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11. Complex emergencies and epidemics

formulation for parenteral use requires a two-step dissolution-dilution process. Parenteral
quinine requires either intravenous infusions or a three-times-a-day intramuscular
regimen, plus the need to monitor blood glucose.
Experience with artesunate suppositories in epidemic situations is limited. Their use
may be appropriate in severely ill patients who are unable to swallow oral medication
when intramuscular artemether (or quinine by intravenous infusion) is unavailable. If
artesunate suppositories are used, patients should be moved as soon as possible to a facility
where intramuscular or intravenous therapy can be started. When the patient cannot be
moved, continued treatment with rectal artesunate is appropriate until oral drugs can be
administered. It is essential that a full course of antimalarial treatment be completed.

box 11.1

Summary recommendations on treatment of uncomplicated malaria in epidemic situations

 the principles of treatment are the same as in section 7.
 the following acts are recommended for antimalarial treatment in P. falciparum or mixed
P. falciparum/ P. vivax malaria epidemics:
– artemether plus lumefantrine
– artesunate plus amodiaquine
– artesunate plus mefloquine
– dihydroartemisinin plus piperaquine.

 the 14-day anti-relapse therapy for vivax malaria patients (where applicable) should be
postponed to the post-epidemic period.

 treatment of severe malaria:
– artemether by the IM route is an acceptable and practical alternative for treatment of severe
falciparum malaria during an epidemic. As soon as intensive case monitoring becomes possible,
artesunate (IV or IM route) is the treatment of choice. Quinine can be used where artesunate is not
available.”

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