Peace Corps Malaria Policy – PCVs and RPCVs respond 0n Peace Corps’ Passport Blog

On August 13, 2013, the  Peace Corps Medical Director addressed the new FDA warnings on the anti-malaria drug,  mefloquine hydrochloride.  His statement was posted on the Peace Corps’s official blog, Passport.  Usually there are no responses to posts on the Passport blog as it usually is informative, but not interactive. For this article, however, PCVs and RPCVsc did comment and those  are important.  To read the article, without the formatting distractions, here is the text to link to:

http://passport.peacecorps.gov/2013/08/09/staying-safe-preventing-malaria/

Here is the article,copied and pasted.  The formatting may be distracting.

Staying safe, preventing malaria

BY PEACE CORPS ON AUGUST 9, 2013 • ( 10 COMMENTS )

By Barry G. Simon, M.D., Peace Corps Medical Director, Office of Medical Services

Last week, the U.S. Food and Drug Administration updated its warning label on the anti-malarial drug mefloquine hydrochloride, and there has been a surge in news coverage lately about the side effects of medications used to prevent malaria.

The Peace Corps takes these warnings very seriously and has taken proactive steps to ensure that Volunteers have all of the information they need to make an informed decision about the anti-malaria medication that is right for them, in collaboration with their Peace Corps Medical Officer.

Before beginning any kind of anti-malaria regimen, every Volunteer has an individual, one-on-one consultation with their Medical Officer to discuss the pros and cons of each medication and all possible risks and side effects. Volunteers can revisit their choice of medication at any time during their service, and while mefloquine continues to be an FDA-approved medication for malaria prevention, Volunteers who wish to request a change in medication can do so simply by talking with their Peace Corps Medical Officer. This policy is in place at every Peace Corps post worldwide, and the Peace Corps is working hard to make sure each and every Volunteer is familiar with the options available to them.

The Peace Corps uses a multi-pronged approach to combat malaria among Volunteers, which includes training on prevention, provision of insecticide-treated bed nets, screening for windows in all Volunteers’ homes, and a choice of one of four types of medication, each of which has proven extremely effective in suppressing malaria. With the proper use of bed nets, protective clothing, insect repellents and anti-malarial medication, the chances of developing active malaria are significantly reduced.

The Peace Corps’ Office of Health Services continually updates its policy on malaria suppressive medications based on the best medical information available and is working closely with the Centers for Disease Control and Prevention to monitor any further developments. Currently serving Volunteers who have questions about their health care can contact the Peace Corps’ Quality Improvement Unit at qualitynurse@peacecorps.gov. Returned Peace Corps Volunteers with concerns about their health care can contact the Peace Corps’ Post Service Unit at psu@peacecorps.gov.

Dr. Barry Simon is board certified in internal medicine and pulmonary diseases and practiced in a private practice setting for 29 years prior to joining Peace Corps.  He previously served as the Chief of Clinical Programs at Peace Corps, beginning in 2008, and for 20 years prior to joining Peace Corps he served as a consultant in pulmonary diseases for the Office of Medical Services.  Dr. Simon received his medical degree from Boston University and completed five years of training in internal medicine and pulmonary diseases at Georgetown University Hospital in Washington, D.C.

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10 replies »

Anonymous 
.comment-author August 10, 2013 at 9:50 pm .comment-metadata 
.comment-meta I am a currently serving volunteer. I had my consultation with my PCMO and they did offer me options, they did seem to lean towards Mefloquine as the best option unless I started to experience side effects, at which point they would happily switch me to another drug. I have yet to experience any side effects but I may have another serious discussion with my PCMO about the full extent of potential side effects of each drug and then decide whether or not I will continue to remain on Mefloquine or switch to one of the other two options. I know that my PCMO has been very willing to work with volunteers who choose to use the other options. My only hope is that now that there is more recognition of the side effects, that the discussions the PCMOs have with their volunteers include a more detailed description of the side effects as well as follow up interviews with volunteers who choose to use Mefloquine.

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Anonymous 
.comment-author August 10, 2013 at 1:23 am .comment-metadata 
.comment-meta “Before beginning any kind of anti-malaria regimen, every Volunteer has an individual, one-on-one consultation with their Medical Officer to discuss the pros and cons of each medication and all possible risks and side effects.”

When does that happen? It’s not happening in Malawi and I doubt that’s standard operating procedure. In order to be taken off of mefloquine, volunteers have to make a convincing case to the PCMO. There’s little education about the side effects of mef and they’re severely diminished. I was fortunate enough to be on Doxy for my service but many of my fellow volunteers still experience symptoms after having returned more than a year ago.

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anonymous 
.comment-author August 10, 2013 at 3:38 pm .comment-metadata 
.comment-meta We did not have this in the Dominican Republic either. When asked about side effects the doctors basically brushed the concerns aside as unimportant. I fortunately was not in a high risk area so quit taking the malaria med shortly after going to my site. Of course I took other precautions. During my COS physical I told my doctor that I had taken myself off the meds and she seemed to understand why. She did say that if I contracted malaria I would be subject to ET and all of the consequences that go along with it. I think the PC needs to reanalyze some of the areas that are required to take malaria meds and possibly only require the meds in specific hot spots within certain countries, and they certainly need to do a more thorough job of answering questions about the safety of the drugs available. I do not agree with the “comply or your out” rule concerning this either.

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Anonymous 
.comment-author August 10, 2013 at 4:46 pm .comment-metadata 
.comment-meta That’s what I was made to feel – take this pill, it’s our only option – until I flat out refused to take it anymore and told my PCMO I *will* be taking Doxy. The option for Malarone wasn’t even on the table because of the cost and I don’t even know what this mysterious fourth option they’re talking about is. Most areas with PCVs that are endemic are also chloroquine resistant, so I hope it’s not that.

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Anonymous 
.comment-author August 11, 2013 at 2:40 pm .comment-metadata 
.comment-meta I didn’t get a consultation. I was just told: here’s a paper of the possible side effects of mefloquine, and you have to sign it.
When I started taking mefloquine, I couldn’t sleep at all for four days straight. I told my PCMO about the side effects, and was told to take a Benadryl and see if that helped me sleep. When that didn’t work, they told me to break the pill in half and take half a dose twice a week.
Eventually they gave me Doxy.

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Peace Corps .comment-author August 13, 2013 at 3:05 pm .comment-metadata 
.comment-meta In early 2013, the Peace Corps Office of Medical Services updated its policy on malaria suppressive medications. This policy now includes a one-on-one conversation between Volunteers and their Peace Corps Medical Officers, and the choice of one of four types of medications proven to suppress malaria, depending on Volunteers’ location. As mentioned above, the Peace Corps continually updates its policy on malaria prevention based on the best medical information available, and the process outlined here reflects the most recent updates. 
If you are an RPCV and have concerns about your health, we strongly encourage you to contact the Peace Corps’ Post Service Unit at psu@peacecorps.gov, so we can directly address your specific case. If you are a current Volunteer, don’t hesitate to reach out to your PCMO to discuss any questions or concerns. 
Your health, safety and security are our top priorities, and we greatly appreciate your feedback to help us better support the Peace Corps community.

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Irene Brammertz 
.comment-author August 9, 2013 at 10:10 pm .comment-metadata 
.comment-meta What are the four choices? I recently served in Malawi as a Response Volunteer and was given two choices: Mefloquine or Doxy. I asked for Chloroquine since that had worked really will during my initial service in the DRC but was told it was not an option. When I developed nightmares the Medical officer told me to split the dosage in half and takes it twice a week instead of once. They said Chloroquine was not effective something disputed by other expats who said since nobody has been taking that there is not really resistance against it.

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Dr. Remington Nevin .comment-author August 9, 2013 at 10:26 pm .comment-metadata 
.comment-meta Regarding the myth of “choice”, the Peace Corps seems reluctant to acknowledge the verifiable fact that in prior fiscal years, it did not adequately budget to provide the safer daily drug Malarone to all PCVs who might request it. In the particular case of travel to Malawi, as any experienced travel physician who consults the primary literature will know, the country has been virtually devoid of chloroquine-resistant malaria for years.

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Dr. Remington Nevin .comment-author August 9, 2013 at 8:57 pm .comment-metadata 
.comment-meta Since the drug was licensed in 1989, the mefloquine package insert has very clearly warned that should certain neuropsychiatric symptoms develop while taking the drug, these should be considered prodromal to a “more serious event”, and the drug immediately discontinued. Yet Dr. Hans Lobel, writing in the Summer 1996 Peace Corps “Healthwise” newsletter, seemed to dismiss these symptoms as “anecdotal”. He wrote “What could explain the many anecdotes about adverse effects of mefloquine in the face of the many investigations indicating that the drug is well tolerated when used for prophylaxis? The anecdotal stories focus on neuropsychological events; insomnia, dizziness, strange dreams (some PCVs reported liking them), anxiety and headache. Such subjective events can occur as a result of stress.” 
Today it is clear that each of these symptoms is a potential indication of a developing toxicity that warrants careful evaluation. According to today’s product labeling, these symptoms mandate the immediate discontinuation of the drug, in order to minimize the risk of “permanent” neurological injury and psychiatric symptoms potentially lasting “years” after use. 
Yet in light of Dr. Lobel’s dismissive commentary, which trivialized the significance of anxiety, it is not clear whether PCVs received even proper counseling consistent with earlier product labeling. It seems probable that many PCVs may have been erroneously instructed to continue use of the drug despite the development of contraindicating symptoms, including anxiety, depression, restlessness, or confusion. Today, we recognize that these and other contraindicating neuropsychiatric symptoms develop in a sizeable minority of prophylactic users, if not a majority.
What will Peace Corps do to identify, diagnose, and treat those RPCVs who have been injured by the toxic effects of this drug, partially as a result of the poor medical advice provided to them by earlier Peace Corps officials?

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Anonymous 
.comment-author August 9, 2013 at 9:21 pm .comment-metadata 
.comment-meta I wholeheartedly concur. I began my PC service on Mefloquine and had almost immediate negative psychological effects. I had violent, disturbing dreams, night terrors, began sleep walking and had what I am guessing we’re anxiety attacks. I would “wake up” and, eyes open, see intruders in my room, see people sitting at the foot of my bed. I would see a recurring hallucination of three yellow birds (during daylight hours). When I reported it to the PCMO, I was regarded with an attitude of “suck it up, it’s just stress from moving to a new country, you’re paranoid now from other PCV horror stories.” I had to stay in it almost five months before, after having suicidal dream, I told the PCMO I was refusing to take it any longer and she could go from there. I was switched to Doxycycline and was on it about four moths and contracted malaria. I was switched back to Mef, had many of the same symptoms, though to a lesser degree, and basically kept quiet about it because of the two strikes policy in regards to contracting malaria. I was on Mef for another two and a half years through my extension. I took my pill on Tuesday, felt like the world was ending on Wednesday & Thursday, couldn’t get any sleep on Friday, Saturday & Sunday, then mellowed out on Monday just in time to take my pill again. I’ve been off it for about four months now and am taking Doxy while continuing to work overseas, but I still see people in my house, I still sleepwalk and I still have sudden bouts of panic. Articles like the one in the NYT make my issues feel justified, but they’re also scary because it’s not something I want to continue to live with. That being said, if I had to choose between the side effects and the malaria that almost killed me, I’ll take the pills every time.

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6 Comments

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  • Gerald,

    Dr. R Nevin is one of the doctors who wrote the letter to Peace Corps, complaining about the malaria drug program. He does address some issues about cost. I also think, based, on the replies from the Volunteers, that there is tremendous difference from country to country.

  • Forty years ago the PC doctor prescribed anti-malaria pills for all volunteers stationed on the Honduran north coast (Atlantic side). I dutifully took it for a few weeks and felt very strange. When I asked the PC doctor, he made all the same threats about expulsion. Ultimately, my health is my responsibility. I just quit taking their crazy, cheap pills. At least forty years ago, the PC seemed to enjoy bullying youngsters. Take Nancy Reagan’s advice and just say no. They have a problem with that? Start calling your senators and congressmen.

  • Gerald,

    I have no idea why the authors decided not to use their names. I don’t know how it would be possible to ask that question. The post is dated August of 2013 and the comment suggestion is closed.

    What might work is to ask the advocacy group “Health Justice for Volunteers” why they think Volunteers or RPCVs might be reluctant to use their names.

    Volunteers are in a legal limbo. They (we) are not employees and so do not have all the legal provisions of civil service employees. They are basically private citizens working under government “control.” and serve only at the pleasure of the President. That authority is delegated down the line and Volunteers can still be “separated” for any number of reasons, with very little appeal success. Serving Volunteers do have some First Amendment rights on political issues. I have argued for years, totally unsuccessfully, that Volunteers should have a contract with the Peace Corps spelling out rights and responsibilities.

  • Joanne – Never much thought about my rights and responsibilities when I was a volunteer, nor did I have any particular complaints with Peace Corps policies and practices at the time. On the other hand, as a naive 22-year old, isolated in a small Turkish village and proud to have been chosen to serve, what did I know?

  • Gerald,

    Experiences in the Peace Corps vary tremendously depending on the year, the country, the program, gender and the in-country staff. Everything is fine, until a Volunteer has a problem.

    I realized that Volunteers were exactly in the same position, legally, as the people with whom we worked, in Colombia. If we had money or political connections, we were better off than those who had to depend totally on the decisions of authorities who had no accountability to us. We needed good patrons to succeed, as well as did our host country people.

    I also served in the time of the Draft. As a woman, it only impacted the men. But I saw the threat of termination used as a club against men who had very legitimate concerns.

    With civil service, as well as unions, as well as employment laws, everyone, at least in law, has an equal chance. Contracts can also offer the same protection. Having a contract would not negate the value of service to one’s country or knowing that it was and is a privilege to serve.

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