Malaria Case MGT Updates of 2023

Malaria Diagnosis and Treatment Updates
Amhara Public Health Institute, PHEM Directorate
February, 2023
©APHI-PHEM Directorate
Outline
• Introduction to malaria
• Mode of transmission of malaria
• Malaria diagnosis and treatment
Introduction
What is malaria?
• Malaria is an infectious disease caused by the protozoan parasites of the genus Plasmodium.
• Malaria case in the elimination context is defined as a parasitologically confirmed case of malaria
(including gametocytaemia) regardless of presence or absence of clinical symptoms of malaria.
• It is a serious public health problem in many parts of the world including Ethiopia.
• The plasmodium species that infect humans include:

 Plasmodium falciparum, vivax, ovale and malariae
 Plasmodium knowlesi-a newly discovered species (Zoonotic malaria).
Modes of Malaria Transmission
Modes of transmission:
• By the bite of infected female Anopheles mosquito (main transmission)
• Accidental
 Blood transfusion
Needle stick injury
• Congenital
Malaria diagnosis and treatment
1. Clinical diagnosis (History plus physical examination)
2. Parasitological diagnosis
Clinical Diagnosis
Clinical malaria diagnosis is based on the case definition:
In malarious areas:
 A patient with fever or history of fever within the past two days (48 hours) is assumed to
have clinical malaria.
In non malarious areas:
 A patient with fever or history of fever within the past two days and history of travel to
malarious area within the last one month is assumed to have clinical malaria.
Treatment based on clinical diagnosis alone is unreliable, and when possible, should be
confirmed by laboratory tests.
Parasitological diagnosis:
• Required for confirmation of the diagnosis of malaria.

• Recommended for all suspected cases in all transmission settings.
• The two main methods of parasitological confirmation are light microscopy
and malaria RDTs.
• Patients who test negative by malaria RDT or microscopy do not need anti-
malarial medications.
Malaria Treatment
• Malaria treatment needs to classify the malaria cases before starting

treatment with antimalarial drugs as:
1. Uncomplicated malaria
2. Severe malaria
Uncomplicated Malaria
Definition of uncomplicated malaria:
symptomatic malaria, in the presence of asexual forms of

malaria parasites in blood sample without signs of severity
or evidence of vital organ dysfunction.
• During elimination, all malaria infections are important, as they

may lead to onward transmission.
Clinical Features of Uncomplicated Malaria
The common clinical signs/symptoms include:

• Fever (The most important clinical feature of malaria)
• Loss of appetite
• Headache
• Joint and muscle pain
• Chills & rigors
• Vomiting
Drug Treatment of Uncomplicated Malaria
RDT or Microscope result Treatment
Positive for PF AL + single dose PQ
Positive for PV CQ + PQ for 14 days
Mixed infection AL + PQ for 14 days
The first dose should be given under the

direct observation (DOT) of the health
workers
Management of Uncomplicated Malaria…
Alternative treatment:
Situation Recommendation
Chloroquine not available for P.vivax Use AL
AL not available for P.falciparum or mixed Use DHA-PPQ

infection
Chloroquine and AL not available for P.vivax Use DHA-PPQ

When do we use second line treatment?
 When the first-line treatment is not available
 During treatment failure (Non-response to first-line treatment).
 First line drug contraindicated
 The second-line treatment for both P. falciparum and P. vivax is oral

Dihydroartemesinin-Piperaquine (DHA-PPQ).
Supportive treatment:
A. Control the fever

• Treat especially in children
• Use paracetamol 15mg/kg every 4hrs
• Fanning, tepid sponging
• Use the IMNCI algorithm
B. Prevent hypoglycemia
• Encourage to take food and fluids.
key messages: Advice Patient that:
• He/she has got malaria
• The medication has to be taken as prescribed completely (full dose)
• Early treatment is important to prevent severe illness and death due to malaria
• Take enough food and fluid (especially fatty meal to enhance drug absorption and to
avoid risk of hypoglycemia).
• To return to the health facility if fever persists or patient is still sick after 72 hours
• Malaria is transmitted by mosquitoes
• Malaria can be prevented by using insecticide treated nets, eliminating mosquito
breeding places, and protecting sprayed houses from re plastering
Signs of severity to consider referral to Hospital
• Altered consciousness (e.g., confusion, • Pallor (Anemia)

sleepy, drowsy, comma) • No urine output in the last 24 hours
• Not able to drink or feed • Bleeding
• Severe dehydration, • Jaundice (yellowish sclera)
• Frequent vomiting • Difficult breathing
• Convulsion or recent history of convulsion • Other conditions that cannot be
• Unable to sit or stand up managed at this level
Pre referral treatments
• Rectal Artesunate
Pre referral drug for children <6years of age or <20kg weight.
• Prevent hypoglycemia
• Anti- pyrectics
• Proper documentation
Drugs information
1. Artemether - Lumefantrine (AL)
• Taken two times a day for three days
• Fixed dose combination treatment
• Very fast parasite elimination
• Prompt reduction in fever
• Effective against immature gametocyte clearance
• Effective in multi-drug resistant areas
• Does not show any evidence of organ or system specific toxicity
• Can be used for infants weighing < 5 kg and first trimester pregnancy
Drugs information AL…
Weight Age Day 1 Day 2 Day 3
(KG) Color code
Immediate After Morning Evening Morning Evening
8hrs
<5kg <4 1Tablet 1Tablet 1Tablet 1Tablet 1Tablet 1Tablet Yellow*

months
5-14 kg 4mths- 1Tablet 1Tablet 1Tablet 1Tablet 1Tablet 1Tablet
2 years
15-24 kg 3 to 7 2 Tablets 2 Tablets 2 Tablets 2 Tablets 2 Tablets 2 Tablets Blue*
yrs
25-34 kg 8 to 10 3 Tablets 3 Tablets 3 Tablets 3 Tablets 3 Tablets 3 Tablets Brown
yrs
>35 =>10 4 Tablets 4 Tablets 4 Tablets 4 Tablets 4 Tablets 4 Tablets Green
years
*Yellow and blue

©APHI-PHEM flavored pediatric dispersible tablets of AL is available for enhancing its use in young children.
Directorate
Contraindications of AL:
• Persons with a previous history of reaction after using the drug.
• For chemoprophylaxis combined with other drugs or alone.
• Persons with severe and complicated malaria should not be treated with
oral medications
Drugs information:- Chloroquine(CQ)
• Used for PV, PO and PM infections.

• It is rapidly and almost completely absorbed from GI tract.
• Has low safety margin and is very dangerous in over dosage.
• Effective against the blood stage parasites.
• If chloroquine syrup is not available, use pediatric AL for children <5 years
of age
• It is contraindicated to persons with known hypersensitivity, known epilepsy
and psoriasis.
Drugs information: Primaquine (PQ)
• Effective against all stages of gametocytes
• The only drug which can act in the hepatic stage of the parasites including the
hypnozoites
• The active metabolites of its byproducts are very toxic which can induce hemolysis.
• Has low safety margins.
Primaquine (PQ) indications and side effects
Indications:
• Radical cure against P.vivax
• Prevention of transmission against P.falciparum
Side effects:
• Anorexia, nausea, vomiting, abdominal pain and cramps
• Vague symptoms such as weakness and uneasiness in the chest.
• Hemolysis in G6PD deficient individuals
PQ Contraindications:
 Pregnant mothers at all trimesters

 Women breast feeding infants less than six months of age
 Infants less than 6 months
 Severe anemia
 Known history of G6PD deficiency
 People with known hyper sensitivity reaction for PQ
©APHI-PHEM Directorate 27
Primaquine treatment schedule
Number of tablets
Age (years) 7.5 mg tablet 15 mg tablet
Weight (kg)
8-19 kg 06 months to <5years ½ -
19 – 24 5–7 1 ½
25 – 35 8 – 10 1 ½
36 – 50 11 – 13 1½ 1
50+ 14+ 2 1
1. The dose of PQ is For radical cure 0.25 mg base/ kg daily for 14 days for radical cure and
0.25 mg base/ kg single dose for PF
NOTE: Patients on 14- days radical cure treatment with Primaquine should be assessed for
hemolysis if any change of urine color or signs of anemia occurs
ፕሪማኩን ለመስጠጥ እርግዝና አለመኖሩን ማረጋገጫ መንገድ (ጤና ኬላ)
ተ.ቁ ጥያቄዎች አዎ የለም
1 ባለፉት 7 ቀናት ውስጥ የወር አበባዎት መጧል?

2 የወር አበባዎ ከመጣ ወዲህ ወይም ከወለዱ ወዲህ ከግብረ ስጋ ግንኙነት ታቅበዋል?
የወር አበባዎ ከመጣ ወዲህ ወይም ከወለዱ ወዲህ ሳያቆራርጡ በትክክል የወሊድ መከላከያ ተጠቅመዋል?
3
4 ባለፉት አራት ሳምንታት ልጅ ወልደዋል?

ከ6 ወር በታች ህጻን አለዎት? አዎ ከሆነ ልጅዎን በትክክል ጡት ያጠባሉ? ከወለዱ ጀምሮ የወርአበባዎ መቶ አያውቅም?
5
6 ባለፉት 7 ቀናት ውርጃ (የጽንስ መቋረጥ) አጋጥሞዎታል?
ማብራሪያ
1. ደንበኛዋ ቢያንስ አንዱን ጥያቄ ‘’አዎ’’ ብላ ከመለሰችና ምንም ዓይነት የእርግዝና ምልክት ከሌለ ነፍሰ-ጡር እንዳልሆነች ማወቅ ይቻላል፡፡
2. ደንበኛዋ ሁሉንም ጥያቄዎች ‘’የለም’’ ብላ ከመለሰች እርግዝና አለመኖሩን ማረጋገጥ ስለማይቻል ለእርግዝናምርመራ ወደጤናጣቢያ መላክ
አለዚያም የሚቀጥለው የወርአበባ እስኪመጣ መጠበቅ አለብን፡፡
When to stop PQ: Health post level
• Urine color: a score of 5 or above on the Hillmen urine color chart or Symptomatic
anemia.
 Refer the patient to the nearest HC
When to stop PQ: Health centers/hospital level
• Hemoglobin < 5g/dL
• Hemoglobin drop of >50% of the baseline.
• Hemoglobin < 7g/dL AND Hemoglobin drop from baseline of

>25%
• Symptomatic anemia.
Drugs information: DHA-PPQ
• A fixed drug combination

• Used to treat P. falciparum and P.vivax malaria
• Used in all age groups and pregnant mothers.
• Side effects are uncommon, and no organ specific toxicity documented.
• Adequate exposure to the drug has excellent cure rates (> 95%)
• Avoid high-fat meals as it increases the absorption of piperaquine leading to
unwanted delayed ventricular repolarization.
• Normal meals do not alter the absorption of piperaquine.
Treatment of malaria in pregnancy
• Artemether - Lumefantrine (AL) and chloroquine are given in all trimesters
• Both single dose & radical cure PQ administration are contraindicated in all stages of
pregnancy
• P. vivax in pregnant women can be treated with CQ for three days
• Weekly CQ prophylaxis until delivery and for six months after delivery is used to prevent
relapse
• Pregnancy is not a criterion to diagnose severe malaria
• Pregnant women with malaria should be treated as severe cases only if they have signs of
severity.
Severe Malaria
• A patient should be regarded as having severe malaria if there are:

 asexual form of parasite in a blood film and
sign of severity and evidence of vital organ dysfunction.
• Note that occasionally, P. vivax infection can also cause severe malaria
illness, but the treatment and management is the same.
Severe manifestation of malaria and frequency in adults and children
Treatment of Severe Malaria…
• Management of severe malaria is complex
• It requires follow-up on many issues.
• Patients with severe malaria should not be treated with oral medicines
• Give primaquine if the patient is awake and tolerate oral drugs
• Primaquine should be postponed in cases of severe anemia.
• First line treatment for severe malaria is Artesunate (IV or Im)
• Alternative treatments are Artemether (IM) or Quinine (IV or IM)
• The treatment of severe P. vivax is similar to severe Pf, except providing radical cure Primaquine after
recovery.
Administration of Artesunate injection
• For adults and children>20kg: Artesunate 2.4 mg/kg iv/im
• For children weighing <20kg: Artesunate 3mg/kg iv/im
• Given on admission (0), at 12 hours and 24 hours
• Evaluate the patient after three doses and change to full dose AL if
the patient’s condition has improved
• It can be continued for 7 days if a patient does not tolerate oral

treatment.
Thank You !!
38

Malaria Case MGT Updates of 2023

Uploaded by

Copyright:

Available Formats

Malaria Case MGT Updates of 2023

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Malaria Case MGT Updates of 2023

Uploaded by

Copyright:

Available Formats

Malaria Diagnosis and Treatment Updates

Amhara Public Health Institute, PHEM Directorate

• Mode of transmission of malaria

• Malaria diagnosis and treatment

(including gametocytaemia) regardless of presence or absence of clinical symptoms of malaria.

• The plasmodium species that infect humans include:

 Plasmodium knowlesi-a newly discovered species (Zoonotic malaria).

• By the bite of infected female Anopheles mosquito (main transmission)

Needle stick injury

1. Clinical diagnosis (History plus physical examination)

In non malarious areas:

• Required for confirmation of the diagnosis of malaria.

• Malaria treatment needs to classify the malaria cases before starting

Definition of uncomplicated malaria:

symptomatic malaria, in the presence of asexual forms of

• During elimination, all malaria infections are important, as they

The common clinical signs/symptoms include:

RDT or Microscope result Treatment

Positive for PF AL + single dose PQ

Positive for PV CQ + PQ for 14 days

Mixed infection AL + PQ for 14 days

The first dose should be given under the

Chloroquine not available for P.vivax Use AL

AL not available for P.falciparum or mixed Use DHA-PPQ

Chloroquine and AL not available for P.vivax Use DHA-PPQ

When do we use second line treatment?

 When the first-line treatment is not available

 During treatment failure (Non-response to first-line treatment).

 First line drug contraindicated

 The second-line treatment for both P. falciparum and P. vivax is oral

A. Control the fever

• Altered consciousness (e.g., confusion, • Pallor (Anemia)

<5kg <4 1Tablet 1Tablet 1Tablet 1Tablet 1Tablet 1Tablet Yellow*

*Yellow and blue

• Persons with a previous history of reaction after using the drug.

• For chemoprophylaxis combined with other drugs or alone.

• Used for PV, PO and PM infections.

• Effective against all stages of gametocytes

• Has low safety margins.

 Pregnant mothers at all trimesters

 Known history of G6PD deficiency

 People with known hyper sensitivity reaction for PQ

ተ.ቁ ጥያቄዎች አዎ የለም

1 ባለፉት 7 ቀናት ውስጥ የወር አበባዎት መጧል?

4 ባለፉት አራት ሳምንታት ልጅ ወልደዋል?

6 ባለፉት 7 ቀናት ውርጃ (የጽንስ መቋረጥ) አጋጥሞዎታል?

• Hemoglobin < 5g/dL

• Hemoglobin drop of >50% of the baseline.

• Hemoglobin < 7g/dL AND Hemoglobin drop from baseline of

• A fixed drug combination

• P. vivax in pregnant women can be treated with CQ for three days

• Pregnancy is not a criterion to diagnose severe malaria

• A patient should be regarded as having severe malaria if there are:

• Management of severe malaria is complex

• It requires follow-up on many issues.

• Give primaquine if the patient is awake and tolerate oral drugs

• Primaquine should be postponed in cases of severe anemia.

• First line treatment for severe malaria is Artesunate (IV or Im)

• Alternative treatments are Artemether (IM) or Quinine (IV or IM)