MALARIA RECENT

GUIDELINESWHO-2015

By Dr. Kiran BikkadDNB Medicine Resident

Nazareth Hospital, Shillong

Malaria is one of the major public health problems of the country.

India reports around one million malaria cases annually.

In India, P. falciparum and P. vivax are the most common species causing malaria, their proportion being around 50% each.

Plasmodium vivax is more prevalent in the plain areas

P. falciparum predominates in forested and hilly areas.

LIFE CYCLE

In the past, chloroquine was effective for treating nearly all cases of malaria.

In recent studies, chloroquine-resistant P. falciparum malaria has been increasing across the country.

CLINICAL FEATURES Fever - cardinal symptom. chills and rigors. accompanied by headache, myalgia,

arthralgia, anorexia, nausea & vomiting. The symptoms -- non-specific and mimic

viral infections, enteric fever, etc. Malaria suspected in patients in

endemic areas or recently visited endemic area & presenting with above symptoms.

Other causes of fever suspected and investigated in the presence of symptoms like running nose, cough and other signs of

respiratory infection diarrhoea/dysentery burning micturition, lower abdominal pain skin rash/infections, abscess painful swelling of joints ear discharge, lymphadenopathy, etc.

All clinically suspected malaria cases should be investigated by microscopy and/or RDT

EARLY DIAGNOSIS AND COMPLETE TREATMENT OF MALARIA AIMS AT:

● Complete cure● Prevention of progression of

uncomplicated malaria to severe disease

● Prevention of deaths● Interruption of transmission● Minimizing risk of selection and spread

of drug resistant parasites

DIAGNOSIS

1 . Microscopy thick and thin blood gold standard for confirmation of

diagnosis of malaria Advantages :

1. Sensitivity is high. It is possible to detect malaria parasites at

low densities2. To quantify the parasite load.3. To distinguish different species of

malaria parasites and their different stages.

2 . Rapid Diagnostic Test Based on the detection of circulating

parasite antigens. Several types of RDTs are available. Some of them can only detect

P.falciparum, while others can detect other parasite species also.

NVBDCP has recently rolled out bivalent RDTs for detecting P. falciparum and P. vivax

Pf HRP-2 based kits may show positive result up to three weeks after successful treatment and parasite clearance

TREATMENT PRINCIPLES1. Early diagnosis & prompt effective

treatment2. Rational use of antimalarial agents3. Use of combination therapy4. Appropriate weight based dosing

TREATMENT OF UNCOMPLICATED MALARIAP. vivax chloroquine 25 mg/kg. In some patients ( 8 - 30%) relapse due to

hypnozoites in liver cells Relapse prevention, primaquine 0.25

mg/kg daily for 14 days under supervision

CHLOROQUINE & PRIMAQUINE REGIMEN

Primaquine is contraindicated in pregnant women, infants and known G6PD deficient patients.

Primaquine can lead to hemolysis in G6PD deficiency Patient should be advised to

stop primaquine immediately if any of the following symptoms: (i) dark coloured urine (ii) yellow conjunctiva (iii) bluish discolouration of lips (iv) abdominal pain (v) nausea (vi) vomiting (vii) breathlessness, etc.

TREATMENT OF UNCOMPLICATED MALARIAP. falciparum ACT

Artemisinin derivative with long acting antimalarial (amodiaquine, lumefantrine, mefloquine, piperaquine

or sulfadoxine-pyrimethamine). The ACT in the National Programme all over India

except northeastern states is Artesunate (4 mg/kg body weight) daily for 3 days Sulfadoxine (25 mg/kg body weight) & Pyrimethamine (1.25 mg/kg body weight) [AS+SP]

on Day 0.

primaquine (0.75 mg/kg) single dose on Day 2

NORTHEASTERN STATESArunachal Pradesh, Assam, Manipur,

Meghalaya, Mizoram, Nagaland, Tripura

due to late treatment failures to AS+SP in P. falciparum, the presently recommended ACT in national drug policy is a FDC of Artemether-lumefantrine (AL)

ACT used in the national programmeNE states = ALRest of India = AS+SP

MONOTHERAPY OF ORAL ARTEMISININ DERIVATIVES IS BANNED IN INDIA

Injectable artemisinin derivatives should be used only in severe malaria.

TREATMENT OF MALARIA IN PREGNANCY

The ACT should be given for treatment of P. falciparum malaria in second and third trimesters of pregnancy

Quinine recommended in the first trimester.

Plasmodium vivax malaria can be treated with chloroquine.

TREATMENT OF MIXED INFECTIONS

Mixed infections with P. falciparum should be treated as falciparum malaria.

Since AS+SP is not effective in vivax malaria, other ACT should be used.

Anti-relapse treatment with primaquine can for 14 days.

TREATMENT BASED ON CLINICAL CRITERIA WITHOUT LABORATORYCONFIRMATION

If RDT for only P. falciparum is used, negative cases showing signs and symptoms of malaria without other obvious cause for fever called as clinical malaria.

Treatment:- chloroquine 25 mg/kg for 3 days

GENERAL RECOMMENDATIONS FOR THE MANAGEMENT OFUNCOMPLICATED MALARIA1. Avoid starting treatment on empty stomach. 2. The first dose is given under observation.3. Dose repeated if vomiting within half hour of

drug intake.4. Patient asked to report back, if no

improvement after 48 hours/deteriorates.5. Investigate for concomittant illnesses

TREATMENT FAILURE/DRUG RESISTANCE

Patient is called cured, if no fever or parasitaemia till Day 28 after treatment.

Patients may not respond to treatment due to 1)drug resistance/ 2)treatment failure.

Early treatment failure (ETF): Development of danger signs on Day 1, 2 or 3 + parasitaemia higher on Day 2

TREATMENT FAILURE/DRUG RESISTANCE

Late clinical failure (LCF): Development of danger signs + parasitaemia on Day 4 - 28

Late parasitological failure (LPF): parasitaemia on Day 7 - 28 + temperature <37.5°C + did not meet criteria of early treatment failure or late clinical failure.

TREATMENT :- ACT or quinine with Doxycycline.

Doxycycline is contraindicated in pregnancy, lactation and in children up to 8 years.

SEVERE FALCIPARUM MALARIADEFINITION:-one / more of the following, occuring in the absence of an identified alternative cause and in the presence of P. falciparum asexual parasitaemia. Impaired consciousness: GCS<11 in

adults Prostration: Generalized weakness &

unable to sit, stand, walk Multiple convulsions: More than two

episodes within 24hrs

Acidosis:A base deficit of >8 mEq/L or bicarbonate level of <15 mmol/L or plasma lactate>=5mmol/L. respiratory distress

Hypoglycaemia: RBS<40mg/dL Severe Malarial anaemia: HB <5,

haematocrit <15%

Renal impairment: creatinine>3mg/dl blood urea>20mmol/L

Jaundice: Sr bilirubin >3mg/dL with a parasite count >1,00 000/µL

Pulmonary oedema: Radiologically confirmed oxygen saturation<92% on room air respiratory rate>30/min with chest indrawing crepitations on auscultation

Significant bleeding: recurrent / prolonged bleeding from the nose, gums or

venepuncture sites, haematemesis or melaena.

Shock: capillary refill>3sec & systolic blood pressure<80mm Hg, with evidence of impaired perfusion(cool peripheries or prolonged capillary refill).

Hyperparasitaemia: P. falciparum parasitaemia>10%

SEVERE MALARIACLINICAL FEATURES SUMMARY● Impaired consciousness/coma● Convulsions● Renal failure (Sr Creatinine >3 mg/dl)● Jaundice (Sr Bilirubin >3 mg/dl)● Severe anaemia (Hb <5 g/dl)● Pulmonary edema/ARDS● Hypoglycaemia (Plasma Glucose <40

mg/dl)

SEVERE MALARIACLINICAL FEATURES SUMMARY● Metabolic acidosis● Circulatory collapse/shock (SBP <80

mmHg)● Abnormal bleeding● Haemoglobinuria● Hyperpyrexia (Temperature >106°F or

>42°C)● Hyperparasitaemia (>5% parasitized

RBCs ) indian guidelines

SEVERE MALARIA TREATMENTThings Necessary In a care centre:

● Parenteral antimalarials, antipyretics, antibiotics, anticonvulsants● Intravenous infusion facilities● Special nursing for coma patients ● Blood transfusion● Laboratory facilities● Facility for Oxygen, dialysis, ventilator, etc.

SEVERE MALARIA TREATMENT Severe manifestations can develop in P.

falciparum infection over time span as short as 12–24 hours

Parenteral artemisinin derivatives or quinine used as specific antimalarial therapy.

Artesunate: 2.4 mg/kg i.v. or i.m. onadmission 0 hour then at 12 & 24 hours, then once a day (dilute artesunate in 5% Sodium bicarbonate)

Quinine: 20 mg/kg on admission(i.v. infusion in 5% dextrose over 4 hours)

maintenance dose :- 10 mg/kg 8 hourly. beyond 48 hours:- 7 mg/kg 8 hourly

NEVER GIVE BOLUS INJECTION

Artemether: 3.2 mg/kg i.m. given on admission then 1.6 mg/kg per day.

Arteether: 150 mg daily i.m. for 3 days in adults only.

ACT containing mefloquine avoided in cerebral malaria due to neuropsychiatric complications.

Severe malaria due to P. vivax It should be treated like severe P.

falciparum malaria

MANAGEMENT OF COMPLICATIONS

Manifestation or complication

Immediate management

Coma(Cerebral malaria)

Maintain airway, place patient on his or her side, exclude other treatable causes of coma(e.g. hypoglycaemia, bacterial meningitis); avoid harmful ancillary treatments, intubate if necessary.

Hyperpyexia Administer tepid sponging, fanning a cooling blanket and paracetamol

Convulsions Maintain airways; treat promptly with intravenous or rectal diazepam, lorazepam, midazolam or intramuscular paraldehyde. Check blood glucose.

Hypoglycaemia Check blood glucose, correct hypoglycemia and maintain with glucose-containing infusion. Although hypoglycaemia is defined as glucose <2.2mmol/L, the threshold for intervention is <3mmol/L for children <5 years and <2.2 mmol/L for older children and adults.

CONTINUED…Severe anaemia Transfuse with screened fresh

whole blood.Acute Pulmonary edema

Prop patient up at an angle of 45◦, give oxygen, give a diuretic, stop intravenous fluids, intubate and add positive end-expiratory pressure or continuous positive airway pressure in life-threatening hypoxaemia.

Acute kidney injury Exclude pre-renal causes, check fluid balance and urinary sodium, if in established renal failure, add haemofiltration or haemodialysis, or if not available, peritoneal dialysis.

Spontaneous bleeding and coagulopathy

Transfuse with screened fresh whole blood (cryoprecipitate, fresh frozen plasma and platelets, if available); give vitamin K injection

CONTINUED…Metabolic acidosis

Exclude or treat hypoglycaemia, hypovalaemia and septicaemia. If severe, add haemofiltration or haemodialsis.

Shock Suspect septicaemia, take blood for cultures; give parenteral broad-spectrum antimicrobials, correct haemodynamic disturbances.

CHEMOPROPHYLAXIS

For :- TravellersMigrantLabourersMilitary personelExposed to malaria in highly endemic areas

CHEMOPROPHYLAXIS

Short-term (< 6 weeks) Doxycycline: 100 mg/day started 2 days before travel till 4 weeks after

leaving area. contraindicated in pregnant and lactating Women

& children less than 8 years.

Long-term (> 6 weeks) Mefloquine: 5 mg/kg (max 250 mg) weekly and 2 weeks before & 4 weeks after leaving the area. contraindicated with H/O convulsions,

neuropsychiatric problems.

THANK YOU