Correspondence

Infectious Diseases in Somalia

N Engl J Med 1993; 329:889-890September 16, 1993

Article

To the Editor:

In their report in the April 8 issue of the Journal,1 Heppner et al. discuss malaria and other infectious diseases in Somalia. Although all the antimalarial agents recommended by the authors are preferred, they are frequently not available at smaller medical facilities. Tetracycline and quinine sulfate are universally available and effective for Plasmodium falciparum malaria, which is resistant to chloroquine. In patients with complicated malaria, exchange transfusion should be strongly considered2. Finally, U.S. military personnel who served in Operation Restore Hope should not donate blood for two years.

(The opinions herein are the private view of the author and should not be considered as official or reflecting the views of the Department of the Air Force.)

Randall Smart, Maj., U.S.A.F., M.C.
Ramstein AFB, Germany, APO AE 09094-5300

2 References

1
Heppner DG Jr, Magill AJ, Gasser RA Jr, Oster CN. The threat of infectious diseases in Somalia. N Engl J Med 1993;328:1061-1068
Full Text | Web of Science | Medline

2
Miller KD, Greenberg AE, Campbell CC. Treatment of severe malaria in the United States with a continuous infusion of quinidine gluconate and exchange transfusion. N Engl J Med 1989;321:65-70
Full Text | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Untreated malaria due to P. falciparum can be rapidly fatal in nonimmune persons. In the absence of mefloquine or halofantrine, uncomplicated falciparum malaria acquired in East Africa may be treated with quinine sulfate, at a dose of 650 mg three times a day for three to seven days, plus tetracycline, at a dose of 500 mg four times a day for seven days, or doxycycline, at a dose of 100 mg twice daily for seven days. A simpler regimen -- three tablets consisting of a combination of 25 mg of pyrimethamine and 500 mg of sulfadoxine (Fansidar) as a single dose plus quinine sulfate, at a dose of 650 mg orally three times a day for three days -- has proved effective against falciparum malaria acquired in Somalia (Magill A: personnal communication). Treatment failures are possible with any regimen; failure in treating falciparum malaria has been reported with oral quinine in West Africa and with intravenous quinine in Thailand1.

Complicated falciparum malaria requires parenteral therapy. In the United States, intravenous quinine has been replaced by its more potent, widely available diastereoisomer quinidine2. Exchange transfusion, an adjunct to effective drug therapy, can be considered in the setting of severe falciparum malaria characterized by parasitemia of more than 10 percent, cerebral malaria, disseminated intravascular coagulation, or acute renal failure3.

The current edition of Standards for Blood Banks and Transfusion Services,4 which is used by military blood-donor centers, requires U.S. military personnel returning from Somalia who have taken antimalarial prophylaxis and remain asymptomatic to avoid blood donation for three years4. Proposed but not yet adopted interim changes to these standards would require only a 12-month wait after military personnel have left an area in which malaria is endemic, whether or not antimalarial prophylaxis was taken, if the potential donors have been asymptomatic.

Because of the occurrence of malaria due to P. vivax among soldiers returning from Somalia, it is now U.S. Army policy to give oral primaquine base, at a dose of 15 mg per kilogram of body weight per day, for 14 days to all such soldiers. Soldiers are not routinely screened for glucose-6-phosphate dehydrogenase deficiency, since the extent of hemolysis, even in persons with severe deficiency, is not clinically important when primaquine is used at this dose if patients are warned to discontinue primaquine should they have scleral icterus or dark urine5. Despite prophylaxis with primaquine, some hepatic infections may not be eliminated, and subsequent attacks of P. vivax malaria are possible.

There is a delayed presentation and attenuated onset of malaria in people who have received chemoprophylaxis. This diagnosis should be actively excluded by serial examination of Giemsa-stained thick blood smears in all febrile patients returning from Somalia.

D. Gray Heppner, Jr., M.D., Maj., M.C., U.S.A.
Alan J. Magill, M.D., Maj., M.C., U.S.A.
Walter Reed Army Institute of Research, Washington, DC 20307

Robert A. Gasser, Jr., M.D., Lt. Col., U.S.A.F., M.C.
Keesler Medical Center, Keesler AFB, MS 39534

Charles N. Oster, M.D., Col., M.C., U.S.A.
Walter Reed Army Medical Center, Washington, DC 20307

5 References

1
Looareesuwan S, Charoenpan P, Ho M, et al. Fatal Plasmodium falciparum malaria after an inadequate response to quinine treatment. J Infect Dis 1990;161:577-580
CrossRef | Web of Science | Medline

2
Treatment with quinidine gluconate of persons with severe Plasmodium falciparum infection: discontinuation of parenteral quinine from CDC Drug ServiceMMWR Morb Mortal Wkly Rep 1991;40:21-23
Medline

3
Phillips P, Nantel S, Benny WB. Exchange transfusion as an adjunct to the treatment of severe falciparum malaria: case report and review. Rev Infect Dis 1990;12:1100-1108
CrossRef | Medline