1. MALARIA THINGS WE NEED TO KNOW.
Name – Mukesh Patel.
Roll no. 384.
STD – S.Y.B.Comm.
DIV – C.

2. Malaria is more deadly than swine flu
H1N1 swine flu has killed 180 people worldwide. And around 45,000 cases reported world-wide (June 19th).
WHO estimates that 3,000 people a day die from malaria in Africa every day, mostly women and children
Unlike influenza, we have no vaccine against malaria.
Now resistance to the MOST effective anti-malarial Artemisinin is being reported from Cambodia – we have nothing left after this.

3. Deadly Stats
Nearly half of the world's population, or about 3.3 billion people, are at risk of malarial infection,
It causes more than 250 million clinical episodes
One million deaths each year.
Pregnant women, under 5 children, and first-timers have more complicated infections.
Kills one child every 20 seconds

4. Malaria - Basics Four species Transmitted by female anopheles
No. 1 priority tropical infectious disease according to WHO
Incidence is increasing by 16 % every year.
No. 3 killer infectious disease in the world

6. India – 15,24,939 / 49 % State/Yr 2002 cases/ p fl 2006 cases/ p fl
2008
Haryana
936/41
42991/199
35683/1397
Punjab
250/18
1650/23
2494/38
Chandigarh
157/6
377/3
347/6
Delhi
694/6
593/5
253/0
India – 15,24,939 / 49 %

9. Clinical Features Fever – atypical pattern
Headache, body ache, altered sensorium, cough breathlessness, acute abdomen pain, vomiting, diarrhea
Malaria can mimic almost
anything and everything !

10. Interesting fact!
Widal test may be positive, even up to a dilution of 1:320 for 'O' and H' and at lower titres for 'AH' and 'BH'. Any or all the four may be positive, suggesting a non-specific response. A positive Widal test in a patient with confirmed malaria should not therefore be considered as suggestive of typhoid fever.

12. Chloroquine (PO/IV) (150 mg Base/ Tablet Syp 50 mg/ 5ml Base)
(LARIAGO, CLOQUIN, NIVAQUINE P)
Oral - 10 mg/kg stat and 5 mg/kg * 3 doses over next 48 hours
IM Not recommended
DoC for P Vivax (uncomplicated)
Quinine
(300/600mg Base tab,
300mg/ml Inj) (CINKONA, KWINIL, QUININE)
Oral - 10 mg/kg 8 hourly for 4 days and 5 mg/kg 8 hourly for 3 days. IV - 16 mg of base/kg in 10 ml/kg NS/5% dextrose over 4 hours, then 8 mg of salt/kg over 4 hours, every 8 hours for 5-7 days.
DoC for P Falciparum
Oral – Uncomplicated
IV – Complicated/ Cerebral Malaria
Mefloquine
(250mg base Tablet)
(LARIMEF, MEFLOTAS, MEFLOC, MQF)
25 mg/kg in 1-2 divided dose
Avoid in seizures, cardiac disease. Do NOT use with Quinine.
Do NOT re-treat with Mefloquine

13. Sulphadoxime/ Pyrimethamine (S/P)
(500 mg / 25 mg)
(LARIDOX, PYRALFIN, METAKELFIN, REZIZ)
Oral – 1.25 mg /kg of Pyrimethamine
Avoid in Sulfa allergy
Add-on therapy for CQR malaria (never alone)
Primaquine
tablets containing 2.5, 7.5 and 15 mg
(PMQ-INGA)
Oral mg/kg/day (once a day) for 14 days in P. vivax; 0.75 mg/kg as single dose in P. falciparum
Avoid with Quinine/ Mefloquine, in severe G6PD Deficient pt.
To be used in ALL cases of Malaria
Other drugs include Tetracyclines, Proguanil, Halofantrine, Lumefantrine, Mepacrine, Bulaquine, clindamycin etc.

14. Artesunate (60 mg/ml Inj, 50 mg tablet)
(FALCIGO, FALCIQUIN, FALCICARE, ARTISIN)
IM/IV 2.4 mg/kg LD, followed by 1.2 mg/kg for 7 days
Oral- 4 mg/kg on the first day followed by 2mg/kg for 6 days
Recommended for Severe Falciparum Malaria, as combination therapy
Arteether
(150mg/ 2ml Inj, 50 mg tablet)
(FALCIGUARD, RAPITHER, MALIJET, ARTISUN)
3 mg/kg OD for 3 days
Well tolerated
Artemether
(80 mg/ml Inj. and 40 mg cap) (LARITHER, MALITHER)
3.2mg/kg as loading dose, followed by 1.6mg/kg daily, until patient is able to swallow or for 5 days.
May cause LFTs rise.

15. Antimalarial drugs – ACT
Artemisinin based combination therapy (ACT)
Increase cure rates,
reduce the development of resistance.
Disadvantages of ACT
High cost
Increased side effects
Pharmacokinetic mismatch
Artesunate + Sulfadoxine/Pyrimethamine (SP) Artesunate 4mg/kg once daily for 3 days and SP single dose of 25mg/kg and 1.25mg/kg respectively
Artesunate (as above) + Mefloquine 8mg/kg daily for three days
Artemether + Lumefantrine,
Artesunate + Doxy, Artesunate + Clinda

16. Treatment
Pregnancy – Quinine in all trimesters; Artemesinin in 2nd and 3rd trimesters
For P. falciparum malaria, follow-up MP tests on 6th and 28th days after treatment.
The 6th day smear is done to assess clearance of parasitemia
28th day smear is done to identify recrudescence.
Failure after 6th day – resistance – treat with second line drugs (Art + Tetra / Clinda; Quinine + Tetra / Clinda)
Failure after 28 days – new infection/ recrudescence – treat with first line drugs again
Relapse – after months – mostly due to Primaquine not given in P vivax – treat with first line drugs

17. Important Points
Oral medicines NOT to be used in severe Falciparum Malaria
It takes 48 hours for fever to subside
Do not administer extra dose, do not change medicine and avoid using newer drugs to reduce drug resistance
Give Primaquine in all cases.

19. Indications for hospitalization of malarial cases
Persistence of fever even after 48 hours of initial treatment.
Continuously worsening headache.
Persistent vomiting.
Any complications of P. falciparum malaria- altered sensorium, convulsions, anemia, jaundice, hyperpyrexia, bleeding and clotting disorders, breathlessness, high coloured urine etc.
Patients who are at higher risk for development of complications of P. falciparum malaria-extremes of age, pregnancy etc.
Patients who appear sick and prostrated
Significant dehydration

20. Preventing Malaria Personal protection
Preventing the mosquitoes from entering the house – Close door / windows, especially toilets. Well-constructed houses with window screens
Preventing the mosquitoes from hiding – Avoid dark corners/ hanging clothes in rooms
Mosquito Control – Avoid stagnant water, insecticide spraying etc.

21. Preventing Malaria Protection from mosquito bites –
Protective clothing,
Mosquito repellants (containing DEET),
Insect vaporizers (coils & mats containing pyrethroids),
Insecticide treated bed nets (most effective),
Airconditioning

22. Chemoprophylaxis - India
AREA 1 -Jammu and Kashmir, Himachal Pradesh and Sikkim – No risk – No Prophylaxis
AREA 2 – North East States (High Risk, High Incidence of CQ resistance) – MEFLOQUINE
AREA 3 – Rest of India (Medium risk, Intermediate CQ resistance) – CQ + PG
CQ alone is NOT recommended in INDIA for prophylaxis

23. Chloroquine (150 mg Base/ Tablet Syp 50 mg/ 5ml Base)
300 mg Once weekly 5 mg/kg weekly
Start one week before exposure, continue during exposure and for 4 weeks thereafter
Proguanil
200 mg Daily < 2yr – 50 mg / day 2-6 yr – 100 mg/day
7-9 yr – 150 mg/day
> 9 yr – 200 mg/day
Start 1-2 days before, continue during exposure and for 4 weeks thereafter
Mefloquine
((Tablet with 250mg base, 274mg salt)
250 mg base once weekly
5mg/kg once weekly
Start 2-3 weeks before, continue during exposure and for 4 weeks thereafter
Other drugs that maybe used for prophylaxis include Doxycycline & Malarone (Atovaquone + Proguanil)

24. Malaria Vaccine – Why is it so difficult?
Researchers must identify which of the Plasmodium parasite's 5,300 proteins provoke a strong immune response.
Parasite makes different proteins at each stage of its lifecycle.
Over two decades, research and hundreds of millions of dollars have been invested in developing a vaccine for malaria.

25. Malaria - Vaccine
The RTS,S vaccine has been more than two decades in the making and more than US $400 million has been invested in the project.
If all goes well (above 50 % protection) it will be in the market by 2012.
On 26th May 2009 phase III trials of the world's most advanced candidate vaccine have started.
16,000 children aged two and under will receive the vaccine over the coming months.

26. SOME THINGS TO BE TAKEN CARE OFF…

27. THANK YOU
PREVENTION IS BETTER THAN CURE