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Overview of MalariaOverview of Malaria Illness in Nigeria Illness in Nigeria
BYBY
Prof. C.T. JOHNProf. C.T. JOHN
Department of Obstetrics & GynaecologyDepartment of Obstetrics & Gynaecology
U.P.T.H.U.P.T.H.
Port Harcourt.Port Harcourt.
Major Causes of Major Causes of MaternalMaternal MortalityMortality in Nigeria in Nigeria
Haemorrhage
Sepsis
Unsafe AbortionHypertensive Disorders
Obstructed Labour
Other Causes
Malaria Malaria Anaemia Anaemia HIV/AIDSHIV/AIDS
TBTB
Overview of Malaria Illness in Overview of Malaria Illness in NigeriaNigeria
MalariaMalaria is: is: Responsible for Responsible for 63% of all clinic 63% of all clinic
attendancesattendances in Nigeria in Nigeria Affects mainly Affects mainly children under the age of 5children under the age of 5
years and years and pregnant womenpregnant women Causes Causes 25% of infant mortality25% of infant mortality and and 30% of 30% of
all childhood deathsall childhood deaths Associated with Associated with 11% of all maternal deaths11% of all maternal deaths
and and 70.5% of morbidity in pregnant women70.5% of morbidity in pregnant women
The Good News!The Good News!
Malaria can be prevented
and/or detected and treated during antenatal care
Where do you stand?Where do you stand?
The old traditional approach,
ORThe refocused
“evidence-based” approach
Facts about Malaria and Facts about Malaria and PregnancyPregnancy
About 6 million Nigerian women are About 6 million Nigerian women are pregnant yearlypregnant yearlyMalaria is more frequent and serious Malaria is more frequent and serious during pregnancyduring pregnancyMalaria during pregnancy may account Malaria during pregnancy may account for:for:– Up to 15% of maternal anaemia Up to 15% of maternal anaemia – 5–14% of low birth weight5–14% of low birth weight– 30% of “preventable” low birth weight30% of “preventable” low birth weight
Overview of Malaria Overview of Malaria Illness in NigeriaIllness in Nigeria
MalariaMalaria is: is: Responsible for Responsible for 63% of all clinic 63% of all clinic
attendancesattendances in Nigeria in Nigeria Affects mainly Affects mainly children under the age of 5children under the age of 5
years and years and pregnant womenpregnant women Causes Causes 25% of infant mortality25% of infant mortality and and 30% of 30% of
all childhood deathsall childhood deaths Is associated with Is associated with 11% of all maternal 11% of all maternal
deathsdeaths and and 70.5% of morbidity in pregnant 70.5% of morbidity in pregnant womenwomen
Effects of Malaria on Pregnant Effects of Malaria on Pregnant WomenWomen
All pregnant women in malaria-endemic areas All pregnant women in malaria-endemic areas are at riskare at risk
Parasites attack and destroy red blood cellsParasites attack and destroy red blood cells
Malaria causes up to 15% of anaemia (low blood Malaria causes up to 15% of anaemia (low blood Haemoglobin) in pregnancyHaemoglobin) in pregnancy
Can cause severe anaemia Can cause severe anaemia
In Africa, anaemia due to malaria causes up to In Africa, anaemia due to malaria causes up to 10,000 maternal deaths per year10,000 maternal deaths per year
The Old Practice of malaria The Old Practice of malaria chemoprophylaxis in pregnancychemoprophylaxis in pregnancy
First ANC visit:First ANC visit:– Stat. dose of Stat. dose of
ChloroquineChloroquine (4 tablets)(4 tablets)
Subsequent ANC Subsequent ANC visits:visits:– Weekly (Sunday-Weekly (Sunday-
Sunday medicine) Sunday medicine) PyrimethaminePyrimethamine tablets during tablets during pregnancy up to 6 pregnancy up to 6 weeks postpartumweeks postpartum
Problems with the Old Problems with the Old Practice…..Practice…..
Poor medication compliancePoor medication compliance due to: due to:– Fear of drug-induced miscarriageFear of drug-induced miscarriage– Experience of generalized itching with chloroquineExperience of generalized itching with chloroquine– Bitter taste of chloroquineBitter taste of chloroquine– Need to swallow too many tabletsNeed to swallow too many tablets– Poor knowledge of health care providers about Poor knowledge of health care providers about
correct dosagescorrect dosages– Inability to buy antimalarial drugs due to povertyInability to buy antimalarial drugs due to poverty– Inadequate health care infrastructuresInadequate health care infrastructures– ForgetfulnessForgetfulness
Problems with the Old Practice…..Problems with the Old Practice…..
Reduced Efficacy due to:Reduced Efficacy due to:– Malaria parasites’ resistance to drugsMalaria parasites’ resistance to drugs– Fake and adulterated drugsFake and adulterated drugs
New Policy for Malaria in New Policy for Malaria in Pregnancy (MIP)Pregnancy (MIP)
1.1. Focused antenatal care (ANC) with Focused antenatal care (ANC) with health health education about malariaeducation about malaria
2.2. Constant use of insecticide-treated nets Constant use of insecticide-treated nets ((ITNsITNs))
3.3. Intermittent preventive treatment (Intermittent preventive treatment (IPTIPT) with ) with sulfadoxine-pyrimethaminesulfadoxine-pyrimethamine
4.4. Early detection & prompt appropriateEarly detection & prompt appropriate case case managementmanagement of women with symptoms and of women with symptoms and signs of malaria signs of malaria
Intermittent Preventive Intermittent Preventive TreatmentTreatment
Although a pregnant woman with malaria Although a pregnant woman with malaria may have no symptoms, malaria can still may have no symptoms, malaria can still affect her and her unborn child.affect her and her unborn child.
Intermittent Preventive Intermittent Preventive TreatmentTreatment: WHO : WHO RecommendationRecommendation
All pregnant women should All pregnant women should receive two doses of receive two doses of IPT after quickeningIPT after quickening, during routinely scheduled , during routinely scheduled ANC visits, but no more frequently than monthly (as ANC visits, but no more frequently than monthly (as DOT)DOT)WHO recommends a schedule of four visits, three WHO recommends a schedule of four visits, three after quickeningafter quickeningPresently, the most effective drug for IPT is Presently, the most effective drug for IPT is sulfadoxine-pyrimethamine (SP) sulfadoxine-pyrimethamine (SP) HIV positive pregnant women should receive at HIV positive pregnant women should receive at least three doses of IPT with SP at ANC visits after least three doses of IPT with SP at ANC visits after quickening, but no more frequently than monthly.quickening, but no more frequently than monthly.
IPT: Special target groupsIPT: Special target groups
Women in their first or second Women in their first or second pregnanciespregnancies
HIV infected womenHIV infected women
Adolescents (10-19 years of age)Adolescents (10-19 years of age)
Women with sickle cell diseaseWomen with sickle cell disease
All pregnant women with unexplained All pregnant women with unexplained anaemiaanaemia
Intermittent Preventive Treatment: Intermittent Preventive Treatment: Dose of SPDose of SP
A single dose is A single dose is three three tablets of SP tablets of SP each each containingcontaining sulfadoxine (500 sulfadoxine (500 mg) + pyrimethamine (25 mg) + pyrimethamine (25 mg)mg)Healthcare providers should Healthcare providers should dispense the dose and dispense the dose and directly observe the client directly observe the client taking the tabletstaking the tablets (DOT (DOT strategy)strategy)
Chemoprophylaxis with Chloroquine: Chemoprophylaxis with Chloroquine: For Women Allergic to Sulfa Drugs*For Women Allergic to Sulfa Drugs*
Dose Chloroquine 150 mg
Timing
1 4 tablets First ANC visit after 16 weeks
2 4 tablets Second day after first dose
3 2 tablets Third day after first dose
Weekly 2 tablets Every week during pregnancy till delivery
*Where chloroquine resistance rates are high, use ITNs
Types of MalariaTypes of Malaria
UncomplicatedUncomplicated– Most commonMost common
ComplicatedComplicated– Life threatening, can Life threatening, can
affect brainaffect brain– Pregnant women more Pregnant women more
likely to get likely to get complicated malaria complicated malaria than non-pregnant than non-pregnant womenwomen
Decerebrate rigidity in complicated (cerebral) malaria
*Each tablet contains 150 mg. of Chloroquine base
Antimalarial drug policy for uncomplicated malaria is currently under review due to increasing chloroquine resistance in some parts of the
country
Current First Line Drug Policy on Case Current First Line Drug Policy on Case Management of Uncomplicated Malaria Management of Uncomplicated Malaria
*Consists of Sulfadoxine(500 mg.) + Pyrimethamine, (25 mg) and Paracetamol (500 mg./tablet)
Antimalarial drug policy for uncomplicated malaria is currently under review due to increasing chloroquine resistance in some parts of the country
Current Second Line Drug Policy on Current Second Line Drug Policy on Case Management of Uncomplicated Case Management of Uncomplicated
Malaria Malaria
Treatment of Severe Malaria with Quinine in ADULTS
Woman diagnosed with severe malaria
First (Loading) dose of IV Quinine: 20 mg/kg in ½ liter of fluid (e.g. 5% dextrose) given over 4 hours (Max. dose 1,200mg)
Maintenance dose: 8 hours after commencing the initial dose give 10 mg/kg in ½ liter of fluid over 4 hours (max 600mg)
Repeat 10mg/kg 8 hourly until the patient can take orally
Change to SP STAT OR
Give oral quinine (10 mg./kg) to complete 7 days therapy
Is patient taking oral drugs?
YesNo
Precautions for use of QuininePrecautions for use of Quinine
Loading dose of quinine should not be used if Loading dose of quinine should not be used if the patient has received any quinine in the last the patient has received any quinine in the last 24 hrs or received mefloquine in the last 7 24 hrs or received mefloquine in the last 7 days. days. Maintenance dose of quinine should be halved Maintenance dose of quinine should be halved in patients with renal failure after 2 days.in patients with renal failure after 2 days.After switching to oral SP, stop quinine After switching to oral SP, stop quinine Hypoglycemia should be looked for and Hypoglycemia should be looked for and corrected with 50% dextrose (1ml/kg)corrected with 50% dextrose (1ml/kg)