Malaria Service Delivery Protocol for Sun Network

Transcription

1 Malaria Service Delivery Protocol for Sun Network Population Services International (Myanmar) May 2010

2 Diagnostic Algorithm Clinical suspected malaria RDT (Combo) Positive Negative Falciparum malaria Non-falciparum malaria Mixed infection Look for Other illnesses With highly suspicion with symptoms Severe malaria Uncomplicated malaria CQ + PQ Refer for further diagnosis Treat accordingly Inj: Antimalarial drugs & Refer ACT ACT + PQ

3 Treatment Protocol for malaria Introduction: All clinically suspected malaria should be tested with rapid diagnostic test kit and treat accordingly. We can save patient s life if we can do the testing and treating within 24 hours. To confirm clinically suspected malaria patient: History taking: When did the symptoms begin (fever, headache)? How did it start? What is the fever pattern? Are there any associated symptoms to exclude the differential diagnosis of malaria (diarrhea, any cough history or fast breathing especially under 5 children)? Is there any traveling history? Is there any blood transfusion history? Past medical history such as is there any cardiac history, any previous history of similar attack, and previous history of taking of anti malarial drugs? Physical examination: Conducting a physical examination is usually the next step after history taking. It is guided by the history that has been taken. In General: Temperature, Blood pressure, Pulse rate and respiratory rate Systemic: Central Nervous System: Check if patient is fully alert, drowsy or comatose and for other CNS signs. The last two occur in severe Malaria. Respiratory system: Abdomen: Look for fast breathing due to fever, occasional difficulty in breathing with basal crepitations due to pulmonary edema in severe malaria. Check for enlarged spleen which is common. Cardiovascular system: This is normal in simple Malaria; however signs of shock in severe complicated malaria may be present. Always look out for possible presentations of the complications of severe malaria and refer the patient to nearest hospital with injection artemisinine. Test with Combo carestart test kit (RDT) According to the results of RDT test kit, treat accordingly. See RDT testing protocol (Page: 8-12)

4 Treatment protocol for uncomplicated falciparum malaria alone: All RDT positive or microscopy confirmed cases of uncomplicated falciparum malaria cases must be treated with coartem two times daily for three days based on age and body weight preferably with fatty meal to get high drug efficacy. Remark: Be aware that negative RDT test can t exclude malaria and should refer to the further diagnostic facility if the patient is highly suspicious of malaria. Age group Weight group (Day 1) (Day 2) (Day 3) 1year to 4 yrs 5 to 15 kg 5 to 9 yrs 15 to 25 kg 10 to 15yrs 25 to 35 kg > 15 yrs > 35 kg 1 tab Morning 1 tab Morning 1 tab Morning 1 tab Evening 1 tab Evening 1 tab Evening 2 tab Morning 2 tab Morning 2 tab Morning 2 tab Evening 2 tab Evening 2 tab Evening 3 tab Morning 3 tab Morning 3 tab Morning 3 tab Evening 3 tab Evening 3 tab Evening 4 tab Morning 4 tab Morning 4 tab Morning 4 tab Evening 4 tab Evening 4 tab Evening Contraindication of Coartem: Patient with signs and symptoms of severe malaria Pregnant women in her first trimester Children under one year of age Breast feeding mother Patient with a history of symptomatic cardiac arrhythmia, clinically relevant bradycardia or severe cardiac disease

5 Patients with hypokalaemia or hypomagnesaemia Possible side effects of Coartem: Very Common: Common: Uncommon: Very Rare: Headache, Dizziness, Anorexia, Abdominal pain Sleep disorder, Nausea, Vomiting, Diarrhea, Cough, Rash, Pruritus, Arthralgia, Myalgia, and Fatigue Somnolence, Involuntary muscle contraction, Par aesthesia, Hypoesthesia, Abnormal Gait and Ataxia Hypersensitivity Supervision of patient treated with Coartem: Watch all patients swallowing the first dose of coartem and observe for one hour after intake. If vomiting within 30 minutes, repeat dose should be given and If within 30 minutes and one hour, repeat half the dose should be given. For younger children, all the cortem should be crushed and given with milk or water. Follow up of uncomplicated falciparum malaria: All the patient with recurrence of symptoms should be tested with blood film examination as HRP2 antigen is present in the blood for 2-4 weeks after taking treatment and PLDH is present in the blood for 1 3 weeks after taking full treatment. If the patient comes back within 14 days of treatment, treat as failure case after excluding the insufficient taking history of coartem (repeat the second dose of coartem for that case); treatment options are Artesunate (4mg/kg followed by 2mg/kg/day) and Doxycycline (3mg/kg/day) (or) Artesunate (4mg/kg followed by 2mg/kg/day) and Clindamycin (10mg/kg BD) (or) Artesunate (4mg/kg followed by 2mg/kg/day) and Tetracyclin (4mg/kg- 4 times daily) For total of 7 days. If the symptoms recur after 14 days of treatment, it most probably due to re infection rather than recrudescence, so treatment options are; 1. Alternative ACT known to be effective in the region. (or) 2. Artesunate with Doxy/Tetra or Clindamycin for 7 days. (or) 3. Quinine with Doxy/Tetra or Clindamycin for 7 days. Note: Doxycycline and Tetracycline are contraindicated for pregnant women, children under 8 year of age and those with known hypersensitivity.

6 Treatment of falciparum malaria in special groups With severe sign and symptoms: See the treatment of severe malaria In the first trimester of pregnancy: Quinine 10 mg/kg BW t.d.s for 7 days and Clindamycin 10 mg/kg BW b.d for 7 days In the under 1 year old infant: Artesunate 4 mg/kg/day OD for 3 days and Mefloquine 8.3 mg/kg/day OD for 3 days Treatment of uncomplicated mixed Falciparum and Non Falciparum Malaria All RDT positive mixed infection should be treated with oral coartem for all four species and add Primaquine to all confirmed vivax or ovale infection by microscopy for radical cure to prevent relapse. Dosage of primaquine: How can we prescribe PQ with different age groups? Age 1 4 year Dosage for 1 day 5 9 year year > 15 year Primaquine 1 tab contain 7.5 mg Note: Before giving primaquine, make sure the patient is not pregnant or doesn t have severe G6PD deficiency. Children less than four year are also contraindicated for primaquine. For mild or moderate G6PD deficiency patient, primaquine can give to the patient as haemolysis is self limiting and primaquine half-life is short.

7 Treatment of Non Falciparum Malaria Patient with non-falciparum malaria must be treated with Chloroquine 25 mg base/kg BW given in divided doses over 3 days. For first day, 10 mg/kg BW For second day, 10 mg/kg BW For third day, 5 mg/kg BW Following therapy with Primaquine (0.25 mg/kg BW once daily for 14 days.) should be given to those with blood film examination result reveals plasmodium vivax or ovale infection for radical cure. How can we prescribe CQ with different age groups? Age First Day Second Day Third Day <1 year 1 4 year 5 9 year year > 15 year Chloroquine 1 tab contain 150 mg of C/Q base Treatment of Severe Complicated Malaria If the patient has one or more of the following signs and symptoms, refer to hospitals as soon as possible. Sign and symptoms of severe malaria are: Impaired consciousness but rousable Hyperpyrexia ( 40 C or 106 F) Hyper parasitaemia (> 5% of RBC) Cannot eat/drink unaided (Prostration)

8 Cerebral malaria (unrousable coma) Severe anaemia Renal Failure Pulmonary Edema Hypoglycemia Shock DIC Repeated convulsion Acidaemia/Acidosis Malaria Haemoglobinuria All the patients with signs and symptoms of severe malaria should be referred to nearest hospitals as soon as possible with injection Artesunate (IV) 2.4 mg/kg followed by 1.2mg/kg 12 hour later and 1.2mg/kg daily (or) Artemeter (IM) 3.2 mg/kg loading dose followed by 1.6 mg/kg once daily (or) Quinine (IV) 20 mg/kg loading dose followed by 10mg/kg every 8 hourly. F/B Oral ACT when the patient can tolerate oral medication for falciparum malaria or CQ + PQ for vivax malaria. Testing protocol for Carestart Combo test kit Introduction Function of the test and limitations: RDT is a rapid self performing, qualitative, two site sandwich immunoassay for the determination of P. falciparum specific histadine rich protein II (Pf HRP II) and Pan specific PLDH in whole blood sample. The test can differentiate P. falciparum and non falciparum malaria and can remain positive for up to two to four weeks after a successful treatment. The results must be correlated with other clinical findings. Storage of RDTs Malaria rapid diagnostic tests are biological tests that can be rapidly degraded by exposure to high temperatures, exposure to moisture, and freezing. Most manufacturers recommend controlledtemperature storage between 4ºC and 30ºC. Expiry dates are generally set according to these conditions. Note: RDTs stored at temperatures exceeding the recommended limits are likely to have a reduced shelf-life.

9 During transportation RDTs baked in non-air-conditioned vehicles or under tin roofs may rapidly lose sensitivity. At the service delivery level Avoid exposure to direct sunlight Store at the place where temperature is not more than 30 C Rapid Diagnostic kit Combo Test kit: To detect the water soluble protein (HRP2) produced by asexual stage and gametocytes of plasmodium falciparum, expressed on the red cell surface membrane. It can be present in the blood for at least two weeks to 28 days after initiation of anti malaria therapy and to detect the Plasmodium lactate dehydrogenase (PLDH); glycolytic enzyme produced by the asexual and sexual stage of the parasite. It can be present in the blood for at least one to three weeks after initiation of anti malaria therapy. It is manufactured by Access Bio, Inc USA. Title Scope Responsible person : Carestart test kit (RDT) : Applies for all clinical suspected malaria patients : SQH doctors and SPH providers Materials Pipette for blood collection Lancet for pricking finger Disposable rubber gloves Alcohol swab (cotton soaked in 70% methyl alcohol) Test kit Buffer solution and timer Permanent marker for patient identification

10 Procedure Seat the patient in comfortable position and explain to him or her what you are about to do Wear a pair of gloves Open the test kit pack Take out the test kit and remove the dessicant Clean the finger tip of patient s left hand with alcohol swab Make a prick with a sterile lancet and squeeze the finger tip Collect the blood up to the marking on pipette (5µl) Place all the collected blood in the sample well of the test kit Add 2 drops of buffer solution in the sample well After 20 minutes, read the result under good lighting Interpretation of the testing results The result on the test kit must read within 30 minutes after adding buffer solution. Test line (1) Test line (2) Control line Interpretation No Confirmed falciparum malaria

11 No No No No No Non- falciparum malaria Falciparum malaria alone or Mixed falciparum and non falciparum malaria Invalid test Invalid test No Invalid test No No No Invalid test Positive result: Two lines 'C' and 'T1 or T2 or both ' appear in the results window. Test is positive even if the test line is faint. Negative: One line C appears in the result window. Invalid results: No 'C' line appears in the results window. Repeat the test using a new RDT if no control line appears.

12 Precaution: Do not smoke, eat or drink in the areas where specimens and test kits are handling. Protect test kit and specimens from dust and debris. Always wear gloves when testing. Test kits must be properly stored (don t leave in the direct sunlight, keep in cold place during transport or storage, should not exceed 30 C) References: 1. WHO Malaria Treatment Guideline Guidelines for Diagnosis and Management of malaria in Myanmar, Malaria Manual Development Committee Malaria Rapid Diagnosis, Making it work, WHO, Malaria rapid diagnostic test performance: results of WHO product testing of malaria RDTs: round 1 (2008).