Overview of Malaria in Nigeria

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)