MALARIA.AYEBARE YVONNE.

UNCOMPLICATED MALARIA. Uncomplicated malaria definition:

Fever and any of the following: Headache, Body and joint pains Feeling cold and sometimes shivering Loss of appetite and sometimes abdominal pains Diarrhoea, nausea and vomiting. Splenomegaly

Confirmed diagnosis of malaria.

All clinically suspected malaria cases require laboratory examination and confirmation.

Only in case where laboratory confirmation is not possible start treatment immediately.

Parasitological confirmation is done by thin-thick blood smear microscopy examination or by dipstick (Rapid Diagnostic Test [RDT]).

Treatment of uncomplicated malaria

• P. falciparum malaria The treatment of uncomplicated P. falciparum

malaria is undertaken after diagnosis of malaria by light microscopy or Dipstick.

Patients with positive think-thick blood smears or dipstick for P. falciparum malaria is treated by blisters of Coartem® (artemether 20mg/lumefantrine 120mg). See Table 1 for details of prescription.

Table 1 : Dosage and administration Coartem (Artemether 20 mg/Lumefantrine 120 mg) for uncomplicated

malaria falciparum. Source: Guideline for the treatment of malaria, WHO; 2006

Age group Weight group Blistercolor (Day 1) (Day 2) (Day 3)

4 months to 5yrs 5 to 14 kg Yellow

1 tb , 1 tb , 1 tb ,

1 tb 1 tb 1 tb

6 to 11y 15 to 24 kg Blue

2 tb , 2 tb , 2 tb ,

2 tb 2 tb 2 tb

12 to 14y 25 to 34 kg Orange

3 tb , 3 tb , 3 tb ,

3 tb 3 tb 3 tb

> 14y > 34 Green

4 tb , 4 tb , 4 tb ,

4 tb 4 tb 4 tb

Coartem® Dosage Schedule

Follow-up of uncomplicated malaria:

If symptoms persist after treatment with coartem® or if the patient comes back before the 14th day after treatment.

Treatment failure within 14 days of receiving coartem® is extremely rare and is more likely to be an inadequate absorption of the drug(s) than resistance of the parasites. It is important to determine from the patient’s history whether he or she vomited during the previous treatment or did not complete the full course.

If patient is in health facility where microscope is available failure of treatment should be confirmed parasitologically and could be treated using the following regimen:

Follow-up of uncomplicated malaria:

• For adult: Quinine (10mg salt /kg bw three times a day)

+ doxycycline (3.0mg/kg bw once a day) for 7 days. Do not give doxycycline with milk or iron, which will reduce its absorption.

If patient is in health facility where microscopy facility is not available patient should be referred to the facility where microscope is available. If refer is not possible treatment should be given Quinine + Doxycycline. Please refer to Table 5 for details of the prescription.

Doxycycline should not be given to pregnant or lactating woman, or child aged up to 8 years.

For pregnant or lactated woman or child less than 8 years:

Quinine (10mg salt /kg bw three times a day) + clindamycin (10mg/kg bw twice a day) for 7days. For small children, (quinine and clindamycin) crush tablets and mix with water and sugar.

NOTEFor high transmission areas

where parasitological confirmation is not available, children <5 yrs of age is recommended to be treated with anti malarial drugs when symptomatic (especially fever).

SEVERE MALARIA. Severe or complicated malaria definition:Fever and any of the following: Impaired consciousnessAnxiety, palpitation and sweatingConvulsions or fits with this feverFast or difficult breathingVomiting every feed / unable to feedPale hands, tongue and inner parts of the eyelidGeneralized body weaknessDehydrationJaundice Severe malnutritionDark urine or no urine

Pre-referral treatment of severe malaria

• A patient who is non responsive should be quickly assessed and managed. This includes assessment of the airway, breathing and circulation. The staff at the first level health facility should be able to maintain airway, provide assisted breathing and manage shock if required.

• Pre-referral treatment for severe malaria the administration of Artesunate by the rectal route is recommended for all except pregnant women first trimester pregnancy. For the complete dosage and treatment.

• Check blood sugar, if possible!

• In case Artesunate suppository is not available IM quinine injection 20mg/kg bw should be given. The Quinine injection dosage should be split and injections given in the anterior part of the thigh.

• In case Artesunate suppository is not available, give also Quinine for children with severe malaria.

Confirmed diagnosis of severe malaria:

• All clinically suspected severe malaria cases require laboratory examination and confirmation.

• Only in case where laboratory confirmation is not possible start treatment immediately. Parasitological confirmation is done by thin-thick blood smear microscopy examination or by dipstick (Rapid Diagnostic Test [RDT]).

Differential diagnosis for complicated malaria

Consider other illnesses, such as: Measles, meningitis, tonsillitis, dengue, otitis

media (ear infection), influenza, pneumonia, typhoid fever, tuberculosis, hypoglycemia.

Specific severe malaria treatment • Artesunate (60 mg): 2.4 mg/kg body weight (bw) IV or IM

on admission (time=0), followed by 2.4 mg/kg at 12 and 24 hours, followed by once daily for seven days. Once the patient can tolerate oral therapy, treatment should be switched to a complete dosage of coartem® for three days as recommended in the national treatment guidelines for uncomplicated malaria .

• The congenital malaria is also treated with Artesunate, where 2.4 mg/kg is initially given through IV, followed by 1.2 mg/kg at 12 and 24 hr then every 24 hr for 3 -5 days.

Specific severe malaria treatment Artemether (80mg for adult and 40 mg for children and

the newborn): 3.2 mg/kg bw IM on the first day followed by 1.6 mg/kg bw daily for seven days. Once the patient can tolerate oral therapy, treatment should be switched to a complete dosage of coartem®.

Arteether (150 mg): 3.2 mg/kg bw IM on the first day, followed by 1.6 mg/kg bw for the next 4 days. Once the patient can tolerate oral therapy, may switch to a complete dosage of coartem®.

• If Coartem® is not available, quinine should be administered in combination with tetracycline or doxycycline or clindamycin, to complete the seven-day treatment, except for pregnant women and children under eight years of age for whom tetracycline/doxycycline is contraindicated.

QUININE.

• Loading dose: Quinine dihydrochloride 20 mg salt/ kg bw diluted in 10 ml/kg bw of 5% dextrose or dextrose saline administered by IV infusion over a period of four hours for both adult and children. In severe Childhood falciparum malaria, if patient received quinine or quinidine or mefloquine in 48 hrs before arrival, give 10 mg/kg over 2 hours.

QUININE. Maintenance dose: Quinine dihydrochloride 10 mg salt/

kg body weight diluted in 10 ml/kg body weight of 5% dextrose or dextrose saline administered by IV infusion. In adults, the maintenance dose is infused over a period of four hours and repeated every eight hours.

Similarly in children including congenital malaria, it is infused over a period of two hours and repeated every eight hours (calculated from the beginning of the previous infusion) until the patient can swallow. To complete the seven-day to eight-day treatment in children, give Quinine sulfate 10 mg/kg per oral three times in a day. Increase the dosage of Quinine sulfate to 15-20 mg/kg after 4 days or add tetracycline 5 mg/kg twice a day for children above 7 years.