXV��KRXUV��RU�D�PHÀRTXLQH� WUHDWPHQW�GRVH�ZLWKLQ� WKH�SUHYLRXV��GD\V��)UHTXHQW�PHDVXUHPHQWV�RI�blood pressure and blood glucose are required as quinine stimulates insulin secretion and can cause K\SRJO\FDHPLD��&DUGLDF�PRQLWRULQJ�LV�DGYLVHG�LI�WKHUH�LV�SUH�H[LVWLQJ�KHDUW�GLVHDVH�

For loading dose, use:

1. quinine dihydrochloride (adult and child) 20 mg/kg IV over 4 hours

OR

* $UWHVXQDWH�LV�DQ�DUWHPLVLQLQ�GHULYDWLYH��,W�LV�QRW�UHJLVWHUHG�IRU�XVH�LQ�$XVWUDOLD�EXW�LV�DYDLODEOH�YLD�WKH�6SHFLDO�$FFHVV�6FKHPH��7HOHSKRQH��ZZZ�WJD�JRY�DX�KS�VDV�KWP!

† Dondorp A, Nosten F, Stepniewska K, Day N, White N for the South East Asian Quinine Artesunate Malaria �6($48$0$7��JURXS��$UWHVXQDWH�YHUVXV�TXLQLQH�IRU�WUHDWPHQW�RI�VHYHUH�IDOFLSDUXP�PDODULD��D�UDQGRPLVHG�WULDO��/DQFHW��KWWS��ZZZ�QFEL�QOP�QLK�JRY�HQWUH]�TXHU\�IFJL"FPG 5HWULHYHGE 3XE0HGGRSW &LWDWLRQOLVWBXLGV ��

Note: Dosing regimens:KHUH�DOWHUQDWLYH�GUXJ�UHJLPHQWV�DUH�OLVWHG��WKH�RUGHU�RI�SUHIHUHQFH�IRU�XVH�RI�HDFK�GUXJ�LV�LQGLFDWHG�E\�WKH�QXPEHU�SODFHG�QHVW�WR�LWV�UHJLPHQ��IRU�¿UVW�SUHIHUHQFH��IRU�VHFRQG�SUHIHUHQFH�DQG�VR�RQ��'UXJV�RI�HTXDO�SUHIHUHQFH�DUH�PDUNHG�ZLWK�the same number and are generally listed in alphabetical order.

16 17


2. quinine dihydrochloride (adult and child) 7 mg/kg IV over 30 minutes, followed immediately by 10 mg/kg IV over 4 hours.

For maintenance dose, use:

quinine dihydrochloride (adult and child) 10 mg/kg IV over 4 hours, 8-hourly, commencing 4 hours after loading regimen is completed and continuing until the patient is able to begin oral treatment (see below).

,I�,9�TXLQLQH�LV�UHTXLUHG�IRU�ORQJHU�WKDQ��KRXUV��VHHN�H[SHUW�DGYLFH�DV�D�GRVH�DGMXVWPHQW�PD\�EH�necessary especially in patients with renal impairment.

:KHQ�WKH�SDWLHQW�KDV�FOLQLFDOO\�LPSURYHG��RUDO�WUHDWPHQW�FDQ�EH�FRPPHQFHG��*LYH�D�IXOO�FRXUVH��GRVHV��RI�DUWHPHWKHU�OXPHIDQWULQH��DV�IRU�XQFRPSOLFDWHG�P. falciparum�PDODULD��,I�DUWHPHWKHU�OXPHIDQWULQH�LV�QRW�DYDLODEOH��XVH�RUDO�TXLQLQH�FRPELQHG�ZLWK�GR[\F\FOLQH�RU�FOLQGDP\FLQ��DV� IRU�XQFRPSOLFDWHG�P. falciparum malaria, to complete a total of 7 days of treatment with quinine.

Other forms of malaria

For Plasmodium vivax acquired outside�,QGRQHVLD��7LPRU�/HVWH�RU�3DFL¿F�,VODQG�1DWLRQV��LQFOXGLQJ�Papua New Guinea, Solomon Islands and Vanuatu), and for Plasmodium malariae and Plasmodium ovale, use:

chloroquine 620 mg base (= 4 tablets of chloroquine phosphate 250 mg) (child: 10 mg base/kg up to 620 mg base) orally, initially, then 310 mg base (= 2 tablets) (child: 5 mg base/kg up to 310 mg base) 6 hours later and on days 2 and 3, making a total adult dose of 10 tablets*.

For Plasmodium vivax acquired in�,QGRQHVLD��7LPRU�/HVWH�RU�3DFL¿F�,VODQG�1DWLRQV��LQFOXGLQJ�3DSXD�1HZ�*XLQHD��6RORPRQ�,VODQGV�DQG�9DQXDWX��DQG�IRU�OHVV�VHYHUH�Plasmodium knowlesi†, use:

1. artemether+lumefantrine, as for uncomplicated Plasmodium falciparum malaria

OR

2. PHÀRTXLQH��PJ��FKLOG��PJ�NJ�XS�WR��PJ��RUDOO\��LQLWLDOO\��WKHQ��PJ��FKLOG��PJ�NJ�XS�to 500 mg) 6 to 8 hours later.

0HÀRTXLQH�VKRXOG�QRW�EH�XVHG�IRU�WUHDWPHQW�RI�PDODULD�LQ�SDWLHQWV�ZKR�WRRN�WKLV�DV�SURSK\OD[LV�

)RU�VHYHUH�P. knowlesi PDODULD��WUHDW�DV�IRU�VHYHUH�PDODULD�

,I� WKH�SDWLHQW� LV� XQDEOH� WR� WROHUDWH�RUDO� WKHUDS\��ZKLFK� LV� EHVW� WDNHQ�ZLWK� IRRG�� WUHDW� DV� IRU� VHYHUH�PDODULD�DQG�VHHN�H[SHUW�DGYLFH�

� &KORURTXLQH�SKRVSKDWH��PJ�LV�HTXLYDOHQW�WR��PJ�FKORURTXLQH�EDVH��&KORURTXLQH�LV�QRW�PDUNHWHG�LQ�$XVWUDOLD�EXW�LV�DYDLODEOH�YLD�WKH�6SHFLDO�$FFHVV�6FKHPH��7HOHSKRQH��ZZZ�WJD�JRY�DX�KS�VDV�KWP!��,Q�DGXOWV��K\GUR[\FKORURTXLQH�FDQ�EH�XVHG�DV�DQ�DOWHUQDWLYH�LI�FKORURTXLQH�LV�QRW�DYDLODEOH��8VH�K\GUR[\FKORURTXLQH�DV�SHU�WKH�FKORURTXLQH�GRVLQJ�VFKHGXOH��K\GUR[\FKORURTXLQH�VXOIDWH��PJ�LV�HTXLYDOHQW�WR��PJ�K\GUR[\FKORURTXLQH�EDVH��

† Plasmodium knowlesi has recently been recognised as an important cause of malaria in parts of South-East Asia and, on microscopy, has the appearance of Plasmodium malariae.

7R�HOLPLQDWH�OLYHU�IRUPV�RI�DOO�P. vivax infections,�LUUHVSHFWLYH�RI�ZKHUH�DFTXLUHG��add:

primaquine 30 mg (child: 0.5 mg/kg up to 30 mg) orally, daily with food, or if nausea occurs 15 mg (child: 0.25 mg/kg up to 15 mg) orally, 12-hourly with food. Treat for a minimum of 14 days or, in adults more than 70 kg, until a total cumulative dose of 6 mg/kg is reached*.

7R�HOLPLQDWH�OLYHU�IRUPV�RI�P. ovale infections, add:

primaquine 15 mg (child: 0.25 mg/kg up to 15 mg) orally, daily with food for 14 days.

,I�WKH�SDWLHQW�UHODSVHV�DIWHU�WKH�SULPDTXLQH�WUHDWPHQW��VHHN�H[SHUW�DGYLFH�

([FOXGH�JOXFRVH��SKRVSKDWH�GHK\GURJHQDVH��*�3'��GH¿FLHQF\�EHIRUH�XVLQJ�SULPDTXLQH��DV�VHYHUH�KDHPRO\VLV�PD\�RFFXU�LQ�WKHVH�SDWLHQWV��,I�WKH�SDWLHQW�LV�*�3'�GH¿FLHQW��VHHN�H[SHUW�DGYLFH�

Prophylaxis

7KH�GHYHORSPHQW�RI�ZLGHVSUHDG�PXOWLGUXJ�UHVLVWDQW�VWUDLQV�RI�Plasmodium falciparum throughout the world, but particularly in South-East Asia, complicates recommendations for prophylaxis.

7KHUH�LV�FRQVLGHUDEOH�YDULDWLRQ�LQ�WKH�PDODULD�SURSK\OD[LV�UHFRPPHQGDWLRQV�PDGH�E\�GLIIHUHQW�KHDOWK�DXWKRULWLHV�DQG�H[SHUWV��8VHIXO�LQIRUPDWLRQ�UHJDUGLQJ�WKH�PDODULD�ULVN�DQG�WKH�GUXJ�VXVFHSWLELOLW\�SUR¿OH�IRU�VSHFL¿F�JHRJUDSKLFDO�ORFDWLRQV�LV�DYDLODEOH�IURP�

� :RUOG�+HDOWK�2UJDQL]DWLRQ��,QWHUQDWLRQDO�WUDYHO�DQG�KHDOWK��ZZZ�ZKR�LQW�LWK�,7+��FKDSWHU��SGI!

� &HQWHUV�IRU�'LVHDVH�&RQWURO�DQG�3UHYHQWLRQ��7UDYHOHUV¶�KHDOWK²<HOORZ�ERRN��KWWS��ZZZQF�FGF�JRY�WUDYHO�\HOORZERRN��FKDSWHU��PDODULD�ULVN�LQIRUPDWLRQ�DQG�prophylaxis.aspx>

$OWHUQDWLYHO\�� WUDYHO�PHGLFLQH� FOLQLFV�� DGYLVRU\� VHUYLFHV� DQG� RWKHU� H[SHUWV� FDQ� SURYLGH� DSSURSULDWH�information. This is particularly recommended for children, pregnant women, people staying in PDODULD�HQGHPLF�UHJLRQV�IRU�PRUH�WKDQ��ZHHNV��SHRSOH�ZLWK�FRPSOH[�WUDYHO�LWLQHUDULHV��DQG�SHRSOH�WUDYHOOLQJ�WR�KLJK�ULVN�DUHDV�

�3ULPDTXLQH�IDLOXUHV�FDQ�RFFXU��HVSHFLDOO\�ZKHQ�WKH�LQIHFWLRQ�KDV�EHHQ�DFTXLUHG�LQ�,QGRQHVLD��7LPRU�/HVWH�RU�3DFL¿F�,VODQG�1DWLRQV��(YLGHQFH�LQGLFDWHV�WKDW�SULPDTXLQH�IDLOXUH�DQG�UHODSVH�ZLWK�LQIHFWLRQ�DUH�PRUH�FRPPRQ�ZKHQ�SULPDTXLQH�LV�QRW�DGPLQLVWHUHG�FRQFXUUHQWO\�ZLWK�WKH�WUHDWPHQW�IRU�EORRG�VWDJH�LQIHFWLRQ��DQG�RU�LI�OHVV�WKDQ�D�WRWDO�FXPXODWLYH�GRVH�RI��PJ�NJ�LV�WDNHQ��HJ�RQO\��GD\V�WUHDWPHQW�LQ�DGXOWV�PRUH�WKDQ��NJ��

18 19


Vector avoidance

6LJQL¿FDQW�SURWHFWLRQ�LV�FRQIHUUHG�E\�WKH�VLPSOH�YHFWRU�DYRLGDQFH�PHDVXUHV�RI�

� XVLQJ�HIIHFWLYH�SHUVRQDO�LQVHFW�UHSHOOHQW�DQG�DQ�LQVHFWLFLGH�IRU�LQGRRU�XVH� � ZHDULQJ�OLJKW�FRORXUHG�ORQJ�WURXVHUV�DQG�ORQJ�VOHHYHG�VKLUWV�LQ�WKH�HYHQLQJ� � sleeping in screened accommodation or using mosquito nets, which can be pyrethroid

impregnated; � DYRLGLQJ�RXWVLGH�DFWLYLWLHV�EHWZHHQ�GXVN�DQG�GDZQ� � DYRLGLQJ�SHUIXPH�DQG�DIWHUVKDYH�

Chemoprophylaxis

7KHUH�LV�QR�GUXJ�UHJLPHQ�WKDW�LV�FRPSOHWHO\�VDIH�DQG�HIIHFWLYH�DJDLQVW�PDODULD��7KH�GHFLVLRQ�WR�XVH�chemoprophylaxis must, therefore, be made by balancing the risk of disease against the potential HI¿FDF\�DQG�WR[LFLW\�RI�WKH�GUXJ�V��WR�EH�XVHG��7KH�ULVN�RI�DFTXLULQJ�PDODULD�GHSHQGV�RQ�IDFWRUV�VXFK�DV�WKH�FRXQWU\�DQG�DUHD�YLVLWHG��WKH�WLPH�RI�\HDU��WKH�GXUDWLRQ�RI�YLVLW�DQG�WKH�W\SH�RI�DFWLYLWLHV�XQGHUWDNHQ��In some places, including many major cities and tourist resorts in malaria-endemic countries, the risk of malaria is low and no prophylaxis needs to be taken. Malaria prophylaxis should be considered when immigrants from malarious areas who are resident in Australia return to a malarious area.

7UDYHOOHUV�WR�PDODULRXV�DUHDV�VKRXOG�EH�DGYLVHG�WKDW�FKHPRSURSK\OD[LV�LV�QRW�DOZD\V�HIIHFWLYH�DQG�DQ\�IHYHU�ZKLOH�DZD\�RU�DIWHU�UHWXUQ�QHHGV�XUJHQW�PHGLFDO�FRQVXOWDWLRQ�DQG�LQYHVWLJDWLRQ�

As malaria can pose a serious problem for pregnant women and postsplenectomy patients, it is strongly recommended that they do not go to malarious areas, particularly those areas with drug-resistant falciparum�PDODULD��3URSK\OD[LV�IRU�FKLOGUHQ�PD\�DOVR�SURYH�SUREOHPDWLF��'R[\F\FOLQH�LV�QRW�UHFRPPHQGHG�IRU�FKLOGUHQ��\HDUV�RU�OHVV��0HÀRTXLQH�LV�QRW�DSSURYHG�IRU�XVH�LQ�FKLOGUHQ�LQ�$XVWUDOLD��EXW�KDV�EHHQ�ZLGHO\�XVHG�RYHUVHDV�

While the combination of chloroquine and proguanil has been widely used for malaria prophylaxis in pregnant women and children, this regimen can no longer be relied on in most areas including Africa, 6RXWK�(DVW�$VLD�DQG�WKH�3DFL¿F�,VODQG�1DWLRQV�

Areas with chloroquine-susceptible malaria

For prophylaxis in areas with chloroquine-susceptible malaria (now only Central America north of Panama), use:

chloroquine 310 mg base (= 2 tablets of chloroquine phosphate 250 mg) (child: 5 mg base/kg up to 310 mg base) orally, once weekly (starting 1 week before entering, and continuing until 4 weeks after leaving the malarious area)*.

�&KORURTXLQH�SKRVSKDWH��PJ�LV�HTXLYDOHQW�WR��PJ�FKORURTXLQH�EDVH��&KORURTXLQH�LV�QRW�PDUNHWHG�LQ�$XVWUDOLD�EXW�LV�DYDLODEOH�YLD�WKH�6SHFLDO�$FFHVV�6FKHPH��7HOHSKRQH��ZZZ�WJD�JRY�DX�KS�VDV�KWP!��,Q�DGXOWV��K\GUR[\FKORURTXLQH�FDQ�EH�XVHG�DV�DQ�DOWHUQDWLYH�LI�FKORURTXLQH�LV�QRW�DYDLODEOH��8VH�K\GUR[\FKORURTXLQH�DV�SHU�WKH�FKORURTXLQH�GRVLQJ�VFKHGXOH��K\GUR[\FKORURTXLQH�VXOIDWH��PJ�LV�HTXLYDOHQW�WR��PJ�K\GUR[\FKORURTXLQH�EDVH��

Areas with chloroquine-resistant malaria

)RU�SURSK\OD[LV�LQ�DUHDV�ZLWK�FKORURTXLQH�UHVLVWDQW�PDODULD��LQFOXGLQJ�3DFL¿F�,VODQG�1DWLRQV��6RXWK�East Asia, Indian subcontinent, China, Africa, South America and the Middle-East), use:

1. atovaquone+proguanil tablets 250+100 mg (adult formulation)

adult and child more than 40 kg: 1 tablet orally, with fatty food or full-fat milk, daily (starting 1 to 2 days before entering, and continuing until 7 days after leaving the malarious area)

atovaquone+proguanil tablets 62.5+25 mg (paediatric formulation)

child 11 to 20 kg: 1 tablet; 21 to 30 kg: 2 tablets; 31 to 40 kg: 3 tablets orally, with fatty food or full-fat milk, daily (starting 1 to 2 days before entering, and continuing until 7 days after leaving the malarious area)

OR

1. doxycycline 100 mg (child more than 8 years: 2.5 mg/kg up to 100 mg) orally, daily (starting 1 to 2 days before entering, and continuing until 4 weeks after leaving the malarious area)

OR

1. PHÀRTXLQH��PJ��FKLOG��WR��NJ��PJ�> ��WDEOHW@��WR��NJ��PJ�> ��WDEOHW@��WR��NJ��PJ�> ��WDEOHW@��WR��NJ��PJ�> ��WDEOHW@��RUDOO\��RQFH�ZHHNO\��VWDUWLQJ��to 3 weeks before entering, and continuing until 4 weeks after leaving the malarious area).

'R[\F\FOLQH�FDQ�FDXVH�RHVRSKDJLWLV��EHVW�DYRLGHG�E\�WDNLQJ�WKH�GUXJ�DIWHU�IRRG�ZLWK�SOHQW\�RI�ÀXLG�DQG�UHPDLQLQJ�XSULJKW�IRU�DW�OHDVW��PLQXWHV�DIWHUZDUGV��SKRWRVHQVLWLYLW\�DQG�YDJLQDO�WKUXVK��0HÀRTXLQH�is contraindicated in patients with neuropsychiatric disorders, epilepsy or cardiac conduction defects. 7UDYHOOHUV�WDNLQJ�PHÀRTXLQH�DV�SURSK\OD[LV�VKRXOG�EH�DZDUH�WKDW�WKHUH�FRXOG�EH�VLJQL¿FDQW�FDUGLRWR[LF�LQWHUDFWLRQV� LI� KDORIDQWULQH�ZHUH� WR�EH�SUHVFULEHG�RYHUVHDV� VXEVHTXHQWO\� IRU� WUHDWPHQW�RI�PDODULD��/XPHIDQWULQH�LV�UHODWHG�FKHPLFDOO\�WR�PHÀRTXLQH�DQG�KDORIDQWULQH��EXW�QR�VLJQL¿FDQW�HIIHFWV�RQ�FDUGLDF�FRQGXFWLRQ��RU�DQ�LQWHUDFWLRQ�ZLWK�PHÀRTXLQH��KDYH�EHHQ�GHVFULEHG�

$UHDV�ZLWK�PHÀRTXLQH�UHVLVWDQW�PDODULD

)RU�SURSK\OD[LV�LQ�DUHDV�ZLWK�PHÀRTXLQH�UHVLVWDQW�PDODULD��LQFOXGLQJ�SDUWV�RI�6RXWK�(DVW�$VLD��XVH��GR[\F\FOLQH�RU��DWRYDTXRQH�SURJXDQLO��VHH�µ$UHDV�ZLWK�FKORURTXLQH�UHVLVWDQW�PDODULD¶�IRU�GRVHV��

Stand-by emergency treatment

6RPH�DXWKRULWLHV�UHFRPPHQG�WKDW� WUDYHOOHUV�ZKR�HOHFW� WR�XVH�FKORURTXLQH�IRU�FKHPRSURSK\OD[LV� LQ�DUHDV�ZLWK�FKORURTXLQH�UHVLVWDQW�PDODULD��RU�ZKR�HOHFW� WR�QRW�XVH�FKHPRSURSK\OD[LV��FDQ�EH�JLYHQ�D� VHOI�WUHDWPHQW� µVWDQG�E\¶� FRXUVH� RI� DUWHPHWKHU�OXPHIDQWULQH� RU� DWRYDTXRQH�SURJXDQLO�� IRU� XVH� LI�PHGLFDO� FDUH� IRU�D� IHEULOH� LOOQHVV� LV�QRW� OLNHO\� WR�EH�DYDLODEOH�ZLWKLQ��KRXUV� �VHH� µ8QFRPSOLFDWHG�Plasmodium falciparum� PDODULD¶� IRU� GRVHV�� +RZHYHU�� WUDYHOOHUV� VKRXOG� EH� ZDUQHG� WKDW� XQFHUWDLQ�GLDJQRVLV� LV� D� SRWHQWLDO� SUREOHP�� ,Q�PDQ\� WURSLFDO� FRXQWULHV�� WUDYHOOHUV�PD\� EH� DEOH� WR� SXUFKDVH��ZLWKRXW� D� SUHVFULSWLRQ�� WUHDWPHQW� FRXUVHV� RI� DQWLPDODULDO� GUXJV�� EXW� VKRXOG� EH� DZDUH� RI� WKH� YHU\�common presence of counterfeit products.

20 21


APPENDIX 2. Malaria Surveillance Case Questionnaire

Northern Territory Malaria Surveillance Case Questionnaire(All questions to be completed for each case or episode of disease)

Part A - CDC investigation

Surname First name Other names DOB ____/____/____ Age HRN Indigenous status Sex M / F Phone Address (Street/No) Suburb/Location District notifying Darwin / Kath / EAR / Barkly / AlicePlace infected 7UXH�RQVHW�GDWH� BBBB�BBBB�BBBB� 1RWL¿FDWLRQ�GDWH� BBBB�BBBB�BBBBMalaria species falciparum / falciparum & malariae / falciparum & vivax / malariae / ovale /

knowlesi / XQVSHFL¿HG��vivaxImported case Y / N Hospitalised Y / NAdmission date ____/____/____ Discharge date ____/____/____Died Y / N Date of death ____/____/____Doctor � &RQ¿UPDWLRQ�VWDWXV� &RQ¿UPHG��3UREDEOHLaboratory Specimen date ____/____/____Specimen type (blood)Laboratory diagnosis method Antigen detection / Microscopy / Nucleic acid testing

Enhanced DataNationality ___________________________________ Arrival date in Australia ____/____/____Case code (please circle): Imported case / Relapsed case / Acquired in Australia (from an imported case) / Acquired in Australia (not from imported case) / Induced (ie blood tx) / Unknown

Overseas travel history*Reason for travel (please circle): Recreation / Refugee / Visiting student / Expatriate visiting relatives / IFF / IMA / Work

Country of travel* Region Entry date Departure date

*If Indonesia, Timor or PNG indicate region Case found by screening: Y / N / Unknown If Yes reason for screen†___________________† 1. Contact tracing, 2 Co-traveller of case, 3. Illegal immigrant, 4. Migrant, 5. Other, 6. Refugee,

7. Unknown, 8. Visiting student. Military Status (please circle) Australian military / International military / Civilian / UnknownCo-travellers screened and given advice Y / N / No co-travellers

Prophylaxis / Pre-departure treatment

Prophylaxis used Y / N Pre-departure treatment Y / N

Drug _________________________________Date comm ___/___/___ Date comp ___/___/___

Compliance (circle below)

Good Missed 1 or more doses No prescribed doses taken Nil prescribed Unknown

Treatment 'DWH�RI�¿UVW�WUHDWPHQW� ___/____/___

Treatment prescription _____________________________________________________

If not admitted to hospital was client contacted 14 days after commencing treatment to check treatment compliance? Y / N

Was eradication treatment (primaquine) used?: Y / N No of days given: _____

Was there infection with more than one species of malaria during this episode? Y / N

Previous malaria diagnosed in the NT: Y / N Date: ____/____/____

Outcome‡: S - Survived DM - Died of malaria DO - Died from another cause U - Unknown

‡ Outcome at discharge from hospital, or if not admitted at the time of followup

(Please tick all species detected for mixed infection)

vivax falciparum malariae ovale knowlesi unknown

Malaria species

Gametocytes detected (Y/N)

/RFDWLRQ�KLVWRU\�IURP�¿UVW�IHYHU

Start date

End date

Visiting / Resident

Street name and number Suburb Town/ Location Mosquito bites (Y / N / UK)

No of bites (few or many)

Time of bites (day/after dark)

*Complete all details for each location, record all places visited after dark not only residential addresses

Has this person been made aware of the possible need for entomological access to place of residence? Y / N

Contact phone no. for property access:_______________________

Interviewer _______________________ Date ____/____/____

(QWRPRORJ\�QRWL¿HG� BBBB�BBBB�BBBB

September 2012

22 23


APPENDIX 3. Use of IV artesunate for severe and complicated malaria

Background

$UWHPLVLQLQ�LV�D�VHVTXLWHUSHQH�ODFWRQH�H[WUDFWHG�IURP�WKH�OHDYHV�RI�$UWHPLVLD�DQQXD��VZHHW�ZRUPZRRG��XVHG�LQ�&KLQD�IRU�WUHDWPHQW�RI�IHYHU�IRU�RYHU�D�WKRXVDQG�\HDUV��,W�LV�D�SRWHQW�DQG�UDSLGO\�DFWLQJ�EORRG�VFKL]RQWRFLGH�DQG�LV�DFWLYH�DJDLQVW�DOO�Plasmodium�VSHFLHV��,W�KDV�EURDG�DFWLYLW\�against asexual parasites, killing all stages from young rings to schizonts. In P. falciparum malaria, artemisinin also kills early-stage (but not mature) gametocytes. Artesunate is a water soluble DUWHPLVLQLQ�GHULYDWLYH�DQG�FDQ�EH�JLYHQ�HLWKHU�E\�LQWUDYHQRXV�RU�LQWUDPXVFXODU�LQMHFWLRQ��$�UHFHQW�ODUJH�PXOWLFHQWUH�UDQGRPLVHG�FRQWUROOHG�WULDO�KDV�VKRZQ�WKDW�PRUWDOLW\�LQ�VHYHUH�P. falciparum malaria is lower when IV artesunate is used rather than IV quinine.

Role in therapy

8UJHQW�,9�WUHDWPHQW�RI�VHYHUH�PDODULD�LV�HVVHQWLDO�LI�WKH�SDWLHQW�KDV�DQ\�RI�WKH�IROORZLQJ�

� DQ\�GHJUHH�RI�DOWHUHG�FRQVFLRXVQHVV��MDXQGLFH��ROLJXULD��VHYHUH�DQDHPLD�RU�K\SRJO\FDHPLD � D�SDUDVLWH�FRXQW�DERYH��PP��!��RI�UHG�EORRG�FHOOV�SDUDVLWLVHG� � WKH�SDWLHQW�KDV�LQWUDFWDEOH�YRPLWLQJ�RU�LV�FOLQLFDOO\�DFLGRWLF�

$UWHVXQDWH�VKRXOG�EH�XVHG�LQ�SUHIHUHQFH�WR�,9�TXLQLQH��LI�LW�LV�LPPHGLDWHO\�DYDLODEOH��8VH�DUWHVXQDWH��PJ�NJ�,9�EROXV�RQ�DGPLVVLRQ�DQG�UHSHDW�DW��KRXUV�DQG��KRXUV��WKHQ�RQFH�GDLO\�XQWLO�RUDO�WKHUDS\�LV�SRVVLEOH��:KHQ�WKH�SDWLHQW�LV�DEOH�WR�WROHUDWH�RUDO�WKHUDS\��JLYH�D�IXOO�FRXUVH�RI�DUWHPHWKHU��OXPHIDQWULQH��PJ��PJ�±�LH��VL[�GRVHV�RI�IRXU�WDEOHWV��WRWDO�FRXUVH�RI��WDEOHWV��JLYHQ�RYHU�D�period of 60 hours, as for uncomplicated Plasmodium falciparum malaria.

,I�SDUHQWHUDO�DUWHVXQDWH�LV�QRW�LPPHGLDWHO\�DYDLODEOH��,9�TXLQLQH�GLK\GURFKORULGH�VKRXOG�EH�XVHG�without delay as per Therapeutic Guidelines Antibiotic 2010 14th Edition. NT hospitals hold HPHUJHQF\�VWRFNV�RI�,9�TXLQLQH��HYHQ�LI�WKH\�DUH�DOVR�KROGLQJ�$UWHVXQDWH�VWRFNV��

Safety

$OOHUJLF�UHDFWLRQV�DUH�UDUH��0DQ\�PLOOLRQV�RI�SDWLHQWV�KDYH�EHHQ�WUHDWHG�ZLWK�DQ�DUWHPLVLQLQ�GUXJ��PRUH�WKDQ��RI�WKHP�DV�SDUWLFLSDQWV�RI�FOLQLFDO�VWXGLHV�DQG�DW�OHDVW��KDYLQJ�IRUPDO�QHXURSK\VLRORJLFDO�HYDOXDWLRQV��ZLWKRXW�DQ\�FRQ¿UPHG�UHSRUWV�RI�QHXURWR[LFLW\��

&RQWUDLQGLFDWLRQV��.QRZQ�K\SHUVHQVLWLYLW\�WR�DUWHPLVLQLQ�GHULYDWLYHV��,Q�YLHZ�RI�WKH�UHGXFHG�ULVN�RI�GHDWK�RI�WKH�PRWKHU��DUWHVXQDWH�VKRXOG�EH�XVHG�LQ�VHYHUH�PDODULD�LQ�SUHJQDQF\��DOWKRXJK�VWXGLHV�RQ�its safety in pregnancy are still ongoing.

Presentation and cost

$UWHVXQDWH�LV�SUHVHQWHG�DV�DUWHVXQLF�DFLG�SRZGHU��PJ��YLDO��DQG�VRGLXP�ELFDUERQDWH��P/��DPSRXOH��5HFRQVWLWXWH�E\�DGGLQJ��P/�VRGLXP�ELFDUERQDWH��WR�WKH�DUWHVXQLF�DFLG�YLDO��WR�IRUP�VRGLXP�DUWHVXQDWH��7KH�DUWHVXQDWH�VROXWLRQ�LV�WKHQ�GLOXWHG�LQ��P/��GH[WURVH��LH��PJ�P/��IRU

Part B – Medical Entomology investigationNT residential address and other localities of potential exposure

Traps set Yes ̆ No ̆ N/A ̆ Vector species at residence Yes ̆ No ̆ N/A ̆

Vector report attached Yes ̆ No ̆�N/A ̆Address Adequately

screenedYes/No

No. of occupants

Distance to nearest

breeding site (km)

Adult record no.

Highest potential vector species

No/ trap/ night

Traps set at nearest breeding and harbouring site Yes ̆ No ̆ N/A ̆ Vectors present Yes ̆ No ̆ N/A ̆Vector Report attached Yes ̆ No ̆ N/A ̆

Previous vector records in vicinity in similar months Yes ̆ No ̆ N/A ̆ Report attached Yes ̆ No ̆ N/A ̆

Part C: ConclusionsPatient vector contact Low ̆��Medium ̆��High ̆ N/A ̆Risk of infected vectors and subsequent transmission Low ̆��Medium ̆��High ̆��N/A ̆

Location of risk

Recommendation for fogging: Yes No N/A Effective fogging practical: Yes No N/A Fogging conducted: Yes No N/A

Recommendations / Action taken / Other comments

,QYHVWLJDWLQJ�0(�2I¿FHU�BBBBBBBBBBBBBBBBBBBBBBBBBBBB

Signature of ME OIC _______________________________ Date / /

24 25


IV bolus administration. The solution should be prepared freshly for each administration and should QRW�EH�VWRUHG��7KH�FRVW�RI�WKH�LQMHFWLRQ�LV�OHVV�WKDQ��SHU�YLDO��

TGA approved indications

The Therapeutic Goods Administration (TGA) has agreed to allow hospital pharmacies to import DQG�KROG�DUWHVXQDWH�IRU�&DWHJRU\�$�XVH�LQ�SDWLHQWV�ZLWK�VHYHUH�PDODULD�XQGHU�WKH�6SHFLDO�$FFHVV�6FKHPH��6$6��&DWHJRU\�$�SDWLHQWV�DUH�GH¿QHG�LQ�WKH�OHJLVODWLRQ�DV�³SHUVRQV�ZKR�DUH�VHULRXVO\�LOO�with a condition from which death is reasonably likely to occur within a matter of months, or from which premature death is reasonably likely to occur in the absence of early treatment”.

NT Hospital Pharmacies at Royal Darwin Hospital (RDH), Katherine Hospital and Alice Springs Hospital stock a limited supply of a batch of parenteral artesunate which has passed endotoxin and sterility testing in an Australian TGA accredited laboratory, and which has been tested to ensure it has a satisfactory content of artesunate. As artesunate is not registered in Australia, responsibility for its use rests primarily with the medical practitioner and the patient. Use of artesunate requires WKH�DSSURYDO�RI�WKH�RQ�FDOO�,QIHFWLRXV�'LVHDVHV�3K\VLFLDQ�LQ�FRQVXOWDWLRQ�ZLWK�WKH�RQ�GXW\�,QWHQVLYH�&DUH�&RQVXOWDQW��7KH�WUHDWLQJ�LQWHQVLYH�FDUH�GRFWRU�VKRXOG�REWDLQ�LQIRUPHG�FRQVHQW�IURP�WKH�patient (with documentation using a hospital consent form) and is required to forward a copy of the Category A SAS form to the TGA within 28 days of its completion.

Evidence

Results from randomised trials in South-East Asia and more recently Africa comparing artesunate DQG�TXLQLQH�VKRZ�FOHDU�HYLGHQFH�RI�EHQH¿W�ZLWK�DUWHVXQDWH��$�UDQGRPLVHG��FRQWUROOHG�PXOWL�FHQWUH�trial (SEAQUAMAT study group: Bangladesh, India, Indonesia and Myanmar) with 1431 patients HQUROOHG��/DQFHW��IRXQG�PRUWDOLW\�RI��LQ�WKH�DUWHVXQDWH�JURXS�ZKLFK�ZDV�VLJQL¿FDQWO\�ORZHU�WKDQ�WKH��LQ�WKH�TXLQLQH�JURXS��DQ�DEVROXWH�ULVN�UHGXFWLRQ�of 7%. Treatment with artesunate was well tolerated, whereas quinine was associated with K\SRJO\FDHPLD��55��&,��±��3� ��

A second large randomised trial published in the Lancet in 2010 randomized 5425 African children ZLWK�VHYHUH�PDODULD�WR�UHFHLYH�,9�DUWHVXQDWH�RU�,9�TXLQLQH��$48$0$7��SDWLHQWV�DVVLJQHG�WR�DUWHVXQDWH�WUHDWPHQW�GLHG�FRPSDUHG�ZLWK��DVVLJQHG�WR�TXLQLQH�WUHDWPHQW��25��²��S ��3RVW�WUHDWPHQW�K\SRJO\FDHPLD�ZDV�OHVV�IUHTXHQW�LQ�SDWLHQWV�DVVLJQHG�WR�DUWHVXQDWH�WKDQ�LQ�WKRVH�DVVLJQHG�WR�TXLQLQH��>��@�YV��>��@��25��²��S ��$UWHVXQDWH�ZDV�ZHOO�WROHUDWHG��ZLWK�QR�VHULRXV�GUXJ�UHODWHG�DGYHUVH�effects.

References

1. :RUOG�+HDOWK�2UJDQLVDWLRQ��:+2��*XLGHOLQHV�IRU�WKH�7UHDWPHQW�RI�0DODULD��$YDLODEOH�DW��KWWS��ZZZ�ZKR�LQW�PDODULD�SXEOLFDWLRQV�DWR]��HQ�LQGH[�KWPO�

2. 6RXWK�(DVW�$VLDQ�4XLQLQH�$UWHVXQDWH�0DODULD�7ULDO��6($48$0$7��JURXS��$UWHVXQDWH�YHUVXV�TXLQLQH�IRU�WUHDWPHQW�RI�VHYHUH�IDOFLSDUXP�PDODULD��D�UDQGRPLVHG�WULDO��The Lancet 2005;366:717-25.

3. $48$0$7�JURXS��$UWHVXQDWH� YHUVXV� TXLQLQH� LQ� WKH� WUHDWPHQW� RI� VHYHUH� IDOFLSDUXP�PDODULD� LQ�$IULFDQ�children (AQUAMAT): an open-label, randomised trial. The Lancet 2010; 1647-57.

4. Editors, Therapeutic guidelines: antibiotic Version 14, 2010. North Melbourne: Therapeutic Guidelines Ltd.

APPENDIX 4. Primaquine: patient information

3ULPDTXLQH�LV�JLYHQ�DIWHU�WKH�FKORURTXLQH�RU�DUWHPHWKHU�OXPHIDWULQH�FRXUVH�LV�FRPSOHWHG�WR�HUDGLFDWH�WKH�OLYHU�IRUPV�RI�P. vivax or P. ovale which can lead to relapse of malaria after months or years.

7KH�HUDGLFDWLRQ�FRXUVH�RI�SULPDTXLQH�LV�JLYHQ�GDLO\�IRU��GD\V�DQG�VKRXOG�EH�WDNHQ�ZLWK�IRRG�WR�SUHYHQW�JDVWURLQWHVWLQDO�VLGH�HIIHFWV�

In case of any darkening of the urine you should stop the primaquine and contact your doctor immediately.

Common side effects

� DEGRPLQDO�SDLQ��QDXVHD�DQG�YRPLWLQJ��ZKHQ�WDNHQ�RQ�DQ�HPSW\�VWRPDFK�

� uncommon side effects

� KDHPRO\WLF�DQDHPLD��LQ�SHUVRQV�ZLWK�*�3'�GH¿FLHQF\�

� methaemoglobinaemia

Rare side effects

� cardiac arrythmias

� hypertension

� anaemia

� leucopenia

� agranulocytosis

Contraindications

� pregnancy � *�3'�GH¿FLHQF\

26 27


$33(1',;��*XLGHOLQHV�IRU�DVVHVVLQJ�XQDXWKRULVHG�,QGRQHVLDQ�¿VKHUSHUVRQV�IRU�malaria

:KHQ�WR�WHVW�¿VKHUSHUVRQV�IRU�PDODULD

7KH�¿VKHUSHUVRQV�ZKR�VKRXOG�EH�WHVWHG�IRU�PDODULD�DUH�WKRVH�ZKR�

1. Are febrile at the time of examination; 2. *LYH�D�FRQYLQFLQJ�KLVWRU\�RI�IHYHU�LQ�WKH�ODVW��ZHHNV��LUUHVSHFWLYH�RI�ZKHWKHU�WKH\�DUH�IHEULOH�DW�WKH�

time of examination; 3. *LYH�D�FRQYLQFLQJ�KLVWRU\�RI�UHFHQW�WUHDWHG�RU�XQWUHDWHG�PDODULD��4. $UH�FR�WUDYHOOHUV�RI�DQ�LQGH[�FDVH�RI�PDODULD��&R�WUDYHOOHUV�DUH�¿VKHUV�IURP�WKH�VDPH�YHVVHO�DV�

the index case;5. )LVKHUV�IURP�D�GLIIHUHQW�YHVVHO�WKDW�KDV�WUDYHOOHG�RYHU�WKH�VDPH�URXWH�DV�WKH�YHVVHO�RI�WKH�LQGH[�

FDVH�RYHU�WKH�SULRU��ZHHNV�

What tests should be done

$OO�¿VKHUSHUVRQV�XQGHUJRLQJ�D�PDODULD�VFUHHQ�VKRXOG�KDYH�

1. 0LFURVFRS\�RI�WKLFN�DQG�WKLQ�EORRG�¿OPV��$1'2. Malaria antigen test (MAT).

1RWH��:KHQ� FR�WUDYHOOHUV�� RU� DQ\� RWKHU� ODUJH� QXPEHU� RI� ¿VKHUV�� DUH� EHLQJ� WHVWHG� IRU�PDODULD�� WKH�ODERUDWRU\�DW�5'+�VKRXOG�EH�LQIRUPHG�LQ�DGYDQFH�

,PSOLFDWLRQV�RI�D�SRVLWLYH�PDODULD�VFUHHQ�IRU�¿WQHVV�WR�WUDYHO

Fisherpersons with P. falciparum, P. malariae and P. knowlesi�PDODULD�DUH�127�¿W�WR�WUDYHO�DQG�UHTXLUH�immediate treatment. Infections caused by P. falciparum�DQG�VHYHUH�P. knowlesi can be fatal.

1. ALL cases of P. falciparum, P. malariae and P. knowlesi malaria and any malaria cases where WKH�VSHFLHV�FDQQRW�EH�FRQ¿UPHG�ZLWKLQ��KRXUV�UHTXLUH�DVVHVVPHQW�LQ�KRVSLWDO�� 7KLV� LV� WKH� SUHIHUUHG� SUDFWLFH� LQ� WKH� 17� WR� SUHYHQW� OLIH� WKUHDWHQLQJ� FRPSOLFDWLRQV� RI�

P. falciparum. � ,W�LV�DOVR�LPSRUWDQW�WR�DYRLG�DQ\�ULVN�RI�WUDQVPLVVLRQ�RI�WKH�SDUDVLWH�WR�WKH�PRVTXLWR�YHFWRUV�

that are present in the Top End of the NT. � Asymptomatic patients with low parasitaemia eg. refugees may be treated through Hospital

LQ�WKH�+RPH��+,7+��DIWHU�UHYLHZ�E\�WKH�,QIHFWLRXV�'LVHDVHV�UHJLVWUDU�RU�FRQVXOWDQW�DW�5'+�

2. )LVKHUSHUVRQV�ZLWK�FRQ¿UPHG�P. vivax, or P. ovale�FDQ�EH�WUHDWHG�E\�+,7+�RU�VXSHUYLVHG�E\�WKHLU�SULPDU\�KHDOWK�FDUH�VHUYLFH�ZKLOH�LQ�LPPLJUDWLRQ�GHWHQWLRQ�SURYLGHG�a. Parasitaemia is <1%;b. 7KHUH�DUH�QR�VLJQL¿FDQW�FR�PRUELGLWLHV�HJ��LVFKDHPLF�KHDUW�GLVHDVH�c. Pregnancy is excluded:d. 7KHUH� LV� QR� HYLGHQFH� RI� FR�LQIHFWLRQ� ZLWK� P. falciparum malaria. This requires blood

PLFURVFRS\�FRQ¿UPDWLRQ�RI�VSHFLHV�E\�DQ�DFFUHGLWHG�VSHFLDOLVW�PLFURVFRSLVW�e. :KHUH� WKH�SDWLHQW� LV�JDPHWRF\WH�SRVLWLYH� WKH�¿UVW�GRVH�RI�DUWHPHWKHU�OXPHIDQWULQH�KDV�

EHHQ�JLYHQ�f. 7KH�SDWLHQW�LV�DIIHFWHG�PLOGO\�E\�PDODULD�LH��WROHUDWLQJ�RUDO�ÀXLGV�DQG�GLHW�DQG�KDV�WROHUDWHG�

WKH�¿UVW�WUHDWPHQW�GRVH�g. The patient agrees to remain indoors in screened or air conditioned accommodation

EHWZHHQ�GXVN�DQG�GDZQ�XQWLO�DUWHPHWKHU�OXPHIDQWULQH�WKHUDS\�LV�FRPSOHWHG�h. 7KH�SULPDU\�KHDOWK�FDUH�VHUYLFH�FDQ�EH�DFFHVVHG�E\�SKRQH�LI�WKH�SDWLHQW�EHFRPHV�XQZHOO�

or there is an emergency*;i. 7KH�SDWLHQW�VSHDNV�D�ODQJXDJH�IRU�ZKLFK�D�WHOHSKRQH�LQWHUSUHWHU�RU�IULHQG�IDPLO\�PHPEHU�

can interpret eg. Swahili, French, Dinka, Arabic, Kirundi. If it is a rare language and no OLQJXD�IUDQFD�FDQ�EH�IRXQG��WKH�SDWLHQW�ZLOO�KDYH�WR�EH�DGPLWWHG�

j. Adequate follow up arrangements are able to be arranged;k. 7KH�SDWLHQW�LV�QRWL¿HG�WR�&'&�VR�WKDW�&'&�RI¿FHUV�FDQ�DVFHUWDLQ�WKDW�SDWLHQWV�WUHDWHG�

DV�+,7+�RXWSDWLHQWV�GR�QRW�SRVH�D�SXEOLF�KHDOWK�ULVN��$�SKRQH�PHVVDJH�PD\�EH�OHIW�ZLWK�CDC after hours; and

l. The case has been discussed with an Infectious Diseases (ID) Physician at RDH �DYDLODEOH��KRXUV�SHU�GD\��WR�FKHFN��

� �7KH�DERYH�SRLQWV�D�WR�O � Clinical condition � Follow-up arrangements � �6SOHHQ�VL]H�DQG�RIIHU�DGYLFH�DERXW�DFWLYLW\�UHVWULFWLRQV�

,I�$//�RI�WKH�DERYH�FULWHULD�DUH�PHW��WKHVH�¿VKHUSHUVRQV�FDQ�EH�JLYHQ�WUHDWPHQW�RQ�DQ�RXWSDWLHQW�EDVLV�WKURXJK�+,7+�RU�VXSHUYLVHG�E\�WKH�SULPDU\�KHDOWK�FDUH�VHUYLFH�DQG�EH�FHUWL¿HG�¿W�WR�EH�repatriated on completion of primary treatment for malaria.

*Please note: There is a HITH nurse on call 24hours, but she only speaks English.8QOHVV�WKH�SDWLHQW�VSHDNV�(QJOLVK��WKHUH�VKRXOG�EH�DQRWKHU�FRQWDFW�SHUVRQ��0HODOHXFD�5HIXJHH�&HQWUH�RU�IULHQG�QHLJKERXU��ZKR�LV�DYDLODEOH�WR�LPPHGLDWHO\�DWWHQG�WKH�KRXVH�LI�FDOOHG�

For all malaria cases

1. Treatment and follow up should be instituted in accordance with the Malaria Guidelines for Health Professionals in the Northern Territory (2012).

CONTACT CDC Darwin 8922 8804

28 29


APPENDIX 6. Advise to parents of students arriving in the NT from malaria endemic areas

ABN: 84 085 734 992 Department of Health is a Smoke Free Workplace

Centre for Disease Control Postal Address: PO Box 40596

Casuarina NT 0811 Tel: 89228804 Fax: 89228310

Centre for Disease Control

Advice to parents of students arriving in the NT from malaria endemic areas

What is Malaria? Malaria is a parasitic disease transmitted by Anopheles mosquitoes. There are 4 types of parasites that cause malaria: Plasmodium ovale, P. malariae, P. knowlesi, P. vivax, and P. falciparum. The last 2 are the most common.

Primarily, malaria is an infection of the red blood cells, but other parts of the body may be affected. Malaria caused by P. falciparum DQG� VHYHUH P. knowlesi is life threatening and can cause multiple organ damage, coma and death.

How is it spread? Malaria is spread by Anopheles� PRVTXLWRHV�� 7KH� SDUDVLWH� HQWHUV� WKH� ERG\� LQ� PRVTXLWR� VDOLYD�when a person is bitten by an infected Anopheles PRVTXLWR�� 7KH� SDUDVLWH� ILUVW� LQIHFWV� WKH� OLYHU�where it begins to multiply. After some days, the resulting parasites are released into the blood VWUHDP�WR� LQIHFW� WKH�UHG�EORRG�FHOOV��ZKHUH� WKH\�FRQWLQXH� WR�PXOWLSO\��HYHQWXDOO\�EXUVWLQJ� WKH�UHG�blood cells and further infecting others. If they reach high numbers they may then clog up blood YHVVHOV�DQG� FDXVH�RUJDQ�GDPDJH�DQG� VHYHUH�GLVHDVH��6RPH�RI� WKH�SDUDVLWHV� LQ� WKH� UHG�EORRG�FHOOV�GHYHORS�LQWR�WKH�VH[XDO�VWDJHV��JDPHWRF\WHV��,I�WKHVH�VWDJHV�DUH�LQJHVWHG�ZKHQ�D�PRVTXLWR�ELWHV�DQ�LQIHFWHG�SHUVRQ��WKH\�GHYHORS�LQ�WKH�JXW�RI�WKH�PRVTXLWR�IRU��±��GD\V��DQG�WKHQ�HQWHU�WKH�VDOLYDU\�JODQGV��UHDG\�WR�LQIHFW�D�SHUVRQ�DW�WKH�QH[W�ELWH��

Where is it found? Malaria is found throughout the tropical and subtropical regions of the world. Areas of high transmission are found predominantly in rural areas in South America (e.g. Brazil), south-east Asia (e.g. Thailand, Indonesia and East Timor), Western Pacific (Papua New Guinea, Solomon Islands and Vanuatu) and throughout sub-Saharan Africa.

The last case of locally acquired malaria in the Northern Territory was in 1962 and Australia was GHFODUHG�IUHH�RI�PDODULD�E\�WKH�:RUOG�+HDOWK�2UJDQLVDWLRQ��:+2��LQ��+RZHYHU��D�QXPEHU�RI�species of Anopheles mosquitoes exist in the NT and the malaria parasite could be re-introduced into local mosquitoes if infected people are bitten. Transmission to mosquitoes could occur anywhere in the Top End, down to latitude of 19 degrees, which is just north of Tennant Creek.

What are the symptoms? Symptoms appear about 9-14 days after a malaria-infected mosquito bite, and coincide with the rupture of the red blood cells. Symptoms are oIWHQ�GHOD\HG�LQ�SHRSOH�ZKR�KDYH�OLYHG�LQ�PDODULRXV�DUHDV�DQG�ZKR�PD\�KDYH�GHYHORSHG�VRPH�LPPXQLW\��

7\SLFDOO\�PDODULD�SURGXFHV�IHYHU��ULJRUV��VKDNHV��VZHDWLQJ��KHDGDFKH��YRPLWLQJ�DQG�RWKHU�IOX�OLNH�symptoms. Sometimes there is a 2 or 3 day period of reduced symptoms before a recurrence on the third or fourth day. Untreated, infection can progress rapidly and become life

30 August 2012 Page 2 of 3 ZZZ�QW�JRY�DXDepartment of Health is a Smoke Free Workplace

threatening. Malaria can kill by infecting and destroying red blood cells (anaemia) and by clogging WKH�EORRG�YHVVHOV�WR�WKH�EUDLQ��FHUHEUDO�PDODULD��RU�YLWDO�RUJDQV��

Prolonged untreated malaria infection can also cause the spleen to enlarge (splenomegaly). Splenomegaly can be a problem if your child is playing sport or suffers an abdominal injury, as the spleen can rupture requiring emergency surgery. Splenic rupture can sometimes be fatal.

Why does malaria relapse? Some forms of malaria such as P. vivax and P. ovale exist as dormant forms that remain in the OLYHU�IRU�PRQWKV�RU�\HDUV�EHIRUH�SURGXFLQJ�WKH�GLVHDVH��

With other forms such as P. falciparum and P. malariae (and in some cases P. vivax), the disease FDQ�UHRFFXU�DIWHU�DSSDUHQW�UHFRYHU\��GXH�WR�HLWKHU� LQDGHTXDWH�WUHDWPHQW�RU� LQIHFWLRQ�ZLWK�D�GUXJ�resistant strain.

How is it diagnosed? Malaria is diagnosed by a blood test. The blood is examined down a microscope looking for malaria parasites inside the red blood cells. An antigen test is done at the same time, which can LQGLFDWH�WKDW�\RXU�FKLOG�KDV�EHHQ�H[SRVHG�WR�PDODULD�EXW�KDV�QR�YLVLEOH�SDUDVLWHV��

What is the treatment? All cases of P. falciparum malaria in the NT are admitted to hospital because it can rapidly become life threatening. Cases of malaria other than P. falciparum can sometimes be treated at VFKRRO�LI�WKH�SDWLHQW�DJUHHV�WR�VWD\�LQGRRUV�EHWZHHQ�GXVN�DQG�GDZQ��7KLV�LV�WR�DYRLG�DQ\�ULVN�RI�transmission of the parasite to the local Anopheles mosquitoes.

7UHDWPHQW�PXVW�EH�JLYHQ�LQ�FRQVXOWDtion with specialist physicians.

What should be done for children coming from areas with malaria? x Arrival screening for malaria

6RRQ�DIWHU�\RXU�FKLOG�DUULYHV�LQ�WKH�17��WKH�VFKRRO�ZLOO�RIIHU�D�PDODULD�V\PSWRP�UHYLHZ�DQG�D�malaria blood test. This blood test will look for the malaria parasite in the blood and test for PDODULD�DQWLJHQ�� ,I�HLWKHU� WHVW� LV�SRVLWLYH�� WKHQ�\RXU�FKLOG�ZLOO�EH�VHHQ�DW� WKH�KRVSLWDO�E\� WKH�LQIHFWLRXV�GLVHDVHV�WHDP�DQG�UHFHLYH�PDODULD�WUHDWPHQW��

x Spleen check :KHQ� FRPLQJ� IURP� DQ� DUHD� ZLWK� PDODULD� D� FKLOG¶V� VSOHHQ� FDQ� EH� HQODUJHG� HYHQ� LI� DFWLYH�PDODULD�LV�QRW�IRXQG�RQ�VFUHHQLQJ�DQG�WKLV�LV�YHU\�LPSRUWDQW�WR�UHFRJQLVH�EHIRUH�HQJDJLQJ�LQ��for instance, sport.

x Early presentation to school nurse for fever or feeling unwell at any time 2FFDVLRQDOO\�WKH�VFUHHQLQJ�WHVWV�DUH�QHJDWLYH�HYHQ�when malaria parasites are present or are LQ� ORZ�QXPEHUV�DQG�VR� LQ� WKH�IXWXUH�\RXU�FKLOG� LV�DGYLVHG�WR�JR�DQG�VHH�WKH�VFKRRO�QXUVH� LI�WKH\�GHYHORS�D�IHYHU�RU�EHFRPH�XQZHOO��

x Screening on each return from holiday or visit from malaria area (YHU\� WLPH� \RXU� FKLOG� UHWXUQV� IURP� KROLGD\V�PDODULD� VFUHHQLQJ�ZLOO� QHHG� WR� RFFXU�� ,Q� VRPH�FDVHV�\RX�PD\�FKRRVH�IRU�\RXU�FKLOG�WR�UHFHLYH�PDODULD�SUHYHQWLYH�WUHDWPHQW�IRU�ZKHQ�WKH\�JR�home for the holidays. In this case, please let the school nurse know and she will organise an DSSRLQWPHQW�ZLWK�D�JHQHUDO�SUDFWLWLRQHU�IRU�PHGLFDO�UHYLHZ�DQG�SUHVFULSWLRQ�RI�PHGLFDWLRQ��,W�LV�important that the child takes the medication according to instructions, including after return to Australia. They will be asked their medication compliance on return. If there is any doubt on their compliance, then they will require a blood test.

30 31


30 August 2012 Page 3 of 3 ZZZ�QW�JRY�DXDepartment of Health is a Smoke Free Workplace

CONSENTScreening will occur at St Johns College after semester break when your child has returned from KROLGD\�RU�YLVLWLQJ�IURP�D�PDODULD�DUHD��

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If your child needs any treatment the Health staff will ask your permission before carrying out any IXUWKHU�HYDOXDWLRQ�RI�WUHDWPHQW��

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For any further queries please contact Centre for Disease Control School Malaria Program Coordinator

(08) 8922 8804

APPENDIX 7. Medical Entomology investigation

0RUH�GHWDLOHG�LQIRUPDWLRQ�LV�DYDLODEOH�IURP�WKH�0HGLFDO�(QWRPRORJ\��0(��GRFXPHQW�Entomological Investigation around Malaria Cases, 2011.

1. $VVHVV�HSLGHPLRORJLFDO�GDWD�SURYLGHG� LQ�&'&�TXHVWLRQQDLUH�� LI�QR�JDPHWRF\WHV�SUHVHQW�QR�action required.

2. $VVHVV� ZKHWKHU� URXWLQH� WUDS� LQIRUPDWLRQ� LV� VXI¿FLHQW�� RU� H[WUD� WUDSV� ZLOO� QHHG� WR� EH� VHW��FRQVLGHULQJ�ORFDWLRQ��SHDN�YHFWRU�DEXQGDQFH�SHULRGV�DQG�SUHYDLOLQJ�HQYLURQPHQWDO�FRQGLWLRQV�

8VLQJ� WKH�0(�GDWDEDVH��DVVHVV� WKH�DFWXDO�RU�SRWHQWLDO� OHYHO�RI�YHFWRU�DFWLYLW\�DURXQG�FDVH�locations from most recent resultsInclude:

� Last 5 years data for similar months � Search for An. farauti, An. bancroftii, An. hilli, An. annulipes, An. amictus � Assess results and further action,I�WKHUH�LV�ORZ�SRWHQWLDO�YHFWRU�SUHVHQFH�ZLWK�QR�H[WUD�DGXOW�WUDSSLQJ�UHTXLUHG�EDVHG�RQ�ORFDWLRQ��SHDN�SHULRGV�DQG�SUHYDLOLQJ�HQYLURQPHQWDO�FRQGLWLRQV��QR�IXUWKHU�DFWLRQ�LV�UHTXLUHG�

3. ,I�WKHUH�LV�D�SRWHQWLDO�IRU�YHFWRUV�SUHVHQW��DVVHVV�WKH�QHDUHVW�EUHHGLQJ�DQG�UHVWLQJ�VLWHV�DW�WKH�FDVH�KRXVH�DQG�ZLWKLQ��NP�XVLQJ�&2��EDLWHG�HQFHSKDOLWLV�YHFWRU�VXUYH\��(96��WUDSV�

4. Triggers for ME action based on current entomological information: � >2 An. farauti at residence or, >10 of all other Anopheles sp. at residence; initiate fogging. � or >10 An. farauti or, >40 other Anopheles sp. at breeding harbouring sites within 1 km;

assess further by setting more traps and assess new results, or initiate fog. � If current Anopheles�VS��DEXQGDQFH� LV� OHVV� WKDQ� WKH� WULJJHU� OHYHOV�� IXUWKHU�DVVHVVPHQW�

VKRXOG�FRQVLGHU�SHDN�DEXQGDQFH�SHULRGV�DQG�SUHYDLOLQJ�HQYLURQPHQWDO�FRQGLWLRQV��ZKLFK�may necessitate extra trapping.

5. ,I�SUHFDXWLRQDU\�IRJJLQJ�LV�WR�EH�FDUULHG�RXW��LQIRUP�WKH�'LUHFWRU�&'&�DQG�&KLHI�+HDOWK�2I¿FHU�(CHO) by email and phone. Fogging is usually in nearest mosquito breeding or harbourage DUHD�RXWVLGH�UHVLGHQWLDO�DUHDV��,I�IRJJLQJ�LV�QHHGHG�LQ�UHVLGHQWLDO�DUHDV��DSSURYDO�LV�UHTXLUHG�from the CHO. Use non residual insecticides eg. bioresmethrin or similar in residential areas, and malathion for non-residential areas.

6. ,I�WUDSSLQJ�RU�IRJJLQJ�LV�UHTXLUHG��FRPSOHWH�WKH�0(�IRUP�µ,QYHVWLJDWLRQ�DURXQG�D�SURYHQ�PDODULD�FDVH��0HGLFDO�(QWRPRORJ\��'R+¶��$�FDVH�UHIHUHQFH�LV�XVHG�LQ�DOO�GRFXPHQWDWLRQ�

7. ,I�0(�XQGHUWDNHV�DQ\�DFWLRQ�� HPDLO�PDODULD� IRUP�DQG� UHOHYDQW� LQIRUPDWLRQ�HJ�� WUDS� UHVXOWV��IRJJLQJ�URXWH��WR�WKH�&'&�0DODULD�6XUYHLOODQFH�2I¿FHU��RU�ID[��DQG�SKRQH�WR�FRQ¿UP�receipt.

8. $OO�GHWDLOV�RI�WKH�FDVH�LQFOXGLQJ�IRJJLQJ�UHVSRQVHV�DUH�¿OHG�LQ�WKH�0(�GDWDEDVH�

32 33



Malaria

MalariaCentre for Disease Control

December 2012

What is Malaria?Malaria is a parasitic disease transmitted by Anopheles mosquitoes. There are 5 types of parasites that cause malaria: Plasmodium ovale, P. malariae, P. knowlesi, P. vivax, and P. falciparum. The last 2 are the most common.

Primarily, malaria is an infection of the red blood cells, causing recurring fever of sudden onset. Malaria caused by P. falciparum is life threatening and can cause multiple organ damage, coma and death.

How is it spread?Malaria is spread by female Anopheles mosquitoes. The parasite enters the body in mosquito saliva when a person is bitten by an LQIHFWHG�PRVTXLWR��7KH�SDUDVLWH�¿UVW�LQIHFWV�WKH�liver where it begins to multiply. After some days, the resulting parasites are released into the blood stream to infect the red blood cells, where they continue to multiply, eventually bursting the red blood cells and further infecting others. If they reach high numbers they may cause severe disease or even death. Some of the parasites in the red blood cells develop into the sexual stages (gametocytes). If these stages are ingested when a mosquito bites an infected person, they develop in the gut of the mosquito for 10 –14 days, and then enter the salivary glands, ready for the next bite.

Where is it found?Malaria is found throughout the tropical and subtropical regions of the world. Areas of high transmission are found predominantly in rural areas in South America (e.g. Brazil), south-east Asia (e.g. Thailand, Indonesia and East 7LPRU��:HVWHUQ�3DFL¿F��3DSXD�1HZ�*XLQHD��Solomon Islands and Vanuatu) and throughout sub-Saharan Africa.

The last case of locally acquired malaria in the 1RUWKHUQ�7HUULWRU\�ZDV�LQ��DQG�$XVWUDOLD�was declared free of malaria by the World

+HDOWK�2UJDQLVDWLRQ��:+2��LQ��+RZHYHU��a number of species of Anopheles mosquitoes H[LVW�LQ�WKH�17�DQG�WKH�PDODULD�SDUDVLWH�FRXOG�be re-introduced into local mosquitoes if infected travellers from overseas are bitten here. The disease could become established anywhere in the Top End, down to a latitude RI��GHJUHHV�ZKLFK�LV�MXVW�QRUWK�RI�7HQQDQW�Creek.

What are the symptoms?6\PSWRPV�DSSHDU�DERXW��GD\V�DIWHU�D�ELWH�from an infected mosquito, and coincide with the rupture of the red blood cells. Symptoms are often delayed in people who have lived in malarious areas and who may have developed some immunity.

Typically malaria produces fever, rigors (shakes), sweating, headache, vomiting and RWKHU�ÀX�OLNH�V\PSWRPV��6RPHWLPHV�WKHUH�is a 2 or 3 day period of reduced symptoms before a recurrence on the third or fourth day. Untreated, infection can progress rapidly and become life threatening. Malaria can kill by destruction of red blood cells (anaemia) and by altering the function of vital organs such as the brain, (cerebral malaria) lungs or kidneys.

Why does malaria relapse?P. vivax and P. ovale exist as dormant forms that remain in the liver for months or years before producing the disease.

With P. falciparum, the disease can reoccur after apparent recovery, due to either inadequate treatment or infection with a drug resistant strain. P. malariae can rarely persist with very low levels of parasite in the peripheral blood for decades.

P. knowlesi produces acute illness but does not cause relapse.

APPENDIX 8. Malaria factsheet


CENTRE FOR DISEASE CONTROL

Malaria

How is it diagnosed?Malaria is diagnosed by a blood test. The blood is examined under a microscope looking for malaria parasites inside the red blood cells. All travellers from malarious areas who become ill or develop a fever should be tested.

What is the treatment?All cases of P. falciparum�PDODULD�LQ�WKH�17�DUH�admitted to hospital because this form of malaria can rapidly become life threatening. Cases of malaria other than P. falciparum can sometimes be treated at home if the house is adequately screened and if the patient agrees to stay indoors between dusk and dawn. This is to avoid any risk of transmission of the parasite to the local Anopheles mosquitoes.

Treatment must be given in consultation with specialist physicians.

Before travelling overseasCheck whether the countries to which you are travelling are affected by malaria by contacting your *3��7UDYHO�+HDOWK�&OLQLF�RU�UHIHUULQJ�WR�WKH�LQWHUQHW�

WHO International Travel and Health website:http://www.who.int/ith/en/

Or the Centers for Disease Control and Prevention:http://wwwnc.cdc.gov/travel/

If you are travelling to an affected country you will often need preventative medication. Contact \RXU�*3�RU�7UDYHO�&OLQLF�WR�RUJDQLVH�DQWL�PDODULDO�medication for your trip. Some medication must be started 1 week prior to entry to the affected area.

How to protect yourself from mosquito bitesWhile in affected areas there are measures which should be taken to reduce the risk of mosquito bites.

�� Avoid being outdoors between dusk and dawn to avoid mosquito bites, particularly in poorly lit areas, rural areas, or the outskirts of large towns.

�� If accommodation is not well screened, sleep inside mosquito netting. Use insecticide treated bed nets and clothing in high risk areas.

�� Avoid scents on the body, e.g. perfume, deodorants, and sweat, since these can attract mosquitoes.

�� Use protective clothing in outdoor situations including covering feet, legs and arms. Loose, light coloured clothing is best.

�� Use personal repellents containing DEET or picaridin on areas of exposed skin in combination with protective clothing.

�� Use electric insecticide devices using repellent treated pads in indoor or enclosed areas.

�� Use mosquito coils, or candle heated or gas operated devices using insecticide treated pads for patio and veranda or relatively sheltered or low wind outdoor situations.

For more information on protection measures see Personal protection from mosquitoes.

If you return from a malarious area and develop symptomsIf you develop symptoms of malaria within 2 years of YLVLWLQJ�D�PDODULRXV�DUHD�FRQWDFW�\RXU�*3�RU�KRVSLWDO�emergency department immediately for an urgent medical assessment. Remember to inform the PHGLFDO�RI¿FHU�RI�ZKHUH�\RX�KDYH�WUDYHOOHG�DV�WKLV�will help determine your risk of malaria and the type of treatment required.

If you have malaria, the people you have travelled with (particularly to high risk areas such as Africa, 31*��(DVW�7LPRU�DQG�SDUWV�RI�,QGRQHVLD�LQFOXGLQJ�Flores, Lombok and surrounding islands) should also be tested.

For more information contact your nearest Centre for Disease Control.

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For more information on mosquitoes and virus ecology contact Centre for Disease Control,

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Further fact sheets and protocols are available at: www.nt.gov.au/health/cdc

34 35


Apakah Malaria?Malaria adalah penyakit yang disebabkan oleh parasit yand ditularkan oleh nyamuk Anopheles. Ada 5 jenis parasit yang dapat menyebabkan malaria: Plasmodium ovale, P. malariae, P. vivax, P.knowlesi dan P. falciparum. Dua jenis terakhir adalah yang paling sering ditemukan.

Pada dasarnya, malaria adalah infeksi pada sel-sel darah merah, yang menyebabkan demam berulang dengan tiba-tiba. Malaria yang disebabkan oleh P. falciparum sangat berbahaya dan dapat menyebabkan kerusakan berbagai organ tubuh, koma dan kematian.

Bagaimana malaria menyebar?Malaria disebarkan oleh nyamuk Anopheles betina. Parasit masuk ke tubuh melalui ludah nyamuk pada saat seseorang digigit oleh nyamuk yang terinfeksi. Parasit ini mula-mula PHQ\HEDENDQ�UDGDQJ�SDGD�OLYHU�GLPDQD�LD�berbiak. Setelah beberapa hari, parasit-parasit yang terbiak dilepas ke saluran darah untuk menjangkiti sel-sel darah merah, dimana mereka terus berbiak, sampai sel-sel darah merah menjadi pecah dan mengakibatkan infeksi pada sel-sel lainnya. Jika jumlahnya menjadi sangat besar, hal ini dapat menimbulkan sakit parah atau bahkan kematian. Sebagian dari parasit dalam sel-sel darah merah berkembang memasuki tahap jantan dan betina (gametosit). Jika pada tahap ini seekor nyamuk mengigit orang yang terinfeksi, parasit akan berkembang dalam perut nyamuk selama 10-14 hari, lalu masuk ke kelenjar ludah, siap untuk dijangkitkan pada saat nyamuk menggigit seseorang.

Dimana penyakit ini menyebar?Malaria ditemukan diseluruh wilayah tropis dan subtropis di dunia. Daerah-daerah dimana terjadi banyak penularan adalah wilayah perkampungan di Amerika Selatan (misalnya Brazil), Asia Tenggara (misalnya Thailand, ,QGRQHVLD�GDQ�7LPRU�7LPXU��3DVL¿N�%DUDW�(Papua Nugini, Kepulauan Solomon dan Vanuatu) serta sub-Sahara di Afrika.

Di Northern Territory, kasus malaria yang terjangkit secara lokal terakhir terjadi pada tahun 1962 dan Australia dinyatakan bebas dari Malaria oleh World Health Organisation (WHO) pada tahun 1981. Namun, beberapa spesies nyamuk Anopheles masih ada di NT dan parasit malaria dapat menjangkiti nyamuk setempat bila ada pendatang yang terinfeksi dari luar negeri digigit oleh nyamuk setempat. Penyakit ini dapat berjangkit di wilayah utara NT, sampai dengan lintang 19 derajat, sedikit di utara Tennant Creek.

Apakah gejala-gejalanya?Gejala-gejala muncul sekitar 9-14 hari setelah digigit oleh nyamuk yang terinfeksi, dan bersamaan dengan pecahnya sel-sel pembuluh darah merah. Pada orang yang tinggal di daerah yang banyak terjangkit malaria, gejala-gejalanya mungkin muncul lebih lambat karena orang tersebut mungkin memiliki sedikit kekebalan.

Pada umumnya malaria mengakibatkan demam, menggigil, keringatan, sakit kepala, muntah-PXQWDK�GDQ�JHMDOD�VHUXSD�ÀX�ODLQQ\D��.DGDQJ�kadang gejala-gejala ini berkurang selama 2-3 hari namun muncul kembali pada hari ketiga atau keempat. Tanpa pengobatan, infeksi dapat berkembang dengan cepat dan membahayakan jiwa. Malaria dapat mengakibatkan kematian melalui penghancuran sel-sel darah merah (anaemia) dan melalui perubahan pada fungsi organ tubuh yang penting seperti otak (cerebral malaria), paru-paru dan ginjal.

Mengapa malaria dapat kambuh?P. vivax dan P. ovale tinggal dalam bentuk WLGDN�DNWLI�SDGD�OLYHU�VHODPD�EHUEXODQ�EXODQ�atau bertahun-tahun sebelum menyebabkan munculnya penyakit. Pada P. falciparum, penyakit dapat kambuh kembali setelah seseorang terlihat sembuh, karena pengobatan yang kurang memadai atau orang tersebut tertular jenis yang kebal terhadap obat. P. malariae jarang dapat bertahan dengan tingkat parasit rendah pada darah selama puluhan tahun.

APPENDIX 9. Malaria factsheet (Indonesian)Bagaimana di-diagnosa ?Malaria di-diagnosa melalui tes darah. Darah diperiksa dibawah mikroskop untuk dilihat apakah terdapat parasit malaria dalam sel-sel darah merah. Semua orang yang bepergian ke daerah dimana malaria berjangkit dan jatuh sakit atau mengalami demam harus diperiksa.

Bagaimana mengobatinya?Seluruh kasus malaria P. falciparum di NT dikirim ke rumah sakit karena malaria jenis ini dapat membahayakan jiwa dalam waktu singkat. Kasus-kasus diluar P. falciparum kadangkala dapat diobati di rumah jika rumah tersebut dilindungi kawat nyamuk dan jika pasien setuju untuk tinggal dalam rumah dari senja hingga fajar. Hal ini untuk menghindari resiko penularan parasit ke nyamuk Anopheles setempat.

Pengobatan harus dilakukan dengan berkonsultasi pada dokter spesialis. Sebelum bepergian ke luar negri, periksalah apakah negara-negara yang akan Anda kunjungi terjangkit malaria dengan menghubungi dokter Anda, Travel Health Clinic atau melalui internet:

Situs web WHO International Travel and HealthKWWS��ZZZ�ZKR�LQW�LWK�LQGH[�KWPOatau Centers for Disease Control and Prevention (Pusat Pengendalian dan Pencegahan Penyakit) KWWS��ZZZ�FGF�JRY�WUDYHO�GLVHDVHV�KWP�PDODULD

Jika Anda akan bepergian ke negara yang terjangkit, pada umumnya Anda memerlukan obat pencegahan. Hubungi dokter Anda atau Travel Clinic untuk memperoleh obat anti-malaria bagi perjalanan Anda. Obat-obat tertentu perlu diminum 1 minggu sebelum memasuki wilayah yang terjangkit.

Bagaimana melindungi diri Anda dari gigitan nyamuk Selama di daerah yang terjangkit, ada hal-hal yang dapat dilakukan untuk mengurangi resiko digigit nyamuk.

� hindari berada di luar bangunan antara senja dan fajar, terutama di daerah yang kurang penerangannya, daerah perkampungan, atau pinggiran kota besar

� tutupi badan Anda (terutama lengan, tungkai kaki dan telapak kaki) antara senja dan fajar

pakaian yang longgar dan berwarna terang adalah yang terbaik

� gunakan penolak serangga pada kulit yang tidak terlindungi pada jam-jam yang beresiko tinggi; pilih penolak yang mengandung DEET atau picaradin

� hindari bau-bauan pada tubuh, misalnya parfum, deodoran, dan keringat, karena dapat menarik nyamuk

� jika akomodasi tidak terlindung dengan baik, tidur dengan menggunakan kelambu. Gunakan kelambu dan pakaian yang telah disemprot penolak serangga di daerah beresiko tinggi

� gunakan obat nyamuk bakar atau pembasmi serangga dalam bentuk uap di ruang tertutup

Jika Anda kembali dari daerah yang terjangkit malaria dan menunjukkan gejala-gejala malariaJika Anda menunjukkan gejala-gejala malaria dalam 2 tahun setelah mengunjungi daerah yang terjangkit malaria, hubungi dokter atau bagian gawat darurat rumah sakit dengan segera untuk pemeriksaan medis. Jangan lupa memberi tahu petugas kesehatan tempat-tempat yang Anda kunjungi karena ini akan membantu menentukan tingkat resiko Anda terkena malaria dan jenis perawatan yang diperlukan.

Jika Anda terkena malaria, orang-orang yang bepergian bersama Anda (terutama ke daerah beresiko tinggi seperti Afrika, PNG, Timor Timur dan bagian dari Indonesia termasuk Flores, Lombok dan kepulauan sekitarnya) perlu juga diperiksa.

Untuk informasi lebih lanjut hubungi cabang CDC atau bagian Entomology Medis terdekat.Entomology Medis 89228548CDC Darwin 89228044CDC Katherine 89739049CDC Nhulunbuy 89870357CDC Tennant Creek 89624259CDC Alice Springs 89517549

Lembaran informasi selanjutnya dan protokol perawatan tersedia diKWWS��ZZZ�QW�JRY�DX�KHDOWK�FGF

July 2011

Northern Territory Guidelines for

Malaria

Northern Territory Department of Health

Centre for Disease Control

www.nt.gov.au/health/cdc/cdc.shtml

Documents

Malaria guidelines 2012.pdf