Case Management, Diagnosis and Drug Policy

	Protocol for Malaria Case Management at the Health Facility
	Antimalarial Drugs
	Recommended Malarial Chemoprophylaxis in Southern Africa
	Case Management, Diagnosis and Drug Policy Chart

Malaria case management forms one of the core interventions of the global strategy for malaria control. Early diagnosis and prompt treatment form the basis of effective case management. It impacts directly on morbidity and mortality by ensuring that simple malaria is treated adequately thereby reducing the chances of it progressing to severe disease. Severe malaria is associated with increased mortality. In this regard, more than 200,000 people die of malaria in southern Africa annually.

Early Diagnosis: Early diagnosis requires knowledge of malaria symptoms and signs and hence the use of IEC materials at home, community and health centre needs to be strengthened. Early diagnosis entails early recognition of malaria symptoms and signs and the ability to take appropriate action. At home/community and health centre level, it requires ability to recognize both simple and severe forms of malaria and to make deliberate decision to refer severe cases. At District and higher levels of care, it will further entail the ability to definitely diagnose suspected severe malaria cases early in order to support treatment.

Prompt treatment: Effective case management requires access to effective anti-malarials. This means that the drugs need to be available as close to the patient as possible. The drugs should be available and accessible and presented in a way that will improve compliance and proper usage at lower levels of care. Prompt and correct treatment does not only reduce progression of simple malaria to severe disease but also contributes in preventing the development of parasite drug resistance. Increased parasite resistance is onother factor that contributes to ineffective case management. In low malaria transmission countries, effective treatment has also been shown to reduce transmission. Hence it is important that national authorities formulate and implement national drug policies with effective first line regimes.

Drug Policy: In southern Africa, parasite resistance to chloroquine ranges between 12-56% with sulphadoxine – pyrimethamine resistance reaching up to 15%. Faced with such increased resistance to mono therapy, there has been a general shift to combination therapy for simple malaria. The type of combinations being adopted for simple malaria are either artemisinin based or non-artemisinin based combinations. To support this process countries have been carrying out drug efficacy studies annually. This helps to monitor the rate of development of parasite resistance and the effectiveness of first line drug regimes. However, the drug of choice for severe malaria still remains quinine.

Bulletins

	Malaria and Anaemia in Southern Africa
	Improving Access and Quality of Management
	Malaria and HIV Co-Infections....
	Malaria in Pregnancy
	Severe Malaria in the African Region - Results of Multicentre Studies
	Combination Therapy for Uncomplicated Malaria in Africa
	RBM-IMCI Linkages: A Strategy for Case Management in Children Below The Age of Five Years
	Malaria in Pregnancy in the Africa Region
	More Publications

Reference Documents

	Assessment of the Safety of Artemisinin Compounds in Pregnancy
	Clinical, Behavioural and Socioeconomic Factors Related to Severe Malaria
	Assessment of Therapeutic Efficacy of Antimalarial Drugs
	Diagnosis and Management of Severe Falciparum Malaria - Learners Guide
	Diagnosis and Management of Severe Falciparum Malaria - Tutors Guide
	Drug Resistance in Malaria
	Guidelines For The Evaluation Of Plasmodium Falciparum Vaccines
	Instructions For Use Of The In Vitro Micro-Test Kit (Mark III)
	Malaria - A Manual for Community Health Workers
	Management of Severe Malaria - A Practical Handbook

Malaria Life Cycle and Mode of Action of Antimalarial Drugs - Site of Antimalarial Drug Actions

Protocol for Malaria Case Management at the Health Facility

WHEN A PATIENT PRESENTS WITH FEVER:		Determine: Age, sex and Last Menstrual Period (if female)
STEP 1	STEP 2	STEP 3	STEP 4	STEP 5
TAKE RELEVANT HISTORY	CONDUCT PHYSICAL EXAMINATION	ESTABLISH DIAGNOSIS	TREATMENT	COUNSELING, NURSING CARE AND FOLLOW UP
Fever Onset and duration Related symptoms Headache, chills, rigors, anorexia or refusal of feeds. Symptoms of severe malaria Inability to feed or drink Protracted vomiting Convulsions Altered level of consciousness Extreme weakness Abnormal behavior Abnormal breathing Reduced urinary output Colour of urine Pregnancy in female patients Exclude other causes of fever ARI-cough and running nose Mumps-parotid swelling Measles-generalized rash Ear ache / discharge UTI -dysuria and loin pain Sore throat Treatment before presentation Antimalarial drugs Name and dose Route Number of doses Time of last dose Any Other treatment	To identify related signs check: Temperature Weight Spleen Signs of severe malaria Level of consciousness Convulsions Severe Pallor Hyperpyrexia Jaundice Dehydration Respiratory distress To exclude other diseases Inflammation of ears / throat Neck stiffness Full fontanels in infants Generalized skin rash Parotid swelling Abnormal fast breathing Abnormal chest finding	Clinical diagnosis Uncomplicated malaria Fever + any related symptoms Severe malaria Malaria + any feature of Severe disease Laboratory diagnosis Blood smear for malaria parasite determination Rapid immunological tests Desirable in all cases but compulsory in the following situations: Severe disease Treatment failure Person from non-endemic areas Other laboratory tests Haematocrit/haemoglobin Blood sugar level Lumber puncture in the unconscious patient Urinalysis Electrolyte and urea	Uncomplicated malaria Chloroquine (orally) 10mg/kg Day 0 and Day 1 5mg/kg day 3 as a single daily doses **If there is repeated vomiting and malaria not severe, then give* IM Chloroquine 3.5mg/kg every 6 hours until patient is able to take orally. Treatment is continued orally to complete 25mg/kg total dose. Sulphadoxine/pyrimethamine If not tolerant of CQ If there is treatment failure Where it is first line drug Dosage: Adults 3 tabs (single dose) Children 5mg/kg of sulfadoxine 1.25mg/kg pyrimethamine Severe Malaria Quinine 20 mg/kg loading dose IV / IM Then 10mg/kg every 12 hr until patient can take orally Then change to oral quinine 10mg/kg 8hrly to complete 7 days or S-P single oral treatment dose. Supportive care Control fever – expose / paracetamol Control convulsion Provide calorie iv or via N-G Tube Blood transfusion in severe anaemia	Counseling Use of antimalarial drugs Features of severity Follow-up visits Severe malaria Nursing and Quality of care Monitor vital signs every 6hrs Monitor fluid input & output Monitor level of consciousness Open a drug chart If pregnant watch for hypoglyceamia, anaemia & pulmonary edema. Also monitor fetal well being. Laboratory monitoring Monitor parasitaemia Monitor blood glucose Monitor Hb/HCT Assessment of recovery Coma Motor function (sit, stand, walk) Assess vision and hearing Organize follow up Give health education on malaria control Personal protection Insecticide treated nets Chemoprophylaxis Environmental sanitation and elimination of mosquito breading sites

COUNTRY	Community level / Across the counter	Primary level	Secondary level	Tertiary Level	Chemoprophylaxis
ANGOLA
BOTSWANA *(1999 – draft)	Restricted	S-P (UM –1^st line)	S-P (UM-1^st line) QN (UM –2^nd line; SM-1^st line)	S-P (UM) QN (UM-2^nd line, SM-1^st line) QN + CO-TIMOXAZOLE or DOXYCYCLINE (SM –QN failure)	CQ + PROGUANIL
MALAWI*(1997)	S-P (UM –1^st line)	S-P (UM –1^st line)	S-P (UM- 1^st line) CQ ( UM-prescription only) QN (UM –2^nd line; SM –1^st line)	S-P (UM) CHLOROQUINE QUININE (UM / SM)	CQ + PROGUANIL PROGUANIL MEFLOQUINE DOXYCYCLINE
MOZAMBIQUE*(1995)	Only on license form the MOH in special circumstances	CQ (UM- 1^st line)	CQ (UM –1^st line) S-P (UM-2^nd line;1^st line during epidemics) HALOFANTRINE (UM –3^rd line) QN (UM – 4^th line; SM – 1^st line)	CQ (UM) S-P (UM – 2^nd line) QUININE (SM –1^st line)	MEFLOQUINE(Tourist) CHLOROQUINE (Pregnant women)
NAMIBIA*(1995)	CQ (UM –1^st line) In special circumstances	CQ (UM- 1^st line)	CQ (UM –1^st line) S-P (UM – 2^nd line) QUININE (SM – 1^st line)	CQ (UM) S-P (UM) QUININE (SM)	CQ + PROGUANIL
SOUTH AFRICA*(1996)	Restricted	S-P (UM –1^st line) QN (UM – 2^nd line) CQ (UM in CQ sensitive areas)	S-P (UM) QN (UM ; SM) CQ (UM –CQ sensitive areas) QN + DOXYCYCLINE (SM) MEFLOQUINE (UM) HALOFANTRINE (UM) PRIMAQUINE(mixed infections) ARTEMISININ DERIVATIVES (SM)	S-P (UM) QN (UM / SM) CQ (UM –CQ sensitive areas) MEFLOQUINE (UM) HALOFANTRINE (UM) PRIMAQUINE (mixed infections) QN + DOXYCYCLINE (SM) ARTEMISININ DERIVATIVES (SM)	CQ + PROGUANIL MEFLOQUINE
SWAZILAND	Restricted	CQ (UM –1^st line)	CQ, S-P (UM –1^st & 2^nd line) QN (SM –1^st line)	CQ, S-P (UM –1^st & 2^nd line) QN (SM –1^st line)	CQ (Pregnant women) CQ + Prog (Tourist)
TANZANIA*(1997)	CQ (UM –1^st line)	CQ (UM –1^st line) i.m CQ (SM – 1^st dose)	CQ (UM –1^st line) S-P (UM – 2^nd line) i.m. CQ (SM 1^st dose)	CQ (UM –1^st line) S-P (UM – 2^nd line) QN (SM – 1^st line)	CQ (pregnant Women)
ZAMBIA*(1997)	CQ (UM – 1^st line)	CQ (UM – 1^st line) S-P (UM –2^nd line) QN (SM –1^st dose)	CQ (UM) S-P (UM –2^nd line) QN (SM – 1^st line)	CQ (UM) S-P (UM) QN (SM)	CQ (CQ sensitive areas) CQ + PROGUANIL Proguanil (SCA)
ZIMBABWE*(1997)	CQ (UM – 1^st line)	CQ (UM - 1^st line) QN (SM –1^st dose)	CQ (UM –1^st line drug) S-P (UM –2^nd line drug) QN (SM –1^st line drug)	CQ (UM) S-P (UM –2^nd line) QN (SM- 1^st line) QN + DOXYCYCLINE (SM –2^nd line)	PYRIMETHAMINE + DAPSONE CQ + PROGUANIL (if dapsone not tolerated especially in pregnancy)
WHO RECOMMENDATIONS	First Line drug for uncomplicated malaria	First line drug for uncomplicated malaria. First dose quinine (i.m.) for severe malaria before referral Chemoprophylaxis in pregnancy	First and second line drug for uncomplicated malaria Quinine (i.v. / oral) for complete treatment of severe disease. Chemoprophylaxis in Pregnancy	First and second line drug for uncomplicated malaria Quinine (i.v. / oral) for complete treatment of severe malaria Chemoprophylaxis in Pregnancy	Tourist (non-immune) Mefloquine or Chloroquine + proguanil Pregnant women - chloroquine

* Year National malaria guidelines were produced

Abbreviations

CQ - Chloroquine
QN – Quinine
S-P – Sulfadoxine / pyrimethamine
UM – Acute uncomplicated malaria
SM – Severe malaria
i.m. – intramuscular injection
SCA – Sickle cell anemia patients.
MOH – Ministry of Health

Recommended Malarial Chemoprophylaxis in Southern Africa

COUNTRY	Pregnant women		Children > 5year		Internal TRAVELLERS		International Travelers		WHO recommendation for international travelers¹
COUNTRY	Drug	Dosage	Drug	Dosage	*Drug*	*Dosage*	*Drug*	*Dosage*	*Drug*	*Dosage*
Angola									MEFL	5mg base/kg wkly1 week before and 4 weeks after.
Botswana* (1999-draft)	CQ + Prog-During pregnancy & until 6 weeks after.	CQ.300mg/wklyProg. 200mg dly			CQ + Prog-1 week before, 4 weeks after	CQ.300mg/wkly (10mg base/kg) Prog. 200mg dly (3.5 mg/kg)	CQ + Prog- 1 week before, 4 weeks after	CQ.300mg/wkly (10mg base/kg) Prog. 200mg dly (3.5 mg/kg)	MEFL	5mg base/kg wkly1 week before and 4 weeks after.
Malawi* (1997)	2 Intermittent therapeutic dose of S-P. 2^nd & 3^rd trimester.	3 tabs. Stat –2^nd trimester, repeat at between 28-34 weeks of gestation.	** Prog.	100 –200 mg/dly			CQ + Prog-1 week before, 4 weeks afterorMEFLOr Doxy	CQ.300mg/wkly (10mg base/kg) Prog. 200mg dly (3.5 mg/kg) MEFL – 5mg/kg Doxy -100mg/dly	MEFL	5mg base/kg wkly1 week before and 4 weeks after.
Mozambique* (1995)	CQ	300mg base/wkly					MEFL	MEFL –5mg/kg	MEFL	5mg base/kg wkly1 week before and 4 weeks after.
Namibia* (1995)	CQ ± Prog.	CQ.300mg/wklyProg. 200mg dly			CQ + Prog	CQ.300mg/wklyProg. 200mg dly	CQ + Prog	CQ.300mg/wklyProg. 200mg dly	CQ+Prog	CQ.300mg/wkly (5mg base /kg) Prog. 200mg dly (3mg /kg)
South Africa* (1996)	CQ + Prog	CQ.300mg/wklyProg. 200mg dly			CQ ± Prog orMEFL or Doxycycline	CQ.300mg/wkly Prog. 200mg dly MEFL –5mg/kg Doxy-100mg/dly	CQ ± Prog orMEFL or Doxycycline	CQ.300mg/wklyProg. 200mg dly MEFL – 5mg/kg Doxy -100mg/dly	MEFL	5mg base/kg wkly1 week before and 4 weeks after.
Swaziland	CQ						CQ + Prog		MEFL	5mg base/kg wkly
Tanzania* (1997)	CQ	Curative dose, then 300mg/wkly till delivery							MEFL	5mg base/kg wkly1 week before and 4 weeks after.
Zambia* (1997)	CQ ± Prog.	CQ.300mg/wklyProg. 200mg dly			CQ ± Prog.	CQ.300mg/wklyProg. 200mg dly	CQ ± Prog.	CQ.300mg/wklyProg. 200mg dly	MEFL	5mg base/kg wkly1 week before and 4 weeks after.
Zimbabwe* (1997)	CQ Pyr/Dap	CQ - Curative dose, then 300mg/wkly till delivery or Pyr/Dap from 2^nd trimester. Folic acid supplement!			Pyr + DapOrCQ + Prog	Pyr 12.5mgDap 100mg/tab(1 tab/ wkly).CQ.300mg/wklyProg..200mg/dly	Advice from country of origin or same as internal travelers.		MEFL	5mg base/kg wkly1 week before and 4 weeks after.

Year National Malaria Guidelines were updated;
** Malawi – under 5’s with recurrent febrile convulsion, persons with Tropical Splenomegaly Syndrome,
Sickle Cell Disease and Splenectomised individuals.

CQ – Chloroquine;
Prog – Proguanil;
Doxy – Doxycycline;
MEFL – Mefloquine;
Pyr – Pyrimethamine;
Dap – Dapsone;
S-P – Sulfadoxine - pyrimethamine