Python Notes for mca i year students osmania university.docx
UPDATES ON MALARIA 2022.pptx
1. UPDATE ON MANAGEMENT OF
MALARIA 2022
Prepared By
DR MOHD HABROL AFZAM BIN ABD WAHAB
Supervised By
DR NORAFIDAH BT MOHAMED @ MOHAMED NOOR
2. CONTENTS
� INTRODUCTION TO MALARIA
� STATISTICS – MALARIA IN MALAYSIA
� LIFE CYCLE OF MALARIA
� PATHOPHYSIOLOGY OF MALARIA INFECTION IN HUMAN
� P.KNOWLESI – FIFTH HUMAN PARASITE
� DIAGNOSTIC OF MALARIA
� MANAGEMENT OF MALARIA
3. INTRODUCTION
What is malaria ?
� An acute febrile illness caused by Plasmodium parasites,
� M.O.T : Bites of infected female Anopheles mosquitoes.
12. MALARIA ZOONOTIK
17
MALARIA DI TERENGGANU
JAN SEHINGGA ME 36/2022
19
Jumlah kes malaria
(semua jenis)
MALARIA MANUSIA
2
KES BARU
0
INDIGENOUS
0
KES BARU
0
INTRODUCED
0
KES BARU
0
IMPORTED
2
(ME7 & ME 27)
KES BARU
0
INDUCED
0
KES BARU
0
ZOONOTIC
MALARIA
17
KUMULATIF
ME 36
Courtesy UKA HSNZ
13. 13
Jan - ME 36/2021 Jan - ME 36/2022
Peratus
meningkat/
menurun
Kumulatif
kes
19 19
- 17 P. knowlesi
- 1 P. falciparum import (ME7)
- 1 P.vivax import (ME 27)
0%
Kematian 1 2 (Zoonotik malaria) 100%
Perbandingan Bil. Kes Malaria Terengganu :
2021 & 2022 (ME36)
Courtesy UKA HSNZ
14. TABURAN MALARIA MENGIKUT DAERAH
JAN - ME 36/2022
DAERAH
MALARIA MANUSIA MALARIA
ZOONOTIK
JUMLAH
Indigenous Introduced Imported Induced JUMLAH
BESUT 0 0 1 (ME 27) 0 1 0 1
SETIU 0 0 0 0 0 6 6
KUALA NERUS 0 0 1 (ME 7) 0 1 0 1
KUALA
TERENGGANU
0 0 0 0 0 1 1
MARANG 0 0 0 0 0 0 0
HULU
TERENGGANU
0 0 0 0 0 8 8
DUNGUN 0 0 0 0 0 1 1
KEMAMAN 0 0 0 0 0 1 1
JUMLAH 0 0 1 0 1 17 19
Courtesy UKA HSNZ
15. BILANGAN KES MALARIA HUMAN DAN ZOONOTIK NEGERI TERENGGANU
2013-2022 (ME36)
2013 2014 2015 2016 2017 2018 2019 2020 2021 2022
Malaria Knowlesi 27 14 6 8 21 38 24 27 36 17
Human Malaria 14 3 5 1 2 7 1 1 0 2
0
5
10
15
20
25
30
35
40
45
Jumlah
Kes
2 Kematian pada tahun 2022
✔(Hulu Terengganu- ME 14/2022 - Mac)
✔(Setiu –ME 16/2022 - April)
Courtesy UKA HSNZ
18. • Kumulatif kematian sehingga ME 36/2022 : 10
- Sabah : 3 (P. knowlesi)
- Terengganu : 2 (P. knowlesi)
- Johor : 1 (P.falciparum)
- Sarawak : 1 (P. knowlesi)
- Pahang : 1 (P. knowlesi)
- Kelantan : 1 (P. knowlesi)
- Selangor : 1 (P. falciparum)
19
KEMATIAN MALARIA MALAYSIA, JAN - ME 36/2022
Courtesy UKA HSNZ
19. Kematian: 2
• 1 di Setiu (ME14/2022) dan
• 1 di Hulu Terengganu (ME16/2022).
• Semua kes kematian adalah melibatkan kes
zoonotik.
Wabak malaria: Tiada
20
KEMATIAN MALARIA TERENGGANU, JAN - ME 36/2022
Courtesy UKA HSNZ
20.
21. Progressing To Pre – Elimination of
Malaria In Malaysia
� Majority of case occur in Sarawak and Sabah
� Incidence in West Malaysia < 0.1/1000
� Control strategies
�Increase use of mosquito nets
�Increase spraying
�Increase use of ACT
� Malaysia now in the pre-elimination phase of malaria
control
� Major species : P. falciparum, P. vivax, P. Knowlesi
25. Pattern of Fever
� Corresponds to the period of infected
erythrocyte rupture and merozoite invasion
Reference
:https://www.pathologyoutlines.com/topic/parasitologymalariapfalciparum.html
26. A male long tailed
macaque macaca
fascicularis on a roof in
bako national
Southern pig-tailed
macaque macaca
nemestrina sepilok
orangutan rehabilitation
27. INFO REGARDING P. KNOWLESI
• In 1965 the first natural human infection was described in a US military surveyor
coming back from the Pahang jungle of the Malaysian peninsula.
• Was again brought to the attention of the medical community when in 2004,
Balbir Singh and his co-workers reported that about 58% of malaria cases
observed in the Kapit district of the Malaysian Borneo were actually caused by P.
knowlesi.
37. DIAGNOSIS OF MALARIA
Suspected Malaria
� Signs + sx 🡪 non specific
� Suspected in
� Malaria endemic area / travelling to
endemic area
� Fever >37.5c @ h.o fever
� No other obvious cause
� Suspected malaria
� Confirmed 🡪 Parasitological test.
� The results should be available within
a short time (< 2 h) of the patient
presenting.
� In settings where parasitological
diagnosis is not possible, a decision to
provide antimalarial treatment must
be based on the probability that the
illness is malaria.
Parasitological Tests
� Light microscopy
� Cheapest / most commonly used
� Rapid detection kits
� Immuno-chromatographic tests for
detecting parasite-specific antigens
in a finger-prick blood sample.
� They are available commercially in
various formats, e.g. dipsticks,
cassettes and cards.
� Immunodiagnosis and nucleic acid
amplification methods
WHO GUIIDELINES FOR MALARIA 3 JUNES 2022 – PAGES 139
39. DIAGNOSIS OF MALARIA
BFMP – Thick Smear Preparation
https://www.cdc.gov/dpdx/diagnosticprocedures/blood/specimenproc.html
1. Place a small drop of blood
in the center of the pre-
cleaned, labeled slide.
2. Using the corner of another
slide or an applicator stick,
spread the drop in a circular
pattern until it is the size of
a dime (1.5 cm2).
3. A thick smear of proper
density is one which, if
placed (wet) over newsprint,
allows you to barely read
the words.
4. Lay the slides flat and allow
the smears to dry
thoroughly (protect from
40. DIAGNOSIS OF MALARIA
BFMP – Thin Smear Preparation
https://www.cdc.gov/dpdx/diagnosticprocedures/blood/specimenproc.html
1. Place a small drop of blood on the
pre-cleaned, labeled slide, near its
frosted end.
2. Bring another slide at a 30-45°
angle up to the drop, allowing the
drop to spread along the contact
line of the 2 slides.
3. Quickly push the upper (spreader)
slide toward the unfrosted end of
the lower slide.
4. Make sure that the smears have a
good feathered edge. This is
achieved by using the correct
amount of blood and spreading
technique.
5. Allow the thin smears to dry. (They
dry much faster than the thick
smears, and are less subject to
detachment because they will be
fixed.)
6. Fix the smears by dipping them in
42. CORES PRINCIPAL OF MALARIA MANAGEMENT
� Early diagnosis and prompt, effective treatment of malaria
�Uncomplicated 🡪 severe ( in low immunity people ) 🡪 fatal outcomes
�Within 24-48h of onset
� Rational use of antimalarial agents
�Limit unnecessary use 🡪 prevent resistance
�Administered only to those who is confirmed
�Adherence to treatment
� Combination therapy
�All episodes of malaria 🡪 at least two effective antimalarial medicines
+ different mechanisms of action (combination therapy).
� Appropriate weight-based dosing
WHO GUIIDELINES FOR MALARIA 3 JUNES 2022 – PAGES 138
43. CORES PRINCIPAL OF MALARIA MANAGEMENT
� Treating uncomplicated malaria P. Falciparum
� Treating uncomplicated malaria caused by P.Vivax , P. Ovale, P. Malariae, P.
Knowlesi
� Treating special risk groups
� Treating severe malaria
WHO GUIIDELINES FOR MALARIA 3 JUNES 2022 – PAGES 138
44. TREATING UNCOMPLICATED MALARIA
Definition
Therapeutic Objectives
Incorrect Tx Approach
• Symptoms of malaria + Positive test
• No features of severe malaria
• To CURE the infection ASAP
• Prevent progression to severe
• Monotherapy – e.g artemisinin alone
• Incomplete dosing
45. TREATING UNCOMPLICATED MALARIA
Use of antipyretics
Should be used if core
temp >38.5c
PCM 15mg/kg 4hly
Ibuprofen 5mg/kg
Use of antiemetics
Parenteral route until
tolerating orally
Used with caution –
neuropsychiatric effect /
sedative
Management of
seizures
Common in P. Falciparum.
Prodrome - severe malaria
IV / Rectal Benzodiazepines
IM Paraldehyde
Additional considerations for clinical management
50. Failure within
28 Days
• Recommended 2nd line – based on
effective ACT in the region
Failure after
28 days
• Recurrence of fever + parasitaemia
> 4 weeks after tx
• Distinction can only be made by
PCR genotyping which is rarely
used in mx,
• Considered as new infection and Tx
as 1st line
Recurrent Malaria
53. TREATING SEVERE MALARIA
� Mortality from untreated severe malaria ( particular cerebral
malaria ) approaching 100%.
� Prompt anti – malaria + appropriate supportive care : reduced
mortality down to 10 – 20%.
� Within broad definition of severe malaria
�Severe anemia : lower mortality rate
�Acidosis : higher mortality rate
54. SEVERE FALCIPARUM MALARIA
- Absence of other identified alternative cause + presence of P.
Falciparum parasitaemia ( parasitaemia >10% )
� Impaired consciousness
� GCS <11 in adults
� Blantyre coma score <3 in children
� Prostration
� Generalized weakness + pt unable to sit /
stand / walk without assistance
� Multiple convulsions
� >2 episodes within 24h
� Acidosis
� Base deficit of >8mEq/L or
� Plasma HCO3 <15mmol/l or
� Lactate ≥ 5 mmol/L
� Hypoglycaemia
� BG < 2.2 mmol/L or 40mg/DL
� Significant bleeding
� Severe malaria anemia (+ parasite count >10000/uL)
� Children : Hb <5g/dl or HCT < 15%
� Adult : Hb < 7g/dL or HCT < 20%
� Renal impairment
� Creat > 265umol/L or urea > 20mmol/L
� Jaundice ( + parasite count > 100000 / uL )
� Serum bilirubin > 30umol/L or >3mg/dL
� Pulmonary oedema
� Radiologically confirmed or
� Spo2 < 92% under RA or
� RR > 30 / min
� Shock
� Compensated shock
� CRT ≥ 3 secs or cold peripheral
without hypotension
� Decompensated shock
� SBP children < 70mmhg / adult <
80mmhg + impaired perfusion
55. SEVERE FALCIPARUM MALARIA
MAIN TREATMENT
ANTIMALARIAL
� Artemesine derivative : artesunate / artemeter
� Chincona alkaloids ( quinine and quinidine )
� Parenteral artesunate is the treatment of choice.
� No adjustment dose needed in renal / hepatic failure or
dysfunction
56. SEVERE MALARIA
MAIN TREATMENT
DRUG NAME DOSE METHOD OF ADMINISTRATION
Artesunate • 2.4mg/kg BW • IV or IM
• At 0H 🡪 12H 🡪 24H then OD until oral tx can be
substituted
• 5-7 days is recommended treatment
Quinine Dihydrochloride • Adult : 20mg/kg then
10mg/kg TDS
• Child : 20mg/kg then
10mg/kg BD
• Slow IV infusion over 4H
• Initial dose should be half in PT who received
quinine / quinidine / mefloquine during
previous 12 or 24h.
Quinine Sulphate • Tablet
• <1 yo : 100 – 200mg OD
• 1-3 yo : 200 – 300mg OD
• >7yo : up to 1g daily in 2 – 3 divided dose
57. SEVERE FALCIPARUM MALARIA
SUPPORTIVE TREATMENT
� Oxygen supplement
� Fluid therapy
� Need to assess individually
� Adult : vulnerable to iatrogenic
overload thus,
� Rapid bolus of colloid / crystalloid is
contraindicated
� Early haemofiltration in acute kidney
injury or severe metabolic acidosis who
does not response to initial fluid
resuscitation.
� In high transmission settings
� Children
� Presented with severe
respiratory distress + severe
anemia : 🡪 Blood Tx
� Fluid therapy
� Adult
� Thin dividing line between
� Overhydration 🡪 fluid
overload
� Underhydration 🡪 shock ,
worsening met.acidosis,
renal impairment
� It is not possible to give general
recommendation of fluid replacement
� Based on patient assessment
� Frequent evaluation of jugular
venous pressure / peripheral
perfusion / CRT / skin turgor /
urine output
58. SEVERE FALCIPARUM MALARIA
SUPPORTIVE TREATMENT
� Blood transfusion
� In high transmission settings ( recommended, but adapted on
individual assessment )
� Children : Hb < 5g/dL or HCT < 15%
� Adult : Hb < 7g/dL or HCT < 20%
� Exchange Blood Transfusion
� Required strict nursing care / large amount of blood /
significant risks, therefore, not possible to make any
recommendation
� Antibiotics
� Administration 🡪 low threshold
� Broad spectrum antibiotics should be initiated until culture
proven otherwise
� Should also initiated if not response to antimalaria treatment /
persistent fever
59. SEVERE FALCIPARUM MALARIA
SUPPORTIVE TREATMENT
� Anticonvulsants
� Recommended : Intravenous route, if not possible rectal
� Choice : benzodiazepines / paraldehyde
� Phenobarbital 20mg/kg 🡪 reduced recurrent seizure in children but
increased risk of mortality in cerebral malaria and should not be
given without ventilatory support
� Prophylaxis against seizure are not recommended until further
information
� Treatments and medications that are not recommended
� Heparin
� High dose corticosteroid ( increased UGIB / seizure incidence )
� Aspirin
� N – Acetyl cysteine
� Adrenaline
� Albumin
60. TREATMENT SEVERE MALARIA IN PREGNANCY
⮚ Prone to be severe in 2nd or 3rd trimester 🡪 50% mortality
⮚ Often complicated with pulmonary oedema / hypoglycaemia
⮚ Fetal death / Premature delivery 🡪 common
⮚ Parenteral Artesunate is the drug of choice in all trimesters
⮚If unavailable 🡪 IM Artemeter
⮚If unavailable 🡪 parenteral quinine until parenteral
artesunate available
⮚ Hypoglycaemia should be expected in pregnancy, especially after quinine
⮚Frequent blood glucose monitoring
⮚ Obstetric 🡪 should be referred earlier
⮚ Paediatrician 🡪 should be alerted
61. TREATMENT SEVERE P. VIVAX MALARIA
⮚ Usually considered as benign, but occasionally can develop as severe as P.
Falciparum
⮚ Prompt Effective Treatment and supportive should be same as P. Falciparum
62. MANAGEMENT OF COMPLICATIONS
• Maintain airway
• Exclude other treatable causes of coma (e.g.
hypoglycaemia, bacterial meningitis)
• Avoid harmful ancillary treatments
• Intubate if necessary.
Coma
( Cerebral Malaria
)
• Tepid sponging, fanning, a cooling blanket
and paracetamol.
Hyperpyrexia
• Maintain airways
• treat promptly with IV or rectal diazepam,
lorazepam, midazolam or IM paraldehyde.
• Check blood glucose.
Convulsions
• Transfuse with screened fresh whole blood.
Severe
Anemia
63. MANAGEMENT OF COMPLICATIONS
• Check blood glucose
• Correct hypoglycaemia and maintain with
glucose-containing infusion.
• The threshold for intervention is < 3 mmol/L for
children < 5 years and <2.2 mmol/L for older
children and adults.
Hypoglycaemia
• Prop patient up at an angle of 45o
• 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 Pulmonary
Oedema
64. MANAGEMENT OF COMPLICATIONS
• 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.
Acute Kidney
injury
65. MANAGEMENT OF COMPLICATIONS
• Transfuse with screened fresh whole blood
❑ Cryoprecipitate, fresh frozen plasma and
platelets, if available
• Give vitamin K injection.
Spontaneous bleeding
and coagulopathy
• Exclude or treat hypoglycaemia,
hypovolaemia and septicaemia.
• If severe, add haemofiltration or
haemodialysis.
Metabolic acidosis
• Suspect septicaemia
• Take blood for cultures
• Give parenteral broad- spectrum antimicrobials
• Correct haemodynamic disturbances.
• Avoid over rehydration
Shock
66. ADMISSION CRITERIA
-BASED ON MALARIA CPG KKM 2014
� All malaria patients should be
admitted.
� In exceptional cases where
this is not possible,
uncomplicated malaria can
be managed at out-patient
clinics with close monitoring.
� Admission is mandatory:
� Severe/ complicated malaria
� Patients who cannot tolerate orally
� Patients with high parasitaemia (>100 000/μl)
[> 20,000/μl for P.knowlesi]
� Patients with G6PD deficiency
� All pregnant mothers with acute malaria
� Patients with severe malnutrition
� Children
67. HDU OR ICU REFERRAL CRITERIA
-BASED ON MALARIA CPG KKM 2014
� If a patient has any of the features of severe malaria, the patient should
be referred to a hospital with a HDU or ICU.
� All patients with complicated malaria should be referred to the Physician
on call.
� An early referral to intensivist should be made for further evaluation and
management.
� If the patient cannot be transferred, then the patient should be
monitored closely in the district hospital in close consultation with the
physician.
68. LIST OF MEDICATION AVAILABLE AT HSNZ
� T RIAMET ( UNCOMPLICATED )
� IV OR IM ARTESUNATE 60MG ( SEVERE – ADULT / CHILDREN )
� T QUININE SULPHATE 300MG ( SEVERE AND COMPLICATED )
� T CHLOROQUINE PHOSPHATE 250MG ( ACUTE ATTACK )
� T PRIMAQUINE 7.5MG ( PROPHYLAXIS / RESISTANCE CASE
P.VIVAX )
69. CASE STUDY
MR H, 51 Years old male
Underlying
1) Post covid Sept 21, 2 doses of sinovac taken
2) Hypertension
3) ? IHD with h.o to Hospital H last year for CCF
-not on ROF
Presented with short history of
+Worsening dyspnoea x2/7
+Fever with chills/rigors in past 4/7
+Orthopnea / reduced effort tolerance x4/7
+On and off cough x4/7
On arrival
Noted pt was in respiratory distress, required
HFMO2,with fine crept findings bibasally. Initially trial
for NIV but subsequently decided for intubation . Pt
then transfer to tertiary hospital with spo2 91 on
arrival, bp normotensive – haemodynamically
supported on ivi norad 3cc/h. HR 128.
Reintubated by MO at ETD ( tertiary hospital ),
subsequently spo2 sustained 100% under hemilton C1
ventilator. Below was bedside ultrasound findings.
1) Homogenous liver, GB not distended, bilateral
kidney no HN, no free fluid seen, IVC kissing.
2) Lung scan shown no B-lines at bilateral lung fields,
no pleural effusion seen.
3) ECHO : good contractility on eyeballing, no RWMA
70. CASE STUDY
List of Differential Diagnosis
1) TRO Pulmonary Embolism
2)Acute Left Ventricular Heart Failure in cardiogenic shock
3) Septic shock secondary to CAP
4)? Acute pulmonary oedema
5) Occult sepsis in shock?
