Malaria 17_03_2021 JC edits.pptx

National Malaria Control Programme-Ghana
Uncomplicated Malaria
MALARIA CASE MANAGEMENT TRAINING 2021

• Objectives of the session
• Definition and Introduction
• Classification of Malaria
• Basic pathogenesis of malaria
• Clinical Management of Uncomplicated Malaria
Outline
1

At the end of this module, participants should be able to:
1. Describe the basic pathogenesis of malaria
2. Perform a thorough clinical assessment of a patient with
suspected malaria
3. Identify a case of suspected malaria
4. Conduct appropriate investigations of suspected malaria
5. Provide appropriate anti-malarials
6. Provide appropriate supportive care
7. Provide follow-up care
Objectives
2

• Malaria is a parasitic disease caused by a
protozoan of the genus Plasmodium
• It is transmitted through the bite of an infective
female Anopheles mosquito
• Malaria is a major cause of illness and death in
Ghana, particularly among children and pregnant
women
Definition and Introduction
3

• Malaria cases are classified as either
"uncomplicated" or "severe“ based on the clinical
severity
Uncomplicated malaria:
• Fever or a recent history of fever with positive
malaria diagnostic test and absence of any signs
of severe disease (evidence of vital organ
dysfunction)
Classification of Malaria
4

Severe Malaria
• It is presence or recent history of fever plus
• Any signs and symptoms of severe disease or
evidence of vital organ dysfunction, and
• Positive malaria diagnostic test
Classification of Malaria
5

• Definitions
• Suspected Uncomplicated Malaria is
• the presence of fever (axillary/infrared temp ≥ 37.5° C
) or recent history of fever ( within the last 2-3 days)
• in the absence of any signs of severe disease or vital
organ dysfunction
• Confirmed Uncomplicated Malaria is
• Suspected uncomplicated Malaria plus
• Detection of the malaria parasite in the blood using
malaria diagnostic test (e.g. RDT or microscopy)
6

• Chills (feeling unusually
cold)
• Rigors (shivering)
• Headache
• Nausea and/or vomiting
• Generalised body and
joint pain
• Loss of appetite
• Sweating
• Abdominal pain
(especially in children)
• Bitter taste in mouth
• Irritability and refusal
to drink or breastfeed
7
Other symptoms of Uncomplicated Malaria

Pathogenesis of Malaria
8

Malaria Life Cycle
9

• The systemic manifestations of malaria are
attributable to various cytokines released in
response to the parasite and red cell membrane
products
• FEVER and rigors,
• Headache
• GIT symptoms – nausea and vomiting, diarrhea,
anorexia,
• Tiredness, aching joints and muscles
• Thrombocytopenia, immunosuppression, coagulopathy
• CNS manifestations
10

Clinical Management of
11

• Appropriately assess and classify fever
• Promptly and effectively treat to avoid
progression to severe disease
• Minimize the risk of developing drug-resistant
parasites
• Limit the duration of disease
• Exclude other common causes of febrile illness
Specific Objectives in the Management of
12

• Age
• Presenting symptoms
• Ask for common symptoms of illness (especially
in children cough or difficulty in breathing,
diarrhoea, ear pain, rash, dysuria, frequency of
urination)
• Past Medical History: Sickle cell disease, HIV
infection, Malnutrition, Diabetes mellitus,
Hypertension etc.
History Taking …1
13

• Medication and vaccination history: antimalarials
(treatment or prophylaxis – time frame), herbal,
malaria vaccine etc.
• Place of residence and recent travel history
• Obstetrics and gynaecological history ( for clients
in child bearing age group)
History Taking …2
14

• Assess the patient for signs of severe
disease in a systematic manner using the
ASK, LOOK and FEEL approach
• For children < 5years
ASK:
• Is the child able to drink or breastfeed
• Does the child vomit everything
• Has the child had convulsions
• How long patient has had the fever (≥ 7days)
Assessment of Severe Disease …1
15

• For all patients, ask for:
• Generalised weakness, such that the patient cannot walk or sit
without assistance
• Change of behaviour, confusion, unresponsiveness
• Convulsions (fits)
• Difficulty in breathing
• Recurrent or prolonged bleeding from the nose, gums, vomiting
blood, dark foul smelling stool or bloody stool
• Yellowish colouration of the eyes, palms etc.
• Inability to take fluids or anything orally
• Repeated vomiting
• Cola-coloured urine
16

• Look for:
• Restless, irritable
• Lethargic, Unconscious
• Convulsion
• Jaundice
• Pallor
• Generalized rash
• Sunken eyes
• Cola-coloured urine
• Abnormal bleeding
• Feel for:
• Fast breathing
• Stiff neck
• Temperature
• 2months – 2 years: <
35.5oC or >37.5oC
• > 2 years : ≥ 38.5oC
• Shock
• Weak rapid pulse
• Cold extremities
17
For children < 5 years

• For all patients look and feel for:
• Altered consciousness (change of behaviour,
confusion, delirium, coma)
• Deep breathing and respiratory distress
• Unexplained abnormal bleeding
• Recurrent or prolonged bleeding from the nose,
gums or venipuncture site, haematemisis or
melena
• Jaundice (yellowish colouration of the eyes)
• Prostration i.e. generalised weakness, such that the
patient cannot walk or sit without assistance
• Axillary temperature ≥ 41.0 °C
18

• Circulatory collapse or shock
• cold limbs, weak rapid pulse, systolic BP of less 80mmHg in adults
and less than 50mmHg in children
• Signs of hypoglycemia
• sweating, pupillary dilation, abnormal breathing
• Pallor – confirm anaemia with diagnostic test
• Renal Impairment - passing very little urine
• Urine Output <25 - 30mls/hour for over at least 6 hours for Adults
or
• < 0.5ml/kg/hr over at least 6 hours for children
• Dark or cola-colored urine
19

• Uncomplicated Malaria is confirmed by either;
• Microscopy (GOLD STANDARD)
• Quantitative test
• It is done by reporting on species, stage and parasite density
when positive
• And reported No Malaria Parasites(No MPs seen) seen when
Negative
• RDT
• Qualitative test
• Reported as either Positive or Negative
• EITHER ONE CAN BE USED TO CONFIRM THE DIAGNOSIS
Laboratory Investigation
20

•If test is positive
• Diagnosis of uncomplicated malaria is
confirmed
•If test is negative
• Malaria is unlikely
• Investigate for other causes of the fever or
illness
Diagnosis of Uncomplicated Malaria
21

1. Viral Infections
• COVID-19
• Acute respiratory infections- Cough/cold, pneumonia,
pharyngitis, ear infections
• Viral exanthems
• Measles (high fever, generalised skin rash with cough, red eyes or
mouth sores)
• Rubella /German measles (Rash tends to spread more quickly, over
24hrs)
• Chicken pox / Varicella-zoster virus (will have a vesicular rash)
• Erythema Infectiosum/Fifth disease (low grade fever, “slapped cheeks”
generalised skin rash)
• Mumps (usually have swelling at the angle of the jaw)
• Hepatitis (jaundice, loss of appetite/vomiting, pain in right
upper abdomen)
• Meningoencephalitis
Other Causes of Febrile Illnesses
22

2. Bacterial infections
• Acute respiratory infection: Tonsillitis, sinusitis Pneumonia
(Cough with fast breathing
• Scarlet fever (Fever, sore throat and rash)
• Acute ear infection in children (ear pain and/or discharge)
• Urinary tract infection (frequency or pain on passing urine,
loin pains)
• Typhoid (persistent fever for over 7 days, general
weakness/prostration)
• Meningitis (fever, neck stiffness)
Other Causes of Febrile Illnesses
23

• The clinical objectives of treating uncomplicated
malaria are to:
• cure the infection as rapidly as possible (Cure is
defined as elimination of all parasites from the
peripheral blood)
• prevent progression to severe disease
• The public health objectives of treatment are to:
• prevent onward transmission of the infection to others
• prevent the emergence and spread of resistance to
antimalarial drugs
Objectives of Treatment
24

• Specific antimalarial treatment
• Supportive treatment
• Counselling on treatment
• Follow-up
Principles of Treatment
25

• Treatment of choice is Artemisinin-based Combination Therapy
• The national recommended options include:
• First – Line
• Artesunate – Amodiaquine (AS-AQ)
• Artemether – Lumefantrine (AL)
• Second – Line
• Dihydroartemisinin - Piperaquine (DHAP)
• Fixed dose formulation is recommended
• Dosage should be weight-based
• Demonstrate how to measure and give the correct dose to the
patients/caregiver
• Give first oral dose under supervision (esp. children)
• PARENTERAL ANTIMALARIALS SHOULD NOT BE GIVEN IN
UNCOMPLICATED MALARIA
Specific Antimalarial Treatment
26

• The concept of ACT is based on the use of 2 drugs with
different modes of action:
• an Artemisinin-derivative that causes rapid and effective reduction
of parasite biomass and gametocyte carriage and
• a partner drug that has a longer duration of action
• Advantage of Artemisinin include:
• rapid action of clearing parasites, acting on all blood stages
• Short half-life reducing the selection of resistant clones from new
infection
• Generally well-tolerated
Rationale for Artemisinin-Based Combination
Therapy (ACT)
27

• Dose:
• Artesunate - 4 mg/kg/day (therapeutic range: 2–10 mg/kg/day)
• Amodiaquine – 10mg/kg/day (therapeutic range: 7.5–15
mg/kg/day)
• It is given orally once or twice a day for 3 days
• Fixed-dose formulations available
• AS – AQ : 25/67.5 mg
• AS – AQ : 50/135 mg
• AS – AQ : 100/270 mg
Artesunate-Amodiaquine
28

Artesunate-Amodiaquine 25mg/67.5mg tablet
Fixed Dose Combination 12 hourly dosing
29
Weight
(kg)
Age
(yr)
Day 1 Day 2 Day 3
<8 2-11 months ½ ½ ½ ½ ½ ½
9-17 1-6 years 1 1 1 1 1 1
18-35 7-13 years
2 2 2 2 2 2
>36 >13 years
4 4 4 4 4 4

Artesunate – Amodiaquine 25mg/67.5mg Fixed
Dose Combination 24-hourly Dosing
30

Artesunate + Amodiaquine 50/135mg Tablets,
given once daily for all ages
31

Artesunate + Amodiaquine 50/135mg Tablets,
given 12hourly for all ages
32

Artesunate – Amodiaquine fixed dosing
100/270mg tablet 12 – hourly dosing
33

Artesunate – Amodiaquine fixed dosing
100/270mg tablet 24 – hourly
34

• Dose:
• Artemether – 1.7mg/kg/dose (therapeutic range: 1.4–4 mg/kg/dose)
• Lumefantrine – 12mg/kg/dose (therapeutic range: 10 –16
mg/kg/dose)
• It is given orally twice a day for 3 days
• First 2 doses should be given 8 hours apart
• Total of 6 doses
• AL : 20/120 mg (can now be given to children <5kg or 6mths)
• Al : 40/240 mg
• AL : 80/480 mg
• The 80/480 artemether-lumefantrine fixed-dose formulation is
recommended for use in patients with weight 35kg and above
for ease of administration
• Lumefantrine is enhanced when taken with a fat – containing
meal e.g. milk
Artemether-Lumefantrine
35

Artemether-Lumefantrine, 20/120mg
36

Artemether – Lumefantrine, 40/240mg
37

Artemether – Lumefantrine 80/480mg
38

• Dose:
• Dihydroartemisinin – 4mg/kg/day (therapeutic range: 2 – 10
mg/kg/day)
• Children < 25kg : Dihydroartemisin minimum of 2.5mg/kg/day
• Piperaquine – 18 mg/kg/day (therapeutic range: 16 – 26
mg/kg/day)
• Children < 25kg : Piperaquine minimum of 20mg/kg/day
• It is given orally once daily for 3 days
• DHAP : 20/160 mg
• DHAP : 40/320 mg
• DHAP : 80/640 mg
• Avoid fatty meals with intake of DHAP as the risk of
arrythmias is increased as a result of accelerated
absorption of piperaquine.
Dihydroartemisinin - Piperaquine
39

Dihydroartemisinin-Piperaquine(DHAP)
20/160mg
40

Dihydroartemisinin-Piperaquine(DHAP) –
40/320mg
41

Dihydroartemisinin-Piperaquine(DHAP) –
80/640mg
42

• Patient with fever(temperature > 37.5oC or feels warm to touch)
• Tepid – sponging
• Give an antipyretic, preferably paracetamol.
• Ibuprofen, aspirin and non steroidal antipyretics are not
recommended because of the risks of gastrointestinal bleeding, renal
impairment and Reye’s syndrome (children).
• Vomiting
• Repeat the dose if patient vomits within 30mins of administration
• Anti-emetics are potentially sedative and may have neuropsychiatric
adverse effects and should therefore be used with caution
• In case of itching
• Explain that itching is a possible adverse drug reaction
• Give an antihistamine
• If mild patients should continue taking the drug
• If severe: consider stopping the medication and change to other
suitable ACTs
Supportive Treatment
43

• Advise mothers/caregivers to give extra fluids, such as
breast milk, drinking water, fresh fruit juices, coconut
water, Oral Rehydration Salt solution (ORS), etc.
• Feed the child during illness
• Tell patient or child’s caregiver the diagnosis
• Tell patient or child’s caregiver the reason for giving the
medicine
• Advise to administer the antimalarials after meals
• Explain that anti-malarials must be taken till the course of
treatment is completed even if the patient feels well
Supportive Treatment and Counselling
44

• Advise the patient to return immediately ( even
within the same day) if symptoms get worse, or if
signs of severe disease develop (even if within
same day)
• Note : Ensure the patient or care-giver has
understood all the treatment advice before
leaving the clinic.
Counselling
45

• Ask patient to come for a review after completion of ACTs
• Assess for anaemia and treat or refer appropriately
• If symptoms are persistent, reassess, treat or refer appropriately
• If patient is not improving i.e. Getting worse after initiation
of treatment or Not getting better after 48 hours
• Reassess (Ask, Look and Feel approach) for:
• Signs of severe disease
• Compliance with therapy
• Co-existing illness
• Request for microscopy
Follow-up Activities
46

Thank You
47

Additional Resources
48

Malaria Life Cycle
49
*assuming uncomplicated infection
1 given in days, unless specified otherwise
2 except those strains with prolonged
incubation periods
3 from infection to the appearance of
detectable parasitaemia
4 from infection to the appearance of
symptoms
5 after the appearance of parasitaemia
6 maximal duration of infection ever recorded

50

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