MALARIA MANAGEMENT

PREPARED BY :

1.MERYEM
MOHAMMED
2.TILAHUN MOGES
3. EMAN
ABDURAHMAN
4.EDLAWIT ADUGNA
08/14/2024
outline
 INTRODUCTION
 EPIDEMIOLOGY
 ETHIOLOGY
 PATHOPHISOLOGY
 CLASSIFICATION
 CLINICAL PRESENTATION/LAB-
 MANAGEMANTS
 REFERENCE

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Introduction
 Malaria is a parasitic infectious disease caused by
protozoan parasites of the genus Plasmodium and is
transmitted by mosquitoes.
 It is characterized by recurrent symptoms of chills, fever
and generalized body pain.
 The five Plasmodium species of human malaria are: P.
falciparum, P. vivax, P. ovale, P. malariae and P. knowlesi.

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EPIDEMIOLOGY
 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
 Malarial death in areas of high malaria transmission
occur primarily in children <5yrs of age
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Etiology and life cycle of parasites
 There are three modes of malaria transmission:
 the bite of an infected female anopheline mosquito
(the main method of transmission);
 accidental transmission via blood transfusion or
needle stick injury; and
 Congenital transmission from mother to child during
pregnancy or parturition.

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Figure 2: Life cycle of malaria
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parasite
 Tissue schizonts
Schizont Trophozoite

Merozoites

Sporozoites Gametocytes

Oocyst
Zygotes

Figure 1: Life cycle of malaria parasite (From Krogstad DJ: Blood and tissue protozoa. In
Schaechter M, Medoff G, Eisenstein BI [eds]: Mechanisms of Microbial Diseases, 2nd ed.
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Baltimore, Williams & Wilkins, 1993, p 600.)
Life cycle of the malaria parasite.
 The upper and lower halves of the diagram indicate
the human and anopheline mosquito parts of the
cycle, respectively.
 Sporozoites from the salivary gland of a female
Anopheles mosquito are injected under the skin (1).
 They then travel through the blood stream to the liver (2)
and mature within hepatocytes to become tissue
schizonts (4).
 Up to 30,000 parasites are then released into the blood
stream as merozoites (5) and produce symptomatic
infection as they invade and destroy red blood cells.
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Cont...
 They are the parasites that cause relapsing
malaria (in P.vivax or P.ovale infection).
 Once within the blood stream,
 merozoites (5) invade red blood cells (6) and
mature to the ring (7, 8),
 trophozoite (9), and schizont (10) asexual stages.
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4
Cont...
 Schizonts lyse their host red blood cells as they mature
and release the next generation of merozoites (11), which
invade previously uninfected red blood cells.
 Within the RBC, some parasites differentiate to sexual forms
(male and female gametocytes) (12).
 When taken up by a female Anopheles mosquito, the
gametocytes mature to male and female gametes, which
produce zygotes (14).
 The zygote invades the gut of the mosquito (15) and
develops into an oocyst (16).
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Cont...
 Mature oocysts produce sporozoites, which migrate
to the salivary gland of the mosquito (1) and repeat the
cycle.
 The horizontal line between 12 and 13 indicates that
absence of the mosquito vector prevents natural
transmission by means of this cycle.
 Infection by the injection of contaminated blood
bypasses this constraint and permits transmission
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PATHOPHISOLOGY
 Plasmodium species have two reproductive cycle
1. Asexual phase
 In human host

 Marked amplification(100 to 1014) occurs here

 Is a two-step process

  Exo erythrocytic phase

  Erythrocytic phase
2. Sexual phase
  In the mosquito
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 Diagnosis of malaria

 Clinical
 Laboratory
 Identify species of malaria

 Microscopy-thick and thin blood films for malaria parasites.

 Rapid diagnostic tests (RDT)-if microscopy is unavailable.

 CBC.

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 Clinical Malaria
 Non-specific symptoms
 Lack of a sense of well-being,
 Headache,
 Fatigue, abdominal discomfort, and muscle aches
 Physical findings
 Fever usually above 38°C
 Mild anemia.
 Common among young children living in areas with stable
transmission (or during the high-transmission period of
seasonal malaria), children with palmar pallor or a
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haemoglobin concentration of < 8 g/dL.
Cont...

 Clinical diagnosis of malaria

 patient who has fever or history of fever in the past 48
hours and lives in malaria-endemic areas or has a
history of travel within the last 30 days to malaria-
endemic areas.
 All patients with malaria should be asked for history of
malaria treatment in the past 28 days.
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Clinical manifestation/Presentation
The parasite incubation period, known as the intrinsic
incubation period, differs for each parasite species.
Children are Asymptomatic during Incubation period
  9-14 d for P. falciparum
  12-17 d for P. vivax
  16-18 d for P. ovale
  18-40 d for P. malaria
Incubation period can be prolonged
  6-12 months for p.vivax
  Patients with partial immunity
  Patients with incomplete chemoprophylaxis
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 Lab Diagnosis

 Microscopic diagnosis of malaria

 Golden standard
 Initial diagnosis level of parasitemia
 Evaluation of rate of clearance of parasitaemia.

 Rapid diagnostic tests (RDTs)

 All cases of suspected malaria should have a
parasitological test (microscopy or RDT) to confirm the
diagnosis.
 Both microscopy and RDTs should be supported by a
quality assurance programme.
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Treatment
Objectives
 Improve quality of life and productivity.
 Prevent uncomplicated malaria from
progressing to severe form.
 Prevent death from malaria complication.
 Prevent the development and transmission of
medicine resistance.
 Decrease malaria transmission to others.

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Supportive treatment for uncomplicated malaria

 Fever management (axillary temp record of ≥37.50℃)

 Antipyretics.
 Paracetamol (acetaminophen) 15 mg/kg (for adults 1000mg) every

4-6 hours, given orally or as a suppository.

 Fanning and tepid sponging
 Check for signs of severity and ability to tolerate oral
medication.
 If there is any sign of severity or the patient is unable to
tolerate oral
medications admit patients for parenteral treatment.
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Flow Chart for the Dx and Rx of
Malaria
Box 1.Patient with fever
or history of fever in the
last 48 hrs and lives in
malaria endemic areas or
has history of travel
within the past 30 days
to
malaria endemic areas

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Pharmacologic Treatment
Parasite First line Alternative

P.vivax Chloroquine for 3 days + Artemether-lumefantrine/oral

primaquine (PQ) for 14 days quinine + PQ for 14 days
Uncomplicated Artemether-lumefantrine for 3 Other ACT*s (3 days) if
P.falciparum days + single dose PQ available or oral quinine +
single dose PQ
Uncomplicated Artemether-lumefantrine for 3 Other ACT*s if available or oral
mixed infections days + PQ for 14 days quinine (7 days) + PQ for 14
days

*ACT(Artemisinin-based Combination Therapy):

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Artemisinin-based Combination
Therapy
 artemether-lumefantrine (AL)
 artesunate-amodiaquine (AS+AQ)
 artesunate-mefloquine (ASMQ)
 dihydroartemisinin-piperaquine (DHAP)
 artesunate + sulfadoxine-pyrimethamine (AS+SP)
 artesunate-pyronaridine (ASPY) (2022)

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Treatment of Uncomplicated
Malaria
 Uncomplicated malaria is defined as
symptomatic malaria without signs of
severity or evidence
(clinical or laboratory) of vital organ
dysfunction.

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 Treatment of Uncomplicated
Malaria
1. P. falciparum positive by multi–species RDT:
 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.

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 Treatment of Uncomplicated
Malaria
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 Yrs 3 tab 3 tab 3 tab 3 tab 3 tab 3 tab

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

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 Treatment of Uncomplicated
Malaria
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: 08/14/2024
 Artemether plus lumefantrine (20/120 mg) plus premaquine
Treatment failure
 Patient with malaria who was treated for malaria in the past
28 days.
 drug resistance, poor adherence or inadequate drug exposure (i.e. under -
dosing, vomiting, drug interaction, misdiagnosis or substandard
medicines.
 If the cause for treatment failure identified early
 (e.g. anti-malarial drug is vomited), address the cause and reinstituted
treatment with the first line anti-malarial drug;
 If no cause is identified, a P. falciparum or P. vivax-infected
patient returns with in 72 hours to 28 day of treatment,
 Treatment by second-line drug,
 e.g.Dihydroartemisnin-piperaquine tablets; 08/14/2024
Cont...
 If a P. falciparum or P. vivax-infected patient returns with fever or
history of fever between days 4 to 28 of treatment, microscopic
blood examination should be made (do not use RDTs).
 If parasites are detected, administer second-line drug, e.g. quinine tablets;
 If blood smear is negative and no other obvious causes found, reevaluate, or
refer

 For treatment failure after 28 days, first line antimalarial drugs

should be used.

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 Treatment of Sever Malaria

 Presence of one or more signs and symptoms of sever

illness and/or
 Demonstrable asexual P. falciparum parasitaemia in
peripheral blood sample

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Treatment of severe and complicated P. falciparum
malaria

 Objectives
 Administer medicines parenterally to ensure adequate
blood-serum concentrations of the medicine and rapid
clearance of parasitaemia.
 Provide urgent treatment for life threatening problems.
e.g. convulsions, hypooglycaemia, dehydration, renal
impairment .
 Prevent death from malaria
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 Treatment of Severe Malaria
Signs Manifestations
Major
Unarousable coma/cerebral Failure to localize or respond appropriately to noxious stimuli;
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 syndrome overhydration
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 >2s
Bleeding/DIC Significant bleeding and hemorrhage from the gums, nose, and
gastrointestinal tract and/or evidence of DIC
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 Treatment of Severe Malaria
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
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Pharmacologic
 General principles of treatment
 Itis a medical emergency
 Regarded patient as having severe P. falciparum malaria (though
p.vivax can also cause it)
 Parenteral administration required (Artesunate >quinine)
 Also involves multiple supportive treatment measures

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 Treatment of Severe Malaria

 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)
 Give parentral Antimalarials in the treatment of
severe malaria for a minimum of 24 hours, once
started (irrespective of the patient’s ability to
tolerate oral medication earlier)
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Treatment of Severe Malaria

 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.

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Treatment of Severe Malaria

 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

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Dose Regime of Artesunate IV, IM

Weight(kg)(approximate) IV10mg/ml IM20mg/ml

0-8 1ml 0.5ml
9 to12 2ml 1ml
13-16 3ml 1.5ml
17-18 4ml 2ml
19-21 5ml 2.5ml
22-25 6ml 3ml
26-29* 7ml 3.5ml
30-33* 8ml 4ml
34-37* 9ml 4.5ml
38-41* 10ml 5ml
42-46* 11ml 5.5ml
47+* 12ml 6ml
* for persons weighing more than 25 kg, a second artesunate vial must be completely
reconstituted as above for each dose, and then each dose administered determined by
the chart. 08/14/2024
Dose regimens of Quinine
Route Loading dose over Rest for next 8 Maintenance dose Rest for 4 hours Maintenance dose
4 hours hours over 4 hours (12hours over 4 hours 8
after start of loading hourly
Dose)
IV 20mg/kg in 500 Give N/Saline or 10mg salt/kg body Give N/Saline or 10mgsalt/
ml of isotonic Ringers lactate to weight in 500 ml Ringers lactateto kgbodyweight in
saline or 5% keep vein open and of5%dextrose over 4 keep vein open and 500 ml of 5%
maintain fluid hours maintain fluid dextrose over 4
dextrose over 4 balance balance hours
hours
(4ml/minute)
IM Loading dose Rest for next 4 hours Maintenance dose 8 hourly

20 mg/kg body weight divided in to 2 10 mg salt/kg body weight IM in to

site (one in each thigh) thigh

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 The parenteral treatment should be changed to P.O.,
 only after 24 hours and as soon as the patient‘s condition
improves and if there is no vomiting.
 Oral treatment should be given with Artemether +
Lumefantrine in the doses as indicated above.
 However, if a patient has a history of intake of Artemether +
Lumefantrine before complications developed,
 give Quinine tablets 10 mg salt per kg TID to complete 7 days
treatment
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 Malaria in Pregnant Women
 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) TID for 7 days
 If pregnant women have P. falciparum or mixed infection and
are in their second or third trimester, Treated with
artemether-lumefantrine (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
artemether IM 08/14/2024
Drugs Used to Treat Malaria
• Chloroquine
• Amodiaquine
• Quinine and
• Mefloquine
• Halofantrine
• Atovaquone-proguanil
• Atemisinin derivatives

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Side effects and other precautions of antimalarial
 AL: C/Is:
 previous history of reaction after using the medicine;
 pregnant women in the first trimester and infants less than 5
kg;
 severeand complicated malaria should not be treated with oral
medications:
 N.B. Artemether-lumefantrine should not be used
as malaria prophylaxis either alone or in
combination;
 P/Cs: It should be stored at temperatures below 30°C.
 Itshould not be removed from the blister if08/14/2024
it is not going to be
used immediately.
Cont...
 Artesunate:
 dizziness, tinnitus, neutropenia, elevated liver

enzymes, ECG abnormalities, type 1

hypersensitivity reaction.
 P/Cs:
 The artesunate solution should be prepared for
each administration and should not be
stored.

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Cont...
 Artemether:
 headache, nausea, vomiting, abdominal pain, drug fever,
abnormal bleeding and dark urine.
 NB: IM Artemether should only be used during the first
trimester of pregnancy when IV/IM artesunate (preferred) and
IV/IM quinine are both unavailable
 Quinine: Cinchonism, headache, nausea, abdominal pain,
rashes, visual disturbances, confusion, blood disorders
(including thrombocytopenia and intra-vascular coagulation),
acute renal failure, and Hypoglycemia
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 C/Is: Haemoglobinuria, optic neuritis
Cont...
 Chloroquine phosphate:
 gastro-intestinal disturbances, headache, also convulsions,
visual disturbances;
 P/Cs: Avoid alcoholic beverages;
 D/Is: Carbamazepine, digoxin, ethosuximide, mefloquine,
phenytoin and valproic acid.

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 Primaquine;
 ADRs: hemolytic anaemia, especially in patients with G6PD
deficiency;
 P/Cs: In patients with G6PD deficiency; systemic diseases associated
with granulocytopenia, (e,g. rheumatoid arthritis, and pregnancy and
breast feeding).
 It is recommended for patients with limited risk of malaria infection in
the future; for patients who are not living in malaria endemic areas.
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 Sites of Action for Antimalarial
Drugs

TISSUE
SCHIZONTOCIDES:
primaquine
pyrimethamine
proguanil
tetracyclines

MOSQUITO HUMAN
BLOOD
SCHIZONTOCIDES
:
chloroquine
mefloquine
SPORONTOCIDES GAMETOCYTOCIDE quinine/quinidine
: S: tetracyclines
primaquine primaquine halofantrine
pyrimethamine sulfadoxine
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proguanil pyrimethamine
 Antimalarial drug actions

 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

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Drugs for prophylaxis

 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

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

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REFERANCE
 WHO Guidelines for malaria pdf - 14 march 2023
 Malaria Case Management Training Manual for Health
Professionals in Ethiopia pdf 2022
 Standard Treatment guideline for general hospitals in
ethiopia 4th Edition. docx. 2020

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