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8/18/2019 Drugpol Timor Leste

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MALARIA TREATMENTPROTOCOL

Third editionJune 2007

Ministry of Health

Republic Democratic of Timor- Leste


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UNCOMPLICATED MALARIA Uncomplicated malaria definition:

Fever and any of the following:

Headache, od! and "oint pain#

$eelin% cold and #ometime# #hi&erin%

Lo## of appetite and #ometime# a'dominal pain# Diarrhoea, na(#ea and &omitin%)

*pleenome%al!


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Confirmed Dia%no#i# of Malaria All clinically suspected malaria cases require

laboratory examination and confirmation.

Only in case where laboratory confirmation isnot possible start treatment immediately)

Parasitological confirmation is done by thin-

thic blood smear microscopy examination or by dipstic !"apid #iagnostic $est %"#$&'.


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Differential dia%no#i# for

(ncomplicated malaria (onsider other illnesses) such as:

Upper re#pirator! tract infection

+Phar!n%iti#, ton#illiti#, ear infection,pne(monia , mea#le#, den%(e, infl(en-a,

t!phoid fe&er)

"emember that the patient may be sufferingfrom more than one illness.


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Uncomplicated malaria treatment P. falciparum malaria

$he treatment of uncomplicated P. falciparum

malaria is undertaen after diagnosis ofmalaria by light microscopy or #ipstic.

Patients with positive thin-thic bloodsmears or dipstic for P. falciparum malaria istreated by blisters of (oartem* !artemether+,mglumefantrine +,mg'. /ee Ta'le . fordetails of prescription.


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Ta'le . : Do#a%e and admini#tration Coartem +Artemether /0

m%1L(mefantrine ./0 m% for (ncomplicated

malaria falciparumAge group

eight group!lister color

"Day #$ "Day 2$ "Day %$

4 months

to 5yrs

5 to 14 kg Yellow1 tb , 1 tb , 1 tb ,

1 tb 1 tb 1 tb

6 to 11y 15 to 24 kg Blue2 tb , 2 tb , 2 tb ,

2 tb 2 tb 2 tb

12 to 14y 25 to 34 kg Orange

3 tb , 3 tb , 3 tb ,

3 tb 3 tb 3 tb

> 14y > 34 reen4 tb , 4 tb , 4 tb ,

4 tb 4 tb 4 tb

Source: Guideline for the treatment of malaria, WHO; 2006


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Coartem2

Do#a%e *ched(le

Source: WHO, 2007


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Important note# +. . 0t is obligatory to give (oartem* to patient whose

dipstic test or blood slide is positive for P. falciparum and to the patient who has mixed

infections P. falciparum and P .vivax. +. 1ive the correct dosage of (oartem* from the

appropriate blister according to the patient2s weightor age.

3. (hildren under 4 g or below 5 months should not be given (oartem instead treat with the followingregimen +#ee ta'le /.


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Ta'le /) Do#a%e and admini#tration Plasmodium

falciparum for !o(n% infant

Age &roupeightgroup

Artesunate or '(uinine

! " 4months

#5 kg

$$ %& 'irst dose (rtesunate 1)2mg*kg or %& (rthemeter 1)6mg*kg+

$$$Oral (rtesunate2mg*kg*dayday 2 to day

Oral

-uinine 1!mg*T%. 'or

4 daysthen 15"2!mg*kg T%.'or 4 days

Source: Malaria in Children, Department of tropical Pediatrics, Facult of !ropical Medicine, Mahidol "ni#ersit$

** Preferal! "rtesunate#"rtemether $% on da! & if a'ailale

*** When "rtesunate#"rtemether $% is una'ailale, (i'e oral "rtesunate from da! & to da! )

* reat the !oun( infant +ith uinine +hen oral "rtesunate is not a'ailale


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Important note# +/5. 0n case parasitological diagnostic facilities are not available

paracetamol could be given to relieve pain and fever and

referred to health facilities where parasitological diagnosiswill be carried out.

3) Onl! in e4ceptional ca#e 5hen there i# pro'lem 5ith the

referrin% patient in other health facilit! coartem2 co(ld'e admini#tered) +The health facilit! mana%er #ho(ld5rite e4planator! note 5h! %i&in% coartem2 5itho(t

para#itolo%ical dia%no#i#.


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Important note# +66. 7atch all patients swallowing the first dose of

coartem* and observe for hour after the intae. 0nthe event of vomiting within one hour of

administration) a repeat dose should be taen.8. 0nform patient that) the coartem* tablets are in the

blister and after breaing should be taenimmediately) as after +5 hours coartem* tabletsexposed to air totally inactivated and can not beused for treatment of malaria.

9. ach blister of coartem* has expiry date and shouldnot be used after the expiry date.


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Important note# +7;. For small children) paracetamol and coartem*

can be crushed) diluted in water and then put

either directly into the mouth using a syringeor given with a spoon.

,. Any patient who sees re-treatment for

malaria within + wees of taing full dose ofany other antimalarial should be treated with

coartem*.


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Uncomplicated malaria treatment P. 'i'a- malaria Re#i#tance of P. 'i'a- to chloro8(ine ha# not 'een fo(nd

in Timor9Le#te and Chloro8(ine i# the dr(% of choice

(hloroquine is safe and has few side effects. For the radical treatment of P. vivax in addition to

chloroquine) primaquine is recommended ,.4mgg per dayfor 5 days !primaquine should always be taen with food'.

Chloro8(ine can 'e %i&en to pre%nant 5omen and

children) Prima8(ine i# not recommended for the children (nder

one !ear and pre%nant 5omen)

< #etails of treatment see table 5a.


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Ta'le 7a) Do#a%e and admini#tration of Chloro8(ine and

Prima8(ine for malaria 'i'a-.

Age &roup' eight

group ")g$

*HL+R+(,./"#0 mg base$ #0 mg1g on the

first t3o 4ays5 mg1g on 4ay %

6RMA(,./"# mg base$05 mg1g b3

i/e 'or 3 days0tart onurrently with -and gi/e daily 'or 14 days.ay 1 .ay 2 .ay 3

months upto #2 months

4 " #1! "

13 months uto 5 years

1! " #1 1 1

6 " years 1 " # 24 1 1 1

7 " 11 years 24 " #35 2 2 1 8

12 " 14 years 35 " # 5! 3 3 2 1

15 9 5! or more 4 4 2 2


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P. 'i'a- malaria o(n% infant le## than 3;% or 'elo5 7month# #ho(ld 'e treated 5ith Chloro8(ine

alone for three da!# con#ec(ti&e +ale )


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Ta'le 7') Do#a%e and admini#tration of Chloro8(ine

for malaria &i'a- in !o(n% infant

Age

&roup

eight

group

*hloro8uine

.ay 1 .ay 2 .ay 3

! " 4months

#5 kg 1! mg*kg 5 mg*kg 5 mg*kg


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P. falciparum and P. 'i'a-

+mi4ed infection#

The t!pe of malaria 5here 'oth infection#

occ(r# in patient re8(ire# treatment '!

Coartem2)


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=otes:Ne%ati&e dip#tic; or thin9thic; 'lood #mear: If the Pf dip#tic; i# ne%ati&e and the clinical #i%n# are t!pical for

malaria, treat 5ith Chloro8(ine +it co(ld 'e a ca#e of P. 'i'a- infection)

0f the Pf dipstic is negative and the clinical signs don2t suggest malaria)do not treat lie malaria> loo for another illness.

0f the blood slide is negative) loo for another illness. 0f symptoms persist) as for another dipstic or blood slide. If dip#tic; and1or thin9thic; 'lood #mear are not a&aila'le:

0f there is no possibility of dipstic or slide results) treat the patient basedon the clinical signs and symptoms. $reat as if the patient has P. falciparum.


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$ollo59(p of (ncomplicated

malaria:

If #!mptom# per#i#t after treatment 5ith coartem2 or ifthe patient come# 'ac; before the 5th day after treatment.

reatment failure +ithin & da!s of recei'in( coartem/ is

e-tremel! rare and is more liel! to e an inade1uateasorption of the dru(s3 than resistance of the parasites. $tis important to determine from the patient4s histor! +hetherhe or she 'omited durin( the pre'ious treatment or did notcomplete the full course)

If patient i# in health facilit! 5here micro#cope i#a&aila'le fail(re of treatment #ho(ld 'e confirmedpara#itolo%icall! and co(ld 'e treated (#in% the follo5in%re%imen:


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$ollo59(p of (ncomplicated

malaria:

$or ad(lt: ?uinine +.0m% #alt 1;% '5 three time# a da! @ doxycycline +6)0m%1;%

'5 once a da! for < da!#) Do not %i&e do4!c!cline 5ith mil; or iron,5hich 5ill red(ce it# a'#orption)

If patient i# in health facilit! 5here micro#cop! facilit! i# nota&aila'le patient #ho(ld 'e referred to the facilit! 5here micro#copei# a&aila'le) If refer i# not po##i'le treatment #ho(ld 'e %i&en ?uinine@ #oxycycline. Please refer to ale 5 for details of the prescription.

Do4!c!cline #ho(ld not 'e %i&en to pre%nant or lactatin% 5oman, orchild a%ed (p to = !ear#)

$or pre%nant or lactated 5oman or child le## than = !ear#: ?uinine +.0m% #alt 1;% '5 three time# a da! @ clindamycin +.0m%1;%

'5 t5ice a da! for


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Note:

$or hi%h tran#mi##ion area# 5here

para#itolo%ical confirmation i# not

a&aila'le, children >3 !r# of a%e i#recommended to 'e treated 5ith anti

malarial dr(%# 5hen #!mptomatic

+e#peciall! fe&er)


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/" BACA"0A

*e&ere or complicated malaria definition:$e&er and an! of the follo5in%: 0mpaired consciousness Anxiety) palpitation and sweating (onvulsions or fits with this fever Fast or difficult breathing omiting every feed unable to feed Pale hands) tongue and inner parts of the eyelid 1eneraliDed body weaness

#ehydration Eaundice /evere malnutrition #ar urine or no urine


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Pre9referral treatment of #e&ere

malaria

A patient who is non responsive should be quicly assessedand managed. $his includes assessment of the airway)

breathing and circulation. $he staff at the first level healthfacility should be able to maintain airway) provide assisted

breathing and manage shoc if required.

Pre-referral treatment for severe malaria the administrationof Artesunate by the rectal route is recommended for allexcept pregnant women first trimester pregnancy. For the

complete dosage and treatment. (hec blood sugar) if possible


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0n case Artesunate suppository is not available

0B quinine inGection +,mgg bw should be

given. $he ?uinine inGection dosage should be split and inGections given in the anterior

part of the thigh.

In ca#e Arte#(nate #(ppo#itor! i# nota&aila'le, %i&e al#o ?(inine for children

5ith #e&ere malaria)


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Confirmed dia%no#i# of #e&ere

malaria: All clinically suspected severe malaria cases

require laboratory examination andconfirmation.

Only in case where laboratory confirmationis not possible start treatment immediately)Parasitological confirmation is done by thin-

thic blood smear microscopy examinationor by dipstic !"apid #iagnostic $est%"#$&'.


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#ifferential diagnosis for complicated

malaria (onsider other illnesses) such as:

Mea#le#, menin%iti#, ton#illiti#, den%(e,

otiti# media +ear infection, infl(en-a,pne(monia, t!phoid fe&er, t('erc(lo#i#,

h!po%l!cemia)


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*pecific #e&ere malaria treatment

Arte#(nate !6, mg': +.5 mgg body weight !bw' 0or 0B on admission !timeH,') followed by +.5 mggat + and +5 hours) followed by once daily for seven

days. Once the patient can tolerate oral therapy)treatment should be switched to a complete dosage ofcoartem* for three days as recommended in thenational treatment guidelines for uncomplicatedmalaria .

The con%enital malaria i# al#o treated 5ithArte#(nate, 5here /)7 m%1;% i# initiall! %i&enthro(%h I@, follo5ed '! .)/ m%1;% at ./ and /7 hrthen e&er! /7 hr for 6 93 da!#)


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*pecific #e&ere malaria treatment

Artemether !9,mg for adult and 5, mg for childrenand the newborn': 3.+ mgg bw 0B on the first dayfollowed by .6 mgg bw daily for seven days.

Once the patient can tolerate oral therapy) treatmentshould be switched to a complete dosage ofcoartem*.

Arteether !4, mg': 3.+ mgg bw 0B on the first

day) followed by .6 mgg bw for the next 5 days.Once the patient can tolerate oral therapy) mayswitch to a complete dosage of coartem*.


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If Coartem2 i# not a&aila'le, 8(inine

#ho(ld 'e admini#tered in com'ination

5ith tetrac!cline or do4!c!cline or

clindam!cin, to complete the #e&en9da!

treatment, e4cept for pre%nant 5omen and

children (nder ei%ht !ear# of a%e for 5homtetrac!cline1do4!c!cline i# contraindicated)


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?(inine oadin( dose: ?uinine dihydrochloride +,

mg salt g bw diluted in , mlg bw of 4I

dextrose or dextrose saline administered by0 infusion over a period of four hours for

both adult and children. 0n severe (hildhood

falciparum malaria) if patient received

quinine or quinidine or mefloquine in 59 hrs

before arrival) give , mgg over + hours.


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?(inine %aintenance dose: ?uinine dihydrochloride , mg salt g

body weight diluted in , mlg body weight of 4I dextroseor dextrose saline administered by 0 infusion. 0n adults) themaintenance dose is infused over a period of four hours and

repeated every eight hours.*imilarl! in children incl(din% con%enital malaria, it i#inf(#ed o&er a period of t5o ho(r# and repeated e&er!ei%ht ho(r# +calc(lated from the 'e%innin% of the pre&io(#inf(#ion (ntil the patient can #5allo5) To complete the

#e&en9da! to ei%ht9da! treatment in children, %i&e ?(inine#(lfate .0 m%1;% per oral three time# in a da!) Increa#e thedo#a%e of ?(inine #(lfate to .39/0 m%1;% after 7 da!# oradd tetrac!cline 3 m%1;% t5ice a da! for children a'o&e <!ear#)


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=otes Artemi#inin deri&ati&e# are #afe, effecti&e, ha&e a 5ider therape(tic

5indo5, can 'e admini#tered intram(#c(larl! and #ho(ld 'econ#idered a #afer alternati&e to 8(inine)

A loading dose of quinine should not be given +. if the patient hasreceived or suspected to have received quinine) quinidine or mefloquinewithin the preceding + hours) and +/ facilities for controlled rate of flowof quinine infusion are not available. 0n order to improve treatmentoutcome of quinine add a course of oral tetracycline 5 mgg bw 5 timesdaily or doxycycline 3 mgg bw once daily except for children under 9years of age and pregnant women) or clindamycin , mgg bw twicedaily for 3-8 days.

0f there is no clinical improvement after 59 hours of parenteral therapy)the maintenance dose of parenteral quinine should be reduced by one-third to a half !i.e., 4-8 mgg bw quinine dihydrochloride'. )

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