1.MALARIA DEFINITION AND EPIDEMIOLOGY
WHAT IS MALARIA?
OCCURRENCE AND DISTRIBUTION (ENDEMICITY)
The level of endemicity of malaria in Africa varies from country to country and sometimes from region to region within the same country. Some of the factors responsible for the variations in endemicity include
High rainfall pattern is associated with high malaria transmission while places with high altitude and low temperatures tend to be associated with lower rates of transmission. These are only factors that affect the occurrence but not necessarily the severity of malaria.
PATTERNS OF MALARIA ENDEMICITY
2.CLINICAL FEATURES OF MALARIA
Malaria characteristically presents with fever. However, patients may complain of headache, muscle pains, joint weakness, chills and rigors. In most cases one will just feel unwell or tired with loss of appetite. Young children may present with abdominal pain, vomiting and poor feeding.
CLASSIFICATION OF SEVERITY OF MALARIA
Malaria infection may present as uncomplicated malaria or severe malaria. It is important for proper patient management to always try and classify a patient with malaria. This will enable the management to be well focused, while helping the health worker to also look out for features that are associated with progression to life threatening disease. A heavy workload should not be used as an excuse not to classify your patient. You will find out that classifying the patient will ease your work and ensure that the patient is well managed.
Presence of the following clinical features with laboratory confirmation (i.e. either slide or RDT positive result).
This is acute malaria with signs of severity and / or evidence of vital organ dysfunction. Severe malaria is most common with P. Falciparum infection. In a patient with P. falciparum asexual parasitaemia and no other confirmed cause for their symptoms, the presence of one or more of the clinical or laboratory features below classifies the patient as suffering from severe malaria
It is recognized that the resources needed to confirm or ascertain many of the features listed above may sometimes not be available in many of our district level health facilities. In view of this difficulty, it has become necessary to classify severe malaria in a manner that would allow for prompt recognition of those who need treatment. Such groupings are particularly important in children, where a single yardstick may not sufficiently address their peculiar needs.
It is an illness usually characterized by a fever without any signs of severe disease but its clinical presentation may mimic other diseases, which often makes diagnosis difficult. A comprehensive presentation of clinical features has already been discussed in the previous learning unit. It is however important to note that some patients may just feel unwell with vague body pains and loss of appetite. In children, they may present with refusal to eat or feed, decreased activity and sometimes the symptoms may be non-specific.
A complete history should include, in addition to the presenting symptoms, the age, place of residence and recent history of travel within or outside the country.
Ask about the following symptoms:
DIAGNOSIS OF UNCOMPLICATED MALARIA
To avoid treatment of patients without malaria as malaria, it is necessary to test all suspected cases using RDTs which are available at all levels or using microscopy where conditions permit. Where an RDT is negative and there is still high suspicion of malaria, a slide for microscopy should be taken and sent to the laboratory. Second opinion should be sought in such cases and referral if in doubt. In children below five years, the Integrated Management of Neonatal and Childhood Illness (IMNCI) guidelines provide clinical criteria for the management of fever in both low and high-risk areas (see IMNCI guidelines at your institution). There is significant overlap in the clinical presentation of acute respiratory tract infections (pneumonia) and malaria. Children with pneumonia could have malaria and the converse is also true. Thus, in areas of high transmission all children presenting with fever, even in the presents of other symptoms, should have an RDT done.
In pregnancy, in low malaria areas, women acquire little immunity and get acute symptomatic disease more severe than non-pregnant women. Primigravidas in high malaria areas also have a high risk for placental infection and chronic anaemia.
Exclude other causes of fever:
All suspected cases of malaria should be confirmed before treatment is commenced. Blood slides for malaria parasites are required in:
Malaria parasites found on a thick blood smear confirm a diagnosis of malaria. If a laboratory is available, it is important to:
Note: Where an RDT is negative and there is still high suspicion of malaria, a slide for microscopy should be taken and sent to the laboratory. A second opinion should be sought in such cases and patients referred if in doubt.
4.TREATMENT OF UNCOMPLICATED MALARIA
Prompt, safe and effective treatment of uncomplicated malaria prevents progression to severe malaria.
Goal of treatment of uncomplicated malaria
Inquiry of malaria treatment before the current illness is important because it may indicate treatment failure and hence the need for second line malaria medicine
Who should receive Malaria Medicine?
Choice of malaria medicine
First line medicine should be given by the oral route
Second line medicines should only be used:
MEDICINES USED IN MALARIA TREATMENT IN ZIMBABWE
First line medicine
Second line medicine
Alternative Second line medicine
Oral Quinine + Doxycycline or Clindamycin
It is important to re-assess the patient thoroughly and perform a blood smear for malaria parasites. Also, ask the patient about adherence to and tolerance of prescribed medicine(s) dosing.
Treatment in Pregnancy
Due to increased risk of severe disease in pregnancy, uncomplicated malaria is an emergency and requires a very effective treatment with lowest possible clinical failure. Some malaria medicines are contraindicated in pregnancy. However, the treatment is usually the same as in any other uncomplicated malaria
Oral Quinine + Clindamycin
Second and third trimester
Co-artemether or AS/AQ
TREATMENT OF NON-FALCIPARUM MALARIAS (MALARIA CAUSED BY P VIVAX, P MALARIAE, P OVALE)
Non-falciparum malarias are susceptible to artemisinin derivatives, thus Coartmether can be used to treat these infections. However, P vivax and P ovale form hypnozoites (parasite stages in the liver) which can result in multiple relapses weeks to months later after the primary infection has been treated, hence the need for radical cure with primaquine. Caution should be taken in scenarios where Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD) deficiency of the patient is not known.
Treatment of P Vivax and P Ovale
Treatment of P Malariae and P Knowlesi
Treat as for P. Falciparum malaria
Mixed P Falciparum and other infections
A 14-day course of Primaquine should be given for mixed infections including P. Vivax and/or P. Ovale.
For high temperature > 38.50C
Tell the patient to return if fever persists for 2 days after commencement of treatment or immediately if condition gets worse or develops signs of severe disease. In case the patient returns, ask whether they adhered to the treatment as advised and do blood smear for malaria parasites. Do a complete assessment to exclude any other possible causes of fever.
Actions to take
1) If a patient adhered to treatment and the blood slide is positive, give second line malaria medicine
2) If a patient adhered to treatment and slide is negative, look for other causes of or refer for further management
3) In case of poor adherence to treatment, repeat the treatment under observation
KEY MESSAGES FOR TAKING ORAL MEDICINES AT HOME
Check that the patient or caregiver has understood the instructions before leaving the health facility.
It is important to note that the presence of any life threatening condition makes malaria severe. Thus, any patient with malaria who is unable to swallow tablets has any evidence of vital organ dysfunction, or a high parasite count is at increased risk of dying. Hence in the assessment of any patient with suspected malaria, you should carefully look for signs of severe malaria.
In areas of high malaria transmission, malaria is the commonest cause of fever and death especially in young children. Patients can deteriorate rapidly within a few hours or days leading to life-threatening situations like coma, repeated convulsions, shock, severe anaemia etc.
Why does severe malaria need special attention?
This is because:
Who are the people at risk for severe malaria?
Factors that influence severity of illness
Species of Plasmodium: Severe malaria is mainly caused by P. falciparum though P. Vivax has been implicated in recent past.
Endemicity: Adults and some older children who have lived for long in endemic malaria areas are less susceptible to severe malaria due to the immunity that are developed in these age groups. However, the under-fives that are non-immune may develop severe malaria.
Host Factors and clinical conditions: Adults visiting endemic areas for the first time, children and pregnant women and people with HIV and AIDS are more susceptible to severe malaria.
Parasite medicine resistance: Degree of parasite medicine resistance that prevails locally also influences severity of malaria.
MECHANISM AND CLINICAL FEATURES OF SOME COMPLICATIONS
The effects of malaria infection range from completely asymptomatic infection to fatal severe disease and many factors influence the clinical manifestations. These factors include:
Severe Malaria Complications
Anaemia is the commonest complication of malaria. It is due to the destruction of red blood cells containing parasites and even those without parasites are more rapidly destroyed during malaria illness. It is of particular importance in African children because of a high prevalence of chronic malnutrition and worm infestation, which often aggravate the anaemia. Anaemia can develop rapidly during malarial illness, especially if there is initial hyper parasitaemia. Children and pregnant women are the ones commonly affected and present with general weakness, severe palmar pallor or pallor of mucous membranes and conjunctiva. If severe it will result in acidosis and heart failure, with fast breathing, swelling of the face or feet, rapid pulse, gallop rhythm and enlarged soft painful liver.
Cerebral malaria is a common presentation of severe malaria and may cause residual problems. A patient with malaria and altered level of consciousness, which is not attributable to convulsions, sedatives medicines, hypoglycaemia alone or a non-malarial cause has cerebral malaria. A child with loss of consciousness after a febrile convulsion should not be considered to have cerebral malaria, unless coma persists for more than an hour after the convulsion. Similarly, a child with malaria and hypoglycaemia who is comatose, diagnosis of cerebral malaria cannot be sustained if consciousness is promptly restored following the administration of glucose.
We do not as of present understand very clearly why patients with malaria develop cerebral malaria. Hence we can only offer some theories (hypothesis) about how cerebral malaria occurs. The facilitator will discuss some of these theories with you. We shall briefly consider some of the features of cerebral malaria and discuss what other conditions may be confused with them.
A patient in coma is not responsive to the surrounding, not able to talk or follow what you are doing or asking. Coma may develop either gradually or suddenly or sometimes follow convulsions and could be moderate or profound (deep coma) with no response to very painful stimuli (following application of gentle pressure over the sternum). Remember that there are many non-malaria causes of coma like meningitis, encephalitis, medicines, etc. carefully look for such causes.
Patients have abnormal movements of the limbs (hands or legs) or the whole body, with sometimes biting of the tongue or urine incontinence. Although may be absent in a patient with cerebral malaria, they are usually multiple and focal when they occur. Convulsions may also be a result of very high temperature, especially in children or may be due to hypoglycaemia. Once there is a history of convulsion, you should find out about measures taken to abort the convulsions such as use of herbal mixtures, putting onions into the eyes, putting the legs in fire, etc.
Patients with severe malaria may present with fast or laboured breathing as a result of any of the following:
Low blood glucose (2.2 mmol/l) may be due to abnormal liver function or because maturing parasites consume large quantities of glucose from the blood. In children hypoglycaemia may also be a result of poor or reduced food intake. Low blood sugar is harmful to the brain. Patients may have change in behaviour, rapid pulse, convulsions or loss of consciousness or deep coma. Sometimes symptoms are vague (weakness, sweating with cold skin).
Coca-Cola coloured urine (Haemoglobinuria)
Passage of Coca-Cola coloured urine may occur in malaria as a result of excessive breakdown of red blood cells due to parasites or medicines (primaquine, quinine, sulphonamides etc.) that leads to passing haemoglobin in urine. Efforts should however be made to distinguish this from concentrated urine which may be an indication of dehydration; another potential complication of severe malaria.
Renal failure develops due to low blood pressure as a result of dehydration or shock and is more common in adults with severe malaria. It is easily reversible but this may take a long time and a patient may require peritoneal dialysis to allow the kidneys recover. It is generally uncommon in children. Patients present with signs of dehydration, passing very little urine (oliguria) or no urine (anuria) and when you do renal function tests you find increased blood urea, creatinine and potassium levels.
Some patients with malaria may have spontaneous bleeding from gums or the skin or prolonged bleeding at injections or vein puncture sites. This is a sign of severe coagulation defect and can lead to death very quickly.
6.CLINICAL ASSESSMENT OF SEVERE MALARIA<
In approaching the clinical assessment of a patient for severe malaria it is important that you bear in mind the following facts:
Place of residence and/or history of travel to an endemic area or of recent treatment with malaria medicines or other medicines may be important. Suspect severe malaria in any patient who presents with any of the above signs. In addition to the general history as in uncomplicated malaria you should ask about the following: -
In children ask and check for the general danger signs:
A child with any general danger sign has severe disease and needs urgent attention. Complete the assessment and commence appropriate treatment for severe disease.
In all patients ask about:-
Ask history to exclude other severe diseases like: -
NB: A LABORATORY CONFIRMATION IS NEEDED.
Enquire about medicines taken for:
Ask about any history of recent febrile illness and treatment, which may suggest treatment failure or relapse (consider typhoid, and other infections).
Severe malaria physical examination:
During physical examination you should aim at:
The following should be assessed: -
You should check;
It is important to examine the patient carefully going through all systems, looking for common signs of severe malaria and to rule out any other serious illnesses. However this should not take too much time. Bear in mind that the most important problems are usually easy to identify.
Central nervous system
Assess the level of consciousness of the patient and if in coma use a coma scale. On admission endeavour to use an objective scale such as the:
In the absence of any of these you can use the AVPU scale
A = alertness (is the patient alert)
V = response to voice command (does the patient respond to his name)
P = response to pain (does the patient feel pain or cry if child)
U = unresponsive. (Patient does not respond at all)
The level of consciousness worsens as you move down the scale.
Severe malaria laboratory investigations
The goal of laboratory investigation in a patient with suspected severe malaria should be to:
The basic (minimum) investigations recommended for patients admitted in hospital for severe malaria should include:
In hospitals where facilities are available more comprehensive investigations can be done such as:
Important points about diagnosis of severe malaria:
7.SEVERE MALARIA TREATMENT
Deaths from severe malaria can result either from direct effect of the disease or the complications. It is therefore important that appropriate emergency supportive measures and malaria treatment be promptly started.
Goal of treatment
If convulsions continue with no clear cause despite above treatment, refer patients for further investigations.
SPECIFIC TREATMENT OF SEVERE MALARIA
As already discussed severe malaria can rapidly lead to death. It is therefore important that irrespective of the level at which a patient is seen efforts must be made to initiate appropriate malaria therapy, in order to halt or stem the progression of illness.
Give parenteral Artesunate or Quinine as an alternative where Artesunate is not available
TREATMENT OF SEVERE NON-FALCIPARUM MALARIA
Treatment of severe P Vivax and P Knowlesi is the same as for severe P falciparum. However, for P Vivax add primaquine for 14 days.
Treatments not recommended:
The following treatments have no role in the treatment of malaria:
NURSING AND QUALITY OF CARE
Severe malaria is a serious condition and the clinicians and nurses should closely monitor patients. Therefore, nursing care should include all the following:
These should be monitored at least every 4 hours but may be done more frequently at the initial stages of treatment.
A strict 24-hour input and output chart should be kept in all patients with severe malaria. Examine regularly for signs of dehydration or fluid overload.
Unconscious or comatose patients need close monitoring of all vital signs more regularly to assess their progress. Monitor the level of consciousness at least every 6 hours using a coma scale. Patients should be turned in bed 2 hourly to avoid bedsores.
A clear medicine chart where all medicines given are recorded should be kept and should include dose, route, frequency, time given and all medicines given should be signed for.
These should be monitored closely ensuring that they don’t become hypoglycaemic and the well-being of the foetus should also be monitored. Watch out for signs of severe anaemia and pulmonary oedema.
Do blood glucose at least 6 hourly, and at any point immediately following deterioration of consciousness or convulsion. If it falls to < 3.4 mmol/l treat as hypoglycaemia. Where you cannot monitor blood sugar, maintain dextrose saline infusion (with dextrose made up to 10%).
Review your fluid infusion or ensure that patient gets oral feeds by nasogastric tube.
If the Hb falls to critical levels or there are clinical signs of heart failure, transfuse the patient even if they had been transfused before.
8.MALARIA IN PREGNANCY
EFECTS OF MALARIA ON PREGNANCY
The symptoms and complications of malaria in pregnancy vary according to transmission intensity and the level of acquired immunity. Pregnant women living in areas of low or unstable malaria transmission have little or no immunity to malaria, and are at higher risk of developing severe malaria than are non-pregnant adults living in the same area.
In these areas, malaria is a major cause of maternal anaemia, spontaneous abortion, stillbirth, premature delivery, low birth weight (birth weight < 2.5kg), neonatal death and maternal death. In non-immune women, severe malaria symptoms (hypoglycaemia, cerebral malaria, and pulmonary oedema being particular problems) are more common in pregnancy.
In stable transmission settings, the deleterious impact of malaria is particularly apparent in first and second pregnancies. Partial clinical immunity acquired during years of exposure to the malaria parasite prior to pregnancy does not prevent infection, but does reduce the risk of severe disease. Clinical malaria is not, therefore, a prominent feature of infection during pregnancy, and the major detrimental effects of infection are low birth weight (LBW) and maternal anaemia.
HIV infection impairs pregnant women’s ability to control P. falciparum infection. Women with HIV infection are more likely to have symptomatic malaria infections and to have an increased risk of an adverse birth outcome due to malaria. In the presence of HIV infection, placental malaria appears to be independent of the number of pregnancies, so that the risk of placental malaria is similar in HIV-infected multigravida and HIV-negative primigravidae.
Severe anaemia, exacerbated by malaria, is an important complication of pregnancy. This may be exacerbated by chronic hookworm infestations. High output anaemic cardiac failure may develop in late pregnancy as a result.
Asymptomatic hypoglycaemia may occur in pregnant women with malaria before antimalarial treatment, and pregnant women with uncomplicated or severe malaria are particularly vulnerable to quinine-induced hypoglycaemia.
There is an increased risk of pulmonary oedema precipitated by fluid overload or by the sudden increase in peripheral resistance, or auto transfusion of hyperparasitaemic blood from the placenta, which occurs just after delivery.
MALARIA CONTROL IN PREGNACY
Since malaria in pregnancy poses significant risk to the mother, her foetus and new-born, a three-pronged approach to prevention and control of malaria among pregnant women is employed in Zimbabwe. The strategies include:
Prevention of malaria in pregnancy
The facilitator should discuss the use of malaria prevention in pregnancy, including the use of indoor residual spraying, use of Long-Lasting Insecticidal Nets (LLINs) and Immune Preventative Therapy
Intermittent Preventive treatment in Pregnancy
Data have shown that when pregnant women took 3 or more doses of Immune Preventative Therapy, they had less placental malaria, delivered fewer low birth weight babies and their infants had higher mean birth weights compared to those who took two doses of Immune Preventative Therapy. Given these data, WHO updated the recommendations on Immune Preventative Therapy including advocating for at least four doses of Immune Preventative Therapy at each of the scheduled focused antenatal care (ANC) visits during pregnancy in areas of moderate and high malaria transmission.
In 2014 Zimbabwe adopted the updated WHO recommendations with the hope of ensuring that more women will receive at least 3 doses of IPTp and have fewer adverse consequences of malaria in pregnancy.
Schedule for immune Preventative Therapy
Considerations for implementation
Suspected malaria in a pregnant woman
The woman should be evaluated for malaria infection before giving Immune Preventive Therapy. If the woman is parasitological confirmed of malaria, she should be treated for malaria according to the National Treatment Policy and IPTp should be commenced or continued after completion of malaria treatment. If there is no parasitological evidence of malaria, and the woman is eligible for Immune Preventive Therapy, she should be given.
TREATMENT OF MALARIA IN PREGNANCY
Treatment of uncomplicated malaria in pregnancy
Pregnant women with symptomatic acute malaria are a high-risk group, and require effective antimalarial medication. There is insufficient information on the safety and efficacy of most antimalarial medicines in pregnancy, particularly for exposure in the first trimester, and treatment recommendations differ from those for non-pregnant adults. Therefore, as a standard practice for the administration of any medicine pregnant women, all women of child-bearing age should be asked whether they are, or could possibly be, pregnant before an antimalarial medicine is prescribed. The following are the antimalarial medicines recommended for the treatment of uncomplicated falciparum malaria during pregnancy:
Treatment of severe malaria in pregnancy
A pregnant woman with severe malaria should be given a parenteral antimalarial medicine in full doses without delay. Parenteral artesunate is more effective than parenteral quinine in reducing the risk of death from severe malaria. Although safety data on the use of artemisinins in the first trimester are limited, saving the mother’s life is the primary objective, and both artesunate (IV or IM) and quinine (IV or IM) may be considered as options.
In the second and third trimesters, parenteral artesunate is preferred over parenteral quinine, because of its antimalarial efficacy and because quinine is associated with recurrent hypoglycaemia.
9.RECOVERY ASSESSMENT AND HEALTH EDUCATION
ASSESSMENT OF RECOVERY
This unit helps to learn about the common requirement of any patient admitted to hospital when they have recovered and are due for discharge. The records and the observations made will provide some progress of the patient's recovery e.g. falling temperature, parasite load, urine output and improving coma. It is also important to record the patient’s ability to:
After full recovery assess for possible residual problems of the disease or treatment. You should at least do the following: -
FOLLOW UP AFTER DISCHARGE
The health workers should give health education to patients or guardians. This should focus on the current illness, treatment and prevention of malaria.