MALARIA:
RECENT MANAGEMENT
KURNIA FITRI JAMIL
Divisi Penyakit Tropik & Infeksi
Bagian/SMF. Ilmu Penyakit Dalam
FK-UNSYIAH/...
Outline
 Case illustration
 Severe malaria
 Facts sheet
 Uncomplicated malaria
 Malaria in pregnancy
 Prevention
Cases (per 1,000) by country, 2009
WHO. World Malaria Report 2010
Estimated 300-500 million
clinical cases each year
Mortality (per 1,000) by country, 2009
Approximately 2.5 million die
each year
WHO. World Malaria Report 2010
WHO. 2010
P. falciparum Resistance, 2009
Countries at risk of transmission, 2009
WHO. 2010
Insidence (per 1,000) Indonesia 2008
ACEH 2,03
SUM-UT 8,15
SUM-BAR 2,58
RIAU 3,06
JAMBI 18,08
SUM-SEL 5,46
BENGKULU 22,96
...
Incidence rate tends to decrease, since Gebrak Malaria or Roll
Back Malaria (RBM) initiative in 2000.
In 2008:
AMI decreas...
Indonesia, Malaria Case Fatality Rate
National target by 2010: number of malaria sufferer would be 5
per 1000 population
M...
New Species Case
Human Malaria is caused by one of 4 protozoan parasites:
Plasmodium falciparum
Plasmodium vivax
Plasmodiu...
Todays challenges
 Malaria is still a big concern in Indonesia
health problem
 Challenge of resistance in antimalarial d...
M A L A R I A
 Many cases worldwide
 High mortality of severe malaria
 Resistance to drugs
 Serious effects in pregnan...
Treatment of malaria
 Ideally all patients should be treated in hospital
 Indications for hospital admission:
 All chil...
Uncomplicated malaria
 Symptomatic malaria without signs of severity or
evidence of vital organ dysfunction.
 Treatment ...
 Treatment coverage:
 Treatment of P.vivax or P.ovale infection
 Treatment of mild/moderate P.falciparum infection, P.
...
Artemisinin derivatives
 Very short T½  should be given in a longer period  to
avoid relaps
Prevent resistance
of antim...
Artemisinin derivatives
SHOULD NOT be used as
monotherapies for the treatment
of uncomplicated malaria as this
will promot...
Drugs Composition Form
Artemether +
lumefantrine
20 mg + 120 mg Fixed dose tablets
Artesunate +
amodiakuin
25 mg + 67,5 mg...
WHO recommended ACTs
 Artemether (20 mg) - lumefantrine (120mg)
(Coarthem®) 2 x 4 tablet, in 3 days
 Artesunate (4mg/BW/...
Guidelines for the treatment of malaria Ministry of Health RI, 2009, WHO 2010
Uncomplicated malaria
FIRST LINE : ACT + PRI...
SECOND LINE
QUININE SULFA + PRIMAQUINE
Uncomplicated malaria
Treatment of P.vivax or P.ovale infection (2)
3 X 400-600 mg/...
Uncomplicated malaria
Treatment of P.vivax or P.ovale infection (3)
1st day : 4 + 2 tablets
2nd & 3rd day : 2 tablets
OR
1...
FIRST LINE
ACT
+
PRIMAQUINE
Uncomplicated malaria
Treatment of mild/moderate P.falciparum infection,
P. falciparum and P.v...
SECOND LINE
QUININE + DOXY/TETRA + PRIMAQUINE
 Quinine: 3x400-600 mg in 7 days
 Doxycycline: 2 x 2 mg/BW in 7 days
 Tet...
 Be Aware: risk factor, incubation period, symptom
 Avoid being Bitten by mosquitoes
 Chemoprophylaxis
 Immediately se...
Malaria Risk Prevention
TIPE I Transmission risk very low Bite avoidance
TIPE II
Risk of malaria vivax or
falciparum which...
Avoid being Bitten by mosquitos
 Insecticide treated net (ITN): (conventional ITN
or Long-lasting insecticidal nets (LLIN...
Causal
Prophylaxis
Suppressive
Prophylaxis
Guidelines for Malaria Prevention in Travellers from the United Kingdom. 2007
C...
 Recommended drugs:
 Chloroquine
 Proguanil
 Chloroquine + proguanil
 Mefloquine
 Doxicycline
 Atovaquone + proguan...
 Recommended by Ministry of Health RI, 2009
 Suppresive prophylaxis (effectivity ~ mefloquine)
 Adult dose: 100mg/day, ...
 Save: chloroquine and proguanil (+ folic acid
5mg/day) less protection to resistant strain
 Mefloquine:
 Few reported...
 Intermittent Preventive Treatment (IPT, WHO 2007):
Recommended Sulfadoxine-pyrimethamine
 Single dose; minimum use is ...
 Chemoprophylaxis is pointed for people who
traveling not in a long period
 Not recommended for long term use (3
months)...
Severe malaria
 Clinical manifestation:
 Prostration
 Impaired consciousness
 Respiratory distress
 Multiple convulsi...
 Treatment objectives:
 Prevent death
 Prevention of recrudescence, transmission or
emergence of resistance
 Preventio...
 Fluid, acid-base, and electrolyte balance
 Antipyretic
 Anti convulsants:
 Diazepam 10 mg, IV
Severe malaria
Supporti...
Artemisinin
 Artemether
▪ Day 1 : 3,2mg/BW/12hours (2 x 1,6mg/BW/12hours;im)
▪ Day 2 - 4 : 1,6mg/BW/day, im
 Artesunate
...
Quinine HCl 25%
 Diluted in 500cc dextrose 5% or NaCl 0.9%, give during
the first 4 hours, then rest in the next 4 hours:...
Severe malaria
Complication management
 Hypoglycaemia
 Dextrose 40%, IV bolus 25-50 cc, then dextrose 10%, drip
500 cc e...
Indication:
 Parasitaemia> 30% without severe complication
 Parasitaemia> 10%:
 With severe complication
 With treatme...
 More common
 More atypical
 More severe
 More fatal
 Selective treatment
 Various complication
Malaria in pregnancy
Malaria in pregnancy
 2nd and 3rd trimesters of pregnancy are more
likely to develop severe malaria
 Complication: anemi...
 Principal treatment:
 Supportive therapy
 Antimalarial drug
 Management of complication
 Management of labour
Malari...
 Supplementation of Fe & folic acid
 Blood transfusion in severe anemia (Hb<7g/dl)
 Adequate nutrition
Malaria in pregn...
 Uncomplicated malaria falciparum (trimester I)
Malaria in pregnancy
Antimalarial drugs (1)
1st Episode
Quinine
+
Clindam...
 Uncomplicated malaria falciparum (trimester II & III)
1st Episode
ACT
Artesunate + Clindamycin
Dose
above
Failure
of
tre...
 Choices of ACT
Artemether (20 mg) +
lumefantrine (120 mg) 2 x 4 tablets/ day 3 days
Artesunate (50 mg) +
Amodiaquine (15...
 Severe malaria
Early fase Artesunate
2 – 4 mg/BW at hour 0, 12
& 24; then every 24 hours
Until able
of oral
drug
Parente...
 Malaria non-falciparum
 Chloroquine (25 mg base /BW); except for P. vivax in
south Asia (around Indonesia) with high re...
Outcomes
WHO standard protocol classification:
 Early treatment failure
 Late treatment failure
 Late clinical failure
...
 Early treatment failure
 Day 1-3 occurrence of severe clinical sign
 Day-2 parasite count > day o
 Day-3 parasite cou...
Guidelines
for the
treatment of
malaria,
WHO 2010
Conclusions
 Reported number of malaria cases & deaths remains high
 Recommended use of ACT + Primaquine for
uncomplicat...
Thank You
Malaria di sabang 2011 (terapi malaria)
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Malaria di sabang 2011 (terapi malaria)

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Malaria di sabang 2011 (terapi malaria)

  1. 1. MALARIA: RECENT MANAGEMENT KURNIA FITRI JAMIL Divisi Penyakit Tropik & Infeksi Bagian/SMF. Ilmu Penyakit Dalam FK-UNSYIAH/RSUZA BANDA ACEH - 2011
  2. 2. Outline  Case illustration  Severe malaria  Facts sheet  Uncomplicated malaria  Malaria in pregnancy  Prevention
  3. 3. Cases (per 1,000) by country, 2009 WHO. World Malaria Report 2010 Estimated 300-500 million clinical cases each year
  4. 4. Mortality (per 1,000) by country, 2009 Approximately 2.5 million die each year WHO. World Malaria Report 2010
  5. 5. WHO. 2010 P. falciparum Resistance, 2009
  6. 6. Countries at risk of transmission, 2009 WHO. 2010
  7. 7. Insidence (per 1,000) Indonesia 2008 ACEH 2,03 SUM-UT 8,15 SUM-BAR 2,58 RIAU 3,06 JAMBI 18,08 SUM-SEL 5,46 BENGKULU 22,96 LAMPUNG 2,79 BANGKA BELITUNG 40,58 RIAU 13,32 DKI JAKARTA 0 JAWA BARAT 0,58 JAWA TENGAH 0,07 D I YOGYAKARTA 0,03 JAWA TIMUR 0,71 BANTEN 0,03 B A L I 0,17 NTB 21,85 NTT 0 KAL-BAR 3,23 KAL-TENG 11,21 KAL-SEL 4,20 KAL-TIM 8,59 SUL-UTARA 16,48 SUL- TENGAH 17,81 SUL- SELATAN 1,51 SUL- TENGGARA 10,26 GORONTALO 13,94 SUL- BARAT 11,98 M A L U K U 39,65 MALUKU UTARA 51,42 IRIAN JAYA BARAT 84,74 PAPUA 167,47
  8. 8. Incidence rate tends to decrease, since Gebrak Malaria or Roll Back Malaria (RBM) initiative in 2000. In 2008: AMI decreased to 17.77 API remains in 0.16 Indonesia, Malaria cases Ministry of Health RI, 2008 API: Annual Parasite Insidence AMI: Annual Malaria Insidence
  9. 9. Indonesia, Malaria Case Fatality Rate National target by 2010: number of malaria sufferer would be 5 per 1000 population Ministry of Health RI, 2008
  10. 10. New Species Case Human Malaria is caused by one of 4 protozoan parasites: Plasmodium falciparum Plasmodium vivax Plasmodium ovale Plasmodium malariae Plasmodium knowlesi ? ( sighh et al, 2008) http://www.tulane.edu/-wiser/malaria/cmb.html
  11. 11. Todays challenges  Malaria is still a big concern in Indonesia health problem  Challenge of resistance in antimalarial drug  Treatment policy to overcome the problem by using artemisinine derivatives  Clinical malaria diagnosis no longer used  Malarial elimination program in Indonesia
  12. 12. M A L A R I A  Many cases worldwide  High mortality of severe malaria  Resistance to drugs  Serious effects in pregnancy What can we do?
  13. 13. Treatment of malaria  Ideally all patients should be treated in hospital  Indications for hospital admission:  All children ≤ 1 year (and consider admitting children up to 5 years where possible)  All pregnant patients  All patients ≥ 65 years  Immuno-compromised patients where possible  Severe malaria or danger signs GUIDELINES FOR THE TREATMENT OF MALARIA IN SOUTH AFRICA, 2009
  14. 14. Uncomplicated malaria  Symptomatic malaria without signs of severity or evidence of vital organ dysfunction.  Treatment objectives:  eradicate the infection  prevent the emergence and spread of drug resistance  combination of two or more antimalarials with different mechanisms of action  Always give a full course of effective treatment Guidelines for the treatment of malaria, WHO 2010
  15. 15.  Treatment coverage:  Treatment of P.vivax or P.ovale infection  Treatment of mild/moderate P.falciparum infection, P. falciparum and P.vivax mixed infection  Antimalarial drugs: Uncomplicated malaria Guidelines for the treatment of malaria in Indonesia, Ministry of Health RI, 2009 ACT (1st line) / non-ACT (2nd line) + Primaquine
  16. 16. Artemisinin derivatives  Very short T½  should be given in a longer period  to avoid relaps Prevent resistance of antimalarial drug Davis TME, Karunajeewa HA, Ilett KF. Artemisinin-based combination therapies for uncomplicated malaria. MJA 2005; 182 (4):181-5. Yeung S, Pongtavornpinyo W, Hastings IM, Mills AJ, White NJ Am. J. Trop. Med. Hyg. 2004; 71(Suppl 2): 179–86. McIntosh H,Olliaro P. Artemisinin derivatives for treating uncomplicated malaria. Cochrane Database of Systematic Reviews 1999. Combination Artemisinin & other antimalarial Drug with different mechanism Duration therapy < T½ >
  17. 17. Artemisinin derivatives SHOULD NOT be used as monotherapies for the treatment of uncomplicated malaria as this will promote resistance to this critically important class of antimalarials
  18. 18. Drugs Composition Form Artemether + lumefantrine 20 mg + 120 mg Fixed dose tablets Artesunate + amodiakuin 25 mg + 67,5 mg Fixed dose tablets50 mg + 135 mg 100 mg + 270 mg 50 mg + 150 mg (base) Co-blistered tablets Artesunate + meflokuin 200 mg + 250 mg Co-blistered tablets Dihidroartemisinin + piperakuin 40 mg + 320 mg Fixed dose tablets Artesunate + sulfadoksin / pyrimethamine 50 mg + 500/25 mg Co-blistered tablets World Health Organization. Antimalarial medicines procured by WHO. 2010 Available ACT in 2010, WHO (Arthemisinin-based Combination Therapy)
  19. 19. WHO recommended ACTs  Artemether (20 mg) - lumefantrine (120mg) (Coarthem®) 2 x 4 tablet, in 3 days  Artesunate (4mg/BW/day) + amodiaquine (10mg/BW/day) (Artesdiaquine®, Artesuamoon®) once daily in 3days  Artesunate (4mg/BW/day once daily in 3 days) + Mefloquine (25 mg/BW split over 2 or 3 days)  Artesunate (4mg/BW/day once daily in 3 days) + Sulfadoxine- pyrimethamine (25mg/1.25mg base/BW on 1st day) Guidelines for the treatment of malaria, WHO 2010
  20. 20. Guidelines for the treatment of malaria Ministry of Health RI, 2009, WHO 2010 Uncomplicated malaria FIRST LINE : ACT + PRIMAQUINE Treatment of P.vivax or P.ovale infection (1) Artesunate (200mg/day, in 3 days) + amodiaquine (600mg/day, in 3 days) Artemether 20 mg + lumefantrine 120 mg; 2x4 tablets for 3 days Dihydroartemisinin 40 mg + piperaquine 320 mg 2 tablets initial dose, 2 tablets in the next 8, 24, and 32 hours 0.25 mg/BW/day in 14 days
  21. 21. SECOND LINE QUININE SULFA + PRIMAQUINE Uncomplicated malaria Treatment of P.vivax or P.ovale infection (2) 3 X 400-600 mg/day in 7 days 0.25 mg/BW/day in 14 days Guidelines for the treatment of malaria, Ministry of Health RI, 2009, WHO 2010
  22. 22. Uncomplicated malaria Treatment of P.vivax or P.ovale infection (3) 1st day : 4 + 2 tablets 2nd & 3rd day : 2 tablets OR 1st & 2nd day : 4 tablets 3rd day : 2 tablets CHLOROQUINE SENSITIVE CHLOROQUINE BASE 150 MG + PRIMAQUINE 1 X 15 mg in 14 days Guidelines for the treatment of malaria, Ministry of Health RI, 2009, WHO 2010
  23. 23. FIRST LINE ACT + PRIMAQUINE Uncomplicated malaria Treatment of mild/moderate P.falciparum infection, P. falciparum and P.vivax mixed infection (1) P falciparum inf. 0.75 mg/BW single dose Mixed infection Day 1-14: 0.25 mg/BW Guidelines for the treatment of malaria, Ministry of Health RI, 2009, WHO 2010
  24. 24. SECOND LINE QUININE + DOXY/TETRA + PRIMAQUINE  Quinine: 3x400-600 mg in 7 days  Doxycycline: 2 x 2 mg/BW in 7 days  Tetracycline:4 x 4-5 mg/BW in 7 days  Primaquine:  0.25mg/BW in 14 days vivax /mixed  0.75mg/BW single dose P.F inf. Uncomplicated malaria Treatment of mild/moderate P.falciparum infection, P. falciparum and P.vivax mixed infection (2)
  25. 25.  Be Aware: risk factor, incubation period, symptom  Avoid being Bitten by mosquitoes  Chemoprophylaxis  Immediately seek Diagnosis & treatment: if fever occur 1 week – 3 months after arrival in endemic areas Key tools of prevention
  26. 26. Malaria Risk Prevention TIPE I Transmission risk very low Bite avoidance TIPE II Risk of malaria vivax or falciparum which sensitive to chloroquine Bite avoidance + Chemoprophylaxis (chloroquine) TIPE III Risk of malaria vivax /falciparum, + probability of chloroquine resistance Bite avoidance + Chemoprophylaxis (according drug sensitivity in the area) TIPE IV  High risk of malaria falciparum + drug resistance  Moderate risk of malaria falciparum + high resistance WHO. International Travel & Health 2008
  27. 27. Avoid being Bitten by mosquitos  Insecticide treated net (ITN): (conventional ITN or Long-lasting insecticidal nets (LLINs)  prevent infectious mosquito bites.  Indoor Residual Spraying (IRS): indoor application of long-lasting chemical insecticides (DDT)  Other vector (mosquito) controls: larviciding and environmental management, repellent, clothes, fogging, domestic insectiside WHO, The Roll Back Malaria Partnership 2008: Global Malaria Action Plan.
  28. 28. Causal Prophylaxis Suppressive Prophylaxis Guidelines for Malaria Prevention in Travellers from the United Kingdom. 2007 Chemoprophylaxis
  29. 29.  Recommended drugs:  Chloroquine  Proguanil  Chloroquine + proguanil  Mefloquine  Doxicycline  Atovaquone + proguanil Chemoprophylaxis Guidelines for Malaria Prevention in Travellers from the United Kingdom. 2007
  30. 30.  Recommended by Ministry of Health RI, 2009  Suppresive prophylaxis (effectivity ~ mefloquine)  Adult dose: 100mg/day, start on 1st -2nd day before arrival, until 4 weeks after leaving out the area  Not recommended for > 3 month of using, children, and pregnant woman. (Ministry of Health RI, 2009)  !! Predisposition of Candidosis vagina Chemoprophylaxis Doxicycline Ohrt, C, Richie TL, Widjaja H et al. Annals of Internal Medicine. 1997;126:963-72 Guidelines for the treatment of malaria in Indonesia, Ministry of Health RI, 2009
  31. 31.  Save: chloroquine and proguanil (+ folic acid 5mg/day) less protection to resistant strain  Mefloquine:  Few reported side effects  Carefully use for 2nd & 3rd trimester pregnancy in area with chloroquine resistance  Doxicycline  CONTRA INDICATED Chemoprophylaxis In pregnant traveller Guidelines for Malaria Prevention in Travellers from the United Kingdom. 2007
  32. 32.  Intermittent Preventive Treatment (IPT, WHO 2007): Recommended Sulfadoxine-pyrimethamine  Single dose; minimum use is twice, since trimester II until partus  Prevalence of HIV in pregnancy > 10%  the 3rd dose should be given on the last antenatal care ? Chemoprophylaxis In pregnant traveller in endemic area • World Health Organization. Malaria in pregnancy: guidelines for measuring key monitoring and evaluation indicators. 2007. • Gamble C, Ekwaru JP, ter Kuile FO. Insecticide-treated nets for preventing malaria in pregnancy. Cochrane Database Syst Rev 2006;2: CD003755.
  33. 33.  Chemoprophylaxis is pointed for people who traveling not in a long period  Not recommended for long term use (3 months)  Consider of using personal protection (net, repellent, etc) Chemoprophylaxis For long term Guidelines for the treatment of malaria in Indonesia, Ministry of Health RI, 2009
  34. 34. Severe malaria  Clinical manifestation:  Prostration  Impaired consciousness  Respiratory distress  Multiple convulsions  Circulatory collapse  Pulmonary oedema  Abnormal bleeding  Haemoglobinuria  Jaundice  Laboratory test:  Severe anaemia  Hypoglycaemia  Acidosis  Renal impairment  Hyperlactataemia  Hyperparasitaemia The presence of one or more of these features: Guidelines for the treatment of malaria, WHO 2010
  35. 35.  Treatment objectives:  Prevent death  Prevention of recrudescence, transmission or emergence of resistance  Prevention of disabilities  Principal treatment:  Supportive therapy  Antimalarial drug  Complication management Severe malaria Guidelines for the treatment of malaria, WHO 2010
  36. 36.  Fluid, acid-base, and electrolyte balance  Antipyretic  Anti convulsants:  Diazepam 10 mg, IV Severe malaria Supportive therapy Guidelines for the treatment of malaria, WHO 2010 Guidelines for the treatment of malaria in Indonesia, Ministry of Health RI, 2009
  37. 37. Artemisinin  Artemether ▪ Day 1 : 3,2mg/BW/12hours (2 x 1,6mg/BW/12hours;im) ▪ Day 2 - 4 : 1,6mg/BW/day, im  Artesunate ▪ Day 1 : 2,4mg/BW, iv in 1st hour,  2,4mg/BW/iv in hour 12 & 24 ▪ Day 2 - 7 : 2,4mg/BW/hr, iv After conscious continue with  Artesunate + amodiaquine OR  Quinine + Tetracycline / doxycycline / clindamycin Severe malaria Antimalarial drugs (1) Guidelines for the treatment of malaria, WHO 2010
  38. 38. Quinine HCl 25%  Diluted in 500cc dextrose 5% or NaCl 0.9%, give during the first 4 hours, then rest in the next 4 hours: ▪ Loading dose: 20 mg/BW (single dose) ▪ Maintenance dose: 10 mg/BW, repeat until the patient able to receive oral medication  After conscious, continue by oral quinine 10mg/BW every 8 hours, + tetracycline / doxicycline / clindamycin until day 7. Severe malaria Antimalarial drugs (2) Guidelines for the treatment of malaria, WHO 2010
  39. 39. Severe malaria Complication management  Hypoglycaemia  Dextrose 40%, IV bolus 25-50 cc, then dextrose 10%, drip 500 cc every 4-6 hours  Keep the nutrition intake (NGT)  Acute kidney failure  Keep the fluid & electrolyte balance  Dyalisis (if there is an indication)  Lung oedema / ARDS  Fluid & electrolyte balance (max 1500 cc/24 hours)  Diuretic  Ventilator Guidelines for the treatment of malaria, WHO 2010
  40. 40. Indication:  Parasitaemia> 30% without severe complication  Parasitaemia> 10%:  With severe complication  With treatment failure after 12-24 hours optimal antimalarial  With bad prognosis (old age, late stage parasites/skizon in blood) Severe malaria Exchange blood transfusion
  41. 41.  More common  More atypical  More severe  More fatal  Selective treatment  Various complication Malaria in pregnancy
  42. 42. Malaria in pregnancy  2nd and 3rd trimesters of pregnancy are more likely to develop severe malaria  Complication: anemia, pulmonary oedema, hypoglycaemia  Maternal mortality is approximately 50%  Fetal death & premature labour are common Guidelines for the treatment of malaria, WHO 2010
  43. 43.  Principal treatment:  Supportive therapy  Antimalarial drug  Management of complication  Management of labour Malaria in pregnancy
  44. 44.  Supplementation of Fe & folic acid  Blood transfusion in severe anemia (Hb<7g/dl)  Adequate nutrition Malaria in pregnancy Supportive therapy Nosten F, McGready R, Mutabingwa T. Case management of malaria in pregnancy. Lancet Infect Dis 2007; 7:118-25.
  45. 45.  Uncomplicated malaria falciparum (trimester I) Malaria in pregnancy Antimalarial drugs (1) 1st Episode Quinine + Clindamycin 3 x 10 mg/BW/day + 3 x 5 mg/BW/day 7 days Failure of treatment Repeat Quinine + Clindamycin ACT Artesunate + Clindamycin 2 mg/BW/day + 3 x 5 mg/BW/day 7 days • World Health organization. Guideline for the treatment of Malaria 2010. Geneva. • Case management of malaria in pregnancy. Lancet Infect Dis 2007; 7:118-25.
  46. 46.  Uncomplicated malaria falciparum (trimester II & III) 1st Episode ACT Artesunate + Clindamycin Dose above Failure of treatment Other ACT Artesunate + Clindamycin Quinine + Clindamycin Dose above 7 days • World Health organization. Guideline for the treatment of Malaria 2006. Geneva. • Case management of malaria in pregnancy. Lancet Infect Dis 2007; 7:118-25. Malaria in pregnancy Antimalarial drugs (2)
  47. 47.  Choices of ACT Artemether (20 mg) + lumefantrine (120 mg) 2 x 4 tablets/ day 3 days Artesunate (50 mg) + Amodiaquine (153 mg) 1 x 4 tablets/ day 3 days Artesunate (50 mg) + Sulfadoxine-pyrimethamine (500/25 mg) 1 x 4 tablets/ day + 3 tablets only at day I 3 days Artesunate (50 mg) + Mefloquine (250 mg) 1 x 4 tablets/ day + 1 x 4 tablets/ day in day I, 1 x 2 tablets/ day in day II 3 days + 2 days Malaria in pregnancy Antimalarial drugs (3) • Case management of malaria in pregnancy. Lancet Infect Dis 2007; 7:118-25.,WHO 2010
  48. 48.  Severe malaria Early fase Artesunate 2 – 4 mg/BW at hour 0, 12 & 24; then every 24 hours Until able of oral drug Parenteral Late fase Artesunate+ Clindamycin 2 mg/BW/day 3 x 5 mg/BW/day 7 day oral Alternative for early fase Quinine 20 mg/BW (loading dose); then 10 mg/BW every 8 hours 7 day Parenteral Alternative for late fase Quinine + Clindamycin 3 x 10 mg/BW/day 3 x 5 mg/BW/day. 7 day oral Malaria in pregnancy Antimalarial drugs (4) • Case management of malaria in pregnancy. Lancet Infect Dis 2007; 7:118-25, WHO 2010.
  49. 49.  Malaria non-falciparum  Chloroquine (25 mg base /BW); except for P. vivax in south Asia (around Indonesia) with high resistance, choose quinine.  Alternative: Amodiaquine  very limited data about effectivity & safety in pregnancy Malaria in pregnancy Antimalarial drugs (5) • Case management of malaria in pregnancy. Lancet Infect Dis 2007; 7:118-25, WHO 2010.
  50. 50. Outcomes WHO standard protocol classification:  Early treatment failure  Late treatment failure  Late clinical failure  Late parasitological failure  Adequate clinical and parasitological response.
  51. 51.  Early treatment failure  Day 1-3 occurrence of severe clinical sign  Day-2 parasite count > day o  Day-3 parasite count >25% day o  Day-3 (+) finding of asexual parasite & also fever  Late treatment failure  Late clinical and parasitological failure: ▪ Day 4-28: occurrence of severe clinical sign ▪ Asexual parasite still existing & also fever  Late parasitological failure: Occurrence of asexual parasite on day 7, 14, 21, and 28 without fever. Outcomes
  52. 52. Guidelines for the treatment of malaria, WHO 2010
  53. 53. Conclusions  Reported number of malaria cases & deaths remains high  Recommended use of ACT + Primaquine for uncomplicated malaria  Recommended use of parenteral artemisinin derivative or quinine for severe malaria  Recommended use of quinine + clindamycin (1st trimester) OR ACT (2nd & 3rd trimester or failure to quinine in 1st trimester), for malaria in pregnancy  Prevention by mosquito control, avoidance of mosquitos bite and chemoprophylaxis
  54. 54. Thank You
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