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. 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. 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. 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.
12. 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
13. 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?
14. 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
15. 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
16. 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
17. 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 >
18. 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
20. 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
21. 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
22. 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
23. 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
24. 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
25. 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)
26. 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
27. 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
28. 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.
30. Recommended drugs:
Chloroquine
Proguanil
Chloroquine + proguanil
Mefloquine
Doxicycline
Atovaquone + proguanil
Chemoprophylaxis
Guidelines for Malaria Prevention in Travellers from the United Kingdom. 2007
31. 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
32. 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
33. 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.
34. 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
35. 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
36. 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
37. 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
38. 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
39. 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
40. 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
41. 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
42. More common
More atypical
More severe
More fatal
Selective treatment
Various complication
Malaria in pregnancy
43. 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
44. Principal treatment:
Supportive therapy
Antimalarial drug
Management of complication
Management of labour
Malaria in pregnancy
45. 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.
46. 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.
47. 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)
48. 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
49. 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.
50. 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.
51. Outcomes
WHO standard protocol classification:
Early treatment failure
Late treatment failure
Late clinical failure
Late parasitological failure
Adequate clinical and parasitological
response.
52. 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
54. 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