Updated Guidelines on Malaria Case

Management 2023
NMEP Online Training Initiative
Dr. Paul Boateng, NMEP
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National
April 2023 Malaria Control Programme-Ghana
National Malaria Elimination Programme-Ghana
Outline

• Introduction
• Classification
• Clinical Management Of Uncomplicated Malaria
• Treatment of Uncomplicated Malaria In Pregnancy
• Treatment Failure
• Recurrent p.f. malaria, relapse malaria
• Management of severe malaria
• Malaria chemoprevention for non-immune travelers
• Other Chemopreventive interventions

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National Malaria Elimination Programme-Ghana
Introduction (1)
• Malaria is one of the Commonest Conditions in
Ghana
– 12 million suspected cases of Malaria in 2021 (41% OPD cases)
– Over 5.7 million confirmed cases 2021 (20% OPD Cases)
– 21% of all admissions is due to malaria
• Malaria is endemic in Ghana/ entire population is at risk
• High risk- Children 5yrs, Pregnant women, Non-immune,
immunocompromised (HIV, DM etc.), comorbidities-e.g., SCD
• Economic cost
– One of the Highest disease expenditure- NHIS
– GDP reduction by 0.25 - 6%

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National Malaria Elimination Programme-Ghana
Introduction (2)

• Caused by a parasite (plasmodium)

• 5 plasmodium species cause illness(malaria) in man:
o P. falciparum mono infection 97.4%
o P. malariae mono infection 1.1 %
o P. ovale mono infection 0.8%
o P. vivax
o P. knowlesi has recently been identified in Malaysia but not yet identified in
Ghana
• 3 main modes of transmission
o Mainly bite of infective female anopheles mosquito
o An accidental transmission via blood transfusion or needle stick
injury
o Congenital transmission from mother to child during pregnancy
or parturition
Malaria Life Cycle

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National Malaria Control Programme-Ghana
Progress with Malaria Control in Ghana (1)

Malaria Parasite Prevalence Among Children 6-59months in Ghana, 2011-2022

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National Malaria Elimination Programme-Ghana
Progress with Malaria Control in Ghana (2)

In-patient malaria Death, Ghana, 2018 -2022

500

428

400

333
312
300
275
Number

200

151

100

0
2018 2019 2020 2021 2022

Year
National Malaria Elimination Programme-Ghana
Malaria Control Interventions in Ghana

MVIP
Changes in Malaria Case Management Guidelines
• Changes to malaria treatment guidelines are made based on:
– Research findings
– Practice observations
– Malaria burden/ programme goals and objectives
– WHO recommendations etc.

• Some major changes in malaria guidelines include

– Change from chloroquine to ACTs
– Change from quinine to inj. Artesunate for severe malaria management
– From presumptive treatment to 3T policy (Test, Treat and Track)

• Current update on malaria case management

– Current update in February 2023 from the 2019 update
• This presentation will highlight the current guidelines, pointing out key changes to
the guidelines
Classification of Malaria
• Uncomplicated malaria
o Fever or recent history of fever (past 2-3 days)
o No severe disease or evidence of vital organ dysfunction
o Positive malaria diagnostic test (RDT or Microscopy)
• Severe Malaria
o Fever
o Severe disease or evidence of vital organ dysfunction (1 or
more)
o Positive malaria diagnostic test (RDT or microscopy)
• The delay in diagnosis and inappropriate treatment of uncomplicated
malaria
Signs/Symptoms of Severe Disease/ Vital Organ
Dysfunction

Signs of Severe DiseaseVital Organ Dysfunction (Signs)

Brain/CNS
(IMCI): • Convulsions, unconsciousness, confusion, restlessness,
lethargy
• Inability to drink
Lungs
• Vomiting everything • Difficulty breathing, deep breathing, respiratory distress
• Presence of convulsions Heart:
• Lethargy/ gen. weakness• Shock: low BP, weak rapid pulse, cold extremities
Liver
• Unconsciousness • Hypoglycemia, Jaundice
Kidney
• Decreased urine output (< 0.5ml/kg/h over at least 6 h)
• *dark-colored urine
Hematological
• Severe anemia, abnormal bleeding
General
• Severe dehydration (sunken eyes etc.), high temp/
hypothermia, prostration, gen. weakness
Lab Features of Severe Disease/ Vital Organ
Dysfunction (Severe Malaria)
• Severe anaemia • Metabolic Acidosis
o Hb <5g/dl for children or Hb • Plasma bicarbonate <15mmol/L
<7g/dl for adults • Hyperlactataemia
• Hypoglycemia • Lactate > 5mmol/L
o Treat for hypoglycaemia if • Haemoglobinuria
blood sugar is <3mmol/L • Positive blood on urine dip stick
plus no RBCs in urine deposit
• Renal Impairment
• Hyperparasitemia
– High serum creatinine levels
• >500,000 p/uL for Immune
– High Serum Urea levels
• >100,000 p/uL for Non-immune
• Jaundice
• Plasma or serum bilirubin • Pulmonary oedema
>50µmol/L • Chest x-ray suggestive
Malaria in Pregnancy- *Complications

• Pregnant women at increased risk of severe

malaria
• Bleeding in pregnancy
• Miscarriage
• Preterm labor
• PPH
• Low birth weight, still birth etc.
• Hypoglycemia, Pulmonary edema*
Laboratory investigations
• Uncomplicated Malaria is confirmed by either;
• Microscopy (GOLD STANDARD)
• Quantitative test
• It is done by reporting on species, stage and parasite density when positive
• And reported No Malaria Parasites(No MPs) seen when Negative
• mRDT (Malaria Rapid Diagnostic Test)
• Qualitative test
• Reported as either Positive or Negative

• EITHER ONE CAN BE USED TO CONFIRM THE DIAGNOSIS

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National Malaria Elimination Programme-Ghana
Diagnosis of Uncomplicated Malaria

• If test is positive
• Diagnosis of uncomplicated malaria is confirmed

• If test is negative
• Malaria is unlikely
• Investigate for other causes of the fever or illness

• If test is negative and you still strongly suspect

malaria, you can conduct a different malaria test
from the 1st (RDT/Microscopy), repeat the test the
ff. day, counsel patient for a short review date.

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National Malaria Elimination Programme-Ghana
Diagnosis of Severe Malaria

Note:
• Don’t delay start of parenteral antimalarial
• START PARENTERAL Antimalarial immediately

• High parasitemia is not always present in severe disease,

and the initial diagnostic test may be negative
• Where there is high clinical suspicion of malaria, the test
should be repeated at 12 hourly intervals up to 3 times
within 24 hours(i.e., 0hr, 12hr and 24hrs) but rule out
other differential diagnoses and this should not delay
treatment
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National Malaria Control Programme-Ghana
Treatment of Uncomplicated
Malaria
Treatment of Uncomplicated Malaria

Treatment Objective
• The clinical objectives of treating uncomplicated
malaria are to:
• cure the infection as rapidly as possible
• (Cure is defined as the elimination of all parasites from the peripheral
blood)
• prevent progression to severe disease

• The public health objectives of treatment are to:

• prevent onward transmission of the infection to others
• prevent the emergence and spread of resistance to antimalarial
drugs

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National Malaria Elimination Programme-Ghana
Principles of Treatment

Specific antimalarial treatment

Supportive treatment

Counselling

Follow-up care

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National Malaria Elimination Programme-Ghana
Treatment of Uncomplicated Malaria
General Population
• 1st line treatment options
• ASAQ, AL, Artesunate- Pyronaridine (AP)
• 2nd line treatment option
• DHAP

Pregnancy
• 1st trimester
• AL
• Other ACTs except AP (ASAQ, DHAP)
• Quinine Clindamycin (QC)
• 2nd, 3rd Trimester and Puerperium
• ASAQ, AL, DHAP (but not AP)
• QC

National Malaria Elimination Programme-Ghana

Malaria Treatment Failure
• Treatment failure (recrudescence) operationally
is the recurrence of asexual parasitemia within 4
weeks (28 days) after treatment due to
recrudescence
• Treatment failure may be due to:
– Inadequate exposure to the drug-
– sub-optimal dosing
– poor adherence
– vomiting
– Substandard medicines
– Drug-drug interactions etc.
– True treatment failure (therapeutic failure)- suspect
drug resistance or unusual pharmacokinetics
Managing Malaria Treatment Failure
• Remember: Need to prove treatment failure with Microscopy!!
REFER
• Look out for other causes of fever!!
• True treatment failure (therapeutic failure):
o Give alternate 1st line ACT / 2nd line ACT (i.e. DHAP)

• Other forms of treatment failure (i.e., vomiting,

non-compliance, under dosing, poor quality
medicine etc.):
o Repeat same ACT (1st line) or
o Alternate 1st line ACT
Reinfection

• Reinfection operationally, parasitemia occurring

after 4 weeks (28 days) of previous treatment
• Treatment:
o 1st Line: ASAQ or AL or AP
Treatment of P. Ovale, P. Vivax (Relapse Malaria)

• Treat with ACTs + Primaquine

–To clear the hypnozoites in the liver
–Primaquine dosage regimen depends on G6PD
status
• Primaquine is contra-indicated in:
1. Pregnant women
2. Infants less than 6 months old
3. Mothers who are breastfeeding infants less than 6 months
old
4. Mothers breastfeeding older infants (>6 months old) whose
G6PD status is unknown
Treatment of P. Ovale, P. Vivax (Relapse Malaria)

• No G6PD deficiency
• Primaquine 0.5mg/kg base daily for 7 days

• G6PD deficiency
• 0.75mg/kg base weekly for 8 Weeks

• Unable to conduct G6PD testing

• Weight risks against benefits
• Monitor closely
Treatment of relapse malaria

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National Malaria Control Programme-Ghana
Comparing Qualitative and Quantitative G6PD Tests

National Malaria Control Programme-Ghana

Treatment of Severe Malaria
Specific Objectives in the Management of
Severe Malaria

• Prevent the patient from dying

• Prevent other complications
• Prevent disabilities
• Prevent recrudescent infection/drug
resistance

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National Malaria Control Programme-Ghana
Severe Malaria- Principles of Management

• Management of severe malaria comprises:

• Resuscitation (Clinical assessment of the patient for
urgent treatment of life- threatening problems)
• Specific antimalarial treatment
• Supportive care
• Counselling
• Follow-up care
• Referral

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National Malaria Control Programme-Ghana
Specific Antimalarial
• All patients with Severe Malaria Must be ADMITTED at a
HOSPITAL for PARENTERAL antimalarials
• Parenteral antimalarials MUST be given for at least 24 hours before switching
to Oral medications (recommended ACTs for 3 days)
• The Preferred order for antimalarials and their route of administration is:

o IV Artesunate
o IM Artesunate
o Supp Artesunate (<25kg or <6years)
o IM Artemether
o IV Quinine infusion
o IM Quinine
Severe malaria in Pregnancy
• All patients with Severe Malaria Must be ADMITTED at a HOSPITAL
for PARENTERAL antimalarials
• Parenteral antimalarials MUST be given for at least 24 hours before switching to
Oral medications (recommended ACTs for 3 days)
• The Preferred order for antimalarials and their route of administration is:

o IV Artesunate (all trimesters)

o IM Artesunate (all trimesters)
o IM Artemether (second, 3rd trimester and puerperium)
o IV Quinine infusion (all trimesters)
o IM Quinine (all trimesters)
Severe Malaria Referral (Treatment)
• Pre-referral treatment (in order of
preference)
• IM Artesunate or
• Rectal Artesunate (for under 6 years only)
• IM Artemether or
• IM Quinine

National Malaria Elimination Programme-Ghana

Treatment failures (Severe Malaria)

• Severe malaria treatment failure with

injection artesunate:
• IV Artesunate+ IV Quinine

National Malaria Elimination Programme-Ghana

 Reducing Transmissibility of P.
falciparum Malaria in low
transmission areas

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National Malaria Elimination Programme-Ghana
Reducing Transmissibility of P. falciparum Malaria

•In low transmission areas

•ACTs are ineffective in clearing matured gametocytes.
• A single low dose of primaquine at 0.25 mg base/kg
(maximum 15mg) is effective and unlikely to cause
serious toxicity in individuals with any of the G6PD-
deficiency variants.
• Added on the first day of ACT administration, preferably as DOT
• Do not give to Pregnant women, breastfeeding mothers, infants
• Clinically significant haemolysis is not expected to
occur at this dose, hence no need for systematic testing
for G6PD deficiency before administering the dose
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National Malaria Elimination Programme-Ghana
Deliberate deployment of MFT
• Deliberate deployment of multiple-first line
Therapy (MFT) i.e. use of more than one 1st line drug
simultaneously
• Previously no recommendation on deliberate
deployment*
• New recommendations- deliberately deploy MFT, take
appropriate remedial measures to prevent drug
resistance
• E.g. of ways/strategies to deliberately deploy MFT
• Geographic approach- deploy different mixes in different
areas of a country
• Rotational approach– rotate 1st lines e.g. every 3 months
• Age-based model– different age groups use different 1st
lines
National Malaria Elimination Programme-Ghana
 Malaria Chemoprophylaxis for Non-
immune travelers

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National Malaria Elimination Programme-Ghana
Chemoprophylaxis for non-immune travelers
DRUG DOSAGE ADVERSE COMMENTS
EFFECTS
Atovaquone- 11–20 kg: 62.5 mg Common: Nausea, Duration: Start 1 day before
Proguanil atovaquone plus vomiting, abdominal departure and continue for 7
combination 25mg proguanil pain, diarrhoea, days after return
tablet increased liver enzyme
21 – 30kg: 125 mg level -Not recommended for
atovaquone plus Pregnancy and Lactating
50mg proguanil Rare: Rash, Mouth mothers
ulcers, Seizures -Not recommended in <11kg
31-40kg:187.5 mg -Take with food or milky
atovaquone plus Contraindication: products
75mg proguanil -Hypersensitivity -may interfere with
-Severe renal Rifampicin, Rifabutin,
>40kg: 250 mg insufficiency Metoclopramide, Tetracycline,
atovaquone plus Live Typhoid vaccine
100mg proguanil

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National Malaria Elimination Programme-Ghana
Chemoprophylaxis for non-immune travelers
DRUG DOSAGE ADVERSE EFFECTS / COMMENTS
CONTRAINDICATION
Doxycycline Paediatrics: Common: Abdominal Duration: Start 1-2 day
1.5mgsalt/kg daily discomfort, before departure and
photosensitivity continue for 4 weeks after
Adult: 100mg daily return
Rare: Worsening of renal
function, blood -increase susceptibility to
dyscrasias, oesophageal sunburn (use protection)
ulceration -increase risk of candida
infection
Contraindication: -Should be taken with
Pregnant women and plenty water
lactating mothers
-Children < 8 years
-Hypersensivity to
Tetracyclines, including
Doxycycline
-Liver dysfunction

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National Malaria Elimination Programme-Ghana
Chemoprophylaxis for non-immune travelers
DRUG DOSAGE ADVERSE EFFECTS / COMMENTS
CONTRAINDICATION
Mefloquine Paediatric: 5mg/kg Common: nausea, vomiting, Duration: Start at least
weekly diarrhoea, dizziness, headache, sleep 1 week (preferably 2-3
disorders, nightmares, mood change weeks before departure
Adults: 250mg once and continue for 4
weekly Rare: seizures, abnormal weeks after return
coordination, forgetfulness, anxiety,
aggression, depression, Panic -Safe in Pregnancy and
Attacks, Psychotic and Paranoid Lactating mothers
reactions, Suicidal ideation, Suicide -Not recommended for
(STOP THE DRUG) children <5kg
Contraindication: -Not to be given within
Hypersensitivity 12 hours of quinine
-Psychiatric Disorders (Depression, treatment
Seizure Disorder, Severe -Not to be given with
Neuropsychiatric disease) Oral Typhoid vaccine
-Concomitant Halofantrine treatment
-Treatment with Mefloquine in the
previous 4 weeks

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National Malaria Elimination Programme-Ghana
Use of Herbal Antimalarials
MoH list of recommended herbal antimalarial medicines
• Must contain one or a combinations of the ff. medicinal plants:
• Cryptolepis sanguinolenta
• Morinda lucida
• Khaya senegalensis
• Cassia occidentalis and
• Azadirachta indica.
• All approved by the FDA- several brand names

• Not recommended for:

• Persons less than 12 years
• Severe malaria management
• Pregnant women
• Lactating mothers
• P. vivax and P. ovale treatment

National Malaria Elimination Programme-Ghana

“New” Interventions – NMESP 2024-2028

• Chemopreventive Interventions
• Intermittent Preventive Treatment of Malaria in School
Children (IPTsc)
• Post discharge malaria chemoprevention (PDMC)
• Mass Drug Administration (MDA)

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National Malaria Elimination Programme-Ghana
Conclusion: Summary of Key Changes
• Expanded list of 1st line treatment options
• Introduction of Artesunate Pyronaridine (AP)
• ACT use in the 1st trimester of pregnancy
• Introduction of low dose primaquine for gametocyte
clearance in low transmission areas
• Revision of primaquine for p. vivax and p. ovale radical
cure/ treatment- 0.5mg/kg daily for 7 days
• More specific guidelines on use of herbal antimalarials
• MoH list of recommended herbal medicines for malaria
included
• Inj. Artesunate + Inj. quinine for Inj. Artesunate failures
• Need to deploy deliberate efforts to prevent resistance
development (multiple first-line therapy)
National Malaria Elimination Programme-Ghana
 Thank You
National Malaria Elimination Programme-Ghana