THE PATTERN OF MALARIA

TREATMENT IN KUALA LIPIS

HOSPITAL, PAHANG

Norsyazana Ab Hashim

Sean Kwong Kien Seang

Phuan Ke Shin

Department of Pharmacy

Hospital Kuala Lipis

INTRODUCTION

Malaria is one of the serious diseases causedby parasitic protozoan, plasmodium spp. thatis spread to people through infectedAnopheles mosquito.

Common features and symptoms of malariaare nonspecific and there include fever,fatigue, headache, muscle and joint painwhich severe case it can lead to coma ordeath.

Malaysia is one of the countries with highrisk of malaria transmission(Rahman et al,1997)

PROBLEM STATEMENT

Among Peninsular Malaysia, Pahang had beenreported as having the highest cases of malaria since1985 (Mak et al, 1992).

In recent years, there are reports of increase in theincidence of malaria cases in Lipis Hospital (UnitRekod,Lipis Hospital) which cause burden in term oftreatment cost to the hospital.

The studies of malaria are scarce in Pahang state,specifically in Lipis district where malaria is known toexist. Information such as knowledge of the commonspecies of malaria in Lipis area is important foreffectiveness treatment of malaria.

RESEARCH QUESTIONS/ OBJECTIVES

General objective:

To identify the relationship between treatment received for

various malaria species and the patients’ clinical outcome

Specific objective:

To determine the demographic features of malaria cases in

Hospital Kuala Lipis, Pahang for past 3 years from 2011 to

2013

To identify the relationship between treatment received for

plasmodium knowlesi and the patients’ clinical outcome.

DEFINITION

Treatment received:

artemisinin-based:

Artemether plus lumefantrine combination

(riamet®) and artesunate are classified as

artemisinin-based regime

non-artemisinin-based:

Combination oral quinine with primaquine

or sulfadoxine-pyrimethamine (fansidar®)

represent as non-artemisinin-based

LITERATURE REVIEW

Malaria category:

Malaria can be divided into complicated and uncomplicatedmalaria(WHO, 2010)

Plasmadium knowlesi:

Previously malaria refers to four strains of plasmodium spp. Fifthmalaria cases caused by plasmodium knowlesi is being recognizedmore and more commonly in Southeast Asia including Malaysia.(Singh B et al, 2004)

There is limited information on treatment guideline forp.knowlesi(Timothy W et al,2011)

Most of uncomplicated p.knowlesi cases responded well towardscholoquine plus primaquine(Daneshvar et al,2009)

LITERATURE REVIEW Treatment option for various malaria species:

Rajahram et al (2012) had highlighted the issue of

standardising the treatment for severe malaria regardless of

the species due to the complications including death

SEAQUAMAT study had also suggested that parenteral

artesunate is preferred over quinine for patients with severe

P. falciparum malaria. (Prof M Abul Faiz et al.,2005)

Artemisinin-based combination therapy such as artemether

and lumefantrine (riamet®) was the treatment of choice for

uncomplicated P. falciparum malaria and P. vivax (Barber et

al.,2013).

P. ovale and P. malariae malaria can be treated adequately

with chloroquine since there was rarely resistance towards

chloroquine( non artemisinin based)(WHO,2010).

RESEARCH METHOD

Study design

cross sectional, retrospective study.

Study Period

Jan 2011 to Decemeber 2013.

Study area

Hospital Lipis

RESEARCH METHOD Study population

Inclusion criteria:

Patients aged 13 years and above with malaria cases

Exclusion criteria:

patients were discharge at their own risk

pregnant or lactating mother

patient with known allergy to any of the anti-malarial

medications.

Sampling

non random purposive sampling based on the name list

recorded in ‘Unit Rekod’ Hospital Lipis

RESEARCH METHOD

Data Collection

Patient case note from ‘Unit Rekod’ Hospital KualaLipis.

The indicator used to determine the clinical outcomes ofmalaria patient

Time taken to achieve afebrile (days)

Length of hospital stay (days)

Time to achieve BFMP clearance (days)

Effectiveness of different type of treatment was measuredby classifying the patients into two groups depending onthe treatment received:

artemisinin-based therapy

non-artemisinin-based therapy

RESEARCH METHOD

Data Analysis

statistical package for social sciences (SPSS) program version19 and Microsoft excel.

Kruskal Wallis test was used to test for an association betweenvarious malaria species against the study variable which aretime to achieve afebrile, BFMP clearance and length ofhospital stay (clinical outcome).

Independent t-tests were used to observe the associationbetween artemisinin based therapies against non- artemisininbased therapy for uncomplicated plamodium knowlesi.

A p-value of <0.05 was defined as significant associationbetween the dependent and independent variables.

FINDINGS/ RESULT

Patients Demographic Data

Variable Number (%)

Gender

Male 102

Female 24

Locality

Felda 20

Rural area 96

Urban area 10

FINDINGS/ RESULT

0

20

40

60

2011 2012 2013

Plasmodium falciparum

Plasmodium malariae

Plasmodim knowlesi

Plasmodium vivax

TOTAL

Trend of Malaria Cases from 2011 to 2013 in Kuala Lipis Hospital

FINDINGS/ RESULT Treatment option among all species of malaria in Kuala

Lipis Hospital

0102030405060

Nu

mb

er o

f P

ati

en

t

Species of Malaria

Treatment option among all malaria

species

artemisinin base

non artemisinin

base

FINDINGS/ RESULT

Type of treatment P-value a

Artemisinin

bases(N=16)

Non artemisinin

bases (N=88)

mean time to

achieve afebrile

(days)

3.13± 0.957 3.31±1.216 P = 0.573

mean time to

achieve BFMP

clearance (days)

4.06± 1.181 4.49± 1.061 P = 0.150

mean length of

hospital

stay(days)

5.94± 1.289 6.26±1.160 P = 0.315

Table: Association between mean time to achieve afebrile, time toachieve BFMP clearance and length of hospital stay with type oftreatment in all species

a independent t-test

FINDINGS/ RESULT

Type of treatment P-value

artemisinin base

(N=15)

Non artemisinin

base (N=16)

mean time to

achieve afebrile

(days)

3.13± 0.957 3.00± 0.926 P = 0.715

mean time to

achieve BFMP

clearance (days)

3.13± 0.957 3.00± 0.926 P = 0.715

mean length of

hospital

stay(days)

5.94± 1.289 5.53± 0.640 P = 0.283

Table: Association between mean time to achieve afebrile, time to

achieve BFMP clearance and length of hospital stay with type of

treatment for plasmodium knowlesi

DISCUSSION

Demographic data:

Majority malaria infected patients (76.2%) were come

from rural area. This could be explained by the

geographical that rural area was near to the forest

and felda was involving in plantation of rubber or

palm oil.

A study done by Barber and his colleague found that

almost all malarial infected patients were reported

forest or plantation exposure.(Barber et al., 2013).

DISCUSSION

Demographic data:

Male was the main contributor for the malaria cases

in Kuala Lipis Hospital. This may be due to the

occupation of the patients. Majority of the infected

male patients were working in plantation such as

rubber tapper or palm oil collector. There was higher

chance for them to expose to the vector (mosquitoes).

DISCUSSION

Species of malaria:

In West Malaysia the vectors for P. knowlesi have

been identified as An. hackeri in Selangor and An.

cracens in Kuala Lipis, Pahang. (Singh & Daneshvar,

2010)

Both of these mosquito species prefer to feed on

monkeys rather than humans, which may explain the

plasmodium knowlesi was one of the highest number

of infected malaria species in Hospital Kuala Lipis.

(Singh & Daneshvar, 2010)

DISCUSSION

Treatment option:

The prescribing pattern of antimalarial in Kuala Lipis Hospital

was the combination of more than 1 antimalarial agent. This

strategy was to prevent the resistance of single antimalarial drug

and to be more efficient to kill parasite in the blood stream.

Before 2013, chloroquine was the core antimalarial in the

treatment of all kind of malaria species.

After national drug surveillance on antimalarial was carried out

in whole Malaysia, only riamet or artequine was prescribed to

patient with the species of falciparum, malariae and

knowlesi.(uncomplicated cases)

Since then¸ the spectrum of antimalarial agents used in Kuala

Lipis Hospital has changed. Chloroquine only reserved for

Plasmodium vivax. For complicated malaria, IV artesunate was

using to treat all kind of malaria regardless of species.

DISCUSSION

Clinical outcome vs different types of treatment

regime in all malaria species:

From previous studies concluded that artemisinin

base drug was more effective compare to chloroquine(

non artemisinin) and antifolate agent (Luxemburger,

Nosten, Raimond, Chongsuphajaisiddhi, & White,

1995)

We compared artemisinin base and non artemisinin

base in uncomplicated malaria and we found that

there was no statistical significant different between

these 2 groups in patients’ clinical outcome.

DISCUSSION

Effect on different type of treatment in Plasmodium

knowlesi:

Chloroquine was shown to be effective for uncomplicated

knowlesi malaria in Kapit (Daneshvar et.al,2010),

The retrospective study at QEH found faster parasite

clearance with oral artemisinin combination therapy

(ACT), artemether-lumefantrine (William et.al, 2011)

In the study, we compared the use of chloroquine and

riamet and we could conclude that 2 groups of treatment

were equally effective in treatment of uncomplicated

plasmodium knowlesi.

LIMITATIONS

Case note for malaria cases from record storage

unit Kuala Lipis Hospital were used as one of the

source of data throughout the study. In few, case

note records were not properly filled, therefore

the information obtained was incomplete and no

follow up could be done on all the malaria cases.

CONCLUSION

The main malaria species isolated from the

patients were plasmodium malariae and

plasmodium knowlesi.

All malaria cases regardless of species were

treated with more than 2 antimalarial agent to

prevent resistance of single antimalarial agent

Use of artemisinin derivative in management of

non-complicated malaria did not show superior

effect in all clinical parameter. Frequently, exert

drug pressure in certain drug will promote the

résistance of that agent.

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