Malaria

In Hajjis &Returned Travelers

Dr. Satti M. SalehChief of Infectious Diseases Department MGH

Director of IC Unit Meeqat General hospital CBAHI SIT Member

Medical Director Meeqat General Hospital

KNOWLEDGE OF THE INFECTING SPECIES

THE LIKELY LOCATION OF INFECTIONGEOGRAPHIC PATTERNS OF DRUG RESISTANCEIF THERE IS ANY DOUBT (TREAT FOR THE WORSE – CASE SCENARIO)CONSIDER ANY FEBRILE ILLNESS FROM MALARIOUS AREA TO BE MEDICAL EMERGENCYCOMPLY WITH TREATMENT GOAL

DEFINITIONmalaria is an acute and chronic disease caused by Protozoa of the genus Plasmodium .

FOUR SPECIES CAUSING HUMAN MALARIA:-

A- Plasmodium Malariae ( Loveran 1881 )B- Plasmodium Vivax ( GRASSI 1981)C- Plasmodium Flaciparum ( Welch 1897)D- Plasmodium Ovale ( Stephens 1922 )

)

300 – 500 million case each year* 3.5 Million death ( Unnecessary

LIFE CYCLE

Life cycle

CLINICAL DIAGNOSIS:- A- HISTORY * TRAVEL TO ENDEMIC AREA WHERE / WHEN* WAS MALARIA DIAGNOSED BEFORE * WHAT MEDICATIONS CHEMO-PROPHYLAXIS* H/O BLOOD TRANSFUSION OR USAGE OF NON-STERILE NEEDLE * ASSOCIATED MEDICAL PROBLEMS

- Cough, fatigue, malaise, shaking chills arthralgia, myalgia.Paroxysms of fever, shaking chills and sweating - no classic paroxysm- maintain a high index of suspension- anorexia, lethargy, nausea, vomiting, diarrhoea, headache.

SYMPTOMS:-

Complications:-A- CEREBRAL MALARIA - coma, altered mental status or multiple seizures with PF in blood- main cause of death in malaria - 15-20 % MortalityB- Seizures C- Renal failure 30% of non-immune adultD- Black water feverHaemolysis, Haemoglobinaemia, Hemoglobinnuria.

E.NON CARDIOGENIC PULMONARY OEDEMA;most common with pregnancy;80% mortalityF. Hypoglycemia Mostly in children and pregnancy- QUININE THERAPY- difficult to diagnose

Lack of adrenergic signs Stupor G. Lactic Acidosis poor prognosis (venous lactate45mg/dl)

H. Anaemia Infected RBCs -haemolysis non-infected RBCs- Dyserythropoeisis- Hypersplenism

LAB. STUDIES

- CBC,electrolytes panel,renal function- Imaging studies- C X-ray- CT

PARASITOLOGICAL TEST:-- thin blood smear- thick blood smear- parasitaemia rate- every 12 hoursOTHERS TEST:- polymerase chain reaction- specific * sensitive- Detect parasitaemia as low as 10 parasites /ml.

-Antigen detection Technique – PFHRP2-fluorescent staining of parasite nuclei- malarial antibody test

stay alert

Criteria for anti malaria treatment policy change ( a change of 1st line treatment) If the total failure proportion > 10 % (12

% in Jazan 2001) Additional factor : the prevalence and

geographical distribution of reported treatment failures (neighboring Yemen)

05/01/2023NATIONAL POLICY OF MALARIA CASE

MANAGEMENT IN KSA 21

بمنطقة والخبيثة الحميدة المالريا لحاالت بياني تخطيطالمنورة المدينة

من الفترة 1/7/2016وحتى ------ 1/1/2016في ΓέϭϧϣϟΔϧϳΩϣϟΔϘρϧϣΑΔΛϳΑΧϟϭΓΩϳϣΣϟΎϳέϼϣϟΕϻΎΣϟϲϧΎϳΑρϳρΧΗ ϥϣΓέΗϔϟ ϲϓ˺/˺/˻ ˹ ˺ ˿ϰΗΣϭ ------ ˺/̀;/˻ ˹ ˺ ˿

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المنورة المدينة منطقة ريا المال حاالتيوليو 2011 ---- 2010 حتى

الميقات بمستشفى المنومة المالريا حاالت يوضح بياني رسمالعام

من الفترة 1/11/1437وحتى------- 1/1/1437في

ϡΎόϟΕΎϘϳϣϟϰϔηΗγϣΑΔϣϭϧϣϟΎϳέϼϣϟΕϻΎΣ ο ϭϳϲϧΎϳΑϡγέ ϥϣΓέΗϔϟ ϲϓ˺/˺/˺ ˽ ˼ ; ˹ϰΗΣϭ -------˺/˺ ˺/˺ ˽ ˼ ;

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Goals Early and correct diagnosis Prompt and effective treatment of all

confirmed and highly suspected cases Prevent the emergence and spread of

resistance to Antimalarial drugs Reduction / interruption of transmission Prevention of relapses in P. vivax and P.

ovale infection



First – line treatmentArtesunate + Sulfadoxine – Pyrimethamine



First – line treatment Artesunate + Sulfadoxine – Pyrimetheramine

Currently available as separate scored tablets containing 50 mg of artesunate, and tablets containing 500 mg sulfadoxine + 25 mg pyrimetheramine.

The total recommended dose is 4 mg/kg bw artesunate once a day , and a single administration of sulfadoxine-pyrimthamine (25/1.25 mg base / kg bw) on day -1



Sulfadoxine- pyrimethamine (500 /25)

Artesunate 50 mg tablets

Age (years) Weight (kg)

Day 1 Day 3 Day 2 Day 1

1/2 1/2 1/2 1/2 Infants 5-10

1 1 1 1 ≤1- <7 > 10-24

2 2 2 2 ≤ 7- 13 >24-50

3 4 4 4 > 13 >50

Reference: guideline for malaria treatment, WHO, 2006



Management of treatment failure

Early treatment failure (EFT) Late clinical failure (LCF) Late parasitological failure



Definition of treatment failure

Failure to resolve or recurrence of fever and/or parasitemia within 28 days of the start of treatment

Can be divided to : early and late



Early treatment failure (EFT) Development of danger signs or severe

malaria on Day 1, Day 2, Day 3, in the presence of parasitemia

Parasitemia on Day 2 higher than Day 0 count irrespective of axillary temperature

Parasitemia on Day 3 with axillary temperature ≥ 37.5˚

Parasitemia on Day 3 ≥ 25 % of count on Day 0



Late clinical failure (LCF) Development of danger signs or severe

malaria after Day 3 in the presence of parasitemia, without previously meeting any of the criteria of early treatment failure

Presence of parasitemia and axillary temperature ≥ 37.5˚ on any day from Day 4 to Day 28, without previously meeting any of the criteria of Early Treatment Failure



Late parasitological failure Presence of parasitemia on any day

from Day 7 to Day 28 and axillary temperature < 37.5 ˚ without previously meeting any of the criteria of Early Treatment Failure or Late Clinical Failure



Second – line treatment



Artemether – Lumefantrine (Coartem)

Tablets contain 20 mg of artemether and 120 mg of lumefantrine

The total recommended treatment is a six-dose regimen of artemether-lumefantrine twice daily for 3 days

Advantage of the combination: lumefantrine is not available it is recommended for patients > 5 kg

Inform the patient to take it with fat-containing food particularly on the second and third days of treatment ( absorption of lumefantrine is enhanced by co-administration with fat



Content of Artemether (AM)+Lumefantrine(LM) per dose

Number of tablets per dose (at 0h, 8h, 24h, 36h, 48h, 60h)

Age in years

Weight (kg)

Not recommended < 5

20 mg A + 120 mg L

1 <3 5-14

40 mg A + 240 mg L

2 ≤ 3-8 >14-24

60 mg A + 360 mg L

3 > 8-14 >24-34

80mg A + 480 mg L

4 > 14 >34

DOSAGE



Management of malaria in pregnancyMalaria in pregnancy is associated with

(abortion, stillbirth, low birth weight, increased anemia, increased risk of severe malaria- in low transmission areas)

1st trimester: Quinine + Clindamycin to be given for 7 days

ACT should be used if it is the only effective treatment available

2nd and 3rd trimesters: ACT



Treatment of severe and complicated malaria

Severe and complicated malaria is a true emergency associated with severe multi systemic complications, warranting ICU care for close monitoring and subsequent management

Management should include

If severe or complicated malaria is anticipated, empiric treatment should be started without any delay.Parenteral ARTESUNATE is the first drug of choice for the treatment of severe and complicated malaria unless otherwise contraindicated i.e. first trimester of pregnancy. Quinine is the second drug of choice in severe and complicated malaria

Artesunate 2.4 mg/kg i.v. or i.m. given on: admission (time = 0) At 12 hours Then Once daily for 7 days SHIFT TO ORAL route immediately

when the patient’s condition permits



Quinine Dihydrochloride 20 mg/kg loading dose in 5 % dextrose over 4

hours followed by 10 mg/kg over 4 hours / 8 hours (Max. 1800 mg/day) for 7 days.

The treatment should be SHIFTER TO ORAL quinine (10 mg/kg every 8 h.) as soon as tolerated

A 7 days course of Doxycycline should be given in order to ensure complete cure

Start dose is 200 mg then daily 100 mg for 7 days C.I: pregnants, children < 8 y. age (use

Clindamycin 300 mg 4 times / day for 5 days)



Management of malaria in lactating women

Special care should be taken when prescribing any antimalarial to a lactating woman (although amount in breast milk are relatively few)



Management of malaria in infants Malaria is common in infants and under 2 y.

of age in endemic areas with high case-fatality rate

Start Antimalarials immediately in case of suspicion

Accurate diagnosis is important Artemisinin derivatives appear to be safe

and well tolerated



Choosing a Drug to Prevent Malaria

drug for malaria prophylaxisRecommendations for drugs to prevent malaria differ by country of travel and can be found in the of the Yellow Book. Recommended drugs for each country are listed in alphabetical order and have comparable efficacy in that country.No antimalarial drug is 100% protective and must be combined with the use of personal protective measures, (i.e., insect repellent, long sleeves, long pants, sleeping in a mosquito-free setting or using an insecticide-treated bednet).For all medicines, also consider the possibility of drug-drug interactions with other medicines that the person might be taking as well as other medical contraindications, such as drug allergies.When several different drugs are recommended for an area, the following table might help in the decision process

Atovaquone/Proguanil (Malarone)

Reasons that might make you consider using this drug Reasons that might make you avoid using this drug

Good for last-minute travelers because the drug is started 1-2 days before traveling to an area where malaria transmission occurs

Some people prefer to take a daily medicine

Good choice for shorter trips because you only have to take the medicine for 7 days after traveling rather than 4 weeks

Very well tolerated medicine – side effects uncommon

Pediatric tablets are available and may be more convenient

Cannot be used by women who are pregnant or breastfeeding a child less than 5 kg

Cannot be taken by people with severe renal impairment

Tends to be more expensive than some of the other options (especially for trips of long duration)

Some people (including children) would rather not take a medicine every day

Chloroquine Some people would rather take

medicine weekly Good choice for long trips because

it is taken only weekly Some people are already taking

hydroxychloroquine chronically for rheumatologic conditions. In those instances, they may not have to take an additional medicine

Can be used in all trimesters of pregnancy

Cannot be used in areas with chloroquine or mefloquine resistance

May exacerbate psoriasis Some people would rather not take

a weekly medication For trips of short duration, some

people would rather not take medication for 4 weeks after travel

Not a good choice for last-minute travelers because drug needs to be started 1-2 weeks prior to travel

Mefloquine(Lariam)

Some people would rather take medicine weekly

Good choice for long trips because it is taken only weekly

Can be used during pregnancy

Cannot be used in areas with mefloquine resistance

Cannot be used in patients with certain psychiatric conditions

Cannot be used in patients with a seizure disorder

Not recommended for persons with cardiac conduction abnormalities

Not a good choice for last-minute travelers because drug needs to be started at least 2 weeks prior to travel

Some people would rather not take a weekly medication

For trips of short duration, some people would rather not take medication for 4 weeks after travel

Primaquine It is the most effective medicine for

preventing P. vivax and so it is a good choice for travel to places with > 90% P. vivax

Good choice for shorter trips because you only have to take the medicine for 7 days after traveling rather than 4 weeks

Good for last-minute travelers because the drug is started 1-2 days before traveling to an area where malaria transmission occurs

Some people prefer to take a daily medicine

Cannot be used in patients with glucose-6-phosphatase dehydrogenase (G6PD) deficiency

Cannot be used in patients who have not been tested for G6PD deficiency

There are costs and delays associated with getting a G6PD test done; however, it only has to be done once. Once a normal G6PD level is verified and documented, the test does not have to be repeated the next time primaquine is considered

Cannot be used by pregnant women

Cannot be used by women who are breastfeeding unless the infant has also been tested for G6PD deficiency

Some people (including children) would rather not take a medicine every day

Some people are concerned about the potential of getting an upset stomach from primaquine

Doxycycline

Some people prefer to take a daily medicineGood for last-minute travelers because the drug is started 1-2 days before traveling to an area where malaria transmission occursTends to be the least expensive antimalarialSome people are already taking doxycycline chronically for prevention of acne. In those instances, they do not have to take an additional medicineDoxycycline also can prevent some additional infections

Cannot be used by pregnant women and children <8 years oldSome people would rather not take a medicine every dayFor trips of short duration, some people would rather not take medication for 4 weeks after travelWomen prone to getting vaginal yeast infections when taking antibiotics may prefer taking a different medicinePersons planning on considerable sun exposure may want to avoid the increased risk of sun sensitivitySome people are concerned about the potential of getting an upset stomach from doxycycline

Choosing a Drug to Prevent Malaria

Malaria

Education

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