malaria

MALARIA

JOY M. NICOLAS MDPIDS – FELLOW IN TRAINING

History

Time of Emperor Shih Huang Ti (2697–2590 BC) Earliest report for malaria - repeated paroxysmal fevers

associated with enlarged spleens and a tendency to epidemic occurrence

name malaria, derived from ‘mal’aria’ (bad air in Medieval Italian) - first used by Leonardo Bruni in a publication of 1476.

first to notice parasites in the blood of a patient suffering from malaria

Charles Louis Alphonse Laveran

Infected anopheline mosquito - Most typical cause of transmission Approximately 45% are effective vectors A population of infected humans is

necessary to sustain transmission ▪ short life span of mosquitoes ( 5 to 20 days)▪ the long incubation period required in the mpsquito (8 to > 10 days)

Life cycle

Life cycle of Plasmodium vivax & ovale

Epidemiology – world wide

Epidemiology – Philippines

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Transmission (Epidemiologic terms)

Endemic malaria – based on the parasite rate in children 2 to 9 years old HYPOENDEMIC – parasite rate 0 to 10% MESOENDEMIC – parasite rate 11 to 50% HYPERENDEMIC - parasite rate consistently >50% , with

a high proportion of adults having enlarged spleen HOLOENDEMIC – parasite rate consistently >75%, with a

low proportion of adults having enlarged spleen

Transmission (Epidemiologic terms)

Autochthonous malaria – acquired locally - Introduced malaria – migrant populations (asymptomatic) provide blood meals for feeding anopheles under conditions that can complete the life cycle enabling the mosquito to infect others

- Imported malaria - Induced malaria – acquired from exposure to infected blood ( blood transfusion, needle stick injury, laboratory accidents)- Cryptic malaria – cases for which no explanation can be found

Blood born transmission – cannot result to relapses

Congenital malaria – cannot occur if the mother is semi-immune Transplacental transmission or breakdown of

placental barrier during delivery

Host – Parasite Reaction

Incidence and severity of malaria – Intensity of exposure Presence of immunity

- children- pregnant woman- reservoirs of infection

Genetic factors▪ Duffy- negative blood type specific receptors – resistant

to infection with P. vivax ▪ Sickle hemoglobinopathies and protection against

severe malaria falciparum

Pathophysiology

Anemia Lysis of RBCs Impaired erythropoiesis bone marrow suppression secondary to folic acid

deficiency Hemoglobinuria (blackwater fever) – intravascular

hemolysis - can result to renal failureCytokines (TNF, Interleukin 1) –

TNF stimulate nitric oxide – correlated with clearance of parasites and recovery and severity of illness

Pathophysiology

Sequestered infected RBC – -facilitate adherence of these cells to vascular endothelium- can be responsible for cerebral malaria, renal failure, watery diarrhea

Hypoglycemia and lactic acidosis –consumption of glucose by late parasites

Clinical features

Recurrent infections RELAPSES - due to delaye maturation of dormant live

stages (hypnozoites) of P. vivax or P. ovale RECRUDESCENCE – parasitemia caused by the same

parasite responsible for the initial infection recurs after clearance or a significant reduction in the initial parasitemia▪ Occurs most commonly with P. falciparum

RE-INFECTION - from different parasites and infection with more than one type of Plasmodium occur especially in areas with high intensity of transmission▪ Noted in P. malaria

Characteristics of Plasmodium species P. falciparum

P. vivax P. ovale P. Malariae

Incubation period

12 (8-25) 14 (8 – 27) 17 (15 - > 18)

28 (15- > 40)

Periodicity of febrile attacks

none 48 48 72

Earliest apperance of gametocytes

10 days 3 days ? ?

Relapse No Yes Yes No

Duration of untreated infection

1-2 yr 1.5 – 4 yr 1.5 – 4 yr 3 – 50 yr

RBC preference

Younger cells (but can invade cells of all ages)

Reticulocytes Reticulocytes Older cells

Characteristics of Plasmodium species P. falciparum

P. vivax P. ovale P. Malariae

Characteristic morphology

Ring formsMultiply infected cellsBanana shaped gametocytes

Schuffner dotsEnlarged RBCs

Schuffner dotsEnlarged RBCs

Normal- sized cellsBand or rectangular forms of trophozoites

Acute malaria

Malaria paroxysm – results from lysis of parasitized RBCs and release of merozoites into the circulation at the completion of asexual reproduction- fever, chills - headache - body ache- fatigue - dizziness- malaise GI symptoms – nausea, vomiting, abdominal pain, diarrhea

CHILDREN – fever, headache or GI symptoms- anemia- Jaundice- hepatospleenomegaly

Laboratory findings

Anemia Thrombocytopenia Leukopenia Abnormal liver function test Hypoglycemia Hyponatremia Elevated creatinine or BUN

Cerebral malaria – most common complication of falciparum malaria

- Occurs mostly in 3 – 6 years old- Alteration of consciousness w/o any explanation during

infection of malaria- Comatose- Generalized convulsions- Increase of intracranial pressure- histopathology – occasional hemorrhages and

perivascular infiltrates

Severe and complicated malaria

SEVERE ANEMIA - Seen most commonly in less than 1 years old Occur most often in areas with year round

transmission Clinical consequences of anemia

▪ Rate of development of anemia, severith of anemia▪ Higher risk of complications as hemoglobin decreases less

than 5 g/dL

HYPOGLYCEMIA Associated with poor prognosis Due to combination of parasite consumption of

glucose and inadequate gluconeogenesis in the liver


ACID-BASE CHANGES Metabolic acidosis – marker of severity HYPERPNEA

RENAL COMPLICATION Acute renal failure – life-threatening

▪ Oliguric and reversible if immediately dialized

• occur more frequently in those patients treated with quinine or quinidine• Histologic changes resembles those of acute

tubular necrosis• Nephrotic syndrome and chronic renal failure –

endemic and associated with P. malariae


• PULMONARY EDEMA- Consistent with pulmonary leak syndrome- Develops late in the course of severe malaria

• HYPERACTIVE MALARIAL SYNDROME- Massive spleenomegaly, high concentrations of

total serum IgM and malarial antibodies of multiple immunoglobulin classes and clinical and immunologic response to antimalarial agents

- Seems to involve chronic exposure to malaria resulting in chronicstimulationof the immune system and genetic factors


• HYPERACTIVE MALARIAL SYNDROME- Huge spleen and enlarged liver- Anemia and increased reticulocyte count;

thrombocytopenia or neutropenia- Increases the risk of acquiring bacterial infection


• History of travel in endemic areas• Microscopy

• Thin smear - speciation of the organism- Giemsa stain – preserves the Schuffner dots- has low sensitivity – low parasite load (<100 to

300 uL) – too small to detect • Thick smear – speciation cannot be identified- Estimating the parasites density – assessing the likelihood

of development of complications associated with high parasite density and for evaluating response to therapy

Diagnosis

• FLUORESCENT MICROSCOPY• Identification of parasitized RBCs stained with acridine orange in the

RBC layer of centrifuged blood• DETECTION OF PARASITE ANTIGEN

Diagnosis

Diagnosis

Treatment

Treatment- Uncomplicated Plasmodium falciparum Malaria

First Line Treatment

Artemether-Lumefantrine tablet twice a day on days 1 to 3

(1 tablet contains 20 mg Artemether and 120 mg Lumefantrine)

ANDPrimaquine tablet on day 4 (single dose)

(1 tablet contains 15 mg base of Primaquine)

Day of treatment

Artemether-Lumefantrine Use body weight in kgs as basis

5-<15 kg 15 - < 25 kg 25-<35 kg > 35 kg

If weight cannot betaken, use age as basis

6 mon- 3 yo 4-8 yo 9-13-yo If > 35 kg

Day 1 1 tab 2 tabs 3 tabs 4 tabs

8 hrs after 1 tab 2 tabs 3 tabs 4 tabs

Day 2 1 tab BID 2 tabs BID 3 tabs BID 4 tabs BID



Primaquine tablet (PQ)

Day4

Use body weight in kgs as basis: use 0.75 mg base/kg BW single dose

If weight cannot be taken use age as basis

< 1 yo 1-3yo 4-6 yo 7 -11 yo > 12 yo

Contraindicated

½ PQ single dose

1 PQ tablet single dose

2 PQ tablets single dose



Second Line Treatment

Quinine sulphate + Doxycycline or Tetracycline or Clindamycin

Age Group/ Condition

Quinine Sulfate (300 or

600 mg/tablet)

Plus any of the three antibiotics below

Doxycycline Tetracycline Clindamycin

Adults, non-pregnant women and children 8 years and above

10 mg salt/kg bw dose every 8 hours for 7 days

3 mg/kg bw once a day (QD) for 7 days

250 mg 4 times a day (QID) for 7 days

10 mg/kg bw twice a day (BID) for 7 days

Children < 8 years old

As above Contra-indicated

Contra-indicated



Parenteral Quinine Dihydrocloride Infusion PLUS

Tetracycline/Doxycycline/Cljndamycin

Treatment- Severe Plasmodium falciparum Malaria in adults and older children

Dosing Schedule of Quinine Dihydrochloride in the Treatment for Severe Plasmodium falciparum Malaria Infection

Age Group Quinine DihydrochlorideLoading Dose Maintenance Dose

Adult 20 mg salt/kg in 500 ml D5W or 0.9NaCl for 4 hours IV drip(The total dose must not exceed 2,000 mg)

10 mg salt/kg in 0.9NaCl or D5W IV drip for 4 hours every 8 hours

Children 8 years to 16 years

15 mg salt/kg IV drip for 4 hours in 10 ml/kg D5W or 0.9 NaCl (infusion rate must not exceed 5mg/kg per hour)

10 mg salt/kg IV drip for 4 hours every 8 hours in D5W or 0.9 NaCl

Children 7 years and younger

10 mg salt/kg in IV drip for 4 hours

10 mg salt/kg IV drip every 12 hours

Management of Severe Pf Malaria in remote peripheral facilities

Dosing Schedule for Pre-referral Treatment with Artesunate Suppository (AS) in Adults Weight (kg) Artesunate

DoseRegimen (single dose)

(Preparation of AS is available in 50, 200 and 400 mg)

< 40 10 mg/kg Use appropriate number of 50 or 200 mg preparation

40 – 59 400 mg One 400 mg preparation

60 – 80 800 mg Two 400 mg preparation

> 80 1200 mg Three 400 mg preparation

Treatment for Plasmodium vivax OR Plasmodium ovale

Chloroquine tablet on Days 1 to 3(1 tablet contains 150 mg base of

Chloroquine) AND

Primaquine tablet on Days 4 to 17(1 tablet contains 15 mg. base of

Primaquine base)

Dosing Schedule of Chloroquine (CQ) and Primaquine (PQ) in the Treatment for Plasmodium vivax or Plasmodium ovale Malaria Infection

Day of Treatment CQ (1) Use weight in kgs as basis

(2) If weight cannot be taken, use age as basis

0-11 mos 1-3 y.o.

4-6 y.o.

7-11 y.o.

12-15 y.o. > 16 y.o.

Day 1 10 mg/kg 1/2 1 1 ½ 2 3 4

Day 2 10 mg/kg ½ 1 1 ½ 2 3 4

Day 3 5 mg/kg 1/2 1/2 1 1 1 ½ 2

Day 4-17 PQ(1) Use weight in kgs as basis


0-11 mos 1-3 y.o.

4-6 y.o.

7-11 y.o. > 12 y.o.

0. 5 mg-base per kilogram per day

contra-indicated

½ daily

½ daily

1 daily 1 daily

Treatment for Plasmodium malariae

Chloroquine tablet on Days 1 to 3( 1 tablet contains 150 mg base of

Chloroquine)AND

Primaquine tablet on Day 4 (single dose)

(1 tablet contains 15 mg base of Primaquine)

Dosing Schedule of Chloroquine (CQ) and Primaquine (PQ) in the Treatment for Plasmodium malariae Malaria Infection

Day of Treatment CQ (1) Use body weight in kgs as basis

(2) If weight cannot be taken, use age as basis0-11 mos. 1-3

y.o.4-6 y.o.

7-11 y.o.

12-15 y.o. > 16 y.o.

Day 1 10 mg/kg 1/2 1 1 ½ 2 3 4Day 2 10 mg/kg ½ 1 1 ½ 2 3 4Day 3 5 mg/kg 1/2 1/2 1 1 1 ½ 2

Day 4 PQ(1) Use body weight in kgs as basis

(2) If weight cannot be taken, use age as basis0-11 mos. 1-3

y.o.

4-6 y.o.

7-11 y.o.

> 12 y.o.

0.75 mg-base per kilogram per day

contra-indicated

½ tab single dose

1 tab single dose

2 tabs singe dose

3 tabs single dose

Treatment for Mixed infections

P. falciparum and P. vivaxArtemether Lumefantrine+ Primaquine.

Day of Treatment AL

(1) Use body weight in kgs as basis 5 - <15

kg15 - <25 kg

25 - <35 kg ≥35 kg

(2) If weight cannot be taken, use age as basis(6 mos.–

3 y.o.)(4- 8 y.o.)

(9-13 y.o.) If (> 13 y.o.)

Day 1 1 tab 2 tabs 3 tabs 4 tabs8 hrs after 1 tab 2 tabs 3 tabs 4 tabsDay 2 1 tab

BID2 tabs BID

3 tabs BID 4 tabs BID

Day 3 1 tab BID

2 tabs BID

3 tabs BID 4 tabs BID


(2) If weight cannot be taken, use age as basis0-11 mos 1-3

y.o.

4-6 y.o.

7-11 y.o. > 12 y.o.


contra-indicated

½ daily

½ daily

1 daily 1 daily


P. falciparum and P. vivax

P. falciparum and P. MalariaeArtemether-Lumefantrine for 3 days

Primaquine (0.75 mg/kg) single dose on Day 4

Treatment for Mixed infections Artemether-Lumefantrine for 3 days (Refer to Table 4.4)

b. Primaquine (0.75 mg/kg) single dose on Day 4 (Refer to Table 4.4

Day of treatment


5-<15 kg 15 - < 25 kg 25-<35 kg > 35 kg


6 mon- 3 yo 4-8 yo 9-13-yo If > 35 kg






Day4



< 1 yo 1-3yo 4-6 yo 7 -11 yo > 12 yo

Contraindicated

½ PQ single dose




Treatment for Mixed infections - P. falciparum and P. Malariae

P. Falciparum, P. vivax and P. MalariaeArtemether-Lumefantrine for 3 days

Primaquine (0.5 mg/kg/day) single dose

on Day 4 for 14 days

Treatment for Mixed infections Artemether-Lumefantrine for 3 days (Refer to Table 4.4)

b. Primaquine (0.75 mg/kg) single dose on Day 4 (Refer to Table 4.4

Day of treatment


5-<15 kg 15 - < 25 kg 25-<35 kg > 35 kg


6 mon- 3 yo 4-8 yo 9-13-yo If > 35 kg






Day4



< 1 yo 1-3yo 4-6 yo 7 -11 yo > 12 yo

Contraindicated

½ PQ single dose

½ PQ single dose



Treatment for Mixed infections - P. falciparum and P. Malariae

P. vivax and P. MalariaeChloroquine (25 mg/kg) for 3 days Primaquine (0.5 mg/kg/day) single

dose on Day 4 for 14 days


Day of Treatment CQ (1) Use weight in kgs as basis


0-11 mos 1-3 y.o.

4-6 y.o.

7-11 y.o.

12-15 y.o. > 16 y.o.

Day 1 10 mg/kg 1/2 1 1 ½ 2 3 4

Day 2 10 mg/kg ½ 1 1 ½ 2 3 4

Day 3 5 mg/kg 1/2 1/2 1 1 1 ½ 2



0-11 mos 1-3 y.o.

4-6 y.o.

7-11 y.o. > 12 y.o.


contra-indicated

½ daily

½ daily

1 daily 1 daily

Treatment for Mixed infections – P. Vivax and P. malaria

Treatment for Pregnant women and Lactating mother

Stage of Pregnancy

Treatment by SpeciesPf Pv/Po/

PmRelapse P. vivax

Mixed InfectionUncomplicated Severe

1st

trimesterQN +

Clindamycin (oral)

Parenteral QN infusion +

Clindamycin IV(1) If Quinine infusion not available,

give QN tab orally or by NGT(2) Shift to oral Clindamycin if

patient can already tolerate oral meds

(3) If QN not available (either tab or infusion), is last resort requiring consent of patient/relatives

CQ CQ QN+

Clindamycin (oral)

2nd

trimesterQN +

Clindamycin (oral)


Clindamycin IV (1) If above not available, give QN

tab orally or by NGT(2) Shift to oral Clindamycin if


(3) If QN + is not available, can be given

CQ CQ QN+

Clindamycin (oral)If above

not available, AL can be

given


Stage of Pregnancy

Treatment by SpeciesPf Pv/Po/

PmRelapse P. vivax

Mixed InfectionUncomplicated Severe

3rd

trimesterQN +

Clindamycin (oral)


Clindamycin IV(1) If above not available, give QN




CQ CQ QN+

Clindamycin (oral)If above

not available, AL can be

given

Post-partum (2 weeks after delivery)

PQ SD PQ SD PQ 14 PQ 14 PQ 14

Lactating QN +

Clindamycin (oral) +

PQ


Clindamycin IV(1) If above not available, give QN




CQ+

PQ

CQ+

PQ 14

QN +

Clindamycin

(oral) +

PQ14orAL +

PQ 14


Uncomplicated Pf MalariaPopulation Group Medicine Dosing Schedule

Pregnant Quinine Sulphate 10 mg/kg every 8 hours for 7 days

Clindamycin 10 mg/kg twice a day for 7 days

Lactating Above Plus PQ on Day 4

0.75 mg per kg, single dose


• Severe Pf MalariaQuinine Dihydrochloride Infusion +

Clindamycin IV

Population Group Medicine Dosing Schedule

Loading Dose Maintenance DosePregnant Women Quinine

Dihydrochloride20 mg/kg infused over 4 hours (in 500 ml 5% dextrose water or 0.9% saline)

10 mg/kg every 8 hours infused over 2-4 hours

If patient can already tolerate oral meds, shift to oral QN Sulphate (10 mg/kg every 8 hours) to complete 7 days at same dose

Clindamycin 10 mg/kg IV twice a day; shift to oral clindamycin; as soon as patient tolerates oral clindamycin at same dose to complete 7 days

Lactating Women Above Plus PQ after 7 days of Clindamycin

0.75 mg per kg, single dose


Plasmodium vivax, ovale, malaria and Mixed Infection acute P. vivax or P. Ovale -

No. of Chloroquine Tablet(150 mg base/tablet)

Primaquine(15 mg base/tablet)

Day of Treatment Day 1 Day 2 Day 3 Pregnant Women: Withheld until delivery.Lactating Women: Take Primaquine beginning Day 4 to Day 17at 0.5 mg/kg b.w. per dayPost-partum Women (2 weeks after delivery) for 14 days at 0.5 mg/kg b.w. per day

By weight 10 mg/kg 10 mg/kg 5 mg/kgIf weight cannot be taken

4 tabs 4 tabs 2 tabs

Treatment for Pregnant women and Lactating mother Dosing Schedule for Pregnant and

Lactating Mothers with Relapse P. vivax Malaria

Infection

Chloroquine Tablet(150 mg base/tablet)

Primaquine Tablet(15 mg base/tablet)

Wk1 Wk2 Wk3 Wk4 Wk5 Wk6 Wk7 Wk8 Pregnant Women: Withheld until deliveryLactating Women: Take Primaquine beginning Day 4 up to Day 17 at 0.5 – 0.75 mg/kg b.w. per day to a maximum of 30 – 45 mg per dayPost-partum Women (2 weeks after delivery) for 14 days at 0.5 – 0.75 mg/kg/b.w. per day to a maximum of 30 – 45 mg per day

2tabs

2tabs

2tabs

2tabs

2tabs

2tabs

2tabs

2tabs

Treatment for Pregnant women and Lactating mother• Dosing Schedule for Pregnant and Lactating

Mothers with P. malariae Malaria Infection

No. of Chloroquine Tablet(150 mg base/tablet)

Primaquine(15 mg base/tablet)

Day of Treatment Day 1 Day 2 Day 3 Pregnant Women: Withheld until deliveryLactating Women: Take Primaquine on Day 4 at 0.75 mg/kg/b.w. Post-partum Women (2 weeks after delivery) single dose at 0.75 mg/kg/b.w.

By weight 10 mg/kg 10 mg/kg 5 mg/kg

If weight cannot be taken

4 tabs 4 tabs 2 tabs

Treatment for Pregnant women and Lactating motherDosing Schedule for 2nd and 3rd Trimester

Pregnant and Lactating Mothers With Mixed

Infection

Day of Treatment ALUse weight in kgs as basis If weight cannot be taken, use

age as basis< 35 kgs (≥35 kg 9 - 13 y.o. > 13 y.o.

Day 1 3 tabs 4 tabs 3 tabs 4 tabs8 hrs after 3 tabs 4 tabs 3 tabs 4 tabsDay 2 3 tabs twice a day

(BID)4 tabs twice a

day (BID)3 tabs twice a

day (BID)4 tabs

Day 3 3 tabs twice a day (BID)

4 tabs twice a day (BID)



Day 4-17 PQ(1) For Pregnant Women: withheld until delivery(2) For Post Partum/Lactating Women: Use 0.5 mg base per kg per day

1 tab daily

Age Group/ Condition

Quinine Sulfate (300 or 600 mg/tablet)

Plus

Clindamycin

Children < 8 years old

10 mg salt/kg bw dose every 8 hours for 7 days


Treatment- Uncomplicated Plasmodium falciparum Malaria in children

< 6 months of age

Day of treatment Artemether-Lumefantrine Use body weight in kgs as basis (

5-<15 kg


6 mon- 3 yo

Day 1 1 tab

8 hrs after 1 tab

Day 2 1 tab BID

Day 3 1 tab BID


6 – 11 months

Day of treatment


5-<15 kg 15 - < 25 kg 25-<35 kg > 35 kg


6 mon- 3 yo 4-8 yo 9-13-yo If > 35 kg







Day4



< 1 yo 1-3yo 4-6 yo 7 -11 yo > 12 yo

Contraindicated

½ PQ single dose




Dosing Schedule of Quinine Dihydrochloride in the Treatment for Severe Plasmodium falciparum Malaria Infection in children

Age Group Quinine DihydrochlorideLoading Dose Maintenance Dose

Children 8 years to 16 years

15 mg salt/kg IV drip for 4 hours in 10 ml/kg D5W or 0.9 NaCl (infusion rate must not exceed 5mg/kg per hour)

10 mg salt/kg IV drip for 4 hours every 8 hours in D5W or 0.9 NaCl

Children 7 years and younger

10 mg salt/kg in IV drip for 4 hours

10 mg salt/kg IV drip every 12 hours

Dosing Schedule for Pre-referral Treatment with Artesunate Suppository In Children Aged 2-15 Years and Weighing at Least 5 kg

Weight (kg)

Age Artesunate dose (mg)

Regimen (single dose) (available in 50 mg, 200 mg and

400 mg suppositories)

5 – 8.9 0 - 12 months 50 One 50 mg

9 – 19 13- 42 months 100 Two 50 mg

20 – 29 43- 60 months 200 One 200 mg

30 – 39 6 - 13 years 300 Two 50 mg and one 200 mg

> 40 > 14 years 400 One 400 mg

Congenital and Neonatal Malaria

In endemic areas, this condition is diagnosed only when parasites are identified within 14 days after birth

If parasites are seen in blood films after the first week of life, neonatal malaria is a possibility

Day 1: 10 mg/kgDay 2: 10 mg/kgDay 3: 5 mg/kg (half dose of Days 1 and 2)

suspected when blood has been transfused within the past six months

Transfusion Malaria

Drug Resistant Malaria - P. falciparum case

Classification of Treatment Outcomes (WHO, 2005)Response Criteria

Adequate Clinical and Parasitological Response (ACPR)

Absence of parasitemia on Day 28 irrespective of temperature, without meeting any of the criteria of Early Treatment Failure or Late Clinical Failure or Late Parasitological Failure.

Early Treatment Failure (ETF)

Development of danger signs or severe malaria on Day 1, Day 2 or Day 3 in the presence of parasitemia; ORParasitemia on Day 2 higher than Day 0 count irrespective of axillary temperature; ORParasitemia on Day 3 with axillary temperature ≥ 37.5 °C; ORParasitemia on Day 3 ≥ 25% of count on Day 0.

Late Clinical Failure (LCF)

Development of danger signs or severe malaria on any day from Day 4 to Day 28 in the presence of parasitemia, without previously meeting any of the criteria of Early Treatment Failure; ORPresence of parasitemia and axillary temperature ≥ 37.5oC (or history of fever) on any day from Day 4 to Day 28, without previously meeting any of the criteria of ETF.

Late Parasitological Failure (LPF)

Presence of parasitemia on any of the scheduled return on Day 7, Day 14, Day 21 or Day 28, and axillary temperature < 37.5oC without previously meeting any of the criteria of ETF.

Dosing Schedule of Artemether-Lumefantrine (AL)and Primaquine (PQ) in the Treatment of Uncomplicated Plasmodium

falciparum Malaria Infection

Drug Resistant Malaria - P. Vivax case

Day of treatment


5-<15 kg 15 - < 25 kg 25-<35 kg > 35 kg


6 mon- 3 yo 4-8 yo 9-13-yo If > 35 kg







Day4



< 1 yo 1-3yo 4-6 yo 7 -11 yo > 12 yo

Contraindicated

½ PQ single dose




Drug Dosages and Schedule for Chemoprophylaxis

Drugs Schedule DosePregnant Adult Pediatric

A. For People Travelling To Endemic AreasDoxycycline Tablet (100 mg)

Start two to three days prior to travel, daily while in the area and continue up to four weeks upon leaving the area

contraindicated

1 tablet < 8 years: contraindicated> 8 years old:2 mg/kg up to 100 mg daily

MefloquineTablet (250 mg base)

Start 1-2 weeks before travel; take weekly while in the area, and continue up to four weeks upon leaving the area

contraindicated

1 tablet weekly < 45 kg: 5 mg/kg bw5-10 kg ⅛ tab10-19 kg ¼ tab 20-30 kg ½ tab31-45 kg ¾ tab

Drug Dosages and Schedule for Chemoprophylaxis

Drugs Schedule DosePregnant Adult Pediatric

A. For People Travelling To Endemic AreasCholoroquine Start 2 weeks

before travel, take weekly while in the area and continue 4 weeks after leaving the area

2 tablets NA < 8 years: 5 mg/kg b.w. < 8 years: 2 tablets

B. For Pregnant Women Residing in Endemic AreasSulphadoxine Pyrimethamiine

If resident in stable transmission area

3 tablets eachon 2nd and 3rd

trimesters only

malaria

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