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Program MCPS/MRCGP/CEFM CME ©

Course Infectious diseases

Module Major infections

Topic Malaria

Credit Hours 2 CME credit hour

Total
Educational 4 educational hour
hours

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

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Prof. Nasir Shah
MCPS, FCPS, MRCGP [INT], FRCGP [INT]

Professor and Head, Department of Family Medicine

University of Health Sciences Lahore

Dean Family Medicine Faculty, College of Physicians and

Surgeons Pakistan

Convener National Family Medicine Committee of

Pakistan

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

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GREATEST KILLER OF HUMANS ®
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MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

PLASMODIUM: UNICELLUAR ORGANISM

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MALARIA: INTRACELLULAR FORM ®
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MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

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MALARIA | ETIOLOGY ®
• Caused by infection of red blood cells with protozoan parasites ©
• Inoculated into the human host by a feeding female anopheline
mosquito
• Species endemic to Pakistan:
▪ Plasmodium falciparum
▪ Plasmodium vivax

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

LIFE CYCLE OF MALARIA ®

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MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

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TYPES OF MALARIA ®
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Type Severity Hypnozoites

Falciparum High

Vivax Low Yes

Ovale Low Yes

Malariae Low

Knowlesi Low

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

NECTAR FOR MALES, BLOOD FOR FEMALES

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MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

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MALARIA ®
• Important cause of illness and death ©
• Requires an integrated approach;
• Prevention (primarily vector control) and
• Prompt treatment with effective antimalarial agents

• Reference: Guidelines for the treatment of malaria, third

edition, 2021

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

SHOULD WE CONTROL MALE OR FEMALE

MOSQUITO? ®
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• Both
- Female bites humans for blood
- She needs blood for ova
- Male fertilizer her. He is also culprit

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

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MOSQUITO REPELLENTS ®
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MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

PERMETHRIN IMPREGNATED NETS ®

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INSECTICIDE SPRAY ®
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MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

LARVACIDAL ®
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FULL SLEEVE CLOTHES ®
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MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

COMMUNITY AWARENESS ®
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MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

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MOSQUITO MAT ®
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MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

MOSQUITO COILS ®
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COW DUNG SMOKE: MOSQUITO REPELLENT
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MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

MUSTARD OIL: NATURAL MOSQUITO

REPELLENT ®
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MALARIA | SYMPTOMS ®
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MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

MALARIA | SYMPTOMS ®
• The first symptoms of malaria are nonspecific and similar to ©
those of a minor systemic viral illness:
▪ Headache
▪ Fatigue
▪ Abdominal discomfort
▪ Muscle and joint aches

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

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MALARIA | SYMPTOMS ®
• Later symptoms are: ©

▪ Fever and chills

▪ Perspiration
▪ Anorexia
• In young children, malaria may also present with lethargy, poor
feeding and cough

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

MALARIA | SUSPECTED MALARIA ®

• The signs and symptoms of malaria are non-specific ©

• Malaria should be suspected in any patient presenting with a

history of fever or temperature ≥ 37.5 °C and no other obvious
cause
• There is no combination of signs or symptoms that reliably
distinguishes malaria from other causes of fever

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

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D/D OF MALARIA: HIGH GRADE FEVER ®
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1. Acute bacterial infections, e.g. streptococcal infections,
typhoid, urinary tract infection
2. Collection of pus in any body cavity
3. Some viral infections e.g., measles, dengue
4. Protozoa e.g., liver abscess
5. Drugs e.g., Amphetamines, CNS drugs

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

PARASITOLOGICAL DIAGNOSIS OF MALARIA ®

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• Prompt parasitological confirmation by microscopy
or alternatively by RDTs is recommended in all
patients suspected of malaria before treatment is
started

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

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INVESTIGATIONS FOR MALARIA ®
• If the initial blood film examination is negative in patients with ©
manifestations compatible with severe malaria:
▪ a series of blood films should be examined at 6–12-h
intervals
▪ or an RDT should be performed
• If both the slide examination and the RDT results are negative,
malaria is extremely unlikely, and other causes of the illness
should be sought and treated

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

RAPID DIAGNOSTIC TEST ®

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MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

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THICK AND THIN FILM FOR MALARIA ®
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• Thick film: To see if parasite is present
• Thin film: to identify the species

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

UNCOMPLICATED MALARIA ®
• A patient who presents with ©
1. Symptoms of malaria
2. And a positive parasitological test (microscopy or RDT)
3. But with no features of severe malaria
is defined as having uncomplicated malaria

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

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VIVAX, OVALE, MALARIE, KNOWLESI ®
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Uncomplicated Complicated/
severe/resistant

Chloroquine (in Chloroquine Same as for Falciparum

susceptible regions) or ACT (except
1st trimester pregnancy)

+ Primaquine for 2 weeks

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

DOSE OF CHLOROQUINE ®
• Total dose of 25 mg base/kg ©
• Day 1: 10 mg base/kg
• Day 2: 10 mg/kg bw
• Day 3: 5 mg/kg bw

• (In the past, the initial 10-mg/kg bw dose was followed by 5

mg/kg bw at 6 h, 24 h and 48 h)

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

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MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

MALARIA ®
• The five ACTs recommended for treatment of uncomplicated P. ©
falciparum malaria are:
▪ Artemether + Lumefantrine
▪ Artesunate + Amodiaquine
▪ Artesunate + Mefloquine
▪ Artesunate + Sulfadoxine–pyrimethamine
▪ Dihydroartemisinin + Piperaquine

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

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MALARIA ®
Artemether + lumefantrine ©
• Twice a day for 3 days (total, six doses)
• Should be taken immediately after food or a fat containing
drink e.g. milk

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

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VIVAX IN PREGNANCY ®
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1st Trimester 2nd Trimester 3rd Trimester

Chloroquine Or Quinine ACT

(in resistant areas)

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

FALCIPARUM IN PREGNANCY ®
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1st Trimester 2nd Trimester 3rd Trimester

Quinine + Clindamycin ACT or

Or Artisunate + Clindamycin or
ACT Quinine + Clindamycin

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

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DOSE OF ARTEMETHER IN CHILDREN ®
A total dose of 5–24 mg/kg bw of Artemether and 29–144 mg/kg ©
bw of Lumefantrine
Body weight (kg) Dose
5 to < 15 20 + 120
15 to < 25 40 + 240
25 to < 35 60 + 360
≥ 35 80 + 480

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

ACT SYRUPS ®
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MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

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HYPNOZOITS OF VIVAX MALARIA ®
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MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

PRIMAQUINE ®
• Primaquine causes dose-limiting abdominal discomfort when ©
taken on an empty stomach; it should always be taken with
food
• Therapeutic dose: 0.25–0.5 mg/kg bw per day primaquine once
a day for 14 days
• In G6PD deficiency:
▪ Consider preventing relapse by giving primaquine base at
0.75 mg base/kg bw once a week for 8 weeks
▪ Close medical supervision for potential primaquine-induced
adverse hematological effects

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

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PREVENTING RELAPSE IN VIVAX AND OVALE ®
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• The G6PD status of patients should be used to guide
administration of Primaquine
• Primaquine is contraindicated in
- Pregnant women
- Infants aged < 6 months
- Women breastfeeding infants aged < 6 months
- People with G6PD deficiency

• 14-day course (0.25-0.5 mg/kg bw daily) of Primaquine

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

WHEN THE G6PD STATUS IS UNKNOWN AND

G6PD TESTING IS NOT AVAILABLE? ®
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• When the G6PD status is unknown and G6PD testing is not
available, a decision to prescribe Primaquine must be based
on an assessment of the risks and benefits of adding
Primaquine

• Clinical judgment

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

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HEMOLYSIS OF PRIMAQUINE IN G6PDD ®
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• Reversible
• Dose dependent
• Stops when Primaquine is stopped
• Hemolysis occurs with other drugs as well

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

VIVAX PROHYLAXIS IN PREGNANCY ®

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• In women who are pregnant or breastfeeding
• Weekly chemoprophylaxis with Chloroquine until delivery and
breastfeeding are completed
• Then, on the basis of G6PD status, treat with Primaquine to
prevent future relapse

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

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MANDATORY QUININE FOR SOLDIERS ®
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MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

RECURRENT FALCIPARUM MALARIA ®

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• Can result from re-infection or recrudescence (treatment
failure)
• Treatment failure may result from
1. Drug resistance
2. Sub-optimal dosing
3. Poor adherence
4. Vomiting
5. Unusual pharmacokinetics in an individual
6. Substandard medicines

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

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RECRUDESCENCE VERSUS RE-INFECTION ®
• May not be possible to distinguish ©
• Lack of resolution of fever
• Lack of resolution of parasitemia
• Recurrence within 4 weeks of treatment
• Considered failures of treatment with currently recommended
ACTs

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

TREATMENT FAILURE AFTER 28 DAYS ®

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• Due to either recrudescence or a new infection
• Treated with the first-line ACT

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

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TREATMENT FAILURE WITHIN 28 DAYS ®
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• Second-line treatment with alternative ACT known to be
effective in the region

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

SEVERE FALCIPARUM MALARIA ®

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• Defined as one or more of the following;
• (In the absence of an identified alternative cause and in the
presence of P. falciparum asexual parasitemia)
1. Impaired consciousness: A Glasgow coma score < 11 in adults
or a Blantyre coma score < 3 in children
2. Prostration: Generalized weakness so that the person is
unable to sit, stand or walk without assistance
3. Multiple convulsions: More than two episodes within 24 h

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

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SEVERE MALARIA ®
1. Acidosis ©
2. Hypoglycemia
3. Hemolysis
4. Renal impairment
5. Jaundice
6. Pulmonary edema
7. Bleeding
8. Shock
9. Hyperparasitemia: P. falciparum parasitemia > 10% (Severe
vivax malaria is defined as for falciparum malaria but with no
parasite density thresholds)

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

CEREBRAL MALARIA ®
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MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

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BLACK WATER FEVER ®
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MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

TREATMENT OF SEVERE MALARIA ®

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• Parenteral artesunate is the treatment of choice for all severe
malaria
• Treat adults and children with severe malaria (including infants,
pregnant women in all trimesters and lactating women) with
intravenous or intramuscular artesunate for at least 24 h
• Once a patient has received at least 24 h of parenteral therapy
and can tolerate oral therapy, complete treatment with 3 days
of an ACT

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

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TREATMENT OF SEVERE MALARIA ®
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• Following antimalarial medicines are recommended in order
of priority
1. Artesunate I.V. or I.M
2. Artemether I.M.
3. Quinine (I.V. infusion or I.M. injection).

• Full course of ACT or Quinine + Clindamycin or Doxycycline

when patient can tolerate oral treatment

MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

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MCPS-MRCGP[INT]-CEFM CME Program | Infectious diseases | Major infections | Malaria

REFERENCES ®
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• https://www.who.int
• Guidelines for the treatment of malaria, third edition, WHO

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