Malaria

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Malaria is a disease caused by the plasmodium parasite, transmitted by the bite of infected mosquitoes. Depending on the degree of parasitaemia, malaria can be uncomplicated or severe (complicated).

Causes

  • Malaria is caused by five species of the plasmodial parasite namely, Plasmodium falciparum, Plasmodium Malariae, Plasmodium ovale, Plasmodium vivax and Plasmodium knowlesi
  • Plasmodium falciparum is the dominant parasite mainly responsible for over 90% of malaria cases and all the severe forms of the disease.

Signs and symptoms (uncomplicated malaria)

  • Fever: temperature above 37.5°C (taken from the axilla) or history of fever
  • Loss of appetite, mild vomiting, diarrhoea
  • Weakness, headache, joint and muscle pain
  • Mild anaemia (mild pallor of palms and mucous membranes)
  • Mild dehydration (dry mouth, coated tongue).
  • Enlarged spleen (in acute malaria it may be minimally enlarged, soft and mildly tender)

Signs and symptoms (complicated malaria)

  • Repeated vomiting
  • Prostration
  • Impaired consciousness
  • Severe anaemia (Haemoglobin < 5g/dl)
  • Circulatory collapse (Algid malaria)
  • Hypoglycaemia (whole blood glucose <2.2mol/L)
  • Pulmonary oedema
  • Abnormal bleeding/DIC
  • Jaundice (serum bilirubin >3g/dl)
  • Haemoglobinuria(Black water fever)
  • Febrile seizures
  • Acute renal failure
  • Hyper-parasitaemia (>5% of RBCs are parasitized)
  • Hyperpyrexia (temp > 40°C)
  • Lactic acidosis

Investigations

  • Microscopy (thick and thin blood smears)
  • Rapid Diagnostic Tests (RDTs)

Differential diagnosis

  • Typhoid fever
  • Respiratory tract infection
  • Urinary tract infection
  • Meningitis, otitis media, tonsillitis
  • Abscess, skin sepsis
  • Measles or other infections with rashes (before rash comes)

Treatment objectives

  • Eradicate parasitaemia
  • Prevent progression to severe malaria

Pharmacological treatment

Uncomplicated Malaria

First Line

Artemether/lumefantrine tabs (AL) for 3 days

Weight

20/120 mg tab

40/240  mg tab

80/480 mg tab

5 kg to <15kg

1 tab two times daily

NA

NA

15kg to <25kg

2 tabs two times daily

1 tab two times daily

NA

25kg to <35kg

3 tabs two times daily

NA

NA

 > 35kg

4 tabs two times daily

2 tabs two times daily

1 tab two times daily

 

Second Line

Artesunate plus amodiaquine (ASAQ) for 3 days

Age

Weight

Tablet strength

Dosage Regimen

2-11 months

4.5kg to <9kg

25mg/67.5mg

1 tablet daily

1 yr to 5yrs

9kg to <18kg

50mg/135mg

1 tablet daily

6 yrs to 13yrs

18kg to 36kg

100mg/270mg

1 tablet daily

14 years and above

36kg and above

100mg/270mg

2 tablets daily

 

Uncomplicated malaria treatment in pregnancy

First trimester

Quinine oral for 7 days

PLUS

Clindamycin oral for 7 days

Second and third trimesters of pregnancy

AL or ASAQ as above

 

Complicated malaria

Artesunate

Age

Route

On admission

12 hours

24 hours

Daily

Adult

IV

2.4mg/kg

2.4mg/kg

2.4mg/kg

2.4mg/kg

Children

IV

 2.4mg/kg

2.4mg/kg

2.4mg/kg

2.4mg/kg

 

Second choice

Age

Route

On admission 

Continuation

Comments

Artemether

IM

3.2mg/kg

1.6 mg/kg daily

 

Quinine 

IV or divided IM injections

20mg salt/kg

10mg/kg every 8 hours

Infusion rate should not exceed 5m/kg/hr

 

Pregnancy

1st choice

Artesunate

 

2nd choice

Artemether

only where artesunate is unavailable

3rd choice

Quinine

 

Intermittent Preventive Treatment in Pregnancy (IPTP)

Medicine

14 weeks

Every 4 weeks thereafter

Comments

Sulphadoxine/pyrimethamine 500/25mg

3 tabs

3 tabs

A minimum of 3 doses throughout the pregnancy

 

Intermittent Preventive Treatment in Infants (IPTi)

Administer SP when giving penta 2, penta 3 and measles vaccines

 

Dosing Schedule for SP

Weight(Kg)

SP given as single dose

5 to < 10

250mg/12.5mg

10 to < 25

500mg/25mg

25 to < 50

1000mg/50mg

≥ 50

1500mg/75mg

 

Chemoprophylaxis for the Non-immune 

  • Mefloquine, atovaquone-proguanil and doxycycline.
  • Mefloquine: 5 mg base/kg weekly, giving an adult dose of 250 mg base weekly and appropriate doses to child aged 8 - 13 years
  • Contraindicated in children <8 years and in pregnant women

For Visitors

  • Commence 2-3 weeks prior to arrival, then weekly while in country, and thereafter for 2-3 weeks after departure.
  • Atovaquone-proguanil can be started 24 hours before arrival and stopped seven days after departure. It is dosed daily.

Non-chemotherapeutic prevention of malaria

  • Use insecticide-treated materials (e.g. bed nets)
  • Destroy adult mosquitoes by indoor residual spraying of dwellings with insecticide or use of knock-down sprays
  • Wear clothes which cover the arms and legs and use repellent mosquito coils and creams/sprays on the skin when sitting outdoors at night
  • Eliminate collections of stagnant water where mosquitoes breed
  • Destroy mosquito larvae by dosing stagnant water bodies with larvicides or with biological methods.