Current

Trends in
management of
Malaria
Presenter DR OBASI C U
Moderator
DR EDDY NDIBUAGU
 Presentation outline
• Introduction
• Case management of malaria
• Current trends highlighted
• Recommendations
• Conclusion
 Introduction

• A major public health problem in 97 countries of the world

• 219million cases per annum world wide, 3.2 billion
persons @risk
• However 2017 the mortality from malaria was 435,000
• 90% cases of malaria deaths occur in sub-Saharan Africa
• Cost the world economically $3.1b in 2017
 Introduction contd. Nigeria
situation
• Nigeria suffers the world greatest burden of malaria
• 51 million cases and 207,000 deaths per annum (WHO
2018 report)
• The country bears 30%of the continent total malaria
burden
 Nigeria situation - contd.
• Accounts for 60% outpatient consultation
• 11% maternal deaths
• 30% of U5 child mortality
• Malaria is majorly caused by Plasmodium falciparum
• Anopheles gambiae, Anopheles funestus, Anopheles
arabiensis, and Anopheles moucheti are the major vectors
that cause year-round transmission
 Nigeria situation contd
• Ranks highest among the notifiable diseases
• Risk is more in the rural areas
• U5 and pregnant women are more at risk
• Natural transmission occur ----stable
• Hence epidemic does not occur due to constant incidence
 The Global Technical Strategy for Malaria

• The WHO Global Technical Strategy for Malaria 2016–

2030 (GTS)
 Reducing malaria case incidence by at least 90%
 Reducing malaria mortality rates by at least 90%
 Eliminating malaria in at least 35 countries
 Preventing a resurgence of malaria in all countries that are
malaria-free
 High burden to high impact” approach, launched alongside WHO’s latest World malaria report

• political will to reduce malaria deaths;

• strategic information to drive impact;
• better guidance, policies and strategies; and
• a coordinated national malaria response.
 uncomplica
ted
Classificat
ion of
malaria
Severe (+ve P.
falciparum)

The above classification is based on organ affectation

or threat to life
 Case management of malaria

• History taking
• Physical examination
• Investigations
• Treatment
 History taking

• Presenting complaints
• History of presenting complaints
• Family and Social History
• History of past treatment efforts,
drug/herbal use
• History of allergies
 Uncomplicated malaria
Symptoms/complaints • Clinical signs on
 Fever examination
 Chills (feeling cold) and rigors
Elevated body temperature ≥
(shaking of the body)
37.5°C.
 Headache
 Joint weakness or tiredness  Enlarged spleen or liver,
 Also ask for the symptoms of other
especially in children.
common childhood diseases  Pallor
• Cough or respiratory distress (children/pregnant women)
• Diarrhoea  Exclude signs of severe
• Ear pain and skin rashes in the last disease.
three months.
• Biodata including history of travel
 Investigations/Parasitological diagnosis

Parasitology
• Advantages of parasitological diagnosis diagnosis is
recommended in
• Cost effective
ALL suspected
• Brings out +ve patients for better care cases of malaria
expect in U5
• Improves malaria case detection and reporting
• Improves tracking of malaria patients
• Allows for alternative exploration of diagnosis in –ve
patients
 mRDT STRIP
Parasitologic
al diagnosis
Lightmicroscopy
Gold standard
 Skilled
 Lateral flow immunochromatographic antigen
microscopist
detection test
 Sensitivity of
 Complements microscopy
86-98%.  Identifies Plasmodium falciparum histidine
 Thick film for
rich protein 2 (PfHRP2)
parasite  identification of the plasmodium lactate
detection and
dehydrogenase enzyme (pLDH) and aldolase
quantification
enzyme. Detect all specie
 Thin films for
specie
 Preferred in the
diagnosis of
severe malaria
 3 T Initiative

test
Strategy
treat
(3T)
track
 3T initiative
• The “T3: Test, Treat, • This initiative set an
Track” initiative was ambitious target of
launched by WHO in April globally achieving access
2012 with the aim of to malaria diagnostic test
improving access to in both private and public
diagnosis and treatment of health facilities by the year
malaria, as well as 2015. The main tool
encouraging surveillance proposed for actualizing
of the disease. this target was RDT
 Treatment of uncomplicated
malaria
 1ST LINE PCR-corrected efficacy of artemeter-lumefantrine (AL) or artesunate-
amodiaquine (AA) at various drug therapeutic efficacy testing sites in
Artesunate Nigeria between 2009 and 2010.

Lumefantrine AL
AL

ACT
 2nd LINE AA
Artesunate

Amodiaquine AA 95.50% 96.00% 96.50% 97.00% 97.50% 98.00% 98.50% 99.00% 99.50%

SENSITIVITY
Treatment for uncomplicated malaria
Artesunate /lumefantrine Artsunate/amodiaquin

 Artesunate-Mefloquine
 Dihydroartemisinin-
piperaquine
 Artemisinin-Piperaquine
 Treatment (ACT)
Artemisinin combination therapy (ACT)
 Treatment failure
• None remission of symptoms within 2 days with
parasitemia
Evaluate the patient and review diagnosis.
 Ensure that appropriate dose of the medicine has
been given
 Do further Investigations to rule out other causes of
fever
• Change line of treatment if parasite still exist
 Monotherapy
Use of
monotherapy
in the treatment
of malaria
 Special group
• <5kg child should treated • 1st trimester Qunine
promptly with ACT @ a +clindamycin
dose meant for 5kg child use ACT if qunine is not
• Incase of no RDT, they can available
be treated 2nd & 3rd trimester ACT is
• Higher risk of death the option
Dosage
 Community management of
malaria
• Key Messages for use of Oral Medicines at Home for children under 5 years of age
• Tablets or dispersible formulations are preferred as oral medications
• Determine the appropriate medicine and dosage according to weight or age charts
• Tell the patient or the caregiver the reasons for giving the medicine
• Demonstrate how to take or give the correct doses
• Watch the patient take the medicine
• Explain that the treatment course must be completed even when the patient feels well
• Tell the patient or parent that the medicines are not to be shared with other family members
• Advise patient or caregiver on when to return to the health worker
• Check that the patient or caregiver understands the instructions before leaving
 Severe malaria
• Multiple convulsions: >2x within 24hours
• severe falciparum malaria is
• Acidosis: A base deficit of >8 meq/L or, if
defined as one or more of the unavailable, a plasma bicarbonate of
following, occurring in the absence <a15mmol/L or venous plasma lactate > 5
of an identified alternative cause, mmol/L. Severe acidosis manifests clinically as
respiratory distress- rapid, deep and laboured
and in the presence of P falciparum breathing.
asexual parasitaemia. • Hypoglycaemia: Blood or plasma glucose
<2.2mmol/L .
• Impaired consciousness: A
Glasgow Coma Score <11 in adults
• Severe malarial anaemia: A haemoglobin
or a Blantyre Coma Score <3 in concentration < 5g/dL or a haematocrit of <
children. 15% in children <12 years of age (<7g/dl and
<20% respectively in adults) together with a
• Prostration parasite count >10,000/μL.
 Severe malaria
• Renal impairment: (acute kidney injury): Plasma or serum creatinine >265μmol/L (3mg/dL) or
blood urea > 20 mmol/L
• Jaundice: Plasma or serum bilirubin > 50μmol/L (3mg/dL) together with a parasite count
>100,000/ μL.
• Pulmonary oedema: Radiologically confirmed, or oxygen saturation <92% on room air with a
respiratory rate >30/minute, often with chest indrawing and crepitations on auscultation.
• Significant bleeding: including recurrent or prolonged bleeding from nose, gums or
venepuncture sites; hematemesis or melaena
• Shock: Compensated shock is defined as capillary refill ≥3 seconds or temperature gradient on
leg (mid to proximal limb), but no hypotension. Decompensated shock is defined as systolic blood
pressure less than 70 mm Hg in children or < 80 mm Hg in adults with evidence of impaired
perfusion (cool peripheries or prolonged capillary refill)
• Hyperparasitaemia: Red blood cell P.falciparum parasitaemia >10%.
 Clinical evaluation of patients
for severe malaria
• History In addition to the general history taken in patient with uncomplicated malaria you should ask about the following In
all patients ask about:-
• Recent history of international travel
• Extreme weakness (Prostration).
• Abnormal behaviour or altered consciousness
• Convulsions.
• Time of last drink or food since the onset of the illness.
• Fast breathing which may occur due to pulmonary oedema or acidosis.
• Reduced urinary output (time patient last passed urine).
• Colour of urine: whether dark or coca-cola coloured (this may suggest excessive breakdown of red blood cells or
dehydration).
• Pregnancy: in adult females.
• Drug History: Ask about antimalarial drugs, salicylates and herbal concoctions that may influence treatment or cause
some of the symptoms.
• Previous illnesses: Ask about any history of recent febrile illness and treatment which may suggest treatment failure or
relapse (consider typhoid, malaria and other infections)
 Physical Examination
• Differential Diagnosis:
• Central Nervous • Meningitis - Patient may have a stiff neck.

System GCS •
•
Encephalopathy- Repeated convulsions or deep coma.
Diabetes Mellitus- Patient may be dehydrated, acidotic
or in coma.

• Ocular examination • Septicaemia- Usually very ill and toxic with warm
extremities.

• Respiratory system
• Epilepsy- Usually no temperature and will have history
of convulsions before.
• Acute renal failure from other causes- usually

• Cardiovascular •
associated with reduced or no urine output
Viral hemorrhagic fevers (Ebola, Lassa, Dengue etc)-
usually associated with jaundice and bleeding tendency
• Abdomen •
and history of contact
ggggggggggggggggggggg n nm
 Investigation
• Haematocrit (PCV) and/or
Haemoglobin concentration • Blood electrolytes, urea
• Blood sugar level and creatinine
• Lumbar puncture in unconscious • Chest X-ray
patients.
• Urinalysis • Complete blood count
• Blood culture • Blood gases(PO2, PCO2
• Feto-maternal surveillance in and pH)
pregnant women
 Treatment/complicated 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 or with the head sideways.
• Insert a naso-gastric tube (NGT).
• Establish an intravenous line. It will be necessary for giving drugs and fluids.
• Correct hypoglycemia:

• Children: 0.5 ml/kg of 50% dextrose diluted to 10-15%. Adults: 25 ml of

50%dextrose. -Where intravenous access is not possible, give dextrose or any sugar
solution through the naso-gastric tube.
 Treatment of severe mal. Contd.
Convulsions • requirement according to the degree of dehydration.
• Ensure patent airway and that the patient is • After correction of the fluid deficit it is important to
breathing. reduce the maintenance fluid to two thirds of the
required volume when the patient is well hydrated.
• Correct hypoglycaemia or control temperature.
• In children give rectal diazepam 0.5 mg/kg or Severe Anaemia
IM paraldehyde 0.1 ml/kg. If convulsions
• Give urgent blood transfusion to patients with severe
continue, give IM phenobarbitone 10-15 mg/kg. anaemia in heart failure. The blood must be
• In adults give 10 mg diazepam IV. screened to ensure that it is HIV, Hepatitis B
and C negative.
Severe dehydration or shock
• Use packed cells (10 ml/kg in children) or whole
• Give 20-30 ml/kg of normal saline and reassess blood (plus frusemide).
the patient within 30 minutes to decide on the • Where blood is not available, give pre-referral
next fluid treatment and refer urgently to a health facility
with blood transfusion services.
 Specific treatment
• Artesunate (IM/IV) 2.4mg/kg Artemeter suppositories
o <20kg use 3mg/kg @ 0, 12, 24hrs until
patient can tolerate orally

• Artemether 3.2mg/kgbw IM
anterior thigh then 16mg/kgbw
daily
• Quinine IV/IM 10 ml/kg of 4.3%
dextrose in 0.18% saline or 5%
dextrose over a period of 4
hours
 CHEMOPREVENTION AND
CHEMOPROPHYLAXIS
• Intermittent Preventive • Sickle cell Anaemia
Treatment (Preg mothers)
No recommended
For pregnant mothers..3tab
medication for SS patients
stat.
3 or more doses should be Some practitioners use
giving at one month interval proguanil
HIV mothers on co-
trimoxozole should not
receive SP
Chemoprophylaxis (does not confer
absolute protection)
Drugs Adult dosage remark
Proguanil 100-200mg(1-2 tablets Start 1-2 before and continue 2-
(paludrine) daily) 4wks after departure
Atovaquone/ 250/100mg daily Start 1-2 days and continue
proguanil 7days after departure
Mefloquine 250mg daily
Sulfadoxine/ 500mg/25mg weekly Start 1-2 before departure
pyrimethamine (SP)
Pregnant women 500mg/25mg After 1st trimester (3x @ one
month interval)
 Current trends highlighted
• Test before treatment
• Monotherapy no-longer acceptable
• Combination therapy AL/AA
• 2nd does of AL should be after 8hrs of the 1st dose
• AL works better with fatty foods
 Gaps in Nigeria
• Finance
• HMIS
• Drugs
• Poor human resource
• Poor commitment by government
• Lack of coordination
 conclusion
• Malaria gives significant burden
• Poor compliance between testing and treatment in our
hospital
• Poor political and financial commitment from the
government
• Malaria vaccine is more realist solution
Thank
you
 References
• https://www.who.int/malaria/publications/atoz/high-impact-response/en/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4938925/
• Obionu C. N. (2016).Primary Healthcare for Developing countries. Enugu: Ezu books Ltd.pg 88-106.
• Edmund O. Ndibuagu et al. Knowledge and Perception of Malaria Rapid Diagnostic Test
among Medical Doctors in a South Eastern Nigeria Tertiary Hospital, JBM>
Vol.5 No.10, October 2017 https://www.scirp.org/journal/PaperInformation.aspx?paperID=79786
• https://www.dhsprogram.com/topics/malaria/index.cfm.
• http://apps.who.int/medicinedocs/documents/s18401en/s18401en.pdf
• National MALARIA Strategic Plan 2014 – 2020
• https
://www.malariavaccine.org/files/content/page/files/RTSS%20vaccine%20candidate%20Factsheet_FI
NAL.pdf
• https://www.who.int/news-room/fact-sheets/detail/malaria