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Overview of Malaria

Illness in Nigeria

BY
Prof. C.T. JOHN
Department of Obstetrics & Gynaecology
U.P.T.H.
Port Harcourt.
Major Causes of Maternal
Mortality in Nigeria
Haemorrhage
Other Causes

Malaria
Anaemia
HIV/AIDS
Obstructed Labour
TB
Sepsis

Hypertensive Disorders
Unsafe Abortion
Overview of Malaria Illness in
Nigeria
Malaria is:
 Responsible for 63% of all clinic
attendances in Nigeria
 Affects mainly children under the age of 5
years and pregnant women
 Causes 25% of infant mortality and 30% of
all childhood deaths
 Associated with 11% of all maternal deaths
and 70.5% of morbidity in pregnant women
The Good News!

Malaria can be
prevented
and/or
detected and
treated during
antenatal care
Where do you stand?

The old
traditional
approach,
OR
The refocused
“evidence-
based” approach
Facts about Malaria and
Pregnancy
About 6 million Nigerian women are
pregnant yearly
Malaria is more frequent and serious
during pregnancy
Malaria during pregnancy may account
for:
– Up to 15% of maternal anaemia
– 5–14% of low birth weight
– 30% of “preventable” low birth weight
Overview of Malaria
Illness in Nigeria
Malaria is:
 Responsible for 63% of all clinic
attendances in Nigeria
 Affects mainly children under the age of 5
years and pregnant women
 Causes 25% of infant mortality and 30% of
all childhood deaths
 Is associated with 11% of all maternal
deaths and 70.5% of morbidity in pregnant
women
Effects of Malaria on Pregnant
Women
All pregnant women in malaria-endemic areas
are at risk
Parasites attack and destroy red blood cells
Malaria causes up to 15% of anaemia (low blood
Haemoglobin) in pregnancy
Can cause severe anaemia
In Africa, anaemia due to malaria causes up to
10,000 maternal deaths per year
The Old Practice of malaria
chemoprophylaxis in pregnancy

First ANC visit: Subsequent ANC


– Stat. dose of visits:
Chloroquine – Weekly (Sunday-
(4 tablets) Sunday medicine)
Pyrimethamine
tablets during
pregnancy up to 6
weeks postpartum
Problems with the Old
Practice…..
Poor medication compliance due to:
– Fear of drug-induced miscarriage
– Experience of generalized itching with chloroquine
– Bitter taste of chloroquine
– Need to swallow too many tablets
– Poor knowledge of health care providers about
correct dosages
– Inability to buy antimalarial drugs due to poverty
– Inadequate health care infrastructures
– Forgetfulness
Problems with the Old Practice…..
Reduced Efficacy due to:
– Malaria parasites’ resistance to drugs
– Fake and adulterated drugs
New Policy for Malaria in
Pregnancy (MIP)
Focused antenatal care (ANC) with health
education about malaria
Constant use of insecticide-treated nets
(ITNs)
Intermittent preventive treatment (IPT) with
sulfadoxine-pyrimethamine
Early detection & prompt appropriate case
management of women with symptoms and
signs of malaria
Intermittent Preventive
Treatment

Although a pregnant woman with malaria


may have no symptoms, malaria can still
affect her and her unborn child.
Intermittent Preventive
Treatment: WHO
Recommendation
All pregnant women should receive two doses of
IPT after quickening, during routinely scheduled
ANC visits, but no more frequently than monthly (as
DOT)
WHO recommends a schedule of four visits, three
after quickening
Presently, the most effective drug for IPT is
sulfadoxine-pyrimethamine (SP)
HIV positive pregnant women should receive at
least three doses of IPT with SP at ANC visits after
quickening, but no more frequently than monthly.
IPT: Special target groups
Women in their first or second
pregnancies
HIV infected women
Adolescents (10-19 years of age)
Women with sickle cell disease
All pregnant women with unexplained
anaemia
Intermittent Preventive Treatment:
Dose of SP
A single dose is three
tablets of SP each
containing sulfadoxine (500
mg) + pyrimethamine (25
mg)
Healthcare providers should
dispense the dose and
directly observe the client
taking the tablets (DOT
strategy)
Chemoprophylaxis with Chloroquine:
For Women Allergic to Sulfa Drugs*

Dose Chloroquine Timing


150 mg
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 Malaria
Uncomplicated
– Most common
Complicated
– Life threatening, can
affect brain
– Pregnant women more
likely to get
Decerebrate rigidity in complicated malaria
complicated (cerebral) malaria than non-pregnant
women
Current First Line Drug Policy on Case
Management of Uncomplicated 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 Second Line Drug Policy on
Case 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
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

No Yes Change to SP STAT


Is patient taking OR
oral drugs? Give oral quinine (10 mg./kg) to
complete 7 days therapy
Precautions for use of Quinine

Loading dose of quinine should not be used if


the patient has received any quinine in the last
24 hrs or received mefloquine in the last 7
days.
Maintenance dose of quinine should be halved
in patients with renal failure after 2 days.
After switching to oral SP, stop quinine
Hypoglycemia should be looked for and
corrected with 50% dextrose (1ml/kg)