MALARIAA manual for communityhealthworkersWorldHealthOrganizationGeneva1996WHOLi braryCatal ogui ngi nPubl i cati onDataMal ari a:amanual forcommuni tyheal thworkers.l.Malaria 2.Communityh e a l t h a i d e s 3.ManualsISBN9241544910 (NLMClassification:WC 750)TheWorldHealthOrganizationwelcomesrequestsforpermissiontoreproduceortranslateitspublications,inpartorinfull.Applicationsandenquiriesshould beaddressedtotheOfficeofPublications,WorldHealth Orgamzation, Geneva, Switzerland, whichwillbegladtoprovidethelatestinformationonanychangesmadetothetext, plans forneweditions,andreprintsandtranslationsalready available.Worl dHeal thOrgani zati on1996PublicationsoftheWorldHealthOrganizationenjoycopyrightprotection inaccordancewiththeprovisionsofProtocol2oftheUniversalCopyrightConvention.Allrightsreserved.Thedesignationsemployedandthepresentationofthe materialinthispublicationdonotimplytheexpressionofanyopinionwhatsoeveronthepartoftheSecretariatoftheWorldHealthOrganization concerningthelegalstatusofanycountry,territory,cityorareaorofItsauthoritics,or concerning: thedelimitationofitsfrontiersorboundaries.Thementionofspecificcompaniesorofspecificmanufacturers productsdoesnotimplythattheyareendorsedorrecommendedbytheWorldHealthOrganizationinpreferencetoothersofasimilarnaturethatarenotmentioned.Errorsandomissionsexcepted,thenamesofproprietaryproductsaredistinguishedbyinitialcapitalletters.TYPESETINHONGKONGPRINTEDINENGLAND95/1 0714-Best-set/Clays-8000Asacommunityhealthworkeryoucanhelpyourvillage,yourfamily,andyourselftocontrolmalaria:! Prompttreatmentofmalariasaveslives! Prompttreatmentofmalariareducesthedurationofdiseaseanditsharmfuleffectsonthehumanbody! PreventivemeasuresinthecommunityreducetheriskofpeoplegettingmalariaContentsPart 1Part 2Part 3PrefaceAcknowledgementsIntroductionWhatyoucandoaboutmalariaMedicinesandequipmentyouwillneedGeneralinformationaboutmalariaandits preventionWhataretheeffectsofmalaria?Howdopeoplegetmalaria?Howdomalariamosquitoslive?Howcanyoupreventmalaria?RecognitionandtreatmentofmalariaClinicalfeaturesofmalariaHowtorecognizemalariaHowtogivestandardmalariatreatmentWhattodoifstandardmalariatreatmentfailsSeveremalariaSpecialgroups,specialcareRecordingandreportingAnnex 1 HowtoorganizeyourantimalariaworkAnnex 2 HowtoorganizeyourvillagePageviiix1357910121321232430373839414345PrefaceThismanualhasbeenpreparedbyDrR.L.Kouznetsov,MalariaControl,incollaborationwithDrP.F. Beales,Chief,Training,DivisionofControlofTropicalDiseases,WorldHealthOrganization,forthetrainingofcommunityhealthworkersinmalariacontrol.Itmayalsobeusedbycommunityhealthworkerstosupporttheirday-to-daywork.Themanualcontainsthebasicinformationandguidancerequiredfortherecognitionofmalaria,itstreatment,andidentificationofcasestobereferred:recordingandreporting;promotionofcommunityawarenessaboutmalaria;andpromotionofrelevantandfeasiblepreventiveactivities.Itisemphasizedthatthismanualshouldserveasabasisforlocaladaptation,sincetheepidemiological,social,andeconomicconditions-aswellashealthcaredeliverysystemsandapproachestomalariatreatmentandcontrol-varyconsiderablyfromcountrytocountryandevenwithineachcountry.Enquiriesregardingadaptationarewelcomed,andshouldbeaddressedinthefirstinstancetotheOfficeofPublications,WorldHealthOrganization,1211Geneva27,Switzerland.ThetextisavailablefromWHOoncomputerdiskettetomakeadaptationeasier.Staffofnationalmalariacontrolprogrammesshouldnotethefollowing:! Itisnormallytheresponsibilityofnationalmalariacontrolprogrammestodefinethefirst-linetreatmentforuncomplicatedmalariatobeusedbycommunityhealthworkers.Thismanualhasbeenwrittenwithchloroquineasthefirst-linetreatment.Wherechloroquineisnotthe first-linetreatment,themanualmustbemodifiedaccordingly.! Onpage27thecommunityhealthworkerisadvisedtoaskhisorhersupervisoraboutwhethermalariaiscommoninthearea.Thus,foroptimaluseofthismanual,communityhealthworkersupervisorsmustbeinformedastowhethertheirareaisclassedasoneofhighorlowmalariarisk.InPrefacecountrieswheremalariaishighlyendemic,itissafetoassumethatmalariaiscommoninthecommunityhealthworkersarea.Commentsandsuggestionsarisingfromthepracticaluseofthismanualwouldbegreatlyappreciated,andshouldbeaddressedtoTraining,DivisionofControlofTropicalDiseases,WorldHealthOrganization,1211Geneva27,Switzerland.AcknowledgementsTheMalariaDivision,MinistryofHealthandMedicalServices,SolomonIslands,allowedextensiveuseoftheirnationalguidelinesforprimaryhealthworkers.TheWorldHealthOrganizationgratefullyacknowledgestheroleofthisvaluablepartnershipinthepreparationofthismanual.TheauthorsalsowishtothankthestaffoftheMalariaControlandTrainingunitsofWHOsDivisionofControlofTropicalDiseases,fortheirconstructivecriticismandencouragementduringthepreparationphase;particularthanksareowedtoDrA.ShapiraforhisvaluablecontributionsandtotheWHORegionalOffices.Part 1IntroductionWhatyoucandoaboutmalariaMalariaisoneofthemostseriousdiseasestoaffectpeopleindevelopingcountrieswithtropicalandsubtropicalclimates.Itisparticularlydangerousforyoungchildrenandforpregnantwomenandtheirunbornchildren,althoughothersmaybeseriouslyaffectedinsomecircumstances.Malariaisacurableandpreventabledisease,butitstillkillsmanypeople.Themainreasonsforthisunsatisfactorysituationare:! Somepeopledonotcomefortreatmentuntiltheyareveryillbecause:-theydonotrealizetheymighthavemalaria(peopleoftenthinktheyhaveacold,influenzaorothercommoninfection);-theydonotrealizethatmalariaisverydangerous;or-theylivefarawayfromhealthcarefacilities.! Peoplelivingfarfromhealthserviceswilloftengotolocalmedicinevendors(sellers)foradvice,whichisnotalwaysappropriate,ortobuymedicines,whicharenotalwayseffective.! Manypeopledonotknowwhatcausesmalariaorhowitisspread,sotheyarenotabletoprotectthemselvesfromthedisease.Asacommunityhealthworkeryoucanimprovethesituationbyperformingthefollowingactivities:Encouragepeopletoseektreatment immediately iftheyhavefever.Thisisespeciallyimportantinyoungchildrenandpregnantwomen,whoshouldreceivetreatmentagainstmalariawithin24hoursofbecomingill.Recognizeandtreatmalariatopreventsevereillnessanddeath.Explainhowtotaketreatmentcorrectly,sothatpeoplecanavoidrepeatedattacksofmalaria.Advisepatientswhodonotimprovewithin48hoursafterstartingtreatment.orwhoseconditionisserious,togoMalaria: a manual for community health workersimmediatelytothenearesthospitalorcliniccapableofmakingadefinitediagnosisandmanagingseveredisease.! Adviseindividualsandfamiliesonhowtoprotectthemselvesfrommosquitobites.! Motivatethecommunitytocarryoutmosquitocontrolmeasuresinordertoreducethenumberofmalariacases.Alloftheseactivitiesareexplainedinthismanual.Remember:PrompttreatmentofmalariasaveslivesPrompttreatmentofmalariareducesthedurationofdiseaseanditsharmfuleffectsonthehumanbodyPreventivemeasuresinthecommunityreducetheriskofpeoplegettingmalaria4MedicinesandequipmentyouwillneedYoushouldhavethefollowingitemsinyourmedicalkit:Antimalarialdrug(s)*Paracetamoloracetylsalicylicacid(aspirin)TreatmentschedulePencils and paperAday-bookandamonthlyreportformMalariahealtheducationmaterialsAcopyofthisbookItisyourresponsibilitytohaveenoughdrugsatalltimesbecausethecommunitywillcometorelyonyoufortreatmentandadvice.Alwaysuseupoldermedicinesbeforeyoustartusinganynewsupplies.Drugsshouldbekeptindoorsawayfromsunlightandheat,preferablyinalockedboxorcupboard,outofchildrensreach.Remember, it is very dangerous to swallow large quantities ofantimalariadrugs atthesametime.*YourgovernmentsMinistryofHealthshouldspecifywhichantimalarialdrug(s)maybeusedbycommunityhealthworkersandhowtheyshouldbegiven-askyoursupervisor.5Part 2GeneralinformationaboutmalariaanditspreventionWhataretheeffectsofmalaria?Malariaisadiseasethatiscausedbythepresenceofverysmallorganisms(malariaparasites)intheblood.Malariaparasitesaresosmallthattheycanonlybeseenunderamicroscope.Theyfeedonthebloodcells,multiplyinsidethemanddestroythem.Later(pages23-28)youwilllearnhowtorecognizemalariainasickperson.Itisoftendifficulttotellwhetherasicknessiscausedbymalariaorsomeotherdisease,becausethefeaturesmaybesimilar.Therefore,ifthepatientsconditionhasnotimprovedwithin2daysafterthestartofanadequatemalariatreatment,heorsheneedsurgentcareinthenearestclinicorhospital(seepage37).Malariaisespeciallydangerousinpregnantwomenand,inparticular,youngchildren(under5yearsold).Ifapregnantwomanoryoungchildgetsmalaria,severeillnessmayrapidlydevelopandmayevenresultindeath.Suchpatientsneedspecialcareinadditiontostandardmalariatreatment(seeSpecialgroups,specialcare (page39)).Inareaswheremalariaisverycommon,peoplemaygetthediseaseseveraltimesduringtheirlives.Thisgivesthemsomeresistancetothedisease,sotheattacksofmalariaoftenbecomelesssevereastheygetolder.However.adultswhocomefromareaswheremalariaisnotcommoncanbecomeveryillwithmalaria.justlikechildren.Malariaisespeciallydangerousforyoungchildrenandpregnantwomen9How dopeopleget malaria?Themalariaparasitesenterandleavethebodythroughmosquitobites(seeFig.1).sick personFigure1malaria mosquitopersonhealthy personWHO 95644! Whenamosquitobitesapersonitsucksupblood.Ifthepersonhasmalaria,someoftheparasitesinthebloodwillbesuckedintothemosquito.! Themalariaparasitesmultiplyanddevelopinthemosquito.After 10-14 daystheyarematureandreadytobepassedontosomeoneelse.1 0Generalinformationaboutmalariaanditsprevention! Ifthemosquitonowbitesahealthyperson,themalariaparasiteswillenterthebodyofthehealthyperson.Thispersonwillthenbecomeill.Mosquitosmaybitepeoplewithmalaria,andthenpassitontomanyotherpeopleinthevillage11Howdomalaria mosquitos live?Therearemanydifferentkindsofmosquitos,butonly maluriamosquitos canpassonmalariaparasites.Allmalariamosquitoshavewhiteandblackspotsontheirwings(butamosquitowithwhiteandblackspotsisnotnecessarilyamalariamosquito).Only femalemosquitosbitepeople.Malemosquitosdonotsuckupbloodandcannotpassonmalariaparasites.Femalemosquitosneedbloodtoproduceeggs.Theeggsareverysmall:youcanhardlyseethem.Theyarelaidonstagnantorslow-flowingwater. Usuallythemosquitosthatbiteyouarebreedingincollectionsofwaterwithin2kilometres(about1.25miles)oftheplacewhereyoulive.Twoorthreedaysaftertheeggsarelaidonthewater,amosquitolarva willcomeoutofeachegg.Thelarvafeedsonverysmallanimalsandplantsinthewater,andgrowsuntilitbecomesapupa Thepuparemainsinthewater,butdoesnotfeed.Afterafewdaystheadult mosquitowillcomeoutofthepupaandflyaway.Ifitisafemalemosquito,itmaybitepeopleandfeedontheirblood.Afterfeeding,themosquitousuallyrestsonanearbysurfacebeforeitfliesaway.Thenitwilllayeggsandeverythingstartsalloveragain.Intropicalcountriesittakes7-14daysforamosquitotogrowfromaneggtoanadultmosquito(seeFig.2).Amosquitoegg,larvaorpupadoesnothavemalariaparasitesinsideit.Adultmosquitosmayhavemalariaparasitesintheirbodies,butonlyiftheyhavebittensomeonewhohasmalaria.watesurlaeggslarval al d on or above takes air fromwater surface water surfacepupatakes air fromwater surfaceadultemergesfrompupaat water surfaceFigure 212How can you prevent malaria?Therearethreemainwaystopreventmalaria:1. Preventmosqnitosfrombitingpeople:-sleepundermosquitonets(ordinaryor insecticide-treated);-screenallwindowsanddoorsinthehouse.oratleastinroomswherepeoplesleep;-applymosquitorepellentstotheskin;-burnmosquitocoils.2.Controlmosquitobreeding:-eliminateplaceswheremosquitoscanlayeggs:-reclaimlandbyfillinganddraining:-introducespecialfishthateatmosquitolarvae;- putspecialinsecticidesinthewatertokillmosquitolarvae.3.Killadultmosquitos:-sprayroomswithinsecticidesbeforegoingtobed:- participateinactivitiescarriedoutbythehealthservices,suchassprayingtheinsidewallsofhouseswithinsecticidesthatkillmosquitos.SomeoftheactivitiesmentionedunderControlmosquitobreeding arecomplexandexpensive.Housesprayingcampaignsarealsoexpensive.Thesemethodsneedplanningandsupervisionbyspecializedstaff.Themeasuresdescribedinthefollowingpagescanbeappliedbyindividualsandcommunitieswithyouradviceandguidance.Discusswithyoursupervisorthepossibilityofapplyingsomeofthesemeasurestoyourarea.Ifyouapplythesemeasurescorrectly,youwillreducetheriskofmalariaforeveryoneinyourvillage.Youwillprobablynotbeabletogetridofmalariafromyourvillagecompletely(itisusuallyimpossibletoeliminateallbreedingplaces),butyoucangreatlyreducethenumberofpeoplewhogetmalaria.Malaria:amanualforcommunityhealthworkersHowtopreventmosquitobitesMosquitonetsAmosquitonet(Fig.3)isaverygoodwaytoprotectpeoplefromgettingmalaria.Mosquitonetsdonotkillmosquitos,butwhileyouareunderneaththemthemosquitoscannotbiteyou.Malariamosquitosusuallybitefromsunsettosunrise.Thereforemosquitonetsareespeciallygoodforprotectingyoungchildrenwhoarealreadyasleepbysunset.Netsarealsogoodforprotectingolderchildrenandadultsbecausesomemosquitosbiteduringthenight.Malariaisparticularlydangerousforyoungchildrenandpregnantwomen(seepages39-40).Itisthereforeveryimportantthattheyusemosquitonets.Youngchildrenandpregnantwomenshouldgotosleepearly(undermosquitonets)toavoidmosquitobitesduringtheevening.WHO 95484Figure 314GeneralinformationaboutmalariaanditspreventionMosquitonetswillnotpreventmalariaunlesstheyareusedcorrectly:! Tornsectionsmustberepaired.! Mosquitonetsshouldbehungupproperlytocoverthesleepingareaandshouldbelowenoughtoallownettingtobetuckedinunderthemattressormatwherethepersonsleeps.! Mosquitosthataretrappedinsidethenetshouldbekilledwithinsecticidesprayorbyhand.Mosquitonetsprovidemuchbetterprotectioniftheyaretreatedwithaspecialinsecticide.Thisinsecticideisnotharmfultopeopleifusedcorrectly,butitkillsmosquitosandkeepsthemawayfromthehouse.Treatednetsalsokillbedbugsandotherinsects.Insecticidesareuseful,buttheyaredangerousifusedincorrectly.Youmustreceivespecialtrainingbeforeyoucanadvisepeopleonhowtotreatnetswithinsecticides.ScreeningAsinglemosquitonetprovidesprotectiononlyforthosesleepingunderit,butscreeningthehousewillprotectthewholefamily(Fig.4).Figure415Malaria:amanualforcommunityhealthworkersEffectivescreeningispossibleonlyinhousesthatarewellconstructedandmaintained.Variousmaterials(usuallymetalorplastic)canbeusedforscreening.Frequentinspectionisnecessarytodetectdamagetothescreensandtomakeearlyrepairs.Anotherwayofkeepingoutmosquitosistousecurtainsmadefromnettingorsimilarmaterials.Thesecurtainsmustbetreatedregularlywithaspecialinsecticideandtheymustbehungupinsuchawaythattheycoverallopeningstothehouse.RepellentsRepellentsarechemicalsthatyouapplytotheskintokeepmosquitosaway(Fig.5).Theyaresoldinpharmaciesandsomeothershops.Repellentspreventmosquitosfromlandingonyourbody.Repellentsareveryusefulearlyintheevening(whenpeoplearenotundermosquitonetsorinsidescreenedhouses).Theyareusuallyactivefor5-8hours,thentheyhavetobeappliedagain.Figure 516GeneralinformationaboutmalariaanditspreventionMosquitocoilsWhenmosquitocoilsburn,theirsmokekeepsmosquitosaway.Ifmosquitosflythroughthesmoke,theymayevenbekilled.Thecoilsarenotveryexpensiveand(liketherepellents)areespeciallyusefulearlyintheeveningwhenpeoplesitoutdoors(Fig.6).HowtocontrolmosquitobreedingMalariamosquitosmaybreedin:- freshwaterorbrackish(slightlysalty)water,especiallyifitisstagnantorslow-flowing;- openstreamswithveryslow-flowingwateralongtheirbanks;- poolsofwaterleftontheriverbedaftertherainshaveended,orasaresultofpoorwatermanagement;Figure617Malaria:amanualforcommunityhealthworkers-swamps,ricefields,andreservoirs;-smallponds,pools,borrow-pits,canals,andditcheswithstagnantwater,inandaroundvillages;-animalhoof-printsfilledwithwater;-cisterns(watertanks)forstorageofwater;and- anythingthatmaycollectwater-plantpots,oldcartyres,etc.Remember-themosquitosthatbiteyouusuallybreedwithin2kilometres(1.25miles)ofwhereyoulive.Individualsandcommunitiescanreducemosquitobreedingbythefollowingactivities:! Usesandtofillinpools,ponds,borrow-pits,andhoof-printsinandaroundthevillage(Fig.7).! Removediscardedcontainersthatmightcollectwater.! Covercisterns(watertanks)withmosquitonetsorlids.! Clearawayvegetationandothermatterfromthebanksofstreams-thiswillspeeduptheflowofwater.! Poolsofwatermaybecausedbyleakingtaps,spillageofwateraroundstand-pipesandwells,orpoordrains.TheseFigure718Generalinformationaboutmalariaanditspreventionpoolscanbeeliminatedbyrepairsorimprovementstothewatersupplyordrainagesystem.Eliminationofmosquitobreedinginlargeexpansesofwater(orinareaswheresmallpoolsofwaterareabundantaftertherains)usuallyrequiresmajorengineeringworks.Wheneveryouhaveaproblem,askyoursupervisorforadvice;ifheorshedoesnotknowtheanswerimmediately,specialistsinmalariaandenvironmentalhealthcanbecontactedforadviceandhelp.Remember,youcanonlycontrolmalariainyourvillageifeverybodyworkstogethertocarryoutthesemeasures.Thevillageneedstobeorganizedsothateverybodyisinvolvedinmosquitocontrol.ReadHowtoorganizeyourvillage (Annex2onpage45).19Part 3Recognition andtreatmentofmalariaTakeenoughtimetopayproperattentiontowhatthepatienthastosayandtoexaminethepatientinordertorecognizedisease correctlyProvideappropriatetreatmentwithoutdelayDonottrytotreatapatientwhorequiresmedicalcarethatisbeyondyourskillsandcompetence-alwaysrefersuchpatientsforexpertconsultationandtreatment22ClinicalfeaturesofmalariaTheclinicalfeaturesofmalariavaryfromverymildtoverysevere,dependingonseveralfactors.Forexample,inareaswheremalariaisverycommon,adultswiththediseasemighthavejustaslightincreaseinbodytemperature.However,pregnantwomenand,inparticular,youngchildrenoftenhaveasevereillnesswithmanysymptomsandsigns,andtheymayevendie.Themostimportantfeatureofmalariaisfever(orahistoryoffeverwithinthelast2-3days).Thefevermaybeeithercontinuousorirregularatthestartoftheillness,butsoonitmaybecomeregular,withattacksevery2-3days.Eachattackmaylastseveralhoursandoftenbeginswithshivering(bodyshaking);thenthereisaperiodoffever,andfinallythereisprofusesweating.Duringanattackthepatientoftencomplainsofheadacheandpainsintheback,joints,andalloverthebody.Theremayalsobelossofappetite,vomiting,anddiarrhoea.Thepatientmayfeelbetterthenextday,buthasanotherattackthedayafterthat,andsoon.Ifuntreated(orinadequatelytreated),malariamaycauseseveralweeksormonthsofpoorhealthbecauseofrepeatedattacksoffever,anaemia(seepage26),andgeneralweakness.Somepatients(usuallyyoungchildren)rapidlybecomeveryillandmaydiewithinafewdays(seeDangersignsofseveremalaria,page24).23HowtorecognizemalariaYoucanrecognizemalariabyasking andlooking (whetheryouareinaclinic,ahealthcentre,orthepatientshome):1. Ask questionsandlistentowhatthepatienthastosay(ifthepatientisayoungchild,listentotheparentorguardian).2. Look-examinethepatientforfeaturesofmalaria.Startbyaskingwhythepatient(orparent)isseekingyourhelp.MalariaisapossibilityifoneofthecomplaintsisFEVER.Ifthepatient(orparent)doesnotmentionfever,askwhethertherehasbeenafeveratanytimeduringthepast2-3days.Insomeplaces,itisbettertoaskwhetherthepatienthasfelthotorcold,orwhetherthechildsbodyhasfelthottotouch.Measurethetemperaturewithathermometer.Ifthetemperatureismorethan 37C, thepatienthasafever.(Ifyoudonothaveathermometerwithyou,feeltheforeheadwiththebackofyourhand.Iftheforeheadfeelshot,thepatientprobablyhasafever.)If there is no fever, and no history of fever during the past 2-3days, the patient doesnot have malaria.Patients who have had fever during the last 2-3 daysmay havemalaria.Ifthepatienthashadfeverduringthepast2-3days,first askaboutandthenlook fordangersigns.Danger signsof severe malariaThedangersignsofmalariaare:-changesinbehaviour(convulsions;unconsciousness;sleepiness;confusion;inabilitytowalk,sit,speak,orrecognizerelatives);24Recognition and treatment of malaria-repeatedvomiting;inabilitytoretainoralmedication;inabilitytoeatortodrink;- passageofsmallquantitiesofurineornourine,orpassageofdarkurine;-severediarrhoea;-unexplainedheavybleedingfromnose,gums,orothersites;- highfever(above39C);-severedehydration(looseskinandsunkeneyes);-anaemia(seepage26);- yellowwhitesofeyes.Ifyouseeanyofthesefeaturesyoushouldthinkaboutmalariaandactimmediately(seepage38).HowtorecognizethedangersignsAsk:! Isthepatientunabletodrink?! Hasthepatienthadconvulsions(fits)?! Doesthepatientvomitrepeatedly?! Howmuchurinedoesthepatientpass?-Verylittle?Noneatall?Isitdark?Look:! Isthepatientabnormallysleepy,difficulttowake,orconfused?! Doesthepatienthaveanaemia(seeboxbelow)?! Doesthepatienthaveseveredehydration?(Lookforsuddenweightloss,looseskin,sunkeneyes,drymouth.Dehydrationisalwaysimportanttorecognize-formoredetails,refertothenotesfromyourdiarrhoeacourseoryourgeneralcourse.)! Isthepatientunabletostandorsit?If the answer to any of these questions is yes, the patient hasseverefebriledisease-probablyseveremalaria.Thepatientslife is in danger. Urgent treatment is needed at a clinic orhospital to save the patients life.25Malaria:amanualforcommunityhealthworkersGivethefirstdoseofantimalariatreatment.Thenreferthepatienttothenearestclinicorhospital.Writeareferralnotetogowiththepatient:includedetailsofwhatyouhaveobservedandwhattreatmentyouhavegivenandwhen.Ifyouthinkapersonhasseveremalaria,youmustactimmediately-readSeveremalaria (page38)fordetailsofwhattodo.AnaemiaAnaemiameansnotenoughhaemoglobinintheblood.Haemoglobinistheredsubstanceinthebloodcellswhichcarriesoxygen.Malariaparasitesdestroythebloodcells,andsomalariamaycauseanaemia.Anaemiamayalsohaveothercauses(forexample,notenoughironinthefood).Youcanrecognizeanaemiabylookingatthepatientshands:thepalmsofapatientwithanaemiadonothavetherednessofa healthy persons palms.Ifyouarenotsure,lookattheredoftheeyebycarefullypullingdownthelowereyelidwithcleanfingers.lookalsointhemouth.Ifthered colour oftheeyeormouthispalerthaninahealthyperson,thepatienthasanaemia.Anaemia is less noticeable than other danger signs, but it isdangerous.Starttreatmentagainstmalariaandreferthepatienttoahospitalorclinic.If there are no danger signsIfthepatienthashadafeverduringthepast2-3days.heorshemayhavemalaria.RecognitionandtreatmentofmalariaAskyoursupervisorwhethermalariaispresentinyourarea.Howoftendoesitoccur?Whereisitmostcommon?Doesitoccuratcertaintimesofyear?Inmanyareasmalariaoccursduringandaftertherainyseason;inotherareas(particularlyareasthatarehotandhumid,andfullofplaceswheremosquitosbreed)malariaiscommonallyearround.Ifyouknowhowcommonmalariaisinyourarea,thiswillhelpyou assess the risk of exposure and the chances that yourpatient may have the disease.IfyouworkinanareawheremalariaisabundantAchildlessthan 5yearsoldorapregnantwoman(especiallyifsheispregnantforthefirsttime)whohashadfeveratanytimeduringthepast2-3daysshouldbetreatedformalariaimmediately,becausemalariacanrapidlybecomedangerousinyoungchildrenandpregnantwomen.Youshouldreferallpregnantwomenwhoaresuspectedtohavemalariatothenearestclinicorhospital.Atthesametimelookforsignsandsymptomsofotherdiseasesandtreatthemaccordingly.Ifthepatientismorethan 5yearsold,lookforothercausesoffeverasdescribedbelow.Ifyoucannotfindanothercauseforthefever,thepatientprobablyhasmalaria.IfyouworkinanareawheremalariaisnotcommonFirst,findoutwhetherthepatienthasafeverorhashadafeverwithinthepast2-3days(seepage24).Ifthepatientdoesnothavefeverwhenexaminedbyyouanddoesnothaveahistoryoffeverwithinthepast2-3days,heorshedoes not havemalaria.Malaria:amanualforcommunityhealthworkersApatientwithfever(orarecenthistoryoffever)mayormaynothavemalaria:! Ifthepatienthasarunnynose,measles,anabscess,earache,orsignsandsymptomsofanyotherwellknowncausesoffever,heorsheprobablydoesnothavemalaria.(Measlesisadiseaseofchildren.Itsfeaturesareredeyes,soremouth,andrash.Youlearntorecognizeitbyobservingsickchildrentogetherwithsomeonewhoisveryexperienced.Anabscessisatender,hotswellingsomewhereonthebody.)! Ifthepatientdoesnothavearunnynose,measles,abscess,etc.,butdoeshavefeverorarecenthistoryoffever,thepatientmayhavemalaria,especiallyifheorsheisseenduringthemalariaseason.! Early diagnosis and adequate treatment are essential inyoungchildrenandpregnantwomen,otherwisetheymaydie! Donottrytomanageapatientwhorequiresmedicalcarethatisbeyondyourskillsandcompetence! Donotbeafraidtorefersickpatientsforexpertconsultationandtreatment-knowandrespectyourownlimitationsPneumoniaYoungchildrenwithmalariaoftenhavepneumoniaatthesamelime.Achildprobablyhaspneumoniaifheorshe:-is2-12monthsofageandbreathes50timesperminuteormore;-isbetween12monthsand5yearsofageandbreathes40timesperminuteormore.Ifyouhavelearnedhowtomanagepneumonia,proceedaccordingly(treatcasesofsimplepneumonia;refercasesof28Recognitionandtreatmentofmalariaseverepneumonia).Ifyouhavenotlearnedhowtomanagepneumonia,referanychildwithsignsofpneumoniabut,ifthechildhashadfeverduringthepast2-3days,starttreatmentformalaria-givethefirstdoseofstandardmalariatreatmentandthenrefertoaclinicorhospital.29Annex 1Howtoorganizeyour antimalariaworkYourworkwillbeeasierandmoreeffectiveifyoufollowafewsimplerules:Rule 1Keep your forms complete and up-to-date! Fillingintheformswillhelpyoutomaketherightdecisionswithoutforgettinganything(ShouldItreatthisperson.yesorno? ShouldIreferthepersontoaclinic,yesorno?).! Theformswilltellyouhowmanypeopleyouhavetreated.! Ifpeoplecomebackwithsignsofmalariayoucaneasilycheckthedatewhenyougavethemtheirlasttreatmentandfindoutwhetherthesearecasesoftreatmentfailure.! Discussingcaseswithyoursupervisorbecomesmucheasierifyoualwayswritedowndetailsofyourcases.Rule 2Keep close contact with your supervisorWhenyouseeyoursupervisor,dothefollowing:! Gothroughtheday-bookanddiscussanyproblematiccases.! Gothroughthelistofcontentsofyourtreatmentkit(seepage5)toseewhetheranythingneedstobesupplied.! Discussanythinginthismanualthatyoudonotunderstand.! Discussanyotherproblemsthatyouhave.Sometimes(despitetheinformationinthismanual)youmaynotbesurehowtotreataparticularpatient-yoursupervisorwillbegladtohelpyou.Thesupervisormayalsobeinabetter43Annex 1positiontodiscussyourworkorotherhealthproblemswiththevillagehead,villagehealthcommittee,andotherpeopleinyourvillage.Do not be afraid to ask questionsRule 3If you leave the village for a couple of days, tell the peoplewhere they should go if they become sick (usually, this will bethe nearest health worker)Rule 4Share your knowledge with others! Iftherearepeopleinyourcommunitywhosellantimalariadrugs,trytoestablishagoodrelationshipwiththem.Firstly,observehowtheyworkoraskthemhowtheyrecognizeandtreatmalaria.Iftheydonotdothiscorrectly,tryinafriendlywayandinprivate toexplaintothemwhatyouhavelearnedaboutthediseaseanditstreatment.Describetothemthedangersignsofseveremalaria,andemphasizethatpatientswithseveremalaria(especiallychildren)requirespecialcareandtreatment.Tellthemaboutthenearestclinicorhospitalwherepatientswithseveremalariashouldbereferredforspecialtreatment.Alsoadvisethemtoreferpatientswhoseconditiondoesnotimproveaftermalariatreatment.! Explaintodrugvendorsthatthishonestapproachwillbegoodfortheirbusinessandreputationbecauseitshowsthattheycareaboutpeopleshealthandknowaboutthedrugstheysell.44Annex 2HowtoorganizeyourvillageSupposethatyoufillinsomepoolsofwateraroundyourhouse,getyourhousescreened,maketheareaaroundthehouseclean,andsoon.Ifthepeoplenextdoordonotdothesame,youwillstillgetmalariabecausemosquitoswillcontinuetobreedintheFigure845Annex2poolsaroundtheirhouses.Thisiswhyitisimportantthateverybody inthevillagehelpstoimprovethesituation.Thisistruenotonlyformalaria,butalsoformanyotherdiseasescarriedbymosquitos.Thevillagemustthereforebeorganizedsothateverybodyworkstogether.Thevillagehealthcommitteecanworkwithyoutoorganizeandleadactivitiestoimprovethehealthofthecommunityandtomakesurethattheseactivitiesarecarriedoutproperly(Fig.8).Duringvillagemeetingsyoucantellothersaboutwhatyouhavelearnedasacommunityhealthworker.Youcanusehealtheducationmaterials(giventoyouduringyourtrainingcourseorwiththetreatmentkit)toexplainmalariatothepeopleandhelpconvincethemofwhattodo.Youorthevillagehealthcommitteecancontactthehealthauthorities(directlyorthroughyoursupervisor)tohelpyouorganizeyourvillageandgiveyousomeideasoradviceonwhatcanbedone.Youcanseekhelpfromthedistrictcouncil,thehealthinspector,themalariaspecialist,thehealtheducator,oranybodyelseyoucanthinkofwhomaybewillingtohelpandadviseyou.Askthehealthauthoritiesinyourdistricttohelpyouorganizeyourvillage46SELECTEDWHOPUBLI CATI ONSOFRELATEDI NTERESTPractical chemotherapy of malaria.Reportof a WHOScientificGroup.WHOTechnicalReportSeries,No.8051990 (158 pages)!Sw.fr.16.-Management of severe and complicated malaria.A practical handbook.H.M. Gilles1991 (vi + 56 pages)! Sw. fr. 9.-Vector control for malaria and othermosquito-bornediseases.Reportof a WHOStudyGroup.WHOTechnicalReportSeries,No.8571995 (vi + 91 pages)! Sw. fr.15.-A global strategy for malaria control.1993 (x + 30 pages) ! Sw. fr. 11.-Implementationoftheglobalmalariacontrolstrategy.Report of a WHO Study Group on the Implementation of the GlobalPlan of Action for Malaria Control1993-2000.WHOTechnicalReportSeries,No.8391993 (v + 57 pages)! Sw. fr. 1O.-Basic malaria microscopy.Part I: Learners guide. 1991 (72 pages)! Sw. fr. 14.-Part II: Tutors guide. 1991 (69 pages) ! Sw. fr. 14.-Entomological field techniques for malaria control.Part I: Learners guide. 1992 (77 pages) ! SW. fr. 15.-Part II: Tutors guide. 1992 (54 pages) ! SW. fr. 12.-Further information on these and other World Health Organizationpublications can be obtained from Distribution and Sales, World HealthOrganization,1211Geneva27,Switzerland.*Pricesindevelopingcountriesare70%ofthoselistedhere.