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MALARIA
 Introduction
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 About 52 million people (68%) live in malaria risk areas

in Ethiopia,
 Primarily at altitudes below 2,000 meters
 Historically, there have been an estimated 10 million
clinical malaria cases annually.
 Since 2006, however, cases have reduced substantially
 60%-70% of malaria cases have been due to P.
falciparum, with the remainder caused by P. vivax.
 Anopheles arabiensis is the main malaria vector
 Malaria-endemic countries in the Americas
(bottom) and in Africa, the Middle East, Asia,
and the South Pacific (top),

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 Tissue schizonts Schizont Trophozoite

Merozoites

Sporozoites Gametocytes

Oocyst
Zygotes
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 Diagnosis of malaria
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 Clinical
 Laboratory
 Identify species of malaria
 Clinical Malaria
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 Nonspecific symptoms
 Lack of a sense of well-being,
 Headache,
 Fatigue, abdominal discomfort, and muscle aches
 Physical findings
 Fever
 Mild anemia
 Commona mong young children living in areas with stable
transmission
 Palpable spleen. (in some cases)
 Lab Diagnosis
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 Microscopic diagnosis of malaria

 Golden standard
 Initial diagnosis level of parasitemia
 Evaluation of rate of clearance of parasitaemia.
 Rapid diagnostic tests (RDTs)
 Management
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 Desired Outcome
 To eradicate the infection within 48 to 72 hours
 To avoid complications such as hypoglycemia, pulmonary
edema, and renal failure that are responsible for increased
mortality in malaria
 Flow Chart for the Dx and Rx of Malaria
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Box 1.
Patient with fever or history of fever in the last 48
hours and lives in malaria endemic areas or has
history of travel within the past 30 days to malaria
endemic areas
Treatment of Uncomplicated Malaria
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 Uncomplicated malaria is defined as symptomatic

malaria without signs of severity or evidence (clinical or
laboratory) of vital organ dysfunction.
Treatment of Uncomplicated Malaria
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1. P. falciparum positive
 First-line:

 Artemether plus lumefantrine (20/120 mg),

 6-dose regimen over a 3-day period

 Alternatives:

 Quinine HCl 600mg PO TID for 7 days

 Artesunate plus amodiaquine,
 Artesunate plus mefloquine,
 Artesunate plus sulfadoxine-pyrimethamine,
 Dihydroartemisinin plus piperaquine.
Treatment of Uncomplicated Malaria
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Tablet containing artemether-lumefantrine (20/120mg) in a fixed dose.

Weight Age Day 1 Day 2 Day 3

(KG) Mornin Evening Mornin Evening Mornin evening
g g g

5 – 14 4 – 2 Yrs 1 tab 1 tab 1 tab 1 tab 1 tab 1 tab

15 – 24 3 – 7 Yrs 2 tab 2 tab 2 tab 2 tab 2 tab 2 tab

25 – 34 8 – 10 3 tab 3 tab 3 tab 3 tab 3 tab 3 tab

Yrs

>35 >10 Yrs 4 tab 4 tab 4 tab 4 tab 4 tab 4 tab

Treatment of Uncomplicated Malaria
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2. P. vivax
 First-line: Chloroquine 150 mg base table (250mg chloroquine

phosphate (salt))
 Dose:

 10 mg base/kg po immediately (Day 1),

 10 mg base/kg po at 24 hours (Day 2), and
 5mg base/kg po at 48 hours (Day 3) for a total dose of 25mg
chloroquine base/kg over three days
 PLUS premaquine 0.25mg/kg for 14 days
 0.25 – 0.5mg/kg/day primaquine once a day for 14 days to eradicate

liver phase in P. vivax and P. ovale infections

3. Mixed infection:
 Artemether plus lumefantrine (20/120 mg) plus premaquine
 Treatment of Sever Malaria
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 Presence of one or more signs and symptoms of sever

illness and/or
 Demonstrable asexual P. falciparum parasitaemia in
peripheral blood sample
 Treatment of Severe Malaria
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Signs Manifestations
Major
Unarousable coma/ Failure to localize or respond appropriately to noxious stimuli;
cerebral malaria coma persisting for >30 min after generalized convulsion
Acidemia/acidosis Arterial pH of <7.25 or plasma bicarbonate level of <15 mmol/L;
venous lactate level of >5 mmol/L; manifests as labored deep
breathing, often termed “respiratory distress”
Severe normochromic, Hematocrit of <15% or hemoglobin level of <5 g/dL with
normocytic anemia parasitemia <10,000/μL
Renal failure Scr >3 mg/dL; urine output (24 h) of < 400 mL in adults or <12
mL/kg in children; no improvement with rehydration
Pulmonary edema/adult Noncardiogenic pulmonary edema, often aggravated by
respiratory distress overhydration
syndrome
Hypoglycemia Plasma glucose level of <40 mg/dL
Hypotension/shock Systolic blood pressure of <50 mmHg in children 1–5 years or
<80 mmHg in adults; core/skin temperature difference of >10°C;
capillary refill >2 s
 Treatment of Severe Malaria
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Signs Manifestations

Hypotension/shock Systolic blood pressure of <50 mmHg in children 1–5 years or <80
mmHg in adults; core/skin temperature difference of >10°C; capillary
refill >2 s
Bleeding/DIC Significant bleeding and hemorrhage from the gums, nose, and
gastrointestinal tract and/or evidence of DIC
Convulsions More than two generalized seizures in 24 h
Others
Hemoglobinuria Macroscopic black, brown, or red urine; not associated with effects of
oxidant drugs and red blood cell enzyme defects (such as
G6PDdeficiency)
Extreme weakness Prostration; inability to sit unaided
Hyperparasitemia Parasitemia level of >5% in nonimmune patients
Jaundice Serum bilirubin level of >3 mg/dL) if combined with a parasite density
of 100,000/μL or other evidence of vital-organ dysfunction
 Treatment of Severe Malaria
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 First-line treatment
 IV or IM artesunate (preferred)
 IM artemether (alternate)
 IV quinine infusion (if artesunate is not available)
 IM quinine (if artesunate is not available)
 Treatment of Severe Malaria
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 Artesunate dosing
 2.4 mg/kg BW IV or IM given on admission (time = 0),

then at 12h and 24h, then daily for up to five days;

 Preparation:
 Contains 60 mg powder within a 7 ml glass vial
 First reconstitute by mixing with a 1 ml glass ampoule of

5% sodium bicarbonate solution (provided) then shaken

2-3 minutes for better dissolution.
 Treatment of Severe Malaria
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 For IV:
 Add 5 ml of 5% glucose (D5W) or NS then infuse
slowly intravenously (3-4 ml per minute IV)
 For IM
 Add 2 ml of 5% glucose (D5W) or NS to the
reconstituted 7 ml vial to make 3 ml of artesunate (20
mg/ml) for IM injection
Malaria in Pregnant Women
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 The first-line treatment for P. falciparum infection in pregnant

women in the first trimester of pregnancy is oral quinine
administered at 10 mg/kg (up to 600 mg) three times a day for
seven days
 If pregnant women have P. falciparum or mixed infection and
are in their second or third trimester, they will be treated with
AL.
 Pregnant women with only P. vivax will be treated with
chloroquine in all trimesters
 The recommended treatment for severe malaria in all patients
including pregnant women is artesunate
infusion, or alternatively quinine infusion or alternatively
Drugs Used to Treat Malaria
• Chloroquine
• Amodiaquine
• Quinine and
• Mefloquine
• Halofantrine
• Atovaquone-proguanil
• Atemisinin derivatives

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 Sites of Action for Antimalarial Drugs

TISSUE SCHIZONTOCIDES:
primaquine
pyrimethamine
proguanil
tetracyclines

MOSQUITO HUMAN
BLOOD
SCHIZONTOCIDES:
chloroquine
mefloquine
quinine/quinidine
SPORONTOCIDES: GAMETOCYTOCIDES: tetracyclines
primaquine primaquine halofantrine
pyrimethamine sulfadoxine
proguanil
22 pyrimethamine
artemisinins
 Antimalarial drug actions
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 Actions
 Blood schizontocidal drugs (suppressive or clinical)–

attack parasite in RBC, preventing or ending clinical

attack
 Gametocytocidal – destroy sexual forms in human,

decreases transmission
 Hypnozoitocidal – kill dormant hypnozoites in liver,

antirelapse drugs
 Sporontocidal – inhibit development of oocysts in

mosquito, decreases transmission

 Antimalarial Chemoprophylaxis
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 Consider:
Immune status
Intensity/duration of exposure
Parasite drug resistance
Resources for diagnosis and treatment
 Drugs for prophylaxis
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 Atovaquone/proguanil (Malarone®): 250/100 mg once daily

 Start 1 day earlier

 continue throughout the stay and for 7 days after returning.

 Chloroquine or mefloquine – resistant

 Doxycycline: 100mg QD
 Chloroquine – or mefloquine – resistant

 Start 2 days before

 Continue daily during travel

 Personal Protection
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 Protective clothing
 Insect repellants
 Household insecticide products
 Window and door screens
 Bed nets