MALARIA – PAEDIATRIC AND ADULT MANAGEMENT
Description
Malaria is a life-threatening infection of red blood cells caused by Plasmodium parasites, transmitted by the bite of an infected female Anopheles mosquito.
Epidemiology in Zambia:
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Plasmodium falciparum accounts for 95% of malaria cases.
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Mixed infections with P. ovale or P. malariae: 3%.
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Mono-infections with P. ovale or P. malariae: 2%.
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P. falciparum is the most common and dangerous species, responsible for severe malaria and mortality.
Types of malaria:
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Uncomplicated malaria: Symptomatic infection with parasitaemia without organ dysfunction.
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Complicated (severe) malaria: Parasitaemia with evidence of major organ dysfunction or danger signs. Delay in diagnosis or inappropriate treatment may lead to rapid deterioration, disability, or death.
Signs and Symptoms
Uncomplicated malaria:
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Fever with rigor
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Chills
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Headache, myalgia, arthralgia
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Anorexia, nausea, vomiting
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Dry cough, flu-like symptoms
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Abdominal discomfort, joint pains
Severe malaria / complicated malaria:
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Cerebral malaria (coma, seizures)
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Severe anaemia
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Pulmonary edema
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Acute kidney injury
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Hypoglycaemia
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Shock (compensated or decompensated)
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Spontaneous bleeding / coagulopathy
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Metabolic acidosis
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Hemoglobinuria
Investigations
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Microscopy: Thick and thin blood smears (gold standard)
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Rapid Diagnostic Tests (RDTs): Detect HRP2 or pLDH antigens
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Additional labs for complicated malaria: FBC, serum electrolytes, renal and liver function, blood glucose, lactate, coagulation profile
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Imaging: Chest X-ray if pulmonary involvement, ultrasound for organ assessment
Treatment
Uncomplicated malaria
First-line therapy: Artemether-Lumefantrine (AL) for all ages and pregnant women (all trimesters)
| Body weight (kg) | AL dosage (mg) 2x/day for 3 days | Number of tablets |
|---|---|---|
| <15 | 20 + 120 | 1 |
| 15–<25 | 40 + 240 | 2 |
| 25–<35 | 60 + 360 | 3 |
| ≥35 | 80 + 480 | 4 |
Additional recommendations:
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Single low-dose Primaquine (0.25 mg/kg) in HFCA with low malaria transmission (<125/1,000) for P. falciparum. Avoid in pregnancy, infants <6 months, and breastfeeding women <6 months.
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Mixed Plasmodium infections: Full 3-day AL course.
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G6PD deficiency: Weekly Primaquine (0.75 mg/kg) for 8 weeks under supervision.
Complicated malaria – supportive management
| Complication | Management | Investigations |
|---|---|---|
| Cerebral malaria | Maintain airway, intubate if necessary, lateral position, monitor blood glucose, empirical antibiotics for meningitis, prevent aspiration, nursing care | Blood slide, RBS, FBC, serum urea/bicarbonate, LP if indicated, coma score monitoring |
| Convulsions | Children: diazepam IV 0.3 mg/kg or rectally 0.5 mg/kg, repeat up to 2x, then phenobarbitone 20 mg/kg IM loading, maintain 5 mg/kg/day; Adults: diazepam 5–10 mg slow IV, then phenobarbitone 20 mg/kg IV if persistent | Urine for urinalysis (rule out eclampsia in pregnancy) |
| Severe anaemia | Oxygen, positioning, transfusion: children packed cells 10 ml/kg, adults whole blood 20 ml/kg; diuretic if needed to prevent overload | Hb, Hct, cross-match, monitoring |
| Pulmonary oedema | Oxygen, diuretics, stop IV fluids, intubate if necessary | O2 sat, respiratory rate, chest X-ray |
| Acute kidney injury | Correct dehydration, avoid nephrotoxic drugs, refer if severe | Urea, creatinine, urine output monitoring |
| Hypoglycaemia | IV glucose 10% 5 ml/kg, maintain caloric intake | Blood glucose monitoring |
| Shock | IV fluids, transfusion if anaemia, broad-spectrum antibiotics | CVP monitoring, cultures, vital signs |
| Bleeding / coagulopathy | Blood products (FFP, platelets), vitamin K | Monitor for bleeding, transfusion reactions |
| Metabolic acidosis | Correct hypoglycaemia, hypovolemia, treat sepsis, hemofiltration if needed | Blood gases, lactate, bicarbonate |
| Hemoglobinuria | Continue antimalarials, transfuse if necessary, refer for renal replacement therapy if indicated | FBC, urea, creatinine, electrolytes, urine output |
Drug therapy:
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Severe malaria: Injectable Artesunate (children <20 kg: 3 mg/kg; ≥20 kg: 2.4 mg/kg) at 0, 12, 24 hours, then daily.
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Transition to oral ACT when patient can tolerate oral intake, with ≥8-hour gap from last IV dose.
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Concomitant antibiotics: Broad-spectrum coverage for suspected bacterial co-infections until ruled out.
Treatment failure
Definition: Failure to clear parasitaemia or prevent recrudescence after therapy, not necessarily due to resistance.
Causes:
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Poor adherence
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Vomiting / incomplete course
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Substandard drug quality
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Parasite resistance
Management:
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Confirm via microscopy.
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Repeat full course of AL with adherence counseling.
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Consider oral or parenteral quinine for confirmed treatment failure.
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Report to National Malaria Elimination Centre.
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Treat new infection (≥21 days after prior clearance) with AL.
Key points
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Malaria is life-threatening, especially P. falciparum in children and non-immune adults.
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Early recognition and prompt treatment prevent progression to severe disease.
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Severe malaria requires hospitalization, IV therapy, and management of complications.
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Monitoring for treatment failure and resistance is crucial.
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Supportive care is as important as antimalarial therapy.