WHO Guidelines for Malaria Treatment 2010 PDF

AMAZON MALARIA INITIATIVE (AMI)/ RAVREDA IX Annual Evaluation Meeting Santa Cruz, Bolivia 2 5 March 2010 Dr Peter OLUMESE Global Malaria Programme WHO, Geneva  The WHO Guidelines for the treatment of mala...

AMAZON MALARIA INITIATIVE (AMI)/ RAVREDA IX Annual Evaluation Meeting Santa Cruz, Bolivia 2 5 March 2010 Dr Peter OLUMESE Global Malaria Programme WHO, Geneva  The WHO Guidelines for the treatment of malaria (MTG)......provide comprehensible, global and evidence-based guidelines for the formulation of policies and protocols for the treatment of malaria provide a framework for development of specific diagnosis and treatment protocols in countries – Taking in account national and local malaria drug resistance pattern and health services capacity It is not a clinical management manual for the treatment of malaria 2nd Edition (2010) – (release date 9 March 2010) www.who.int/malaria/docs/TreatmentGuidelines2010.pdf 2 | Guidelines for the Treatment of Malaria  Contents and scope of the MTG Malaria diagnosis and treatment – policies and strategies from a clinical and a public health perspective – What to use – in diagnosis, curative/palliative treatment – How and where to use Indications, contraindications and precautions Best practices in clinical management Strategies for the use of medicines 3 | Guidelines for the Treatment of Malaria  The WHO Guidelines for the Treatment of Malaria......provides evidence based recommendations for the treatment of: uncomplicated malaria severe malaria in special groups (young children, pregnant women, HIV /AIDS) in travellers (from non-malaria endemic regions) in epidemics and complex emergency situations 4 | Guidelines for the Treatment of Malaria  Formulation of Recommendations for Malaria Treatment Based on evidence - on a consideration of the safety, efficacy, overall cost- benefit – from a clinical and a global public health perspective – Considering, in the case of a medicine, procedure or a strategy, the benefits against the the risks, burden of cost the implications for the health system, the feasibility of implementation 5 | Guidelines for the Treatment of Malaria  Current Recommendations including updates in the 2nd edition (2010) 6 | Guidelines for the Treatment of Malaria  Malaria Diagnosis Prompt parasitological confirmation by microscopy or alternatively by RDTs is recommended in all patients suspected of malaria before treatment is started. Treatment solely on the basis of clinical suspicion should only be considered when a parasitological diagnosis is not accessible. 7 | Guidelines for the Treatment of Malaria Treatment of Uncomplicated Falciparum Malaria Artemisinin-based combination therapies (ACTs) are the recommended treatments for uncomplicated falciparum malaria. The following ACTs are recommended: – Artemether + lumefantrine; artesunate + amodiaquine; artesunate + mefloquine; artesunate + sulfadoxine-pyrimethamine, and dihydroartemisinin + piperaquine. Second-line antimalarial treatment: – Alternative ACT known to be effective in the region; – Artesunate plus tetracycline or doxycycline or clindamycin. Any of these combinations to be given for 7 days; and – Quinine plus tetracycline or doxycycline or clindamycin. Any of these combinations should be given for 7 days. 8 | Guidelines for the Treatment of Malaria Treatment of Uncomplicated falciparum malaria Artemisinin-based combination therapies should be used in preference to non-artemisinin based combination (sulfadoxine- pyrimethamine + amodiaquine). ACTs should include at least 3 days of treatment with an artemisinin derivative Dihydroartemisinin + piperaquine (DHA+PPQ) is an option for the treatment of uncomplicated P. falciparum malaria worldwide Single dose of primaquine (0.75mg/kg) used for its antigamecytocidal action in the treatment of falciparum malaria, especially in the pre-elimination and elimination programmes. 9 | Guidelines for the Treatment of Malaria  Treatment of severe malaria Severe malaria is a medical emergency. Full doses of parenteral antimalarial treatment should be started without delay with whichever effective antimalarial is first available. For adults, artesunate i.v. or i.m – Quinine remains an acceptable alternative. For children (especially in the malaria endemic areas of Africa) the following antimalarial medicines are recommended as there is insufficient evidence to recommend any of these antimalarial medicines over another: – artesunate i.v. or i.m. – quinine (i.v. infusion or divided i.m. injection) – artemether i.m. Give parenteral antimalarials for a minimum of 24hrs once started (irrespective of the patient's ability to tolerate oral medication earlier), and, thereafter, complete treatment by giving a complete course of: – an ACT – artesunate + clindamycin or doxycycline – quinine + clindamycin or doxycycline. 10 | Guidelines for the Treatment of Malaria  Treatment of vivax malaria Chloroquine combined with primaquine is the treatment of choice for chloroquine-sensitive infections. In areas with chloroquine resistant P. vivax, ACTs (with partner medicines with long-half lives) is recommended for the treatment of P. vivax malaria At least a 14-day course of primaquine is required for the radical treatment (0.25 – 0.5mg/kg/day) In mild - moderate G6PD deficiency, primaquine 0.75 mg base/kg bw given once a week for 8 weeks. In severe cases, primaquine is contraindicated. 11 | Guidelines for the Treatment of Malaria  Special Groups Pregnancy First trimester: – Quinine + clindamycin – An ACT is indicated only if this is the only treatment immediately available, or if treatment with quinine + clindamycin fails or compliance issues with a 7-day treatment. Second and third trimesters: – ACTs known to be effective in the country/region or artesunate + clindamycin or quinine + clindamycin 12 | Guidelines for the Treatment of Malaria  Special Groups Lactating women – Lactating women should receive standard antimalarial treatment (including ACTs) except for dapsone, primaquine and tetracyclines. Infants and young children – ACTs with attention to accurate dosing and ensuring Travellers returning to non-endemic countries: – atovaquone-proguanil – Artemether +lumefantrine – dihydroartemisinin + piperaquine – quinine + doxycycline or clindamycin. 13 | Guidelines for the Treatment of Malaria  Next Steps Wide dissemination Review and updates of national guidelines Updates of relevant treatment manuals and algorithms (e.g. IMCI, severe malaria) Begin the process of review of evidence for the preventive use of antimalarial medicines for inclusion in the next edition of the Guidelines 14 | Guidelines for the Treatment of Malaria  National treatment policy (current?) P.vivax ACT Adoption treatment severe failur mala e ria pregnancy treatment lab-confirmed treatment Boliva AS+MQ QN+CL CQ+PQ 2001 QN; (AS+AQ -2nd &3rd trimester); Brazil AL AS;AM;QN CQ for vivax CQ+PQ(7d) 2006 QN(3d)+CL( Colombia AS+MQ 5d) QN(7d) QN; (AS+AQ -2nd &3rd trimester); CQ+PQ 2004 Ecuador AS+SP; AL QN+T,D,CL CQ+PQ 2004 Guyana AL QN+T CQ+PQ 2004 Peru (Amazon AS+MQ (one province); area) AS+SP CQ+PQ 2001 Suriname AL QN(7d) CQ+PQ 2004 15 | Guidelines for the Treatment of Malaria  What is Malaria? A vector-borne infectious disease that is widespread in tropical and subtropical regions. One of the most common infectious diseases and an enormous public-health problem. Disease is caused by protozoan parasites of the genus Plasmodium. Malaria  Most serious forms of the disease are caused by Plasmodium falciparum and Plasmodium vivax Malarial parasites are transmitted by - female Anopheles mosquitoes. What is Malaria? Transmission of Malaria Parasites  What are the signs and symptoms of malaria? malaria should be suspected in the setting of fever (temperature ≥37.5°C) and relevant epidemiologic exposure (residence in or travel to an area where malaria is endemic) Febrile paroxysms may occur - every other - day for P. vivax, P. ovale, and P. falciparum and every third day for P. malariae.  Uncomplicated malaria – initial symptoms of malaria are nonspecific and may also include tachycardia, tachypnea, chills, malaise, fatigue, diaphoresis (sweating), headache, cough, anorexia, nausea, vomiting, abdominal pain, diarrhea, arthralgias, and myalgias – Physical findings may include manifestations of anemia and a palpable spleen. – Mild jaundice may also develop in patients with otherwise uncomplicated falciparum malaria. – Splenic enlargement is a frequent finding among otherwise healthy individuals in endemic areas  Severe malaria – Altered consciousness with or without seizures – Respiratory distress or acute respiratory distress syndrome (ARDS) – Circulatory collapse – Metabolic acidosis – Renal failure, hemoglobinuria ("blackwater fever") – Hepatic failure – Coagulopathy with or without disseminated intravascular coagulation – Severe anemia or massive intravascular hemolysis – Hypoglycemia  Cerebral malaria The severity depends on a combination of factors including parasite virulence, host immune response, and time between onset of symptoms and initiation of therapy. impaired consciousness, delirium, and/or seizures; focal neurologic signs are unusual. The onset may be gradual or sudden following a convulsion.  How to diagnose Malaria? The diagnosis of malaria is established in the setting of symptoms consistent with malaria and a positive malaria diagnostic test. Clinical tools for parasite-based diagnosis include microscopy (visualization of parasites in stained blood smears) and rapid diagnostic tests (RDTs; which detect antigen or antibody).  Microscopy – allows identification of the Plasmodium species as well as quantification of parasitemia. – Disadvantages include it being labor intensive and requiring substantial training and expertise  Rapid diagnostic tests – increasingly important diagnostic tools in resource- limited endemic settings due to their accuracy and ease of use. – require no electricity or laboratory infrastructure, give results within 15 to 20 minutes, and can be performed successfully even by health workers with limited training. – provide a qualitative result but cannot provide quantitative information regarding parasite density.  What is the treatment for Malaria? Treatment of malaria involves supportive measures as well as specific antimalarial drugs like: – Quinine – Chloroquine – Cotrifazid – Primaquine – Doxycycline – Mefloquine – Hydroxychloroquine  In the Philippines, – The Artemether-Lumefantrin (AL) combination will be the first line medicine in the treatment of confirmed uncomplicated and severe Plasmodium falciparum malaria – If AL is not available, whether the patient is conscious or unconscious, and in case of treatment failure, quinine in combination with either tetracycline or doxycycline or clindamycin will be the second line treatment.  What are the preventive measures of Malaria? Strategies to disrupt malaria transmission include effective deployment of antimalarial drugs, personal mosquito protection, mosquito vector control, and research (including vaccine development)  Methods used to prevent the spread of the disease, or to protect individuals in areas where malaria is endemic, include: – Prophylactic (preventive) drugs against malaria – Mosquito eradication – Prevention of mosquito bites