Drugpol Timor Leste
Transcript of Drugpol Timor Leste
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MALARIA TREATMENTPROTOCOL
Third editionJune 2007
Ministry of Health
Republic Democratic of Timor- Leste
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UNCOMPLICATED MALARIA Uncomplicated malaria definition:
Fever and any of the following:
Headache, od! and "oint pain#
$eelin% cold and #ometime# #hi&erin%
Lo## of appetite and #ometime# a'dominal pain# Diarrhoea, na(#ea and &omitin%)
*pleenome%al!
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Confirmed Dia%no#i# of Malaria All clinically suspected malaria cases require
laboratory examination and confirmation.
Only in case where laboratory confirmation isnot possible start treatment immediately)
Parasitological confirmation is done by thin-
thic blood smear microscopy examination or by dipstic !"apid #iagnostic $est %"#$&'.
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Differential dia%no#i# for
(ncomplicated malaria (onsider other illnesses) such as:
Upper re#pirator! tract infection
+Phar!n%iti#, ton#illiti#, ear infection,pne(monia , mea#le#, den%(e, infl(en-a,
t!phoid fe&er)
"emember that the patient may be sufferingfrom more than one illness.
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Uncomplicated malaria treatment P. falciparum malaria
$he treatment of uncomplicated P. falciparum
malaria is undertaen after diagnosis ofmalaria by light microscopy or #ipstic.
Patients with positive thin-thic bloodsmears or dipstic for P. falciparum malaria istreated by blisters of (oartem* !artemether+,mglumefantrine +,mg'. /ee Ta'le . fordetails of prescription.
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Ta'le . : Do#a%e and admini#tration Coartem +Artemether /0
m%1L(mefantrine ./0 m% for (ncomplicated
malaria falciparumAge group
eight group!lister color
"Day #$ "Day 2$ "Day %$
4 months
to 5yrs
5 to 14 kg Yellow1 tb , 1 tb , 1 tb ,
1 tb 1 tb 1 tb
6 to 11y 15 to 24 kg Blue2 tb , 2 tb , 2 tb ,
2 tb 2 tb 2 tb
12 to 14y 25 to 34 kg Orange
3 tb , 3 tb , 3 tb ,
3 tb 3 tb 3 tb
> 14y > 34 reen4 tb , 4 tb , 4 tb ,
4 tb 4 tb 4 tb
Source: Guideline for the treatment of malaria, WHO; 2006
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Coartem2
Do#a%e *ched(le
Source: WHO, 2007
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Important note# +. . 0t is obligatory to give (oartem* to patient whose
dipstic test or blood slide is positive for P. falciparum and to the patient who has mixed
infections P. falciparum and P .vivax. +. 1ive the correct dosage of (oartem* from the
appropriate blister according to the patient2s weightor age.
3. (hildren under 4 g or below 5 months should not be given (oartem instead treat with the followingregimen +#ee ta'le /.
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Ta'le /) Do#a%e and admini#tration Plasmodium
falciparum for !o(n% infant
Age &roupeightgroup
Artesunate or '(uinine
! " 4months
#5 kg
$$ %& 'irst dose (rtesunate 1)2mg*kg or %& (rthemeter 1)6mg*kg+
$$$Oral (rtesunate2mg*kg*dayday 2 to day
Oral
-uinine 1!mg*T%. 'or
4 daysthen 15"2!mg*kg T%.'or 4 days
Source: Malaria in Children, Department of tropical Pediatrics, Facult of !ropical Medicine, Mahidol "ni#ersit$
** Preferal! "rtesunate#"rtemether $% on da! & if a'ailale
*** When "rtesunate#"rtemether $% is una'ailale, (i'e oral "rtesunate from da! & to da! )
* reat the !oun( infant +ith uinine +hen oral "rtesunate is not a'ailale
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Important note# +/5. 0n case parasitological diagnostic facilities are not available
paracetamol could be given to relieve pain and fever and
referred to health facilities where parasitological diagnosiswill be carried out.
3) Onl! in e4ceptional ca#e 5hen there i# pro'lem 5ith the
referrin% patient in other health facilit! coartem2 co(ld'e admini#tered) +The health facilit! mana%er #ho(ld5rite e4planator! note 5h! %i&in% coartem2 5itho(t
para#itolo%ical dia%no#i#.
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Important note# +66. 7atch all patients swallowing the first dose of
coartem* and observe for hour after the intae. 0nthe event of vomiting within one hour of
administration) a repeat dose should be taen.8. 0nform patient that) the coartem* tablets are in the
blister and after breaing should be taenimmediately) as after +5 hours coartem* tabletsexposed to air totally inactivated and can not beused for treatment of malaria.
9. ach blister of coartem* has expiry date and shouldnot be used after the expiry date.
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Important note# +7;. For small children) paracetamol and coartem*
can be crushed) diluted in water and then put
either directly into the mouth using a syringeor given with a spoon.
,. Any patient who sees re-treatment for
malaria within + wees of taing full dose ofany other antimalarial should be treated with
coartem*.
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Uncomplicated malaria treatment P. 'i'a- malaria Re#i#tance of P. 'i'a- to chloro8(ine ha# not 'een fo(nd
in Timor9Le#te and Chloro8(ine i# the dr(% of choice
(hloroquine is safe and has few side effects. For the radical treatment of P. vivax in addition to
chloroquine) primaquine is recommended ,.4mgg per dayfor 5 days !primaquine should always be taen with food'.
Chloro8(ine can 'e %i&en to pre%nant 5omen and
children) Prima8(ine i# not recommended for the children (nder
one !ear and pre%nant 5omen)
< #etails of treatment see table 5a.
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Ta'le 7a) Do#a%e and admini#tration of Chloro8(ine and
Prima8(ine for malaria 'i'a-.
Age &roup' eight
group ")g$
*HL+R+(,./"#0 mg base$ #0 mg1g on the
first t3o 4ays5 mg1g on 4ay %
6RMA(,./"# mg base$05 mg1g b3
i/e 'or 3 days0tart onurrently with -and gi/e daily 'or 14 days.ay 1 .ay 2 .ay 3
months upto #2 months
4 " #1! "
13 months uto 5 years
1! " #1 1 1
6 " years 1 " # 24 1 1 1
7 " 11 years 24 " #35 2 2 1 8
12 " 14 years 35 " # 5! 3 3 2 1
15 9 5! or more 4 4 2 2
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P. 'i'a- malaria o(n% infant le## than 3;% or 'elo5 7month# #ho(ld 'e treated 5ith Chloro8(ine
alone for three da!# con#ec(ti&e +ale )
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Ta'le 7') Do#a%e and admini#tration of Chloro8(ine
for malaria &i'a- in !o(n% infant
Age
&roup
eight
group
*hloro8uine
.ay 1 .ay 2 .ay 3
! " 4months
#5 kg 1! mg*kg 5 mg*kg 5 mg*kg
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P. falciparum and P. 'i'a-
+mi4ed infection#
The t!pe of malaria 5here 'oth infection#
occ(r# in patient re8(ire# treatment '!
Coartem2)
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=otes:Ne%ati&e dip#tic; or thin9thic; 'lood #mear: If the Pf dip#tic; i# ne%ati&e and the clinical #i%n# are t!pical for
malaria, treat 5ith Chloro8(ine +it co(ld 'e a ca#e of P. 'i'a- infection)
0f the Pf dipstic is negative and the clinical signs don2t suggest malaria)do not treat lie malaria> loo for another illness.
0f the blood slide is negative) loo for another illness. 0f symptoms persist) as for another dipstic or blood slide. If dip#tic; and1or thin9thic; 'lood #mear are not a&aila'le:
0f there is no possibility of dipstic or slide results) treat the patient basedon the clinical signs and symptoms. $reat as if the patient has P. falciparum.
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$ollo59(p of (ncomplicated
malaria:
If #!mptom# per#i#t after treatment 5ith coartem2 or ifthe patient come# 'ac; before the 5th day after treatment.
reatment failure +ithin & da!s of recei'in( coartem/ is
e-tremel! rare and is more liel! to e an inade1uateasorption of the dru(s3 than resistance of the parasites. $tis important to determine from the patient4s histor! +hetherhe or she 'omited durin( the pre'ious treatment or did notcomplete the full course)
If patient i# in health facilit! 5here micro#cope i#a&aila'le fail(re of treatment #ho(ld 'e confirmedpara#itolo%icall! and co(ld 'e treated (#in% the follo5in%re%imen:
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$ollo59(p of (ncomplicated
malaria:
$or ad(lt: ?uinine +.0m% #alt 1;% '5 three time# a da! @ doxycycline +6)0m%1;%
'5 once a da! for < da!#) Do not %i&e do4!c!cline 5ith mil; or iron,5hich 5ill red(ce it# a'#orption)
If patient i# in health facilit! 5here micro#cop! facilit! i# nota&aila'le patient #ho(ld 'e referred to the facilit! 5here micro#copei# a&aila'le) If refer i# not po##i'le treatment #ho(ld 'e %i&en ?uinine@ #oxycycline. Please refer to ale 5 for details of the prescription.
Do4!c!cline #ho(ld not 'e %i&en to pre%nant or lactatin% 5oman, orchild a%ed (p to = !ear#)
$or pre%nant or lactated 5oman or child le## than = !ear#: ?uinine +.0m% #alt 1;% '5 three time# a da! @ clindamycin +.0m%1;%
'5 t5ice a da! for
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Note:
$or hi%h tran#mi##ion area# 5here
para#itolo%ical confirmation i# not
a&aila'le, children >3 !r# of a%e i#recommended to 'e treated 5ith anti
malarial dr(%# 5hen #!mptomatic
+e#peciall! fe&er)
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/" BACA"0A
*e&ere or complicated malaria definition:$e&er and an! of the follo5in%: 0mpaired consciousness Anxiety) palpitation and sweating (onvulsions or fits with this fever Fast or difficult breathing omiting every feed unable to feed Pale hands) tongue and inner parts of the eyelid 1eneraliDed body weaness
#ehydration Eaundice /evere malnutrition #ar urine or no urine
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Pre9referral treatment of #e&ere
malaria
A patient who is non responsive should be quicly assessedand managed. $his includes assessment of the airway)
breathing and circulation. $he staff at the first level healthfacility should be able to maintain airway) provide assisted
breathing and manage shoc if required.
Pre-referral treatment for severe malaria the administrationof Artesunate by the rectal route is recommended for allexcept pregnant women first trimester pregnancy. For the
complete dosage and treatment. (hec blood sugar) if possible
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0n case Artesunate suppository is not available
0B quinine inGection +,mgg bw should be
given. $he ?uinine inGection dosage should be split and inGections given in the anterior
part of the thigh.
In ca#e Arte#(nate #(ppo#itor! i# nota&aila'le, %i&e al#o ?(inine for children
5ith #e&ere malaria)
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Confirmed dia%no#i# of #e&ere
malaria: All clinically suspected severe malaria cases
require laboratory examination andconfirmation.
Only in case where laboratory confirmationis not possible start treatment immediately)Parasitological confirmation is done by thin-
thic blood smear microscopy examinationor by dipstic !"apid #iagnostic $est%"#$&'.
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#ifferential diagnosis for complicated
malaria (onsider other illnesses) such as:
Mea#le#, menin%iti#, ton#illiti#, den%(e,
otiti# media +ear infection, infl(en-a,pne(monia, t!phoid fe&er, t('erc(lo#i#,
h!po%l!cemia)
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*pecific #e&ere malaria treatment
Arte#(nate !6, mg': +.5 mgg body weight !bw' 0or 0B on admission !timeH,') followed by +.5 mggat + and +5 hours) followed by once daily for seven
days. Once the patient can tolerate oral therapy)treatment should be switched to a complete dosage ofcoartem* for three days as recommended in thenational treatment guidelines for uncomplicatedmalaria .
The con%enital malaria i# al#o treated 5ithArte#(nate, 5here /)7 m%1;% i# initiall! %i&enthro(%h I@, follo5ed '! .)/ m%1;% at ./ and /7 hrthen e&er! /7 hr for 6 93 da!#)
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*pecific #e&ere malaria treatment
Artemether !9,mg for adult and 5, mg for childrenand the newborn': 3.+ mgg bw 0B on the first dayfollowed by .6 mgg bw daily for seven days.
Once the patient can tolerate oral therapy) treatmentshould be switched to a complete dosage ofcoartem*.
Arteether !4, mg': 3.+ mgg bw 0B on the first
day) followed by .6 mgg bw for the next 5 days.Once the patient can tolerate oral therapy) mayswitch to a complete dosage of coartem*.
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If Coartem2 i# not a&aila'le, 8(inine
#ho(ld 'e admini#tered in com'ination
5ith tetrac!cline or do4!c!cline or
clindam!cin, to complete the #e&en9da!
treatment, e4cept for pre%nant 5omen and
children (nder ei%ht !ear# of a%e for 5homtetrac!cline1do4!c!cline i# contraindicated)
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?(inine oadin( dose: ?uinine dihydrochloride +,
mg salt g bw diluted in , mlg bw of 4I
dextrose or dextrose saline administered by0 infusion over a period of four hours for
both adult and children. 0n severe (hildhood
falciparum malaria) if patient received
quinine or quinidine or mefloquine in 59 hrs
before arrival) give , mgg over + hours.
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?(inine %aintenance dose: ?uinine dihydrochloride , mg salt g
body weight diluted in , mlg body weight of 4I dextroseor dextrose saline administered by 0 infusion. 0n adults) themaintenance dose is infused over a period of four hours and
repeated every eight hours.*imilarl! in children incl(din% con%enital malaria, it i#inf(#ed o&er a period of t5o ho(r# and repeated e&er!ei%ht ho(r# +calc(lated from the 'e%innin% of the pre&io(#inf(#ion (ntil the patient can #5allo5) To complete the
#e&en9da! to ei%ht9da! treatment in children, %i&e ?(inine#(lfate .0 m%1;% per oral three time# in a da!) Increa#e thedo#a%e of ?(inine #(lfate to .39/0 m%1;% after 7 da!# oradd tetrac!cline 3 m%1;% t5ice a da! for children a'o&e <!ear#)
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=otes Artemi#inin deri&ati&e# are #afe, effecti&e, ha&e a 5ider therape(tic
5indo5, can 'e admini#tered intram(#c(larl! and #ho(ld 'econ#idered a #afer alternati&e to 8(inine)
A loading dose of quinine should not be given +. if the patient hasreceived or suspected to have received quinine) quinidine or mefloquinewithin the preceding + hours) and +/ facilities for controlled rate of flowof quinine infusion are not available. 0n order to improve treatmentoutcome of quinine add a course of oral tetracycline 5 mgg bw 5 timesdaily or doxycycline 3 mgg bw once daily except for children under 9years of age and pregnant women) or clindamycin , mgg bw twicedaily for 3-8 days.
0f there is no clinical improvement after 59 hours of parenteral therapy)the maintenance dose of parenteral quinine should be reduced by one-third to a half !i.e., 4-8 mgg bw quinine dihydrochloride'. )