MALARIA TREATMENT PROTOCOLThird editionJune 2007Ministry of Health Republic Democratic of Timor- LesteUNCOMPLICATED MALARIA nUncomplicated malaria definition: Fever and any of the following: oHeadache,oBody and joint painsoFeeling cold and sometimes shiveringoLoss of appetite and sometimes abdominal painsoDiarrhoea, nausea and vomiting.oSpleenomegaly Confirmed Diagnosis of MalariaoAll clinically suspected malaria cases require laboratory examination and confirmation. oOnly in case where laboratory confirmation is not possible start treatment immediately. oParasitological confirmation is done by thin- thick blood smear microscopy examination or by dipstick (Rapid Diagnostic Test RDT).Differential diagnosis for uncomplicated malaria Consider other illnesses, such as:oUpper respiratory tract infection (Pharyngitis, tonsillitis, ear infection), pneumonia , measles, dengue, influenza, typhoid fever. Remember that the patient may be suffering from more than one illness.Uncomplicated malaria treatmentP. falciparum malariaoThe treatment of uncomplicated P. falciparum malaria is undertaken after diagnosis of malaria by light microscopy or Dipstick. oPatients with positive think-thick blood smears or dipstick for P. falciparum malaria is treated by blisters of Coartem (artemether 20mg/lumefantrine 120mg). See Table 1 for details of prescription.Table 1 : Dosage and administration Coartem (Artemether 20 mg/Lumefantrine 120 mg) for uncomplicated malaria falciparumAge groupWeight groupBlister color(Day 1)(Day 2)(Day 3)4 months to 5yrs5 to 14 kgYellow1 tb R,1 tb R,1 tb R,1 tb Z1 tb Z1 tb Z6 to 11y15 to 24 kgBlue2 tb R,2 tb R,2 tb R,2 tb Z2 tb Z2 tb Z12 to 14y25 to 34 kgOrange3 tb R,3 tb R,3 tb R,3 tb Z3 tb Z3 tb Z 14y 34Green4 tb R,4 tb R,4 tb R,4 tb Z4 tb Z4 tb ZSource: Guideline for the treatment of malaria, WHO; 2006Coartem Dosage ScheduleSource: WHO, 2007Important notes (1) 1. It is obligatory to give Coartem to patient whose dipstick test or blood slide is positive for P. falciparum and to the patient who has mixed infections P. falciparum and P .vivax. 2. Give the correct dosage of Coartem from the appropriate blister according to the patients weight or age. 3. Children under 5 kg or below 4 months should not be given Coartem instead treat with the following regimen (see table 2).Table 2. Dosage and administration Plasmodium falciparum for young infantAge GroupWeight groupArtesunate or *Quinine0 - 4 months5 kg* IM first dose Artesunate 1.2 mg/kg or IM Arthemeter 1.6 mg/kg)*Oral Artesunate 2mg/kg/day day 2 to day 7Oral Quinine 10 mg/TID for 4 days then 15-20 mg/kg TID for 4 daysSource: Malaria in Children, Department of tropical Pediatrics, Faculty of Tropical Medicine, Mahidol University. * Preferably Artesunate/Artemether IM on day 1 if available * When Artesunate/Artemether IM is unavailable, give oral Artesunate from day 1 to day 7 * Treat the young infant with Quinine when oral Artesunate is not availableImportant notes (2)oIn case parasitological diagnostic facilities are not available paracetamol could be given to relieve pain and fever and referred to health facilities where parasitological diagnosis will be carried out. oOnly in exceptional case when there is problem with the referring patient in other health facility coartem could be administered. (The health facility manager should write explanatory note why giving coartem without parasitological diagnosis). Important notes (3)6. Watch all patients swallowing the first dose of coartem and observe for 1 hour after the intake. In the event of vomiting within one hour of administration, a repeat dose should be taken. 7. Inform patient that, the coartem tablets are in the blister and after breaking should be taken immediately, as after 24 hours coartem tablets exposed to air totally inactivated and can not be used for treatment of malaria. 8. Each blister of coartem has expiry date and should not be used after the expiry date. Important notes (4)9. For small children, paracetamol and coartem can be crushed, diluted in water and then put either directly into the mouth using a syringe or given with a spoon. 10. Any patient who seeks re-treatment for malaria within 2 weeks of taking full dose of any other antimalarial should be treated with coartem.Uncomplicated malaria treatment P. vivax malariaqResistance of P. vivax to chloroquine has not been found in Timor-Leste and Chloroquine is the drug of choice oChloroquine is safe and has few side effects. oFor the radical treatment of P. vivax in addition to chloroquine, primaquine is recommended 0.5mg/kg per day for 14 days (primaquine should always be taken with food). oChloroquine can be given to pregnant women and children.oPrimaquine is not recommended for the children under one year and pregnant women. Details of treatment see table 4a.Table 4a. Dosage and administration of Chloroquine