Lecture by: Dr. Satti M. Saleh Chief of Infectious Diseases Department MGH Director of IC Unit Meeqat General hospital CBAHI SIT Member Medical Director Meeqat General Hospital

1. In Hajjis &Returned Travelers

2. Dr. Satti M. Saleh
Chief of Infectious Diseases Department MGH
Director of IC Unit Meeqat General hospital
CBAHI SIT Member
Medical Director Meeqat General Hospital

3. .

5. KNOWLEDGE OF THE INFECTING
SPECIES
THE LIKELY LOCATION OF INFECTION
GEOGRAPHIC PATTERNS OF DRUG
RESISTANCE
IF THERE IS ANY DOUBT
(TREAT FOR THE WORSE – CASE SCENARIO)
CONSIDER ANY FEBRILE ILLNESS FROM
MALARIOUS AREA TO BE MEDICAL
EMERGENCY
COMPLY WITH TREATMENT GOAL

7. DEFINITION
malaria is an acute and
chronic disease caused by
Protozoa of the genus
Plasmodium .

8. A- Plasmodium Malariae ( Loveran 1881 )
B- Plasmodium Vivax ( GRASSI 1981)
C- Plasmodium Flaciparum ( Welch 1897)
D- Plasmodium Ovale ( Stephens 1922 )
)

9. 300 – 500 million case each year
* 3.5 Million death ( Unnecessary

10. Life cycle

12. - Cough, fatigue, malaise, shaking chills arthralgia,
myalgia.
Paroxysms of fever, shaking chills and sweating
- no classic paroxysm
- maintain a high index of suspension
- anorexia, lethargy, nausea, vomiting, diarrhoea,
headache.
SYMPTOMS:-

13. Complications:-
A- CEREBRAL MALARIA
- coma, altered mental status or multiple
seizures with PF in blood
- main cause of death in malaria
- 15-20 % Mortality
B- Seizures
C- Renal failure 30% of non-immune adult
D- Black water fever
Haemolysis, Haemoglobinaemia,
Hemoglobinnuria.

14. E.NON CARDIOGENIC PULMONARY
OEDEMA;most common with pregnancy;80%
mortality
F. Hypoglycemia Mostly in children and
pregnancy
- QUININE THERAPY
- difficult to diagnose
Lack of adrenergic signs Stupor
G. Lactic Acidosis
poor prognosis (venous lactate45mg/dl)

15. H. Anaemia
Infected RBCs
-haemolysis
non-infected RBCs
- Dyserythropoeisis
- Hypersplenism

16. LAB. STUDIES
- CBC,electrolytes panel,renal
function
- Imaging studies
- C X-ray
- CT

17. PARASITOLOGICAL TEST:-
- thin blood smear
- thick blood smear
- parasitaemia rate
- every 12 hours
OTHERS TEST:
- polymerase chain reaction
- specific * sensitive
- Detect parasitaemia as low as 10 parasites
/ml.

18. -Antigen detection Technique –
PFHRP2
-fluorescent staining of parasite nuclei
- malarial antibody test

20. stay alert

21. Criteria for anti malaria treatment policy change ( a
change of 1st line treatment)
 If the total failure proportion > 10 % (12
% in Jazan 2001)
 Additional factor : the prevalence and
geographical distribution of reported
treatment failures (neighboring Yemen)
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22. ‫المدي‬ ‫بمنطقة‬ ‫والخبيثة‬ ‫الحميدة‬ ‫المالريا‬ ‫لحاالت‬ ‫بياني‬ ‫تخطيط‬‫نة‬
‫المنورة‬
‫من‬ ‫الفترة‬ ‫في‬1/1/2016------‫وحتى‬1/7/2016
//------//
0
2
4
6
8
10
12
vivax
falciparm
total

23. 0
20
40
60
80
100
120
140
160
2010 2011
‫المنورة‬ ‫المدينة‬ ‫منطقة‬ ‫ريا‬ ‫المال‬ ‫حاالت‬
2010----2011‫يوليو‬ ‫حتى‬

24. ‫الميقات‬ ‫بمستشفى‬ ‫المنومة‬ ‫المالريا‬ ‫حاالت‬ ‫يوضح‬ ‫بياني‬ ‫رسم‬
‫العام‬
‫من‬ ‫الفترة‬ ‫في‬1/1/1437-------‫وحتى‬1/11/1437
//-------//
0
5
10
15
20
25
30
35
falciparm vivax

25. Goals
 Early and correct diagnosis
 Prompt and effective treatment of all
confirmed and highly suspected cases
 Prevent the emergence and spread of
resistance to Antimalarial drugs
 Reduction / interruption of transmission
 Prevention of relapses in P. vivax and P.
ovale infection
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26. First – line treatment
Artesunate + Sulfadoxine – Pyrimethamine
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27. First – line treatment
Artesunate + Sulfadoxine – Pyrimetheramine
 Currently available as separate scored
tablets containing 50 mg of artesunate, and
tablets containing 500 mg sulfadoxine + 25
mg pyrimetheramine.
 The total recommended dose is 4 mg/kg bw
artesunate once a day , and a single
administration of sulfadoxine-pyrimthamine
(25/1.25 mg base / kg bw) on day -1
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28. Sulfadoxine-
pyrimethamine (500
/25)
Artesunate 50 mg
tablets
Age (years)Weight (kg)
Day 1Day 3Day 2Day 1
1/21/21/21/2Infants5-10
1111≤1- <7> 10-24
2222≤ 7- 13>24-50
3444> 13>50
Reference: guideline for malaria treatment, WHO, 2006
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29. Management of treatment
failure
 Early treatment failure (EFT)
 Late clinical failure (LCF)
 Late parasitological failure
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30. Definition of treatment failure
 Failure to resolve or recurrence of fever
and/or parasitemia within 28 days of the
start of treatment
 Can be divided to : early and late
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31. Early treatment failure (EFT)
 Development of danger signs or severe
malaria on Day 1, Day 2, Day 3, in the
presence of parasitemia
 Parasitemia on Day 2 higher than Day 0
count irrespective of axillary temperature
 Parasitemia on Day 3 with axillary
temperature ≤ 37.5˚
 Parasitemia on Day 3 ≤ 25 % of count
on Day 0
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32. Late clinical failure (LCF)
Development of danger signs or severe
malaria after Day 3 in the presence of
parasitemia, without previously meeting
any of the criteria of early treatment
failure
Presence of parasitemia and axillary
temperature ≤ 37.5˚ on any day from
Day 4 to Day 28, without previously
meeting any of the criteria of Early
Treatment Failure
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33. Late parasitological failure
 Presence of parasitemia on any day
from Day 7 to Day 28 and axillary
temperature < 37.5 ˚ without previously
meeting any of the criteria of Early
Treatment Failure or Late Clinical
Failure
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34. Second – line treatment
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35. Artemether – Lumefantrine (Coartem)
 Tablets contain 20 mg of artemether and 120 mg of
lumefantrine
 The total recommended treatment is a six-dose
regimen of artemether-lumefantrine twice daily for 3
days
 Advantage of the combination: lumefantrine is not
available it is recommended for patients > 5 kg
 Inform the patient to take it with fat-containing food
particularly on the second and third days of treatment (
absorption of lumefantrine is enhanced by co-
administration with fat
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36. Content of
Artemether
(AM)+Lumefantrin
e(LM) per dose
Number of
tablets per
dose (at 0h,
8h, 24h, 36h,
48h, 60h)
Age in
years
Weight
(kg)
Not recommended< 5
20 mg A + 120 mg
L
1<35-14
40 mg A + 240 mg
L
2≤ 3-8>14-24
60 mg A + 360 mg
L
3> 8-14>24-34
80mg A + 480 mg
L
4> 14>34
DOSAGE
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37. Management of malaria in
pregnancy
 Malaria in pregnancy is associated with
(abortion, stillbirth, low birth weight,
increased anemia, increased risk of severe
malaria- in low transmission areas)
 1st trimester: Quinine + Clindamycin to be
given for 7 days
 ACT should be used if it is the only effective
treatment available
 2nd and 3rd trimesters: ACT
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38. Treatment of severe and
complicated malaria
Severe and complicated malaria is a
true emergency associated with severe
multi systemic complications,
warranting ICU care for close monitoring
and subsequent management

39. Management should include
If severe or complicated malaria is anticipated, empiric
treatment should be started without any delay.
Parenteral ARTESUNATE is the first drug of choice for the
treatment of severe and complicated malaria unless
otherwise contraindicated i.e. first trimester of pregnancy.
Quinine is the second drug of choice in severe and
complicated malaria

40. Artesunate
 2.4 mg/kg i.v. or i.m. given on:
 admission (time = 0)
 At 12 hours
 Then Once daily for 7 days
 SHIFT TO ORAL route immediately
when the patient’s condition permits
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41. Quinine Dihydrochloride
 20 mg/kg loading dose in 5 % dextrose over 4
hours followed by 10 mg/kg over 4 hours / 8
hours (Max. 1800 mg/day) for 7 days.
 The treatment should be SHIFTER TO ORAL
quinine (10 mg/kg every 8 h.) as soon as
tolerated
 A 7 days course of Doxycycline should be
given in order to ensure complete cure
 Start dose is 200 mg then daily 100 mg for 7
days
C.I: pregnants, children < 8 y. age (use
Clindamycin 300 mg 4 times / day for 5 days)
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42. Management of malaria in lactating
women
 Special care should be taken when
prescribing any antimalarial to a lactating
woman (although amount in breast milk are
relatively few)
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43. Management of malaria in infants
 Malaria is common in infants and under 2 y.
of age in endemic areas with high case-
fatality rate
 Start Antimalarials immediately in case of
suspicion
 Accurate diagnosis is important
 Artemisinin derivatives appear to be safe
and well tolerated
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44. Choosing a Drug to Prevent
Malaria

45. drug for malaria
prophylaxis
Recommendations for drugs to prevent malaria differ by country of
travel and can be found in the of the Yellow Book. Recommended
drugs for each country are listed in alphabetical order and have
comparable efficacy in that country.
No antimalarial drug is 100% protective and must be combined with
the use of personal protective measures, (i.e., insect repellent, long
sleeves, long pants, sleeping in a mosquito-free setting or using an
insecticide-treated bednet).
For all medicines, also consider the possibility of drug-drug
interactions with other medicines that the person might be taking as
well as other medical contraindications, such as drug allergies.
When several different drugs are recommended for an area, the
following table might help in the decision process

46. Atovaquone/Proguanil
(Malarone)
Reasons that might make you consider using this drug
Reasons that might make you avoid using this
drug
 Good for last-minute travelers
because the drug is started 1-2 days
before traveling to an area where
malaria transmission occurs
 Some people prefer to take a daily
medicine
 Good choice for shorter trips
because you only have to take the
medicine for 7 days after traveling
rather than 4 weeks
 Very well tolerated medicine – side
effects uncommon
 Pediatric tablets are available and
may be more convenient
 Cannot be used by women who are
pregnant or breastfeeding a child
less than 5 kg
 Cannot be taken by people with
severe renal impairment
 Tends to be more expensive than
some of the other options (especially
for trips of long duration)
 Some people (including children)
would rather not take a medicine
every day

47. Chloroquine
 Some people would rather take
medicine weekly
 Good choice for long trips because
it is taken only weekly
 Some people are already taking
hydroxychloroquine chronically for
rheumatologic conditions. In those
instances, they may not have to
take an additional medicine
 Can be used in all trimesters of
pregnancy
 Cannot be used in areas with
chloroquine or mefloquine
resistance
 May exacerbate psoriasis
 Some people would rather not take
a weekly medication
 For trips of short duration, some
people would rather not take
medication for 4 weeks after travel
 Not a good choice for last-minute
travelers because drug needs to be
started 1-2 weeks prior to travel

48. Mefloquine
(Lariam)
 Some people would rather
take medicine weekly
 Good choice for long trips
because it is taken only
weekly
 Can be used during
pregnancy
 Cannot be used in areas with mefloquine
resistance
 Cannot be used in patients with certain
psychiatric conditions
 Cannot be used in patients with a seizure
disorder
 Not recommended for persons with cardiac
conduction abnormalities
 Not a good choice for last-minute travelers
because drug needs to be started at least 2
weeks prior to travel
 Some people would rather not take a weekly
medication
 For trips of short duration, some people
would rather not take medication for 4 weeks
after travel

49. Primaquine
 It is the most effective medicine for
preventing P. vivax and so it is a
good choice for travel to places
with > 90% P. vivax
 Good choice for shorter trips
because you only have to take the
medicine for 7 days after traveling
rather than 4 weeks
 Good for last-minute travelers
because the drug is started 1-2
days before traveling to an area
where malaria transmission occurs
 Some people prefer to take a daily
medicine
 Cannot be used in patients with glucose-6-
phosphatase dehydrogenase (G6PD)
deficiency
 Cannot be used in patients who have not
been tested for G6PD deficiency
 There are costs and delays associated with
getting a G6PD test done; however, it only
has to be done once. Once a normal G6PD
level is verified and documented, the test
does not have to be repeated the next time
primaquine is considered
 Cannot be used by pregnant women
 Cannot be used by women who are
breastfeeding unless the infant has also
been tested for G6PD deficiency
 Some people (including children) would
rather not take a medicine every day
 Some people are concerned about the
potential of getting an upset stomach from
primaquine

50. Doxycycline
 Some people prefer to take a daily
medicineGood for last-minute
travelers because the drug is started
1-2 days before traveling to an area
where malaria transmission
occursTends to be the least expensive
antimalarialSome people are already
taking doxycycline chronically for
prevention of acne. In those instances,
they do not have to take an additional
medicineDoxycycline also can prevent
some additional infections
Cannot be used by pregnant women and
children <8 years old
Some people would rather not take a
medicine every day
For trips of short duration, some people
would rather not take medication for 4
weeks after travel
Women prone to getting vaginal yeast
infections when taking antibiotics may
prefer taking a different medicine
Persons planning on considerable sun
exposure may want to avoid the increased
risk of sun sensitivity
Some people are concerned about the
potential of getting an upset stomach from
doxycycline

52. Choosing a Drug to Prevent Malaria