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Malaria

Malaria

Poverty

The Malaria Burden

Infected Mosquito

Acute Febrile Illness

Severe Illness

Hypoglycaemia Anaemia Respiratory Death distress Cerebral Malaria

Anaemia Infected Human Chronic effect Neurologic/C ognitive Developmental Low birth weight Acute Illness Anaemia Impaired growth & development Malnutrition

Fetus Pregnancy Maternal

Infant mortality
Impaired productivity

Malaria Epidemic Prone Areas Malaria Endemic Areas Malaria Endemic - Roll Back Malaria Pilot Areas

Proportion of P. falciparum has increased


significantly in Bangladesh Failure rate for CQ and S-P high

Ear of The HIPPO

Types of Severe Manifestations (n=829)


Type SCM (Major) Full Death Recovery N (Row%, CFR) Others 2 Total N (cum%)

CNS Manifestations
Unrousable Coma Impaired Conscious Convulsion Severe Prostation Hyper-parasitaemia Severe Anamia

304
86 185 33 193 172 51

39 (31)
36 (27) 2 (1) 1 (3) 0 0 0

19
10 8 1 4 6 16

362 (44)
132 (16) 195 (24) 35 (4) 197 (24) 178 (22) 67 (8)

Hyperpyrexia
Others Total n (row%)

14
7 741 (89)

1 (7)
0 40 (4.8)

0
3 48 (6)

15 (2)
10 829

Predominant Presentations of Severe Malaria by Categories of Hospital (n = 909)


Presentations Total cases Severe Prostration Hypoglycemia Unrousable coma Convulsion Severe anaemia Impaired consciousness Hyper pyrexia Primary (Number, %) 339 248 (73.2) 9 (2.7) 7 (2.1) 23 (6.8) 10 (2.9) 20 (5.9) 15 (4.4) Secondary (Number, %) 382 101 (26.4) 123 (32.2) 17 (4.5) 54 (14.1) 27 (7.1) 16 (4.2) 18 (4.7) Tertiary (Number, %) 188 30 (16.0) 3 (1.6) 91 (48.4) 22 (11.7) 16 (8.5) 8 (4.3) 6 (3.2)

Jaundice

2 (0.5)

6 (3.2)

Out come of Severe Malaria (n = 909)

Out come Full recovery Recovery with sequelae Death (CFR)

THC (n, %0) 286 (84.4) 9 (2.7) 5 (1.5)

DH (n, %) 321 (84.0) 2 (0.5) 19 (5.0)

MC (n, %) 140 (74.5) 2 (1.1) 34 (18.1)

Malaria case Definitions:


According to Revised Treatment Regimen:

Uncomplicated Malaria Confirmed (UMC)


Uncomplicated Malaria Presumptive (UMP) Severe Malaria (SM) Previous definitions: - Uncomplicated Malaria (UM) - Treatment Failure Malaria (TFM) - Severe Malaria (SM)

Revised Malaria treatment Regimen 2004. Uncomplicated malaria confirmed (UMC)

For p.falciparum-Coartem, Q7, Q7+T7, Q7+D7.


For P.vivax-CQ3+PQ14. - Uncomplicated malaria presumptive(UMP)-CQ3 Severe malaria(SM)-IVQ/IMQ, AM/Artesunate, IMQ/Rectal Artesunate.

Artesunate Versus Quinine for Treatment of Severe Falciparum Malaria: a Randomised Trial
South East Asian Quinine Artesunate Malaria Trial (SEAQUAMAT) group* Lancet 2005; 366: 71725

Malaria Control Program Objectives


To enhance awareness about prevention and
control in 80% of the target areas by 2010 and promote malaria supportive environment. BCC Community, outreach centers and mass media.

Coordination and partnership for malaria


supportive environment.

Malaria Control Program Objectives


To strengthen epidemiological
surveillance and rapid response capacity to outbreaks and epidemics in 13 districts by 2010. Prediction and containment of epidemic. Strengthen surveillance Operations research

Infected Mosquito

Acute Febrile Illness

Severe Illness

Hypoglycaemia Anaemia Respiratory Death distress Cerebral Malaria

Anaemia Infected Human Chronic effect Neurologic/ Cognitive Developmental Low birth weight Acute Illness Anaemia Impaired growth & development Malnutrition

Fetus Pregnancy Maternal

Infant mortality
Impaired productivity

Critical points in natural history of disease, CP = Critical point

Drugs (treatment, prevention)

Personal Protection (insecticide impregnated materials

Insecticides ( house spraying, larvicides)

Environmental and Behavioral Modification

Vacciness preerythrocytic, blood stage, transmission-blocking Future Inverventions

Genetic modification of vectors

Antimalarial Drugs as Control Measure

Rapid diagnosis and Prompt treatment

Rapid Diagnosis and Prompt treatment (UM)


Pl falciparum

Malaria

Pl vivax

32%
After inclusion of physicians impression

19%
23%

14%
14%

37%

Faiz et al; AJTMH: 2002

RMM RDT PM RRM PPL Diagnostic 64% Capability (SM) 65% 69% 27%

RDT: Addition of 5%

JITMM 2002

Newer Diagnostic Tools


Antigen based rapid diagnostic tests

Antimalarial Drug Resistance in Bangladesh (In Vitro)


Bangladesh Thailand

Chloroquine Quinine Mefloquin


Artesunate
AJTMH, 2003

84% 30% 61%


--

95% 18% 82%


--

Diagnostic Facilities
1995- clinical diagnosis
2004-shift to laboratory confirmation RDT or microscopy Need for development of facilities of diagnosis at periphery by RDT and fixed centers by

microscopy

QA Process for Diagnosis


Malaria RDTs have potential for significant improvement of quality of malaria Rx RDT complementary to microscopy

providing accurate diagnosis in areas


where it was unavailable previously QA integral part of RDT QA system for quality microscopy

Newer Antimalarials
For Uncomplicated Malaria
Artemisinin based Combination Antimalarials Artemether-Lumefantrine

Newer Anti Malarials


For Severe Malaria Artemisinin based Per rectal and Parenteral treatment

Combination Treatment
Artemisininn based treatment
Either Artemether+Lumefantrine (Bangladesh) Artesunate + mefloquine

Introduction of Newer Antimosquito Measures

No new insecticide over last 2 decades Pyrethroids: Newer insecticide Use of OPC and Carbamet ITMN or LLN Ensure adequate number of mosquito nets

Insecticide-treated Mosquito Nets

Insecticide-treated Mosquito nets


Limited information from Bangladesh

Risk reduction 50% - 80%


(Coxsbazar1997, Khagrachori 2003).

How to Improve Coverage of ITN


Involvement of NGOs Public participation Cost sharing? Operational Research KAP study

Conclusion
Morbidity & mortality from malaria in BD remained significant & unchanged over last 5

years.
Planning and implementation at micro level The umbrella to be provided by the national Government NMCP, BD needs to be strengthened attitude,

capacity building, logistics & country specific


evidence. New updated policy & regimen needs to be

Malaria Control is Achievable in Bangladesh

Thank You

REVISED MALARIA TREATMENT REGIMEN 2004

Introduction:

National malaria control program in Bangladesh adopted the treatment regimen in 1994 which is currently practised.

Evidence suggests Chloroquine resistance for P. falciparum malaria is 40 70% in high endemic areas in Bangladesh. To ensure radical cure Govt. of Bangladesh in collaboration with WHO adopted and approved

Case Definitions: Uncomplicated Malaria Confirmed (UMC): Diagnosis is confirmed by Blood slide examination or

Rapid diagnostic test (RDT)


Fever or History of Fever over last 48 hours. Absence of convincing feature of any other febrile illness. High index of suspicion: Endemic zone; susceptible

population; Transmission season.

Case Definitions:
Uncomplicated Malaria Presumptive (UMP): When microscopy or Rapid diagnostic test (RDT) is not available Fever or History of Fever over last 48 hours. Absence of convincing feature of any other febrile illness.

High index of suspicion :Endemic zone;


susceptible population; Transmission season.

Case Definitions:
Severe Malaria (SM): Presence of asexual form of P. falciparum in blood slide examination (or + ve RDT) Fever or History of Fever over last 48 hours. With one or more of the following features of severity: Unconsciousness Convulsion Unable to stand or walk Vomiting or severe Diarrhoea Severe anaemia Confused or abnormal behavior

Management of Severe Malaria

Treatment objectives:
Primary: Save life. Secondary: Prevention of recrudescence, transmission or emergence of resistance. Pregnancy: saving the mothers life

Management of Severe Malaria (SM)


Four main areas:
Assessment of the patient

Specific antimalarial treatment


Adjunctive therapy Supportive care

After

rapid

clinical

assessment

and

confirmation of the diagnosis of severe malaria, full doses of antimalarial treatment should be started without delay.

Specific Antimalarial Treatment Severe Malaria (SM) :


The drugs should be: IVQ/IMQ followed by oral quinine for upto 7 days. AM/Artesunate will be used in selected cases. IMQ/Rectal Artesunate may be used as prehospital treatment in the community. Immediate referral should be made to the

nearest health facility where treatment is


available.

Evidence for Severe Malaria Treatment Recommendations

There

is

insufficient

evidence

to

recommend one antimalarial over another for severe malaria.

Treatment Recommendations
(WHO)
Quinine: 20mg salt/kg on admission (i.v.
infusion over 4 hours, or i.m.) 10mg/kg 8 hourly. Artemether: 3.2mg/kg i.m. given on then

admission then 1.6mg/kg daily.

Artesunate: 2.4mg/kg i.v. or i.m given on 0


hr at 12 and 24 hours, then once daily.

TREATMENT ALGORITHM FOR SEVERE MALARIA:WHO


SEVERE MALARIA

IMPAIRED CONSCIOUSNESS?

YES

NO

PARENTERAL ARTEMETHER*, ARTESUNATE* OR QUININE & OTHER SUPPORTIVE CARE

IS ORAL ADMINISTRATION OF DRUG FEASIBLE?

NO

YES GIVE ACT AND TREAT MAIN COMPLICATIONS

Follow-up treatment of severe malaria


Oral medication: when recovered
sufficiently. More likely to recrudesce than milder

infections. Important source of resistance. Important that a full course of curative treatment is completed.

Pre-referral treatment options:


Most deaths from SM are at or near home.
Prompt and effective oral treatment will reduce the probability of developing SM. Until controlled there will still be many patients who are too ill take oral medicine.

If a patient with suspected malaria cannot


take oral treatment and is far from a health post where parenteral treatment can be given then rectal artesunate, artemisinin or IM quinine (10mg/kg for all drugs) should be

administered, and the patient transferred to


hospital. A full course of treatment must be completed.

Uncomplicated Malaria
Uncomplicated malaria is defined as symptomatic malaria without signs of vital

organ dysfunction

Uncomplicated Malaria :Treatment Objectives To cure the infection rapidly and reliably.

Achieving a prompt clinical response, and


then preventing recrudescence.

Preventing the progression to severe disease


and the additional morbidity associated with treatment failure. Reduction of transmission and prevention of resistance

Specific Antimalarial Treatment

Uncomplicated Malaria Confirmed (UMC)


The drug should be depending on the species which are as follows: For P.falciparum infection: Arthemethur+Lumefantrin combination(Coartem)-24 tablets in 6 divided

dosages for adults(in 3 days).


Q7 (an alternative in specific & special situation).

Uncomplicated Malaria Confirmed: (UMC)


For P. vivax infection: CQ3+PQ14 (Tab.Chroloquine for 3days and Tab Primaquine for 14 days.)

Artemisinin-based combinations are the recommended treatments for uncomplicated falciparum malaria: Likely to be effective everywhere artemether-lumefantrine; 1.5 / 12 mg/kg twice daily for 3 days artesunate + mefloquine; 4 / 8 mg /kg daily for 3 days Only likely to be effective in certain areas (depending on the efficacy of the partner drug) artesunate + amodiaquine; 4 / 10 mg /kg daily for 3 days artesunate + SP; 4mg/kg daily for 3 days/ single dose 1.25/25mg/kg on day 1.

Co-artem vs Q3+SP
Randomized, 28-day in-vivo test, 8-day hospitalization

Failure rate- 4% (Co-artem) & 12% (Q3+SP)

14 12 10 8 6 4 2 0
Day-0 Day-1 Day-2

Q3SP Coartem

Day-3

Day-4

Day-5

Day-6

Day-7

Day-14

Day-21 Day-28

Specific Antimalarial Treatment Uncomplicated malaria Presumptive (UMP)


The drug should be CQ3(Chroloquine) but effort should be adopted for confirming the diagnosis as soon as possible by blood slide examination.

Summary
Revised Malaria Rx Case definition Uncomplicated malaria presumptive (UMP)Blood slide/RDT-ve Uncomplicated malaria confirmed (UMC)-

Previous regimen
Uncomplicated malaria (UM)

Treatment failure
malaria (TFM) Severe malaria (SM)

Slide/RDT+ve
Severe malaria(SM)Slide/RDT +ve

Thank you.