Malaria – Things We Need To Know !


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SImplified Malaria overview for practising pediatricians in India - north india more specifically with a low incidence of malaria. By Dr Gaurav Gupta MD Pediatrician, Charak Clinics, Mohali, Chandigarh

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Malaria – Things We Need To Know !

  1. 1. Malaria – Filling in the blanks ! Dr Gaurav Gupta MAAP, MIAP, DCH, DNB Charak Clinics, Mohali
  2. 2. Malaria is more deadly than swine flu <ul><li>H1N1 swine flu has killed 180 people worldwide. And around 45,000 cases reported world-wide (June 19th). </li></ul><ul><li>WHO estimates that 3,000 people a day die from malaria in Africa every day, mostly women and children </li></ul><ul><li>Unlike influenza, we have no vaccine against malaria. </li></ul><ul><li>Now resistance to the MOST effective anti-malarial Artemisinin is being reported from Cambodia – we have nothing left after this. </li></ul>
  3. 3. Deadly Stats <ul><li>Nearly half of the world's population, or about 3.3 billion people, are at risk of malarial infection, </li></ul><ul><li>It causes more than 250 million clinical episodes </li></ul><ul><li>One million deaths each year. </li></ul><ul><li>Pregnant women, under 5 children, and first-timers have more complicated infections. </li></ul><ul><li>Kills one child every 20 seconds </li></ul>
  4. 4. Malaria - Basics <ul><li>Four species </li></ul><ul><li>Transmitted by female anopheles </li></ul><ul><li>No. 1 priority tropical infectious disease according to WHO </li></ul><ul><li>Incidence is increasing by 16 % every year. </li></ul><ul><li>No. 3 killer infectious disease in the world </li></ul>
  5. 6. India – 15,24,939 / 49 % 593/5 377/3 1650/23 42991/199 2006 cases/ p fl 253/0 694/6 Delhi 347/6 157/6 Chandigarh 2494/38 250/18 Punjab 35683/1397 936/41 Haryana 2008 cases/ p fl 2002 cases/ p fl State/Yr
  6. 9. Clinical Features <ul><li>Fever – atypical pattern </li></ul><ul><li>Headache, body ache, altered sensorium, cough breathlessness, acute abdomen pain, vomiting, diarrhea </li></ul><ul><li>Malaria can mimic almost </li></ul><ul><li>anything and everything ! </li></ul>
  7. 10. Diagnosis <ul><li>Microscopy – Thin Smear for species & stage identification </li></ul><ul><li>Microscopy – Thick Smear for detection of MP & for the degree of parasitemia </li></ul><ul><li>Non microscopy – RDT – May have lower sensitivity, more sensitive for P. Falciparum </li></ul>
  8. 11. Diagnosis - RDT
  9. 12. RDT – Pros & Cons <ul><li>High sensitivity, good specificity, reliable for P. Falciparum, may be positive when a smear is negative </li></ul><ul><li>Expensive, does not differentiate mixed infections, cannot be used to judge therapeutic response, does not measure severity of infection, still may have false positive and negatives </li></ul><ul><li>Consensus: Use it in conjunction with PBF (thick and thin smears) </li></ul>
  10. 13. Interesting fact! <ul><li>Widal test may be positive, even up to a dilution of 1:320 for 'O' and H' and at lower titres for 'AH' and 'BH'. Any or all the four may be positive, suggesting a non-specific response. A positive Widal test in a patient with confirmed malaria should not therefore be considered as suggestive of typhoid fever. </li></ul>
  11. 15. Hold the third finger of the left hand and wipe its tip with spirit/Savlon swab; allow to dry Prick the finger with disposable needle/lancet; allow the blood to ooze out Take a clean glass slide. Take 3 drops of blood 1 cm from the edge of the slide, take another drop of blood one cm from the first drop of blood
  12. 16. Take another clean slide with smooth edges and use it as a spreader ...and make thick and thin smears. Allow it to dry Prepared smear. Slide number can be marked on the thin smear with a lead pencil.)
  13. 18. Avoid in seizures, cardiac disease. Do NOT use with Quinine. Do NOT re-treat with Mefloquine 25 mg/kg in 1-2 divided dose Mefloquine (250mg base Tablet) (LARIMEF, MEFLOTAS, MEFLOC, MQF) Quinine (300/600mg Base tab, 300mg/ml Inj) (CINKONA, KWINIL, QUININE) Chloroquine (PO/IV) (150 mg Base/ Tablet Syp 50 mg/ 5ml Base) (LARIAGO, CLOQUIN, NIVAQUINE P) Oral - 10 mg/kg 8 hourly for 4 days and 5 mg/kg 8 hourly for 3 days. IV - 16 mg of base/kg in 10 ml/kg NS/5% dextrose over 4 hours, then 8 mg of salt/kg over 4 hours, every 8 hours for 5-7 days. Oral - 10 mg/kg stat and 5 mg/kg * 3 doses over next 48 hours DoC for P Falciparum Oral – Uncomplicated IV – Complicated/ Cerebral Malaria IM Not recommended DoC for P Vivax (uncomplicated)
  14. 19. Other drugs include Tetracyclines, Proguanil, Halofantrine, Lumefantrine, Mepacrine, Bulaquine, clindamycin etc. Avoid with Quinine/ Mefloquine, in severe G6PD Deficient pt. To be used in ALL cases of Malaria Oral - 0.25mg/kg/day (once a day) for 14 days in P. vivax; 0.75 mg/kg as single dose in P. falciparum Primaquine tablets containing 2.5, 7.5 and 15 mg (PMQ-INGA) Avoid in Sulfa allergy Add-on therapy for CQR malaria (never alone) Oral – 1.25 mg /kg of Pyrimethamine Sulphadoxime/ Pyrimethamine (S/P) (500 mg / 25 mg) (LARIDOX, PYRALFIN, METAKELFIN, REZIZ)
  15. 20. May cause LFTs rise. 3.2mg/kg as loading dose, followed by 1.6mg/kg daily, until patient is able to swallow or for 5 days. Artemether (80 mg/ml Inj. and 40 mg cap) (LARITHER, MALITHER) Well tolerated 3 mg/kg OD for 3 days Arteether (150mg/ 2ml Inj, 50 mg tablet) (FALCIGUARD, RAPITHER, MALIJET, ARTISUN) Recommended for Severe Falciparum Malaria, as combination therapy IM/IV 2.4 mg/kg LD, followed by 1.2 mg/kg for 7 days Oral- 4 mg/kg on the first day followed by 2mg/kg for 6 days Artesunate (60 mg/ml Inj, 50 mg tablet) (FALCIGO, FALCIQUIN, FALCICARE, ARTISIN)
  16. 21. Antimalarial drugs – ACT <ul><li>Artemisinin based combination therapy (ACT) </li></ul><ul><ul><li>Increase cure rates, </li></ul></ul><ul><ul><li>reduce the development of resistance. </li></ul></ul><ul><li>Disadvantages of ACT </li></ul><ul><ul><li>High cost </li></ul></ul><ul><ul><li>Increased side effects </li></ul></ul><ul><ul><li>Pharmacokinetic mismatch </li></ul></ul><ul><li>Artesunate + Sulfadoxine/Pyrimethamine (SP) Artesunate 4mg/kg once daily for 3 days and SP single dose of 25mg/kg and 1.25mg/kg respectively </li></ul><ul><li>Artesunate (as above) + Mefloquine 8mg/kg daily for three days </li></ul><ul><li>Artemether + Lumefantrine, </li></ul><ul><li>Artesunate + Doxy, Artesunate + Clinda </li></ul>
  17. 23. Treatment protocol <ul><li>P Vivax – Chloroquine + Primaquine for 14 days </li></ul><ul><li>P Falciparum - Treat depending on severity & sensitivity, </li></ul><ul><ul><li>Use Quinine Or ACT + Primaquine single dose for gametocidal activity. </li></ul></ul><ul><li>Severe Malaria/ Cerebral Malaria – Always treat with IV drugs </li></ul><ul><ul><li>Quinine / Artemisinin + Tetra/ Clinda till accepting orally and then switch to oral medicines </li></ul></ul>
  18. 24. Treatment <ul><li>Pregnancy – Quinine in all trimesters; Artemesinin in 2 nd and 3 rd trimesters </li></ul><ul><li>For P. falciparum malaria, follow-up MP tests on 6th and 28th days after treatment. </li></ul><ul><ul><li>The 6th day smear is done to assess clearance of parasitemia </li></ul></ul><ul><ul><li>28th day smear is done to identify recrudescence. </li></ul></ul><ul><li>Failure after 6 th day – resistance – treat with second line drugs (Art + Tetra / Clinda; Quinine + Tetra / Clinda) </li></ul><ul><li>Failure after 28 days – new infection/ recrudescence – treat with first line drugs again </li></ul><ul><li>Relapse – after months – mostly due to Primaquine not given in P vivax – treat with first line drugs </li></ul>
  19. 25. Important Points <ul><li>Oral medicines NOT to be used in severe Falciparum Malaria </li></ul><ul><li>It takes 48 hours for fever to subside </li></ul><ul><li>Do not administer extra dose, do not change medicine and avoid using newer drugs to reduce drug resistance </li></ul><ul><li>Give Primaquine in all cases. </li></ul>
  20. 26. Indications for hospitalization of malarial cases <ul><li>Persistence of fever even after 48 hours of initial treatment. </li></ul><ul><li>Continuously worsening headache. </li></ul><ul><li>Persistent vomiting. </li></ul><ul><li>Any complications of P. falciparum malaria - altered sensorium, convulsions, anemia, jaundice, hyperpyrexia, bleeding and clotting disorders, breathlessness, high coloured urine etc. </li></ul><ul><li>Patients who are at higher risk for development of complications of P. falciparum malaria-extremes of age, pregnancy etc. </li></ul><ul><li>Patients who appear sick and prostrated </li></ul><ul><li>Significant dehydration </li></ul>
  21. 27. Preventing Malaria <ul><li>Personal protection </li></ul><ul><li>Preventing the mosquitoes from entering the house – Close door / windows, especially toilets. Well-constructed houses with window screens </li></ul><ul><li>Preventing the mosquitoes from hiding – Avoid dark corners/ hanging clothes in rooms </li></ul><ul><li>Mosquito Control – Avoid stagnant water, insecticide spraying etc. </li></ul>
  22. 28. Preventing Malaria <ul><li>Protection from mosquito bites – </li></ul><ul><li>Protective clothing, </li></ul><ul><li>Mosquito repellants (containing DEET), </li></ul><ul><li>Insect vaporizers (coils & mats containing pyrethroids), </li></ul><ul><li>Insecticide treated bed nets (most effective), </li></ul><ul><li>Airconditioning </li></ul>
  23. 29. Chemoprophylaxis - India <ul><li>AREA 1 -Jammu and Kashmir, Himachal Pradesh and Sikkim – No risk – No Prophylaxis </li></ul><ul><li>AREA 2 – North East States (High Risk, High Incidence of CQ resistance) – MEFLOQUINE </li></ul><ul><li>AREA 3 – Rest of India (Medium risk, Intermediate CQ resistance) – CQ + PG </li></ul><ul><li>CQ alone is NOT recommended in INDIA for prophylaxis </li></ul>
  24. 30. Other drugs that maybe used for prophylaxis include Doxycycline & Malarone (Atovaquone + Proguanil) Start 2-3 weeks before, continue during exposure and for 4 weeks thereafter 250 mg base once weekly 5mg/kg once weekly Mefloquine ((Tablet with 250mg base, 274mg salt) 200 mg Daily < 2yr – 50 mg / day 2-6 yr – 100 mg/day 7-9 yr – 150 mg/day > 9 yr – 200 mg/day 300 mg Once weekly 5 mg/kg weekly Start 1-2 days before, continue during exposure and for 4 weeks thereafter Proguanil Start one week before exposure, continue during exposure and for 4 weeks thereafter Chloroquine (150 mg Base/ Tablet Syp 50 mg/ 5ml Base)
  25. 31. Malaria Vaccine – Why is it so difficult? <ul><li>Researchers must identify which of the Plasmodium parasite's 5,300 proteins provoke a strong immune response. </li></ul><ul><li>Parasite makes different proteins at each stage of its lifecycle. </li></ul><ul><li>Over two decades, research and hundreds of millions of dollars have been invested in developing a vaccine for malaria. </li></ul>
  26. 32. Malaria - Vaccine <ul><li>The RTS,S vaccine has been more than two decades in the making and more than US $400 million has been invested in the project. </li></ul>On 26th May 2009 phase III trials of the world's most advanced candidate vaccine have started. 16,000 children aged two and under will receive the vaccine over the coming months. If all goes well (above 50 % protection) it will be in the market by 2012.