MANAGEMENT OF MALARIA IN PRIMARY CARE SETTINGS

DR.M ABBAS. SUBHANI
MBBS DCH

Malaria is very common in children. Usually it is more severe is pre-school children because of incompletely developed immunity.
While managing the suspected patients of malaria, the physicians should try to find out the
 answers to the following questions and act accordingly.

    -IS IT MALARIA?
     -IS IT SEVERE / COMPLICATED MALARIA AND NEEDS HOSPITALIZATION?
     -IS IT RESISTANT MALARIA ?

 Presentation of malaria in children may vary and may distract physicians attention leading
 to misdiagnosis, inappropriate treatment and ultimately development of complications.  Periodicity of fever is not marked and fever may be continuous. The classical stages of attack described as cold stage; hot stage and sweating stage are not usually observed. Vomiting and loss of appetite are common. In children it may also manifest as fever, vomiting and diarrhea or fever, cough and rapid respiration, but in uncomplicated malaria patients, there is no respiratory distress. Splenomegaly is not universal, and its detection is difficult. Malaria may cause anemia.

For this reason, in children presenting as febrile illness or respiratory problems or gastroenteritis in endemic areas keep the possibility of malaria. On clinical grounds malaria is suspected, not proved. The only confirmatory diagnostic method is identification of parasite on blood film examination
IF THE BLOOD FILM EXAMINATION IS NOT POSSIBLE THERE IS NO HARM IN THERAPEUTIC TRIAL.
 For the treatment of simple (uncomplicated) malaria, use oral chloroquin.
     10mg / kg stat and 5mg /kg 6-8 hours later
     from next day 5mg /kg /day for three days
     Side-effects--anorexia, nausea, vomiting, itching

Use of Amodiaquin is re-emerging because of its efficacy against chloroquin resistant P.falciparum . Pruritis, toxic hepatitis may occur. possibility of fatal agranulocytosis prevents its widespread use.
Cotrimoxazole may be used as both clinical conditions (malaria and pneumonia) are effectively covered by this drug in majority of the cases. Increasing resistance is the problem.

Patient suffering from malaria and having  following presentations (even one) are severe / complicated malaria patients. They should be dealt as medical emergency and advised hospitalization.

     *Altered sensorium, convulsion, neurological deficit.
     * Clinical evidence of shock.
     * Bleeding from any site.
     * Respiratory distress.
     * Increasing respiratory rate ( even without respiratory distress),
       Specially unresponsive to usual and adequate treatment
     * Decrease or cessation of urine.
     * Severe anemia (Hemoglobin < 6 gm%).
     * Hypoglycemia.

NOTE:-The convulsion may be febrile only without the involvement of brain, but consider the possibility of  cerebral malaria (complicated malaria) if the convulsion occurred first time or associated with altered consciousness for more than 20 minutes.

Complicated malaria and resistant malaria are not synonymous. In the majority complicated malaria is caused by  P.falciparum .

RESISTANT-MALARIA
Malaria not responding to Anti-Malarial drugs is called Resistant Malaria. Resistance is on the increase in some areas of Pakistan because of subtherapeutic doses of drugs (reason being undue fear of drug toxicity) and development of cross-resistance to Fansidar because of the wide spread indiscriminate and injudicious use of co-trimoxozole.

plasmodium falciparum was first parasite to develop resistance. Now it has been noted in other species also.Resistance to Chloroquin is the commonest but the resistance to other drugs is also increasing.
Majority of the patients, suspected as resistant malaria are not properly evaluated.

IDEALLY FOR THE CONFIRMATION OF RESISTANT MALARIA REPEATED BLOOD FILM EXAMINATION IS REQUIRED BUT IT MAY NOT BE PRACTICABLE.GRADING OF RESISTANCE IS NEITHER PRACTICABLE NOR REQUIRED IN PRIMARY CARE

BEFORE SUSPECTING RESISTANT MALARIA ONE SHOULD MAKE IT SURE:

Is it malaria? Rule out other febrile illnesses. Positive blood smear in endemic area does not necessarily mean that the clinical picture is because of malaria. Patient may have two concurrent problems.
 Has the adequate dose been prescribed? Some of the physicians do not advise the required dose because of the fear that patient will not be convinced and they will lose the patient.

 Has the adequate dose been taken? Some of the patients do not take the dose advised by the physician because of undue fear of toxicity.

Has adequate dose been absorbed? Make it sure patient has not vomited the drug. If so, has the dose been repeated?

Has adequate time passed? The fever may persist upto 48 hours after the effective treatment. This should not be taken as resistance.

 On clinical grounds, only the suspicion of resistance can be made. But confirmation is possible by repeated blood examination only.

Failure to reduce parasitemia in first 24-48 hours of treatment is suggestive of resistance.

Recommended treatment for uncomplicated Chloroquin resistant cases.

DRUGS
 Fansidar---single dose 25 mg sulfadoxine/kg PO resistance is on the increase
 Side effects-- skin rashes hemolysis, blood dyscrasias, Stevens Johnson syndrome
 (a form of drug reaction characterized by rash and fever may be fatal)

  Quinine----10mg/kg/8hour for 7 days PO. best oral drug for complicated malaria.
  Resistance is rare
  Side-effects--tinnitus, deafness, dizziness, nausea, vomiting, rashes,
   hemoglobinuria, may cause Black water fever

  Mefloquine----15mg/kg single dose PO
  not to be used in young children, resistance is on the increase
  Side-effects--neuro-psychiatric disturbances

  Halofantrine--- 8mg/kg/8 hourly for 3 days PO costly, and not easily available.
 Cross-resistance with mefloquin has been reported.

  NOTE:- In chloroquin resistant cases, a second drug in addition to quinine is recommended,
  once parasitaemia is no longer detectable, cotrimoxazole or in children over 8 years oral
  Tetracycline 250mg/6 hourly for 7 days. Tetracycline may be used with chloroquin. Doxycycline is vey effective, for the resistant malaria, it is also to be used after 8 years of age. It is cheap and given in convenient OD or BD doses (2-4 mg / kg /day for 7 days)

CHEMOPROPHYLAXIS :-

 It is not completely protective. Generally it is not advised for those residing in the endemic areas of malaria. It is advised for the visitors from the non-endemic areas to the endemic areas. If advised it should be started well before the visit (2 weeks before the entry in endemic zone) and continued for 4-6 weeks after leaving the area
Chloroquin Pyrimethamine, Proguanil and Mefloquin are commonly used.
Doxycycline may be used in children over 8 years of age.

COMMON PITFALLS ABOUT MALARIA:

• UNDUE RELIANCE ON BLOOD FILM  REPORT BLOOD FILM EXAMINATION IS VERY USEFUL BUT NEGATIVE RESULT DOES NOT RULE OUT MALARIA . EXCLUDING MALARIA ON SINGLE NEGATIVE FILM IS A COMMON PITFALL
• 
  AND POSITIVE RESULT IN THE IMMUNE / SEMI IMMUNE PERSONS (RESIDENTS OF ENDEMIC AREA LIKE PAKISTAN )DOES NOT CONFIRM THAT THE CLINICAL PICTURE IS DUE TO MALARIA ONLY ( ASSESS AND MANAGE THE PATIENT AS A WHOLE . ONE PATIENT MAY HAVE TWO PROBLEMS )
• Diagnosing resistant malaria without proper evaluation and exclusion (not considering possibility other than malaria, inappropriate drug and dose, possibility of vomiting out the drug , not waiting the response to occur, the fever may persist upto 24-36 hour after effective therapy)
• Not considering the possibility of malaria in all the encephalopathy patients
• Not considering the possibility of malaria in the patients presenting with cough and chest findings. In children malaria may present as pneumonia. ( malaria should always be considered in all patients presenting with cough and chest findings , specially if they do not improve with conventional pneumonia treatment. In these patients therapeutic trial with anti malarial drugs may be given.