Malaria Case Management

October, 2024
Debre Berhan
©APHI-PHEM Directorate
 Outline

• Introduction

• Mode of Transmission

• Life Cycle of malaria parasites

• Clinical presentation and Diagnosis

• Management of uncomplicated malaria

• Management of complicated malaria

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 • Humanity has but three great enemies: Fever,
famine, and war; of these by far the greatest,
by far the most terrible, is fever.
William Osler

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 Introduction (1)

What is Malaria?

• Malaria is a parasitic infectious disease caused by parasites of the

genus Plasmodium.

• It is a serious public health problem in many parts of the world

including Ethiopia.

• Transmitted by the bite of infected female anopheles mosquito

(main transmission).
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 Introduction (2)

• Five species of plasmodium that infect humans include:

 Plasmodium falciparum
 Plasmodium vivax
 Plasmodium ovale
 Plasmodium malariae
 Plasmodium knowlesi distributed in South East Asia

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 Introduction (3)

• P. falciparum
• It is found worldwide, mainly in tropical and subtropical areas

• It is mostly the cause for severe and complicated malaria

• P. vivax
• Found mainly in Asia, Latin America, and some parts of Africa
• Can rarely cause severe illness
• Has dormant liver stages (hypnozoites) that can cause clinical
relapses weeks, months, or years after initial infection
• Does not infect individuals negative for the Duffy blood group,
common in sub-Saharan Africa

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 Introduction (4)

• Plasmodium ovale
• Found mostly in West Africa and Western Pacific islands
• Biologically and morphologically similar to P. vivax
• Rarely reported in Ethiopia
• Plasmodium malariae
• Found worldwide
• Causes persistent chronic infection, possibly lifelong
• Small number of patients develop serious complications like nephrotic syndrome
• Plasmodium knowlesi
• Found in Malaysia, Thailand, and other Southeast Asian countries
• Mainly transmitted in forests and forest fringes
• Indistinguishable from P. malariae under the microscope
• Can cause severe disease and death in some individuals

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 Mode of Transmission (1)

Three modes of transmission:

• Malaria is mainly transmitted by the bite of infected female

anopheles mosquito.

• Accidental

• Blood transfusion

• Needle stick injury

• Congenital
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 Mode of Transmission (2)

• 528 species and subspecies of Anophelinae

• 70 can transmit malaria parasites

• 40 are known vectors

• Unstable transmission

• Epidemics

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 Malaria Vectors in Ethiopia
• The main malaria vectors are
• Anopheles arabiensis (The principal malaria vector in Ethiopia)
• Anopheles pharoensis ( secondary)
• Anopheles funestus (Secondary)
• Anopheles nili (Secondary)
• An .stephensi (not determined) new and invasive vector
• An coustani (not determined)

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 Life cycle and Transmission (1)

Two hosts:
• Definitive host- Female Anopheles mosquito
• Intermediate host - Human

Three cycles:
• Exo- erythrocytic cycle: in the liver
• Erythrocytic cycle: in the erythrocytes
• Sporogonic cycle: in the mosquito

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 Life cycle and Transmission (2)

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 Clinical presentation and Diagnosis

Malaria Diagnosis

1. Clinical diagnosis (History plus physical examination)

2. Parasitological diagnosis

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 Clinical Diagnosis (1)
Clinical malaria diagnosis is based on the case definition;

In malarious areas:

A patient with fever or history of fever within the past two days (48
hours) is assumed to have clinical malaria.

In non malarious areas:

A patient with fever or history of fever within the past two days and
history of travel to malarious area within the last one month is assumed to
have clinical malaria.
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 Clinical Diagnosis (2)

• Basing the diagnosis on clinical features alone is not

recommended.

• Malaria treatment based on clinical diagnosis must be the

last option when there is no availability of RDTs or
microscopy.

• The health worker examining a suspected malaria case

should look for other causes of fever
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 Parasitological Diagnosis (1)

• Required for confirmation

• Recommended for all suspected malaria cases in all
transmission settings.
• The two main methods are light microscopy and rapid
diagnostic tests (RDTs).
• In health centers, all types of hospitals and private health
facilities with microscopes, malaria is diagnosed with
microscopy.
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 Malaria Diagnostic Methods

I. Routine lab diagnostic methods

 Microscopy

• Identify malaria parasites from the blood

 Rapid Diagnostic Testing /RDT/

• Detect antigens produced by malaria parasite in

blood
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 Advantages of parasitological diagnosis:

• Improve care of parasite-positive patients.

• Identification of parasite-negative patients for whom another

diagnosis must be sought

• Prevent the unnecessary use of anti malarial drugs.

• Used to confirm treatment failure

• Improve malaria case detection & reporting.

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 Treatment Approaches

• Treatment of malaria should be based upon a parasitologically

confirmed diagnosis whenever the situation permits.

• Severe malaria should be treated preferably at hospitals and will

be managed in health centers where referral is not possible due
to various reasons.

• Laboratory evidence confirming malaria (i.e., microscopy or

RDTs) by malaria species requires prompt treatment with the
appropriate anti-malarial drugs. 19
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 Malaria treatment
Need to classify the malaria cases before starting treatment with
antimalarial drugs;

1. Uncomplicated malaria

2. Severe malaria

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 Uncomplicated Malaria

• A patient who presents with symptoms of malaria and a positive

parasitological test (microscopy or RDT) but with no features of
severe malaria is defined as having uncomplicated malaria (WHO,
2021).

• The main manifestation of uncomplicated malaria is fever.

• Other symptoms are chills, rigors, headaches, and body pains,

malaise, nausea, vomiting, and joint weakness.

• Physical examination may reveal pallor and hepatosplenomegaly.

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 Treatment of Uncomplicated Malaria (1)

Objectives:-

1-Clinical Objective:

• to cure the infection as rapidly as possible and

• to prevent progression to severe disease.

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 Treatment of Uncomplicated Malaria (2)

2-Public Health Objective:

• to prevent onward transmission of the infection to others and

• to prevent the emergence and spread of resistance to

antimalarial drugs.

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Recommended first-line antimalarial drugs at Health Post and
Health Center/Hospital

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 Alternative Treatment

Situation Recommendation

Chloroquine not available for P.vivax Use AL

AL not available for P.falciparum or mixed

Use DHA-PQ
infection

Chloroquine and AL not available for P.vivax Use DHA-PQ

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 Treatment of uncomplicated malaria

• AL tablets are given according to body weight in six doses over

three days.

• Treat uncomplicated P. falciparum malaria in pregnant women

including first trimester and breastfeeding women with AL.

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 Treatment of uncomplicated malaria

• The first dose should be given under direct supervision of the

health worker.

• AL should preferably be taken with food or fluids.

A fatty meal or milk improves absorption of the drug.

• If vomiting occurs within half an hour after the patient swallows

the drug, the dose should be repeated and the health
worker/pharmacist should provide the patient with a
replacement dose to ensure completion of treatment.
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 Treatment of uncomplicated malaria

• AL is available in co-formulated tablets containing artemether

20 mg and lumefantrine 120 mg per tablet.

• The dose ranges from 1-4 tablets (depending on the patient’s

body weight) taken every 12 hours for 3 days.

• To reduce the transmission of P. falciparum infection give a

single dose of 0.25 mg/kg body weight primaquine with AL

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 Tablet containing 20 mg Artemether plus 120 mg
Lumefantrine in a fixed dose combination.

Day 1 Day 2 Day 3

Color
Weight code
Age Immedia After
(Kg) Morning Evening Morning Evening
te 8hrs

14 kg < 2 yrs 1 Tablet 1 Tablet 1 Tablet 1 Tablet 1 Tablet 1 Tablet Yellow*

2 Tablets 2 Tablets 2 Tablets 2 Tablets 2 Tablets 2 Tablets Blue*

15-24 kg 3 - 7 yrs

8 - 10 3 Tablets 3 Tablets 3 Tablets 3 Tablets 3 Tablets 3 Tablets Brown

25-34 kg
yrs

> 35 > 10 yrs 4 Tablets 4 Tablets 4 Tablets 4 Tablets 4 Tablets 4 Tablets Green
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 Drug Information for AL (1)

Course-of-therapy
blister packs with simplified
instructions for illiterate
patients

4 different packs:
<14 kg (< 2 yrs.)
15-24 kg (3-7 yrs.)
25-34 kg (8-10 yrs.)
35+ kg (10+ yrs.)
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 Drugs information for AL (2)

• Taken two times a day for three days

• Very fast parasite elimination

• Prompt reduction in fever

• Effective gametocyte clearance

• Effective in multi-drug resistant areas

• Does not show any evidence of organ or system specific toxicity

• Fixed dose combination treatment

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 Indication of AL
• Uncomplicated P. Falciparum malaria

• Uncomplicated mixed (P.f and P.v) malaria

• Epidemic outbreak.

• Treatment of malaria based on clinical diagnosis (if no

RDT/BF)

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 Contraindications of AL

• Persons with a previous history of reaction after using the

drug.

• Persons with severe and complicated malaria should not be

treated with oral medications

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 Chloroquine Treatment Schedule (1)

• Never take more than four 250 mg chloroquine

phosphate tablets in one day.

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 Chloroquine Treatment Schedule (2)

Weight (kg) Age Day 1 Day 2 Day 3

<6 < 4 months ½ tablet OR ½ tablet OR ¼ tablet OR

5 ml syrup 5 ml syrup 2.5 ml syrup
7 – 10 4 – 11 months ¾ tablet OR ¾ tablet OR ½ tablet OR
7.5 ml syrup 7.5 ml syrup 5 ml syrup
11 – 14 1 – 2 years 1 tablet OR 1 tablet OR 0.5 tablet OR
12.5 ml syrup 12.5 ml syrup 7.5 ml syrup
15 – 18 3 – 4 years 1.2 tablet OR 1.2 tablet OR 0.6 tablet OR
15 ml syrup 15 ml syrup 7.5 ml syrup
19 – 24 5 – 7 years 1 ½ tablets OR 1 ½ tablets OR 1 tablet OR
20 ml syrup 20 ml syrup 15 ml syrup
25-35 8-11 yrs 2 ½ tablets 2 ½ tablets 1 tablet

36-50 12-14 yrs 3 tablets 3 tablets 1.5 tablets

51+ 15 yr + adult 4 tablets 4 tablets 2 tablets

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 Drug Information

• Used for PV, PO and PM infections.

• It is rapidly and almost completely absorbed from GI tract.

• Has low safety margin and is very dangerous in over dosage.

• Effective against the blood stage parasites.

• If chloroquine syrup is not available for children <5 years of

age, use pediatric AL tablet

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 Chloroquine preparation and dosing

• 250 mg phosphate salt chloroquine tablet contains 150 mg

base

• Chloroquine syrup is prepared as 50mg/5ml for children <5

years of age

• The total dose of chloroquine is 25mg base/kg over 3 days

10mg base/kg on days 1 and 2

5mg base/kg on day 3

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 Chloroquine(CQ)…
• Side effects of Chloroquine

• Dizziness, skeletal muscle weakness, mild gastrointestinal

disturbance (nausea, vomiting, abdominal discomfort and
diarrhea) and pruritus

• Chronic use (>5yrs) as prophylaxis may lead to eye disorders

(kerato-retinopathy)

• Contraindications

• Persons with known hypersensitivity, known epilepsy, and psoriasis

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 Primaquine Treatment Schedule (1)

Primaquine phosphate dose:

1. For radical cure, 0.25 mg /kg daily for 14 days
2. For reducing transmission of P. falciparum, 0.25 mg/ kg single
dose

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 Primaquine Treatment Schedule (2)

Number of tablets per day for 14 days

Weight (kg) Age (years)
7.5 mg tablet 15 mg tablet

6 months to <5
<19 ½ ¼
years

19-24 5-7 ¾ -

25-35 8-10 1 ½

36-50 11-13 1½ ¾

50+ 14+ 2 1
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 Drug information for PQ (1)

• Effective against the gametocytes

• The only drug which can act in the hepatic stage of the
parasites including the hypnozoites

• The active metabolites of its by product are very toxic which can
induce hemolysis.

• Has low safety margins.

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 Drug information for PQ (2)

Indications:
• Radical cure against P.V

• Gametocidal against P.F

Contraindications:
a.Pregnancy
b.Women breast feeding infants less than six months of age
c.Infants less than six months of age
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 Drug information for PQ (3)
Side effects:
• Primaquine is generally well tolerated.

• Dose-related gastrointestinal discomfort, including abdominal

pain, nausea and vomiting.

• The most important adverse effect is hemolysis in some

patients.

• Fortunately, Primaquine is eliminated from the body rapidly, so

that hemolysis stops once the drug is stopped.
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 Supportive Treatment

• Fever
• Treat especially in children
• Use paracetamol
• Fanning, tepid sponging
• Use the ICCM algorithm

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 Patient Counselling/Advice
• He/she has got malaria

• Malaria is transmitted by mosquitoes

• Malaria can be prevented by using LLINs, IRS, eliminating mosquito breeding

places, and protecting sprayed houses from re-plastering

• Early treatment is important to prevent severe illness and death due to malaria

• To take/give enough food and fluid (especially fatty meal to enhance drug
absorption and to avoid risk of hypoglycemia).

• To return to the health post if fever persists or patient is still sick after 72 hours
or any time before 72 hours if condition worsens
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 Second-line treatment (1)

• Second-line drug is used in the following two conditions:

• Treatment failures within 14 days of initial treatment with first

line regimens;

• For all patients with contraindications or intolerance to first line

regimens.

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 Second-line treatment (2)

• In Ethiopia, dihydro-artemisnin-piperaquine (DHA-PPQ) is recommended

as a second-line treatment for both P. falciparum and P. vivax.

• It has a longer prophylactic effect for P. vivax compared to AL.

• DHA-PPQ is a new co-formulated ACT and is well tolerated.

• It is proved to be highly effective against uncomplicated P. falciparum

and P. vivax malaria.

• The drug is WHO approved and registered in Ethiopia.

• It is available in global market. It has pediatric and adult preparations.

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 Treatment of malaria in pregnancy

• Artemether - Lumefantrine (AL) and chloroquine are given in

all trimesters

• Both single dose & radical cure PQ administration are

contraindicated in all stages of pregnancy

• Severe malaria is treated similarly as non pregnant patients

• Pregnant women with malaria are treated in the ANC room

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 Severe Malaria

• A patient should be regarded as having severe malaria if there

are asexual form of parasite in a blood film and sign of severity
and evidence of vital organ dysfunction.

• Note that occasionally, P. vivax infection can also cause severe

malaria illness, but the treatment and management is the
same.

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 Clinical Features of Severe Malaria (1)
• Clinical Features
• Prostration (Unable to sit or stand up)
• Altered consciousness (e.g. confusion, sleepy, drowsy, comma)
• Not able to drink or feed
• Severe dehydration
• Circulatory collapse or shock
• Frequent vomiting
• Multiple convulsions
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 Clinical Features of Severe Malaria (2)

Clinical Features:
• Pallor (Severe Anemia)
• No urine output in the last 24 hours
• Abnormal bleeding
• Hemoglobinuria
• Difficult breathing
• Respiratory distress
• Jaundice (alone is not)
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 Severe Malaria Presentations (3)

Laboratory Findings:

• Severe anemia

• Hypoglycemia

• Acidosis

• Hyperlactatemia

• Hyper-parasitemia

• Acute renal impairment

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 Treatment of Severe Malaria (4)
• Management of severe malaria is complex

• It requires follow-up on many issues.

• Patients with severe malaria should not be treated with oral medicines

• First line treatment for severe malaria is Artesunate (IV or IM)

• Give primaquine if the patient is awake and tolerate oral drugs

• Primaquine should be postponed in cases of severe anemia.

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 Administration of Artesunate injection

• For adults and children >20kg: Artesunate 2.4 mg/kg IV/IM

• For children weighing <20kg: Artesunate 3mg/kg IV/IM

• Given on admission (0), at 12 hours and 24 hours

• Evaluate the patient after three doses and change to full dose
AL if the patient’s condition has improved

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