Treatment of malaria
For the treatment of Malaria, we have to identify the nature of malaria. After confirmation of specific malaria, disease means what type of Malaria disease it is. It may be viva malaria, falciparum malaria, severe falciparum malaria, or Chemoprophylaxis.
Radical treatment of vax malaria. Chloroquine 25 mg/kg body weight in 3 days (as in the case of falciparum malaria then primaquine 0.25 nag/kg daily for 5-14 days.
Treatment of falciparum malaria (uncomplicated). A. In areas where P. falciparum is sensitive to 4-ciminoquinolines.: (i) Presumptive treatment (pending receipt of results of blood slide examination) : Chloroquine or amodiaquine 600 mg base with primaquine 30-45 mg (adult dose). This treatment is not recommended where laboratory confirmation is delayed. (ii) Radical treatment (after diagnosis is confirmed): Chloroquine 25 mg/kg body weight in 3 days: Day 1— chloroquine 600 mg base followed 6 hours later by 300 mg base (adult): Day 2—chloroquine 300 mg base (adult): Day 3chloroquine 300 mg base (adult). Then primaquine 0.75 mg/kg (single dose).
In areas where P. falciparum is resistant to 4-arninoquinolines: (i) Presumptive treatment: Sulfadoxine/sulfalene (1000 mg)- pyrimethamine (50 mg) combination (adult single dose) with primaquine 30-45 mg (single dose). (ii) Radical treatment: sulfadoxine /sulfalene (1500 mg) pyrimethamine (75 mg) combination (SP) plus primaquine 30-45 mg (single dose). If the patient is seriously i:1 but conscious and oral _ therapy is possible: quinine sulfate 1800 mg (in divided doses) daily for 2-3 days followed by SP and primaquine as above.
Artemisinin and its derivatives are used in the treatment of multi-drug resistant severe malaria in some countries:
Artesunate (1M or IV) 2 mg/kg body weight followed by 1 mg /kg at 12 and 24 hours and then daily (not to be ‘given to pregnant worn in). Artemether capsule (40 mg), artesunate tablet (50 mg) and artemisinin capsule or tabs (250mg) and also in suppository form are available for administration. Artemether is also available for IM injection.
Treatment of severe falciparum malaria
When a patient suffering from malaria shows signs of impairment of consciousness (confusion, delirium, stupor, drowsiness, coma), convulsive disorders, focal neurological disturbances. acute, renal failure, intravascular hemolysis. pulmonary edema or hypoglycemia mia. he should immediately be transferred to the net: rest health institution.
Management of cerebral malaria
(A) In the situation where intravenous therapy is possible: Quinine dihydrochloride 20 mg salt/kg body weight (loading dose) by infusion over 4 hours in 5% dextrose saline (5-10 ml/kg bodyweight depending on the patient’s overall fluid balance). Eight to twelve hours after the start of the loading dose, administer a maintenance dose of quinine dihydrochloride 10 mg salt/kg of body weight in dextrose saline diluted as above over 4 hours. This maintenance dose should be repeated every 8-12 hours until the patient can swallow tablets: a total of at least 7 days’ quinine treatment to be given. Infusion volume (fluid) to be regulated as follows: 5 nil/kg if the patient is over-hydrated; 10 ml/kg if the patient is normally hydrated and 20 ml/kg if the patient is dehydrated. As infusion fluid, 5% dextrose saline is better. because of the presence of hypoglycemia. If quinine is not available but quinidine is readily available then the latter may be used: quinidine 7.5 mg base /kg by intravenous drip in 4 hours. repeated every 8 hours. (B) Where intravenous (IV) infusion therapy is not possible: (i) Quinine hydrochloride 10 mg/kg by deep intramuscular injection or intramuscular injection of sulfadoxine 1000 mg with .pyrimethamine 50: mg may be given (if quinine is not available); the patient should be referred•for intravenous: therapy as soon as possible (ii) In remote areas where IV infusion therapy is not possible and the patient is critically ill the folloWing therapy has been used as a life-saving measure: Quinine dihydrochloride 250 mg base in 20 ml glucose saline-injected IV slowly’ over 15 minutes (push-method). (iii) In areas where falciparum malaria is sensitive to chloroquine and quinine is not available, chloroquine may be administered parenterally: Chloroquine (5 mg/kg) base in 500 ml isotonic saline given as IV infusion over 4-8 hours. However, thiS is not recommended because of its potential toxicity. For the control of convulsion: Diazepam iv/IM (0.2 mg/kg). may be repeated every 5-10 -minutes, if required or Phenobarbital sodium (10-15 mg/kg) • single injection. If hypoglycemia is present: IV bolus injection of 50% glucose (up to 1.0 ml/kg) followed by intravenous infusion of 10-20% dextrose.
Chemoprophylaxis. SP compound is –,pot recommended for prophylaxis. The status of proguanil in prophylaxis is unset..a.in. Pyrimethamine alone is no longer considered adequate. Mefloquine should be reserved for future use. Mass prophylaxis in children under five years of age. is not recommended because: (a)it is impossible to achieve continuous suppression in a significant proportion of population; (b) it may interfere with the development of protective immunity; (c) it may accelerate development of drug resistance; (d) it utilizes scarce resources that may better be used for treatment.
Groups of persons to be considered for prophylaxis: (1) Non-immune visitors to malarious areas (a) Where plasmodium species is sensitive to 4 aminoquinolines: Chloroquine 300 mg base weekly (b) Where low to moderate grade of chloroquine-resistant P. falciparum is present: Chloroquine 300 mg weekly or chloroquine 300 mg weekly plus proguanil 200 mg daily. The visitor` should keep standby drug, SP for the treatment of attack. (c) In areas of high chloroquine resistance: SP one tablet weekly plus chloroquine 300 mg weekly. Since SP is not recommended for prophylaxis, it is necessary to keep stand by drug quinine or quinine plus tetracycline ready for treatment of an attack. (2) Semi-immune residents of malarious areas (only high-risk groups like pregnant women may be considered for prophylaxis): Chloroquine 300 mg weekly. SP compound is not to be given to pregnant women and infants under 3 months. Tetracycline is to be administered in divided doses every 6 hours: not to.be given to pregnant women and children. Primaquine is not to be administered to pregnant women and children below 5 years of age.
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Prevention and control of malaria epidemics
This involves: (i) ‘Epidemiological stratification to define epidemic-prone strata in terms of geographical areas and population groups; (ii) Development of an epidemic monitoring system. and encouraging peripheral health workers and community volunteers to report early any unusual rise of suspected malaria cases for quick confirmation of the situation; (iii) Prompt diagnosis and adequate treatment to minimize clinical consequences; this implies provision of adequate stock of antimalarials; (iv) Prevention of spread of epidemic will require residual insecticide spraying.