JOY M. NICOLAS MDPIDS – FELLOW IN TRAINING
   Time of Emperor Shih Huang Ti (2697–2590 BC)     Earliest report for malaria - repeated paroxysmal fevers associated ...
Charles Louis Alphonse Laveran first to notice parasites in the blood of a patient suffering from malaria
   Infected anopheline mosquito - Most typical    cause of transmission     Approximately 45% are effective vectors    ...
   ng
   Endemic malaria – based on the parasite rate in children 2 to 9 years old     HYPOENDEMIC – parasite rate 0 to 10%   ...
   Autochthonous malaria – acquired locally    - Introduced malaria – migrant populations (asymptomatic)    provide blood...
   Blood born transmission – cannot result to relapses   Congenital malaria – cannot occur if the mother is semi-    imm...
   Incidence and severity of malaria –     Intensity of exposure     Presence of immunity      - children      - pregna...
   Anemia     Lysis of RBCs     Impaired erythropoiesis     bone marrow suppression secondary to folic acid      defic...
   Sequestered infected RBC –    -facilitate adherence of these cells to vascular    endothelium    - can be responsible ...
   Recurrent infections     RELAPSES - due to delaye maturation of dormant live stages      (hypnozoites) of P. vivax or...
P. falciparum        P. vivax        P. ovale         P. MalariaeIncubation        12 (8-25)            14 (8 – 27)     17...
P. falciparum     P. vivax         P. ovale         P. MalariaeCharacteristic   Ring forms        Schuffner dots   Schuffn...
   Malaria paroxysm – results from lysis of parasitized RBCs and release of merozoites into    the circulation at the com...
   Anemia   Thrombocytopenia   Leukopenia   Abnormal liver function test   Hypoglycemia   Hyponatremia   Elevated c...
   Cerebral malaria – most common complication of falciparum    malaria-   Occurs mostly in 3 – 6 years old-   Alteration...
   SEVERE ANEMIA -     Seen most commonly in less than 1 years old     Occur most often in areas with year round transm...
   ACID-BASE CHANGES     Metabolic acidosis – marker of severity  HYPERPNEA   RENAL COMPLICATION     Acute renal fail...
•   PULMONARY EDEMA    - Consistent with pulmonary leak syndrome    - Develops late in the course of severe malaria•   HYP...
•   HYPERACTIVE MALARIAL SYNDROME    - Huge spleen and enlarged liver    - Anemia and increased reticulocyte count; thromb...
•   History of travel in endemic areas•   Microscopy    • Thin smear - speciation of the organism         - Giemsa stain –...
•   FLUORESCENT MICROSCOPY    •   Identification of parasitized RBCs stained with acridine orange in the RBC layer of     ...
   First Line Treatment          Artemether-Lumefantrine tablet twice a day on days 1 to 3        (1 tablet contains 20 m...
Day of                                    Artemether-Lumefantrinetreatment          Use body weight in kgs as basis       ...
   Second Line Treatment        Quinine sulphate + Doxycycline or          Tetracycline or Clindamycin
Age Group/      Quinine           Plus any of the three antibiotics below  Condition       Sulfate       Doxycycline      ...
Parenteral Quinine Dihydrocloride Infusion                  PLUS  Tetracycline/Doxycycline/Cljndamycin
Age Group                     Quinine Dihydrochloride                               Loading Dose           Maintenance Dos...
   Dosing Schedule for Pre-referral Treatment with    Artesunate Suppository (AS) in Adults    Weight (kg)   Artesunate  ...
Chloroquine tablet on Days 1 to 3(1 tablet contains 150 mg base of Chloroquine)                     AND      Primaquine ta...
Day of Treatment                                            CQ                    (1) Use weight in kgs (2) If weight cann...
Chloroquine tablet on Days 1 to 3( 1 tablet contains 150 mg base of Chloroquine)                      AND   Primaquine tab...
Day of Treatment                                           CQ                   (1) Use body weight (2) If weight cannot b...
   P. falciparum and P. vivax    Artemether Lumefantrine+ Primaquine.     Day of Treatment                               ...
P. falciparum and P. vivaxDay 4-17                                       PQ             (1) Use weight in (2) If weight ca...
Artemether-Lumefantrine for 3 days (Refer to Table 4.4)          b. Primaquine (0.75 mg/kg) single dose on Day 4 (Refer to...
Day of                                    Artemether-Lumefantrinetreatment          Use body weight in kgs as basis       ...
Artemether-Lumefantrine for 3 days (Refer to Table 4.4)          b. Primaquine (0.75 mg/kg) single dose on Day 4 (Refer to...
Day of                                    Artemether-Lumefantrinetreatment          Use body weight in kgs as basis       ...
   P. vivax and P. Malariae          Chloroquine (25 mg/kg) for 3 days        Primaquine (0.5 mg/kg/day) single dose     ...
Day of Treatment                                            CQ                    (1) Use weight in kgs (2) If weight cann...
Stage of                                 Treatment by SpeciesPregnancy                          Pf                        ...
Stage of                                    Treatment by SpeciesPregnancy                             Pf                  ...
   Uncomplicated Pf Malaria      Population Group         Medicine           Dosing Schedule    Pregnant             Quin...
•    Severe Pf Malaria        Quinine Dihydrochloride Infusion + Clindamycin IV    Population Group       Medicine        ...
Plasmodium vivax, ovale, malaria and Mixed  Infection    acute P. vivax or P. Ovale -                  No. of Chloroquine...
   Dosing Schedule for Pregnant and Lactating Mothers with              Relapse P. vivax Malaria Infection               ...
•    Dosing Schedule for Pregnant and Lactating Mothers with                  P. malariae Malaria Infection               ...
Dosing Schedule for 2nd and 3rd Trimester Pregnant and         Lactating Mothers With Mixed InfectionDay of Treatment     ...
< 6 months of age   Age Group/ Condition     Quinine Sulfate           Plus                             (300 or 600       ...
6 – 11 monthsDay of treatment          Artemether-Lumefantrine                   Use body weight in kgs as basis (        ...
Day of                                    Artemether-Lumefantrinetreatment          Use body weight in kgs as basis       ...
Age Group                       Quinine Dihydrochloride                                Loading Dose          Maintenance D...
Weight         Age         Artesunate       Regimen (single dose) (kg)                      dose (mg)    (available in 50 ...
   In endemic areas, this condition is diagnosed only when    parasites are identified within 14 days after birth   If p...
   suspected when blood has been transfused    within the past six months
Classification of Treatment Outcomes (WHO, 2005)    Response                                               CriteriaAdequat...
Dosing Schedule of Artemether-Lumefantrine (AL)and Primaquine (PQ) in the Treatment of Uncomplicated Plasmodium falciparum...
Primaquine tablet (PQ)       Use body weight in kgs as basis: use 0.75 mg base/kg BW single dose       If weight cannot be...
Drugs            Schedule                                Dose                                         Pregnant            ...
Drugs            Schedule                          Dose                                       Pregnant       Adult        ...
Malaria
Malaria
Malaria
Malaria
Malaria
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Malaria

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  • Requires a population of Anopheles mosquito and infected human - only 45
  • Imported malaria – may occur in non-endemic area but results from infection in an endemic areaCRYPTIC MALARIA – airport mlaria – proximity to international airports – mosquito arriving with airplanes from endemic area infect individuals working in or living near airports
  • Blood transfusion, organ-donation or needle stick injury – -cannot result to relapses even if it causes P. vivax or ovale because the infection is produced by transmission of infected RBC rather than the forms that invade the liver-Congenital malaria – cannot occur if the mother is semi-immune because of passage of maternal antibody at the time of birth
  • Adults in endemic areas continue to becme infected but with lower levels of parasetemia- infants born to mothers with acquired immunity may be protected transiently by placental passage of maternal antibody- the highest incidence of infection in malaria occurs in infants /young children who are no longer protected by maternal antibody but who are too young for significant acquired immunity to develop – more susceptible to cerebral malaria- in children lacking with acquired immunity accounts to the increased risk of acquiring the disease and severe manifestation acquired immunity diminishes during pregnancy – development for severe complications of pneumonia Reservoirs of infection – individuals who remain asymptomatic but harbor gametocytes in their blood are reservoirs of infecton when bitten by mosquitoes- individuals with previous acquired immunity who then leave endemic areas for long periods may lose their immunity and poses a greater risk for severe disease if re –exposedDuffy- negative blood type specific receptors for invasion of merozoites of P vivax– resistant to infection with P. vivax – basis for low invasion of vivax malaria in Africa
  • Hemoglobinuria (blackwater fever) – complication associated with using quinine as treatmentCytokines (TNF, Interleukin 1) – TNF
  • - Plasmodium falciparum – late stage parasites induce host cells to develop knobs on the surface of erythrocytes that facilitate adherence of these cells to vascular endothelium-- the effects of these sequestered RBCs on the perfusion, nutrition, oxygenation of surrounding tissue
  • Stimulates a polyclonal increase in immunoglobulins associated with rapid production of malaria-specific antibodies and reduced complement levels- false-positive tests for syphillis, rheumatoid factor, heterophilagglutinns and cold agglutinins
  • Factors associated with neurologic sequelae - prolonged coma, severe anemia, multiple seizureMortality 15 to 30 percent Most survivors recover completely but approx 10% have neurologic sequelae in gambiahemiplagia, cortical blindness, aphasia ataxiaContributing factors to Cerebral malaria – hypoglycemia, anemia, microvascular obstruction, acidosis and elaboration of inflammatory mediatord contribute to the syndrome of cerebral malaria
  • HYPOGLYCEMIA – result as treatment with quinine – due to rapid IV transfusion may cause hypoglycemia by stimulating insulin secretionPregnant women are susceptible for this condition- hypoglycemia may occur several days into a course of oral quinine, presumably caused by resolution of the reduced tissue sensitivity to insulin – a feature of acute malaria
  • ACID-BASE CHANGES - fluid resuscitation and treatment with antimalarial drugs – rapid resolution of acidosis persistence of acidosis results to mortalityRENAL COMPLICATIONS - have asymptomatic proteinuria and gradual development of hypertension and deterioration of renal function - adults more commonly have hematuria and azotemia while hematuria is common for adults and children - disease does not respond to antimalarial agents - treatment with steroids, cyclophosphamide and azathioprine had variable result with remission occuring only with mild changes on renal biopsy
  • PULMONARY EDEMA - Treatment of supplemental oxygen and mechanical ventilation with positive end-expiratory pressure HYPERACTIVE MALARIAL SYNDROME (TROPICAL SPLENOMEGALY SYNDROME, HYPERACTIVE MALARIAL SPLEENOMEGALY) - correlated with malaria endemicity (0.5 to 80%) of adult population - PE – huge spleen and an enlarged liver -
  • PULMONARY EDEMA - Treatment of supplemental oxygen and mechanical ventilation with positive end-expiratory pressure HYPERACTIVE MALARIAL SYNDROME (TROPICAL SPLENOMEGALY SYNDROME, HYPERACTIVE MALARIAL SPLEENOMEGALY) - correlated with malaria endemicity (0.5 to 80%) of adult population - PE – huge spleen and an enlarged liver - suggested to have hyperactive malarial syndrome is a premalignant condition
  • Both thick and thin smear can be used to determine the densityWhen thin smear is used the proportion of RBCs infected is counted while the smear is viewed under an oil-immersion lens
  • Both thick and thin smear can be used to determine the densityWhen thin smear is used the proportion of RBCs infected is counted while the smear is viewed under an oil-immersion lens
  • Both thick and thin smear can be used to determine the densityWhen thin smear is used the proportion of RBCs infected is counted while the smear is viewed under an oil-immersion lens
  • -Advise to take AL with milk or fat containing food - absorption is enhanced by co administration of fat- Low blood levels with resultant treatment failure could potentially result from inadequate fat intake
  • -Advise to take AL with milk or fat containing food - absorption is enhanced by co administration of fat- Low blood levels with resultant treatment failure could potentially result from inadequate fat intake
  • -Advise to take AL with milk or fat containing food - absorption is enhanced by co administration of fat- Low blood levels with resultant treatment failure could potentially result from inadequate fat intake
  • A total of 25 mg/kg given over 3 days
  • Withhold Primaquine during the entire period of pregnancy, but give it 2 weeks after delivery in single
  • Primaquine should not be given for infants below 1 year oldAL should not be given to infants less than 6 months or less than 5 kgsClosely monitor infants for side effects such as methemoglobinemia, hemolytic anemia, hemoglobinuria in G6PD deficiency neutropenia and renal dysfunction
  • onset of symptoms in congenital malaria with detectable peripheral blood parasitemia may be up to two months after birth and delayed in vivax malariarare in highly endemic areas
  • - For transfusion-induced vivax malaria, give the recommended treatment and single dose Primaquine since there are no secondary exo-erythrocytic forms in transfusion-induced vivax malaria
  • still no documented P.vivax resistance in the country, it is important that health care providers be conscious of possibility of such cases coming from other countries such as Papua New Guinea, Thailand, East Timor Indonesia and Myanmar
  • and increase the dose of Primaquine to 0.5 - 0.75 mg/kg body weight per day for 14 days or to a maximum of 30-45 mg per day for 14 days.
  • Malaria

    1. 1. JOY M. NICOLAS MDPIDS – FELLOW IN TRAINING
    2. 2.  Time of Emperor Shih Huang Ti (2697–2590 BC)  Earliest report for malaria - repeated paroxysmal fevers associated with enlarged spleens and a tendency to epidemic occurrence name malaria, derived from ‘mal’aria’ (bad air in Medieval Italian) - first used by Leonardo Bruni in a publication of 1476.
    3. 3. Charles Louis Alphonse Laveran first to notice parasites in the blood of a patient suffering from malaria
    4. 4.  Infected anopheline mosquito - Most typical cause of transmission  Approximately 45% are effective vectors  A population of infected humans is necessary to sustain transmission ▪ short life span of mosquitoes ( 5 to 20 days) ▪ the long incubation period required in the mpsquito (8 to > 10 days)
    5. 5.  ng
    6. 6.  Endemic malaria – based on the parasite rate in children 2 to 9 years old  HYPOENDEMIC – parasite rate 0 to 10%  MESOENDEMIC – parasite rate 11 to 50%  HYPERENDEMIC - parasite rate consistently >50% , with a high proportion of adults having enlarged spleen  HOLOENDEMIC – parasite rate consistently >75%, with a low proportion of adults having enlarged spleen
    7. 7.  Autochthonous malaria – acquired locally - Introduced malaria – migrant populations (asymptomatic) provide blood meals for feeding anopheles under conditions that can complete the life cycle enabling the mosquito to infect others - Imported malaria - Induced malaria – acquired from exposure to infected blood ( blood transfusion, needle stick injury, laboratory accidents) - Cryptic malaria – cases for which no explanation can be found
    8. 8.  Blood born transmission – cannot result to relapses Congenital malaria – cannot occur if the mother is semi- immune  Transplacental transmission or breakdown of placental barrier during delivery
    9. 9.  Incidence and severity of malaria –  Intensity of exposure  Presence of immunity - children - pregnant woman - reservoirs of infection  Genetic factors ▪ Duffy- negative blood type specific receptors – resistant to infection with P. vivax ▪ Sickle hemoglobinopathies and protection against severe malaria falciparum
    10. 10.  Anemia  Lysis of RBCs  Impaired erythropoiesis  bone marrow suppression secondary to folic acid deficiency  Hemoglobinuria (blackwater fever) – intravascular hemolysis - can result to renal failure Cytokines (TNF, Interleukin 1) – TNF stimulate nitric oxide – correlated with clearance of parasites and recovery and severity of illness
    11. 11.  Sequestered infected RBC – -facilitate adherence of these cells to vascular endothelium - can be responsible for cerebral malaria, renal failure, watery diarrhea Hypoglycemia and lactic acidosis – consumption of glucose by late parasites
    12. 12.  Recurrent infections  RELAPSES - due to delaye maturation of dormant live stages (hypnozoites) of P. vivax or P. ovale  RECRUDESCENCE – parasitemia caused by the same parasite responsible for the initial infection recurs after clearance or a significant reduction in the initial parasitemia ▪ Occurs most commonly with P. falciparum  RE-INFECTION - from different parasites and infection with more than one type of Plasmodium occur especially in areas with high intensity of transmission ▪ Noted in P. malaria
    13. 13. P. falciparum P. vivax P. ovale P. MalariaeIncubation 12 (8-25) 14 (8 – 27) 17 (15 - > 18) 28 (15- > 40)periodPeriodicity of none 48 48 72febrile attacksEarliest 10 days 3 days ? ?apperance ofgametocytesRelapse No Yes Yes NoDuration of 1-2 yr 1.5 – 4 yr 1.5 – 4 yr 3 – 50 yruntreatedinfectionRBC preference Younger cells Reticulocytes Reticulocytes Older cells (but can invade cells of all ages)
    14. 14. P. falciparum P. vivax P. ovale P. MalariaeCharacteristic Ring forms Schuffner dots Schuffner dots Normal- sizedmorphology Multiply infected Enlarged RBCs Enlarged RBCs cells cells Band or Banana shaped rectangular gametocytes forms of trophozoites
    15. 15.  Malaria paroxysm – results from lysis of parasitized RBCs and release of merozoites into the circulation at the completion of asexual reproduction - fever, chills - headache - body ache - fatigue - dizziness - malaise GI symptoms – nausea, vomiting, abdominal pain, diarrheaCHILDREN – fever, headache or GI symptoms - anemia - Jaundice - hepatospleenomegaly
    16. 16.  Anemia Thrombocytopenia Leukopenia Abnormal liver function test Hypoglycemia Hyponatremia Elevated creatinine or BUN
    17. 17.  Cerebral malaria – most common complication of falciparum malaria- Occurs mostly in 3 – 6 years old- Alteration of consciousness w/o any explanation during infection of malaria- Comatose- Generalized convulsions- Increase of intracranial pressure- histopathology – occasional hemorrhages and perivascular infiltrates
    18. 18.  SEVERE ANEMIA -  Seen most commonly in less than 1 years old  Occur most often in areas with year round transmission  Clinical consequences of anemia ▪ Rate of development of anemia, severith of anemia ▪ Higher risk of complications as hemoglobin decreases less than 5 g/dL HYPOGLYCEMIA  Associated with poor prognosis  Due to combination of parasite consumption of glucose and inadequate gluconeogenesis in the liver
    19. 19.  ACID-BASE CHANGES  Metabolic acidosis – marker of severity  HYPERPNEA RENAL COMPLICATION  Acute renal failure – life-threatening ▪ Oliguric and reversible if immediately dialized • occur more frequently in those patients treated with quinine or quinidine • Histologic changes resembles those of acute tubular necrosis • Nephrotic syndrome and chronic renal failure – endemic and associated with P. malariae
    20. 20. • PULMONARY EDEMA - Consistent with pulmonary leak syndrome - Develops late in the course of severe malaria• HYPERACTIVE MALARIAL SYNDROME - Massive spleenomegaly, high concentrations of total serum IgM and malarial antibodies of multiple immunoglobulin classes and clinical and immunologic response to antimalarial agents - Seems to involve chronic exposure to malaria resulting in chronicstimulationof the immune system and genetic factors
    21. 21. • HYPERACTIVE MALARIAL SYNDROME - Huge spleen and enlarged liver - Anemia and increased reticulocyte count; thrombocytopenia or neutropenia - Increases the risk of acquiring bacterial infection
    22. 22. • History of travel in endemic areas• Microscopy • Thin smear - speciation of the organism - Giemsa stain – preserves the Schuffner dots - has low sensitivity – low parasite load (<100 to 300 uL) – too small to detect • Thick smear – speciation cannot be identified - Estimating the parasites density – assessing the likelihood of development of complications associated with high parasite density and for evaluating response to therapy
    23. 23. • FLUORESCENT MICROSCOPY • Identification of parasitized RBCs stained with acridine orange in the RBC layer of centrifuged blood• DETECTION OF PARASITE ANTIGEN
    24. 24.  First Line Treatment Artemether-Lumefantrine tablet twice a day on days 1 to 3 (1 tablet contains 20 mg Artemether and 120 mg Lumefantrine) AND Primaquine tablet on day 4 (single dose) (1 tablet contains 15 mg base of Primaquine)
    25. 25. Day of Artemether-Lumefantrinetreatment Use body weight in kgs as basis 5-<15 kg 15 - < 25 kg 25-<35 kg > 35 kg If weight cannot betaken, use age as basis 6 mon- 3 yo 4-8 yo 9-13-yo If > 35 kgDay 1 1 tab 2 tabs 3 tabs 4 tabs8 hrs after 1 tab 2 tabs 3 tabs 4 tabsDay 2 1 tab BID 2 tabs BID 3 tabs BID 4 tabs BIDDay 3 1 tab BID 2 tabs BID 3 tabs BID 4 tabs BID Primaquine tablet (PQ) Use body weight in kgs as basis: use 0.75 mg base/kg BW single dose If weight cannot be taken use age as basisDay4 < 1 yo 1-3yo 4-6 yo 7 -11 yo > 12 yo Contraindicated ½ PQ single 1 PQ tablet 2 PQ tablets 3 PQ tablets dose single dose single dose single dose
    26. 26.  Second Line Treatment Quinine sulphate + Doxycycline or Tetracycline or Clindamycin
    27. 27. Age Group/ Quinine Plus any of the three antibiotics below Condition Sulfate Doxycycline Tetracycline Clindamycin (300 or 600 mg/tablet)Adults, non- 10 mg 3 mg/kg bw 250 mg 4 times 10 mg/kg bwpregnant salt/kg bw once a day (QD) a day (QID) for 7 twice a daywomen and dose every 8 for 7 days days (BID) for 7 dayschildren 8 hours for 7years and daysaboveChildren < 8 As above Contra- Contra- 10 mg/kg bwyears old indicated indicated twice a day (BID) for 7 days
    28. 28. Parenteral Quinine Dihydrocloride Infusion PLUS Tetracycline/Doxycycline/Cljndamycin
    29. 29. Age Group Quinine Dihydrochloride Loading Dose Maintenance DoseAdult 20 mg salt/kg in 500 ml 10 mg salt/kg in D5W or 0.9NaCl for 4 0.9NaCl or D5W IV drip hours IV drip for 4 hours every 8 (The total dose must not hours exceed 2,000 mg)Children 8 years to 16 15 mg salt/kg IV drip for 4 10 mg salt/kg IV dripyears hours in 10 ml/kg D5W or for 4 hours every 8 0.9 NaCl hours in D5W or 0.9 (infusion rate must not NaCl exceed 5mg/kg per hour)Children 7 years and 10 mg salt/kg in IV drip for 10 mg salt/kg IV dripyounger 4 hours every 12 hours
    30. 30.  Dosing Schedule for Pre-referral Treatment with Artesunate Suppository (AS) in Adults Weight (kg) Artesunate Regimen (single dose) Dose (Preparation of AS is available in 50, 200 and 400 mg) < 40 10 mg/kg Use appropriate number of 50 or 200 mg preparation 40 – 59 400 mg One 400 mg preparation 60 – 80 800 mg Two 400 mg preparation > 80 1200 mg Three 400 mg preparation
    31. 31. Chloroquine tablet on Days 1 to 3(1 tablet contains 150 mg base of Chloroquine) AND Primaquine tablet on Days 4 to 17 (1 tablet contains 15 mg. base of Primaquine base)
    32. 32. Day of Treatment CQ (1) Use weight in kgs (2) If weight cannot be taken, use age as basis as basis 0-11 mos 1-3 4-6 7- 12-15 y.o. > 16 y.o. y.o. y.o. 11 y.o.Day 1 10 mg/kg 1/2 1 1½ 2 3 4Day 2 10 mg/kg ½ 1 1½ 2 3 4Day 3 5 mg/kg 1/2 1/2 1 1 1½ 2Day 4-17 PQ (1) Use weight in (2) If weight cannot be taken, use age as basis kgs as basis 0-11 mos 1-3 4-6 7-11 y.o. > 12 y.o. y.o. y.o. 0. 5 mg-base per contra- ½ ½ 1 daily 1 daily kilogram per day indicated dail dail y y
    33. 33. Chloroquine tablet on Days 1 to 3( 1 tablet contains 150 mg base of Chloroquine) AND Primaquine tablet on Day 4 (single dose) (1 tablet contains 15 mg base of Primaquine)
    34. 34. Day of Treatment CQ (1) Use body weight (2) If weight cannot be taken, use age as basis in kgs as basis 0-11 mos. 1-3 4-6 7- 12-15 y.o. > 16 y.o. y.o. y.o. 11 y.o.Day 1 10 mg/kg 1/2 1 1½ 2 3 4Day 2 10 mg/kg ½ 1 1½ 2 3 4Day 3 5 mg/kg 1/2 1/2 1 1 1½ 2Day 4 PQ (1) Use body weight (2) If weight cannot be taken, use age as basis in kgs as basis 0-11 mos. 1-3 4-6 7-11 > 12 y.o. y.o. y.o. y.o. 0.75 mg-base per contra- ½ 1 2 tabs singe 3 tabs single kilogram per day indicated tab tab dose dose sin sin gle gle dos dos e e
    35. 35.  P. falciparum and P. vivax Artemether Lumefantrine+ Primaquine. Day of Treatment AL (1) Use body weight in kgs as basis 5 - <15 15 - 25 - <35 kg ≥35 kg kg <25 kg (2) If weight cannot be taken, use age as basis (6 mos.– (4- 8 (9-13 y.o.) If (> 13 3 y.o.) y.o.) y.o.)Day 1 1 tab 2 tabs 3 tabs 4 tabs8 hrs after 1 tab 2 tabs 3 tabs 4 tabsDay 2 1 tab 2 tabs 3 tabs BID 4 tabs BID BID BIDDay 3 1 tab 2 tabs 3 tabs BID 4 tabs BID BID BID
    36. 36. P. falciparum and P. vivaxDay 4-17 PQ (1) Use weight in (2) If weight cannot be taken, use age as basis kgs as basis 0-11 mos 1-3 4-6 7-11 y.o. > 12 y.o. y.o y.o . . 0. 5 mg-base per contra- ½ ½ 1 daily 1 daily kilogram per day indicated dai dai ly ly
    37. 37. Artemether-Lumefantrine for 3 days (Refer to Table 4.4) b. Primaquine (0.75 mg/kg) single dose on Day 4 (Refer to Table 4.4  P. falciparum and P. Malariae Artemether-Lumefantrine for 3 days Primaquine (0.75 mg/kg) single dose on Day 4
    38. 38. Day of Artemether-Lumefantrinetreatment Use body weight in kgs as basis 5-<15 kg 15 - < 25 kg 25-<35 kg > 35 kg If weight cannot betaken, use age as basis 6 mon- 3 yo 4-8 yo 9-13-yo If > 35 kgDay 1 1 tab 2 tabs 3 tabs 4 tabs8 hrs after 1 tab 2 tabs 3 tabs 4 tabsDay 2 1 tab BID 2 tabs BID 3 tabs BID 4 tabs BIDDay 3 1 tab BID 2 tabs BID 3 tabs BID 4 tabs BID Primaquine tablet (PQ) Use body weight in kgs as basis: use 0.75 mg base/kg BW single dose If weight cannot be taken use age as basisDay4 < 1 yo 1-3yo 4-6 yo 7 -11 yo > 12 yo Contraindicated ½ PQ single 1 PQ tablet 2 PQ tablets 3 PQ tablets dose single dose single dose single dose
    39. 39. Artemether-Lumefantrine for 3 days (Refer to Table 4.4) b. Primaquine (0.75 mg/kg) single dose on Day 4 (Refer to Table 4.4  P. Falciparum, P. vivax and P. Malariae Artemether-Lumefantrine for 3 days Primaquine (0.5 mg/kg/day) single dose on Day 4 for 14 days
    40. 40. Day of Artemether-Lumefantrinetreatment Use body weight in kgs as basis 5-<15 kg 15 - < 25 kg 25-<35 kg > 35 kg If weight cannot betaken, use age as basis 6 mon- 3 yo 4-8 yo 9-13-yo If > 35 kgDay 1 1 tab 2 tabs 3 tabs 4 tabs8 hrs after 1 tab 2 tabs 3 tabs 4 tabsDay 2 1 tab BID 2 tabs BID 3 tabs BID 4 tabs BIDDay 3 1 tab BID 2 tabs BID 3 tabs BID 4 tabs BID Primaquine tablet (PQ) Use body weight in kgs as basis: use 0.75 mg base/kg BW single dose If weight cannot be taken use age as basisDay4 < 1 yo 1-3yo 4-6 yo 7 -11 yo > 12 yo Contraindicated ½ PQ single ½ PQ single 1 PQ tablets 1 PQ tablets dose dose single dose single dose
    41. 41.  P. vivax and P. Malariae Chloroquine (25 mg/kg) for 3 days Primaquine (0.5 mg/kg/day) single dose on Day 4 for 14 days
    42. 42. Day of Treatment CQ (1) Use weight in kgs (2) If weight cannot be taken, use age as basis as basis 0-11 mos 1-3 4-6 7- 12-15 y.o. > 16 y.o. y.o. y.o. 11 y.o.Day 1 10 mg/kg 1/2 1 1½ 2 3 4Day 2 10 mg/kg ½ 1 1½ 2 3 4Day 3 5 mg/kg 1/2 1/2 1 1 1½ 2Day 4-17 PQ (1) Use weight in (2) If weight cannot be taken, use age as basis kgs as basis 0-11 mos 1-3 4-6 7-11 y.o. > 12 y.o. y.o. y.o. 0. 5 mg-base per contra- ½ ½ 1 daily 1 daily kilogram per day indicated dail dail y y
    43. 43. Stage of Treatment by SpeciesPregnancy Pf Pv/Po/P Relapse P. Mixed Uncomplicated Severe m vivax Infection 1st QN Parenteral QN infusion CQ CQ QN trimester + + + Clindamycin (oral) Clindamycin IV Clindamyci (1) If Quinine infusion not available, n (oral) give QN tab orally or by NGT (2) Shift to oral Clindamycin if patient can already tolerate oral meds (3) If QN not available (either tab or infusion), is last resort requiring consent of patient/relatives 2nd QN Parenteral QN infusion CQ CQ QN trimester + + + Clindamycin (oral) Clindamycin IV Clindamyci (1) If above not available, give QN n (oral) tab orally or by NGT If above (2) Shift to oral Clindamycin if not patient can already tolerate oral available, meds AL can be (3) If QN + is not available, can be given given
    44. 44. Stage of Treatment by SpeciesPregnancy Pf Pv/Po/P Relapse Mixed Uncomplicated Severe m P. vivax Infection 3rd QN Parenteral QN infusion CQ CQ QN trimester + + + Clindamycin (oral) Clindamycin IV Clindamyc (1) If above not available, give QN in (oral) tab orally or by NGT If above (2) Shift to oral Clindamycin if not patient can already tolerate oral available, meds AL can be (3) If QN + is not available, can be given givenPost-partum PQ SD PQ SD PQ 14 PQ 14 PQ 14(2 weeks afterdelivery)Lactating QN Parenteral QN infusion CQ CQ QN + + + + + Clindamycin (oral) Clindamycin IV PQ PQ 14 Clindamyc + (1) If above not available, give QN in PQ tab orally or by NGT (oral) (2) Shift to oral Clindamycin if + patient can already tolerate oral PQ14 meds or (3) If QN + is not available, can be AL given + PQ 14
    45. 45.  Uncomplicated Pf Malaria Population Group Medicine Dosing Schedule Pregnant Quinine Sulphate 10 mg/kg every 8 hours for 7 days Clindamycin 10 mg/kg twice a day for 7 days Lactating Above Plus PQ on Day 0.75 mg per kg, single 4 dose
    46. 46. • Severe Pf Malaria Quinine Dihydrochloride Infusion + Clindamycin IV Population Group Medicine Dosing Schedule Loading Dose Maintenance DosePregnant Women Quinine 20 mg/kg infused over 10 mg/kg every 8 hours Dihydrochloride 4 hours (in 500 ml 5% infused over 2-4 hours dextrose water or 0.9% If patient can already saline) tolerate oral meds, shift to oral QN Sulphate (10 mg/kg every 8 hours) to complete 7 days at same dose Clindamycin 10 mg/kg IV twice a day; shift to oral clindamycin; as soon as patient tolerates oral clindamycin at same dose to complete 7 daysLactating Women Above Plus PQ 0.75 mg per kg, single dose after 7 days of Clindamycin
    47. 47. Plasmodium vivax, ovale, malaria and Mixed Infection  acute P. vivax or P. Ovale - No. of Chloroquine Tablet Primaquine (150 mg base/tablet) (15 mg base/tablet)Day of Treatment Day 1 Day 2 Day 3 Pregnant Women:By weight 10 mg/kg 10 mg/kg 5 mg/kg Withheld until deliveryIf weight cannot be 4 tabs 4 tabs 2 tabs .taken Lactating Women: Take Primaquine beginning Day 4 to Day 17at 0.5 mg/kg b.w. per day Post-partum Women (2 weeks after delivery) for 14 days at 0.5 mg/kg b.w. per day
    48. 48.  Dosing Schedule for Pregnant and Lactating Mothers with Relapse P. vivax Malaria Infection Chloroquine Tablet Primaquine Tablet (150 mg base/tablet) (15 mg base/tablet)Wk1 Wk2 Wk3 Wk4 Wk5 Wk6 Wk7 Wk8 Pregnant Women: Withheld 2 2 2 2 2 2 2 2 until deliverytabs tabs tabs tabs tabs tabs tabs tabs Lactating Women: Take Primaquine beginning Day 4 up to Day 17 at 0.5 – 0.75 mg/kg b.w. per day to a maximum of 30 – 45 mg per day Post-partum Women (2 weeks after delivery) for 14 days at 0.5 – 0.75 mg/kg/b.w. per day to a maximum of 30 – 45 mg per day
    49. 49. • Dosing Schedule for Pregnant and Lactating Mothers with P. malariae Malaria Infection No. of Chloroquine Tablet Primaquine (150 mg base/tablet) (15 mg base/tablet) Day of Treatment Day 1 Day 2 Day 3 Pregnant Women: By weight 10 mg/kg 10 mg/kg 5 mg/kg Withheld until delivery Lactating Women: If weight cannot be 4 tabs 4 tabs 2 tabs Take Primaquine on taken Day 4 at 0.75 mg/kg/b.w. Post-partum Women (2 weeks after delivery) single dose at 0.75 mg/kg/b.w.
    50. 50. Dosing Schedule for 2nd and 3rd Trimester Pregnant and Lactating Mothers With Mixed InfectionDay of Treatment AL Use weight in kgs as basis If weight cannot be taken, use age as basis < 35 kgs (≥35 kg 9 - 13 y.o. > 13 y.o.Day 1 3 tabs 4 tabs 3 tabs 4 tabs8 hrs after 3 tabs 4 tabs 3 tabs 4 tabsDay 2 3 tabs twice a day 4 tabs twice a 3 tabs twice a 4 tabs (BID) day (BID) day (BID)Day 3 3 tabs twice a day 4 tabs twice a 3 tabs twice a 4 tabs twice a (BID) day (BID) day (BID) day (BID)Day 4-17 PQ (1) For Pregnant Women: withheld until delivery (2) For Post Partum/Lactating Women: Use 0.5 mg base per kg 1 tab daily per day
    51. 51. < 6 months of age Age Group/ Condition Quinine Sulfate Plus (300 or 600 Clindamycin mg/tablet) Children < 8 years old 10 mg salt/kg bw 10 mg/kg bw twice a day dose every 8 hours (BID) for 7 days for 7 days
    52. 52. 6 – 11 monthsDay of treatment Artemether-Lumefantrine Use body weight in kgs as basis ( 5-<15 kg If weight cannot betaken, use age as basis 6 mon- 3 yoDay 1 1 tab8 hrs after 1 tabDay 2 1 tab BIDDay 3 1 tab BID
    53. 53. Day of Artemether-Lumefantrinetreatment Use body weight in kgs as basis 5-<15 kg 15 - < 25 kg 25-<35 kg > 35 kg If weight cannot betaken, use age as basis 6 mon- 3 yo 4-8 yo 9-13-yo If > 35 kgDay 1 1 tab 2 tabs 3 tabs 4 tabs8 hrs after 1 tab 2 tabs 3 tabs 4 tabsDay 2 1 tab BID 2 tabs BID 3 tabs BID 4 tabs BIDDay 3 1 tab BID 2 tabs BID 3 tabs BID 4 tabs BID Primaquine tablet (PQ) Use body weight in kgs as basis: use 0.75 mg base/kg BW single dose If weight cannot be taken use age as basisDay4 < 1 yo 1-3yo 4-6 yo 7 -11 yo > 12 yo Contraindicated ½ PQ single 1 PQ tablet 2 PQ tablets 3 PQ tablets dose single dose single dose single dose
    54. 54. Age Group Quinine Dihydrochloride Loading Dose Maintenance DoseChildren 8 years to 16 15 mg salt/kg IV drip for 4 10 mg salt/kg IV dripyears hours in 10 ml/kg D5W or for 4 hours every 8 0.9 NaCl hours in D5W or 0.9 (infusion rate must not NaCl exceed 5mg/kg per hour)Children 7 years and 10 mg salt/kg in IV drip for 10 mg salt/kg IV dripyounger 4 hours every 12 hours
    55. 55. Weight Age Artesunate Regimen (single dose) (kg) dose (mg) (available in 50 mg, 200 mg and 400 mg suppositories) 5 – 8.9 0 - 12 months 50 One 50 mg 9 – 19 13- 42 months 100 Two 50 mg20 – 29 43- 60 months 200 One 200 mg30 – 39 6 - 13 years 300 Two 50 mg and one 200 mg > 40 > 14 years 400 One 400 mg
    56. 56.  In endemic areas, this condition is diagnosed only when parasites are identified within 14 days after birth If parasites are seen in blood films after the first week of life, neonatal malaria is a possibilityDay 1: 10 mg/kgDay 2: 10 mg/kgDay 3: 5 mg/kg (half dose of Days 1 and 2)
    57. 57.  suspected when blood has been transfused within the past six months
    58. 58. Classification of Treatment Outcomes (WHO, 2005) Response CriteriaAdequate Clinical Absence of parasitemia on Day 28 irrespective of temperature, without meetingand Parasitological any of the criteria of Early Treatment Failure or Late Clinical Failure or LateResponse (ACPR) Parasitological Failure.Early Treatment Development of danger signs or severe malaria on Day 1, Day 2 or Day 3 in theFailure (ETF) presence of parasitemia; OR Parasitemia on Day 2 higher than Day 0 count irrespective of axillary temperature; OR Parasitemia on Day 3 with axillary temperature ≥ 37.5 °C; OR Parasitemia on Day 3 ≥ 25% of count on Day 0.Late Clinical Failure Development of danger signs or severe malaria on any day from Day 4 to Day 28(LCF) in the presence of parasitemia, without previously meeting any of the criteria of Early Treatment Failure; OR Presence of parasitemia and axillary temperature ≥ 37.5oC (or history of fever) on any day from Day 4 to Day 28, without previously meeting any of the criteria of ETF.Late Parasitological Presence of parasitemia on any of the scheduled return on Day 7, Day 14, Day 21Failure (LPF) or Day 28, and axillary temperature < 37.5oC without previously meeting any of the criteria of ETF.
    59. 59. Dosing Schedule of Artemether-Lumefantrine (AL)and Primaquine (PQ) in the Treatment of Uncomplicated Plasmodium falciparum Malaria InfectionDay of Artemether-Lumefantrinetreatment Use body weight in kgs as basis 5-<15 kg 15 - < 25 kg 25-<35 kg > 35 kg If weight cannot betaken, use age as basis 6 mon- 3 yo 4-8 yo 9-13-yo If > 35 kgDay 1 1 tab 2 tabs 3 tabs 4 tabs8 hrs after 1 tab 2 tabs 3 tabs 4 tabsDay 2 1 tab BID 2 tabs BID 3 tabs BID 4 tabs BIDDay 3 1 tab BID 2 tabs BID 3 tabs BID 4 tabs BID
    60. 60. Primaquine tablet (PQ) Use body weight in kgs as basis: use 0.75 mg base/kg BW single dose If weight cannot be taken use age as basisDay4 < 1 yo 1-3yo 4-6 yo 7 -11 yo > 12 yo Contraindicated ½ PQ single 1 PQ tablet 2 PQ tablets 3 PQ tablets dose single dose single dose single dose
    61. 61. Drugs Schedule Dose Pregnant Adult PediatricA. For People Travelling To Endemic AreasDoxycycline Tablet Start two to contraindicate 1 tablet < 8 years: (100 mg) three days d contraindicated prior to travel, > 8 years old: daily while in 2 mg/kg up to 100 the area and mg daily continue up to four weeks upon leaving the areaMefloquine Start 1-2 contraindicate 1 tablet weekly < 45 kg: 5 mg/kg bwTablet weeks before d 5-10 kg ⅛ tab(250 mg base) travel; take 10-19 kg ¼ tab weekly while 20-30 kg ½ tab in the area, 31-45 kg ¾ tab and continue up to four weeks upon leaving the area
    62. 62. Drugs Schedule Dose Pregnant Adult PediatricA. For People Travelling To Endemic AreasCholoroquine Start 2 weeks 2 tablets NA < 8 years: 5 mg/kg before travel, b.w. take weekly < 8 years: 2 tablets while in the area and continue 4 weeks after leaving the areaB. For Pregnant Women Residing in Endemic AreasSulphadoxine If resident in 3 tablets eachPyrimethamiine stable on 2nd and 3rd transmission trimesters area only
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