Malaria Site: Guidelines for Management of Malaria in Dakshina Kannada

History, Aetiology, Pathophysiology, Clinical Features, Diagnosis, Treatment, Complications And Control Of Malaria

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Guidelines for Management of Malaria in Dakshina Kannada (Revised 2010)

Introduction: Malaria is on the rise once again with the arrival of monsoon. The thrust of the Malaria Control Programme is to minimise morbidity and mortality from malaria and we seek your fullest co-operation. The World Health Organization has also greatly emphasized the importance of Early Diagnosis and Prompt Treatment in reducing the parasite load in the community and thereby in malaria control.

Clinical features of malaria include fever, chills, rigors, headache, vomiting etc. and in a typical case, these occur in paroxysms once in 48 hours. However in an endemic area, it is common to find patients with atypical manifestations like severe headache, giddiness, chest pain, acute abdominal pain, diarrhoea, vomiting, jaundice, cough, breathlessness, 'weakness' and hypotension etc., with or without fever. Therefore, it is always wiser to get a blood test for malaria parasites in all doubtful cases. Do not wait for chills or rigors to do MP Test.

Diagnosis of malaria is made by either peripheral smear examination or by the QBC technique. The QBC technique is faster and more sensitive, but identification of the species and assessment of severity is difficult or even impossible. Therefore, when in doubt, ask for a peripheral smear. The new rapid diagnostic tests for malaria (Dip Stick RDTs) may not be reliable due to occurrence of false positive, false negative results and cross reaction between asexual and sexual forms of the parasite as well as between different species.

Treatment of malaria: All cases of P. vivax malaria should be treated with chloroquine over 48 hours and primaquine for 14 days. The National Vector Borne Disease Control Programme has revised its guidelines for management of P. falciparum malaria in Mangalore in view of the identification of chloroquine resistance in P. falciparum. Accordingly, a combination of Artesunate (4mg/kg/day in two divided doses) for 3 days and a single dose of Pyrimeth/sulfadoxine (as shown in the table below) and Primaquine single dose (as shown in the table below) have been recommended. These drugs are available for free with the District Malaria Office. Uncomplicated mixed infections must be treated with Artesunate+ Pyrimethamine/sulfadoxine + Primaquine 14 days

Complications of P. falciparum Malaria: P.falciparum can cause various organ dysfunction resulting in dramatic and life threatening complications. Hyperpyrexia, pallor, jaundice, prostration, breathlessness, CNS manifestations, oliguria, hypotension etc., are indicators of complications. Patients at extremes of age, pregnant, alcoholics and patients developing malaria for the first time are prone for these complications. All cases of complicated P. falciparum malaria should be admitted and treated.

Please keep the following in mind:

Consider malaria in all cases of fever and/or atypical presentations listed above. Please get the blood tested for malaria in ALL cases of fever and in all doubtful cases.

Presumptive antimalarial treatment has been abandoned by the NVBDCP. If blood test (smear or RDT) is not available on time, chloroquine for 3 days should be started for suspected cases and the appropriate treatment should be given after the parasitological diagnosis is available.
Administer PRIMAQUINE to ALL cases of proven malaria. In P. vivax and mixed infections, it should be given for 14 days (as tissue schizonticidal to prevent relapse) and in P. falciparum infection, a single dose is enough (as gametocytocidal). Failure to administer primaquine leads to increased transmission of malaria.

Ensure adequate dosage and complete treatment. In case the patient vomits within one hour of administration of the drugs, the same should be re-administered

It takes at least 48 hours for the patient to be afebrile after starting the treatment. If the patient continues to be febrile even after 72 hours, consider other possibilities.

Primaquine cannot be used in pregnancy and therefore, pregnant women with P. vivax malaria should be started on weekly Chloroquine 500 mg as suppressive chemotherapy. After the delivery, treat the mother with full dose of chloroquine and primaquine.

Repeat blood smear should be done on the 6^th day in all cases of malaria (to confirm response to therapy) and on the 14^th and 28^th day in cases of P. falciparum (to look for early and late recrudescence).

Recurrence of malaria could be due to relapse (in case of P. vivax), recrudescence (in case of P. falciparum) or re-infection. Re-infection is the most common cause for recurrence and can occur any time after 10 days of completing the treatment. DO NOT treat all cases of recurrent malaria as cases of RESISTANT malaria. In cases of proven P. falciparum recrudescence (recurrence of symptoms within 28 days of treatment), re-treat with Artesunate + Pyrimethamine/Sulfadoxine and also administer primaquine single dose again.

Consider severe malaria in patients presenting with hyperpyrexia, anaemia, jaundice, altered behaviour, altered sensorium, convulsions, prostration, hypotension, breathlessness, oliguria etc. and refer them to higher centres immediately. In all such cases, consider P. falciparum malaria even if the QBC or peripheral smear reports show P. vivax malaria.

Treat all cases of complicated/severe malaria with PARENTERAL antimalarials. Do not use oral drugs, for their absorption may be erratic in the presence of severe illness. Also, DO NOT use mefloquine in severe malaria as it has a long half-life and acts slowly. (See below)

Decide on antimalarial drugs before starting treatment. Do not change the treatment in-between unless warranted. Co-administration of chloroquine/quinine/mefloquine or quinine/mefloquine/ primaquine can have synergistic neuropsychiatric adverse effects.

Widal test may be positive (up to 1:320 dilution) in malaria and one should not start treatment for typhoid when MP test is positive unless the Widal titer is more than 1:640 or increases by four fold.

Report ALL positive as well as negative results of MP tests to Mangalore City Corporation (Telephone 105) on a weekly basis. Deaths should be reported IMMEDIATELY and in such cases, an unstained peripheral smear should be preserved for documentation.

All cases of P. vivax malaria should be treated with chloroquine for 3 days and primaquine for 14 days. All P. falciparum infections should be treated with ACT (Artesunate+SP) and a single dose of primaquine. Mixed infections should be treated with ACT plus primaquine for 14 days as for P. vivax.

Dosage of Chloroquine and Primaquine

Age (yrs.)

Dosage of CHLOROQUINE
(as base, single dose)

Dosage of PRIMAQUINE
(as early as possible)

Day 1

Day 2

Day 3

P. falciparum single dose (0.75mg/kg)

P. vivax/Mixed OD X 14 days (0.25mg/kg)

0-1 75 mg 75 mg 37.5 mg Nil Nil

≥1 - 4 150 mg 150 mg 75 mg 7.5 mg 2.5 mg

≥5 - 8 300 mg 300 mg 150 mg 15 mg 5 mg

≥9-14 450 mg 450 mg 225 mg 30 mg 10 mg

≥15 600 mg 600 mg 300 mg 45 mg 15 mg

Dosing of Artesunate + Sulfadoxine�Pyrimethamine (WHO, 2010, NVBDCP 2010)[1,2]
Age	Dose of Artesunate (No of 50mg Tablet) Once daily for 3 days	Dose of SP (No. of 500/25mg Tablet) Single dose on Day 1
<1 year	25 (� tablet)	125/6.25 (� tablet)
≥1-4 years	50 (1 tablet)	500/25 (1 tablet)
≥5-8 years	100 (2 tablets)	750/37.5 (1�tablets)
≥9-14 years	150 (3 tablets)	1000/50 (2 tablets)
≥15 years	200 (4)	1500/75 (2 tablets)

NVBDCP recommends ASP as the ACT of choice for treating P. falciparum malaria all across India.
NVBDCP also recommends single dose of primaquine (0.75mg/kg) on Day 2 for all cases of P. falciparum malaria.
Under the NVBDCP, Artesunate + Sulfadoxine�pyrimethamine kits are available for free at all the PHCs.

*For patients allergic to sulfa, Doxycycline or Clindamycin can be used.

In cases of uncomplicated P. falciparum infection, if the patient does not improve clinically and/or the parasite count does not reduce by >75% of pre-treatment levels after 72 hours, resistance should be considered and such cases should be treated with quinine plus tetracycline or doxycycline (see below) All such cases should be immediately reported to the District or State Malaria Officer.

Treatment of severe P. falciparum malaria: All cases of complicated P. falciparum malaria should be treated with parenteral anti-malarial drugs ONLY. The following regimen can be used:

Artemisinin Derivatives: (Followed by ACT)
- Artesunate: 2.4mg/kg IV/IM loading followed by 1.2mg/kg at 12 and 24 hours and then 1.2mg/kg daily
- Artemether: 3.2mg/kg loading; 1.6mg/kg/day
- Arteether: 3mg/kg IM OD (Not preferred; use if this is the only drug available)
Quinine: (Followed by Doxycycline OR Clindamycin as below)
- 20 mg/kg infusion over 4 h, then 10 mg/kg every 8 hrs; IV or IM.
Any of the above should be given for at least 24 hours or until the patient is able to swallow, whichever is earlier, and should then be followed with:
1. After artemisinin, full dose of ACT as above
2. After quinine, Doxycycline 100mg bd OR Clindamycin (10mg/kg bd) for 7 days

Click Here to Download Treatment Protocol Ready Reckoner

Monitoring P. falciparum Malaria: 4 hourly blood glucose; 12 hourly hemoglobin, PCV, parasite count; 24 hourly S. bilirubin, S. creatinine.

Sources:

Guidelines for the treatment of malaria. 2^nd Edition. World Health Organization. Geneva, 2010. pp 19-21. Available at http://whqlibdoc.who.int/publications/2010/9789241547925_eng.pdf
Malaria Drug Policy (2010). Directorate of National Vector Borne Disease Control Programe. New Delhi. 2010. Available at http://nvbdcp.gov.in/Doc/drug-policy-2010.pdf Accessed Sep 8, 2010

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Dr. B.S. Kakkilaya's Malaria Web Site
Last Updated: Sep 8, 2011

B. S. Kakkilaya 2011-2013
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