1 The National Antimalarial Drug Policy - Yemen

Ministry of Public Health & Population

Primary Health Care Sector
National Malaria Control Programme

The National Policy

For
Antimalarial Drugs

1
 2 The National Antimalarial Drug Policy - Yemen

CONTENTS Page

Abbreviations 3
Introduction 4
What is the “Antimalarial Drug Policy” 5
Purposes of “Antimalarial Drug Policy” 5
Simple (Uncomplicated )Malaria 6
Severe Malaria 9
Management of malaria in pregnancy 12
Treatment of non-falciparum malaria cases 13
Protection against malaria 14
Annexes 16

2
 3 The National Antimalarial Drug Policy - Yemen

Abbreviations:

ACT: Artemisinin based combination therapy

AMD: Anti-malarial drug
AQ: Amodiaquine
ART: Artesunate
CQ: Chloroquine
HQ: headquarters
i.m.: intramuscular
IMCI: Integrated Management of Childhood Illnesses
IVM: integrated vector management
LUM: Lumefantrine
NMCP: national malaria control programme
PQ: Primaquine
Qn: Quinine
RDT: Rapid diagnostic test
SP: Sulfadoxine-pyrimethamine
Unicef: United Nations Children’s Fund
VBD: Vector borne disease
WB: World Bank
WHO: World Health Organization
LLIN: Long Lasting Insecticides Mosquito Bednets

3
 4 The National Antimalarial Drug Policy - Yemen

Introduction
Malaria continues to be one of the major and priority health problems in Yemen. About 78% of
the population living in areas at risk of malaria transmission. The pregnant women and children
under five are the mostly affected groups whereas all age groups are at great risk in the epidemic
prone areas where epidemics may occur following unusual climatic changes, e.g., heavy rainfalls,
unexpected warming and rise in humidity.

Plasmodium falciparum, the life threatening species of malaria, is the dominant species
accounting for more than 90-95% of malaria cases annually. Anopheles arabiensis, the most
effective malaria vector worldwide is the major vector in the mainland and this aggravates the
seriousness of the problem. In Socotra island and Al Mahra governorate, Anopheles culicifacies, a
moderately effective vector, is the main malaria vector.

In the late nineties, the malaria burden in Yemen was estimated to be about 3 million suspected
and confirmed cases with an estimate of 1% related deaths. It has been estimated that families
living in the malaria endemic areas spend a significant proportion of their income on the
management of malaria cases and this proves that an effective and successful NMCP will positively
contribute to the ‘Poverty Reduction’ strategy of the country. In 2005 and early 2006, the results
of the parasite prevalence surveys in Tihama and Socotra island show that the recent estimate of
the malaria burden does not exceed one million suspected and confirmed malaria cases per year.

The main outputs since 2000 were in the form of strategic planning with the formulation of the
National Strategic Plan for malaria control in Yemen 2001-2005 and the National Strategic Plan
2006-2010, organized structure, national capacity building, new qualified and dedicated staff,
improved case management and setting a national anti-malarial treatment policy, monitoring the
efficacy of anti-malarial drugs, quality assurance system, an organized vector control based on
geographical reconnaissance (or GIS) and entomological surveys, health education, national
monitoring and evaluation plan, epidemic preparedness and response in addition to the efforts to
improve surveillance and information system .
The program is still facing several challenges that should be addressed in the coming years. There
is a need to strengthen the information and surveillance system especially that the public health
services’ coverage does not exceed 50% of the population and a plan to involve the private sector
in the information and surveillance system should be developed.
The strategic directions 2006-2010 are as follows:
1. Maintenance and strengthening of the high level political commitment to combat malaria
2. Strengthening the infrastructure of the NMCP at the national, governorate and district levels.
3. Human resource development
4. Early and correct diagnosis followed by prompt and effective treatment of malaria cases
5. Integrated vector management
6. Efficient epidemic preparedness and response
7. Strengthening the information system and surveillance (M&E)
8. Increasing the capability of the community to recognize, prevent and control malaria
9. Developing the capacity to plan and implement operational field research

The above mentioned fourth strategic direction is related to case management and antimalaria drug
policy which should be improved and monitored. In the eighties and nineties of the last century some
studies were conducted to monitor the efficacy of chloroquine, the former first line of treatment of
simple malaria cases and in 2002 a national plan was set to monitor the efficacy of the antimalarial
drugs in sentinel sites established exclusively for this purpose. 8 studies were conducted between
2002 and 2005 in 4 sentinel sites representing different epidemiological strata and the results showed
high level of resistance of P.falciparum to chloroquine, while the sulfadoxine pyrimethamine was still
effective. These results (refer to annex 6) were presented and discussed in the 3rd national seminar of

4
 5 The National Antimalarial Drug Policy - Yemen

the NMCP in November 2005 and the new national antimalarial drug policy was agreed upon.
International and national experts participated in this seminar. The national experts included
professors from the faculties of medicine and pharmacy in Sana’a, Aden, Dhamar, Hodeida universities,
representatives of the private sector and the general directors of the health offices in the governorates.

This manual is mainly to present the updated national policy for antimalaria drugs. Besides it aims at
educating and/or refreshing the knowledge of the medical and paramedical staff by highlighting the
key and important issues in the area of clinical malariology.

It is worth mentioning that the challenge is not only in the area of updating and approving the new
lines of treatment but is mostly in the area of procurement and supply and budgeting systems to
ensure the availability, adequacy, accessibility, acceptability, affordability and sustainability.

What is “Antimalarial Drug Policy”?

The National Antimalarial Drug Policy is the set of recommendations and regulations concerning
antimalarial drugs and their utilization in a country. It is part of the National Drug Policy (WHO, 1988)
and of the National Malaria Control Policy.

Purposes of “Antimalarial Drug Policy”

The development of the National Antimalarial Drug Policy aims to achieve the
following:
1. To ensure early diagnosis and prompt, effective treatment of malaria and prevent the
progression of the uncomplicated malaria cases to severe malaria especially in people with no
or low immunity where severe falciparum malaria can be fatal if not treated.

2. To provide a guidance for medical practitioners and health workers on the optimal dosage
regimens for different clinical situations of malaria. The dosage regimens should be based on
the patient’s weight, effective concentrations of antimalarial drugs and for sufficient time to
cure the patient and eliminate the infection in all target populations.

3. To ensure the rational use of antimalarial drugs and limit the unnecessary use of antimalarial
drugs. The antimalarial drugs should be administered only to patients who are infected by
malaria.

4. To prevent the emergence and spread of resistance to antimalarial drugs.

5
 6 The National Antimalarial Drug Policy - Yemen

Simple (Uncomplicated) Malaria

Case Definition:

Patient with fever or history of fever within the past 48 hours (with or without other symptoms such
as nausea, vomiting and diarrhea, headache, back pain, chills, myalgia) in whom other obvious causes
of fever have been excluded.

Confirmed malaria case:

Patient with simple or severe malaria with laboratory confirmation of diagnosis by malaria blood film
or other diagnostic test for malaria parasites.

Treatment:
First line treatment of simple falciparum malaria cases:

The first line treatment of simple falciparum malaria is Artesunate + sulfadoxine-pyrimethamine

which is available as separate scored tablets containing 50mg or 100mg of artesunate, and tablets
containing 25mg of pyrimethamine and 500mg of sulfadoxine. The total recommended treatment is
4mg/kg body weight of Artesunate given once a day for 3 days, and a single administration of
sulfadoxine-pyrimethamine (25/1.25 mg/kg) in the first day.

The addition of a single dose Primaquine (0.25mg/kg) to ACT in the first day as anti gametocyte
medicine, is recommended as component of pre–elimination or an elimination programme. Safety
of use of Primaquine in G6PD deficient individual must always be considered.
Note: Primaquine not used for pregnant women, infants aged < 6 months and women
breastfeeding infants aged < 6 months)

Sulfadoxine-
Artesunate 50 mg tablets Pyrimethamine
Age (years)
(500/25)

Day 1 Day 2 Day 3 Day 1

Infants ½ ½ ½ ½

≥1 - 6 1 1 1 1

≥7 - 13 2 2 2 2

>13 4 4 4 3

Reference: GUIDELINES FOR TREATMENT OF MALARIA, WHO, 2006

Artesunate is safe and remarkably well tolerated. There have been reports of mild gastrointestinal
disturbances, dizziness, tinnitus, reticulocytopenia, neutropenia, elevated liver enzyme values. The
only potentially serious adverse effect reported with this class of drugs is type 1 hypersensitivity
reactions in approximately 1 in 3000 patients

6
 7 The National Antimalarial Drug Policy - Yemen

Sulfadoxine-
Artesunate 100 mg tablets Pyrimethamine
Age (years)
(500/25)

Day 1 Day 2 Day 3 Day 1

Infants ¼ ¼ ¼ ½

≥1 - 6 ½ ½ ½ 1

≥7 - 13 1 1 1 2

>13 2 2 2 3

Sulfadoxine/pyrimethamine (SP) shares the adverse effect profile of other sulfonamides, although
allergic reactions can be severe because of its slow elimination. Nausea, vomiting, anorexia and
diarrhoea may occur. Cutaneous manifestations can be severe and include pruritus, photosensitivity
reactions, exfoliative dermatitis, erythema nodosum, toxic epidermal necrolysis and Stevens-Johnson
syndrome. Treatment with SP should be stopped in any patient developing a rash because of the risk
of severe allergic reactions.
Second line treatment of simple falciparum malaria cases
If the patient cannot tolerate artesunate plus SP or had a previous allergic reactions to this medicine,
he or she should be treated with the second line treatment.
If a patient has been treated with artesunate plus SP and is still sick after 72 hours, or if symptoms
recur within one month after treatment, he or she should be referred to a health facility for microscopy
examination of malaria. In case a malaria diagnosis is confirmed, within 14 days of the initial
treatment, he or she should be treated with the second-line treatment, which is artemether-
lumefantrine (each tablets contains artemether 20mg and lumefantrine 120 mg in fixed dose
combination). The treatment regimen consists in six doses, given over three days with twice daily
administration, as shown in the table below.

Content of Artemether
Number of tablets per dose (at 0h,
Weight (kg) Age in years (A) + Lumefantrine (L)
8h, 24h, 36h, 48h and 60h)
per dose

Treat infants weighing < 5 kg with

uncomplicated P. falciparum malaria with
<5
ACT at the same mg/kg body weight target
dose as for children weighing 5 kg.

5 – 14 <3 1 20 mg A + 120 mg L

15 – 24 ≥3-8 2 40 mg A + 240 mg L

25 – 34 > 8 - 14 3 60 mg A + 360 mg L

> 34 > 14 4 80 mg A + 480 mg L

7
 8 The National Antimalarial Drug Policy - Yemen

Reference: GUIDELINES FOR TREATMENT OF MALARIA, WHO, 2006

This medicine is remarkably well tolerated. Despite similarities with halofantrine, lumefantrine does
not significantly prolong the electrocardiographic QT interval. Reported side effects are generally
mild, including nausea, abdominal discomfort, headache and dizziness. Recurrence of fever and
parasitaemia more than 2 weeks after treatment can be retreated with the first-line ACT.
Severe malaria
Case definition:

In a patient with P. falciparum asexual parasitaemia and no other obvious cause of their symptoms,
the presence of one or more of the following clinical or laboratory features classifies the patient as
suffering from severe malaria:

Clinical manifestations:
– Prostration
– Impaired consciousness
– Respiratory distress (acidotic breathing)
– Multiple convulsions
– Circulatory collapse
– Pulmonary oedema (radiological)
– Abnormal bleeding
– Jaundice
– Haemoglobinuria

Laboratory detected manifestations :

– Severe anaemia
– Hypoglycaemia
– Acidosis
– Renal impairment
– Hyperlactataemia
– Hyperparasitaemia

Principles of management of severe falciparum malaria cases:

Severe malaria is a medical emergency.

1. The airway should be secured in unconscious patients and

2. Breathing and circulation should be assessed.
3. The patient should be weighed or body weight estimated so that drugs, including
antimalarials and fluids can be given on a body weight basis.
4. An intravenous cannula should be inserted and immediate measurements of blood glucose
(stick test), haematocrit/haemoglobin, parasitaemia and, in adults, renal function should be
taken.
5. A detailed clinical examination should be conducted, with particular note of the level of
consciousness and record of the coma score.
6. Unconscious patients should have a lumbar puncture for cerebrospinal fluid analysis to
exclude bacterial meningitis.
7. The degree of acidosis is an important determinant of outcome; the plasma bicarbonate or
venous lactate level should therefore be measured if possible.

8
 9 The National Antimalarial Drug Policy - Yemen

8. Blood should be taken for cross-match, and (if possible) full blood count, platelet count,
clotting studies, blood culture and full biochemistry should be conducted. The assessment of
fluid balance is critical in severe malaria.
9. Respiratory distress, in particular with acidotic breathing in severely anaemic children, often
indicates hypovolaemia and requires prompt rehydration and, where indicated, blood
transfusion.
10. Nurse the patient appropriately (e.g. comatose patients on the side, clear airway and turn
frequently).

Management of severe (complicated) falciparum malaria cases:

After rapid clinical assessment and confirmation of the diagnosis, full doses of parenteral antimalarial
treatment should be started as soon as possible without delay
Initial treatment
Parenteral artesunate (IV or IM) is the medicine of choice for severe malaria in all age groups, and in
all trimesters of pregnancy. Artesunate significantly reduces the risk of death, and lowers the risk of
treatment-associated side effects including hypoglycemia.

 Artemether or quinine are acceptable alternatives if artesunate is not available.

Follow-on treatment
Once the patient recovers sufficiently and can tolerate oral treatment, or after at least 24 hours of
parenteral treatment, a full course of an effective ACT should be administered to complete the
treatment of the patient.

Artesunate powder for injection 60 mg:

It should be administered in a dose of 2.4 mg/kg body weight IV or IM given on admission (time =
0), then at 12 h and 24 h, then once daily. As soon as the patient can swallow provide a full ACT
treatment course.
The vial of Artesunate powder should be mixed with 1 ml of 5% sodium bicarbonate solution
(provided) and shaken 2-3 minutes for better dissolution. Then,
1. For IV administration: add 5 ml of 5% glucose or normal saline to make the
concentration of artesunate as 10 mg/ml and administer by slow infusion.
2. For IM administration: add 2 ml of 5% glucose or normal saline to make the
concentration of artesunate as 20 mg/ml

Artemether i.m. for the treatment of severe malaria:

At present the mainstay of management of severe malaria in Yemen is artesunate for parenteral
administration. If it is not possible, artemether i.m. can be used at the dosage indicated below.
Doses of i.m. artemether and rectal artesunate:
Artemether i.m.:
- Artemether i.m. 3.2 mg / kg divided into two doses in the first day (1.6mg/kg every 12hours
in the first day), followed by 1.6 mg / kg daily for the next 6 days;
or
- Artemether i.m. 3.2 mg / kg divided into two doses in the first day (1.6mg/kg every 12hours
in the first day), followed by 1.6 mg / kg daily for at least 3 days ( to be the total 4 days of
treatment by Artemether i.m), and provide a full treatment course of the first line oral
treatment of Artesunate-Sulfadoxine/Pyrimethamine.

Quinine dihydrochloride injection for the treatment of severe malaria:

9
 10 The National Antimalarial Drug Policy - Yemen

- Intravenous quinine dihydrochloride should be given by rate-controlled infusion in saline or

5% dextrose solutions at a rate not exceeding 5 mg salt/kg body weight per hour. The loading
dose of quinine is 20 mg salt /kg by iv infusion followed by 10 mg/kg as a maintenance dose
every 8 hours until the patient can tolerate oral dosages, then he/she should be shifted to oral
Quinine tablets in a dose of 10 mg/kg every 8 hours for the rest of a total of 7 days. The
alternative option is to give parenteral quinine for at least 3 days and then shift to the first-
line treatment (As+SP) if the patient can take oral medication. Ensure patient takes full oral
course (As+SP).

- Dose of Quinine for children : 20 mg of salt/kg (loading dose) by IV infusion over 4 hours ,
then 12 hours after the start of the loading dose give a maintenance dose of quinine , 10 mg
salt/kg over 2hours . this repeated every 12 hours ,until the patient can swallow , then quinine
tablets ,10 mg salt /kg ,8 hourly to complete 7- days course , or quinine IV given for at least 3
days and then shift to the first line (AS+S/P) if the patient can swallow .
- If this is not possible to give quinine by intravenous infusion, then it should be given by
intramuscular injection to the anterior thigh, not the buttock (to avoid sciatic nerve injury).
The first dose should be split, 10 mg/kg bw to each thigh. Undiluted quinine dihydrochloride
at a concentration of 300 mg/ml is acidic (pH 2) and painful when given by intramuscular
injection, so it is best either formulated or diluted to concentrations of 60–100 mg/ml for
intramuscular injection

The recommended line of treatment of choice for the management of severe malaria is
Artesunate i.v. (or i.m. if i.v. is not possible and no alternatives are available), artemether i.m.
Or quinine i.v or i.m

Recommendations for use of antimalarial medicines in remote public health units run
by middle level health workers

Rectal artesunate is the drug of choice for pre-referral treatment of severe malaria in the remote health
facilities where health workers do not have access (or cannot practice) safe intramuscular injections
of artesunate or artemether or quinine

Artesunate rectal capsules / suppositories used as pre-referral measures or in home

management of malaria:
Artesunate rectal capsules / suppositories (50 or 200 mg per retocap): 10 mg / kg should be
given rectally as soon as possible, once a diagnosis of severe malaria is made. If the rectal
capsule is expelled within the first hour, another rectal capsule should be inserted
immediately. A second dose can be repeated after 24 hours.

10
 11 The National Antimalarial Drug Policy - Yemen

Management of malaria in pregnancy

Malaria in pregnant women with low or no immunity

Effects on mother:
- Hyperpyrexia (very high fever)
- Hypoglycemia (low blood sugar)
- Severe haemolytic anemia
- Cerebral malaria
- Pulmonary edema

Effects on the fetus or neonate:

- Miscarriage
- Premature delivery
- Low birth weight
- Perinatal death
- Congenital infection

 Malaria in pregnant women with pre-existing immunity

The main complications of malaria in pregnancy in these settings are:
- Maternal anemia
- Low birth weight babies

 Treatment of simple malaria in pregnancy:

Treatment of simple malaria in pregnancy should be oral Quinine, 10mg/kg administrated 8 hourly
for 7 days in the 1st trimester, while in 2nd and 3rd trimesters first line ( AS+SP) is the drug of choice .

 Treatment of severe malaria during pregnancy:

Initial treatment
Parenteral artesunate (IV or IM) is the medicine of choice for severe malaria in all trimesters of
pregnancy. Artesunate significantly reduces the risk of death, and lowers the risk of treatment-
associated side effects including hypoglycaemia.

 Artemether or quinine are acceptable alternatives if artesunate is not available.

Follow-on treatment
Once the patient recovers sufficiently and can tolerate oral treatment, or after at least 24 hours of
parenteral treatment, a full course of an effective ACT should be administered to complete the
treatment of the patient.
.

11
 12 The National Antimalarial Drug Policy - Yemen

Treatment of non-falciparum malaria cases

Vivax and ovale malaria cases:

- Chloroquine as a schizonticidal drug in a dose of 10mg/kg at the first and second days and then
5mg/kg at the third day.
- Primaquine as an anti-relapse measure in a dose of 0.25 mg/kg daily for 14 days or 0.75 mg/kg
weekly for 8 weeks in G6PD deficient patients. Primaquine is contraindicated in children under
1 year and in pregnant women.

< 1 year 1 – < 4 years 4 - < 10 years 10 - < 15 years 15 years +

(< 10 kg) (10 - < 17 kg) (17 - < 30 kg) (30 - < 45kg) (45 kg +)

½ tablet or
1st day: 1 tablet or 3
1½ 2 tablets 3 tablets 4 tablets
chloroquine teaspoonful
teaspoonful

½ tablet or
1 tablet or 3
2nd day: CQ 1½ 2 tablets 3 tablets 4 tablets
teaspoonful
teaspoonful

1/3 tablet or ½ tablet or

3rd day: CQ 1 1½ 1 tablet 1½ tablet 2 tablets
teaspoonful teaspoonful

PQ for anti- 2 tablets

1/2 tab daily 1 tab daily 1 ½ tab daily
relapse* Nothing daily for 14
for 14 days for 14 days for 14 days
treatment days

CQ: chloroquine PQ: primaquine (the strength recommended is 7.5 mg tablet)

* In case of moderate G6PD deficiency, PQ as an anti-relapse measure is used in a dose of 0.75 mg/kg
weekly for 8 weeks. The weekly dose is 3 times the amount indicated in the tablet above for the daily
doses.

Malariae malaria cases:

Chloroquine as a schizonticidal drug.
Primaquine as a gametocytocidal drug in a single dose of 0.75 mg/kg following the chloroquine course.
The dose per age-group is 3 times the amount indicated in the table above of daily doses for radical
treatment of P. vivax.

12
 13 The National Antimalarial Drug Policy - Yemen

PROTECTION AGAINST MALARIA

Non immune individuals, whether visitors from non-malarious countries intending to visit Yemen
for tourism, business or any other purpose, or Yemeni nationals from non malarious areas in Yemen
intending to visit malaria-endemic areas in their country, should take the necessary measures to
protect themselves from malaria.
These measures include:
1) Mosquito bite prevention by sleeping under bednet, if possible treated with insectide, and
using a mosquito repellant after sunset .
2) Chemoprophylaxis.
If possible, travelers should seek medical advice on chemoprophylaxis of malaria.
The recommended drug to be used as chemoprophylaxis for malaria is mefloquine in Yemen;
Doxycycline can be used if mefloquine is contraindicated.
None of the medicine used for chemoprophylaxis provides a 100% protection from malaria infection:
all fever in travelers to malarious areas should be considered malaria until proven otherwise by
laboratory examination (microscopy or RDTs).

The recommended type of prevention for visitors to malarious areas in

Yemen:
Yemen is classified as high risk area for malaria in travelers. So bite prevention is highly recommended
plus chemoprophylaxis by mefloquine. The dosage of doxycycline as altenative of mefloquine is shown
in the next table.
Use of mefloquine:
 Dosage regimen
 Duration of prophylaxis
 Use in special groups:
Pregnancy
Breast feeding
Children
 Main contraindications
 Comments
5mg/kg weekly ( Children )
Adult dose: 1 tablet of 250 mg weekly
Start at least 1 week (Preferably 2-3 weeks) before departure and
continue for 4 weeks after return
Not recommended in first trimester because of lack of data
Safe
Not recommended under 5 kg because of lack of data
Hypersensitivity to mefloquine; psychiatric (including depression) or
convulsive disorders; history of severe neuropsychiatric disease;
concomitant halofantrine treatment; treatment with mefloquine in
previous 4 weeks; not recommended in view of limited data for people
performing activities requiring fine coordination and spatial
discrimination, e.g. pilots, machine operators.
Do not give mefloquine within 12 hours of quinine treatment.
Mefloquine and other cardioactive drugs may be given concomitantly
only under close medical supervision. Ampicillin, tetracycline and
metoclopramide can increase mefloquine blood levels. Vaccination
with live bacterial vaccines (e.g. oral live typhoid vaccine, cholera
vaccine) should be completed at least 3 days before the first
prophylaxis dose of mefloquine.

Reference of the above tables is the WHO publication of Travel Medicine, 2005.

13
 14 The National Antimalarial Drug Policy - Yemen

Use of doxycycline:

 Dosage regimen 1.5 mg salt/kg daily;

adult dose: 1 tablet of 100 mg daily
 Duration of prophylaxis Start 1 day before departure and continue for 4 weeks after return.
 Use in special groups:
Pregnancy Contraindicated
Breast feeding Contraindicated
Children Contraindicated under 8 years of age
 Main contraindications Hypersensitivity to tetracyclines; liver dysfunction.
 Comments Doxycycline makes the skin more susceptible to sunburn. People with
sensitive skin should use a highly protective (UVA) sunscreen and
avoid prolonged direct sunlight, or switch to another drug.
Doxycycline should be taken with plenty of water to prevent
oesophageal irritation. Doxycycline may increase the risk of vaginal
Candida infections.
Reference of the above tables is the WHO publication of Travel Medicine, 2005.

14
 15 The National Antimalarial Drug Policy - Yemen

Annexes

1) Laboratory Diagnosis
Malaria Microscopy
Detection of malaria parasites using malaria microscopy is done by preparing both thin and thick
blood films on one glass slide. The thin blood film is fixed and both films are then stained by Giemsa
stain. The examination starts by examining 100 fields of the thick blood film using the X100 oil
immersion objective and this may be increased to 200 fields in case of suspicion or for the sake of more
accuracy. This will take 5-10 minutes for each slide. The thin blood film may be examined to confirm
the species. The result written by a lab technician should show the following:
- the parasite species, e.g. Pf, Pv, Po, Pm or mixed infection
- the density of parasitaemia, i.e. the parasite count
- the stages of parasites especially in Pf infections, e.g ring forms, gametocytes or schizonts

Parasite count:

How to measure the density of parasitaemia?

In severe cases especially those admitted in the hospital, the parasite count should be recorded as
number of parasites per microlitre of blood.

Parasite count per microlitre of blood is calculated as per the following equation assuming that the
average WBC (white blood cell) count is 8000 / microlitre in case the actual WBC count has not been
done. If available, the actual WBC count should be used instead of 8000 (WBC/μl).

Number of asexual parasite forms against 200 WBCs X 8000

200
The plus system is less accurate and, if possible, should be replaced by counting the number of
parasites or WBC. The plus system is used as follows:
+ 1-10 asexual parasite forms in 100 microscopic fields of a thick blood film
++ 11-100 asexual parasite forms in 100 microscopic fields of a thick blood film
+++ 1-10 asexual parasite forms in ONE microscopic field of a thick blood film
++++ > 10 asexual parasite forms in ONE microscopic field of a thick blood film

Rapid Diagnostic Tests (RDTs)

Malaria RDTs, sometimes called “dipsticks”, detect specific antigens (proteins) produced by
malaria parasites. These antigens are present in the blood of people with ongoing or recent infection.
The RDT signifies their presence by a colour change on an absorbing nitrocellulose strip.
The development of RDTs over the past decade has offered the potential for the extension of
accurate diagnosis to remote and poorly-resourced areas that are beyond the reach of high quality
microscopy services. Special care must be taken not to expose RDT to high temperatures above 35 °C.

15
 16 The National Antimalarial Drug Policy - Yemen

2) Summary of the management of severe falciparum malaria

In all cases an appropriate antimalarial drug should be started immediately and complications
managed appropriately as below.

Complication immediate management

Coma (cerebral Maintain airway; nurse on side; exclude other treatable causes of coma (e.g.
malaria) hypoglycaemia,
bacterial meningoencephalitis). Avoid harmful adjuvant treatments such as
corticosteroids,
heparin and epinephrine (adrenaline).

Convulsions Maintain airway; treat with diazepam given intravenously or intrarectally,

or intramuscular paraldehyde injection
Severe anaemia Transfuse screened fresh whole blood or packed cells.
Acute renal failure Exclude dehydration; maintain strict fluid balance; carry out dialysis if indicated
Hypoglycaemia Check blood glucose, correct hypoglycaemia and maintain with
glucose-containing infusion .
. Metabolic acidosis Exclude or treat hypoglycaemia, hypovolaemia and Gram-negative septicaemia. If
severe add haemofiltration or haemodialysis

Acute pulmonary Prevent by avoiding excessive rehydration. Prop patient up; give oxygen. If
oedema pulmonary oedema
is due to over-hydration, stop intravenous fluids, give a diuretic (furosemide
(frusemide) 40 mg
intravenously) and withdraw 3 ml/kg of blood by venesection into a donor bag.

Shock, Suspect Gram-negative septicaemia; take blood samples for culture. Give
parenteral antimicrobials;
correct haemodynamic disturbances.

. Spontaneous bleeding Transfuse screened fresh whole blood or clotting factors; give vitamin K, 10
and coagulopathy mg intravenously.
Hyperpyrexia Give antipyretic (paracetamol 15 mg/kg of body weight) and use tepid sponging
and fanning
Hyperparasitaemia Give initial dose of parenteral antimalarial therapy; consider exchange transfusion
if there are
other signs of severity.

Malarial Continue antimalarial treatment; transfuse screened fresh blood if needed.

haemoglobinuria
Aspiration pneumonia Give parenteral antimicrobials; change position of patient; give physiotherapy;
give oxygen

3) Ancillary treatment contraindicated in severe malaria:

The following have been used or suggested for the treatment of cerebral malaria but are now
considered either useless or dangerous, and should not be given:
- corticosteroids,
- acetylsalicylic acid and other anti-inflammatory agents,
- urea,
- low molecular weight dextran,
- epinephrine (adrenaline),

16
17 The National Antimalarial Drug Policy - Yemen

- heparin,
- prostacyclin,
- epoprostenol (prostacyclin),
- ciclosporin (cyclosporin A),
- deferoxamine (desferrioxamine),
- pentoxifylline,
- phenobarbital.

17