2. UNCOMPLICATED MALARIA.
Uncomplicated malaria definition:
Fever and any of the following:
Headache,
Body and joint pains
Feeling cold and sometimes shivering
Loss of appetite and sometimes abdominal pains
Diarrhoea, nausea and vomiting.
Splenomegaly
3. Confirmed diagnosis of malaria.
All clinically suspected malaria cases require
laboratory examination and confirmation.
Only in case where laboratory confirmation is
not possible start treatment immediately.
Parasitological confirmation is done by thin-
thick blood smear microscopy examination or
by dipstick (Rapid Diagnostic Test [RDT]).
4. Treatment of uncomplicated malaria
• P. falciparum malaria
The treatment of uncomplicated P. falciparum
malaria is undertaken after diagnosis of
malaria by light microscopy or Dipstick.
Patients with positive think-thick blood
smears or dipstick for P. falciparum malaria is
treated by blisters of Coartem® (artemether
20mg/lumefantrine 120mg). See Table 1 for
details of prescription.
5. Table 1 : Dosage and administration Coartem (Artemether 20
mg/Lumefantrine 120 mg) for uncomplicated
malaria falciparum. Source: Guideline for the treatment of malaria, WHO; 2006
Age group Weight group
Blister
color
(Day 1) (Day 2) (Day 3)
4 months
to 5yrs
5 to 14 kg Yellow
1 tb , 1 tb , 1 tb ,
1 tb 1 tb 1 tb
6 to 11y 15 to 24 kg Blue
2 tb , 2 tb , 2 tb ,
2 tb 2 tb 2 tb
12 to 14y 25 to 34 kg Orange
3 tb , 3 tb , 3 tb ,
3 tb 3 tb 3 tb
> 14y > 34 Green
4 tb , 4 tb , 4 tb ,
4 tb 4 tb 4 tb
7. Follow-up of uncomplicated malaria:
If symptoms persist after treatment with coartem®
or if the patient comes back before the 14th day
after treatment.
Treatment failure within 14 days of receiving
coartem® is extremely rare and is more likely to be
an inadequate absorption of the drug(s) than
resistance of the parasites. It is important to
determine from the patient’s history whether he or
she vomited during the previous treatment or did
not complete the full course.
If patient is in health facility where microscope is
available failure of treatment should be confirmed
parasitologically and could be treated using the
following regimen:
8. Follow-up of uncomplicated malaria:
• For adult:
Quinine (10mg salt /kg bw three times a day)
+ doxycycline (3.0mg/kg bw once a day) for 7
days. Do not give doxycycline with milk or
iron, which will reduce its absorption.
9.
If patient is in health facility where
microscopy facility is not available
patient should be referred to the facility
where microscope is available. If refer
is not possible treatment should be
given Quinine + Doxycycline. Please
refer to Table 5 for details of the
prescription.
Doxycycline should not be given to
pregnant or lactating woman, or child
aged up to 8 years.
10. For pregnant or lactated woman or child
less than 8 years:
Quinine (10mg salt /kg bw three times a
day) + clindamycin (10mg/kg bw twice a
day) for 7days. For small children,
(quinine and clindamycin) crush tablets
and mix with water and sugar.
11. NOTE
For high transmission areas
where parasitological
confirmation is not available,
children <5 yrs of age is
recommended to be treated
with anti malarial drugs when
symptomatic (especially fever).
12. SEVERE MALARIA.
Severe or complicated malaria definition:
Fever and any of the following:
Impaired consciousness
Anxiety, palpitation and sweating
Convulsions or fits with this fever
Fast or difficult breathing
Vomiting every feed / unable to feed
Pale hands, tongue and inner parts of the eyelid
Generalized body weakness
Dehydration
Jaundice
Severe malnutrition
Dark urine or no urine
13. Pre-referral treatment of severe malaria
• A patient who is non responsive should be quickly
assessed and managed. This includes assessment
of the airway, breathing and circulation. The staff
at the first level health facility should be able to
maintain airway, provide assisted breathing and
manage shock if required.
• Pre-referral treatment for severe malaria the
administration of Artesunate by the rectal route is
recommended for all except pregnant women first
trimester pregnancy. For the complete dosage and
treatment.
• Check blood sugar, if possible!
14. • In case Artesunate suppository is not available
IM quinine injection 20mg/kg bw should be
given. The Quinine injection dosage should be
split and injections given in the anterior part of
the thigh.
• In case Artesunate suppository is not
available, give also Quinine for children with
severe malaria.
15. Confirmed diagnosis of severe malaria:
• All clinically suspected severe malaria cases
require laboratory examination and
confirmation.
• Only in case where laboratory confirmation is
not possible start treatment immediately.
Parasitological confirmation is done by thin-
thick blood smear microscopy examination or
by dipstick (Rapid Diagnostic Test [RDT]).
16. Differential diagnosis for complicated malaria
Consider other illnesses, such as:
Measles, meningitis, tonsillitis, dengue, otitis
media (ear infection), influenza, pneumonia,
typhoid fever, tuberculosis, hypoglycemia.
17. Specific severe malaria treatment
• Artesunate (60 mg): 2.4 mg/kg body weight (bw) IV or IM
on admission (time=0), followed by 2.4 mg/kg at 12 and 24
hours, followed by once daily for seven days. Once the
patient can tolerate oral therapy, treatment should be
switched to a complete dosage of coartem® for three days
as recommended in the national treatment guidelines for
uncomplicated malaria .
• The congenital malaria is also treated with Artesunate,
where 2.4 mg/kg is initially given through IV, followed by
1.2 mg/kg at 12 and 24 hr then every 24 hr for 3 -5 days.
18. Specific severe malaria treatment
Artemether (80mg for adult and 40 mg for children and
the newborn): 3.2 mg/kg bw IM on the first day followed
by 1.6 mg/kg bw daily for seven days. Once the patient
can tolerate oral therapy, treatment should be switched
to a complete dosage of coartem®.
Arteether (150 mg): 3.2 mg/kg bw IM on the first day,
followed by 1.6 mg/kg bw for the next 4 days. Once the
patient can tolerate oral therapy, may switch to a
complete dosage of coartem®.
19. • If Coartem® is not available, quinine should
be administered in combination with
tetracycline or doxycycline or clindamycin, to
complete the seven-day treatment, except
for pregnant women and children under eight
years of age for whom
tetracycline/doxycycline is contraindicated.
20. QUININE.
• Loading dose: Quinine dihydrochloride 20 mg
salt/ kg bw diluted in 10 ml/kg bw of 5%
dextrose or dextrose saline administered by IV
infusion over a period of four hours for both
adult and children. In severe Childhood
falciparum malaria, if patient received quinine
or quinidine or mefloquine in 48 hrs before
arrival, give 10 mg/kg over 2 hours.
21. QUININE.
Maintenance dose: Quinine dihydrochloride 10 mg salt/
kg body weight diluted in 10 ml/kg body weight of 5%
dextrose or dextrose saline administered by IV infusion.
In adults, the maintenance dose is infused over a period
of four hours and repeated every eight hours.
Similarly in children including congenital malaria, it is
infused over a period of two hours and repeated every
eight hours (calculated from the beginning of the
previous infusion) until the patient can swallow. To
complete the seven-day to eight-day treatment in
children, give Quinine sulfate 10 mg/kg per oral three
times in a day. Increase the dosage of Quinine sulfate to
15-20 mg/kg after 4 days or add tetracycline 5 mg/kg
twice a day for children above 7 years.
