Management of Malaria (Rachel Elliot) Flashcards
Where is malaria found?
Large areas of Africa and Asia Central and South America Haiti and Dominican Republic parts of the Middle East some Pacific Islands
What are the factors that expose travellers to Malaria?
The optimum temperatures of 20º - 30º C and high humidity. Transmission does not normally occur with temperates below 16ºC
Parasite maturation in the mosquito usually cannot take place > 2000m above sea level
Seasonal rainfall in creases mosquito breeding and in some places malaria is highly seasonal
Rural v urban location
Backpackers staying in cheap accommodation have a higher risk of being bitten compared to tourists staying in air conditioned hotels
Being outdoors between dusk and dawn when Anopheles mosquitos bite risk increases
What is the ABCD approach to prevention of malaria?
Awareness of the risk; travel information
Bite prevention - insect repellant, covering arms and legs and using an insecticide treated mosquito net
Check whether you need to take prevention tablets; check you get the right tablets, correct dose and whole course
Diagnosis - seek immediate medical advice if you develop malaria symptoms including up to a year after you have travelled.
How can patients prevent bites?
Stay somewhere with air conditioning, screened windows and doors and make sure they close properly or sleep under an intact mosquito net that has been treated with insecticide.
Use insect repellant on skin and in sleeping environments, re-apply frequently.
DEET is most effective repellent bit not for babies < 2 months old
Wear light fitting clothes and long sleeves
Do herbal products offer protection?
No evidence to suggest that homeopathic remedies, electric buzzers, vit B1 or B12, garlic, yeast, extract spread, tree oils or bath oils offer any protection.
What determines the choice of drug for malarial chemoprophylaxis?
Destination Medical history, allergies Current medication Any previous problems with anti-malarials Age Pregnancy
What does casual malarial prophylaxis target?
The liver stage; takes 7 days to develop, continue for 7 days after leaving the malarial zone
What does suppressive prophylaxis do?
Targets the erythrocytic stage; continue for 4 weeks after leaving the malarious zone
What is hypnozoites prophylaxis?
P. vivax and P. ovale, no prophylactic drugs against these
Which strain of malaria is effectively chloroquine resistnat universally?
P. falciparum
Which strain of malaria has virtually no recorded treatment resistance?
P. ovale
Which treatment is P. malariae resistant to?
Chloroquine
What are the drugs included in Malarone?
Atovaquone plus proguanil
What are the indications for use of Malarone?
Prevents development of liver schizonts; casual prophylactic
Also works on erythrocytic phase so is used for treatment also
90% effective against P. falciparum and vivax
What are the side effects associated with Malarone?
Headache, GI upset, skin rash and mouth ulcers
What are the contraindications of Malarone?
Pregnant or breastfeeding
Renal impairment / problems
What is the active ingredient in Lariam?
Mefloquine
What are the indications for Lariam?
Suppressive prophylactic
90% effective against P. falciparum (some resistant in southeast Asia
When is Lariam contraindicated?
Not recommended in epilepsy, seizures, depression or other MH problems, severe heart or liver problems
What are the side effects associated with Lariam?
Dizziness, headache, sleep disturbances, psychiatric reactions (anxiety, depression, panic attacks, hallucinations)
What is recommended in Lariam?
A three week trial recommended to test for development of any side effects
What are the indications for Doxycycline?
Prevents development of erythrocytic stages; suppressive prophylaxis
Comparable efficacy to mefloquine (lariam)
What are the contraindications in use of Doxycycline?
Pregnant or breastfeeding women, children <12 y/o
People who are sensitive to tetracycline antibiotics or people with liver problems
What are the possible side effects of Doxycycline?
Sunburn due to light sensitivity, stomach upset, heartburn and thrush. Should always be taken with foot preferably when standing or sitting.
When is chloroquine and proguanil chosen as a treatment?
Rarely chosen because mostly ineffective against P. falciparum
May be recommended for some particular destinations where P. falciparum is less common that other types such as India and Sri Lanka
What is ayurvedic medicine?
Is one of the world’s oldest holistic (“whole-body”) healing systems. It was developed more than 3,000 years ago in India. It’s based on the belief that health and wellness depend on a delicate balance between the mind, body, and spirit.
What factors affect adherence to Malarial Prophylaxis / Treatment
Mainly choice of treatment; effectiveness, side effects, previous experiences, dosing convenience
What dosing factor can have a large impact on adherence?
Post-travel regimen shorter = improved adherence
What is the incubation period for P. falciparum, P. vivax, P. ovale?
8-12 days
What is the incubation period for P. malariae?
18 days to 6 weeks
What are the pro-dromal symptoms of malaria?
Headache, muscular aches and pains, malaise, nausea and vomiting the second week after exposure
What is a typical paroxymysal episode after history of travel to an endemic country?
Chills, fever, thrombocytopenia, jaundice and positive identification of parasite in blood confirms diagnosis
What are the three stages of malarial febrile paroxysms?
Cold stage - marked vasoconstriction 30 - 60 mins, intense cold and uncomfortable feeling
Hot stage abruptly follows and lasts for 2-6 hours - patient feels intensly hot and uncomfortable and may be delirious
Sweating stage - bedclothes drenched, patient is fatigued and exhausted
How often does fever occur in P. vivax and P. ovale?
Fever occurs every other day
What is a complication associated with P. falciparum?
RBCs develop knobs and stick to the endothelium, causes severe organ damage to kidneys, liver, brain and GI tract.
What are the complications that can arise when treating malaria?
If > 2 % RBCs infected then cerebral malaria and blackwater fever is possible
Splenic rupture, jaundice, diarrhoea, severe anaemia, hypoglycaemia, acidosis, pulmonary oedema
What is cerebral malaria?
Marked inc in body temperature, rapid deterioration in consciousness, convulsions, coma and death
What is blackwater fever?
Dark brown urine from intravascular haemolysis
Only P. falciparum
Leads to acute renal failure
What are the associated risks of malaria in pregnant women?
Increased maternal mortality
Risk of lbw and infant mortality
What is Tropical Splenomegaly Syndrome?
Can occur when malaria is hyperendemic: responds to antimalarial therapy.
Immunological over-stimulation to repeated attacks of malarial infection over a long period of time. Condition is usually seen in malaria-endemic areas like Africa and Indian subcontinent.
What are the treatment options for severe malaria?
Quinine dihydrochloride infusion or IM TDS
as well as respiratoy support, glucose, blood transfusion, BZDs in children
What is the treatment of choice in emergencies when malaria is resistant to first line?
Artesunate IV/IM
What are the treatment options for uncomplicated malaria?
Artemether-lumefantrine bd 3 days with food / milk
Artesunate + mefloquine for 3 days
OR dyhydroartemesinin-piperaquine for 3 days
What are the emergency stand by formulations of malaria? i.e. can be taken enroute with travellers
Malarone (atavoquone and prguanil)
Riamet (artemether and lumefantrine)
Or quinine together with doxycycline
What are the malaria elimination strategy stages?
Stage 1- Aggressive control in Malaria Heartland
Strengthened and expanded malaria control programmes to reduce transmission and mortality.
Stage 2 - Progressive Elimination from the Endemic Margins
Progressively shrinking the malaria map; reducing no. of countries that need to invest in control programs fully.
Stage 3 - Research to Bring Forward New Tools
Bringing forward new and improved drugs, insecticides and vaccines.
What are LLINs?
Long lasting impregnated nets (LLINs)
Easy to use
Require less technical and capital outlay
