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Malaria

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Malaria

  1. 1. JOY M. NICOLAS MDPIDS – FELLOW IN TRAINING
  2. 2.  Time of Emperor Shih Huang Ti (2697–2590 BC)  Earliest report for malaria - repeated paroxysmal fevers associated with enlarged spleens and a tendency to epidemic occurrence name malaria, derived from ‘mal’aria’ (bad air in Medieval Italian) - first used by Leonardo Bruni in a publication of 1476.
  3. 3. Charles Louis Alphonse Laveran first to notice parasites in the blood of a patient suffering from malaria
  4. 4.  Infected anopheline mosquito - Most typical cause of transmission  Approximately 45% are effective vectors  A population of infected humans is necessary to sustain transmission ▪ short life span of mosquitoes ( 5 to 20 days) ▪ the long incubation period required in the mpsquito (8 to > 10 days)
  5. 5.  ng
  6. 6.  Endemic malaria – based on the parasite rate in children 2 to 9 years old  HYPOENDEMIC – parasite rate 0 to 10%  MESOENDEMIC – parasite rate 11 to 50%  HYPERENDEMIC - parasite rate consistently >50% , with a high proportion of adults having enlarged spleen  HOLOENDEMIC – parasite rate consistently >75%, with a low proportion of adults having enlarged spleen
  7. 7.  Autochthonous malaria – acquired locally - Introduced malaria – migrant populations (asymptomatic) provide blood meals for feeding anopheles under conditions that can complete the life cycle enabling the mosquito to infect others - Imported malaria - Induced malaria – acquired from exposure to infected blood ( blood transfusion, needle stick injury, laboratory accidents) - Cryptic malaria – cases for which no explanation can be found
  8. 8.  Blood born transmission – cannot result to relapses Congenital malaria – cannot occur if the mother is semi- immune  Transplacental transmission or breakdown of placental barrier during delivery
  9. 9.  Incidence and severity of malaria –  Intensity of exposure  Presence of immunity - children - pregnant woman - reservoirs of infection  Genetic factors ▪ Duffy- negative blood type specific receptors – resistant to infection with P. vivax ▪ Sickle hemoglobinopathies and protection against severe malaria falciparum
  10. 10.  Anemia  Lysis of RBCs  Impaired erythropoiesis  bone marrow suppression secondary to folic acid deficiency  Hemoglobinuria (blackwater fever) – intravascular hemolysis - can result to renal failure Cytokines (TNF, Interleukin 1) – TNF stimulate nitric oxide – correlated with clearance of parasites and recovery and severity of illness
  11. 11.  Sequestered infected RBC – -facilitate adherence of these cells to vascular endothelium - can be responsible for cerebral malaria, renal failure, watery diarrhea Hypoglycemia and lactic acidosis – consumption of glucose by late parasites
  12. 12.  Recurrent infections  RELAPSES - due to delaye maturation of dormant live stages (hypnozoites) of P. vivax or P. ovale  RECRUDESCENCE – parasitemia caused by the same parasite responsible for the initial infection recurs after clearance or a significant reduction in the initial parasitemia ▪ Occurs most commonly with P. falciparum  RE-INFECTION - from different parasites and infection with more than one type of Plasmodium occur especially in areas with high intensity of transmission ▪ Noted in P. malaria
  13. 13. P. falciparum P. vivax P. ovale P. MalariaeIncubation 12 (8-25) 14 (8 – 27) 17 (15 - > 18) 28 (15- > 40)periodPeriodicity of none 48 48 72febrile attacksEarliest 10 days 3 days ? ?apperance ofgametocytesRelapse No Yes Yes NoDuration of 1-2 yr 1.5 – 4 yr 1.5 – 4 yr 3 – 50 yruntreatedinfectionRBC preference Younger cells Reticulocytes Reticulocytes Older cells (but can invade cells of all ages)
  14. 14. P. falciparum P. vivax P. ovale P. MalariaeCharacteristic Ring forms Schuffner dots Schuffner dots Normal- sizedmorphology Multiply infected Enlarged RBCs Enlarged RBCs cells cells Band or Banana shaped rectangular gametocytes forms of trophozoites
  15. 15.  Malaria paroxysm – results from lysis of parasitized RBCs and release of merozoites into the circulation at the completion of asexual reproduction - fever, chills - headache - body ache - fatigue - dizziness - malaise GI symptoms – nausea, vomiting, abdominal pain, diarrheaCHILDREN – fever, headache or GI symptoms - anemia - Jaundice - hepatospleenomegaly
  16. 16.  Anemia Thrombocytopenia Leukopenia Abnormal liver function test Hypoglycemia Hyponatremia Elevated creatinine or BUN
  17. 17.  Cerebral malaria – most common complication of falciparum malaria- Occurs mostly in 3 – 6 years old- Alteration of consciousness w/o any explanation during infection of malaria- Comatose- Generalized convulsions- Increase of intracranial pressure- histopathology – occasional hemorrhages and perivascular infiltrates
  18. 18.  SEVERE ANEMIA -  Seen most commonly in less than 1 years old  Occur most often in areas with year round transmission  Clinical consequences of anemia ▪ Rate of development of anemia, severith of anemia ▪ Higher risk of complications as hemoglobin decreases less than 5 g/dL HYPOGLYCEMIA  Associated with poor prognosis  Due to combination of parasite consumption of glucose and inadequate gluconeogenesis in the liver
  19. 19.  ACID-BASE CHANGES  Metabolic acidosis – marker of severity  HYPERPNEA RENAL COMPLICATION  Acute renal failure – life-threatening ▪ Oliguric and reversible if immediately dialized • occur more frequently in those patients treated with quinine or quinidine • Histologic changes resembles those of acute tubular necrosis • Nephrotic syndrome and chronic renal failure – endemic and associated with P. malariae
  20. 20. • PULMONARY EDEMA - Consistent with pulmonary leak syndrome - Develops late in the course of severe malaria• HYPERACTIVE MALARIAL SYNDROME - Massive spleenomegaly, high concentrations of total serum IgM and malarial antibodies of multiple immunoglobulin classes and clinical and immunologic response to antimalarial agents - Seems to involve chronic exposure to malaria resulting in chronicstimulationof the immune system and genetic factors
  21. 21. • HYPERACTIVE MALARIAL SYNDROME - Huge spleen and enlarged liver - Anemia and increased reticulocyte count; thrombocytopenia or neutropenia - Increases the risk of acquiring bacterial infection
  22. 22. • History of travel in endemic areas• Microscopy • Thin smear - speciation of the organism - Giemsa stain – preserves the Schuffner dots - has low sensitivity – low parasite load (<100 to 300 uL) – too small to detect • Thick smear – speciation cannot be identified - Estimating the parasites density – assessing the likelihood of development of complications associated with high parasite density and for evaluating response to therapy
  23. 23. • FLUORESCENT MICROSCOPY • Identification of parasitized RBCs stained with acridine orange in the RBC layer of centrifuged blood• DETECTION OF PARASITE ANTIGEN
  24. 24.  First Line Treatment Artemether-Lumefantrine tablet twice a day on days 1 to 3 (1 tablet contains 20 mg Artemether and 120 mg Lumefantrine) AND Primaquine tablet on day 4 (single dose) (1 tablet contains 15 mg base of Primaquine)
  25. 25. Day of Artemether-Lumefantrinetreatment Use body weight in kgs as basis 5-<15 kg 15 - < 25 kg 25-<35 kg > 35 kg If weight cannot betaken, use age as basis 6 mon- 3 yo 4-8 yo 9-13-yo If > 35 kgDay 1 1 tab 2 tabs 3 tabs 4 tabs8 hrs after 1 tab 2 tabs 3 tabs 4 tabsDay 2 1 tab BID 2 tabs BID 3 tabs BID 4 tabs BIDDay 3 1 tab BID 2 tabs BID 3 tabs BID 4 tabs BID Primaquine tablet (PQ) Use body weight in kgs as basis: use 0.75 mg base/kg BW single dose If weight cannot be taken use age as basisDay4 < 1 yo 1-3yo 4-6 yo 7 -11 yo > 12 yo Contraindicated ½ PQ single 1 PQ tablet 2 PQ tablets 3 PQ tablets dose single dose single dose single dose
  26. 26.  Second Line Treatment Quinine sulphate + Doxycycline or Tetracycline or Clindamycin
  27. 27. Age Group/ Quinine Plus any of the three antibiotics below Condition Sulfate Doxycycline Tetracycline Clindamycin (300 or 600 mg/tablet)Adults, non- 10 mg 3 mg/kg bw 250 mg 4 times 10 mg/kg bwpregnant salt/kg bw once a day (QD) a day (QID) for 7 twice a daywomen and dose every 8 for 7 days days (BID) for 7 dayschildren 8 hours for 7years and daysaboveChildren < 8 As above Contra- Contra- 10 mg/kg bwyears old indicated indicated twice a day (BID) for 7 days
  28. 28. Parenteral Quinine Dihydrocloride Infusion PLUS Tetracycline/Doxycycline/Cljndamycin
  29. 29. Age Group Quinine Dihydrochloride Loading Dose Maintenance DoseAdult 20 mg salt/kg in 500 ml 10 mg salt/kg in D5W or 0.9NaCl for 4 0.9NaCl or D5W IV drip hours IV drip for 4 hours every 8 (The total dose must not hours exceed 2,000 mg)Children 8 years to 16 15 mg salt/kg IV drip for 4 10 mg salt/kg IV dripyears hours in 10 ml/kg D5W or for 4 hours every 8 0.9 NaCl hours in D5W or 0.9 (infusion rate must not NaCl exceed 5mg/kg per hour)Children 7 years and 10 mg salt/kg in IV drip for 10 mg salt/kg IV dripyounger 4 hours every 12 hours
  30. 30.  Dosing Schedule for Pre-referral Treatment with Artesunate Suppository (AS) in Adults Weight (kg) Artesunate Regimen (single dose) Dose (Preparation of AS is available in 50, 200 and 400 mg) < 40 10 mg/kg Use appropriate number of 50 or 200 mg preparation 40 – 59 400 mg One 400 mg preparation 60 – 80 800 mg Two 400 mg preparation > 80 1200 mg Three 400 mg preparation
  31. 31. Chloroquine tablet on Days 1 to 3(1 tablet contains 150 mg base of Chloroquine) AND Primaquine tablet on Days 4 to 17 (1 tablet contains 15 mg. base of Primaquine base)
  32. 32. Day of Treatment CQ (1) Use weight in kgs (2) If weight cannot be taken, use age as basis as basis 0-11 mos 1-3 4-6 7- 12-15 y.o. > 16 y.o. y.o. y.o. 11 y.o.Day 1 10 mg/kg 1/2 1 1½ 2 3 4Day 2 10 mg/kg ½ 1 1½ 2 3 4Day 3 5 mg/kg 1/2 1/2 1 1 1½ 2Day 4-17 PQ (1) Use weight in (2) If weight cannot be taken, use age as basis kgs as basis 0-11 mos 1-3 4-6 7-11 y.o. > 12 y.o. y.o. y.o. 0. 5 mg-base per contra- ½ ½ 1 daily 1 daily kilogram per day indicated dail dail y y
  33. 33. Chloroquine tablet on Days 1 to 3( 1 tablet contains 150 mg base of Chloroquine) AND Primaquine tablet on Day 4 (single dose) (1 tablet contains 15 mg base of Primaquine)
  34. 34. Day of Treatment CQ (1) Use body weight (2) If weight cannot be taken, use age as basis in kgs as basis 0-11 mos. 1-3 4-6 7- 12-15 y.o. > 16 y.o. y.o. y.o. 11 y.o.Day 1 10 mg/kg 1/2 1 1½ 2 3 4Day 2 10 mg/kg ½ 1 1½ 2 3 4Day 3 5 mg/kg 1/2 1/2 1 1 1½ 2Day 4 PQ (1) Use body weight (2) If weight cannot be taken, use age as basis in kgs as basis 0-11 mos. 1-3 4-6 7-11 > 12 y.o. y.o. y.o. y.o. 0.75 mg-base per contra- ½ 1 2 tabs singe 3 tabs single kilogram per day indicated tab tab dose dose sin sin gle gle dos dos e e
  35. 35.  P. falciparum and P. vivax Artemether Lumefantrine+ Primaquine. Day of Treatment AL (1) Use body weight in kgs as basis 5 - <15 15 - 25 - <35 kg ≥35 kg kg <25 kg (2) If weight cannot be taken, use age as basis (6 mos.– (4- 8 (9-13 y.o.) If (> 13 3 y.o.) y.o.) y.o.)Day 1 1 tab 2 tabs 3 tabs 4 tabs8 hrs after 1 tab 2 tabs 3 tabs 4 tabsDay 2 1 tab 2 tabs 3 tabs BID 4 tabs BID BID BIDDay 3 1 tab 2 tabs 3 tabs BID 4 tabs BID BID BID
  36. 36. P. falciparum and P. vivaxDay 4-17 PQ (1) Use weight in (2) If weight cannot be taken, use age as basis kgs as basis 0-11 mos 1-3 4-6 7-11 y.o. > 12 y.o. y.o y.o . . 0. 5 mg-base per contra- ½ ½ 1 daily 1 daily kilogram per day indicated dai dai ly ly
  37. 37. Artemether-Lumefantrine for 3 days (Refer to Table 4.4) b. Primaquine (0.75 mg/kg) single dose on Day 4 (Refer to Table 4.4  P. falciparum and P. Malariae Artemether-Lumefantrine for 3 days Primaquine (0.75 mg/kg) single dose on Day 4
  38. 38. Day of Artemether-Lumefantrinetreatment Use body weight in kgs as basis 5-<15 kg 15 - < 25 kg 25-<35 kg > 35 kg If weight cannot betaken, use age as basis 6 mon- 3 yo 4-8 yo 9-13-yo If > 35 kgDay 1 1 tab 2 tabs 3 tabs 4 tabs8 hrs after 1 tab 2 tabs 3 tabs 4 tabsDay 2 1 tab BID 2 tabs BID 3 tabs BID 4 tabs BIDDay 3 1 tab BID 2 tabs BID 3 tabs BID 4 tabs BID Primaquine tablet (PQ) Use body weight in kgs as basis: use 0.75 mg base/kg BW single dose If weight cannot be taken use age as basisDay4 < 1 yo 1-3yo 4-6 yo 7 -11 yo > 12 yo Contraindicated ½ PQ single 1 PQ tablet 2 PQ tablets 3 PQ tablets dose single dose single dose single dose
  39. 39. Artemether-Lumefantrine for 3 days (Refer to Table 4.4) b. Primaquine (0.75 mg/kg) single dose on Day 4 (Refer to Table 4.4  P. Falciparum, P. vivax and P. Malariae Artemether-Lumefantrine for 3 days Primaquine (0.5 mg/kg/day) single dose on Day 4 for 14 days
  40. 40. Day of Artemether-Lumefantrinetreatment Use body weight in kgs as basis 5-<15 kg 15 - < 25 kg 25-<35 kg > 35 kg If weight cannot betaken, use age as basis 6 mon- 3 yo 4-8 yo 9-13-yo If > 35 kgDay 1 1 tab 2 tabs 3 tabs 4 tabs8 hrs after 1 tab 2 tabs 3 tabs 4 tabsDay 2 1 tab BID 2 tabs BID 3 tabs BID 4 tabs BIDDay 3 1 tab BID 2 tabs BID 3 tabs BID 4 tabs BID Primaquine tablet (PQ) Use body weight in kgs as basis: use 0.75 mg base/kg BW single dose If weight cannot be taken use age as basisDay4 < 1 yo 1-3yo 4-6 yo 7 -11 yo > 12 yo Contraindicated ½ PQ single ½ PQ single 1 PQ tablets 1 PQ tablets dose dose single dose single dose
  41. 41.  P. vivax and P. Malariae Chloroquine (25 mg/kg) for 3 days Primaquine (0.5 mg/kg/day) single dose on Day 4 for 14 days
  42. 42. Day of Treatment CQ (1) Use weight in kgs (2) If weight cannot be taken, use age as basis as basis 0-11 mos 1-3 4-6 7- 12-15 y.o. > 16 y.o. y.o. y.o. 11 y.o.Day 1 10 mg/kg 1/2 1 1½ 2 3 4Day 2 10 mg/kg ½ 1 1½ 2 3 4Day 3 5 mg/kg 1/2 1/2 1 1 1½ 2Day 4-17 PQ (1) Use weight in (2) If weight cannot be taken, use age as basis kgs as basis 0-11 mos 1-3 4-6 7-11 y.o. > 12 y.o. y.o. y.o. 0. 5 mg-base per contra- ½ ½ 1 daily 1 daily kilogram per day indicated dail dail y y
  43. 43. Stage of Treatment by SpeciesPregnancy Pf Pv/Po/P Relapse P. Mixed Uncomplicated Severe m vivax Infection 1st QN Parenteral QN infusion CQ CQ QN trimester + + + Clindamycin (oral) Clindamycin IV Clindamyci (1) If Quinine infusion not available, n (oral) give QN tab orally or by NGT (2) Shift to oral Clindamycin if patient can already tolerate oral meds (3) If QN not available (either tab or infusion), is last resort requiring consent of patient/relatives 2nd QN Parenteral QN infusion CQ CQ QN trimester + + + Clindamycin (oral) Clindamycin IV Clindamyci (1) If above not available, give QN n (oral) tab orally or by NGT If above (2) Shift to oral Clindamycin if not patient can already tolerate oral available, meds AL can be (3) If QN + is not available, can be given given
  44. 44. Stage of Treatment by SpeciesPregnancy Pf Pv/Po/P Relapse Mixed Uncomplicated Severe m P. vivax Infection 3rd QN Parenteral QN infusion CQ CQ QN trimester + + + Clindamycin (oral) Clindamycin IV Clindamyc (1) If above not available, give QN in (oral) tab orally or by NGT If above (2) Shift to oral Clindamycin if not patient can already tolerate oral available, meds AL can be (3) If QN + is not available, can be given givenPost-partum PQ SD PQ SD PQ 14 PQ 14 PQ 14(2 weeks afterdelivery)Lactating QN Parenteral QN infusion CQ CQ QN + + + + + Clindamycin (oral) Clindamycin IV PQ PQ 14 Clindamyc + (1) If above not available, give QN in PQ tab orally or by NGT (oral) (2) Shift to oral Clindamycin if + patient can already tolerate oral PQ14 meds or (3) If QN + is not available, can be AL given + PQ 14
  45. 45.  Uncomplicated Pf Malaria Population Group Medicine Dosing Schedule Pregnant Quinine Sulphate 10 mg/kg every 8 hours for 7 days Clindamycin 10 mg/kg twice a day for 7 days Lactating Above Plus PQ on Day 0.75 mg per kg, single 4 dose
  46. 46. • Severe Pf Malaria Quinine Dihydrochloride Infusion + Clindamycin IV Population Group Medicine Dosing Schedule Loading Dose Maintenance DosePregnant Women Quinine 20 mg/kg infused over 10 mg/kg every 8 hours Dihydrochloride 4 hours (in 500 ml 5% infused over 2-4 hours dextrose water or 0.9% If patient can already saline) tolerate oral meds, shift to oral QN Sulphate (10 mg/kg every 8 hours) to complete 7 days at same dose Clindamycin 10 mg/kg IV twice a day; shift to oral clindamycin; as soon as patient tolerates oral clindamycin at same dose to complete 7 daysLactating Women Above Plus PQ 0.75 mg per kg, single dose after 7 days of Clindamycin
  47. 47. Plasmodium vivax, ovale, malaria and Mixed Infection  acute P. vivax or P. Ovale - No. of Chloroquine Tablet Primaquine (150 mg base/tablet) (15 mg base/tablet)Day of Treatment Day 1 Day 2 Day 3 Pregnant Women:By weight 10 mg/kg 10 mg/kg 5 mg/kg Withheld until deliveryIf weight cannot be 4 tabs 4 tabs 2 tabs .taken Lactating Women: Take Primaquine beginning Day 4 to Day 17at 0.5 mg/kg b.w. per day Post-partum Women (2 weeks after delivery) for 14 days at 0.5 mg/kg b.w. per day
  48. 48.  Dosing Schedule for Pregnant and Lactating Mothers with Relapse P. vivax Malaria Infection Chloroquine Tablet Primaquine Tablet (150 mg base/tablet) (15 mg base/tablet)Wk1 Wk2 Wk3 Wk4 Wk5 Wk6 Wk7 Wk8 Pregnant Women: Withheld 2 2 2 2 2 2 2 2 until deliverytabs tabs tabs tabs tabs tabs tabs tabs Lactating Women: Take Primaquine beginning Day 4 up to Day 17 at 0.5 – 0.75 mg/kg b.w. per day to a maximum of 30 – 45 mg per day Post-partum Women (2 weeks after delivery) for 14 days at 0.5 – 0.75 mg/kg/b.w. per day to a maximum of 30 – 45 mg per day
  49. 49. • Dosing Schedule for Pregnant and Lactating Mothers with P. malariae Malaria Infection No. of Chloroquine Tablet Primaquine (150 mg base/tablet) (15 mg base/tablet) Day of Treatment Day 1 Day 2 Day 3 Pregnant Women: By weight 10 mg/kg 10 mg/kg 5 mg/kg Withheld until delivery Lactating Women: If weight cannot be 4 tabs 4 tabs 2 tabs Take Primaquine on taken Day 4 at 0.75 mg/kg/b.w. Post-partum Women (2 weeks after delivery) single dose at 0.75 mg/kg/b.w.
  50. 50. Dosing Schedule for 2nd and 3rd Trimester Pregnant and Lactating Mothers With Mixed InfectionDay of Treatment AL Use weight in kgs as basis If weight cannot be taken, use age as basis < 35 kgs (≥35 kg 9 - 13 y.o. > 13 y.o.Day 1 3 tabs 4 tabs 3 tabs 4 tabs8 hrs after 3 tabs 4 tabs 3 tabs 4 tabsDay 2 3 tabs twice a day 4 tabs twice a 3 tabs twice a 4 tabs (BID) day (BID) day (BID)Day 3 3 tabs twice a day 4 tabs twice a 3 tabs twice a 4 tabs twice a (BID) day (BID) day (BID) day (BID)Day 4-17 PQ (1) For Pregnant Women: withheld until delivery (2) For Post Partum/Lactating Women: Use 0.5 mg base per kg 1 tab daily per day
  51. 51. < 6 months of age Age Group/ Condition Quinine Sulfate Plus (300 or 600 Clindamycin mg/tablet) Children < 8 years old 10 mg salt/kg bw 10 mg/kg bw twice a day dose every 8 hours (BID) for 7 days for 7 days
  52. 52. 6 – 11 monthsDay of treatment Artemether-Lumefantrine Use body weight in kgs as basis ( 5-<15 kg If weight cannot betaken, use age as basis 6 mon- 3 yoDay 1 1 tab8 hrs after 1 tabDay 2 1 tab BIDDay 3 1 tab BID
  53. 53. Day of Artemether-Lumefantrinetreatment Use body weight in kgs as basis 5-<15 kg 15 - < 25 kg 25-<35 kg > 35 kg If weight cannot betaken, use age as basis 6 mon- 3 yo 4-8 yo 9-13-yo If > 35 kgDay 1 1 tab 2 tabs 3 tabs 4 tabs8 hrs after 1 tab 2 tabs 3 tabs 4 tabsDay 2 1 tab BID 2 tabs BID 3 tabs BID 4 tabs BIDDay 3 1 tab BID 2 tabs BID 3 tabs BID 4 tabs BID Primaquine tablet (PQ) Use body weight in kgs as basis: use 0.75 mg base/kg BW single dose If weight cannot be taken use age as basisDay4 < 1 yo 1-3yo 4-6 yo 7 -11 yo > 12 yo Contraindicated ½ PQ single 1 PQ tablet 2 PQ tablets 3 PQ tablets dose single dose single dose single dose
  54. 54. Age Group Quinine Dihydrochloride Loading Dose Maintenance DoseChildren 8 years to 16 15 mg salt/kg IV drip for 4 10 mg salt/kg IV dripyears hours in 10 ml/kg D5W or for 4 hours every 8 0.9 NaCl hours in D5W or 0.9 (infusion rate must not NaCl exceed 5mg/kg per hour)Children 7 years and 10 mg salt/kg in IV drip for 10 mg salt/kg IV dripyounger 4 hours every 12 hours
  55. 55. Weight Age Artesunate Regimen (single dose) (kg) dose (mg) (available in 50 mg, 200 mg and 400 mg suppositories) 5 – 8.9 0 - 12 months 50 One 50 mg 9 – 19 13- 42 months 100 Two 50 mg20 – 29 43- 60 months 200 One 200 mg30 – 39 6 - 13 years 300 Two 50 mg and one 200 mg > 40 > 14 years 400 One 400 mg
  56. 56.  In endemic areas, this condition is diagnosed only when parasites are identified within 14 days after birth If parasites are seen in blood films after the first week of life, neonatal malaria is a possibilityDay 1: 10 mg/kgDay 2: 10 mg/kgDay 3: 5 mg/kg (half dose of Days 1 and 2)
  57. 57.  suspected when blood has been transfused within the past six months
  58. 58. Classification of Treatment Outcomes (WHO, 2005) Response CriteriaAdequate Clinical Absence of parasitemia on Day 28 irrespective of temperature, without meetingand Parasitological any of the criteria of Early Treatment Failure or Late Clinical Failure or LateResponse (ACPR) Parasitological Failure.Early Treatment Development of danger signs or severe malaria on Day 1, Day 2 or Day 3 in theFailure (ETF) presence of parasitemia; OR Parasitemia on Day 2 higher than Day 0 count irrespective of axillary temperature; OR Parasitemia on Day 3 with axillary temperature ≥ 37.5 °C; OR Parasitemia on Day 3 ≥ 25% of count on Day 0.Late Clinical Failure Development of danger signs or severe malaria on any day from Day 4 to Day 28(LCF) in the presence of parasitemia, without previously meeting any of the criteria of Early Treatment Failure; OR Presence of parasitemia and axillary temperature ≥ 37.5oC (or history of fever) on any day from Day 4 to Day 28, without previously meeting any of the criteria of ETF.Late Parasitological Presence of parasitemia on any of the scheduled return on Day 7, Day 14, Day 21Failure (LPF) or Day 28, and axillary temperature < 37.5oC without previously meeting any of the criteria of ETF.
  59. 59. Dosing Schedule of Artemether-Lumefantrine (AL)and Primaquine (PQ) in the Treatment of Uncomplicated Plasmodium falciparum Malaria InfectionDay of Artemether-Lumefantrinetreatment Use body weight in kgs as basis 5-<15 kg 15 - < 25 kg 25-<35 kg > 35 kg If weight cannot betaken, use age as basis 6 mon- 3 yo 4-8 yo 9-13-yo If > 35 kgDay 1 1 tab 2 tabs 3 tabs 4 tabs8 hrs after 1 tab 2 tabs 3 tabs 4 tabsDay 2 1 tab BID 2 tabs BID 3 tabs BID 4 tabs BIDDay 3 1 tab BID 2 tabs BID 3 tabs BID 4 tabs BID
  60. 60. Primaquine tablet (PQ) Use body weight in kgs as basis: use 0.75 mg base/kg BW single dose If weight cannot be taken use age as basisDay4 < 1 yo 1-3yo 4-6 yo 7 -11 yo > 12 yo Contraindicated ½ PQ single 1 PQ tablet 2 PQ tablets 3 PQ tablets dose single dose single dose single dose
  61. 61. Drugs Schedule Dose Pregnant Adult PediatricA. For People Travelling To Endemic AreasDoxycycline Tablet Start two to contraindicate 1 tablet < 8 years: (100 mg) three days d contraindicated prior to travel, > 8 years old: daily while in 2 mg/kg up to 100 the area and mg daily continue up to four weeks upon leaving the areaMefloquine Start 1-2 contraindicate 1 tablet weekly < 45 kg: 5 mg/kg bwTablet weeks before d 5-10 kg ⅛ tab(250 mg base) travel; take 10-19 kg ¼ tab weekly while 20-30 kg ½ tab in the area, 31-45 kg ¾ tab and continue up to four weeks upon leaving the area
  62. 62. Drugs Schedule Dose Pregnant Adult PediatricA. For People Travelling To Endemic AreasCholoroquine Start 2 weeks 2 tablets NA < 8 years: 5 mg/kg before travel, b.w. take weekly < 8 years: 2 tablets while in the area and continue 4 weeks after leaving the areaB. For Pregnant Women Residing in Endemic AreasSulphadoxine If resident in 3 tablets eachPyrimethamiine stable on 2nd and 3rd transmission trimesters area only

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