Malaria-related health issues (to be completed before receiving the Malaria Survival kit)
MALARIA SURVIVAL KIT
This kit is provided for the emergency treatment of acute uncomplicated Plasmodium Falciparum Malaria, the malignant cerebral malaria commonly found in Africa / Asia Pacific / Latin America and other malaria areas. This form of malaria can kill in 24–36 hours from first symptoms. Uncomplicated means early symptoms of malaria such as fever, headache, and general malaise. This kit is provided for emergency use in situations where medical help and effective drugs are not immediately available. However, it is always better to seek appropriate medical attention. The medication provided in the kit is typically Coartem. Alternative medication may be provided depending on the consent of the governing authorities in the malaria-prone area. There are a number of contraindications that must be considered before using this kit. If any of these apply, do not use this kit: • Complicated malaria (anything other than early symptoms) • Pregnancy or lactation • Other types of malarial infection such as recurrence of benign malaria • Any family history of sudden death • Any strong family or personal history of heart disease (also any known ECG abnormalities) Should you choose to take the medication, you should also seek medical assistance IMMEDIATELY. There are a number of special precautions where you must seek medical advice before taking the medication. These include, but are not limited to: • Any liver or kidney impairment • Any abnormalities of the heart rhythm such that the pulse is not entirely regular There are also some drug interactions, which should rule out the use of the kit. These include: • Cispride • Anti-depressants • Some antibiotics • Anti-fungals • Any drug to stabilize the rhythm of the • Other anti-malarials (a malarial heart breakthrough is considered complicated) As with most medications, there may be some side effects with the medication. These are uncommon, but may include: • Headache • Dizziness • Sleep disturbance • Palpitation • Nausea or indigestion • Itching • Rash • Joint or muscle pains • Fatigue • Cough I confirm that I have read and understood the above statements and this kit has been provided for my sole use for the emergency treatment of acute uncomplicated P. Falciparum Malaria when professional medical assistance and treatment are not quickly available. The kit is for my exclusive use and will not be given to another individual. I also confirm that I will not use the kit in situations where contraindications apply.
Employee Name : Employee Signature:
BHI Operation / Current Malaria Work Product and Location (Country, City): Technology: Survival Kit #: Survival Kit Delivery Date: O / P&T-MCO Date: Signature: NOTE: Retain a signed original of this form in the employee’s personnel record.