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Malaria Lecture
Malaria Lecture
Malaria Lecture
BY
DR C.U. ONUBOGU
• UNCOMPLICATED MALARIA
• All cases should be confirmed parasitologically
• WHO now recommends the use of Artemisinin-based
Combination Therapy.
• The recommended ACTs include:
Artemether-lumefantrine @ 1.5/9 mg/kg twice daily for
three days
Artesunate+Amodiaquine (@ Artesunate 4 mg/kg dly for
3 days + Amodiaquine 10mg /kg for 3 days)
Artesunate+Mefloquine
Dihydroartemisinin-piperaquine
Treatment of severe malaria
Initial antimalarial therapy must be parenteral
Artesunate Injection : Give 2.4 mg/kg IV bolus @ 0, 12, 24, 48hrs. Give full
course of ACT as soon as patient can take orally
• In the absence of IV artesunate other alternatives include
Intramuscular Artemether:- 3.2 mg/kg IM on the first day and then 1.6
mg/kg daily for a maximum of 3 days until the patient can take oral
treatment, then give a full 3-day course of ACT OR
Alpha-beta arteeter 3mg/kg/day
Intravenous quinine 20 mg/kg of Quinine dihydrochloride salt loading dose
diluted in 10 ml/kg of 5% dextrose over a period of 4 hours. Then 8 hours
after the start of the loading dose, give 10 mg salt /kg infusion over 4 hours 8
hourly until when patient is able to take orally. Change to oral ACT once
patient can tolerate oral medication OR
• Intramuscular Quinine: Where IV access is not possible give quinine
dihydrochloride at a dosage of 20 mg/kg salt (loading dose), then 8hours
after the start of the loading dose give 10mg/kg 8hourly until patient is able
take orally, then ACT
Supportive treatment continued
• Pulmonary oedema : Prop up the patient, give oxygen and
furosemide 2-4 mg/kg IV and exclude anaemic heart failure.
• Renal failure : Initial renal challenge with 20 ml/kg of normal
saline and furosemide 1-2 mg/kg, monitor fluid-input output,
restrict fluid to 300ml/m2 + previous day’s output in
established renal failure. If patient does not pass urine within
24 hours, consider peritoneal or haemodialysis.
• Profuse bleeding: transfuse with screened fresh whole blood
• High temperature: Give paracetamol (oral/rectal) if
temperature is > 38.5 o C, tepid sponge and apply other
measures to reduce body temperature
Supportive treatment for severe malaria
• Coma or unconscious patient : Ensure airway is patent; gentle
suction of nostrils and the oro- pharynx, make sure the patient is
breathing, nurse the patient lying on the side, naso-gastric tube
feeding, establish IV line for fluid and drugs
• Hypoglycaemia: correct with 4ml/kg of 10% dextrose and maintain
with dextrose containing fluid.
• Convulsions: Ensure patent airway and that the patient is breathing,
correct hypoglycaemia or control temperature, give rectal diazepam
0.5 mg/kg or IM paraldehyde 0.1 ml/kg. If convulsions continue, give
IM phenobarbitone 10-15 mg/kg.
• Severe dehydration or shock : Give 20-30 ml/kg of normal saline and
reassess the patient within 30 minutes to decide on the next fluid
requirement according to the degree of dehydration. Place the
patient on maintenance fluid as soon as the patient is well hydrated.
• Severe Anaemia : Urgent blood transfusion. The blood must be
screened to ensure that it is HIV, Hepatitis B and C negative.
Nursing care in severe malaria
• Monitor and document vital signs (Pulse, Temperature,
Respiratory rate, Blood pressure) at least 6 hourly but may be
more frequent at the initial stages.
• Monitor input and output
• A strict 24-hour input /output chart should be kept in all
patients with severe malaria. Examine regularly for signs of
dehydration or fluid overload.
• Monitoring unconscious patient : Monitor the level of
consciousness at least 6 hourly, regular turning to avoid
bedsores.
• Drug chart : Keep a clear drug chart where all name, dosage
and timing of all given drugs are recorded.
• Laboratory Monitoring : monitor parasitaemia by daily blood
smear. If still high after 2-3 days, review adequacy of the
drug dose. Monitor blood glucose and PCV as indicated
Key recommendations for malaria tmt
• Prompt parasitological confirmation by microscopy or RDTs in all
patients suspected of malaria before treatment.
• Use Artemisinin-based combination therapies (ACTs) for uncomplicated
P. falciparum malaria.
• ACTs recommended for use in Nigeria are; Artemether-lumefantrine,
Artesunate-amodiaquine.
• Artemisinin and its derivatives should not be used as monotherapy in
the treatment of uncomplicated malaria.
• Oral Quinine is the recommended medicine for the treatment of
uncomplicated malaria in the first trimester of pregnancy.
• ACTs is the recommended treatment of uncomplicated malaria in the
second and third trimesters of pregnancy.
• Treat infants less than 5kg with ACTs under supervision by the health
care provider
Key recommendations for malaria tmt contd
• Severe malaria is a medical emergency. Commence immediate
treatment with parenteral medication using intravenous artesunate .
• Children weighing < 20 kg should receive a higher dose of artesunate (3
mg/kg bw per dose) than larger children and adults (2.4 mg/kg bw per
dose) to ensure equivalent exposure to the drug.
• Parenteral artemether or quinine is an acceptable alternative only if
artesunate is not available.
• Give parenteral medication for a minimum of 24 hours once started
(irrespective of the patient’s ability to tolerate oral medication earlier)
and thereafter, complete treatment with a complete course of an ACT.
• Where complete treatment of severe malaria is not possible, patients
should be given pre-referral treatment and referred immediately to an
appropriate facility for further treatment.
• The recommended pre-referral treatment options include; artesunate
IM or rectal artesunate or quinine IM, in the order of preference
Antimalarial resistance
• Cure : clearance of asexual parasitaemia within 7 days of
starting treatment and no recrudescence
• Drug resistance: ability of the parasite to survive at a
concentration of a drug equal to or higher than that
obtained by recommended dosage.
R1 = clearance of asexual parasitaemia within 7 days of
starting treatment with recrudescence
R11: marked reduction in asexual parasitaemia but no
clearance
R111 : no marked reduction in asexual parasitaemia
• Mechanisms for drug resistance include baseline genetic
predisposition, host immunity and drug pressure (poor
compliance, low dosage, adulterated drug)
PREVENTION OF MALARIA
o Use five levels of prevention
o ROLL BACK MALARIA
• The Roll Back Malaria (RBM) Partnership was launched on 31 st July 1998 by the
WHO, UNICEF, UNDP and the World Bank.
• This is a global partnership to fight malaria building on existing framework of
national governments, international organizations and private sector with
original goal of halving malaria burden by 2010 in affected population.
• RBM involves multiple strategies targeted to meet local malaria control needs.
• Six Principles of RBM
Early detection
Rapid diagnosis and effective treatment
Multiple prevention
Focused research
Well coordinated actions
Dynamic movement