02/04/2019

MALARIA

• Malaria, a curable disease Economic implications

remains a leading cause of  reduction of 1.3% in the
morbidity and mortality annual per capita economic
world-wide, especially in growth rate
pregnant women and  long term impact of this is a
children, and particularly in reduction of the GNP by more
tropical Africa, where at least than a half
90% of the malaria deaths
occur.  Lose of over N135 billion from
cost of treatment and
• over 100 million people at absenteeism from work,
risk of malaria every year in school and farms.
Nigeria
 There are over 100 million
• causes maternal anaemia, people at risk of malaria
increases miscarriage and low every year in Nigeria
birth weight

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Nigerian Malaria Facts and Figures

FACTS FIGURES
• Perception of malaria is poor-few • Eighty per cent of malaria cases are
people link mosquito to malaria. inadequately managed at community
• Improper use parenteral level and home based caregivers.
antimalarials • Ninety six per cent of caregivers
• Non- availability of treatment initiate actions within 24 hours but
guidelines in most of the sampled only 15% of their actions are
health facilities. appropriate
• Poor laboratory support in • Sixty per cent of mothers had no
diagnosis knowledge of the current
• Forty per cent of patients with management of convulsions. Only
severe malaria die due to poor 15% referred such cases to hospital
quality of care. while most either go to traditional
healers.
• Treatment of malaria illnesses • Eighty-five per cent of health facilities
accounted for 46% of the curative surveyed in the rural areas had stock-
health care cost incurred by out. None has packaged drugs.
households with a mean of N
300.00 per month. • Fifty-one per cent of mothers obtain
• Record keeping and reporting of drugs from patent medicine vendors,
malaria is poor in the country. 89% of the drugs were found to be
substandard and 43% of syrups
unsatisfactory.

MALARIA

SEVERE
UNCOMPLICATED
(COMPLICATED)

Life cycle of P. falciparum

SPOROZOITES
(45 mins)

MOSQ (salivary gland)

- Sporozoits (59 days)
- 1000x more infective >oocytes
Liver (9-16 days)
-more antigenic due to circumsporozoite - Merozoits
polypeptide on plasmalemma
-micronemes ducts - hypnozoits

MOSQ (midgut)
Blood
- Microgametes
-Merozoits (48hrs)
-zygotes (18-24hrs)
- Ookinetes -Gametocytes (10-
12days)
-oocytes

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CLINICAL MANIFESTATIONS
UNCOMPLICATED MALARIA COMPLICATED MALARIA
• headache, P. falciparum asexual parasitaemia and
no other obvious cause of their
• lassitude, symptoms, the presence of one or
• fatigue, more of the following clinical or
• abdominal discomfort and laboratory features
• muscle and joint aches, : Prostration,
Impaired consciousness, Respiratory
• followed by fever, chills, distress (acidotic breathing),
• perspiration, Multiple convulsions, Circulatory
• anorexia, collapse, Pulmonary oedema
(radiological), Abnormal bleeding,
• vomiting Jaundice, Haemoglobinuria
• and worsening malaise Severe anaemia,
Hypoglycaemia, Acidosis, Renal
impairment, Hyperlactataemia,
Hyperparasitaemia

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DIAGNOSIS

CLINICAL-history of
fever in the previous
24 h and/or the
presence of anaemia

IMMUNOLOGICAL/
PARASITOLOGIC AND MOLECULAR-
AL- Light Parasite nucleic acids
are detected using
microscopy and Polymerase Chain
rapid diagnostic Reaction (PCR),
Immunoflourescence
tests (RDTs). (IFA) or Enzyme-
RDTs -parasite linked
antigens Immunosorbent
Assays (ELISA)

DIAGNOSIS

MANAGEMENT AIMS
• REDUCTION OF MORBIDITY AND
MORTALITY PREVENTION
• TO ENCOURAGE RATIONAL DRUG USE
TO PREVENT OR DELAY THE
DEVELOPMENT OF ANTIMALARIAL
DRUG RESISTANCE.
• REDUCTION OF PARASITAEMIA
CLEARANCE TIME
• REDUCTION OF FEVER CLEARANCE
TIME
• REDUCTION OF COMA RECOVERY TIME
• IMPROVEMENT OF QUALITY OF LIFE
• PREVENTION OF END ORGAN DEMAGE

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Malaria Treatment Policy Strategy in Nigeria

RBM AIMS
• National malaria treatment policy • Access to appropriate and
is that of Roll Back Malaria (RBM) adequate treatment within 24
hours of the onset of
• This strategy seeks to establish a:
symptoms.
• social movement in which the • Pregnant women particularly
local communities, in their 1st and 2nd
• public and private sectors, all tiers pregnancies should have
of government and non- access to effective
governmental development antimalarial prophylaxis and
agencies come together in a treatment.
partnership and network to • Insecticide treated nets and
implement malaria control other materials should be
interventions. available and accessible to
persons at risk of malaria
• RBM is a global initiative - particularly pregnant women
reduction of malaria burden and children under 5 years of
everywhere by 50% by the year age.
2010.

Why new policy?

National treatment protocol and guidelines - 2005

• The current national antimalarial • Severe malaria is a medical
drug policy in use in Nigeria -
artemether-Lumefantrine in the emergency and requires
treatment of uncomplicated malaria parenteral treatment. The current
caused by P.falciparum confirmed or
unconfirmed drugs for its management are:
• Quinine should be used for 7 days if • Injection quinine 300mg/ml in 2ml
there is treatment failure and in the
treatment of severe malaria. ampoule-10mg/kg 8-12 hourly for
• In pregnancy, Sulfadoxine- 5-7 days
Pyrimethamine should used • Injection artemether 80mg/ml in
• One full treatment dose during 2nd
and 3rd trimesters and the last dose 1ml ampoule-2mg/kg twice daily
should be given not later than one on 1st day then 2mg/kg daily for 4-
month before the expected date of
delivery. 6 days
• In uncomplicated malaria during • Injection artesunate 60mg/1ml
pregnancy Quinine is considered safe vial- 2mg/kg twice daily on 1st day
and can be used in all trimesters.
Artemether-Lumefantrine is then 2mg/kg daily for 4-6 days.
considered safe in 2nd and 3rd
trimesters and can be used when • Suppository artesunate 50mg
there is no suitable alternatives. suppository for pre- referral
treatment only.

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Treatment chart

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Supportive care in Severe Malaria

• In an attempt to reduce the unacceptably high mortality of
severe malaria, there are various adjunctive treatments for its
complications.
• 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
treatment such as corticosteroids, heparin and adrenaline;
intubate if necessary.
• Hyperpyrexia: Administer tepid sponging, fanning, cooling
blanket and antipyretic drugs.
• Convulsions: Maintain airways; treat promptly with
intravenous or rectal diazepam or intramuscular paraldehyde.
• Hypoglycaemia: (Blood glucose concentration of <2.2 mmol/l;
<40 mg/100ml)
• Check blood glucose, correct hypoglycaemia and maintain
with glucose-containing infusion.
• Severe Anaemia: (haemoglobin <5 g/100ml or packed cell
volume <15%):Transfuse with screened fresh whole blood

Supportive care in Severe Malaria cont’d

• Acute pulmonary oedema: Prop patient up at an angle of 45o,
give oxygen, give a diuretic, stop intravenous fluids, intubate
and add positive end-expiratory pressure/continuous positive
airway pressure in life-threatening hypoxaemia.
• Acute Renal Failure: Exclude pre-renal causes, check fluid
balance and urinary sodium; if in established renal failure add
haemofiltration or haemodialysis, or if unavailable, peritoneal
dialysis. The benefits of diuretics/dopamine in acute renal
failure are not proven.
• Spontaneous Bleeding and Coagulopathy: Transfuse with
screened fresh whole blood (cryoprecipitate, fresh frozen
plasma and platelets if available); give vitamin K injection.
• Metabolic Acidosis: Exclude or treat hypoglycaemia,
hypovolaemia and septicaemia. If severe add haemofiltration
or haemodialysis.
• Shock: Suspect septicaemia, take blood for cultures; give
parenteral antimicrobials, correct haemodynamic
disturbances.

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