Essential information about Malaria-a common parasitic disease- and its treatment according to Sudanese porotocol which follows WHO guidelines.

1. Dr. Mona Mohammed
Ali

3. • Malaria is the most important parasitic
disease of humans and often the most
common cause of fever in the tropics .
• The term Malaria originate from Italian
( mala air ) which means bad air .
3

4. •World wide :
• 2.3 billion people at risk.
• 300 – 500 million cases annually .
• 1.5 – 2.7 million deaths annually .
• One death every 20 – 30 seconds , somewhere in
the world .
• 300,000 children deaths per day under the age of
5 years.

5. • It is caused by the protozoa plasmodium.
• There are more than 400 species of plasmodium,
but the most important human species are :
• P.falciparuum.
• P.vivax .
• P.ovale .
• P.malare .
• P.knowlesi.

6. • P. falciparum :
• In Africa , New Guinea and Haiti .
• P. vivax :
• In Central and South America , North Africa , The horn
of Africa , Middle East and India.
• P.ovale :
• In West Africa
• P.malarae:
• Uncommon outside Africa .

8. • In SUDAN :
• P.falciparum is the most common cause of
infection ( 87.3%), and also responsible for
about 80% of malarial deaths.
• P.vivax is increasing in incidence. (13%)

9. • Malaria is a vector borne disease , transmitted by the
bite of the female Anopheles mosquito.
• Many species can transmit malaria :
- North America--------An.free borni
- Central America------An.albimanus
- Asia----------------------An.kolienses
- Mediterranean------------An.atroparvus
- Afro-tropical------------An.arabienses , An.gambiae .

10. •Other modes of transmission :
- Blood transfusion
- Needles injections.
- Transplacental.

21. • Uncomplicated malaria should be suspected in:
• Any child with fever, headache, aches and pains.
• A young child who is irritable, refuse to eat and has vomiting.
• Children with pallor or a hemoglobin concentration of <8 g/dL.
• In any case laboratory confirmation with microscopy or RDTs
is mandatory, as diagnosis based only on clinical features has
very low specificity and results in overtreatment .
• Other possible causes of fever ,and whether alternative or
additional treatment is required must always be carefully
considered

25. According to the Sudanese protocol 2017

26. • First line treatment in Sudan:
ARTEMETHER – LUMEFANTRINE (AL) :
• Fixed dose combination 20/120 & 80/480 as dispersible
tablets.
• The recommended dosage regimen as follows :
The 2nd dose should be taken 8 hours after the 1st dose .
The 3rd dose should be taken 24 hours after the 1st dose
The remaining 3 doses should be taken every 12 hours.
The total is 6 doses.
• The recommended dose :5-24mg/kg body weight for
artemether and 29-144mg/kg body weight for lumefantrine.
• No serious adverse reactions and no cardiotoxicity.

27. •Treatment Failure :
•Consider treatment failure if fever
and parasitaemia persist or recur
within 4 weeks after the initial
treatment .
•What are the causes of treatment
failure?

28. • Second line Treatment :
• DIHYDROARTEMISININ + PIPERAQUINE (DHAP) :
• Fixed dose combination 20/160 & 40/320 as dispersible
tablets .
• The recommended regimen is :
Once daily for 3 consecutive days.
• The recommended dose :
For dihydroartemisinin is : 4 mg/kg body weight (2-10) .
For piperaquime is :
• 16-27 mg/kg bodyweight for children weighing more than
or equal to 25 kg.
• 20-32 mg/kg for children weighing less than 25 kg .

29. • Alternative treatment for the second line is
ORAL QUININE :
10 mg salt/kg bodyweight, 8 hourly ,for 7 days .
• Treatment of Uncomplicated Vivax Malaria :
AlL must be followed by PRIMAQUINE :
0.25mg/kg bodyweight for 14 days.

30. According to the Sudanese protocol 2017

31. Clinical
1. Impaired level of
consciousness.
2. Respiratory distress
(acidotic breathing).
3. Repetitive convulsion
(more than one in 24 hours).
4. Circulatory collapse.
5. Pulmonary oedema.
6. Abnormal bleeding.
7. Jaundice.
8. Haemoglobinurea.
9. Prostration.
10. Continuous vomiting.
11. Acute kidney injury.

32. Laboratory
1. Severe anemia :
In children : Hb less than 5 g/d , PCV less than 15%
In adults : Hb less than7 g/d , PCV less than 20%
2. Hypoglycemia :
less than 2.2 mmol/l i.e. less than 40mg /l.
3. Metabolic Acidosis :
plasma bicarbonate less than 15 mmol/l.

33. • Laboratory
4. Hyperlactataemia :
Lactate more than 5 mmol/l.
5. Hyperparasitaemia :
Parasite count more than 100,000/ml in low
transmission area , and more than 250,000/ml in high
transmission area (more than or equal to 5%
parasitaemia of RBCs)
6. Renal Impairment :
Serum creatinine more than 265mmol/l.

34. • Consider the following (8 + 8 + 4) points in the managementof patient
with severe malaria:
• Do the following 8 immediate measures:
• 1. Start resuscitation, particularly maintenance of a
patent ABCs.
• 2. Establish IV line.
• 3. Make a thick blood smear for immediate malaria
parasite count. RDTs can be useful in certain areas
• 4. Classify the degree of dehydration, assess
patient’s fluid requirements and correct
accordingly.

35. 5. Control fever if the axillary temperature is
38.5ºC or above: Tepid sponge, fanning and oral
or rectal paracetamol (15mg/kg every 4 to 6 hours)
6. Control convulsions .
7. Detect and treat Hypoglycemia
8.. Start Quinine IV or Artesunate IV(if not
accessible, Quinine IM or Artesunate suppositories
can be administered; notably in case of
Hyperparasitaemia).

36. • Look and deal withthe following 8 complications:
1. Shock, algid malaria.
2. Consider the need for blood transfusion. Transfuse blood if
there is:
1. Cardio respiratory symptoms e.g. severe anaemia.
2. PCV<20 or Hb<5g/ dL.
3. In case of metabolic acidosis.
4. If there is spontaneous bleeding and coagulation disorder :
Transfuse screened fresh whole blood or clotting factors; give
vitamin K 1 mg/day for infant, 2 -3 mg/day for children, and 5
-10 mg/day for adolescent. Vitamin K should be given SC or
IV.

37. 5. Detect &Treat cute renal failure.
6.Detect &Treat Malarial haemoglobinuria
(black-water fever):Continue with suitable
anti-malarial treatment; transfuse screened
fresh blood if needed.
7.Detect &Treat Acute pulmonary oedema.
8. Exclude common infections/conditions
that present like severe malaria.

38. • Monitor considering the following 4 points:
• 1. Level of consciousness .
• 2. Fluid input/output: Detect dehydration and
avoid fluid overload. Prevent pulmonary
oedema
• 3. Vital signs.
• 4. Level of parasitaemia

39. • Specifictreatment of patientswith SM:
1 . Pre-referral treatment at peripheral units:
This could be Quinine I.M. or Artesunate suppositories .
2.Treatment of SM at hospital settings:
1/ Treatment with IV quinine:
• Quinine can be given in one of the 3 ways depending on the patient
condition and according to the level of health facility.
1.Quinine I.V. for 7 days .
2.Quinine I.M.
3.Quinine I.V. for at least 3 days and then first-line.
• Quinine side effects:
• Rapid intravenous administration of Quinine can precipitate
hypoglycemia, hypotension and fatal cardiovascular toxicity.

40. 2. Treatment with intravenous artesunate:
Artesunate side effects:
Artesunate is generally well-tolerated and has a
better safety profile than quinine in severe
malaria .
It side-effects includes hypersensitivity reactions,
gastrointestinal disturbances, cough, rash,
arthralgia and dizziness. Clinically, the most
significant side effect is haemolysis, which has
been reported up to weeks after treatment.

41. Treatment of severe P. vivaxmalaria:
• It can also occasionally result in severe disease, as in P. falciparum
malaria.
• Severe P. vivax malaria manifestations that have been reported are
cerebral malaria, severe anemia , severe thrombocytopenia or
pancytopenia, jaundice, spleen rupture, acute renal failure and acute
respiratory distress syndrome.
• Severe anemia and acute pulmonary edema are not uncommon.
• The underlying mechanisms of severe manifestations are not fully
understood.
• Prompt and effective treatment and case management should be the
same as for severe and complicated falciparum malaria in addition
to primaquine

42. • Other antimalarial drugs that can be used :
1/ Halofantrine :
S.E. : Cardiotoxicity .
2/ Mefloquine :
S.E.: Hallucination

43. 1. Rabid Diagnosis and Treatment .
2. Artemisinin-based Combination Therapies .
3. Indoor Residual Spray.
4. Intermittent Preventive Therapy .
5. Larval Source Management .
6. Long Lasting Nets.