Malaria

• Description
• Diagnosis
• General measures
• Medicine treatment
• Malaria, non-severe/uncomplicated
• Referral
• Malaria, severe/complicated
• Malaria, prophylaxis (self-provided care)

Note: notifiable medical conditions.

Refer to the most recent Malaria Treatment Guidelines from the Department of Health for the most suitable management in the various endemic areas.

Global malaria endemic areas:
https://www.iamat.org/risks/malaria?gclid=CjwKEAiAjIbBBRCitNvJ1o257WESJADpoUt072u5_X4Wb0fVtkQLiEFrWye263Ef_on8eykkOwLK_hoCFtDw_wcB

Local endemic areas:
https://www.santhnet.co.za/index.php/travel-health-advice/travel-advice/malaria-advice-for-travellers/item/330-malaria-risk-map-for-south-africa-2017.html

DESCRIPTION

Malaria is an infection of red blood cells by a parasite micro-organism called Plasmodium. Five species of Plasmodium are known to cause malaria in humans in Africa. The five species are:

• Plasmodium falciparum (P. falciparum)
• Plasmodium vivax (P. vivax)
• Plasmodium ovale (P. ovale)
• Plasmodium malariae (P. malariae)
• Plasmodium knowlesi (P. knowlesi)

The parasites are usually transmitted to humans by the bite of a vector mosquito. In South Africa, P. falciparum is the most common and the most dangerous of the malaria species. Malaria caused by P. falciparum is an acute febrile illness that may progress rapidly to severe disease if not diagnosed early and treated adequately.

Symptoms and signs of malaria are non-specific.

The most important element in the diagnosis of malaria is a high index of suspicion in both endemic and non-endemic areas. Any person resident in or returning from a malaria area and who presents with fever (usually within 3 months of possible exposure to vector mosquito bites) should be tested for malaria. The progression of P. falciparum malaria to severe disease is rapid and early diagnosis and effective treatment is crucial. Pregnant women, young children ≤ 5 years of age and people living with HIV/AIDS are at particularly high risk of developing severe malaria.

Symptoms and signs of malaria may include:

• severe headache
• fever > 38°C
• muscle and joint pains
• shivering episodes
• nausea and vomiting
• flu-like symptoms
• diarrhoea
• dry cough

Severe disease may present with one or more of the following additional clinical features:

• prostration (severe general body weakness)
• sleepiness, unconsciousness or coma, convulsions
• respiratory distress and/or cyanosis
• jaundice
• renal failure
• shock
• repeated vomiting
• hypoglycaemia
• severe anaemia (Hb < 7 g/dL)
• haemoglobinuria/black urine
• abnormal bleeding

DIAGNOSIS

Microscopic examination of thick and thin blood smears. Thick films are more sensitive than thin films in the detection of malaria parasites.
Where rapid diagnostic tests, e.g. HRP2 antigen dipsticks are available, these can be used to diagnose malaria within 10–15 minutes.

Note:

• Rapid tests may remain positive up to 1 month after successful treatment
• One negative malaria test does not exclude the diagnosis of malaria. Request a 2nd test.

GENERAL MEASURES

• Provide supportive and symptomatic relief.
• Monitor for complications.
• Ensure adequate hydration.
• Carefully observe all patients with P. falciparum malaria for the first 24 hours for features of severe malaria.

MEDICINE TREATMENT

All first doses of antimalarial medicines must be given under supervision and patients must be observed for at least an hour as vomiting is common in patients with malaria. Treatment must be repeated if the patient vomits within the first hour. Vomiting oral treatment is one of the commonest reasons for treatment failure.

In areas with high incidence of malaria (whether locally transmitted or imported) it should be definitively diagnosed and treated at PHC level. In other areas, patients should be referred for treatment.

MALARIA, NON-SEVERE/UNCOMPLICATED

B51.9/B52.9/B53.0/B54

Note: notifiable medical condition.

MEDICINE TREATMENT

• Artemether/lumefantrine, oral, 20/120 mg with fat-containing food/full cream milk to ensure adequate absorption.
  • Give the first dose immediately.
  • Follow with second dose 8 hours later.
  • Then 12 hourly for another 2 days (total number of doses in 3 days = 6).

For fever in children < 5 years of age:

Children

• Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See paediatric dosing table

REFERRAL

Urgent

• All patients in areas that do not stock antimalarials.
• Vomiting leading to inability to retain medication.
• Patients not responding to oral treatment within 48 hours.
• After 1st dose of artemether/lumefantrine 20/120 mg:
  • All patients with any sign of severe (complicated) malaria, see Malaria, severe/complicated.
  • All children < 2 years of age.
  • Pregnant women.
  • Patients with co-morbidities such as HIV, diabetes etc.
  • Patients > 65 years of age.

MALARIA, SEVERE/COMPLICATED

B50.0/B50.8

Note: notifiable medical condition.

DESCRIPTION

Any one of the following is a sign of severe (complicated) malaria, is associated with a higher mortality, and requires urgent referral (after initial quinine dose as below):

• prostration (severe general body weakness)
• sleepiness, confusion, unconsciousness or coma, convulsions
• respiratory distress and/or cyanosis
• jaundice
• renal failure
• shock
• repeated vomiting
• hypoglycaemia
• severe anaemia (Hb<7g/dL)
• haemoglobinuria/black urine
• abnormal bleeding

MEDICINE TREATMENT

Treatment may be commenced before referral in clinics designated by the regional malaria control programme provided they have facilities to diagnose malaria (either microscopy or rapid antigen point of care tests) and healthcare workers trained in the management of severe malaria.
Correct hypoglycaemia immediately, if present.

The preferred agent is parenteral artesunate:

• Artesunate IM, 2.4 mg/kg IM immediately as a single dose and refer urgently.
  • If transferral to referral hospital is delayed, administer second dose at 12 hours and third dose at 24 hours.

If parenteral artesunate is not available:

• Quinine, IV or IM, 20 mg/kg immediately as a single dose and refer urgently. See paediatric dosing table.
  • IV: dilute with 5–10 mL/kg of dextrose 5% and administer over 4 hours. If facilities not available for IV administration then:
  • IM: dilute quinine dihydrochloride in sodium chloride 0.9% to between 60 and 100 mg/mL. Inject half the volume immediately as a single dose in each thigh (anterolateral) to reduce pain and prevent sterile abscess formation.

Note: For all patients requiring referral, the patient must be transferred to reach the referral hospital within 6 hours of being seen at the PHC facility.

Advise referral hospital that a loading dose has been administered.

REFERRAL

Urgent

All patients.

MALARIA, PROPHYLAXIS (SELF-PROVIDED CARE)

Z29.1

In South Africa, malaria prophylaxis should be used, together with preventive measures against mosquito bites, from September to May in high-risk areas. State facilities do not provide prophylactic therapy. It is recommended that persons intending to travel to high-risk areas take the relevant prophylactic therapy.

Preventative measures against mosquito bites between dusk and dawn include:

• Use of di-ethyl 3-methylbenzamid (DEET) insecticide impregnated mosquito nets, insecticide coils or pads.
• Application of insect repellent to exposed skin and clothing.
• Wearing long sleeves, long trousers and socks, if outside, as mosquitoes are most active at this time.
• Visiting endemic areas only during the dry season.

CAUTION

Immunocompromised patients, pregnant women and children < 5 years of age should avoid visiting malaria-endemicareas, as they are more prone to the serious complications of malaria.

Refer to National Department of Health Malaria Guidelines.