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Dr Kabera René Family Physician Kabutare Hospital

• • • • • • • • Introduction Risk factors Causes Types Diagnosis Differential diagnosis Treatment Complications

• Malaria is a mosquito borne disease caused by protozoan parasites of the genus plasmodium. • Transmitted by a Female Anopheles mosquito • 18th century: from Italian, from mal'aria, contracted form of mala aria 'bad air'. • The term originally denoted the unwholesome atmosphere caused by the exhalations of marshes, to which the disease was formerly attributed.

• Kabutare Hospital: 503 confirmed cases /2013 Mortality 1case(Ped)/2013 • Rwanda : 42% (2001),7.6% (2012) mortality all ages 425 = 6% (2011-2012) • Worldwide: 300-500 million cases per year and one million deaths – 90% in sub-Saharan Africa – 75% of those deaths are African children U5 – A child dies every 30 seconds from malaria – Most malaria deaths occur in rural areas 90% of child deaths occur in the home

• Some families spend up to 25% of income on malaria treatment • Malaria endemic countries can be caught in a cycle of poverty and malaria • More people die today from malaria than 40 years ago • 8th highest contributor to the global burden of disease and 2nd highest in Africa

Malaria Global burden
Red=Malaria Endemic Regions

Plasmodium species recognized: • Falciparum • Malariae • Vivax • Ovale • Knowlesi


Plasmodial life Cycle

Risk factors
• • • • • Endemic regions Children U5 Elderly HIV Blood transfusions organ transplant

Types of Malaria
• Simple Malaria • Simple Malaria with minor digestive symptoms • Severe Malaria: cerebral form, anemic form Different literature • Pulmonary, Renal, Intestinal, other forms

Simple malaria Definition Uncomplicated malaria is defined as symptomatic malaria without signs of severity or evidence of vital organ dysfunction. Symptoms • chills • fever • sweating • Headache • myalgia

Simple malaria with minor digestive symptoms Symptoms • Fever • Chills • Headaches • Myalgia • Sweating • Nausea ,Vomiting or Diarrhea

Severe malaria Malaria with signs and symptoms of severity Unconsciousness Shock Prostration Dyspnea • …

Severe Malaria Cerebral form (WHO) • Unconsciousness (Glasgow coma scale <11). • Malaria with coma persisting for >30 min after a seizure is considered to be cerebral malaria. • Convulsions ≥ 2 in 24hrs

Severe malaria Anemic form (WHO) The signs and symptoms of malaria Anemia Hb<5g

Differential Diagnosis
• • • • Flu Meningitis Septicemia Typhus

Parasitological diagnosis • Light microscopy :Giemsa-stained thick and thin blood smears • Rapid Diagnostic Tests (RDTs) Others • FBC • Urea Creatinine, Elecrolytes • ALT/AST • Plasma glucose • Chest x ray • LP CSF exam

Antimalarial treatment policy • National antimalarial treatment policies should aim to offer antimalarials that are highly effective • These malaria treatment guidelines recommend that antimalarial treatment policy should be changed at treatment failure rates considerably lower than those recommended previously

Four point strategy: • Prompt access to treatment, especially for young children • Prevention and control in pregnant women • Vector control • Prediction and containment of epidemics

Non-artemisinin based combination therapy • sulfadoxine–pyrimethamine with chloroquine (SP+CQ) • sulfadoxine-pymethamine with amodiaquine (SP+AQ) Artemisinin-based combination therapy (ACTs) • artemether-lumefantrine • artesunate + amodiaquine • artesunate + mefloquine • artesunate + sulfadoxine–pyrimethamine Cinchona alkaloids • Quinine Sulfate • Quinidine gluconate

Simple malaria • Arthemeter and Almefantrine (CO-ARTEM)

Simple Malaria with Minor digestive symptoms • Artesunate IV: 2.4 mg/kg (time = 0) then at 12 hour, then daily thereafter or Quinine • If no more vomiting, change to oral ArtemetherLumefantrine twice a day for three consecutive days

Severe Malaria Anemic Form • Quinine • Transfusion Cerebral Form • Quinine • Ampicillin IV 50mg/kg QD, • Chloramphenicol IV 25mg/kg QD

Add treatment of complications • • • • • • • Fever, convulsions, hypoglycemia, dyspnea, anemia, vomiting …

• • • • • Severe anemia Acute renal failure Hypoglycemia Pulmonary edema/ALI/ARDS DIC

• • • • WHO Malaria Treatment Guidelines Rwanda DHS 2010 Ministry of Health of Rwanda Annual report.2012 Rwanda National Treatment Guidelines. Malaria 2012

Thank you