Malaria is a protozoan disease transmitted by the bite of infected Anopheles mosquitoes.

Most important of the parasitic diseases of humans, with transmission in 103 countries, 300 million acute cases annually, and causing between 1 and 3 million deaths each year Four (or 5 ?) species of the genus Plasmodium cause nearly all malarial infections in humans : P. falciparum, P. vivax, P. ovale, and P. malariae (the 5th is P. knowlesi) Almost all deaths are caused by falciparum malaria.

3 www.ch.ic.ac.uk/wiki/images/f/fb/Malaria_map.gif

Year 2006 City/Distric Endemic Malaria 106 39 8 42 56 59 310 271

tot pop 1 2 3 4 5 6 Sumatera Jawa Bali NTB Kalimantan Sulawesi 5 eastern prov Total Outer Jawa Bali 46,093,801 131,066,903 4,077,857 11,842,361 15,253,699 8,993,888 217,328,509

at risk 35,676,341 37,622,507 3,742,147 9,090,549 13,095,085 8,558,550 107,785,179 70,162,672

City/Distric 132 124 9 52 63 61 441 317

Indonesia Sumatera Jawa Bali NTB Kalimantan Sulawesi 5 eastern prov

% Pop at risk =

49.60 77.40 28.70 91.77 76.76 85.85 95.16

% Distric Endc = Indonesia 70.29 Sumatera 80.30 Jawa Bali 31.45 NTB 88.89 Kalimantan 80.77 Sulawesi 88.89 96.72 5 eastern prov

Clinical symptoms include the following: Fatigue, Malaise, Shaking chills, Arthralgia, Myalgia, Paroxysm of fever, shaking chills, and sweats The classic paroxysm begins with a period of shivering and chills, which lasts for approximately 1-2 hours, and is followed by a high fever. Finally, the patient experiences excessive diaphoresis, and the body temperature of the patient drops to normal or below normal Other common symptoms include the following: Anorexia and lethargy, nausea and vomiting Diarrhea, headache Sign of anemia, thrombocytopenia, splenomegaly

Signs Unarousable coma/cerebral malaria Acidemia/acidosis

Manifestations Failure to localize or respond appropriately to noxious stimuli; coma persisting for >30 min after generalized convulsion Arterial pH <7.25 or plasma bicarbonate level of <15 mmol/L; venous lactate level of >15 mmol/L manifests as labored deep breathing, often termed "respiratory distress"

Severe normochromic, normocytic anemia

Renal failure ARDS

Hematocrit of <15% or hemoglobin level of <50 g/L (<5 g/dL) with parasitemia level of >100,000/mL
Urine output (24 h) of <400 mL in adults or <12 mL/kg in children; no improvement with rehydration; serum creatinine level of >265 mmol/L (>3.0 mg/dL) Noncardiogenic pulmonary edema, often aggravated by overhydration

Hypoglycemia
Hypotension/shock Bleeding/disseminated intravascular coagulation

Plasma glucose level of <2.2 mmol/L (<40 mg/dL)

Systolic blood pressure of <50 mmHg in children 1-5 years or <80 mmHg in adults; core/skin temperature difference of >10C Significant bleeding and hemorrhage from the gums, nose, and gastrointestinal tract and/or evidence of disseminated intravascular coagulation

Convulsions
Hemoglobinuriaa Other Impaired consciousness Extreme weakness Hyperparasitemia Jaundice

More than two generalized seizures in 24 h

Macroscopic black, brown, or red urine; not associated with effects of oxidant drugs and red blood cell enzyme defects (such as G6PD deficiency) Obtunded but arousable Prostration Parasitemia level of >5% in nonimmune patients Serum bilirubin level of >50 mmol/L (>3.0 mg/dL)

a Hemoglobinuria may occur in uncomplicated malaria. NOTE: G6PD, glucose-6-phosphate dehydrogenase.

Giemsa-stained thick and thin peripheral blood smears These smears are the criterion standard for malaria detection and should be sent to the laboratory immediately, since malaria is a potentially lifethreatening infection. When reading the smear, 200-300 oil-immersion fields should be examined (more if the patient recently has taken prophylactic medication, because this temporarily may decrease parasitemia). Rapid diagnosis test PF test, ICT test, paracheck, OptiMAL

Prompt parasitological confirmation by microscopy or alternatively by RDTs is recommended in all patients suspected of malaria before treatment is started. Note: Treatment solely on the basis of clinical suspicion may be considered in areas of high transmission where parasitological diagnosis is not available or is likely to delay treatment, particularly in high risk groups such as: in severe malaria cases, in children under 5 yrs of age and in pregnant women

To cure infection and reduce morbidity and mortality

The Public health goal is to reduce the infectious reservoir

Specifically

Early detection and prompt effective treatment to cure the infection and prevent progression to severe disease
Proper management of severe disease to prevent death

Prevent drug resistance

Reduce malaria transmission

Uncomplicated Malaria

P. vivax or P. ovale Mild P. falciparum Mix Malaria

Severe Malaria Malaria in Pregnancy Malaria Chemoprophylaxis

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Chloroquine sensitive

Chloroquine base 150 mg

Day I

: 4+2 tablets Day II & III : 2 tablet Or Day I & II : 4 tablets Day III : 2 tablets

+ Primaquine 1x15/30 mg for 14 days

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Failure/ Chloroquine resistant

Quinine 3x400-600 mg for 7days or Amodiaquine 10 mg/kg/day for 3 days or

One dose of Mefloquine 15 mg/kg

ACT

+ primaquine 1x15/30 mg for 14 days

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Uncomplicated Falciparum Malaria Uncomplicated Mix Malaria

Artesunate (200 mg/day for 3 days) + amodiaquine (600 mg/day for 3 days) Co-artem (= artemether 20 mg+lumefantrin 120 mg) 2x4 tablets for 3 days DHP (Dihidroartemisinin 2-4mg/kgBW +piperaquine 16-32mg/kg BW), as a single daily dose for 3 days For young infant: Artesunate or Quinine

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All clinically suspected severe malaria cases require laboratory examination and confirmation. Only in case where laboratory confirmation is not possible start treatment immediately. Parasitological confirmation is done by thinthick blood smear microscopy examination or by dipstick (Rapid Diagnostic Test [RDT]).

RAPID DETECTION & EARLY MANAGEMENT SUPPORTIVE TREATMENT SPECIFIC TREATMENT

ANTI MALARIAL DRUGS

ORGAN FAILURE TREATMENT ANCILLARY TREATMENT

AIRWAY FLUID REQUIREMENT : HYDRATION / OVERHYDRATION CONVULSION : DIAZEPAM/PHENOBARBITAL MONITORING GCS & VITAL SIGN LAB : FBC, GLUCOSE, PAR.COUNT, CREATININE, UREUM, BLOOD GAS, URINE S.G, SODIUM, POTASSIUM. PREVENT : SHOCK, SEPTICAEMIA, ACIDOSIS, ARDS, HYPOGLYCAEMIA, ASPIRATION, BEDSORES. TREAT HYPERPYREXIA VOLUME URINE & CATHETERIZATION

PARENTERAL DRUGS & DOSAGE START IMMEDIATELY MONITORING RESPONSE SWITCHED TO ORAL WHEN POSSIBLE MONITORING SIDE EFFECTS

QUININE CHLOROQUINE ARTEMISININ :

ARTESUNATE : I.V/ I.M / SUPPOSITORIES ARTEMETHER : I.M ARTEMISININ SUPP

DRUGS Quinine
20 mg of dihydrochloride salt/kg by iv infusion over 4 hr, then after loading, followed by 10 mg/kg over 4 hr every 8 hr. Patients should not received quinine or mefloquine within last 24 hr Alternatively, 7 mg of salt/kg can be infused over a period of 30 min, followed by 10 mg salt/kg over a period of 4 hr, or 10 mg of salt/kg (500 mg for adult) by i.v infusion over 8 hr continously 3 x a day

SIDE EFFECTS Hypoglycemia, chinchonism, tinnitus, hearing impairment, nausea, dysphoria, vomiting, prolonged QT interval, dysrhythmias, hypotension

Artesunate

2,4 mg/Kg/ with 3-5 ml 5% Dekstrose, IV in 2 minutes. Repeat in 12 hours. Then every 24 hours with same dose Oral Preparations after the patient can eat and drink well

DRUGS Artemeter Artemisinin Chloroquine

SIDE EFFECTS

3.2 mg/kg im initially, followed by 1.6 mg/kg daily. Not to be given iv (1 amp = 80 mg) Suppositories, 10 mg/kg at 0 & 4 hr followed by 7 mg/kg at 24,36,48 & 60 hrs. 10 mg base/kg infusion at constant rate over 8 hrs followed by 15 mg/kg over 24 hrs, or 3.5 mg base/kg 6 hourly or 2.5 mg base/kg 4 hourly by im or sc injection. Total dose 25 mg base /kg

Hypotension

ARTESUNATE I.V / I.M

ARTEMETHER I.M
1 Amp = 80mg

1 Fl = 60 mg

27 Harijanto PN. 2006

ENCEPHALOPATHY/ CONVULSION RENAL FAILURE ACIDOSIS HYPOGLYCAEMIA HYPERBILIRUBINAEMIA RESPIRATORY FAILURE HYPOTENSION SEPSIS SEVERE ANAEMIA

Indication :
Parasitemia > 30% in Uncomplicated Malaria Parasitemia > 10%: with severe malaria Treatment failure after 12-24 hours optimal antimalaria therapy, persistent schizont in peripheral blood smear

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Early treatment failure

Severe malaria in day 1-3 Parasite count in day 2 > day 0 Parasite count in day 3 > 25% of day 0 Positive asexual parasite in day 3 with fever

Late treatment failure

Late clinical and parasitological failure: Severe malaria in day 4-28 Positive asexual parasite with fever Late parasitological failure: Positive asexual parasite in day 7, 14, 21, and 28 without fever
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WHO Regional Office for Africa. A Strategic Framework for Malaria Prevention and Control during Pregnancy in the African region. 2004.

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Uncomplicated Falciparum Malaria

Time 1st trimester Criteria 1st episode Anti malaria Quinine + Clindamycin Repeat above ACT Artesunate + Clindamycin Dose 3 x 10 mg/kg / day 3 x 5 mg/kg / day Duration 7 days

Failure

2 mg/kg BB / day + 3 x 5 mg/kg BB / day

7 days

World Health organization. Guideline for the treatment of Malaria 2006. Geneva. Nosten F, McGready R, Mutabingwa T. Case management of malaria in pregnancy. Lancet Infect Dis 2007; 7:118-25.

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Time
2nd and 3rd trimester

Criteria
1st episode failure

Anti malaria
ACT Artesunate+ Clindamycin Artesunate + Clindamycin Quinine + Clindamycin

Dose
As above

Duration
7 days

As above

7 days 7 days

World Health organization. Guideline for the treatment of Malaria 2006. Geneva. Nosten F, McGready R, Mutabingwa T. Case management of malaria in pregnancy. Lancet Infect Dis 2007; 7:118-25.

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ACT
Artemether (20 mg) + lumefantrin (120 mg) Artesunat e(50 mg) + Amodiaquin e(153 mg) Artesunat e(50 mg) + Sulfadoxin-pyrimetamine (500/25 mg) Artesunate(50 mg) + Mefloquine (250 mg) Dose 2 x 4 tablets / day Duration 3 days

1 x 8 tablet s/ day

3 days

1 x 4 tablets / day + 3 tables in day 1 1 x 4 tablets / day + 1 x 4 tablets/ day I, 1 x 2 tablets / day II

3 days

3 days + 2 days

Note: for Uncomplicated non-Falciparum Malaria Chloroquine ACT

World Health organization. Guideline for the treatment of Malaria 2006. Geneva. Nosten F, McGready R, Mutabingwa T. Case management of malaria in pregnancy. Lancet Infect Dis 2007; 7:118-25. 34

Severe Falciparum Malaria : (Parenteral until oral route is possible)

Chloroquine Early trimester: Quinine/Artesunate Late trimester: Artesunate/Quinine

Oral combination with: Clindamycin

Supportive

Fe and folic acid supplement Blood tranfusion (Hb < 7 g/dL) Nutrition

Nosten F, McGready R, Mutabingwa T. Case management of malaria in pregnancy. Lancet Infect Dis 2007; 7:118-25. 36

Prevention requires A, B, C and D

(Easmon,2009)

Awareness of risk. Bite avoidance. Chemoprophylaxis Diagnosis made promptly, with early treatment of an infected case.

Areas with chloroquine sensitive P. falciparum Start one week before exposure, continue during exposure and for 4 weeks thereafter

Chloroquine

Areas with chloroquine resistant P. falciparum (low degree, not wide spread)

Chloroquine Plus

Start one week before, continue during exposure and for 4 weeks thereafter

Proguanil

Start 1-2 days before, continue during exposure and for 4 weeks thereafter

Areas with chloroquine resistant P. falciparum (High degree, widespread)

Chloroquine Plus Proguanil

As above

OR Mefloquine

Start 2-3 weeks before, continue during exposure and for 4 weeks thereafter

OR Doxycycline

Start 2 days before, continue during exposure and for 4 weeks thereafter

OR Atovaquone Plus Proguanil Start 2 days before, continue during exposure and for 7 days thereafter