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

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.

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

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

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 %

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

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.

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

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 - 0.25mg/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.

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.

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

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

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.

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

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.

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

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

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)

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.

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.

SOME THINGS TO BE TAKEN CARE OFF…

THANK YOU PREVENTION IS BETTER THAN CURE