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Pdf 1.46 MB Guidelines on the Diagnosis and Treatment of Malaria Foreword Malaria is still a major cause of sickness and death in Zambia. Children under five years of age and pregnant women are at risk of serious illness, but malaria affects all levels of society. The Ministry of Health (MoH) is absolutely dedicated to ensuring that this disease is addressed at all levels and on all fronts. The MoH approach to ensure maximum impact on malaria focuses on the integration of the most effective prevention and treatment tools. Both indoor residual spraying (IRS) of insecticides and large-scale use of long-lasting insecticide-treated nets (LLINs) will be promoted to have the most rapid and sizable impact on the transmission of the disease. The importance attached to the management of malaria at the community level, availability of the most effective medicines at all levels of the health system, and use of the newest diagnostic tools including rapid diagnostic tests to ensure proper diagnosis at lower health facilities and at the community level are all key approaches to ensure the highest possible quality of case management. With this combination of approaches, the MoH aims to have a dramatic impact on the level of malaria in the country. It is with this background that I sincerely welcome the revisions made in the Guidelines for the Diagnosis and Treatment of Malaria in Zambia to reflect the updated policy recommendations. These fourth edition guidelines are intended to provide useful updated information to all health Guidelines for the Diagnosis and Treatment of Malaria in Zambia ii workers on the diagnosis and management of malaria at all levels of the health care system. It also contains additional information such as a chapter on malaria prophylaxis for special populations. I hope that these guidelines will continue to serve as an important source of reference material for general malaria management. I equally want to take this opportunity to thank all the organizations and individuals that have provided both technical and financial support to ensure a successful revision of the guidelines. Dr Davy Chikamata Permanent Secretary Ministry of Health Guidelines for the Diagnosis and Treatment of Malaria in Zambia iii Acknowledgements The revisions to the previous edition of the Guidelines for the Diagnosis and Treatment of Malaria in Zambia have been made possible through the concerted efforts of the National Malaria Control Centre (NMCC) together with its many collaborating partners. The NMCC would therefore like to thank all individuals and organizations that put in a tremendous amount of work to ensure that the information was updated, leading to the production of this fourth edition. NMCC would especially like to acknowledge the contributions of the following individuals: Dr Mulakwa Kamuliwo, the late Dr Chibesa Wamulume, Dr John Banda, Hawela Moonga, and Busiku Hamainza from NMCC; Prof. C. Chintu (University Teaching Hospital); Dr James Chipeta (University of Zambia School of Medicine); Dr Fred Masaninga (World Health Organization [WHO]); Dr Rodgers Mwale (United Nations Children’s Fund [UNICEF]); Dr David Hamer (Zambia Centre for Applied Health Research and Development/Boston University); Dr Victor Chalwe (Maina Soko Military Hospital); Dr Micky Ndhlovu (Chainama Hospital); Dr Nantalile Mugala (Zambia Integrated Systems Strengthening Program); Gamariel Sinpungwe and Rabson Zyambo (John Snow Inc.); Dr C. Sinyangwe and Dr Mark Maire (US President’s Malaria Initiative); Dr John Miller (Malaria Control and Evaluation Partnership in Africa, a program at PATH); and Nakululombe Kwendeni (Clinton Guidelines for the Diagnosis and Treatment of Malaria in Zambia iv Health Access Initiative). The revision of the guidelines also benefited from comments from Dr Peter Olumese (WHO Global Malaria Programme) and Dr Josephine Namboze (Inter-country Support Team, Harare, Zimbabwe). We also acknowledge comments and suggestions made by partners through the Malaria Case Management Technical Working Group. Dr Elizabeth Chizema-Kawesha Director Disease Control, Surveillance and Research Guidelines for the Diagnosis and Treatment of Malaria in Zambia v Acronyms ACT Artemisinin-based combination therapy ADR Adverse drug reaction AL Artemether-lumefantrine cm Centimeter CHA Community health assistants CHW Community health workers CRF Case Report Form DIC Disseminated intravascular coagulation DHA-PQ Dihydroartemisinin-piperaquine Hb Haemoglobin HIV Human immunodeficiency virus HMIS Health Management Information System iCCM Integrated community case management IM Intramuscular IMCI Integrated Management of Childhood Illness IPTp Intermittent preventive treatment ITNs Insecticide-treated nets IV Intravenous kg Kilogram LLINs Long-lasting insecticide-treated nets mg Milligram ml Millilitre Mm Hg Millimetre of mercury µL Micro litre MoH Ministry of Health NMCP National Malaria Control Programme Guidelines for the Diagnosis and Treatment of Malaria in Zambia vi RBC Red blood cell RDT Rapid diagnostic test SP Sulfadoxine-pyrimethamine UNICEF United Nations Children’s Fund WHO World Health Organization ZPVC Zambia Pharmacovigilance Centre Guidelines for the Diagnosis and Treatment of Malaria in Zambia vii Contents FOREWORD ii ACKNOWLEDGEMENTS iv ACRONYMS vi CHAPTER 1: INTRODUCTION 1 1.1 Introduction 1 1.2 Policy on Parasite-Based Diagnosis 5 1.3 Pathogenesis of Malaria 7 CHAPTER 2: CLINICAL FEATURES 11 2.1 Introduction 11 2.2 Clinical Manifestations 12 2.3 Uncomplicated Malaria 12 2.4 Severe Malaria 13 2.5 Occurrence Indicators of Severe Malaria 16 CHAPTER 3: DIAGNOSIS 17 3.1 Introduction 17 3.2 Confirmatory (Laboratory) Diagnosis 18 3.3 Light Microscopy 19 3.4 Rapid Diagnostic Tests (RDTs) and Antigen Detection Tests 21 3.5 Supportive Investigations 23 Guidelines for the Diagnosis and Treatment of Malaria in Zambia viii CHAPTER 4: INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS 25 4.1 Assessment of Fever 26 4.2 Classification of Fever 27 4.3 Very Severe Febrile Disease 30 4.4 Malaria 30 4.5 Classify Anaemia 31 CHAPTER 5: MANAGEMENT OF UNCOMPLICATED MALARIA AT ALL LEVELS 36 5.1 Introduction 36 5.2 Treatment of Uncomplicated Malaria 36 5.3 Management of Fever 39 5.4 Treatment Failure or Non-Response to Treatment 40 5.5 Management of Treatment Failure and Non-Response 41 5.6 Integrated Community Management of Malaria (iCCM) 43 5.7 Referral 44 CHAPTER 6 MANAGEMENT OF SEVERE MALARIA 46 6.1 Features of Severe Malaria 46 6.2 Treatment of Severe Malaria 48 CHAPTER 7 MANAGING COMPLICATIONS OF SEVERE MALARIA 60 Guidelines for the Diagnosis and Treatment of Malaria in Zambia ix 7.1 Introduction 60 7.2 Hyperpyrexia 60 7.3 Severe Anaemia 62 7.4 Haemoglobinuria 65 7.5 Hypoglycaemia 65 7.6 Metabolic Acidosis 67 7.7 Referral 68 CHAPTER 8 MALARIA IN PREGNANCY 69 8.1 Introduction 69 8.2 Clinical Features 70 8.3 Diagnosis 70 8.4 Treatment 71 8.5 Intermittent Preventive Treatment (IPTp) 72 8.6 Health Education 73 CHAPTER 9 ANTIMALARIAL MEDICINES 74 9.1 Introduction 74 9.2 Combination Therapy 74 9.3 Artemether-lumefantrine 76 9.4 Dihydroartemisin-piperaquine 80 9.5 Sulfadoxine-pyrimethamine (SP) 83 9.6 Artesunate 87 9.7 Quinine 89 Guidelines for the Diagnosis and Treatment of Malaria in Zambia x CHAPTER 10 MALARIA PROPHYLAXIS 93 10.1 Risk Groups 93 CHAPTER 11 PHARMACOVIGILANCE 95 11.1 Definitions 95 11.2 Why pharmacovigilance is needed in Zambia 97 REFERENCES 102 APPENDICES 104 Appendix A1 Algorithm for Malaria Diagnosis and Treatment, First Visit 104 Appendix A2 Updated IMCI Algorithm 105 Appendix A3 Algorithm for Management of Severe Malaria 106 Appendix B Glasgow and Blantyre Coma Scales 107 Appendix C Adverse medicine reaction reporting form 109 Appendix D The use of antimalarias for prophlaxis in travellers 110 Guidelines for the Diagnosis and Treatment of Malaria in Zambia xi Chapter 1: Introduction 1.1 Introduction Malaria is a protozoa infection of the genus Plasmodium. It is transmitted through the bite of an infected female mosquito belonging to the genus Anopheles (An.). In Zambia, there are three species that can transmit human malaria: An. gambiae, An. arabiensis, and An. funestus. They differ from many other mosquitoes common in Zambia by being late-night feeders (thus the rationale for sleeping under insecticide-treated mosquito nets [ITNs]). Malaria is generally endemic throughout the country although the country is stratified by high (hyper-endemic), moderate (meso-endemic), and low (hypo-endemic) areas. Urban areas of the country, including Lusaka, tend to have very low transmission. Malaria is by and large more prevalent in rural parts of Zambia. Five species of Plasmodium (P.) parasites cause infections in humans: P. falciparum, P. vivax, P. malariae, P. ovale, and P. knowlesi. Each species has a different biological pattern through which it affects humans. The most common species that is clinically significant and causes the most lethal form of malaria is P. falciparum. In Zambia, P. falciparum accounts for more than 95% of malaria cases, with P. malariae comprising 3%, and P. Guidelines for the Diagnosis and Treatment of Malaria in Zambia 1 ovale 2%. P. vivax is rare in Zambia and no documented cases of P. knowlesi have been reported in Zambia to date. Tremendous efforts have been made to reduce the burden of malaria in the country; the national incidence rate is now 373 cases per 1,000 people (Ministry of Health [MoH] (a), 2012). The malaria parasite prevalence of infection in children under five years of age has decreased from 22.1% in 2006 to 14.9% in 2012 (MoH (c), 2012). The National Malaria Control Centre estimates that there are fewer than 4,000 deaths per year due to malaria (MoH (a), 2012). Malaria also has an impact on pregnant women, contributing significantly to maternal deaths, maternal anaemia, premature delivery, and low-birth-weight infants. Hospital admissions due to malaria and fatality rates have also increased during the same period. Since 2003, the MoH has adopted the use of artemisinin- based combination therapy (ACT) as treatment for uncomplicated malaria in order to reduce the malaria disease burden in Zambia.
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