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Posted Monday, November 25, 2002

Doctors to debate malaria drugs

By Lauran Neergaard, AP Medical Writer

WASHINGTON, Nov. 25, (AP)  - About 800 Americans a year bring home a bad souvenir from a trip abroad: malaria. A few die, and the rest suffer weeks of miserable symptoms that usually hit shortly after they unpack.

Most of the several million Americans who travel to malaria-plagued countries come home healthy thanks to swallowing protective drugs during the trip.

But the number sickened each year because they didn't take those pills has risen by a few hundred since the mid-1990s. Even as tourism in developing countries grows, too many travelers don't know to take anti-malaria medicines — or skip them from worry about side effects, such as rare psychiatric symptoms linked to Lariam, the most-prescribed drug.

Now doctors are looking to a meeting of the world's malaria experts in January to settle just which medication is the best choice for different people heading on vacations, military duty or other trips to malaria-ridden countries.

Don't expect a simple answer.

The malaria parasite has developed resistance to that old standby drug, chloroquine, in most of the world, rendering it largely useless. That leaves most travelers three options: Lariam, a newer and possibly safer drug called Malarone, and the antibiotic doxycycline.

Each has pros and cons that make declaring a No. 1 choice for everybody all but impossible, cautions Dr. Bradley Connor, a New York travel-medicine specialist.

"Your one-week business traveler vs. your teenage backpacker across Africa have very different risks," agreed Dr. Kevin Kain, director of the University of Toronto's Center for Travel and Tropical Medicine.

All three drugs "work well if you take them," Kain said. Customizing the prescription to each patient's health and destination can limit side effects, ensuring travelers don't abandon their pills.

For example, Lariam isn't supposed to be used by anyone with depression, a history of other psychiatric disorders, or epilepsy. Also, it's losing effectiveness in parts of Thailand, Cambodia and Myanmar. On the other hand, Lariam is the only once-a-week pill; the others require remembering a daily dose.

But the backpacker spending three months amid malaria-carrying mosquitoes may want the cheapest option, doxycycline. The busy executive may prefer Malarone because treatment ends one week after returning home; the other two drugs must be taken for a month after returning to kill any still-lurking malaria.

Large areas of Central and South America, the Dominican Republic and Haiti, Africa, the Indian subcontinent, Southeast Asia, the Middle East, and Oceania are considered malaria-risk areas, according to the Centers for Disease Control and Prevention.

Adding to the complex decision, the Food and Drug Administration (news - web sites) recently took two steps that may influence prescriptions:

_The FDA strengthened warnings that Lariam may cause psychiatric side effects ranging from anxiety and dreams to hallucinations, depression, occasionally even psychotic behavior. Those risks have long been known, but the updated warnings stress that people with active or recent depression and other risk factors shouldn't take Lariam.

However, the FDA cautions that the drug's alleged link to suicide has not been proven, and calls Lariam an important option. Travel-medicine specialists estimate serious side effects occur in one in 10,000 to one in 15,000 Lariam users.

_Separately, the FDA added to competitor Malarone's label results of a new study of 1,000 travelers that favorably compared Malarone to Lariam. The drugs appeared equally effective, but 5 percent of Lariam users had side effects bothersome enough to stop the drug, compared with 1.2 percent of Malarone users, says Kain. The Toronto physician headed the study funded by Malarone maker GlaxoSmithKline. The side effects were bothersome but not serious.

Malarone isn't risk-free — people with serious kidney damage can't use it — and after just two years of sales, it doesn't have Lariam's 17-year track record. Likewise, doxycycline's side effects include nausea, heartburn, sunburn and, for women, yeast infections.

Those advantages and disadvantages are the reason the Centers for Disease Control and Prevention wants to debate the matter at its January meeting, before it updates the government's official health advice for travelers.

Meanwhile, specialists advise people heading for developing countries to consult a travel clinic or other doctor with specific expertise in the destination; a regular doctor might not know they need anti-malaria pills, much less which one. Give the clinic a complete history of medical or psychiatric problems.

"It's not in any of our interests to make people sick with malaria drugs. What we're trying to do is stop people from coming back in body bags from their holiday," Kain said.

___ EDITOR'S NOTE — Lauran Neergaard covers health and medical issues for The Associated Press in Washington. ___ On the Net: CDC information on malaria: http://www.cdc.gov/travel/malinfo.htm  

Copyright 2002 The Associated Press.

                                                                                                                                                                                         Posted Tuesday, November 20, 2002                                                                                                                                              Destination: Better health in Haiti Anapolis neighbor

By Sue du Pont to The Sun, originally published November 18, 2002

JUST AS the cool autumn weather rolled into our area, Annapolis resident Janice Fisher headed to the Caribbean. The weather there was warm, but her trip was no vacation. Fisher and four other health care professionals were on a mission to take care of infants and children at an orphanage in Haiti. In four days, Fisher, a physical therapist at Hospital for Sick Children in Washington, and a doctor, two nurses, and a nutritionist evaluated and treated more than 375 children and a few adults.

When Fisher signed up for the trip with Caribbean Perinatal Associates Inc., she knew it would be a whirlwind but did not know what to expect. "I was a little concerned about crime and feeling overly conspicuous," she said.

The group was met at the airport in Port-au-Prince by Brother Karl Nozil, director of the Foyer Marie Reine des Apotres orphanage, where they would be working, and Maryse Chapoteau, director of public relations with the National Airport Authority, and immediately felt at ease. Throughout the trip, Fisher said, she felt that they were treated "like kings and queens," and they quickly bonded with the people there.

Shortly after their arrival, the health care professionals left the chaotic capital city and traveled for two hours through lush countryside to reach the orphanage in the town of Leogane. They immediately began evaluating and taking care of the approximately 200 children who live there.

The pace never slowed as they worked with children - infants through late teens - from sunup to sundown. Thanks to Fisher's headlamp, they were able to continue working into the evenings and conduct minor surgical procedures during the day. She said she almost didn't bring it, but it turned out to be one of the more important items she brought aside from medical supplies.

She found that her physical-therapy rehabilitation expertise was needed less than were general wound care, lessons in and hands-on hygiene, and evaluations in childhood development. Mostly the health care workers treated standard childhood illnesses, but they also treated several illnesses related to malnutrition, tropical infestation and wounds.

Although the hands-on care is important, members of the group take a longer view of their efforts. "I think that our major goal would be to do more extensive, long-lasting training that would carry on after we left," says Fisher. "We had some language barriers which may have limited us in this department, but Chimene Castor, our group coordinator and Haitian native, speaks Creole. She gave the best long-lasting education piece on HIV education, nutrition and personal hygiene by speaking to the orphanage employees and kids who were of age."

Fisher also felt that their presence gave the kids a sense of hope, and a glimpse of the "outside world."

"The kids loved hanging out with us and socializing," she said. "By the end of the trip, we felt like we were really accepted into the orphanage community. I got the feeling that we left an impression on the group, and that they really looked forward to us coming back again."

Fisher didn't realize how well off the children at the orphanage were until they opened their "clinic" one day to the townspeople. Working with people outside the orphanage, they found colds, fevers, more serious health problems, and less respect for the assistance they were providing. They treated about 150 villagers.

Fisher believes that the differences in health and attitudes among the townspeople and the orphanage children has much to do with the strict daily structure at the orphanage. It makes children's lives predictable, and teaches them values and a sense of responsibility. All of the children have certain responsibilities or chores that become weightier as they grow older, and all go to school, whether on site or in Port-au-Prince.

Caribbean Perinatal Associates is an all-volunteer, nonprofit organization dedicated to proving health care services for children in the Caribbean region. Dr. Robert Blake of Ellicott City, a pediatric and neonatology specialist, founded it in 1994. A native of the region, he felt that providing health services for newborns was a way to give back to the people of the Caribbean. This year, the group traveled twice to Jamaica and once to Haiti. It plans to provide services and training in Grenada and Antigua next year, to expand to include two new islands or countries each year, and to return to previously served areas.

Fisher looks forward to continuing her work in the Caribbean. She became involved with CPAI earlier this year because of her interests in the Caribbean and in working with children.

"I had done a clinical affiliation in 1992 in Kingston, Jamaica, as part of my physical-therapy training," she said. "I recognized the need for medical assistance, and wanted to do more. It is also interesting to compare and contrast the different Caribbean islands in terms of people, culture and medical needs."

Blake led the team while in Haiti. Castor, a registered dietitian who lives in the Washington area, planned the trip and served as mission leader. Laurel resident Anna Petrof, a nurse at Hospital for Sick Children, Wendy Knight, a pediatric intensive care nurse at National Children's Medical Center in Washington, and Fisher rounded out the group.

To help fund future activities, CPAI will hold a fund-raising dinner with dancing, door prizes, and other activities from 6 p.m. to 10 p.m. Saturday in Clarksville. Information: 240-475-4188.

To learn more about CPAI, to make a donation or to offer health care services on a future mission in the Caribbean: www. cpa-inc.org or 410-992-0982.   

Copyright 2002, The Baltimore Sun

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