Communicable Diseases
Subtopic:
Malaria
Malaria is a sudden illness characterized by fever, triggered by parasites of the genus Plasmodium. These parasites infect and multiply within red blood cells in the human body.
It is a communicable disease where microscopic protozoa of the Plasmodium genus infect red blood cells. This multiplication process within the red blood cells is responsible for the diverse range of symptoms observed in malaria.
Aetiology:
Parasite: The root cause of malaria is a single-celled parasite, a protozoan, classified under the genus Plasmodium. Several species can infect humans, each with unique characteristics:
Plasmodium falciparum: This is the most dangerous type of malaria parasite. It is responsible for the majority of severe illnesses and deaths associated with malaria.
Plasmodium vivax: This species causes a type of malaria where fever occurs roughly every other day (benign tertian malaria). While generally considered less deadly than P. falciparum, it can still lead to serious health problems in some individuals.
Plasmodium ovale: This species causes a form of malaria similar to P. vivax malaria but is encountered less frequently.
Plasmodium malariae: This species causes a type of malaria where fever occurs roughly every third day (quartan malaria). Although typically less severe, it can lead to long-term health issues.
Plasmodium knowlesi: This species primarily infects monkeys but can also be transmitted to humans, making it a zoonotic disease.
Vector: The means by which the malaria parasite is transmitted to humans is through the bite of an infected female Anopheles mosquito. This mosquito is specifically known as the “malaria mosquito” due to its role in the disease’s transmission.
Incubation Period
The time between being bitten by an infected mosquito and the start of feeling sick with malaria is usually between one and three weeks, which is about 7 to 21 days. However, some types of malaria, specifically those caused by P. vivax and P. ovale, can have much longer incubation periods, sometimes taking as long as eight to ten months before symptoms appear. This extended delay happens because these particular parasites can enter a resting or inactive phase within the liver cells. Sadly, even after someone recovers from malaria, some of these dormant parasites can remain in the liver, and later become active again, leading to a return of the illness, known as a malaria relapse.
Transmission:
Mosquito Bite: When a female Anopheles mosquito carrying malaria parasites bites a human, it injects a form of the parasite called sporozoites into the person’s bloodstream. These sporozoites are the stage of the parasite capable of causing infection in humans.
Liver Stage: The sporozoites then travel through the bloodstream to the liver. Once there, they invade liver cells and begin to multiply asexually, creating many copies of themselves within these cells.
Blood Stage: After a period of multiplication in the liver, the parasites are released back into the bloodstream in a different form called merozoites. These merozoites then invade red blood cells.
Blood Stage Multiplication: Inside the red blood cells, the merozoites continue to multiply asexually. Eventually, the red blood cells burst open, releasing even more merozoites into the bloodstream, which then infect other red blood cells. This cycle of red blood cell invasion and bursting is what causes the symptoms of malaria.
Sexual Stage: Some of the parasites within the red blood cells develop into male and female forms called gametocytes. This is the sexual stage of the parasite’s life cycle.
Mosquito Ingestion: If another mosquito bites an infected human at this stage, it ingests the gametocytes along with the blood.
Mosquito Development: Inside the mosquito’s gut, the male and female gametocytes fuse together (fertilization) and undergo further development, eventually forming new sporozoites.
Mosquito Transmission: These newly formed sporozoites migrate to the mosquito’s salivary glands. When this mosquito bites another human, it injects these sporozoites, starting the cycle all over again.
Predisposing Factors:
Geographic Location: Malaria is predominantly found in tropical and subtropical regions of the world where the climate is warm and humid, providing ideal conditions for Anopheles mosquitoes to breed and thrive.
Age: Young children, particularly those under the age of five, have not yet developed full immunity to malaria, making them highly susceptible to developing severe illness.
Immune Status: Individuals with weakened immune systems, such as those living with HIV/AIDS or suffering from malnutrition, have a reduced ability to fight off the malaria parasite, increasing their risk of severe disease.
Pregnancy: Pregnant women experience changes in their immune system, making them more vulnerable to malaria infection. Malaria during pregnancy can also pose serious risks to the developing fetus.
Travel History: Individuals who travel to regions where malaria is common are at risk of contracting the disease if they are not taking appropriate preventive measures.
Genetic Factors: Some people inherit specific genetic traits that offer a degree of protection against malaria. For example, individuals with sickle cell trait are less likely to develop severe forms of the disease.
Signs and Symptoms of Malaria
Malaria presents with a range of signs and symptoms, with fever being the most significant and defining characteristic. The fever associated with malaria typically follows a recurring pattern, meaning it comes and goes in cycles. A typical malaria episode can be divided into three distinct stages:
The Cold Stage:
This stage begins abruptly with intense chills, often accompanied by uncontrollable shaking or shivering.
The person feels intensely cold all over their body, even if the external temperature is warm.
The Hot Stage:
The chills subside, and a sensation of intense heat develops.
A high fever sets in, often reaching 104°F (40°C) or even higher.
A severe headache is common, frequently felt in the front of the head.
Muscle pain, characterized by aching and stiffness, particularly affects the back and limbs.
Feelings of sickness and vomiting are common, especially during the peak of the fever.
The Sweating Stage:
The fever begins to break, and the person starts to sweat profusely.
The heavy sweating is often accompanied by a feeling of relief as the other symptoms begin to lessen.
Other Symptoms Include:
A. Uncomplicated Malaria
i. In children under 5 years:
High fever: Elevated body temperature, which can be confirmed using a thermometer, by feeling the child’s skin, or as reported by the person caring for the child.
Rigors: Shivering or trembling fits associated with the fever.
Loss of appetite: A noticeable decrease in the child’s desire to eat, particularly evident in reduced frequency of feeding for breastfed infants.
Weakness and inactivity: Reduced energy levels, making the child less playful and less active than usual.
Lethargy: The child may appear unusually drowsy, sluggish, and unresponsive.
Vomiting and diarrhea: Episodes of throwing up and loose stools may occur along with the fever.
ii. In older children and adults:
Fever: Recurring episodes of fever, often accompanied by chills, sweating, and other related symptoms.
Loss of appetite: A diminished desire for food.
Nausea and vomiting: Feeling sick to the stomach and throwing up.
Headache: Intense pain in the head, often localized to the forehead area.
Joint pains: Aching and stiffness in the joints.
Muscle aches: Soreness and pain in the muscles throughout the body.
Weakness and lethargy: A general feeling of tiredness and lack of energy.
B. Complicated/ Severe Malaria (Cerebral Malaria)
i. In children 5 years and below:
The child will exhibit signs of uncomplicated malaria along with any of the following more serious symptoms:
Convulsions: Seizures that have occurred within the past two days or are happening currently.
Inability to breastfeed or drink: Significant difficulty or outright refusal to take breast milk or other fluids.
Vomiting everything: Persistent vomiting, where the child throws up anything they try to eat or drink.
Altered mental state: Changes in awareness and responsiveness, including excessive drowsiness, confusion, sluggishness, or loss of consciousness.
Extreme weakness (prostration): The child is too weak to move or even sit up without assistance.
Severe respiratory distress/ dyspnea: Noticeable difficulty breathing, rapid breathing, or struggling to breathe.
Severe anemia: Paleness of the skin, noticeable fatigue, and shortness of breath due to a dangerously low number of red blood cells.
Severe dehydration: Signs of significant fluid loss, such as a dry mouth, sunken eyes, and reduced urine output.
Hepatosplenomegaly: Abnormal enlargement of the liver and spleen, which can sometimes be felt during a physical examination.
Hemolytic jaundice: Yellowing of the skin and the whites of the eyes caused by the rapid destruction of red blood cells.
ii. In children 5 years and above (adults):
The individual will show signs of uncomplicated malaria along with any of the following more serious symptoms:
Mental confusion and hallucinations: Disorientation, being confused about time and place, experiencing delusions, or seeing things that are not actually there.
Unconsciousness: Loss of awareness and inability to respond to stimuli.
Extreme weakness (unable to stand without support): Severe weakness making it impossible to stand without assistance.
Illustration of the Malaria Parasite Life Cycle:
The infection begins when an infected female Anopheles mosquito bites a human, and injects Plasmodium sporozoites into the bloodstream. This is the initial stage of transmission.
These sporozoites quickly travel through the bloodstream to the human liver.
Over approximately 7 to 10 days, the sporozoites undergo asexual reproduction within the liver cells. During this phase, the infected individual typically experiences no noticeable symptoms.
The parasites then transform into merozoites and are released from the liver cells. They travel through the bloodstream, passing through the heart and reaching the capillaries of the lungs. Here, vesicles containing the merozoites break down, releasing the merozoites into the bloodstream, marking the beginning of the blood phase of the parasite’s development.
Once in the bloodstream, the merozoites invade red blood cells (erythrocytes). Inside these cells, they continue to multiply asexually. This multiplication continues until the red blood cells rupture, releasing more merozoites. These newly released merozoites then invade more red blood cells, repeating this destructive cycle. The cyclical bursting of red blood cells is responsible for the characteristic fever spikes seen in malaria.
A portion of the infected blood cells do not follow the asexual multiplication path. Instead, they develop into the sexual forms of the parasite, known as gametocytes. These gametocytes, both male and female forms, circulate in the bloodstream.
When a mosquito bites an infected human, it ingests these circulating gametocytes along with the blood. Inside the mosquito’s gut, these gametocytes mature into sexually active gametes.
Fertilization occurs within the mosquito, where the male gamete fertilizes the female gamete. The resulting fertilized female gamete transforms into a motile ookinete, which penetrates the wall of the mosquito’s midgut and forms an oocyst on its outer surface.
Within the oocyst, numerous active sporozoites develop through asexual reproduction. Eventually, the mature oocyst ruptures, releasing the sporozoites into the mosquito’s body cavity. These sporozoites then migrate to the mosquito’s salivary glands, ready to be injected into a new human host.
The cycle of human infection restarts when this infected mosquito bites another person, injecting the sporozoites and initiating the liver stage once more.
Diagnosis of Malaria
Diagnosing malaria involves evaluating the patient’s clinical presentation, but this can be challenging as malaria symptoms can mimic those of other illnesses, including yellow fever, typhoid fever, respiratory infections, meningitis, otitis media, tonsillitis, skin infections, and measles. Therefore, laboratory confirmation is crucial.
Clinical Evaluation:
Signs and Symptoms: A healthcare professional will assess the patient’s condition by looking for key indicators like fever, chills, sweating episodes, headache, muscle aches, general weakness, and any other relevant symptoms reported by the patient.
Laboratory Tests:
Microscopy:
Blood Smear Examination (Malaria Parasite Smear – MPS): This is the primary method for confirming a malaria diagnosis. A small blood sample is collected, spread onto a glass slide, stained with specific dyes, and then examined under a microscope. This allows for the direct visualization of malaria parasites within the infected red blood cells. Furthermore, microscopy can help identify the specific Plasmodium species causing the infection.
Rapid Diagnostic Tests (RDTs):
RDTs are designed to quickly detect specific proteins (antigens) produced by malaria parasites in a blood sample. These tests are convenient and can be performed rapidly, making them useful in settings where microscopy is not readily available. However, RDTs may not be as sensitive as microscopy, particularly when the number of parasites in the blood is low.
Quantitative Buffy Coat Test (QBCT):
QBCT is a laboratory technique used to estimate the number of red blood cells infected with malaria parasites. It involves centrifuging a blood sample in a special capillary tube and then examining the concentrated layer of white blood cells and platelets (the buffy coat) under ultraviolet light. This method can be more sensitive than standard microscopy for detecting low levels of parasites but requires specialized equipment.
Complete Blood Count (CBC):
A CBC is a common blood test that evaluates various components of the blood, including red blood cells, white blood cells, and platelets. In malaria, a common finding is anemia, which is a lower-than-normal red blood cell count, resulting from parasite destruction of these cells.
Hemoglobin Estimation:
This test measures the concentration of hemoglobin, the oxygen-carrying protein in red blood cells. Malaria infection frequently leads to a significant reduction in hemoglobin levels due to the destruction of red blood cells by the parasites.
Liver Function Tests (LFTs):
LFTs are a group of blood tests that assess the health and function of the liver. Since malaria parasites initially multiply in the liver, these tests can help evaluate any liver damage or dysfunction associated with the infection.
Blood Chemistry Panel:
A blood chemistry panel provides a broad assessment of the patient’s overall health status. It measures various substances in the blood, including electrolytes, indicators of kidney function, and liver enzymes, which can be affected by malaria.
Polymerase Chain Reaction (PCR):
PCR is a sophisticated molecular biology technique that can detect the genetic material (DNA) of malaria parasites in the blood. It is an extremely sensitive method, capable of identifying even very low numbers of parasites. PCR is also highly specific and can accurately differentiate between the different Plasmodium species.
Serological Tests:
Serological tests are designed to detect antibodies in the blood. Antibodies are produced by the body’s immune system in response to a malaria infection. While not typically used for diagnosing an active infection, these tests can be helpful for determining if someone has been exposed to malaria in the past.
Management of Malaria
The treatment approach for malaria depends on several factors, including the specific Plasmodium species causing the infection, the severity of the illness, and individual patient characteristics such as age, pregnancy status, and any known drug allergies or intolerances. Management strategies are generally divided into treating uncomplicated and severe malaria.
Management Of Uncomplicated Malaria
The standard first-line treatment for uncomplicated malaria is a combination medication called Artemether/Lumefantrine (brand name Coartem).
If Artemether/Lumefantrine is not available, an alternative first-line treatment is a combination of Artesunate and Amodiaquine.
The recommended second-line medication is a combination of Dihydroartemisinin and Piperaquine (brand name Duocotecxin). If this is also unavailable, Quinine tablets can be used as an alternative.
For uncomplicated malaria, artemisinin-based combination therapies (ACTs) are the generally recommended first-line treatment. ACTs contain two different antimalarial drugs that work through different mechanisms, ensuring a more effective and rapid clearance of the parasites from the body and also helping to prevent the development of drug resistance. Commonly used ACTs include:
Artemether-lumefantrine (Coartem)
Artesunate-amodiaquine
Artemisinin-piperaquine
Dihydroartemisinin-piperaquine
First-Line Treatment:
Artemether (20mg) + Lumefantrine (120mg/tab) (Coartem):
The initial dose of Coartem should be administered under the direct supervision of a healthcare professional to monitor for any immediate adverse reactions.
The absorption of Lumefantrine, one of the active ingredients in Coartem, is enhanced when taken with fatty foods or milk. Therefore, it is often recommended to administer the medication with or after a meal containing some fat.
If the patient vomits within 20 minutes of swallowing the Coartem dose, the entire dose should be repeated to ensure adequate medication is absorbed.
Coartem is effective against various stages of the malaria parasite in the blood, including blood schizonts (the stage responsible for symptoms) and gametocytes (the sexual stage), particularly for Plasmodium falciparum infections.
Coartem is generally not recommended for pregnant women during their first trimester due to potential risks to the developing fetus, and it is also not suitable for children weighing less than 5 kg.
If ACTs like Coartem are not available or if there are specific reasons why they cannot be used (contraindications), alternative antimalarial medications such as quinine or atovaquone-proguanil may be considered.
Alternative First-Line Treatment:
Artesunate (50mg/tab) + Amodiaquine (153mg/tab): This combination therapy serves as an alternative first-line treatment for uncomplicated malaria when Artemether/Lumefantrine is not accessible or cannot be used. Artesunate is an artemisinin derivative that acts quickly to reduce the number of parasites, while Amodiaquine is a longer-acting quinoline antimalarial drug that helps to clear the remaining parasites.
Second-Line Treatment:
The recommended second-line medication for uncomplicated malaria is a combination of Dihydroartemisinin + Piperaquine (Duocotecxin). Like other ACTs, this combination utilizes two drugs with different mechanisms of action to effectively clear the malaria parasites. Dihydroartemisinin has a rapid onset of action, quickly reducing the parasite load, while Piperaquine has a longer half-life, providing sustained antimalarial activity. If Dihydroartemisinin + Piperaquine is unavailable, Quinine Tablets (300mg/tab) can be used. Quinine is a longer-standing antimalarial drug and is considered if first-line treatments are ineffective or cannot be used due to specific contraindications. Examples of such contraindications include pregnancy in the first trimester or treating children weighing less than 5 kg. The precise dosage of Quinine depends on the patient’s body weight and should be determined by a healthcare professional.
Supportive Treatment
In addition to antimalarial medications, supportive treatments play a crucial role in managing malaria symptoms and promoting patient comfort.
Antipyretics (Paracetamol): Paracetamol, also known as acetaminophen, is used to reduce fever, a prominent symptom of malaria. Lowering the fever can significantly improve the patient’s well-being and alleviate discomfort. The standard dosage for Paracetamol is 10mg per kilogram of body weight, administered three times a day (tds) for a duration of 3 days. It’s important to adhere to the recommended dosage to ensure safety and effectiveness.
Tepid sponging, fresh air, cold compress, fluids: These methods are employed to help manage fever by promoting heat loss from the body. Tepid sponging involves using lukewarm water to gently sponge the skin, fresh air aids in convective heat loss, cold compresses applied to areas like the forehead or neck can provide localized cooling, and ensuring adequate fluid intake helps regulate body temperature and prevents dehydration.
Nutrition: Providing appropriate nutrition is essential for recovery. This includes offering easily digestible light foods to minimize digestive strain, ensuring a generous intake of plenty of fluids to maintain hydration, and specifically encouraging breastfeeding for infants as breast milk provides essential nutrients and antibodies.
Counseling And Health Education
It is vital to ensure the patient understands the cause of malaria, which is infection by the Plasmodium parasite transmitted through mosquito bites. Furthermore, it is critical to emphasize the importance of complying with the full course of treatment as prescribed, even if symptoms improve.
Patients should be educated on the symptoms of malaria, reinforcing awareness for future episodes or relapses. They must understand the importance of completing the entire course of prescribed medication to fully eradicate the parasites and prevent drug resistance. Patients should also be instructed on the need to consult a health worker if symptoms worsen or persist after two days of starting treatment, as this may indicate treatment failure or a more severe form of the disease.
Prevention measures like sleeping under insecticide-treated mosquito nets should be thoroughly discussed to reduce the risk of future infections.
Treatment of Malaria
Treatment of Uncomplicated Malaria:
The recommended first-line medication for uncomplicated malaria is Artemether/Lumefantrine (Coartem). This combination therapy is highly effective at clearing the parasites from the bloodstream.
In cases where Artemether/Lumefantrine is unavailable, the first-line alternative treatment is Artesunate + Amodiaquine. This combination provides a viable alternative with similar efficacy.
The recommended second-line medication is Dihydroartemisinin + Piperaquine (Duocotecxin). This option is considered if the first-line treatments are not effective or are contraindicated.Treatment of Severe and Complicated Malaria:
Parenteral Artesunate (administered via injection) is the recommended treatment for managing severe malaria in all patients, including children and pregnant women. It acts rapidly to reduce parasite load and improve outcomes.
In the absence of Artesunate, Parenteral Quinine or Artemether can be used as alternatives. These are also given by injection and are effective in treating severe malaria, although Artesunate is generally preferred.Treatment of Malaria in Pregnancy:
Uncomplicated malaria:
First trimester: Quinine tablets 600mg 8 hourly for 7 days is the recommended treatment due to concerns about the safety of some other antimalarials during early pregnancy. (If Quinine is not available, an ACT may be used under careful medical supervision).
Second and third trimesters: The first line treatment is Dihydroartemisinin/Piperaquine 3 tablets (each typically containing 1080mg of the combination) once daily for 3 days. This is generally safe and effective during the later stages of pregnancy. If there is no response to this treatment, Quinine tablets are used as an alternative.
Severe malaria in pregnancy should be treated aggressively. The recommended regimen is intravenous Artesunate 2.4mg/kg administered at 0, 12, and 24 hours, then once daily until the mother is able to tolerate oral medication. The intravenous treatment should be followed by a complete oral treatment with ACTs within 3 days.
An alternate first line treatment, if IV Artesunate is unavailable, is intramuscular artemether 3.2 mg/kg as a loading dose, then 1.6mg/Kg once daily until the mother can tolerate oral medications. This should also be followed by a complete course of ACTs within 3 days.
If artesunate or artemether are not available, Quinine 10mg/kg every 8 hours in Dextrose 5% can be used.
Remember quinine is associated with an increased risk for hypoglycemia in late pregnancy, so careful monitoring of blood sugar levels is essential.
Additional Treatment Measures:
Antipyretic to Reduce Body Temperature:
Paracetamol: The dosage for children is 10mg/kg body weight every six hours. For adults, the dosage is typically 1g every 6-8 hours.
Tepid sponging or fanning can also be used as non-pharmacological methods to help reduce fever.
Anticonvulsants:
Diazepam: The recommended dose for adults is 0.2mg/kg body weight intravenously or intramuscularly to manage convulsions.
Treat Detectable Causes of Convulsions:
For example, hypoglycemia (low blood sugar) can be managed with the administration of Dextrose.
Nursing Care:
Provide supportive care and symptomatic treatment, such as tepid sponging for fever.
Regularly observe temperature, pulse, respiration rate, and blood pressure. Record all observations meticulously.
Educate patients on personal protection against mosquito bites, malaria prevention strategies, and the importance of adhering to the prescribed treatment regimen.
Administer antiemetic medicine 30 minutes to 1 hour before antimalarial drugs if vomiting occurs to improve drug absorption.
Advise patients to rest for 1-2 hours after taking the medicine to minimize the risk of dizziness, vomiting, and hypotension.
Offer psychological support and comfort to patients to alleviate anxiety and promote well-being.
Encourage a nourishing diet with plenty of oral fluids. In cases where the patient has difficulty eating or drinking, consider passing a naso-gastric tube for feeding and hydration.
Monitor fluid intake and output and maintain a fluid balance chart to ensure adequate hydration.
Ensure proper patient and environmental hygiene to prevent secondary infections.
Management of Severe Malaria (Cerebral Malaria)
This is a critical medical situation that demands immediate and aggressive intervention.
A. At OPD/ Health Center Level:
* i. Reception:
* Welcome the patient and attendant: Creating a calm and supportive environment is crucial in a stressful situation.
* Resuscitative measures:
* Establish an IV line: This is critical for the rapid administration of fluids and medications.
* Infuse IV fluids: Utilize isotonic solutions like normal saline or Ringer’s lactate to help raise blood pressure and combat dehydration.
* Assess vital signs: Continuously monitor heart rate, blood pressure, respiratory rate, and temperature.
* Assess level of consciousness: Use the Glasgow Coma Scale (GCS) to objectively evaluate the patient’s mental status.
* ii. Urgent Treatment (First Aid Management):
* Administer IM quinine: Inject 10mg/kg body weight of quinine intramuscularly (IM) as an initial antimalarial treatment.
* Control temperature: Use antipyretics like paracetamol (10mg/kg orally or per NGT) to reduce fever.
* Treat convulsions:
* Rectal diazepam: Administer 5 to 10mg rectally for children to stop seizures.
* IV diazepam: Use IV diazepam for adults to control seizures.
* Provide hydration:
* Oral glucose: Administer via nasogastric tube (NGT) if the patient can swallow to address potential hypoglycemia.
* IV fluids: Infuse isotonic fluids to correct dehydration.
* Counsel on transfer: Explain the urgency of transferring the patient to a higher level of care where more comprehensive treatment is available. Write referral letter: Include the patient’s vital signs, medications administered, and the reason for referral.
* NB: The patient’s well-being is paramount. It is essential to do everything possible to ensure safe and timely transport to a facility equipped to manage severe malaria.
B. At Health Center IV or Hospital Management:
* i. Reception in Emergency Department/ Intensive Care Unit:
* Assess briefly: Conduct a rapid assessment of the patient’s condition, noting vital signs, level of consciousness, and signs of respiratory distress.
* Inform the doctor immediately: While simultaneously initiating resuscitative measures, promptly notify the physician about the patient’s arrival and condition.
* Resuscitation:
* Airway management: Ensure a patent airway by clearing any obstructions, such as secretions or foreign material.
* Positioning: Place the patient in a comfortable position, typically supine with the head slightly elevated to aid breathing.
* IV line: Establish an IV line for the administration of fluids and medications.
* Blood sample: Draw blood for:
* 1. Malaria parasite smear (B/S): For confirmation of malaria and identification of the specific Plasmodium species.
* 2. Hemoglobin (Hb) grouping and cross-matching: To prepare for a potential blood transfusion if needed.
* Hypertonic glucose: Administer a 50% dextrose bolus (0.5-1ml/kg in children, 30-50ml in adults) to treat potential hypoglycemia.
* ii. Doctor’s Orders: Ensure the doctor’s orders are carried out promptly and effectively.
* iii. Admission:
* Admit to ICU/ Medical Ward: Select the most appropriate unit based on the patient’s condition and the resources available.
* Equipment: Ensure the room is equipped with:
* IV trays: For medication and fluid administration.
* Oxygen apparatus: For oxygen therapy as needed.
* Suction apparatus: For airway clearance.
* Monitoring equipment: For continuous monitoring of vital signs.
* Breathing equipment: Ventilator if respiratory support is required.
* Ventilation: Ensure the room is well-ventilated with fresh air.
* Positioning: Maintain the patient in a comfortable and supportive position.
* Oxygen therapy: Provide supplemental oxygen if the patient is dyspneic (having difficulty breathing) or anemic.
* iv. Investigations:
* Malaria parasite smear: Obtain a blood smear for confirmation and species identification if not already done.
* Hemoglobin (Hb) grouping and cross-matching: Perform blood typing and cross-matching in preparation for potential transfusion.
* Lumbar puncture (LP): Assist the physician in performing a lumbar puncture to rule out meningitis as a possible cause of altered mental status.
* v. Chemotherapy:
* Intravenous quinine: Administer an intravenous infusion of quinine (10mg/kg body weight) in 5 to 10ml/kg of 5% glucose solution over 4 hours.
* Avoid loading dose: Do not give a 20mg/kg loading dose as quinine can cause hypotension and hypoglycemia.
* Maximum dose: Do not exceed the adult dose even if weight-based calculations suggest a higher dose.
* Dosage: Continue administering quinine at 10mg/kg every 8 hours until symptoms improve. After three doses, consider transitioning to oral quinine or a first-line artemisinin-based combination therapy (ACT) such as Coartem.
* Anticonvulsants: Administer diazepam rectally (5 to 10mg PRN) or intramuscularly (IM 0.2mg/kg for children, 10mg for adults) for seizures.
* Antipyretics: Administer 10 mg/ kg orally or per NGT, or 500 to 1000 mg (paracetamol) i.e., 1 to 2 tablets for adults, three times a day (tds).
* I.V fluids: Administer oral fluids depending on the dehydration level.
* Artemisinin-based combination therapy (ACT): After the initial quinine infusion, consider switching to an ACT like Coartem (artemether-lumefantrine) for continued treatment.
* Dosage: Follow the specific dosage guidelines based on the patient’s weight and age.
* Route: Administer orally, ensuring the patient swallows each tablet whole.
* Duration: Continue for the recommended duration as per the treatment regimen.
* Alternative ACTs: If Coartem is unavailable or not tolerated, other ACT options include:
* Malarone: (atovaquone-proguanil)
* Riamet: (artemether-piperaquine)
* Asunapril: (artesunate-amodiaquine)
* Other Anti-Malarials: Consider adding doxycycline (100mg twice daily for 7 days) if the patient has multidrug-resistant malaria or if the clinical response is poor.
* Antifungal therapy: If there is suspicion of fungal infection (e.g., cryptococcal meningitis), initiate appropriate antifungal therapy, such as fluconazole.
* vi. Management of complications:
* Cerebral edema:
* 1. Mannitol: Administer IV mannitol as a diuretic to reduce swelling in the brain.
* 2. Corticosteroids: Consider using corticosteroids like dexamethasone to reduce inflammation.
* Hypoglycemia: Monitor blood glucose levels regularly and administer IV dextrose if necessary.
* Electrolyte imbalance: Monitor electrolyte levels and correct imbalances with appropriate intravenous solutions.
* Hemoglobinuria: This may indicate severe hemolytic anemia. Consider blood transfusion if necessary.
* vii. Supportive Care:
* Oxygen therapy: Provide supplemental oxygen if the patient is hypoxic (has low blood oxygen levels).
* Fluids: Continue IV fluid administration to maintain adequate hydration.
* Nutrition: Provide nutritional support via nasogastric tube (NGT) or parenteral nutrition if oral intake is inadequate.
* Blood transfusion: Perform blood transfusion if necessary to manage anemia and maintain adequate blood volume.
* viii. Monitoring:
* Vital signs: Monitor heart rate, blood pressure, temperature, and respiratory rate frequently.
* Level of consciousness: Continue to assess the patient’s GCS score regularly.
* Blood glucose levels: Monitor blood glucose levels closely, especially if the patient is receiving intravenous glucose.
* Electrolyte levels: Monitor electrolyte levels to detect and correct imbalances.
* ix. Discharge:
* Follow-up: Arrange for close follow-up with the doctor to monitor the patient’s progress and address any concerns.
* Repeat blood smear: Perform a blood smear 2 weeks after completing treatment to ensure that the patient is no longer parasitemic.
* Malaria prophylaxis: Advise the patient and family members about the importance of malaria prophylaxis if returning to a malaria-endemic area.
Complications of Malaria:
Impaired consciousness/coma
Severe anemia
Renal failure
Pulmonary edema
Acute respiratory distress syndrome
Shock
Spontaneous bleeding
Acidosis
Hemoglobinuria (hemoglobin in urine)
Jaundice
Repeated generalized convulsions.
TREATMENT OF COMPLICATIONS
a. Hypoglycemia:
* Give glucose 50%:
* Children: 0.5 to 1 ml/kg IV bolus (slowly).
* Adults: 30 to 50 ml IV bolus.
* Dilute: Dilute glucose with an equal volume of water for injection when giving to children to prevent vein irritation.
* Follow-up:
* Adults: Administer glucose 20 to 30 ml TDS for 3 or more doses after the initial bolus.
* Monitor: Monitor blood glucose frequently.
* Ensure: The patient is feeding as soon as they are able.
b. Acidosis (Loss of Electrolytes):
* Give IV fluids:
* Ringer’s Lactate: Alternate with 5% glucose solution.
* Normal Saline (N/S): Alternate with 5% glucose solution.
c. Pulmonary Edema:
* Regulate IV infusions: Carefully adjust the rate of IV fluid administration to prevent fluid overload.
* Positioning: Prop the patient up in bed (high Fowler’s position) to aid breathing.
* Frusemide (Lasix):
* Adults: 40 to 80 mg IV.
* Children: 0.5 to 1.5 mg/kg body weight PRN.
d. Severe Anemia:
* Blood Grouping and Cross-Matching: Perform blood typing and cross-matching in preparation for potential transfusion.
* Blood Transfusion: Administer blood (packed red blood cells) at a rate of 20 ml/kg.
e. Shock:
* Criteria:
* Systolic BP: Less than 80 mmHg.
* Capillary refill: Slow, more than 2 seconds.
* Management:
* Positioning: Raise the foot of the bed to promote blood flow to the brain.
* Fluid Resuscitation: Administer normal saline by rapid infusion.
* Fluid Maintenance: Maintain adequate fluid intake.
* Assess Anemia: Check for anemia and consider blood transfusion if necessary.
f. Acute Renal Failure:
* Assess Cause: Determine if oliguria (reduced urine output) is due to shock or dehydration.
* Frusemide: Administer frusemide as in pulmonary edema (above).
g. Convulsions:
* Refer to: Management of Severe Malaria (see previous sections for detailed treatment).
h. Coma:
* Intensive Care: The patient requires admission to an intensive care unit (ICU) for close monitoring and support.
* Management:
* IV Drip: Maintain an IV line for fluid and medication administration.
* Urinary Catheter: Place a urinary catheter for monitoring urine output.
* Nasogastric Tube (NGT): Place an NGT for nutritional support if necessary.
* Positioning: Turn the patient every 2 hours to prevent pressure sores.
i. Hyperpyrexia:
* Antipyretics: Administer antipyretics, such as paracetamol or ibuprofen.
j. Hemoglobinuria (Blackwater Fever):
* Management:
* Investigate and treat the cause, which is often related to quinine use in glucose-6-phosphate dehydrogenase (G6PD) deficient individuals.
* Discontinue the suspected drug.
* Steroids: Administer steroids (e.g., hydrocortisone, prednisolone, dexamethasone).
NURSING CARE
Feeding:
IV fluids: Administer IV fluids as needed.
Oral fluids: Encourage oral fluid intake.
Diet: Provide a soft, bland diet that is easily digestible.
Other Nursing Care:
Hygiene: Maintain good personal hygiene to prevent secondary infections.
Counseling: Provide psychosocial support (psychotherapy) to the patient and their family to address anxieties and concerns.
OTHER COMPLICATIONS
Hemolytic Jaundice: A complication of severe malaria characterized by the breakdown of red blood cells leading to yellowing of the skin and eyes.
Intrauterine Fetal Death (in Pregnancy): Can occur in pregnant women with severe malaria, highlighting the seriousness of the infection during pregnancy.
Hepatosplenomegaly: Enlargement of the liver and spleen, often found in individuals with malaria.
Prevention and Control of Malaria
Implement Effective Treatment and Prophylaxis:
Early and accurate diagnosis followed by prompt treatment with effective antimalarial drugs is crucial for eliminating the parasites from infected individuals and halting further transmission within the community. Timely treatment of malaria cases is a cornerstone of preventing its spread.
Vulnerable groups, particularly pregnant women, should receive chemoprophylaxis – the preventative use of antimalarial medication. Several drugs are used for this purpose, including Chloroquine, Doxycycline, Mefloquine, and Primaquine, although the specific choice may depend on local resistance patterns and individual patient factors.
It is recommended that all pregnant women in malaria-endemic areas receive Intermittent Preventive Treatment (IPT) during their antenatal care visits. IPT involves administering specific antimalarial drugs at defined intervals to protect both the mother from contracting malaria and the unborn child from the harmful effects of the infection.Reduce Human-Mosquito Contact:
Encouraging the consistent use of insecticide-treated nets (ITNs) while sleeping provides a crucial physical barrier, preventing mosquitoes from biting individuals during the night when they are most active. The insecticide on the nets also helps to kill or repel mosquitoes, offering added protection.
Implementing indoor residual spraying of dwellings with insecticides involves applying long-lasting insecticides to the walls and ceilings of houses. This targets adult mosquitoes that rest indoors, significantly reducing their populations. Alternatively, knockdown sprays can be used to quickly kill adult mosquitoes within households.
Advising individuals to wear clothing that covers the arms and legs, especially during peak mosquito biting times (dusk and dawn), minimizes exposed skin. The use of mosquito repellent coils and creams when sitting outdoors at night further deters mosquitoes from biting.Control Breeding Sites:
Efforts to eliminate stagnant water collection sites are vital in reducing mosquito populations. Mosquitoes lay their eggs in standing water, so removing these breeding grounds disrupts their life cycle. Common breeding sites include empty cans/containers, discarded tires, potholes, and plastic bags that collect rainwater. This can be achieved through proper disposal of these items, draining stagnant water, or covering water containers with soil or lids.
In situations where eliminating stagnant water is not feasible, insecticides can be used to treat these water bodies, effectively destroying mosquito larvae. Alternatively, biological control methods, such as introducing larvae-eating fish (e.g., Gambusia affinis) to ponds or other water sources, can naturally reduce mosquito populations.Provide Public Health Education:
Conducting comprehensive public health education campaigns is essential to empower communities to protect themselves from malaria. These campaigns should focus on raising awareness about malaria prevention measures, including the proper and consistent use of mosquito nets, the importance of personal protection measures against mosquito bites, and the critical need for seeking early diagnosis and treatment if malaria symptoms develop.
It is also important to educate communities about the significance of eliminating mosquito breeding sites around their homes and promoting good environmental hygiene practices to reduce local mosquito populations.
Test Questions.
What is the primary mode of transmission of malaria to humans?
a) Contaminated food and water
b) Contact with infected animals
c) Bites from female Anopheles mosquitoes
d) Airborne droplets from infected individuals
Answer: c) Bites from female Anopheles mosquitoes
Explanation: Female Anopheles mosquitoes transmit malaria by injecting malaria parasites (sporozoites) into the bloodstream during their bite.
Which diagnostic test is considered the gold standard for confirming malaria infection?
a) Rapid Diagnostic Test (RDT)
b) Polymerase Chain Reaction (PCR)
c) Complete Blood Count (CBC)
d) Blood smear examination
Answer: d) Blood smear examination
Explanation: The blood smear examination under a microscope is the classic and most widely used diagnostic test for malaria. It allows visualization of malaria parasites inside red blood cells, helping to identify the Plasmodium species and guide appropriate treatment.
What is the recommended first-line treatment for uncomplicated malaria?
a) Artemether/Lumefantrine (Coartem)
b) Dihydroartemisinin + Piperaquine (Duocotecxin)
c) Quinine tablets
d) Doxycycline
Answer: a) Artemether/Lumefantrine (Coartem)
Explanation: Artemether/Lumefantrine is the recommended first-line medicine for treating uncomplicated malaria cases.
Which antimalarial drug is used as chemoprophylaxis to protect vulnerable groups from malaria?
a) Paracetamol
b) Chloroquine
c) Artemether
d) Diazepam
Answer: b) Chloroquine
Explanation: Chloroquine is one of the drugs used for chemoprophylaxis to protect vulnerable groups, such as pregnant women, from contracting malaria.
What intervention can help reduce human-mosquito contact and prevent malaria transmission?
a) Wearing clothes that cover the arms and legs
b) Spraying dwellings with insecticides
c) Drinking boiled water
d) Applying sunscreen
Answer: a) Wearing clothes that cover the arms and legs
Explanation: Wearing clothes that cover the arms and legs can help reduce mosquito bites and lower the risk of malaria transmission.
In severe malaria cases, what is the recommended first-line treatment for all patients?
a) Parenteral Quinine
b) Parenteral Artesunate
c) Intramuscular Artemether
d) Parenteral Mefloquine
Answer: b) Parenteral Artesunate
Explanation: Parenteral Artesunate is the recommended first-line treatment for severe malaria in all patients.
How long is the incubation period for malaria?
a) 1-3 days
b) 1-3 weeks
c) 1-3 months
d) 1-3 years
Answer: b) 1-3 weeks
Explanation: The incubation period for malaria is usually 1-3 weeks (7 to 21 days) after the mosquito bite.
Which complication of malaria is characterized by the presence of hemoglobin in urine?
a) Severe anemia
b) Jaundice
c) Acidosis
d) Hemoglobinuria
Answer: d) Hemoglobinuria
Explanation: Hemoglobinuria is the presence of hemoglobin in urine, which can occur as a complication of malaria.
What method is used to control mosquito breeding sites and prevent malaria transmission?
a) Introducing larvae-eating fish
b) Using insect repellent coils
c) Administering antimalarial drugs
d) Fumigating dwellings with pesticides
Answer: a) Introducing larvae-eating fish
Explanation: Introducing larvae-eating fish to stagnant water bodies is a biological method used to control mosquito larvae and prevent malaria transmission.
How can midwifery students contribute to malaria prevention in pregnant women?
a) Administering chemoprophylaxis during pregnancy
b) Providing insecticide-treated nets to pregnant women
c) Educating pregnant women about personal protection measures
d) All of the above
Answer: d) All of the above
Explanation: Midwifery students can play a vital role in malaria prevention for pregnant women by administering chemoprophylaxis, distributing insecticide-treated nets, and educating them about personal protection measures against malaria.