Malaria Case Management PM Final After HR Input April 24 2024

1
FOREWORD
Malaria is a major public health problem in Ethiopia. About 75% of the total area of the
country is considered malarious, and about 69% of the population living in these areas is at
risk of malaria. According to the 2014 Annual Performance Report of the FMOH MOH
(2021/22), there were a total of 1,612,2 cases of which 1,504,405 (93.3%) were laboratory-
confirmed. 71% were due to Plasmodium falciparum. There were 180 deaths due to malaria.
Ethiopia is currently working concertedly towards malaria elimination by 2030. To this end
the National Malaria Elimination Program (NMEP) needs to have appropriately planned and
targeted delivery of essential antimalaria interventions, including early testing of suspected
malaria and prompt treatment of confirmed cases with effective antimalaria drugs; and
application of appropriate vector control interventions, particularly the use of insecticide-
treated nets (LLINs) and indoor residual spraying (IRS). To implement these interventions,
the availability and readiness of a trained and skilled health workforce is critical.
This training manual on malaria case management has been revised to support the staff
involved in malaria prevention, control, and elimination programs in Ethiopia in the effective
organization and execution of malaria diagnosis and case management services. The manual
incorporates basics on vector control, epidemics detection and response, supply chain
management, and monitoring and evaluation relevant for clinicians. Thus, it is believed this
training material will equip clinical health workers to implement malaria diagnosis and
treatment according to the national guidelines. Therefore, all partners working in the area are
advised to strictly use this manual whenever they organize training for clinicians. This avoids
the use of different training materials for similar competence and provides a basic
understanding of malaria prevention, control, and elimination interventions.
Lastly, as the country is implementing a malaria elimination program, there is a critical need
for having well-trained health personnel at all levels. Thus, it is my firm belief that our
program partners would redouble their efforts in supporting the Ministry in its ambitious goal
of ensuring the availability of well-trained clinicians who could accurately diagnose and
manage malaria cases at all tiers of the health system. I can assure you that the Ministry will
maximize its efforts in the fight against malaria until the disease is wiped out from the
country.
APPROVAL STATEMENT OF THE MINISTRY
ACKNOWLEDGEMENTS
This training manual was reviewed and prepared by the Federal Ministry of Health (FMOH)
of Ethiopia with the participation of numerous in-country partners. FMOH gratefully
acknowledges the technical expert group who guided the review and preparation of this
training manual. The agencies and partner organizations that have actively and directly
participated through their experts who contributed to the review and preparation of the first
edition document include USAID/PMI, WHO, UNICEF, ICAP in Ethiopia, IFHP, AMREF,
PATH/S4ME- Ethiopia office, Addis Ababa and EPSS.
Most of the contents of this training manual have been adopted from the WHO training
manual on malaria control: Case Management, a guide for participants. It also incorporates
information from the recent national malaria guidelines, 2022. Training materials from the
FMOH and partner organizations have also been used.
The review and preparation process for this training manual was coordinated by the National
Malaria and Other Vector Born Diseases Control Program (MoVBDCP). Financial support
for workshops to review the training material was provided by ICAP in Ethiopia and
AMREF.
LIST OF CONTRIBUTORS IN THE PREPARATION OF THE GUIDE
Name Organization
Dr. Hiwot Solomon FMOH
Mr. Gudissa Assefa FMOH
Dr. Ekulinet Misganaw FMOH
Dr. Kebede Etana FMOH
Mr. Degu Mehari FMOH
Mr. Hizikiyas Gerawork FMOH
Mr. Bisrat Nigussie FMOH/ICAP in Ethiopia
Dr. Samuel Girma PMI/USAID
Mr. Leta Tagesu FMOH
Dr. Bereket Hailegiorgis ICAP in Ethiopia
Mr. Mekonnen Tadesse ICAP in Ethiopia
Dr. Negash Seyoum ICAP in Ethiopia
Feleke Belachew ICAP in Ethiopia
Dr. Yonas Petros Easy Way Health Consultancy
Dr. Simeneh Atnafu ICAP in Ethiopia
Hiwot Aklilu ICAP in Ethiopia
Dr. Yonas Temesgen ICAP in Ethiopia
Dr. Ayele Zewde PATH/S4ME
Mr. Gezahegn Tesfaye PATH/MACEPA
ACRONYMS
Abt/PHSP Abt Associates Private Health Sector Program
ACIPH Addis Continental Institute of Public Health
ACT Artemisinin-based Combination Therapy
API Annual Parasite Incidence
EPHI Ethiopian Public Health Institute
EPSS Ethiopian Pharmaceuticals Supply Service
FMOH Federal Ministry of Health
G6PD Glucose-6- Phosphate Dehydrogenase
HEW Health Extension Worker
HMIS Health Management Information System
HRP-2 Histidine Rich Protein II
IFHP Integrated Family Health Program
IMNCI Integrated Management of Newborn and Childhood Illness
IPD Inpatient Department
IPLS Integrated Pharmaceuticals Logistics System
IPT Intermittent Preventive Treatment
IRS Indoor Residual Spraying
LLIN Long Lasting Insecticide Treated Nets
LMIS Logistics Management Information System
MACEPA Malaria Control and Elimination Partnership in Africa
M&E Monitoring and Evaluation
MFTT Mass Fever Testing and Treatment
MIS Malaria Indicator Survey
MPFT Mass Presumptive Fever Treatment
MoVBDCP Malaria and Other vector Born diseases Control Program
OPD Outpatient Department
PATH Program for Appropriate Technology in Health
PCR Polymerase Chain Reaction
PHCU Primary Health Care Unit
PHEM Public Health Emergency Management
pLDH Plasmodium Lactate Dehydrogenase
PLMP Pharmaceuticals Logistics Master Plan
PMI President’s Malaria Initiative
RBC Red Blood Cell
RDT Rapid Diagnostic Test
RRF Report and Requisition Form
SARA Service Availability and Readiness Assessment
SBCC Social Behavioral Change Communication
SCM Supply Chain Management
SPA Service Provision Assessment
SOP Standard Operating Procedure
SPR Slide Positivity Rate
TAC Technical Advisory Committee
TET Therapeutic Efficacy Testing
TOR Terms of Reference
TWG Technical Working Group
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
WBC White Blood Cell
WHO World Health Organization
TABLE OF CONTENTS
FOREWORD.............................................................................................................................2
APPROVAL STATEMENT OF THE MINISTRY...................................................................3
ACKNOWLEDGEMENTS.......................................................................................................4
LIST OF CONTRIBUTORS IN THE PREPARATION OF THE GUIDE...............................5
ABBREVIATIONS....................................................................................................................6
INTRODUCTION TO THE MANUAL..................................................................................11
SCHEDULE/ TIME TABLE...................................................................................................18
CHAPTER ONE: EPIDEMIOLOGY OF MALARIA............................................................20
Session 1.1 - Etiologic agents of malaria, modes of transmission, and life cycle of malaria
parasites................................................................................................................................20
Session 1.2 - Contributing Factors for Malaria Transmission in Ethiopia...........................24
CHAPTER TWO: APPROACH TO FEVER IN ADULTS...................................................27
Session 2.1- Identification of an adult with a fever.............................................................28
Session 2.4 – Principles of the management of Adults with Fever......................................47
CHAPTER THREE: APPROACH TO FEVER IN CHILDREN, IMNCI (INTEGRATED
MANAGEMENT OF NEWBORN AND CHILDHOOD ILLNESSES)................................54
Session 3.1: Identification of a Child with a Fever..............................................................54
Session 3. 2 Common Causes of Fever in Children.............................................................57
Session 3. 3-Assessment of a Child with Fever...................................................................59
Session 3. 4-Classification and treatment of a child with fever...........................................68
Session 3. 5: Assessment Classification and Treatment of a Child with Measles...............73
CHAPTER FOUR: MANAGEMENT OF UNCOMPLICATED MALARIA........................79
Session 4.1- Definition and diagnosis of uncomplicated malaria........................................79
Session 4.2-Treatment of uncomplicated malaria................................................................83
Session 4.3- Patient counseling during uncomplicated malaria management......................92
Session 4.4- Management of treatment failure and referral.................................................94
Session 4. 5-Antimalaria Pharmacovigilance.......................................................................97
Session 5.1: Definition of severe malaria...........................................................................104
5.1. Definition of Severe Malaria...................................................................................105
Session 5.2: Determinants and pathogenesis of severe malaria.........................................110
5.2.1. Determinants of severe malaria and high risk groups...........................................110
5.2.2. Pathophysiology of severe falciparum malaria.....................................................111
Session 5. 3: Treatment of severe malaria..........................................................................117
5.3.1. Principles and Components of Treatment.............................................................117
5.3.2.-Immediate supportive treatment...........................................................................118
5.3.3. Continued supportive treatment............................................................................119
5.3.4. Specific antimalarial treatment.............................................................................120
5.3.5. Pre-referral treatment............................................................................................124
5.3.6. Continuing treatment and nursing care.................................................................124
CHAPTER SIX: TITLE: OVERVIEW OF MALARIA LABORATORY DIAGNOSIS AND
QUALITY ASSURANCE.....................................................................................................131
Session 6.1. Malaria Diagnosis Methods...........................................................................131
Session 6.1. Malaria Diagnosis methods............................................................................132
Parasitological Diagnosis/ Laboratory Methods................................................................132
Session 6.2. Malaria microscopy........................................................................................133
Session 6.3. Malaria Rapid Diagnostic Testing..................................................................137
Session 6.4. Quality Assurance of Malaria Laboratory Diagnosis.....................................143
CHAPTER SEVEN: OVERVIEW OF PHARMACEUTICALS MANAGEMENT...........147
Session 7.1: Overview of Pharmaceuticals Supply Chain..................................................147
Logistics Cycles and Activities..........................................................................................148
Session 7.2: Requesting and Getting Pharmaceuticals.......................................................154
7.2.1. Roles & Responsibilities.......................................................................................155
7.2.2. Requesting and Getting Pharmaceuticals from EPSS...........................................156
7.2.2 Tools used in managing pharmaceutical logistics............................................157
CHAPTER EIGHT: MALARIA EPIDEMICS DETECTION AND RESPONSE................159
Session 8.1: Overview of malaria Epidemic and factors precipitating malaria epidemic,
epidemic forecasting, detection, and preparedness............................................................159
Session 8.2.: Malaria epidemic confirmation and response...............................................173
Session 8.3: Reporting malaria epidemic...........................................................................175
CHAPTER NINE: RECORDING REPORTING AND DATA USE....................................181
Session 9.1 Malaria program data source and indicators...................................................181
Session 9.2 Malaria Cases Recording and Reporting.........................................................187
Annexes..................................................................................................................................199
List of tables
Table 1.The integrated disease surveillance report of 2007 EC. 43
Table 2.Differential Diagnosis: Fever 7 days or less without clinically obvious focus or site
45
Table 3.Differential Diagnosis: Fever more than 7 days without clinically obvious focus or
site. 48
Table 4.Tablet containing 20 mg Artemether plus 120 mg Lumefantrine in a fixed dose 94
Table 5.Tablets of chloroquine 150 mg base or syrup 50 mg base per 5 ml 95
Table 6. tablet containing 7.5 mg of Primaquine 96
Table 7. Dihydroartemisinin-piperaquine dose 98
Table 8.Mefloquine: 5 mg /kg mefloquine salt once weekly 106
Table 9.Atovaquone-proguanil 107
Table 10. Glasgow Coma Scale 116
Table 11. Types and characteristics of thin and thick blood film 144
Table 12. Chart for assessing the usual number of weekly cases (confirmed or clinical) and
the threshold at a health facility. 172
Table 13. Construction of the threshold (norm) when five years' historical data are available
to monitor the current year 174
Table 14. Construction of threshold (norm) with single recent year morbidity data 176
Table 15. Reporting form for active surveillance and treatment 183
Table 16. Five years of malaria data 185
Table 17. List of Health Management Information System (HMIS) formats 192
Table 18. PHEM Weekly Disease Report Form for Outpatient and Inpatient malaria Cases
and Deaths 192
INTRODUCTION TO THE MANUAL
The trends of malaria have been decreasing in Ethiopia in the past decade. However, it has
been increasing since 2019. According to the FMOH (2015GC) Health Management
Information System (HMIS) report, the number of confirmed malaria cases declined from 1.7
million cases in 2016 to 0.9 million cases in 2019, respectively.
Revision of the Manual
Taking into consideration the importance of quality-assured malaria diagnosis and treatment
in all healthcare tier systems, MoH successively revised national malaria guidelines in 2002,
2007, and 2012 based on the latest evidence-based recommendations.
A simplified and standardized training manual for clinical health workers on malaria case
management was prepared in 2017 through a process involving a technical expert committee
representing malaria experts from key partners, training and academic institutions, malaria
researchers, and MoH malaria experts.
The national malaria guidelines were again revised in 2022 following new recommendations,
and hence the training manual was revised to incorporate the new recommendations from the
latest guidelines.
The addition in 2022 malaria guidelines that warranted revision of this manual include:
1. Use of radical cure with primaquine for mixed malaria infections at health post level
(instead of single dose when multi-species RDT is used)
2. Use of AL in all trimesters of pregnancy including the first trimester (which was a
contraindication in previous versions)
3. Weekly chloroquine prophylaxis for pregnant women with P. vivax malaria, change of
second-line drug (from Quinine to DHA-PPQ)and
4. Management of severe malaria and approaches to management of possible treatment
failures at each health care setting.
Several reports from supervision and onsite observation of performances of trained health
care providers in the past six years have indicated that the training material and approaches
need to be oriented to be more practical, vastly participatory, and focus highly on the real
tasks of providers at service outlets. Cognizant of this, the Ministry of Health has updated this
training material to ensure that the training material is reoriented to achieve this purpose.
The use of updated and standardized malaria guidelines and training materials is strongly
recommended in order to ensure the availability of early diagnosis and prompt and effective
treatment at all levels of health services. It also simplifies and facilitates training and
supervision of health care providers, delays the development of antimicrobial resistance,
improves surveillance, and assists in more rational drug procurement for the treatment of
malaria.
To this effect, the MOH has developed this updated training material for the proper malaria
case management in the country.
Core Competencies
 Control Malaria induced fever in adults, children and new born

 Manage severe Malaria
 Conduct treatment of complicated and uncomplicated malaria
 Conduct Rapid Malaria Rapid Diagnostic tests
 Apply malaria Epidemic detection and response principles
 Perform recording, reporting and data utilization of malaria investigation and
treatment
Course Syllabus
Course Description: These 5 days training Course is designed for all health care
professionals (Physicians, Nurses, HOs, and Midwives) to equip them with all the essential
knowledge, skills and attitudes on the epidemiology of malaria, diagnosis and treatment of
patient with malaria, and documentation that participants need to manage all malaria cases at
all health care settings
Course Goal
Up on the successful completion of this course, participants will be able to: Manage all
malaria cases at all health care settings and record according to the national malaria treatment
guidelines
Course Objectives:
Upon the completion of this Course, participants will be able to:
● Identify the etiologic agents of malaria, modes of transmission, the life
cycle of the malaria parasite, and factors contributing to malaria

transmission
● Describe the management of adult patients presenting with fever
● Describe management of Fever in Children and new Borns.
● Explain management of all forms of uncomplicated malaria as per the

national standard.
● Describe the basics of malaria diagnosis and quality assurance systems and
perform malaria diagnosis using RDTs
● Identify comprehensive clinical evaluation for all febrile patients
● Identify antimalarial drugs & related supply chain management in
Ethiopia.
Chapter Title Duration Sessions

(hours)
1 Epidemiology of 1. Etiology of malaria and its life
Malaria cycle
2 hours
2. Contributing factors for malaria
transmission
2 Approach to fever in 1. Identification of an adult with a
adults fever
2. Common causes of fever in adults
3:30 hours 3. Assessment steps during fever
evaluation in adults
4. Management principles of fever
in adults
3 Approach to fever in 1. Identify a child with fever
children 2. Common causes of fever in
children
3. Assessment of a child with fever
3 hours 4. Classification and treatment of a
child with fever
5. Assess and classify a child with
measles
4 Management of 1. Definition and diagnosis of

uncomplicated malaria uncomplicated malaria
2. Treatment of uncomplicated
malaria
3. Patient counseling during
3 hours uncomplicated malaria
management
4. Management of treatment failure
5. The pharmacovigilance in
uncomplicated malaria
5 Management of severe 1. Definition of severe malaria

malaria
2. Pathogenesis and determinants of
5:30 hours severe malaria
3. Treatment of severe malaria
6 Overview of Malaria 1. Malaria diagnosis methods
laboratory diagnosis and 2. Malaria microscopy
quality assurance 3. Malaria rapid diagnostic testing
2 hours
4. Quality assurance of malaria
laboratory diagnosis
7 Overview of 1 hours 1. Overview of pharmaceuticals
pharmaceutical supply chain
management 2. Requesting and getting
pharmaceuticals
8 Malaria epidemics 1. Overview of malaria epidemic and
detection and response factors precipitating malaria
epidemic, epidemic forecasting,
2 hours detection, and preparedness
2. Epidemic confirmation and
response
3. Reporting malaria epidemic
9 Recording, reporting 1. Malaria program data and

and data use indicators
2 hours
2. Malaria case recording and
reporting
Training Methods
● Interactive lecture and discussion
● Group learning activities (small group work, large group discussion, role play)
● Case-based discussions
● Demonstration
● Guided practice with feedback
● Health facility visits
Training Materials
● Participant manual
● Facilitator Guide
● PPT
● Audio-visual aids
● Malaria rapid diagnostic test kits (RDTs kits)

Evaluation Methods
Participant
Formative
● Quizzes. Q/A, Q&A, and feedback
● Direct observation of performance with feedback
Summative
● Written cognitive knowledge tests (MCQ)
Course evaluation methods

Certification criteria
● Cumulative score (Post KS test score) 80% and above
● 100% attendance
● Course continuing education unit (CEU) = 15
● Course duration: 5-days
Training venue: Accredited CPD centers
Composition: Trainer: Participant ratio: 1:5
The training will be evaluated at different level of learning, which includes evaluation of:
● Participant’s satisfaction using daily evaluation form and end-of-training
evaluation forms
● Participant’s learning using written cognitive and performance tests (pre-
post)
● Participant’s behavior (transfer of learning) using direct observation checklist
(mentoring) at the workplace

Participants Selection Criteria
The target audiences include physicians, health officers, midwives, and nurses who are
providing services in health care facilities
Trainers should be:-
● Experts who participated in the preparation of this training manual TWG
members who are certified with facilitation skill training
● TOT-Certified with basic malaria case management skills.
● Expert who has basic malaria case management training and certified in
facilitation skill training
● Malaria experts with previous experience of providing training
● National or regional malaria program leaders and experts who fulfill the above
mentioned criteria
SCHEDULE/ TIME TABLE
Malaria Case Management Training schedule

DAY 1
8:30-9:00 Registration
9:00-9:15 Welcome remarks/opening
Objectives and overview of the training,
9:15-9:45
and introduction of participants
9:45-10:30 Pre-training assessment
10:30-11:00 Coffee/Tea Break
11:00-12:00 Chapter 1:Epidemiology of Malaria
12:- 12:30 Chapter 2: Approach to fever in adults
12:30-1:30 Lunch break
Chapter 2: Approach to fever in
1:30- 3:30
adults cont'd
4:00-5:30
adults cont'd
DAY 2
8:30-9:00 Summary / Recap Day 1 Participants
9:00-10:30 Chapter 3: Approach to fever in children
11:00-12:30
children cont'd.
12:30 – 1:30 Lunch break
Chapter 4: Management of
1:30-3:30
uncomplicated malaria
Chapter 4: Management of
4:00-11:30
uncomplicated malaria cont'd.
DAY 3
8:30-9:00 Summary/Recap of Day 2 Participants
Chapter 5: Management of severe
9:00-10:30
malaria.
11:00-12:30
malaria Cont'd.
12:30 – 1:30 Lunch break
1:30-3:30
malaria Cont'd.
Chapter 6: Overview of malaria
4:00-5:30
laboratory diagnosis and quality
assurance
DAY 4
Chapter 7: Overview of pharmaceutical
9:00-10:30
management
Chapter 8: Malaria epidemics detection
11:00-12:30
and response
Chapter 8: Malaria epidemics detection
1:30-4:00
and response cont'd.
Chapter 8: Recording, reporting, and
4:30-5:30
data use
DAY 5
9:00-12:30 Health facility visit
Feedback from health facility visits &
1:30-3:00
general discussion
3:00- 3:30 Post-training assessment
4:30- 5: 30 General discussion & closing
CHAPTER ONE: EPIDEMIOLOGY OF MALARIA
Duration: 2 hours
Chapter Description: -
This chapter will focus on the etiologic agents of malaria, modes of transmission, the life
cycle of malaria parasites, and contributing factors for malaria transmission to enable you to
demonstrate an understanding of the epidemiology of malaria
Chapter Objective
After the completion of this chapter, participants will be able to identify the etiologic agents
of malaria, modes of transmission, the life cycle of the malaria parasite, and factors
contributing to malaria transmission
Learning Objectives: After the completion of this chapter participants will be able to:
● Identify the common etiologic agents of malaria
● Describe modes of transmission and life cycle of malaria parasites
● Explain factors contributing to malaria transmission
Chapter Outline / Sessions
1.1 -Etiologic agents of malaria, modes of transmission, and life cycle of malaria
parasites
1.2 -Contributing factors for malaria transmission
1.1 - Etiologic agents of malaria, modes of transmission, and life cycle of malaria
parasites
Activity 1: Group exercise
Instruction: Go over the following questions just to retrieve your prior
knowledge/experience. Feel free to answer/reflect/respond to the questions
Which malaria parasite is more dominant in your area? Why? How do you Know?
Time: 10 minutes
Etiology of Malaria:
Plasmodium falciparum, P. vivax, P. ovale, P. malarae, and P. knowlesi are globally known
malaria parasites that cause malaria illness. P. falciparum and P. vivax are the two most
common malaria parasites in Ethiopia. They are prevalent in all malaria-endemic areas in the
country with P. falciparum representing about 71% (HMIS 2022) of the total reported
malaria cases. Relative frequency varies in time and space within a given geographical range.
P. malariae and P. ovale are rare and account for <1% of all confirmed malaria cases.
Incubation Period
Incubation period is the time between the bite of an infective anopheles mosquito and the
onset of the first malaria symptoms. The incubation period in most cases varies from 7 to 30
days. The shorter periods are observed frequently with P. falciparum and the longer ones
with P. malariae.
Anti-malarial drugs taken for prophylaxis by travelers can delay the appearance of malaria
symptoms by weeks or months, long after the traveler has left the malaria-endemic area.
(This can happen particularly with P. vivax and P. ovale. Such long delays between exposure
and the development of symptoms can result in misdiagnosis or delayed diagnosis because of
reduced clinical suspicion by the healthcare provider. Returned travelers should always
remind their healthcare providers of any travel in areas where malaria has occurred during the
past 12 months.
The major malaria vector incriminated in Ethiopia is Anopheles arabiensis; in some areas A.
pharoensis, A. funestus, and A. nili also play minor roles in transmission of malaria. Moreover,
recent studies and entomological monitoring documented the appearance and spread of an exotic
invasive vector species, An. stephensi, in eastern Ethiopia and expanding its distribution to other parts
of the country.
The figure below describes the Life cycle of the malaria parasite in humans and vector host
Figure 1. Life cycle of the malaria parasite in humans and vector host
(https://www.cdc.gov/malaria/about/biology/index.html)
As indicated in Figure 1, the infected female anopheles mosquito transmits sporozoites to
humans during a blood meal. The sporozoites reaches the liver through blood circulation
within 30 minutes. The sporozoites invade hepatocytes and mature to become tissue schizonts
and this cycle is called the exo erythrocytic cycle. Schizonts multiply the infection by
producing large numbers of merozoites (10,000 – 30,000) from each sporozoite-infected
hepatocyte (P. vivax and P. ovale have a dormant stage).
Each merozoite released from the liver is capable of infecting a human RBC and establishing
the asexual cycle of replication in the RBCs (erythrocytic cycle). The asexual cycle starts
with merozoite invasion and continues to schizont rupture (merozoite → ring stage → mature
trophozoite → schizont → merozoites), leading to invasion of more RBCs. Some intra-
erythrocytic parasites develop into the sexual forms, gametocytes. Gametocytes are necessary
for the sexual reproductive cycle that takes place in the vector.
When potent gametocytes are ingested by a female anopheline mosquito during a blood meal,
micro- & macro-gametocytes mature to become male and female gametes to follow the
sporogonic cycle. Fertilization of the female gametes produces diploid zygotes which mature
to become ookinete. Ookinete then undergoes a meiotic reduction division called oocyst to
produce haploid sporozoites, which migrate to the salivary glands of the mosquito & reinfect
humans. The dormant forms (hypnozoites) eventually mature to become tissue schizonts
which release infectious merozoites, resulting in a clinical relapse.
Scan the QR code or go to the link below to watch the video on the life cycle of malaria
parasite:
Video watch time allowed 10 minutes https://youtu.be/1v55yg0RfoY
Activity::1.1 Case study on the etiology of malaria.

Objective: To be able to identify etiologic agents of malaria.
Instruction: Be in a group of 4-6. Read and discuss the scenario below and report your
group’s response by answering the questions.
Case scenario.
A 30 years old male living in none malarious kebele developed fever, headache joint pain,
and nausea in the last 3 days. He went to a nearby health center and told his travel history to
malarious kebele 3 weeks before presenting to the clinician, and the clinician suspected
malaria and ordered laboratory investigation and the result turned positive for malaria. The
clinician treated him with anti-malaria medicine. After 2 months he presented with the same
complaint and his laboratory result turned positive for malaria again with no travel to a
malarious area.
Question: Which malaria species do you expect? Why?
Time: 20 minutes
1.2 - Contributing Factors for Malaria Transmission in Ethiopia
Activity 1.2 : Think, Pair and Share
Instruction: Go over the following questions just to retrieve your prior

knowledge/experience. Feel free to answer/reflect/respond to the questions.
A health worker noticed that malaria cases are high in some months of the year and low in
others.
● Why are malaria cases high in some months of the year?
Time allowed:- 10 minutes
Malaria in Ethiopia:
Malaria is a serious health problem in Ethiopia. Three-fourths (75%) of the country’s land
mass is malarious and about 69% of the total population is at risk of malaria infection (NSP
2024).
Malaria transmission in Ethiopia mainly occurs up to the 2000-meter (m) elevation but also
occasionally affects areas up to 2300m elevation. The levels of malaria risk & transmission
intensity within these geographical ranges, however, show marked seasonal and spatial
variability because of large differences in climate (temperature, rainfall & relative humidity),
topography (altitude, surface hydrology, land vegetation cover & land use, etc.) & human
settlement and population movement patterns.
Classification of Malaria Transmission
Stable (endemic): Transmission is generally high, could be seasonal but not subject to annual
fluctuations, and the resulting population immunity is high. Under endemic conditions,
children under the age of five years, and pregnant mothers, are most likely to develop severe
malaria as they have weaker immunity. Individuals who are exposed to repeated malaria
infection, over several years, become semi-immune. This means that although they are still at
risk of infection when bitten by an infected mosquito, they either do not have symptoms (are
asymptomatic), or their symptoms are not severe. This kind of partial immunity is not
common in Ethiopia because of the unstable nature of the disease. Partial immunity will be
lost with a few years’ absence from the malaria-endemic area
Unstable (epidemic): Malaria transmission is variable, being subject to marked annual
fluctuations. Consequently, the collective population immunity is low. Malaria epidemics
generally occur when the population in an area has weak immunity to the disease because so
many people in the population will be vulnerable to malaria. However, it is important to
remember that children & pregnant women are at most risk, so they need particular attention.
Altitude and climate (rainfall, temperature, and relative humidity) are the most important
determinants of malaria transmission in Ethiopia. Transmission is seasonal and largely
unstable in character. The major transmission of malaria follows the June – September rains
and occurs between September - December while the minor transmission season occurs
between April – May following the February – March rains. Areas with bimodal patterns of
transmission are limited and restricted to a few areas that receive the small/’Belg’ rains.
Activity: 1.2 Case study

Objective: To identify contributing factors for malaria transmission
Instruction: Be in groups of 4-6 and read and discuss the given scenario and report your
response by answering the question
Scenario:
A woreda in Northeast Ethiopia has a total population of 200,000. Of the woreda population,
4% and 15% are pregnant mothers and under-five children respectively. The woreda altitude
is 1750m asl and has a relative humidity of 70-75% and min annual rainfall of 500ml. The
woreda is malaria endemic and reports high malaria cases.
Task
Which factors contribute to the occurrence of malaria?
Which population of the woreda is at high risk of dying from malaria? Why?
Time: 20 minutes
Chapter Summary:
 There are five types of malaria parasites that cause malaria disease globally.
 P. falciparum and P. vivax are the most important causes of malaria disease in
Ethiopia.
 The malaria parasite has three cycles which are: the exo-erythrocytic cycle in human
liver, the erythrocytic cycle in the human RBCs, and the sporogonic cycle in the
malaria vector host
 Altitude and climate (rainfall, temperature, and relative humidity) are the most
important determinants of malaria transmission in Ethiopia.
 Transmission is seasonal and largely unstable in character.
 The major transmission of malaria occurs from September - December and minor
transmission occurs from April to May.
 Age and immunity are host factors affecting the risk of morbidity and mortality.
Hence, children under five and pregnant women are at greatest risk, so they need
particular attention.
Reference & Resources for Further Reading
● National malaria guidelines 5th edition, 2022
● National malaria strategic plan, 2024/25—2026/27
● WHO Guidelines for the treatment of malaria, 3rd edition, 2015
CHAPTER TWO: APPROACH TO FEVER IN ADULTS
Duration: 3:30 hours

Chapter Description:-
Fever is one of the most common reasons for visits to primary health care services worldwide
and is a common symptom of many illnesses. In this chapter, we will discuss the assessment,
diagnosis, management, and evaluation principles of fever in adults to enable effective
management of all patients presenting with fever.
Chapter Objective
Upon the completion of this chapter, participants will be able to describe the management of
adult patients presenting with fever
Learning Objectives: at the end of this chapter, participants will be able to:
● Identify adult patients with fever
● Explain the pathogenesis of fever

● List the common causes of fever in adults
● Discuss the basic components of history, physical examination & laboratory
tests used to assess a patient with fever.
● Outline the management principles of fever
Chapter Outline
2.1-Identification of an adult with a fever
2.2-Common causes of fever in adults
2.3-Assessment steps during fever evaluation in adults
2.4-Management principles of fever in adults
2.1- Identification of an adult with a fever
Activity: 1 Brain storming
Before starting the session, please go over the following questions just to retrieve your prior
knowledge & experience. Feel free to reflect on the questions:
Time:5 minutes
Did you recently evaluate an adult patient with fever?
What were the criteria you used to identify fever?
Definition of fever
Many patients use “fever” very loosely, often meaning that they feel too warm, or sweaty, but
they have not measured their temperature. However, fever is defined as an elevated body
temperature >37.50C that occurs when the body's thermostat (located in the hypothalamus)
resets at a higher temperature, primarily in response to an infection.
Normal body temperature varies based on the site of measurement and the time when the
measurement is taken.
The common sites to measure temperature are axilla, the oral cavity and the rectum. Other
sites include the tympanic membrane and the skin of the forehead. Rectal and tympanic
membrane temperatures are about 0.6° C higher than oral temperatures, whereas skin
temperatures are about 0.6° C lower. Oral and rectal temperature is now typically measured
using an electronic thermometer; older mercury thermometers take longer to equilibrate and
are more difficult to read. Forehead and tympanic membrane temperature is typically
measured using an infrared scanning device.
Within 24 hours period the temperature reading of an individual varies hence the lowest level
recorded in the early morning and the highest in late afternoon, however the maximum
variation is about 0.6° C.
Pathophysiology of Fever
Fever occurs when either endogenous or exogenous pyrogens cause an elevation in the body's
thermoregulatory set-point. In hyperthermia, the set point is unaltered, and the body
temperature becomes elevated in an uncontrolled fashion due to exogenous heat exposure or
endogenous heat production.
Patients with fever usually exhibit warm, flushed skin, tachycardia, involuntary muscular
contractions or rigors, and sweating or night sweats. Piloerection and positioning of the body
to minimize exposed surface area are also seen. Occasionally these signs are absent or
minimal, and dry, cold skin or extremities are detected despite a significant rise in core
temperature.
Hyperpyrexia is the term for exceptionally high fever (greater than 41 0C), which can occur in
patients with severe infections. Hyperpyrexia may also be seen in patients with CNS
hemorrhages and is associated with a poor outcome. Elevated brain temperature may lead to
increased intracranial pressure, ischemic brain injury, exacerbation of cerebral edema, and
death. Drugs like aspirin and acetaminophen can help reduce fever.
Observation of a pattern of fever can be helpful in certain conditions. For example, a fever
that occurs every 48 to 72 hours occurs in certain types of malaria, and a fever that occurs
predominantly in the evening is typical of tuberculosis.
The everyday highs and lows of typical temperatures are emphasized in many fevers.
However, these variations might be turned around in typhoid fever and disseminated
tuberculosis. Temperature-pulse dissociation occurs in typhoid fever, brucellosis,
leptospirosis, some medication-prompted fevers, and factitious fever.
In healthy individuals, the temperature-pulse relationship is directly proportional, with an
expansion in the pulse of 4.4 beats/minute for each 1 0C (2.44 beats/minute for each 10F)
increase in core temperature.
During infections, fever may not be observed in babies, older adults, patients with chronic
kidney disease, or patients taking corticosteroids; instead, hypothermia may be present.
Fever classification:
Fever can be classified based on the duration & pattern of its occurrence as:
● Acute: for a short time (less than 2 weeks)
● Chronic: fever persisting for more than two weeks

● Intermittent: falls to normal in regular periodical intervals.
● Remittent: temperature is always elevated but swings may be large
● Relapsing: short febrile periods between one or several days of normal
temperature
Health workers face the challenge of managing non-malaria acute febrile illnesses when a
parasitological diagnosis is negative. To improve the compliance of health workers with
malaria test results, this chapter will give guidance on managing non-malaria febrile illness.
Improving the management of fever not only reduces unnecessary use of antimalarial drugs
but also ensures appropriate treatment and referral of patients with non-malaria febrile illness,
thus reducing morbidity and mortality.
Group Activity:2 Case study
Be in a group of 4-6 Participants.
Read and analyze the below case scenario and give your response orally.
Time allowed: 20 minutes (10 for discussion and 10 min for reflection).
Case Scenario
A 30-year-old woman who lives in a rural part of the country presents to the outpatient
department at a health center with a three days history of feeling too warm and sweaty.
⮚ What is the main reason why the patient seeks medical advice?
⮚ What additional information you ask to characterize the complaint?
⮚ What objective measure will you take as the first step?

2-Common causes of fever in adults
Common Causes of fever in adults
The causes of fever can vary according to geography, season, the age and immunity of the
patient. There is a wide spectrum of diseases that can cause fever which can be minor like
upper respiratory tract infection or serious and life-threatening like pyogenic meningitis.
Priority should be given to identifying the cause of the fever before instituting specific
treatment.
Broadly causes of fever can be classified as infectious and non- infectious causes.
The commonest causes of fever in our settings are infectious; however non- infectious causes
are also contributing a significant proportion.
Common diseases causing fever and their causative agents are described below.
A- Infectious causes: Viral infections
● Main viral agents: measles, mumps, chicken pox, varicella-zoster virus,
hemorrhagic fevers (e.g. Ebola, Dengue, yellow fever), rhinovirus, influenza

virus, HIV, hepatitis virus (HAV, HBV, HCV).
Bacterial infections
● Common diseases: tonsillitis, otitis media, sinusitis, dental abscess, pneumonia,
urinary tract infection, pelvic inflammatory disease (PID), cellulitis, septic

arthritis, osteomyelitis, meningitis, secondary syphilis, typhoid (enteric fever),
relapsing fever
● Main bacterial agents: group A β-hemolytic streptococci, Streptococcus
pneumoniae, Mycobacterium tuberculosis, Haemophilus influenzae,

Staphylococcus aureus, Mycoplasma pneumoniae, Klebsiella pneumoniae,
Escherichia coli, Neisseria meningitidis, Treponema pallidum, Salmonella typhi,
Salmonella paratyphi, Shigella spp., Borrelia recurrentis.
Rickettsial infections
● Louse-borne typhus fever

Fungal infections
● Cryptococcal meningitis
Protozoan infections
● Malaria, leishmaniasis, amebic liver abscess
Helminthic infections
● Schistosomiasis
B- Non-infectious causes of fever:
Consider these after ruling out common infectious causes:
● Inflammatory diseases: rheumatoid arthritis, auto-immune diseases.
● Malignancy: lymphoma, acute leukemia.
● Injury: crushing injury.
● Thrombosis: pulmonary embolism, myocardial infarction (heart attack).
● Drug reactions.
● Allergic reaction.
Common differential diagnosis of fever in adults
Based on the duration, pattern of fever and other associated factors; the common differential
diagnoses for fever are listed in the following tables.
Table 2. Differential Diagnosis: Fever 7 days or less without clinically obvious focus or site
Condition In favor
Malaria Living in, or traveling to a malaria-endemic area

Positive malaria test (RDT or microscopy)
Typhoid fever Remittent fever

Condition In favor
Malaria ruled out

No focus of infection
Risk factor for typhoid (poor hygiene)
Louse-borne typhus fever High-grade intermittent fever

Poor hygiene may cause visible body lice
Malaria and relapsing fever ruled out
Usually occurs as an epidemic
Bacterial sepsis Seriously ill with no obvious apparent cause

Hypotension
Complete blood count (CBC) – leukocytosis, leukopenia, or
thrombocytopenia
Risk factors – HIV, immunocompromised
Blood cultures – positive
Any sign of organ dysfunction – confusion, low urine output,
respiratory depression
Blood chemistry if available – acidosis, elevated creatinine
Meningococcal Maculopapular hemorrhagic petechial rash

septicemia
Shock, hypotension
Dengue fever History of travel to an endemic area or local outbreak (e.g. Somali,
Dire Dawa, or Afar regions)
Positive dengue RDT for non-structural protein 1 (NS1) or IgM
Headache, pain behind the eyes
Backache, arthralgia, myalgia
Fine macular rash, petechiae
CBC – leukopenia, thrombocytopenia
In severe cases:
● signs of plasma leakage, shock

Condition In favor
● severe bleeding, e.g. from GI or orifices, dark urine
● organ failure
Chikungunya Resembles non-severe dengue fever
Severe joint pains with fever and rash
No simple test is available to confirm the diagnosis (PCR is
available at EPHI)
Influenza Sudden onset of fever and cough

Sometimes rhinitis or sore throat
Frequent systemic symptoms (headache, arthralgia, or myalgia)
Local epidemics, or history of travel to endemic areas
Close contact with a person with a similar illness, or contact with a
person from epidemic area with influenza
Yellow fever History of travel to an endemic area or local outbreak (Gambella,

South Omo)
Sudden onset of acute fever and rigors
Headache, backache, bone pains
Followed by jaundice within 2 weeks
Primary HIV Lymphadenopathy

Rash, pharyngitis
History of unprotected sexual contact in the last 3 months
HIV rapid test may be negative
Drug-induced fever New drug initiated days or weeks prior

Associated rash
Patient on drugs – ART (NVP, ABC, EFV) , cotrimoxazole,
dapsone, B-lactams, INH, anticonvulsants
Measles in adolescents Conjunctivitis, coryza, and cough

and adults
Koplik’s spots on the buccal mucosa (“grains of salt on a red
background”)
Maculopapular, blanching rash
Condition In favor
Lymphadenopathy
Complications include:
• respiratory tract infection (pneumonia, tracheobronchitis,
bronchiolitis)
• encephalitis (acute and chronic)
• keratitis
Relapsing fever Recurrent fever

Spread from person to person among louse-infested populations
(e.g. prisons, refugee camps, street children, war, or famines with
overcrowded populations with poor personal hygiene)
Rash, often petechial
Jaundice, impaired liver function
Spirochetes on Giemsa-stained thick or thin blood film,
Jarisch-Herxheimer reaction (fever, rigors, hypotension within 2
hours of antibiotic administration)
Acute schistosomiasis Exposure to fresh water in an endemic area (with sometimes skin
(Katayama fever) itch just after exposure)
Between 2 and 12 weeks after infection
CBC – eosinophilia
.
Table 3.Differential Diagnosis: Fever more than 7 days without clinically obvious focus or site.
Condition In favor
Malaria Living in, or traveling to a malaria-endemic area

Positive malaria test (RDT or microscopy)
Typhoid fever Remittent fever

Malaria ruled out
No focus on infection
Risk factor for typhoid (poor hygiene)
Tuberculosis Loss of weight, night sweats, fever, malaise

Cough >2 weeks
Condition In favor
Signs of extrapulmonary disease – e.g. lymphadenopathy, pallor,

abdominal pain
The common complication of HIV
Osteomyelitis Limb pain, tenderness, and swelling

Contiguous skin infection or chronic ulcer
X-ray showing periosteal reaction or bone destruction (after 2 to 4
weeks)
Endocarditis Low-grade fever, night sweats

New heart murmur (or change in old heart murmur)
Signs of embolic disease (stroke, petechiae, splinter hemorrhage)
Splenomegaly
Risk factors: known cardiac valvular disease
Liver abscess Right upper quadrant pain or tenderness

Liver focal lesion at ultrasound
Yellow fever History of travel to an endemic area or local outbreak (Gambella,

South Omo)
Sudden onset of acute fever and rigors
Headache, backache, bone pains
Followed by jaundice within 2 weeks
Lymphoma Weight loss, night sweats

Enlarged lymph nodes, hepatosplenomegaly
Visceral leishmaniasis Endemic area

Fever, wasting syndrome, pallor of mucous membranes
Generalized lymphadenopathy
Splenomegaly, darkening of skin
Some often-missed sites that may cause fever include:
● Dental abscesses
● Sinusitis – percuss face and forehead
● Endocarditis – auscultate for murmur, if possible, perform blood cultures
● Urinary tract infection
● Prostatitis and pelvic inflammatory disease
● Intra-abdominal, retroperitoneal, or paraspinal abscess
● Cholangitis, liver abscess
● Deep venous thrombosis – examine for lower limb swelling
● Malignancy – check for breast lumps, cervical nodes, splenomegaly,
hepatomegaly, prostate abnormalities
● Connective tissue diseases (e.g. lupus, rheumatoid arthritis)
● Fever due to medications
● Pus that cannot drain (after trauma)
● Drug fever
2-3: Principles of assessment of a patient with fever
Group Activity: 3
Before starting the session, please go over the

following question just to retrieve your prior
knowledge/experience.
Feel free to reflect on the questions:
Time: 5 minutes.
This is a patient assessment report from a

certain health center, what are your
observations and how do you evaluate the
information in the chart and how do you
improve it?
Assessment of fever in adults:

The following principles are important while examining a patient with a fever.
● Observe the general condition of the patient, take vital signs, and ask targeted
questions to determine if there is any life-threatening condition. Respiratory distress

(use of accessory muscles, grunting, nasal flaring), very weak/unable to stand,
lethargy, decreased level of consciousness, convulsions, severe abdominal pain and
deranged vital signs (hypotension, rapid pulse or respiratory rate) indicate the
possibility of severe disease like severe malaria, severe pneumonia, pyogenic
meningitis or sepsis. Such patients will require urgent lifesaving treatments (IV
fluids, IV glucose, oxygen, proper positioning of the patient, blood transfusion and
other immediate emergency cares).
● After ruling out the possibility of severe life-threatening conditions (or initiating
lifesaving management for patients with severe disease), the next step is to
determine if the patient has a focus of infection by thorough history and targeted
physical examination. The focus of infection is the organ or system that is affected
by the infection and is believed to be the source/cause of the fever. For example, the
lungs are the focus of infection in a patient with pneumonia.
● In addition, consider causes of acute febrile illnesses based on the epidemiology and
associated risk factors test for malaria if the patient has malaria risk (lives in a
malarious area or has a travel history to the malarious area in the previous month);
typhus or relapsing fever if the patient has poor hygiene and visible body lice;
typhoid fever if there is possible orofecal contamination; dengue or yellow fever or
chikungunya or leishmaniasis if there is a risk (living in at-risk areas or travel
history). It is also good to consider possible exposure to certain pathogens e.g.,
contact with patients with meningitis, measles, chicken pox, and dog or animal bite
in rabies.
● Give attention to underlying conditions like HIV, diabetes, chronic respiratory or
cardiac diseases, malignancies, and malnutrition
● Unless the patient is in a critical condition demanding emergency and empirical
treatment, it is good to take the time to confirm the underlying cause of the fever
before initiating specific treatment.
● Patients should be followed to document responses or detect complications after
initiating treatment.
● Consider reporting to health program managers as most conditions causing acute
febrile illnesses are reportable.
The clinical evaluation steps for patients with fever

1-History: the purpose of history-taking is to:
● Obtain a professional rapport with the patient and gain his confidence.
● Obtain all relevant information which allows assessment of the illness, and
provisional diagnosis.
● Obtain general information regarding the patient, his background, social situation,
and problems. In particular, it is necessary to find out how the illness has affected
him, his family, friends, colleagues, and his life.
● Understand the patient’s ideas about his problems, his major concerns, and what he
expects from the hospital admission, outpatient, or general practice consultation.
While a health care provider evaluates patients, the provider is expected to use good
communication skills.
Good communication skills will:
 Create trust between the provider and the client (e.g. Clients will tell all the
required information without hesitations),
 Builds confidence between the provider and the client (e.g. Clients will accept all
the recommendations and management plans)
 Bring required behavioral change/practice (e.g. Adherence to treatment)
The following points highlight some good practices with regard to good communication
● Sit so that your head is at level with your client
● Maintain eye contact and pay attention
● Don’t take notes while talking to your client
● Don’t act hurried
● Use open and closed-ended questions, don’t use leading questions
o How are you feeling today? (open-ended question)

o Do you have a fever? (closed-ended question)
o Are you taking your medicine properly? You are better today, aren’t
you? (leading questions)
● Show gestures that show interest like nodding

● Reflect on what the client says
● Avoid using judging (blaming) words
● Empathize, show that you understand how the client feels
● Listen carefully to the patient, and don’t interrupt frequently
Important components of history while evaluating fever:

I-Patient Identification/ Demographic Data
The age, sex, place, occupation, and marital status may help to consider some clinical
conditions. For example, malaria tends to be severe in children under five and pregnant
women; a health worker may acquire relapsing fever from his/her patient.
II-Describe the chief complaint fever with duration
III-History of present illness
Describe the chief complaint fever based on:
 Duration of fever (less than 7days or more)
 Pattern of fever (intermittent, relapsing, step ladder, remittent)
 Other associated symptoms: there are group of symptoms that point to
dysfunction in a certain system. For example, fever with cough, chest pain, and
shortness of breath may indicate disease of the respiratory or cardiovascular
system. Fever with urinary urgency, frequency, dysuria, and flank pain indicates
disease of the urinary system. Fever with seizure, altered consciousness,
paralysis, numbness, or loss of sensation indicates disease of the nervous system.
The presence of symptoms that point to the dysfunction of a certain system may
suggest a focus on infection.
 The common risk factors for fever causes:
 Check the exposure to locally endemic diseases. Consider the local
geographical distribution of diseases, e.g. malaria, dengue, leishmaniasis
 Consider outbreaks of specific infections, e.g. malaria, meningitis
 Consider a seasonal variation of diseases
 Ask about recent travel – consider diseases that are common in the area that
was visited
 Contact with animals and birds (brucellosis, rabies, Q fever)
 Known TB contact
 Recent unprotected sex (acute HIV syndrome, syphilis)
 Intravenous drug use
 Comorbidities
⮚ consider infections that a patient may be predisposed to as a result of
comorbidities such as diabetes, HIV, chronic respiratory, cardiac or kidney

diseases, cancer, malnutrition
⮚ medical history of recent illness and the possibility of incompletely treated
disease or drug resistance, e.g. malaria, typhoid, TB;
⮚ current medications;
⮚ consider drug reactions if the patient has recently initiated a new medication
known to commonly cause drug reactions, e.g. cotrimoxazole, ART

(especially nevirapine or abacavir), or TB medication.
Physical Examination
All patients with fever should be examined, even if they don’t report symptoms of local
infection. Examine the patient thoroughly paying attention to sites of possible infection:
● General examination
⮚ monitor temperature (might be normal at that particular moment)
⮚ assess for confusion or decreased level of consciousness
⮚ assess hydration, count heart rate and respiratory rate
⮚ look for pallor, jaundice, lymphadenopathy, nail abnormalities (splinter
hemorrhages)
⮚ skin lesions, including rash
⮚ insect or animal bites

⮚ nutritional status (wasting)
● Head and neck
⮚ neck pain or stiffness, sinus tenderness
⮚ throat, tonsils, mouth ulcers or lesions
⮚ ears for inflammation and discharge
● Chest and precordium
⮚ difficult breathing, fast breathing, crackles, bronchial breathing, absent
breath sounds
⮚ new heart murmur, change in an old murmur
● Abdominal or genitourinary
⮚ enlarged liver or spleen
⮚ abdominal tenderness or mass
⮚ pain over kidneys (flank tenderness)
⮚ pelvic tenderness or mass
⮚ rectal and vaginal examination for pain, discharge, ulcers, mass
● Muscles and joints
⮚ red, hot, swollen, painful joint(s) with reduced mobility
⮚ Swollen, painful limb (deep venous thrombosis, cellulitis).
● Nervous system
 Level of consciousness
 Meningeal signs,
 Paralysis etc.
● If there is evidence of focal infection like pneumonia or UTI treat the patient as
per the national standard treatment guideline.

Laboratory Investigations
Laboratory tests are complementary to history and physical investigation to make appropriate
diagnosis. They should be interpreted in line with the clinical presentation; e.g. reactive widal
test does not indicate typhoid if the patient does not have fever.
For all patients, consider
● Complete Blood Count (CBC)
● Blood film(Malaria test, borrelia identification)
● Urine analysis
● Hemoglobin level
Additional tests, as indicated (see Differential Diagnosis tables in next Section):
● complete blood count with differential white cell count
● Organ function tests( LFT, RFT)
● Imagings ( X-ray, ultrasound, CT or MRI)
● sputum for microscopy, acid-fast bacilli, and sometimes culture
● Culture (blood, urine, stool or body fluids)
● lumbar puncture for CSF analysis
● bone marrow, lymph node, or splenic aspirate for microscopy (leishmaniasis)
● stool microscopy
Widal and Weil Felix tests are not recommended as per the existing scientific literatures due
to their lack of sensitivity and specificity. However, these tests are still widely used in
Ethiopia. These tests may be relevant under the following conditions.
● The patient should have clinical features of typhus or typhoid (almost all
patients with typhoid or typhus have fever)
● Tube titration (not slide agglutination) should be done.
● Interpretation should be based on demonstration of fourfold increase in
antibody level after 7-10 days of first test; or single test which is above local
cut-off value for that particular location. The limitation of using cut-off
values is; usually these values are not available, and they vary with time in
the same place and from place to place
Activity; 4 Role Play: Clinical evaluation of adult with fever
Objective: To conduct a clinical evaluation of an adult patient with a fever
Role Description:
- Patient role: Age = 65 years old, a farmer in a rural area, feeling warm for 3 days.
- Clinician Role: A clinician working in a small town health center OPD.
Instructions:
- One participant act as an adult patient with a fever.
- One participant act as the treating clinician at OPD.
- The rest of the participants: observe the role play focusing on the communication skill of
the clinician for subsequent feedback.
Situation: A clinician working at a small town health center OPD encounters an adult patient with
a fever.
Task: The participant acting as a clinician will conduct a clinical evaluation for the patient, the
rest of the participants should observe the role play closely and comment on the performance
afterward.
Time: 30 Minutes.
Discussion Points:
1. Did the clinician establish positive, respectful collaborative working relationship with the patient?
2. Did the clinician demonstrate empathy?
3. Did the clinician actively listen to the patient (made eye contact, let the patient finish sentences
repeat /paraphrase what the patient is saying)?
4. Did the clinician use appropriate verbal and non-communication?
5. Was the clinician able to elicit all relevant history, perform focused physical examination, and
order appropriate laboratory investigations?
6. Did the clinician inform and counsel the patient effectively?
2.4 – Principles of the Management of Adults with Fever.
Activity: 4 Brainstorming
Before starting the session, please go over the following question just to retrieve your prior
knowledge/experience.
Feel free to respond to the questions:
Time:
What do you do first (your initial management) for patients with fever? Why?
Do you always lay out the treatment options to your patients and let them choose their
preferred treatment plans? Why?
How is their Compliance /Adherence? Why?
Management of fever principles

With fever, unlike hyperthermia, body temperature is well regulated by a hypothalamic set-
point that balances heat production and heat loss so effectively that the temperature does not
climb up relentlessly and does not exceed an upper limit of 42 °C. Within this upper range,
40 °C to 42 °C, there is no evidence that there will be tissue injury. About 20 percent of
children seen in the emergency rooms have temperatures over 40 °C but they usually have a
full recovery. If there is morbidity or mortality, it is due to the underlying disease. The
associated fever may well be protective.
In the management of patients with fever, the listed management principles may be utilized
1. As much as possible try to make a specific diagnosis (with initial and subsequent
evaluations if the patient doesn’t have a life-threatening condition).
2. Definitive treatment (the underlying disease with specific treatment)
3. Symptomatic treatment of fever pain and dehydration.
4. Educate the patient about the diagnosis, choice of treatment available, adherence to
treatment, expected side effects, and complications, and when to return (if the fever
does not improve or comes back after treatment; if the fever is accompanied by a
cough, diarrhea, severe pain, confusion, stiff neck or change in consciousness)
5. Ensure adequate follow-up of patients.
How to ensure adequate follow up?
The follow-up and subsequent evaluation are an essential step in the care process. It is the
step in which actual results and outcomes from drug therapies are observed, evaluated, and
documented. This is the important step where you see the results of your previous work.
Although most follow-up visits require a brief amount of time compared to initial
assessments, the follow-up evaluation is the step in which you gain new clinical experience
and knowledge.
The follow-up evaluation solidifies your commitment to your patient, strengthens the
therapeutic relationship, and demonstrates your willingness to work with your patient to
achieve the desired goals of therapy. The primary purpose of every follow-up evaluation is to
determine the patient's outcomes that have resulted from the drug therapies and care plans
you have provided. Be sure to evaluate both effectiveness and safety parameters each time.
Health workers may not be able to reach to a specific diagnosis in some patients with acute
fever. They may choose to follow them up or initiate empiric treatment based on a suspected
diagnosis. Such patients may develop new symptoms during subsequent days which may help
in reaching to a specific diagnosis. For example, a patient with fever may develop pain during
swallowing on subsequent days and may be diagnosed as tonsillitis later.
Health workers may also reach to a specific diagnosis. Such patients should be advised to
return if they are not recovering as expected or have worsening of symptoms. Follow-up
visits should be arranged within 48 - 72 hours after the initial visit.
Patients who come back to health facilities due to new symptoms, delayed recovery or
worsening of symptoms should be evaluated with detailed history, physical examination,
appropriate laboratory tests and review of their medical record. This should include review of
● Initial symptoms, whether they are worsening, getting better or same
● New symptoms
● Adherence to prescribed medicines.
● Possible symptoms of drug side effects
Health workers may treat patients at their health facilities or refer patients to a higher level if
they need referral.
The World Health Organization defines an outcome as a “change in the health of an

individual, group of people, or population that is attributable to an intervention or series of
interventions.” Healthcare intervention outcomes are the quality and cost target that
healthcare facilities should try to improve.
Listed are the most common outcomes of healthcare interventions:
● Cure/ Improvement
● Readmissions / Complication
● Disability
● Mortality
Possible ways that your facility can utilize for follow-up of patients include:
● Phone
● Secure email
● Texting
● Automated calling system. These types of systems can be used for reminders
and to collect information from patients

Activity 5:Group e exercise
Be in a group of 4-6 Participants.
Read and analyze the below case scenario and give your response orally
Time allowed: 20 minutes (10 min. for discussion and 10 min oral presentation
Case Scenario 2.3.
The 30-year-old woman who lives in a rural part of the country presented to the outpatient
department at a health center with a 3-day history of feeling too warm and sweaty.
A- With an additional history of non-productive cough, joint & muscle pain,

headache, abdominal pain, and constipation and also the fever is worsening over
time
⮚ Up on physical examination she was an acutely sick-looking woman, with
● BP=90/60, RR=30, T°=40°C, and PR=60,
● left side Costo-vertebral angle tenderness.
● Her spleen is palpable at 4 cm BLCM.
● No other abnormal finding
⮚ Lab tests showed
● BF negative, Hgb: 13g/dl,
● WBC: 15,600/uL, PITC: NR,
● U/A: protein and sugar negative, many pus cells/HPF seen)

Chapter summary:
 Fever in an adult patient is defined if a patient had history of fever or if the provider
feels hot or if an axillary temperature record is 37.5oC and above.
 Fever can be classified based on pattern as intermittent, relapsing and remittent and
based on duration as acute and chronic.
 What is the relevant history, physical examination & laboratory tests to diagnose a
patient with fever?
 Describe the associated risk factors for a patient with a fever.
Resources & References:
● WHO, Guidelines for the treatment of malaria, 3rd edition, 2015.
● National malaria guidelines, 5th edition, 2022, Addis Ababa.
● World medical association, medical ethics manual, 3rdedition,2015
Activity: Health facility visit/ practical attachment- 1

Activity Objectives: Upon the completion of the health facility visit participants will be able
to practice the management of adult patients with fevers in the clinical setting
Instructions: This healthcare facility visit is independent work and you are expected to
complete and report the task mentioned below. Use the checklist to record and report your
work.
Tasks:
- Visit the health facility where clinical evaluation is made for adult patients with fever+
- Pick a patient with a fever from the outpatient department of the health facility
- Directly observe the clinical evaluation methods of adult patients with fever
- Review patient charts and document relevant history, physical examination,
laboratory/imaging investigation included in assessing adult patients with fever and report
- Properly complete the attached checklist.
- Report /present your work for a plenary session and get feedback
Use the annex checklist for health facility visit for fever in an adult patient
CHAPTER THREE: APPROACH TO FEVER IN CHILDREN, IMNCI

(INTEGRATED MANAGEMENT OF NEWBORN AND CHILDHOOD ILLNESSES)
Duration: 3 hours
Chapter Description:
This chapter will focus on fever in children and the techniques in patient evaluation that will
enable you to assess, classify, treat, and follow a child with a fever.
Chapter Objective: at the end of this chapter, participants will be able to explain the
management of Fever in Children and new Borns.
Learning Objectives: - at the end of this chapter, participants will be able to:
● Identify fever in children
● Explain the common causes of fever in children
● Identify children with the general danger signs
● Asses and classify a child with a fever
● Identify the appropriate treatment for a child with a fever
● Counsel a mother/ caregiver with a febrile child and follow up
Chapter Outline/sessions
3. 1-Identify a child with a fever
3. 2-Common causes of fever in children
3. 3-Assessment of a child with a fever
3.4-Classification and treatment of a child with fever
3.5-Assessment and classification of a child with measles

3.6. Summary
3.1: Identification of a Child with a Fever
Reflection
Instructions: Please go over the following question just to retrieve your prior
knowledge/experience. Feel free to answer/reflect/respond to the question.
A 6-month-old infant presented to the IMNCI clinic with a fever of 3 days’ duration and
upon examination, the axillary temperature record was 370c.
● What is your decision regarding the fever (Do you evaluate this child for fever or not
and why?)
Time: 10 Minutes
A child has the main symptom of fever if:
* The child has a history of fever OR
* The child feels hot OR
* The child has an axillary temperature of 37.5°C 99.5°F)or above
The child has a history of fever if the child has had any fever with this illness. Use words for
"fever" that the mother understands. Make sure the mother understands what fever is. For
example, ask the mother if the child's body has felt hot.
Feel the child's abdomen or axilla and determine if the child feels hot.
Measure and record the temperature on the child's chart. If the child has a temperature of
37.5°C or above, the child has a fever. High fever is defined when the axillary temperature is
38.5°C (101.3°F) or more.
Activity 3.1 Case study

Practice exercises on identifying cases of fever
(Think, Pair and Share)
Instruction: Read the cases below in pairs & decide whether the cases have a fever or not.
Case Scenarios:
Case1: An 8-month-old infant with an axillary temperature of 37.9°C.
Case 2: A 6-month-old infant with an axillary temperature of 37.3°C and a history of fever
Case 3: A 3 -year-old child with a history of fever and axillary temperature of 37°C.
Case 4: A 24-month-old child with no history of fever and an axillary temperature of 37°C.
Case 5: A 24-month-old child with no history of fever and an axillary temperature of

37°C.
Tasks: Identify the children who have the criteria for fever and why.
Time: 15 minutes
3. 2 Common Causes of Fever in Children
Duraon: 30 minutes
Group activity:3.2 Individual reflection

Instructions: Go over the following questions just to retrieve your prior
A 10-month-old infant presented to the IMNCI clinic with a fever of three -day duration and
upon examination, the axillary temperature record was 370c.
● What are your common differentials for the fever?
Time: 10 minutes
A child with a fever may have:
● Malaria,
● Measles,
● A simple cough or cold or other viral infection.
● Other severe disease (Sepsis, meningitis, encephalitis, severe pneumonia,
dysentery…)
Malaria
Fever is the main symptom of malaria. It can be present all the time or recur at irregular
intervals. Other symptoms of malaria are shivering, sweating, and vomiting. A child with
malaria may have chronic anemia (with no fever) as the only sign of illness.
Signs of malaria can overlap with signs of other illnesses. For example, a child may have
malaria and cough with fast breathing, a sign of pneumonia. Studies show that cough and
fast breathing are common in children who have a fever and P. falciparum malaria
confirmed by blood smear. Even expert clinicians need laboratory tests to reliably
distinguish P. falciparum malaria from pneumonia in a child with fever, cough, and fast
breathing. This child needs treatment for both P. falciparum malaria and pneumonia.
Children with malaria may also have diarrhea.
In areas with very high malaria transmission, malaria is a major cause of death in children. A
case of uncomplicated malaria can develop into severe malaria within 24 hours of onset of
the illness. Severe malaria is malaria with complications such as cerebral malaria, severe
anemia, or hypoglycemia. The child can die if s/he does not receive urgent treatment.
Measles:
Fever and a generalized rash are the main signs of measles. Measles is highly infectious.
Maternal antibodies protect young infants against measles for about 6 months. Then the
protection gradually disappears. Most cases occur in children between 6 months and 2 years
of age. Overcrowding and poor housing increase the risk of measles occurring early.
Measles affects the skin and the layer of cells that line the lungs, gut, eye, mouth, and throat.
The measles virus damages the immune system for many weeks after the onset of measles.
This leaves the child at risk for other infections.
Complications of measles occur in about 30% of all cases. The most important are diarrhea
(including dysentery and persistent diarrhea), pneumonia, stridor, mouth ulcers, ear
infections, and severe eye infections (which may lead to corneal ulceration and blindness).
Encephalitis occurs in about one in one thousand cases. A child with encephalitis may have a
general danger sign such as convulsions, lethargy or unconsciousness.
Measles contributes to malnutrition because it causes diarrhea, high fever, and mouth ulcers.
These problems interfere with feeding. Malnourished children are more likely to have severe
complications due to measles. This is especially true for children who are deficient in vitamin
A. One in ten severely malnourished children with measles may die. For this reason, it is
very important to help the mother to continue to feed her child during measles.
(Think Pair and Share)
Objective-to identify the common cause of fever

Instruction: Read the case below in pairs and answer the given question
Case-1 A child having fever and maculopapular rash with a runny nose and red eyes?
Case-2 A child with fever, neck pain, and stiffness with projectile vomiting
Case 3- A child with bloody diarrhea and vomiting with fever
Child 4 An infant with cough, fast breathing, and chest in drawing
Case 5- A child with fever, headache, chills, and BF positive for P. vivax
Tasks: What is the most likely diagnosis for each case and justify why?
Time- 10 minutes
3. 3-Assessment of a Child with Fever
Activity 3.4; Case study

Objective-to identify relevant information (history, physical examination, laboratory
investigation, etc.…) to reach at diagnosis
Instructions: Be in a group of 4-6, go over the following questions just to retrieve your prior
knowledge/experience. Feel free to answer/reflect/respond to the questions.
Case Scenario- A 10-month-old male infant weighs 8.2 kg. His length is 71 cm. His
temperature is 37.5°C. His mother says he has a rash and cough.
Tasks
● What is the possible diagnosis and differential diagnosis of child?
● What additional history is needed to reach the diagnosis?
● What important physical assessment should the health worker do?
● What important test should the health worker order?
Time : 20 minutes
Steps in assessing a child with fever:
A general danger sign is present if the child:

 is not able to drink or breastfeed
 vomits everything
 has had convulsions
 is convulsing now
First look for presence of general danger signs
Step-1-Check for General danger symptoms and signs
When you check for general danger signs:
ASK: Is the child able to drink or breastfeed?
A child has the sign "not able to drink or breastfeed" if the child is not able to suck or
swallow when offered a drink or breast milk.
ASK: Does the child vomit everything?
A child who vomits after each feed has the sign "vomits everything." What goes
down comes back. A child who vomits everything will not be able to hold down food,
fluids, or oral drugs. A child who vomits several times but can hold down some fluids
does not have this general danger sign.
ASK: Has the child had convulsions?
Convulsions can be generalized or localized. Focal convulsions can present with

twitching of the fingers, the mouth, or rolling of the eyes. Focal convulsions can easily
be missed and therefore need to be carefully assessed.
LOOK: See if the child is convulsing now.
During a convulsion, the child's arms and legs stiffen because the muscles are
contracting. There may be drooling of saliva and rolling of the eyes upwards. The child
may lose consciousness. If the child is convulsing in the health facility now, treat the
child by managing the airway and giving Diazepam, before completing the assessment.
LOOK: See if the child is lethargic or unconscious.
A lethargic child is abnormally sleepy and is difficult to awaken by calling and even by
gentle shaking. If he wakes up, he immediately relapses into sleep. He is too weak to
sustain an alert state even under stimulation. Sometimes a lethargic child may stare
blankly into space without noticing what is going on around him.
An unconscious child may not respond to verbal or physical stimuli or may respond
inappropriately. However, ask the mother if the child seems unusually sleepy or if she
cannot wake the child. Look to see if the child wakes when the mother talks or shakes
the child or when you clap your hands.
If malaria risk is high/low or there is a history of travel to a malarious area, then do a

blood film or RDT if NO severe classification.
The box below lists the steps for assessing a child for fever. There are two parts to the
box. The top half of the box (above the broken line) describes how to assess the child
for signs of malaria, measles, meningitis, and other causes of fever. The bottom half of
the box describes how to assess the child for signs of measles complications if the child
has measles now or within the last 3 months.
 Does the child have a fever? (by history or feels hot or temperature 37.5 oC or
above)
Doblood
IFfilm
YES:or RDT, if malaria risk is
High/Low or history of travel to a malarious
area, AND Decide
there malaria
is no Severe risk: High/Low
Classification. or No.
 If “No” malaria risk, then ask:
 Has the child traveled outside this area during the previous 30 days?
 • If yes, has he been to a malarious area?
LOOK AND FEEL:
THEN ASK  Look or feel for a stiff neck.
 Look or feel for bulging fontanels (< 1 year of
 For how long has the child had age)
a fever?  Look for signs that suggest any bacterial cause
 If more than 7 days, had fever of fever
every day?  Look for a runny nose.
 Has the child had measles  Look for signs of MEASLES
within the last 3 months?  Generalized rash, AND one of these: cough,
runny nose, or red eyes.
 Look for mouth ulcers:
If the child has measles now or  Are they deep or extensive?
within the last 3 months:  Are they not deep or extensive?
 Look for pus draining from the eye.
 Look for clouding of the cornea.
Step-2-Deciding Malaria Risk:

Malaria risk is defined as the presence of malaria transmission in the area where the patient
lives or travel history to the malarious area in the past 30 days.
Many mothers will know whether the area they have traveled to with the child has malaria
transmission. If she does not know or is not sure, ask about the area and use your knowledge
of whether the area has malaria. If you are still not sure, assume the malaria risk is high.
If the malaria risk in the area is absent, ask the mother about travel:
Has the child traveled outside this area to a malaria area during the previous 30 days?
If she has traveled to a malarious area, decide whether the malaria risk is low or high
depending on the level of malaria risk of the visited area. If the area she had traveled to is
known to be malarious but not specified as low or high, then decide the area as high malaria
risk.
Circle the malaria risk (high/low or no) on the Recording Form.
You will use this information when you classify the child's fever.
Step-3: Check duration of fever
Ask the mother how long the child has had a fever. If the fever has been present for more
than 7 days, ask if the fever has been present every day.
Most fevers due to viral illnesses go away within a few days. A fever that has been present
every day for more than 7 days can mean that the child has a more severe disease such as
typhoid fever. Refer this child for further assessment.
Step 4: Check for common causes of fever
A-Meningitis
LOOK or FEEL for a stiff neck.
A child with a fever and a stiff neck may have meningitis. A child with meningitis
needs urgent treatment with injectable antibiotics and referral to a hospital.
While you talk with the mother during the assessment, look to see if the child moves
and bends his neck easily as he looks around. If the child is moving and bending his
neck, he does not have a stiff neck.
If you do not see any movement, or if you are not sure, draw the child's attention to his
umbilicus or toes. For example, you can shine a flashlight on his toes or umbilicus or
tickle his toes to encourage the child to look down. Look to see if the child can bend
his neck when he looks down at his umbilicus or toes.
If you still have not seen the child bend his neck himself, ask the mother to help you lay
the child on his back. Lean over the child; gently support his back and shoulders with
one hand. With the other hand, hold his head. Then carefully bend the head forward
toward his chest. If the neck bends easily, the child does not have a stiff neck. If the
neck feels stiff and there is resistance to bending, the child has a stiff neck. Often a
child with a stiff neck will cry when you try to bend the neck.
LOOK or FEEL for bulging fontanels (age < 12 months).

Hold the infant in an upright position. The infant must not be crying. Then look at and
feel the fontanels. If the fontanel is bulging rather than flat, this may mean the young
infant has meningitis.
LOOK for a runny nose.
A runny nose in a child with a fever may mean that the child has a common cold.
If the child has a runny nose, ask the mother if the child has had a runny nose only with
this illness.
When malaria risk is low, a child with a fever and a runny nose does not need an
antimalarial. This child's fever is probably due to the common cold.
B-MEASLES
ASK: Has the child had measles within the last 3 months?
Measles damages the child's immune system and leaves the child at risk for other
infections for many weeks. A child with a fever and a history of measles within the last
3 months may have an infection due to complications of measles.
Assess a child with a fever to see if there are signs suggesting measles. Look for a
generalized rash and for one of the following signs: cough, runny nose, or red eyes.
Generalized rash
In measles, a red rash begins behind the ears and on the neck. It spreads to the face.
During the next day, the rash spreads to the rest of the body, arms and legs. After 4 to 5
days, the rash starts to fade and the skin may peel. Some children with severe
infections may have more rash spread over more of the body. The rash becomes more
discolored (dark brown or blackish), and there is more peeling of the skin.
Measles rash does not have vesicles (blisters) or pustules. The rash doesn't itch. Do not
confuse measles with other common childhood rashes such as chicken pox, scabies, or
heat rash. (The chickenpox rash is a generalized rash with vesicles. Scabies occur on the
hands, feet, ankles, elbows, buttocks, and vesicles which itch. It also itches. Heat rash
can be a generalized rash with small bumps and vesicles which itch. A child with a heat
rash is not sick. You can recognize measles more easily during times when other cases
of measles are occurring in your community.
Cough, Runny Nose, or Red Eyes
To classify a child as having measles, the child with fever must have a generalized rash
AND one of the following signs: cough, runny nose, or red eyes. The child has "red
eyes" if there is redness in the white part of the eye in the absence of other causes.
If the child has MEASLES check for complications:
Look to see if the child has mouth or eye complications. Other complications of
measles such as stridor in a calm child, pneumonia, and diarrhea are assessed earlier;
malnutrition and ear infections are assessed later.
LOOK for mouth ulcers.
Mouth ulcers are common complications of measles which interfere with the feeding of
a sick child. Look for mouth ulcers in every child with measles and determine whether
they are deep or extensive or a mouth ulcer that is not deep or extensive.
The mouth ulcers should be distinguished from Koplik spots. Koplik spots occur inside
the cheek during the early stages of measles infection. They are small irregular bright
spots with a white center. They do not interfere with feeding.
LOOK for pus draining from the eye.
Pus draining from the eye is a sign of conjunctivitis. If you do not see pus draining from
the eye, look for pus on the conjunctiva or the eyelids.
Often the pus forms a crust when the child is sleeping and seals the eye shut. It can be
gently opened with clean hands. Wash your hands after examining the eye of any child
with pus draining from the eye.
LOOK for clouding of the cornea.
Look carefully for corneal clouding in every child with measles. Corneal clouding is a
dangerous complication. The corneal clouding may be due to Vitamin A deficiency
which has been made worse by measles. If the corneal clouding is not treated, the
cornea can ulcerate and cause blindness. A child with clouding of the cornea needs
urgent referral and treatment with Vitamin A.
If there is a clouding of the cornea, ask the mother how long the clouding has been
present. If the mother is certain that clouding has been there for some time, ask if the
clouding has already been assessed and treated at the hospital. If it has, you do not need
to refer to this child again for corneal clouding.
C-Check for other causes other than malaria and measles
LOOK for local tenderness; oral sores; refusal to use a limb; hot tender swelling; red tender
skin or boils; lower abdominal pain or pain on passing urine in older children
Step-5: Order blood microscopy

Do blood film, if malaria risk is High/Low or history of travel to a malarious area, and there
is no Severe Classification
Activity: 3.5 : Case study

Assess a child with a fever & record the finding
Objective- To assess a child with fever and record the assessment findings using IMNCI
protocol.
Instruction: Read the case below individually and record your assessment findings using the
IMNCI recording form.
Case scenario- A 3-year-old male child who weighs 9.4 kg and height is 92 cm. His
temperature is 37°C. His mother says he feels hot and has a cough. The health worker
checked for general danger signs. He was able to drink, had not vomited, did not have
convulsions, and was not convulsing, lethargic, or unconscious. He had been coughing for 3
days. The breathing rate was 51 breaths a minute. There was no chest in drawing and stridor
when he was calm. The health worker also thought that the patient felt hot. He assessed the
child further for fever. The risk of malaria is high. He has felt hot for 5 days, the mother
said. He has not had measles within the last 3 months. He did not have a stiff neck; there
was no runny nose, and no generalized rash. Blood film is found to be positive for P.
falciparum.
Task-Record the child's symptoms and signs on the IMNCI recording form and show it to
your facilitator.
Time-20 minutes
3. 4-Classification and treatment of a child with fever
Activity3.6 Brain storming

How to classify and treat
Objective-To classify and treat a child with fever using IMNCI protocol.
Instruction: Read the case below in pairs and answer the given question
Case scenario- A 4-year-old female patient weighing 12 kg presented with a fever of 1-day
duration. On examination, she is febrile and had one episode of convulsion during
evaluation. Blood film showed P. falciparum
Tasks: What will be the classification and treatment of this child according to IMNCI
protocol?
Time: 20 minutes
Classify Fever
If the child has a fever and no signs of measles, classify the child for fever only.
If the child has signs of both fever and measles, classify the child for fever and measles.
There are two fever classification tables on the ASSESS & CLASSIFY chart. One is for
classifying fever when the risk of malaria is high/low and the second is for classifying fever
when there is no malaria risk. To classify fever, you must know if the malaria risk is
high/low or not. Then you select the appropriate classification table.
HIGH/LOW MALARIA RISK:
There are three possible classifications of fever when the malaria risk is high/low.
● VERY SEVERE FEBRILE DISEASE

● MALARIA
● FEVER: NO MALARIA
Fever classification in children high/low malaria risk

HIGH/LOW MALARIA RISK
SIGNS CLASSIF TREATMENT
Y
 Any general VERY Give the first dose of Artesunate or artemether for
danger signs, SEVERE severe malaria*
OR FEBRILE  Give the first dose of IV/IM Ampicillin and
 Stiff neck, OR DISEASE Gentamycin
 Bulging  Treat the child to prevent low blood sugar
fontanels (<  Give Paracetamol in health facility for high fever
1yr) (≥38.5°C)
 Refer or admit URGENTLY to hospital or health
center
 Positive blood  Treat with Artemether-Lumefantrine** for P.
film OR MALARIA falciparum or mixed or no confirmatory test done.
 If blood film is  Treat with Chloroquine for confirmed P. vivax***.
not available  Give Paracetamol in health facility for high fever
and with no (38.5°C or above)
other obvious  Give an appropriate antibiotic for the identified bacterial
cause of fever cause of fever
 Advise mother when to return immediately.
 Follow-up in 2 days if fever persists.
 If fever is present every day for more than 7 days, refer
for assessment
 Blood film  Give one dose of Paracetamol in a health facility for
negative OR FEVER: high fever (≥38.5°C)
 Other obvious N0  Give an appropriate antibiotic for the identified
causes of fever MALARIA bacterial cause of fever
present  Advise mother when to return immediately
 Follow-up in 2 days if fever persists.
 If fever is present every day for more than 7 days,
refer for assessment.
* IM Artemether is also an option in the absence of Artesunate for the treatment of severe
malaria
**Add single dose primaquine for children more than six months of age
*** Add radical cure with primaquine for 14 days for children more than six months of age.
VERY SEVERE FEBRILE DISEASE (High/Low Malaria Risk) If the child with fever has
any general danger sign or a stiff neck or bulging fontanel in less than one year of age,
classify the child as having VERY SEVERE FEBRILE DISEASE.
Fever Management/Treatment
A child with fever and any general danger sign or stiff neck or bulged fontanel (in less than
one year of age) may have meningitis, severe malaria (including cerebral malaria), or sepsis.
It is not possible to distinguish between these severe diseases without laboratory tests. A
child classified as having a VERY SEVERE FEBRILE DISEASE needs urgent treatment and
referral. Before referring urgently, you will give several treatments for the possible severe
diseases (Refer to Treat the Child Course).
MALARIA (High/Low Malaria Risk)

If a general danger sign or stiff neck or bulged fontanel is not present, look at the yellow row.
Because the child has a fever (by history, feels hot, or temperature 37.5°C or above) in a high
malaria risk area, classify the child as having MALARIA if RDT is positive.
When the risk of malaria is high/low, the chance is also high that the child's fever is due to
malaria.
Treatment
If a child has a fever, cough, and fast breathing, the child may have malaria in addition to
pneumonia. It is not possible without laboratory tests to find out if the child has malaria.
Therefore, the child should be treated for malaria and pneumonia with Artemether-
Lumefantrine and Amoxicillin respectively, if there is no RDT or blood film.
Most viral infections last less than a week. A fever that persists every day for more than 7
days may be a sign of typhoid fever or another severe disease. If the child's fever has
persisted every day for more than 7 days, refer the child for additional assessment.
FEVER: NO MALARIA
In high/low-risk malaria areas if blood film or RDT is negative for malaria, classify as having
FEVER: NO MALARIA. In many areas of the country health extension workers are
deployed and are treating malaria. They use RDT for malaria diagnosis.
FOR NO MALARIA RISK ONLY:
There are two possible classifications of fever in a child with No malaria risk:
VERY SEVERE FEBRILE DISEASE
FEVER
NO MALARIA RISK and No Travel to Malarious Area
VERY  Give the first dose of IV/IM Ampicillin and
● Any general
danger sign, SEVERE Gentamycin
OR FEBRILE  Treat the child to prevent low blood sugar.
● Stiff neck, DISEASE  Give Paracetamol in health facility for high
OR fever (≥38.5°C)
● Bulging fontanels
 Refer URGENTLY to the hospital
(< 1 year of age)
 Give one dose of Paracetamol in a health
● Any fever FEVER facility for high fever (≥38.5°C)
 Give an appropriate antibiotic for the identified
bacterial cause of fever
 Advise mother when to return immediately
 Follow-up in 2 days if fever persists
 If fever is present every day for more than 7
days refer for assessment
VERY SEVERE FEBRILE DISEASE (No Malaria Risk)

If the child has any general danger sign, a stiff neck, or bulging fontanel, and there is no
malaria risk, classify the child as having VERY SEVERE FEBRILE DISEASE.
Treatment
The treatment for a child classified as having a VERY SEVERE FEBRILE DISEASE when
there is no malaria risk is not the same as a VERY SEVERE FEBRILE DISEASE in a
high/low malaria risk area (see Section 5.2).
FEVER
If the child does not have any signs of a VERY SEVERE FEBRILE DISEASE, look at the
next row. When there is NO MALARIA RISK, a child with a fever and who has not traveled
to a malarious area should be classified as FEVER. The fever may be due to a problem
included in another classification – such as a cold, pneumonia, dysentery, or ear infection. Or
the fever may be due to another obvious cause such as cellulitis or an abscess.
Treatment
If the child’s fever is high, give Paracetamol. Advise the mother to return for follow-up in 2
days if fever persists. If the fever has been present every day for more than 7 days, refer for
assessment
Acticiy 3.7;Case study

Objective- To classify and treat a child with fever using IMNCI protocol
Instruction: Read the case below individually and record your assessment findings using the
IMNCI recording form.
Case scenario- A 3-year-old male child who weighs 9.4 kg and height is 92 cm. His
temperature is 37°C. His mother says he feels hot and has a cough. The health worker
checked for general danger signs. He was able to drink, had not vomited, did not have
convulsions, and was not convulsing, lethargic, or unconscious. He had been coughing for 3
days. The breathing rate was 51 breaths a minute. There was no chest indrawing and stridor
when he was calm. The health worker also thought that the patient felt hot. He assessed the
child further for fever. The risk of malaria is high. He has felt hot for 5 days, the mother
said. He has not had measles within the last 3 months. He did not have a stiff neck; there
was no runny nose, and no generalized rash. Blood film is found to be positive for
Falciparum.
Task-Record, classify, and treat the child's symptoms and signs on the IMNCI recording
form and show it to your facilitator.
Time: 20 minutes

3. 5: Assessment Classification and Treatment of a Child with Measles
●
Activity 3.7: Group discussion

Instructions: Go over the following questions just to retrieve your prior
What signs do you see in the above pictures and what are your differential diagnoses?
Why?
Time: 10 Minutes
Classify Measles
A child who has the main symptom "fever" and measles now or within the last 3 months is
classified both for fever and for measles. First, you must classify the child's fever. Next, you
classify measles.
If the child has no signs suggesting measles or has not had measles within the last three
months, do not classify measles. Ask about the next main symptom, an ear problem.
There are three possible classifications of measles:
● SEVERE COMPLICATED MEASLES
● MEASLES WITH EYE OR MOUTH COMPLICATIONS
● MEASLES
The chart classifying measles if present now or within the last 3 months is shown below.
 Give Vitamin A, first dose

● Any general
danger sign, SEVERE  Give the first dose of IV/IM Ampicillin and
OR COMPLICATED Gentamycin
● Clouding of the MEASLES ***  If clouding of the cornea or pus draining from
cornea, the eye, apply Tetracycline eye ointment
OR
 Refer URGENTLY to the hospital
● Deep or
extensive
mouth ulcers
MEASLES  Give Vitamin A, a therapeutic dose
● Pus draining
from the eye or WITH  If pus draining from the eye, treat eye
● Mouth ulcers EYE OR MOUTH infection with Tetracycline eye ointment If

(not deep or COMPLICATIONS mouth ulcers, treat with gentian violet
extensive) ***  Advise mother when to return immediately
 Follow–up in 2 days
MEASLES  Give Vitamin A, a therapeutic dose
● Measles now or
within the last 3  Advise mother when to return immediately
months
SEVERE COMPLICATED MEASLES
If the child has any general danger sign, clouding of the cornea, or deep or extensive mouth
ulcers, classify the child as having SEVERE COMPLICATED MEASLES. This child needs
urgent treatment and referral to the hospital.
Children with measles may have other serious complications of measles. These include
stridor in a calm child, severe pneumonia, severe dehydration, or severe malnutrition. You
assess and classify these signs in other parts of the assessment. Their treatments are
appropriate for the child with measles.
Treatment
Some complications are due to bacterial infections. Others are due to the measles virus which
causes damage to the respiratory and intestinal tracts. Vitamin A deficiency contributes to
some of the complications such as corneal ulcers. Any Vitamin A deficiency is made worse
by the measles infection. Measles complications can lead to severe disease and death.
All children with SEVERE COMPLICATED MEASLES should receive urgent treatment.
Also, give the first dose of Vitamin A and an appropriate antibiotic and refer.
If there is clouding of the cornea, or pus draining from the eye, apply eye ointment. If it is
not treated, corneal clouding can result in blindness. Ask the mother if the clouding has been
present for some time. Find out if it was assessed and treated at the hospital. If it was, you
do not need to refer the child again for this eye sign.
MEASLES WITH EYE OR MOUTH COMPLICATIONS

If the child has pus draining from the eye or mouth ulcers that are not deep or extensive,
classify the child as having MEASLES WITH EYE OR MOUTH COMPLICATIONS. A
child with this classification does not need a referral.
You assess and classify the child for other complications of measles (pneumonia, diarrhea,
ear infection, and malnutrition) in other parts of this assessment. Their treatments are
appropriate for the child with measles.
Treatment
Identifying and treating measles complications early in the infection can prevent many
deaths. These children should be treated with Vitamin A. It will help correct any Vitamin A
deficiency and decrease the severity of the complications. The mother should be taught how
to treat the child's eye infection or mouth ulcers at home. Treating mouth ulcers helps the
child to more quickly resume normal feeding.
Activity 3.8: Case study
Objective-: To assess, classify, and treat a child with measles using the IMNCI protocol
Instruction: Read the case below individually and record your assessment findings, classify
the problem, and write the appropriate treatment using on IMNCI recording form.
Scenario- A 4-year-old female child whose weight is 10 kg and height are 91 cm presented
with fever and rash. Her axillary temperature is 38°C. The health worker checked for general
danger signs. She was able to drink, she had not been vomiting everything, and she did not
have convulsions. She was not convulsing, lethargic, or unconscious. The mother told the
health worker that she had been coughing for 2 days. The health worker counted 42 breaths
per minute. The health worker did not see chest indrawing and did not hear stridor. Next, the
health worker assessed her fever. It is the dry season and the risk of malaria is low. She had a
recent travel history to a malaria-endemic area. She has felt hot for 3 days. She does not
have a stiff neck. The health worker identified a hot tender swelling on the right arm. She
does not have a runny nose. She has a generalized rash. Her eyes are red. She has mouth
ulcers that are not deep and extensive. Pus is not draining from the eye. There is no
clouding of the cornea. Blood film showed P. falciparum and P. vivax infection.
Task-Record, classify, and treat the child's symptoms and signs on the IMNCI recording
form below and show it to your facilitator.
Time-10 minutes
Classify all Sick Young Infants for Very Severe Disease

Classify all sick young infants for bacterial infection. Compare the infant's signs to the signs
listed and choose the appropriate classification. If the infant has any sign in the top row,
select VERY SEVERE DISEASE.
Here is the classification chart for very severe diseases.
SIGNS CLASSIFY TREATMENT*

(Urgent pre-referral treatments are in bold
print)
 Not feeding well, ● Give the first dose of intramuscular
OR VERY
 History of SEVERE Ampicillin and Gentamycin
Convulsions/convulsing DISEASE ● Treat to prevent low blood sugar
now,
OR ● Warm the young infant by skin-to-skin
 Fast breathing (≥60 contact if the temperature is less than
breaths per minute), 36.5°C (or feels cold to the touch) while
OR arranging a referral
 Severe chest indrawing,
● Advise the mother on how to keep the
OR
 Fever (≥37.5°C* or feels young infant warm on the way to the
hot), hospital
OR ● Refer URGENTLY to the hospital
 Low body temperature
(< 35.5°C* or feels
cold),
OR
Movement only when
stimulated or no movement
even when stimulated.
* Consider malaria if the neonate lives in a malaria-risk area.
Chapter Summary:
A child is said to have a fever if the child has a history of fever OR the child feels hot OR the
child has an axillary temperature of 37.5°C or above.
The common causes of fever in children are malaria, measles, simple cough or cold, or other
viral infections. Other severe diseases (Sepsis, meningitis, encephalitis, severe pneumonia,
dysentery…) are also other common causes
Steps in the assessment of fever in children using the IMNCI protocol are
1. Check for general danger symptoms and signs

2. Decide the malaria risk
3. Check the duration of the fever
4. Assess the child for measles and other causes of fever
5. Order blood film if a child has malaria risk
 A child with fever will be classified for malaria based on the risk of malaria, clinical
severity features, and blood film/RDT result.
 If a child has malaria risk: the classification will be either very severe febrile disease or
Malaria or fever no malaria.
If a child has no malaria risk the classification will be either very severe febrile disease or
Fever.
 A child with a fever will be checked for measles now or within the last three months
 If a child has measles, he/she will be classified for complications of measles: Severe
complicated measles or Measles with eye/mouth complications
 And if there is no complication the child will be classified as measles only
Chapter questions
Answer the following question to summarize the chapter
1. What are the criteria to define fever in children?

2. What are the common causes of fever in children?
3. List the general danger symptoms and signs.
4. What are the physical findings we check for a child with fever?
5. What ate the common clinical manifestations and complications of measles.
6. List the drugs we used for the treatment of malaria and measles
MoH (2021) Integrated management of newborn and childhood illness, Addis Ababa.
MoH (2022) National malaria guidelines, 5th edition, Addis Ababa
WHO (2019) Integrated management of newborn and childhood illness: caring for newborns
and children in the community, WHO, Geneva.
Activity: Health Facility Visit/ Practical Attachment

Activity Objectives: Upon completion of the health facility visit participants will be able
to assess, classify, and treat a child with fever and also record the assessment and
classification findings using an IMNCI recording chart.
Instructions: Be in a group of 8-10 participants and visit the health facility where clinical
evaluation is made for a child with a fever. Use the IMNCI recording forms to complete
your tasks.
Task:
 Visit the health facility where clinical evaluation is made for a child with a
fever.
 Pick a patient with a fever from the outpatient department of the health facility
 Observe the demonstration session while a facilitator assesses & classifies a
child with a fever.
 Select 3-4 participants who will assess and classify other children with fever
and record their findings using the IMNCI recording form.
 All participants will record and classify the findings.
 Review the IMNCI log book of the health facility and record the strengths and
weaknesses.
Time: Add time 30 minutes
CHAPTER FOUR: MANAGEMENT OF UNCOMPLICATED MALARIA
Duration: 3 hours
Chapter description:
This chapter is prepared to familiarize participants with the recent knowledge and practice on
how to diagnose, treat, follow, and counsel patients with uncomplicated malaria.
Chapter objective:
At the end of this chapter, participants will be able to describe the management all forms of
uncomplicated malaria as per the national standard.
Learning Objectives: At the end of this chapter, participants will be able to:
 Define uncomplicated malaria
 Describe the common clinical features of uncomplicated malaria
 Explain the advantages of parasitological diagnosis over clinical diagnosis
 Describe the types and steps used in the parasitological diagnosis of malaria
Chapter Outline
4.1-Definition and diagnosis of uncomplicated malaria

4.2-Treatment of uncomplicated malaria
4.3-Patient counseling during uncomplicated malaria management
4.4-Management of treatment failure
4.5-The pharmacovigilance in uncomplicated
4.1- Definition and diagnosis of uncomplicated malaria
Activity 4.1 : Case study

Instructions: Go over the following questions just to retrieve your prior knowledge/experience. Feel
free to answer/reflect/respond to the questions
Case Scenario
A 34 years old male patient from a malarious area presented to OPD with fever of three-day duration.
The axillary temperature record was 380c.
 What are the common differential diagnoses for this patient?

 What other history and diagnostic steps should be taken to diagnose the problem?
Time: 10 minutes
Uncomplicated malaria
Uncomplicated malaria is symptomatic malaria with parasitemia without signs of severity or

evidence of vital organ dysfunction.
Clinical features of uncomplicated malaria
The main manifestation of uncomplicated malaria is fever. Other additional symptoms are
chills, rigors, headaches, malaise, nausea, vomiting, and joint weakness. Physical
examination may reveal fever, pallor, and hepato-splenomegaly.
Diagnosis of uncomplicated malaria
Malaria diagnosis is made by:
● Proper history taking
● Physical examination and
● Laboratory method (parasitological diagnosis)
Malaria Suspect
Malaria should be suspected in a patient who has a fever or history of fever in the last 48
hours and lives in malaria-endemic areas or has a history of travel within the last 30 days to
malaria-endemic areas.
Basing the diagnosis on clinical features alone is not recommended, as this often has low
specificity and increases the chances of the patient being misdiagnosed. 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 (e.g., pneumonia, pyelonephritis, meningitis, tonsillitis, typhoid fever,
relapsing fever, visceral leishmaniasis) and manage the case accordingly. Malaria should still
be considered, even if the individual has another obvious cause for the fever. The national
algorithm of the Integrated Management of Neonatal and Childhood Illness (IMNCI) and the
Ethiopian Primary Health Care Guidelines (EPHCG) should also be employed for the
management of sick patients presenting with fever.
Parasitological Diagnosis
Parasitological diagnosis is required for confirmation of the presence of malaria parasites. It

is recommended for all suspected malaria cases in all transmission settings. The advantages
of parasitological diagnosis are:
● Improved care of parasite-positive patients owing to greater certainty that the
cause of the present illness is malaria;
● Identification of parasite-negative patients for whom another diagnosis must be
sought;
● Prevention of unnecessary use of anti-malaria medicines, thereby reducing the risk
of adverse side effects and drug interactions;
● Confirmation of treatment failures; and
● Improved malaria case detection and reporting.
N.B. Patients who test negative by malaria RDT or microscopy do not need anti-malarial
medications.
The two main methods in routine use for parasitological confirmation of malaria are light
microscopy and rapid diagnostic tests (RDTs). For the management of a new fever episode,
quality-assured microscopy, and RDTs are equivalent in terms of performance for the
diagnosis of uncomplicated malaria. Light microscopy using thick blood films can be very
sensitive, detecting as few as 5-10 parasites/µl of blood. Thin blood film stained with Giemsa
helps identify the malaria parasite species and has a sensitivity of 30 parasites/µl. The
recommended method to determine parasite load is by counting the number of malaria
parasites per microliter of blood on a thick blood film. Currently, multi-species RDTs capable
of specifically detecting both P. falciparum and P. vivax, are being supplied by MOH to
health posts, enhancing malaria diagnosis by species at the periphery and reducing the need
for empiric treatment and wastage of anti-malarial drugs. RDTs have a sensitivity to detect
malaria parasites above 100 parasites/µl.
In addition, molecular diagnosis (e.g., polymerase chain reaction / PCR) is usually applied in
research settings, and in surveillance in areas where elimination of malaria is in progress.
Serological tests for malaria have no place in the management of febrile patients.

Instructions: Read and analyze the case below individually and answer the given question
Case Scenario
A 34 years old male patient from a malarious area presented to a rural OPD with fever,
headache, chills and rigors of three-day duration. No other remarkable complaints
The axillary temperature record was 380c and no other remarkable physical findings. The
blood film revealed P. falciparum parasites, and other findings (Hgb and RBS) are within
normal range.
Task
 What other tests are important for this patient?
 What is the diagnosis of this patient? Why?
Time-10 minutes
4.2-Treatment of uncomplicated malaria

1-The first-line treatment of uncomplicated malaria at health center and hospitals level
A. P. falciparum positive by microscopy:
Artemether-Lumefantrine (AL) plus single-dose primaquine are the recommended first-line
drugs. AL tablets are given according to body weight in six doses over three days as indicated
in the table below.
The first dose of AL and the single dose PQ should be given under the direct supervision of
the health worker to make sure that the patient can take the medicine without any problem.
AL should preferably be taken with food or fluids. A fatty meal or milk improves the
absorption of the drug.
The single dose primaquine phosphate dose is 0.25 mg base per kg
NB: A single dose doesn’t mean a single tablet. The patient will take one dose, but the
number of tablets may be different
If vomiting occurs within half an hour after swallowing 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.
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.
Table 4. Tablet containing 20 mg Artemether plus 120 mg Lumefantrine in a fixed dose
Weight Day 1 Day 2 Day 3 Color

(KG) code
Immediate After 8 Morning Evening Morning Evening Total
hours tablets
<5kg 1 1 tablet 1 1 1 1 tablet 6
tablet tablet tablet tablet Yellow*
5-14 1 1 tablet 1 1 1 1 tablet 6
kg tablet tablet tablet tablet
15-24 2 2 tablets 2 2 2 2 Blue*
kg tablets tablets tablets tablets tablets 12
25-34 3 3 tablets 3 3 3 3 Brown
kg tablets tablets tablets tablets tablets 18
>35 4 4 tablets 4 4 4 4 24 Green
tablets tablets tablets tablets tablets
* (Yellow, Blue) flavored pediatric formulation (dispersible tablets) of Artemether-
Lumefantrine (AL) is available for enhancing its use in young children.
Side effects:
The following adverse effects have been reported; dizziness and fatigue, anorexia, nausea,
vomiting, abdominal pain, palpitations, myalgia, sleep disorders, arthralgia, headache, and
rash.
Contraindications:
● AL should not be used as malaria prophylaxis either alone or in combination;
● Persons with a previous history of reaction after using the drug;
● Persons with severe and complicated malaria should not be treated with oral
medications as a standard treatment.

B- P. vivax malaria:
The first line drug of choice is chloroquine at a total dose of 25 mg base/kg and a daily dose
of 0.25mg/kg primaquine (radical cure) orally for 14 days with close clinical follow-up. It is
vital to support patients’ adherence with a phone call reminder or other means.
Table 5. Tablets of chloroquine 150 mg base or syrup 50 mg base per 5 ml
Weight Day 1 Day 2 Day 3 Total tabs

(kg)
5–6 ½ tablet OR ½ tablet OR ¼ tablet OR 1.1/4 tabs
5 ml syrup 5 ml syrup 2.5 ml syrup 12.5ml
7 – 10 ½ tablet OR ½ tablet OR ½ tablet OR 1 ½ tabs
7.5 ml syrup 7.5 ml syrup 5 ml syrup 20ml
11 – 14 1 tablet OR 0.5 tablet OR 0.5 tablet OR 2 tabs
12.5 ml syrup 12.5 ml syrup 7.5 ml syrup 32.5ml
15 – 18 1 tablet OR 1 tablet OR 1 tablet OR 3 tabs
15 ml syrup 15 ml syrup 15 ml syrup 45ml
19 – 24 1 ½ tablets OR 1 ½ tablets OR 1 tablet OR 4 tabs
20 ml syrup 20 ml syrup 15 ml syrup 55ml
25-35 2 ½ tablets 2 tablets 1 tablet 5.5tabs
36-50 3 tablets 2 tablets 2 tablets 7 tabs
51+ 4 tablets 4 tablets 2 tablets 10 tabs
(Note, one 250 mg chloroquine phosphate salt tablet contains 150 mg chloroquine base).
Never take more than four 250 mg chloroquine phosphate tablets in one day.
Side effects of chloroquine:
Dizziness, skeletal muscle weakness, mild gastrointestinal disturbances (nausea, vomiting,
abdominal discomfort, and diarrhea), and pruritus. Pruritus may be severe but usually passes
within 48-72 hours.
Contraindications:
● Persons with known hypersensitivity after using the drug.
● Persons with a history of epilepsy
● Persons suffering from psoriasis
Primaquine:
Indications
1-Gametocye clearance for P.falciparum
2-Radical cure (prevention of relapse) for P.vivax
Table 6. Tablet containing 7.5 mg of Primaquine
Weight (kg) 7.5 mg tablet 15 mg tablet

8-18 ½ ¼
19 – 24 ¾ ½
25 – 35 1 ½
36 – 50 1½ ¾
50+ 2 1
Side effects of primaquine:

Hemolytic anemia due to G6PD deficiency is a rare side effect in Ethiopia; however it can be
serious if it occurs. Though the prevalence of G6PD deficiency is very low in Ethiopia, health
workers should closely follow up with patients started on primaquine for hemolysis by
informing the patient about symptoms of hemolytic anemia such as dark urine color. Patients
with dark urine color should discontinue primaquine and come back to the health facility. If
there is evidence of hemolysis, primaquine should be discontinued and should not be given to
the patient in the future.
Anorexia, nausea, vomiting, abdominal pain, and cramps are dose-related and relatively rare
at daily doses up to 0.25 mg base/kg. They may also be accompanied by vague symptoms
such as weakness and uneasiness in the chest.
Contraindications:
● Pregnancy
● Women breastfeeding infants less than six months of age
● Infants less than six months of age
C- Mixed infection: The recommended first-line treatment for mixed infection is AL and
primaquine radical cure for 14 days.
Note: Do not treat a patient with confirmed mixed infection with AL plus chloroquine.
D- Microscopy is negative for all malaria species, malaria is unlikely. Other causes of fever
should be investigated.
E- If no parasitological test is available: Where microscopy and RDT are not available, and
the patient fulfills the clinical criteria of malaria, AL with a single dose of Primaquine
should be given.
2. Supportive treatment for uncomplicated malaria
If patients, especially children present with axillary temperature ≥38.5 0C, treat with
antipyretics and fanning and tepid sponging. Paracetamol (acetaminophen) 15 mg/kg every 4
hours is widely used; it is safe and well-tolerated, given orally or as a suppository. Pain
should be treated and the patient should be encouraged to take food and fluids.
Treatment of uncomplicated malaria at the health post and primary clinic level:
The diagnosis of malaria is based on rapid diagnostic test results. Health extension workers
may be using clinical criteria only if RDT is not available.
A. The first and second-line treatment of uncomplicated P. falciparum, P. vivax, and

mixed malaria at health posts is the same as the treatment at the health center and
hospital, including supportive treatment and patient counseling.
B. If multispecies RDT is negative, malaria is unlikely. Other causes of fever should be
investigated.
C. If RDT test is not available and the patient fulfills the clinical criteria of malaria, AL
with a single dose of Primaquine should be given.
Second line treatment
Second-line treatment is a drug used after failure of first-line treatment or in patients who are
allergic to or unable to tolerate the first-line treatment.
In Ethiopia, Dihydroartemesinin-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. Dihydroartemesinin-piperaquine is a new co-formulated ACT and is well
tolerated. It is proven 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 the global
market. It has pediatric and adult preparations. DHA-PPQ treatment should be followed by
single dose primaquine for P. falciparum and radical cure for P. vivax malaria.
Dihydroartemesinin-Piperaquine Treatment Schedule

Formulations: Currently available as a fixed-dose combination in tablets containing 40 mg
dihydroartemisinin and 320 mg piperaquine and pediatric tablets contain 20 mg
dihydroartemisinin and 160 mg piperaquine.
● Child 5 to < 25 kg: 2.5 to 10 mg/kg daily of DHA + 20 to 32 mg/kg daily of PPQ
● Tablets are to be taken once daily for 3 days.
Table 7. Dihydroartemisinin-piperaquine dose
Weight 20 mg/160 mg tablet 40 mg/320 mg tablet

5 to < 8 kg 1 –
8 to < 11 kg 1½ –
11 to < 17 kg – 1
17 to < 25 kg – 1½
25 to < 36 kg – 2
36 to < 60 kg – 3
60 to < 80 kg – 4
Contra-indications, adverse effects, precautions
 Do not administer in the event of cardiac disorders (bradycardia, heart rhythm

disorders, congestive heart failure).
 Do not combine with drugs that prolong the QT interval: amiodarone, other
antimalarials, antipsychotics, fluconazole, fluoroquinolones,
hydroxyzine, macrolides, ondansetron, etc.
 Administer with caution to patients > 60 years old or with renal or hepatic
impairment.
 May cause cardiac disorders (QT prolongation, tachycardia); rarely,
gastrointestinal disturbances, pruritus, hepatic disorders, joint and muscle pain.
 Monitor combination with antiretroviral (increased blood levels of these drugs),
and enzyme inducers such as rifampicin, carbamazepine, phenytoin, and
phenobarbital (reduced blood levels of DHA/PPQ).
 If the patient vomits within 30 minutes after administration, re-administer the full
dose. If the patient vomits between 30 minutes and 1 hour after administration, re-
administer half of the dose.
 Pregnancy: no contra-indication
Malaria in Pregnancy
The symptoms and complications of malaria in pregnancy vary according to transmission
intensity and the level of acquired immunity. Pregnant women living in areas of low or
unstable malaria transmission (like many malarious areas in Ethiopia) have little or no
immunity to malaria and are at higher risk of developing severe malaria than non-pregnant
adults living in the same area.
In these areas, malaria is a major cause of maternal anemia, spontaneous abortion, stillbirth,
premature delivery, low birth weight (birth weight < 2.5kg), neonatal death, and maternal
death. In non-immune women, severe malaria symptoms (hypoglycemia, cerebral malaria,
and pulmonary edema being particular problems) are more common in pregnancy.
In stable transmission settings, the deleterious impact of malaria is particularly apparent in

first and second pregnancies. Partial clinical immunity acquired during years of exposure to
the malaria parasite before pregnancy does not prevent infection but does reduce the risk of
severe disease. Clinical malaria is not, therefore, a prominent feature of infection during
pregnancy, and the major detrimental effects of infection are low birth weight (LBW) and
maternal anemia.
HIV infection impairs pregnant women’s ability to control P. falciparum infection. Women
with HIV infection is more likely to have symptomatic malaria infections and to have an
increased risk of an adverse birth outcome due to malaria. In the presence of HIV infection,
placental malaria appears to be independent of the number of pregnancies, so the risk of
placental malaria is similar in HIV-infected multigravida and HIV-negative primigravida.
Severe anemia, exacerbated by malaria, is an important complication of pregnancy in many

tropical countries. Especially in communities where chronic hookworm anemia is prevalent,
high-output anemic cardiac failure may develop in late pregnancy.
Asymptomatic hypoglycemia may occur in pregnant women with malaria before antimalarial
treatment and pregnant women with uncomplicated or severe malaria are particularly
vulnerable to quinine-induced hypoglycemia.
There is an increased risk of pulmonary edema precipitated by fluid overload or by the

sudden increase in peripheral resistance, or auto transfusion of hyper-parasitaemic blood from
the placenta which occurs just after the delivery
Treatment of uncomplicated malaria in pregnancy
Pregnant women with symptomatic acute malaria are a high-risk group and require effective
antimalarial medication. There is insufficient information on the safety and efficacy of most
antimalarial medicines in pregnancy, particularly for exposure in the first trimester, and
treatment recommendations differ from those for non-pregnant adults. Therefore, as a
standard practice for the administration of any medicine for pregnant women, all women of
child-bearing age should be asked whether they are, or could be, pregnant before an
antimalarial medicine is prescribed.
The following are the antimalarial medicine recommendations:
For the treatment of uncomplicated falciparum malaria:
 In all trimesters, give Artemether-Lumefantrine (AL)

For the treatment of P. vivax malaria:
 Chloroquine, which is the treatment of choice for P. vivax (chloroquine-sensitive),
P. ovale, and P. malaria, is safe in pregnancy.
 Primaquine is contraindicated during pregnancy
Provide weekly chloroquine prophylaxis at a dose of 2 tabs weekly (300mg base/500mg salt),
until after delivery and breastfeeding for 6 months and then radical cure.
Prevention of malaria during pregnancy

Pregnant women should be given priority in LLIN utilization. Intermittent preventive
treatment of malaria during pregnancy (IPTp) is recommended in high transmission areas,
however, it is not recommended in Ethiopia
Malaria and Malnutrition

 Malaria and malnutrition frequently coexist.
 Malnutrition may result in inaccurate dosing if we use the age or weight of the child.
 Different conditions may hamper the absorption of anti-malarial drugs if given orally
or parenteral, e.g. Chronic(persistent) diarrhea, vomiting, rapid gut transit, or atrophy
of the small intestine villi (enteropathy)
 Diminished muscle mass may also make repeated intramuscular injection difficult.
 Hypoalbuminemia may also lead to rapid clearance of the drugs as some drugs need
albumin for binding.
 Although these findings are concerning, they are insufficient to warrant dose
modification of any anti-malarial drugs in a patient with malnutrition, however, their
response to treatment should be monitored more closely.
Malaria and HIV

 There is a geographical overlap between malaria and HIV, and many people are co-
infected.
 Worsening HIV-related immunodeficiency may lead to manifestation of severe
malaria
 In areas of stable malaria transmission patients have more frequent and higher-density
infections due to partial immunity while in unstable transmission areas, HIV infection
is associated with an increased risk of severe malaria and malaria-related death.
 Early studies suggested that HIV-related immunosuppression was associated with
decreased response to anti-malarial drugs but now there is insufficient information to
change the drugs and dose of anti-malarial drugs we used for non-HIV-infected
individuals.
Malaria and TB
 There is evidence that shows patients taking Rifampicin with quinine, ACTs, and
mefloquine have a three-to-nine-fold decrease of the anti-malarial drugs in the serum
as well as a higher recrudescence rate.
 However, there is insufficient evidence to change the drug and dosing in patients who
are taking anti-TB drugs. However, these patients are at higher risk of recrudescent
infection, so they should be monitored closely.
4.3- Patient counseling during uncomplicated malaria management

●
Activity 4.3: Case study
Instructions: Go over the following questions just to retrieve your prior knowledge/
experience. Feel free to answer/reflect/respond to the questions
Case scenario
A 45 years old migrant worker was diagnosed with uncomplicated mixed malaria infection
and the proper anti-malaria drugs were given by the OPD nurse.
● What messages should be provided by the nurse and why?
Time: 10 Minutes
Patient counseling during uncomplicated malaria management

Health workers should clearly explain malaria diagnosis and treatment, e.g. making patients
understand drug labels and instructions. Social and Behavioral Change (SBC) messages
should include the following:
● H/she has got malaria
● Malaria is transmitted by mosquito that bites mainly at night
● Malaria is a killer disease if treatment is not sought early and treatment is not
taken properly
● Whenever a family member has a fever, take the person to the nearest health
facility immediately or at least within 24 hours
● Do not interrupt taking medication. Take all (full course) of the anti-malarial
drugs, prescribed by health personnel
● Take/give enough food and fluid (especially fatty meals) to enhance drug
absorption and avoid the risk of hypoglycemia
● Do not share drugs with others, including family members.
● Come back to the health facility after three days if no improvement in symptoms
after malaria treatment or any time if there is a worsening of symptoms.
● Malaria can be prevented by using LLINs/ITNs, eliminating mosquito breeding
sites, and indoor residual spray;
● All family members, especially women and children should sleep under LLINs
every night and protect the sprayed house from plastering
- Activity4.4 Role Play

Objectives: To Counsel a patient with uncomplicated malaria
Roles description
 One trainee will act out as health care provider working in health facility informing the
blood film result and counsel the key messages during the treatment of uncomplicated
malaria
 One trainee will act out as a client: The client will listen to the health care provider
information and ask questions
 Role of others participants: observe the key aspects of the role play and give feedback
Scenario
A 30 years old patient presented to the OPD with fever of 4- day duration and headache,
chills and rigors. No other complaints. Physical examinations are normal. A nurse working
in a rural health center OPD and ordered blood film to the patient and the result came with
P. falciparum malaria. He/she is informing the result and providing counselling for a
patient with uncomplicated malaria.
Task for health care provider:

Counsel a patient with uncomplicated malaria during the treatment session.
Discussion question (after the role-play)
Did the health care provider?
 Clearly explained that the patient’s diagnosis?
 Described what will happen to the patient if the patient delays seeking treatment?
 Explained common prevention methods, Adherence to drugs and when to return?
Time-30 minutes
4.4- Management of treatment failure and referral
Activity 4.5: Group discussion

experience. Feel free to answer/reflect/respond to the questions.
 When do you say a patient has failed for malaria treatment?
 What are the common causes for treatment failure?
 How will you manage?
Time: 10 minutes
Treatment failure
Treatment failure is defined as the failure of an anti-malarial drug to resolve fever and/or
parasitemia. For clinical purposes, consider treatment failure in a patient with malaria who
was treated for malaria in the past 28 days. Treatment failures may result from drug
resistance, poor adherence, inadequate drug exposure (i.e., under-dosing, vomiting, or
unusual pharmacokinetic properties in that individual), drug interaction, misdiagnosis, or
substandard medicines. It is essential to determine whether the antimalarial was vomited or
the full course was not completed from the patient’s history. Monitoring treatment failure is
critical because it can signal the appearance of anti-malarial drug resistance.
Anti-malarial drug resistance refers to the ability of a parasite strain to survive and/or
multiply despite the administration and absorption of medicine given in doses equal to or
higher than those usually recommended, but within the tolerance of the subject, and the drug
must gain access to the parasite or the infected red blood cell for the duration of the time
necessary for its normal action and anti-malarial drug resistance can cause treatment failure
but not all treatment failure is due to parasite resistance to the drugs.
Appropriate management of treatment failure is critical because the patient may progress to
severe malaria, and resistant parasites may be present and transmitted to others. All malaria
patients should be asked for a history of malaria treatment in the past 28 days. If they have
such a history, they should be diagnosed using a microscopy test.
Treatment failure within first 28 days: Owing to the potency of AL, treatment failure within
28 days of receiving AL is very unusual. Recurrence of P. falciparum malaria may be the
result of a reinfection, or a recrudescence (i.e., treatment failure). It may not be possible to
distinguish between recrudescence and reinfection in an individual patient. However, if fever
and parasitemia fail to resolve or recur within four weeks of treatment, then the treatment has
failed. Wherever possible, treatment failure should be confirmed parasitologically;
preferably, a blood smear should be obtained and labeled correctly to verify–amongst others–
Plasmodium species and parasite count and to rule out other diseases (e.g., relapsing fever).
RDTs may remain positive for weeks after the initial infection, even without recrudescence.
This requires referring a patient from a health post to a health center where microscopy is
available; referral may also be necessary to obtain second-line treatment which is available at
the health center level.
Treatment failure after 28 days: Most treatment failures occur after two weeks of initial
treatment. Such failures can result from either recrudescence or a new infection. This
distinction can only be made through parasite genotyping by PCR, which is not used in
patient management in Ethiopia. Thus, to simplify operational management and medicine
deployment, all presumed treatment failures after four weeks of initial treatment should be
considered as new infections, and be treated with the first-line antimalarial drug.
Management of treatment failure: The following recommendations should be followed
after a complete history, clinical assessment, and laboratory examination:
 If a cause for treatment failure is identified (e.g., the anti-malarial drug is vomited),
such cause must be addressed and treatment reinstituted with the first-line anti-
malarial drug. If a patient with treatment failure is still taking primaquine, it is
recommended to finish the started course and no additional course is required;
 If no cause is identified, a P. falciparum or P. vivax-infected patient returns to the
health facility with fever or a history of fever between 4 to 28 days of treatment, and
if parasites are detected by microscopy (Note: do not use RDTs), the treatment should
be changed to the second-line drug, i.e. Dihydroartemisnin-piperaquine tablets. Single
dose primaquine will be given for P. falciparum and radical cure for P. vivax if the
first radical cure course is completed;
 In patients who are suspected of having treatment failure after 28 days, the first-line
anti-malarial drug should be used;
 If the blood smear is negative and no other apparent causes are found, the patient
should be re-evaluated or referred to the next level of health care for proper
management.
Referral
All patients must be assessed for the presence of danger signs (refer chapter 5). Children and
adults with severe signs at health centers should be provided with the first dose of injectable
artesunate and be referred urgently to hospital.
REMEMBER: A delay in referral could cause unnecessary death of the patient.
Chemoprophylaxis
Persons who travel to malaria-endemic areas are at risk of acquiring malaria. Health workers
should advise all persons traveling to such places to avoid mosquito bites, specifically by
sleeping under LLINs at night and using mosquito repellent. Chemoprophylaxis is an option
and mefloquine or atovaquone-proguanil can be used as anti-malarial chemoprophylaxis in
Ethiopia (refer to WHO travel health guidelines).
(2 weeks before departure once weekly during the stay and once per week for 4 weeks after
return)
Table 8. Mefloquine: 5 mg /kg mefloquine salt once weekly
Weight (Kg) Age (approx.) Number of tablets per week

<9 < 3 months Not Recommended
9 – 19 3 – 23 months ¼
20 – 30 2 – 7 years ½
31 – 45 8 – 10 years ¾
36 – 50+ 11 – 14+ 1
(1-2 days before departure daily during the stay and daily for 7 days after return)
Table 9. Atovaquone-proguanil
Weight (kg) Atovaquone/ Proguanil HCl Dosage Regimen

11-20 62.5 mg/25 mg 1 Pediatric Tablet daily
21-30 125 mg/50 mg 2 Pediatric Tablets as a single dose daily
31-40 187.5 mg/75 mg 3 Pediatric Tablets as a single dose daily
>40 250 mg/100 mg 1 Tablet (adult strength) as a single dose daily
4. 5-Antimalaria Pharmacovigilance
●
Activity 4.6 : Group discussion

● What are the common anticipated adverse drug reactions of the antimalarial
medicines?
● What action steps will you take if a patient develops the ADRs?
Time: 10 minutes
Definition
Pharmacovigilance is the science and activities relating to the detection, assessment,
understanding, and prevention of adverse effects or any other medicine/vaccine-related
problem.
The Importance of Pharmacovigilance
1. Improve patient care and safety in relation to the use of medicines and all medical
interventions
 Improve public health and safety in relation to the use of medicines;

 Detect problems related to the use of medicines and communicate findings in a timely
manner
 Contribute to the assessment of the benefit-risk ratio, effectiveness, and risk of
medicines, leading to the prevention of harm and maximization of benefits
 Encourage the safe, rational, and more effective (including cost-effective) use of
medicines
 Promote the understanding, education, and training of pharmacovigilance and its
effective communication to the public.
Pharmacovigilance process/Stages
Stage 1: Detection. Collection of Individual Case Safety Reports (ICSRs) ...
Stage 2: Assessment.
Stage 3: Understanding the drug safety profile.
Stage 4: Prevention of adverse effects.
Components of Pharmacovigilance
It is essential to monitor for adverse effects even after a drug or therapy has been on the
market for some time, as new ones may emerge. It has three main components/ phases:
● Pre-clinical
● Clinical trial and
● Post-marketing
Each phase has its importance in ensuring the safety of medicines

Pharmacovigilance Methods
1. Passive surveillance: spontaneous reporting cases
2. Active surveillance: sentinel sites drug event monitoring registers
3. Comparative observational studies: Cohort, case-control, and cross-sectional studies.
4. Stimulated reporting and
5. Targeted clinical investigations
Major factors predisposing to adverse effects
1. Extremes of age
2. Intercurrent illness:
● Drug interactions:
● Incompatibilities between medicines and IV fluids
● Adverse effects caused by traditional medicines
● The effect of food on drug absorption
● Medication errors common in developed countries and
● Product quality defect
What to report
It is mandatory to report all adverse drug events that contain adverse drug reactions, product
quality defects, and medication errors.
Adverse drug reactions which include:
● All suspected reactions to medicines
● Unknown or unexpected reactions
● Serious adverse drug reactions
● Unexpected therapeutic effects
● All suspected drug interactions, including interactions with other medicines,
chemicals, and food.
● Treatment failures
When to report
Any suspected ADR, medication error, or quality defect should be reported as soon as
possible after all relevant information is compiled. Delays in reporting will make reports
inaccurate and unreliable. Reporting while the patient is still in the health institution will give
chance to the reporter to clear any ambiguity by re-questioning or examining the patient.
How to report suspected ADEs
The national PV system has reporting tools to receive encountered and observed ADEs from
healthcare professionals, using the following mechanisms:
1. The yellow prepaid report forms available at the facility
2. 8482 (toll free line)
3. Online reporting: (www.efda.gov.et-services-e-Reporting)
4. Med safety (using a mobile application that can be downloaded)
Targeted malaria medicines
 All malaria medicines will be under observation

 Primaquine radical cure regimen with big emphasis
 Artesunate injection
Objectives
 To identify the risk factors for ADR
 To identify the common adverse drug reactions of the anti-malaria drugs
 Record and report the ADRs?
 To diagnose ADR
 To forward the necessary steps in reporting ADRs
Instruction: Read and analyze the case below individually and answer the given questions
Case Scenario: A 78 years old known chronic liver disease patient from a malarious area
presented to a rural health center with fever, headache, chills and rigors of three-day
duration. No other complaints. The axillary temperature record was 39 0c, no other
pertinent physical findings. The blood film revealed P. vivax parasites and other findings
(Hgb and RBS) are within normal range.
The clinician gave him chloroquine and primaquine radical cure and sends him home. On
the 4th day he came back with dark urine color change and shortness of breath with
generalized body swelling. Physical examination showed RR-40/min, paper white
conjunctiva and Hgb-7gm/dl
Task
 Does this patient have any ADRs? Why?
 If yes which drug is most likely responsible?
 Does the patient have any risk factors? If yes, what are they?
 What management steps should the health care provider do to manage the ADRs?
Time-10 minutes
Malaria diagnosis and treatment Algorithm
Suspected Malaria Case (See Box 1)
Signs and symptoms of

severe malaria
No
History of malaria treatment in

the past 4 weeks
Yes
Refer to the
algorithm for Yes No
malaria treatment
failure
Microscopy
Manage Look for other Negative
accordingly or causes of fever
refer to higher
level P. vivax
P. falciparum Mixed (Pf, Pv)
Treat with
Treat with AL and Treat with AL & chloroquine** and
single dose PQ* radical cure PQ* 14 days PQ unless
unless there is unless there is there is
contraindication contraindication contraindication
**Give AL if chloroquine syrup is

not available
Box 1.
*Contraindications of primaquine are pregnancy,
breast feeding mothers less than six months Patient with fever or history of fever in the
infants, infants under six months, moderate to last 48 hours and lives in malaria-endemic
severe anemia, known hypersensitivity to areas or has history of travel within the past
primaquine 30 days to malaria-endemic areas.
Figure 3. flowchart for the diagnosis and treatment of malaria at the health center and
hospital level
Suspected Malaria Case (See Box 1)
Signs and symptoms of

severe malaria
No
History of malaria treatment in

the past 4 weeks
Yes
No malaria
treatment failure No yes
Microscopy
Manage Look for other Negative
accordingly or causes of fever
refer to higher
level
P. P.v or Mixed (Pf, Pv)
falciparum
A species different
from the first parasite
is treated with first- Treat with Treat with
line drugs Dihydroartemisnin- Dihydroartemisnin-
piperaquine and piperaquine & radical
single-dose PQ* cure PQ* unless there is
unless there is contraindication
contraindication
Box 1.
Patient with fever or history of fever in
*Contraindications of primaquine are the last 48 hours and lives in malaria-
pregnancy, breast feeding mothers less endemic areas or has history of travel
than six months infants, infants under six within the past 30 days to malaria-
months, moderate to severe anemia, endemic areas.
known hypersensitivity to primaquine
Figure 4. Flowchart for the management of malaria treatment failure at Hospitals and
HCs
Chapter Summary
 Artemether-Lumefantrine (AL) plus single-dose primaquine (0.25mg/kg) is the

recommended first-line drug for P. falciparum.
 P. vivax malaria: The first-line drug of choice is chloroquine at a total dose of 25 mg
base/kg and primaquine for radical cure with close clinical follow-up at a daily dose
of 0.25mg/kg orally for 14 days. It is vital to support patients’ adherence with a phone
call reminder or other means.
 Mixed infection: The recommended first-line treatment for mixed infection is AL and
primaquine radical cure for 14 days
 If microscopy is negative for all malaria species, malaria is unlikely. Other causes of
fever should be investigated.
 Where microscopy and RDT are not available, and the patient fulfills the clinical
criteria of malaria, AL with a single dose of Primaquine should be given
 Health workers should clearly explain malaria diagnosis and treatment social and
behavioral change (SBC) messages, e.g. making patients understand drug labels and
instructions.
 Treatment failure is defined as the failure of an anti-malarial drug to resolve fever
and/or parasitemia.
 For clinical purposes, consider treatment failure in a patient with malaria who was
treated for malaria in the past 28 days.
 Treatment failures may result from drug resistance, poor adherence, inadequate drug
exposure (i.e., under-dosing, vomiting, or unusual pharmacokinetic properties in that
individual), drug interaction, misdiagnosis, or substandard medicines.
 All patients must be assessed for the presence of danger signs. Children and adults
with severity signs at health centers should be provided with the first dose of
injectable artesunate and be referred urgently to hospitals
References & resources for further reading
● National Malaria Guidelines. 5th edition 2022, FMHO: Addis Ababa.
● Guidelines for the treatment of malaria. 3rd edition. 2015 WHO: Geneva.
● Malaria Case Management: Guide for participants. 2012 WHO: Geneva.

CHAPTER FIVE: SEVERE MALARIA

Chapter Description:
This chapter focuses on approaches to cases with severe malaria which include identification
of severity signs of malaria, pathogenesis of severe malaria, and identification and
management of complications related to severe malaria.
Chapter Objective
At the end of this chapter, a participant will be able to discuss the diagnosis and treat severe
malaria.
Learning Objectives: by the end of this chapter, participants will be able to:
 Define severe malaria.

 Identify determinants of severe malaria and high-risk groups.
 Explain the host-parasite interaction that contributes pathogenesis of severe malaria.
 Describe the recommended antimalarial regimens for severe malaria.
Chapter Outline/ Sessions

5.1: Definition of severe malaria
5.2: Pathogenesis and determinants of severe malaria
5.3: Treatment of severe malaria
5.4. Summary
Activity5.1; group discussion
experience. Feel free to answer/reflect/respond to the questions.
 What are the common signs and symptoms that clinicians use to admit patients
diagnosed with malaria?
 Many clinicians admit patient with parasite count of +++ or ++++ to admit
patients, do you agree with them? If yes or no Justify your answers?
Time: 10 minutes
5.1. Definition of Severe Malaria
For epidemiological purposes, severe falciparum malaria is defined as one or more of the
following, occurring in the absence of an identified alternative cause and in the presence of
P. falciparum asexual parasitemia: impaired consciousness, prostration, multiple convulsions,
acidosis, hypoglycemia, severe malarial anemia, renal impairment, jaundice, pulmonary
oedema, significant bleeding, compensated or decompensated shock or hyperparasitemia.
A correct diagnosis of severe malaria should be based on a complete case history, a physical
examination, and laboratory investigations. Both thick and thin blood films should be
examined to demonstrate the presence of P. falciparum asexual parasites.
Detailed definition of the above terms and conditions

1. Impaired consciousness: unarousable state of coma lasting for more than 30 minutes
b. A Glasgow coma score < 11 in adults
c. or a Blantyre coma score < 3 in children
2. Prostration: generalized weakness (unable to sit, stand, or walk without assistance)
3. Multiple convulsions: More than two episodes within 24 h
4. Acidosis: A base deficit of > 8 mEq/L or, if not available, a plasma bicarbonate level of
< 15 mmol/L or venous plasma lactate ≥ 5 mmol/L.
a. Severe acidosis manifests as respiratory distress (rapid, deep, labored
breathing).
5. Hypoglycemia: Blood or plasma glucose < 2.2 mmol/L (< 40 mg/dl)
6. Severe malarial anemia:
 Hemoglobin concentration ≤ 5 g/ dL or a hematocrit of ≤ 15% in children < 12
years of age with a parasite count > 10 000/µL
 Hemoglobin concentration < 7 g/dL or a hematocrit of < 20% in adults with a
parasite count > 10 000/µL.
7. Renal impairment: plasma or serum creatinine > 265 µmol/L (3 mg/dL) or blood urea >
20 mmol/L.
8. Jaundice: Plasma or serum bilirubin > 50 µmol/L (3 mg/dL) with parasite count > 100
000/ µL.
9. Pulmonary oedema: Radiologically confirmed or oxygen saturation < 92% on room air
with a respiratory rate > 30/ min, often with chest indrawing and crepitations on
auscultation.
10. Significant bleeding: Including recurrent or prolonged bleeding from the nose, gums, or
venipuncture sites; hematemesis or melena.
11. Shock: compensated or decompensated shock
● Compensated shock is defined as capillary refill ≥ 3 s or temperature gradient
on the leg (mid to proximal limb), but no hypotension.
● Decompensated shock is defined as systolic blood pressure < 70 mm Hg in
children or < 80 mmHg in adults, with evidence of impaired perfusion (cool
peripheries or prolonged capillary refill).
12. Hyperparasitaemia: P. falciparum parasitaemia > 2%
 Severe vivax and knowlesi malaria: defined as falciparum malaria but with no
parasite density thresholds.
Table 10. Glasgow Coma Scale
Parameter Response Score

Eye opens Spontaneously 4
To speech 3
To pain 2
Never 1
Best verbal response Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
Best motor response Obeys command 6
Localizes pain 5
Withdrawal from pain 4
Flexion to pain 3
Extension to pain 2
None 1
Total score 3-15
The Blantyre’s Coma Scale (for children)
Parameter Response Score
Eye movements Directed (e.g. follows mother’s face) 1
Not directed 0
Best verbal Appropriate cry 2
response Moan or inappropriate cry 1
None 0
Best motor Localizes painful stimulus (rub knuckles on patient’s 2

response sternum or firm pressure on thumbnail bed with horizontal
pencil)
Withdraws limb from pain 1
Nonspecific or absent response 0
Total score 5
Practice exercise
(Think Pair and Share)

Objective-to identify the severity signs of malaria (clinical and laboratory)
Instruction: Read the cases below in pairs and verify if it is severity sign/symptom of
malaria. All cases below had fever with P. falciparum positive with blood film
examination and the following additional signs or symptoms.
Case-1: The patient was having loss of consciousness for 5 minutes.
Case-2: The patient came to health facility carried by four people on a bed.
Case 3- The patient came to health facility supported and pushes your hand trying to lie
on the couch while you are assessing his chest.
Case 4: The patient had a single episode of abnormal body movement during breakfast
yesterday morning.
Case 5: The patient has hemoglobin of 6mg/dl and parasite count >10,000/µl.
Case 6: The patient came with yellowish discoloration of the eyes.
Case 7: A patient with pulse oximetry finding with oxygen saturation of 88%.
Case 8: A patient with single episode of nose bleeding last night.
Case 9: A patient with nose bleeding came to OPD with a big pack in the nose as the
bleeding couldn’t stop.
Case 10. Systolic blood pressure of 70 mmHg
Case 11: parasitemia of 1% with serum creatinine of 300µmol/L
Case 12: A walking patient with parasitemia of 3%
Tasks: Identify those with severity signs and justify your answers.
Time- 20 minutes
5.2: Determinants and pathogenesis of severe malaria
Activity5.2: Group discussion
a) What are the risk groups of severe malaria?

b) What are the pathophysiologic mechanisms that lead to?
o Cerebral malaria
o Hypoglycemia,
o Anemia, and
o Acute renal failure?
Time: 10 minutes
5.2.1. Determinants of severe malaria and high risk groups

Any infection with P. falciparum can become severe if treatment is delayed or inadequate.
However, people who have been repeatedly exposed to falciparum malaria develop partial
immunity and are less likely to experience severe falciparum malaria.
Those most at risk are:
● People of all ages in areas of low endemicity (like most endemic places in
Ethiopia)
● Residents of areas where there is little or no falciparum malaria travel to a high

transmission area: this may involve travel within a country or between countries.
● Non-immune pregnant women (at risk of some specific complications)
● Internally displaced persons moving from areas of low to high malaria

transmission.
● Children in areas of high endemicity – especially those aged 6 months - 5 years
● People returning to highly endemic areas after a few years’ residence in areas
with little or no falciparum malaria.
● Patients who have had a splenectomy.
Severe non-falciparum malaria
● P. vivax and more recently P. knowlesi have been recognized as causes of severe
malaria particularly in Asia and in certain forested areas of South-East Asia

respectively. Severe vivax malaria may present with pathologies similar to severe P.
falciparum malaria and can be fatal. Severe anemia, respiratory distress, multiple
organ failure, and impaired consciousness (cerebral malaria) occur in all age groups
but the risk is greatest among young children and pregnant women.
5.2.2. Pathophysiology of severe falciparum malaria

Mechanism of malaria disease
The possible effects of malarial infection cover an enormous range, from completely
asymptomatic infection to severe fatal disease.
Factors are known to influence the severity of disease in malaria infection.
● The species of parasite: P. falciparum causes almost all cases of severe malaria.
However, P. vivax is being increasingly recognized as a cause of severe malaria.
● The immunity of individuals: Adults who lived all their lives in an endemic area
are less susceptible to severe disease than those who visit an endemic area for the
first time.
● Young children living in the same endemic area.
● Pregnancy
● The availability and efficacy of antimalarial medicines.
● The degree of parasite drug resistance that prevails locally.
● HIV/AIDS, especially in pregnant women & those with advanced immune
deficiency.
● Some genetically inherited conditions in the human host, e.g. sickle-cell trait, s-
thalassemia, and probably G6PD deficiency have a protective effect;

How parasites cause severe disease
Micro vascular obstruction of vital organs
In falciparum malaria, a consistent pathological feature is the sequestration of red blood cells
containing maturing parasites (schizonts, large trophozoites) in deep capillaries and venules.
This phenomenon is observed in many different organs and tissues, including the brain,
lungs, heart, bone marrow, and gut. It seems likely that sequestration is involved in
complications such as altered consciousness and acidosis, through pathophysiological
mechanisms that are not fully understood.
Sequestration contributes to microvascular obstruction and mechanical obstruction causes

hypoxia. In addition, sequestered parasites, which are known to be highly active
metabolically, may use up vital substances such as glucose, so that these are not available to
host cells, such as brain cells. The parasites may also release substances, e.g. lactate or toxins,
free iron, and toxic oxygen radicals that are directly injurious to local host tissues.
It is thought that sequestration may also serve to concentrate schizonts in vital tissues. The
rupture of schizonts stimulates the release of large quantities of cytokines locally with a
powerful local effect even if cytokine levels in the general circulation are not particularly
high.
Sequestration is due to
● Cytoadherence: is the attachment of parasitized red blood cells to the endothelial wall.
Sequestration appears to be confined to P. falciparum and does not occur in P. vivax

infection. At approximately 12–14 hours of development, P. falciparum parasites
begin to exhibit a high molecular weight protein strain specific to this variant –
Plasmodium falciparum Erythrocytic Membrane Protein1 (pfEMP1) – on the surface
of infected red blood cells which mediate attachment to vascular endothelium. This is
associated with knob-like projections from the erythrocyte membrane. The red cells
progressively adhere to the walls of venules and capillaries (cytoadherence) in vital
organs, producing sequestration.
● Rosetting: There is also the formation of ‘rosettes’ by un-parasitized red blood cells
within microvasculature. In vitro, a parasitized cell may attract unparasitized red cells
which adhere to its surface to form a rosette.
● Agglutination: is the attachment of parasitized red blood cells with each other
Cytokines
It is possible, but still not proven, that excessive production of pro-inflammatory cytokines
causes severe disease in addition to fever. The cytokine TNF is known to be secreted by the
individual in response to malaria. Large quantities of TNF circulate in severe falciparum
malaria, especially in fatal cases, and TNF is known to be capable of causing many of the
symptoms, signs, and complications that are typical of severe malaria, e.g. coma,
hypoglycemia, acidosis, anemia, and respiratory distress syndrome. The ratio of pro-
inflammatory to anti-inflammatory cytokines has been observed to be high in fatal cases of
malaria.
Figure 5. Brain tissue from a patient who died of cerebral malaria, showing microvascular
sequestration of parasitized red blood cells in both capillaries and small venules, with mild
perivascular edema around the larger vessels
Processes contributing to specific complications.
Altered consciousness or coma.
It is believed that altered consciousness or coma (cerebral malaria) is caused by the

sequestration of parasites in the brain. However, complete obstruction to blood flow is
unlikely since the survivors rarely have any permanent neurological deficit. Other processes
like hypoglycemia, convulsion, and concomitant CNS infections may cause or contribute to
altered consciousness or coma.
Hypoglycemia
Hypoglycemia may be due to impaired production or release of glucose in the liver and to
increased intake in the tissues. There is also increased consumption of glucose by the
parasite. In children, hypoglycemia complicates other childhood infections in addition to
malaria. Hypoglycemia can also develop during prolonged fasting.
Another mechanism leading to hypoglycemia, most commonly but not exclusively seen in
pregnant women, may develop during treatment with quinine infusion. These medicines
stimulate the production of insulin which contributes to hypoglycemia.
Convulsions
In relation to a convulsion, unconsciousness occurs both during the convulsion (ictal) and for
a period of up to several hours after the convulsion (post-ictal). Convulsions may be due to
the direct effect of parasites in the brain or may result from accompanying metabolic
disorders, e.g. hypoglycemia, severe acidosis, hyponatremia, or hypoxia. A very high
temperature may exacerbate any of these causes of convulsion or may itself trigger a
convulsion.
Anemia
Anemia is partly due to the destruction of red blood cells that contain parasites. Several other
mechanisms may accelerate the development of anemia: non-parasitized red cells are
destroyed more quickly than normal during malarial illness and the bone marrow does not
function adequately to replace them. Anemia is exacerbated if there is abnormal bleeding,
intravascular hemolysis, or renal failure.
Acidosis
Acidosis is probably due to a relative shortage of oxygen in tissues occupied by sequestered

parasites. Shortage of oxygen is worsened by hypovolemia and/or severe anemia, as both
conditions impair the supply of oxygen to tissues. Lack of oxygen forces tissues to obtain
energy by other pathways not dependent on oxygen; one result is the release of lactic acid,
leading to metabolic acidosis. Medicines containing salicylates, that are given to lower fever,
may exacerbate metabolic acidosis. Concomitant gram-negative septicemia aggravates
acidosis.
Acute renal failure
Acute renal failure – acute tubular necrosis – is a common complication in adults, but is
rarely seen in children. It is fully reversible if the patient is kept alive for long enough,
usually between a few days to three weeks, e.g. by peritoneal dialysis. Renal failure is most
likely to develop if there has been a period of low blood pressure or shock. Sequestration is
also observed in the kidneys.
Pulmonary edema and acute respiratory distress syndrome

Pulmonary edema (non-cardiogenic) may result from excessive fluid replacement by
intravenous infusion, especially if there is renal failure. Acute respiratory distress syndrome
(ARDS) appears to be due to a direct effect of parasites sequestered in the lungs, possibly
through the release of cytokines. Both of these complications are unusual in children in
endemic areas.
Hemoglobinuria
Hemoglobinuria results from the rapid breakdown of red blood cells in the circulation
(massive intravascular hemolysis).
Jaundice
Jaundice is more common in adults than in children and is due partly to hemolysis and partly
to liver dysfunction.
Shock
Shock is due to inadequate cardiac output and poor tissue perfusion. In some patients, it may
occur concurrently with bacteremia.
Bleeding disorders
In falciparum malaria, the platelet count is typically low. Nevertheless, spontaneous bleeding
is rare in both children and adults. When it develops it results from disseminated
intravascular coagulation (DIC).
Box 4: Essential laboratory tests
● Parasitological test (microscopy)
● Blood glucose level
● Hemoglobin (Hb) estimation or packed cell volume (hematocrit)
● Lumbar puncture
● White blood count
Box 5: Differential diagnosis of severe malaria

Decreased Level of Consciousness
● Viral encephalitis
● Bacterial meningoencephalitis
● Cerebral typhoid
● Cerebrovascular event (stroke)
● Complicated typhus, relapsing fever
● Febrile illness with hypoglycemia
● Sepsis
● Convulsion in a patient with fever
Impaired Renal Function
● Acute tubular necrosis due to hypovolemia or hypotension

Jaundice associated with fever
● Viral hepatitis
● Yellow fever
5. 3: Treatment of severe malaria

Activity 5.3 : Brain storming
Think of a severe malaria case you have admitted/ referred to other health facilities. How did
you manage the case and the complications?
Time: 10 minutes
5.3.1. Principles and Components of Treatment

The main objective of treatment is to prevent the patient from dying; secondary objectives are
prevention of recrudescence, transmission or emergence of resistance, and prevention of
disabilities.
Special attention is required because severe falciparum malaria is a common cause of
avoidable death and because correct early treatment and careful nursing can greatly improve
the outcome. Death from severe malaria often occurs within hours of admission to a hospital
or clinic, so it is essential that therapeutic concentrations of a highly effective antimalarial
drug be achieved as soon as possible. Management of severe malaria comprises mainly
clinical assessment of the patient, specific antimalarial treatment, additional treatment, and
supportive care.
The following special measures are indicated:
● Antimalarial medicines should be given parenterally, if possible, under close
supervision.
● Treatment should be undertaken in a hospital.
● Medicines that are ineffective and potentially dangerous should not be used.
Under ideal conditions, a severely ill patient, especially one who is comatose, should be
managed in an intensive care unit. Where this is not possible, as in most places in Ethiopia,
the health worker has to provide emergency care. Meticulous nursing care should be provided
as it can be lifesaving, especially for the unconscious patient.
5.3.2.-Immediate supportive treatment
In severe malaria, the patient has a number of life-threatening complications (s) which can be
fatal if not urgently treated. The most urgent measures that will be required are to:
 Start immediate resuscitation measures, paying attention to the ABC of life
 airway: In an unconscious or convulsing patient, the airway must be free of obstructions.
In convulsing patients, thrust the jaw forward to ensure a clear airway.
 B -breathing: Check that the patient is breathing by looking for chest movements and
listening for breath sounds, and support breathing by giving oxygen.
 C - circulation: Feel hands and check for capillary refill, check, monitor, and record vital
signs, i.e., blood pressure, pulse rate, and respiratory rate. In addition, support circulation
by giving IV fluids, preferably plasma expanders, if this cannot be achieved, perform
either venous cut-down or in life-threatening situations, establish an intra-osseous
infusion; Intravenous route help to administer medicines and fluids;
 Once basic resuscitation has been implemented, assess and record the Glasgow Coma
Scale or Blantyre score. Take blood while establishing an IV line for: Malaria blood slide
(thick and thin), Hematocrit or Hb determination, WBC (total and differential count),
Glucose level
 Correct hypoglycemia if present by infusing dextrose over a period of 3–5 minutes. This
can be done by any one of the following procedures:
 ml/kg of 50% dextrose diluted with an equal volume of normal saline (1ml/kg ) IV
slowly over several minutes OR
 5 ml/kg for adults and 4ml/kg for children of 10% dextrose by slow IV infusion
(If ready-made 10% dextrose is not available, it can be prepared by adding 10 ml
of 50% dextrose per 100ml of 5% dextrose solution) OR
 40–60ml of 40% dextrose given as intravenous bolus in adults.
(* For other strengths of dextrose, calculate accordingly.)
 where intravenous access is impossible, give sugar solution by nasogastric tube
(NGT)
 Re-check blood glucose 2–4 hourly during the course of treatment, particularly in
comatose patients.
 Control convulsions:
 correct hypoglycemia if it is present.
 give rectal paracetamol if the temperature is above 39°C.
 If the convulsions continue for more than 5 minutes give diazepam by slow
intravenous injection (0.15mg/kg body weight, maximum 10mg for adults).
Children always calculate according to weight to avoid dangerous respiratory
depression. Diazepam 0.5–1.0mg/kg bw) can be given intra-rectally using a rectal
tube or NG tube (only if the injection is not possible. IM diazepam should not be
given as it is poorly absorbed.
 If the first dose of diazepam fails to control convulsions, a second dose may be
given after 10 minutes.
 Monitor the breathing carefully.
 If seizures continue, give phenytoin (18mg/kg infused over 20 minutes as a
loading dose, followed by 2.5mg/kg twice daily for 48 hours).
 If you have given two doses of diazepam and seizures continue, and if
phenobarbitone is the only additional anticonvulsant drug available, you may give
phenobarbitone (15mg/kg IM or IV loading dose, then 5mg/kg daily for 48 hours),
but extreme vigilance is necessary because these two drugs (phenobarbitone and
diazepam) in combination may cause respiratory arrest - monitor breathing
continuously and be ready to give assisted ventilation, by bag-and-mask if a
manual ventilator is not available.
5.3.3. Continued supportive treatment.
Assess the patient’s fluid requirements. The rate of infusion will be determined based on the
degree of dehydration. Children with severe metabolic acidosis may benefit from a
resuscitation bolus of fluid, preferably a plasma expander, e.g. normal saline. The usual route
for fluid infusion is intravenous, if this cannot be achieved use intraosseous or nasogastric
infusions. Intra-osseous infusion may be performed when life-threatening hypovolemia
occurs.
Reduce body temperature if greater than 38.5ºC to prevent convulsion. This is best done by
giving paracetamol, by mouth, if possible, alternatively by suppository. In addition, remove
the patient’s clothes and start tepid sponging and fanning from the sides or back of the
patient.
Consider the need for blood transfusion. The most common indication for blood transfusion
is severe anemia (Hgb < 5g/dl). Assess the patient’s clinical condition rather than relying on
the hematocrit and/or Hb level. “Does the patient need blood?” is a more important question
than “What is the PCV/Hgb?” If the patient’s life is threatened by anemia-associated acidosis,
or by shock, or the parasitemia is so high that a critical drop is predictable, packed cells
(10ml/kg in children) or whole blood transfusion should be given urgently with frusemide as
follows:
 If the patient has spontaneous bleeding give whole fresh blood if available or a platelet
transfusion if possible; where blood is unavailable, give pre-referral treatment and refer
the patient.
If the patient is unconscious, insert a nasogastric tube and start the procedures for the
management of the comatose patient.
Decide whether to insert a urinary catheter. This is necessary if either acute renal failure or
pulmonary edema is suspected, to guide fluid balance. Be cautious of catheter-associated
urinary tract infections.
Decide whether a central venous pressure line is to be set up. This is of most value where
pulmonary edema is suspected and may be useful in the patient with shock or impending
renal failure. It requires the necessary facilities, sterile procedures, expertise, and a sufficient
number of trained staff to use it properly.
Consider the need for intubation & mechanical ventilation, if necessary, facilities are
available.
Consider antibiotics if there is a suspicion of concomitant bacterial infections.
 Patients diagnosed with concomitant infections like pneumonia, UTI, meningitis

 Patients suspected to have infections (shock which is not responding to fluid
management, metabolic acidosis with hypotension especially if not responding to fluid
management, comatose patients when CSF analysis is not possible)
5.3.4. Specific antimalarial treatment
Parenteral antimalarial medicines should be administered to patients with severe malaria
without delay. Patients with severe malaria. The national malaria guidelines recommend first-
line treatment for severe malaria at the health center and hospital level in order of priority:
1. Artesunate
 Artesunate reduces mortality in both adults and children, has fewer side effects,
and is easy to administer as compared to quinine infusion.
 It is available in ampoules, containing 60mg anhydrous artesunic acid with a
separate ampoule of 5% sodium bicarbonate solution.
 For children < 20kg: The dose of Artesunate is 3mg/kg; Above 20 kg-it is 2.4
mg/kg
 IV artesunate will substitute for rectal artesunate or any IM anti-malarial
treatment that may have been started as pre-referral therapy.
 Intravenous (IV) administration is the preferred choice however if the health care
provider fails to secure the IV route, intramuscular (IM) injection is also
effective.
 Administer at least three times on time 0 (admission), 12h, and 24h after
admission
 Preparation steps of artesunate injection solution:
o Reconstitution: the vial of artesunate powder should be mixed with 1ml
of 5% sodium bicarbonate solution (provided) and shaken for 2–3
minutes for better dissolution. The solution should be prepared freshly
and should not be stored.
o IV administration: add 5ml of 5% glucose or normal saline to make the
concentration of artesunate 10mg/ml and administer by slow infusion;
o IM administration: add 2ml of 5% glucose or normal saline to make the
concentration of artesunate 20mg/ml. (See video on Artesunate
preparation)
 After administration of at least three doses (0, 12, 24 hours), then if the patient
can take orally change to full dose oral Artemether-lumefantrine. If the patient
can’t take Artemether-lumefantrine for any reason, complete treatment with a
full (three days) course of second-line drug (Dihydroartemisinin-piperaquine
(DHA-PPQ) Additionally, a single-dose primaquine will be added for P.
falciparum cases. A 14-day primaquine should be given for P. vivax cases
 Artesunate can be continued for up to 7- days if the patient does not tolerate oral
treatment.
 IM artesunate (2.4 mg/kg for >20kg or 3mg based for <20kg) on time 0
(admission), 12h, and 24h after admission, then plan to change to full dose oral
Artemether-lumefantrine. If the patient can’t take Artemether-lumefantrine for
any reason, complete treatment with a full course of second-line drugs.
2. Artemether
Artemether is the second alternative parenteral treatment when parenteral artesunate is not
available for severe malaria.
Dosage: Adults & children: 3.2 mg/kg body weight on 1 st day;1.6 mg/kg body weight 2nd and
3rd day
Administration: IM (never administered by IV route)

Preparation of artemether for administration:
 Injectable artemether contains 80 mg in 1 ml ampoule (80 mg/ml), oily solution
for IM injection only.
 When the dose required is less than 1 ml, use a 1 ml syringe graduated in 0.01 ml.
 Note: The anterior thigh is the preferred site for providing IM injection;
Frequency of administration – once daily
 Duration of treatment: It can be provided up to a total of 3 days. It can be
discontinued if the patient tolerates oral treatment after 48 hours (two doses), a
full course of oral AL therapy should be started to complete the treatment.
Additionally, a single-dose primaquine will be added for P. falciparum cases. A
14-day primaquine should be given for P. vivax cases
3. Quinine dihydrochloride
Quinine is the alternative parenteral treatment when parenteral artesunate and artemether are
not available for severe malaria
Dosage: Adults and children: 20 mg/kg body weight on first dose (loading dose); 10 mg/kg
body weight eight hours after start of loading dose (maintenance dose)
Caution:
 A loading dose of quinine should not be used if (i) the patient received quinine within
the preceding 24 hours; (ii) mefloquine within the preceding 24 hours; or (iii)
mefloquine within the preceding seven days;
 Rapid administration of quinine is not safe and may cause sudden death due to
arrhythmia or refractory hypotension. Each dose of parenteral quinine must be given
as a slow, rate-controlled infusion (usually diluted in 5% dextrose and infused over
four hours). The infusion rate should not exceed 5 mg salt/kg body weight per hour. If
it is possible, continuous infusion should be given.
Administration: IV or IM (IV preferred and IM is provided if IV is not possible)

Preparation of Quinine dihydrochloride for administration:
 A 2 ml ampule contains 600 mg Quinine dihydrochloride (300mg/ml)

 For IV infusion – For adults and children weighing > 20 Kg- administer each dose of
Quinine in 250 ml of 5% dextrose (D5W) or normal saline and infuse slowly
intravenously over 4 hours
 For children under 20 Kg, administer each dose of Quinine in 10 ml/kg volume of 5%
dextrose or normal saline and infuse slowly over 4 hours.
 For IM injection preparation - quinine should be diluted in normal saline to a
concentration of 60–100mg salt/ml.
Note: The anterior thigh is preferred for providing IM injection. There is a risk of sciatic
nerve injury if provided on the gluteal region. Loading dose should be provided in two thighs
by dividing the full dose equally.
Frequency of administration – every eight hours (Note that eight hours is counted from the
start of the last dose)
Duration of treatment
 It should be discontinued if the patient tolerates oral treatment after 48 hours, and a
full course of oral AL therapy should be started to complete the treatment, as in
Annex C. Additionally, a single-dose primaquine will be added for P. falciparum
cases. A 14-day primaquine should be given for P. vivax cases (Annex F).
 In patients requiring more than 48 hours of parenteral therapy, the quinine
maintenance dose should be reduced by one-third to one-half (i.e. 5-7 mg salt/kg of
body weight every eight hours). It is unusual to have to continue IV infusions of
quinine for more than 4-5 days
 Quinine is not given by subcutaneous injection
 Quinine is safe in pregnancy and anemic patients if the doses are carefully calculated
by body weight.
NOTE: Always calculate drug doses according to the body weight of the patient. Where
available, use a burette to ensure correct fluid volumes and to prevent fluid overload in
the patient.
REMEMBER: Patients with severe malaria should not be treated with oral antimalarial
drugs.
Parenteral antimalarial in the treatment of severe malaria should be given for a minimum
of 24 hours (48 hours for quinine), once started (irrespective of the patient’s ability to
tolerate oral medication earlier).
5.3.5. Pre-referral treatment
At health center and hospital levels
If health workers decide to refer a patient with severe malaria to a higher level of care, they
should provide a pre-referral treatment as the risk for death from severe malaria is greatest in
the first 24 hours. The recommended pre-referral treatment options in descending order of
preference, are intramuscular artesunate; intramuscular artemether; and intramuscular
quinine. For the conscious patient, give paracetamol if a high fever is present, encourage fluid
intake during transfer and continue breastfeeding in young infants and ensure that the referral
form is completed with detailed information including the reason for referral. For the
unconscious patient, show family members how to position the patient on the side to ensure a
clear airway is maintained. Family members can do tepid sponging and give paracetamol
suppositories for high fever if possible. Fill in a referral form with complete information
including the reason for referral.
5.3.6. Continuing treatment and nursing care

Continuing care calls for close cooperation between medical and nursing staff. Proper nursing
care of the unconscious patient, in an intensive care unit if available, is of utmost importance
in patients with cerebral malaria. The patient must be turned every two hours and not be
allowed to lie in a wet bed. Attention must be paid to pressure points and the patient should
be nursed on his/her side to avoid aspiration of fluids.
The following are the parameters to be monitored on a routine basis:
 Level of consciousness (see Blantyre and Glasgow coma scales in Session 5.1);
 Vital signs: blood pressure, temperature, pulse rate, and respiratory rate;
 Fluid input and output. Examine regularly for signs of dehydration or fluid overload;
urine volume, color and specific gravity;
 Check Parasitemia and Hemoglobin levels (Hgb/Hct)
 Blood glucose levels.
 Occurrence of convulsions; Uterine contractions and fetal heart rate in pregnant
women.
A record chart should be kept on which the important complications of the patient’s illness
are summarized; the treatment prescribed, and all important observations are recorded at
suitable intervals. The record chart is useful as a checklist to observe and follow all important
parameters and not overlook important ones that may cost the life of the patient.
A decision is taken on how frequently observations should be made; this should be done as
often as possible with the available staff (e.g. every four hours), but will also depend on the
particular circumstances of each patient and the severity, stage, and complications of the
illness.
Activity 5.4; Case study
Case study, Patient A
Objective: Treat malaria patients presenting to health facility services with complications
Instruction: Read and analyze the case study in groups and answer the following questions.
Select a rapporteur to present the answers.
Scenario: The place: A country where P. falciparum malaria is transmitted in forested areas
but not in main cities.
The patient: A woman aged 25 years is brought to the outpatient department of the central
hospital in the capital. She is a local resident of the city, the wife of a business executive, and
is in the seventh month (28 weeks) of her first pregnancy.
The patient became ill five days ago, with chills, sweating, and headaches. An antibiotic was
prescribed, and her condition seemed to improve, but yesterday she developed rigors and
persistent vomiting. A blood film at the local clinic showed P. falciparum parasites, and
artemether lumefantrine was prescribed. She took two doses.
Today she has been referred to your hospital because of restlessness and increasing mental
confusion. Examination shows a semiconscious woman who is unable to speak. She
withdraws her hand from a painful stimulus but cannot localize a stimulus applied to the
sternum or forehead. There is no neck stiffness, jaundice, pallor, or rash. Axillary
temperature is 39°C, pulse rate 90/min, blood pressure 110/70mmHg. The uterine fundus is
palpable (26–28 weeks), and the fetal heart can be heard.
Discussion question:
A. What tests are urgently required?
B. If the blood glucose is 1.2mmol/l (22mg/dl) what treatment should be given?
C. The blood film shows P. falciparum rings, and the cerebrospinal ﬂuid is normal
except for low glucose
D. What antimalarial drug should be administered and by which route?
E. What nursing procedures are important during this treatment?
F. After six hours the patient becomes increasingly restless. The respiratory rate
increases to 40/minute. The blood glucose level is normal. Under these conditions,
what diagnostic steps should be taken?
G. A chest X-ray suggests pulmonary edema or acute respiratory distress syndrome
(ARDS). What is the treatment of this patient?
H. What other observations are particularly important in this patient?
Time: 15 minutes
Practice exercise:
Activity 5.5 : Case study, Patient B
Instruction: Read and analyze the case study in a group and answer the following
questions. Select a rapporteur to present the answers.
Case scenario: The place: A rural clinic in an area where P. falciparum is hyperendemic.
Various antimalarial medicines are available, but intravenous infusions cannot be given.
The patient: A child aged 20 months became feverish two days ago and has vomited
several times today. One hour ago the child had a convulsion, described by the mother as a
repetitive twitching of limbs and mouth, followed by unresponsiveness for a few minutes.
The child is now febrile (39.3°C), conscious, and able to localize and respond to a painful
stimulus. Malaria microscopy test shows a positive result for P. falciparum. The child
repeatedly vomits any antimalarial medicine given by mouth.
A. What should be done about the convulsions?
B. The district hospital is 30km away; the journey will probably take several hours by bus.
Should the patient be referred to the hospital? What treatment should be given in the
meantime?
C. On arrival at the district hospital, the child was still unable to take oral medication and
was admitted. A thick blood smear showed P. falciparum rings and he was given
Artesunate IV. On the third day, there had been some improvement, but the child was
still febrile and the parasitemia reduced a little. Does this suggest that the child has
drug-resistant malaria?
D. The child was able to feed and take oral medication on the third day. Should the
parenteral treatment with artesunate be continued?
E. On the third day of the treatment, a further blood test showed gametocytes. What
should be done about the gametocytes present in the blood after treatment?
Time: 15 minutes
Practice exercise:
Activity5.6 :Case study,
Patient C
Instruction: Read and analyze the case study and answer the following questions
Case scenario: The place: A country where P. falciparum is hyperendemic.
The patient: A male economist aged 28 years, was born and brought up locally but attended
university in northern Europe for five years. He returned home last month. One week ago he
developed a fever. He decided this could not be malaria because he had grown up in a
malaria-endemic area and believed he was therefore immune. Two days ago he became
confused, especially at night. He stayed in bed and was attended by a servant who called the
doctor today because the patient was increasingly confused. The last urine he had passed was
a small volume of very dark ﬂuid 24 hours ago.
On examination, the patient was a well-nourished adult man. He was afebrile with a rectal
temperature of 36.5°C. He was restless but could give brief appropriate answers to questions
and could localize the site of a painful stimulus. He was jaundiced and his mucous
membranes were pale. There was some bleeding from the gums, and there were a few retinal
hemorrhages in both eyes.
A. What else should be looked for in the thin blood film?
B. What other tests are necessary to investigate the bleeding tendency?
C. What treatment is needed for the bleeding?
D. The patient has not passed urine for 24 hours. What kind of investigations and actions are
appropriate?
E. 15ml of dark brown urine was obtained by catheter. The urine ‘stix’ tests showed albumin
“++”, blood “++++”, conjugated bilirubin “++”, and urobilinogen “++”. Microscopy of
the urine showed no cells and a few casts. How are the results of the urine test to be
interpreted?
F. Acute renal failure is confirmed. Is it possible that the kidneys may recover? And what
therapy should be given to this patient with acute renal failure?
Time: 15 minutes
Practice exercise:
Activity 5.7: Case study,
Patient D
Instruction: Read and analyze the case study and answer the following questions
Case scenario: The place: A country with hyperendemic P. falciparum malaria in low-lying
areas but no malaria transmission on the high central plateau.
The patient: A woman aged 19 years was brought to a clinic in the malaria-endemic area. The
medical officer recorded that the patient had a history of fever for the past three days with
rigors and vomiting. On examination, she was febrile with an axillary temperature of 39.1°C
and slightly jaundiced. She was fully conscious. Because she had never been out of the
country, the doctor considered it unlikely that she was suffering from P. falciparum malaria
but nevertheless checked a thin blood film. No malaria parasites were seen on the film so he
diagnosed hepatitis and advised rest and a fat-free diet.
A. What was the wrong interpretation of investigations?
B. Two days later the patient was brought back to the clinic by anxious relatives. She had
become drowsy and was not answering questions properly. On examination, the patient was
afebrile, slightly jaundiced, and confused. She could not answer questions but could
withdraw her hand from a painful stimulus. The possible diagnoses considered were
fulminant hepatitis, sickle-cell crisis, relapsing fever, and cholecystitis. Malaria was ruled out
because she was not febrile. Treatment was started urgently with tetracycline intravenously
and enemas to empty the large bowel. She remained unconscious and her temperature rose to
38°C; a blood film now showed scanty P. falciparum parasitemia. This was considered
“probably incidental” because low-grade parasitemia was common among young adults in
the area.
1. What errors were made in clinical judgment?
2. What errors were made in the treatment of the patient?
C. The next day the patient was increasingly febrile and the parasitemia had increased. The
parenteral Artesunate (IV or IM), the preferred antimalarial medicine for the treatment of
severe malaria, was out of stock. Therefore, quinine 20mg base/kg was given intravenously
to run over one hour in normal saline, to be repeated for 8 hours. Twenty-four hours later the

Chapter Summar
 Each of the individual clinical features is important for the diagnosis of severe malaria.
 A patient may have any single complication or any combination of complications listed
above.
 A patient with one or more of the complications may go on to develop others.
 Other possible diagnoses in such a patient must be carefully considered.
 Waiting for a blood smear result must not be allowed to delay the start of treatment
unduly; if clinical features strongly suggest severe falciparum malaria, treatment should
be started before the results are available. Occasionally blood films may be negative
while the patient has severe falciparum malaria. Following a negative result, blood films
should be repeated, e.g. every 6 hours. Parenteral Artesunate should be continued in such
patients.
 A positive blood film does not prove that severe falciparum malaria is the only cause of
the severe illness. Other possible causes should also be considered.
Chapter Question
1. What are the most common manifestations of severe malaria?

2. Mention four differential diagnoses of severe malaria.
3. Who are the most at-risk groups for severe falciparum malaria?
4. Mention four complications of falciparum malaria and the causes of each?
5. What are the underlying principles in managing severe malaria?
6. List antimalarial drugs used to treat severe malaria in the order of priority of
selection and the reasons.
7. How do you treat complications of malaria? Mention three complications and how to
treat each of them.
CHAPTER SIX: OVERVIEW OF MALARIA LABORATORY DIAGNOSIS AND
QUALITY ASSURANCE
Duration: 2 hours
This chapter provides an overview of the malaria laboratory diagnosis and quality assurance
system. The contents are aligned in a way to familiarize clinicians with the whole concepts,
process, and importance of malaria diagnosis for case management and elimination activities.
Chapter objective:
By the end of this chapter, participants will be able to discuss the basics of malaria diagnosis
and quality assurance systems and perform malaria diagnosis using RDTs.
Learning objectives: at the end of this training, participants will be able to:
● Describe the different methods used for diagnosing malaria.
● Identify required supplies and activities to perform malaria microscopy.
● Demonstrate malaria diagnosis using RDTs.
● Discuss malaria quality assurance system and its benefits.
Chapter Outline/Sessions:
6.1. Malaria Diagnosis Methods

6.2. Malaria microscopy
6.3. Malaria Rapid Diagnostic Testing
6.4. Quality Assurance of Malaria Laboratory Diagnosis
6.7. Summary
6.1. Malaria Diagnosis methods
Activity 6.1: Brain storming and discussion
Before starting the session, go over the following questions just to retrieve your prior
Question: From your experience, what malaria testing methods do you use and what are the
pros and cons of parasitological and clinical diagnosis?
Time 10 minutes
Clinical Diagnosis
A clinical diagnosis entails making a clinical assessment by taking an accurate history of the
illness and performing a physical examination. Malaria should be suspected in a patient who
has a fever or history of fever in the last 48 hours and lives in malaria-endemic areas or has a
history of travel within the last 30 days to malaria-endemic areas. Basing the diagnosis on
clinical features alone is not recommended, as this often has low specificity and increases the
chances of the patient being misdiagnosed. All patients who fulfill the clinical criteria should
be confirmed with a parasitological test
Parasitological Diagnosis/ Laboratory Methods
Laboratory diagnostic methods can be classified into two:
1. Routine lab diagnostic methods
● Microscopy
● Rapid Diagnostic Testing/RDT
2. Advanced diagnostic methods
● Quantitative Buffy Coat /QBC/test
● Microscopy using fluorochromes.

● Polymerase chain Reaction/PCR/
● Serology: Ab detection
● Flow cytometry
Microscopic diagnosis and RDTs are the routine methods employed for confirmation of
malaria etiology in Ethiopia. Confirmed malaria is suspected malaria confirmed with
microscopic diagnosis or RDTs for plasmodium parasites.
Benefits of parasitological diagnosis:
● Rational drug use and hence cost saving.
● Improved patient care in parasite-positive patients owing to greater
certainty that the patient has malaria.
● Consideration and searching for alternative diagnoses on identification of
parasite-negative patients.
● Prevention of unnecessary treatment with antimalarials, thereby reducing
side effects, drug interactions, and selection pressure.
● Improved health information.
● Confirmation of treatment failures.
6.2. Malaria microscopy
Activity 6.2: group discussion
From your experience, reflect the advantages and disadvantages of malaria microscopy.
Malaria microscopy
Microscopy has a high degree of sensitivity and specificity when performed well. In addition,
it allows the quantification of malaria parasites and the identification of the infecting species.
It is inexpensive and considered to be the “Gold standard” against which the sensitivity and
specificity of other methods must be assessed.
Quality of microscopy is ensured by supporting laboratories to perform internal quality
control, performing external quality assessment, especially using blinded rechecking,
proficiency testing methods, and onsite evaluation. Quality microscopy will provide reliable
results and will help to build the trust of clinicians in laboratory results.
Advantages of light microscopy:
● Low direct costs, in areas of high turnover, if the infrastructure to
maintain the service is available.
● High sensitivity if the quality of microscopy is high.
● Differentiation between plasmodia species and the stage of the parasite
● Determination of parasite densities
● Diagnosis of treatment failure
● Can be used to diagnose many other conditions like borrelia and
leishmania parasites
Required materials, reagents, and equipment for microscopy.
● Binocular microscope
● Giemsa solution (Powder, methanol & glycerol)
● Frosted slide
● Immersion oil
● Tally counter
● Patient Register and pen
● Lens paper
● Lens cleaning solution
● Tissue paper
● Slide boxes
● Staining and drying rack
Type of blood films

There are two types of blood films, thin and thick blood film. Both thin and thick blood films
should be prepared on a single microscope slide. Giemsa stain is the best stain for the
identification of malaria parasites. It stains cells and blood parasites (e.g. malaria, Borelliae,
leishmania, trypanosomes, etc.). Malaria parasites are identified by microscopic examination
of thick and thin blood films stained with Giemsa stain. Other stains that can be used to stain
blood film are Wright’s stains, Leishman’s stains, and Field’s stains. Thick smears are more
sensitive for detecting the presence of parasites, and thin smears can provide more details for
species determination. An adequate amount of time must be spent to analyze multiple forms
and to determine if there is a mixed infection.
Types and characteristics of thin and thick blood film:
Table 11. Types and characteristics of thin and thick blood film
Thick smear Thin smear
● Lysed RBCs ● Fixed RBCs
● Many layers ● Single layer
● Smaller volume
● Large volume
● Good species differentiation

● Good screening test
● Low-density infection can be

missed.
● Low-density infection can be detected.
● More difficult to diagnose species
Slide examination
● Giemsa stain thick blood smears are the basis for microscopic diagnosis
with a standard of looking at 100 fields.
● The limit of detection is usually 5-10 parasites per μl of blood. If the
blood film is negative, look for other causes of fever.
● If malaria parasites are detected on a thick film, species differentiation
should be done on a thin film

Parasite density
Clinicians should order parasite density for patients with features of severe malaria. For
patients without features of severe malaria, laboratory professionals should count parasites if
they see more than ten malaria parasite per field in at least five fields. Knowledge of the
degree of parasitemia may be of diagnostic and prognostic value in the case of severe malaria
infection and also helps in following up the changes produced by treatment and helps to
measure the therapeutic efficacy of antimalarial drugs.
Methods of counting malaria parasites:
● % of parasitized RBC (thin film)
● Number of parasites/µL of blood (thick film)
● Number of parasites/µL of blood (thin film)
● Semi-quantitative count /Plus system (thick film)
The “plus system” is an old, simplified method of enumerating parasites in thick blood films.
However it is less accurate for establishing parasite density in thick smears and therefore it is
no longer recommended.
Activity 6.3: Cas study
Instruction: Form a pairing and discuss the case

scenario
Duration-15mins (10 min for group work and 5 min for discussion) .
Scenario:
During a community campaign in Gambella town a 25 years old male prisoner was screened for
malaria using microscopy and the result reported as P. falciparum (++++) and the provider gave
him AL and single dose PQ.
Qn-1 What are the other components the microscopy result should have incorporated?
On the fourth day the patient came back to the nearby health center with worsening symptoms
like fever, bleeding from noses, fatigue and prostration.
Qn-2 What laboratory tests will you order with justification?
The result showed P. falciparum schizont stage with a parasite density of 250,000/ µL and also
Borrelia parasite.
Qn-3 What is the lesson you learned and what is the treatment plan?
Time: 15 minutes
6.3. Malaria Rapid Diagnostic Testing
Activity 6.4: Brain storming
Have you ever performed malaria RDT ? if so, explain the principle and general procedure
of RDT.
Malaria Rapid Diagnostic Testing

Malaria RDTs detect antigens from the malaria parasites in blood using an immune
chromatographic process. An antigen-antibody reaction leads to a visible color change that
indicates a positive test result. A useful tool to diagnose sequestrated malaria.
These tests use finger-stick or venous blood, take only a few minutes, and do not require a
laboratory, electricity, or any special equipment.
Currently, multi-species RDTs capable of specifically detecting both P. falciparum and P.

vivax, are being supplied by FMOH /EPSS. Malaria RDT is recommended to be used at the
health posts level.
Basic Principles of RDTs
Rapid diagnostic tests are immune-chromatographic tests that detect specific parasite antigens
mainly Histidine Rich Protein 2 (HRP2) or Plasmodium lactate dehydrogenase (pLDH).
Plasmodium aldolase is another antigen that is used in some tests. Some RDTs can detect
only one species (Plasmodium falciparum) while others detect one or more species of malaria
parasites that infect humans. Antigens detected by currently used RDTs are:
1. Histidine-rich protein II (HRP-2): is a protein produced by trophozoites and young

gametocytes of P. falciparum. A substantial amount of HRP 2 is secreted by the parasite into
the host bloodstream and the antigen can be detected in erythrocytes, serum, plasma,
cerebrospinal fluid, and even urine as a secreted water-soluble protein. Tests based on HRP-2
detect only P. falciparum. HRP-2 has been shown to persist and may be detectable for more
than a month after clinical symptoms of malaria have disappeared and parasites are cleared
from the host. HRP-2-based tests are relatively more stable at high ambient temperatures and
humidity and are usually less costly.
2. Plasmodium Lactic Acid (Lactate) Dehydrogenase (pLDH): is produced by both

trophozoites and gametocytes of malaria parasites. The pLDH antigen is present in and
released from parasite-infected erythrocytes. pLDH is found in all 4 human malaria species,
and different isomers of pLDH for each of the 4 species exist. Currently, available pLDH
RDTs detect pLDH specific to P. falciparum, and P. vivax or are pan-specific detecting all
Plasmodium species that infect humans. Some pLDH RDTs are specific for P. vivax. Since
pLDH disappears from the circulation within five days of successful antimalarial therapy, this
test can differentiate untreated from treated malaria, and may therefore be used for patient
follow-up, although pLDH is also produced by gametocytes. Tests based on pLDH are less
stable at high ambient temperatures and humidity and are more costly.
3. Plasmodium aldolase: is an enzyme produced in the glycolytic pathway by all species of

human Plasmodium parasites (pan-specific) and has been used in a combined 'P.f/P.v'
immune-chromatographic test. Tests that detect aldolase appear to be less sensitive than tests
that detect the other parasite products. Aldolase behaves in much the same way as pLDH.
The various RDTs appear to be similar; they vary considerably in their functioning due to the
intrinsic character of the critical components employed and their final result.
Mode of action malaria RDT

Lateral flow antigen-detection tests rely on the capture of dye-labeled antibodies to produce a
visible band on a strip. The dye-labeled antibody first binds to a parasite antigen, and the
resultant complex is captured on the strip by a band of bound antibody, forming a visible line
(test line). A control line gives information on the integrity of the antibody-dye conjugate
Figure 4. Mode of action malaria RDT.
Procedure of RDT
The contents of the test kit are:
● Test device
● Assay buffer
● Pipette/dropper
● Alcohol pads
● Lancet
● Procedure card
Materials required while doing RDT.
● Timer or hand watch
● Sharp disposal box
● Biohazard bag
● Lead pencil or pen for labeling
Procedure
● Open the test pouch: check all kit items are in place
● Prepare the RDT device and label it with the name of the patient or give
the serial number.
● Clean the finger of the patient with an alcohol swab.
● After the alcohol dries out prick the finger of the patient
● Wipe out the first drop of blood
● Collect the sample from the finger prick using the pipette provided, and
while gently squeezing the tube, immerse the open end in the blood drop
and then gently release the pressure to draw blood into the sample pipette
● Add 5μl of whole blood into the sample well (refer to insert kit)
●
● Add three drops of assay buffer into the buffer well (refer to insert kit).
Figure 5. RDT test procedure
● Place the cassette on a table or a flat surface for 25-35 minutes (refer to
insert kit).
● Read the test result in 35 minutes, and the result is interpreted as follows:
Interpretation of the test result:
● Negative reaction: The presence of only one band in the control area
within the result window indicates a negative result.
● Invalid: The test is invalid if the line in the control area does not appear.
If this occurs, the test should be repeated using a new strip.
● Positive reaction - P. falciparum: The presence of two color bands (one
band in the control area and another band in the "1" area) indicates a
positive result for P. falciparum.
● Positive reaction -P. vivax, P. malaria, or P. ovale: The presence of two-
color bands (one band in the Control Area and another band in the "2"
area) indicates a positive result for P. vivax.
● Positive reaction - Mixed infection of P. falciparum and P.vivax the
presence of three color bands (three bands in the Control, "2" and "1"
areas) indicates a positive result for P. falciparum or mixed infection of
P. falciparum and P.vivax.
Precaution on the interpretation of RDT results: A positive RDT result does not always
signify malaria illness because the antigen of malaria parasites might sometimes be detected
after treatment or due to the persistence of malaria gametocytes in the absence of illness,
presence of other substances in the blood might occasionally produce a false-positive result.
Advantages and disadvantages of using RDT:

Advantages
● Easy to use and rapid, on-spot test results.
● No/little manipulation of the sample.
● No refrigeration of sample or reagent
● Use of whole blood possible.
● Can detect sequestrated malaria.
Disadvantages:
1. Short shelf life (storage and distribution)
2. Only qualitative results no quantification of the malaria parasite
3. Less sensitive and specific compared to microscopy.
4. Inability to identify sexual and asexual parasite stage.
5. Post-treatment positive results due to long survival of malaria antigen in
peripheral blood
● Sometimes presence of abnormal antibodies in the patient peripheral
blood may block the Ag – Ab reaction on nitrocellulose to see the visible

reaction.
● Band intensity depends on the Ag – Ab reaction.
Points to remember when performing RDT.
● Product instructions should be strictly followed.
● Management plan for results must be in place.
● Blood-safety precautions should be followed.
● Should be discarded if the envelope is punctured or badly damaged.
● The test envelope should be opened only when it has reached ambient
temperature.
● The RDT should be used immediately after opening.
● The result should be read within the time specified by the manufacturer.
Activity 6.5 : Demonstration of RDT testing
Objective: To enable the participants to practice RDT testing
Instruction:
● Read the checklist/SOP once.
● Observe the skill/Procedure using the checklist while the facilitator
demonstrates the skills.
● Perform RDT on each other in groups of 4

● Review the key skills once in the SOP after the feedback.
● Reflect on where and when to apply the skill in the real workplace.
Time: 20 minutes
6.4. Quality Assurance of Malaria Laboratory Diagnosis
Activity 6.6: Reflections
From your experience, reflect on what quality & quality assurance are to you.
Quality Assurance (QA) is a system designed to improve the reliability and efficiency of
laboratory services.
Components of QA:
● Quality Control (QC): internal monitoring of work practices, technical
procedures, equipment, and materials
● External Quality Assessment (EQA): Assessment of laboratory
performance by external higher body
● Quality Improvement (QI): the components of malaria microscopy
services are analyzed with the aim of identifying and permanently

correcting any deficiencies.
External Quality Assessment Methods
1- Proficiency testing /PT/
● The laboratory performs malaria microscopy on a set of prepared slides received
from the reference laboratory.

● It is used to check the staining procedure as well as the ability of the personnel to
recognize and identify any malaria parasite present.
● It provides a rapid picture of the proficiency of many laboratories.
2- Blinded Rechecking
● It is a rereading of randomly selected slides collected from the “testing” laboratory
at the higher-level laboratory.
● Detects malaria misdiagnosis in routine work and assesses the overall quality of
testing.
● It reflects the true performance of laboratories offering routine diagnostic services at
the peripheral level.
● Checks not only the result of the blood film but also the performance of the stain
and the quality of the blood film.
● Feedback to the participant site with comments and recommendations should be
given timely.
3- Onsite Supervision
● OS is a comprehensive assessment of essential elements of laboratory quality
systems.
● It is an ideal means of obtaining a realistic picture of the conditions and practices in
a laboratory.
● Provides an opportunity to immediately identify sources of errors, provide onsite
corrective actions, and implement appropriate measures to resolve problems.
● It is done for both microcopy and RDT service facilities.
Activity 6.7 :Think Pair and Share

Instruction: First think about the following question and
then discus in pair with a participant sitting next to you
and share your idea.
Question: Discuss the component and benefit quality

assurance program from patients, health professionals and
organizational perspectives
Time: 5 min
Summary:
❖ To improve the quality of laboratory service robust quality assurance program should
be in place.
❖ External quality assessment (EQA) is one of the components of quality assurance
which assess and improve laboratory service performance.
Chapter Summary
❖ Basing the diagnosis on clinical features alone is not recommended.
❖ The routine malaria diagnostic methods in Ethiopia are Microscopy at health centers
and hospitals level and RDTs at health posts level
❖ Microscopy has the benefit of confirming treatment failure.
❖ Microscopy is the gold standard method in diagnosing malaria.
❖ Both thick and thin films should be prepared and examined for malaria detection and
species identification
❖ Malaria density estimation helps to monitor the response to treatment in patients with
severe malaria.
References
● Manual for laboratory diagnosis of malaria, Ethiopian Public Health
Institute, second edition, September 2020.
● Integrated external quality assessment guidelines for Tuberculosis and
Malaria Microscopy, Ethiopian Public Health Institute, First edition,

September 2022.
● Malaria microscopy quality assurance manual, Version 2, World Health
Organization,2016.
● Manual for malaria rapid diagnostic test in Ethiopia, EPHI, First Edition,
May 2023
● WHO guidelines for malaria, 25 November,2022

CHAPTER SEVEN: OVERVIEW OF PHARMACEUTICALS MANAGEMENT
This chapter provides healthcare professionals with basic understanding of pharmaceutical
supply chain management in the context of malaria case management.
Chapter Objective: After the completion of this chapter participants will be able to discuss
antimalarial drugs & related supply chain management in Ethiopia.
Learning Objectives
● Describe the pharmaceutical supply chain in the malaria context
● Identify Logistics Cycles and Activities
● Demonstrate requesting antimalarial drugs & related supplies using RRF.
Chapter Outlines
7.1 Overview of Pharmaceuticals Supply Chain
7.2. Requesting and Getting Pharmaceuticals
7.3. Chapter summary
7.1: Overview of Pharmaceuticals Supply Chain

Session Objective

Activity 7.1;
Instruction: Go over the following question just to retrieve your prior knowledge/
experience. Feel free to answer/reflect/respond to the question.
Question:
● Describe the steps involved supplying anti-malarial drugs to health facilities

Time: 10 minutes
Pharmaceutical supply chain management: in health facilities is a critical component of

ensuring the availability, accessibility, and efficient distribution of medicines and healthcare
products. It encompasses the planning and management of all activities involved in the
selection, quantification, procurement, storage, distribution, and delivery of a final product or
service, from the supplier’s supplier to the customer’s customer. In essence, supply
management should integrate supply and demand management within and across the health
facilities and supply chain levels.
Logistics: Management of materials in motion and at rest. Some scholars also define it as the
flow of material, information, and money between consumers and suppliers or what is
happening in the supply chain. Logistics is part of SCM.
The purposes of logistics are to ensure the SIX Rights to serve customers, ensuring health
commodity security exists for each client:
Ensuring the six rights:
● The right product in the
● The right quantity of the
● The right quality at the
● Right place at the
● The right time for the
● Right cost
Logistics Cycles and Activities

Logistics cycles refer to the series of interconnected activities involved in managing the flow
of goods, information, and resources within a supply chain to meet customer demands.
Logistics cycles encompass demand planning, procurement, transportation, warehousing &
inventory management, Order fulfillment, distribution, reverse logistics & information
management.
The logistics cycles for malaria diagnosis and treatment tools involve activities such as
demand planning and forecasting for diagnostic tests and antimalarial medicines, the
activities are:
 Product selection.
 Quantification.
 Procurement
 Storage, inventory management, distribution and
 Logistics management information system (LMIS)
The following figure summarizes the logistics cycles and activities.
Figure 8. Logistics Cycle and Activities

Product Selection
Product selection is the first “action area” for our pharmaceuticals supply chain system.
When we select the products that we intend to put into our system and distribute to the
customer, we must take into account things like the capacity of our system: if we are
selecting products that require cold chain, for example, then we must ensure that we have the
facilities required to safely store and transport those products to the customer. The process is
expected to be participatory.
Quantification
Quantification, a critical supply chain management activity, links information on
pharmaceutical demand from the health facility level with program policies and plans at the
national level to estimate the quantities and costs of the pharmaceuticals required for a health
program. Quantification is important for informing supply chain decisions for financing,
procurement, and delivery. It is not a one-time exercise; it should be exercised regularly
depending on the pharmaceuticals to be determined. Health facilities are required to forecast
their need (estimating the quantity of each product that will be dispensed or used for the next
year) and adjust their expected budget. Pharmaceutical needs can be quantified by using one
or a combination of more than two standard methods.
Consumption and Morbidity methods are the two major quantification methods that are
relevant and practical at the health facility level.
Consumption-based method
 It estimates the commodity needs based on records of past consumption.
 Works well where all records are available, up-to-date and the information is
reliable.
 Adjustments are made for stock-outs, wastage, losses, and growth in number of
clients /patients.
Morbidity Method
 This method is used in new and scaling up programs or disaster assistance.
 Uses incidence or prevalence rates of specific diseases, or health conditions,
occurring within a defined population group.
Definition Common Terms Used in Quantification Procedures
1. Stock on hand.
2. Maximum stock
3. Minimum stock
4. “Push system”
5. “Pull system”
6. Safety stock
7. Lead time.
8. Total consumption
9. Average monthly consumption
10. Months out of stock (MoS)
Procurement
Procurement is the process of locating and agreeing to terms and purchasing goods, services
or other works from an external source often with the use of a tender or competitive bidding
process. Once we select the product and quantities that we need to meet our needs, then we
must obtain those products from our supplier, that is, we must procure our needs. Health
facilities procure preferentially through EPSS, products that are not found at EPSS can be
procured from private suppliers using stock out certificate.
Storage, Inventory Management, and Distribution

Once the products have been procured and received in a health facility, there should be
appropriate storage and distribution within hospitals and health centers. Storage must be
adequate to maintain the quality of our products and storage capacity must be adequate to
manage all of the products in our system. The purpose of an inventory control system is to
inform personnel when and how much pharmaceuticals to order and to maintain an
appropriate stock level to meet the needs of patients. A well-designed and well-operated
inventory control system helps to prevent shortages, oversupply, and expiry of
pharmaceuticals.
In Ethiopia's health facilities, IPLS (Integrated Pharmaceutical Logistics System) is

implemented to manage the procurement, storage, distribution, and inventory management of
pharmaceutical products and medical supplies. The SOP for IPLS in health facilities dictates
all hospitals and health centers are required to order on a fixed schedule from EPSS.
 Hospitals and health centers place orders every 2 months; orders are placed using
RRF.
LMIS
LMIS is shown at the center of the cycle, and we consider it to be the engine that drives the
supply chain system. The LMIS is the means through which we gather and communicate the
information that allows managers to make the decisions they need to make in order to ensure
product availability and customer service. Every function in the supply chain cycle needs
accurate information in order to work. For example, without a properly functioning LMIS:
 We do not know which products are being accepted and used by our customers (which
products to continue to select or stop selecting).
 We do not know if we are obtaining the right quantities at the health facility level to serve
the customers’ needs.
 We do not know if stores are empty or products are piling up and not being dispensed.
 EPSS does not know what, when, and how many products HFs need.
The other activities found at the center of the supply chain cycle are management support
activities that are also essential to the functioning of the system.
As a result of well-functioning supply chains; public health programs will benefit by:
 Increasing their impact
 Enhancing quality of care
 Improving cost-effectiveness and efficiency.
Figure 9. Flow of Pharmaceuticals and Information in the Integrated Pharmaceutical

Logistics System (IPLS)
Activity 7.2. Gorup Exercise:
Objective: Identify challenges in pharmaceutical supply chain management.
Instruction: Be in small group of 3-4, Read and analyze the following question and answer
the following questions.
Question: What are the challenges related to prescriber, supplier, and health facility
management?
Time:10 minutes
Challenges of anti-malarial drugs & supplies chain management
Managing the supply chain for anti-malarial drugs and supplies can be challenging due to
various factors. Some of the most common challenges are:
1. Inventory management: Effective inventory management is crucial to ensure the
availability of anti-malarial drugs and supplies. Challenges in inventory management can
include inadequate forecasting, inaccurate demand estimation, and insufficient stock
monitoring.
2. Drug resistance: Resistance to common and relatively inexpensive anti-malarial
medicines, such as chloroquine and sulfadoxine-pyrimethamine, poses a significant
challenge. This resistance necessitates the use of more expensive and less accessible
alternative drugs, impacting the supply chain.
3. Policy changes: Changes in national malaria drug policies can affect the supply chain
management of anti-malarial drugs. Implementing new policies and transitioning from old
drugs to new ones can lead to disruptions in the supply chain.
4. Weak infrastructure: Inadequate infrastructure, including storage facilities, transportation
systems, and electricity supply, can hinder the efficient management of the supply chain for
anti-malarial drugs and supplies.
5. Stock-outs and shortages: Stock-outs of anti-malarial drugs at the front-line level can
occur due to various reasons, such as inadequate ordering, seasonal demand fluctuations, and
supply chain disruptions. These stock-outs can impact the availability of essential medicines
for malaria treatment.
6. Global supply chain issues: Challenges in the global supply chain, such as shortages of
active pharmaceutical ingredients (APIs), manufacturing problems, and supply chain
disruptions, can also affect the availability of anti-malarial drugs and supplies.
7. Health system coordination: Weak coordination between the health information system
and the medicines ordering system can make it difficult for the health system to assess the
appropriate quantities of anti-malarial drugs needed. This can lead to underordering or
overordering, contributing to supply chain challenges.
It is important to address these challenges to ensure the availability and accessibility of anti-
malarial drugs and supplies, particularly in regions heavily affected by malaria. Efforts to
strengthen supply chain management, improve infrastructure, enhance forecasting, and
inventory management systems, and promote collaboration among stakeholders can help
overcome these challenges.
N.B. Supply chain management issues peculiar to anti – malarial pharmaceuticals and
supplies:
 Seasonality – significant variation in disease burden from one time to the other
affecting demand-supply balances.
 Disease patterns – rapid transmission in the form of outbreak causing acute strains
in supplies.
 Geographic variability
 Service delivery model – service is provided from the highest health care level to
the community level.
Frequent updates and changes in diagnostic and management protocols – suppliers and
recipients need to be keen to adapt to the protocol changes made nationally.
7.2: Requesting and Getting Pharmaceuticals

Activity 7.3: Reflections
Instruction: Go over the following question just to retrieve your prior knowledge/
experience. Feel free to answer/reflect/respond to the question.
 Where and how does your health facility get antimalarial drugs?
Time: 10 minutes
In IPLS, hospitals and health centers are expected to summit all pharmaceutical transaction
reports and orders/requisitions bimonthly by using a form called Report and Requisition
Form (RRF) to a nearby EPSS branch. RRF should be completed at the end of the month and
sent to EPSS by the 10th day of the month following the end of the reporting period. This
report is expected to be completed by the Health Centre or Hospital Store Manager (verified
by the Pharmacy Head and Approved by the Head of the Health Centre or Hospital.
Unless EPSS receives requests from HFs timely and completely/accurately EPSS will face
the challenge of resupplying pharmaceuticals to HFs and this will negatively affect the
service.
Figure 10. Integrated pharmaceutical logistic system.

7.2.1. Roles & Responsibilities
EPSS central/FMOH
● Forecast national pharmaceuticals need.
● Procure, store, and distribute pharmaceuticals to health facilities.
● Receive reports and orders from health facilities.
● Coordinate and lead partners working on supply management and rational
pharmaceutical use.
● Monitor and evaluate the performance of the logistics system.
● Advocate for financial support for pharmaceuticals.
● Coordinate donor contributions to pharmaceutical stocks.
RHB/ZHO/WHO/THO
● Receive and review health facility/Woreda aggregated reports
● Provide technical assistance and supervision in logistics management to health facilities
● Supervise stock management, ordering, and reporting functions of Hospitals/HCs
● Monitor and evaluate system performance
● Enforce policies related to pharmaceutical logistics management
Health facilities
● Receive pharmaceuticals from EPSS.
● Conduct visual inspection of pharmaceuticals received.
● Store pharmaceuticals using appropriate storage procedures
● Dispose of damaged/expired stock as per the national disposal guideline.

● Maintain Bin Cards Stock Record Cards, and consumption records for all
pharmaceuticals
● Complete the Report and Requisition Form every two months and submit it to EPSS and
RHB
● Dispense products to clients
Drug and Therapeutic Committee

The role of the drug and therapeutic committee (DTC) in inventory management, storage, and
distribution of pharmaceuticals within health facilities includes:
● Monitor the bi-monthly report and requisition form (RRF) is completed timely and sent
to EPSS and internal reporting is implemented as indicated by the IPLS SOP manual.
● The DTC should also check and evaluate the quality of the data on the RRF regularly.
● Approve the pharmaceuticals list of each dispensing unit.
● Approve and ensure the implementation of SOPs for guiding the whole process of
distribution.
● Monitor the application of storage guidelines in the pharmacy store and dispensing units.
● Make sure that a system is in place to monitor the stock status at the main pharmacy
store and dispensing units, and disposal of unfit-for-use pharmaceuticals is working.

7.2.2. Requesting and Getting Pharmaceuticals from EPSS
In IPLS hospitals and health centers, centers are expected to submit all pharmaceutical
transaction reports & orders/requisitions bimonthly by using a form called Report &
Requisition Form (RRF) to a nearby EPSS branch. RRF should be completed at the end of
the month and sent to EPSS by the 10th day of the month following the end of the reporting
period. This report is expected to be completed by the Health Centre or Hospital Store
Manager (verified by the Pharmacy Head and Approved by the Head of the Health Centre or
Hospital. Unless the EPSS receives requests from HFs timely & completely/accurately EPSS
will face the challenge of resupplying pharmaceuticals to HFs, & this will negatively affect
the service.
Reporting and resupply form/ RRF/
According to the new Integrated Pharmaceutical Logistics System (IPLS), health centers and
hospitals are required to report and order every two months using RRF. They calculate their
order quantities to bring stock levels up to the maximum level (4 months).
● Max stock = 4 month
● Min stock = 2month
● EOP = 0.5 month
EPSS will resupply them accordingly.

Health Post re‐supply
Health Posts complete one part of the Health Post Monthly Report and Re-Supply Form
(HPMRRF) every month and send the report to the health Centre. The health Centre uses the
information found on the Health Post Monthly Report and Re-Supply Form to complete the
form and calculate the quantity of pharmaceuticals needed by the Health Post. Each month,
the health center will issue enough stock to bring the Health Post up to its Maximum Stock
Level of 2 months of stock.
Private health facilities/clinics
● Private health facility monthly request and resupply form (RRF)
● RHB/THO/WHO/EPSS/public facility
● Month /2month/ quarter.
7.2.2 Tools used in managing pharmaceutical logistics

● Bin card/stock record card
● RRF
● IFRR
● HPMRR
Others
● Expiry recording tool

● Receiving note/voucher
Chapter summary
 Pharmaceutical supply chain management in health facilities is a critical component of
ensuring the availability, accessibility, and efficient distribution of medicines and
healthcare products.
 The logistics cycles for malaria diagnosis and treatment tools involve activities such as
demand planning and forecasting for diagnostic tests and antimalarial medicines,
procurement of these tools from suppliers, transportation of the goods to healthcare
facilities, warehousing, and inventory management.
 In IPLS, hospitals and health centers are expected to summit all pharmaceutical
transaction reports and orders/requisitions bimonthly by using a form called Report and
Requisition Form (RRF)
 RRF should be completed at the end of the month and sent to EPSS by the 10th day of the
month following the end of the reporting period.
References
 www.ncbi.nlm.nih.gov
● Practices of anti-malaria pharmaceuticals inventory control system . ghsupplychain.org
● Guidelines for Managing the Malaria Supply Chain: A Companion
to .www.ncbi.nlm.nih.gov
● The challenges of changing national malaria drug policy to
bmcpublichealth.biomedcentral.com
● Medicines and vaccines supply chains challenges in Nigeria:
a .malariajournal.biomedcentral.com
CHAPTER EIGHT: MALARIA EPIDEMICS DETECTION AND RESPONSE
Duration: 2 hours
This chapter aims to equip training participants with all the required knowledge and skills in
identifying malaria epidemic precipitating factors, detecting malaria epidemic, and designing
responses.
Chapter Objective
Upon the successful completion of this chapter, participants will be able to describe the
detection of malaria epidemic and design appropriate responses.
Learning Objectives
At the end of this chapter, participants should be able to:
● Define malaria outbreak and epidemic
● Describe the purpose of malaria epidemic forecasting and early warning
● Explain the basic principles of malaria epidemic detection and response.
Chapter outline
8.1. Overview of malaria Epidemic and factors precipitating malaria epidemic, forecasting,
detection, and preparedness
8.2. Epidemic confirmation and response
8.3. Reporting malaria epidemic – 45 minutes
8,4. Summary
8.1: Overview of malaria Epidemic and factors precipitating malaria epidemic,

epidemic forecasting, detection, and preparedness
Activity 8.1: Brain storming and reflections

Think for a while and reflect on the following question
● What do you know about the malaria epidemic in Ethiopia?

● Describe the current situation of malaria in your area.
Time: 10 minutes
Outbreak: an increase in the number of cases of a disease compared with the expected number. An
outbreak lasts for only a short time, or it occurs only in a limited area.
Epidemics: is also an excess number of cases compared with the number expected. However, an
epidemic is more general than an outbreak, the increase in the number of cases continues far longer,
and the cases are distributed across a wider area.
Malaria epidemics: are the occurrence of a number of cases above what is expected in a place in a
particular time. Sometimes it is hard to distinguish malaria epidemics from the usual seasonal upsurge
of malaria. Malaria epidemics can be one of the most serious public health emergencies. Malaria
epidemics may occur with little or no warning and may challenge the health system to prevent or
effectively respond to the problem and may strain health facilities and systems and cause public
outcry resulting in intense political pressure for rapid and decisive intervention.
Overview of Malaria Epidemics in Ethiopia
A devastating malaria epidemic occurred in 1958, involving about three million cases and 150,000
deaths, and covering about 100,000 square miles (259,000 square kilometers) of highland area. Since
1958, major epidemics of malaria have occurred at approximately 5-8-year intervals, and there have
been more frequent smaller-scale sporadic epidemics and seasonal case build-ups. In 1998, a
widespread severe malaria epidemic occurred in most highland and lowland areas in the country.
Many localized but severe outbreaks of malaria occurred in Amhara and SNNP Regional States,
leading to widespread epidemic malaria in highland and highland fringe areas (up to 2,500 meters) in
2003. However, there has not been any major malaria epidemic since 2003.
Factors Precipitating Malaria Epidemics, Epidemic Detection and Preparedness

Question
● What is your experience in predicting the malaria epidemic in your area, how did you
detect it, and what preparations you made to handle the malaria epidemic
Factors precipitating the malaria epidemic

Malaria epidemics can occur because of variability or changes in the rate of infection and
population immunity. Generally, malaria epidemics occur in places where there is low and
unstable transmission, and where people have low or no immunity against malaria. There
could be epidemics in high transmission areas as well if there is deterioration of the health
system, interruption of anti-malarial measures, or migration of non-immune individuals, such
as population movement in search of labor to these areas. Other triggering factors include:
● Unusual local weather phenomena and activities result in environmental
modification that increases vector population.
● Increased vulnerability of the population from famine and malnutrition.
● Interruptions of anti-malarial measures which have kept malaria under control.
● Resistance to anti-malarial medications and/or insecticide used for vector
control.
Epidemic Detection
There are two methods of epidemic detection. Method 1 is the classic method, based on
epidemic monitoring charts and thresholds. This is currently recommended and probably will
continue to be used for some time in areas of higher transmission. Method 2 (cluster
mapping) will be tested and gradually introduced, where applicable; as malaria incidence and
transmission in an area falls to low levels this new method will improve management of the
relatively few clusters of malaria infection that remain within communities.
In a strict sense, an epidemic of malaria is defined as a situation when the number of malaria
cases is more than the “normal number” at a specific period and place. Therefore, the "normal
expected number” called the threshold must be estimated. One way to do this is by using past
weekly data from five previous years to construct a third quartile (second largest number) as
a threshold line in an epidemic monitoring chart.
Most malaria illnesses in Ethiopia probably represent micro-clustering of local malaria
transmission near a household, whereas isolated non-clustered infections might represent
importations or relapses (though possibilities of indigenous transmission should be
scrutinized and ruled-out). Local “micro-clusters” of malaria infections are defined as three
or more indigenous cases of malaria of the same species occurring in homes within 1 km
distance of one another within a 28-day interval, indicating probable local transmission.
These should be detectable early by the HEW at the health post when approximate map
sector locations of homes of ill persons with malaria are systematically documented in
malaria registers along with the date of illness (Method 2).
Question
● What do you think is the appropriate method to calculate the threshold currently in
Ethiopia? Discuss your choice
The key principles of epidemic detection and action (using any detection method) are:
● Defining epidemics according to a particular period and area (usually health
facility catchment area). The basic unit of time is a week; epidemics in Method 1
are defined according to a weekly threshold, while Method 2 uses a time
window of up to four weeks.
● In both cases, taking action to avert the epidemic as soon as it is detected is
important.
● Both methods use a combination of passive and active surveillance and
necessary containment actions (e.g. promoting LLIN use, other vector control,
requesting supplies, and further support if needed) once an epidemic has been
detected. Method 2 provides an evidence basis for SBC efforts and other
resources focused on areas within the kebele with the most intense recent
malaria transmission, i.e. malaria “micro-cluster” hot spots localized to within 1
km sectors.
● There is no need to wait for formal confirmation of an epidemic before starting
active surveillance and containment actions. Epidemics that spread beyond the
kebele or woreda level may need further support and confirmation from zonal,
regional, or national levels to release additional resources and supplies.
Method 1: Epidemic charts and thresholds
To establish a threshold for any given week, a health facility’s past data by week should be
compiled and a threshold determined using the ‘third quartile’ method. Current data may then
be compared with the threshold. If an increase above the weekly threshold is observed, it
implies that there may be an epidemic.
Under Method 1, an epidemic is defined as: “The occurrence in a health facility catchment
area of cases of an illness, clearly more than normal expectancy”.
The definition involves clear time, place, and person.
For this we need to know:
● Where? Which health facility catchment or other defined area

● When? The time
● What is the “normal expectancy” for that area and during that time?
● What do we mean by “cases” (case definition)? How many of these and what
proportion tested have malaria by RDT or microscopy?
● What is regarded as “excess”?
● Who has become ill? – which age group is more affected?
Where – e.g. Health post or kebele: is the smallest administrative/operational unit to

monitor and will be defining epidemics in its catchment area. Hence, recording the addresses
of patients in registers is essential as people from another catchment area may prefer your
facility for various reasons (e.g. proximity, availability of drugs). The catchment area
population may appear to change due to the temporary non-functioning of adjacent health
posts or because of newly created health posts nearby. If the addresses of the patients are
properly registered, district health offices and health centers can monitor kebele malaria
trends using kebele-level disaggregated data.
Time: Since malaria is a weekly reportable disease, the week is the primary time unit used in
defining the malaria epidemic. The weeks in the year are defined in a standard way by WHO
week number (Table 18).
“Normal expectancy”/Threshold is defined based on that same case definition, catchment,

and week in previous years. We have two choices, depending on what information we have.
● The third quartile (second highest number from the five previous years’ data for
that week);
● and doubling the previous year’s number of cases (in the absence of five years
of data).
Case definition: Choose ONE indicator as the primary one for defining epidemics. Ideally, it
would be confirmed malaria cases (either as evidenced by a positive RDT or a microscopy
slide) in all age groups. If confirmation is not possible in your location, then use clinical
malaria cases, but these must be classified as presumptive malaria (not parasitologically
confirmed). The threshold must be based on the same indicator, which is the most
challenging requirement of Method 1, since often at the facility level malaria cases are
diagnosed both clinically as well as parasitologically based on the availability of RDTs or
microscopy at facilities.
Note: If you have five years’ previous data (all years must be “normal” years, without an
epidemic), you can determine that when malaria cases exceed the third quartile number (or
exceed the line on the chart) then there is an epidemic for that week. If you have less than
five years’ data, you can say that any number of malaria cases more than double the number
in the same week of last year’s data is an epidemic. In a strict sense, if no historical data (the
last 5 years) is available at all for the catchment area, an epidemic cannot be detected since
there is no known “normal”. However, an alarmingly rapid rise in cases or mortality can be
detected by doing a week-to-week comparison of case registers. Alternatively, Method 2
could be used to monitor the malaria situation provided that the system is established.
Why do we need a threshold? It can be very difficult to distinguish an epidemic from a

normal seasonal case increase. Once it is apparent that the seasonal case increase is much
higher than “normal”, the epidemic is well underway. Because health staff often move around
to different health facilities, they may not be aware of the expected number of cases in the
local area.
How to calculate the threshold? The following tables give examples of how to tabulate data
for estimating a threshold by two methods. The data in the tables is illustrative and for this
example only. Table 18 is the empty sheet. Table 19 is filled with the past five years’ data
and shows the third quartile threshold. Table 20 shows what to do if you have one-year data
only.
Thresholds can be calculated for any health facility or any other unit including kebele,
woreda, or zone. However, the heath post catchment area (usually kebele) is defined to be the
smallest geographic area for monitoring epidemics. Higher levels could also monitor
epidemics provided that the data thresholds for monitoring are disaggregated by health post-
catchment area.
Activity 8.2 : Group exercise
Be in groups of 4-6
Read and analyze the given scenario and reflect on it
Scenario
In a kebele, the number of malaria cases markedly decreased compared to last year’s same
period. However, the case remains to be higher than the threshold. The woreda malaria focal
person thinks the problem is because of the threshold calculation.
Questions
Discuss and justify the woreda focal person’s argument
Time: 10 minutes
Table 12. Chart for assessing the usual number of weekly cases (confirmed or clinical) and the threshold at a
health facility.
WHO Year Year Year Year Year Third Quartile or This year’s
Week 1 2 3 4 5 second largest cases
No. number or 2x last
year’s cases
1
51
52
(53)
Note:
1. Week number: the WHO week number system is used, and weeks run from
Monday to Sunday. Week 1 according to the WHO week is the first week of
January.
2. If 5 years of data are available, the Third Quartile can be filled in (Table 18). The
Third Quartile is the second highest number from the five values for each week.
3. The current year’s data should be added in the right column, by week (“this
year”).
4. If only last year’s data is available, a threshold is twice the last year’s number for
that week.
5. A new chart must be prepared each year, adding the new annual data (unless an
epidemic year) and dropping the oldest year.
6. The data can be plotted manually onto a norm chart with the threshold line and the
current year by week (Table 19).
7. For higher-level health workers with computer capacity, a Microsoft Excel file
can be used to estimate the third quartile. For example, the formula for the third
quartile in a second week (row-3) with five years’ data (B3 to F3) of a Microsoft
Excel work book sheet is given by =QUARTILE (B3:F3, 3). Then, draw charts
(Table 20) and update the threshold each year.
Table 13. Construction of the threshold (norm) when five years' historical data are available to monitor the
current year
WHO Year Year Year Year Year Third Quartile or second This
Week 1 4 largest number or 2x last year’s
2 3 5
No. year’s cases cases
1 8 42 6 36 14 36 20
2 12 42 27 38 17 38 22
3 10 42 43 49 21 43 35
4 20 17 34 59 32 34 26
5 34 17 46 20 30 34 25
6 18 10 34 22 23 23 20
7 12 19 33 24 25 25 21
8 37 10 27 61 23 37 25
9 32 18 37 29 26 32 16
10 31 24 28 17 13 28 5
11 22 19 22 12 23 22 15
12 17 39 31 22 43 39 25
13 5 19 19 16 21 19 16
14 22 19 28 25 21 25 30
15 29 16 28 19 13 28 45
16 17 32 25 6 11 25 60
17 28 11 32 8 8 28 62
18 17 34 40 13 9 34 60
19 12 17 27 9 10 17 25
20 16 18 14 1 9 16 10
21 31 34 29 2 8 31 15
22 38 22 23 1 9 23 16
23 29 33 14 1 17 29 17
24 19 32 35 1 32 32 18
25 27 10 25 1 34 27 22
26 36 20 34 1 47 36 30
27 15 32 36 4 62 36 35
28 19 42 44 8 38 42 36
29 52 49 47 10 62 52 101
30 31 44 45 12 73 45 122
31 31 51 53 94 142 94 135
32 97 67 56 114 104 104 176
33 42 73 67 94 67 73 200
34 74 61 71 82 124 82 250
35 53 123 46 57 130 123 261
36 41 58 92 79 129 92 261
37 76 136 118 70 125 125 255
38 116 113 134 37 87 116 244
39 94 145 128 73 138 138 230
40 93 102 194 103 139 139 269
41 108 692 171 52 178 178 267
42 34 178 168 59 208 178 233
43 49 165 232 59 164 165 199
44 27 183 145 44 114 145 145

45 16 283 111 34 103 111 67
46 55 141 150 40 105 141 53
47 33 133 112 20 105 112 52
48 40 122 87 25 81 87 45
49 40 95 102 30 42 95
50 19 67 71 30 33 67
51 26 56 21 38 27 38
52 23 55 34 29 6 34
(53)
Note: The threshold is the 3rd quartile. The epidemic weeks in the current year are shaded in
the right column.
Table 14. Construction of threshold (norm) with single recent year morbidity data
WHO Year Year Year Year Year Threshold This Year’s

Week No. 1 2 3 4 5 (norm) = 2x cases
last year’s
cases
1 14 28 20
2 17 34 22
3 21 42 35
4 32 64 26
5 30 60 25
6 23 46 20
7 25 50 21
8 23 46 25
9 26 52 16
last year’s
cases
10 13 26 5
11 23 46 15
12 43 86 25
13 21 42 16
14 21 42 30
15 13 26 45
16 11 22 60
17 8 16 62
18 9 18 60
19 10 20 25
20 9 18 10
21 8 16 15
22 9 18 16
23 17 34 17
24 32 64 18
25 34 68 22
26 47 94 30
27 62 124 35
28 38 76 36
29 62 124 101
30 73 146 122
last year’s
cases
31 142 284 135
32 104 208 176
33 67 134 200
34 124 248 250
35 130 260 261
36 129 258 261
37 125 250 255
38 87 174 244
39 138 276 230
40 139 278 269
41 178 356 267
42 208 416 233
43 164 328 199
44 114 228 145
45 103 206 67
46 105 210 53
47 105 210 52
48 81 162 45
49 42 84
50 33 66
51 27 54
last year’s
cases
52 6 12
(53)
Note: The threshold (norm) is 2x the previous year’s value for the week. The epidemic weeks
in the current year are shaded in the right column.
Question
What is one major difference you notice between Table 19 and 20? What do you think is the major
reason for this difference?
Epidemic Preparedness
Preparedness includes the availability of trained human resources, diagnostics, anti-malarial

drugs, supplies, and insecticides. As a rule, an additional 25% of the annual drug, lab
supplies, and consumables requirement should be kept as a contingency at the woreda or
health center level since there is always uncertainty about when will an epidemic occur. This
25% stock should only be spent when a verified malaria epidemic occurs. The contingency
stock needs to be replenished promptly following its utilization for an epidemic.
Contingency supplies must be transported to various levels well in advance. All RHBs and
woredas should plan, request, and budget the needed contingency supplies at each level as
accurately and realistically as possible. This is part of the annual malaria commodity “micro-
planning” process. All levels of the public health system should report to the next level at
least monthly about the finding of their inventories, the quantity of supplies available with
their expiry date.
8.2.: Malaria epidemic confirmation and response
Activity 8.2: Think pair and share

Think Pair and Share
Take 10 minutes and discuss with a participant sitting near you. When do you need to
confirm the presence of the malaria epidemic and what is the necessary information you
need to collect to confirm it? Also, discuss how to respond to a confirmed malaria
epidemic.
Epidemic confirmation
Epidemics detected through health facility registers using epidemic charts (Method 1) are by
definition epidemics and do not need additional confirmation, assuming that they were based
upon RDT or microscopy-confirmed cases. Epidemics detected by mapping micro-clusters of
cases (Method 2) also assume RDT or microscopy verification and should be handled
immediately by HEWs. In both situations, large epidemics will require that microscopy slides
be collected for analysis by regional laboratory experts; and in certain cases, where evidence
generation is needed, dried blood spots on filter paper may be collected for serological
analysis.
Initially, the most important information needed for malaria epidemic confirmation will be:
a) How many suspected malaria cases (persons) were documented within a specified
time interval (week, month) within a specific district or kebele (place)?
b) How many of these suspected malaria cases were tested by RDT or microscopy?
c) How many of the suspected malaria cases tested were also diagnosed as positive
for malaria
d) How many laboratory-confirmed malaria cases were P. falciparum how many
were P. vivax and how many were mixed?
e) How many deaths, hospitalizations, and severe malaria cases occurred?
f) Are there adequate supplies of RDTs, AL, chloroquine, rectal artesunate, and IV
artesunate?
g) If available, compare current malaria case numbers with previous malaria registry
data.
For large epidemics (several woredas or zones), a detailed emergency plan of action should
be rapidly, but carefully, prepared to optimally use available personnel, finance,
transportation, supplies, and time. In this plan, the responsibilities, localities to be covered,
and schedule of work for each control team should be shown clearly and shared as
appropriate at the kebele, zonal, and regional levels.
Response to Malaria Epidemics
Whether an epidemic is detected by Method 1 or 2, certain active surveillance and other

control actions are triggered and should continue for up to one month or until no further cases
are detected for at least two weeks. At the end of the four-week period, epidemic status
should be reassessed, and a decision made to continue active surveillance or revert to normal
passive surveillance and treatment. If an epidemic is detected, the active surveillance should
be as follows:
Mass Fever Testing and Treatment (MFTT): Test everyone with fever and treat those with
confirmed malaria. This step should be taken when sufficient RDTs are in stock and as long
as RDT positivity drops below 50%, upon examination of 50 febrile patients. Treatment must
be species-specific.
Mass Presumptive Fever Treatment (MPFT): When, upon examination of 50 febrile

patients, RDT positivity is equal to or greater than 50%, action should switch to MPFT (treat
all persons with fever presumptively). This should be done when stocks of RDTs are low
(while waiting for supply), or if RDT positivity among at least 50 actively detected and tested
suspected cases increases to more than 50%. MPFT indicates treatment with DP plus PQ
unless the cause of the epidemic is confirmed to be P. falciparum only.
Both MFTT and MPF are most rational within malaria ‘hot zones’ (i.e. households especially
within 500 meters of a cluster of known recent malaria transmission/cases) beginning with
the nearest homes. Registers must be kept of individuals actively tested and treated.
Other interventions to be taken simultaneously with MFTT and MPF: Treat and refer
severe malaria cases; request more supplies to replace those consumed; use effective anti-
malarial medication that is closest to expiry date; SBC for improving LLIN use; consider IRS
if evidence from epidemiological analysis ensures that transmission will continue despite
treatment interventions.
8.3: Reporting malaria epidemic
Activity 8.3 : Reflections
Individual reflection
● What do you think is the importance of reporting the malaria epidemic?
Listings of persons tested and treated during ‘mass presumptive fever treatment’ or ‘mass
fever testing and treatment’ active surveillance must be reported. The following table may be
used for recording ‘mass presumptive fever treatment’ or ‘mass fever testing and treatment’.
Starting from one randomly selected household in the highly affected part of the village, take
20 houses in sequence and fill in the following format:
Table 15. Reporting form for active surveillance and treatment
HH Total no. No. of sick No. of blood No. and proportion Treatment
of HH (febrile) samples of positives out of given
No.
members household examined
(RDT or
members
microscopically) (if applicable)
examined
RDT Microscopy RDT Microscopy
1
20
HH Total no. No. of sick No. of blood No. and proportion Treatment
of HH (febrile) samples of positives out of given
No.
members household examined
(RDT or
members
microscopically) (if applicable)
examined
RDT Microscopy RDT Microscopy
Total
Note: Indicate the type of diagnosis, i.e. RDT or microscopy. Then determine the fever rate
and test positivity rate from the sampled households. Health posts should also report the
status of malaria supplies inventory.
Whether an epidemic is detected by Method 1 or 2 anywhere in the satellite health post’s

catchment area, the report must be immediately relayed to all responsible higher levels. The
mitigation activities initiated by the health post must be supervised and leveraged by the
health center and woreda health office. Any epidemics beyond the capacity of the health
center should be handled at the woreda level using local contingency supplies. Progress on
mitigation activities and gaps must be reported to higher levels on a daily and weekly basis.
When an epidemic is detected and reported by any primary health care unit, this must be
immediately relayed to all responsible higher levels. The mitigation activities initiated must
be followed-up and supportive supervision planned and implemented as frequently as
necessary. Any epidemics beyond the capacity of the woreda should be handled by the
zone/RHB. Progress on mitigation activities and gaps must be reported to higher levels on a
daily/weekly basis throughout the mitigation process. Once an epidemic is evident at the
woreda level, the situation is probably quite serious and the zone as well as the RHB must be
informed. The epidemic report form (PHEM form) must be completed and disseminated to
higher levels.
Case Management (See Case Management Guidelines for details)
P. falciparum epidemics: AL+ single low-dose PQ is the first-line anti-malarial drug

recommended for the treatment of uncomplicated P. falciparum malaria. AL is indicated for
the treatment of pregnant women in any trimester and young infant <3months (5kg).
P. vivax epidemics: Use chloroquine and 14 days PQ, if the cause of the epidemic has been
established as only P. vivax.
Mixed P. falciparum and P. vivax epidemics: Use AL+ 14 days PQ treatment.
Management of severe malaria in epidemic situations should take place in hospitals and
health centers using intravenous medications, whenever possible. Hence, severe malaria cases
diagnosed at health posts or community level should be referred to the nearby health center or
hospital as promptly as possible.
Stabilizing therapy, such as artesunate suppositories or IM artemether, may be needed in

temporary posts or situations in which staff shortages and high workloads make intensive
care monitoring difficult. The following should be done before the referral of the patient:
● Always nurse patients in a coma, lateral position to avoid aspiration;
● Give 40% or 50% glucose to all patients with severe manifestations;
● Use tepid sponging as needed to control the fever
Record all your findings and drugs given in a referral slip and refer the patient to the nearest
health center or hospital.
Activity 8.4: Group exercise
Be in groups of 4-6
Analyze the following tables containing five years’ weekly data on malaria cases and
then answer the questions below.
Question
● Identify the threshold for each scenario.
● Draw the chart using the given data.
● Interpret the result.
Time: 20 minutes
Table 16. Five years of malaria data
Week Week second

This
no. no 2003 2004 2005 2006 2007 largest
year
(EFY) (WHO) number
1 28 19 42 44 8 38 36
2 29 52 49 47 10 62 101
3 30 31 44 45 12 73 122
4 31 31 51 53 94 142 135
5 32 97 67 56 114 104 176
6 33 42 73 67 94 67 200
7 34 74 61 71 82 124 250
8 35 53 123 46 57 130 261
9 36 41 58 92 79 129 261
10 37 76 136 118 70 125 255
11 38 116 113 134 37 87 244
12 39 94 145 128 73 138 230
13 40 93 102 194 103 139 269
14 41 108 692 171 52 178 267
15 42 34 178 168 59 208 233
16 43 49 165 232 59 164 199
17 44 27 183 145 44 114 145
18 45 16 283 111 34 103 67
19 46 55 141 150 40 105 53
20 47 33 133 112 20 105 52
21 48 40 122 87 25 81 45
22 49 40 95 102 30 42 18
23 50 19 67 71 30 33 22
24 51 26 56 21 38 27 30
25 52 23 55 34 29 6 35
26 1 8 42 6 36 14 20
Week Week second
This
no. no 2003 2004 2005 2006 2007 largest
year
(EFY) (WHO) number
27 2 12 42 27 38 17 22
28 3 10 42 43 49 21 35
29 4 20 17 34 59 32 26
30 5 34 17 46 20 30 25
31 6 18 10 34 22 23 20
32 7 12 19 33 24 25 21
33 8 37 10 27 61 23 25
34 9 32 18 37 29 26 16
35 10 31 24 28 17 13 5
36 11 22 19 22 12 23 15
37 12 17 39 31 22 43 25
38 13 5 19 19 16 21 16
39 14 22 19 28 25 21 30
40 15 29 16 28 19 13 45
41 16 17 32 25 6 11 60
42 17 28 11 32 8 8 62
43 18 17 34 40 13 9 60
44 19 12 17 27 9 10 25
45 20 16 18 14 1 9 10
46 21 31 34 29 2 8 15
47 22 38 22 23 1 9 16
48 23 29 33 14 1 17 17
49 24 19 32 35 1 32
50 25 27 10 25 1 34
51 26 36 20 34 1 47
52 27 15 32 36 4 62
Chapter Summary
● The key principles of epidemic detection and action are defining epidemic according
to particular period and . The basic unit of time is a week; epidemics in Method 1 are
defined according to a weekly threshold, while Method 2 uses a time window of up to
four weeks.
● Epidemics detected through health facility registers using epidemic charts (Method 1)
are by definition epidemics and do not need additional confirmation, assuming that
they were based upon RDT or microscopy-confirmed cases.
● Epidemics detected by mapping of micro-clusters of cases (Method 2) also assume
RDT or microscopy verification and should be handled immediately by HEWs
● Whether an epidemic is detected by Method 1 or 2, certain active surveillance and
other control actions are triggered and should continue for up to one month or until no
further
CHAPTER NINE: RECORDING REPORTING AND DATA USE
Chapter Description
This Chapter focuses on malaria case data sources, and malaria case management indicators
to enable you to record transcribe, and report all malaria cases by using ESV-ICD 11 to
inform malaria decision-making for the malaria program.
Chapter Objective
At the end of this chapter, participants will be able to record transcribe, and report all malaria
cases by using ESV-ICD 11.
Learning Objectives
Upon the completion of this chapter, participants will be able to:
● Demonstrate understanding of proper use of malaria case management data
● Identify key malaria program indicators
● Demonstrate how to record all malaria cases using OPD/IPD registration
Chapter Outline
9.1: Malaria Program Data and Indicators
9.2: Malaria Cases Recording and Reporting

9.3. Summary
9.1 Malaria program data source and indicators

Session Objective
●
Activity 9.1 : Individual reflection
Introduction: Go over the following questions to retrieve your previous knowledge and
experience. Feel free to answer /reflect on the question.
● From your experience what are the types of data sources for malaria case management
activities?
Time: 10 minutes
Importance of data
There are many important uses of data. Primarily data should be used to inform decision-
making, which occurs at multiple levels – from the programmatic level to the policy level.
Listed below are a few examples of how data collected from a program or an intervention can
be used:
● To help inform policies, planning, or program decisions.
● To raise additional resources for the scale-up of programs or future programs.
● To assess whether a policy, plan, or program has produced the desired or intended
impacts.
● To strengthen programs by improving their results, their efficiency, and/or quality
of services provided by the program
● To identify factors and/or interventions that influence health outcomes.
● To ensure accountability and for reporting purposes.
● To contribute to global lessons learned that can aid other malaria control and
prevention programs in implementing effective programs.

Health information system
● It refers to a system that captures, stores, manages, or transmits information related
to the health of individuals or the activities of organizations, which improves health

care management decisions at all levels of the health system
● Information is crucial to inform on the performance of the health system and about
health challenges
● A health information system is required for timely intelligence on the other building
blocks of the health system.
Data source
What are HIS Data sources?
1. Institution-based sources; its components are Individual records, service records,
supplies, resource records, administrative reports Routine HMIS, supportive supervision,
review meetings, inspection, and surveillance Facility-based surveys: SARA, SPA+, …
2. Population-based sources; its components are Census, civil registration, population-
based surveillance, population surveys (Demography health survey DHS, Malaria
indicator survey/MIS, Multiple Indicators Cluster survey/MICS, etc.), and other
program-specific surveys and research.
Data sources by level: Community, Facility (HCs, Hosp. Private Facilities), Woreda, Zonal
and Regional levels, and National level
Question; What is HMIS?

What are the Purposes of HMIS?
Malaria program indicators
What is HMIS?
Health Management Information System (HMIS) is the routine collection, aggregation,
analysis, presentation, and utilization of health and health-related data for evidence-based
decisions for health workers, managers, policymakers, and others.
Purposes of HMIS
● Availing accurate, timely, and complete data to support decision-making at each
level of the health system.
● Strengthening the use of locally generated data for evidence-based decision-making
Components of HMIS
1. Information management
● Data collection: Recording of health data using individual and family folders,
registers, tally, and reporting formats
● Data processing: is a process of cleaning, entering, and aggregating data.
● Data analysis and presentation: is a process of interpretation and comparison of
generated information in the form of sentences, tables, and graphs.

2. Using information for management purposes
● Problem identification: identifying problems using key indicators.
● Prioritizing problems and decision making: Problems identified should be
prioritized and what types of actions need to be taken.
● Action taken: Implementing the agreed action.
● Result monitoring: Assessing the desired result has been achieved.

National malaria-related indicators
 Morbidity attributed to malaria: this indictor is defined as, Malaria cases per
1000 population and the source of data are Patient registers at HP, HC, private
health facilities, and hospitals outpatient/inpatient service-based registers
 Facility-based malaria deaths: this indictor is defined as: Percentage of all
deaths due to malaria (according to confirmed malaria diagnosis). Data for this
indicator are generated from the Inpatient register at health facilities (Health
Centers, Hospitals, Private health facilities)
 Malaria positivity rate: Percentage of slides or rapid diagnostic tests found
positive among all slides and rapid diagnostic tests performed and data are
generated from Laboratory registers at health centers and hospitals, patient
registers at HP
 Confirmed malaria cases (number and rate): Number of confirmed malaria
cases (by microscopy or RDT) divided by Mid-year resident population by age per
1000 persons at risk of malaria
 The proportion of confirmed malaria cases fully investigated and classified:
this is defined as the proportion of confirmed malaria cases fully investigated and
classified from the total malaria cases. The total number of malaria cases fully
investigated and classified was divided by the Total number of malaria cases in
elimination targeted Woredas x 100 and the sources of data are Malaria
notification, screening, and registration.
 The proportion of foci fully investigated and classified: It is the proportion of
foci in elimination targeted Woredas where foci were fully investigated and
classified from the total new potential and active foci. The total number of new
potential and active foci that were fully investigated was divided by the Total
number of foci in elimination targeted Woredas X 100 and the sources of data are
Malaria notification, screening and registration, and Malaria elimination form.
 Proportion of unit structures covered by Indoor residual spraying: Proportion
of unit structures in IRS-targeted areas that were sprayed in the last 12 months.
The number of unit structures sprayed divided by the Total number of unit
structures in the target area for IRS X 100 and the source of data is administrative
records.
 The proportion of health facilities covered by External Quality Assurance
(EQA) for Malaria Diagnosis: Health facilities (Public & Private) conducting
malaria microscopy that are participating in the quarterly national/regional/sub-
regional EQA with blinded rechecking, Panel, and/or onsite evaluation method.
The number of health facilities participating in the quarterly blinded rechecking
EQA for malaria diagnosis is divided by the total number of health facilities
conducting malaria laboratory diagnosis (microscopy) X 100 and the source of
data are Administrative Record (Lab record)
Table 17. List of Health Management Information System (HMIS) formats
S/n Name of the Reporting Form Data generated from
1 Health Centre OPD Disease Monthly Report OPD registrations book
2 Health Centre Monthly Service Delivery Report Laboratory registration book
3 Health Centre/hospital IPD Disease Morbidity and IPD registrations book
Mortality Monthly Report
4 Health Centre/ Hospital Quarterly Service Delivery Monthly service delivery
Report report
5 Health Post Monthly Disease Report form OPD registrations book
6 Health Post Monthly Service Delivery Report form OPD registrations book,
iCCM log book
Source: National PHEM Guidelines, 2021
Practice exercise: 9.3 group discussion

Objective: To understand data elements and indicators
Instruction; Be in groups of 4-6, Read, analyze, and identify the given data element and
indicators.
o Morbidity attributed to malaria o Malaria cases with travel history

o HMIS disease classification o Number of index cases investigated and
(disaggregated by age, sex, and visit classified
type) o Number of secondary cases
o New visit o Malaria positivity rate
o Facility-based death attributed to o Repeat visit
malaria o Annual parasite incidence
o The proportion of confirmed malaria
cases fully investigated and classified
o Proportion of foci fully investigated
and classified
Time: 30 minutes
Reportable Data Element

1. Malaria cases with travel history
2. Number of index cases investigated and classified
3. Number of secondary cases
4. Number of foci investigated and classified
Summary activity
Think for a while and write when and how to use the indicators
9.2 Malaria Cases Recording and Reporting
Session Objective at the end of this session, participants will able to:
Activity 9.4 : Reflections

Instruction: Before moving to the session, go over the following questions to retrieve your
previous knowledge and experience. Feel free to answer /reflect on the question
Q. What is the Importance of Medical Records in Healthcare?
Time: 10 minutes
HMIS Recording, Reporting tools and procedures

HMIS revision has recently been done by the Federal Ministry of Health. The revision
resulted in the addition of new indicators and modification and/or removal of the existing
indicators. Following the revised list of indicators, the existing recording and reporting
formats have been modified and new recording formats have also been developed.
The recording instruments are developed based on the level & capacity of the health
institutions and the scope of health services they deliver. Health posts use a family folder to
record health services that they provide while health centers and hospitals (including private
for-profit and private for-profit facilities) use individual medical records and registers to
capture medical and health services from each individual. Registers will be used to capture
selected data elements from individual medical records that are important for reporting. To
simplify report compilation, tally sheets are developed for each level, including for health
posts. Routine reports follow the health system’s hierarchy to reach the Federal Ministry of
Health of Ethiopia so that evidence-based decisions and policy-making can be made.
Individual medical recording tools and procedure
• Individual Medical record is an important compilation of facts about a patient’s life
and health.
• It includes documented data on past and present illnesses and treatments written by
health care professionals caring for the patient.
Patient form/patient card
The patient card is a free form and has three sections:
a. Section to write a chief complaint and detailed clinical notes
b. Section to write the main diagnosis and other diagnosis (if any).
c. Section to write NCoD (National Classification of Disease)
The main diagnosis may or may not exactly fit NCoD; however, it should be made to match
into the NCoD for national reporting. The main diagnosis is always one disease entity;
however, a patient can have one or more other diagnoses for clinical management and to be
recorded in the card but not to be reported.
OPD/IPD registration
A new Visit is a patient visit for a new episode of illness.
Repeat Visits a patient who visits the health facility for the same episode of illness and or for
following etc.
Note: The ultimate decision, whether a client/patient is defined as a new or repeat diagnose is
left to the knowledge of the attending clinician
Importance of medical records
1. Reduces Risk of Malpractice
Documenting all information helps mitigate the risk of malpractice. A record that has been
well-maintained will be able to reduce liability concerns if a claim is made.
2. Helps to Maintain Communication amongst Healthcare Personnel
Proper documents help to communicate the quality of care a provider delivers to patients and
help them easily continue their care all their lives.
3. Ensure You Get Reimbursed
A medical record that has been appropriately documented can help in facilitating an effective
revenue process, reduce the hassles of claims processing, get health facility reimbursements,
and expedite payment.
4. It measures Health service quality
It helps the health facility with value-based purchase and service quality also measured by the
service provided to the client and it is also an indicator of service quality in the health facility.
Transcribing and Reporting
Ethiopia simplified the version of the international classification of disease (ESV ICD-
11)
• International Classification of Diseases is a tool for recording, reporting, and

grouping conditions and factors that influence health
• Its purpose is to allow the systematic recording, analysis, interpretation, and
comparison of mortality and morbidity data collected
• Classification is mainly based on anatomical sites & has a single hierarchy
• Has rules and conventions to record and report causes of morbidity and mortality
• The main condition is defined as the condition, diagnosed at the end of the episode
of health care, primarily responsible for the patient’s need for treatment or
investigation.
• If there is more than one such condition, the one held most responsible for the
greatest use of resources should be selected.
• ‘Not elsewhere classified’: Serves as a warning that certain specified variants of the
clinical concept may appear in other parts of the classification
• ‘……Unspecified’ implying the source documentation used for classifying did not
provide more detail beyond the term. Unable to further classify the disease. E.g.
Syphilis, Unspecified.
• ‘Other specified….’ implying the source document /clinician can specify the
diagnosis but not included in the list.
• If no diagnosis was made, the main symptom, abnormal finding, or problem should
be selected as the main condition.
• The underlying cause of death: is the disease that has initiated the series of illnesses
leading directly to death, or the circumstances connected with an accident or an act
of violence which caused the injury or poisoning leading to death.
• The concept of the ‘Underlying Cause of Death’ (UCOD) is central to mortality
recording and reporting.
• Immediate cause of death: It refers to the disease, or failure of injury whose
symptoms cause the person to die.
• Intermediate cause of death: refers to the condition that leads from the underlying
cause of death to the immediate cause of death.
General rule
Rule 1 A disease or a condition recorded as the cause of morbidity or mortality on the

patient chart at the final stage of the episode of care by the treating clinician shall
be considered the main diagnosis of the patient.
Rule 2 A disease or a condition shall be labeled as either a “New” or “Repeat” episode
of illness by the treating clinician
Rule 3 The name and code of a specific diagnosis or condition shall be written on the
abstract register (all service units where the diagnosis is made) at the end of the
episode of care.
Rule 4 Only a single condition or diagnosis shall be recorded and reported as a cause
of morbidity or mortality on the abstract register for an individual diagnosed to
have one or more diagnoses or conditions at the end of the episode of care.
Rule 5 The name of a disease or a condition shall not be written in abbreviations form
on the abstract register.
Rule 6 The treating clinician shall put the main diagnosis in clear handwriting and in
expanded form on the patient chart to avoid errors of interpretation during
mapping onto ESV-ICD 11 and recording on IPD/OPD registers.
Rule 7 Only ESV-ICD 11 diagnosis or condition is allowed to be written on the abstract
register as the cause of morbidity or mortality by the treating clinician or
the Nurse Assistant with a transcription/ mapping role.
Rule 8 If the main diagnosis or condition to be mapped onto ESV-ICD 11 can’t be found
in the list, search for its parent category in the hierarchy to write its name and
code on the register. If you can’t get the immediate parent category, consider the
next higher-level category.
Rule 9 During a diagnosis or a condition mapping, if you can’t get it in the edition
recommended to the level of the health facility you are working for, use editions
meant to a higher level before you look for the parent category.
Rule 10 The ICD has historically used body systems as an organizing principle.
Traditional divisions of body systems facilitate the creation of meaningful
subsets for coding and analysis. If you can’t get the corresponding diagnosis or
condition in the chapter categorized based on the anatomic site, try to search for
it in the relevant special group chapters before you opt for the parent category.
e.g. Polycythaemia
Rule 11 Working diagnosis or condition we want to rule out or under question mark
shouldn't be recorded or reported as a cause of morbidity or immortality if the
treating clinician couldn’t reach a definitive diagnosis at the end of the episode of
care. Rather record and report the Clinical finding or Investigation result for
which you have been treating the patient as the main diagnosis or condition.
Rule 12 ESV-ICD 11 contains some services for which clients can visit a health facility
other than for diseases or injuries. During the analysis of morbidity and mortality
data, such as producing top causes of morbidity or mortality, one should exclude
service data from the list before analysis.
Morbidity Specific Rules

Rule 1: Only the treating clinician can determine the ‘main condition’ or ‘primary diagnosis
of the episode of care on the patient’s card to be transcribed.
Rule 2: If there is more than one main diagnosis or condition identified at the end of the
episode of care, the one that takes the facility’s resources more will be recorded and reported
as a ‘main diagnosis’. To determine the resource consumed during the care of the patient the
clinician can consider the severity of the illness.
Rule 3: The type of episode of an illness as ‘New’ or ‘Repeat’ can only be determined by the
treating clinician’, expected to mark the main diagnosis or the condition as ‘New’ or ‘Repeat’
on the patient chart.
NB: When a patient with a chronic illness such as Diabetes Mellitus visits a health facility for
a new complication, a treating clinician can mark and report the new condition as a ‘main
diagnosis’ and ‘New’ episode of illness. E.G: A known Diabetic Type 1 case with the acute
complication of Diabetic Ketoacidosis (DKA), the case can be reported as a new case of
DKA rather than a Diabetic Mellitus Type 1 repeat case.
Rule 4: For an admitted or a referred case, the patient’s main condition shall not be written
on the outpatient abstract register. Instead, the ‘Admitted’ or ‘Referred” will be filled as
status (according to HMIS recording and reporting standards). However, the diagnosis of
cases who are referred to other facilities shall be written on the Liaison Referral In and Out
Register.
Mortality Specific Rules

Rule 1: The clinician who is well informed about the medical history of the patient and who
has carefully examined the deceased shall write the causes of death (the immediate,
intermediate, and underlying cause of death) on the medical certificate (Death notification
form) and the underlying causes of death on the discharge diagnosis column of the IPD
abstract register.
Rule 2: The treating clinician must indicate or mark the ‘underlying’ cause of death so that it
will be recorded on the IPD register under the column labeled as ‘Discharge Diagnosis’.
Rule 3: In case of death due to injury or poisoning, the external cause of the injury such as
‘road traffic accident with dimension’ should be reported as the underlying cause of death.
However, if the treatment outcome is not death, the actual body damage or injury shall be
reported as a cause of morbidity.
Rule 4: The mode of death such as cardiac arrest or respiratory failure should not be
reported as the immediate cause of death.
N.B When filling out the Death notification form all three causes of death (immediate,
intermediate, and underlying causes of death should be recorded)
Malpractices of disease recording & reporting
▪ Using a smaller list for certain service unit
▪ Recording ‘abbreviation’
▪ Unmasking the main diagnosis
▪ Unable to identify the main diagnosis as new or repeat
▪ Writing the clinician’s textbook diagnosis on the register (no transcription)
▪ No communication and feedback among participating actors (Clinicians, HIT, and
Nurse Assistants)
The procedure of morbidity/injury recording and reporting
1. Recording
 Done by a clinician on the patient card/form
 Write a chief complaint and detailed clinical notes
 Free/open diagnosis: As many diagnoses as possible based on terminologies from
medical/health science education, clinical experience, or common medical science
sources to manage the patient
 ‘Main Diagnosis”: Based on ESV-ICD 11 naming/coding convention for reporting to
the next-to-next level.
 Use CAPITAL LETTER/UPPER Case to highlight/single out the ‘main diagnoses in
the patient form/card.
 A disease or a condition recorded as a cause of morbidity on the patient’s chart at the
final stage of the episode of care by the treating clinician; no working diagnosis
should be put as a ‘main diagnosis’.
 Single condition reporting: Only a single condition or diagnosis and its code are
recorded as the cause of morbidity (main diagnosis) at the end of the episode of
healthcare
 New versus Repeat: In addition, the ‘main diagnoses have to be labeled ‘new’ and
‘repeat’ after a full stop of the main diagnosis’ based on the definition in the ‘ESV-
ICD implementation guideline’
2. Transcription to registers
● Once all the above basic recordings are made by clinicians and only by
clinicians on the patient form/card, the next step is to transcribe into the
registers stated above depending on the units the patient is diagnosed and
treated.
● Transcription should be word for word/verbatim
● Transcribe ‘New’ and ‘Repeat” status on the ‘New’ and ‘Repeat’ or ‘Remark’
columns of the corresponding registers
● The transcription is done by the below cadres depending on circumstances.
● Nurse assistant: Tertiary and general hospitals, as well as and also primary
hospitals and health centers, depending on availability.
● Clinicians: Mostly at primary hospitals and health centers in situations where
nurse assistants are not available.
3. Summarizing the data into the tally sheet

● Once the ‘Main diagnosis (New/repeat) is transcribed into the different registers, the
next step is to tally into the ‘ESV-ICD 11 tally sheets.
● Tally only ‘New episodes’ from the registers to the tally sheet.
● Again, this can be done optionally depending on the circumstances by the below
professionals.
 Nurse assistant: Tertiary and general hospitals as well as and also primary
 OPD/IPD coordinators: Tertiary and general hospitals as well as and also

primary hospitals and health centers, depending on availability.
 Clinicians: Mostly at primary hospitals and health centers in situations where

nurse assistants or OPD/IPD coordinators are not available
4. Entry into DHIS2/eCHIS

● In general, this is expected to be done by HITs unless absence/shortage prompts other
options.
● Entry into eCHIS can be done by Health extension workers upon design in the future
The procedure of mortality recording and reporting

1. Recording
● Done by a clinician on the patient card/form
 Write a chief complaint and detailed clinical notes
 Free/open diagnosis: As many diagnoses as possible based on terminologies
from medical/health science education, clinical experience, or common medical
science sources to manage the patient
 Cause of death: In the event of a death, the health care provider who attends
the death is expected to document/ record the cause of death in three levels
based on the definition in the ESV-ICD 11 implementation guide:
Immediate/direct; Intermediate, and Underlying
 A disease or a condition recorded as a cause of mortality on the patient’s chart
at the final stage of the episode of care by the treating clinician; no working
diagnosis should be put as a ‘main diagnosis’.
 All three levels must be copied to the ‘death notification form’ and for
communication to the nearby civil status or vital registration office as part of
the implementation of Civil Registration and Vital Statistics (CRVS)
 Health facility death is mostly expected in IPD, emergency, and Intensive Care
Units
 Patients who died at arrival before admission/at emergency should not be
counted as deaths from OPD, emergency, IPD, ICU, and NICU
 Such deaths should be recorded as ‘Death on Arrival’ in health facilities that
use patient form/card and in pastoralist health posts under the ‘remark ‘section
of ‘curative care register.
 •’ Death on arrival’ cases should generally follow Verbal autopsy procedures
depending on the type/level of health facilities
 As a guideline is expected to define who should do a verbal autopsy is
underway, in general, it can potentially be done at the health facility at which
death on arrival happens, by the next /upper-level health facilities, or by the
respective Immigration, Nationality Vital Events Agency offices.
2. Transcription to registers
● Once all the above basic recordings are made by clinicians and only by clinicians on
the patient form/card, the next step is to transcribe into the registers stated above
depending on the units the patient is diagnosed and treated.
● Transcription should be word for word/verbatim
● For HMIS/DHIS2 reporting purposes, it is the ‘underlying cause of death’ that has
to be transcribed to registers, tally sheets, and eventually to DHIS2.
● Deaths on arrival should not be transcribed to registers
● The transcription is done by the below cadres depending on circumstances.
 Nurse assistant: Tertiary and general hospitals, as well as and also primary
 Clinicians: Mostly at primary hospitals and health centers in situations where

nurse assistants are not available.
3. Summering the data into the tally sheet
● Once the ‘underlying cause of death’ is transcribed into the different registers, the
next step is to tally into the ‘ESV-ICD 11 tally sheets.
● Again, this can be done optionally depending on the circumstances by the below
professionals.
● Nurse assistant: Tertiary and general hospitals as well as and also primary hospitals
and health centers, depending on availability.
● OPD/IPD coordinators: Tertiary and general hospitals as well as and also primary
● Clinicians: Mostly at primary hospitals and health centers in situations where nurse
assistants or OPD/IPD coordinators are not available
4. Entry into DHIS2/eCHIS
● Only ‘underlying cause of death entered into DHIS2/eCHIS
● In general, this is expected to be done by HITs unless absence/shortage prompts other

options.
● Entry into eCHIS can be done by comprehensive health posts upon implementation of
the health extension roadmap and design of ESV-ICD 11 in eCHIS in the future.
Malaria Program data collection system

Malaria data information is based on data collected through regular reporting systems (PHEM
and HMIS) and surveys and evaluations conducted periodically which include MIS, malaria
program review, and drug efficacy studies.
Information collected through HMIS is organized under the following data flow structure for
all health-related data according to the national HMIS guidelines: health posts and health
centers (PHCU) report to the woreda. Woreda-based hospitals report to the woreda in which
they are located. Other hospitals report to the zone or the region. Woredas report to the zone
or the region. Zones report to regions. Region’s report to the FMOH
Figure 9. Routine Data Collection (HMIS)
Activity: 9.5 Case study
Objective: recording cases on the OPD register and tallies Objective: To understand how to
record cases based on NCoD/ ESV-ICD 11
Instruction; Be in pairs and
1. Fill in the OPD abstract register accordingly.
2. What NCoD do you write on this register?
3. List appropriate tally/ies W/ro Almaz can be considered.
Q. case scenario: A 25-year-old woman was brought in supported by her family on

September 10, 2016. Her old card is found (MRN 12340). She complains of high-grade fever,
chills, and rigors. On arrival, the nurse measured the vital signs and documented a
temperature of 39.8 0C, pulse was 120/minute & BP was 110/70 mmHg. Pallor is found on
physical examination. Laboratory results confirmed the diagnosis of plasmodium Falciparum
malaria and Anemia. She was given a prescription for Co-Artem and sent home.
She returns after 7 days on September 17. Her fever has resolved. She now complains that
she has persistent watery diarrhea for the last 2 days. The vital signs are normal and physical
examination is normal & Stool examination is 0negative. She was given ORS and advised to
return if she has no improvement. She is offered counseling & testing for HIV at this visit but
declines to be tested without talking to her husband.
She returns after two days on September 19. She still has diarrhea and you gave her
additional ORS & reassured her that she will get better. She has discussed getting tested for
HIV with her husband and wants to be tested today. An HIV test was performed & was
negative. Let us assume that W/ro Almaz is admitted to the medical ward on her subsequent
visit.
Time: 20 minutes
Chapter Summary
 Indicator: Measures, usually a core set of indicators (determinants, inputs, outputs,

outcomes & health status)
 The sources for the HMIS indicators are primarily data collected from routine health and
administrative services. The indicators from the routine HMIS can further be triangulated
with other sources such as household surveys, facility surveys, surveillances, research
studies, and others.
 Indicator: Measures, usually a core set of indicators (determinants, inputs, outputs,
outcomes & health status)
 The sources for the HMIS indicators are primarily data collected from routine health and
administrative services. The indicators from the routine HMIS can further be triangulated
with other sources such as household surveys, facility surveys, surveillances, research
studies, and others.
● The main diagnosis may or may not exactly fit NCoD; however, it should be made to
match into the NCoD for national reporting.
● If there is more than one such condition, the one held most responsible for the greatest
use of resources should be selected.
● The mode of death such as cardiac arrest or respiratory failure should not be reported as
the immediate cause of death.
● Deaths on arrival should not be transcribed to registers
Annexes
Checklist for Health Facility Visit
Fever in an adult patient
Identify a patient with acute fever and use this checklist to complete your work.
Demographic Data:
Chief complaint:
History of present illness:
Physical Examination:
Differential diagnosis:
Laboratory investigations that you

order:
Actual laboratory findings:
Most likely diagnosis:
Treatment:
Counseling/ Advice Provided:
Possible Complications:
Follow-up Plans:
Management of severe malaria: daily observation sheet (acute phase)
Date of admission: …………/…………/………… Time (h/min): …………/…………
Name of patient: ..............................................................
Record No. ..........
Age: .............
Sex: M ☐ F ☐
Weight ...............Kg
Medicines given before
admission (including
OPD) ..............
Time 1 4 8
...............
Real time (h) minutes
Investigations done on Temperature (2x/day)

admission Pulse (2x/day)
Parasite count Respiratory rate (2x/day)

......................................... Blood pressure
Haematocrit/Hb (2x/day)
.........................................
Blood sugar Glasgow/Blantyre coma
......................................... scale (3x/day)
Urine Convulsions (Y N)
analysis ................................. Able to drink (Y N)
........ Able to sit (Y N)
Cerebral spinal fluid
(CSF) .................................... Parasite count
..... Haemotocrit/Hb
Blood group Blood sugar
................................... iv artesunate or quinine in
mg
iv fluids – dextrose saline
Other medicines, e.g. iv
diazepam/antibiotics
Urine volume
Blood transfusion
Checklist for health facility visit, IMNCI
MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS

Child’s Name: __________________________ Age______ months, Sex _____
0
Weight: _____kg Lt/Ht _______ cm Temp _____ C
ASK: What are the child’s problems?
______________________________________________ Initial visit? _____ Follow-up
visit? ____
ASSESS (Circle all signs present, tick or fill dashes/spaces)
CLASSIFY
CHECK FOR GENERAL DANGER SIGNS
NOT ABLE TO DRINK OR BREASTFEED
CONVULSING NOW
VOMITS EVERYTHING
LETHARGIC OR UNCONSCIOUS
History of CONVULSIONS
DOES THE CHILD HAVE A COUGH OR DIFFICULTY
BREATHING? Yes _____ No_____
 Count the breaths in 1 minute.
For how long? ______ Days ______ breaths/minute. Fast
breathing?
 Look for chest indrawing.
 Look and listen for stridor.
DOES THE CHILD HAVE DIARRHOEA?
Yes _____ No____
 Look at the child’s general condition.
For how long? _________ Is the child: Lethargic or
Days unconscious? Restless and irritable?
 Look for sunken eyes.
Is there blood in the stool?  Offer the child fluid. Is the child: Not
able to drink or drinking poorly?
Drinking eagerly, thirsty?
 Pinch the skin of the abdomen. Does
it go back: Very slowly (> 2
seconds)? Slowly?
DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature
≥37.50C) Yes___ No____
- Decide MALARIA risk:  Look or feel for a stiff neck.
High/Low No,  Look for bulging fontanel
- If “low or no” malaria risk,  Look for runny nose
Has the child traveled to a  Look for signs of MEASLES NOW:
malarious area in the last 30 Generalized rash,
days? And one of these: Cough, Runny
- For how long has the child had nose, or red eyes.
a fever? _ Days  Blood Film or RDT: Positive __
-If >7 days, has fever been Negative___ Not Done ____
present every day?
- Has the child had measles
within the last 3 months?
 Look for mouth ulcers: If yes, are they
If the child has measles now or deep and extensive?
within the last 3 months:  Look for pus draining from the eye.
 Look for clouding of the cornea.
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1

Revision of the Manual

 Control Malaria induced fever in adults, children and new born

Upon the completion of this Course, participants will be able to:

● Identify the etiologic agents of malaria, modes of transmission, the life

cycle of the malaria parasite, and factors contributing to malaria

● Describe the management of adult patients presenting with fever

● Describe management of Fever in Children and new Borns.

● Explain management of all forms of uncomplicated malaria as per the

perform malaria diagnosis using RDTs

● Identify comprehensive clinical evaluation for all febrile patients

● Identify antimalarial drugs & related supply chain management in

Chapter Title Duration Sessions

4 Management of 1. Definition and diagnosis of

5 Management of severe 1. Definition of severe malaria

9 Recording, reporting 1. Malaria program data and

● Interactive lecture and discussion

● Guided practice with feedback

● Health facility visits

● Malaria rapid diagnostic test kits (RDTs kits)

● Quizzes. Q/A, Q&A, and feedback

● Direct observation of performance with feedback

● Written cognitive knowledge tests (MCQ)

Course evaluation methods

● Cumulative score (Post KS test score) 80% and above

● Course continuing education unit (CEU) = 15

● Course duration: 5-days

Training venue: Accredited CPD centers

Composition: Trainer: Participant ratio: 1:5

● Participant’s satisfaction using daily evaluation form and end-of-training

● Participant’s learning using written cognitive and performance tests (pre-

● Participant’s behavior (transfer of learning) using direct observation checklist

(mentoring) at the workplace

Trainers should be:-

● Experts who participated in the preparation of this training manual TWG

members who are certified with facilitation skill training

● TOT-Certified with basic malaria case management skills.

facilitation skill training

● Malaria experts with previous experience of providing training

Malaria Case Management Training schedule

● Identify the common etiologic agents of malaria

● Describe modes of transmission and life cycle of malaria parasites

● Explain factors contributing to malaria transmission

Chapter Outline / Sessions

Activity::1.1 Case study on the etiology of malaria.

Activity 1.2 : Think, Pair and Share

Instruction: Go over the following questions just to retrieve your prior

● Why are malaria cases high in some months of the year?

Time allowed:- 10 minutes

Classification of Malaria Transmission

Activity: 1.2 Case study

Reference & Resources for Further Reading

● National malaria guidelines 5th edition, 2022

● National malaria strategic plan, 2024/25—2026/27

● WHO Guidelines for the treatment of malaria, 3rd edition, 2015

CHAPTER TWO: APPROACH TO FEVER IN ADULTS

Duration: 3:30 hours

● Identify adult patients with fever

● Explain the pathogenesis of fever

● Discuss the basic components of history, physical examination & laboratory