Dengue

Introduction Dengue is one of the most important arthropod-borne viral diseases in terms of human morbidity and mortality. Widespread in tropical and subtropical regions around the world predominantly in urban and semi urban areas. Dengue occurs from bite of an infected female Aedes mosquito. Aedes mosquito is most frequently found in or near human habitations. There is a significant risk for travelers in areas where Dengue is endemic and in areas affected by epidemics of Dengue. Causative agent: Dengue virus - Flavivirus of which there are four (4) serotypes. Transmission: Transmitted by the Aedes aegypti mosquito, which bites during day light hours. There is no direct person- to-person transmission. Incubation period: 3 - 14days, commonly 4-7 days Sign & Symptoms Pointers to the clinical diagnosis of Dengue infection;

High continous fever of 3 days or more Headache, backache and retrobital pain Abdominal pain, vomiting, loose stools Petechial haemorrhage and/or spontaneous bleeding Rash - generalized flushing/maculopapular/confluent rash with small islands of normal skin. Hepatomegaly Fall in platelet count that precedes or occurs simultaneously with a rise in the haematocrit Normal WBC or leucopenia with relative lymphocytosis Normal ESR ( Shock

Dengue virus infection may present in four different clinical syndromes:

Undifferentiated fever Dengue fever

An acute febrile illness with sudden onset of fever with two or more of the following manifestations: Headache, retro orbital pain, myalgia, arthralgia, skin rash, haemorrhagic manifestations and leucopenia. AND Supportive serology (refer to lab diagnosis) OR Occurance at the same location and time as other confirmed cases of DF. It is known as 'breakbone fever' because of severe muscular pains. The fever maybe biphasic (i.e two separate episodes or waves of fever) Most patients recover after a few days.

Dengue haemorrhagic An acute onset of fever followed by other symptoms resulting from thrombocytopenia, increased vascular permeability and haemorrhagic manifestations. Dengue Shock Syndrome Supervenes in a small proportion of cases. Severe hypotension develops, requiring urgent medical treatment to correct hypovolaemia. Without appropriate treatment, 40%-50% of cases are fatal. While with timely therapy, the mortality rate is 1% or less.

Complication Hepatomegaly, pleural effusion, ascites, bleeding in any forms, unusual neurological presentations include mononeuropathies, polyneuropathies, encephalitis and transverse myelitis. Encephalopathy occurs occasionally and may result from liver failure or electrolyte imbalances and sometimes shock which may lead to death. Treatment Specific treatment ? None Symptomatic treatment Advise rest, drink plenty of fluids and take regular painkillers (e.g. Paracetamol or Ibuprofen) to relieve symptoms of fever or aching

Fluid replacement (Plenty of oral or IV fluids), Blood transfusion ( packed red cells) in significant bleeding, Platelet transfusion is generally avoided unless there is significant bleeding regardless of the severity of thrombocytopenia or platelet count < 10,000/mm3

with impending or established CNS bleed or continuous bleeding from preexisting peptic ulcer and Antipyretic for fever. Prevention & Precautions No vaccine available Precautions

Minimize exposure to bites by modifying activities to avoid exposure to vector bites. Aedes mosquitoe peak biting times are a few hours before dusk and after dawn. Avoid outdoor activity during these periods. Avoid mosquito bite by applying mosquito repellent to exposed skin. When using sunscreen or lotions, apply repellants last. Reapply whenever sweat or water has removed it. Active ingredient in a repellent repels but does not kill insects. Repellent that contains DEET (N, N-diethylmetatoluamide) is most reliable and long-lasting type (35% DEET provides protection for 12 hours). DEET formulations as high as 50% are recommended for both adults (including pregnant women) and children >2 months of age. It is toxic when ingested and may cause skin irritation. Permethrin is highly effective both as an insecticide and as a repellent. There is little potential for toxicity from Permethrin-treated clothing. Use long sleeved clothes and long pant. Avoid wearing dark colours (attract mosquitoes). Close windows or shutters at night when indoors. Use pyrethrum insecticide spray (aerosol insecticides), pyrethroid coils or insecticide impregnated tablets in evening before sleep. Avoid strong perfumes, hair sprays or after-shaves (attract mosquitoes)! Use air-conditioning or good mosquito net especially treated with Permethrin.

References organisation/ support International Travel & Health, WHO 2006 Control of Communicable Diseases Manual, 18th Edition by David L. Heymann, MD, Editor, 2004 Clinical Practice Guidelines, Management of Dengue Infection in Adults, Ministry of Health Malaysia and Academy of Medicine of Malaysia. http://travelhealth.co.uk/

Cholera
Introduction Cholera is one of the oldest and best understood epidemic diseases. Cholera is a bacterial infection which causes severe diarrhea and can eventually lead to death through severe dehydration. Typical settings for cholera are periurban slums where basic infrastructure is missing. Outbreaks of cholera can also occur on a seasonal basis in endemic areas of Asia and Africa. Causative agent: Vibrio cholera bacteria serogroups 01 and 0139 Transmission: Infection occurs through ingestion of food or water contaminated directly or indirectly by faeces or vomitus of infected persons. Incubation Period: Few hours to 5 days. Usually 2-3 days Risk for travelers: Very low for most travelers, even in countries where cholera epidemics occur. Humanitarian relief workers in disaster areas and refugee camps are at risk. Sign & Symptoms Most infections are asymptomatic. In mild cases, diarrhea occurs without other symptoms. In severe cases, there is sudden onset of profuse, painless watery diarrhea/stools (rice water stools), nausea and profuse vomiting. Complication In untreated cases, rapid dehydration, acidosis, circulatory collapse, hypoglycemia and renal failure. Death may occur within few hours due to dehydration leading to circulatory collapse. Treatment Rehydration: Prompt fluid therapy with volumes of electrolyte solution Mild or moderate fluid loss can be treated with Oral Rehydration salts, Patient in shock should be given IV rehydration with a balanced multi-electrolyte solution.

Antibiotic: To shorten the duration of the diarrhea and reduce the volume of rehydration solutions required. The antimicrobial agents such as Tetracycline, Trimethoprim and Sulfamethoxazole (TMP-SMX), Furazolidone or Erythromycin. Prevention & Precautions Cholera vaccines. Vaccination is not usually advised for travelers.

Indication 1. Travellers in high-risk environments (low sanitary conditions) e.g. relief workers in refugee camps. Recommendation 1. There are various new vaccines but they are of poor efficacy and have relatively high rate of side effects. Oral Cholera vaccines appear to provide better immunity and fewer side effects than previously available injectable vaccine. It is effective for 6 months in a single dose but is only effective against the El Tor strain. 2. Some countries (e.g. Tanzania, Kenya, Egypt and Saudi Arabia during Hajj or Umrah) are known to require, on occasion, proof of cholera immunisation in travellers from cholera-infected countries. It is advisable to contact embassy or consulate at a destination country to confirm this requirement for cholera immunisation.

Type of vaccine: Killed and live attenuated oral Number of doses: two (2), at least one (1) week apart (killed vaccine); one (1) dose (live vaccine) Contraindications: Hypersensitivity to previous dose Adverse reactions: Mild local reaction of short duration, mild systematic reaction Before to departure: 3 weeks (killed vaccine), 1 week (live vaccine) Consider for: Travellers with extreme risks (i.e emergency relief) Special precautions: No antibiotics from 1 week before until 1 week after vaccination (live vaccine) General advices to prevent infection via faeco-oral route:

Wash hands and soap before eating, handling food and after using toilet. Boil any drinking water of unsure cleanliness or drink bottled water (checking seal is in place) or carbonated water. Foods that require little handling are safer. Peel all fruit. Avoid salads or uncooked vegetables.

Ensure that seafood, fish and meat are thoroughly cooked and eaten hot whenever possible. Eat early if one is served a buffet. Avoid ready - to - eat food from roadside vendors. Drink plenty of clear, clean fluids if diarrhoea develops. It might be helpful to take diarrhoea medication and Oral Rehydration Salt along. If diarrhoea continues for more than 48 hours, inability to drink or is passing blood - seek immediate medical attention.

References organisation/ support International Travel & Health, WHO 2006 Control of Communicable Diseases Manual, 18th Edition by David L. Heymann, MD, Editor, 2004 http://travelhealth.co.uk/

Tuberculosis (TB)
Introduction Tuberculosis (TB) is an infectious disease caused by a bacteria known as Mycobacterium tuberculosis that usually affects the lungs, although it can affect any part of the body like bones, joints, genito-urinary, intestines, skin, tuberculous meningitis and others. TB is one of the major global public health challenges and is a re-emerging infectious disease. WHO estimates that one third of world's population is infected with TB almost 9 million people develop TB disease every year and around 2 million deaths every year. It is the major cause of death from a single infectious agent among adults in the developing world. Generally, incidence is high in Africa, Asia and South America The risk of infection differs between countries. In many countries of Africa and Asia, infection with HIV has further increased morbidity and mortality from TB. Drug-resistant TB is increasing in many areas of the world. Risk for travellers is limited but travellers are advised to avoid exposure to known TB patients in crowded environments (e.g. hospitals, prisons, or homeless shelters). Risk of tuberculosis transmission on airplane is similar to any other enclosed space. Causative agent: Mycobacterium tuberculosis is a rod-shaped,nonmotile, acid-fast bacterium,. Humans can also become infected by bovine tuberculosis, caused by M. bovis Transmission: Infection is usually by direct airborne transmission from person to person. Bovine TB (caused by the closely related Mycobacterium bovis) can be transmitted by ingestion of contaminated, unpasteurized dairy products from the infected cattle. Exposure to M.tuberculosis may lead to infection, but most infections do not lead to disease. The risk of developing disease following infection is generally 5 to 10% during the lifetime, but may be increased by various factors notably immunosuppression (example, advanced HIV infection) Incubation period: 2 - 10 weeks Sign & Symptoms

The most common symptoms of TB include; A cough that lasts for more than two (2) weeks Cough with sputum which is occasionally bloodstained Loss of appetite and loss of weight Fever

Dyspnoea, night sweats, chest pain and hoarseness of voice.

Diagnosis Laborating diagnosis of TB can be made when acid-fast bacilli (AFB) are seen on sputum smear or in other body tissues or fluids. Diagnosis of TB disease is further confirmed by culturing M. tuberculosis from sputum or other respiratory specimens for pulmonary TB and from other affected body tissues or fluids for extrapulmonary TB. On average, it takes about 2 to 4 weeks to culture and identify M. tuberculosis, even with rapid culture techniques. A diagnosis of TB disease can be made by using clinical criteria in the absence of microbiologic confirmation. Complication Haemoptysis, pneumothorax and empyema Treatment TB disease is treated with a multiple drug regimen for 6-8 months (usually isoniazid, rifampin, ethambutol and pyrazinamide for 2 months, followed by isoniazid and rifampin for 4 to 6 months) if the TB is not drug resistant. Drug resistant TB is more difficult, requiring 4-6 drugs for 18-24 months; it should be managed by a trained specialist. Inpatient treatment (Patient who are hospitalised)

Gravely ill patients Acute disseminated TB TB involving Central Nervous System (CNS), pericardium, adrenal and spine Multiple Drug Resistance -TB (MDR-TB) Patients who default frequently or compliance is suspect Complications such as haemoptysis, pneumothorax and empyema Associated diseases such as uncontrolled diabetes and renal failure Severe side effects such as severe skin reactions or jaundice Patients who need desensitization to anti-tuberculosis drugs.

Directly Observed treatment (DOTS) A standardized short course tuberculosis treatment regimen of six to eight months under direct observation by a trained supervisor (usually healthcare workers) to ensure that the patient takes every dose of medication.

Prevention & Precautions Prophylaxis Baille Calmette Guerin (BCG) should only be offered to those not previously immunised and who have a negative Tuberculin test. Protection from vaccine is only achieved after about 4 - 6 weeks. Boosters are not normally required. BCG immunisation has been shown to give 70% - 80% protection against TB meningitis. In the first year of life it provides good protection against complications of TB. In countries with high TB prevalence like Malaysia, infants are generally immunized as soon after birth as possible with a single dose of BCG, which protects against severe forms of TB in infancy and early childhood. BCG is one of the most difficult vaccines to administer and reconstituted vaccine must be given intradermally. Symptomatic HIV-infected individuals should not be vaccinated. BCG vaccine is of limited use for travelers. BCG immunisation is advised for those who are at risk. Type of vaccine: Live bacterial BCG Number of doses: One Contraindications: Symptomatic HIV infection Adverse reactions: Local - abscess, regional lymphadenitis Distant (rare) - Osteitis, disseminated disease Consider for: Infants under 6 months of age traveling to high risk countries and health workers and the recommended to be given 4 weeks before departure Precautions Risk for travelers from non-endemic countries is limited but travelers are advised to avoid exposure to known TB patients in crowded environments (e.g. hospitals, prisons, or homeless shelters). All healthcare workers should be advised on personal respiratory protective devices (e.g. N-95 respirators). For travelers from low incidence countries who may be exposed to infection in relatively high incidence countries (e.g. health professionals, humanitarian relief workers, missionaries), a baseline tuberculine skin test is advisable in order to compare with retesting after return.

If the skin reaction to tuberculin suggests recent infection, the traveler should receive, or be referred for, treatment for latent infection. Patients under treatment for tuberculosis SHOULD NOT TRAVEL until the treating physician is satisfied that the patient is not infectious and therefore of no risk to others. The importance of COMPLETING THE PRESCRIBED COURSE OF TREATMENT SHOULD BE STRESSED. References organisation/ support International Travel & Health, WHO 2006 Control of Communicable Diseases Manual, 18th Edition by David L. Heymann, MD, Editor, 2004 Clinical Practice Guidelines, Management of Pulmonary Tuberculosis, Ministry of Health Malaysia, 2002. WHO. Global tuberculosis control-surveillance, planning, financing: WHO Report 2007. Geneva: World Health Organization; 2007. http://travelhealth.co.uk/

Malaria
Introduction Most important parasitic disease in tropical and subtropical countries. It is currently endemic in over 100 countries and It is a serious and sometimes fatal disease. Tropical Africa is a much higher-risk destination compared to Latin America and Asia for following reasons:1. Tourists in Africa spend considerable time in rural areas e.g. game parks. However, tourists in Latin America and Asia spend more time in urban or resort areas. 2. Malaria is transmitted even in most large cities in sub-Saharan Africa. In Latin America and Asia, transmission is more seasonal or focally distributed in rural areas. 3. The infection rate of Mosquitoes with malaria parasites in Africa is higher and more apt to be carrying Malaria parasites. Causative agent: Human Malaria is caused by four different species of the protozoan parasite Plasmodium: Plasmodium falciparum, P.vivax, P.ovale and P.malariae. Transmission: Transmitted by various species of Anopheles mosquitoes, which bite mainly between sunset and sunrise Incubation period: 7 days or longer Pregnant women, young children and elderly travelers are particularly at risk. Chloroquine-resistant P. falciparum malaria is widespread. Exceptions are north / west of Panama Canal, Egypt and most of Middle East. Mefloquine-resistant P. falciparum malaria is found in border areas of Thailand, Vietnam and Laos. Multi-drug resistant P. falciparum malaria is reported from Vietnam and Amazon basin of South America. Sign & Symptoms Any individual who experiences a fever at any time between the seventh day of first possible exposure to malaria and three months (or rarely later), should immediately seek diagnosis and effective treatment.

(Fever developing less than one week after the first possible exposure is NOT Malaria). Most severe form is caused by P. falciparum with variable clinical features include fever, chills, headache, muscular aching and weakness, vomiting, cough, diarrhea and abdominal pain. The forms of Malaria caused by other Plasmodium species are less severe and rarely lifethreatening. Complication Acute organ failure, generalized convulsions, circulatory collapse followed by coma and death. Treatment Early diagnosis and appropriate treatment can be life saving. Many travelers will be able to obtain proper medical attention within 24hrs of the onset of fever. Stand-By Emergency Treatment (SBET) is taken by a traveler who

is sick in a remote location and cannot easily reach a hospital or qualified health professional may already be taking antimalarials for prophylaxis may have to self-diagnose malaria based on non specific clinical symptoms such as fever.

Travelers carrying SBET should observe the following guidelines;

Consult a physician immediately if fever occurs 1 week or more after entering an area with Malaria risk If it is impossible to consult a physician and/or establish a diagnosis within 24hours of the onset of fever, start the emergency treatment and seek medical care as soon as possible for complete evaluation and to exclude other serious causes of fever Complete the SBET course and resume antimalarial prophylaxis 1 week after the first treatment dose. Do Not treat suspected Malaria with the same drugs used for prophylaxis, because of the increased risk of toxicity and resistance.

Note: A drug selected for SBET should always be different from the drugs used for prophylaxis, and should be one to which no resistance has been reported in the countries to be visited. Choice of SBET according to recommended chemoprophylactic regimen

Recommended prophylactic Regimen None Chloroquine alone OR Proguanil Mefloquine Doxycycline Atovaquone/ proguanil

SBET Chloroquine (for P.Vivax areas Only),Mefloquine, Quinine Artemether and lumefantrine* Atovaquone/proguanil* Mefloquine, Quinine Quinine**, Quinine + Doxycycline Or tetracycline for 7 days** Mefloquine Quinine + Tetracycline for 7 days Quinine + Doxycycline/ Tetracycline For 7 days

* Limited experience at present on drug interactions of artemether/lumefantrine and atovaquone/proguanil with other antimalarial drugs. Therefore, if the patient is already taking an antimalarial as prophylaxis, these drugs should only be used if no other antimalarial treatment option is available. ** Mefloquine prophylaxis should only be resumed 7 days after the last self-treatment dose of quinine. Prevention & Precautions Four principles of protection 1. Be Aware of risk, incubation period, main symptoms and possible late onset of Malaria due to P. vivax and P. ovale. 2. Avoid being Bitten by mosquitoes, especially between dusk and dawn and use personal protective measures 3. Take Chemoprophylaxis. Be aware that no regimen gives complete protection although it does reduce risk of fatality. Relapse Malaria is not prevented by current chemoprophylactic regimens. 4. Immediately seek Diagnosis and treatment if a fever develops one week or more after entering and up to four years after departure from a risk area. Minimize exposure to bites by modifying activities to avoid exposure to vector bites. Anopheles mosquitoes feed between dusk and dawn Avoid outdoor activity during these periods. Avoid mosquito bite by applying mosquito repellent to exposed skin. When using sunscreen or lotions, apply repellants last. Reapply whenever sweat or water has removed it. Active ingredient in a repellent repels but does not kill insects. Repellent that contains DEET (N, N-diethylmetatoluamide) is most reliable and long-lasting type (35% DEET provides protection for 12 hours). DEET formulations as high as 50% are recommended for both adults (including pregnant women) and children >2 months of age. It is toxic when ingested and may cause skin irritation. Permethrin is highly effective both as an insecticide and as a repellent. There is little potential for toxicity from Permethrin-treated clothing.

Use long sleeved clothes and long pant. Avoid wearing dark colours (attract mosquitoes). Close windows or shutters at night when indoors. Use pyrethrum insecticide spray (aerosol insecticides), pyrethroid coils or insecticide impregnated tablets in evening before sleep. Avoid strong perfumes, hair sprays or after-shaves (attract mosquitoes)! Use air-conditioning or good mosquito net especially treated with Permethrin. There is No immunisation against Malaria presently. Pregnant women and young children require special attention because of potential effects of Malaria illness on the fetus and the inability of pregnant women and young children to tolerate certain drugs. The possible malaria prophylaxis regimens are: check with VBDCP Chloroquine phosphate (Aralen) - not effective against Plasmodium falciparum Malaria in most countries. Weekly Chloroquine should be started 1 week before arrival. Mefloquine (Lariam) - used for areas where drug-resistant P. falciparum exists. Not for pregnant women, children less than 13.6 kg in weight or people taking heart or epileptic medications. Weekly Mefloquine should be started at least one week but preferably 2 - 3 weeks before departure. Pyrimethamine / Sulfadoxime (Fansidar) - not for use by people who are allergic or sensitive to sulfphur drugs and infants less than 2 months of age. Self-treatment with Fansidar is not a substitute for prompt medical care, but is rather an attempt to prevent life-threatening Malaria infection. Doxycycline (Vibratab) - may cause photosentivity. Not for use by people who are allergic to tetracycline drugs, pregnant women or children less than 8 years of age. Proguanil/atovaquone (Malarone) - in combination with weekly Chloroquine phosphate, is used when travelling in East Africa and when use of Mefloquine is not possible. Should not be used for prophylaxis in children weighing 11kg because of lack of data on safety and efficacy. All prophylactic drugs should be continued for 4 weeks after last possible exposure. Exception is Proguanil which can be stopped one week after return. Drugs used in the prophylaxis of Malaria Drug Atovaquone / proguanil Usage Prophylaxis in areas with Adult Dose Pediatric Dose Comments Adult tablets Pediatric tablets Begin 1-2 days contain 250 mg contain 62.5 mg before travel to

(Malarone)

chloroquineresistant or mefloquineresistant P. falciparum.

Chloroquine phosphate (Aralen and generic)

Prophylaxis only in areas with chloroquinesensitive P. falciparum.

malarious areas. Take daily at the same time each day while in the atovaquone and malarious area and 25 mg proguanil for 7 days after hydrochloride. leaving such areas. atovaquone and Contraindicated in 11-20 kg: 1 tablet 100 mg persons with severe proguanil renal impairment 21-30 kg: 2 hydrochloride. (creatinine clearance tablets atovaquone proguanil should be 1 adult tablet 31-40 kg: 3 taken with food or a orally, daily tablets milky drink. not recommended for 41 kg or more: 1 prophylaxis children adult tablet daily 11 pregnant and women breastfeeding infants weighing kg. Begin 1-2 weeks before travel to malarious areas. 5 mg/kg base (8.3 Take weekly on the 300 mg base mg/kg salt) orally, same day of the (500 mg salt) once/week, up to week while in the orally, maximum adult malarious area and once/week dose of 300 mg for 4 weeks after leaving such areas. base. May exacerbate psoriasis. 100 mg orally, 8 years of age: 2 Begin 1-2 days daily mg/kg up to adult before travel to dose of 100 malarious areas. mg/day. Take daily at the same time each day while in the malarious area and for 4 weeks after leaving such areas. Contraindicated in children8 years of age and pregnant

Doxycycline (Many brand names and generic)

Prophylaxis in areas with chloroquineresistant or mefloquineresistant P. falciparum.

An alternative to chloroquine for prophylaxis Hydroxychloroonly in areas quine sulfate with (Plaguenil) chloroquinesensitive P. falciparum.

310 mg base (400 mg salt) orally, once/week

Mefloquine (Lariam and generic)

Prophylaxis in areas with chloroquineresistant P. falciparum.

228 mg base (250 mg salt) orally, once/week

Primaquine

An option for

30 mg base

women. Begin 1-2 weeks before travel to 5 mg/kg base (6.5 malarious areas. mg/kg salt) orally, Take weekly on the once/week, up to same day of the maximum adult week while in the dose of 310 mg malarious area and base. for 4 weeks after leaving such areas. Begin 1-2 weeks 9 kg: 4.6 kg base before travel to 5 week malarious areas. atovaquone Take weekly on the proguanil should same day of the be taken with week while in the food or a milky malarious area and drink. not for 4 weeks after recommended for leaving such areas. prophylaxis Contraindicated in children 11 persons allergic to pregnant and mefloquine or women related compounds breastfeeding (e.g., quinine and infants weighing quinidine) and in kg. <8 years="" persons with active of="" age="" depression, a recent and="" history of pregnant="" depression, p=""> generalized anxiety disorder, psychosis, 10-19 kg: 1/4 schizophrenia, other tablet once/week major psychiatric disorders, or 20-30 kg: 1/2 seizures. Use with tablet once/week caution in persons with psychiatric 31-45 kg: 3/4 disturbances, or a tablet once/week previous history of depression. Not 46 kg: 1 tablet recommended for once/week persons with cardiac conduction abnormalities. 0.6 mg/kg base Begin 1-2 days

prophylaxis in special circumstances. Call Malaria (52.6 mg salt) Hotline (770- orally, daily 488-7788) for additional information.

before travel to malarious areas. Take daily at the same time each day while in the malarious area and for 7 days after leaving such areas. (1.0 mg/kg salt) up to adult dose orally, daily

Primaquine

Contraindicated in persons with G6PD1 deficiency. Also contraindicated during pregnancy and lactation unless the infant being breastfed has a documented normal G6PD level. Use in consultation with malaria experts. Indicated for persons who have had prolonged Used for exposure to P. vivax presumptive 0.6 mg/kg base 30 mg base and P. ovale or both. anti-relapse (1.0 mg/kg salt) (52.6 mg salt) Contraindicated in therapy up to adult dose orally, once/day persons with G6PD1 (terminal orally, once/day for 14 days deficiency. Also prophylaxis) to for 14 days after after departure contraindicated decrease the risk departure from from the during pregnancy of relapses of P. the malarious malarious area. and lactation unless vivax and P. area. the infant being ovale. breastfed has a documented normal G6PD level.

Glucose-6-phosphate dehydrogenase. All persons who take primaquine should have a documented normal G6PD level prior to starting the medication. References organisation/ support International Travel & Health, WHO 2006 Control of Communicable Diseases Manual, 18th Edition by David L. Heymann, MD, Editor, 2004

http://travelhealth.co.uk/