National Malaria

control programme

Roll back malaria

• P.Falciparum is the most common
cause of malaria in Sudan (90%).
• There are three principal ways in
which malaria can contribute to death
in young children:
3. Cerebral malaria
4. Repeated malaria lead to severe anemia
and risk of death
5. Low birth weight due to maternal malaria
is a major cause of death in the first
month of life
 Life cycle
: (sexual reproduction (in mosquito -1
Transformation of male and female gametes of Plasmodium*
Falciparum to sporozoites within salivary glands and stomach of
.female Anopheles mosquito. *Duration of process: 2 weeks
:Pre- (exo)Erythrocytic Phase .2
Following a mosquito bite, the injected sporozoites head for the human*
.liver via the blood stream
During the next 10-15 days within the liver hepatocytes, the*
.sporozoites are transformed into merozoites
:(ErythrocyticPhase (Asexual Reproduction .3
.Merozoites leave the liver hepatocytes to invade the red blood cells*
.Schizogony= Transformation of Merozoitesto Schizonts*
:Duration of Schizogony*
.)hours )P.falciparum 36-48
.)hours )P.ovale/vivax 48
.)hours )P. malariae 72
 4. Post ErythrocyticPhase:
*Rupture of RBCs leads to the release of transformed
schizonts as male and female gametes into the blood
stream, where they cause the symptoms of malaria
)fever, rigors etc).
*Rupture of RBCs occur when the concentration of
Schizonts within the RBCs reach a critical minimum. The
RBCs rupture in synchrony and produce the clinical
symptoms of malaria.
 Transmission of malaria
•The bite of an infected female Anopheles mosquito transmits
malaria.
•Malaria can be transmitted through blood transfusion.
Among people living in malarious areas, semi-immunity to
malaria allows donors to have parasitaemia without any fever
or other clinical manifestations. The malaria transmitted is by
the merozoites, which do not enter the liver cells. Because the
liver stage is not present, curing the acute attack results in
complete cure.
•Organ transplantation may transmit malaria.
•Transplacental malaria )i.e., congenital malaria) can be
significant in populations who are semi-immune to malaria. The
mother may have placental parasitaemia, peripheral
parasitaemia, or both, without any fever or other clinical
manifestations. Vertical transmission of this infestation may be
as high as 40% and is associated with anemia in the baby.
 Case definitions:
• SUSPECTED MALARIA: when pt present with fever or
history of fever and other symptoms and signs
suggestive of malaria ( vom. , head ache, sweating )
after clinical exclusion of other common cause of
fever at that area
• CONFIRMED MALARIA: when the case is confirmed by
the presence of asexual form of the parasite in thick
or thin blood film or by rapid test in the presence of
fever.
• CLINICAL MALARIA: it is considered when there are
no facilities to confirm the suspected case of malaria.

• SEVER MALARIA: it is malaria that caused by

P.falciparum which is sufficiently serious to be a life
treating. { malaria with complications
Laboratory diagnosis of malaria
• For microscopic diagnosis of malaria, thick blood
film is required using giemsa stain.
• The result form should include:
1.Presence of infection) +ve or –ve )
2.stage of the parasite
3.parasite count
• Rapid diagnostic test )RDTs)
) ICT ) immuno-chromatographic test
:Despite of there high coast RDTs are useful
.Can be don by unskilled person -1
.At emergency& epidemics situation -2
Where the cost of new malaria treatment is high to avoid -3
.unnecessary use of drugs
 Treatment of malaria

• Treatment of uncomplicated malaria

• Treatment of complicated malaria
 Treatment of
uncomplicated malaria
• It has been changed from mono therapy to
combination therapy )CT)
• CT is simultaneous use of two or more
blood schizonticidal drugs
• They are tow forms of CT:
1. Artemisinin based combination
2. non artemisinin based combination
THE NATIONAL MALARIA CONTROL
PROGRAMME (NMCP) Recommends the
use of ARTEMISININ based combination
)ACT):-

1- Rapid & substantial reduction of parasite

biomass.
2- Rapid resolution of clinical symptoms.
3- Effective action against multi drug-resistance
p.falciparum.
4- Reduction of gametocyte carriage, which reduce
transmission of resistance & sensitive alleles.
FIRST LINE TREATMENT:-
“ARTESUNATE + SULFADOXINE
PYRIMETHAMINE”
Artesunate: water soluble, effective against p.f,
potent schizonocidal, but rapidly eliminated, so
administered in combination with another drug.
Its reduce the gametocyte carriage rate.
Available in 3 conc. : 50mg for children, 100mg &
200mg for adults.
SE: )not common)
1- transient rise in transamenases.
2- transient reduction in reticulocyte count.`
Sulfadoxine-Pyrimethamine: combination of
antifolate compounds, available as TABLETS
)500mg sulfa + 25mg pyri) & INJECTIONS.

SE : )mild & reversible)

1- GI upset.
2- cutaneous reaction.
3- anorexia.
THE DOSE :
FIRST DOSE : give both AS+SP simultaneously :-
)4mg/kg BW AS) + )25mg/kg sulfa +
1.25mg/kg pyri)

SECOND DOSE : give AS only :-

4mg/kg BW 24hr after the first dose.

THIRD DOSE : give AS only :-

4mg/kg BW 24 hr after the second dose.
AGE .Wt DAY 1 DAY 2 DAY 3
IN IN
YEARS KGs
SP AS AS AS
((500 s 2 p mg tab) (50mg tabs )50mg tabs) )50mg tabs)

1< 10 < 1/2 1/2 1/2 1/2

7 < -1 20<-10 1 1 1 1
13 - 7 40 - 20 2 2 2 2
+ 14 + 40 4 3 4 4
TTT FAILURE :-
NOT always due to parasite resistance
1- Take proper Hx.
2- Re-examine the Pt.
3- Check the adequacy of AS + SP dose,
regimen & whether vomiting occur during
ttt.

If blood film or RDTs +ve, SHIFT TO

SECOND LINE.
SECOND LINE TREATMENT :-
“ARTEMETER-LUMEFANTRINE”
Highly effective FIXED dose combination
antimalrial ttt, every tablet contain 20mg
artemeter & 120mg lumefantrine.
SE : Dizziness, Fatigue, Anorexia, Nausea,
Vomiting, Abd pain, Palpitation, Myalgia,
Arthralgia, Headache, Skin rash.
The regimen is of )6) doses:-

Twice/day for 3 days.

Best given with fatty meal like milk.

The drug should be repeated if VOMITING

occur after ONE hour of drug taken.
AGE .Wt DAY 1 DAY 2 DAY 3 Total
IN no. of
IN
YEAR initially Aft morn even morn even tablets
KGs
hr 8
1< 10< The use is not recommended. Give oral Quinine
.instead
-
3<-1 10-14 1 1 1 1 1 1 6

8<-3 15-24 2 2 2 2 2 2 12

8-10 25-34 3 3 3 3 3 3 18

+ 11 + 35 4 4 4 4 4 4 24
THIRD LINE TREATMENT :-
“QUININE”
Quinine dihydrochloride, Quinine hydro chloride or
Quinine sulfate orally used if no response to 2nd
line ttt.
The oral dose:- is 10mg salt/kg BW 8 hr for
7 days.
The injectable :- IM if Pt can’t take orally or
repeated vomiting .
ONCE vomiting stopped oral route resumed.
The dose is:- 10mg salt/kg BW after
dilution with N.S to a conc. Of
60mg/ml divided into 2 halves & inj
into both ant. upper thighs.
 AGE Wt. / KG No. of
IN tablets/dose
YEARS )300mg tab)
1< 10 < 1/4
4-1 18- 10 1/2
7-5 24- 19 1
10 - 8 35- 25 1/4 1
15 – 11 50 - 36 1/2 1
Above 15 50 > 2
 GENERAL
(symPLAN
YES Pt. c/o fever or PMH of fever NO
Obvious cause & sin of malaria)
of fever
Look for
Yes
something else
TTT the cause With no obvious cause

ve + BFFM ve-
classify Look for other causes
(Hx /exam/ inves)
SM
Q or ARM UM
general+ 1st line Failure Malaria Malaria
management (AS + SP) Fever 48 hr later possibility excluded

Become Repeat
sever BFFM 1st line TTT
TTT of+ Of other
ve+ ve- causes
Other causes
2nd line Look for
Other causes
 Treatment of severe
malaria
• Who at risk?
2. Children from 6month to 6 weeks
3. Pregnant women
4. People in area of low endemicity )north
sudan)
5. People return to endemic area after few
years of absence
6. Visitors from non-endemic area
 Pt considered having severe malaria if has one
or more of the following conditions

Clinical Laboratory finding

manifestation of of SM
SM of
•Impaired level •sever anemia (Hb <5g/dl)
consciousness •hypoglycaemia (<40mg/dl)
•Respiratory distress •acidosis
•Repetitive convulsions •hyperlactinaemia
•Circulatory collapse •hyper parasitaemia
•Pulmonary oedema (250,000/ul or ring stage
•Abnormal bleeding =5%of RBCs or more
•Jaundice •renal impairment
•Haemoglobinurea •electrolytes imbalance
•prostration (hypo Na)
Important remarks:
• Severe malaria should be managed at
hospitals
• Attention should be given to the general
management )good nursing care)
• Case fatality rate CFR is important
indicator for hospital
CFR= no. malaria deaths X 100
no. of admitted cases
 General management of pt
with severe malaria
• It includes )8+8+4)
do 8 immediate measures
deal with 8 complications
monitor 4 pionts
 Do the following 8 immediate
measures
• Start resuscitation )air way)
• Establish IV line
• Make thick blood film for immediate parasite
count
• Classify degree of dehydration assess fluid
&electrolyte and correct it
• Control fever )tepid sponge,fanning and oral or
rectal paracetamol)
6. Control convulsions ) air way +diazepam)
7. Detect and treat hypoglyceamia
Caused by high prasitaemia,fasting and quinine therapy
* if BG < 2.2 mmol or <40 mg/dl ; give 1ml/kg D50 % IV
diluted with an equal volume of NS(slowlly over 3-5
min) follow with D10 infusion at 5ml/kg/hr
8. Start Quinine IV or Artemether IM ) if not accessible
quinine IM or artesunate suppositories )
Qui ni ne IV infusion (5 or 10% glucose). The dose is
.10mg salt/kg BW administered 8-hr for 7 days
If IV quinine is not possible, the same dose can be given
IM diluted with N.S to a conc. Of 60mg/ml into ant
.upper thigh
or for 3days followed by first linequinine given for 7 days*
treatment
Artemet her injecti on .The dose is1.6mg/kg twice in
the 1st day (12hr apart), followed by 1.6mg/kg daily for
.6 days
 Look and deal with the following
8 complications
• Shock or algid malaria )antibiotics+O2+IV fluids)
• Severe aneamia )blood transfusion)
• Metabolic acidosis )IV fluids +blood)
• Bleeding or coagulopathy)fresh blood, FFP+ vit K)
• Acute renal failure )fluid balance, dialysis)
• Black water fever )anti malrial+fresh blood)
• Acute pulmonary oedema )diuretic ,venesection )
• Exclude ather conditions present like sever malaria
 Monitor considering the
following 4 points
1. Level of consciousness
2. Fluid input / output
3. Vital signs
4. Level of parasitaemia
 Severe malaria in children
• The most common complications:
2. Severe anaemia ,anaemic HF
3. Cerebral malaria
4. Repeated convulsions
5. Hypoglycaemia
6. Respiratory distress
• Immediate tests must include:
2. Thick and thin blood films
3. Random blood glucose
4. Lumbar puncture
5. PCV

• Immediate measures include:

8. ABC
9. Abort convulsions
10. Correct hypoglycaemia
11. Use tepid sponging and antipyretics
12. Treat severe anaemia
13. Insert NGT to prevent aspiration
 Malaria prophylaxis
• Who at higher risk?
2. Travelers from malaria free areas
3. Pregnant women
4. People with sickle cell disease
5. Splenectomized pt
6. Children on steroid or immune suppressive
drugs
7. Expatriates and Sudanese returning from non-
malariaous area
Mefloquine
• For adult: 250 mg )once tab) every 7 days,
starting once weekly while in then area ,
and once weekly for 4 weeks after leaving
the area.
• For children: 5mg/kg with the same
interval as for adults