02/04/2019
MALARIA
• Malaria, a curable disease
remains a leading cause of
morbidity and mortality
world-wide, especially in
pregnant women and
children, and particularly in
tropical Africa, where at least
90% of the malaria deaths
occur.
• over 100 million people at
risk of malaria every year in
Nigeria
• causes maternal anaemia,
increases miscarriage and low
birth weight
Economic implications
 reduction of 1.3% in the
annual per capita economic
growth rate
 long term impact of this is a
reduction of the GNP by more
than a half
 Lose of over N135 billion from
cost of treatment and
absenteeism from work,
school and farms.
 There are over 100 million
people at risk of malaria
every year in Nigeria
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Nigerian Malaria Facts and Figures
FACTS
• Perception of malaria is poor-few
people link mosquito to malaria.
• Improper use parenteral
antimalarials
• Non- availability of treatment
guidelines in most of the sampled
health facilities.
• Poor laboratory support in
diagnosis
• Forty per cent of patients with
severe malaria die due to poor
quality of care.
• Treatment of malaria illnesses
accounted for 46% of the curative
health care cost incurred by
households with a mean of N
300.00 per month.
• Record keeping and reporting of
malaria is poor in the country.
MALARIA
UNCOMPLICATED
Life cycle of P. falciparum
SPOROZOITES
(45 mins)
MOSQ (salivary gland)
- Sporozoits (59 days)
- 1000x more infective >oocytes
-more antigenic due to circumsporozoite
polypeptide on plasmalemma
-micronemes ducts
MOSQ (midgut)
- Microgametes
-zygotes (18-24hrs)
- Ookinetes
-oocytes
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FIGURES
• Eighty per cent of malaria cases are
inadequately managed at community
level and home based caregivers.
• Ninety six per cent of caregivers
initiate actions within 24 hours but
only 15% of their actions are
appropriate
• Sixty per cent of mothers had no
knowledge of the current
management of convulsions. Only
15% referred such cases to hospital
while most either go to traditional
healers.
• Eighty-five per cent of health facilities
surveyed in the rural areas had stock-
out. None has packaged drugs.
• Fifty-one per cent of mothers obtain
drugs from patent medicine vendors,
89% of the drugs were found to be
substandard and 43% of syrups
unsatisfactory.
SEVERE
(COMPLICATED)
Liver (9-16 days)
- Merozoits
- hypnozoits
Blood
-Merozoits (48hrs)
-Gametocytes (10-
12days)
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CLINICAL MANIFESTATIONS
UNCOMPLICATED MALARIA
• headache,
• lassitude,
• fatigue,
• abdominal discomfort and
• muscle and joint aches,
• followed by fever, chills,
• perspiration,
• anorexia,
• vomiting
• and worsening malaise
02/04/2019
COMPLICATED MALARIA
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
: Prostration,
Impaired consciousness, Respiratory
distress (acidotic breathing),
Multiple convulsions, Circulatory
collapse, Pulmonary oedema
(radiological), Abnormal bleeding,
Jaundice, Haemoglobinuria
Severe anaemia,
Hypoglycaemia, Acidosis, Renal
impairment, Hyperlactataemia,
Hyperparasitaemia
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DIAGNOSIS

CLINICAL-history of
fever in the previous
24 h and/or the
presence of anaemia

IMMUNOLOGICAL/
PARASITOLOGIC AND MOLECULAR-
AL- Light Parasite nucleic acids
are detected using
microscopy and Polymerase Chain
rapid diagnostic Reaction (PCR),
Immunoflourescence
tests (RDTs). (IFA) or Enzyme-
RDTs -parasite linked
antigens Immunosorbent
Assays (ELISA)

DIAGNOSIS

MANAGEMENT AIMS
• REDUCTION OF MORBIDITY AND
MORTALITY PREVENTION
• TO ENCOURAGE RATIONAL DRUG USE
TO PREVENT OR DELAY THE
DEVELOPMENT OF ANTIMALARIAL
DRUG RESISTANCE.
• REDUCTION OF PARASITAEMIA
CLEARANCE TIME
• REDUCTION OF FEVER CLEARANCE
TIME
• REDUCTION OF COMA RECOVERY TIME
• IMPROVEMENT OF QUALITY OF LIFE
• PREVENTION OF END ORGAN DEMAGE

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Malaria Treatment Policy Strategy in Nigeria
RBM
• National malaria treatment policy
is that of Roll Back Malaria (RBM)
• This strategy seeks to establish a:
• social movement in which the
local communities,
• public and private sectors, all tiers
of government and non-
governmental development
agencies come together in a
partnership and network to
implement malaria control
interventions.
• RBM is a global initiative -
reduction of malaria burden
everywhere by 50% by the year
2010.
Why new policy?
National treatment protocol and guidelines - 2005
• The current national antimalarial
drug policy in use in Nigeria -
artemether-Lumefantrine in the
treatment of uncomplicated malaria
caused by P.falciparum confirmed or
unconfirmed
• Quinine should be used for 7 days if
there is treatment failure and in the
treatment of severe malaria.
• In pregnancy, Sulfadoxine-
Pyrimethamine should used
• One full treatment dose during 2nd
and 3rd trimesters and the last dose
should be given not later than one
month before the expected date of
delivery.
• In uncomplicated malaria during
pregnancy Quinine is considered safe
and can be used in all trimesters.
Artemether-Lumefantrine is
considered safe in 2nd and 3rd
trimesters and can be used when
there is no suitable alternatives.
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AIMS
• Access to appropriate and
adequate treatment within 24
hours of the onset of
symptoms.
• Pregnant women particularly
in their 1st and 2nd
pregnancies should have
access to effective
antimalarial prophylaxis and
treatment.
• Insecticide treated nets and
other materials should be
available and accessible to
persons at risk of malaria
particularly pregnant women
and children under 5 years of
age.
• Severe malaria is a medical
emergency and requires
parenteral treatment. The current
drugs for its management are:
• Injection quinine 300mg/ml in 2ml
ampoule-10mg/kg 8-12 hourly for
5-7 days
• Injection artemether 80mg/ml in
1ml ampoule-2mg/kg twice daily
on 1st day then 2mg/kg daily for 4-
6 days
• Injection artesunate 60mg/1ml
vial- 2mg/kg twice daily on 1st day
then 2mg/kg daily for 4-6 days.
• Suppository artesunate 50mg
suppository for pre- referral
treatment only.
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Treatment chart

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Supportive care in Severe Malaria

• In an attempt to reduce the unacceptably high mortality of
severe malaria, there are various adjunctive treatments for its
complications.
• Coma (cerebral malaria): Maintain airway, place patient on his
or her side, exclude other treatable causes of coma (e.g.
hypoglycaemia, bacterial meningitis); avoid harmful ancillary
treatment such as corticosteroids, heparin and adrenaline;
intubate if necessary.
• Hyperpyrexia: Administer tepid sponging, fanning, cooling
blanket and antipyretic drugs.
• Convulsions: Maintain airways; treat promptly with
intravenous or rectal diazepam or intramuscular paraldehyde.
• Hypoglycaemia: (Blood glucose concentration of <2.2 mmol/l;
<40 mg/100ml)
• Check blood glucose, correct hypoglycaemia and maintain
with glucose-containing infusion.
• Severe Anaemia: (haemoglobin <5 g/100ml or packed cell
volume <15%):Transfuse with screened fresh whole blood

Supportive care in Severe Malaria cont’d

• Acute pulmonary oedema: Prop patient up at an angle of 45o,
give oxygen, give a diuretic, stop intravenous fluids, intubate
and add positive end-expiratory pressure/continuous positive
airway pressure in life-threatening hypoxaemia.
• Acute Renal Failure: Exclude pre-renal causes, check fluid
balance and urinary sodium; if in established renal failure add
haemofiltration or haemodialysis, or if unavailable, peritoneal
dialysis. The benefits of diuretics/dopamine in acute renal
failure are not proven.
• Spontaneous Bleeding and Coagulopathy: Transfuse with
screened fresh whole blood (cryoprecipitate, fresh frozen
plasma and platelets if available); give vitamin K injection.
• Metabolic Acidosis: Exclude or treat hypoglycaemia,
hypovolaemia and septicaemia. If severe add haemofiltration
or haemodialysis.
• Shock: Suspect septicaemia, take blood for cultures; give
parenteral antimicrobials, correct haemodynamic
disturbances.

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