its brief lecture how to diagnosis and to manage uncomplicated and severe malaria.

1. Complicated and
Uncomplicated Malaria
Banadir Hospital-somalia
Pediatric department
Emergency ward –CME lectures
Mohamed Adan Aweys (Marwan)
dr.awies02@gmail.com

3. Introduction
Malaria continues to be a major global health problem, with
over 40% of the world’s population—more than 3.3 billion
people—at risk for malaria to varying degrees in countries
with on-going transmission.
Malaria is parasitic infection due to the protozoa of the
genius plasmodium, transmitted to humans by bite of
Anopheles mosquitoes . Transmission by transfusion of
parasite infected blood and transplacental transmission
are also possible .
Most infections are due to 5 species : P.vivax , P.ovale P.
malaria , P.knowlesi , P. falciparum is the most virulent
malaria parasite in the world and also the most common
malaria parasite in somalia.
All species may cause uncomplicated malaria ; severe malaria
is almost always due to P.falcipaarum .

4. Uncomplicated Malaria
• A patient who presents with symptoms of malaria and
positive parasitological test ( microscopy or RDT) but with no
features of severe malaria is defined as having uncomplicated
malaria.
• The effect of the presence of malaria parasites in the body
varies from person to person. There may be no symptoms
(asymptomatic infection), mild illness (uncomplicated
malaria), or severe illness (severe malaria). If uncomplicated
malaria is not recognized early and treated promptly, it is
likely to deteriorate to severe malaria .
• The incubation period of malaria ranges from 10 to 14 days
depending on the parasite species .

5. Clinical features of
Uncomplicated Malaria
Fever is the most characteristic symptom of
malaria. The fever in malaria is intermittent: it
comes and goes many times. Three phases
can be distinguished in a typical attack of
malaria:
 The cold stage is when the patient feels cold and shivers.
 The hot stage is when the patient feels hot.
 The sweating stage is associated with sweating and
relief of symptoms.

6. • When people are frequently exposed to malaria,
they develop partial immunity. In such people (with
partial immunity), the above classical stages of a
malaria attack may not be observed. Also, in people
who have had partial treatment with antimalarial
medicines, those classical stages may not be
pronounced .

8. Physical examination
Always take the temperature, weigh the patient, and carry
out a general examination. Check of Common signs of
uncomplicated malaria.
Common signs of uncomplicated malaria
 Raised body temperature (above 37.5oC as taken from
the axilla)
 Mild anaemia (mild pallor of palms and mucous
membranes); occurs commonly in children
 Dehydration (dry mouth, coated tongue, and sunken
eyes). In adults, sunken eyes are usually a sign of severe
dehydration.
 Enlarged spleen (in acute malaria it may be minimally
enlarged, soft and mildly tender

9. Severe Malaria
Complicated malaria Caused by P. falciparum infection
It is an immediate threat to life and is therefore a medical
emergency which requires hospitalization. Malaria is
regarded as severe if there are asexual forms of P.
falciparum in blood plus one or more of the following
complications:
- Change of behaviour, confusion, or drowsiness
- Altered level of consciousness or coma
- Convulsions ( siezure , generalized or focal )
- Hypoglycemia
- Acidosis
- Difficulty in breathing
- Pulmonary oedema or respiratory distress syndrome ( rapid
and laboured breathing or slow , deep breathing.

10. - Prostration ( extreme weakness , in children : in ability to sit or
drink suck ) .
- Acute renal failure ( urine output < 12ml /kg / day in children )
- Severe anaemia
Haematocrit <20%, Hb <6g/dL
Dizziness, tiredness, pallor
- Circulatory collapse ( Shock ) : cold extremities , weak or absent
pulse , slow capillary refill time > 2 seconds , cyanosis .
- Haemoglobinuria
- Oliguria with very dark urine (coca-cola or coffee- colour)
- Jaundice (check mucosal surfaces of the mouth , conjunctive palms
- Bleeding tendency ( skin –petechia
- Hyperparasitaemia (≥100,000 parasites/μL, MPs +++ or above)
- Hyperpyrexia ≥400C
- Severe vomiting
- Organomegly ( hepatomegaly , splenomegaly )

11. Danger signs of severe
illness
a. Convulsions or fits within the last two days
or at present
b. Not able to drink or breastfeed
c. Vomiting everything
d. Altered mental state (lethargy,
drowsiness, unconsciousness, or confusion)
e. Prostration or extreme weakness (unable
to stand or sit without support)
f. Severe respiratory distress or difficulty in
breathing .
g. Severe anaemia (severe pallor of palms and

12. Diagnosis
Laboratory
Parasitological diagnosis of malaria
Parasitological diagnosis of malaria requires examination of
blood smear for the presence of malaria parasites. The 'gold
standard' of malaria diagnosis is the examination of blood
smear for malaria parasites.
Microscopy
• Thick blood film: Detection and quantification of parasites
• Thin blood film: Species identification
Note : blood films may be negative due to sequestration of the
parasitized erythrocyte in peripheral capillary in severe
malaria , as well as in placental vessels in pregnant women .

13. Rapid diagnostic test ( RDTs)a
Rapid test detect parasite antigens. They give only a
qualitative result ( +ve or –ve ) and may remain
positive several days or weeks followig effective
treatment.
Note : even with positive diagnostic results ,rule
out other causes of fever.
Additional examinations
Hemoglobin ( Hb) level or complete blood count
Blood glucose level – to be measured routinely to
detect hypoglycemia (<3mmol/l or < 55mg/dl in
patients with severe malaria and those with
malnutrition .

14. Where laboratory facilities exist, blood
examination for malaria parasites must be
done for the following groups of patients:
 Patients who present with clinical features of
severe malaria
 Patients who have taken antimalarial
treatment for 2 days and symptoms persist
 Children aged less than 4 months with
symptoms of uncomplicated malaria
 Pregnant women with symptoms of
uncomplicated malaria

15. Management
Treatment of uncomplicated F. malaria
• the treatment is an artemisinin-based therapy ( ACT)d given by the oral route for
3 days . The first line ACT is chosen according to the therapeutic efficacy in the
area under consideration .
- Coformulations ( 2 antimalarials combined in the same tablet ) are preferred over
coblisters
- coblisters ( 2 distinct antimalarials presented in same blister ) .
• The recommended first line medicine is Artemether/ Lumefantrine. Any other
ACT that has been recommended by WHO and MOH .
• Children below 4 months of age:
- Artemether/Lumefantrine or other ACTs are not recommended for
children below 4 months of age or 5kg body weight. Such children should
be treated with quinine.
- If vomiting precludes oral therapy , treatment is started using Iv or IM
artesunate or IM artemether or rectal artesunate depending on
availability , until the patient can tolerate a complete 3-day oral
treatment with an ACT
-

20. Efficacy studies on AS+SP and AL in
Somalia
General objective
– to assess the therapeutic efficacy and safety of
artesunate+sulfadoxine/ pyrimethamine (AS+SP) and
artemether- lumefantrine (AL) for the treatment of
uncomplicated falciparum malaria in Somalia.
– to measure the clinical and parasitological efficacy of
AS+SP and AL in patients aged between 6 months and
60 years suffering from uncomplicated falciparum
malaria, by determining the proportion with early
treatment failure, late clinical failure, late
parasitological failure or an adequate clinical and
parasitological response as indicators of efficacy;

21. Study Design:
– one arm cohorts evaluation of clinical and
parasitological responses to directly observed
treatment for uncomplicated malaria.
Study Sites:
– AS+SP: Jamame, Janale, Jowhar and Bosaso
– AL: Janale, Jowhar and Bosaso
Population:
– between 6 months and 60 years, inclusive,
– female minors aged 12 to 17 years and unmarried
women aged 18 years and above exclude

22. Inclusion criteria
• age between 6 months and 60 years with the exception of 12-
17years old female minors and unmarried females 18 years and
above;
• mono-infection with P. falciparum detected by microscopy;
• parasitaemia of 500 - 200000/µl asexual forms;
• presence of axillary or tympanic temperature ≥ 37.5 °C or history of
fever during the past 24 h;
• ability to swallow oral medication;
• ability and willingness to comply with the study protocol for the
duration of the study and to comply with the study visit schedule;
• informed consent from the patient or from a parent or guardian in
the case of children aged less than 18 years;
• informed assent from any minor participant aged from 12 to age of
majority years; and
• consent for pregnancy testing: married female of 18 years and above

23. Exclusion criteria
• general danger signs in <5 children or signs of severe falciparum
malaria;
• weight under 5 kg;
• mixed or mono-infection with another Plasmodium species detected
by microscopy;
• presence of severe malnutrition (defined as a child who has a mid-
upper arm circumference < 115 mm);
• febrile conditions due to diseases other than malaria or other known
underlying chronic or severe diseases;
• regular medication, which may interfere with antimalarial
pharmacokinetics;
• history of hypersensitivity reactions or contraindications to any of
the medicine(s) being tested or used as alternative treatment(s);
• a positive pregnancy test or breastfeeding of married women aged
18 years and above; and
• unable /unwilling to take pregnancy test or to use contraception for
women of child-bearing age and who are sexually active.

24. Conclusion
• Unacceptably high treatment failure in Jamame (22.2%) and in
Bosaso (12.3%).
– These rates are above the WHO recommended ≥10% threshold for
treatment policy change
• High rate of quadruple or quintuple mutations (41% in Jowhar and
59% in Jamame) confirms that SP resistance is well established.
• Day 3 parasitaemia were zero in all sites confirming the absence of
artemisinin resistance.
• The findings indicate that SP is failing.
• Sustained use of an ACT with a failing partner drug will eventually
compromise the artemisinin component
• There is a need to replace the AS+SP with a more effective ACT.
• AL is highly effective and is an appropriate ACT to replace AS+SP.

25. Treatment of Severe Malaria
At hospital level
IV line: Establish an IV infusion line
Fluids: Correct dehydration by assessing and administering fluid requirements according to body
weight
Antipyretic: Reduce body temperature if >38.5oC:
Paracetamol 1g max = 4g/day Child: 10mg-15mg /kg every 6 hours
Tepid sponging or fanning
Anticonvulsant: Treat detectable causes (e.g. hypoglycaemia, hyperpyrexia). Then if necessary,
give an anticonvulsant, e.g. diazepam (IV 0.3mg/ kg (max: 10mg) rectally ( 0.4mg /kg )
• If they still persist: Give phenobarbital 200mg IM (child: 10-15mg/kg) then 2.5mg/kg once or
twice daily if still necessary
1st
line treatment
IV quinine 600mg/2ml
- Loading dose 20mg salt/kg to be administrated over 4 hours then keep the vein open
- Maintenance dose IV 10mg salt/kg q8 hourly
- (Dilute quinine in D5% 5-10ml/kg and run over a 4 hours)
- As soon as the patient can tolerate oral treatment , administer either a 3 day of ACT course
or oral quinine to complete 7 days of treatment .
• D2-7: IV Quinine 10mg salt/kg q8h
AND
• Doxycycline (>8yrs) (3.5 mg/kg OD) OR Clindamycin (<8yrs)

26. Treatment of Severe Malaria
2nd
line treatment
The drugs of choice is artesunate Iv or IM ; if artesunate is not
avalaible , use IM artemether .
For the patients in shock : use artesunate Iv or if not avalaible ,
Quinine Iv.
Artesunate slow Iv injection ( 3 to 5 minute) or if not possible ,
slow IM injection into Anterior thigh.
 Children less than 20kg : 3mg/kg/dose
 Children 20kg and over and adults : 2.4mg/kg/dose .
- One dose on admission ( H0)
- One dose 12 hours after admission( H12)
- One dose 24 hours after admission ( H24)
- Then one dose once daily
Administer at least 3 doses ,then , if the patient can tolerate
oral route change to an ACT .

27. Artemether IM ( Anterior thigh )
 Children and adults : 3.2mg/kg on admission ( D1) then
1.6mg/kg once daily .
As soon as the patient can tolerate oral route , change to
an ACT.
For completion of therapy by oral route :
- If the duration of parenteral treatment was less than 7
days : treat 3 days with an ACT.
- If the duration of parenteral treatment was les7 days:
do not give additional oral treatment.
NB : Primaquine for Treatment of chloroquine-resistant P.
vivax, knowlesi or malariae and may cause life
threatening haemolysis in individuals with G6PD
deficiency. G6PD testing is required before administration
of Primaquine..
In severe G6PD deficiency Primaquine is contraindicated.

28. Symptomatic treatment and Management of complications
Hypoglycaemia:
- If the patient is able to swallow :
50ml of 10% glucose
or 40ml of water +10ml of 50% glucose
or 50ml of water + 5 g (1 teaspoon of granulated sugar
or 50ml of milk.
- In an unconscious patient :
Children : 5ml/kg of 10% glucose by slow IV injection .
- Check blood level after 30 minutes. If blood glucose level remains
< 3mmol/l or 55 mg/dl , administer another dose or give glucose
by oral route , according to the patient’s clinical condition .
Hypoglycemia my recur : maintain regular sugar intake
- The risk of hypoglycemia is higher in patients receiving IV quinine.

29. Acidosis: Correct fluid & electrolyte balance
- If there is severe acidosis without sodium depletion:
- Give sodium bicarbonate 8.4% infusion 50mL IV
- Monitor plasma pH
Pulmonary oedema
- Regulate the IV infusion
- Prop up the patient
- Give oxygen
- Give furosemide (1mg/kg or 0.1cc/kg )
Acute renal failure
• Urine output: <0.3mL/kg/hour (child)
• Check to ensure that the cause of oliguria is not
dehydration or shock .
• If due to acute renal failure: Give a challenge dose of
furosemide 20mg slow IV (child: 1mg/kg)

30. Severe anaemia
- Blood transfusion is indicated :
• In children with Hb < 4g/dl ( or between 4 and 6 g/dl with signs
of decompensation)
- Do blood grouping and cross-matching
- Transfuse patient with packed cells 10-15mL/kg or whole blood
20mL/kg especially if the anaemia is also causing heart failure
- Repeat Hb/PCV before discharge and preferably on day 28 days
after discharge .
Shock:
If systolic BP <50mm Hg (child) or if peripheral pulse absent and
capillary refill is slow (>2 seconds)
- Raise the foot of the bed
- Give sodium chloride 0.9% by fast IV infusion ( 20ml/kg )
- Review fluid balance and urinary outputs
- Look for evidence of haemorrhage or Septicaemia and treat
accordingly

31. Coma:
Provide intensive nursing care with :
- Check / ensure the airway is clear , measure blood glucose
level , and asses level of consciousness ( by GSC )
- IV drip (for rehydration and IV medication
- NGT (for feeding and oral medication)
- Urethral catheter (to monitor urine output)
- Turning of patient frequently every 2 hrs to avoid
bedsores.
- Exclude meningitis ( lumbar puncture ) or proceed directly
to administration of an Antibiotic .
- Monitor vital signs , blood glucose level , level of
consciousness , urine output , hourly until stable and then
every 4 hours .
- Monitor fluid blance

32. Congenital malaria
Congenital malaria is rare. It is acquired from the mother
prenatally or perinatally, usually occurring in the newborn of a
non-immune mother with P. vivax or P. malariae infection,
although it can be observed with any of the human malarial
species.. The first sign or symptom most commonly occur
between 10 and 30 days of age (range: 14hr to several months
of age).
Signs and symptoms include fever, restlessness, drowsiness,
pallor, jaundice, poor feeding, vomiting, diarrhea, cyanosis and
hepatosplenomegaly. It can mimic a sepsis like illness.
Parasitemia in neonates within 7 days of birth implies
transplacental transmission
Treatment:
Chloroquine, total dose of 25mg base/kg orally divided over 3
days
• D1: 10 mg base/kg stat then 5 mg base/kg 6 hours later
• D2: 5 mg base/kg OD
• D3: 5 mg base/kg OD .

33. Malaria prophylaxis
• Not recommended for all those living in a
highly endemic area like somalia .
However, it is recommended for certain
high-risk groups but is not 100% effective.
• Pregnancy Give intermittent preventive
treatment (IPT) SP single dose (3 tabs) to
ensure the well-being of the mother and foetus .

34. Malaria prevention and control
Give effective treatment and prophylaxis
- Eliminate parasites from the human population by early diagnosis and effective
treatment
- Protect vulnerable groups with chemoprophylaxis
- Give IPT to all pregnant women
• Reduce human-mosquito contact
• Use insecticide-treated materials (e.g. bed nets)
• Destroy adult mosquitoes by residual spraying of dwellings with insecticide
or use of knock-down sprays
• Screen houses
• Carefully select house sites avoiding mosquito-infested areas
• Wear clothes which cover the arms and legs and use repellent mosquito coils
and creams/sprays on the skin when sitting outdoors at night
• Control breeding sites
• Eliminate collections of stagnant water where mosquitoes breed, e.g. in
empty cans/ containers, potholes, old car tyres, plastic bags, and footprints
by disposal, draining, or covering with soil or sand

35. References
- A practical handbook MANAGEMENT OF
SEVERE MALARIA 3rd
edition .
- Guidelines for the treatment of malaria 3rd
edition
- UGANDA CLINICAL GUIDELINES 2012 National Guidelines
for Management of Common Conditions .
- PAEDIATRIC PROTOCOLS For Malaysian Hospitals 3rd
edition .
- MSF clinical guidelines diagnosis and treatment manual
2016 edition.
- Updating malaria treatment policy Somalia / Global
malaria program WHO dr marian warsame

36. Thanks for your listening