malaria icddrb. 26.2.06

Malaria

Poverty

Malaria

The Malaria Burden

Infected Mosquito

Infected Human

Acute Febrile Illness

Chronic effect

Pregnancy

Severe Illness

Anaemia

Neurologic/Cognitive

Developmental

Fetus

Maternal

HypoglycaemiaAnaemiaRespiratory distressCerebral Malaria

Impaired growth & development

Low birth weight

Acute Illness

Anaemia

Death

Malnutrition

Infant mortality

Impaired productivity

Malaria Epidemic Prone AreasMalaria Endemic Areas

Malaria Endemic - Roll BackMalaria 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)

15 (2)01 (7)14Hyperpyrexia

82948 (6)40 (4.8)741 (89)Total n (row%)

10307 Others

67 (8)16051Severe Anamia

178 (22)60172Hyper-parasitaemia

197 (24)40193Severe Prostation

35 (4)1 1 (3)33Convulsion

195 (24)82 (1)185Impaired Conscious

132 (16)1036 (27)86Unrousable Coma

362 (44)1939 (31)304CNS Manifestations

Total

N (cum%)

Others 2Death

N (Row%, CFR)

Full Recovery

Type SCM (Major)

Predominant Presentations of Severe Malaria

by Categories of Hospital (n = 909) Presentations Primary

(Number, %) Secondary

(Number, %)Tertiary

(Number, %)

Total cases 339 382 188

Severe Prostration

248 (73.2) 101 (26.4) 30 (16.0)

Hypoglycemia 9 (2.7) 123 (32.2) 3 (1.6)

Unrousable coma 7 (2.1) 17 (4.5) 91 (48.4)

Convulsion 23 (6.8) 54 (14.1) 22 (11.7)

Severe anaemia 10 (2.9) 27 (7.1) 16 (8.5)

Impaired consciousness

20 (5.9) 16 (4.2) 8 (4.3)

Hyper pyrexia 15 (4.4) 18 (4.7) 6 (3.2)

Jaundice 0 2 (0.5) 6 (3.2)

Out come of Severe Malaria (n = 909)

Out come THC (n, %0)

DH (n, %)

MC (n, %)

Full recovery 286 (84.4) 321 (84.0) 140 (74.5)

Recovery with sequelae

9 (2.7) 2 (0.5) 2 (1.1)

Death (CFR) 5 (1.5) 19 (5.0) 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: 717–25

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

Infected Human

Acute Febrile Illness

Chronic effect

Pregnancy

Severe Illness

Anaemia

Neurologic/Cognitive

Developmental

Fetus

Maternal

HypoglycaemiaAnaemiaRespiratory distressCerebral Malaria

Impaired growth & development

Low birth weight

Acute Illness

Anaemia

Death

Malnutrition

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)

Genetic modification of vectors

Vacciness preerythrocytic, blood stage,

transmission-blocking

Environmental and

Behavioral Modification

Future Inverventions

Antimalarial Drugs as Control Measure

• Rapid diagnosis and Prompt treatment

Rapid Diagnosis and Prompt treatment (UM)

MalariaPl

falciparumPl vivax

32% 19% 14%

After inclusion of physicians’ impression

37% 23% 14%

Faiz et al; AJTMH: 2002

RMM RDT PM RRM PPL

Diagnostic

Capability (SM)64% 65% 69% 27%

JITMM 2002

RDT: Addition of 5%

Newer Diagnostic Tools

• Antigen based rapid diagnostic tests

Antimalarial Drug Resistance in Bangladesh (In Vitro)

Bangladesh Thailand

Chloroquine 84% 95%

Quinine 30% 18%

Mefloquin 61% 82%

Artesunate -- --

AJTMH, 2003

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%

(Cox’sbazar1997, 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

implemented.

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 arevised malaria treatment regimen in Oct. 2004.

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

Jaundice etc.

Management of Severe Malaria

Treatment objectives:

• Primary: Save life.

• Secondary: Prevention of recrudescence,

transmission or emergence of resistance.

• Pregnancy: saving the mother’s 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.) then

10mg/kg 8 hourly.

• Artemether: 3.2mg/kg i.m. given on

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.

SEVERE MALARIA

IMPAIRED CONSCIOUSNESS?

YES NO

TREATMENT ALGORITHM FOR SEVERE MALARIA:WHO

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 without signs of vital

organ dysfunctionorgan 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).

Q7+T7 or Q7+D7 may be second alternative(s).

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 Artemisinin-based combinations are the recommended treatments

for uncomplicated falciparum malaria: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)

0

2

4

6

8

10

12

14

Day-0 Day-1 Day-2 Day-3 Day-4 Day-5 Day-6 Day-7 Day-14 Day-21 Day-28

Q3SP

Coartem

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)-

Slide/RDT+ve

– Severe malaria(SM)-

Slide/RDT +ve

• Previous regimen

– Uncomplicated

malaria (UM)

– Treatment failure

malaria (TFM)

– Severe malaria (SM)

Thank you.