MALARIA

Trial questions on malaria

1. What is the rationale for the 3-day therapy regimen for ACTs?
-The 3 day course is to allow the artemisinin derivative to cover 2 asexual cycles
The plasmodium parasite undergoes 2 main cycles. The sexual and asexual cycle. The sexual
cycle occurs in the mosquito where there is fusion of gametocytes whereas the asexual cycle
occurs in the humans.
The asexual cycle length differs depending on the species of plasmodium. Plasmodium
knowlesi undergoes a 24hr cycle known as a quotidian cycle. P. falciparum, P. ovale and P. vivax
undergo a 48hr cycle called a tertian cycle whereas P. malariae undergoes a 72hr cycle called the
quartan cycle.
So in managing malaria, we want to give a 3-day regimen that would cover 1-2 asexual cycles
to ensure adequate eradication. That will mean apart from P. malariae which will have a 1 cycle
coverage, the rest will have the 3-day regimen cover for about 2 asexual cycles

2. Which antimalarials are considered safe in the first trimester of pregnancy?

-Artesunate, Quinine alone or plus clindamycin
3. Which regimen is recommended for uncomplicated malaria in the 1st trimester?
-Quinine
4. Can a pregnant woman who is on 0.4mg daily folic acid take SP as IpTp at the same time?
-They can be taken at the same time. Studies have shown that 0.4mg folic acid does not
interfere with SP. It is 5mg that affects SP's action
5. Which species of plasmodium causes malaria relapse?
-Plasmodium Vivax and Ovale
6. Can a G6PD patient be given primaquine for P. vivax malaria?
-Primaquine causes haemolysis in G6PD patients but there is a conditional recommendation.
According to WHO, in radical cure for normal patients, we give primaquine 0.25-0.5mg/
kg bw daily x 14days but in G6PD, we give 0.75mg/kg bw weekly x 8wks and monitor(by an
infectious disease specialist). If the G6PD patient is pregnant, give chloroquine prophylaxis from
pregnancy till breastfeeding ends, then initiate primaquine therapy
7. Why mefloquine for chemoprohylaxis is started 1-2weeks prior to travelling and continued for
4wks after leaving malaria endemic region?
-Mefloquine has a long half life so it takes a longer time to reach plasma concentrations
necessary to offer prophylactic efficacy
There are 2 main types of prophylaxis for travellers entering a malaria endemic region; causal
prophylaxis and suppressive prophylaxis. Causal prophylaxis targets the liver stage of the
parasite which is also known as the pre-erythrocytic stage whereas the suppressive prophylaxis
targets the asexual blood forms of the parasites, so for causal prophylaxis since they target
the pre-erythrocytic forms, it prevents the development of the parasite into blood forms hence
no need continuing for a month after leaving an endemic region since no new parasites will be
moving into to the blood from the liver. On the other hand, the suppresive prophylaxis targets
only the blood forms hence after leaving an endemic region, there is the need to continue for
about 4weeks since those in the liver stages will now be moving to the RBCs. The purpose of
starting 1 to 2 days or 1-2wks before entering an endemic region is to assess tolerability and
those with long half-lives like mefloquine(21-22days) to achieve therapeutic concentration
before entering endemic regions
Eg of causal prophylaxis: Atovaquone-proguanil, primaquine
Eg of suppressive prophylaxis: Mefloquine
8. What is the preferred 1st line therapy for uncomplicated malaria in Ghana?
-Atermether Lumefantrine and Atersunate Amodiaquine but the preferred first line is Artesunate
Amodiaquine
9. Why patients infected with malaria have periods of fever alternating with cold and chills?
-There is a classic paroxysm of fever, chills and sweats every 48hrs or 72hrs. When it occurs
every 48hrs, we call it tertian fever. Tertian may be benign as seen in P vivax and P ovale or
malignant as seen in P falciparum. On the other hand, if it occurs every 72hrs, it's referred
to as quartan fever as seen in P malariae. This cycle normally begin with 1-2hrs of chills and
shivering followed by very high fever and subsequently, sweating(diaphoresis) occurs leading
to temperature reduction. It occurs every 48 or 72hrs depending on the species. That of P.
knowlesi occurs every 24hrs and is referred to as the quotidian cycle
10. Can artemether injection be given iv?
-Artemether is an oil based injection and should only be given by the IM route
11. What is the dosing regimen for artemether injection?
-3.2mg/kg loading dose on day 1, then 1.6mg/kg daily up to 7 days. The maintenance dose is
started 8hours after the loading dose
12. Why is artesunate injection preferred over artemether injection in severe malaria?
-Artemether is dissolved in oil and therefore may be absorbed more slowly and erratically than
artesunate thus, it is recommended only if injectable artesunate is not available
13. What is the difference between relapse, recrudescence and reinfection?
-Recrudescence: recurrence of asexual parasitemia by the same genotype that caused original
disease following antimalarial therapy
Relapse: recurrence of asexual parasitemia in P.vivax or P.ovale from persisting liver stage
Reinfection: new infection following primary infection by parasite of different genotype
14. How would you differentiate reinfection from treatment failure?
-Reinfection is parasitaemia occurring 28 days after the start of anti-malaria treatment while
treatment failure is parasitaemia within 28 days of starting anti malaria treatment
15. What is the rationale for adding Clindamycin to quinine therapy in uncomplicated malaria?
-There is a synergistic effect with the combination of clindamycin and quinine. It also allows for
reduced treatment time from 7 days to 5days. The other reason is to prevent recrudescence of
malaria parasite after quinine therapy
16. Can we give quinine as an IV bolus?
-There is a risk of lethal hypotension when administered as a bolus
17. Can we give IM quinine at the buttocks?
-There is a risk of sciatic nerve injury when administered to the glutes
18. What is the appropriate time to initiate oral ACTs after receiving the last dose of IV
artesunate
-It can be initiated at least 4hrs after the last parenteral dose, but some reference state up to
12hrs after
Parenteral doses of artemether and artesunate are given for a maximum of 7days
19. Can we give oral ACTs if patient can tolerate orals 16hrs after IV artesunate?
-No, it is recommended that the IV should be given for at least 24 hours before you can switch to
orals
20. How is artesunate reconstituted and administered?
-Using a 60 mg vial as an example. Add 1ml of sodium bicarbonate to the vial containing the
powder. Shake till you form a clear solution and add 2mls of Normal saline or 5% dextrose to
the vial to form a 20mg/ml solution for IM administration. For IV, 5ml of NS is used to obtain a
10mg/ml solution
Using the dose, you can withdraw the required amount and administer IV or IM
21. How would you term severe malaria complicated by circulatory shock?
-Algid Malaria
22. What scale is used to assess level of consciousness in children with severe malaria?
-Blantyre score
23. Why is it recommended to take artemether lumefantrine with a fatty meal?
-Taking A/L with fatty meal increases its absorption.
24. Why is it not recommended to take dihydroartemisin piperaquine with a fatty meal?
-It accelerates the absorption of piperaquine leading to increased risk or arrhythmogenic
delayed ventricular repolarization i.e. prolongation of QT interval
25. Why patients with severe malaria usually present with hypoglycaemia?
-The plasmodium parasite metabolises glucose at a rate 70 times higher than RBCs hence risk
of hypoglycemia in severe malaria
26. Why 5% dextrose is recommended for quinine infusion in pregnant women and children
below 5years?
-Risk of quinine related hypoglycemia is higher in these group
27. What is seasonal malaria chemoprevention?
-SMC is defined as the intermittent administration of full treatment courses of an antimalarial
medicine during the malaria season to prevent malarial illness with the objective of maintaining
therapeutic antimalarial drug concentrations in the blood throughout the period of greatest
malarial risk.
28 Which antimalarial is recommended for SMC?
-Sulphadoxine-Pyrimethamine plus Amodiaquine
Infants <12 months old: AQ–half (½) of a 153mg tablet given once daily for three days and a
single dose of SP ‐half of a 500/25mg tablet.
Children 12–59 months: AQ –a full tablet of 153 mg given once daily for three days and a single
dose of SP ‐a full tablet of 500/25mg.
29. How is malaria prevented in pregnancy?
-Intermittent Preventive Treatment using a minimum of 3 doses of SP. It is recommended to be
initiated just after quickening (13-16wks) which is when the mother starts to feel the baby kick.
This is usually a confirmation that organogenesis is completed. Since some may miss it, 16wks
is an ideal time to start to prevent neural tube defects
30. A patient being managed for severe malaria was to be given IV artesunate but IV access was
difficult. But after 4hrs the IV access was found. Can we give the already prepared artesunate?
-It should always be freshly prepared and administered due to its unstable nature. It should be
discarded if not used after 1hr of reconstitution