10 yr old odisha child was treated for vivax malaria with ACT and primaquine. he had severe anemia and jaundice during treatment eventhough his sensorium was normal. parents are screened and are normal.He turns up after 2 months with mixed infection vivax and falciparum.
when to suspect malaria?
how to dx malria?
how do we manage malria?
when will call it svere?
how to manage severe malaria?
can artesunate be used below 3 yrs?
People living in malaria-endemic areas need to be informed that any febrile disease might be malaria and that malaria can rapidly become a very dangerous disease. They also need to be informed about where they can obtain qualified care for malaria. This is particularly important for migrants to endemic areas (for example temporary labour), who may be ignorant both of what malaria is and where treatment is available.
Diagnosis of malaria-A patient with fever and no other obvious cause is considered a case of suspected malaria
Health professional observing a case of suspected malaria must immediately initiate a diagnostic test by a. Microscopy of blood for malarial parasites and/or b. Rapid Diagnostic Test If a microscopy result can be made available to the provider managing the patient within same day, then only microscopy is done. Antimalarial treatment is given on the basis of a positive slide result. If a microscopy result cannot be available within same day, RDTs are to be used.Diagnosis of malaria
An RDT is done in front of the patient and a slide is taken. If the RDT is negative, the slide is sent for microscopy. If it is positive, the patient is treated according to diagnosis and the slide is discarded in order to reduce the load on microscopy services. Wherever a microscopy result can be made available within same day, microscopy should be maintained as the only routine method
Treatment of Vivax Malaria
Diagnosis of vivax malaria may be made by the use of RDT (Bivalent) or microscopic examination of the blood smear. On confirmation following treatment is to be given: Drug schedule for treatment of P vivax malaria:
1. Chloroquine: 25 mg/kg body weight divided over three days i.e.
10 mg/kg on day 1,
10 mg/kg on day 2 and 5 mg/kg on day 3.
2. Primaquine*: 0.25 mg/kg body weight daily for 14 days.
Primaquine is contraindicated in infants, pregnant women and individuals with G6PD deficiency. Primaquine causes hemolysis in G6PD deficient persons, resulting in dark coloured urine, yellow Conjunctiva, bluish discoloration of lips, abdominal pain, nausea and vomiting, and should be reported to the doctor immediately.
14 day regimen of Primaquine should be given under supervision
Treatment of Falciparum Malaria
Diagnosis of falciparum malaria may be made by the use of RDT (Monovalent or Bivalent) or microscopic examination of the blood smear. It is imperative to start the treatment for falciparum malaria immediately on diagnosis. The treatment for falciparum malaria is as follows:
In North-Eastern States (NE States):
1. ACT-AL Co-formulated tablet of ARTEMETHER( 20 mg) – LUMEFANTRINE (120 mg)
(Not recommended during the first trimester of pregnancy and for children weighing < 5 kg)
5–14 kg( > 5 months to < 3 years) =20 mg/ 120 mg twice daily for 3 days
15–24 kg (≥ 3 to 8years) = 40 mg /240 mg twice daily for 3 days
25–34 kg (≥ 9 to14 years) =60 mg /360 mg twice daily for 3 days
2. Primaquine*: 0.75 mg/kg body weight on day 2
In other States:
1. Artemisinin based Combination Therapy (ACT-SP)*
Artesunate (AS), available as 50 mg tablets are given for three days, and Sulfadoxine-
Pyrimethamine (S-P) tablets, containing 500 mg Sulfadoxine and 25 mg pyrimethamine are given for one day, as shown in the dosage chart below. All tablets for a day should be taken together, Swallowed with water. In addition, Primaquine (PQ Large) tablets should be given on the second day.
Dose schedule for Treatment of uncomplicated P.falciparum cases:
a. Artemisinin based Combination Therapy (ACT-SP)*
Artesunate 4 mg/kg body weight daily for 3 days Plus Sulfadoxine (25 mg/kg body weight) –Pyrimethamine (1.25 mg/kg body weight) on first day.
* ACT is not to be given in 1st trimester of pregnancy.
b. Primaquine*: 0.75 mg/kg body weight on day 2.
Treatment of mixed infections (P.vivax + P.falciparum) cases:
All mixed infections should be treated with full course of ACT and Primaquine 0.25 mg per kg
body weight daily for 14 days.
In North-Eastern States: Treat with: Age-specific ACT-AL for 3 days + Primaquine 0.25 mg per kg body weight daily for 14 days.
In Other States: SP-ACT 3 days + Primaquine 0.25 mg per kg body wt. daily for 14 days.
2.Pvivax_
Dr. Jayaprakash
Superintendent, ICH.
Institute of Child Health.
Gov. Medical College Kottayam.
Kerala, India.