Dr. lokesh Garg md., MR. Satish kamboj

1. Indian Guidelines &
Protocols For The Treatment
Of Malaria
Dr. Lokesh Garg MD.
{MED.}
Santosh hopital Yamuna nagar

2. Introduction
Major public health problem of India
Around 1.5 million confirmed cases are reported
annually (NVBDCP)
50% are due to Plasmodium falciparum.
( most severe form of disease )

4. 
Causative agent: intracellular plasmodium protozoa.

Species : P.falciparum , P.malariae , P.ovale , P.vivax.
(P.knowlesi -documented in malaysia ,
, indonesia,singapur,phillippines)

Transmission: Female anopheles mosquitoes.
( Also transmitted through blood transfusion ,use of
contaminated needles, from pregnant women to fetus)

6. 
Malaria kills in one year what AIDS kills in
15 years. For every death due to HIV/AIDS
there are about 50 deaths due to malaria. To
add to the problem is the increasing drug
resistance to the established drug.

7. Exo-erythrocytic (hepatic) Cycle:
Sporozoites infect liver cells and develop
into schizonts, which release merozoites
into the blood
Sporozoites injected into
human host during blood
meal
Parasites
mature in
mosquito
midgut and
migrate to
salivary glands
MOSQUITO
Parasite undergoes
sexual reproduction in
the mosquito
HUMAN
Some merozoites
differentiate into male or
female gametocyctes
Dormant liver stages
(hypnozoites) of P.
vivax and P. ovale
Erythrocytic Cycle:
Merozoites infect red
blood cells to form
schizonts

8. Malaria Life Cycle
Oocyst
Sporozoites
Mosquito Salivary
Gland
Zygote
Exoerythrocytic
(hepatic) cycle
Gametocytes
Erythrocytic
Cycle
Hypnozoites

9. The Malaria Transmission Cycle
Sites of Action for Antimalarial Drugs
TISSUE SCHIZONTOCIDES:
primaquine
pyrimethamine
proguanil
tetracyclines
MOSQUITO
SPORONTOCIDES:
primaquine
pyrimethamine
proguanil
HUMAN
GAMETOCYTOCIDES:
primaquine
BLOOD
SCHIZONTOCIDES:
chloroquine
mefloquine
quinine/quinidine
tetracyclines
halofantrine
sulfadoxine
pyrimethamine
artemisinins

10. Artemisinin derivatives
Dihydroartemisin
Ethyl Ether
Arteether
Qinghaosu
("ching-how-soo")
Methyl Ether
Artemether
Hemisuccinate
Artesunate

11.  Artemisinin-based
combination therapy
(ACT) is an antimalarial combination
therapy with an artemisinin derivative as
one component of the combination given for
at least 3 days.

13. Clinical features
Fever -The cardinal symptom of malaria.
chills and rigors.
Headache
 myalgia,
Arthralgia
 anorexia
Nausea
vomiting.

14. Why Early Diagnosis &
Treatment

15. Microscopy
Microscopy of stained thick and thin blood smears - gold standard
 The sensitivity is high.
 Detect malaria parasites at low densities.
Helps to quantify the parasite load.
Distinguish the various species of malaria parasite and
their different stages.

16. 

Based on the detection of circulating parasite antigens
RDT - based on the detection of P falciparum histidine -rich
protein-2 (PfHRP-2) ,does not detect the other 3 species.

For Vivax and Falciparum -Dipstick tests based on parasite
lactate dehydrogenase are now available.

These tests have high sensitivity and specificity, require no
special equipment or training, and produce results rapidly.

However, they remain positive for a week or more after the
treatment and cure, and, in this situation, can yield false-positive
results.

17. Treatment of P. Vivax Malaria
1. Chloroquine : - Drug of choice
25 mg/kg divided over three days i.e.10 mg/kg (600 mg ) on day
1, 10 mg/kg ( 600 mg ) on day 2 & 5 mg/kg on day 3.
2. Primaquine : 0.25 mg/kg 15 mg/day daily for 14 days.
Primaquine is contraindicated in
known G6PD deficient patients, infants and
pregnant women.

18. ACT drug of choice
Artemisinin Combination Therapy (ACT)
+
single dose primaquine (0.75 mg/kg or 45 mg ) on Day 2.
The ACT recommended in the National Programme of India is
Artesunate (4 mg/kg body weight) daily for 3 days
&
Sulfadoxine (25 mg/kg body weight)
- pyrimethamine (1.25 mg/kg body weight) on Day 0.

19. Other ACT can also be used Artemether + Lumefantrine
Artesunate + Amodiaquine
Oral artemisinin monotherapy is banned in India
Artemisinin derivatives must never be administered as
monotherapy for uncomplicated malaria. These rapidly acting
drugs, if used alone, can lead to development of drug resistance.

20. Short half-life; hence good for combination
 Rapid substantial reduction of the parasite biomass
 Rapid resolution of clinical symptoms
 Effective action against multi-drug resistant P.
falciparum
 Reduction of gametocyte carriage
 No documented parasite resistance yet
 Few reported adverse effects.


21. 
Uncomplicated Pf.
- Quinine - Drug for choice in first trimester.
- ACT is recommended in 2nd & 3rd trimester

P. vivax malaria
CQ drug choice in all trimester

22.  Treated
as falciparum malaria with ACT.
 Antirelapse
treatment with primaquine can be
given for 14 days

24. 


Impaired consciousness/coma
Repeated generalized convulsions

Renal failure (Serum Creatinine >3 mg/dl)

Jaundice (Serum Bilirubin >3 mg/dl)

Severe anaemia (Hb <5 g/dl)

Pulmonary oedema/acute respiratory distress syndrome

Hypoglycaemia (Plasma Glucose <40 mg/dl)

25. 
Metabolic acidosis

Circulatory collapse/shock (Systolic BP <80 mm Hg, <50
mm Hg in children)

Abnormal bleeding and Disseminated intravascular
coagulation (DIC)

Haemoglobinuria

Hyperpyrexia (Temperature >106o F or >42o C)

Hyperparasitaemia (>5% parasitized RBCs )

26. 


Severe malaria is an emergency and treatment should be given
promptly. Parenteral artemisinin derivatives or quinine should
be used irrespective of chloroquine sensitivity.
Artesunate: 2.4 mg/kg body weight i.v. or i.m. given on
admission (time=0), then at 12 hours and 24 hours, then
once a day (Till patient takes orally or for 7 days). Then full
course of ACT for 3 days
Other drugs used are arteether , artemether, quinine ( along with
doxycycline/clindamycin)

27. Artemether : 3.2 mg/kg body weight i.m. given
on admission then 1.6 mg/kg body weight per day.
α−β Arteether: 150 mg daily i.m. for 3 days in
adults only
(not recommended for children).

28. Quinine: 20 mg quinine salt/kg body weight on admission
 (i.v. infusion in 5% dextrose/dextrose saline over a period of 4 hours)
 Maintenance dose of 10 mg/kg body weight 8 hourly
 Infusion rate should not exceed 5 mg/kg body weight per hour.
 Loading dose of 20 mg/kg body weight should not be given, if the
patient has already received quinine..
 NEVER GIVE BOLUS INJECTION OF QUININE.
 If parenteral quinine therapy needs to be continued beyond
 48 hours, dose should be reduced to 7 mg/kg body weight 8 hourly.


29. Patients receiving parenteral quinine should be
treated with
 oral quinine 10 mg/kg body weight three times a
day 4 days, along with doxycycline 3 mg/ kg body
weight per day for 7 days.


(Doxycycline is contraindicated in pregnant women
and children under 8 years of age; instead,
clindamycin 10 mg/kg body weight 12 hourly for 7
days should be used).

30. 
First trimester of pregnancy parenteral quinine is the drug of choice.
- If quinine is not available Artemisinin derivatives may be
given to save the life of mother

In second and third trimester.
- Parenteral artemisinin derivatives are preferred.

31. 
Doxycycline:
100 mg daily in adults and 1.5 mg/kg body weight for
children more than 8 years old.
Should be started 2 days before travel and continued for
4 weeks after leaving the malarious area.

32. 
Mefloquine:
 5 mg/kg body weight (up to 250 mg) weekly
and should be administered two weeks before,
during and four weeks after leaving the area.

33. Blood
transfusion, IVDU , Organ transplantation
I.P.
- short ( no preerythrocytic stage )
C/F
& management - same as for naturally acquired infection
Primaquin
is unnecessary ( no preerythrocytic stage so
relapses do not occur.