Overview of Malaria Control

Program in Nepal
• Nepal launched a large-scale malaria control
project as early as 1954 with financial
assistance from the United States Agency for
International Development (USAID)
• A National Malaria Eradication Programme
(NMEP) was launched in 1958 to eradicate the
disease.
• With failure of global malaria effort aimed at
eradication, program changed to Malaria
control program in 1978.
• Prevailing ecological,epidemiological and socio-
economic suggested changes in malaria control
strategy, as a result malaria control program
was revised in 1992 in accordance with global
malaria control strategy of WHO.

• In 1993,Malaria control division was dissolved

and activities were then carried out under
epidemiology and disease control division.
• The Global Fund to fight AIDS,
tuberculosis and malaria (GFATM)
started supporting a malaria control
programme in high-priority, malaria-risk
districts in Nepal since April 2004 .
• recently adopted a long-term malaria
elimination strategy with the ambitious vision
of a malaria-free Nepal by the year 2025
 Strategy of Malaria Control Program

• Early Diagnosis,prompt and effective

treatment of uncomplicated malaria cases and
development of referral system of
complicated and severe cases.

• Development of lab facilities for strengthening

early diagnosis.
• Rational use of antimalarial agents

• Encouragement to community for minor

environmental manipulations facilitating
malaria control.
• Promotion of insecticide impregnated bed net
whenever possible as a measure of vector control
and transmission risk reduction

• Development of skill of peripheral level health

staffs on different aspect of malaria control.

• Development of skill of MO and DHOs in

management of severe and drug resistant malaria
• Promote operational field research on malaria
on regular basis.
Life cycle
 CLINICAL FEATURES
• Fever - cardinal symptom.
• chills and rigors.
• accompanied by headache, myalgia,
arthralgia, anorexia, nausea & vomiting.
• Malaria suspected in patients in endemic
areas or recently visited endemic area &
presenting with above symptoms.
• All clinically suspected malaria cases should be
investigated by microscopy and/or RDT
Early diagnosis and complete treatment of malaria aims at:

●Complete cure
●Prevention of progression of uncomplicated
malaria to severe disease
●Prevention of deaths
●Interruption of transmission
 DIAGNOSIS

1 . Microscopy
• thick and thin blood
• gold standard for confirmation of diagnosis of malaria
• Advantages :
1. Sensitivity is high.
It is possible to detect malaria parasites at low densities
2. To quantify the parasite load.
3. To distinguish different species of malaria parasites and
their different stages.
2 . Rapid Diagnostic Test
• Based on the detection of circulating parasite
antigens.
• Several types of RDTs are available.
• Some of them can only detect P.falciparum,
while others can detect other parasite species
also.
 TREATMENT
• PRINCIPLES
1. Early diagnosis & prompt effective treatment
2. Rational use of antimalarial agents
3. Use of combination therapy
4. Appropriate weight based dosing
TREATMENT OF UNCOMPLICATED
MALARIA
P. vivax
• chloroquine 25 mg/kg.
• In some patients ( 8 - 30%) relapse due to
hypnozoites in liver cells
• Relapse prevention, primaquine 0.25 mg/kg daily for
14 days under supervision
• Primaquine is contraindicated in pregnant
women, infants and known G6PD deficient
patients.
• Primaquine can lead to hemolysis in G6PD
deficiency.
TREATMENT OF UNCOMPLICATED MALARIA

P. falciparum
• ACT
– Artemisinin derivative with long acting antimalarial
• In Nepal National Malaria program has
recommended use of 3 days course of
Artemether 20 mg + Lumefantrine 120 mg

• Primaquine (0.25mg/kg) single dose on Day 3

 Treatment of malaria in pregnancy

• The ACT should be given for treatment of P.

falciparum malaria in second and third
trimesters of pregnancy
• Quinine recommended in the first trimester
(10mg/kg TDS for 7 days)
• Plasmodium vivax malaria can be treated with
chloroquine.
 Treatment of mixed infections

• Mixed infections with P. falciparum should be

treated as falciparum malaria.

• Anti-relapse treatment with primaquine can

for 14 days.
General recommendations for the management of
uncomplicated malaria

1. Avoid starting treatment on empty stomach.

2. The first dose is given under observation.
3. Dose repeated if vomiting within half hour of
drug intake.
4. Patient asked to report back, if no
improvement after 48 hours/deteriorates.
5. Investigate for concomittant illnesses
 SEVERE MALARIA
Clinical features summary
● Impaired consciousness/coma
● Convulsions
● Renal failure (Sr Creatinine >3 mg/dl)
● Jaundice (Sr Bilirubin >3 mg/dl)
● Severe anaemia (Hb <7 g/dl)
● Pulmonary edema/ARDS
● Hypoglycaemia (Plasma Glucose <40 mg/dl)
● Metabolic acidosis
● Circulatory collapse/shock (SBP <80 mmHg)
● Abnormal bleeding
● Haemoglobinuria
● Hyperpyrexia (Temperature >106°F or >42°C)
● Hyperparasitaemia (>5% parasitized RBCs )
indian guidelines
 SEVERE MALARIA TREATMENT
Things Necessary In a care centre:

● Parenteral antimalarials, antipyretics, antibiotics,

anticonvulsants
● Intravenous infusion facilities
● Special nursing for coma patients
● Blood transfusion
● Laboratory facilities
● Facility for Oxygen, dialysis, ventilator, etc.
 SEVERE MALARIA TREATMENT
• Severe manifestations can develop in P. falciparum
infection over time span as short as 12–24 hours
• Parenteral artemisinin derivatives or quinine used as
specific antimalarial therapy.

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

admission 0 hour then at 12 & 24 hours, then once
a day (dilute artesunate in 5% Sodium bicarbonate)
• Quinine: 20 mg/kg on admission
(i.v. infusion in 5% dextrose over 4 hours)
• maintenance dose :- 10 mg/kg 8 hourly.
• beyond 48 hours:- 7 mg/kg 8 hourly

• NEVER GIVE BOLUS INJECTION

 Management of Complications
Manifestation or Immediate management
complication
Coma(Cerebral malaria) Maintain airway, place patient on his or her side,
exclude other treatable causes of coma(e.g.
hypoglycaemia, bacterial meningitis); avoid harmful
ancillary treatments, intubate if necessary.

Hyperpyexia Administer tepid sponging, fanning a cooling blanket

and paracetamol
Convulsions Maintain airways; treat promptly with intravenous or
rectal diazepam, lorazepam, midazolam or
intramuscular paraldehyde. Check blood glucose.

Hypoglycaemia Check blood glucose, correct hypoglycemia and

maintain with glucose-containing infusion. Although
hypoglycaemia is defined as glucose <2.2mmol/L, the
threshold for intervention is <3mmol/L for children
<5 years and <2.2 mmol/L for older children and
adults.
 Continued…
Severe anaemia Transfuse with screened fresh whole blood.
Acute Pulmonary edema Prop patient up at an angle of 45◦, give oxygen,
give a diuretic, stop intravenous fluids, intubate
and add positive end-expiratory pressure or
continuous positive airway pressure in life-
threatening hypoxaemia.
Acute kidney injury Exclude pre-renal causes, check fluid balance and
urinary sodium, if in established renal failure, add
haemofiltration or haemodialysis, or if not
available, peritoneal dialysis.
Spontaneous bleeding and Transfuse with screened fresh whole blood
coagulopathy (cryoprecipitate, fresh frozen plasma and
platelets, if available); give vitamin K injection
 Continued…
Metabolic acidosis Exclude or treat hypoglycaemia, hypovalaemia and
septicaemia. If severe, add haemofiltration or
haemodialsis.
Shock Suspect septicaemia, take blood for cultures; give
parenteral broad-spectrum antimicrobials, correct
haemodynamic disturbances.
 CHEMOPROPHYLAXIS

For :-
– Travellers
– Migrant
– Labourers
– Military personel
– Exposed to malaria in highly endemic areas
 CHEMOPROPHYLAXIS

• Short-term (< 6 weeks)

• Doxycycline: 100 mg/day
• started 2 days before travel till 4 weeks after leaving area.
• contraindicated in pregnant and lactating Women &
children less than 8 years.

• Long-term (> 6 weeks)

• Mefloquine: 5 mg/kg (max 250 mg) weekly and
• 2 weeks before & 4 weeks after leaving the area.
• contraindicated with H/O convulsions, neuropsychiatric
problems.
THANK YOU