MALARIA

Paediatrics Department
 MALARIA
Date April 23, 2024
Topic Malaria
System Infectious disease
Phase MBBS Phase-3
CBME Competency (Maximum Upto 3)
Yes 34.19
Learning Domain Knowledge ± Skill ± Attitude ±
Communication
Level of Learning Knows / Knows How

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 Specific Learning Objectives (SLO-3 to 5) :
At the end of the session, students should be able to:
1 Etiology and clinical presentation Malaria
2 Courses of management in Malaria
3 Preventive measures
4 Complication
5 Special conditions

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Instruction Method Lecture / SGL
Plan of Instruction
Total Duration of Session 1
Media PPT / Chalk-Board

Presentation by Teacher 40 minutes

Student Activity 20 minutes
Type of Student Activity Think-Pair-Share,
Summary 5-10 minutes
Suggested References 2 minutes
Plan of Classroom Formative Assessment (At least One)
One-Minute Paper 5 minutes
Quiz 5-10 minutes ( Same / Next Session)
Attendance (Manual) 5-10 minutes
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• Malaria is one of the major public health
problems of the country.
• India reports around one million malaria cases
annually.
• In India, P. falciparum and P. vivax are the
most common species causing malaria, their
proportion being around 50% each.
• Plasmodium vivax is more prevalent in the
plain areas
• P. falciparum predominates in forested and
hilly areas.
Life cycle
• In the past, chloroquine was effective for
treating nearly all cases of malaria.
• In recent studies, chloroquine-resistant P.
falciparum malaria has been increasing across
the country.
 STAGES
• COLD STAGE- Lassitude, nausea, headache,chilling
sensation
Temperature rises rapidly 39-41 degree
Last for ½ to 1 hour.

• HOT STAGE- Burning hot, skin dry, headache is intense

Lasts for 2 to 3 hours.

• SWEATING STAGE- Fever comes down

profuse sweating
Lasts for 2 to 4 hours.
 Early diagnosis and complete treatment of malaria aims at:

• ● Complete cure
• ● Prevention of progression of uncomplicated
malaria to severe disease
• ● Prevention of deaths
• ● Interruption of transmission
• ● Minimizing risk of selection and spread of
drug resistant parasites
 DIAGNOSIS
• 1 . Microscopy
• thick and thin blood
• gold standard for confirmation of diagnosis of
malaria
• Advantages :
– 1. Sensitivity is high.
– It is possible to detect malaria parasites at low densities
– 2. To quantify the parasite load.
– 3. To distinguish different species of malaria parasites
and their different stages.
• 2 . Rapid Diagnostic Test
• Based on the detection of circulating parasite
antigens.
• Several types of RDTs are available.
• Some of them can only detect P.falciparum,
while others can detect other parasite species
also.
• NVBDCP has recently rolled out bivalent RDTs
for detecting P. falciparum and P. vivax
• Pf HRP-2 based kits may show positive result
up to three weeks after successful treatment
and parasite clearance
 TREATMENT
• PRINCIPLES
• Early diagnosis & prompt effective treatment
• Rational use of antimalarial agents
• Use of combination therapy
• Appropriate weight based dosing
 TREATMENT OF
UNCOMPLICATED MALARIA
P. vivax
• chloroquine 25 mg/kg.
• In some patients ( 8 - 30%) relapse due to
hypnozoites in liver cells
• Relapse prevention, primaquine 0.25 mg/kg daily
for 14 days under supervision
Chloroquine & Primaquine Regimen
• Primaquine is contraindicated in pregnant women, infants and
known G6PD deficient patients.
• Primaquine can lead to hemolysis in G6PD deficiency Patient
should be advised to
• stop primaquine immediately if any of the following symptoms:
– (i) dark coloured urine
– (ii) yellow conjunctiva
– (iii) bluish discolouration of lips
– (iv) abdominal pain
– (v) nausea
– (vi) vomiting
– (vii) breathlessness, etc.
 TREATMENT OF UNCOMPLICATED
P. falciparum
MALARIA
• ACT
– Artemisinin derivative with long acting antimalarial
– (amodiaquine, lumefantrine, mefloquine, piperaquine or
sulfadoxine-pyrimethamine).
– The ACT in the National Programme all over India except
northeastern states is
– Artesunate (4 mg/kg body weight) daily for 3 days
– Sulfadoxine (25 mg/kg body weight) &
– Pyrimethamine (1.25 mg/kg body weight) [AS+SP] on Day 0.

• primaquine (0.25 mg/kg) single dose on Day 2

 Northeastern states

Arunachal Pradesh, Assam, Manipur,

Meghalaya, Mizoram, Nagaland, Tripura
• due to late treatment failures to AS+SP in P.
falciparum, the presently recommended ACT
in national drug policy is a FDC of
Artemether-lumefantrine (AL)
• ACT used in the national programme
– NE states = AL
– Rest of India = AS+SP
• MONOTHERAPY OF ORAL
ARTEMISININ DERIVATIVES IS
BANNED IN INDIA
• Injectable artemisinin derivatives should be
used only in severe malaria.
 Treatment of malaria in pregnancy

• The ACT should be given for treatment of P.

falciparum malaria in second and third
trimesters of pregnancy
• Quinine recommended in the first trimester.
• Plasmodium vivax malaria can be treated with
chloroquine.
 Treatment of mixed infections

• Mixed infections with P. falciparum should be

treated as falciparum malaria.

• Anti-relapse treatment with primaquine can

for 14 days.
 Treatment based on clinical criteria without
laboratory
confirmation

• If RDT for only P. falciparum is used, negative

cases showing signs and symptoms of malaria
without other obvious cause for fever called as
clinical malaria.
• Treatment:- chloroquine 25 mg/kg for 3 days
 General recommendations for the management of
uncomplicated malaria

• Avoid starting treatment on empty stomach.

• The first dose is given under observation.
• Dose repeated if vomiting within half hour of
drug intake.
• Patient asked to report back, if no
improvement after 48 hours/deteriorates.
• Investigate for concomittant illnesses
 TREATMENT FAILURE/DRUG RESISTANCE

• Patient is called cured, if no fever or parasitaemia till

Day 28 after treatment.

• Patients may not respond to treatment due to 1)drug

resistance/ 2)treatment failure.

• Early treatment failure (ETF): Development of danger

signs on Day 1, 2 or 3 + parasitaemia higher on Day 2
 TREATMENT FAILURE/DRUG RESISTANCE

• Late clinical failure (LCF): Development of danger signs +

parasitaemia on Day 4 - 28

• Late parasitological failure (LPF): parasitaemia on Day 7 - 28 +

temperature <37.5°C + did not meet criteria of early treatment
failure or late clinical failure.

• TREATMENT :-
• ACT or quinine with Doxycycline or clindamycin.

• Doxycycline is contraindicated in pregnancy, lactation and in

children up to 8 years.
 Severe Falciparum Malaria

• DEFINITION:-
• one / more of the following, occuring in the absence
of an identified alternative cause and in the presence
of P. falciparum asexual parasitaemia.
• Impaired consciousness: GCS<11 in adults
• Prostration: Generalized weakness & unable to sit,
stand, walk
• Multiple convulsions: More than two episodes within
24hrs
• Acidosis:
– A base deficit of >8 mEq/L or
– bicarbonate level of <15 mmol/L or
– plasma lactate>=5mmol/L.
– respiratory distress
• Hypoglycaemia: RBS<40mg/dL
• Severe Malarial anaemia: HB <5, haematocrit
<15%
• Renal impairment:
– creatinine>3mg/dl
– blood urea>20mmol/L

• Jaundice: Sr bilirubin >3mg/dL with a parasite count

• >1,00 000/µL

• Pulmonary oedema:
• Radiologically confirmed
• oxygen saturation<92% on room air
• respiratory rate>30/min
• with chest indrawing
• crepitations on auscultation
• Shock: capillary refill>3sec & systolic blood
pressure<80mm Hg, with evidence of impaired
perfusion(cool peripheries or prolonged capillary refill).

• Hyperparasitaemia: P. falciparum parasitaemia>10%

• Significant bleeding:
• recurrent / prolonged bleeding from the nose, gums or
venepuncture sites, haematemesis or melaena.
 SEVERE MALARIA
Clinical features summary
• ● Impaired consciousness/coma
• ● Convulsions
• ● Renal failure (Sr Creatinine >3 mg/dl)
• ● Jaundice (Sr Bilirubin >3 mg/dl)
• ● Severe anaemia (Hb <5 g/dl)
• ● Pulmonary edema/ARDS
• ● Hypoglycaemia (Plasma Glucose <40
mg/dl)
 SEVERE MALARIA
Clinical features summary

• ● Metabolic acidosis
• ● Circulatory collapse/shock (SBP <80 mmHg)
• ● Abnormal bleeding
• ● Haemoglobinuria
• ● Hyperpyrexia (Temperature >106°F or >42°C)
• ● Hyperparasitaemia (>5% parasitized RBCs )
indian guidelines
 SEVERE MALARIA TREATMENT
• Things Necessary In a care centre:
•
● Parenteral antimalarials, antipyretics, antibiotics,
anticonvulsants
● Intravenous infusion facilities
● Special nursing for coma patients
● Blood transfusion
● Laboratory facilities
● Facility for Oxygen, dialysis, ventilator, etc.
 SEVERE MALARIA TREATMENT

• Severe manifestations can develop in P. falciparum

infection over time span as short as 12–24 hours
• Parenteral artemisinin derivatives or quinine used
as specific antimalarial therapy.

• Artesunate: 3 mg/kg i.v. or i.m. on

admission 0 hour then at 12 & 24 hours, then once
a day (dilute artesunate in 5% Sodium bicarbonate)
• Quinine: 20 mg/kg on admission
(i.v. infusion in 5% dextrose over 4 hours)
• maintenance dose :- 10 mg/kg 8 hourly.
• beyond 48 hours:- 7 mg/kg 8 hourly
•
• when able to take orally 10 mg/kg/day to be taken with doxycyclin 100mg daily
or with clindamycin (for pregnant females and children <8 yrs) for 7 days.

• NEVER GIVE BOLUS INJECTION

• Artemether: 3.2 mg/kg i.m. given on admission then 1.6 mg/kg per day.
• Arteether: 150 mg daily i.m. for 3 days in adults only.
• ACT containing mefloquine avoided in
cerebral malaria due to neuropsychiatric
complications.

• Severe malaria due to P. vivax

• It should be treated like severe P. falciparum
malaria
 Management of Complications
Manifestation or Immediate management
complication
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 treatments, intubate if necessary.

Hyperpyexia Administer tepid sponging, fanning a cooling blanket

and paracetamol
Convulsions Maintain airways; treat promptly with intravenous or
rectal diazepam, lorazepam, midazolam or
intramuscular paraldehyde. Check blood glucose.

Hypoglycaemia Check blood glucose, correct hypoglycemia and

maintain with glucose-containing infusion. Although
hypoglycaemia is defined as glucose <2.2mmol/L, the
threshold for intervention is <3mmol/L for children
<5 years and <2.2 mmol/L for older children and
adults.
 Continued…
Severe anaemia Transfuse with screened fresh whole blood.
Acute Pulmonary edema Prop patient up at an angle of 45◦, give oxygen,
give a diuretic, stop intravenous fluids, intubate
and add positive end-expiratory pressure or
continuous positive airway pressure in life-
threatening hypoxaemia.
Acute kidney injury Exclude pre-renal causes, check fluid balance and
urinary sodium, if in established renal failure, add
haemofiltration or haemodialysis, or if not
available, peritoneal dialysis.
Spontaneous bleeding and Transfuse with screened fresh whole blood
coagulopathy (cryoprecipitate, fresh frozen plasma and platelets,
if available); give vitamin K injection
 Continued…
Metabolic acidosis Exclude or treat hypoglycaemia, hypovalaemia and
septicaemia. If severe, add haemofiltration or
haemodialsis.
Shock Suspect septicaemia, take blood for cultures; give
parenteral broad-spectrum antimicrobials, correct
haemodynamic disturbances.
 CHEMOPROPHYLAXIS

• For :-
– Travellers
– Migrant
– Labourers
– Military personel
– Exposed to malaria in highly endemic areas
 CHEMOPROPHYLAXIS

• Short-term (< 6 weeks)

• Doxycycline: 100 mg/day
• started 2 days before travel till 4 weeks after leaving area.
• contraindicated in pregnant and lactating Women & children
less than 8 years.

• Long-term (> 6 weeks)

• Mefloquine: 5 mg/kg (max 250 mg) weekly and
• 2 weeks before & 4 weeks after leaving the area.
• contraindicated with H/O convulsions, neuropsychiatric
problems.
 MCQ
• 1. Besides R.B.C. Plasmodium attacks one
more type of human body cells during its
normal course of life cycle. Name that human
body cells :
• (a) liver cells
• (b) muscle cells
• (c) columnar cells of intestine
• (d) nerve cell

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• 2. The malarial parasite is introduced into the
blood of man as a:
• (a) metacryptozoite
• (b) crypotozoite
• (c) schizont
• (d) sporozoite

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• 3. Which of the following is not a clinical
feature of severe malaria
a. Impaired consciousness/coma
b. Convulsions
c. Severe anaemia (Hb <5 g/dl)
d. Hypoglycaemia (Plasma Glucose <40 mg/dl)

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• 4. What is the treatment of choice of
TREATMENT FAILURE/DRUG
RESISTANCE?
• A. doxycycline
• B. Chloroquine + Primaquine
• C. ACT or quinine with Doxycycline or
clindamycin
• D. None of the above

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 Thank You!

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