Malaria Case Management Training Manual For Health Professionals in Ethiopia Participants Manual

Malaria Case Management Training Manual for Health
Professionals in Ethiopia
Participants Manual
January 2022
Addis Ababa
i
Table of Contents
List of Figures ....................................................................................... Error! Bookmark not defined.
Foreword v
Abbreviations vi
Acknowledgements ............................................................................................................................. viii
Methodology x
INTRODUCTION................................................................................................................................. xi
LEARNING UNIT ONE........................................................................................................................ 1
Malaria Program Overview .................................................................................................................... 1
Learning objectives ........................................................................................................................ 1
Epidemiology of Malaria in Ethiopia............................................................................................. 1
National Malaria Strategies ............................................................................................................ 7
LEARNING UNIT TWO ..................................................................................................................... 12
Malaria Vector Control ........................................................................................................................ 12
Learning objectives ...................................................................................................................... 12
Malaria Vectors’ Biology and Behavior ...................................................................................... 12
LEARNING UNIT THREE ................................................................................................................. 20
Uncomplicated Malaria ........................................................................................................................ 20
Learning Objectives ..................................................................................................................... 20
Definition and Etiologic Agents .................................................................................................. 20
Biological and clinical characteristics of different malaria species ............................................. 21
Mode of transmission and life cycle of parasites ......................................................................... 21
Life Cycle of Malaria Parasite ..................................................................................................... 22
Clinical presentation and Diagnosis ............................................................................................. 23
Treatment at Different Levels of Health Facility ......................................................................... 25
Chemoprophylaxis ....................................................................................................................... 37
LEARNING UNIT FOUR ................................................................................................................... 39
Approach to Fever in Children, IMNCI (Integrated Management of Newborn and Childhood Illnesses) 39
Assess and Classify Fever ............................................................................................................ 39
Fever Management/Treatment ..................................................................................................... 50
Exercises ...................................................................................................................................... 55
LEARNING UNIT FIVE ..................................................................................................................... 67
Fever in Adults ..................................................................................................................................... 67
Definition ..................................................................................................................................... 67
Causes of fever ............................................................................................................................. 68
Principles of evaluation of a patient with fever ........................................................................... 69
Management of fever Principles .................................................................................................. 81
Exercises: Group Work ................................................................................................................ 82
LEARNING UNIT SIX ....................................................................................................................... 83
Severe Malaria ..................................................................................................................................... 83
Diagnosis of Severe Malaria ........................................................................................................ 83
Treatment of severe malaria ......................................................................................................... 93
Immediate supportive treatment................................................................................................... 94
Specific antimalarial treatment .................................................................................................... 96
Pre-referral treatment ................................................................................................................... 99
Continuing treatment and nursing care ...................................................................................... 101
Exercises .................................................................................................................................... 111
LEARNING UNIT SEVEN ............................................................................................................... 121
Malaria in Special Groups .................................................................................................................. 121
Learning Objectives ................................................................................................................... 121
Malaria in Pregnancy ................................................................................................................. 121
i
Malaria and Malnutrition ........................................................................................................... 123
Malaria and HIV ........................................................................................................................ 124
Malaria and TB .......................................................................................................................... 124
LEARNING UNIT EIGHT ................................................................................................................ 125
Malaria Laboratory Diagnosis and Quality Assurance ...................................................................... 125
Learning objectives .................................................................................................................... 125
Clinical Diagnosis ...................................................................................................................... 125
Parasitological Diagnosis/ Laboratory Methods ........................................................................ 125
Quality Assurance of Malaria Laboratory Diagnosis................................................................. 134
LEARNING UNIT NINE .................................................................................................................. 136
Supply Chain Management ................................................................................................................ 136
Learning objectives .................................................................................................................... 136
Overview of Pharmaceuticals Supply Chain.............................................................................. 136
Logistics Cycles and Activities .................................................................................................. 137
Requesting and Getting Pharmaceuticals from PFSA ............................................................... 139
LEARNING UNIT TEN .................................................................................................................... 141
Malaria Epidemics Detection and Response ...................................................................................... 141
Definition ................................................................................................................................... 141
Overview of Malaria Epidemics in Ethiopia.............................................................................. 141
Factors Precipitating Malaria Epidemics ................................................................................... 142
Epidemic Preparedness .............................................................................................................. 142
Epidemic Detection .................................................................................................................... 142
Epidemic Confirmation .............................................................................................................. 152
Response to Malaria Epidemics ................................................................................................. 152
Reporting.................................................................................................................................... 153
Weekly malaria cases in 2004–2008 (EFY). ..................................................................... 160
LEARNING UNIT ELEVEN ............................................................................................................ 161
Monitoring and Evaluation ................................................................................................................ 161
Definition and purpose of M&E ................................................................................................ 161
Monitoring and Evaluation Frameworks ................................................................................... 163
Ethiopian Malaria Program M&E system .................................................................................. 164
LEARNING UNIT TWELVE ........................................................................................................... 168
Health Facility Visit ........................................................................................................................... 168
Divided into five groups consists of 5 to 8 members. ........................................................................ 168
References 174
A. BIN CARD .............................................................................................................................. III
B. STOCK RECORD CARD ................................................................................................ IV
C. Health Post Monthly Report and Re-supply Form .............................................................V
D. Report and Requisition Form for Program Drugs .................................................................. VII
ii
List of Tables
Table 1 List of Contributors .......................................................................................................... ix
Table 2 Malaria Interventions by Strata ........................................ Error! Bookmark not defined.
Table 3 Distinguishing Anopheline and Culicine Mosquitoes ......................................................15
Table 4 General guide to determine the number of nets per household based on family sizeError!
Bookmark not defined.
Table 5 The integrated disease surveillance report of 2007 EC .... Error! Bookmark not defined.
Table 6 Differential Diagnosis: Fever 7 days or less without clinically obvious focus or site .....75
Table 7 Differential Diagnosis: Fever more than 7 days without clinically obvious focus or site 78
Table 8Tablet containing 20 mg artemether plus 120 mg lumefantrine in a fixed dose. ..............27
Table 9 Chloroquine dose ..............................................................................................................28
Table 10 Primaquine phosphate dose: 0.25 mg base per kg daily schedule for 14 days ...............29
Table 11 Primaquine phosphate dose: 0.25 mg base per kg (dose of sldPQ for Pf cases) ............29
Table 12 Mefloquine: 5 mg /kg mefloquine salt once weekly ......................................................37
Table 13 Atovaquone-proguanil ....................................................................................................38
Table 14 Glasgow Coma Scale ......................................................................................................84
Table 15 The Blantayers Coma Scale (for children) .....................................................................85
Table 16 Management of Severe Malaria: Daily observation sheet (acute phase)Error! Bookmark
not defined.
Table 17 Appropriate actions for clinical and laboratory abnormalities .....................................106
Table 18 Chart for assessing usual number of weekly cases (confirmed or clinical) and threshold at
health facility. ..............................................................................................................................146
Table 19 Construction of the threshold (norm) when five years' historical data are available to
monitor the current year...............................................................................................................147
Table 20 Construction of threshold (norm) with single recent year morbidity data ...................149
Table 21 Reporting form for active surveillance and treatment ..................................................154
Table 22 List of Health Management Information System (HMIS) formats ..............................167
Table 23 PHEM Weekly Disease Report Form for Outpatient and Inpatient malaria Cases and
Deaths ..........................................................................................................................................167
iii
iv
Foreword
Malaria is a major public health problem in Ethiopia. About 75% of the total area of the country is
considered malarious and about 52% of the population living in these areas is at risk of malaria.
According to the Annual Performance Report of the FMOH, 2013 (2020/21), there were a total of
1,220,027 cases of which 1,135,338 (93.1%) were laboratory confirmed. 80.1% were due to
Plasmodium falciparum. There were 132 deaths due to malaria.
Ethiopia currently working concertedly towards malaria elimination by 2030. To this end the
National Malaria Elimination Program (NMEP) needs to have appropriately planned and targeted
delivery of essential malaria interventions, including: early diagnostic testing of suspected malaria
and prompt treatment of confirmed cases with effective antimalarial drugs; and application of
appropriate vector control interventions, particularly the use of insecticide-treated nets (LLINs) and
indoor residual spraying (IRS). To implement these interventions, the availability and readiness of
trained and skilled health workforce is critical.
This training manual on malaria case management has been revised to support the staff involved in
malaria prevention, control and elimination program in Ethiopia in the effective organization and
execution of malaria diagnosis and case management services. The manual incorporates basics on
vector control, epidemics detection and response, supply chain management, and monitoring and
evaluation relevant for clinicians. Thus, it is believed this training material will equip clinical health
workers to implement malaria diagnosis and treatment according to the national guideline. Therefore,
all partners working in the area are advised to strictly use this manual whenever they organize training
for clinicians. This avoids use of different training materials for similar competence and provides
basic understanding on malaria prevention, control and elimination interventions.
Lastly, as the country is implementing malaria elimination program, there is a critical need for having
well trained health personnel at all levels. Thus, it is my firm belief that our program partners would
redouble their efforts in supporting the Ministry in its ambitious goal of ensuring availability of well-
trained clinicians who could accurately diagnose and manage malaria cases at all tier of the health
system. I can assure that the Ministry would maximize its efforts in the fight against malaria until the
disease is wiped out from the country. The revision of this manual (of October 2016) was made
taking into account the changes made in the revised national malaria guidelines, 2022.
Dereje Duguma (MD,MIH)

State Minister of Health
v
Abbreviations
Abt/PHSP Abt Associates Private Health Sector Program
ACIPH Addis Continental Institute of Public Health
ACT Artemisinin-based Combination Therapy
API Annual Parasite Incidence
EPHI Ethiopian Public Health Institute
FMOH Federal Ministry of Health
G6PD Glucose-6- Phosphate Dehydrogenase
HEW Health Extension Worker
HMIS Health Management Information System
HRP-2 Histidine Rich Protein II
IFHP Integrated Family Health Program
IMNCI Integrated Management of Newborn and Childhood Illness
IPD Inpatient Department
IPLS Integrated Pharmaceuticals Logistics System
IPTp Intermittent Preventive Treatment in Pregnancy
IRS Indoor Residual Spraying
LLIN Long Lasting Insecticide Treated dal Nets
LMIS Logistics Management Information System
M&E Monitoring and Evaluation
MACEPA Malaria Control and Elimination Partnership in Africa
MFTT Mass Fever Testing and Treatment
MIS Malaria Indicator Survey
MPFT Mass Presumptive Fever Treatment
NMCP National Malaria Control Program
OPD Outpatient Department
PATH Program for Appropriate Technology in Health
PCR Polymerase Chain Reaction
PFSA Pharmaceuticals Fund and Supply Agency
PHCU Primary Health Care Unit
PHEM Public Health Emergency Management
pLDH Plasmodium Lactate Dehydrogenase
PLMP Pharmaceuticals Logistics Master Plan
vi
PMI President’s Malaria Initiative
RBC Red Blood Cell
RDT Rapid Diagnostic Test
RRF Report and Requisition Form
SBCC Social Behavioral Change Communication
SCM Supply Chain Management
SOP Standard Operating Procedure
SPR Slide positivity rate
TAC Technical Advisory Committee
TET Therapeutic Efficacy Testing
TOR Terms of Reference
TWG Technical Working Group
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
WBC White Blood Cell
WHO World Health Organization
vii
Acknowledgements
This training manual was reviewed and prepared by the Federal Ministry of Health (FMOH) of
Ethiopia with participation of numerous in-country partners. FMOH gratefully acknowledges the
technical expert group who guided the review and preparation of this training manual. The agencies
and partner organizations that have actively and directly participated through their experts who
contributed to the review and preparation of this document include: USAID/PMI, WHO, UNICEF,
ICAP in Ethiopia, IFHP, Addis Continental Institute of Public Health, Abt Associates,
MACEPA/PATH- Ethiopia office, Addis Ababa University, College of Health Sciences, Faculty of
Medicine and PFSA.
Most of the contents of this training manual have been adopted from the WHO training manual on
malaria control: case management, guide for participants. It also incorporates information from the
recent national malaria guidelines, 2022. Also, training materials from the FMOH and partner
organizations have been used.
The review and preparation process for this training manual was coordinated by the National Malaria
Elimination Program (NMEP). Dr. Kebede Etana, NMCP/FMOH has played a pivotal role in overall
coordination of the process. Financial support for the workshop to develop the training material was
provided by Abt Associates/PHSP.
viii
List of Contributors to the current and previous edition
Name Organization
Mrs Hiwot Solomon FMoH/ NMCP
Dr Kebede Etana FMoH/ NMCP
Mr Mebrhatom Haile FMoH/ NMCP
Mr Degu Mehari FMoH/ NMCP
Mr Mersha Worku FMoH/ NMCP
Mr Gudissa Assefa FMoH/ NMCP
Dr Samuel Girma PMI/USAID
Dr Ayele Zewde ACIPH
Dr Dereje Muluneh UNICEF/Ethiopia
Dr Eshetu Gezahegn Abt Associate
Dr Wondwosen Amogne AAU/ Tikur Anbesa Hospital
Dr Daniel Yilma Jimma University
Mekonnen Tadesse ICAP in Ethiopia
Dr Negash Seyoum ICAP in Ethiopia
Dr Yonas Petros ICAP in Ethiopia
Mr Feleke Belachew ICAP in Ethiopia
Dr Worku Bekele WHO/Ethiopia
Mr Ajeme Wogi IFHP/Ethiopia
Mr Azmeraw Mulualem PFSA
Mr Berhane Hailesilase MACEPA/Ethiopia
Mr Gezahegn Tesfaye MACEPA/Ethiopia
Mr Honelegn Nahusenay ACIPH
Mr Mesele Damte Abt Associate
ix
Methodology
The content of the training manual has been prepared based mainly on WHO training module on
malaria control: case management, guide for participants and on WHO Guidelines for Malaria, 13
July 2021, the national malaria guideline, 2022 and on other technical documents and existing
FMOH training materials. The manual was prepared through a process involving a Technical Expert
Committee representing malaria experts from key partners, training and academic institutions,
malaria researchers, and FMOH malaria experts.
The need for a simplified and standardized training manual for clinical health workers on malaria
case management that would serve for all on-the job training, both for public and private sectors, all
over the country was felt during field missions to regions and during observations made in training
sessions on malaria case management. In addition to this, there were recommendations from
researchers and trainers at various health training institutions on the need to have a standardized
training manual. These observations and recommendations were taken up by FMOH that requested
the malaria technical advisory committee (TAC) to prepare the manual. The TAC delegated the
malaria case management technical working group (TWG) to develop the manual. Accordingly, the
TWG took the responsibility to review the existing manual and prepare an updated one. The
following steps were followed to prepare the guide:
 Several TWG consultations were held at FMOH level
 The initial draft and outline was prepared by FMOH experts
 A 4-day retreat was held from 19 - 22 September 2016 for in-depth technical consultation on the
draft document and to review and finalize the initial draft
 Further updated draft circulated to the TWG member for final inputs
 The TWG met again on 3 October 2016 to review the updated draft document for its content and
completeness
 The draft document was reviewed and finalized by the TWG and submitted to FMOH for
comments /or endorsement.
 It was submitted for Human Resources Directorate of FMOH for approval and registration
 Based on feedback from consultations and FMOH’s endorsements, the manual text was finalized
for publication.
 This training manual was revised following the revision of national malaria case management
guidelines to accommodate the latest updates
x
INTRODUCTION
In 2020, a total of 241 million malaria cases and 627,000 malaria deaths reported globally and 96%
of deaths occur in Sub-Saharan Africa and 77% deaths are children under five (WHO 2021) The
incidence rate of malaria is estimated to have decreased by 37% globally between 2000 and 2015.
Malaria death rates have decreased by 60% over the same period (WHO, 2015). Malaria case
incidence (i.e. cases per 1000 population at risk) reduced from 81 in 2000 to 59 in 2015 and 56 in
2019, before increasing again to 59 in 2020. The increase in 2020 was associated with disruption to
services during the COVID-19 pandemic (WHO 2021)
The trends of malaria have showed a consistently decline in Ethiopia. It has successful achieved the
Millennium Development Goals. According the FMOH (2015) Health Management Information
System (HMIS) report shows the number of confirmed malaria cases declines form 1.7 million cases
in 2016 to 0.9 million cases in 2019, respectively.
Cognizant of the importance of prevention, control and elimination of malaria as a major public
health interventions and providing standardized quality assured prompt malaria diagnosis and
treatment in all health tier system, which a globally recommended best practice. Hence, the FMOH
developed four series of national malaria guidelines in 2002, 2007, 2012 and 2022. The main
recommendation consists of adding radical cure with primaquine for mixed malaria infections at
health post level, AL is indicated for pregnant women in first trimester, weekly chloroquine
prophylaxis for pregnant women with p. vivax malaria, second line drug, management of severe
malaria and approaches to management of possible treatment failures at each health care settings.
The use of updated and standardized malaria guidelines and training materials is strongly
recommended in order to ensure the availability of prompt diagnosis and effective treatment at all
level of health of services. It also simplifies and facilitates training and supervision of health care
providers, delay the development of anti-microbial resistance, improve surveillance, and assists in
more rational drug procurement for the treatment of malaria.
To this effect, the Federal Ministry of Health has developed this updated training material for the
proper malaria case management in the country.
xi
The contents for each Learning Unit are summarized as follows:
Learning Unit I: Introduction to epidemiology of malaria in Ethiopia and specific regional state. It
deals with the trend of malaria and the eco-epidemiological stratification for Ethiopia. Finally, it
introduces the national strategic plans for malaria prevention, control and elimination and 2020-
2025).
Learning Unit II: it describes the malaria vector biology, behavior, similarities and differences of
adult mosquito and larvae. This learning unit introduce the life cycle of mosquitos and factors
affecting the development cycle. Finally, it deals with vector control strategies and their importance.
Learning Unit III: this learning unit deals with the etiologic agents of malaria. It describes the mode
of transmission and the life cycle of the parasites. In addition, the clinical and laboratory evidences
for uncomplicated malaria, its treatment at different levels of health facilities will be discussed.
Learning Unit IV: This learning unit introduces training participants with the approach in fever
among children using assess, classify, identify and treat principles of integrated management of
newborn and childhood illnesses (IMNCI). Furthermore, the unit explores the assessment of fever in
a child with measles.
Learning Unit V: it deals with the approach to an adult patient with fever and identify possible
causes of fever in adults. Trainees are expected to be capable of taking a comprehensive medical
history and performing physical examination. In addition they will also be able to order and interpret
laboratory investigations and reach to relevant diagnosis
Learning Unit VI: it covers the definition of severe malaria and explains its pathophysiology. In
addition, it identifies factors that expose patients for the development of severe malaria and covers
the chemotherapeutic regimens, emergency and supportive measures.
Learning Unit VII: explore the effect of malaria in pregnancy, HIV, malnutrition and tuberculosis.
It also deals with the management of uncomplicated and severe malaria in these special groups.
xii
Learning Unit VIII: deals with the different methods of parasitological confirmation of malaria
parasites and explain the components of quality assurance. It also explains the advantages and
limitations of thin & thick blood films and RDTs.
Learning Unit IX: Covers the national Integrated Pharmaceutical Logistics Management System
(IPLS). It introduces with the tools of supply chain management system (bin card, stock cards, RRF,
IRRF etc.)
Learning Unit X: Introduce malaria outbreak and epidemics to trainees. It also describes the
scientific methods of forecasting, early warning, detection and responses. It demonstrates the filling
and interpretation of epidemic monitoring chart
Learning Unit XI: Introduce the national malaria monitoring and evaluation framework. It covers
the advantage of gathering health facility data, and demonstrate utilization of information for
evidence based decision making.
Learning Unit XII: Participants will visit a health facility to have practical experience on the
theoretical explanations. It also gives opportunities for trainees to develop their skill in history taking,
physical examination, ordering and interpreting laboratory results, appreciate clinical findings in
patients with uncomplicated and severe febrile diseases, malaria logistics management system and
malaria Health Management Information System.
The Learning Units
The module is designed for health professionals who diagnose and treat patients with malaria in the
course of their work in health centers, hospitals and private health facilities.
The principal objectives of the training are listed in the introduction to the training manual for
participants, which facilitators are asked to read before proceeding. This module is intended to
stimulate active learning by working through a series of exercises. The exercises will be carried out
on the basis of the training manual for participants, preferably in small groups.
Participants are taught the salient clinical manifestations of malaria. Common errors in malaria case
management are highlighted. The participants acquire step by step all the knowledge and skills they
need to suspect, diagnose and manage uncomplicated and severe malaria. This type of training is
performance-based and is highly effective. Each learning unit of the training manual for participants
xiii
begins with a list of learning objectives which summarize the knowledge, skills and attitudes that
each trainee should have acquired by the end of the unit.
Facilitators and their colleagues should be satisfied that everyone has achieved the stated objectives
before proceeding to the next learning unit It is convenient to arrange the work of the participants in
small group sessions; some discussion work can be done in plenary sessions.
Core Competencies for trainees
After completing this course, the following core competencies are expected to attain by all trainees:
 Identify the larvae and adult forms of anopheles mosquito

 Perform a comprehensive clinical evaluation that is history taking, performing physical
examination, order and interpret laboratory tests for patients with fever
 Assess, classify and select appropriate treatment for a child with fever using the IMNCI
approach.
 Diagnose, treat and conduct follow up care for uncomplicated malaria cases as per the
national malaria guideline.
 Identify cases with treatment failure and provide the appropriate management.
 Assess, diagnose, treat and conduct follow up for patients with severe and complicated
malaria cases as per the national guidelines
 Identify patients who need urgent referral and give the appropriate pre referral treatment.
 Assess, Diagnose and treat malaria in special groups like patients with HIV, malnutrition and
pregnancy
 Describe the malaria drugs and diagnostics supply chain system
 Fill and interpret malaria epidemic monitoring chart
 Record and report timely all malaria cases using HMIS and PHEM requirements.
 Use data for informed decision making.
Course syllabus for five days basic malaria case management training for health professionals
Course goal
To equip health professionals with the basic knowledge, skills, attitudes and practices needed to
manage malaria cases in line with the national recommendations.
Course objectives:
 Describe global and national burden of malaria
xiv
 Identify principles of approach to fever in children and adult patients
 Able to take a comprehensive history, perform physical examination, order and interpret
laboratory tests.
 Describe the basis of malaria diagnosis and treatment according to the national guideline
 Identify larva and adult forms of anopheles mosquito
 Explain malaria microscopy and rapid diagnostic test.
 Explain malaria commodities supply chain system
 Able to fill and interpret malaria epidemic monitoring chart
 Able to record and report malaria data
Training/Learning Methods
Different method will be used to deliver this training:
 Presentation and discussion

 Group Exercises./work
 Case studies
 Demonstration
 Video show
 Practical attachment
Learning equipment
 Participant manual
 LCD projector
 Computer (Laptop)
 Screen for slide projection (a white sheet is an adequate substitute)
 Colored markers
 PowerPoint Presentation (LCD & Laptop)
 Flip chart/white board
 Video shows
 Malaria Rapid Diagnostic Test kits (RDTs kits)
 Check lists for the practical clinical session
 Sheets of paper for the exercises during the working groups
 IMNCI recording forms
 Malaria Epidemic monitoring chart
xv
 IPLS tools (bin Card, Stock Card, RRF and IRRF)
 Notebook
 Ballpoint pens
Trainers’ Qualification and requirement
Trainers should be certified with Malaria Case Management TOT (with the current Malaria Case
Management manual for Health Professionals)
Target audience
The trainees should be practicing clinicians (physicians, health officers or nurses) or those involved
in teaching clinical students
Evaluation of training
Evaluation of the training is achieved by collecting feedback from learners and trainers at the end of
each day of the training and at the end of the course. When trainers review feedbacks from learners
daily, they can often make immediate changes to improve the course. Daily evaluation and end of
course evaluation forms are included in this manual. Pretest questionnaires are included in this
trainers guide to assess participants’ knowledge and experience before the training so as to reorient
the course content and approach after reviewing the test results. Moreover, the pretest results will be
used to assess the knowledge and competence gained after the training by comparing against the post
test results.
Criteria for certificate

 100% of attendance
 Post test score greater than 70% for basic training and 80% for TOT.
Adaptation of course content
This training manual is prepared for a standalone, learner centered course for a group of 25-30
trainees. Adaptation may be needed to address learners’ need, the number of learners attending and
the time or logistical constraints.
xvi
Table.1 Malaria Case Management Training Schedule.
Day Time Topic

1 8:30-9:00 Registration
9:00-10:30 Opening remark
Introduction to the training
Objectives and expected outcomes
Introduction of facilitators and participants
Setting ground rules
Expectations of participants
Admin issues
Pretest
10:30-11:00 Tea break
11:00-12:30 Malaria program overview
12:30-2:00 Lunch
2:00-3:30 Malaria vector control
3:00-4:00 Uncomplicated malaria
4:00-4:30 Tea break
4:30-5:30 Uncomplicated malaria
2 8:30-9:00 Recap
9:00-10:00 Approach to fever in children (1)
10:00-10:30 Tea break
10:30-12:30 Approach to fever in children including exercises (2)
12:30-2:00 Lunch
2:00-3:30 Approach to fever in adults (1)
3:30-4:00 Tea break
4:00-5:30 Exercises on approach to fever in adults (2)
3 8:30-9:00 Recap
9:00-10:00 Severe malaria (1)
10:00-10:30 Tea break
10:30-11:30 Severe malaria (2)
11:30-12:30 Severe malaria exercises (1)
12:30-2:00 Lunch
xvii
Day Time Topic
2:00-3:00 Severe malaria exercises (2)
3:00-4:00 Malaria in special groups
4:00-4:30 Tea break
4:30-5:30 Malaria laboratory diagnosis (1)
4 8:30-9:00 Recap
9:00-10:00 Malaria laboratory diagnosis (2)
10:00-10:30 Tea break
10:30-12:30 Malaria epidemic including exercise on EMC
12:30-2:00 Lunch
2:00-3:30 Supply chain management including introducing IPLS tools
4:00-4:30 Tea break
4:30-5:30 Malaria monitoring and evaluation including introducing M&E tools
5 8:30-12:30 Health facility visit
 OPD (fever in children and adults)
 IPD (severe febrile disease preferably severe malaria)
 Recording and reporting
 Supply chain management (malaria commodities)
12:30-2:00 Lunch
2:00-4:00 Feedback from health facility visit
4:00-4:30 Tea break
4:30-5:30  Post test
 Course evaluation
 Closing
xviii
LEARNING UNIT ONE
Malaria Program Overview
Learning objectives
At the end of this training, participants will be able to:
 Describe the epidemiology of malaria in Ethiopia

 Describe the malaria trend in Ethiopia
 Describe the eco-epidemiological strata of malaria in Ethiopia
Epidemiology of Malaria in Ethiopia

In 2020, a total of 241 million malaria cases and 627,000 malaria deaths reported globally and 96%
of deaths occur in Sub-Saharan Africa and 77% deaths are children under five (WHO 2021). The
incidence rate of malaria is estimated to have decreased by 37% globally between 2000 and 2015.
Malaria death rates have decreased by 60% over the same period (WHO, 2015).
Malaria is a leading health problem in Ethiopia. Three quarters (75%) of the country’s landmass is
malaria endemic and about 52% of the total population is at risk of malaria infection (CSA 2020).
Malaria transmission in Ethiopia mainly occurs up to the 2000 meter (m) elevation but can also
occasionally affect areas up to 2300m elevation. The levels of malaria risk and transmission intensity
within these geographical ranges, however, show marked seasonal, inter-annual and spatial
variability because of large differences in climate (temperature, rainfall and relative humidity),
topography (altitude, surface hydrology, land vegetation cover and land use, etc.) and human
settlement and population movement patterns.
Classification of malaria transmission (stable and unstable)
Stable (endemic): Transmission is generally high, could be seasonal but not subject to annual
fluctuations, and the resulting population immunity is high. Under endemic conditions, children
under the age of five years, and pregnant mothers, are most likely to be infected as they have weaker
immunity.
Unstable (epidemic): Malaria transmission is variable, being subject to marked annual fluctuations.
Consequently, the collective population immunity is low. Malaria epidemics generally occur when
the population in an area has weak immunity to the disease, because so many people in the population
1
will be vulnerable to malaria. However, it is important to remember that children and pregnant
women are always at most risk, so they need particular attention.
Trend of malaria in Ethiopia
The annual number of malaria cases varies from year to year. The 2015 HMIS report indicated that
total malaria cases reported across all health facilities was 1.9 million cases with over 95%
completeness report. There has been a consistent decline in the number of malaria cases in the past
four years despite an alarming increase in health facilities with increased access to diagnosis and case
management (Figure below). On the other hand, there has also been a dramatic reduction in number
of cases, admissions and deaths in some facilities (ii).
7,000,000
6,611,801 6,471,958
6,000,000 5,913,799
5,403,951
5,000,000
4,000,000
3,000,000
2,000,000
1,718,505
1,530,730
1,000,000 962,087 904,495
0
2016 2017 2018 2019
Number of confirmed malaria cases Number of supected malaria cases
Figure 1: Trend of suspected and confirmed malaria cases, 2016-2019, NMEP, Ethiopia (taken
from NMSP,2020-2025)
Since 2004, there was no large scale epidemic reported in Ethiopia which has been coinciding with
the scaling up of major malaria interventions such as vector control and diagnosis and treatment.
2
Figure 2: Reduction of malaria cases and deaths in Ethiopia (WHO 2021)
Number of malaria deaths

2500
2173
2000
1451
1500
1000
764
662
510
500 356
156 213
0
2012 2013 2014 2015 2016 2017 2018 2019
Figure 3: Trend of malaria-attributed deaths in Ethiopia from 2012 to 2019, NMEP, Ethiopia
3
Factors affecting malaria transmission
Altitude and climate (rainfall, temperature and relative humidity) are the most important
determinants of malaria transmission in the country. Transmission is seasonal and largely unstable
in character. The major transmission of malaria follows the June – September rains and occurs
between September - December while the minor transmission season occurs between April – May
following the February – March rains. Areas with bimodal pattern of transmission are limited and
restricted to a few areas that receive the small/Belg rains.
Age and immunity are host factors affecting risk of morbidity. Individuals who are exposed to
repeated malaria infection, over a period of several years, become semi-immune. This means that
although they are still at risk of infection when bitten by an infected mosquito, they either do not
have symptoms (are asymptomatic), or their symptoms are not severe. This kind of partial immunity
is not common in Ethiopia because of the unstable nature of the disease. Partial immunity will be lost
with few years’ absence from malaria endemic area
Historically, the unstable nature of malaria transmission has been characterized by frequent focal and
cyclical epidemics which reach national scale at irregular intervals of 5–8 years.
The malaria parasites and vectors
Plasmodium falciparum and P. vivax are the two most dominant malaria parasites in Ethiopia. They
are prevalent in all malaria endemic areas in the country with P. falciparum representing about 81%
(HMIS 2021) of the total reported malaria cases. Relative frequency varies in time and space within
a given geographical range. P. malariae and P. ovale are rare and account for <1% of all confirmed
malaria cases. The major malaria vector incriminated in Ethiopia is Anopheles arabiensis; in some
areas A. pharoensis, A. funestus and A. nili also play minor role in transmission of malaria. Anopheles
stephensi is a recently introduced malaria vector in Ethiopia.
Eco-epidemiologic strata
The diverse ecology of the country supports a wide range of transmission intensities, ranging from
low-hypo-endemic transmission in the highlands and semi-arid regions to high-endemic perennial
transmission in the lowland regions and valley floors. Accordingly, the current stratification of
malaria in Ethiopia has been developed using Woreda/district-level API data. Data from PHEM and
microplan was used to determine API level of each Woreda.
4
Figure 4: Malaria Stratification (FMOH 2014).
Figure 5: Malaria Stratification map (NMEP 2020).
5
Table 2: Malaria stratification with estimated population distribution, NMEP, June 2020.
Malaria Classification Population(2020) Number of

endemicity Districts
High API ≥ 50 4,929,814 (4.8%) 68
Moderate API ≥ 10 and <50 13,480,217 (13.1%) 177
Low API >5 & <10 4,999,818 (4.9%) 80
Very low API >0 & ≤ 5 30,168,016 (29.3%) 485
Free API=0 49,272,928 (47.9%) 236
Total NA 102,850,793 (100%) 1046
Table 3: Proposed malaria interventions by stratum, July 2020, NMEP.
Malaria Recommended Interventions

Strata Case ITNs IRS LSM Surveillance SBCC
Management
HIGH X X X X* X X
MODERATE X X - X* X X
LOW X X - X X X
Very Low X X** - - X X
Free X - - - X X***
*Larviciding if feasible, environmental management in feasible areas of high, moderate and low strata
**Only 51% living in areas having API 1-5 will be covered by ITNs
*** In areas with a risk of resurgence
6
National Malaria Strategies
The national malaria program in collaboration with program partners develops national malaria
strategy every five years in line with global strategies to sustain the gains achieved and incorporate
new tools and strategies as deemed necessary. Accordingly, the 2020-2025, National Strategic Plan
was developed in 2020.
The National Malaria Strategic Plan, 2020-2025
Goals
1. By 2025, reduce malaria morbidity and mortality by 50 percent from baseline of 2020.
2. By 2025, achieve zero indigenous malaria in districts with API less than 10 and prevent
reintroduction of malaria in districts reporting zero indigenous malaria cases.
Strategic Objectives
Objective 1: By 2025, achieve adoption of appropriate behaviour and practices towards antimalarial
interventions by 85% households living in malaria endemic areas.
Objective 2: By 2021 and beyond, conduct confirmatory testing for 100% of suspected malaria cases
and treat all confirmed cases according to the national guidelines.
Objective 3: By 2021 and beyond, cover 100% of the population at risk of malaria with one type of
globally recommended vector control interventions.
Objective 4: By 2021 and beyond, conduct cases or foci investigation, classification and response in
districts having API less than 10 and prevent reintroduction of malaria into areas reporting zero
indigenous malaria cases.
Objective 5: By 2021 and beyond, generate 100% evidence that facilitates appropriate decision
making. Objective 6: By 2021 and beyond, build capacity of all levels of the health offices to
coordinate and implement malaria elimination interventions.
7
Strategies and Key Interventions
This subsection summaries main strategies and corresponding key interventions.
A. Enhancing community engagement, empowerment and mobilization
Community empowerment and mobilization will be done mainly by the HEWs and WDA. CSOs
and other community platforms will be used to empower the community. Community engagement
mechanisms at health facilities and at levels of the health management will enable a malaria service
delivery that is responsive to community needs.
a) Carry out targeted advocacy, communication, and social mobilization activities to promote
desired positive behavior for effective implementation and proper utilization of malaria
interventions.
b) Engage, empower and mobilize communities in order to foster ownership of anti-malaria

interventions and active participation in planning and implementation of interventions.
B. Ensuring early diagnosis and prompt treatment
Malaria early diagnosis and prompt treatment will be implemented all over the country, at all sectors
and at all levels of malaria transmission. Treatment of malaria cases will be based on parasitological
diagnosis. RDTs will be used at health posts level and microscopy is to be used in health centers and
hospitals. In other words, universal access to confirmatory testing and treatment of malaria cases
will be ensured and case management implemented as per the national guidelines.
The following are some of the key interventions used to implement malaria case management.
a) Provide universal access to appropriate and quality malaria parasitological diagnosis to all
suspected malaria cases.
b) Sustain universal coverage of effective and efficacious treatment as per the national
guidelines.
c) Generate evidence on suitability of chemoprophylaxis or seasonal chemoprevention

targeting special population group (seasonal migrant laborers) to protect them from malaria
and reduce the risk of carrying parasites to their hometown.
8
d) Establish a quality assurance system for malaria microscopy and RDTs. e) Support
integrated community malaria case management activities.
C. Strengthening vector control
In Ethiopia, the main malaria vector control measures are those, which help reducing-humanvector
contact and controlling adult mosquito. Hence, campaign based distribution of ITNs and targeted
IRS are key strategies for malaria prevention, control and elimination in Ethiopia. Larval source
management (LSM) is a supplementary strategy. Key interventions include the following:
a) Maintain universal coverage of ITNs among at-risk populations and improve appropriate
utilization by identifying and responding to barriers.
b) Deploy quality IRS in selected districts/villages where epidemiological and operational

suitability ascertained.
c) Implement targeted LSM (environmental management and larviciding) where appropriate
D. Improving malaria surveillance and response system
Improving malaria surveillance and response system will focus on increasing the sensitivity and
specificity of surveillance to detect, characterize and monitor all cases. Transforming malaria
surveillance into a core intervention, which mainly focuses on malaria cases and foci investigation,
response, characterization, classification, and follow-up.
a) Strengthen surveillance, monitoring and evaluation activities and undertake routine and
periodic data collection analysis, and use of data for decision-making and archiving/proper
documentation of data/information.
b) Transform malaria surveillance into a core intervention (conduct cases and foci
investigation, classification and response; assess risk of reintroduction and mitigate
receptivity and vulnerability of areas).
c) Assess, establish and support functional malaria elimination learning districts or centers at
each region. Assess and recognize best performing regions/zones/woredas and crossfertilize
best practices
9
E. Improving malaria supply chain and quality of antimalarial commodities
This strategy will ensure participatory, robust logistic planning, procurement and supply of quality
antimalarial commodities. It will abolish delay in procurement and commodity stock outs; and ensure
continuous supply and availability of quality antimalarial commodities.
a) Improve and sustain uninterrupted supply of antimalarial commodities.
b) Conduct pre- and post-marketing surveillance of antimalarial commodities.
F. Ensuring human rights and gender equality in accessing malaria services
Ethiopia has made impressive progress in improving access to health services in the public sector.
Ninety-five (95%) of the population has access to public health service. However, there are barriers
to access among different segment of population like mobile and migrant, refugees and people in
emergencies. The following are some of the strategies used to address human rights and gender issues
in malaria control and elimination.
a) Review the existing equity disparities in delivering antimalarial interventions among

seasonal migrant workers, refugees, pastoralists, industrial parks and IDP and across genders.
b) Develop and implement strategy to improve access to malaria prevention, diagnosis and
treatment services for refugees, IDPs, pastoralists, mobile and migrant workers.
c) Improve coordination and collaboration with relevant national and international agencies
responsible for refuges, prison facilities, industrial parks, seasonal workers, IDPs and
universities or other boarding schools. d) Monitor implementation status of antimalarial
interventions among migrant laborers, hard to reach areas, IDPs and refugees and across
genders.
G. Strengthen engagement of all stakeholders, including CSOs and private sectors
Ethiopia’s malaria programme has been backed up by a very strong partnership forum - the MCST.
The NMEP will continue using the existing (and new as well) platforms to work together with health
partners as well as non-health sector partners. At Ministry level, the programme will engage with
various directorates and agencies that have roles in malaria prevention, control and elimination in
order to ensure malaria services are provided as per the national guidelines. Some of the interventions
to improve engagement of stakeholders are:
10
a) Mapping potential malaria affiliated CSOs and other stakeholders, and identify areas of
collaboration.
b) Implement malaria public-private mix manual.
c) Monitor and review implementation status of CSOs and other stakeholders’ malaria
activities.
H. Strengthening malaria program management, operational research and M&E
The NMEP requires strong programme management at all levels. Among other things, the NMEP
provides technical guidance, conducts partner and resource mobilization, and provides policy guides
and technical support. For these to happen, the NMEP will be reorganized and reinforced with
appropriate mix of technical staff while also pushing the RHBs to take similar strengthening of their
management. In addition, operational researches and M&E activities will be implemented to review
and update antimalarial strategies or tools. The following interventions will be undertaken:
a) Review and update malaria programme’s organizational structure at national, regional and
district levels to suit the envisaged national malaria elimination endeavor.
b) Build capacity of health workers and media outlets on malaria advocacy, communication,
and social mobilization to effectively provide accurate and relevant malaria information to
leadership, community and patients.
c) Improve the capacity of health workers to provide quality malaria case management, and
planning, implementation, monitoring and reporting of vector control activities.
d) Monitoring efficacy of antimalarial drugs and susceptibility of insecticides and assess

dynamics and behaviour of vectors through the established sentinel sites.
e) Evaluate new diagnostics, drugs, vector control tools, insecticides and larvicides; and
generate strategic information to update malaria epidemiological and entomological profile
and facilitate appropriate decision-making.
f) Promote the effectiveness, efficiency and accountability of malaria elimination programme

at all levels by strengthening collaboration with all stakeholders (regions, partners and other
sectors)
g) Develop comprehensive and costed annual operational plan.

11
LEARNING UNIT TWO
Malaria Vector Control
Learning objectives
At the end of the training, participants will be able to:
 Describe the malaria vector biology, behavior, and differentiate the different mosquito types
and their larvae,
 Describe the life cycle of mosquitoes and factors that affecting the life cycle,
Malaria Vectors’ Biology and Behavior

Anopheline mosquitoes are responsible for transmitting malaria. Anophines comprise approximately
490 species including sibling species, of which only about 60-70 species worldwide can transmit
malaria and of these, about 30 are vectors of major importance. With the exception of the Antarctica,
there are malaria vectors in all continents of the world. The mosquito picks up the Plasmodium
parasite when it sucks the blood of an infected person. Once inside the mosquito, the parasite
multiplies as it moves from the stomach of the mosquito to the salivary glands, from where it is
passed on the next time the infected mosquito bites another person.
Malaria vector biology

Vector is a carrier, especially animal (usually an arthropod) which transfers an infective agent from
one host to another. There are two types of vector: biological and mechanical.
Biological vector: an arthropod vector in whose body the infecting organism develops or multiplies
before becoming infective to the recipient individual.
Mechanical vector: an arthropod vector which transmits an infective organism from one host to
another but which is not essential to the life cycle of the parasite.
Anopheles Mosquito Life Cycle
The life cycle of the Anopheles mosquito has four main stages: egg, larva, pupa and adult. Water is
necessary for the egg, larval and pupal stages of the life-cycle. Understanding the life cycle, the
timings and the factors influencing the life cycle is important to fully understand the epidemiology
of malaria transmission and for considerations about disease control.
12
Figure 6: The life cycle of the Anopheles mosquito
Eggs:
 Each adult female will lay between 70 – 200 eggs per oviposition.
 Eggs are laid singly on water, they are about 0.5mm long and have floats on each side.
 Unlike Aedes eggs, Anopheles eggs are not resistant to drying.
 The female will lay a batch of eggs every 2-3 days.
Larvae:
 An active stage that feeds and grows rapidly moving through four instars (different sizes of
larvae).
 Larvae feed on nutrients in the water using the brushes around their well-developed mouth to
move the nutrients into their mouth.
 Larvae must breathe oxygen. Unlike Culicine larvae, Anopheline larvae do not have a siphon to
breathe through, instead they breathe through small spiracles on the surface of their abdomen.
This means that larvae must lie parallel to the water surface to keep the spiracles in contact with
the air above.
 Larvae can descend into the water when startled and then return to the surface when they need
oxygen.
13
 After the 4th instar has been reached the next phase of development is metamorphosis into a
pupa.
 Larvae can dry out and must be in pools of water with some nutrients to survive.
 Anopheline larvae most times prefer clean water in temporary habitats such as pools, puddles,
hoof prints, borrow pits, and rice fields.
 Anopheles mosquitoes rest parallel to the surface of the water, whereas the latter two species
larvae rest at an angle to the surface.
Pupae:
 An inactive stage. The mosquito develops inside the pupa into an adult, no feeding takes place
during this stage.
 Pupae are small and comma shaped and can move up and down through the water, descending
from the water surface to avoid perceived threats, such as if a shadow falls over the water surface.
 The pupa also requires oxygen, they breathe whilst at the water surface through a pair of
respiratory trumpets.
 After a few days as a pupa splits and an adult mosquito emerges.
Adults:
 The same or the following evening after emergence the female mosquitoes will mate with a male
mosquito. She will usually mate only once in her life and stores the sperm in her body to be used
for each batch of eggs she lays.
 Anopheline and culicine mosquitoes both have piercing and biting mouth parts. Male mosquitoes
only feed on water and nectar; female mosquitoes also feed on water and nectar for energy but
also use these mouth parts to feed on blood.
 Blood meals are taken every 2-3 days, the female rests after the blood meal to digest it and use
the protein from the blood meal to develop her eggs. Mosquitoes will lay a batch of eggs every
2-3 days.
The most feasible ways of telling the difference in the field for adult mosquitoes are:
 Resting position of the adult: angled in Anopheles, flat – with the proboscis and body at angles
to one another in Culex and Aedes.
 Palps of the adult: long in Anopheles female, short in Culex and Aedes females; long with
swollen ends (club shaped) in anopheles male, along with non-swollen ends (tapered) in Culex
and Aedes male.
14
Table 4: Distinguishing Anopheline and Culicine Mosquitoes
Anophelines Culicines
Eggs Float separately and have Clump together in a raft (Culex) or float
“floaters” separately (Aedes)
Larvae No siphon Has siphon
Rests parallel to water surface Hangs down from the water surface
Pupae Trumpet is short and has wide Trumpet is long and slender with a
opening narrow opening
Female Adults Palps as long as proboscis Palps very much shorter than proboscis
Male Adults Palps as long as proboscis, club- Palps longer than proboscis, with tapered
shaped at tips tips
Figure 7: Differentiation of Anopheles, Aedes and Culex mosquitoes at various stages of development.
15
Factors affecting the life cycle
Water, temperature and humidity are the main environmental factors affecting the life cycle. At each
stage different conditions are required for the mosquito to survive, and a range of suitable conditions
can result in big differences in the timing of the life cycle.
Water
 Different mosquito species require different types of water in which to lay their eggs,
- some preferring more shaded sites, other sunnier sites;
- some preferring deeper more permanent water bodies, others shallower
temporary water bodies;
 Anopheles species can only survive in fairly clean water (unlike some culicines which can breed
in water rich with organic pollutants such as pit latrines).
Temperature
 Temperature affects whether the mosquitoes can survive at all as well as the timing of the life
cycle
 Above 35°C the adult mosquito will die much sooner
 Temperature affects the length of time each life stage takes
- whilst eggs may hatch 2-3 days in ideal conditions, they may take as long
as several weeks at the lower temperature limits
- larvae can progress through their four instars in about seven days at 31°C
but this can take up to 20 days at 20°C.
Humidity
 Below 50% humidity the adult mosquito will die much sooner
 Ideal humidity is around 65% - 75%
Malaria Vector Behavior

There are a few specific behaviors that vary between mosquito species and these can have an
important impact on levels of transmission.
16
Host preference
Female anopheles mosquitoes must all take a blood meal to be able to develop eggs, however the
source of that blood can vary considerably. Mosquito’s species that are important human malaria
vectors must feed sometimes on humans, otherwise they would not be important in transmission of
the disease. An. Gambiae species complex is an extremely efficient malaria vector that is responsible
for much of the heavy malaria burden in Africa south of the Sahara. This species complex includes
the most important vectors in Africa and consists of seven species. Each of these subspecies has
different habitats, the most important two are Anopheles gambiae and Anopheles arabiensis.
Members of the Anopheles gambiae complex feed almost exclusively on humans. Likewise, An.
funestus which is found in Ethiopia also feeds mostly on humans.
In Ethiopia the main malaria vector is An. arabiensis which feeds both on humans and cattle. It is
important to know about the vector species feeding preferences for control measures. In countries
where An. gambiae and An. funestus are the main vectors, IRS would focus on spraying human
dwellings only as this will ensure almost all mosquitoes trying to take a blood meal rest on the
insecticide-treated surface. Where vectors such as An. arabiensis are important an effective IRS
strategy will need to spray both human dwellings and animal sheds, to ensure that even those
mosquitoes taking a blood meal on the animals are likely to rest on the insecticide-treated surface.
This is important for the overall effectiveness of the control strategy.
Biting times
Whilst some mosquitoes, e.g. Aedes the dengue vector, bite in the daytime, Anopheles mosquitoes
bite in the evening and night time. Some species bite in the early evening and some late at night. The
biting time is important in that it can impact on how effective some different control measures may
be. For example sleeping under insecticide-treated nets (ITNs) will be particularly effective if the
malaria vectors feed only later at night when most people are asleep.
Indoor or outdoor biting
Different mosquitoes prefer to take their blood meals in different locations. Some prefer to find their
hosts outdoors, others come inside to find the blood meal. The terms for this are:
 Endophagic – feeds indoors
17
 Exophagic – feeds outdoors
In Ethiopia the main vector, An. arabiensis likes to both indoors and outdoors, whilst An. funestus,
feeds mostly indoors.
Resting location
After a mosquito has taken a blood meal it must rest somewhere to digest the blood and produce
eggs. Some mosquitoes prefer to rest indoors and some prefer to rest outdoors. The terms for this are:
 Endophilic – rests indoors
 Exophilic – rests outdoors
In Ethiopia the main vector, An. arabiensis rests both indoors and outdoors, whilst An. funestus, rests
mostly indoors. It is important to understand that resting preference is not necessarily linked to
feeding preference, for example some mosquitoe species that prefer to feed outdoors may come
indoors to rest and digest the meal. Knowing about resting behaviour is very important for the
selection of control measure. IRS where the mosquito must rest on the walls where the insecticide
has been sprayed in order for the strategy to work.
Flight range
Most Anopheles mosquitoes can fly up to 2-3 km from their larval habitat. However, where food
sources and breeding sites are readily available mosquitoes may actually move very little from where
they have emerged as adults. In some urban areas where this is the case, this can result in some very
focal areas of transmission. Occasionally mosquitoes travel much further than 2-3 km, but this
dispersal is usually wind assisted – or relies on transport in vehicles. Understanding dispersal patterns
can be important for planning environmental control measures where the breeding sites are targeted.
18
Figure 8: Schematic representation of malaria vector lifecycle and vector control methods
19
LEARNING UNIT THREE
Uncomplicated Malaria
Learning Objectives
At end of this training, participants will be able to:
 Identify the etiologic agents of malaria

 Describe modes of transmission and life cycle of malaria parasites
 Explain clinical presentation of non-complicated malaria
 Diagnose and treat non complicated malaria
 Manage malaria at different levels of the health facility in Ethiopia
Definition and Etiologic Agents

Malaria is a parasitic infectious disease caused by protozoan parasites of the genus Plasmodium and
is transmitted by mosquitoes. It is characterized by recurrent symptoms of chills, fever and
generalized body pain.
The five Plasmodium species of human malaria are: P. falciparum, P. vivax, P. ovale, P. malariae
and P. knowlesi.
Plasmodium falciparum and vivax are the two most common etiologies in Ethiopia
▶ Plasmodium falciparum is found worldwide, mainly in tropical and subtropical areas. It is the
main species that causes severe, potentially fatal malaria.
▶ Plasmodium vivax is found mainly in Asia, Latin America, and in some parts of Africa (e.g.
Ethiopia and Madagascar). Evidence shows that P. vivax can cause severe illness. P. vivax and P.
ovale) have dormant liver stages (hypnozoites) which would be activated and invade the blood to
cause clinical relapse several weeks, months or years after the infectious mosquito bite. P.vivax does
not infect individuals who are negative for the Duffy blood group, as are many residents of sub-
Saharan Africa.
▶ Plasmodium ovale is found mostly in the countries of west Africa and the islands of the western
Pacific. It is biologically and morphologically similar to P. vivax. It is rarely reported in Ethiopia.
▶ Plasmodium malariae is found worldwide. It causes a persistent chronic infection which may be
lifelong. A small number of patients develop serious complications such as the nephrotic syndrome.
20
▶ Plasmodium knowlesi is found in Malaysia, Thailand and other South East Asian countries. It is
mainly transmitted in forests and along forest fringes. Under the microscope, it is indistinguishable
from P. malariae. It can cause severe disease and death in some individuals.
Biological and clinical characteristics of different malaria species

The parasite incubation period, known as the intrinsic incubation period, differs for each parasite
species. The incubation period of P. falciparum is 9–14 days, P. vivax 12–17 days, P. ovale 16–18
days and P. malariae 18–37 days. The erythrocytic cycle, which is responsible for clinical
paroxysms, takes about 48 hours in P. falciparum, P. vivax, and P. ovale infections (tertian cycle),
but lasts about 72 hours with P. malariae infection (quartan cycle).
The malaria parasite species also differ in the number of merozoites they produce in the
exoerythrocytic and erythrocytic phases and the type of the red blood cells they invade. P. falciparum
produces the greatest number of merozoites in both phases followed by P. vivax. P. falciparum, which
is responsible for the severe forms of malaria, infects red blood cells of all ages, unlike P. malariae
which infects older red blood cells, and P. vivax and P. ovale which infect young red cells.
Mode of transmission and life cycle of parasites

There are three modes of malaria transmission:
 the bite of an infected female anopheline mosquito (the main method of transmission);
 accidental transmission via blood transfusion or needle stick injury; and
 Congenital transmission from mother to child during pregnancy or parturition.
Malaria transmission by mosquitoes
The parasite incubation period in the vector mosquito, known as extrinsic incubation, is temperature-
dependent. P. falciparum takes 8–11 days to complete the mosquito phase at an optimal ambient
temperature of 28°C and 22 days at 20°C. The temperature of the mosquito gut equals that of its
surroundings; a low environmental temperature therefore results in a longer development time for
the parasite in the mosquito. P. falciparum is unable to develop below 19 °C while P. vivax can
develop in the mosquito at temperatures as low as 16°C; consequently P. vivax transmission is found
in some areas where the average temperature is too low for P. falciparum transmission. Due to this
difference in temperature sensitivity, P. falciparum is common in tropical regions while P. vivax
prevails in both tropical and temperate cold regions
21
Other modes of transmission
Transmission via blood transfusion, accidental needle stick, or needle sharing, leads to transfer of
asexual stages of the parasite. The incubation period of the disease is therefore much shorter than it
is after transmission of sporozoites by mosquito bite. Transfusion of blood infected with P. vivax and
P. ovale parasites does not lead to clinical relapse because pre-erythrocytic schizogony does not
occur and hence the dormant hepatic forms are not produced.
Transmission of malaria across the placenta from mother to fetus is diagnosed when parasitaemia is
found in the neonate within seven days of birth, or later if there has not been any other possibility of
transmission to the neonate (by blood or mosquito bite). Despite the high prevalence of placental
infection, congenital transmission of malaria is rare.
Life Cycle of Malaria Parasite
Humans acquire malaria from sporozoites transmitted by the bite of an infected female anopheline
mosquito. The sporozoites then travel through the bloodstream to the liver within about 30 minutes,
where they invade hepatocytes and mature to become tissue schizonts (pre-erythrocytic schizogony).
Tissue schizonts are a central feature of all plasmodium species that infect humans. They amplify the
infection by producing large numbers of merozoites (10 000 – 30 000) from each sporozoite-infected
hepatocyte.
Each merozoite released from the liver is capable of infecting a human red blood cell (RBC) and
establishing the asexual cycle of replication in the red blood cells. The asexual cycle starts with
merozoite invasion and continues to schizont rupture (merozoite → ring stage → mature trophozoite
→ schizont → merozoites), leading to invasion of more red blood cells. Some intraerythrocytic
parasites develop into the sexual forms, the gametocytes, which are necessary for the sexual
reproductive cycle that takes place in the vectors.
When potent gametocytes are ingested by a female anopheline mosquito during a blood meal, micro-
and macrogametocytes mature to become male and female gametes. Fertilization of the female
gametes produces diploid zygotes which mature to become ookinetes. Ookinetes then undergo a
meiotic reduction division to produce haploid sporozoites, which migrate to the salivary glands of
the mosquito and subsequently reinfect humans. In the P. vivax and P. ovale life cycles, some
sporozoites can lie dormant in the liver cells for months or years after the initial bloodstream infection
22
and do not cause symptoms during this time. The dormant forms, called hypnozoites, eventually
mature to become tissue schizonts which release infectious merozoites, resulting in a clinical relapse.
Figure 9: Life cycle of malaria parasite
Clinical presentation and Diagnosis
Non-complicated malaria is symptomatic malaria with parasitaemia without signs of severity or

evidence of vital organ dysfunction. The main manifestation of uncomplicated malaria is fever. Other
symptoms are chills, rigors, headaches, and body pains, malaise, nausea, vomiting, and joint
weakness. Physical examination may reveal pallor and hepatosplenomegaly.
23
Malaria diagnosis is made by
 Proper history taking, physical examination and laboratory method (parasitological diagnosis)
Clinical diagnosis (Malaria Suspect)
A clinical diagnosis entails making a clinical assessment by taking an accurate history of the illness
and performing a physical examination. Malaria should be suspected in a patient who has fever or
history of fever in the last 48 hours and lives in malaria-endemic areas or has a history of travel
within the last 30 days to malaria-endemic areas.
Basing the diagnosis on clinical features alone is not recommended, as this often has low specificity
and increases the chances of the patient being misdiagnosed. Malaria treatment based on clinical
diagnosis must be the last option when there is no availability of RDTs or microscopy. The health
worker examining a suspected malaria case should look for other causes of fever (e.g. pneumonia,
pyelonephritis, meningitis, tonsillitis, typhoid fever, relapsing fever, visceral leishmaniasis) and
manage the case accordingly. Malaria should still be considered, even if the individual has another
obvious cause for the fever. The national algorithm of the Integrated Management of Neonatal and
Childhood Illness (IMNCI) and the Ethiopian Primary Health Care Guidelines (EPHCG) should also
be employed for the management of the sick child presenting with fever.
Parasitological diagnosis
Parasitological diagnosis is required for confirmation of the diagnosis of malaria. It is recommended

for all suspected malaria cases in all transmission settings. The advantages of parasitological
diagnosis are:
 improved care of parasite-positive patients owing to greater certainty that the cause of the
present illness is malaria;
 identification of parasite-negative patients for whom another diagnosis must be sought;
 prevention of unnecessary use of antimalarials, thereby reducing the risk of adverse side effects
and drug interactions;
 confirmation of treatment failures; and
 Improved malaria case detection and reporting.
The two main methods in routine use for parasitological confirmation of malaria are light microscopy
and rapid diagnostic tests (RDTs). For the management of a new fever episode, quality-assured
24
microscopy and RDTs are equivalent in terms of performance for the diagnosis of uncomplicated
malaria. Light microscopy using thick blood films can be very sensitive, detecting as few as five
parasites/µl of blood. Thin blood film stained with Giemsa is helpful for identifying the malaria
parasite species and has a sensitivity of 20 parasites/µl. The recommended method to determine
parasite load is by quantifying the number of malaria parasites per microliter of blood on thick blood
film. Currently, multi-species RDTs capable of specifically detecting both P. falciparum and P. vivax,
are being supplied to health posts, enhancing malaria diagnosis by species at the periphery and
reducing the need for empiric treatment and wastage of anti-malarial drugs. RDTs have a sensitivity
to detect malaria parasites above 100 parasites/µl.
In addition, molecular diagnosis (e.g. polymerase chain reaction / PCR) is usually applied in research
settings, and in surveillance in areas where elimination of malaria is in progress. Serological tests for
malaria have no place in the management of febrile patients.
Table 5: Treatment at Different Levels of Health Facility

Parasite Health post (RDT) H.Center/Hospital
P. vivax, without contraindication to PQ CQ + PQ (radical cure) CQ + PQ(radical cure)
P. vivax in pregnant women CQ +weekly CQ CQ +weekly CQ prophylaxis*

prophylaxis*
P. vivax with contraindication to PQ other CQ CQ
than pregnancy
Uncomplicated P. falciparum malaria AL + PQ (single dose) AL + PQ (single dose)
without contraindication to PQ
Uncomplicated P. falciparum in AL AL
pregnancy including first trimester**
Uncomplicated P. falciparum with AL AL
contraindication to PQ other than
pregnancy
Uncomplicated mixed infection without AL + PQ (radical cure) AL + PQ (radical cure)
contraindication to PQ*
Uncomplicated mixed infection with AL AL
contraindications to PQ
*CQ treatment should be followed by weekly CQ prophylaxis until delivery and six months of
breastfeeding. Then give PQ radical cure if there is no contraindication
N.B. Patients who test negative by malaria RDT or microscopy do not need anti-malarial medications.
Health post level: diagnosis of malaria is based on rapid diagnostic test result. Health extension workers may
treat using clinical criteria only if RDT is not available. Severe malaria should be referred as soon as possible.
25
Suspected Malaria Case (See
Box 1)
Signs and symptoms of

severe malaria present?
No
History of malaria treatment in

the past 4 weeks
Yes
Refer for possible
management for Yes No
malaria treatment
failure
Multispecies RDT
Refer (Give first Negative
dose of rectal Use National
Artesunate if ICCM Algorithm
the patient P. vivax
P. falciparum Mixed (Pf, Pv)
<6years of age)
Treat with AL and single dose Treat with AL & radical Treat with
PQ* unless there is cure PQ* unless there is chloroquine** and 14
contraindication contraindication days PQ unless there is
contraindication
**Give AL if chloroquine syrup is not available
*Contraindications of primaquine are Box 1.

pregnancy, breast feeding mothers less than Patient with fever or history of fever in the last 48 hours and
six months infants, infants under six months, lives in malaria-endemic areas or has history of travel within
moderate to severe anemia, known the past 30 days to malaria-endemic areas.
hypersensitivity to primaquine
Figure 10. Flowchart for the diagnosis and treatment of malaria at the health post level
26
First line of treatment of uncomplicated malaria
P. falciparum positive by multi–species RDT: Artemether-Lumefantrine (AL) plus single dose

primaquine (0.25mg/kg) is the recommended first-line drug for the treatment of uncomplicated P.
falciparum malaria. AL tablets are given according to body weight in six doses over three days as
indicated in the table below
Table 6: Tablet containing 20 mg artemether plus 120 mg lumefantrine in a fixed dose.
Weight Age Day 1 Day 2 Day 3 Color

(KG) Immediate After 8hrs Morning Evening Morning Evening
<5kg <4 1Tablet 1Tablet 1Tablet 1Tablet 1Tablet 1Tablet Yello
months
5-14 kg 4mns- 2 1Tablet 1Tablet 1Tablet 1Tablet 1Tablet w*
1Tablet
years
15-24 kg 3 to 7 2 Tablets 2 Tablets 2 2 2 Tablets 2 Blue*
yrs
Tablets Tablets Tablets
25-34 kg 8 to 10 3 Tablets 3 Tablets 3 3 3 Tablets 3 Brown
yrs
>35 =>10 4 Tablets 4 Tablets 4 4 4 Tablets 4 Green
years
*Yellow and blue flavored pediatric dispersible tablets of AL is available for enhancing its use in
young children.
Side effects:
The following adverse effects have been reported; dizziness and fatigue, anorexia, nausea, vomiting,
abdominal pain, palpitations, myalgia, sleep disorders, arthralgia, headache and rash.
Contraindications:
 AL should not be used as malaria prophylaxis either alone or in combination;
 Persons with a previous history of reaction after using the drug;
 Persons with severe and complicated malaria should not be treated with oral medications.
Note: AL has a shelf life of only two years. The drug should be stored at temperatures of below 30oC
and should not be removed from the blister if it is not going to be used immediately.
27
The first dose should be given under direct supervision of the health worker to make sure that the
patient can take the medicine without any problem. AL should preferably be taken with food or fluids.
A fatty meal or milk improves absorption of the drug.
If vomiting occurs within half an hour of the patient swallowing the drug, the dose should be repeated
and the health worker/pharmacist should provide the patient with a replacement dose to ensure
completion of treatment.
AL is available in co-formulated tablets containing artemether 20 mg and lumefantrine 120 mg per

tablet. The dose ranges from 1-4 tablets (depending on the patient’s body weight) taken every 12
hours for 3 days.
P. vivax, and malaria species positive other than P. falciparum by RDT: The first line drug of
choice is chloroquine at a total dose of 25 mg base/kg.
Tablets of chloroquine 150 mg base or syrup 50 mg base per 5 ml (Note, one 250 mg chloroquine
phosphate salt tablet contains 150 mg chloroquine base). Never take more than four 250 mg
chloroquine phosphate tablets in one day.
Table 7: Chloroquine dose
Weight (kg) Age Day 1 Day 2 Day 3

5–6 < 4 months ½ tablet OR ¼ tablet OR ¼ tablet OR
5 ml syrup 5 ml syrup 2.5 ml syrup
7 – 10 4 – 11 months ½ tablet OR ½ tablet OR ½ tablet OR
7.5 ml syrup 7.5 ml syrup 5 ml syrup
11 – 14 1 – 2 years 1 tablet OR 0.5 tablet OR 0.5 tablet OR
12.5 ml syrup 12.5 ml syrup 7.5 ml syrup
15 – 18 3 – 4 years 1 tablet OR 1 tablet OR 1 tablet OR
15 ml syrup 15 ml syrup 15 ml syrup
19 – 24 5 – 7 years 1 ½ tablets OR 1 ½ tablets OR 1 tablet OR
20 ml syrup 20 ml syrup 15 ml syrup
25-35 8-11 yr 2 ½ tablets 2 tablets 1 tablet
36-50 12-14 yr 3 tablets 2 tablets 2 tablets
51+ 15 yr + adult 4 tablets 4 tablets 2 tablets
28
Side effects:
Dizziness, skeletal muscle weakness, mild gastrointestinal disturbances (nausea, vomiting,
abdominal discomfort and diarrhea) and pruritus. Pruritus may be severe but usually passes within
48-72 hours.
Contraindications:
 persons with known hypersensitivity
 persons with a history of epilepsy
 persons suffering from psoriasis
Primaquine will be given for p. vivax cases for radical cure with close clinical follow up at a dose of
0.25mg/kg orally for 14 days. Primaquine should also be given for P. falciparum cases at a dose of
0.25mg base/kg to reduce malaria transmission
Table 8 :Primaquine phosphate dose: 0.25 mg base per kg daily schedule for 14 days
Number of tablets per day for 14 days

Weight (kg) Age (years) 7.5 mg tablet 15 mg tablet
<19 06months to < 5 years ½ ¼
19 – 24 5–7 ¾ -
25 – 35 8 – 10 1 ½
36 – 50 11 – 13 1½ ¾
50+ 14+ 2 1
Table 9 Primaquine phosphate dose: 0.25 mg base per kg (dose of single PQ for Pf cases)
Weight (kg) Age (years) 7.5 mg tablet

<19 06months to < 5 years ½
19 – 24 5–7 ¾
25 – 35 8 – 10 1
36 – 50 11 – 13 1½
50+ 14+ 2
Side effects:
29
Anorexia, nausea, vomiting, abdominal pain and cramps are dose related and relatively rare at daily
doses up to 0.25 mg base/kg. They may also be accompanied by vague symptoms such as weakness
and uneasiness in the chest.
Contraindications:
 Pregnancy
 Women breast feeding infants less than six months of age
 Infants less than six months of age
Table 10: Dihydroartemisinin + piperaquine (DHA-PPQ) dose
Body weight (kg) Dihydroartemisinin + piperaquine dose

(mg) given daily for 3 days
5 to < 8 20 + 160
8 to < 11 30 + 240
11 to < 17 40 + 320
17 to < 25 60 + 480
25 to < 36 80 + 640
36 to < 60 120 + 960
60 < 80 160 + 1280
>80 200 + 1600
Multi-species RDT is positive for P. falciparum or mixed infection: The recommended first-line
treatment for mixed infection is AL. and primaquine radical cure for 14 days.
Note: do not treat a patient with confirmed mixed infection with both AL and chloroquine.
Multi-species RDT negative for malaria: If the result of the multi-species RDT is negative for all
malaria species, malaria is unlikely. Other causes of fever should be investigated. Treat or refer to
health center or hospital as per the CCM algorithm.
No parasitological test available: Where multi-species RDT is not available, and the patient fulfills
clinical criteria of malaria, AL should be given.
30
Supportive treatment
If patients, especially children are present with axillary temperature ≥37.5oC, treat with antipyretics
and, if necessary, fanning and tepid sponging. Paracetamol (acetaminophen) 15 mg/kg every 4 hours
is widely used; it is safe and well-tolerated, given orally or as a suppository. Pain should be treated
and the patient should be encouraged to take food and fluids.
Patient advice
Health workers should clearly explain malaria diagnosis and treatment, e.g. making patients
understanding drug labels and instructions. SBCC messages should include the following:
 H/she has got malaria; Malaria is transmitted by mosquito that bites mainly at night
 Malaria is a killer disease if treatment is not sought early and treatment is taken properly.
 Whenever a family member has a fever, take them to the nearest health facility, immediately or
at least within 24 hours.
 Do not interrupt taking medication. Take all (full course) of the anti-malarial drugs, prescribed
by health personnel.
 Take/give enough food and fluid (especially fatty meal to enhance drug absorption and to avoid
risk of hypoglycaemia
 Do not share drugs with others, including family members.
 Come back to the health facility after three days if no improvement in symptoms after malaria
treatment or any time if there is worsening of symptoms.
 Malaria can be prevented by using LLINs/ITNs, eliminating mosquito breeding sites and indoor
residual spray; All family members, especially women and children should sleep under LLINs
every night and protecting sprayed house form plastering.
Referral
It is important that all patients are assessed for the presence of danger signs (see below). If a
patient present at a health post with danger signs or is found to have any of the following danger
signs, they require URGENT medical attention and should be referred to a higher level facility
as soon as possible. Children under six years should be provided with rectal
artesunate(suppository), antibiotics and necessary advice during referral (refer IMNCI). Adults
with severity signs at health centres should be provided with first dose of injectable artesunate
and be referred urgently to hospitals.
31
Danger signs of severe malaria
 Altered consciousness (e.g. sleepiness, confusion, drowsiness, coma)
 Prostration, i.e. generalized weakness so that the patient is unable to walk or sit up without
assistance
 Unable to eat or drink
 Repeated vomiting, resulting in inability to retain oral medication, inability to eat or drink
 Severe dehydration
 Convulsion or recent history of convulsions
 Difficult breathing
 Jaundice (yellowish discoloration of the eyes)
 Anemia (paleness of palms is most reliable symptom in children)
 Hemoglobinuria (cola colored urine)
 Abnormal spontaneous bleeding
 No urine output in the last 24 hours
Any patient presenting with any of the above-mentioned danger signs, regardless of whether the
RDT result is negative or positive, should be given pre-referral treatment and be referred to the
next higher level health facility as soon as possible.
REMEMBER: A delay in referral could cause the unnecessary death of the patient.
32
Suspected Malaria Case

No

the past 4 weeks
Yes
Refer to the
algorithm for Yes No
malaria treatment
failure
Microscopy
Manage Look for other Negative
accordingly or causes of fever
refer to higher
level P. vivax
Treat with
Treat with AL and single Treat with AL & chloroquine** and
dose PQ* unless there is radical cure PQ* 14 days PQ unless
contraindication unless there is there is
contraindication contraindication
**Give AL if chloroquine syrup is not available

Box 1. Patient with fever or history of fever in the last
*Contraindications of primaquine are 48 hours and lives in malaria-endemic areas or has
pregnancy, breast feeding mothers less than history of travel within the past 30 days to malaria-
six months infants, infants under six months, endemic areas.
moderate to severe anemia, known
hypersensitivity to primaquine
Figure 11: Flowchart for the diagnosis and treatment of malaria at the health center and hospital
level
33
Health center and hospital level:
First-line treatment of uncomplicated malaria: First-line treatment of uncomplicated P.

falciparum malaria at the health center or hospital level is nearly the same as that health post,
including the advice and supportive treatment. Though the prevalence of G6PD deficiency is very
low in Ethiopia, health workers should closely follow-up patients started on primaquine for
hemolysis by informing the patient the symptoms of hemolytic anemia like weakness, dizziness,
lightheadedness, dark urine color and discontinue primaquine and come back to the health facility if
there is any side effect. If there is evidence of hemolysis, primaquine should be discontinued and
should not be given to the patient in the future. It is vital to support patients’ adherence with a phone
call reminder or other means. Regarding supportive treatment, the difference from health posts is that
health workers at health center and hospital-level can assess and manage mild and moderate anaemia.
Second line treatment of uncomplicated malaria: Second-line treatment is used when the first-
line treatment is not available, or during failure or non-response to first-line treatment. The second-
line treatment for both P. falciparum and P. vivax is Dihydroartemisinin-piperaquine (DHA-PPQ)
instead of oral quinine.
34
Treatment failure: Treatment failure is defined as failure of anti-malarial drug to resolve fever
and/or parasitemia. For clinical purpose, consider treatment failure in a patient with malaria who was
treated for malaria in the past 28 days. Treatment failures may result from drug resistance, poor
adherence or inadequate drug exposure (i.e., under-dosing, vomiting or unusual pharmacokinetic
properties in that individual), drug interaction, misdiagnosis or substandard medicines. Anti-malarial
drug resistance refers to the ability of a parasite strain to survive and/or multiply despite the
administration and absorption of medicine given in doses equal to or higher than those usually
recommended, but within the tolerance of the subject, and the drug must gain access to the parasite
or the infected red blood cell for the duration of the time necessary for its normal action and anti-
malarial drug resistance can cause treatment failure but not all treatment failure is due to parasite
resistance to the drugs. It is essential to determine whether the antimalarial was vomited or the full
course was not completed from the patient’s history. Monitoring treatment failure is critical because
it can signal the appearance of anti-malarial drug resistance.
Treatment failure within first 28 days: Owing to the potency of AL, treatment failure within 28
days of receiving an AL is very unusual. Recurrence of P. falciparum malaria may be the result of a
reinfection, or a recrudescence (i.e., treatment failure). It may not be possible to distinguish between
recrudescence and reinfection in an individual patient. However, if fever and parasitemia fail to
resolve or recur within four weeks of treatment, then the treatment has failed. Wherever possible,
treatment failure should be confirmed parasitologically; preferably, a blood smear should be obtained
and labelled correctly to verify–amongst others– Plasmodium species and parasite count and to rule
out other diseases (e.g., relapsing fever). RDTs may remain positive for weeks after the initial
infection, even without recrudescence. This requires referring a patient from a health post to a health
center where microscopy is available; referral may also be necessary to obtain second-line treatment
which is available at health center level
Treatment failure after 28 days: Most treatment failures occur after two weeks of initial treatment.
Such failures can result from either recrudescence or a new infection. This distinction can only be
made through parasite genotyping by PCR, which is not used in patient management in Ethiopia.
Thus to simplify operational management and medicine deployment, all presumed treatment failures
after four weeks of initial treatment should be considered as new infections, and be treated with the
first-line antimalarial drug.
35
Suspected Malaria Case

N0

the past 4 weeks
Yes
No malaria
treatment failure No yes
Microscopy
Manage Negative
Look for other
accordingly or
causes of fever
refer to higher
level P. vivax
A species different
from the first parasite
is treated with first-line Treat with second-line Treat with second-
drugs ACT and single-dose line ACT & radical
PQ* unless there is cure PQ* unless
contraindication there is
contraindication
*Contraindications of primaquine are pregnancy, Box 1: Patient with fever or history of fever in
breast feeding mothers less than six months the last 48 hours and lives in malaria-endemic
infants, infants under six months, moderate to areas or has history of travel within the past
severe anemia, known hypersensitivity to 30 days to malaria-endemic areas.
primaquine
Figure 12. Flowchart for the management of malaria treatment failure
36
Management of treatment failure: The following recommendations should be followed after a complete
history, clinical assessment, and laboratory examination:
 If a cause for treatment failure is identified (e.g. anti-malarial drug is vomited), such cause must be
addressed and treatment reinstituted with the first-line anti-malarial drug;
 If no cause is identified, a P. falciparum or P. vivax-infected patient returns to the health facility with
fever or history of fever between 72 hours to 28 day of treatment, and if parasites are detected by
microscopy (Note: do not use RDTs), the treatment should be changed to the second-line drug, i.e.
Dihydroartemisnin-piperaquine tablets;
 In patients who are suspected of having treatment failure after 28 days, the first-line anti-malarial drug
should be used;
 If the blood smear is negative and no other apparent causes are found, the patient should be re-
evaluated or referred to the next level of health care for proper management.
Appropriate management of treatment failure is critical because the patient may progress to severe malaria,
and resistant parasites may be present and transmitted to others. All malaria patients should be asked for
history of malaria treatment in the past 28 days. If they have such history they should be diagnosed at least at
the health center level with microscopy; health extension workers should refer such patients.
Chemoprophylaxis
Persons who travel to malaria-endemic areas are at risk of acquiring malaria. Health workers should advise
all persons traveling to such places to avoid mosquito bites, specifically by sleeping under LLINs at night and
using mosquito repellent. Chemoprophylaxis is an option and mefloquine or atovaquone-proguanil can be
used as anti-malarial chemoprophylaxis in Ethiopia (Table 9 and refer to WHO travel health guidelines).
NB: If the person develops fever while on chemoprophylaxis he/she should seek medical advice.
Table 11: Mefloquine: 5 mg /kg mefloquine salt once weekly
Weight (Kg) Age (approx.) Number of tablets per week

<9 < 3 months Not Recommended
9 – 19 3 – 23 months ¼
20 – 30 2 – 7 year ½
31 – 45 8 – 10 year ¾
36 – 50+ 11 – 14+ 1
37
Table 12 Atovaquone-proguanil
Atovaquone/
Weight (kg) Proguanil HCl Dosage Regimen
11-20 62.5 mg/25 mg 1 Pediatric Tablet daily
21-30 125 mg/50 mg 2 Pediatric Tablets as a single dose daily
31-40 187.5 mg/75 mg 3 Pediatric Tablets as a single dose daily
>40 250 mg/100 mg 1 Tablet (adult strength) as a single dose daily
PHARMACOVIGILANCE
Pharmacovigilance is the science and activity of detecting, assessing, understanding and preventing
the adverse effects or any other possible drug-related problems, such as substandard medicines,
medication errors, lack of efficacy reports, use of medicines for indications that are not approved and
for which there is an inadequate scientific basis, case reports of acute and chronic poisoning,
assessment of drug-related mortality, abuse and misuse of medicines and adverse interactions of
medicines with chemicals, other medicines, and food. The rationale for the importance of this activity
is the limitation of drug safety information obtained during the initial premarketing phases of drug
development.
To maintain safety and prevent the public from injury because of the use of medicines at large, a
national adverse event monitoring system or pharmacovigilance is necessary. In Ethiopia, a
pharmacovigilance center was established in 2002 and is situated at the Ethiopian Food and Drug
Authority (EFDA). This important activity is carried out through the active collaboration of various
stakeholders and partners, including health providers, health facilities, academic institutions, drug
manufacturers, professional associations, consumers and the media. Health workers can use the
report form (Annex R) which clearly states what and to whom to report in these instances. It is also
possible to report drug reactions directly by telephone using the toll free number 8482 or using the
mobile application Medsafety that can be downloaded from Google play store for android phones
and apple store for iphones or using the e-reporting that is available on the EFDA website
www.efmhaca.gov.et/services/e-reportingADR or using the link http://primaryreporting.who-
umc.org/Reporting?ReporterOrganizationID=ET .Experts will analyze each report, and measures
will be taken based on the information obtained to protect against drug-related injury.
38
LEARNING UNIT FOUR
Approach to Fever in Children, IMNCI (Integrated Management of Newborn and Childhood

Illnesses)
Learning objectives
By the end of this training, participants will be able to:
 Ask the mother about fever in children.

 Check for general danger signs.
 Assess a child with fever
 Classify a child with fever
 Select appropriate treatment for a child with fever
Assess and Classify Fever

A child with fever may have malaria, measles or another severe disease. Or, a child with fever may
have a simple cough or cold or other viral infection.
P. falciparum and P. vivax are the two dominant parasite species causing malaria in Ethiopia, with
relative frequencies of about 60% and 40%, respectively. This proportion varies from place to place
and from season to season. P. falciparum is the dominant parasite species in malaria epidemic
situations, and this species causes severe and complicated manifestations and almost all malaria
deaths.
Fever is the main symptom of malaria. It can be present all the time or recur at regular intervals.
Other signs of falciparum malaria are shivering, sweating and vomiting. A child with malaria may
have chronic anemia (with no fever) as the only sign of illness.
Signs of malaria can overlap with signs of other illnesses. For example, a child may have malaria
and cough with fast breathing, a sign of pneumonia. Studies show that cough and fast breathing are
common in children who have fever and falciparum malaria confirmed by blood smear. Even
expert clinicians need laboratory tests to reliably distinguish falciparum malaria from pneumonia
in a child with fever, cough and fast breathing. This child needs treatment for both falciparum
malaria and pneumonia. Children with malaria may also have diarrhoea. They need an anti-malarial
and treatment for the diarrhoea.
39
In areas with very high malaria transmission, malaria is a major cause of death in children. A case
of uncomplicated malaria can develop into severe malaria within 24 hours of onset the illness. Severe
malaria is malaria with complications such as cerebral malaria, severe anemia or hypoglycaemia.
The child can die if he does not receive urgent treatment.
Deciding Malaria Risk: Malaria risk is defined as the presence of malaria transmission in the area
where the patient lives or travel history to malarious area in the past 30 days.
MEASLES: Fever and a generalized rash are the main signs of measles. Measles is highly infectious.
Maternal antibody protects young infants against measles for about 6 months. Then the protection
gradually disappears. Most cases occur in children between 6 months and 2 years of age.
Overcrowding and poor housing increases the risk of measles occurring early.
Measles affects the skin and the layer of cells that line the lung, gut, eye, mouth and throat. The
measles virus damages the immune system for many weeks after the onset of measles. This leaves
the child at risk for other infections.
Complications of measles occur in about 30% of all cases. The most important are: diarrhoea
(including dysentery and persistent diarrhoea), pneumonia, stridor, mouth ulcers, ear infection and
severe eye infection (which may lead to corneal ulceration and blindness).
Encephalitis occurs in about one in one thousand cases. A child with encephalitis may have a general
danger sign such as convulsions or lethargic or unconscious.
Measles contributes to malnutrition because it causes diarrhoea, high fever and mouth ulcers. These
problems interfere with feeding. Malnourished children are more likely to have severe complications
due to measles. This is especially true for children who are deficient in vitamin A. One in ten severely
malnourished children with measles may die. For this reason, it is very important to help the mother
to continue to feed her child during measles.
Assess Fever
A child has the main symptom fever if:
* the child has a history of fever or
* the child feels hot or
* the child has an axillary temperature of 37.5C or above
40
When the axillary temperature is taken: fever is 37.5C (99.5F), high fever is 38.5C (101.3F) or
more.
Decide the malaria risk (High/low or no).
If the malaria risk in the area is absent, ask the mother about travel:
Has the child traveled outside this area to a malarias area during the previous 30 days?
If she has traveled to a malarious area, decide the malaria risk as low or high depending on the level
of malaria risk of the visited area. If the area she had traveled is known to be malarious but not
specified as low or high then decide the area as high malaria risk.
Then assess a child with fever for:
 General danger signs

 How long the child has had fever
 History of measles
 Stiff neck
 Bulging fontanels (< 1 year of age)
 Look for signs suggest any bacterial cause of fever
 Runny nose
 Signs suggesting measles -- which are generalized rash and one of these: cough, runny nose, or
red eyes.
 If the child has measles now or within the last 3 months, assess for signs of measles
complications. They are: mouth ulcers, pus draining from the eye and clouding of the cornea.
A general danger sign is present if the child:
 is not able to drink or breastfeed

 vomits everything
 has had convulsions
 is convulsing now
 is lethargic or unconscious
41
When you check for general danger signs:
ASK: Is the child able to drink or breastfeed?
 A child has the sign "not able to drink or breastfeed" if the child is not able to suck or swallow
when offered a drink or breast milk.
ASK: Does the child vomit everything?
A child who vomits after each feed has the sign "vomits everything." What goes down
comes back. A child who vomits everything will not be able to hold down food, fluids or oral
drugs. A child who vomits several times but can hold down some fluids does not have this
general danger sign.
ASK: Has the child had convulsions?
Convulsions can be generalised or localized. Focal convulsions can present with twitching of
the fingers, the mouth or rolling of the eyes. Focal convulsions can easily be missed and
therefore needs to be carefully assessed.
LOOK: See if the child is convulsing now.
During a convulsion, the child's arms and legs stiffen because the muscles are contracting.
There may be drooling of saliva and rolling of the eyes upwards. The child may lose
consciousness. If the child is convulsing in the Health facility now, treat the child by managing
the airway and giving Diazepam, before completing the assessment.
LOOK: See if the child is lethargic or unconscious.
A lethargic child is abnormally sleepy and is difficult to awaken by calling and even by gentle
shaking. If he wakes up he immediately relapses into sleep. He is too weak to sustain an alert
state even under stimulation. Sometimes a lethargic child may stare blankly into space without
noticing what is going on around him.
An unconscious child may not respond to verbal or physical stimulus or may respond inappropriately.
However, ask the mother if the child seems unusually sleepy or if she cannot wake the child. Look
to see if the child wakens when the mother talks or shakes the child or when you clap your hands.
If malaria risk is high/low or there is history of travel to a malarious area, then do a blood film or
RDT if NO severe classification.
42
Microscopic test and RDTs are the methods employed for parasitological confirmation or malaria
classification. Laboratory evidence providing confirmation of malaria (i.e., microscopy or RDT) by
malaria species requires prompt treatment with the appropriate antimalarial medications. The
availability of multi-species RDTs is capable of specifically detecting both P. falciparum and P. vivax
and mixed infections. It also provides the opportunity to accurately identify parasite-negative patients
in whom another cause of fever (diagnosis) must be sought without delay. Patients who test negative
by malaria RDT or microscopy do not need antimalarial medications.
The box below lists the steps for assessing a child for fever. There are two parts to the box. The top
half of the box (above the broken line) describes how to assess the child for signs of malaria, measles,
meningitis and other causes of fever. The bottom half of the box describes how to assess the child
for signs of measles complications if the child has measles now or within the last 3 months.
Does the child have fever? (by history or feels hot temperature 37.5oC or above)
IF YES: Do blood film or RDT, if malaria risk is High/Low or
history of travel to a malarious area, AND there is no
• Decide Malaria Risk: High/Low or No .
Severe Classification.
If “ no” malaria risk, then ask:
• Has the child traveled outside this area during the previous 30 days?
• If yes has he been to a malarious area?
THEN ASK
LOOK AND FEEL:
Look or feel for stiff neck.
For how long has the child had
Look or feel for bulging fontanels (< 1 year of age)
fever?
Look for signs suggest any bacterial cause of fever
If more than 7 days, has fever
Look for runny nose.
been present every day?
Look for signs of MEASLES
Has the child had measles within
- Generalized rash, AND one of these: cough, runny
the last 3 months?
nose or red eyes.
Look for mouth ulcers:

If the child has measles now or - Are they deep or extensive?
within the last 3 months: - Are they not deep or extensive?
Look for pus draining from the eye.
Look for clouding of the cornea.
43
Ask about (or measure) fever in ALL sick children.
ASK: Does the child have fever?
Check to see if the child has a history of fever, feels hot or has a temperature of 37.5C or
above.
The child has a history of fever if the child has had any fever with this illness. Use words for
"fever" that the mother understands. Make sure the mother understands what fever is. For
example, ask the mother if the child's body has felt hot. Feel the child's abdomen or axilla and
determine if the child feels hot.
Look to see if the child's temperature was measured today and recorded on the child's chart. If
the child has a temperature of 37.5C or above, the child has fever. If the child's temperature
has not been measured, and you have a thermometer, measure the child's temperature.
If the child does not have fever (by history, doesn’t feel hot or temperature <37.5C), tick (√)
No on the Recording Form. Ask about the next main symptom, ear problem. Do not assess
the child for signs related to fever.
If the child has fever (by history, feels hot or temperature 37.5C or above), assess the child for
additional signs related to fever. Assess the child's fever even if the child does not have a
temperature of 37.5C or above or does not feel hot now. History of fever is enough to assess
the child for fever.
DECIDE Malaria Risk
Decide if there is malaria risk. In some areas, the malaria risk is always high. If the malaria
risk in the local area is low or absent, ask:
Has the child traveled outside this area to a malarious area during the previous 30 days?
Reclassify the malaria risk as high/low if there has been travel to a malarious area. The child
may have acquired malaria during travel.
Many mothers will know whether the area they have traveled to with the child has malaria
transmission. If she does not know or is not sure, ask about the area and use your own
44
knowledge of whether the area has falciparum malaria. If you are still not sure, assume the
malaria risk is high.
Circle the malaria risk (high/low) on the Recording Form.
You will use this information when you classify the child's fever.
ASK: For how long? If more than 7 days, has fever been present every day?
Ask the mother how long the child has had fever. If the fever has been present for more than 7
days, ask if the fever has been present every day.
Most fevers due to viral illnesses go away within a few days. A fever which has been present
every day for more than 7 days can mean that the child has a more severe disease such as
typhoid fever. Refer this child for further assessment.
ASK: Has the child had measles within the last 3 months?
Measles damages the child's immune system and leaves the child at risk for other infections for
many weeks.
A child with fever and a history of measles within the last 3 months may have an infection due
to complications of measles.
LOOK or FEEL for stiff neck.
A child with fever and stiff neck may have meningitis. A child with meningitis needs urgent
treatment with injectable antibiotics and referral to a hospital.
While you talk with the mother during the assessment, look to see if the child moves and bends
his neck easily as he looks around. If the child is moving and bending his neck, he does not
have a stiff neck.
If you did not see any movement, or if you are not sure, draw the child's attention to his
umbilicus or toes. For example, you can shine a flashlight on his toes or umbilicus or tickle his
toes to encourage the child to look down. Look to see if the child can bend his neck when he
looks down at his umbilicus or toes.
If you still have not seen the child bend his neck himself, ask the mother to help you lay the
child on his back. Lean over the child; gently support his back and shoulders with one hand.
45
With the other hand, hold his head. Then carefully bend the head forward toward his chest. If
the neck bends easily, the child does not have stiff neck. If the neck feels stiff and there is
resistance to bending, the child has a stiff neck. Often a child with a stiff neck will cry when
you try to bend the neck.
LOOK or FEEL for bulging fontanels (age < 12 months).
Hold the infant in an upright position. The infant must not be crying. Then look at and feel the
fontanels. If the fontanel is bulging rather than flat, this may mean the young infant has
meningitis.
LOOK for local tenderness; orals sores; refusal to use a limb; hot tender swelling; red tender skin or
boils; lower abdominal pain or pain on passing urine in older children
LOOK for runny nose.
A runny nose in a child with fever may mean that the child has a common cold.
If the child has a runny nose, ask the mother if the child has had a runny nose only with this
illness.
When malaria risk is low, a child with fever and a runny nose does not need an antimalarial.
This child's fever is probably due to the common cold.
LOOK for signs suggesting MEASLES.
Assess a child with fever to see if there are signs suggesting measles. Look for a generalized
rash and for one of the following signs: cough, runny nose, or red eyes.
Generalized rash
In measles, a red rash begins behind the ears and on the neck. It spreads to the face. During
the next day, the rash spreads to the rest of the body, arms and legs. After 4 to 5 days, the rash
starts to fade and the skin may peel. Some children with severe infection may have more rash
spread over more of the body. The rash becomes more discoloured (dark brown or blackish),
and there is more peeling of the skin.
Measles rash does not have vesicles (blisters) or pustules. The rash does not itch. Do not confuse
measles with other common childhood rashes such as chicken pox, scabies or heat rash. (The
46
chicken pox rash is a generalized rash with vesicles. Scabies occurs on the hands, feet, ankles,
elbows, buttocks and vesicles which itch. It also itches. Heat rash can be a generalized rash
with small bumps and vesicles which itch. A child with heat rash is not sick. You can recognize
measles more easily during times when other cases of measles are occurring in your
community.
Cough, Runny Nose, or Red Eyes
To classify a child as having measles, the child with fever must have a generalized rash AND
one of the following signs: cough, runny nose or red eyes. The child has "red eyes" if there is
redness in the white part of the eye in the absence of other causes.
If the child has MEASLES now or within the last 3 months:
Look to see if the child has mouth or eye complications. Other complications of measles such
as stridor in a calm child, pneumonia, and diarrhoea are assessed earlier; malnutrition and ear
infection are assessed later.
LOOK for mouth ulcers. Are they deep or extensive, or not deep or extensive?
Mouth ulcers are common complications of measles which interfere with the feeding of a sick
child. Look for mouth ulcers in every child with measles and determine whether they are deep
or extensive or a mouth ulcer which is not deep or extensive.
The mouth ulcers should be distinguished from Koplik spots. Koplik spots occur inside the
cheek during the early stages of measles infection. They are small irregular bright spots with a
white center. They do not interfere with feeding.
LOOK for pus draining from the eye.
Pus draining from the eye is a sign of conjunctivitis. If you do not see pus draining from the
eye, look for pus on the conjunctiva or on the eyelids.
Often the pus forms a crust when the child is sleeping and seals the eye shut. It can be gently
opened with clean hands. Wash your hands after examining the eye of any child with pus
draining from the eye.
47
LOOK for clouding of the cornea.
Look carefully for corneal clouding in every child with measles. Corneal clouding is a
dangerous complication. The corneal clouding may be due to Vitamin A deficiency which has
been made worse by measles. If the corneal clouding is not treated, the cornea can ulcerate and
cause blindness. A child with clouding of the cornea needs urgent referral and treatment with
Vitamin A.
If there is clouding of the cornea, ask the mother how long the clouding has been present. If
the mother is certain that clouding has been there for some time, ask if the clouding has already
been assessed and treated at the hospital. If it has, you do not need to refer this child again for
corneal clouding.
Classify Fever
If the child has fever and no signs of measles, classify the child for fever only.
If the child has signs of both fever and measles, classify the child for fever and for measles. There
are two fever classification tables on the ASSESS & CLASSIFY chart. One is for classifying fever
when the risk of malaria is high/low and the second for classifying fever when there is no malaria
risk. To classify fever, you must know if the malaria risk is high/low or no. Then you select the
appropriate classification table.
HIGH/LOW MALARIA RISK:
There are three possible classifications of fever when the malaria risk is high/low.
 VERY SEVERE FEBRILE DISEASE

 MALARIA
 FEVER: NO MALARIA
48
HIGH/LOW MALARIA RISK
SIGNS CLASSIFY TREATMENT (Urgent pre-referral treatments are in bold
print)
Any general danger VERY Give first dose Artesunate , arthemeter or Quinine for severe
sign, OR SEVERE malaria*
Stiff neck, OR FEBRILE Give first dose of IV/IM Ampicillin and Gentamycin
Bulging fontanels DISEASE Treat the child to prevent low blood sugar
(< 1yr) Give Paracetamol in health facility for high fever (≥38.5°C)
Refer or admit URGENTLY to hospital or health center
Positive blood Treat with Artemeter-Lumefantrine** for P. Falciparum or
film/RDT, OR MALARIA mixed or no confirmatory test done.
If blood film/RDT Treat with Chloroquine for confirmed P. vivax***.
not available, any Give Paracetamol in health facility for high fever (38.5°C or
fever above)
(by history, or feels Give an appropriate antibiotic for identified bacterial cause of
hot, or temp ≥ 37.5ºC fever
) Advise mother when to return immediately.
Follow-up in 2 days if fever persists.
If fever is present every day for more than 7 days, refer for
assessment
RDT negative, OR Give one dose of Paracetamol in health facility for high fever
Blood film negative FEVER: (≥38.5°C)
Other cause of fever N0 Give an appropriate antibiotic for identified bacterial cause of
present MALARIA fever
Advise mother when to return immediately Follow-up in 2
days if fever persists.
If fever is present every day for more than 7 days, refer for
assessment.
* IM Artemether is also an option in the absence of Artesunate for treatment of severe malaria
**Add single dose primaquine for children more than six months of age
*** Add radical cure with primaquine
49
VERY SEVERE FEBRILE DISEASE (High/Low Malaria Risk)
If the child with fever has any general danger sign or a stiff neck or bulging fontanel in less than one
year of age, classify the child as having VERY SEVERE FEBRILE DISEASE.
Fever Management/Treatment
A child with fever and any general danger sign or stiff neck or bulged fontanel (in less than one year
of age) may have meningitis, severe malaria (including cerebral malaria) or sepsis. It is not possible
to distinguish between these severe diseases without laboratory tests. A child classified as having
VERY SEVERE FEBRILE DISEASE needs urgent treatment and referral. Before referring urgently,
you will give several treatments for the possible severe diseases (Refer to Treat the Child module).
MALARIA (High/Low Malaria Risk)

If a general danger sign or stiff neck or bulged fontanel is not present, look at the yellow row.
Because the child has a fever (by history, feels hot, or temperature 37.5C or above) in a high malaria
risk area, classify the child as having MALARIA if RDT is positive.
When the risk of malaria is high/low, the chance is also high that the child's fever is due to malaria.
Treatment
If a child has fever, cough and fast breathing, the child may have malaria in addition to pneumonia.
It is not possible without laboratory tests to find out if the child has malaria. Therefore, the child
should be treated for malaria and pneumonia with Artemeter-Lumefantrine and Amoxicillin
respectively, if there is no RDT or blood film.
Most viral infections last less than a week. A fever that persists every day for more than 7 days may
be a sign of typhoid fever or other severe disease. If the child's fever has persisted every day for
more than 7 days, refer the child for additional assessment.
FEVER: NO MALARIA
In high/low risk malaria area and if blood film or RDT is negative for malaria, classify as having
FEVER: NO MALARIA. In many areas of the country health extension workers are deployed and
are treating malaria. They use RDT for malaria diagnosis.
50
FOR NO MALARIA RISK ONLY:
There are two possible classifications of fever in a child with No malaria risk:
VERY SEVERE FEBRILE DISEASE
FEVER
NO MALARIA RISK and No Travel to Malarious Area
 Any general VERY Give first dose of IV/IM Ampicillin and Gentamycin
danger sign, OR SEVERE Treat the child to prevent low blood sugar.
 Stiff neck, OR FEBRILE Give Paracetamol in health facility for high fever (≥38.5°C)
 Bulging DISEASE Refer URGENTLY to hospital
fontanels
(< 1 year of age)
 Any fever Give one dose of Paracetamol in health facility for high fever
FEVER (≥38.5°C)
Give an appropriate antibiotic for identified bacterial cause of
fever
Advise mother when to return immediately
Follow-up in 2 days if fever persists
If fever is present every day for more than 7 days refer for
assessment
VERY SEVERE FEBRILE DISEASE (No Malaria Risk)

If the child has any general danger sign, a stiff neck or bulging fontanel, and there is no malaria risk,
classify the child as having VERY SEVERE FEBRILE DISEASE.
Treatment
The treatment for a child classified as having VERY SEVERE FEBRILE DISEASE when there is
no malaria risk, is not the same as VERY SEVERE FEBRILE DISEASE in high/low malaria risk
area (see Section 5.2).
51
FEVER
If the child does not have any signs of VERY SEVERE FEBRILE DISEASE, look at the next row.
When there is NO MALARIA RISK, a child with fever and who has not traveled to a malarious area
should be classified as FEVER. The fever may be due to a problem included in another classification
– such as a cold, pneumonia, dysentery or ear infection. Or the fever may be due to another obvious
cause such as cellulitis or an abscess.
Treatment
If the child’s fever is high, give Paracetamol. Advise the mother to return for follow-up in 2 days if
fever persists. If the fever has been present every day for more than 7 days, refer for assessment
Classify Measles
A child who has the main symptom "fever" and measles now or within the last 3 months is classified
both for fever and for measles. First you must classify the child's fever. Next you classify measles.
If the child has no signs suggesting measles, or has not had measles within the last three months, do
not classify measles. Ask about the next main symptom, ear problem.
There are three possible classifications of measles:
 SEVERE COMPLICATED MEASLES

 MEASLES WITH EYE OR MOUTH COMPLICATIONS
 MEASLES
52
The table for classifying measles if present now or within the last 3 months is shown below.
Any general Give Vitamin A, first dose

danger sign, OR SEVERE Give first dose of IV/IM Ampicillin and Gentamycin
Clouding of
COMPLICATED If clouding of the cornea or pus draining from the eye,
cornea, or
Deep or extensive MEASLES *** apply Tetracycline eye ointment
mouth ulcers Refer URGENTLY to hospital
Pus draining from MEASLES Give Vitamin A, therapeutic dose
the eye or WITH If pus draining from the eye, treat eye infection with
Mouth ulcers (not
EYE OR MOUTH Tetracycline eye ointment If mouth ulcers, treat with
deep or extensive)
COMPLICATIONS gentian violet
*** Advise mother when to return immediately
Follow–up in 2 days
Measles now or MEASLES Give Vitamin A, therapeutic dose
within the last 3 Advise mother when to return immediately
months
SEVERE COMPLICATED MEASLES
If the child has any general danger sign, clouding of cornea or deep or extensive mouth ulcers,
classify the child as having SEVERE COMPLICATED MEASLES. This child needs urgent
treatment and referral to hospital.
Children with measles may have other serious complications of measles. These include stridor in a
calm child, severe pneumonia, severe dehydration, or severe malnutrition. You assess and classify
these signs in other parts of the assessment. Their treatments are appropriate for the child with
measles.
Treatment
Some complications are due to bacterial infections. Others are due to the measles virus which causes
damage to the respiratory and intestinal tracts. Vitamin A deficiency contributes to some of the
complications such as corneal ulcer. Any Vitamin A deficiency is made worse by the measles
infection. Measles complications can lead to severe disease and death.
53
All children with SEVERE COMPLICATED MEASLES should receive urgent treatment. Also
give the first dose of Vitamin A and an appropriate antibiotic and refer
If there is clouding of the cornea, or pus draining from the eye, apply eye ointment. If it is not treated,
corneal clouding can result in blindness. Ask the mother if the clouding has been present for some
time. Find out if it was assessed and treated at the hospital. If it was, you do not need to refer the
child again for this eye sign.
MEASLES WITH EYE OR MOUTH COMPLICATIONS

If the child has pus draining from the eye or mouth ulcers which are not deep or extensive, classify
the child as having MEASLES WITH EYE OR MOUTH COMPLICATIONS. A child with this
classification does not need referral.
You assess and classify the child for other complications of measles (pneumonia, diarrhoea, ear
infection and malnutrition) in other parts of this assessment. Their treatments are appropriate for the
child with measles.
Treatment
Identifying and treating measles complications early in the infection can prevent many deaths. These
children should be treated with Vitamin A. It will help correct any Vitamin A deficiency and decrease
the severity of the complications. The mother should be taught how to treat the child's eye infection
or mouth ulcers at home. Treating mouth ulcers helps the child to more quickly resume normal
feeding.
MEASLES
A child with measles now or within the last 3 months and with none of the complications listed in
the pink or yellow rows is classified as having MEASLES. Give the child therapeutic dose of Vitamin
A to help prevent measles complications. All children with measles should receive therapeutic dose
of Vitamin A.
54
Exercises
In this exercise, you will classify illness in children with signs of fever and, if present, signs
suggesting measles. First, you will study an example. Then you will begin the exercise.
Read the example case study that begins on this page. Also study how the health worker classified
this child's illness. When all the participants are ready, there will be a group discussion about this
example.
* * *
EXAMPLE: Pawlos is 10 months old male infant. He weighs 8.2 kg. His length is 71 cm. His
temperature is 37.5C. His mother says he has a rash and cough.
The health worker checked Pawlos for general danger signs. Pawlos was able to drink, was not
vomiting, did not have convulsions and was not convulsing, lethargic or unconscious.
The health worker next asked about Pawlos’s cough. The mother said Pawlos has been coughing for
5 days. He counted 43 breaths per minute. He did not see chest in drawing. He did not hear stridor
when Pawlos was calm.
Pawlos did not have diarrhoea.
Next the health worker asked about Pawlos’s fever. The malaria risk is high. The mother said Pawlos
has felt hot for 2 days. Pawlos did not have a stiff neck. He has had a runny nose with this illness,
his mother said.
Pawlos has a rash covering his whole body. Pawlos’s eyes were red. The health worker checked the
child for complications of measles. There were no mouth ulcers. There was no pus draining from
the eye and no clouding of the cornea. Blood film or RDT is not available in the health facility.
55
Here is how the health worker recorded Pawlos's case information and signs of illness.
MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS

Child’s Name: Pawlos Age 10 months Sex M Weight: 8.2kg Lt/Ht 71
cm Temp 37.5oC
ASK: What are the child’s problems? Rash and Cough Initial visit?  Follow-up visit? ____
ASSESS (Circle all signs present, tick or fill dashes/spaces)
CLASSIFY
CHECK FOR GENERAL DANGER SIGNS
NOT ABLE TO DRINK OR BREASTFEED
CONVULSING NOW
VOMITS EVERYTHING
LETHARGIC OR UNCONSCIOUS
History of CONVULSIONS
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?
Yes  No_____ Cough/cold
Count the breaths in 1 minute. 43
For how long? 5 Days breaths/minute. Fast breathing?
Look for chest indrawing.
Look and listen for stridor.
DOES THE CHILD HAVE DIARRHOEA? Yes ____ No 
Look at the child’s general condition. Is the
For how long? _________ Days child: Lethargic or unconscious? Restless &
irritable?
Is there blood in the stool? Look for sunken eyes.
Offer the child fluid. Is the child: Not able to
drink or drinking poorly? Drinking eagerly,
thirsty?
Pinch the skin of the abdomen. Does it go back:
Very slowly (> 2 seconds)? Slowly?
DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature ≥37.50C)
Yes  No____
56
- Decide MALARIA risk: Look or feel for stiff neck.
High/low No, Look for bulging fontanel
- If no” malaria risk, Has child Look for any other cause of fever Malaria
traveled to Look for runny nose
malarious area in the last 30 Look for signs of MEASLES NOW :
days? Generalized rash ,

- For how long has the child had And one of these: Cough, Runny nose
fever? 2 Days or Red eyes .
- If >7 days, has fever been
Blood Film or RDT: Positive____
present every day?
Negative____ Not Done 
- Has child had measles within the
last 3 months?
Look for mouth ulcers: If Yes, are they deep
If the child has measles now or and extensive? Measles
within the last 3 months: Look for pus draining from the eye.
2. To classify Pawlos's fever, the health worker looked at the table for classifying fever when there
is a High Malaria Risk.
a. He checked to see if Pawlos had any of the signs in the pink row. He thought, "Does Pawlos
have any general danger signs? No, he does not. Does Pawlos have a stiff neck? No, he
does not. Pawlos does not have any signs of VERY SEVERE FEBRILE DISEASE."
b. Next, the health worker looked at the yellow row. He thought, "Pawlos has a fever. His
temperature measures 37.5oC. He also has a history of fever because his mother says
Pawlos felt hot for 2 days. He classified Pawlos as having MALARIA."
c. Because Pawlos had a generalized rash and red eyes, Pawlos has signs suggesting measles.
To classify Pawlos's measles, the health worker looked at the classification table for
classifying measles.
d. He checked to see if Pawlos had any of the signs in the pink row. He thought, "Pawlos does
not have any general danger signs. The child does not have clouding of the cornea. There
57
are no deep or extensive mouth ulcers. Pawlos does not have SEVERE COMPLICATED
MEASLES."
e. Next the health worker looked at the yellow row. He thought, "Does Pawlos have any signs
in the yellow row? He does not have pus draining from the eye. There are no mouth ulcers.
Pawlos does not have MEASLES WITH EYE OR MOUTH COMPLICATIONS."
f. Finally the health worker looked at the green row. Pawlos has measles, but he has no signs
in the pink or yellow row. The health worker classified Pawlos as having MEASLES.
Now read the following case studies. Record each child's signs and their classifications on the
Recording Form. Remember to look at the chart to classify the signs.
Case 1: Abdi
Abdi is 3 years old male child. He weighs 9.4 kg. His height is 92 cm His temperature is 37C. His
mother says he feels hot. He also has a cough, she says. The health worker checked for general
danger signs. Abdi was able to drink, had not vomited, did not have convulsions, and was not
convulsing, lethargic or unconscious. The mother said Abdi had been coughing for 3 days. The
health worker counted 51 breaths a minute. He did not see chest in drawing. There was no stridor
when Abdi was calm. Abdi does not have diarrhoea.
The health worker also thought that Abdi felt hot. He assessed the child further for signs of fever.
The risk of malaria is high. He has felt hot for 5 days, the mother said. He has not had measles
within the last 3 months. He did not have a stiff neck; there was no runny nose, and no generalized
58
rash. RDT is found to be positive. Record the child's signs and classify them on the Recording Form
below.
Child’s Name: __________________________ Age______ months Sex _____ Weight: _____kg

Lt/Ht _______ cm Temp _____0C
ASK: What are the child’s problems? ______________________________________________ Initial
visit? _____ Follow-up visit? ____
CLASSIFY
CONVULSING NOW
VOMITS EVERYTHING
Yes _____ No_____
Count the breaths in 1 minute. ______

breaths/minute. Fast breathing?
For how long? ______ Days
DOES THE CHILD HAVE DIARRHOEA? Yes

_____ No____
Look at the child’s general condition. Is the child:

For how long? _________ Days Lethargic or unconscious? Restless and irritable?
Look for sunken eyes.
Is there blood in the stool? Offer the child fluid. Is the child: Not able to drink
or drinking poorly? Drinking eagerly, thirsty?
Yes___ No____
59
High/Low No, Look for bulging fontanel
- If “low or no” malaria risk, Has Look for runny nose
child traveled to malarious area Look for signs of MEASLES NOW : Generalized
in the last 30 days? rash,
- For how long has the child had And one of these: Cough, Runny nose or
fever? _ Days Red eyes.
-If >7 days, has fever been present Blood Film or RDT: Positive √__
every day? Negative___ Not Done ____
last 3 months?
Look for mouth ulcers: If Yes, are they deep and
If the child has measles now or extensive?
Case 2: Leya
Leya is 5 months old female infant. She weighs 5 kg. Her length is 55 cm. Her temperature is 36.5C.
Her family brought her to the Health facility because she feels hot and has had cough for 2 days. She
is able to drink. She has not vomited or had convulsions, and is not convulsing, lethargic or
unconscious.
The health worker said, "I am going to check her cough now." The health worker counted 43 breaths
per minute. There was no chest indrawing and no stridor when Leya was calm. Leya did not have
diarrhoea. "Now, I will check her fever," said the health worker. Leya lives in an area where many
cases of malaria occur all year long (high malaria risk). Her mother said, "Leya has felt hot on and
off for 2 days." She has not had measles within the last 3 months. She does not have stiff neck or
runny nose. Leya has a generalized rash. Her eyes are red. She has mouth ulcers. They are not deep
and extensive. She does not have pus draining from the eye. She does not have clouding of the
cornea. Neither blood film nor RDT is available at the health facility. Record the child's signs and
classify them on the Recording Form below.
60
Child’s Name: _____________ Age____ months Sex ____Weight: _____kg Lt/Ht _____ cm Temp
_____0C
ASK: What are the child’s problems? __________________________ Initial visit? _____ Follow-up
visit? ____
CLASSIFY
CONVULSING NOW
VOMITS EVERYTHING
Yes _____ No_____
For how long? ______ Days breaths/minute. Fast breathing?
DOES THE CHILD HAVE DIARRHOEA? Yes _____ No____
For how long? child:
_______Days Lethargic or unconscious? Restless and
irritable?
Offer the child fluid. Is the child:
Not able to drink or drinking poorly? Drinking
eagerly, thirsty?
Pinch the skin of the abdomen. Does it go
back:
DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature
≥37.50C) Yes___ No____
- If “low or no” malaria risk, Look for runny nose
Has child traveled to Look for signs of MEASLES NOW :
malarious area in the last 30 Generalized rash, And one of these:
61
days? Cough, Runny nose or Red eyes.
- For how long has the child Blood Film or RDT: Positive____
had fever? _____ Days Negative____ Not Done ____
- If >7 days, has fever been
present every day?
- Has child had measles
within the last 3
months?
If the child has measles now and extensive?
or Look for pus draining from the eye.
within the last 3 months: Look for clouding of the cornea.
Case 3: Sitti
Sitti is 12 months old female infant. She weighs 7.2 kg. Her length is 73 cm and her axillary
temperature is 36.5C. Her mother brought Sitti to the health centre today because she feels hot.
Sitti has no general danger signs. She does not have cough or difficult breathing. When asked about
diarrhoea, the mother said, "Yes, Sitti has had diarrhoea for 2 to 3 days." She has not seen any blood
in the stool. Sitti has not been lethargic or unconscious. Her eyes are not sunken. She drinks
normally. Her skin pinch returns immediately. The health worker said, "You brought Sitti today
because she feels hot. I will check her for fever." The risk of malaria is low. She has no recent
travel history. Her mother said that Sitti has felt hot for 2 days. She has not had measles within the
last 3 months. There is no stiff neck, no runny nose, and no generalized rash. She has no other cause
of fever. RDT is negative.
Record the child's signs and classify them on the Recording Form below.
62
Child’s Name: _____________________Age______ months Sex _____ Weight: _____kg
Lt/Ht _______ cm Temp _____0C
ASK: What are the child’s problems? ____________________________________________Initial
CLASSIFY
CONVULSING NOW
VOMITS EVERYTHING LETHARGIC OR
UNCONSCIOUS History of CONVULSIONS
Yes _____ No_____
For how long? _________ child:
Days Lethargic or unconscious? Restless and
irritable?
Not able to drink or drinking poorly?
Drinking eagerly, thirsty?
back:
Very slowly (> 2 seconds)?
Slowly?
DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature
≥37.50C) Yes___ No____
- If “low or no” malaria risk, Look for runny nose
Has child traveled to Look for signs of MEASLES NOW :
malarious area in the last 30 Generalized rash,
days? And one of these: Cough, Runny
63
- For how long has the child nose or Red eyes.
had fever? _____ Days Blood Film or RDT: Positive____
- If >7 days, has fever been Negative____ Not Done ____
present every day?
- Has child had measles
within the last 3 months?
If the child has measles now and extensive?
or Look for pus draining from the eye.
within the last 3 months: Look for clouding of the cornea.
Case 4: Lemlem
Lemlem is 3 years old female child. She weighs 10 kg. Her height is 91 cm. Her axillary temperature
is 38C. Her mother brought her to the health centre because she has a cough. She also has a rash.
The health worker checked for general danger signs. She was able to drink, she had not been
vomiting everything, and she did not have convulsions. She was not convulsing, lethargic or
unconscious. The health worker assessed Lemlem's cough. The mother told the health worker
Lemlem had been coughing for 2 days. The health worker counted 42 breaths per minute. The health
worker did not see chest indrawing. He did not hear stridor when Lemlem was calm. When the health
worker asked if Lemlem had diarrhoea, the mother said, "No." Blood film was negative. Next the
health worker assessed Lemlem's fever. It is the dry season and the risk of malaria is low. She has
no recent travel history. She has felt hot for 3 days, the mother said. She does not have stiff neck.
Health worker identified a hot tender swelling on the right arm. She does not have a runny nose.
Lemlem has a generalized rash. Her eyes are red. She does not have mouth ulcers. Pus is not
draining from the eye. There is no clouding of the cornea. Record the child's signs and classify them
on the Recording Form below.
64
Child’s Name: __________Age___ months Sex ___Weight: ___kg Lt/Ht __ cm Temp ___0C
ASK: What are the child’s problems? __________________Initial visit? _____ Follow-up visit? ____
CLASSIFY
CONVULSING NOW
VOMITS EVERYTHING
Yes _____ No_____
Count the breaths in 1 minute. _____
For how long? _________ Days child:
Lethargic or unconscious? Restless &
Is there blood in the stool? irritable?
Not able to drink or drinking poorly?
Drinking eagerly, thirsty?
back:
Yes___ No____
child traveled to malarious area in Look for signs of MEASLES NOW:
the last 30 days? Generalized rash, And one of these:
- For how long has the child had Cough, Runny nose or Red eyes.
fever? ____ Days Blood Film or RDT
- If >7 days, has fever been present Positive____ Negative____ Not Done ____
every day?
65
last 3 months?

If the child has measles now or and extensive?
Classify all Sick Young Infants for Very Severe Disease

Classify all sick young infants for bacterial infection. Compare the infant's signs to signs listed and
choose the appropriate classification. If the infant has any sign in the top row, select VERY SEVERE
DISEASE.
Here is the classification table for very severe disease.
SIGNS CLASSIFY TREATMENT*

AS (Urgent pre-referral treatments are in bold
print)
Not feeding well, OR  Give first dose of intramuscular
History of VERY Ampicillin and Gentamycin
Convulsions/convulsing now, SEVERE  Treat to prevent low blood sugar
OR DISEASE  Warm the young infant by skin-to-skin
Fast breathing (≥60 breaths per contact if temperature is less than 36.5°C
minute), OR (or feels cold to touch) while arranging
Severe chest indrawing, OR referral
Fever (≥37.5°C* or feels  Advise mother how to keep the young
hot), OR infant warm on the way to the hospital
Low body temperature (<  Refer URGENTLY to hospital
35.5°C* or feels cold), OR
Movement only when
stimulated or no movement
even when stimulated.
* consider malaria if the neonate lives in malaria risk area
66
LEARNING UNIT FIVE
Fever in Adults
Learning objectives
At the end of this training, participants will be able:
 Define acute fever

 List possible causes of fever
 List common reported caused of fever in Ethiopia
 Describe clinical approach (History, physical examination and investigation) to a patient with
acute febrile illness
 List differential diagnosis of acute febrile illnesses
 Outline management principles of acute febrile illnesses
Definition
Acute fever is defined as a report of recent fever (<2 weeks) of elevated axillary temperature
(>37.5°C). Acute fever can have different patterns although it may not strongly correlate with
specific diagnosis. The pattern may not also be observed due to treatment with antipyretics. Pattern
of acute fever can be
 Acute: for a short time (less than 2 weeks)
 Chronic: fever persisting for more than two weeks
 Intermittent: falls to normal in regular periodical intervals.
 Remittent: temperature always elevated but swings may be large
 Relapsing: short febrile periods between one or several days of normal temperature
When the result of a malaria test (RDT or microscopy) is positive for a patient with fever, the
episode is considered to be malaria. When the result is negative, the fever is considered not to be
due to malaria and is sometimes referred to as ‘non-malaria febrile illnesses’.
These definitions are suitable for the clinical management of patients and hence decisions on
treatment. The national malaria guideline recommends that all patients with a positive malaria test
result should be treated with an antimalarial medicine, while those with a negative result do not
require such treatment. From the clinical point of view, all patients should be fully assessed, as they
67
may have more than one disease (e.g. malaria and pneumonia) and would require more than one
treatment.
Health workers face the challenge to manage non malaria acute febrile illnesses when
parasitological diagnosis is negative. To improve the compliance of health workers with malaria
test results, guidance is needed on managing non-malaria febrile illness, especially in peripheral
health care facilities. Improving the management of fever not only reduces unnecessary use of
antimalarial drugs, but also ensures appropriate treatment and referral of patients with non-malaria
febrile illness, thus reducing morbidity and mortality.
Causes of fever
The causes of fever can vary according to geography, season, the age and immunity of the patient
and the level of care (outpatient, inpatient, ICU…). There is a wide spectrum of diseases that can
cause fever which can be minor like upper respiratory tract infection or serious and life threatening
like pyogenic meningitis. Priority should be given to identify the cause of the fever before
instituting specific treatment.
The most common cause of fever is infection. Infection may be due to organisms such as viruses,
bacteria, fungi or parasites. Fever may also be due to inflammatory processes in the body. Common
and important conditions that are associated with fever, and their causative agents, include the
following.
 Infections
- Viral infections
 Main clinical manifestations: tonsillitis, laryngitis, pharyngitis, tracheitis,
laryngotracheobronchitis (LTB or croup), bronchitis, bronchiolitis, pneumonia.
 Main viral agents: measles, mumps, chicken pox, varicella-zoster virus, hemorrhagic fevers
(e.g. Ebola, Dengue, yellow fever), rhinovirus, influenza virus, HIV, hepatitis virus (HAV,
HBV, HCV).
- Bacterial infections
 Main clinical manifestations: tonsillitis, otitis media, sinusitis, dental abscess, pneumonia,
urinary tract infection, pelvic inflammatory disease (PID), cellulitis, septic arthritis,
osteomyelitis, meningitis, secondary syphilis, typhoid (enteric fever), relapsing fever
 Main bacterial agents: group A β-hemolytic streptococci, Streptococcus pneumoniae,
Mycobacterium tuberculosis, Haemophilus influenzae, Staphylococcus aureus, Mycoplasma
68
pneumoniae, Klebsiella pneumoniae, Escherichia coli, Neisseria meningitidis, Treponema
pallidum, Salmonella typhi, Salmonella paratyphi, Shigella spp., Borrelia recurrentis.
- Rickettsial infections
 Louse borne typhus fever
- Fungal infections
 Cryptococcal meningitis
- Protozoan infections
 Malaria, leishmaniasis, amebic liver abcess
- Helminthic infections
 Schistosomiasis,
 Noninfectious causes of fever: consider these after ruling out common infectious causes in the
appropriate clinical situation
- Inflammatory diseases: rheumatoid arthritis, auto-immune diseases.
- Malignancy: lymphoma, acute leukemia.
- Injury: crushing injury.
- Thrombosis: pulmonary embolus, myocardial infarction (heart attack).
- Drug reactions.
- Allergic reaction.
Globally there are very few studies that describe the pattern of diseases that cause fever in adults.
In studies in northern United Republic of Tanzania (inpatients), Cambodia and the Lao People’s
Democratic Republic (outpatients) of non-malaria causes of fever (patients with ARI or other
clinically documented local infections included), Leptospira was found in 10%, 13% and 12% of
patients, dengue in 0%, 7% and 25%, typhus group rickettsioses in 1%, < 1% and 25%, spotted
fever rickettsioses in 9%, 0% and 0%, and scrub typhus in 0%, 4% and 26%, respectively. In the
United Republic of Tanzania, 8% of patients had Q fever, 5% brucellosis and 6% chikungunya
Principles of evaluation of a patient with fever

The following principles are important while examining a patient with fever.
 Observe the general condition of the patient, take vital signs and ask targeted questions to
determine if there is any life threatening condition. Respiratory distress (use of accessory
muscles, grunting, nasal flaring), very weak/unable to stand, lethargy, decreased level of
consciousness, convulsions, severe abdominal pain and deranged vital signs (hypotension,
69
rapid pulse or respiratory rate) indicate possibility of severe disease like severe malaria, severe
pneumonia, pyogenic meningitis or sepsis. Such patients will require urgent lifesaving
treatments.
 After ruling out the possibility of severe life threatening conditions (or initiating lifesaving
managements for patients with severe disease), the next step is to determine if the patient has
focus of infection by thorough history and targeted physical examination. Focus of infection is
the organ or system which is affected by the infection and is believed to be the source/cause of
the fever. For example the lungs are the focus of infection in a patient with pneumonia.
 In addition consider causes of acute febrile illnesses based on the epidemiology. Consider to
test for malaria if the patient has malaria risk (lives in malarious area or has travel history to
malarious area in the previous one month); typhus or relapsing fever if the patient has poor
hygiene and visible body lice; typhoid fever if there is possible oro-fecal contamination;
dengue or yellow fever or chikungunya or leishmaniasis if there is a risk (living in at risk areas
or travel history). It is also good to consider possible exposure to certain pathogens e.g. contact
to patients in meningitis, measles, chicken pox and dog or animal bite in rabies.
 Give attention to underlying conditions like HIV, diabetes, chronic respiratory or cardiac
diseases, malignancies and malnutrition
 Unless the patient is in critical condition demanding emergency and empirical treatment, it is
good to take the time to confirm the underlying cause of fever before initiating specific
treatment.
 Patients should be followed to document response or detect complications after initiating
treatment.
 Consider reporting to health program managers as most conditions causing acute febrile
illnesses are reportable.
70
Clinical evaluation
History: the purpose of history taking is to
- Obtain a professional rapport with the patient and gain his confidence.
- Obtain all relevant information which allows assessment of the illness,

and provisional diagnoses.
- Obtain general information regarding the patient, his background, social
situation and problems. In particular it is necessary to find out how the
illness has affected him, his family, friends, colleagues and his life.
- Understand the patient’s own ideas about his problems, his major
concerns and what he expects from the hospital admission, outpatient or
general practice consultation.
Good communication skills are important to enable patients tell their stories with confidence,
without fear or lie. Patients will most probably accept the recommendations of the health worker
with regard to laboratory tests (e.g. if they don’t require widal or weil felix tests), treatments (e.g. if
they don’t require antimalarial for negative malaria test; antibiotics for common cold) or behavior
change advices (e.g. adherence to treatment). The following points highlight some good practices
with regard to good communication
 Sit so that your head is in level with your client
 Maintain eye contact and pay attention
 Don’t take note while talking to your client
 Don’t act hurried
 Use open and closed ended questions, don’t use leading questions
- How are you feeling today? (open ended question)
- Do you have fever? (closed ended question)
- Are you taking your medicine properly? You are better today, aren’t you?
(leading questions)
 Show gestures that show interest like nodding
 Reflect back what the client says
 Avoid using judging (blaming) words
 Empathize, show that you understand how the client feels
 Listen carefully the patient, don’t interrupt frequently
71
Identifying data (age, sex, occupation, and marital status) may help to consider some clinical
conditions. For example malaria tends to be severe in children under five and pregnant women; a
health worker may acquire relapsing fever from his/her patient.
Describe the chief and associated complaints of the patient according to onset, course, severity,
timing, relation with meals, effect on sleep and normal daily activities and body location of the
symptom.
There are group of symptoms that point to dysfunction to a certain system. For example cough, chest
pain, shortness of breathing may indicate disease of respiratory or cardiovascular system. Urgency,
frequency, dysuria and flank pain indicate disease of urinary system. Seizure, altered consciousness,
paralysis, numbness or loss of sensation indicates disease of nervous system. The presence of
symptoms that point to dysfunction of a certain system may suggest focus of infection.
Important features of the history

 duration of fever (less than or more than 7 days)
 exposure to locally endemic diseases
- consider the local geographical distribution of diseases, e.g. malaria,
dengue, leishmaniasis
- consider outbreaks of specific infections, e.g. malaria, meningitis
- consider seasonal variation of diseases
 recent exposure history
- ask about recent travel – consider diseases that are common in the area
that was visited
- contact with animals and birds (brucellosis, rabies, Q fever)
- known TB contact
- recent unprotected sex (acute HIV syndrome, syphilis)
- intravenous drug use
 co-morbidities
- consider infections that a patient may be predisposed to as a result of
comorbidities such as diabetes, HIV, chronic respiratory, cardiac or
kidney diseases, cancer, malnutrition
- medical history of recent illness and the possibility of incompletely
treated disease or drug resistance, e.g. malaria, typhoid, TB;
72
- current medications;
- consider drug reactions if the patient has recently initiated a new
medication known to commonly cause drug reactions, e.g. cotrimoxazole,
ART (especially nevirapine or abacavir), TB medication.
Physical examination
All patients with fever should be examined, even if they don’t report symptoms of local infection.
Examine the patient thoroughly paying attention to sites of possible infection:
 general examination
- monitor temperature (might be normal at that particular moment)
- assess for confusion or decreased level of consciousness
- assess hydration, count heart rate and respiratory rate
- look for pallor, jaundice, lymphadenopathy, nail abnormalities (splinter
hemorrhages)
- skin lesions, including rash
- insect or animal bites
- nutritional status (wasting)
 head and neck
- neck pain or stiffness
- throat, tonsils, ears for inflammation and discharge
- sinus tenderness
- mouth (ulcers or lesions)
 chest and precordium
- difficult breathing, fast breathing
- crackles, bronchial breathing, absent breath sounds
- new heart murmur, change in old murmur
 abdominal or genitourinary:
- enlarged liver or spleen
- abdominal tenderness or mass
- pain over kidneys (flank pain)
- pelvic tenderness or mass
- rectal and vaginal examination for pain, discharge, ulcers, mass
73
 muscles and joints
- red, hot, swollen, painful joint(s) with reduced mobility
- Swollen, painful limb (deep venous thrombosis, cellulitis).
 Nervous system
- Level of consciousness
- Meningeal signs,
- Paralysis
If there is evidence of focal infection like pneumonia or UTI treat the patient as per the national
standard treatment guideline.
Laboratory investigations
Laboratory tests are complementary to history and physical investigation to make appropriate
diagnosis. They should be interpreted in line with the clinical presentation; e.g. reactive widal test
does not indicate typhoid if the patient does not have fever.
For all patients, consider

 Malaria test (if the patient fulfils clinical criteria)
 Urinalysis
 Hemoglobin and WBC count
Additional tests, as indicated (see Differential Diagnosis tables in next Section):
 full blood count with differential white cell count
 blood smear for louse-borne relapsing fever (Borrellia recurrentis), in endemic areas
 liver function tests
 chest X-ray
 sputum for microscopy, acid fast bacilli, and sometimes culture
 urine culture
 lumbar puncture
 bone marrow, lymph node, or splenic aspirate for microscopy (leishmaniasis)
 serum or whole blood for rapid test
 stool microscopy (antibiotics should not be given for the mere presence of “many bacteria”)
 stool culture
74
 ultrasound
 Blood cultures.
Widal and weil felix tests are not recommended as per the existing scientific literature due to their
lack of sensitivity and specificity. However these tests are still widely used in Ethiopia. These tests
may be relevant under the following conditions
 The patient should have clinical features of typhus or typhoid (almost all patients with typhoid
or typhus have fever)
 Tube titration (not slide agglutination) should be done
 Interpretation should be based on demonstration of four fold increase in antibody level after 7-
10 days of first test; or single test which is above local cut-off value for that particular location.
The limitation of using cut-off values is; usually these values are not available, and they vary
with time in the same place and from place to place
 At the moment there is no good laboratory test for typhus and blood culture where available
should be considered for typhoid
Consider likely differential diagnosis using Differential Diagnosis tables

Classify the fever according to its duration and symptoms or signs found on examination and
laboratory investigations:
 fever with obvious focus of infection – treat accordingly as per the national standard treatment
guidelines
 fever 7 days or less without clinically obvious focus (use the first Differential Diagnosis table
below)
 fever more than 7 days (use the second Differential Diagnosis table below)
 For the severely ill patient – refer to severe malaria section.
Table 13 Differential Diagnosis: Fever 7 days or less without clinically obvious focus or site
Condition In favor
Malaria Living in, or travelled to malaria endemic area
Positive malaria test (RDT or microscopy)
Typhoid fever Remittent fever
Malaria ruled out
No focus of infection
75
Condition In favor
Risk factor for typhoid (poor hygiene)
Louse borne typhus fever High grade intermittent fever
Poor hygiene, may have visible body lice
Malaria and relapsing fever ruled out
Usually occur as epidemic
Bacterial sepsis Seriously ill with no obvious apparent cause
Hypotension
Complete blood count (CBC) – leucocytosis, leucopoenia, or
thrombocytopenia
Risk factors – HIV, immunocompromised
Blood cultures – positive
Any sign of organ dysfunction – confusion, low urine output,
respiratory depression
Blood chemistry if available – acidosis, elevated creatinine
Meningococcal septicemia Maculopapular hemorrhagic petechial rash
Shock, hypotension
Dengue fever History of travel to endemic area or local outbreak (e.g. Somali,
Dire Dawa or Afar regions)
Positive dengue RDT for non-structural protein 1 (NS1) or IgM
Headache, pain behind the eyes
Backache, arthralgia, myalgia
Fine macular rash, petechiae
CBC – leukopenia, thrombocytopenia
In severe cases:
 signs of plasma leakage, shock
 severe bleeding, e.g. from GI or orifices, dark urine
 organ failure
Chikungunya Resembles non-severe dengue fever
Severe joint pains with fever and rash
No simple test available to confirm the diagnosis (PCR available at
EPHI)
76
Condition In favor
Influenza Sudden onset of fever and cough
Sometimes rhinitis or sore throat
Frequent systemic symptoms (headache, arthralgia, or myalgia)
Local epidemics, or history of travel to epidemic areas
Close contact with a person with a similar illness, or contact with
person from
epidemic area with influenza
Yellow fever History of travel to endemic area or local outbreak (Gambella,
South Omo)
Sudden onset of acute fever and rigors
Headache, backache, bone pains
Followed by jaundice within 2 weeks
Primary HIV Lymphadenopathy
Rash, pharyngitis
History of unprotected sexual contact in the last 3 months
HIV rapid test may be negative
Drug induced fever New drug initiated days or weeks prior
Associated rash
Patient on drugs – ART (NVP, ABC, EFV) , cotrimoxazole,
dapsone, B-lactams, INH, anticonvulsants
Measles in adolescents and Conjunctivitis, coryza, and cough
adults Koplik’s spots on buccal mucosa (“grains of salt on a red
background”)
Maculopapular, blanching rash
Lymphadenopathy
Complications include:
• respiratory tract infection (pneumonia, tracheobronchitis,
bronchiolitis)
• encephalitis (acute and chronic)
• keratitis
77
Condition In favor
Relapsing fever Recurrent fever
Spread from person-to-person among louse-infested populations
(e.g. prisons, refugee camps, street children, war, or famines with
overcrowded populations with poor personal hygiene)
Rash, often petechial
Jaundice, impaired liver function
Spirochetes on Giemsa-stained thick or thin blood fi lm,
Jarisch-Herxheimer reaction (fever, rigors, hypotension within 2
hours of antibiotic administration)
Acute schistosomiasis Exposure to fresh water in an endemic area (with sometimes skin
(Katayama fever) itch just after exposure)
Between 2 and 12 weeks after infection
CBC – eosinophilia
Table 14: Differential Diagnosis: Fever more than 7 days without clinically obvious focus or
site
Condition In favor
Malaria Living in, or travelled to malaria endemic area
Positive malaria test (RDT or microscopy)
Typhoid fever Remittent fever
Malaria ruled out
No focus of infection
Risk factor for typhoid (poor hygiene)
Tuberculosis Loss of weight, night sweats, fever, malaise
Cough >2 weeks
Signs of extrapulmonary disease – e.g. lymphadenopathy, pallor,
abdominal pain
Common complication of HIV
Osteomyelitis Limb pain, tenderness and swelling
Contiguous skin infection or chronic ulcer
78
Condition In favor
X-ray showing periosteal reaction or bone destruction (after 2 to 4
weeks)
Endocarditis Low grade fever, night sweats
New heart murmur (or change in old heart murmur)
Signs of embolic disease (stroke, petechiae, splinter hemorrhage)
Splenomegaly
Risk factors: known cardiac valvular disease
Liver abscess Right upper quadrant pain or tenderness
Liver focal lesion at ultrasound
Yellow fever History of travel to endemic area or local outbreak (Gambella,
South omo)
Sudden onset of acute fever and rigors
Headache, backache, bone pains
Followed by jaundice within 2 weeks
Lymphoma Weight loss, night sweats
Enlarged lymph nodes, hepatosplenomegaly
Visceral leishmaniasis Endemic area
Fever, wasting syndrome, pallor of mucous membranes
Generalized lymphadenopathy
Splenomegaly, darkening of skin
79
Approach to diagnosis of acute fever in adults
Acute Fever Box 1: Associated symptoms

Fever/history of fever, or axillary temperature ≥37.5°C
-Pain during swallowing
(Tonsillitis/pharyngitis)
Life Threatening conditions present?
-Ear pain discharge (Otitis media)
Decreased level of consciousness, convulsion
weak/unable to stand or walk, lethargy, respiratory -Jaundice and right upper quadrant
distress, severe abdominal pain and deranged vital signs pain(Hepatitis)
-Runny nose and sneezing(URTI)

Yes No
-Cough, chest pain, shortness of
breath(Pneumonia)
ABC of Life Take

-Consider detailed Tips for Diagnosis Treat the patient
causes of history
very severe Malaria (Fever in Treat the underlying
Characterize malarious area or travel to problem
febrile
fever such place in the past 1
diseases like
severe Ask and month and blood film
malaria, characterize showing plasmodium
species) Advice the patient
pyogenic associated
meningitis, symptoms Typhoid fever (Fever Tell the diagnosis, the
and severe (See Box 1) persisting for more than cause, treatment and
pneumonia three days, no focus of prevention, adherence
infection and blood film
negative for
Do Targeted hemoparasites)
Physical
Examination Typhus fever (Fever,
Follow the patient
overcrowding, /visible
body lice and blood film Tell to come back if not
Order Laboratory Tests negative responding as expected
Blood film, WBC, Relapsing fever (fever, Tell to come back if

differential, Hgb, PITC overcrowding/ visible body condition worsens
lice and blood film showing anytime
Other tests based on Borellia)
clinical presentation
Figure 13: Approach to Diagnosis of Acute Fever in Adults
80
Management of fever Principles
1. As much as possible try to make specific diagnosis (with initial and subsequent
evaluations if the patient doesn’t have life threatening condition)
2. Definitive treatment (the underlying disease with specific treatment)
3. Symptomatic treatment of fever pain and dehydration
4. Educate the patient about the diagnosis, adherence to treatment, expected side effects,
when to return (if fever does not improve or comes back after treatment; if the fever is
accompanied by a cough, diarrhea, severe pain, confusion, stiff neck or change in
consciousness)
5. Ensure adequate follow up
Some often-missed sites that may cause fever include:
 dental abscesses
 sinusitis – percuss face and forehead
 endocarditis – auscultate for murmur, if possible perform blood cultures
 urinary tract infection
 prostatitis and pelvic inflammatory disease
 intra-abdominal, retroperitoneal, or paraspinal abscess
 cholangitis, liver abscess
 deep venous thrombosis – examine for lower limb swelling
 malignancy – check for breast lumps, cervical nodes, splenomegaly, hepatomegaly, prostate
abnormalities
 connective tissue diseases (e.g. lupus, rheumatoid arthritis)
 fever due to medications
 pus that cannot drain (after trauma)
81
Exercises: Group Work
 A 28 year old female Bank manager living in malaria endemic area came to you with fever of
two days duration. She has arthralgia and myalgia. She had two episodes of vomiting.
- What additional information will you ask her?
- Physical examination showed, acutely sick looking woman, To=39.3oC,
left side costo vertebral angle tenderness. No other abnormal finding
 What is your differential diagnosis
 What laboratory test will you order? And what do you expect?
 What is the treatment for your most likely diagnosis?
 A 20 year old man living in a malaria endemic area presents with a 1 week history of fever,
headache, abdominal pain and constipation. He has a high temperature (39°C) and his spleen is
palpable. He says the fever is worsening over time.
- What additional information will you ask him?
- What causes do you think of?
- What laboratory tests will you order?
- Write the complications for your first differential diagnosis
 A thirty year old man visited a health center because he had fever for three days. He lives in
Addis Ababa. He gives history of travel to malaria endemic area three weeks back.
- What additional history and physical examination will you check?
- If blood film shows P.falciparum ring stage, outline the steps in the
management of this patient
 A 22 year old male patient presented with high grade fever, head ache and vomiting of four
days. On physical examination he is restless and talks irrelevant words. You find that he has
stiff neck. History is obtained from his father.
- What additional history will you ask?
- How do you treat him?
82
LEARNING UNIT SIX
Severe Malaria
Learning objectives
By the end of this training, participants should be able to:
 Define severe malaria

 Discuss the host-parasite interaction that contributes to the pathogenesis of severe malaria
 List the determinants of severe malaria and identify groups at high risk
 Make a diagnosis of severe falciparum malaria
 Describe the recommended antimalarial chemotherapeutic regimens for severe malaria
 Specify the emergency and supportive measures and follow-up guidance for malaria patients
with different types of complications
Diagnosis of Severe Malaria

Characteristics of severe falciparum malaria
Definitions
Severe falciparum malaria: For epidemiological purposes, severe falciparum malaria is defined as one or
more of the following, occurring in the absence of an identified alternative cause and in the presence of P.
falciparum asexual parasitaemia.
 Impaired consciousness: A Glasgow coma score < 11 in adults or a Blantyre coma score < 3 in children
 Prostration: Generalized weakness so that the person is unable to sit, stand or walk without assistance
 Multiple convulsions: More than two episodes within 24 h
 Acidosis: A base deficit of > 8 mEq/L or, if not available, a plasma bicarbonate level of < 15 mmol/L
or venous plasma lactate ≥ 5 mmol/L. Severe acidosis manifests clinically as respiratory distress
(rapid, deep, laboured breathing).
 Hypoglycaemia: Blood or plasma glucose < 2.2 mmol/L (< 40 mg/dL
 Severe malarial anaemia: Haemoglobin concentration ≤ 5 g/ dL or a haematocrit of ≤ 15% in children

< 12 years of age (< 7 g/dL and < 20%, respectively, in adults) with a parasite count > 10 000/µL
 Renal impairment: Plasma or serum creatinine > 265 µmol/L (3 mg/dL) or blood urea > 20 mmol/L
 Jaundice: Plasma or serum bilirubin > 50 µmol/L (3 mg/dL) with a parasite count > 100 000/ µL
83
 Pulmonary oedema: Radiologically confirmed or oxygen saturation < 92% on room air with a
respiratory rate > 30/ min, often with chest indrawing and crepitations on auscultation
 Significant bleeding: Including recurrent or prolonged bleeding from the nose, gums or venepuncture
sites; haematemesis or melaena
 Shock: Compensated shock is defined as capillary refill ≥ 3 s or temperature gradient on leg (mid to
proximal limb), but no hypotension. Decompensated shock is defined as systolic blood pressure < 70
mm Hg in children or < 80 mmHg in adults, with evidence of impaired perfusion (cool peripheries or
prolonged capillary refill).
 Hyperparasitaemia: P. falciparum parasitaemia > 2%
*Severe vivax and knowlesi malaria: defined as for falciparum malaria but with no parasite density
thresholds.
Table 15: Glasgow Coma Scale
Parameter Response Score

Eye opens Spontaneously 4
To speech 3
To pain 2
Never 1
Best verbal response Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
Best motor response Obeys command 6
Localizes pain 5
Withdrawal from pain 4
Flexion to pain 3
Extension to pain 2
None 1
Total score 3-15
84
A state of unarousable coma is reached at a score of <11. This scale can be used repeatedly to assess
improvement or deterioration.
Table 16: The Blantayers Coma Scale (for children)
Parameter Response Score
Eye movements Directed (e.g. follows mother’s face) 1
Not directed 0
Best verbal response Appropriate cry 2
Moan or inappropriate cry 1
None 0
Best motor response Localizes painful stimulus (rub knuckles on patient’s 2

sternum or firm pressure on thumbnail bed with horizontal
pencil)
Withdraws limb from pain 1
Nonspecific or absent response 0
Total score 0 -5
A state of unarousable coma is reached at a score of <3. This scale can be used repeatedly to assess
improvement or deterioration.
Note that:
 Each of the individual clinical features is important for the diagnosis of severe malaria;
 An individual patient may have any single complication or any combination of the complications
listed above;
 A patient with one or more of the complications may go on to develop others;
 Other possible diagnoses in such a patient must be carefully considered.
85
Risk groups for severe falciparum malaria
Any infection with P. falciparum can become severe if treatment is delayed or inadequate. However,
people who have been repeatedly exposed to falciparum malaria develop partial immunity and are
less likely to experience severe falciparum malaria.
Those most at risk are:
 People of all ages in areas of low endemicity (like most malaria endemic places in Ethiopia)
 Residents of areas where there is little or no falciparum malaria who travel to a high transmission
area: this may involve travel within a single country or between countries;
 Non-immune pregnant women (at risk of some specific complications);
 Internally-displaced persons moving from an area of low transmission to an area of high

transmission;
 Children in areas of high endemicity – especially those aged from 6 months to 5 years;
 People returning to highly endemic areas after a few years’ residence in area with little or no
falciparum malaria;
 Patients who have had a splenectomy.
Diagnosis of severe falciparum malaria
A correct diagnosis should be based upon a complete case history, a physical examination, and
laboratory investigations.
Both thick and thin blood films should be examined at health center or hospital level to demonstrate
the presence of P. falciparum asexual parasites.
However, it is important to note that:
 Waiting for a blood smear result must not be allowed to delay the start of treatment unduly: if
clinical features strongly suggest severe falciparum malaria, treatment may be started before the
results are available.
 Occasionally blood films may be negative even though the patient is suffering from severe
falciparum malaria. Following a negative result, blood films should be repeated, e.g. every 6
hours. Parenteral Artesunate may be initiated in such patients.
86
 A positive blood film does not prove that severe falciparum malaria is the only cause of the
severe illness. Other possible causes should also be considered.
Pathophysiology of severe falciparum malaria
Mechanism of malaria disease
The possible effects of malarial infection cover an enormous range, from completely asymptomatic
infection to severe fatal disease.
Factors known to influence the severity of disease in a malaria infection
 The species of parasite. P. falciparum causes almost all cases of severe malaria. However, P.
vivax is being increasingly recognized as a cause of severe malaria;
 The immunity of the individual. Adults who have lived all their life in an endemic area are less
susceptible to severe disease than:
 Adults who visit an endemic area for the first time
 Young children living in the same endemic area
 Pregnancy
 The availability and efficacy of antimalarial medicines;
 The degree of parasite drug-resistance that prevails locally;
 HIV/AIDS, especially in pregnant women and those with advanced immune deficiency;
 Some genetically inherited conditions in the human host, e.g. sickle-cell trait, s-thalassemia, and
probably G6PD deficiency have a protective effect;
87
How parasites cause severe disease
Microvascular obstruction of vital organs
In falciparum malaria, a consistent pathological feature is the sequestration of red blood cells
containing maturing parasites (schizonts, large trophozoites) in deep capillaries and venules. This
phenomenon is observed in many different organs and tissues, including the brain, lungs, heart, bone
marrow and gut. It seems likely that sequestration is involved in complications such as altered
consciousness and acidosis, through pathophysiological mechanisms that are not fully understood.
Sequestration contributes to microvascular obstruction and mechanical obstruction causes hypoxia.

In addition, sequestered parasites, which are known to be highly active metabolically, may use up
vital substances such as glucose, so that these are not available to host cells, such as brain cells. The
parasites may also release substances, e.g. lactate or toxins, free iron, and toxic oxygen radicals that
are directly injurious to local host tissues.
It is thought that sequestration may also serve to concentrate schizonts in vital tissues. Rupture of
schizonts may then stimulate the release of large quantities of cytokines locally with a powerful local
effect even if cytokine levels in the general circulation are not particularly high.
Sequestration is due to
 Cytoadherence: is attachment of parasitized red blood cells to endothelial wall. Sequestration

appears to be confined to P. falciparum and does not occur in P. vivax infection. At
approximately 12–14 hours of development, P. falciparum parasites begin to exhibit a high
molecular weight protein strain-specific to this variant – Plasmodium falciparum Erythrocytic
Membrane Protein1 (pfEMP1) – on the surface of infected red blood cells which mediate
attachment to vascular endothelium. This is associated with knob-like projections from the
erythrocyte membrane. The red cells progressively adhere to the walls of venules and capillaries
(cytoadherence) in vital organs, producing sequestration.
 Rosetting: There is also formation of ‘rosettes’ by un parasitized red blood cells within
microvasculature. In vitro, a parasitized cell may attract unparasitized red cells which adhere to
its surface to form a rosette.
 Agglutination: is the attachment of parasitized red blood cells with each other
Cytokines
88
It is possible, but still not proven, that excessive production of pro-inflammatory cytokines may cause
severe disease in addition to fever. The cytokine TNF is known to be secreted by the individual in
response to malaria. Large quantities of TNF circulate in severe falciparum malaria, especially in
fatal cases, and TNF is known to be capable of causing many of the symptoms, signs and
complications that are typical of severe malaria, e.g. coma, hypoglycaemia, acidosis, anaemia and
respiratory distress syndrome. The ratio of pro-inflammatory to anti-inflammatory cytokines has
been observed to be high in fatal cases of malaria.
Figure 13: Brain tissue from a patient who died of cerebral malaria, showing microvascular sequestration of
parasitized red blood cells in both capillaries and small venules, with mild perivascular edema around the larger
vessels
89
Processes contributing to specific complications
Altered consciousness or coma
It is believed that altered consciousness or coma (cerebral malaria) is caused by sequestration of

parasites in the brain. However, complete obstruction to blood flow is unlikely, since the survivors
rarely have any permanent neurological deficit. Other processes like hypoglycemia, convulsion and
concomitant CNS infections may cause or contribute to altered consciousness or coma.
Hypoglycaemia
Hypoglycaemia may be due to impaired production or release of glucose in the liver, and to increased
intake in the tissues. There is also increased consumption of glucose by the parasite. In children,
hypoglycaemia complicates other childhood infections in addition to malaria. Hypoglycaemia can
also develop during prolonged fasting.
Another mechanism leading to hypoglycaemia, most commonly but not exclusively seen in pregnant
women, may develop during the course of treatment with quinine infusion. These medicines
stimulate the production of insulin which contributes to hypoglycaemia.
Convulsions
In relation to a convulsion, unconsciousness occurs both during the convulsion (ictal) and for a period
of up to several hours after the convulsion (post-ictal). Convulsions may be due to the direct effect
of parasites in the brain, or may result from accompanying metabolic disorders, e.g. hypoglycaemia,
severe acidosis, hyponatraemia or hypoxia. A very high temperature may exacerbate any of these
causes of convulsion, or may itself trigger a convulsion.
Raised intracranial pressure
The majority of children with cerebral malaria have a high opening pressure of the cerebrospinal
fluid, indicating raised pressure in the brain and spinal column. The presence of high pressure may
vary over time. It has also been observed in some adults. The cause of raised intracranial pressure is
not clear, but it is probably largely due to cerebral edema. Additional contributing factors may include
the increased mass of red blood cells sequestered in the brain, and the dilatation of vessels in the
brain in response to mechanisms triggered by parasite sequestration and schizont rupture. Raised
intracranial pressure is not the cause of coma or of death in the majority of cases. Therefore it doesn’t
need specific treatment like steroid or mannitol.
90
Anemia
Anemia is partly due to the destruction of red blood cells that contain parasites. Several other
mechanisms may accelerate the development of anemia: non-parasitised red cells are destroyed more
quickly than normal during malarial illness and the bone marrow does not function adequately to
replace them. Anemia is exacerbated if there is abnormal bleeding, intravascular hemolysis or renal
failure.
Acidosis
Acidosis is probably due to a relative shortage of oxygen in tissues occupied by sequestered parasites.
This shortage of oxygen is made worse when there is hypovolemia and/or severe anemia, as both of
these conditions may impair the supply of oxygen to tissues. Lack of oxygen forces tissues to obtain
energy by other biochemical pathways not dependent on oxygen; one result is the release of lactic
acid, leading to metabolic acidosis. There is evidence that medicines containing salicylates, which
are often given to lower the fever, may exacerbate the metabolic acidosis. Concomitant gram-
negative septicaemia aggravates the acidosis.
Acute renal failure
Acute renal failure – acute tubular necrosis – is a common complication in adults, but is rarely seen
in children. It is fully reversible if the patient is kept alive for long enough, usually between a few
days to three weeks, e.g. by peritoneal dialysis. Renal failure is most likely to develop if there has
been a period of low blood pressure or shock. Sequestration is also observed in the kidneys.
Pulmonary edema and acute respiratory distress syndrome
Pulmonary edema (non-cardiogenic) may result from excessive fluid replacement by intravenous
infusion, especially if there is renal failure. Acute respiratory distress syndrome (ARDS) appears to
be due to a direct effect of parasites sequestered in the lungs, possibly through release of cytokines.
Both of these complications are unusual in children in endemic areas.
91
Hemoglobinuria
Hemoglobinuria results from the rapid breakdown of red blood cells in the circulation (massive
intravascular hemolysis).
Jaundice
Jaundice is more common in adults than in children and is due partly to hemolysis and partly to liver
dysfunction.
Shock
Shock is due to inadequate cardiac output and poor tissue perfusion. In some patients it may occur
concurrently with bacteremia.
Bleeding disorders
In falciparum malaria, the platelet count is typically low. Nevertheless, spontaneous bleeding is rare
in both children and adults. When it develops it results from disseminated intravascular coagulation
(DIC).
Severe non-falciparum malaria
P. vivax and more recently P. knowlesi have been recognized as causes of severe malaria particularly
in Asia and in certain forested areas of South-East Asia respectively. Severe vivax malaria may
present with pathologies similar to severe P. falciparum malaria and can be fatal. Severe anemia,
respiratory distress, multiple organ failure and impaired consciousness (cerebral malaria) occur in all
age groups but the risk is greatest among young children and pregnant women.
Box 4: Essential laboratory tests
 Parasitological test (microscopy)
 Blood glucose level
 Hemoglobin (Hb) estimation or packed cell volume (hematocrit)
 Lumbar puncture
 White blood count
92
Box 5: Differential diagnosis of severe malaria
Decreased Level of Consciousness
 Viral encephalitis
 Bacterial meningoencephalitis
 Cerebral typhoid
 Cerebrovascular event (stroke)
 Complicated typhus, relapsing fever
 Febrile illness with hypoglycemia
 Sepsis
 Convulsion in a patient with fever
Renal failure
 Glomerulonephritis
 Acute tubular necrosis due to hypovolemia or hypotension
Jaundice associated with fever
 Viral hepatitis
 Yellow fever
 Acute cholecystitis
 Choledocholithiasis
Treatment of severe malaria

The main objective of treatment is to prevent the patient from dying; secondary objectives are
prevention of recrudescence, transmission or emergence of resistance and prevention of disabilities.
Special attention is required because severe falciparum malaria is a common cause of avoidable death
and because correct early treatment and careful nursing can greatly improve the outcome. Death from
severe malaria often occurs within hours of admission to a hospital or clinic, so it is essential that
therapeutic concentrations of a highly effective antimalarial drug be achieved as soon as possible.
Management of severe malaria comprises mainly clinical assessment of the patient, specific
antimalarial treatment, additional treatment and supportive care
The following special measures are indicated:
 Antimalarial medicines should be given parenterally if possible, under close supervision;
 Treatment should be undertaken in hospital if possible;
 Medicines that are ineffective and potentially dangerous should not be used.
93
Under ideal conditions the severely ill patient, especially one who is comatose, should be managed
in an intensive care unit. Where this is not possible, as in most places in Ethiopia, the health worker
has to provide emergency care. Meticulous nursing care can be life-saving, especially for the
unconscious patient.
Immediate supportive treatment

In severe malaria, the patient has a number of life-threatening complication(s) which can be fatal if
not urgently treated. Some of the most urgent measures that will be required are to:
 Start immediate resuscitation measures, paying particular attention to the airways, breathing and
circulation
 Establish an intravenous infusion, which is necessary to administer medicines and fluids;
 Correct hypoglycemia if present by infusing dextrose over a period of 3–5 minutes. This can be
done by any one of the following procedures:
 4ml/kg of 10% dextrose given by slow intravenous infusion over several minutes in
children;
 40–60ml of 40% dextrose given as intravenous bolus in adults;
 where intravenous access is impossible, give sugar solution by nasogastric tube (NGT);
 Re-check blood glucose 2–4 hourly during the course of treatment, particularly in
comatose patients.
 Control convulsions: correct hypoglycemia if it is present and give rectal paracetamol if the
temperature is above 39°C. If the convulsions continue for more than 5 minutes give diazepam
by slow intravenous injection (0.15ml/kg body weight, maximum 10mg for adults). In children
always calculate according to weight in order to avoid dangerous respiratory depression.
Diazepam can be given intra-rectally (0.5–1.0mg/kg bw) only if injection is not possible.
Monitor the breathing carefully. If the first dose of diazepam fails to control convulsions, a
second dose may be given after 10 minutes. If seizures continue, give phenytoin (18mg/kg
infused over 20 minutes as a loading dose, followed by 2.5mg/kg twice daily for 48 hours). If
you have given two doses of diazepam and seizures continue, and if phenobarbitone is the only
additional anticonvulsant drug available, you may give phenobarbitone (15mg/kg IM or iv
loading dose, then 5mg/kg daily for 48 hours), but extreme vigilance is necessary because these
two drugs (phenobarbitone and diazepam) in combination may cause respiratory arrest - monitor
94
breathing continuously and be ready to give assisted ventilation, by bag-and-mask if a manual
ventilator is not available.
Continued supportive treatment
 Assess the patient’s fluid requirements. The rate of infusion will be determined based on the
degree of dehydration. Children with severe metabolic acidosis may benefit from a resuscitation
bolus of fluid, preferably a plasma expander, e.g. normal saline. The usual route for fluid infusion
is intravenous; if this cannot be achieved alternatives are intraosseous or nasogastric infusions.
Intra-osseous infusion may be performed when there is life threatening hypovolemia, under strict
sterile procedure.
 Reduce body temperature if greater than 39.5ºC to prevent convulsion. This is best done by
giving paracetamol, by mouth if possible, alternatively by suppository. In addition, remove the
patient’s clothes and start tepid sponging and fanning from the sides or back of the patient.
Relatives can help with this task.
 Consider the need for blood transfusion. The most common indication for blood transfusion is
severe anemia (Hb < 5g/dl). Assess the patient’s clinical condition rather than relying on the
hematocrit and/or Hb level. “Does the patient need blood?” is a more important question than
“What is the PCV/Hb?” If the patient’s life is threatened by anemia-associated acidosis, or by
shock, or the parasitemia is so high that a critical drop is predictable, packed cells (10ml/kg in
children) or whole blood transfusion should be given urgently with frusemide as follows:
 if the patient has spontaneous bleeding give whole fresh blood if available or a
platelet transfusion if possible;
 where blood is unavailable, give pre-referral treatment and refer the patient;
 If the patient is unconscious, insert a nasogastric tube and start the procedures for
management of the comatose patient.
 Decide whether to insert a urinary catheter. This is necessary if either acute renal failure or
pulmonary edema is suspected, in order to guide fluid balance. Be cautious of catheter associated
urinary tract infection
 Decide whether a central venous pressure line is to be set up. This is of most value where
pulmonary edema is suspected, and may be useful in the patient with shock or impending renal
95
failure. It requires the necessary facilities, sterile procedures, expertise and a sufficient number
of trained staff to use it properly.
 Consider the need for intubation and mechanical ventilation if the necessary facilities are
available.
 Consider antibiotics if there is a suspicion of concomitant bacterial infections.
 Patients diagnosed with concomitant infections like pneumonia, UTI, meningitis
 Patients suspected to have infections (shock which is not responding to fluid
management, metabolic acidosis with hypotension especially if not responding to
fluid management, comatous patients when CSF analysis is not possible)
Specific antimalarial treatment

After rapid clinical assessment and confirmation of the diagnosis, appropriate and correct regimen
of parenteral antimalarial medicines should be administered to patients with severe malaria without
delay. Patients with severe malaria should not be treated with oral medications. The Ethiopian
national malaria guidelines recommendation for first line treatment for severe malaria at the health
center and hospital level in order of priority is:
1. Artesunate
 Above 20 kg,: IV is preferable/IM Artesunate (2.4 mg/kg on time 0 (admission), 12h and 24h
after admission, then if the patient can take orally and is improving change to full dose oral
Artemether-lumefantrine. If the patient can’t take Artemether-lumefantrine for any reason,
complete treatment with full (three days) course of second line drug (Dihydroartemisinin-
piperaquine (DHA-PPQ)
 For children under 20kg: The dose of Artesunate is 3mg/kg.
 Artesunate reduces mortality in both adults and children, has fewer side effects and is
easy to administer as compared to quinine infusion.
 It is available in ampoules, containing 60mg anhydrous artesunic acid with a separate
ampoule of 5% sodium bicarbonate solution.
 Reconstitution: the vial of artesunate powder should be mixed with 1ml of 5% sodium
bicarbonate solution (provided) and shaken 2–3 minutes for better dissolution. The
solution should be prepared freshly for each administration and should not be stored.
Then:
96
 IV administration: add 5ml of 5% glucose or normal saline to make the
concentration of artesunate as 10mg/ml and administer by slow infusion;
 IM administration: add 2ml of 5% glucose or normal saline to make the
concentration of artesunate as 20mg/ml. (See video on Artesunate preparation)
 IM artesunate (2.4 mg/kg on time 0 (admission), 12h and 24h after admission, then plan to
change to full dose oral Artemether-lumifantrene. If the patient can’t take Artemether-
lumifantrene for any reason, complete treatment with full course of second line drug. The dose
of Artesunate is 3mg/kg for children under 20 kg of weight or under 3 years of age).
Duration of treatment
• It should be discontinued when the patient tolerates oral treatment any time after 24
hours of parenteral artusnate, a full course of oral AL therapy should be started to complete
the treatment. Additionally, a single-dose primaquine will be added for P. falciparum cases.
A 14-day primaquine should be given for P. vivax cases
• It can be continued up to a total of 7 days if patient does not tolerate oral treatment.
• IV artesunate will substitute for rectal artesunate or any IM anti-malarial treatment
that may have been started as pre-referral therapy.
The shelf life of artesunate is three years from production date, to be stored below 30oC
temperature and protected from sunlight.
2. Artemether
Artemether is the alternative parenteral treatment when parenteral artusnate is not available for severe
malaria.
Dosage:
Adults and children - 3.2 mg/kg body weight on first day
-1.6 mg/kg body weight second and third day
Administration: IM (NEVER ADMINISTER BY IV ROUTE)

Preparation of artemether for administration:
• Injectable artemether contains 80 mg in 1 ml ampoule (80 mg/ml), oily solution for IM
injection only.
• When the dose required is less than 1 ml, use a 1 ml syringe graduated in 0.01 ml.
97
Note: anterior thigh is preferred site for providing IM injection
Frequency of administration – once daily
• It can be provided up to a total of 3 days.
• It can be discontinued if the patient tolerates oral treatment after 48 hours (two doses), a full
course of oral AL therapy should be started to complete the treatment,. Additionally, a single-dose
primaquine will be added for P. falciparum cases. A 14-day primaquine should be given for P. vivax
cases
3. Quinine dihydrochloride
Quinine is the alternative parenteral treatment when parenteral artusnate and artemether are not
available for severe malaria
Dosage:
Adults and children - 20 mg/kg body weight on first dose (loading dose)
-10 mg/kg body weight eight hours after start of loading dose (maintenance dose)
Caution:
 A loading dose of quinine should not be used if (i) the patient received quinine within the
preceding 24 hours; (ii) mefloquine within the preceding 24 hours; or (iii) mefloquine within
the preceding seven days;
 Rapid administration of quinine is not safe and may cause sudden death due to arrhythmia or
refractory hypotension. Each dose of parenteral quinine must be given as a slow, rate-
controlled infusion (usually diluted in 5% dextrose and infused over four hours). The infusion
rate should not exceed 5 mg salt/kg body weight per hour. If it is possible, continuous infusion
should be given.
Administration: IV or IM (IV preferred and IM is provided if IV is not possible)
Preparation of Quinine dihydrochloride for administration:
 a 2 ml ampule contains 600 mg Quinine dihydrochloride (300mg/ml)

 For IV infusion – For adults and children weighing > 20 Kg- administer each dose of Quinine
in 250 ml of 5% dextrose (D5W) or normal saline and infuse slowly intravenously over 4
hours
98
 For children under 20 Kg, administer each dose of Quinine in 10 ml/kg volume of 5%
dextrose or normal saline and infuse slowly over 4 hours
 For IM injection preparation - quinine should be diluted in normal saline to a concentration
of 60–100mg salt/ml.
Note: anterior thigh is preferred for providing IM injection. There is risk of sciatic nerve injury if
provided on gluteal region. Loading dose should be provided in two thighs by dividing full dose
equally.
Frequency of administration – every eight hours (Note that eight hours is counted from the start of last dose)
 It should be discontinued if the patient tolerates oral treatment after 48 hours, a full course of
oral AL therapy should be started to complete the treatment, as in Annex C. Additionally, a single-
dose primaquine will be added for P. falciparum cases. A 14-day primaquine should be given for P.
vivax cases (Annex F).
 In patients requiring more than 48 hours of parenteral therapy, the quinine maintenance dose
should be reduced by one-third to one-half (i.e. 5-7 mg salt/kg of body weight every eight
hours). It is unusual to have to continue IV infusions of quinine for more than 4-5 days
 Quinine is not given by subcutaneous injection
 Quinine is safe in pregnancy and anemic patients, if the doses are carefully calculated by body weight.
NOTE: Always calculate drug doses according to the bodyweight of the patient. Where available, use a burette
to ensure correct fluid volumes and to prevent fluid overload in the patient.
REMEMBER: Patients with severe malaria should not be treated with oral antimalarial drug.
3. Parenteral antimalarials in the treatment of severe malaria should be given for a minimum of
24 hours (48 hours for quinine), once started (irrespective of the patient’s ability to tolerate
oral medication earlier).
Pre-referral treatment
At health center and hospital levels
If health workers decide to refer a patient with severe malaria to a higher level of care, they should
provide a pre-referral treatment as the risk for death from severe malaria is greatest in the first 24
hours. The recommended pre-referral treatment options in descending order of preference, are
99
intramuscular artesunate; intramuscular artemether; and intramuscular quinine. For the conscious
patient, give paracetamol if high fever is present, encourage fluid intake during transfer and continue
breastfeeding in young infants and ensure that referral form is completed with detailed information
including the reason for referral. For the unconscious patient, show family members how to position the
patient on the side to ensure a clear airway is maintained. Family members can do tepid sponging and give
paracetamol suppositories for high fever if possible. Fill in a referral form with complete information including
reason for referral
At Health Post level
The conscious patient:
 Give rectal artesunate at a dose of 10mg/kg for children under six years of age. Artesunate
suppositories are currently available in 50mg and 200mg formulations. If the suppository is
expelled from the rectum within 30 minutes of insertion, re-insert another dose and, especially
in young children, the buttocks should be held together for 10 minutes to ensure retention of the
suppository
 If high fever is present, give paracetamol or tepid sponging;
 Encourage fluid intake during the transfer; continue breastfeeding in young infants;
 Ensure that the referral form is completed with detailed information including:
 Clinical presentation/patient’s medical history;
 Suspected diagnosis;
 Any tests performed and results (RDT);
 List of all drugs/medication given, route, dose and time of administration;
 Reason for transfer.
100
The unconscious patient:
a. Ensure “ABC” Airway, Breathing and Circulation;
b. Show family members how to position the patient on side to ensure a clear airway is
maintained;
c. Give rectal artesunate at a dose of 10mg/kg for children under six years as pre-referral
treatment;
d. Do tepid sponging and give paracetamol suppositories for high fever if possible. This will
prevent vomiting and convulsions;
e. Nurse the unconscious patient on alternate sides to protect the airway, prevent aspiration and
avoid pressure sores.
At Health Center and Hospital levels

Give pre-referral treatment with IV/IM Artesunate, IM Artemether or IM Quinine. Provide the
necessary supportive care (ABC, Treat high fever, prevent or treat hypoglycemia, coma care). Ensure
that the referral form is filled with the necessary information (history, physical findings, laboratory
results, drugs and fluids administered and reason for referral)
Continuing treatment and nursing care

Continuing care calls for close cooperation between medical and nursing staff. Proper nursing care
of the unconscious patient, in an intensive care unit if available, is of utmost importance in patients
with cerebral malaria. The patient must be turned every two hours and not allowed to lie in a wet
bed. Particular attention must be paid to pressure points and the patient should be nursed on his/her
side to avoid aspiration of fluids. Sufficient nutritional support is necessary for patients who have a
prolonged illness.
Following are the parameters to be monitored on a routine basis:
 Level of consciousness (see Blantyre and Glasgow coma scales in Annex 1);
 vital signs: blood pressure, temperature, pulse rate and respiratory rate;
 Fluid input and output. Examine regularly for signs of dehydration or fluid over load;
 urine volume, color and specific gravity;
 Blood glucose;
 Parasitemia;
 Hemoglobin (Hb/Ht) if anemia is suspected to be worsening;
101
 Occurrence of convulsions;
 Uterine contractions and fetal heart rate in pregnant women.
A record chart should be kept on which the important complications of the patient’s illness are
summarized; the treatment prescribed, and all important observations are recorded at suitable
intervals. The record chart is useful as a checklist to observe and follow all important parameters and
not to overlook important ones which may cost the life of the patient.
A decision is taken on how frequently observations should be made; this should be as often as
possible with the avail-able staff (e.g. every four hours), but will also depend on the particular
circumstances of each patient and the severity, stage and complications of the illness. For example,
blood glucose should be checked hourly in a comatose pregnant woman receiving intravenous
quinine, but less frequently in a man whose condition is steadily improving.
102
Table 17: Management of severe malaria: daily observation sheet (acute phase)
Date of admission: …………/…………/………… Time (h/min): …………/…………
Name of patient: ..............................................................
Record No. ..........

Age: .............
Sex: M ☐ F ☐
Weight ...............Kg
Medicines given before
admission (including
OPD) .............................
1 4 8
Real time (h) minutes
Investigations done on Temperature (2x/day) Pulse

admission (2x/day)
Parasite count Respiratory rate (2x/day)
......................................... Blood pressure
Haemotocrit/Hb (2x/day)
......................................... Glasgow/Blantyre coma
Blood sugar scale (3x/day)
......................................... Convulsions (Y N)
Urine analysis Able to drink (Y N)
......................................... Able to sit (Y N)
Cerebral spinal fluid Parasite count
(CSF) Haemotocrit/Hb
......................................... Blood sugar
Blood group iv artesunate or quinine in
................................... mg
iv fluids – dextrose saline
Other medicines, e.g. iv
diazepam/antibiotics
Urine volume
Blood transfusion
103
Hours
12 16 20 24
104
Management of severe malaria: Observation sheet (convalescent phase- discharge)
Date of admission: …………/…………/………… Time (h/min): …………/…………
Name of patient: ............................................................................................................................
Frequency D ay D ay D ay D ay D ay D ay D ay D ay D ay D ay Outcome
…… …… …… …… …… …… …… …… …… ……
Record No---------- of and
Observations follow up
visits
Hours 0 12 0 12 0 12 0 12 0 12 -100%
recovery /
with
sequelae
Rectal/axillary 12 hourly
(specify) /
temperature
death
/unknown
Level of 12 hourly (absconded)
consciousness -Fever
(Glasgow/Blantyre clearance
coma scale) time (day/h)
Pulse per minute 12 hourly ……
Respiratory rate 12 hourly -Coma
(per minute) recovery
Blood pressure Once in 24 time (day/h)
(mmHg) hrs ………
Parasite count per day 3 and 7 -
mm Parasitaemia
Haematocrit (%) or day 3 and 7 clearance
Hb (g/dl) time (day /
Dihydroartemisinin- once daily h) ………
piperaquine (DHA-
PPQ) (mg)
First-line When
antimalarial (ACT) patient can
oral treatment* take oral
treatment
Other medication
Brief comments
Different abnormalities may be noted during observation which should be managed based on the
following table. The above follow up form and the following table should be available at health
facilities as health workers’ support tool to help them manage severe malaria.
105
Table 18: Appropriate actions for clinical and laboratory abnormalities
observations Possible abnormality Appropriate actions

A.CLINICAL
1.Breathing Increased rate or Review urine output and fluid balance. Assess lung,
difficulty, Deep heart and liver size. Chest X-ray if available. If
breathing in children pulmonary oedema is demonstrated, or seems likely,
prop the patient up, give oxygen, IV frusemide 2–
4mg/kg. Treat acidosis with normal saline and
bicarbonate.
2. Body Rectal temperature: > Give paracetamol (rectal or oral) if not already given
temperature 40°C OR within past 4 hours. Tepid sponging and fanning.
axillary temperature: > Aspirin can be given to adults (instead of
39.5°C paracetamol) but not to children.
If temperature remains high or rises despite 24 hours
of antimalarial therapy, reconsider your diagnosis,
while continuing treatment
3. Blood Falls < 80mmHg Review fluid balance, urine output, quinine infusion
pressure systolic in an adult, and rate and haematocrit. Give plasma or saline infusion
< 50mmHg in infants if hypovolaemia is present. Look for haemorrhage.
and children. In Take blood for bacteriological culture if facilities are
children, BP is not available. Give broad spectrum antibiotics for
always reliable: check possible sepsis.
for peripheral perfusion,
looking at nailbed refill
4. Fluid Oliguria: < 17ml/hour in Catheterize if acute renal failure or pulmonary
balance (Use an adult or < oedema is suspected; Review adequacy of hydration
input and 0.3ml/kg/hour in infants and infusion. Correct deficit if necessary. Prevent or
output chart), and children manage acute renal failure if suspected. Give fluid
Weigh challenge 20ml/kg of normal saline with frusemide 2–
patients 3mg/kg. Dialysis if this fails
accurately
5. Coma Deterioration Immediately check blood glucose. Reconsider other
score diagnoses. provide appropriate nursing care for the
unconscious patient.
106
The following boxes indicate common errors in diagnosis and treatment of severe malaria
Errors in the diagnosis of severe malaria

▶ Failure to think of malaria in a patient with either typical or atypical illness
▶ Failure to elicit a history of exposure (travel history) – including travel within a country
with variable transmission
▶ Misjudgment of severity
▶ Failure to do a thick blood film in a non-immune patient
▶ Failure to identify P. falciparum in a dual infection with P. vivax (the latter may be more
obvious)
▶ Missed hypoglycaemia
▶ Failure to diagnose alternative or associated infections (bacterial, viral, etc.)
▶ Misdiagnosis making an alternative diagnosis in a patient who is actually suffering from
malaria (e.g. influenza,
viral encephalitis, hepatitis, scrub typhus, etc.)
▶ Failure to recognize respiratory distress (metabolic acidosis)
▶ Failure to carry out an ophthalmoscopic examination for the presence of papilloedema,
and malarial retinopathy
107
Errors in the management of severe malaria
▶ Inadequate nursing care
▶ Errors of fluid and electrolyte replacement
– failure to control the rate of intravenous infusion
▶ Delay in starting antimalarial therapy
▶ Use of an inappropriate medicine
– ineffective antimalarial medicine
– unjustified withholding of an antimalarial treatment
– dosage of antimalarial medicine not correctly calculated
– inappropriate route of administration
– unjustified cessation of antimalarial treatment
– failure to adjust the dose to prevent cumulative effects of antimalarial medicines
– failure to switch patients from parenteral to oral therapy as soon as they can take oral
medication
– unnecessary continuation of chemotherapy beyond the recommended length of treatment
– failure to review antimalarial treatment in a patient whose condition is deteriorating
▶ Failure to elicit a history of recent intake of medicines
▶ Failure to identify or treat metabolic acidosis
▶ Unnecessary endotracheal intubation
▶ Unduly delayed endotracheal intubation (when it is indicated and possible)
▶ Failure to prevent or control convulsions
▶ Failure to recognize minor (“subtle”) convulsions
▶ Failure to recognize and treat severe anaemia
▶ Delay in considering obstetrical intervention in late pregnancy
▶ Failure to recognize and manage pulmonary oedema
▶ Undue delay in starting peritoneal dialysis or haemodialysis
▶ Failure to pass a nasogastric tube to prevent aspiration pneumonia
▶ Failure to cover with antibiotics if the decision is taken to delay lumbar puncture
108
How to assess the patient’s recovery
The records and observations will provide some indications of patient recovery e.g. lowering
temperature, decreasing parasite count, and an improving coma score. In addition, the patient’s ability
to drink, eat, talk, sit, stand or walk should be recorded. When a patient has recovered, an assessment
should be made of possible sequelae of the disease or the treatment. In particular you should:
 Perform a neurological examination: In particular, assess the patient’s functional capacity to
hold and use objects, ability to feed, the gait and posture. Try to determinate whether the patient
can do the things that he or she was able to do before the illness began. For a young child this
requires asking parents or guardians about the child’s previous activities.
 Assess vision and hearing: Use the best available methods. Simple bedside measures can be
used, especially for infants and children (e.g. does the child turn his/her head towards a noise?
does the child watch the mother when she moves?). Use audiometry and vision charts if these
are available.
Review and synopsis
When the patient is discharged, a discharge summary should be prepared of the events of the
patient’s illness, indicating the distinguishing features of the illness and the patient’s
responses to treatment. A discharge form to enter this information should be attached to the
patients chart (card).
Key points
a. Severe malaria is a medical emergency requiring nursing, medical and laboratory staff to be
alert at all times. Prompt action is especially important for high-risk groups such as young
children and pregnant women.
b. Artesunate IV or IM should be used in preference to quinine IV or IM for the treatment of
severe malaria.
c. The management of the patient is as important as chemotherapy and here the nurse has a
crucial role to play.
d. Regular monitoring of the core temperature, respiration (rate and depth), blood pressure, level
of consciousness and other vital signs is essential. These observations will make it possible
to identify the late onset of important complications such as hypoglycaemia, metabolic
acidosis, pulmonary edema and shock. Urine output should be recorded. Use checklist to
follow your patient
109
e. Laboratory measurements should include regular checks on Hb, glucose, urea or creatinine
(also electrolytes and arterial blood gases when possible).
f. A proportion of children who survive cerebral malaria have neurological sequelae which
persist into the convalescent period.
110
Exercises
Picture quiz
The picture plates provided below are intended to help the participants to interpret physical signs of
severe disease in children and adults, decide on differential diagnoses, and determine tests that need
to be carried out.
Figure 1: Pictures for questions 1-3
111
The children seen in Figures 13.1, 13.2 and 13.3 were all brought to a clinic in an area where P.
falciparum is hyperendemic. Each child is unconscious and has a heavy P. falciparum
parasitaemia. The children are 3 to 5 years old. They are febrile (axillary temperature: 38°C– 40
°C). They have been immunized against measles,
diphtheria, tetanus, and whooping cough through the EPI services.
Question 1: what do pictures 13.1-13.3 show?
Question 2: what is the differential diagnosis?
Question 3: what tests should be carried out?
The children seen in Figures 14.1 and 14.2 each have a short history of fever followed by
progressive loss of consciousness. Both are in deep coma and have a heavy P. falciparum
parasitaemia. They are 3 and 4 years old. Neither has been immunized against the common
childhood diseases.
Figure 2: Pictures for questions 4 and 5
Question 4: what do the pictures seen in 14.1 and 14.2 show?

Question 5: what could be the explanation for this?
The patient seen in pictures of Figure 15 has P. falciparum malaria. She was admitted in coma, treated
with quinine and recovered consciousness. Two days later she had a convulsion and collapsed into
coma again.
112
Figure 3: Picture for questions 6-8
Question 6. What are the possible causes of comma and subsequent convulsion?
Question 7. What investigations would you carry out to ascertain the causes?
Question 8. How would you manage this patient?
Figure 16. Shows the supportive treatment given to a patient with severe malaria
113
Figure 4: Picture for question 9-11
Question 9. What exactly does the picture seen in Figure 16 show?

Question 10. What is the most frequent complication in severe malaria that lead the physician to do
this procedure?
Question 11. What are the complications to be feared in carrying out this procedure in rural
hospitals?
Figures 17.1 and 17.2 refer to the clinical and radiological presentation of a woman soon after
delivery. She has severe falciparum malaria with hyperparasitaemia and the condition shown in
Figures 17.1 and 17.2 was preceded by difficulty in breathing with an increased respiratory rate.
114
Figure 5: Picture for questions 12 and 13
Question 12. What is the condition suggested by these pictures?

Question 13. What is the differential diagnosis for this condition?
PATIENT A
The place: A country where P. falciparum malaria is transmitted in forested areas but not in
the main cities.
The patient: A woman aged 25 years is brought to the outpatient department of the central
hospital in the capital. She is a local resident, the wife of a business executive, and is in the
seventh month (28 weeks) of her first pregnancy.
The patient became ill five days ago, with chills, sweating and headaches. An antibiotic was
prescribed and her condition seemed to improve, but yesterday she developed rigors and
persistent vomiting. A blood film at the local clinic showed malaria parasites, and oral quinine
(600mg every 8 hours) was prescribed. She took two doses.
Today she has been referred to your hospital because of restlessness and increasing mental
confusion. Examination shows a semiconscious woman who is unable to speak. She withdraws
her hand from a painful stimulus but cannot localize a stimulus applied to the sternum or
forehead. There is no neck stiffness, jaundice, pallor or rash. Axillary temperature is 39°C, pulse
rate 90/min, blood pressure 110/70mmHg. The uterine fundus is palpable (26–28 weeks), and
the fetal heart can be heard.
Question 1
What tests are urgently required?
115
Question 2
If the blood glucose is 1.2mmol/l (22mg/dl) what treatment should be given?
Question 3
The blood film shows P. falciparum rings “++++”, and the cerebrospinal fluid is normal except for
low glucose.
a. What antimalarial drug should be administered and by which route?
b. Should a loading dose of quinine be given? Justify your answer.
c. What nursing procedures are important during this treatment? d. In a health unit without
facilities for parenteral therapy, what alternative treatment could be considered?
Question 4
After six hours the patient becomes increasingly restless. The respiratory rate increases to
40/minute. The blood glucose level is normal.
Under these conditions, what diagnostic steps should be taken?
Question 5
A chest X-ray gives the picture shown (Fig. 18). What is the diagnosis and treatment?
Fig 18
Fig 18
Figure 6: Chest X ray
Question 6
What other observations are particularly important in this patient?
116
Question 7
What other questions should this patient’s relatives be asked?
PATIENT B
The place: A rural clinic in an area where P. falciparum is hyperendemic. Various antimalarial
medicines are available, but intravenous infusions cannot be given.
The patient: A child aged 20 months became feverish two days ago and has vomited several times
today. One hour ago the child had a convulsion, described by the mother as a repetitive twitching of
limbs and mouth, followed by unresponsiveness for a few minutes. The child is now febrile (39.3°C),
conscious, and able to localize and respond to a painful stimulus. Malaria rapid diagnostic test shows
a positive result for P. falciparum. The child repeatedly vomits any antimalarial medicine given by
mouth.
Question 1
a. Does the child have cerebral malaria?
b. What should be done about the convulsions?
Question 2
The district hospital is 30km away; the journey will probably take several hours by bus.
a. Should the patient be referred to hospital?
b. What treatment should be given in the meantime?
Question 3
On arrival at the district hospital, the child was still unable to take oral medication and was
admitted. A thick blood smear showed P. falciparum rings “++++” and he was given quinine IV.
On the third day, there had been some improvement but the child was still febrile and the
parasitaemia reduced a little. Does this suggest that the child has drug-resistant malaria?
117
Question 4
The child was able to feed and take oral medication on the third day.
Should the parenteral treatment with quinine be continued?
Question 5
On completion of the treatment, a further blood test showed gametocytes “+”. What should be done
about the gametocytes present in the blood after treatment?
PATIENT C
The place: A country where P. falciparum is hyperendemic.
The patient: A male economist aged 28 years, was born and brought up locally, but attended
university in northern Europe for five years. He returned home last month. One week ago he
developed fever. He decided this could not be malaria because he had grown up in a malaria-
endemic area and believed he was therefore immune. Two days ago he became confused,
especially at night. He stayed in bed and was attended by a servant who called the doctor today
because the patient was increasingly confused. The last urine he had passed was a small volume of
very dark fluid 24 hours ago.
On examination, the patient was a well-nourished adult man. He was afebrile with a rectal
temperature of 36.5°C. He was restless but could give brief appropriate answers to questions, and
could localize the site of a painful stimulus. He was jaundiced and his mucous membranes were
pale. There was some bleeding from the gums, and there were a few retinal haemorrhages in both
eyes.
Question 1
a. What is the differential diagnosis?
b. Was the patient right to think he was immune to malaria? Justify your answer.
Question 2
The thick blood film shows P. falciparum rings “++++” and the thin blood film shows that 26% of
red cells are parasitized.
a. What else should be looked for in the thin blood film?
b. What other tests are necessary to investigate the bleeding tendency?

118
c. What treatment is needed for the bleeding?
Question 3
The patient has not passed urine for 24 hours.
What kind of investigations and actions are appropriate?
Question 4
15ml of dark brown urine was obtained by catheter. The urine ‘stix’ tests showed albumin “++”,
blood “++++”, conjugated bilirubin “++”, urobilinogen “++”. Microscopy of the urine showed no
cells and a few casts.
How are the results of the urine test to be interpreted?
Question 5
Acute renal failure is confirmed.
a. Is it possible that the kidneys may recover?
b. What therapy should be given to this patient with acute renal failure?
PATIENT D
The place: A country with hyperendemic P. falciparum malaria in low-lying areas but no malaria
transmission on the high central plateau.
The patient: A woman aged 19 years was brought to a clinic in the malaria-endemic area. The
medical officer recorded that the patient gave a history of fever for the past three days with rigors
and vomiting. On examination she was febrile with an axillary temperature of 39.1°C and slightly
jaundiced. She was fully conscious. Because she had never been out of the country, the doctor
considered it unlikely that she was suffering from P. falciparum malaria, but nevertheless checked a
thin blood film. No malaria parasites were seen on the film so he diagnosed hepatitis and advised
rest and a fat-free diet.
Question 1
a. Do you think the medical officer was right to decide that this patient did not have malaria?
Justify your answer.
b. Could the doctor have done better with:
119
i. The history?
ii. The investigations?
Question 2
Two days later the patient was brought back to the clinic by anxious relatives. She had become
drowsy and was not answering questions properly. On examination the patient was afebrile, slightly
jaundiced and confused. She could not answer questions but could withdraw her hand from a
painful stimulus. The possible diagnoses considered were fulminant hepatitis, sickle-cell crisis,
relapsing fever and cholecystitis. Malaria was ruled out because she was not febrile. Treatment was
started urgently with tetracycline intravenously and enemas to empty the large bowel. She
remained unconscious and her temperature rose to 38°C; a blood film now showed scanty P.
falciparum parasitaemia. Tis was considered “probably incidental” because low-grade parasitaemia
was common among young adults in the area.
a. What errors were made in clinical judgment?
b. What errors were made in the treatment of the patient?
Question 3
The next day the patient was increasingly febrile and the parasitaemia had increased. The parenteral
artesunate (IV or IM), the preferred antimalarial medicine for the treatment of severe malaria, was
out of stock. Therefore, quinine 20mg base/kg was given intravenously to run over one hour in
normal saline, to be repeated 8-hourly. Twenty-four hours later the patient became increasingly
breathless. There were no signs in the chest but pneumonia was diagnosed and treated with
penicillin. Twelve hours later the patient was still breathless and suddenly had a convulsion.
Her level of consciousness deteriorated and she died ten hours later.
a. What errors were made in administration of quinine?
b. What errors were made in diagnosis of clinical complications?
120
LEARNING UNIT SEVEN
Malaria in Special Groups

Learning Objectives
By the end, participants should be able to:
 Describe the relationship between malaria and pregnancy and lactation
 List measures to prevent malaria during pregnancy
 State the recommended therapeutic regimens for the treatment of uncomplicated and severe
malaria during pregnancy and lactation
 Describe the prevention of malaria during pregnancy
 Describe the effect of malnutrition on malaria
 Describe the effect of HIV on malaria
Malaria in Pregnancy
The symptoms and complications of malaria in pregnancy vary according to transmission

intensity and the level of acquired immunity. Pregnant women living in areas of low or unstable
malaria transmission (like many malarious areas in Ethiopia) have little or no immunity to
malaria, and are at higher risk of developing severe malaria than are non-pregnant adults living
in the same area.
In these areas, malaria is a major cause of maternal anaemia, spontaneous abortion, stillbirth,
premature delivery, low birth weight (birth weight < 2.5kg), neonatal death and maternal death.
In non-immune women, severe malaria symptoms (hypoglycaemia, cerebral malaria, and
pulmonary oedema being particular problems) are more common in pregnancy.
In stable transmission settings, the deleterious impact of malaria is particularly apparent in first and
second pregnancies. Partial clinical immunity acquired during years of exposure to the malaria
parasite prior to pregnancy does not prevent infection, but does reduce the risk of severe disease.
Clinical malaria is not, therefore, a prominent feature of infection during pregnancy, and the major
detrimental effects of infection are low birth weight (LBW) and maternal anaemia.
121
HIV infection impairs pregnant women’s ability to control P. falciparum infection. Women with HIV
infection are more likely to have symptomatic malaria infections and to have an increased risk of an
adverse birth outcome due to malaria. In the presence of HIV infection, placental malaria appears to
be independent of the number of pregnancies, so that the risk of placental malaria is similar in HIV-
infected multigravidae and HIV-negative primagravidae.
Severe anaemia, exacerbated by malaria, is an important complication of pregnancy in many tropical

countries. Especially in communities where chronic hookworm anaemia is prevalent, high output
anaemic cardiac failure may develop in late pregnancy.
Asymptomatic hypoglycaemia may occur in pregnant women with malaria before antimalarial
treatment, and pregnant women with uncomplicated or severe malaria are particularly vulnerable to
quinine-induced hypoglycaemia.
There is an increased risk of pulmonary oedema precipitated by fluid overload or by the sudden
increase in peripheral resistance, or autotransfusion of hyperparasitaemic blood from the placenta
which occurs just after the delivery
Treatment of uncomplicated malaria in pregnancy

Pregnant women with symptomatic acute malaria are a high-risk group, and require effective
antimalarial medication. There is insufficient information on the safety and efficacy of most
antimalarial medicines in pregnancy, particularly for exposure in the first trimester, and treatment
recommendations differ from those for non-pregnant adults. Therefore, as a standard practice for the
administration of any medicine pregnant women, all women of child-bearing age should be asked
whether they are, or could possibly be, pregnant before an antimalarial medicine is prescribed.
The following are the antimalarial medicines recommended for the treatment of uncomplicated
falciparum malaria during pregnancy:
 In all trimesters, give Artemether-lumefantrine (AL)

For the treatment of vivax malaria in pregnancy,
 chloroquine, which is the treatment of choice for P. vivax (chloroquine-sensitive), P. ovale and
P. malaria, is safe in pregnancy.
 Primaquine is contraindicated during pregnancy
 Provide weekly chloroquine prophylaxis until after delivery and breastfeeding for 6 months
122
Treatment of severe malaria in pregnancy
A pregnant woman with severe malaria should be given a parenteral antimalarial medicine in full
doses without delay. Parenteral artesunate is more effective than parenteral quinine in reducing the
risk of death from severe malaria.
Although safety data on the use of artemisinins in the first trimester are limited, saving the mother’s
life is the primary objective. Therefore artesunate (IV or IM) is the preferred drug for all severe forms
of malaria in all trimesters of pregnancy. IM Artemether is the second option while Quinine (IV or
IM) may be considered as the last option. After 24 hours of parenteral drug administration, treatment
should be completed with full dose of AL including the first trimester
The amount of antimalarial drugs passed into breast milk and consumed by the breast feeding
infant is very small, so the treatment is the same as the non-pregnant adults except primaquine
should be avoided.
Prevention of malaria during pregnancy

Pregnant women should be given priority in LLIN utilization. Intermittent preventive treatment of
malaria during pregnancy (IPTp) is recommended in high transmission areas, however it is not
recommended in Ethiopia
Malaria and Malnutrition

 Malaria and malnutrition frequently coexist.
 Malnutrition may result in in accurate dosing if we use age or weight of the child.
 Different conditions may hamper the absorption of anti-malarial drugs if given orally or
parenteral, e.g. Chronic(persistent) diarrhoea, vomiting, rapid gut transit or atrophy of the small
intestine villi (enteropathy)
 Diminished muscle mass may also make repeated intramuscular injection difficult.
 Hypoalbuminemia may also lead rapid clearance of the drugs as some drugs need albumin for
binding.
 Although these findings are concerning, they are insufficient to warrant dose modification of
any anti-malarial drugs in a patient with malnutrition, however, their response to treatment
should be monitored more closely.
123
Malaria and HIV
 There is geographical overlap between malaria and HIV, and many people are co-infected.
 Worsening HIV related immunodeficiency may lead to manifestation of severe malaria
 In areas of stable malaria transmission patients have more frequent and higher density infection
due to partial immunity while in unstable transmission area, HIV infection is associated with
increased risk for severe malaria and malaria related death.
 Early studies suggested that HIV related immunosuppression was associated with decreased
response to anti-malarial drugs but now there is insufficient information to change the drugs
and dose of anti-malarial drugs we used for non HIV infected individuals.
Malaria and TB
 There are evidences that show patients taking Rifampicin with quinine, ACTs and
mefloquine have a three to nine fold decrease of the anti-malarial drugs in the serum as
well as higher recrudescence rate.
 However, there is insufficient evidence to change the drug and dosing in patients who
are taking anti-TB drugs.
 But these patients are at higher risk of recrudescent infection, they should be monitored
closely.
124
LEARNING UNIT EIGHT
Malaria Laboratory Diagnosis and Quality Assurance
Learning objectives
At end of this training, participants should be able to:
 Describe the different methods used for diagnosing malaria

 Explain the significance of microscopy and RDT in malaria control
 Explain the principle and general procedure of microscopy and RDT
 Describe the significance of performing microscopic thick and thin blood film slides
 Describe the principles of quality assurance of malaria laboratory diagnosis
 Describe activities of External Quality Assessment (EQA) schemes of malaria laboratory
diagnosis
Clinical Diagnosis
A clinical diagnosis entails making a clinical assessment by taking an accurate history of the illness
and performing a physical examination. Clinical diagnosis of malaria is made in a patient who has
fever or history of fever in the last 48 hours and lives in malaria-endemic areas or has a history of
travel within the last 30 days to malaria-endemic areas. Basing the diagnosis on clinical features
alone is not recommended, as this often has low specificity and increases the chances of the patient
being misdiagnosed.
Parasitological Diagnosis/ Laboratory Methods

Laboratory diagnostic methods can be classified in to two:
 Routine lab diagnostic methods (Microscopy & Rapid Diagnostic Testing/RDT)

 Advanced diagnostic methods
- Quantitative Buffy Coat /QBC/test
- Microscopy using fluorochromes
- Polymerase chain Reaction/PCR/
- Serology: Ab detection
- Flowcytometry
125
Microscopic diagnosis and RDTs are the routine methods employed for confirmation of malaria
etiology in Ethiopia. Confirmed malaria is suspected malaria confirmed with microscopic diagnosis
or RDTs for plasmodium parasites.
Benefits of parasitological diagnosis:

 Rational drug use and hence cost saving
 improved patient care in parasite-positive patients owing to greater certainty that the patient has
malaria;
 consideration and searching for alternative diagnoses on identification of parasite-negative
patients;
 prevention of unnecessary treatment with antimalarials, thereby reducing side-effects, drug
interactions and selection pressure;
 improved health information;
 Confirmation of treatment failures.
Malaria microscopy
Microscopy has a high degree of sensitivity and specificity when performed well. In addition, it
allows quantification of malaria parasites and identification of the infecting species. It is inexpensive
and considered to be the “Gold standard” against which the sensitivity and specificity of other
methods must be assessed.
Quality of microscopy is ensured by supporting laboratories to perform internal quality control,

performing external quality assessment especially using the blinded rechecking, proficiency testing
methods and by onsite evaluation. Quality microscopy will provide reliable result and will help to
build the trust of clinicians on laboratory results.
Light microscopy has important advantages:

 Low direct costs, in areas of high turnover, if the infrastructure to maintain the service is
available
 High sensitivity if the quality of microscopy is high
 Differentiation between plasmodia species and the stage of the parasite
126
 Determination of parasite densities
 Can be used to diagnose many other conditions.
Type of blood films

There are two types of blood films, thin and thick blood film. Both thin and thick blood film should
be prepared on a single microscope slide. Giemsa stain is the best stain for identification of malaria
parasites. It stains cells and blood parasites (e.g. malaria, Borelliae, trypanosomes etc.). Malaria
parasites are identified by microscopic examination of thick and thin blood films stained with Giemsa
stain. Other stains that can be used to stain blood film are Wright’s stains, Leishman’s stain, and
Field’s stain. Thick smears are more sensitive for detecting the presence of parasites, and thin smears
can provide more details for species determination. An adequate amount of time must be spent to
analyze multiple forms and to determine if there is a mixed infection.
Types and characteristics of thin and thick blood film:
Thick smear Thin smear

 Lysed RBCs 1. Fixed RBCs
 Many layers 2. Single layer
 Large volume 3. Smaller volume
 Good screening test 4. Good species differentiation
 Low density infection can be detected 5. Low density infection can be
 More difficult to diagnose species missed
Slide examination
 Giemsa stain thick blood smears are the basis for microscopic diagnosis with a standard of
looking at 100 fields.
 The limit of detection is usually 5-10 parasites per μl of blood. If blood film is negative, look
for other causes of fever.
Parasite density
In addition to definitive diagnosis of malaria and differential diagnosis of the species of malaria
parasites, microscopic examination also enables their number in a unit volume of blood to be
127
determined. Knowledge of the degree of parasitaemia may be of diagnostic and prognostic value in
the case of severe P. falciparum malaria infection and also helps in following up the changes
produced by treatment and also helps to measure therapeutic efficacy of antimalarial drugs.
Methods of counting malaria parasites:

 % of parasitized RBC ( thin film)
 Number of parasites/µL of blood (thick film)
 Number of parasites/µL of blood (thin film)
 Semi quantitative count /Plus system (thick film)
The semi quantitative (plus) system should be used only when it is not possible to undertake the more
acceptable parasite count per µl of blood.
Malaria Rapid Diagnostic Testing
Malaria RDTs detect antigens from the malaria parasites in blood using an immunochromatographic
process. An antigen-antibody reaction leads to a visible colour change that indicates a positive test
result.
These tests use finger-stick or venous blood, take only few minutes, and do not require a laboratory,
electricity, or any special equipment.
Currently multi-species RDTs capable of specifically detecting both P. falciparum and P. vivax, are
being supplied by FMOH /PFSA. Malaria RDT is recommended to be used in the health posts.
Basic Principles of RDTs
Rapid diagnostic tests are immune-chromatographic tests that detect specific parasite antigens mainly
Histidine Rich Protein 2 (HRP2) or Plasmodium lactate dehydrogenase (pLDH). Plasmodium
aldolase is another antigen that is used in some tests. Some RDTs can detect only one species
(Plasmodium falciparum) while others detect one or more species of malaria parasites that infect
humans. Antigens detected by currently used RDTs are:
1. Histidine Rich Protein II (HRP-2): is a protein produced by trophozoites and young gametocytes
of P. falciparum. A substantial amount of HRP 2 is secreted by the parasite in to the host bloodstream
128
and the antigen can be detected in erythrocytes, serum, plasma, cerebrospinal fluid and even urine as
a secreted water-soluble protein. Tests based on HRP-2 detect only P. falciparum. HRP-2 has been
shown to persist and may be detectable for more than a month after clinical symptoms of malaria
have disappeared and parasites are cleared from the host. HRP-2 based tests are relatively more stable
at high ambient temperatures and humidity, and usually less costly.
2. Plasmodium Lactic Acid (Lactate) Dehydrogenase (pLDH): is produced by both trophozoites

and gametocytes of malaria parasites. The pLDH antigen is present in and released from parasite-
infected erythrocytes. pLDH is found in all 4 human malaria species, and different isomers of pLDH
for each of the 4 species exist. Currently available pLDH RDTs detect pLDH specific to P.
falciparum, P. vivax or are pan-specific detecting all Plasmodium species that infect humans. Some
pLDH RDTs are specific for P. vivax. Since pLDH is disappeared from the circulation within five
days of successful antimalarial therapy, this test has the ability to differentiate untreated from treated
malaria, and may therefore be used for patient follow up, although pLDH is also produced by
gametocytes. Tests based on pLDH are less stable at high ambient temperatures and humidity, and
are more costly.
3. Plasmodium aldolase: is an enzyme produced in the glycolytic pathway by all species of human
Plasmodium parasites (pan-specific) and has been used in a combined 'P.f/P.v' immune-
chromatographic test. Tests that detect aldolase appear to be less sensitive than tests that detect the
other parasite products. Aldolase behaves in much the same way as pLDH.
The various RDTs appear to be similar; they vary considerably in their functioning due to the intrinsic
character of the critical components employed and their final result.
Mode of action malaria RDT

Lateral flow antigen-detection tests, which rely on the capture of dye-labeled antibodies to produce
a visible band on a strip. The dye-labeled antibody first binds to a parasite antigen, and the resultant
complex is captured on the strip by a band of bound antibody, forming a visible line (test line). A
control line gives information on the integrity of the antibody-dye conjugate (See figure 1)
129
Figure 14: Mode of action malaria RDT
Procedure of RDT (e.g. Care Start test kit)
Content of test kit are:

 Test device
 Assay buffer
 Pipette/dropper
 Alcohol pads
 Lancet
 Procedure card
Materials required while doing RDT

 Timer or hand watch
 Sharp disposal box
 Biohazard bag
 Lead pencil or pen for labeling
Procedure
 Open the test pouch: check all kit items are in place; if not then discard
 Prepare the RDT device and label it with name of the patient or give serial number
 Clean the finger of the patient with alcohol swab
130
 After the alcohol dries out prick the finger of the patient
 Wipe out the first drop of blood
 Collect sample from the finger prick using pipette provided, and while gently squeezing the
tube, immerse the open end in the blood drop and then gently release the pressure to draw blood
into the sample pipette up to the black line (5μl).
 Add 5μl of whole blood into the sample well
 Add two drops (60μl) of assay buffer into the buffer well
 Place the cassette on table or on flat surface for 20 minutes

 Read the test result in 20 minutes; and the result is interpreted as follows:
Interpretation of the test result:
Figure 15: RDT procedure and interpretation

131
 Negative reaction: The presence of only one band in the control area within the result window
indicates a negative result.
 Invalid: The test is invalid if the line in the control area does not appear. If this occurs, the test
should be repeated using a new strip.
 Positive reaction - P. falciparum: The presence of three color bands (three bands in the Control,
"2" and "1" areas) or two bands (one band in the control area and another band in the "1" area)
indicates a positive result for P. falciparum.
 Positive reaction -P. vivax, P. malaria, or P. ovale: The presence of two color bands (one band
in the Control Area and another band in the "2" area) indicates a positive result for P. vivax, P.
malariae, or P. ovale. The pLDH present in the sample reacts with the pan anti-pLDH conjugate
and move through the test strip where the pLDH is captured by pan specific anti pLDH.
 Positive reaction - Mixed infection of P. falciparum and other species the presence of three
color bands (three bands in the Control, "2" and "1" areas) indicates a positive result for P.
falciparum or mixed infection of P. falciparum and other species.
Precaution on the interpretation of RDT results: A positive RDT result does not always signify
malaria illness because the antigen of malaria parasites might be sometimes be detected after
treatment or due to the persistence of malaria gametocytes in the absence of illness, presence of other
substances in the blood might occasionally produce a false-positive result.
Advantage and disadvantages of using RDT:

Advantages
 Easy to use and rapid, on spot test results
 No/little manipulation of sample
 No refrigeration of sample or reagent
 Use of whole blood possible.
 Can detect sequestrated malaria
Disadvantages:
 Short shelf life (storage and distribution)
 Only qualitative result no quantification of malaria parasite
132
 Less sensitive and specific compared to microscopy, however has little clinical implication on
patient care (RDT negative: malaria unlikely; positive treat for malaria)
 Inability to identify sexual and asexual parasite stage
 Less accurate on identifying species of the parasite
 Post treatment positive result due to long survival of malaria antigen in peripheral blood
 Sometime presence of abnormal antibody in the patient peripheral blood may block Ag – Ab
reaction on nitrocellulose to see visible reaction.
 Band intensity depends on Ag – Ab reaction.
Points to remember when performing RDT
 Product instructions should be strictly followed

 Management plan for results must be in place
 Blood-safety precautions should be followed
 Should be discarded if the envelope is punctured or badly damaged
 The test envelope should be opened only when it has reached ambient temperature
 The RDT should be used immediately after opening
 The result should be read within the time specified by the manufacturer
133
Quality Assurance of Malaria Laboratory Diagnosis
 Quality Assurance (QA) is a system designed to improve the reliability and efficiency of
laboratory services.
 Components of QA:
 Quality Control (QC): internal monitoring of work practices, technical procedures,
equipment, and materials
 External Quality Assessment (EQA): Assessment of laboratory performance by
external higher body
 Quality Improvement (QI): the components of malaria microscopy services are
analyzed with the aim to identify and permanently correct any deficiencies
External Quality Assessment methods
1- Proficiency testing /PT/
 The laboratory performs malaria microscopy on a set of prepared slides received from the
reference Laboratory
 It is used to check the staining procedure as well as the ability of the personnel to recognize
and identify any malaria parasite present
 It provides a rapid picture of the proficiency of many laboratories
2- Blinded Rechecking
 It is rereading of randomly selected slides collected from the “testing” laboratory at higher
level laboratory
 Detects malaria misdiagnosis in routine work and assess the overall quality of testing
 It reflects a true performance of laboratories offering routine diagnostic services at the
peripheral level
 Checks not only the result of the blood film, but also the performance of the stain and quality
of blood film
 Feedback to the participant site with comments and recommendation should be given timely
3- Onsite Supervision
134
 Is comprehensive assessment of essential elements of laboratory quality system
 It is ideal means of obtaining a realistic picture of the conditions and practices in a
laboratory
 Provides opportunity for immediately identify sources of errors, provide onsite corrective
actions, and implement appropriate measures to resolve problems
 It is done for both microcopy and RDT service facilities
135
LEARNING UNIT NINE
Supply Chain Management
Learning objectives
By the end of this training, participants should be able to:
 Describe supply chain management
 Define pharmaceutical supply chain management
 Understand logistics cycles
 Define and understand drug quantification
 Fill the different LMIS forms
Overview of Pharmaceuticals Supply Chain

Pharmaceuticals supply chain management: encompasses the planning and management of all
activities involved in selection, quantification, procurement, storage, distribution and delivering a
final product or service, from the supplier’s supplier to the customer’s customer. In essence, supply
management should integrate supply and demand management within and across the health facilities
and supply chain levels.
Logistics: Management of materials in motion and at rest. Some scholars also defined as the flow of
material, information, and money between consumers and suppliers or what is happening in the
supply chain. Logistics is part of SCM.
The purposes of logistics are to ensure the SIX Rights in order to serving customers, ensuring health
commodity security exists for each client:
Ensuring the six rights:
 Right product in the
 Right quantity of the
 Right quality at the
 Right place at the
 Right time for the
136
 Right cost
Well-functioning supply chains benefit public health programs in important ways by:
• Increasing program impact
• Enhancing quality of care
• Improving cost effectiveness and efficiency.
Logistics Cycles and Activities

The following figure summarizes the logistics cycles and activities.
Figure 16: Logistics Cycle and Activities
Product Selection
Product selection is the first “action area” for our pharmaceuticals supply chain system. When we
select the products that we intend to put into our system and distribute to the customer, we must take
into account things like the capacity of our system: if we are selecting products that require cold
chain, for example, then we must ensure that we have the facilities required to safely store and
transport those products all the way to the customer. The process expected to be participatory.
137
Quantification
Quantification, a critical supply chain management activity, links information on pharmaceuticals
demand from the health facility level with program policies and plans at the national level to estimate
the quantities and costs of the pharmaceuticals required for a health program. Quantification is
important for informing supply chain decisions for financing, procurement, and delivery. It is not a
one-time exercise; it should be exercised in a regular manner depending on the pharmaceuticals to
be determined. Health facilities are required to forecast their need (estimating the quantity of each
product that will be dispensed or used for the next year) and adjust their expected budget.
Pharmaceutical needs can be quantified by using one or a combination of more than two standard
methods. Consumption and Morbidity method are the two major quantification methods which are
relevant and practical at health facility level.
Procurement
Once we know the quantities that we need to meet our needs, then we must obtain those products
from our supplier, that is, we must procure our need. Health facilities procure preferentially through
PFSA, products which are not found at PFSA can be procured from private suppliers using stock out
certificate.
Storage, Inventory Management and Distribution

Once the products have been procured and received in health facility, there should be appropriate
storage and distribution within a hospitals and health centers. Storage must be adequate to maintain
the quality of our products and storage capacity must be adequate to manage all of the products in
our system. The purpose of an inventory control system is to inform personnel when and how much
of a pharmaceuticals to order and to maintain an appropriate stock level to meet the needs of patients.
A well designed and well operated inventory control system helps to prevent shortages, oversupply,
and expiry of pharmaceuticals.
The SOP for the IPLS in health facilities of Ethiopia dictates all hospitals and health centers are
required to order on a fixed schedule from PFSA
- Hospitals and health centers place order every 2 months
- Orders are placed using RRF
138
LMIS: the LMIS is shown at the center of the cycle, and we consider it to be the engine which drives
the supply chain system. The LMIS is the means through which we gather and communicate the
information that allows managers to make the decisions they need to make in order to ensure product
availability and customer service. Every function in the supply chain cycle needs accurate
information in order to work. For example, without a properly functioning LMIS:
 We do not know which products are being accepted and used by our customers (which
products to continue to select or stop selecting).
 We do not know if we are obtaining the right quantities at the health facility level to
serve the customers’ needs.
 We do not know if stores are sitting empty or if products are piling up and not being
dispensed.
 PFSA do not know what, when and how much products HFs need.
The other activities found at the center of the supply chain cycle are management support activities
that are also essential to the functioning of the system as a whole.
Figure 17: Flow of Pharmaceuticals and Information in the Integrated Pharmaceutical Logistics System
Requesting and Getting Pharmaceuticals from PFSA

In IPLS hospitals and health centers are expected to summit all pharmaceutical transaction reports
and orders/requisitions bimonthly by using a form called Report and Requisition Form (RRF) to a
nearby PFSA branch. RRF should be completed at the end of the month and sent to PFSA until the
10th day of the month following the end of the reporting period. This report is expected to be
139
completed by Health Centre or Hospital Store Manager (verified by the Pharmacy Head and
Approved by Head of the Health Centre or Hospital.
Unless PFSA receives request from HFs timely and completely/accurately PFSA will face challenge
to resupply pharmaceuticals to HFs and this will negatively affect the service.
The role of drug and therapeutic committee (DTC) in inventory management, storage and distribution
of pharmaceuticals within health facility includes:
 Monitor the bi-monthly report and requisition form (RRF) is completed timely and sent to
PFSA and internal reporting is implemented as indicated by the IPLS SOP manual.
 The DTC should also check and evaluate the quality of the data on the RRF on regular
basis.
 Approve pharmaceuticals list of each dispensing units.
 Approve and ensure the implementation of SOPs for guiding the whole process of
distribution.
 Monitor the application of storage guidelines in the pharmacy store and dispensing units.
 Make sure that system is in place to monitor stock status at main pharmacy store and
dispensing units, and disposal of unfit for use pharmaceuticals is working.
140
LEARNING UNIT TEN
Malaria Epidemics Detection and Response
Learning Objectives
At the end of this training, participants should be able to:
 Define malaria outbreak and epidemics

 Describe the purpose of malaria epidemic forecasting and early warning
 Explain the basic principles of malaria epidemic detection and response.
Definition
Outbreak: is an increase in number of cases of a disease compared with the expected number. An
outbreak lasts for only a short time, or it occurs only in a limited area.
Epidemics: is also an excess number of cases compared with the number expected. However, an
epidemic is more general than an outbreak, the increase in the number of cases continues far longer,
and the cases are distributed across a wider area.
Malaria epidemics: are the occurrence of numbers of cases above what is expected in a place in a
particular time period. Sometimes it is hard to distinguish malaria epidemics from usual seasonal
upsurge of malaria. Malaria epidemics can be one of the most serious public health emergencies.
Malaria epidemics may occur with little or no warning and may challenge the health system to
prevent or effectively respond to the problem and may strain health facilities and systems, and cause
public outcry resulting in intense political pressure for rapid and decisive intervention.
Overview of Malaria Epidemics in Ethiopia

A devastating malaria epidemic occurred in 1958, involving about three million cases and 150,000
deaths, and covering about 100,000 square miles (259,000 square kilometers) of highland area. Since
1958, major epidemics of malaria have occurred at approximately 5-8 year intervals, though there
has been a trend towards smaller-scale, more frequent, sporadic epidemics and seasonal case build
ups. In 1998, a widespread severe malaria epidemic occurred in most highland as well as lowland
areas in the country. Many localized but severe outbreaks of malaria occurred in Amhara and SNNP
Regional States, leading to widespread epidemic malaria in highland and highland fringe areas (up
to 2,500 meters) in 2003. However, there has not been any major malaria epidemic since 2003.
141
Factors Precipitating Malaria Epidemics
Malaria epidemics can occur as a result of variability or changes in the rate of infection and
population immunity. Generally malaria epidemics occur in places where there is low and unstable
transmission, and where people have low or no immunity against malaria. There could be epidemics
in high transmission areas as well if there is deterioration of health system, interruption of anti-
malarial measures or migration of non-immune individuals, such as population movement in search
of labor to these areas. Other triggering factors include:
 Unusual local weather phenomena and activities resulting in environmental modification that
increase vector population;
 Increased vulnerability of population from famine and malnutrition;
 Interruptions of anti-malarial measures which have kept malaria under control;
 Resistance to anti-malarial medications and/or insecticide used for vector control.
Epidemic Preparedness
Preparedness includes availability of trained human resources, diagnostics, anti-malarial drugs,
supplies and insecticides. As a rule, an additional 25% of the annual drug requirement should be kept
as contingency at woreda or health center level, since there is always uncertainty regarding where
the epidemic will occur. The additional 25% need only be spent until a verified malaria epidemic
occurs; following the response to an epidemic outbreak, the contingency stock would have to be
replenished.
Contingency supplies must be transported to the various levels well in advance. All RHBs and
woredas should plan, request and budget the amount of contingency supplies required at each level
as accurately and realistically as possible. This is part of the annual malaria commodity “micro-
planning” process. All levels of the public health system should report at least monthly to higher
levels the status of their inventories of critical supplies as well as expiry status.
Epidemic Detection
There are two methods of epidemic detection. Method 1 is the classic method, based on norm charts
and thresholds. This is currently recommended and probably will continue to be used for some time
in areas of higher transmission. Method 2 (cluster mapping) will be tested and gradually introduced,
where applicable; as malaria incidence and transmission in an area falls to low levels this new method
142
will improve management of the relatively few clusters of malaria infection that remain within
communities.
In a strict sense, an epidemic of malaria is defined as a situation when the number of malaria cases
is in excess of the normal number at a specific period of time and place. Therefore, the "normal"
expected number has to be estimated. One way to do this is by using past weekly data of up to five
previous years to construct a third quartile (second largest number) threshold line in an epidemic
monitoring chart.
Many, if not most, malaria illness in Ethiopia probably represents micro-clustering of local malaria
transmission near a home, whereas isolated non-clustered infections might represent importations or
relapses (though possibilities of indigenous transmission should be scrutinized and ruled-out). Local
“micro-clusters” of malaria infections are defined as three or more indigenous cases of malaria of the
same species occurring in homes within 1 km distance of one another within a 28-day interval,
indicating probable local transmission. These should be detectable early by the HEW at the health
post, when approximate map sector locations of homes of ill persons with malaria are systematically
documented in malaria registers along with date of illness (Method 2).
The key principles of epidemic detection and action (using any detection method) are:
 Defining epidemics according to a particular time period and area (usually health facility
catchment area). The basic unit of time is a week; epidemics in Method 1 are defined according
to a weekly threshold, while Method 2 uses a time window of up to four weeks.
 In both cases, taking actions to avert the epidemic as soon it is detected.
 Both methods use a combination of active surveillance and other containment actions (e.g.
promoting LLIN use, other vector control, requesting supplies and further support if needed)
once an epidemic has been detected. Method 2 provides an evidence basis for SBCC efforts and
other resources focused on areas within the kebele with the most intense recent malaria
transmission, i.e. malaria “micro-cluster” hot spots localized to within 1 km sectors.
 There is no need to wait for formal confirmation of an epidemic before starting active surveillance
and containment actions. Epidemics which spread beyond the kebele or woreda level may need
further support and confirmation from zonal, regional or national levels to release additional
resources supplies.
143
Method 1: Norm charts and thresholds
To establish a threshold for ‘normal’ for any given week, a health facility’s past data by week should
be compiled and a threshold determined using the ‘third quartile’ method. Current data may then be
compared with the threshold. If an increase above the weekly threshold is observed, it implies that
there may be an epidemic.
Under Method 1, an epidemic is defined as: “The occurrence in a health facility catchment area of
cases of an illness, clearly in excess of normal expectancy”.
Definition involves: clear time, place, and person
For this we need to know:
 Where? Which health facility catchment or other defined area
 When? What time period (“occurrence”)
 What is “normal expectancy” for that area and time period?
 What do we mean by “cases” (case definition)? How many of these and what proportion tested
have malaria by RDT or microscopy?
 What is regarded as “excess”?
 Who has become ill?
Health post or kebele: is the smallest administrative/operational unit to monitor and will be defining
epidemics in its catchment area. Hence, recording the address of people in registers is mandatory as
people from other catchment area may prefer your facility for various reasons (e.g. proximity,
availability of drugs). Catchment area population may appear to change due to temporary
malfunctioning of adjacent facilities or as a result of newly created facilities. However, district health
offices, health centers (primary health care units) can also monitor malaria trends using kebele-level
disaggregated data, since aggregated data might mask what is happening in individual kebeles.
Time period: the week is the primary time unit. ‘Week’ is defined in a standard way by WHO week
number (Annex T).
Normal expectancy: is defined based on that same case definition, catchment and week in previous
years. We have two choices, depending on what information we have.
144
“Normal” is: The third quartile (second highest number from the five previous years’ data for that
week); and doubling of the previous year’s number of cases (in the absence five years data).
Case definition: Choose ONE indicator as the primary one for defining epidemics. Ideally, it would
be CONFIRMED malaria cases (either as evidenced by a positive RDT or a positive microscopy
slide) in all age groups. If confirmation is not possible in your location then use clinical malaria cases,
but these must be classified as presumptive malaria (not parasitologically confirmed). The threshold
must be based on the same indicator, which is the most challenging requirement of Method 1, since
often at facility-level that malaria cases are diagnosed both clinically as well as parasitologically
based on the availability of RDTs or microscopy at facilities.
Note: If you have five years’ previous data (all years must be normal years, without an epidemic),
you can definitely determine that when malaria cases exceed the third quartile number (or line on the
chart) then there is an epidemic for that week. If you have less than five years’ data, you can say that
any number of malaria cases more than double the number in the same week of last year’s data is an
epidemic. In a strict sense, if no historical data (the last 5 years) is available at all for the catchment
area, an epidemic cannot be detected, since there is no known “normal”. However, an alarmingly
rapid rise in cases or mortality can be detected by doing a week-to-week comparison of case registers.
Alternatively, Method 2 could be used to monitor the malaria situation provided that the system is
established.
Why do we need a threshold? It can be very difficult to distinguish an epidemic from a normal
seasonal case increase. Once it is apparent that the seasonal case increase is much higher than normal,
the epidemic is well underway. Because health staff often move around to different health facilities,
they may not be aware of the expected number of cases in the local area.
How to calculate the threshold? The following tables give examples of how to tabulate data for
estimating a threshold by two methods. The data in the tables is illustrative and for this example only.
Table 18 is the empty sheet. Table 19 is filled in with the past five years’ data and shows the third
quartile threshold. Table 20 shows what to do if you only have one year’s data.
Thresholds can be calculated for any health facility or any other unit including kebele, woreda or
zone. However, the heath post catchment area (usually kebele) is defined to be the smallest
145
geographic area for monitoring epidemics. Higher levels could also monitor epidemics provided that
the data thresholds for monitoring are disaggregated by health post catchment area.
Table 19: Chart for assessing usual number of weekly cases (confirmed or clinical) and
threshold at health facility.
WHO Year Year Year Year Year Third Quartile or This year’s
Week 1 2 3 4 5 second largest cases
No. number or 2x last
year’s cases
1
2
.
.
.
51
52
(53)
Note:
1) Week number: the WHO week number system is used, and weeks run from Monday to
Sunday.
2) If 5 years of data are available, the Third Quartile can be filled in (Table 18). The Third
Quartile is the second highest number from the five values for each week.
3) The current year’s data should be added in right column, by week (“this year”).
4) If only last year’s data is available, a threshold of twice the last year’s number for that
week should be entered.
5) A new chart must be prepared each year, adding the new annual data (unless an epidemic
year) and dropping the oldest year.
6) The data can be plotted manually onto a norm chart with the threshold line and the current
year by week (Table 19).
7) For higher level health workers with computer capacity, a Microsoft Excel file for the can
be used to estimate the third quartile. For example, the formula for third quartile in a
second week (row-3) with five years’ data (B3 to F3) of a Microsoft Excel work book
sheet is given by =QUARTILE(B3:F3, 3). Then, draw charts (Table 20) and update the
threshold each year.
146
Table 20: Construction of the threshold (norm) when five years' historical data are available
to monitor the current year
WHO Year Year Year Year Year Third Quartile or second This
Week 1 2 3 4 5 largest number or 2x last year’s
No. year’s cases cases
1 8 42 6 36 14 36 20
2 12 42 27 38 17 38 22
3 10 42 43 49 21 43 35
4 20 17 34 59 32 34 26
5 34 17 46 20 30 34 25
6 18 10 34 22 23 23 20
7 12 19 33 24 25 25 21
8 37 10 27 61 23 37 25
9 32 18 37 29 26 32 16
10 31 24 28 17 13 28 5
11 22 19 22 12 23 22 15
12 17 39 31 22 43 39 25
13 5 19 19 16 21 19 16
14 22 19 28 25 21 25 30
15 29 16 28 19 13 28 45
16 17 32 25 6 11 25 60
17 28 11 32 8 8 28 62
18 17 34 40 13 9 34 60
19 12 17 27 9 10 17 25
20 16 18 14 1 9 16 10
21 31 34 29 2 8 31 15
22 38 22 23 1 9 23 16
23 29 33 14 1 17 29 17
24 19 32 35 1 32 32 18
25 27 10 25 1 34 27 22
26 36 20 34 1 47 36 30
27 15 32 36 4 62 36 35
28 19 42 44 8 38 42 36
29 52 49 47 10 62 52 101
30 31 44 45 12 73 45 122
31 31 51 53 94 142 94 135
32 97 67 56 114 104 104 176
33 42 73 67 94 67 73 200
34 74 61 71 82 124 82 250
35 53 123 46 57 130 123 261
36 41 58 92 79 129 92 261
37 76 136 118 70 125 125 255
147
38 116 113 134 37 87 116 244
39 94 145 128 73 138 138 230
40 93 102 194 103 139 139 269
41 108 692 171 52 178 178 267
42 34 178 168 59 208 178 233
43 49 165 232 59 164 165 199
44 27 183 145 44 114 145 145
45 16 283 111 34 103 111 67
46 55 141 150 40 105 141 53
47 33 133 112 20 105 112 52
48 40 122 87 25 81 87 45
49 40 95 102 30 42 95
50 19 67 71 30 33 67
51 26 56 21 38 27 38
52 23 55 34 29 6 34
(53)
Note: The threshold is the 3rd quartile. The epidemic weeks in the current year are shaded in the
right column.
148
Table 21 Construction of threshold (norm) with single recent year morbidity data
WHO Year Year Year Year Year Threshold This Year’s

Week No. 1 2 3 4 5 (norm) = 2x cases
last year’s
cases
1 14 28 20
2 17 34 22
3 21 42 35
4 32 64 26
5 30 60 25
6 23 46 20
7 25 50 21
8 23 46 25
9 26 52 16
10 13 26 5
11 23 46 15
12 43 86 25
13 21 42 16
14 21 42 30
15 13 26 45
16 11 22 60
17 8 16 62
18 9 18 60
19 10 20 25
20 9 18 10
21 8 16 15
22 9 18 16
23 17 34 17
24 32 64 18
25 34 68 22
26 47 94 30
27 62 124 35
28 38 76 36
29 62 124 101
30 73 146 122
31 142 284 135
32 104 208 176
33 67 134 200
34 124 248 250
35 130 260 261
36 129 258 261
37 125 250 255
38 87 174 244
39 138 276 230
40 139 278 269
149
WHO Year Year Year Year Year Threshold This Year’s
Week No. 1 2 3 4 5 (norm) = 2x cases
last year’s
cases
41 178 356 267
42 208 416 233
43 164 328 199
44 114 228 145
45 103 206 67
46 105 210 53
47 105 210 52
48 81 162 45
49 42 84
50 33 66
51 27 54
52 6 12
(53)
Note: The threshold (norm) is 2x the previous year’s value for the week. The epidemic weeks in the
current year are shaded in right column.
Figure 18: Norm chart for plotting weekly morbidity data: confirmed cases
150
Threshold third quartile This year
Number of malaria cases
Week number
Figure 19: Chart drawn from Table 19 showing epidemic weeks in current year above third quartile threshold
Threshold 2x last year This year

Number of malaria cases
Week number
Figure 20: Chart drawn from Table 20 showing epidemic weeks in current year based on threshold of twice last
year's weekly data
151
Epidemic Confirmation
Epidemics detected through health facility registers using norm charts (Method 1) are by definition
epidemics and do not need additional confirmation, assuming that they were based upon RDT or
laboratory confirmed cases. Epidemics detected by mapping of micro-clusters of cases (Method 2)
also assume RDT or microscopy verification, and should be handled immediately by HEWs. In both
situations, large epidemics will require that microscopy slides be collected for analysis by FMOH
(EPHI) experts; and in certain cases dried blood spots on filter paper may be collected for serological
analysis.
Initially, the most important information needed for an assessment will be:
a) How many suspected malaria cases (persons) were documented within a specified time
interval (week, month) within a specific district or kebele (place)?
b) How many of these suspected malaria cases were tested by RDT or microscopy?
c) How many of the suspected malaria cases tested were also diagnosed as positive for
malaria
d) How many laboratory-confirmed malaria cases were P falciparum and how many were
P. vivax?
e) How many deaths, hospitalizations and severe malaria cases occurred?
f) Are there adequate supplies of RDTs, AL and chloroquine (and quinine, rectal artesunate,
IV artesunate)?
g) If available, compare current malaria case numbers with previous malaria registry data.
For large epidemics (several woredas or zones), a detailed emergency plan of action should be
rapidly, but carefully, prepared in order to optimally use available personnel, finance, transportation,
supplies and time. In this plan, the responsibilities, localities to be covered and schedule of work for
each control team should be shown clearly and shared as appropriate at the kebele, zonal and regional
levels.
Response to Malaria Epidemics

Whether an epidemic is detected by Method 1 or 2, certain active surveillance and other control
actions are triggered and should continue for up to one month or until no further cases are detected
for at least two months. At the end of the four-week period, epidemic status should be reassessed and
152
a decision made to continue active surveillance or revert to normal passive surveillance and
treatment. If an epidemic is detected, the active surveillance should be as follows:
Mass fever testing and treatment (MFTT): Test everyone with fever and treat those with
confirmed malaria. This step should be taken when sufficient RDTs are in stock and as long as RDT
positivity is below 50%, upon examination of 50 febrile patients. Treatment must be species-specific
(refer to Learning unit three).
Mass presumptive fever treatment (MPFT): When, upon examination of 50 febrile patients, RDT
positivity is equal to or greater than 50%, action should switch to MPFT (treat all persons with fever
presumptively). This should be done when stocks of RDTs are low (while waiting for supply), or if
RDT positivity among at least 50 actively detected and tested suspected cases increases to more than
50%. MPFT indicates treatment with AL plus PQ, unless the cause of the epidemic is definitely
confirmed to be P. vivax only.
Both MFTT and MPF are most rational within malaria ‘hot zones’ (i.e. households especially within
500 meters of a cluster of known recent malaria transmission/cases) beginning with the nearest
homes. Registers must be kept of persons actively tested and treated.
Other interventions to be taken simultaneously with MFTT and MPF: Treat and refer severe
malaria cases; request more supplies to replace those expended; use effective anti-malarial
medication that are closest to expiry date; SBCC for improving LLIN use; consider IRS if evidence
from epidemiological analysis ensures that transmission will continue despite treatment
interventions.
Reporting
Listings of persons tested and treated during ‘mass fever treatment’ or ‘mass test and treat’ active
surveillance must be reported. The following table may be used for recording ‘mass fever treatment’
or ‘mass test and treat’.
Starting from one randomly selected household in the highly affected part of the village, take 20
houses in sequence and fill in the following format:
153
Table 12: Reporting form for active surveillance and treatment
HH Total no. No. of No. of blood samples No. and proportion of Treatment
No. of HH sick (RDT or positives out of given
members (febrile) microscopically) examined
household examined (if applicable)
members RDT Microscopy RDT Microscopy
1
20
Total
Note: Indicate the type of diagnosis, i.e. RDT or microscopy. Then determine fever rate and test
positivity rate from the sampled households. Health posts should also report status of malaria
supplies inventory.
Whether an epidemic is detected by Method 1 or 2 anywhere in the satellite health post’s catchment
area, the report must be immediately relayed to all responsible higher levels. The mitigation activities
initiated by the health post must be supervised and leveraged by the health center and woreda health
office. Any epidemics beyond the capacity of the health center should be handled at the woreda level
using local contingency supplies. Progress on mitigation activities and gaps must be reported to
higher levels on a daily and weekly basis.
When an epidemic is detected and reported by any primary health care units, this must be
immediately relayed to all responsible higher levels. The mitigation activities initiated must be
followed-up and supportive supervision planned and implemented if necessary. Any epidemics
beyond the capacity of the woreda should be handled by the zone/RHB. Progress on mitigation
activities and gaps must be reported to higher levels on a daily/weekly basis throughout the mitigation
process. Once an epidemic is evident at the woreda level, the situation is probably quite serious and
154
the zone as well as the RHB must be informed. The epidemic report form (PHEM form) must be
completed and disseminated to higher levels.
Case Management (See Case Management Guidelines for detail)
P. falciparum epidemics: AL+PQ is the first-line anti-malarial drug recommended for the treatment
of uncomplicated P. falciparum malaria. AL is recommended for the treatment of pregnant women
in the first trimester with uncomplicated malaria.
P. vivax epidemics: Use chloroquine if the cause of the epidemic has been established as only P.
vivax.
Mixed P. falciparum and P. vivax epidemics: Use AL+ PQ treatment for mixed P. falciparum and
P. vivax infections.
Management of severe malaria in epidemic situations should take place in hospitals and health
centers using intravenous medications, whenever possible. Hence, severe malaria cases diagnosed in
health posts or community level should be referred to the nearby health center or hospital as promptly
as possible.
Stabilizing therapy, such as artesunate suppositories or IM artemether or IM quinine, may be needed

in temporary posts or situations in which staff shortages and high workloads make intensive care
monitoring difficult. The following should be done before referral of the patient:
- Always nurse patients in a coma in a lateral position to avoid aspiration;
- Give 40% or 50% glucose to all patients with severe manifestations;
- Use tepid sponging as needed,
Record all your findings and drugs given in a referral slip and refer the patient to the nearest health
center or hospital.
Exercise:
Group work: The following two tables contains last year’s and five year’s weekly data on malaria
cases. Study the table and then answer the questions below it.
Identify the threshold for each scenarios?
155
Draw the chart using the give data?
Interpret the result?
Exercise 1: One year data
Week Week no 2007 doubling This year (2008)

no. (WHO) Previous
(EFY) year data
1 28 38 36
2 29 62 101
3 30 73 122
4 31 142 135
5 32 104 176
6 33 67 200
7 34 124 250
8 35 130 261
9 36 129 261
10 37 125 255
11 38 87 244
12 39 138 230
13 40 139 269
14 41 178 267
15 42 208 233
16 43 164 199
17 44 114 145
18 45 103 67
19 46 105 53
20 47 105 52
21 48 81 45
22 49 42 18
23 50 33 22
24 51 36 30
25 52 38 35
26 1 24 20
27 2 20 22
28 3 21 35
156
Week Week no 2007 doubling This year (2008)
no. (WHO) Previous
(EFY) year data
29 4 32 26
30 5 30 25
31 6 23 20
32 7 25 21
33 8 23 25
34 9 26 16
35 10 13 5
36 11 23 15
37 12 43 25
38 13 21 16
39 14 21 30
40 15 13 45
41 16 11 60
42 17 8 62
43 18 9 60
44 19 10 25
45 20 9 10
46 21 8 15
47 22 9 16
48 23 17 17
49 24 32
50 25 34
51 26 47
52 27 62
157
Exercise 2: Five years data
Week Week second

This
no. no 2003 2004 2005 2006 2007 largest
year
(EFY) (WHO) number
1 28 19 42 44 8 38 36
2 29 52 49 47 10 62 101
3 30 31 44 45 12 73 122
4 31 31 51 53 94 142 135
5 32 97 67 56 114 104 176
6 33 42 73 67 94 67 200
7 34 74 61 71 82 124 250
8 35 53 123 46 57 130 261
9 36 41 58 92 79 129 261
10 37 76 136 118 70 125 255
11 38 116 113 134 37 87 244
12 39 94 145 128 73 138 230
13 40 93 102 194 103 139 269
14 41 108 692 171 52 178 267
15 42 34 178 168 59 208 233
16 43 49 165 232 59 164 199
17 44 27 183 145 44 114 145
18 45 16 283 111 34 103 67
19 46 55 141 150 40 105 53
20 47 33 133 112 20 105 52
21 48 40 122 87 25 81 45
22 49 40 95 102 30 42 18
23 50 19 67 71 30 33 22
24 51 26 56 21 38 27 30
25 52 23 55 34 29 6 35
26 1 8 42 6 36 14 20
27 2 12 42 27 38 17 22
28 3 10 42 43 49 21 35
29 4 20 17 34 59 32 26
30 5 34 17 46 20 30 25
31 6 18 10 34 22 23 20
32 7 12 19 33 24 25 21
33 8 37 10 27 61 23 25
34 9 32 18 37 29 26 16
158
Week Week second
This
no. no 2003 2004 2005 2006 2007 largest
year
(EFY) (WHO) number
35 10 31 24 28 17 13 5
36 11 22 19 22 12 23 15
37 12 17 39 31 22 43 25
38 13 5 19 19 16 21 16
39 14 22 19 28 25 21 30
40 15 29 16 28 19 13 45
41 16 17 32 25 6 11 60
42 17 28 11 32 8 8 62
43 18 17 34 40 13 9 60
44 19 12 17 27 9 10 25
45 20 16 18 14 1 9 10
46 21 31 34 29 2 8 15
47 22 38 22 23 1 9 16
48 23 29 33 14 1 17 17
49 24 19 32 35 1 32
50 25 27 10 25 1 34
51 26 36 20 34 1 47
52 27 15 32 36 4 62
159
Weekly malaria cases in 2004–2008 (EFY).
Week Week second
This year
no. no 2003 2004 2005 2006 2007 2008 largest
(2009)
(EFY) (WHO) number
1 28 16 42 105 36 14 42 33
2 29 12 42 100 38 17 22 35
3 30 16 42 103 49 21 34 40
4 31 20 17 134 59 32 40 39
5 32 34 17 146 20 30 39 33
6 33 18 10 134 29 23 27 30
7 34 30 19 133 24 25 25 29
8 35 37 10 127 41 23 42 42
9 36 32 18 137 29 26 29 35
10 37 31 24 128 17 13 32 30
. . . . . . . .
51 26 26 40 134 32 39 39 .
52 27 23 35 110 27 25 33 .
a. Which year do you think the data shows an abnormally high number of malaria cases? What
do you do with this year before you start identifying the second largest number?
b. Identify the second largest number for the six years of data (2003 –2008) and fill in the
column in the table.
c. Use the blank epidemic monitoring chart and plot a reference line of the second largest
numbers and the data for the year 2009 against it.
d. Does the graph show weeks when an epidemic occurred? If yes, in which weeks?
160
LEARNING UNIT ELEVEN
Monitoring and Evaluation
Learning Objectives
By the end of this session, participants will be able to:
 Identify the definition and purpose of M&E.
 Explain the Ethiopian Malaria Program M&E framework
 Recognize national malaria related indicators and how they are generated
 Recognize the importance of evidence-based decision making
 Demonstrate how to fill different M&E forms
Definition and purpose of M&E

Definition: Monitoring and Evaluation refers to a process by which data are collected and analyzed
in order to provide the information necessary for effective program planning and management.
Monitoring is a process of measuring progress towards program/project objectives through tracking
activities conducted, resource utilization, and the outputs generated.
Evaluation is a process of determining systematically and objectively the relevance, effectiveness,
and impact of interventions in relation to their objectives.
Purpose: The overall purpose of monitoring and evaluation of malaria program is to improve the
program based on evidence regarding the effective and efficient use of program resources. M&E also
helps to track changes in the services provided, and in the desired outcomes. It also generates new
knowledge by identifying factors (individual, community, programmatic) that influence health
outcomes, and justifying use of allocated resources (increasing cost-effectiveness). Furthermore
M&E helps to meet an organizational requirement (e.g., reporting to development partners). Hence,
M&E is a backbone of malaria program that enables effective and efficient implementation of
interventions.
161
The Difference between Monitoring and Evaluation
Monitoring
Monitoring involves the routine tracking of progress of the implementation of a program’s activities
and changes in program performance over time. It is a continuous oversight of the implementation
of a program’s activities. Its purpose is to allow the program’s stakeholders to understand if the
program is achieving its objectives and utilizing its resources efficiently. Examples of monitoring
questions are indicated below.
 Were inputs made available to program/ project in the quantities and at the time specified by the
program/project work plan?
 Were the scheduled activities carried out as planned?
 How well were they carried out? Did the expected changes occur at the program/project level,
in terms of people reached, materials distributed?
Monitoring seeks to establish if the resources invested (inputs), the activities undertaken, the quality
of those activities (processes), and number of activities performed (outputs) are proceeding according
to plan. It also includes the regular collection and analysis of data to assist in timely decision-making,
to aid in program planning and management, to ensure accountability and lastly, to provide a basis
for evaluation and learning.
Evaluation
Intends to measure how well the program activities have met their expected objectives and/or whether
the changes in the outcomes observed can be attributed to the program. Evaluation entails the process
of determining the worth or significance of a program or intervention.
Evaluation answers the question “what have we achieved?” Questions to be asked in evaluation:
 Did the LLINs national distribution program reduce inequity in household ownership of
insecticide-treated nets?
 Was the program effective in increasing the population’s knowledge of the proper use of LLINs?
 Did the program’s activities to increase access to ACT treatment for children under five-age lead
to a decline in malaria-specific mortality?
162
Summary of the difference between M&E
Monitoring Evaluation
Routine and continuous Time bound
Internal to program External or internal
Regular Periodic assessment
Measures actual performance Impact Evaluation
Tracks cost Evidence of changes due to program
Done by those in the program Rigorous and requires a design
Monitoring and Evaluation Frameworks

Frameworks are useful in helping us understand the relationships between each element of the
program; inputs, processes, outputs, outcomes and between the program activities and the
environmental context where the program will be implemented.
Inputs: The resources invested in a program, for example, technical assistance, financial resources,
infrastructure and equipment.
Processes: The activities carried out to achieve the program’s objectives, such as training and
outreach.
Outputs: The immediate deliverables of a program achieved through implementation of activities,
such as providers trained or bed nets distributed.
Outcomes: Short-term and intermediate results at the population level achieved by the program
through the implementation of program activities, such as changes in people’s knowledge, attitudes
or behavior.
Impact: The long-term effects of a program, for example, changes in health status.
163
Figure 21: Logical framework for monitoring and evaluation
Ethiopian Malaria Program M&E system

The Ethiopian malaria monitoring and evaluation system is based on data collected through regular
reporting systems (PHEM and HMIS) and surveys and evaluations conducted periodically which
includes MIS, malaria program review and drug efficacy studies.
Information collected through HMIS is organized under the following data flow structure for all
health related data according to the national HMIS guidelines: health posts and health centers
(PHCU) report to the woreda. Woreda-based hospitals report to the woreda in which they are located.
Other hospitals report to the zone or to the region. Woredas report to the zone or the region. Zones
report to regions. Regions report to the FMOH
164
Figure 22: Regular reporting system (PHEM and HMIS)
The national malaria program M&E plan has identified M&E related targets during the control and
elimination phases. The realization of these targets is vital for the overall achievement of the national
vision of seeing malaria free Ethiopia. The targets identified are:
Control Phase
 100% of health facilities and health offices engaged in malaria control phase send weekly
malaria report to the next higher level
 100% of health facilities in epidemic prone areas adhere to the national epidemic and response
plan.
 100% of health facilities in epidemic prone areas have developed epidemic thresholds defined
by time period using all available past data of confirmed cases.
 100% of health facilities and Woreda health offices using epidemic monitoring charts based on
confirmed cases.
 100% of all detected malaria epidemics properly controlled per the national epidemic and
response plan within two weeks of onset.
Elimination Phase
 100% of facilities in the selected elimination districts will have standardized data capturing tools.
 100% of the clusters/Kebeles in selected elimination districts will have a trained functional
surveillance assistant.
165
 100% of health facilities in selected elimination districts will report weekly malaria data using
rapid reporting system.
 100% of index cases family and neighbors will be traced and tested.
Sources of Routine Data Collection

1. Health Management Information System: should be complete, timely and reliable at all levels
2. Public Health Emergency Management/ Surveillance: encompasses reporting of morbidity and
mortality data from health posts, health centers and hospitals through PHEM, including clinical
malaria (outpatient and inpatient), confirmed malaria by species and severe malaria.
3. Integrated Pharmaceuticals Logistical System (IPLS): developed to track all health
commodities from procurement to distribution to the Woredas level.
4. Activity and Performance Reports: Tracking program performance, and ensuring availability of
financial, human and other resources. Determining the level of service delivery that is achieved
during implementation efforts.
National malaria case management related indicators
Morbidity attributed to malaria: this indictor is defined as, Malaria cases per 1000 population and
the source of data are Patient register at HP; outpatient/ inpatient service-based registers
Facility-based malaria deaths: this indictor is defined as: Percentage of all deaths due to malaria
(according to confirmed malaria diagnosis). Data for this indicator are generated from Inpatient
register at health centers and hospitals.
Malaria positivity rate: Percentage of slides or rapid diagnostic tests found positive among all slides
and rapid diagnostic tests performed and data are generated from Laboratory register at health centers
and hospitals, patient register at HP
Confirmed malaria cases (number and rate): Number of confirmed malaria cases (by microscopy
or RDT) divided by Mid-year resident population by age per 1000 persons at risk of malaria
Percentage of out-patient malaria cases that received appropriate anti-malarial treatment

according to national policy: this is defined as number of outpatient malaria cases receiving ant
malarial treatment at health facility divided by number of outpatient patients malaria cases expected
to be treated at health facility level with appropriate treatment x 100 and the source of data are Health
facility records and registers
166
Table 2 List of Health Management Information System (HMIS) formats
S/n Name of the Reporting Form Data generated from

1 Health Centre OPD Disease Monthly Report OPD registrations book
2 Health Centre Monthly Service Delivery Report Laboratory registration
book
3 Health Centre IPD Disease Morbidity And Mortality IP registrations book
Monthly Report
4 Health Centre/ Hospital Quarterly Service Delivery Report Monthly service delivery
report
5 Health Post Monthly Disease Report form OPD registrations book
6 Health Post Monthly Service Delivery Report form OPD registrations book
Public Health Emergency Management/ Surveillance Form: takes account of Data generated
from Morbidity and mortality data from health posts, health centers and hospitals through PHEM,
including clinical malaria (outpatient and inpatient), confirmed malaria by species and severe
malaria. The recording format is indicated blow;
Table 3 PHEM Weekly Disease Report Form for Outpatient and Inpatient malaria Cases and
Deaths
Source: National PHEM Guidelines, 2012
167
LEARNING UNIT TWELVE
Health Facility Visit
Learning Objectives
By the end of this session, participants will be able to:
 Describe the profile of malaria patients with uncomplicated and severe malaria seen in the
hospital in the past month or quarter
 Take a history and conduct a clinical examination of (a) a child with fever at Pediatric outpatient,
(b) a patient with an uncomplicated febrile illness, and (c) a patient with severe malaria, who are
being treated in the hospital
 Assess the basis for diagnosis and the details of the management of the patients reviewed in the
second bullet above
 Describe the Integrated Pharmaceutical Logistics' System
 Describe completeness, timeliness and consistency of Health Management Information System
(HMIS) and Public Health Emergency Management (PHEM) hospital data.
Activities
Divided into five groups consists of 5 to 8 members.
Use the checklists and complete using:

 Feverish child (under five years) at paediatric outpatient department
 Febrile adult at adult outpatient department
 Very severe febrile disease (in patients)
 HMIS (OPD, Lab and other relevant team member
 Pharmaceutical Logistics Department
168
Checklist for Health Facility Visit
Malaria data management
Review the data from the previous reporting period
1. HMIS
a. OPD HMIS register
i. Number of malaria suspected cases _____________
ii. Number of malaria cases
1. Plasmodium falciparum ________
2. Plasmodium vivax ____________
3. Mixed infection (p.falciparum and p.vivax) _____
b. Tally sheet
i. Number of clinical malaria cases ___________
ii. Plasmodium falciparum ________
iii. Plasmodium vivax ____________
iv. Mixed infection (p.falciparum and p.vivax) ________
c. Laboratory register
i. Number of patients tested for malaria __________
ii. Plasmodium falciparum ________
iii. Plasmodium vivax ____________
iv. Mixed infection (p.falciparum and p.vivax) ________
d. HMIS reporting form
i. Number of patients suspected for malaria __________
ii. Number of patients tested for malaria __________
iii. Plasmodium falciparum ________
iv. Plasmodium vivax ____________
v. Mixed infection (p.falciparum and p.vivax) ________
e. Give your comments with regard to data completeness, consistency
___________________________________________________________________
_____
2. PHEM
a. Review the PHEM book
i. Number of patients suspected for malaria __________
ii. Number of patients tested for malaria __________
iii. Plasmodium falciparum ________
iv. Plasmodium vivax ____________
v. Mixed infection (p.falciparum and p.vivax) ________
b. Give your comments with regard to data completeness
__________________________________________________________________
3. Epidemic monitoring chart
a. Comment on threshold, is it updated? What is the interpretation?
169
Malaria drug supply management
Visit pharmacy
Review RRF and IRRF forms of the previous reporting period
 Are all columns filled appropriately? ______________
Check availability of drugs

 Artemether-lumefantrine
 Chloroquine
 Artesunate injection
 Quinine tablets
 Quinine injection
 Primaquine
 RDT
 Dihydroartemisinin + piperaquine (DHA-PPQ)
If there is drug shortage, find out the reason _____________________

Fever in adult patient and severe malaria
Identify a patient with acute fever or a patient with severe febrile disease
Age ____________ sex __________ Address ____________
Chief compliant:
History of present illness:
170
Systemic review
Normal or Describe if abnormal
abnormal?
General
HEENT
Respiratory
Cardiovascular
Gastrointestinal
Genitourinary
Integumentary
Musculoskeletal
CNS
Differential diagnosis:
Laboratory investigations that you order:
Actual laboratory findings:
Most likely diagnosis:
Treatment:
171
Checklist for health facility visit, IMNCI

Child’s Name: __________________________ Age______ months Sex _____ Weight: _____kg
Lt/Ht _______ cm Temp _____0C
ASK: What are the child’s problems? ______________________________________________ Initial
CLASSIFY
CONVULSING NOW
VOMITS EVERYTHING
Yes _____ No_____

breaths/minute. Fast breathing?
For how long? ______ Days
DOES THE CHILD HAVE DIARRHOEA? Yes

_____ No____
Look at the child’s general condition. Is the child:

For how long? _________ Days Lethargic or unconscious? Restless and irritable?
Is there blood in the stool? Offer the child fluid. Is the child: Not able to drink
or drinking poorly? Drinking eagerly, thirsty?
Yes___ No____

child traveled to malarious area Look for signs of MEASLES NOW : Generalized
in the last 30 days? rash,
- For how long has the child had And one of these: Cough, Runny nose or
fever? _ Days Red eyes.
172
-If >7 days, has fever been present Blood Film or RDT: Positive __ Negative___
every day? Not Done ____
last 3 months?
Look for mouth ulcers: If Yes, are they deep and

If the child has measles now or extensive?
173
References
WHO (2021). World Maria Report 2021. WHO: Geneva.
FMOH (2020). National Malaria Strategic Plan 2020-2025. FMOH: Addis Ababa.
FMOH (1998). Malaria diagnosis and treatment guidelines for health workers in Ethiopia. 1st
edition. FMHO: Addis Ababa.
FMOH (2004). Malaria diagnosis and treatment guidelines for health workers in Ethiopia. 2st
edition. FMHO: Addis Ababa.
FMOH (2012). National Malaria Guidelines. 3rd edition. FMOH: Addis Ababa.
FMOH (2022). National Malaria Guidelines. 4rd edition. FMOH: Addis Ababa.
FMOH (2015). Integrated management of newborn and childhood illness. FMOH: Addis
Ababa.
FMOH(2015). Training manual for syndromic management of sexually transmitted

infections: Trainer’s Guide. FMOH: Addis Ababa
WHO (2005). Malaria control in complex emergency: an inter-agency field handbook. WHO:
Geneva.
WHO (2011).Integrated Management of Childhood illness: caring for newborns and children
in the community .WHO Geneva. Available at
http://apps.who.int/iris/bitstream/10665/44398/4/9789241548045_Chart_Booklet_eng.pdf. Accessed on
February 7, 2017.
WHO (2012). Malaria Case management: Guide for participants. WHO: Geneva.
WHO (2012). Malaria Case management: Guide for tutors. WHO: Geneva.
WHO (2015). Guidelines for the treatment of malaria. 3rd ed. WHO: Geneva.
WHO (2016). Malaria elimination: Guide for participants. WHO: Geneva.
WHO (2016). Malaria elimination: Guide for tutors. WHO: Geneva.
174
Annexure
A. BIN CARD
Name of Health Facility:
Product Name, Strength and Dosage orm
Unit of issue:
Maximum Stock Level: Emergency Order Point:
Average Monthly Consumption (AMC):___________________
Doc. No. Received

Quantity Expiry
Date (Receiving from or Batch No. Remarks
Date
or Issuing) Issued to
Received Issued Loss/Adj Balance
III
B. STOCK RECORD CARD
Name of Health Facility:
Product Name, Strength and Dosage Form:
Unit of Issue: Location:
Maximum Stock Level: Emergency Order Point:
Average Monthly Consumption (AMC):___________________

Price
Doc. No. Received
Quantity Expiry
Date (Receiving from or Unit Price Remarks
Date
or Issuing Issued to
Received Issued Loss/Adj Balance Birr Cent
IV
C. Health Post Monthly Report and Re-supply Form
Name of the Health Post: Health Post ID Code:
Supplying Health Centre: Health Center ID Code:

Completed by Health Post Completed by Health Centre
Calculat
ed
Quantit Quantity
Consum Calculate
y Needed
Unit of Beginni Loss / Ending ption d Maximum Quantity
Receive to Reach
issue ng Adjustm Balanc this Consump Quantity to be
Ser. Product Code/Product d Max.
Balance ent e month tion last Supplied
No. Name/Unit G=E+F
month H=G–
E=
D
A+B+/-
C-D
A B C D E F G H I
Product description (pre-

1
printed)
2
Remarks:
Completed by (Name, Date and Signature) Completed by (Name, Date and Signature)
Approved by (Name, Date and Signature) :
Reporting Period From: (month/day/year) To: (month/day/year) Maximum Level: 2 months of stock
V|
Internal Facility Report and Resupply Form
Name of Reporting Period From: To:

Dispensing Unit:
Maximum Level (ML):_____________

COMPLETED BY UNIT COMPLETED BY STORE
Unit of Calculated Quantity

Maximu
issue Loss/ Consumptio Needed to
Ser. Beginning Quantit Ending m Quantity to
Item Adjustm n Reach
No. Balance y Balance Quantity be Supplied
ent E = A+B+/- Max.
Receive F =E * 2
C-D G=F–C
d
A B C D E F G H
1
2
3
4
5
Remarks :
Completed by (Name, Date and Signature) : Completed by (Name, Date and Signature) :
Approved by (Name, Date and Signature) :
VI |
D. Report and Requisition Form for Program Drugs
Health Facility: Region: ____________________________________________
______________________________________________ Zone:______________________________ Woreda:_______________
Supplying
Branch:______________________________________________ Maximum Stock Level = 4 Months of Stock
_
Reporting Period: From:___________To:
Emergency Order Point = 0.5 Months of Stock
______________________________
Report Part Requisition Part
Ending Balance Days

Quantit
Beginni Losses/ Calculated Out Maximu Quantity
y Quantity
ng Adjustme Consumpti of m Stock Needed to
Product Unit of Receiv DU Store Ordered
SN Balance nts on Stoc Quantity Reach Max
Description Issue ed
k
F G
F
= H= G-D-E
=A+B
A B C D E (120*F)
+/- C – D
/(60 –
–E
F)
1
2
3
Products with shelf life < 6 months (S/No, Quantity and Expiry date): Remarks:
Completed by:_________________________________________________ Signature:_____________________________________
Date:__________________________
Verified by:_________________________________________________ Signature:_____________________________________
Date:__________________________
Approved by:_________________________________________________ Signature:_____________________________________
Date:__________________________
VII |
|

Malaria Case Management Training Manual For Health Professionals in Ethiopia Participants Manual

Uploaded by

Document Informationclick to expand document information

Copyright:

Available Formats

Malaria Case Management Training Manual For Health Professionals in Ethiopia Participants Manual

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Malaria Case Management Training Manual For Health Professionals in Ethiopia Participants Manual

Uploaded by

Copyright:

Available Formats

Malaria Case Management Training Manual for Health

Dereje Duguma (MD,MIH)

The Learning Units

Core Competencies for trainees

 Identify the larvae and adult forms of anopheles mosquito

Different method will be used to deliver this training:

 Presentation and discussion

Criteria for certificate

Day Time Topic

 Describe the epidemiology of malaria in Ethiopia

Epidemiology of Malaria in Ethiopia

Classification of malaria transmission (stable and unstable)

Trend of malaria in Ethiopia

Number of confirmed malaria cases Number of supected malaria cases

Number of malaria deaths

The malaria parasites and vectors

Figure 5: Malaria Stratification map (NMEP 2020).

Malaria Classification Population(2020) Number of

Table 3: Proposed malaria interventions by stratum, July 2020, NMEP.

Malaria Recommended Interventions

The National Malaria Strategic Plan, 2020-2025

This subsection summaries main strategies and corresponding key interventions.

A. Enhancing community engagement, empowerment and mobilization

b) Engage, empower and mobilize communities in order to foster ownership of anti-malaria

B. Ensuring early diagnosis and prompt treatment

c) Generate evidence on suitability of chemoprophylaxis or seasonal chemoprevention

C. Strengthening vector control

b) Deploy quality IRS in selected districts/villages where epidemiological and operational

c) Implement targeted LSM (environmental management and larviciding) where appropriate

D. Improving malaria surveillance and response system

a) Improve and sustain uninterrupted supply of antimalarial commodities.

b) Conduct pre- and post-marketing surveillance of antimalarial commodities.

F. Ensuring human rights and gender equality in accessing malaria services

a) Review the existing equity disparities in delivering antimalarial interventions among

G. Strengthen engagement of all stakeholders, including CSOs and private sectors

b) Implement malaria public-private mix manual.

H. Strengthening malaria program management, operational research and M&E

d) Monitoring efficacy of antimalarial drugs and susceptibility of insecticides and assess

f) Promote the effectiveness, efficiency and accountability of malaria elimination programme

g) Develop comprehensive and costed annual operational plan.

Malaria Vectors’ Biology and Behavior

Malaria vector biology

Anopheles Mosquito Life Cycle

Malaria Vector Behavior

Indoor or outdoor biting

 Identify the etiologic agents of malaria

Definition and Etiologic Agents

Biological and clinical characteristics of different malaria species

Mode of transmission and life cycle of parasites

Malaria transmission by mosquitoes

Life Cycle of Malaria Parasite

Figure 9: Life cycle of malaria parasite

Clinical presentation and Diagnosis

Non-complicated malaria is symptomatic malaria with parasitaemia without signs of severity or

Clinical diagnosis (Malaria Suspect)

Parasitological diagnosis is required for confirmation of the diagnosis of malaria. It is recommended

Table 5: Treatment at Different Levels of Health Facility

P. vivax, without contraindication to PQ CQ + PQ (radical cure) CQ + PQ(radical cure)

Child’s Name: ______________________ Age months Sex _ Weight: ___kg