MALARIA INDIA

1. By Dr. Kiran Bikkad
DNB Medicine Resident
Nazareth Hospital, Shillong

2.  Malaria is one of the major public health
problems of the country.
 India reports around one million malaria
cases annually.

3.  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.

5.  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.

6.  Fever - cardinal symptom.
 chills and rigors.
 accompanied by headache, myalgia,
arthralgia, anorexia, nausea & vomiting.
 The symptoms -- non-specific and mimic viral
infections, enteric fever, etc.
 Malaria suspected in patients in endemic
areas or recently visited endemic area &
presenting with above symptoms.

7.  Other causes of fever suspected and
investigated in the presence of symptoms
like
 running nose, cough and other signs of
respiratory infection
 diarrhoea/dysentery
 burning micturition, lower abdominal pain
 skin rash/infections, abscess
 painful swelling of joints
 ear discharge, lymphadenopathy, etc.
 All clinically suspected malaria cases should
be investigated by microscopy and/or RDT

8. ● 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

9. 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.

10. 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

11.  Pf HRP-2 based kits may show positive result
up to three weeks after successful
treatment and parasite clearance

12.  PRINCIPLES
1. Early diagnosis & prompt effective
treatment
2. Rational use of antimalarial agents
3. Use of combination therapy
4. Appropriate weight based dosing

13. 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

15.  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.

16. P. falciparum
 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 (0.75 mg/kg) single dose on Day 2

18. 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

19.  MONOTHERAPY OF ORAL ARTEMISININ
DERIVATIVES IS BANNED IN INDIA
 Injectable artemisinin derivatives should
be used only in severe malaria.

20.  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.

21.  Mixed infections with P. falciparum should be
treated as falciparum malaria.
 Since AS+SP is not effective in vivax
malaria, other ACT should be used.
 Anti-relapse treatment with primaquine can
for 14 days.

22.  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

23. 1. Avoid starting treatment on empty stomach.
2. The first dose is given under observation.
3. Dose repeated if vomiting within half hour of drug
intake.
4. Patient asked to report back, if no improvement
after 48 hours/deteriorates.
5. Investigate for concomittant illnesses

26.  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

27.  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.
 Doxycycline is contraindicated in pregnancy,
lactation and in children up to 8 years.

28. 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

29.  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%

30.  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
 Significant bleeding:
 recurrent / prolonged bleeding from the nose, gums or
venepuncture sites, haematemesis or melaena.

31.  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%

32. ● 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)

33. ● Metabolic acidosis
● Circulatory collapse/shock (SBP <80 mmHg)
● Abnormal bleeding
● Haemoglobinuria
● Hyperpyrexia (Temperature >106°F or
>42°C)
● Hyperparasitaemia (>5% parasitized RBCs )
indian guidelines

34. 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.

35.  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: 2.4 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)

36.  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
 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.

37.  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

38. Manifestation or
complication
Immediate management
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.

39. 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 coagulopathy
Transfuse with screened fresh whole blood
(cryoprecipitate, fresh frozen plasma and
platelets, if available); give vitamin K
injection

40. 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.

41. For :-
 Travellers
 Migrant
 Labourers
 Military personel
 Exposed to malaria in highly endemic areas

42.  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.