260 / LYMPHOGRANULOMA VENEREUM
and rectovaginal septum, resulting in proctitis, stricture of the rectum and
fisrulae. Proctitis may result from rectal intercourse and LGV is a fairly
common cause of severe proctitis in homosexual men Elephantiasis of the
genitalia may occur in either sex. Fever, chills, headache, ioint pain! and
anorexia are present. The disease course is often long and disability great, but
generally not fatal. A rare occurrence is generalized sepsis with arthritis and
meningitis
Diagnosis is made by demonstration of chlamydial organisms by lr' or by
culture of bubo aspirate, or by specific micro-IF serologic test. CF testing is of
diagnostic value if there is a fourfold rise or a single titer of 21:64. A negative
CF test rules out the diagnosis.
2. Infectious agent—Chlamydia trachomatis, related to the organisms of
trachoma and oculogcnital chlamydial infections, but of immunotypet M, L-2
and L-3.
3. Occurrence—Worldwide, especially in tropical and subtropical areas;
more common than ordinarily believed. Endemic in Asia Africa, particularly
among lower socioeconomic classes. Age incide corresponds with sexual
activity. Less commonly diagnosed in worn probably due to frequency of
asymptomatic infections, however, differences arc not pronounced in
countries with high endemicity. races are affected. In temperate climates,
found predominantly am male homosexuals.
4. Reservoir—Man, often asymptomatic (particularly females).
5. Mode of transmission—Direct contact with open lesions of fected
persons, usually during sexual intercourse.
6. Incubation period—Variable, with a range of 3-30 days fat) primary
lesion; if a bubo is the first manifestation. 10-30 days, to months.
7. Period of eommunicability—Variable, from weeks to years, ing
presence of active lesions.
8. Susceptibility and resistance—Susceptibility is general;
natural or acquired resistance unclear
9- Methods of control—
A. Preventive measures: Except for measures which are
for syphilis, preventive measures are those for sexually
muted diseases. See Syphilis, 9A.
B. Control of patient, contacts and the immediate envi
I) Report to local health authority: A reportable
selected endemic areas; not a reportable disease ■■
countries, Class 3B (see Preface).
MALARIA I 261
2) Isolation: None. Refrain from sexual contact until all lesions
are healed.
Concurrent disinfection: None; care in disposal of discharges
from lesions and of articles soiled therewith. Quarantine:
•ii None.
Immunization of contacts: Not applicable; prompt treatment
on recognition or clinical suspicion of infection. Investigation
of contacts and source of infection: Search for infected sexual
contacts of patient. Recent contacts of confirmed active cases
should receive specific therapy. Specific treatment:
7 Tetracycline antibiotics are effective for all stages, including
>
buboes and ulcerative lesions. Administer orally for at least 2
weeks. Erythromycin or sulfonamides may be used when
tetracycline is con train dicated. Do not incise buboes;
drain by aspiration through healthy tissue.
C". Epidemic measures: Not applicable.
D. Disaster implications: None.
E. International measures: See Syphilis, 9E.
§
maLARIA ICD-9 084
I. Identification—The four human malarias can be sufficiently similar ' •
early symptoms to make species differentiation difficult without tory
studies. Furthermore, the fever pattern of the first few days of ion
resembles that seen in early stages of many other illnesses rial, viral and
parasitic). Even the demonstration of parasites does cessarily mean that
malaria is all that the patient has (e.g., early fever, Lassa fever, etc.). The
most serious malarial infection, m malaria (malignant tertian), may
present a quite varied clinical incluJing fever, chills, sweats and headache,
and may progress to , coagulation defects, shock, renal and liver failure,
acute enccph-y, pulmonary and cerebral edema, coma and death. It is a
possible of coma and orher CNS symptoms, such as disorientation and in
any person recently returned from a tropical area. Prompt ent is essential,
even in mild cases, since irreversible complications pear suddenly; case
fatality rates among untreated children and une adults exceeds 103F. by a
considerable margin, other human malarias, vivax (benign tertian),
malanae (quartan), bvale, generally are not life-threatening except in the
very young, the
262 / MALARIA
very old and in patients with concurrent disease or immunodencieiw^ Illness
may begin with indefinite malaise and a slowly rising fever o several days
duration, followed by a shaking chill and rapidly rising temperature, usually
accompanied by headache and nausea, and ending with profuse sweating.
After an interval free of fever, the cycle of chills, fever and sweating is
repeated, either daily, every other day or every third day. Duration of an
untreated primary attack varies from a week to a month or longer. True
relapses following periods with no parasitemia (seen with vivax and ovale
infections) arc common and may occur at irregular intervals for up to 2 and 5
years, respectively; malariae infections may persist for as many as 50 years
with recurrent febrile episode*. Individuals who are partially immune or who
have been taking prophylactic drugs may show an atypical clinical picture and
wide variation* in the incubation period.
Laboratory confirmation is made by demonstration of malaria parasite* in
blood films. Repeated microscopic examinations may be necessary] because
of variation in density of P. falciparum parasitemia during the asexual cycle;
furthermore, parasites are often not demonstrable in fi." from patients recently
or actively under treatment. Several tests are utt study involving the
demonstration of parasite DNA in blood with pro' as are techniques permitting
visual recognition of specific ant: antibody interactions. Antibodies,
demonstrable by IFA or other t appear after the first week of infection and
may persist for y indicating past malarial experience, and are not helpful for
diagnosi* current illness.
2. Infectious agents—Plasmodium max. P. malarial. P. lain and P.
ovale. Mixed infections are not infrequent in endemic areas.
i. Occurrence—Endemic malaria no longer occurs in many tcm-zone
countries and well-developed areas of tropical countries, but major cause
of ill health in many parts of the tropics and subtropics < socioeconomic
developmenr is deficient; high transmission areas are found on the
fringes of forests in S America (i.e., Brazil) and SE Asia Indonesia).
Ovale malaria is seen mainly in sub-Sahnran Afric* vivax malaria is
absent. P. falciparum, refractory to cure 4-aminoquinoIines (such as
chloroquine), occurs in the tropical of both hemispheres. Current
information on foci of drug-malaria is published annually by the WHO
and can be obtained i Malaria Branch, CDC, Atlanta (see Preface). In
the USA. outbreaks of mosquito-transmitted malaria occurred in
California late 1980s.
4. Reservoir—Man is the only important reservoir of human
Nonhuman primates are naturally infected by many malarial
including P. knowltsi, P. cynomolgi, P- branlianum. P. iitui. P. sc.
MALARIA I 263
\imium. which can infect man, but natural transmission is extremely
5. Mode of transmission—By the bite of an infective female anopheline
mosquito. Most species feed at dusk and during early night hours, some
important vectors have biting peaks around midnight or rhe early hours of the
morning. When a female Anepbtlti mosquito ingests blood containing the sexual
stages of the parasite (gamerocytes). male and female gametes are set free in the
mosquito stomach where they unite and enter the stomach wall to form a cyst in
which thousands of sporozoites develop; this requires 8-35 days, depending on
the species of parasite and the temperature to which the vector is exposed.
These sporozoites migrate to various organs of the infected mosquito, and some
that reach pbe salivary glands mature and are infective when injected into a
person the insect takes a blood meal.
In the susceptible host, rhe sporozoites enter heparocytes and develop to
exoerythrocytic schizonts. The heparocytes rupture and asexual *asites (tissue
merozoites) reach the bloodstream through the hepatic usoids and invade the
erythrocytes to grow and multiply cyclically, ost will develop into asexual
forms, from trophozoites to mature blood onfs, which rupture to liberare
erythrocytic merozoites, which ■'e other erythrocytes. Clinical symptoms
arc produced by the '■re of large numbers of erythrocytic schizonts. Within
infected ocytcs, some of the merozoites may develop into the male (micro-
tocyte) or the female (macrogamciocyte) sexual forms. 2 period between the
infective bite and the appearance of the ire in the blood is the "prepatent
period," which varies from 6 to 9 with /'. falciparum, P. virax and P. ovale,
and 12-16 days in the case f malarial. Gametocytes usually appear within 3
days of parasitemia P. max and P. male, and after 12-14 days in P.
falciparum. Some "Tthrocytic forms of P. vivax and probably /'. wait exist as
dormant _thvpnozoires) which remain in hepatucyres to mature months later
woducc relapses. This phenomenon does not occur in falciparum or ■c
malaria, and reappearance of these forms of the disease is the af inadequate
treatment or of infection with drug-refractory strains. . malariae, low levels of
erythrocytic parasites may persist for many «o multiply at some future time to
a level that may result again in disease Malaria may also be transmitted by
injection or transfu-hlood of infected persons or by use of contaminated
needles and , as by drug users. Congenital transmission occurs rarely, "ubation
period—The time between the infective bite and the e ol clinical symptoms is
approximately 12 days for P. faUi-14 days for P vitax and P. male, and 30
days for P. malariae. With ns of P. max. mostly from temperate areas, there
may be a incubation period of 8-10 months; even longer with P. Male. turn by
blood transfusion, incubation periods depend on rhe
264 / MALARIA
Mlhri of parasites infused; they are usually short, but may range up to about 2
months.
7. Period of communicability—For infection of mosquitoes, as long as infective
gametocytes arc present in the blood of patients; this varies with species and
strain of parasite and with response to therapy. Untreated or insufficiently
treated patients may be a source of mosquito infection for more than 3 years in
malariae, from 1-2 years in vivax. and generally not more than 1 year in
falciparum malaria, the mosquito remains infective for life. Transmission by
transfusion may occur as long as asexual forms remain in the circulating blood;
with P. malariae this can i continue for ^40 years. Stored blood can remain
infective for 16 days, i 8. Susceptibility and resistance—Susceptibility is
universal except in I people with certain genetic traits. Tolerance or
refractoriness to disease is j present in adults in highly endemic communities
where exposure to j infective anophelincs is continuous over many years. Most
black Africans I show,a natural resistance to infection with P. lit ax. possibly
associated I with the absence of Duffy factor on their erythrocytes. Persons
wirkj sickle cell trait have relatively low parasitemia when infected with P.J
falciparum.
9- Methods of control— A.
Preventive meaiures:
1) Encourage sanitary improvements (such as filling mm
draining areas of impounded water) that will rcsuk ■
permanent elimination or reduction of anophelinc breefl ing
habitats. Larvicides and biological control with brmt vorous
fish may be useful.
2) Any use of a residual insecticide should be preceded ba
careful appraisal of the particular problem area, mt
development of specific plans, and their approval by d
government concerned. Where appropriate, apply rrmW ual
insecticide on the inside walls of dwellings and M other
surfaces upon which endophilic vector anopheJ habitually
rest; this will generally result in effective H laria control,
except where vector resistance to 4H insecticides has
developed or the vectors do not J
houses.
3) Nightly spraying of screened living and sleeping quaM
with a liquid or aerosol preparation of pyrethrum or J
insecticide is useful.
4) In endemic areas, install screens and use bed nets, m
effectiveness <>1 bed r.ct, is greatly enhanced by iwrnt
nation with a synthetic pyrethroid (e.g., pcrnic-thn^B
5) Insect repellents applied to uncovered skin of P^l
MALARIA ' 265
exposed to bites of vector anophelincs are useful when
applied repeatedly. The most effective repellent presendy
available is diethyltoluarmde (Deet®).
6) Blood donors should be questioned for a history of malaria or
possible exposure to the disease. In the USA, blood donors
who have not taken antimalarial drugs and have been free of
symptoms may donate 6 months after return from an endemic
area. If they have been on antimalarial prophylaxis, have had
malaria, have immigrated, or are visiting from endemic areas,
they may be accepted as donors 3 years after cessation of
chemoprophylaxis or chemotherapy and departure from the
endemic area, if they have remained asymptomatic A migrant
or visitor from an area where malariae malaria is or had been
endemic may be a source of transfusion-induced infection for
many years. Such areas include, but arc not limited to,
tropical Africa and countries such as Greece and Romania
7) Prompt and effective treatment of acute and chronic cases is
an important adjunct to malaria control.
8) Non-immune travelers who will he exposed to mosquitoes in
malarious areas should regularly use suppressive drugs; in
most endemic countries, chemoprophylaxis is recommended
for pregnant women and young children as well. The
possible side-effects of the drug or drug combination
recommended for use in any particular area should be
weighed against the actual likelihood of being bitten by an
infected mosquito. The risk of exposure to those living in
cities in most malarious areas is minimal, but it can be
reduced further by the judicious use of supplementary
methods of protection, such as nets and repellents
a) In areas where travelers will be at risk of acquiring
chloroquine-resistant P. falciparum (Asia, Africa, S
America), mefloquine (a quinoline methanol) alone Is
recommended. The dose (250 mg for an adult) should be
taken weekly, starting one week before travel.
Prophylaxis should be continued weekly during travel in
malarious areas and for 4 weeks after a person leaves
such areas. Mefloquine is contraindicated in pregnant
women, children under 30 lbs, individuals using beta-
blockers or other drugs which may prolong or alter
cardiac conduction, individuals with a history of psychi-
atric disorders or leprosy and individuals involved in
tasks requiring fine coordination and spatial discrimina-
CDC recommendation. MMWR Sep 1990; 39:630.
266 / MALARIA
tion, such as airline crews.
Doxycyclinc alone, 100 nig once daily, is an alter-
native regimen for short-term travelers who are unable to
take mefloquine. Doxycycline may cause diarrhea.
monilial vaginitis, and photosensitivity. It should not be
given to pregnant women and children less than 8 years
old. Doxycycline prophylaxis can begin 1-2 days prior to
travel to malarious areas, and should be continued daily
during travel and for A weeks after leaving the malarious
area.
Long-term travelers at risk of infection by
chloroquine-rcsistant P. falciparum strains for whom
mefloquine is contraindicated (including pregnant
women, children under 30 lbs and those intolerant of the
drug, etc.) should take once-weekly chloroquine alone.
They should be given a treatment dose of Fansidar®
(sulfadoxine 500 mg-pyrimethamine 2) mg) unless they
have a history of sulfonamide intolerance In the event of a
febrile illness when profession^ medical care is not
readily available, administer l-'ansi-dar® (adult dose 3
tablets) and obtain medical consu latinii as soon as
possible. It must be emphasiz that such presumptive self-
treatment is only temporary measure and that prompt
medical ev« uation is imperative.
b) For suppression of malaria in nonimmunes temp rarily
residing in or traveling through endemic where the
Plasmodia are chloroquine-sensitive (1 die America west
of the Panama Canal, the island i Hispaniola and
malarious areas of the Middle chloroquine (Aralert®), 5
mg base/kg body (300 mg base or 500 mg chloroquine
phosphate 1 the average adult), once weekly. Pregnancy is
contraindication. The drug must be continued i same
schedule for 4-6 weeks alter leaving areas.
c) These chemosuppressive drugs do not eliminate j
hepatic parasites, so that clinical relapses of i ovale
malaria may occur after the drug is disconti|
Primaquine, 0.25 mg basc.'kg/day for 14 days Q base
or 26.3 mg of primaquine phosphate average adult),
is effective and may be given i rently with or
following the suppressive ^^ leaving endemic areas;
however, it can produce I ysis in those with glucose-
6-phosphate dchydr (G-6-PD) deficiency. The
decision to
MALARIA / 267
maquine is made on an individual basis, considering the potential
risk of adverse reactions. Larger daily doses (22.5 mg base) may be
required for some SE Asian and southwest Pacific srrains.
Alternatively, primaquine. 0.75 mg base/kg, may be given once
weekly for 8 doses (45 mg base or 79 mg primaquine phosphate for
the average adult) after leaving endemic areas. If possible, prior to
primaquine administration, the patient should be tested for
possible G-6-PD deficiency. Primaquine should not be
administered during pregnancy; chloroquine should be continued
weekly for the duration of the pregnancy. Control a/patient,
contacts and the immediate environment: I) Report to local
health authority: Obligatory case report as a Disease under
Surveillance by WHO, Class 1A (see Preface), in nonendemic
areas, preferably limited to smear-confirmed cases (USA); Class
3C is the more practical procedure in endemic areas.
2) Isolation: For hospitalized patients, blood precautions.
Patienrs should be in mosquito-proof areas at night.
3) Concurrent disinfection: None.
4) Quarantine: None.
5) Immunization of contacts: Not applicable
6) Investigation of contacts and source of infection: Deter
mine history of previous infection or of possible expo
sure. If a history of needle sharing is obtained from the
patient, investigate and treat all persons who shared the
equipment. In transfusion-induced malaria, all donors
must be located and their blood examined for malarial
parasites and for antimalarial antibodies; parasite-positive
donors should receive treatment.
?) Specific treatment lor all forms of malaria:
a) The trearmenr o( malarias due ro infection with P. lieax,
P. malartat. and P. wale is the oral administration of a
total of 25 mg of chloroquine base/kg adminisrered over a
3-day period: 15 mg/kg rhe first day (10 mg/kg initially
and 5 mg/kg 6 hours later. 600 and 300 mg doses for the
average adult); 5 mg*kg the second day; and 5 mg'kg the
third day.
b) For emergency treatment of adults with grave infections
or for persons unable to retain orally administered
medication, use quinine dihydrochloride. 20 mg base/kg,
diluted in 500 ml ol normal saline, glucose or plasma,
administered by slow IV (over 2-4 hours); repeat in 8
hours at a lower dose (10 mg/kg) if needed.
268 / MALARIA
and then the same dose every 8 hours until it can be
c supplanted by oral quinine. The pediatric dosage is the
same
If there is evidence of renal failure, quinine dosage should
be reduced. If parenteral quinine is not available, parenteral
quinidine is equally effective in treatment of severe
malaria. A loading dose of 10 m* quinidine gluconate/kg
body weight is administered bf slow IV over 1-2 hours,
followed by a constant IV infusion of 0.02 mg quinidine
gluconate/kg/minute. preferably controlled by a constant-
infusion pump. The infusion may continue for a maximum
of "2 hours. | All parenteral drugs should be discontinued as
soon i oral drug administration can be initiated. In
extremerfl severe falciparum infections., particularly those
altered mental status or with a parasitemia approac' or
exceeding 50% (some consider 10% adetj exchange
transfusion should be considered. All teral drugs should be
discontinued as soon as oral dr administration can be
initiated. c) For P. falciparum infections acquired in areas
chloroquine-resisrant strains are present, admi quinine, 25
mg/kg/day divided into 3 doses, for I days. (For grave
infections, administer quinine described above) Along with
quinine, administer f racycline, 15 rag/kg given in 4 doses
daily, for 7 Mefloquine has been in use for several years i*
Asia, and treatment failures have been reported, effort
should be made to determine the the; course producing rhe
best results in the area where disease was contracted, since
drug-resistance may vary in time and locale, d) For
prevention of relapses in mosquito-acq i -■/ax and P. wale
infections, administer primaq; described in 9A8b, above,
upon completion treatment of an acute attack. It is desirable
to patients (especially blacks, Asians and Medic for G-6-
PD deficiency to prevent drug-induced ysis. Many,
particularly blacks, are able to to" hemolysis, but
consideration may have to be discontinuing primaquine,
balancing the induced lem against rhe possible recurrence
of maqume is not required in non-mosquiro-c disease (e.g.,
transfusion), since no liver phase
Epidemic measurr$: Determine the nature and extenr
MEASLES ' 269
epidemic situation. Intensify control measures directed against
adult and larval stages of the important vectors, including
elimination of breeding places, trearment of acute cases, use of
personal protection and suppressive drugs. Mass treatment may be
considered.
Disaster implications: Throughout history the malarias have been a
concomitant or the result of wars and social upheavals. Any
abnormal climatic or edaphic change which increases the
availability of mosquito-breeding sices in endemic areas can lead
to an increase in malaria
International measures:
11
Disinsectization of aircraft before departure ot in transit using
a space-spray application of an insecticide of a type to which
the vectors are susceptible. Dismsectization of aircraft, ships
2) and other vehicles on arrival if the health authority at the place
of arrival has reason to suspect importation of malaria vectors.
Enforce and maintain rigid antimosquito sanitation within the
H mosquito flight range of all ports and airports. In special
circumstances, administer antimalarial drugs to potentially
4> infected migrants, refugees, seasonal workers and persons
taking part in periodic mass movement mto an area or country
where malaria has been elunioMed. Primaquine, 30-45 mg
base (0.5-0.75 mg/kg>. gweo «s a single dose, renders the
gamctocyres of falciparum asm-laria noninfectious.
» Malaria is a Disease under Surveillance by WHO. at km
considered an essential element of the world strategy i
primary health care. Narional health administrate** are
expected to notify WHO twice a year of. those | originally
malarious with no present risk of M those malaria cases
imported into areas in the i nance phase of eradication, those
areas with i-hlcxu, resistant strains of parasites, and those
intrrnaoaarif and airports free of malaria. WHO Collaborate^
(see Preface).
LES
Hard measles, Red measles and I