Malaria di sabang 2011 (terapi malaria)

MALARIA:
RECENT MANAGEMENT
KURNIA FITRI JAMIL
Divisi Penyakit Tropik & Infeksi
Bagian/SMF. Ilmu Penyakit Dalam
FK-UNSYIAH/RSUZA
BANDA ACEH - 2011

Outline
 Case illustration
 Severe malaria
 Facts sheet
 Uncomplicated malaria
 Malaria in pregnancy
 Prevention

Cases (per 1,000) by country, 2009
WHO. World Malaria Report 2010
Estimated 300-500 million
clinical cases each year

Mortality (per 1,000) by country, 2009
Approximately 2.5 million die
each year
WHO. World Malaria Report 2010

WHO. 2010
P. falciparum Resistance, 2009

Countries at risk of transmission, 2009
WHO. 2010

Insidence (per 1,000) Indonesia 2008
ACEH 2,03
SUM-UT 8,15
SUM-BAR 2,58
RIAU 3,06
JAMBI 18,08
SUM-SEL 5,46
BENGKULU 22,96
LAMPUNG 2,79
BANGKA BELITUNG 40,58
RIAU 13,32
DKI JAKARTA 0
JAWA BARAT 0,58
JAWA TENGAH 0,07
D I YOGYAKARTA 0,03
JAWA TIMUR 0,71
BANTEN 0,03
B A L I 0,17
NTB 21,85
NTT 0
KAL-BAR 3,23
KAL-TENG 11,21
KAL-SEL 4,20
KAL-TIM 8,59
SUL-UTARA 16,48
SUL- TENGAH 17,81
SUL- SELATAN 1,51
SUL- TENGGARA 10,26
GORONTALO 13,94
SUL- BARAT 11,98
M A L U K U 39,65
MALUKU UTARA 51,42
IRIAN JAYA BARAT 84,74
PAPUA 167,47

Incidence rate tends to decrease, since Gebrak Malaria or Roll
Back Malaria (RBM) initiative in 2000.
In 2008:
AMI decreased to 17.77
API remains in 0.16
Indonesia, Malaria cases
Ministry of Health RI, 2008
API: Annual Parasite Insidence
AMI: Annual Malaria Insidence

Indonesia, Malaria Case Fatality Rate
National target by 2010: number of malaria sufferer would be 5
per 1000 population
Ministry of Health RI, 2008

New Species Case
Human Malaria is caused by one of 4 protozoan parasites:
Plasmodium falciparum
Plasmodium vivax
Plasmodium ovale
Plasmodium malariae
Plasmodium knowlesi ?
( sighh et al, 2008)
http://www.tulane.edu/-wiser/malaria/cmb.html

Todays challenges
 Malaria is still a big concern in Indonesia
health problem
 Challenge of resistance in antimalarial drug
 Treatment policy to overcome the problem by
using artemisinine derivatives
 Clinical malaria diagnosis no longer used
 Malarial elimination program in Indonesia

M A L A R I A
 Many cases worldwide
 High mortality of severe malaria
 Resistance to drugs
 Serious effects in pregnancy
What
can
we
do?

Treatment of malaria
 Ideally all patients should be treated in hospital
 Indications for hospital admission:
 All children ≤ 1 year (and consider admitting
children up to 5 years where possible)
 All pregnant patients
 All patients ≥ 65 years
 Immuno-compromised patients where possible
 Severe malaria or danger signs
GUIDELINES FOR THE TREATMENT OF MALARIA IN SOUTH AFRICA, 2009

Uncomplicated malaria
 Symptomatic malaria without signs of severity or
evidence of vital organ dysfunction.
 Treatment objectives:
 eradicate the infection
 prevent the emergence and spread of drug resistance
 combination of two or more antimalarials with different
mechanisms of action
 Always give a full course of effective treatment
Guidelines for the treatment of malaria, WHO 2010

 Treatment coverage:
 Treatment of P.vivax or P.ovale infection
 Treatment of mild/moderate P.falciparum infection, P.
falciparum and P.vivax mixed infection
 Antimalarial drugs:
Guidelines for the treatment of malaria in Indonesia, Ministry of Health RI, 2009
ACT (1st line) / non-ACT (2nd line) + Primaquine

Artemisinin derivatives
 Very short T½  should be given in a longer period  to
avoid relaps
Prevent resistance
of antimalarial drug
Davis TME, Karunajeewa HA, Ilett KF. Artemisinin-based combination therapies for uncomplicated malaria. MJA 2005; 182 (4):181-5.
Yeung S, Pongtavornpinyo W, Hastings IM, Mills AJ, White NJ Am. J. Trop. Med. Hyg. 2004; 71(Suppl 2): 179–86.
McIntosh H,Olliaro P. Artemisinin derivatives for treating uncomplicated malaria. Cochrane Database of Systematic Reviews 1999.
Combination Artemisinin
& other antimalarial
Drug with different mechanism
Duration
therapy <
T½ >

Artemisinin derivatives
SHOULD NOT be used as
monotherapies for the treatment
of uncomplicated malaria as this
will promote resistance to this
critically important class of
antimalarials

Drugs Composition Form
Artemether +
lumefantrine
20 mg + 120 mg Fixed dose tablets
Artesunate +
amodiakuin
25 mg + 67,5 mg
Fixed dose tablets50 mg + 135 mg
100 mg + 270 mg
50 mg + 150 mg (base) Co-blistered tablets
Artesunate +
meflokuin
200 mg + 250 mg Co-blistered tablets
Dihidroartemisinin
+ piperakuin
40 mg + 320 mg Fixed dose tablets
Artesunate +
sulfadoksin /
pyrimethamine
50 mg + 500/25 mg Co-blistered tablets
World Health Organization. Antimalarial medicines procured by WHO. 2010
Available ACT in 2010, WHO
(Arthemisinin-based Combination Therapy)

WHO recommended ACTs
 Artemether (20 mg) - lumefantrine (120mg)
(Coarthem®) 2 x 4 tablet, in 3 days
 Artesunate (4mg/BW/day) + amodiaquine (10mg/BW/day)
(Artesdiaquine®, Artesuamoon®) once daily in 3days
 Artesunate (4mg/BW/day once daily in 3 days) + Mefloquine (25
mg/BW split over 2 or 3 days)
 Artesunate (4mg/BW/day once daily in 3 days) + Sulfadoxine-
pyrimethamine (25mg/1.25mg base/BW on 1st day)

Guidelines for the treatment of malaria Ministry of Health RI, 2009, WHO 2010
FIRST LINE : ACT + PRIMAQUINE
Treatment of P.vivax or P.ovale infection (1)
Artesunate (200mg/day, in 3 days) +
amodiaquine (600mg/day, in 3 days)
Artemether 20 mg +
lumefantrine 120 mg;
2x4 tablets for 3 days
Dihydroartemisinin 40 mg + piperaquine
320 mg
2 tablets initial dose,
2 tablets in the next 8, 24, and 32 hours
0.25 mg/BW/day
in 14 days

SECOND LINE
QUININE SULFA + PRIMAQUINE
3 X 400-600 mg/day
in 7 days
0.25 mg/BW/day
in 14 days
Guidelines for the treatment of malaria, Ministry of Health RI, 2009, WHO 2010

1st day : 4 + 2 tablets
2nd & 3rd day : 2 tablets
OR
1st & 2nd day : 4 tablets
3rd day : 2 tablets
CHLOROQUINE SENSITIVE
CHLOROQUINE BASE 150 MG + PRIMAQUINE
1 X 15 mg
in 14 days

FIRST LINE
ACT
+
PRIMAQUINE
Treatment of mild/moderate P.falciparum infection,
P. falciparum and P.vivax mixed infection (1)
P falciparum inf.
0.75 mg/BW
single dose
Mixed infection
Day 1-14: 0.25 mg/BW

SECOND LINE
QUININE + DOXY/TETRA + PRIMAQUINE
 Quinine: 3x400-600 mg in 7 days
 Doxycycline: 2 x 2 mg/BW in 7 days
 Tetracycline:4 x 4-5 mg/BW in 7 days
 Primaquine:
 0.25mg/BW in 14 days vivax /mixed
 0.75mg/BW single dose P.F inf.
Treatment of mild/moderate P.falciparum infection,
P. falciparum and P.vivax mixed infection (2)

 Be Aware: risk factor, incubation period, symptom
 Avoid being Bitten by mosquitoes
 Chemoprophylaxis
 Immediately seek Diagnosis & treatment: if fever
occur 1 week – 3 months after arrival in endemic
areas
Key tools of prevention

Malaria Risk Prevention
TIPE I Transmission risk very low Bite avoidance
TIPE II
Risk of malaria vivax or
falciparum which sensitive to
chloroquine
Bite avoidance +
Chemoprophylaxis
(chloroquine)
TIPE III
Risk of malaria vivax
/falciparum, + probability of
chloroquine resistance
Bite avoidance +
Chemoprophylaxis
(according drug
sensitivity in the area)
TIPE IV
 High risk of malaria
falciparum + drug resistance
 Moderate risk of malaria
falciparum + high resistance
WHO. International Travel & Health 2008

Avoid being Bitten by mosquitos
 Insecticide treated net (ITN): (conventional ITN
or Long-lasting insecticidal nets (LLINs) 
prevent infectious mosquito bites.
 Indoor Residual Spraying (IRS): indoor application
of long-lasting chemical insecticides (DDT)
 Other vector (mosquito) controls: larviciding and
environmental management, repellent, clothes,
fogging, domestic insectiside
WHO, The Roll Back Malaria Partnership 2008: Global Malaria Action Plan.

Causal
Prophylaxis
Suppressive
Prophylaxis
Guidelines for Malaria Prevention in Travellers from the United Kingdom. 2007
Chemoprophylaxis

 Recommended drugs:
 Chloroquine
 Proguanil
 Chloroquine + proguanil
 Mefloquine
 Doxicycline
 Atovaquone + proguanil
Chemoprophylaxis

 Recommended by Ministry of Health RI, 2009
 Suppresive prophylaxis (effectivity ~ mefloquine)
 Adult dose: 100mg/day, start on 1st -2nd day before
arrival, until 4 weeks after leaving out the area
 Not recommended for > 3 month of using, children, and
pregnant woman. (Ministry of Health RI, 2009)
 !! Predisposition of Candidosis vagina
Chemoprophylaxis
Doxicycline
Ohrt, C, Richie TL, Widjaja H et al. Annals of Internal Medicine. 1997;126:963-72

 Save: chloroquine and proguanil (+ folic acid
5mg/day) less protection to resistant strain
 Mefloquine:
 Few reported side effects
 Carefully use for 2nd & 3rd trimester pregnancy in area with
chloroquine resistance
 Doxicycline  CONTRA INDICATED
Chemoprophylaxis
In pregnant traveller

 Intermittent Preventive Treatment (IPT, WHO 2007):
Recommended Sulfadoxine-pyrimethamine
 Single dose; minimum use is twice, since trimester II
until partus
 Prevalence of HIV in pregnancy > 10%  the 3rd dose
should be given on the last antenatal care
?
Chemoprophylaxis
In pregnant traveller in endemic area
• World Health Organization. Malaria in pregnancy: guidelines for measuring key monitoring and evaluation indicators. 2007.
• Gamble C, Ekwaru JP, ter Kuile FO. Insecticide-treated nets for preventing malaria in pregnancy. Cochrane Database Syst Rev 2006;2:
CD003755.

 Chemoprophylaxis is pointed for people who
traveling not in a long period
 Not recommended for long term use (3
months)
 Consider of using personal protection (net,
repellent, etc)
Chemoprophylaxis
For long term

Severe malaria
 Clinical manifestation:
 Prostration
 Impaired consciousness
 Respiratory distress
 Multiple convulsions
 Circulatory collapse
 Pulmonary oedema
 Abnormal bleeding
 Haemoglobinuria
 Jaundice
 Laboratory test:
 Severe anaemia
 Hypoglycaemia
 Acidosis
 Renal impairment
 Hyperlactataemia
 Hyperparasitaemia
The presence of one or more of these features:

 Treatment objectives:
 Prevent death
 Prevention of recrudescence, transmission or
emergence of resistance
 Prevention of disabilities
 Principal treatment:
 Supportive therapy
 Antimalarial drug
 Complication management
Severe malaria

 Fluid, acid-base, and electrolyte balance
 Antipyretic
 Anti convulsants:
 Diazepam 10 mg, IV
Severe malaria
Supportive therapy

Artemisinin
 Artemether
▪ Day 1 : 3,2mg/BW/12hours (2 x 1,6mg/BW/12hours;im)
▪ Day 2 - 4 : 1,6mg/BW/day, im
 Artesunate
▪ Day 1 : 2,4mg/BW, iv in 1st hour,  2,4mg/BW/iv in hour 12 & 24
▪ Day 2 - 7 : 2,4mg/BW/hr, iv
After conscious continue with
 Artesunate + amodiaquine OR
 Quinine + Tetracycline / doxycycline / clindamycin
Severe malaria
Antimalarial drugs (1)

Quinine HCl 25%
 Diluted in 500cc dextrose 5% or NaCl 0.9%, give during
the first 4 hours, then rest in the next 4 hours:
▪ Loading dose: 20 mg/BW (single dose)
▪ Maintenance dose: 10 mg/BW, repeat until the patient able to
receive oral medication
 After conscious, continue by oral quinine 10mg/BW
every 8 hours, + tetracycline / doxicycline / clindamycin
until day 7.
Severe malaria

Severe malaria
Complication management
 Hypoglycaemia
 Dextrose 40%, IV bolus 25-50 cc, then dextrose 10%, drip
500 cc every 4-6 hours
 Keep the nutrition intake (NGT)
 Acute kidney failure
 Keep the fluid & electrolyte balance
 Dyalisis (if there is an indication)
 Lung oedema / ARDS
 Fluid & electrolyte balance (max 1500 cc/24 hours)
 Diuretic
 Ventilator

Indication:
 Parasitaemia> 30% without severe complication
 Parasitaemia> 10%:
 With severe complication
 With treatment failure after 12-24 hours optimal
antimalarial
 With bad prognosis (old age, late stage
parasites/skizon in blood)
Severe malaria
Exchange blood transfusion

 More common
 More atypical
 More severe
 More fatal
 Selective treatment
 Various complication
Malaria in pregnancy

 2nd and 3rd trimesters of pregnancy are more
likely to develop severe malaria
 Complication: anemia, pulmonary oedema,
hypoglycaemia
 Maternal mortality is approximately 50%
 Fetal death & premature labour are common

 Principal treatment:
 Supportive therapy
 Antimalarial drug
 Management of complication
 Management of labour

 Supplementation of Fe & folic acid
 Blood transfusion in severe anemia (Hb<7g/dl)
 Adequate nutrition
Supportive therapy
Nosten F, McGready R, Mutabingwa T. Case management of malaria in pregnancy. Lancet
Infect Dis 2007; 7:118-25.

 Uncomplicated malaria falciparum (trimester I)
1st Episode
Quinine
+
Clindamycin
3 x 10 mg/BW/day
+
3 x 5 mg/BW/day
7 days
Failure
of
treatment
Repeat Quinine
+ Clindamycin
ACT
Artesunate
+
Clindamycin
2 mg/BW/day
+
3 x 5 mg/BW/day
7 days
• World Health organization. Guideline for the treatment of Malaria 2010. Geneva.
• Case management of malaria in pregnancy. Lancet Infect Dis 2007; 7:118-25.

 Uncomplicated malaria falciparum (trimester II & III)
1st Episode
ACT
Artesunate + Clindamycin
Dose
above
Failure
of
treatment
Other ACT
Artesunate + Clindamycin
Quinine + Clindamycin
Dose
above
7 days
• World Health organization. Guideline for the treatment of Malaria 2006. Geneva.
• Case management of malaria in pregnancy. Lancet Infect Dis 2007; 7:118-25.

 Choices of ACT
Artemether (20 mg) +
lumefantrine (120 mg) 2 x 4 tablets/ day 3 days
Artesunate (50 mg) +
Amodiaquine (153 mg) 1 x 4 tablets/ day 3 days
Sulfadoxine-pyrimethamine
(500/25 mg)
1 x 4 tablets/ day
+
3 tablets only at day I
3 days
Mefloquine (250 mg)
1 x 4 tablets/ day
+
1 x 4 tablets/ day in day I,
1 x 2 tablets/ day in day II
3 days
+
2 days
• Case management of malaria in pregnancy. Lancet Infect Dis 2007; 7:118-25.,WHO 2010

 Severe malaria
Early fase Artesunate
2 – 4 mg/BW at hour 0, 12
& 24; then every 24 hours
Until able
of oral
drug
Parenteral
Late fase
Artesunate+
Clindamycin
2 mg/BW/day
3 x 5 mg/BW/day
7 day oral
Alternative
for
early fase
Quinine
20 mg/BW (loading dose);
then 10 mg/BW every 8
hours
7 day Parenteral
Alternative
for late fase
Quinine +
Clindamycin
3 x 10 mg/BW/day
3 x 5 mg/BW/day.
7 day oral
• Case management of malaria in pregnancy. Lancet Infect Dis 2007; 7:118-25, WHO 2010.

 Malaria non-falciparum
 Chloroquine (25 mg base /BW); except for P. vivax in
south Asia (around Indonesia) with high resistance,
choose quinine.
 Alternative: Amodiaquine  very limited data about
effectivity & safety in pregnancy
• Case management of malaria in pregnancy. Lancet Infect Dis 2007; 7:118-25, WHO 2010.

Outcomes
WHO standard protocol classification:
 Early treatment failure
 Late treatment failure
 Late clinical failure
 Late parasitological failure
 Adequate clinical and parasitological
response.

 Early treatment failure
 Day 1-3 occurrence of severe clinical sign
 Day-2 parasite count > day o
 Day-3 parasite count >25% day o
 Day-3 (+) finding of asexual parasite & also fever
 Late treatment failure
 Late clinical and parasitological failure:
▪ Day 4-28: occurrence of severe clinical sign
▪ Asexual parasite still existing & also fever
 Late parasitological failure:
Occurrence of asexual parasite on day 7, 14, 21, and 28
without fever.
Outcomes

Guidelines
for the
treatment of
malaria,
WHO 2010

Conclusions
 Reported number of malaria cases & deaths remains high
 Recommended use of ACT + Primaquine for
uncomplicated malaria
 Recommended use of parenteral artemisinin derivative or
quinine for severe malaria
 Recommended use of quinine + clindamycin (1st trimester) OR
ACT (2nd & 3rd trimester or failure to quinine in 1st trimester), for
malaria in pregnancy
 Prevention by mosquito control, avoidance of mosquitos bite
and chemoprophylaxis

Malaria di sabang 2011 (terapi malaria)

Empfohlen

Empfohlen

Weitere ähnliche Inhalte

Was ist angesagt?

Was ist angesagt? (20)

Andere mochten auch

Andere mochten auch (20)

Ähnlich wie Malaria di sabang 2011 (terapi malaria)

Ähnlich wie Malaria di sabang 2011 (terapi malaria) (20)

Kürzlich hochgeladen

Kürzlich hochgeladen (20)

Malaria di sabang 2011 (terapi malaria)