Parasitic infection due to protozoa of genus Plasmodium transmitted by the female Anopheles mosquito. There are four plasmodia species: P. falciparum, P. vivax, P. malariae, and P. ovale.
Malaria is an acute and chronic protozoan illness characterized by paroxysms of fever, chills, sweats, fatigue, anaemia and splenomegaly. In atypical cases, classical symptoms may not manifest.
Falciparum malaria (severe and complicated malaria) severe manifestations can develop over a short span of 12-24 hours and is associated in varying degrees with the following clinical signs:
Cerebral: Mental clouding, coma, convulsions, delirium and occasionally localizing signs. Hyperpyrexia (>40.5ºC), haemolysis, haematocrit <15% or Hb <5 g/dl, hypoglycaemia, oliguria, anuria, pulmonary oedema, macroscopic haemoglobinuria and jaundice.
Diagnosis is made by presence of protozoa in the blood in thick and thin smear slides. Thick smear for easy detection of parasite and thin smear for identification of species. Note that blood films may be negative even in a severe attack because of sequestration of parasites in the deep capillaries. Rapid diagnostic kits (RDK) can be used for detection of P. falciparum where microscopy results are not obtainable within 24 hours of sample collection
Treatment of malaria
1. All fever cases suspected to be malaria should be investigated by microscopy or RDT.
2. Patients of uncomplicated malaria can be managed at primary level but patients with severe malaria with complications should be admitted and managed in a hospital where facilities for detailed investigations and blood transfusion exist.
3. P. vivax cases should be treated with chloroquine for three days and Primaquine for 14 days. Primaquine is used to prevent relapse but is contraindicated in pregnant women, infants and individuals with G6PD deficiency. Note: Patients should be instructed to report back in case of haematuria or high-coloured urine/cyanosis or blue coloration of lips and Primaquine should be stopped in such cases. Care should be taken in patients with anaemia.
4. P. falciparum cases should be treated with ACT (Artesunate 3 days + Sulphadoxine- Pyrimethamine 1 day). This is to be accompanied by single dose primaquine on day 2.
5. Pregnant women with uncomplicated P. falciparum should be treated as follows:
1st trimester: Quinine
2nd & 3rd trimester: ACT
Note: Primaquine is contraindicated in pregnant woman
6. In cases where parasitological diagnosis is not possible due to non-availability of either timely microscopy or RDT, suspected malaria cases should be treated with full course of chloroquine, till the results of microscopy are received. Once the parasitological diagnosis is available, appropriate treatment as per the species, is to be administered.
7. Presumptive treatment with chloroquine is no more recommended.
8. Resistance should be suspected, if in spite of full treatment with no history of vomiting, diarrhoea, patient does not respond within 72 hours, clinically and parasitologically. Such cases not responding to ACT, should be treated with oral Quinine with Tetracycline/Doxycycline. These instances should be reported to concerned District Malaria/State Malaria Officer/ROHFW for initiation of therapeutic efficacy studies. Treatment of P. vivax cases
1. Chloroquine: 25 mg/kg body weight divided over three days, i.e. 10 mg/kg on day 1, 10 mg/kg on day 2 and 5 mg/kg on day 3.
2. Primaquine: 0.25 mg/kg body weight daily for 14 days.
Treatment of uncomplicated P. falciparum cases
1. Artemisinin based combination therapy (ACT): Artesunate 4 mg/kg body weight daily for 3 days plus Sulfadoxine (25 mg/kg body weight) -Pyrimethamine (1.25 mg/kg body weight) on first day.
(Caution: ACT is not to be given in 1st trimester of pregnancy).
2. Primaquine: 0.75 mg/kg body weight on day 2: 0.75 mg/kg body weight on day 2.
Treatment of uncomplicated P. falciparum cases in pregnancy
1st trimester: Quinine salt 10 mg/kg 3 times daily for 7 days (Caution: Quinine may induce hypoglycaemia; pregnant women should not start taking quinine on an empty stomach and should eat regularly, while on quinine treatment).
2nd and 3rd trimesters: ACT as per dosage given above. Treatment of mixed infections (P. vivax + P. falciparum) case
All mixed infections should be treated with full course of ACT and Primaquine 0.25 mg per kg daily for 14 days. Treatment of severe malaria cases
Severe malaria is an emergency and treatment should be given as per severity and associated complications which can best be decided by the treating physician.
Inj. Artesunate 2.4 mg/kg IV or IM given on admission (time = 0h); then at 12 hand 24 h and then once a day.
(Caution: Care should be taken to dilute artesunate powder in 5% sodium bicarbonate provided in the pack only) Or
Inj. Artemether 3.2 mg/kg IM given on admission and then 1.6 mg/kg per day. Or
Inj. Arteether 150 mg IM daily for 3 days in adults only (not recommended for children). Or
Inj. Quinine: 20 mg/kg on admission (IV infusion or divided IM injection) followed by maintenance dose of 10 mg/kg 8 hourly. The infusion rate should not exceed 5 mg salt/kg per hour. Loading dose of Quinine, i.e. 20 mg/kg on admission may not be given, if the patient has already received quinine or if the clinician feels inappropriate). NEVER GIVE BOLUS INJECTION OF QUININE. If parenteral quinine therapy needs to be continued beyond 48 hours, reduce dose to 7 mg/kg 8 hourly.
Note: The parenteral treatment in severe malaria cases should be given for minimum of 24 hours once started irrespective of the patient’s ability to tolerate oral medication earlier than 24 hours) followed by a full course of ACT for 3 days.
Those patients who received parenteral Quinine therapy and can take orally should receive: Oral Quinine 10 mg/kg three times a day for 7 days (including the days, when parenteral Quinine was administered) plus Doxycycline 3 mg/kg once a day or Clindamycin 10 mg/kg 12-hourly for 7 days (Doxycycline is contraindicated in pregnant women and children under 8 years of age; instead, give clindamycin 10 mg/ kg 12 hourly for 7 days). Monitoring
Monitor core temperature (preferably rectal), respiratory rate and depth, pulse, blood pressure and level of consciousness every 4 hours; Record urine output, and look for the appearance of brown or black urine (haemoglobinuria) or oliguria; Monitor therapeutic response, both clinical and parasitological, by regular observation and blood films; Carry out regular laboratory evaluation of haematocrit or haemoglobin, glucose, urea or creatinine and electrolytes; Avoid drugs that increase the risk for gastrointestinal bleeding (aspirin, corticosteroids). Supportive treatment
Treat fever, hypoglycaemia, electrolyte imbalance, hypotension, renal failure, anaemia, convulsions appropriately (for details see respective sections). Chemoprophylaxis
Chemoprophylaxis should be administered only in selective groups in high P. falciparum endemic areas. Use of personal protection measures including insecticide treated bed nets (ITN) / long lasting insecticidal nets (LLIN) should be encouraged for pregnant women and other vulnerable population including travellers for longer stay. However, for longer stay of military and para-military forces in high Pf endemic areas, the practice of chemoprophylaxis should be followed wherever appropriate, e.g. troops on night patrol duty and decisions of their medical administrative authority should be followed.
Short-term chemoprophylaxis (up to 6 weeks) Tab. Doxycycline 100 mg once daily for adults and 1.5 mg/kg once daily for children (contraindicated in children below 8 years). The drug should be started 2 days before travel and continued for 4 weeks after leaving the malarious area. Note: It is not recommended for pregnant women and children less than 8 years.
Chemoprophylaxis for longer stay (more than 6 weeks) Tab. Mefloquine 250 mg weekly for adults and should be administered two weeks before, during and four weeks after exposure. Note: Mefloquine is contraindicated in individuals with history of convulsions, neuropsychiatric problems and cardiac conditions. Therefore, necessary precautions should be taken and all should undergo screening before prescription of the drug. Patient education
1. To take measures to stop mosquito breeding and protection from mosquitoes, e.g.mosquito nets, repellents, long sleeves, long trousers, etc.
2. Fever without any other signs and symptoms should be reported to nearest health facility.
3. Chloroquine should be given with plenty of water after food and not on empty stomach. If chloroquine syrup is not available for children, the tablet should be crushed and given with honey or thick syrup.
4. Watch for side effects of drugs prescribed. Chloroquine may cause nausea, vomiting and diarrhoea, mild headache and skin allergy/rash.
5. If vomiting occurs within 30 minutes of chloroquine intake, repeat the dose of chloroquine.
6. Chloroquine, primaquine and sulphadoxine + pyrimethamine should not be given, if patient is suffering from G6PD deficiency.
7. To report back if haematuria or high-coloured urine, cyanosis develops stop primaquine immediately.
8. If no improvement after 48 hours or if condition worsens, occurrence of cerebral malaria symptoms should seek medical help immediately.