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about AMC

           A Malaria Free Sri Lanka

about AMC

Plan and implement a comprehensive programme to sustain intensive surveillance and outbreak preparedness, prevention and rapid response for malaria elimination in Sri Lanka and to prevent re-introduction of malaria to Sri Lanka.

about AMC

Travellers to malaria endemic countries have an increased risk of getting malaria and should take the necessary precautions to reduce contracting the disease.

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about AMC

There is a scope of work to be performed when a patient is diagnosed with malaria infection. Before the treatment of malaria positive patients, identification of the species of Plasmodium ...
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Treatment_Guide

Guidelines on Malaria Chemotherapy & management of patients with malaria

1. Background

With no indigenous malaria cases being reported since October 2012, Sri Lanka is currently in the malaria elimination and prevention of re-introduction phase. With progressively increasing incidence of imported malaria cases in recent years, early diagnosis and treatment of such cases have become the highest priority for prevention of re-introduction. Most of these infections have been acquired in India, Pakistan and African countries.

Currently, a low level of clinical suspicion in the backdrop of a very low disease burden has led to a significant delay in diagnosis of imported malaria cases. As a result, there were several patients who presented to the health care institutions with uncomplicated fever progressing to develop severe malaria while being at the hospital.

2. Patients likely to have malaria

Malaria should be suspected in:

1. any febrile individual (including foreign nationals):
- with unexplained fever and a history of recent travel (within 1 year) to a malaria endemic country (esp. India, Pakistan, Haiti and African countries). Refer Annex I for a list of countries where malaria transmission occurs).
- belonging to high risk groups e.g. businessmen, pilgrims and seamen returning from malaria endemic countries, re-settled communities, skilled and unskilled foreign workers, illegal/irregular migrants, refugees, asylum seekers, security forces returning from peace keeping missions etc.
- with a history of malaria infection within the past 3 years.
- with fever of unknown origin.
2.any individual presenting with clinical features of severe malaria (refer Annex II for clinical features).
3. Patients with anaemia of unknown cause.
4.Patients with hepatomegaly and/or splenomegaly.
5.Recipients of blood or blood products who develop fever within 3 months of transfusion.

Please note:
- Malaria can present with non specific symptoms even if there is no fever.
- Thrombocytopaenia has been a frequent finding among patients with malaria reported in the recent years, yet a diagnosis of malaria has not been considered as a result of them being misdiagnosed as having dengue. This had led to a delayed malaria diagnosis resulting in adverse sequelae.

3. Notification of malaria patients

Any patient suspected of having malaria should immediately be notified via telephone to the Regional Malaria Officer (RMO) and Anti Malaria Campaign Headquarters. In addition, it should be notified to the Medical Officer of Health (MOH) of the area where the patient resides following the standard notification procedure (Form H544).

The AMC will ensure:
- confirmation of specific diagnosis.
- provision of appropriate anti-malarial drugs.
- guidance on treatment.
- initiation of rapid response to search for additional cases and prevent onward transmission of the disease.
- follow up of the patient in the field in order to achieve radical cure.

The contact numbers of the AMC Headquarters and the RMOs are given below.

4. Diagnosis of Malaria

In every suspected case of malaria, laboratory confirmation by microscopic examination of blood smears and/or Rapid Diagnostic Test (RDT) is mandatory, prior to initiation of anti-malarial treatment. Treating malaria based on clinical suspicion without laboratory confirmation should be avoided.

If there is a strong clinical suspicion of malaria, and the blood smears/RDT are negative at the time of initial testing, three consecutive blood smears/RDT should be done prior to concluding that the patient is negative for malaria.

Blood should be collected for investigations prior to the administration of anti-malarials:
- In all confirmed malaria patients.
- If anti-malarial treatment is required as a life saving measure based on clinical suspicion without laboratory confirmation of malaria.

Blood should be collected in the following manner:
- 2ml of venous blood collected to an EDTA bottle and refrigerated until transported to the AMC headquarters.
- Dried blood spots on filter paper: drop the blood (approx. 1.5 ml) in the syringe on the filter paper labeled with the patients name; four blood spots with 3 drops per each spot. Air dry for one hour at room temperature. Place each filter paper in an individual envelope. Store at room temperature until transported to the AMC Headquarter (please contact AMC Headquarters for details).

5. Monitoring during treatment and follow up of patients

To ensure an effective parasitological response to the anti-malarial drugs a blood smear and a finger prick filter paper sample should be obtained daily over the three day that the patient is admitted. If parasitaemia persists beyond 3 days blood smears should be taken daily until parasitaemia clears.

Thereafter the patient will be followed up to one year (frequency and duration will depend on the species) by the AMC field staff.

6. Treatment of patients with malaria

Specific treatment and management of malaria will depend on the parasite species causing infection, severity of disease and the biological factors of the patient.

Objectives of treatment:
- Primary objective of treatment: to ensure rapid and complete elimination of the Plasmodium parasite from the patient’s blood in order to prevent progression of uncomplicated malaria to severe disease or death.
- From a public health perspective: to reduce transmission of the infection to others by reducing the infectious reservoir and to prevent the emergence and spread of resistance to anti-malarial medicines.
All confirmed malaria patients should be admitted to a medical institution for a minimum of 3 days to be managed under supervision.
If facilities are available, a test for G6PD deficiency should be carried out prior to administration of primaquine.

6.1 Mono-infection with Plasmodium vivax

For radical cure of vivax malaria, the patient should be treated with chloroquine and primaquine.

Chloroquine: base at a total dose of 25 mg/kg body weight (bw) over three days. This dose should be divided as 10mg/kg on the first and second day followed by 5 mg/kg bw on the third day.

Primaquine: the adult dose is 15mg base (0.25mg/kg per day) for fourteen days unless it is contraindicated. The administration of primaquine is not recommended for pregnant mothers, children under 1 year of age and patients with severe G6PD deficiency (<10% of residual enzyme activity).

In patient with mild to moderate G6PD deficiency (10-60% of residual enzyme activity) primaquine can be administered in a dosage of 0.75 mg/kg weekly for 8 weeks under specialized supervision.

6.2 Uncomplicated mono-infection with Plasmodium falciparum

For radical cure of falciparum malaria, the patient should be treated with ACT and primaquine.

ACT: Weight appropriate dose. Coartem®(containing 20mg of artemether and 120mg of lumefantrine) is the ACT used in Sri Lanka.

Artemisinin and its derivatives should never be used as monotherapy.

Coartem® is not recommended for children whose body mass is less than 5kg.

Coartem® tablets are packed in four colour coded blister packs. The recommended treatment is 6-dose regimen over a three day period according to the weight of the patient as indicated in table 1.

Table 1. Number of ACT (Coartem®) tablets administered based on weight of patient.

Interval between doses

5 -14 kg
(Yellow Pack)

15 - 24 kg
(Blue Pack)

25- 34 kg
(Orange pack)

> 35 kg
(Green pack)

0 Hours

1

2

3

4

8 Hours

1

2

3

4

24 Hours

1

2

3

4

36 Hours

1

2

3

4

48 Hours

1

2

3

4

60 Hours

1

2

3

4

Total

6

12

18

24



ACT should be taken immediately after a meal or drink containing at least 1.2g of fat (e.g. a glass of milk) since its absorption is enhanced by co-administration with fat. As low blood levels of ACT with treatment failure could potentially result from inadequate fat intake, it is essential that patients or carers are informed of the need to take Coartem® with milk or fat containing food, particularly on the second or third day of treatment.

Primaquine: A weight appropriate single dose of primaquine (0.75mg/kg) should be administered unless contraindicated, on day 3 of treatment or prior to discharge from hospital to destroy gametocytes.

Uncomplicated P.falciparum malaria in infants and young children.

ACT (Coartem®) is the first line treatment in infants and young children.
Premaquine should be avoided in children less than 1 year of age.
An acutely ill child requires carefull clinical monitoring as she/he may dereriorate rapidly.
Please contact Anti Malaria Campaign Headquarters for further guidance.

Uncomplicated P.falciparum malaria in Pregnancy.

1st Trimester: Uncomplicated falciparum malaria is treated with oral quinine sulfate 10mg/kg at 8 hourly intervals plus clindamycin (10 mg/kg twice a day) for 7 days. If clindamycin in unavailable, quinine monotherapy may be given.
2nd and 3rd Trimester: Uncomplicated falciparum malaria is treated with Coartem®.
Primaquine should not be administered during pregnancy.

Uncomplicated falciparum malaria during Lactation.

Lactating women can receive the recommended dose of Coartem®.
Primaquine should not be given during lactation.

6.3 Uncomplicated mixed infections with Plasmodium falciparum and Plasmodium vivax

Artemisinin based combination therapy: Coartem® is given at a weight appropriate dose.

Primaquine base: at a dose of 0.25mg/kg per day for fourteen days unless it is contraindicated.

6.4 Severe Plasmodium falciparum infection

Intravenous artesunate, 2.4mg/kg BW given on admission (time = 0), then at 12 hour and 24 hour, then once a day until the patient is able to take oral medication. If intra venous administration is not possible, it can also be given as an intramuscular injection.

If parenteral artesunate is NOT available:.
Quinine dihydrochloride, 20mg salt/kg bw (loading dose) on admission, then 10mg/kg every 8 hours. Each dose is given as a rate controlled intra venous infusion diluted in 10ml/kg bw of isotonic fluid over 2-4 hours at an infusion rate that should not exceed 5mg salt/kg body weight per hour.

This administration should be accompanied by frequent blood glucose monitoring to prevent hypoglycaemia and cardiac monitoring.

Duration of parenteral treatment

Give parenteral antimalarials in the treatment of severe malaria for a minimum of 24 hours, even if the patient can tolerate oral medication.

Follow on oral treatment Complete the treatment by giving a full course of Coartem® as soon as the patient is able to take oral medication, but not before a minimum of 24 hours of parenteral treatment. This should be followed by a single dose of primaquine.

Artesunate is dispensed as a powder of artesunic acid. This powder is dissolved in 1ml of 5% sodium bicarbonate to form sodium artesunate. The solution is then diluted with 5 ml of 5% dextrose and given immediately by intravenous bolus (‘push’) injection or by intramuscular injection (to the anterior thigh). The solution should be prepared freshly for each administration and should not be stored.

Treatment of severe Plasmodium falciparum malaria in pregnancy

1st Trimester: should be treated with parenteral quinine until clinical improvement, followed by oral quinine therapy for a total of 7 days.

2nd and 3rd Trimester of pregnancy: parenteral artesunate/quinine can be administered as above. After clinical improvement, Coartem® should be administered in the weight appropriate dose.
Please note: Primaquine should not be administered during pregnancy.

Severe Plasmodium falciparum and Plasmodium vivax mixed infections

Parenteral administration of artesunate or quinine dihydrochloride followed by a full course of oral Coartem® (as described in management of severe falciparum malaria).

These patients should be given a course of primaquine base at a dose of 0.25mg/kg per day for fourteen days unless it is contraindicated.

6.5 Patients infected with other malaria parasites

The recommended treatment for relapsing malaria caused by P.ovale is the same as that given to achieve radical cure in vivax malaria, i.e. with chloroquine and primaquine. P. malariae should be treated with the standard regimen of chloroquine as for vivax malaria, but it does not require radical cure with primaquine.

7. Chemoprophylaxis for malaria

Chemoprophylaxis is not needed for visitors to Sri Lanka and anyone living within the country including pregnant women.

Chemoprophylaxis is recommended for travelers to malaria endemic countries (the list of countries where malaria transmission occurs is given below). Contact Anti Malaria Campaign to obtain chemoprophylactic drugs and for further details.

Countries where malaria transmission occurs

Afghanistan, Angola, Bangladesh, Belize, Benin, Bhutan, Bolivia, Botswana, Brazil, Burkina Faso, Burundi, Cambodia, Cameroon, Central African Rep, Chad, China, Colombia, Comoros, Congo, Costa Rica, Cote d’Ivoire, Djibouti, Dominican Republic, Ecuador, Equatorial Guinea, Eritrea, Ethiopia, French Guiana, Gabon, Gambia, Ghana, Gautamala, Guinea, Guinea- Bissau, Guyana, Haiti, Honduras, India, Indonesia, Iran, Iraq, Kenya, Lao PDR, Liberia, Madagascar, Malawi, Malaysia, Mali, Mauritania, Mayotte, Mozambique, Myanmar, Mexico, Namibia, Niger, Nigeria, Nepal, Nicaragua, Pakistan, Panama, Papua New Guinea, Peru, Philippines, Paraguay, Rwanda, Sao Tome & Principe, Saudi Arabia, Senegal, Sierra Leone, Solomon Islands, Somalia, South Africa, Sudan, Swaziland, Suriname, Thailand, Timor Leste, Togo, Tajikistan, Turkey, Uganda, Tanzania, Vanuatu, Vietnam, Venezuela, Yemen Socotra Island, Zambia, Zimbabwe .

Telephone numbers related to Anti Malaria Campaign

Please contact Anti Malaria Campaign Headquarters, 555/5 Elvitigala Mawatha,Colombo 05 (Telephone 011-2588408/2368173/2581918 Fax-2368360) or from the respective Regional Officer of the Anti Malaria Campaign in the districts of Jaffna, Kilinochchi, Mulativu, Mannar, Vavuniya, Trincomalee, Anuradhapura, Polonnaruwa, Puttalam, Kurunagala, Maho, Matale, Batticaloa, Ampara, Kalmunai, Monaragala, Badulla, Hambanthota, Embilipitiya & Kegalle.

For further details and clarifications please contact Director Anti Malaria Campaign/Consultant Community Physicians on the telephone numbers indicated above.