Malaria

B54

*Notifiable disease.

• P. Falciparum malaria, non-severe, uncomplicated
• P. Falciparum malaria, severe, complicated
• P. Ovale , P. Vivax and P. Malariae
• Malaria prophylaxis - self provided care

DESCRIPTION

Malaria is transmitted by the bite of an infected female Anopheles mosquito. The incubation period varies with the species of the parasite, Plasmodium falciparum being shortest, usually 7–21 days, and P. malariae the longest. The incubation period may be prolonged by use of malaria prophylaxis or certain antibiotics.

The confirmation of the diagnosis and treatment of malaria is an emergency as complications develop rapidly. Malaria can be missed outside transmission areas.

DIAGNOSTIC CRITERIA

Clinical

• A child living in, or with recent travel history to a malaria transmission area.
• Fever, which may be intermittent.
• Flu-like symptoms including sweating or rigors, i.e. cold shaking feeling.
• Body pains and headache.
• Occasionally diarrhoea, loss of appetite, nausea and vomiting, tachypnoea and cough.
• A young child may present with fever, poor feeding, lethargy, vomiting, diarrhoea or cough.
• Clinical features are non-specific and overlap with many other infections.

Investigations:

• Testing is urgent. Obtain the result immediately.
  • Rapid diagnostic test.
    In areas where malaria transmission occurs, rapid tests should always be available for malaria screening but cannot be used for monitoring response to treatment as they may remain positive for over 4 weeks.
• Malaria parasites in blood smear – thick and thin smears.
  • One negative malaria test does not exclude the diagnosis.
  • Repeat smears if initially negative, and malaria suspected.
  • If severe malaria suspected, commence therapy and repeat smears after 6–12 hours.
  • Repeat smears after 48 hours and if no improvement in degree of parasitaemia, consider alternative therapy.

If severe malaria is suspected and diagnosis cannot be confirmed immediately, treat while awaiting laboratory results.

P. FALCIPARUM MALARIA, NON-SEVERE, UNCOMPLICATED

B50.9

DESCRIPTION

A child with uncomplicated malaria is alert, can tolerate oral medication, has an age appropriate level of consciousness and has no clinical or laboratory evidence of severe malaria.

Ideally treatment should be started in hospital. Initial doses should be directly observed. Observe for 1 hour to ensure dose is not vomited.

MEDICINE TREATMENT

Treat according to the National Malaria Guidelines.

Option 1:
Only for clearly uncomplicated, low risk malaria cases (>5 kg):

• Artemether/lumefantrine 20/120mg, oral, with fat-containing food/milk to ensure adequate absorption.
  • Give first dose immediately.
  • Follow with second dose 8 hours later.
  • Then 12 hourly for another 2 days (total number of doses in 3 days = 6).

OR
Option 2:
Manage children <5 kg with uncomplicated malaria with quinine plus clindamycin:

• Quinine, oral, 10 mg/kg/dose 8 hourly for 7–10 days.

2–3 days after initiating treatment with quinine:

• Clindamycin, oral, 10 mg/kg/dose 12 hourly for 7 days.

Children who are vomiting but who have no other indications of severe malaria:

• Quinine, IV, 10 mg/kg/dose 8 hourly administered over 4–6 hours.
  • ECG and heart rate monitoring.
  • Monitor blood glucose levels regularly.
  • Switch to oral medication once able to do so.

P. FALCIPARUM MALARIA, SEVERE, COMPLICATED

(OR IF REPEATED VOMITING)

B50.0/B50.8

DIAGNOSTIC CRITERIA

Clinical

• Unable to drink or breastfeed.
• Vomits everything.
• Renal failure.
• Cerebral malaria: manifests with convulsions, which may be subtle, and/or any change in mental state, ranging from irritability, lethargy to coma, stiff neck or bulging fontanelle.
• Respiratory distress and metabolic acidosis similar to pneumonia.
• Anaemia: can be severe and lead to cardiac failure and a depressed mental state.
• Shock: cold moist skin, low blood pressure and evidence of poor peripheral perfusion.
• Hypoglycaemia: can present with convulsions and a depressed mental state.
• Jaundice, bleeding, acute renal failure and ARDS are less common in children than adults.

Investigations

• Hyperparasitaemia: >5% of RBCs infected indicates severe malaria but a lower parasite density does not exclude severe malaria.
• Low Hb (< 6 g/dL).
• Test glucose immediately with a fingerprick test. Low blood glucose (< 2.2mmol/L).
• Acidosis: serum lactate (venous) >5mmol/L or bicarbonate <15mmol/L.
• Severe thrombocytopaenia: <50x10⁹/L.
• In severe cases, repeat smear after 72 hours and after the completion of the course of treatment.

GENERAL AND SUPPORTIVE MEASURES

• Check airway, breathing, circulation (ABC).
• Admit to high care or intensive care unit.
• Review the child at least twice daily, including holidays.
• Avoid overhydration.
• Control convulsions.
• Ventilatory support, if necessary.
• Agitation and respiratory distress can be as a result of severe metabolic acidosis. Treat shock and acidosis. See Chapter: Emergencies and Trauma, Shock .
• Nutritional support.

MEDICINE TREATMENT

Urgent:

• Prefered option: Artesunate, IVI, 2.4mg/kg at hours 0, 12 and 24, then daily until patient is able to tolerate oral treatment.
  Alternative option: Quinine, IV infusion, diluted in 5–10 mL/kg dextrose 5% or sodium chloride 0.9%.
  • Loading dose: 20mg/kg over 4 hours (loading dose).
  • Follow with 10mg/kg over 4–6 hours at 8 hourly intervals until able to take oral therapy.
  • ECG monitoring.
  • Monitor blood glucose levels.

2–3 days after initiating treatment with artesunate or quinine and able to swallow, switch to any of the 2 regimens:

Children > 5 kg:

• Artemether/lumefantrine 20/120mg, oral, with fat-containing food/milk to ensure adequate absorption.
  • Give first dose immediately.
  • Follow with second dose 8 hours later.
  • Then 12 hourly for another 2 days (total number of doses in 3 days = 6).

OR

Children < 5 kg

• Quinine, oral, 10 mg/kg/dose 8 hourly to complete 7–10 day course.
  

PLUS

• Clindamycin, oral, 10 mg/kg/dose 12 hourly for 7 days.

For concurrent bacterial sepsis:

• Ceftriaxone, IV, 100 mg/kg as a single daily dose once daily for 10 days.
  • Maximum dose: 4 000 mg/24 hours.

For fever:

• Paracetamol, oral, 15 mg/kg/dose, 6 hourly as required.

For hypoglycaemia:

• Dextrose 10%, IV, 4 ml/kg.

If Hb < 7 g/dL:

• Packed red cells, IV, 10 mL/kg over 3 hours.

Note:

Fluid loss is often underestimated in a febrile, vomiting, sweating child.

REFERRAL

• Urgent: Severe or complicated malaria.
• High-risk children under 2 years, splenectomised patients.
• Malaria not responding clinically to adequate treatment within 48–72 hours (possible resistance).

P. OVALE , P VIVAX AND P. MALARIAE

B53.0/B51.9/B52.9

• Chloroquine, oral, 10 mg base/kg as a single dose,
  • Follow with 5 mg base/kg given 6, 24 and 48 hours after the first dose.

PLUS (for P. Ovale and/or P. vivax )
To eradicate the organism:

• Primaquine, oral, 0.25mg base/kg/day for 14 days (obtained using section 21 approval).
  • Continue chloroquine once weekly until primaquine is obtained.

Note: Exclude G6PD deficiency before prescribing primaquine for non-falciparum malaria.

MALARIA PROPHYLAXIS - SELF PROVIDED CARE

In the high-risk malaria areas from September to May in South Africa, malaria prophylaxis should be used, together with preventive measures against mosquito bites. State facilities do not provide prophylactic therapy. It is recommended that persons intending to travel to high-risk areas take the relevant prophylactic therapy.

Preventative measures against mosquito bites include:

• Use of treated mosquito nets, screens, coils or pads.
• Application of insect repellent to exposed skin and clothing.
• Wearing long sleeves, long trousers and socks if outside between dusk and dawn, as mosquitoes are most active at this time.
• Visiting endemic areas only during the dry season.

CAUTION
Pregnant women and children under 5 years should avoid visiting malaria-endemic areas, as they are more prone to the serious complications of malaria

For chemoprophylaxis refer to National Malaria Prevention Guidelines, 2009.