Unit 9
Contents
1. 14 Special s aeo secas ye see soe ek i ka 16 SECTION 3 MANAGEMENT OF MALARIA 20 PREVENTION M 21 Personal Prevention and Prevention in Pregnant 21 Malaria Prevention in the Community eee 23 dli Wu DUE rcm c N 24 URCORIDICUICO eeu tu toto ets trie an ue preda debat 24 Ma OTTA 26 Evaluation and Management of some Specific Clinical Manifestations of Severe and Complicated OREO iud e ETE eL Ati TS SOT Ae EET FEES NE A Per 27 CEREBRAL MALARIA ORE 27 SEVERE ANAEMIA 27 HYPOGLYCEMIA 27 RRENALIMIPATRMEN Uc H 28 RESPIRA TORY COMPLICA TIONS eth sv eset quee alos e ia eUe ess oc aes e eee esae Uv eo rea eoa aea I aa Tea 28 OTHER COMPLICATIONS co ease eoa eaae ouch eue suoi eese esas esu redes eg de Qv VER VOTE I CE E ea ete 28 CHRONIC COMPLICA TIONS o eeesete eceneeveteeeesseVesnt nex vsae dun eve apes idee CU Wo i Ue 28 TREATMENT OF SEVERE AND ICOMPLICATED MALARIA eee eere errore eee ooo teet eee eeee 29 SUPPORTIVE THERAPY lesus2. DIRECTORATE OF LEARNING SYSTEMS DISTANCE EDUCATION PROGRAMME COMMUNICABLE DISEASES COURSE Unit 9 Malaria Allan and Nesta Ferguson Trust Unit 9 Malaria A distance learning course of the Directorate of Learning Systems AMREF O 2007 African Medical Research Foundation AMREF This course is distributed under the Creative Common Attribution Share Alike 3 0 license Any part of this unit including the illustrations may be copied reproduced or adapted to meet the needs of local health workers for teaching purposes provided proper citation is accorded AMREF If you alter transform or build upon this work you may distribute the resulting work only under the same similar or a compatible license AMREF would be grateful to learn how you are using this course and welcomes constructive comments and suggestions Please address any correspondence to The African Medical and Research Foundation AMREF Directorate of Learning Systems P O Box 27691 00506 Nairobi Kenya Tel 254 20 6993000 Fax 254 20 609518 Email amreftraining amrefhq org Website www amref org Writer Dr Beth Rapuoda Chief Editor Anna Mwangi Cover design Bruce Kynes Technical Co ordinator Joan Mutero The African Medical Research Foundation AMREF wishes to acknowledge the contributions of the Commonwealth of Learning COL and the Allan and Nesta Ferguson Trust whose financial assistance made the development of this course possib
3. 11 13 Yeas 0 PENNE es Proguanil 200mgonce day 5 8 lt 8 Paludrine 9 16 8Months 3Years ve 17 24 4 7 ears 0 00 85 35 8 10 Yeas i 36 50 11 13 Years 1 EN eorum Ee Proguanil 1 Tab once day recommended Malarone 11 20 X 22Mns 4Years 1 Paediatric tab 21 30 4 23Mns 9 Year 2 Paediatrictab _ EE 31 40 10 12 Years 3 Paediatric tab 22 When administering these drugs you MUST be aware of their side effects Take Note Mefloquine may cause nausea dizziness disturbed sleep pattern and neuropsychiatric reaction manifested as confusion convulsions and psychosis but itis SAFE in pregnancy Doxycycline may cause photosensitivity and CANNOT be used in children below 8 years NOT SAFE in pregnancy Proguanil is well tolerated and considered the SAFEST drug in pregnancy Malaria Prevention in the Community Public education is the most effective way of malaria prevention in he community Health information education and communication are critical intervention for behavioural change towards improved health practices Public awareness needs to be done and the following information should be provided to the patient caretaker and community members e Recognition of symptoms and signs of severe disease e Seeking prompt treatment of fevers e Adherence to treatment plan e Use of
4. a Rees us aree EAEEREN 32 TUTOR MARKED ASSIGNMENT ERROR BOOKMARK NOT DEFINED INTRODUCTION Welcome to Unit 9 of your course on communicable diseases In the previous units you covered the basic concepts of communicable diseases the epidemiological approaches and also disease surveillance and epidemics control You also learnt about travel medicine in relation to communicable diseases immunization as well as the prevention and control of contact vector borne and sexually transmitted diseases In this Unit we will focus on the concepts and principles applicable to the prevention and control of malaria We expect that by the end of this unit you should be able to apply the infection prevention and control measures in protecting patients health workers and the community in general from this diseases which can be deadly Specific objectives By the end of this unit you should be able to e Give a definition of malaria e Describe the epidemiological zones in Kenya e Describe the mode of transmission of malaria e Make aclinical assessment of malaria e Outline the treatment prevention and control of malaria e Discuss malaria in special circumstances such as pregnancy Now that you know what to expect in this Unit let us start by looking into the epidemiology and mode of transmission of malaria Section 1 Epidemiological Zones And Mode Of Transmission Malaria is an acute infection of the blood caused by the parasite Pl
5. are at risk of malaria infection The consequences of malaria in pregnancy include anaemia and febrile illnesses in the mother foetal loss and low birth weight Women in their first and second pregnancy are at a greater risk All pregnant women at risk should be advised on malaria prevention measures Intermittent Preventive Treatment IPT is recommended in areas of high malaria transmission p The current recommended medicine for IPT is Sulphadoxine 500mg Pyrimethamine 25mg given as a dose of three tablets IPT should be given under direct observed therapy DOT in the antenatal clinic and can be given on an empty stomach Women known to be HIV infected or with unknown HIV status living in areas of high HIV prevalence 1096 among pregnant women should receive at least 3 doses of IPT Pregnant women who are HIV positive and are also taking antiretroviral therapy for PMTCT should receive IPT Pregnant women who are HIV positive and are on daily Cotrimoxazole chemoprophylaxis should not be given SP Now study carefully Table 1 which indicates the dosage schedule for chemoprophylaxis Table 1 Dosage schedule for Chemoprophylactic Agents DRUG ADULT DOSAGE CHILD DOSAGE WT Ka AGE ___ TABS WEEK on 5 12 X 3 283Monhs 12 7 Yea D amp 25 35 4 840 Years a Se ae Doxycycline 100mg once day 25 lt 8 Years Contraindicated 85 35 8 10 Yeas 36 50
6. deep and fast breathing chest in drawing Other Complications These include septicemia aspiration pneumonia catheter induced infections hyperpyrexia gt 39 C jaundice anaemia Hb 5gm dl hyperparasitaemia of gt 5 of total red cells Chronic Complications Tropical splenomegaly syndrome TSS Repeated malarial infections produce anaemia and splenomegaly in people living in malaria endemic areas The splenic enlargement that is seen is 28 immunological characterized by a rise in immunoglobulins IgM Patients present with an abdominal mass a dragging sensation anaemia and or pancytopenia due to pooling of the blood cells to the spleen Even if a blood slide for malaria parasites is done there will be none that will be seen WHY Large spleens are dangerous because in the event of mild trauma the spleen may rupture leading to severe blood loss Treatment of Severe and Complicated Malaria The drug reserved for treatment of severe and complicated malaria is Quinine Administration of quinine must be closely monitored due to occurrence of arrythmias hypoglycemia hypotension and cinchonism Dosage is 10 mg kg as intravenous infusion of 5 or 10 dextrose 500 mls of this should run for 4 hours every 8 hours Care should be taken that after 3 intravenous IV doses of quinine one should try to change to oral treatment Treatment should be for a total of 7 days Quinine can be combined with the following drugs where a
7. name and address before sending the assignment Once you complete this assignment post or bring it in person to AMREF Training Centre We will mark it and return it to you with comments Our address is AMREF Distance Education Project P O Box 27691 00506 Nairobi Kenya Email amreftraining amrefha org
8. the patient s body Physical examination includes Inspection to look and see Palpation Touch and feel Percussion Use the middle fingers of both hands to elicit resonance sounds in cavities like the thorax and abdomen Auscultation Use a stethoscope to detect sounds in the thorax and abdominal cavities The same is used for detecting bruits sound or murmur especially an abnormal one such as with the brachial pulse when taking blood pressure BP Physical examinations are divided into two main types e General Physical examination e Systemic physical examination General Physical Examination In patients with malaria check the vital signs such as temperature blood pressure pulse rate and respiratory rate Observe also if there is jaundice goose skin appearance pall of varying degrees loss of skin turgor dryness of mucous membrane or absence of tears Clinical Features Although it is not necessary to memorize the transmission cycle of malaria it is good to go back to Figure 3 and revise it once again as this will help you to understand why malaria presents itself the way it does Malaria can present in the following ways Uncomplicated Malaria This is the most common presentation of malaria and is usually seen in people living in malaria endemic areas This is usually characterized by fever in the presence of peripheral parasitaemia List down any other features that you know of then compare how many of t
9. 00mg Repeat 10mg Kg 8 hourly until the patient can take orally Change to a full course of oral Artemether Lumefantrine full course 6 doses or oral quinine to complete 7 days of quinine Assessment of fluid status should be monitored regularly including urine output Take Note If the patient cannot be weighed the IV quinine loading dose should be 900 mg followed by 600 mg 8 hourly Put up IV quinine drip 20mg Kg body weight loading dose in 15mls kg of isotonic fluid to run over 4 hours Fluid intake should be calculated according to weight bolus 20mls kg minimum 10mls Kg and maintenance 4 6 mls Kg hr 12 hours after the start of the initial dose of quinine give 10mg kg in 10mls kg of isotonic fluid to run over 4 hours Repeat 10mg kg body weight 12 hourly until the patient can take medication orally Thereafter quinine is continued orally at 10mg kg every 8 hours to complete a total parenteral oral of 7 days or a complete course of Artemether Lumefantrine is given Other drugs that can be given in cases of severe or complicated malaria include 1 Tetracycline 4 mg kg every 6 hours for 7 days Tetracycline is contraindicated in 31 pregnancy and children 8 years 2 Clindamycin Dalacin C 150 mg every 8 hours for 3 5 days 3 Artemether compounds Paluther Cotexin Artenam 2 4 mg kg 1M stat followed by 1 2 mg kg every 12 hours for 3 days This should be followed by Mefloquine 25 mg kg i
10. appropriate prevention measures In addition the community health worker should be able to respond quickly in case of an epidemic outbreak Epidemic preparedness and response should include strengthening routine surveillance of buffer stocks such as chemicals spray pumps and medicines among others providing logistic support advocacy and social mobilization and putting in place plans for rapid epidemic response 29 Treatment Chloroquine is no longer the first line of management in Falciparum malaria This is because of the high resistance that has been developed throughout Kenya The World Health Organisation discourages the use of mono therapy and recommends the use of combination therapy for treatment of uncomplicated malaria Uncomplicated Malaria The first line of treatment for uncomplicated malaria is Artemether Lumefantrine Administer 20 120mg as a 6 dose regimen given over three days For number of tablets per dose to be taken at 0 8 24 36 48 60 and 72 hours see Table 2 Table 2 Dosage Schedule for Artemether Lumefantrine WEIGHT AGE YRS NUMBER OF CONTENT OF ARTEMETHER Kg TABLETS PER A LUMEFANTRINE L DOSE 20 mg A 120 mg L 15 25 40 mg A 240 mg L 25 lt 35 60 mg A 360 L Above 35 80 mg A 480 mg L Second line of treatment is Oral Quinine administered as a daily dose of 30mg kg in three divided doses of 10mg kg body weight 8 hourly for 7 days Study carefully the instructions in Ta
11. asmodium which is directly or indirectly responsible for much ill health and death The malaria parasites are transmitted from one infected person to another by the bite of a female mosquito of the genus Anopheles Only certain species of the anopheline mosquitoes known as vectors or carriers of malaria can transmit the parasite Vectors of malaria in Kenya and our region are Anopheles gambiae sl and Anopheles funestus But different Anopheles vectors are involved in the transmission of malaria in other countries in Africa Malaria remains a leading cause of morbidity and mortality especially in children and pregnant women It accounts for 30 of outpatient attendances and 19 of admissions to health facilities The level of malaria endemicity varies regionally Malaria is endemic in the humid low lying areas of the coastal plains around the shores of Lake Victoria and by the swamps of most rivers These ecological zones are classified as high malaria risk areas It is not so common in the highlands When a malaria outbreak occurs in the highlands it is referred to as highland malaria and the infection in these areas may also be caused by P falciparum The severe malaria condition usually experienced in the highlands is due to the lack of immunity among the inhabitants and the fact that all age groups are affected The risks of an individual acquiring a malaria infection is dependent on the level of chance that he she will come into con
12. ble 3 a and 3 b 24 Table 3 Dosing Schedule for quinine tablets a Quinine sulphate 200mg salt WEIGHT No of Tabs 7 12 15 MARO 6 3 t 39 39 2 b Quinine 300 mg salt sulphate dihydrochloride hydrochloride WEIGHT Kg No of Tabs C 18 28 T For children below 4 Kg the dosage is 10mg kg body weight given three times a day for 7 days Other anti malarial drugs for uncomplicated malaria include Amodiaquine 10 mg Kg daily for three days plus Artesunate 4 mg kg body weight given daily for 3 days It is NOT recommended during the first trimester of pregnancy e Mefloquine plus Artesunate 4mg kg once a day for 3 days plus Mefloquine 25mg of base per kg given as a single or split dose on second or third day e Halofantrine Halfan 2 tablets every 6 hours for a total of doses This drug can cause cardiac arryhtmias so if not sure do not use Contraindicated in patients with heart disease ZS Severe Malaria oevere malaria is a medical emergency Delay in the diagnosis of severe malaria and inappropriate treatment especially in infants and children leads to rapid worsening of the condition The keys to effective management are early recognition assessment and appropriate anti malarial and supportive therapy The clinical features of sever malaria include the following e Prostration e X Altered level of consciousness e Multip
13. cking Prick the patient s finger to get a small drop of blood 7 flock or Aner Immediately touch the tip 7 of the tube with blood in the smaller hole Put five 5 drops 8 of buffer into the larger hole 9 Read results exactly fifteen 15 minutes after adding buffer Do not read the results before fifteen 15 minutes Reading too early or too late can give false results 1 HOW READ NEGATIVE no malaria one control line near mark C POSITIVE falciparum malaria line near mark C and line in the middle POSITIVE falciparum or mixed malaria line near mark and line in the middle and line to the right POSITIVE vivax malaria line near mark C and line to the right NO RESULT no control line near mark C If the control line does NOT appear any other lines should be disregarded The test should be repeated P 1 1 Record Results 12 Dispose of infectious waste properly Figure 5 Instructions for Performing the Test L9 Take Note RDT s Do s and Don t s DO open the package immediately prior to performing the test DO collect only enough blood on the blood collection device as specified in instructions too much blood will obscure the bands lines on the test strip DO dispose of test cassette after recording results Cassettes should be disposed of with hazardous waste DON T leave the test exposed to air for long per
14. d specificity when used by well trained staff Rapid Diagnostic Tests RDTs Rapid diagnostic kits RDTs have been developed for malaria diagnosis The implementation of the new drug policy of ACTs requires that all suspected cases of malaria should be confirmed In view of the limited laboratory services in rural health facilities the use of RDTs is necessary so as to complement the use of microscopy Principle Purpose of RDTs RDTs are used for the identification or exposure to malaria parasites by the detection of antibodies parasite antigens parasitic metabolic products or parasite enzymes They usually use immune chromatographic methods performed on lysed blood containing antigens antibodies and other parasites metabolic products 14 What are RDTs Malaria rapid diagnostic tests or RDTs detect antigens proteins produced by malaria parasites These antigens are present in the blood of infected or recently infected people To detect the antigens RDTs indicate infection by use of immunochromatography lateral flow of an antigen or antibody that is the protein produced by a person in response to an antigen in a filter paper resulting in a colour change Some RDTs detect only one species of malaria and some detect one or more species The tests come in different formats dipstick cassette or card We ll look at an example of a cassette test that detects an infection with Plasmodium falciparum Why are RDT
15. he features given below you have in your list Other features may include e Headache e Chills e Profuse sweating e Muscle pains e Joint pains e Nausea vomiting and diarrhoea e Irritability and refusal to feed e Other findings are mild anaemia and or splenic enlargement Take Note These features may occur singly or in combination LO Malaria Outpatient Algorithm for Older Children 55 Yrs and Adults Assess patient for clinical signs of severe malaria If No signs of severe malaria is there any other cause of fever a Sore throat or runny nose b Frequent or painful urination C Soft tissue infection or abscess d any other identifiable cause of fever If No to all amp If No to all amp microscopy RDT If Yes to any regardless microscopy available availability of microscopy RD RDT not available Request blood slide RDT Do not request blood slide RDT Treat for malaria Do not treat Do not treat for Artemether lumefantrine or for malaria malaria Treat other dp Treat for malaria AL quinine if pregnant OPE Treat cause of fever or Quinine if pregnant symptoms Provide COUNSELLING Provide advice on FOLLOW UP Figure4 Malaria Outpatient Algorithm for Older Children gt 5 Yrs and Adults LL Investigations In the case of malaria taking the patient s history and conducting a physical examination may not be enough to help a diagnosis It may be necessary to confirm your findings with some inve
16. infect liver cells 2 and mature into schizonts 3 which rupture and release merozoites 4 In P vivax and P ovale a dormant stage hypnozoites can persist in the liver and cause relapses by invading the bloodstream weeks or even years later After this initial replication in the liver exo erythrocytic schizogony A the parasites undergo asexual multiplication in the erythrocytes erythrocytic schizogony B Merozoites infect red blood cells 5 The ring stage trophozoites mature into schizonts which rupture releasing merozoites 6 Some parasites differentiate into sexual erythrocytic stages gametocytes 7 Blood stage parasites are responsible for the clinical manifestations of the disease The gametocytes male microgametocytes and female macrogametocytes are ingested by an Anopheles mosquito during a blood meal 8 The parasites multiplication in the mosquito is known as the sporogonic cycle C While in the mosquito s stomach the microgametes penetrate the macrogametes generating zygotes 9 The zygotes in turn become motile and elongated ookinetes 10 which invade the midgut wall of the mosquito where they develop into oocysts 11 The oocysts grow rupture and release sporozoites 12 which make their way to the mosquito s salivary glands Inoculation of the sporozoites into a new human host perpetuates the malaria life cycle 1 Section 2 Clinical Assessment In Malaria Clinical assessment is the process
17. iod before using humidity and heat may lead to incorrect results when using DON T store RDTs for reference DON T store and THEN look for result Results become invalid they tend to turn positive with exposure to air and a humid environment DON T re use cassettes DON T freeze DON T mix reagents buffer from different kit lots 20 Section 3 Management Of Malaria Let us now turn our attention to the management of malaria We shall divide this section into prevention and treatment Prevention We already discussed some methods for protection In Unit 3 on Travel Medicine in Relation to Communicable Diseases Here we shall elaborate further on some of them Personal Prevention and Prevention in Pregnant Women The most common methods for personal protection include the use of insecticide impregnated nets ITNs long lasting insecticide nets LLINs or chemoprophylaxis Recommendation for prophylaxis depends on the knowledge of local patterns of drug sensitivity and infection Chemoprophylaxis is not always feasible The groups of people recommended to take prophylaxis are Non immune travellers The recommended prophylaxis for this category is Mefloquine or Atovaquone Proguanil or Doxycycline e Children born to non immune mothers in endemic areas e Patients with sickle cell disease proguanil e Patients with tropical splenomegaly syndrome hyperimune malaria splenomegaly proguanil Pregnant women
18. le CONTENTS INTRODUCTION J LLL 1 SPECIEIC GOB JEG ELVES ss ene eecieeetecten 1 SECTION 1 EPIDEMIOLOGICAL ZONES AND MODE OF TRANSMISSION A 1 OCCURRENCE AND DISTRIBUTION OF MALARIA IN KENYA eeeeee eee e eee eee eee eee ee esee eos 3 Lakeside 4 COGS GT LRA EMI CNET 4 JL ITI TI FH ROC 4 4 Low Mala ri RISK I IA 5 LIFE CYCLE OF THE HUMAN MALARIA PARASITE scscssssssssssssssssssssssssssssscescccsccssccsssssssssssssssssssssssssss 6 SECTION 2 CLINICAL ASSESSMENT IN MALARIA eae 8 HISTORY LAKING 8 PHYSICAE EXAMINATION DNE ova PH 9 General EXaminitloti 9 CLINICAL PEA TURES rr 9 Uncomplicateq MaOIGEI Rc tege oes 10 INVESTIGATIONS END CT 12 Blood 12 WHILE bD OOT CCC WBC ir a 13 Blood Haemopelobin Hb Estimat On ewe aa 13 CENAS Tr 13 Bood GH OU DUA E N A etie NENNI 13 DIAG NOSIS P E E EE EAEE E NE E O NEP NE EEA 13 MICROSCOP aAa 14 RAPID DIAGNOSTIC TESTS RDIS cun ueeo VE YE Sub uen Ecos
19. le convulsions e Respiratory distress e Circulatory collapse e Pulmonary oedema e Jaundice e Haemoglobinuria e Abnormal bleeding The laboratory features of severe malaria include e Severe anaemia Hb 5gm dl or Hct lt 15 e blood sugar lt 2 2mmol l e Hyperparasitaemia e Renal impairment e Acidosis e Hyperlactatemia Take Note Severe malaria can occur in the absence of fever 205 Evaluation and Management of some Specific Clinical Manifestations of Severe and Complicated Malaria This is a presentation that is unique to Plasmodium Falciparum malaria It is a life threatening condition characterized by P Falciparum in the peripheral blood in the presence of any of the following clinical or laboratory features singly or in combination Cerebral Malaria Complicated malaria may manifest as a cerebral malaria Clinical assessment On clinical assessment coma is the usual finding which is associated with a high mortality rate Neurological signs are unusual There may be presence of convulsions which are generalized and often repeated Start by assessing the level of consciousness using the coma score standard Then determine the hydration status Assess for evidence of disseminated intravascular coagulopathy Determine the presence of stiff neck Laboratory tests In children with alteration in the level of consciousness initiate treatment for both malaria and meningitis until l
20. mia Urinalysis The reason for carrying out urinalysis is to exclude urinary tract infection as a cause of fever and also for haemoglobinuria as in malaria Blood Grouping This may be ordered before blood transfusion Diagnosis Fever in both adults and children is quite common and can have many causes Often in our malarial areas most of these other causes are missed and all fevers are treated as malaria i gt 1 What are the diseases that are often confused with malaria in your centre 2 How do you normally make sure that the case is one of malaria and not something else 3 How do you normally make sure that the case is one of malaria and not one of the above Microscopy Microscopy is the gold standard for the diagnosis of malaria parasites in the peripheral blood of the patient Demonstration of malaria parasites can easily be done by obtaining thick and or thin blood slides from the patient The thick blood slides can then be stained using Field s stain or Giemsa The slides are then mounted under a microscope with oil immersion with lens x100 and ring forms of the parasites can then be counted The thin slides should be fixed using methanol then stained with Giemsa When using a Leishman stain fixing is not required The thin slide is more reliable because the parasitaemia can be estimated and also the red cell morphology can be seen The advantages of microscopy include its low cost high sensitivity an
21. n and pregnant women Transmission is perennial and the parasite prevalence amongst childhood communities often exceeds 50 Coastal Endemic The Coast is similar in endemicity to the Lakeshore with parasite prevalence often exceeding 50 However the transmission and maximal disease risk period exhibit stronger seasonality and the intensity of transmission is lower towards the Somali border There are also areas where malaria is only seasonal generally soon after the rains These are known as Epidemic areas Highlands A common feature of malaria in highland districts is that whilst there is always a potential for limited transmission lending itself to an overall low disease risk on an average year variations in rainfall and ambient temperatures between years can lead to epidemics affecting all members of the community The parasite prevalence is low in these districts but varies widely over small spatial distances Arid Seasonal oeveral districts in a large part of North Eastern North Western and Central areas of the country only experience malaria where communities are located close to water bodies The arid intervals between rainfalls limit the transmission of parasites only to a few months of the year or transmission may even be absent on occasional low rainfall years Other districts might experience transmission every year for a few months Overall all districts in this category will support low infection prevalence ra
22. n two divided doses 12 hours apart Supportive Therapy In addition to the main treatment you need to make the patient comfortable by administering some supportive therapy such as e Antipyrexia treatment tepid sponging paracetamol administration e Blood transfusion if anemia develops rapidly e Hypoglycaemia correct with glucose IV or oral and ensure adequate caloric intake nutritional support thereafter e Convulsions Treat with anti convulsants such as Diazepam 0 3 mg Kg IV or 0 5mg Kg by rectal administration OR Paraldehyde 0 4ml Kgintramuscular injection You have now finished the work of Unit 9 Look back at the objectives If you are uncertain about any of them revise the unit again If you think that you have learnt well close your books and complete the attached assignment 32 REFERENCES Adapted from the following references 1 Kenya MOH 2006 National Guidelines for Diagnosis Treatment and Prevention of Malaria for Health Workers in Kenya DOMC 2 MOH 2006 National Guidelines for Laboratory Diagnosis of Malaria in Kenya User s Manual 3 Health and Disease in Kenya published by the East African Literature Bureau 3S DIRECTORATE OF LEARNING SYSTEMS DISTANCE EDUCATION COURSES Student Number Name e Address COMMUNICABLE DISEASES COURSE Tutor Marked Assignment Unit 9 Malaria Instructions Answer all the questions in this assignment 1 A 4 year old child is brought
23. orded since the results shown on the test cassette are unreliable beyond the recommended time for reading How does an RDT work T6 The test cassette contains a strip with antibodies against malaria parasite When blood is added it flows along the strip If malaria parasite antigens are present two bands are formed a control band and a positive test band In the absence of malaria parasite antigens only the control band is formed The test kit may contain some of the following materials Instruction sheet package insert Packaged cassettes Blood collection devices micropipettes or micro capillary tubes Reagent buffer Swabs 70 alcohol cotton wool or gauze Lancets Sharps disposal container Pencil or fine marker pen Laboratory register Extra gauze or cotton wool Note that these items may or may not be included in a box containing many kits Lancets and swabs are optional and a buffer is often one bottle for 25 tests Now study carefully Figure 5 which illustrates how to conduct and RDT test Ly 4 FIRST read carefully these instructions Collect 1 alcohol gloves Look at the expiry date at the back of the package Use another package if expiry date has passed Open the package and look for the following Dessin En e 4 e ee A Write patient s name at the back of the device Clean the patient s finger with alcohol The finger MUST be dry before pri
24. s being used RDTs have become quite common because they are simple and fast Now that new treatment policy guidelines recommend parasitological diagnosis of malaria especially for older children 255 years and adults in malaria high risk areas and for all age groups in low malaria risk areas it is important to have a test that is easy to use and can give results quickly Are the results obtained by RDTs accurate 29 Yes RDTs are sensitive in detecting parastaemia When tests in good condition some of them can achieve sensitivity similar to that commonly achieved by microscopy looking at blood smears under a microscope Take Note When a parasitological test is needed RDTs are NOT entirely interchangeable with a blood smear RDTs ARE NOT recommended for e Follow up of patients who have been treated for malaria since most tests remain positive for up to 2 weeks following effective anti malarial treatment Determination of parasite density These test are NOT quantitative RDTs cannot be stored for reference The results are unreliable beyond the manufacturer s recommended time for reading e g 15 20 minutes depending on the test Special Storage Requirements Prior to use boxes containing RDTs should be stored in the least humid coolest place in the facility The storage site should be clean and as dry as possible Used RDTs should be disposed of as soon as the results have been interpreted and rec
25. stigations especially where these facilities are present Laboratory investigations can range from a simple laboratory procedure to radiological and other complex procedures A medical laboratory investigation is a procedure done on a specimen in order to confirm or exclude the presence of a disease In humans the specimens that are commonly investigated include e Blood e Urine e Sputum e Stool e Pus e Urethral or vaginal discharge e Biopsy specimens etc The following Investigations should be done on a patient who presents with signs and symptoms of malaria Blood Slide There are two types of blood slides e Thick blood slide film for screening of malaria parasites e Thin blood slide film is for identification of various species of Malaria parasites A blood slide helps you to do the following e Confirm or exclude malaria e Follow up treatment for malaria e Screen donated blood for malaria e Screen for other haemoparasites e Confirm type of anaemia L2 White Blood Cell WBC Total and differential counts may be ordered for e P U O Pyrexia of unknown origin e Lymphocyte count e Leukaemia Remember these are some of the conditions that present with fever Blood Haemoglobin Hb Estimation diagnose anaemia e Screening for anaemia e monitor and follow up during treatment for anaemia Take Note d Malaria is one of the most common causes of anaemia including severe anae
26. tact with one of the principal mosquito vectors An gambiae sl or An funestus and that these vectors carry the malaria parasite P falciparum There are four types of Plasmodia species falciparum vivax ovale and malariae Of these Plasmodium falciparum is the commonest in Kenya and is known to cause severe and complicated malaria Do you know the dynamics of malaria transmission Try to make your own sketch on a piece of paper and then compare what you have written with Figure 1 Determinants of Malaria Parasite Figure 1 Dynamics of Malaria transmission Occurrence and Distribution of Malaria in Kenya The level of endemicity of malaria in Kenya varies from region to region and there is a big diversity in risk largely driven by climate and temperature including the effects of altitude Based on malaria risk districts in Kenya can be broadly categorized into one of five classes of malaria ecology see Figure 2 We are now going to look in detail at each one of these categories Lakeside Endemic Looking at the map on malaria transmission in Kenya you see areas where malaria exists all the year round These areas are known as malaria endemic areas The Lakeside endemic area includes mainly districts close to Lake Victoria where malaria transmission is common every year Here the community acquires immunity before adulthood and the risks of disease and death from malaria are concentrated amongst childre
27. tes in childhood The last group is where there is no active transmission Low Malaria Risk These areas cover the highlands within Central Province and Nairobi province Parasitological surveys in these areas on the whole suggest low parasite prevalence among children aged 0 14 years Several areas will experience almost no malaria risk for example the central areas of Nairobi Nyeri and Nakuru Take Note For clinical management purposes the ecological zones are classified into 1 High malaria risk areas which include Lakeside Coastal Highland and arid areas 2 Low malaria risk areas which are the Highlands within Central Province Now check the map on Figure 2 and note whether the place that you are working at is a malarial endemic or epidemic zone Legend Endemicity aem rid Seasonal Endemic Coast Highland E Ty ERE Lake Endemic cM es d 100 Low risk UE d kilometers Figure 2 Endemicity of Malaria in Kenya Courtesy Ministry of Health Life Cycle of the Human Malaria Parasite How is malaria transmitted Try to draw your own illustration of the life cycle of the human malaria parasite Then compare to figure 3 amd ud Figure 3 Life Cycle of the human Malaria Parasite Courtesy of CDC The malaria parasite life cycle involves two hosts During a blood meal a malaria infected female Anopheles mosquito inoculates sporozoites into the human host 1 oporozoites
28. that you should follow in order to make a correct diagnosis of malaria Before you read any further take a piece of paper and write down the three steps in clinical assessment Then compare your answers to what is written below History Taking otep 1 is history taking This is the systematic inquiry into the patient s life in relation to the illness by obtaining relevant information from the patient or the patient s caretaker for the purpose of making diagnosis The medical history includes e Identification data Name Sex Ethnicity Religion Next of Kin Residential Address and date of visit in the health unit e Presenting complaint The problem causing the patient to come for medical attention History of the presenting complaint When it started how it started was the onset sudden or slow and what was the sequence of occurrence e Past Medical History Ask whether the patient has had the same illness before any other past illness whether the patient has been admitted or has chronic illness Treatment History Ask the patient what other treatments have been taken during the present illness and history of drug allergy Family social history Ask if any one else is sick general health of other family members if mother and father are alive if the condition runs in the family sanitary conditions Physical Examination This is a procedure carried out by a health worker on a patient in order to assess the physical state of
29. to you with convulsions On taking the temperature you find it is 40 C a What conditions could this child be suffering from b What history would you take C You quickly order a blood slide for malaria parasites and it is reported as heavy parasitaemia What steps would you then take d From the results of your investigations what is your conclusion regarding the condition e What causes the condition f If this patient does not get prompt treatment what complications do you anticipate 2 How is malaria transmitted 3 List the three significant symptoms of uncomplicated malaria 4 What drug do you use for treating uncomplicated malaria in your area 5 What drug do you use as second line treatment for uncomplicated malaria 6 Whatis severe malaria 7 Which are the high risk groups of people likely to develop severe malaria 8 What drug is used for treatment of severe malaria 9 Which season or period does malaria transmission take place in your area 10 List 3 factors that you consider responsible for deaths associated with malaria 11 Which three conditions in children may be confused with malaria 12 What are the three effects of malaria on pregnancy 13 What do you do to reduce the effect of malaria in pregnancy 14 Name the groups of people that you would consider for malaria prophylaxis Congratulations You have now come to the end of this unit Remember to indicate your Student Number
30. umbar puncture results can exclude meningitis Do blood glucose levels to rule out hypoglycaemia Severe Anaemia Clinical assessment i Determine the presence of severe anaemia by examining ii Hypoglycemia This is an important complication of severe malaria and is associated with poor prognosis in children and pregnant women Hypoglycemia may be due to the increase in glucose consumption 25 both by host and parasite defunct liver gluconeogenesis production of glucose use of quinine as mode of treatment Clinical assessment Assess the level of consciousness Laboratory test Determine the blood glucose level Renal Impairment This is a common finding in adults There is interference of renal microcirculatory flow leading to obstruction infarction necrosis of the tubular cells acute renal failure Respiratory Complications Patients with severe malaria may develop non cardiogenic pulmonary oedema This is also referred to as Adult Respiratory Distress Syndrome ARDS This condition is aggravated by over judicious use of intravenous fluids Care must be taken when treating a patient with severe malaria A strict input and output chart MUST be recorded Make frequent physical examination especially chest auscultation abdominal palpation monitoring of any pedal oedema or a rise in the Jugular Venous Pressure JVP Determine presence of respiratory distress
31. vailable q e Quinine should only be given as an intravenous infusion and NEVER given as an intravenous bolus injection Loading dose should be omitted if patient has received quinine in the last 24 hours or has received Mefloquine in the last 7 days Quinine is not contraindicated in severe anaemia Full doses of quinine should be administered In renal insufficiency the dose of quinine remains unchanged In hepatic insufficiency the dose of quinine should be reduced by 25 Hypoglycaemia is a potential side effect of quinine administration particularly in pregnant women Provide glucose supplement to these patients 29 Now study carefully Table 4 which illustrates the dosage of intramuscular injections of quinine to be administered in cases of severe or complicated malaria Table 4 Dosage of intramuscular injections of quinine After dilutions BODY VOLUMES OF DILUTED QUININE NUMBER OF WEIGHT Kg INJECTION ml TO BE INJECTION SITES ADMINISTERED 276 300 60 TW 376 400 80 The _ 426 450 90 Thre _ Quinine Intravenous Infusion Intravenous quinine is administered in isotonic fluid either 596 dextrose or normal saline as follows 30 Adults A Children The first dose 20 mg Kg in 500mls of isotonic fluid given over 4 hours max 1 200mg Then 8 hours after commencing the initial dose give 10 mg Kg in 500mls of isotonic fluid over 4 hours max 6
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