Malaria

Description

Malaria is a life-threatening infection of red blood cells by a parasite micro-organism called Plasmodium. The parasites are usually transmitted to humans by the bite of an infected female anopheles’ mosquito. In Zambia, P. falciparum accounts for 95% of all malaria cases, 3% in mixed infection with either P. ovale or P. malariae while mono-infection with P. ovale and P. malaria contribute 2%. the most common and the most dangerous of the malaria species.

Uncomplicated Malaria: Symptomatic infection with malaria parasitaemia without signs of severity and/or evidence of vital organ dysfunction.

Complicated Malaria is the presence of asexual malaria parasites with evidence of major clinical or laboratory major organ dysfunction in the absence of any other alternative diagnosis. Inappropriate treatment or delay in diagnosis—especially in infants, children, and nonimmune adults—leads to rapid deterioration which may lead to disability or death. Patients with complicated malaria should, therefore, be managed by the administration

of antimalarial medicine for complicated malaria and the management of organ dysfunction. The table below shows the features of complicated malaria and its management.

Signs and Symptoms

Fever rigor
Chills
Headache
Myalgia
Arthralgia
Anorexia
Nausea
Dry cough
Flu-like symptoms
Joint pains
Abdominal discomfort/pain
Vomiting

Severe disease may present with one or more of the following additional clinical features as described under complicated malaria section.

Investigations

Microscopy (MPS)
Malaria RDT

Uncomplicated Malaria - Treatment

All confirmed uncomplicated malaria cases should be promptly treated with effective, recommended first-line antimalarial medicines. Currently, the recommended drug therapy for uncomplicated malaria for the general population—including women in all trimesters of pregnancy—is Artemether-Lumefantrine (AL). AL should be given twice day for three (3) days, with the doses 8 hours apart on day one (1) and then 12 hours apart on days two (2) and three (3). The dose is weight dependent, as outlined in Table 81.

Table 81: Dosage schedule for Artemether-Lumefantrine (AL)

Body weight (kg)	AL dosage (mg), 2x/day for 3 days (first day 8 hr. apart and then 12 hr. apart)	Number of tablets
< 15	20 + 120	1
15 to < 25	40 + 240	2
25 to < 35	60 + 360	3
≥ 35	80 + 480	4

To reduce malaria transmission in Health Facility catchment Areas (HFCAs0 with annual malaria incidences under 125 per 1,000 of the population, the recommendation is to give a single low dose of Primaquine (0.25-mg per kg of body weight) plus AL to all patients with P. falciparum malaria (except pregnant women, infants under 6 months old, and women breastfeeding infants under 6 months old). Glucose-6-phosphate dehydrogenase (G6PD) testing is not required.

Mixed Plasmodium infection
For all mixed or non-P. falciparum infections, the recommended treatment is a full 3-day drug regimen of AL. In people with G6PD deficiency, relapse can be prevented by giving 0.75 mg of Primaquine per kg of body weight once weekly for eight weeks, with close medical supervision for potential Primaquine-induced
haemolysis. Primaquine should not be given to women who are pregnant or breastfeeding until delivery and breastfeeding are completed (after which, based on G6PD status, they can be treated with Primaquine to prevent future relapse)

Complicated Malaria - Treatment

Table 82: Management of specific underlying complications of Malaria

Manifestation/ complication	Management	Evaluation/investigation
Coma (cerebral malaria): impaired consciousness (or a Glasgow coma score < 11 in adults or a Blantyre coma score < 3 in children)	• Maintain airway; intubate, if necessary. • Place the patient on their side. • Check for hypoglycemia and manage it if present. • Give recommended empirical parental antibiotic for bacterial meningitis. • Ensure proper nursing care to prevent aspiration and bed sores. • Catheterize and record fluid input and urine output.	• Blood slide, random blood sugar, full blood count, serum urea/bicarbonate +/- LP • Glasgow and Blantyre coma score monitoring
Convulsions (multiple convulsions): more than two episodes in 24 hr.	Maintain airway In children:	Fit chart Urine for urinalysis to rule out eclampsia in pregnant women
	• Treat promptly with diazepam (0.3 mg/ kg by IV or 0.5 mg/kg rectally), which can be repeated twice, and then shift to phenobarbitone
	• Administer phenobarbitone (20 mg/kg IM loading dose over 20 min.) with respiratory support; if convulsions persist, give a maintenance dose of 5 mg/kg/day in two divided doses. Commence maintenance dose 24 hours after loading dose.
	In adults:
	• Give a slow bolus of IV diazepam 5–10 mg
	• If convulsions continue, give a second dose.
	• If they persist, give phenobarbitone 20 mg/ kg (IM or IV) over 20 min. as a loading dose (max. 100 mg); if convulsions persist, repeat phenobarbitone at 6 mg/kg after a 20-min. interval.
	• For both children and adults, ensure the patient has received glucose and that body temperature is controlled
Severe malarial	Administer oxygen (2.5 L/mm) to improve	Monitoring for transfusion reactions
anemia: hemoglobin	oxygen delivery
concentration ≤5 g/dL or	Prop up the patient with pillows or clothing
a hematocrit of ≤ 15% in	Collect blood for cross match and hemoglobin
children under 12 years	estimations and transfuse, as appropriate
old (< 7 g/dL and < 20%,	Give packed cells at l0 ml/kg and whole blood
respectively, in adults),	at 20 ml/kg in cases of hypovolemic shock; give
with a parasite count	IV start (bolus) dose of a loop diuretic (e.g.,
> 10,000/μ	furosemide) at 1–2 mg/kg (provided the blood
	pressure is not low) during blood transfusion to
	avoid circulatory overload

Manifestation/ complication

Management

Evaluation/investigation

Pulmonary edema: radiologically confirmed or oxygen saturation

< 92% on room air with a respiratory rate > 30/min, often with chest indrawing and crepitation’s on

auscultation

Prop up the patient and administer oxygen

Give a diuretic (furosemide at 1 mg/kg IV bolus in children and 40 mg IV stat in adults)

Stop IV fluids

Intubate, where necessary

Monitoring oxygen saturation, respiratory rate, and breathing difficulties Catheterization and monitoring of fluid input and urine output

Chest x-ray

Acute kidney injury:

urine output < 400 ml

/ 24 hr. (< 1 ml/kg in children) with a plasma or serum creatinine

> 265 μmol/L (3 mg/

dL) or blood urea > 20 mmol/L

Check for and correct dehydration Exclude heart failure

Avoid herbal medication and nonsteroidal

anti-inflammatory and nephrotoxic drugs (e.g.,

Gentamicin)

Quickly refer patient to next level

Blood draw for urea and creatinine

Monitoring of fluid input and urine output

Hypoglycemia: blood glucose < 2.2 mmol/L or

< 40 mg/dL

Check blood glucose

Correct hypoglycemia (≤ 3 mmol/L) with glucose (IV or oral); ensure adequate caloric intake (nutritional support) thereafter Immediately give 5 ml/kg of 10% dextrose through a peripheral line

Continue with a slow IV infusion of 5 ml/kg/

hr of 10% or 10 ml/kg/hr. of 5% to prevent the recurrence of hypoglycemia

Monitoring of blood sugar levels and general condition

Shock: compensated (capillary refill ≥ 3 sec. or temperature gradient on leg [mid to proximal

limb] but no hypotension) or decompensated (systolic blood pressure

< 70 mm Hg in children or < 90 mm Hg in adults, with evidence of impaired perfusion [cool peripheries or prolonged

capillary refill])

Administer IV saline or Ringer’s lactate solution if serum lactate is normal

Administer blood transfusion if the patient has associated anemia

Give a third-generation cephalosporin or benzyl penicillin with Gentamicin to cover for bacteremia

Monitoring of the central venous pressure while infusing the fluids, keeping it at 0–5 cm of H2O to avoid fluid overload

Blood samples for culture

Spontaneous bleeding and coagulopathy

Transfuse with screened fresh whole blood (cryoprecipitate, fresh frozen plasma, and platelets, if available)

Give vitamin K injection (1 mg IM stat in

children, 30 mg IM stat in adults)

Monitoring for bleeding and transfusion reactions

Metabolic acidosis: symptomology of rapid, deep, labored breathing with a base deficit of

> 8 mEq/L or a plasma

bicarbonate level of

< 15 mmol/L or venous plasma lactate of ≥ 5 mmol/L or pH of < 7.35

Exclude or treat hypoglycemia. Correct hypovolemia

Treat septicemia with a third-generation cephalosporin

If severe, consider hemofiltration or hemodialysis, or refer if these facilities are not available

Close monitoring of vitals

Blood samples for random blood sugar, culture, lactate, and bicarbonate

Manifestation/ complication

Management

Evaluation/investigation

Hemoglobinuria: passing of dark, cola- colored urine

Continue appropriate antimalarial treatment. Transfuse screened fresh blood, if necessary

If oliguria develops and blood urea and serum creatinine levels rise (i.e., if acute renal injury occurs), consider renal replacement therapy

If possible, refer the patient to a dialysis unit or

center

Monitoring of input and output

Full blood count, urea, creatinine, and electrolytes

Blood group match/save

Injectable artesunate is the drug of choice for the general population (children, adults, and pregnant women in all trimesters) with severe malaria.
• The recommended dosing schedule for artesunate is as follows:
• On admission (time = 0).
• After 12 hours.
• 24 hours after the initial dose.
• Once daily thereafter for a maximum of 6 days if the patient can still not tolerate oral medication.
The dosage is for artesunate is 3mg/kg for patient below 20kg and 2.4mg/kg for those 20kg and above.
After administering the initial parenteral treatment for a minimum of 24 hours, and once the patient regains
consciousness and can take medications orally, discontinue parenteral therapy and commence the full course of an oral ACT. There should be an interval of at least 8 hours between the last dose of Artesunate and the first dose of an oral ACT.
Concomitant use of antibiotics
Septicemia and severe malaria may occur concurrently, particularly in children. Thus, broad-spectrum
antibiotic treatment should be given with antimalarial drugs until bacterial infection is ruled out. Antibiotic
treatment should be based on bacterial culture and sensitivity results or, if not available, follow local antibiotic
sensitivity patterns

Referral Criteria

Complicated malaria should always be referred after initial management to a higher facility

Malaria in Pregnancy

See also Obstetrics Malaria in pregnancy

Intermittent presumptive treatment (IPT) – Sulphadoxine + Pyrimethamine is the drug of choice for prevention of malaria in pregnancy. Sulphadoxine + Pyrimethamine is given after 16 weeks following the last menstrual period (LMP). Two consecutive doses are given at least 4 weeks apart during the second and third trimester. A total of 3 doses should be given during the entire duration of pregnancy.

Individuals who are intolerant to SP should be counselled about personal preventive measures to reduce contact with mosquitoes.

Summary of management of Malaria

Take and record a confirmatory history
Do a confirmatory clinical assessment including body temperature.
Make a differential diagnosis on clinical basis.
Do a lumbar puncture if there is need to exclude meningitis
Prepare a thick and thin blood smear
Do a full blood count
Decide on treatment and method of administration.
Keep treatment, follow-up and referral records. Record treatment failures and adverse events.
Give oral, subcutaneous or intramuscular medications
Decide on the need for referral

Supportive therapy

Monitoring of fluid and electrolyte balance
Correction of fluid and electrolyte imbalance
Correct management of anaemia
Management of hypoglycemia
Management of any other complications

Referred PatientsPatients referred from the community need to have a thorough clinical examination to exclude other causes of fever. Criteria for Referral from the Health Centre to Hospital

The following are criteria for a referral from the Health Centre to Hospital:

Neurological manifestation e.g. convulsions and altered/disturbed consciousness.
Persistent vomiting
Hyperpyrexia (>39 0C).
Hypothermia (< 35.7 0C).
Severe Anaemia.
Jaundice.
Pregnancy with fever
Failure to respond to treatment after 2 days.
Reaction to drugs interfering with normal daily activity e.g. severe rash, severe itch, sulphonamide sensitivity.
Conditions that cannot be managed locally
Rapidly deteriorating condition of the patient.
Conditions that cannot be managed locally

Prevention

Get rid of mosquito breeding sites near residential areas
Use impregnated mosquito nets, repellents and sprays
Give public health education on the dangers of malaria and how to prevent it.

Counselling Points:

Provide health education information on malaria i.e. personal protection measures e.g. bed nets, repellents, general sanitation around the house and in the community, such as reducing breeding sites and clearing of vegetation.
In Children; advise caregiver on the need for growth monitoring, feeding, Vitamin A supplementation and immunisation in children.
Prophylaxis in sickle cell anaemia and post-splenectomy use Pyrimethamine 25mg once weekly.

Zambia has no prophylaxis policy for visitors. Recommendations are provided from their country of origin. Some countries e.g. the United Kingdom are using Mefloquine. Sulphadoxine + Pyrimethamine is not recommended for this purpose.

The use of other drugs like Amodiaquine, Dapsone-Pyramethamine, (maloprim) and Mefloquine for prophylaxis needs further evaluation and is not therefore recommended.

Treatment Failure

Treatment failure is defined as the inability to clear malaria parasite or prevent recrudescence after
administration of the therapeutic regimen of an antimalarial drug, regardless of clinical symptoms. Treatment
failure is not synonymous with drug resistance.
The following are the causes of treatment failure:
• Unusual pharmacokinetic properties in an individual.
• Poor drug quality.
• Parasite resistance to antimalarials.

Treatment failure should be confirmed by microscopy examination of malaria blood slides. In facilities without microscopy services, patients with suspected treatment failure should be referred to centers with such services.
To manage treatment failure:
• Evaluate for causes of non-response to treatment, such as vomiting, non-adherence, failure to complete
treatment, and inadequate dosage. If these are present, repeat a full course of AL and provide sufficient counselling to the patient.
• Seek a potential alternative diagnosis and adequately manage it.
• In cases of confirmed treatment failure, provide oral or parenteral quinine treatment (the recommended
therapy for treatment failure in Zambia) and contact the National Malaria Elimination Centre.
• Where there is development of symptoms 21 days after initiation of treatment after prior clearance of
symptoms, treat as new infection using AL, as treatment failure is unlikely