NATIONAL GUIDELINES FOR THE DIAGNOSIS,

TREATMENT AND PREVENTION OF MALARIA IN

KENYA

Fifth Edition

Ministry of Health

April 2016

FIFTH EDITION 1
©MINISTRY OF HEALTH

Any part of this document may be freely quoted, reproduced or translated in full or in part, provided
the source is acknowledged. It may not be sold or used in conjunction with commercial purposes or
for profit.

National Guidelines for the diagnosis, treatment and prevention of malaria in Kenya

Published by: Ministry of Health

National Malaria Control Program
P. O. Box 19982 KNH
Nairobi, 00202, Kenya
Email: [email protected]
http://www.nmcp.or.ke

2 FIFTH EDITION
Contents
Contents .............................................................................................................. 3
List of figures and tables ............................................................................................ 4
Preface ................................................................................................................. 5
Acknowledgements ................................................................................................... 6
Abbreviations .......................................................................................................... 7
Glossary of terms ..................................................................................................... 8
1. Introduction ................................................................................................... 11
1.1 Background ........................................................................................... 11
1.2 Objective ............................................................................................. 11
1.3 Target Audience ..................................................................................... 11
1.4 Formulations ......................................................................................... 11
1.5 Diagnosis Based Treatment ........................................................................ 12
2. Malaria in Kenya .............................................................................................. 13
2.1. Epidemiology of Malaria in Kenya ................................................................. 13
3. Clinical features and classification of malaria .......................................................... 15
3.1. Uncomplicated Malaria ............................................................................. 15
3.2. Severe Malaria ....................................................................................... 15
4. Parasitological diagnosis of malaria ....................................................................... 16
4.1. Microscopy ............................................................................................ 16
4.2. Rapid Diagnostic Tests .............................................................................. 16
4.3. Other Parasite Detection Methods ................................................................ 17
5. Management of uncomplicated malaria .................................................................. 18
5.1. Diagnosis .............................................................................................. 18
5.2. Treatment Of Uncomplicated Falciparum Malaria .............................................. 18
5.3. Treatment Failure ................................................................................... 19
5.4. Treatment of Uncomplicated Vivax Malaria ..................................................... 20
5.5. M & E Indicators ..................................................................................... 21
6. Management of severe malaria ............................................................................ 22
6.1. Diagnosis .............................................................................................. 22
6.2. Evaluation of Some Clinical Manifestations ..................................................... 24
6.3. Treatment of Severe Malaria ...................................................................... 25
6.4. Supportive Treatment .............................................................................. 28
6.5. Pre-Referal Management of Severe Malaria ..................................................... 30
6.6. Follow-Up of All Patients With Severe Malaria .................................................. 31
7. Malaria in pregnancy ......................................................................................... 32
7.1. Management of Uncomplicated Malaria ......................................................... 32
7.2. Management of Severe Malaria .................................................................... 33
7.3. Prevention of Malaria in Pregnancy ............................................................... 34
8. Basic techniques in managing malaria medicines ...................................................... 36
8.1. Concept of Essential Drugs ......................................................................... 36
8.2. Quantification of Antimalarial Medicines ........................................................ 37
8.3. Rational Use of Anti-Malarial Medicines ......................................................... 40
8.4. Pharmacovigilance .................................................................................. 41
9. Malaria prevention ........................................................................................... 44
9.1. Chemoprophylaxis for Non-Immune Populations ............................................... 44
9.2. Vector Control ....................................................................................... 47
9.3. Epidemic Preparedness and Response ............................................................ 48
9.4. Prevention of Malaria Infection Through Blood Transfusion ................................... 48
9.5. Advocacy Communication and Social Mobilization ............................................. 48
10. Annexes ......................................................................................................... 49
ANNEX 1: Outpatient Algorithm for Diagnosis and Management of Malaria for Children and Adults .... 49
ANNEX 2: The Pharmacology of Antimalarials .................................................................... 50
ANNEX 3: Additional Information on Antimalarials .............................................................. 51
ANNEX 4: Coma Monitoring Scales ................................................................................. 58
ANNEX 5: Updated IMCI Algorithm ................................................................................. 60
ANNEX 6: Third Edition Guideline Review Team ................................................................. 61

FIFTH EDITION 3
List of figures and tables
FIGURES
Figure 1: 2009 Kenya malaria endemicity map .................................................................. 14
Figure 2: The pharmaceutical management cycle .............................................................. 36
Figure 3: Flow of logistical management information ......................................................... 39
Figure 4: The medicine use cycle ................................................................................ 40
Figure 5: Flow of information on adverse drug reactions ..................................................... 43

TABLES
Table 1: Dosing schedule for artemether-lumefantrine ........................................................ 18
Table 2: Dosing schedule for dihydroartimisinin-piperaquine ................................................. 20
Table 3: Signs and symptoms of severe malaria in adults and children ...................................... 22
Table 4: Clinical Parameters ........................................................................................ 23
Table 5: Clinical Chemistry Parameters ........................................................................... 23
Table 6: Supportive treatment for manifestations of severe malaria ........................................ 28
Table 7: Symptoms and signs of uncomplicated malaria in pregnant women .............................. 32
Table 8: Symptoms and signs of severe malaria in pregnant women ........................................ 33
Table 9: Convulsions in pregnancy ................................................................................ 34
Table 10: Types of inventory records ............................................................................. 39
Table 11: Dosing schedule for mefloquine ....................................................................... 45
Table 12: Dosing schedule for proguanil .......................................................................... 45
Table 13: Dosing schedule for atovaquone-proguanil ........................................................... 46
Table 14: If tablets are available, fractions can be administered to patients age 8 to 13 years ........ 47
Table 15: Common antimalarials classified by mode of action ................................................ 50
Table 16: Dosing schedule for artemether-lumefantrine powder for suspension ........................... 51
Table 17: Quinine tablets equivalence table ..................................................................... 52
Table 18: Dosing schedule for quinine 200mg tablets .......................................................... 53
Table 19: Dosing schedule for quinine 300mg tablets .......................................................... 53
Table 20: Dosing schedule for IM quinine injections ........................................................... 54
Table 21: Dosing schedule for Parenteral Artesunate ......................................................... 57
Table 22: Glasgow coma scale for adults and children >5 years .............................................. 58
Table 23: Adjusted GCS verbal responses for children <5 years .............................................. 58
Table 24: Blantyre coma scale for children <5 years .......................................................... 59

4 FIFTH EDITION
Preface
The ultimate goal of malaria control is to reduce morbidity and prevent mortality due to
malaria thereby mitigating the socio-economic burden of the disease on Kenya. One of
the key strategic interventions therefore is to provide early parasitological diagnosis and
prompt treatment of malaria using effective medicines.

The Ministry of Health have developed these guidelines for malaria diagnosis, treatment
and prevention with an aim of improving malaria case management by all health workers
and having a harmonized approach in efforts aimed at the reduction of morbidity and
mortality due to malaria.

It is recommended that diagnosis of malaria be confirmed by testing. Management

should be based on testing outcomes. The fifth edition of the guidelines contains new
information in line with the revised WHO guidelines (3rd edition).

The guideline document is intended to serve as a guide to all health professionals both
pre- and in-service and including those in the private sector, researchers, trainers in
medical training institutions and all partners involved in the implementation of malaria
case management in Kenya.

These guidelines will continue to be updated periodically taking into consideration

continuous monitoring and evaluation and emerging research findings and lessons learned.
We have carefully considered the cost effectiveness of recommended interventions. We
expect users to continually give feedback regarding the use of relevant sections of the
guidelines.

Dr. Jackson Kioko,

Acting Director Of Medical Services

FIFTH EDITION 5
Acknowledgements
The Ministry of Health is indebted to many individuals and organisations whose support
and collaboration have made possible the updating of this fifth edition of the national
guidelines for the treatment and prevention of malaria for health workers.

We are grateful to the Malaria Interagency Coordinating Committee, members of the

Case Management Technical Working Group and staff of the Division of Malaria Control
for their contributions to the development of this document. We are grateful for the
financial support from the United States President’s Malaria Initiative (PMI) through
MSH/HCSM programme as well as support from the United Kingdom’s Department for
International Development. Technical support was received from the World Health
Organization’s Kenya Country Office, Inter-country Support Team and Global Malaria
Program.

It is our sincere hope that the guidelines will be useful in improving prevention and
case management of malaria in Kenya. By implementing the recommendations in the
guidelines, there is no doubt that we shall reduce malaria related illnesses and deaths
and put Kenya on the path towards a malaria free future.

6 FIFTH EDITION
Abbreviations
ACSM Advocacy communication and social mobilization
ACT Artemisinin based combination treatment
ADR Adverse drug reaction
AIDS Acquired immune-deficiency syndrome
AL Artemether-lumefantrine
ANC Antenatal care or clinic
CQ Chloroquine
CSF Cerebro-spinal fluid
DHA-PPQ Dihydroartemisinin-piperaquine
DHIS District Health Information System
DOMC Division of Malaria Control
DOT Directly observed treatment
DNA Deoxyribonucleic acid
EPR Epidemic preparedness and response
GCS Glasgow coma scale
G6PD Glucose 6-phosphate dehydrogenase
Hb Haemoglobin
HIV Human immune-deficiency virus
HRP2 Histidine-Rich Protein 2
IM Intramuscular
IMCI Integrated management of childhood illnesses
IPTp Intermittent preventive treatment of malaria in pregnancy
IV Intravenous
kg kilogram
LLIN Long lasting insecticidal nets
M&E Monitoring and Evaluation
mg milligram
ml millilitre
NSAID Non-steroidal anti-inflammatory drug
PCR Polymerase chain reaction
pLDH Parasite lactate dehydrogenase
PPB Pharmacy and poisons board
RDT Rapid diagnostic test
SOP Standard operating procedure
SP Sulphadoxine or Sulphalene/pyrimethamine
WBC White blood cell
WHO/GMP World Health Organization Global Malaria Program

FIFTH EDITION 7
Glossary of terms
Afebrile: Without fever
Anaemia: A reduction in the quantity of the oxygen-carrying pigment haemoglobin in
the blood
Anti-pyretic: A drug such as paracetamol that relieves fever without affecting the
causative agent (in this case the parasite)
Artemisinin-based combination therapy (ACT): A combination of artemisinin or one of
its derivatives with an antimalarial or antimalarials of a different class
Asexual cycle: The life cycle of the malaria parasite in the host from merozoite invasion
of red blood cells to schizont rupture (merozoite → ring stage → trophozoite → schizont
→ merozoites). Duration approximately 48 h in Plasmodium falciparum, P. ovale and P.
vivax; 72 h in P. malariae.
Asexual parasitaemia: The presence in host red blood cells of asexual parasites. The
level of asexual parasitaemia can be expressed in several different ways: the percentage
of infected red blood cells, the number of infected cells per unit volume of blood, the
number of parasites seen in one microscopic field in a high-power examination of a thick
blood film, or the number of parasites seen per 200–1000 white blood cells in a high-
power examination of a thick blood film.
Base: The main active part of a drug (see also salt)
Cerebral malaria: Severe P. falciparum malaria with cerebral manifestations, usually
including coma (Glasgow coma scale <11, Blantyre coma scale <3). Malaria with coma
persisting for > 30 min after a seizure is considered to be cerebral malaria.
Cinchonism: Poisoning caused by an overdose of cinchona or the alkaloids quinine,
quinidine, or cinchonine derived from it.
Combination treatment: A combination of two or more different classes of antimalarial
medicines with unrelated mechanisms of action.
Cure: Elimination of the symptoms and asexual blood stages of the malaria parasite that
caused the patient or caregiver to seek treatment.
Drug resistance: The World Health Organization (WHO) defines resistance to
antimalarials as the ability of a parasite strain to survive and/or to multiply despite
the administration and absorption of a medicine given in doses equal to or higher than
those usually recommended but within the tolerance of the subject, provided drug
exposure at the site of action is adequate. Resistance to antimalarials arises because
of the selection of parasites with genetic mutations or gene amplifications that confer
reduced susceptibility.
Endemic: Occurring frequently in a particular region or population
Febrile: With an increase in temperature compared with the normal Fever. An increase
in body temperature above the normal temperature i.e. above an oral temperature of
37.5°C.

8 FIFTH EDITION
Febrile convulsions: Convulsions occurring in children aged 6 months - 6yrs due to fever
caused by infection outside the central nervous system
Gametocytes: Sexual stages of malaria parasites present in the host red blood cells.
Hyperpyrexia: Temperature over 39.5°C
Hypersensitivity: An abnormal response to the presence of a particular antigen, which may
cause a variety of tissue reactions ranging from serum sickness to an allergy.
Hypnozoites: Persistent liver stages of P. vivax and P. ovale malaria that remain dormant
in host hepatocytes for an interval (most often 3–45 weeks) before maturing to hepatic
schizonts. These then burst and release merozoites, which infect red blood cells.
Hypnozoites are the source of relapses.
Immunity: All those natural processes which prevent infection, re-infection, or super-
infection, or which assist in destroying parasites or limiting their multiplication, or which
reduce the clinical effects of infection.
Lumbar puncture: The insertion of a needle into the fluid-filled space of the spinal cord
in the lumbar region and the removal of a sample of that fluid for examination
Monotherapy: Antimalarial treatment with a single medicine (either a single active
compound or a synergistic combination of two compounds with related mechanism of
action).
Non-immune: Having no immunity at all to a particular organism or disease
Parenteral: The provision of medication into the body by any means other than through
the alimentary canal (oral route or rectal), such as by subcutaneous, intramuscular or
intravenous injection.
Plasmodium: A genus of protozoan vertebrate blood parasites that includes the causal
agents of malaria. Plasmodium falciparum, P. malariae, P. ovale and P. vivax cause
malaria in humans. Human infections with the monkey malaria parasite, P. knowlesi
have also been reported from forested regions of South-East Asia.
Pre-erythrocytic development: The life-cycle of the malaria parasite when it first
enters the host. Following inoculation into a human by the female anopheline mosquito,
sporozoites invade parenchyma cells in the host liver and multiply within the hepatocytes
for 5–12 days, forming hepatic schizonts. These then burst liberating merozoites into the
bloodstream, which subsequently invade red blood cells.
Proficiency assessment: It is a process of exposing practicing microscopists to slides of
known results with a view of assessing their ability to correctly read slides.
Pruritus: Itching caused by local irritation of the skin or at times nervous disorders.
Radical cure: In P. vivax and P. ovale infections only, this comprises a cure as defined
above plus prevention of relapses by killing hypnozoites.
Rapid diagnostic test (RDT): Is an immunochromatographic test for malaria presented in
form of a dipstick, cassette or card in which the coloured line indicates that plasmodial
antigens have been detected.
Recrudescence: The recurrence of asexual parasitaemia after treatment of the infection

FIFTH EDITION 9
with the same infection that caused the original illness. This results from incomplete
clearance of parasitaemia due to inadequate or ineffective treatment. It is, therefore,
different to a relapse in P. vivax and P. ovale infections, and it differs from a new
infection or re-infection (as identified by molecular genotyping in endemic areas).
Recurrence: The recurrence of asexual parasitaemia following treatment. This can be
caused by a recrudescence, a relapse (in P. vivax and P. ovale infections only) or a new
infection.
Relapse: The recurrence of asexual parasitaemia in P. vivax and P. ovale malaria deriving
from persisting liver stages. Relapse occurs when the blood stage infection has been
eliminated but hypnozoites persist in the liver and mature to form hepatic schizonts.
After variable intervals of weeks to months, the hepatic schizonts burst and liberate
merozoites into the bloodstream.
Resistance: See drug resistance.
Salt: Any compound of a base and an acid, e.g. quinine dichloride or quinine sulphate.
Schizonts: Mature malaria parasites in host liver cells (hepatic schizonts) or red blood
cells (erythrocytic schizonts) that are undergoing nuclear division. This process is called
schizogony.
Sensitive: Possessing the ability to respond to a stimulus.
Severe anaemia: Haemoglobin concentration of < 5g/100 ml (haematocrit < 15%). Severe
falciparum malaria. Acute falciparum malaria with signs of severity and/or evidence of
vital organ dysfunction.
Slide rechecking: It is a verification process where slides are reexamined by a second
reader and a third reader where there is disagreement.
Sporozoites: Motile malaria parasites that are infective to humans, inoculated by a
feeding female anopheline mosquito. The sporozoites invade hepatocytes.
Treatment failure: A failure to achieve the desired therapeutic response after the
initiation of therapy. Treatment failure is not synonymous with drug resistance.
Trophozoites: A stage of development of the malaria parasites within host red blood
cells. Mature trophozoites contain visible malaria pigment.
Uncomplicated malaria: Symptomatic infection with malaria parasitaemia without signs
of severity and/or evidence of vital organ dysfunction.

10 FIFTH EDITION
1. Introduction
1.1 BACKGROUND
Malaria is one of the leading causes of morbidity and mortality, particularly in children under
five years of age in Kenya. Plasmodium falciparum is the commonest cause of malaria in
Kenya. Interventions to control malaria in Kenya have been integrated and include:
● Provision of prompt and effective treatment or malaria case management
● Vector control using long lasting insecticidal nets, indoor residual spraying and
other integrated vector management strategies
● Prevention and treatment of malaria in pregnancy
● Epidemic preparedness and response and
● Advocacy, communication and Social mobilization
The provision of prompt and effective treatment is the cornerstone of malaria case
management. The treatment policy for malaria has changed in the past due to failing
therapeutic efficacy from chloroquine (CQ) to sulphadoxine-pyrimethamine (SP) in
1998 and subsequently to the currently recommended artemisinin- based combination
therapies (ACTs) in 2004. ACTs are at present the best treatment for uncomplicated
malaria and the efficacy of the treatments recommended in this guideline continue to
be monitored regularly.

1.2 OBJECTIVE
The objective of this treatment guideline is to provide the target audience with
evidence-based recommendations for the treatment of malaria. Information is shown on
the treatment of uncomplicated malaria and severe malaria including disease in special
risk groups for example young children and pregnant women as well as chemoprophylaxis
for special groups including travellers from non-malaria endemic countries.

1.3 TARGET AUDIENCE

These guidelines are intended for: All health professionals (doctors, nurses, clinical officers,
pharmacists and laboratory technologists). Public health and policy specialists working
in hospitals, research institutions, medical schools, non­ governmental organizations and
agencies; working as partners in health or malaria control may also find this guideline useful.

1.4 FORMULATIONS
Only ACTs that are co-formulated (both medicines combined in the same tablet) should be
used for the treatment of uncomplicated malaria in Kenya. In order for the ACT to provide
its intended benefits of effective treatment and extended useful therapeutic life of both
drugs, it is strongly recommended that ACTs should include at least 3 days of treatment
with an artemisinin derivative1. Paediatric formulations should be used for infants and
children in order to ensure the correct dosing. Where available, child friendly formulations
(flavoured / liquefiable by dose) should be used. All other previously used monotherapies
including oral artemisinins should not be used to for treatment of malaria and will not be
licensed for this purpose anymore.

1 World Health Organization 2010. Guidelines for the treatment of malaria 2nd edition. WHO-GMP Geneva.

FIFTH EDITION 11
1.5 DIAGNOSIS BASED TREATMENT
Diagnosis of malaria is based on detection of parasites and parasite products in the blood
(parasitological or confirmatory diagnosis) following clinical suspicion. It is currently
recommended to confirm diagnosis of malaria in all age-groups and in all epidemiological
settings. The use of a confirmatory diagnosis with either microscopy or RDTs is expected
to ensure that patients with fever arising from other causes are managed accordingly
and treatment is targeted to patients with confirmed malaria infection.

Efforts are underway to ensure diagnostic tests are available at all levels of the health
care system. Under no circumstances should a patient with suspected malaria be denied
treatment, or provided with delayed treatment for lack of a parasitological diagnosis.

Although a parasitological diagnosis of malaria is recommended for all patients

with suspected malaria, appropriate treatment should NEVER be delayed or
denied due to inability to test for malaria

12 FIFTH EDITION
2. Malaria in Kenya
Malaria is a disease caused by parasites of the genus Plasmodium. Nationally, Plasmodium
falciparum is the predominant species (98.2 per cent) while P. malariae, P.ovale is 1.8
per cent often occurring as mixed infections. The last three surveys (KMIS) have not
identified presence of P.vivax in the country.

2.1. EPIDEMIOLOGY OF MALARIA IN KENYA

Kenya has four malaria epidemiological zones, with diversity in risk determined largely
by altitude, rainfall patterns and temperature. The zones are:

● Endemic: Areas of stable malaria have altitudes ranging from 0 to 1,300 metres
around Lake Victoria in western Kenya and in the coastal regions. Rainfall,
temperature and humidity are the determinants of the perennial transmission
of malaria. The vector life cycle is usually short and survival rates are high
because of the suitable climatic conditions. Transmission is intense throughout
the year, with annual entomological inoculation rates between 30 and100.

● Seasonal transmission: Arid and semi-arid areas of northern and south-eastern

parts of the country experience short periods of intense malaria transmission
during the rainfall seasons. Temperatures are usually high and water pools
created during the rainy season provide breeding sites for the malaria vectors.
Extreme climatic conditions like the El Niño southern oscillation lead to
flooding in these areas, resulting in epidemic outbreaks with high morbidity
rates owing to the low immune status of the population.

● Epidemic prone areas of western highlands of Kenya: Malaria transmission

in the western highlands of Kenya is seasonal, with considerable year-to-
year variation. Epidemics are experienced wheno climatic conditions favour
sustainability of minimum temperatures around 18 C. This increase in minimum
temperatures during the long rains favours and sustains vector breeding,
resulting in increased intensity of malaria transmission. The whole population
is vulnerable and case fatality rates during an epidemic can be up to ten times
greater than those experienced in regions where malaria occurs regularly.

● Low risk malaria areas: This zone covers the central highlands of Kenya
including Nairobi. The temperatures are usually too low to allow completion
of the sporogonic cycle of the malaria parasite in the vector. However, the
increasing temperatures and changes in the hydrological cycle associated with
climate change are likely to increase the areas suitable for malaria vector
breeding with the introduction of malaria transmission in areas where it had
not existed before.

FIFTH EDITION 13
In 2009, a model-based map of the intensity of P. falciparum transmission in Kenya as defined
by the proportion of infected children aged 2-10 years in the community was produced. Based
on the malaria risk map and the eco-epidemiology of malaria in Kenya, subcounties have
been stratified into four categories: Lake stable endemic & Coast seasonal stable endemic
(risk class equal to or above 20 per cent); Highland epidemic-prone subcounties (risk class 5-
<20 per cent); Seasonal low transmission including arid and Semi arid subcounties (risk class
less than 5 per cent); low risk subcounties (risk class less than 0.1 per cent).

Figure 1: 2009 Kenya malaria endemicity map2

2 Abdisalan M Noor et al. The risks of malaria infection in Kenya in 2009 BMC Infectious Diseases 2009, 9:180

14 FIFTH EDITION
3. Clinical features and classification of malaria
Malaria can be classified as either uncomplicated or severe based on clinical presentation.

3.1. UNCOMPLICATED MALARIA

This is characterized by fever in the presence of peripheral parasitaemia. Other
features may include chills, profuse sweating, muscle pains, joint pains, abdominal
pain, diarrhoea, nausea, vomiting, irritability and refusal to feed. These features may
occur singly or in combination.

3.2. SEVERE MALARIA

This is a life threatening manifestation of malaria, and is defined as the detection of P.
falciparum in the peripheral blood in the presence of any one or more of the clinical or
laboratory features listed below:

● Prostration (inability or difficulty to sit upright, stand or walk without support in

a child normally able to do so, or inability to drink in children too young to sit)
● Alteration in the level of consciousness (ranging from drowsiness to deep coma)
● Cerebral malaria (unrousable coma not attributable to any other cause in a
patient with falciparum malaria)
● Respiratory distress (acidotic breathing)
● Multiple generalized convulsions (2 or more episodes within a 24 hour period)
● Shock (circulatory collapse, septicaemia)
● Pulmonary oedema
● Abnormal bleeding (Disseminated Intravascular coagulopathy)
● Jaundice
● Haemoglobinuria (black water fever)
● Acute renal failure – presenting as oliguria or anuria
● Severe anaemia (Haemoglobin<5g/dl or Haematocrit< 15%)
● Hypoglycaemia (blood glucose level < 2.2.mmol/l)
● Hyperlactataemia

FIFTH EDITION 15
4. Parasitological diagnosis of malaria
The recommended confirmatory tests to detect the presence of malaria parasites and
parasite products are microscopy or rapid diagnostic tests (RDTs). Quality assurance of
microscopy and RDTs is vital for ensuring the reliability of test results.

4.1. MICROSCOPY
● Microscopy is the gold standard method for parasitological diagnosis of malaria.
This is performed by examining a stained thick or thin blood smear for the
presence of malaria parasites.
● Thick films are recommended for parasite detection and quantification and can
be used to monitor response to treatment.
● Thin films are recommended for species identification.
● Quality assurance microscopy should be assured through slide rechecking and
proficiency assessments.

4.1.1. Recommended procedure for microscopy

● Make a thick and thin blood film on a clean microscope slide
● Stain using giemsa stain
● Examine under power 100 oil immersion objective lens starting with the thick
followed by the thin film
● Report the type of parasite(s) seen, developmental stage and parasite count as
parasites per 200 WBCs or parasites per microlitre of blood
● Ensure you always use relevant Standard Operating Procedures (SOPs) for all
processes

4.2. RAPID DIAGNOSTIC TESTS

Rapid diagnostic tests (RDTs) are immunochromatographic tests based on detection of
specific parasite antigens. Tests which detect histidine-rich protein 2 (HRP2) are specific
for P.falciparum while those that detect parasite lactate dehydrogenase (pLDH) or
aldolase have the ability to differentiate between P.falciparum and non-P.falciparum
malaria (vivax, malariae and ovale). With the appropriate training, support supervision
and mentorship, RDTs are simple to use and sensitive in detecting low parasitemia RDTs
are simple to use and sensitive in detecting low parasitaemia.

The use of RDTs is however not recommended for follow-up of previously confirmed cases as
most of the tests remain positive for between 2 to 3 weeks following effective antimalarial
treatment and clearance of parasites. RDTs cannot be used to determine parasite density.

When using RDTs, it is important to adhere strictly to the manufacturer’s instructions

especially the time of reading amount of blood and the test results. Remember to
observe safe medical waste disposal at all times. RDTs for use in Kenya are based on the
annual recommendations of the WHO.

An RDT is a concusive test, it is therefore unnecessary to reconfirm with

microscopy, except for treatment follow up.

16 FIFTH EDITION
4.2.1: Quality assurance of RDTs
The following key steps are involved in quality assurance of RDTs to ensure quality/
accurate results.

QA process QA location
GMP in production Manufacturer
Product evaluation FIND/WHO
Lot - lot testing INCOUNTRY
(Pre-shipment/post-shipment)
Positive control wells At end user point
Post Market Surveillance INCOUNTRY

4.3. OTHER PARASITE DETECTION METHODS

Other parasite detection techniques include:
1. Detection of antibodies to malaria parasites and
2. Detection of parasite DNA, by use of polymerase chain reaction (PCR).

The above two methods are not used for routine clinical management in Kenya. The first
is non-specific while the second is highly sensitive and very useful for detecting mixed
infections, in particular at low parasite densities. PCR is mainly used in drug efficacy
studies.

FIFTH EDITION 17
5. Management of uncomplicated malaria
5.1. DIAGNOSIS
Patients presenting with signs and symptoms of uncomplicated malaria should be tested
for malaria. Only those who test positive should be treated for malaria. Patients should
also be assessed for other conditions that may cause fever and be managed accordingly.

5.2. TREATMENT OF UNCOMPLICATED FALCIPARUM MALARIA

5.2.1. First line treatment in all age groups

The recommended first line treatment for uncomplicated malaria in Kenya is artemether-
lumefantrine (AL). It is currently available as a co-formulated tablet containing 20 mg
of artemether and 120 mg of lumefantrine. Child friendly dispersible tablets are also
available. AL is administered as a 6-dose regimen given over three days (See table below)

Table 1: Dosing schedule for Artemether Lumefantrine

Weight Age in years Dose of AL to be administered at 0 hrs, 8 hrs, 24
hrs, 36 hrs, 48 hrs and 60 hrs
5 - 14 Kg 5 months - < 3years 20mg Artemether and 120mg Lumefantrine
15 - 24 Kg 3 – 7 years 40mg Artemether and 240mg Lumefantrine
25 - 34 Kg 8 – 11 years 60mg Artemether and 360mg Lumefantrine
Above 35 Kg ≥ 12 years 80mg Artemether and 480mg Lumefantrine

● In children below 5 kg, if appropriate weight for age, evaluation of other causes
of fever including malaria should be undertaken. Where malaria is confirmed,
the current recommended treatment is half a tablet of AL given according to
the schedule in table 1 under close supervision3.
● For children < 24kg, dispersible tablets should be administered where available.
Place the tablet in a cup or spoon, add a little water to it, wait a few minutes
for tablets to disperse and then administer the resulting suspension to the
child.

● Directly observe the first treatment dose at the health facility.

nd
3 World Health Organization 2010. Guidelines for the treatment of malaria 2 edition. WHO-GMP Geneva.

18 FIFTH EDITION
5.2.3. Counselling and follow up
● Show all caregivers of young children how to prepare the dispersible
tablet prior to administration. Ensure she/he understands how to
administer the same to the child prior to leaving the facility
● If vomiting occurs within 30 minutes after drug administration, the dose should
be repeated. And if vomiting persists, the patient should return to the facility
for review
● Explain the dosing schedule, use probing questions to confirm the patient’s
understanding.
● Emphasize that all 6 doses must be taken over 3 days even if the patient feels
better after a few doses.
● Advise patients to return immediately to the nearest health facility if the
condition deteriorates at any time or if symptoms have not resolved after 3
days.

5.2.4. Supportive treatment

● Fever management: Administer paracetamol as the recommended antipyretic
for fever. Other methods for reducing temperature like exposure, fanning and
tepid sponging may be used.
● Encourage adequate fluids and food: Caregivers should be encouraged to give
extra fluids and where applicable continue breastfeeding. Food and fluid should
be administered in small quantities at frequent intervals especially when the
child is still very sick.

5.3. TREATMENT FAILURE

Treatment failure can be defined as a failure to achieve the desired therapeutic
response after the initiation of therapy. Treatment failures should be suspected if
patient deteriorates clinically at any time or symptoms persists 3-14 days after initiation
of drug therapy in accordance with the recommended treatment regimen. Whenever
possible, treatment failure must be confirmed parasitologically preferably by blood-slide
examination. Use of RDTs is not recommended.4

Treatment failure may result from poor adherence to treatment, unusual pharmacokinetic
properties in that individual or drug resistance. In evaluating a patient with treatment
failure, it is important to determine from the patient’s history whether he or she vomited
previous treatment or did not complete a full treatment course. Treatment failure is not
synonymous with drug resistance.

Development of symptoms 14 days after initiation of therapy where there has been prior
clearance of symptoms should be considered as a new infection and be treated with the
first line drug.

nd
4 World Health Organization 2010. Guidelines for the treatment of malaria 2 edition. WHO-GMP Geneva

FIFTH EDITION 19
5.3.2. Management of suspected treatment failure
Confirmed cases of treatment failure should be treated with the 2nd line ACT
dihydroartemisinin-piperaquine. Other potential differential diagnosis should be sought
for and adequately managed. In centres with no microscopy facilities, patients with
suspected treatment failures should be referred. In cases of non-adherence with or non-
completion of medicine, repeat a full course of the first line drug.

5.3.3. Second line treatment in all age groups

The recommended second line treatment for uncomplicated malaria in Kenya is
dihydroartemisinin-piperaquine (DHA-PPQ). This is currently available as a fixed-dose
combination with adult tablets containing 40 mg of dihydroartemisinin and 320 mg of
piperaquine and paediatric tablets containing 20mg dihydroartemisinin and 160mg of
piperaquine. These are administered once daily for three days as shown in table 2 below.

Therapeutic dose: A target dose of 4 mg/kg/day of dihydroartemisinin and 18 mg/kg/

day of piperaquine once a day for 3 days. The therapeutic dose range is between 2–10
mg/kg/day dihydroartemisinin and 16–26 mg/kg/dose piperaquine.

Table 2: Dosing schedule for dihydroartemisinin-piperaquine

Number of tablets to be administered

Age in Years Day 1 Day 2 Day 3
0 hours 24 hours 48 hours
3 months <3 years 1 paediatric tablet 1 paediatric tablet 1 paediatric tablet
3 - 5 years 2 paediatric tablets 2 paediatric tablets 2 paediatric tablets
6- 11 years 1 ½ adult tablets 1 adult tablet 1 adult tablet
12 – 16 years 2 adult tablets 2 adult tablets 2 adult tablets
Above 16 years 3 adult tablets 3 adult tablets 3 adult tablets

5.4. TREATMENT OF UNCOMPLICATED VIVAX MALARIA

The recommended treatment for vivax malaria is AL. It is vital to have confirmed lab
diagnosis of P. vivax malaria before commencing treatment. Unlike p. falciparum,
P. vivax has dormant liver stages which require treatment. In order to achieve a
radical cure and prevent relapses, Primaquine, must also be given. Primaquine causes
abdominal discomfort when taken on an empty stomach; it should always be taken with
food. Primaquine may also cause haemolysis in patients with glucose-6-­phosphatase
dehydrogenase (G6PD) deficiency. Stop treatment immediately bleeding is observed.

Therapeutic dose: Primaquine dose ranges between 0.25 and 0.5mg/kg/day once a day
for 14 days.
In mild-to-moderate G6PD deficiency, Primaquine 0.75 mg base/kg body weight should be
given once a week for 8 weeks. In severe G6PD deficiency, primaquine is contraindicated
and should not be used.
The decision to give or withhold Primaquine should depend on the posibility of giving the
treatment under close medical supervision, with ready access to health facilities with
blood transfusion services.

20 FIFTH EDITION
5.5. M & E INDICATORS
i. Proportion of patients with fever presenting to health facility who are
managed in accordance with national malaria treatment guidelines
ii. Proportion of patients presenting to health facility with fever and ACT
prescribed, to whom counselling and ACT dispensing tasks were performed
according to national guidelines

iii. Number of confirmed malaria cases treated with ACT

FIFTH EDITION 21
6. Management of severe malaria
Severe malaria is a medical emergency and should be managed in a facility with
inpatient services. In the absence of this, pre-refferal management should be
initiated and patients reffered to facilities that are able to comprehensively manage
the patients. (Refer to section 6.5). Delay in diagnosis and inappropriate treatment,
especially in infants, children and non-immune adults leads to rapid deterioration of the
situation which is often fatal. The key to effective management is early recognition,
assessment, appropriate antimalarial and supportive therapy. The commonest cause
of severe malaria is P. falciparum. In rare circumstances P.vivax may also manifest as
severe disease.

6.1. DIAGNOSIS
The clinical manifestations of malaria severity depend on various factors including age
and the levels of malarial immunity. In children the common presentations of severe
malaria are severe anaemia, respiratory distress and cerebral malaria. Severe malaria
can occur in the absence of fever. An outline of the presentations, their frequency of
occurrence is summarized in the table below.

6.1.1. Clinical features of severe falciparum malaria

The clinical features of severe malaria are outlined in table 3.

Table 3: Signs and symptoms of severe malaria in adults and children

Sign or symptom Adults Children
Duration of illness 5–7 days Shorter (1–2 days)
Respiratory distress/ deep breathing Common Common
(acidosis)
Convulsions Common (12%) Very common (30%)
Posturing (decorticate/decerebrate and Uncommon Common
opisthotonic rigidity)
Prostration/obtundation Common Common
Resolution of coma 2–4 days Faster (1–2 days)
Neurological sequelae after cerebral Uncommon (1%) Common (5-30%)
malaria
Jaundice* Common Uncommon
Hypoglycaemia* Less common Common
Metabolic acidosis* Common Common
Pulmonary oedema Uncommon Rare
Renal failure* Common Rare
CSF opening pressure* Usually normal Usually raised
Bleeding/clotting disturbances* Up to 10% Rare
Invasive bacterial infection (co-infection)* Uncommon (<5%) Common (10%)

*Laboratory confirmation required

22 FIFTH EDITION
For epidemiological purposes, severe malaria is defined as one or more of the following
parameters, occurring in the absence of an identified alternative cause and in the
presence of P. falciparum asexual parasitaemia.

Table 4: Clinical Parameters

Clinical state Definition

Impaired Consciousness Glasgow coma scale <11, Blantyre coma Scale <3 in children

Prostration Generalized weakness so that the person is unable to sit,

stand or walk without assistance

Multiple convulsions More than 2 episodes within 24 hours

Pulmonary oedema Radiologically confirmed oxygen saturation <92% on room air

with respiratory rate >30/minute often with chest indrawing
and crepitations on auscultations.

Significant bleeding Including recurrent or prolonged bleeding from the nose,

gums or venepuncture sites; haematemesis or malaena

Shock Compensated shock is defined as capillary refill≥3s or

temperature gradient on leg (mid to proximal limb), but no
hypotension. Decompensated shock is defined as systolic
blood pressure <70mmHg in children or 80mmHg in adults,
with evidence of impaired perfusion (cool peripheries or
prolonged capillary refill).

Table 5: Clinical Chemistry Parameters

Lab parameters Definition

Acidosis A base deficit of >8mEq/L or, if not available, plasma

bicarbonate level<15mmol/L or venous plasma lactate
≥5mmol/L. Sever acidosis manifests clinically as respiratory
distress (rapid, deep, labored breathing).

Hypoglycaemia Blood or plasma glucose <2.0mmol/L (<40mg/dL)

Severe malaria anaemia Haemoglobin concentrations ≤ 5g/dL or haematocrit of ≤15%

in children<12 years of age (< 7g/dL and <20%, respectively in
adults) with a parasite count >10000/µL

Renal impairment Plasma or serum creatinine >265 µ/L (3g/dL) or blood urea
>20mmol/L

Jaundice Plasma or serum bilirubin >50 µ /L (3mg/dL) with a parasite

count of 100000/ µL

Hyperparasitaemia Plasmodium falciparum >10%

FIFTH EDITION 23
 ● In all patients with suspected severe malaria the use of parasitological diagnosis
is recommended irrespective of whether the patient had fever or history of fever
● Antimalarial treatment should not be withheld if parasitological diagnosis is
not possible. Presumptive treatment should be started immediately while
efforts to confirm diagnosis are ongoing
● Frequent monitoring of the parasitemia (every 12 hours) is important during
the first three days of treatment in order to monitor parasite response to
treatment with antimalarial medicine. A negative RDT result may be indicative
of another cause of infection.
● Other investigations to determine severity and prognosis should be undertaken
where feasible.

In all suspected cases of severe malaria, a parasitological diagnosis of malaria is

recommended. In the absence of or delay in obtaining a parasitological diagnosis,
patients should be treated for severe malaria on clinical grounds.

6.1.2. Clinical features of severe P. vivax malaria

Severe vivax malaria may present with some symptoms similar to those of severe P.
falciparum malaria and can be fatal. Prompt and effective treatment and follow-up
should be the same as for severe falciparum malaria.

6.2. EVALUATION OF SOME CLINICAL MANIFESTATIONS

Along with other clinical and laboratory evaluation for severe malaria, the following
should be undertaken as the minimal investigation package for the different clinical
scenarios described below:

6.2.1 Cerebral malaria

Clinical assessment
a. Assess level of consciousness using coma score (Annex 4).
b. Determine the presence of severe anaemia by examining for pallor on the
palms and conjunctiva
c. Determine presence of respiratory distress (deep and fast breathing, chest in-
drawing)
d. Determine hydration status (check for sunken eyes, loss of skin tugor, dry
tongue and measuring blood pressure).
e. Assess for renal insufficiency (oliguria)
f. Assess for evidence of disseminated intravascular coagulopathy (spontaneous
bleeding from the gums, injection sites, or any other site.
g. Check for clinical signs of meningitis (stiff neck, Kernig’s sign in children,
photophobia) cerebral malaria does not cause menigism although patients may
present with opisthotonus.

24 FIFTH EDITION
Laboratory Tests
Eliminate other causes of alteration in the level of consciousness including Cerebral
Spinal Fluid (CSF) analysis to rule out meningitis, blood glucose levels to rule out
hypoglycaemia, and other common causes of coma.

6.2.2 Severe anaemia

Clinical assessment
a. Determine the presence of severe anaemia by examining for pallor on the
palms and conjunctiva
b. Determine presence of respiratory distress (deep and fast breathing, chest in-
drawing)
c. Assess for evidence of disseminated intravascular coagulopathy (spontaneous
bleeding from the gums, injection sites, or any other site).
d. Assess for evidence of cardiac failure (respiratory distress, tachycardia,
peripheral oedema)

Laboratory tests
a. Determine haemoglobin levels, Packed Cell Volume (PCV), peripheral blood
film assessment and blood group and cross match where applicable.
b. Liver Function Tests (LFTs), Renal Function Tests and Blood Culture.

6.2.3 Hypoglycaemia
Clinical assessment
Assess the level of consciousness
Laboratory test
Determine the blood glucose level.

6.3. TREATMENT OF SEVERE MALARIA

The recommended treatment for severe malaria is parenteral Artesunate. The preferred
route of administration is intravenous (IV). However intramuscular (IM) can be used as
an alternative where the intravenous route is not feasible. In the absence of artesunate,
parenteral quinine or IM artemether should be administered.

6.3.1 Artesunate
Artesunate is dispensed as a powder of artesunic acid. This must be dissolved in sodium
bicarbonate (5%) to form sodium artesunate. The solution is then diluted in approximately
5 ml of normal saline and given by intravenous injection or by intramuscular injection to
the anterior thigh. The solution should be freshly prepared prior to administration and
should be used within 1 hour. The solution should NEVER be stored.
Administer artesunate as follows:
Dosage:
● For children below 20 kg administer 3.0 ml/kg
● For patients above 20 kg administer 2.4 ml/kg
● An example of body weights and dose (ml) is given in Annex 3: Table 22

FIFTH EDITION 25
Administer Artesunate as follows:

6.3.1.1. Intravenous
● Intravenous route is preffered.
● Weigh the patient to determine the dosage needed and therefore the number
of vials required.
● Dissolve each vial of Artesunic powder with all the 5% sodium bicarbonate
solution provided with each vial. Shake gently until the resultant solution is
clear.
● Dilute resultant solution with 5 ml normal saline or 5% dextrose*.
● The resultant solution has a strength of 10 mg/ml.
● Administer by slow IV over 3-5 minutes.

6.3.1.2. Intramuscular
● Weigh the patient to determine the dosage needed and therefore the number
of vials required.
● Dissolve each vial of Artesunic powder with all the 5% sodium bicarbonate
solution provided with each vial. Shake gently until the resultant solution is
clear.
● Dilute resultant solution with 2 ml normal saline or 5% dextrose*.
● The resultant solution has a strength of 20 mg/ml.
● Administer by IM route.
● Spread the doses of more than 2 ml over different sites for babies and 5 ml for
adults.

* This refers to 60 mg Artesunate. For all other strengths refer to product insert for
diluent volume.

Artesunate should be administered at 0hrs, 12hrs, 24hrs, then once a day until
patient can take orally (Maximum of 7 days). When the patient can take orally give
a full course of AL. The first dose of AL should be administered 8 to12 hours after
the last injection of Artesunate. Water for injection is not an appropriate diluent.

26 FIFTH EDITION
6.3.2. Artemether
Artemether is dispensed as a clear oily solution of differing concentrations. Artemether
must only be given by intramuscular injection.

Administer artemether as follows:

● Artemether is administered by the intramuscular route at a loading dose of 3.2
mg/kg IM stat then 1.6 mg/kg IM daily until the patient is able to tolerate oral
medications (Maximun of 7 days).
● Thereafter a complete course of Artemether-lumefantrine is given.

6.3.3. Quinine administration

● Quinine should only be given as an intravenous infusion and NEVER given as an
intravenous (bolus) injection.
● Loading dose should be omitted if patient have received quinine in the last 24
hours or have received mefloquine in the last 7 days.
● Quinine is not contraindicated in severe anaemia.

● In renal insufficiency the dose of quinine should be reduced by a 1/3 rd to 10 mg/

Kg every 12 hours.
● In hepatic insufficiency, the dose of quinine should be reduced by 25%.
Hypoglycaemia is a potential side effect of quinine administration particularly
in pregnant women and should therefore be administered in a glucose
containing infusion.

6.3.2.1 Quinine administration in children

In order to standardise practice and comply with WHO guidelines, it is therefore

recommended to use the dosing interval of 8 hours in children.

Administer quinine as follows:

● Put up IV quinine drip 20 mg/kg body weight loading dose in 15mls/kg of 5%
dextrose or normal saline to run over 4 hours.
● 8 hours from commencement of the initial dose of quinine, give 10mg/kg in
10mls/kg of isotonic solution (5% dextrose or normal saline) to run in a way as
not to exceed 5 mg salt/kg body weight per hour.
● Repeat l0mg/kg quinine infusion every 8 hours until the patient can take
medication orally. Thereafter a complete course of artemether-lumefantrine
(AL) is given.

● Alternatively, oral quinine may be given at 10mg/kg every 8 hours to complete

a total (parenteral + oral) of 7 days.

FIFTH EDITION 27
6.3.2.2 Quinine administration in adults
Administer quinine as follows:
● A loading dose of quinine 20mg/kg (maximum 1200mg) diluted in 15mls/kg
(maximum 500ml) of isotonic solution (5% dextrose or normal saline) is given
intravenously to run over 4 hours.
● 8 hours from commencement of the initial dose of quinine, give 10mg/kg
(maximum 600mg) diluted in 10mls/kg (maximum 500ml) of isotonic solution
(5% dextrose or normal saline) to run over 4 hours.
● Repeat l0mg/kg quinine infusion every 8 hours until the patient can take
medication orally.
● Thereafter a complete course of artemether-lumefantrine (AL) is given.
● Alternatively oral quinine is continued at 10mg/kg (maximum 600mg) every 8
hours to complete a total of 7 days treatment, in combination with clindamycin
or doxycycline also for 7 days.

In the absence of injectable artemisinins or quinine, patients particularly children

with severe malaria who are able to tolerate orally should be given AL or other
available ACT to initiate treatment. If the patient is unable to take oral medications,
a nasogastric tube should be used to administer AL.

Note: In the case of severe P.vivax malaria, once the patient has completed
treatment, a full dose of primaquine should be administered to clear liver stages.

6.3.3. Severe malaria patients who may be able to tolerate oral treatment
Patients with the following features:
● Severe anaemia (haemoglobin level of <5g/dl or haematocrit of <15% or
● Two or more convulsions within a 24-h period or
● Hyperparasitaemia and who are stable but show none of the features of
prostration, respiratory distress (acidotic breathing) or alteration in the level
of consciousness:
Can be treated with AL, DHA-PPQ or oral quinine where ACT is not available. They should
however be treated as in-patients for close monitoring. Thus any emerging complications
of severe malaria should be managed promptly and appropriately.

6.4. SUPPORTIVE TREATMENT

Supportive treatment is crucial in reducing the high mortality associated with severe
malaria. The table below highlights specific management for manifestations or
complications of severe malaria.

28 FIFTH EDITION
Table 6: Supportive treatment for manifestations of severe malaria
Manifestation/Complication Immediate Managementa
Coma (cerebral malaria) Maintain airway, place patient on his or her side, manage
other treatable causes of coma (e.g. hypoglycaemia, bacterial
meningitis); avoid harmful ancillary treatment, such as
corticosteroids, heparin and adrenaline; intubate if necessary.
Proper nursing care to avoid aspiration and pressure sores.
Hyperpyrexia Administer tepid sponging, fanning, a cooling blanket and
antipyretic drugs (Paracetamol is preferred).
Convulsions Maintain airways; treat promptly with:
Diazepam ( 0.3 mg/kg IV, or 0.5mg/kg by rectal administration) or
Phenobarbitone (15 mg/kg IM loading dose then a maintenance
dose of 4 - 8mg/kg/day for 48 hours) if convulsions persist.
Phenytoin (18 mg/kg loading dose then maintenance dose of 5
mg/kg/day for 48 hours) may be used instead of phenobarbitone.
Check blood glucose and control temperature.
Hypoglycaemia Check blood glucose, correct hypoglycaemia with glucose (IV or
oral), and ensure adequate caloric intake (nutritional support)
thereafter. Hypoglycaemia (≤3 mmol/l) should be corrected with
500 mg/kg of glucose. Using parenteral dextrose, immediately
give 5 mls/kg of 10% dextrose through a peripheral line, followed
by a slow intravenous infusion of 5 ml/kg per hour of 10% or 10
ml/kg per hour of 5% to prevent recurrence of hypoglycaemia.
Severe anaemia Transfuse with screened fresh whole blood as per national blood
transfusion guidelines. It is recommended that in the paediatric
age group to transfuse for severe malarial anaemia when Hb<4g/
dl and that if Hb is between 4 and 5g/dl transfuse if signs of
respiratory distress or cardiac failure are present.
Fluid and electrolyte Ensure adequate fluid and electrolyte balance. Note that strict fluid
imbalance management is vital in the comatose patient. Fluid used in administration
of antimalarials and any other transfusions (e.g. blood transfusion) must
be calculated as part of the total fluid requirement of the patient.
Acute pulmonary oedemac Prop patient up at an angle of 45°, give oxygen, give a diuretic, stop
intravenous fluids, intubate and add positive end-expiratory pressure/
continuous positive airway pressure in life-threatening hypoxaemia.
Acute renal failure Exclude pre-renal causes, check fluid balance and urinary
sodium; if in established renal failure refer for specialised care.
Spontaneous bleeding and Transfuse with screened fresh whole blood (cryoprecipitate, fresh
coagulopathy frozen plasma and platelets, if available); give vitamin K injection.
Metabolic acidosis Exclude or treat hypoglycaemia, hypovolaemia and septicaemia.
If severe, refer for haemofiltration or haemodialysis.
Shock Suspect septicaemia, take blood for cultures; give parenteral broad-
spectrum antimicrobials, correct haemodynamic disturbances.

a. It is assumed that appropriate antimalarial treatment will have been started in all cases.
c. Prevent by avoiding excess hydration.

FIFTH EDITION 29
6.5. PRE-REFERAL MANAGEMENT OF SEVERE MALARIA
Since severe malaria is a medical emergency, treatment of a patient with severe malaria
should begin in the primary health facility (while waiting for referral) so that life-saving
therapy is not delayed.
The risk for death from severe malaria is greatest in the first 24 hours, therefore,
upon recognition of severe malaria, pre-referral treatment should be initiated at the
peripheral facility using IM artesunate or rectal artesunate. In the absence of artesunate,
IM artemether should be used. All efforts should be made to move the patient to a centre
where the expertise and infrastructure exist for the adequate management of severe
malaria.
In patients with alteration in the levels of consciousness, parenteral antibiotics
(ceftriaxone) should also be administered along with the antimalarial.
If for any reason referral is not possible or delayed, treatment for severe malaria with
the use of IM artesunate should be continued. Health workers at such facilities should
ensure that treatment continues until the patient PHYSICALLY moves to another facility.

NOTE
It is not enough to give a referral letter and assume that the patient has been
referred. The referral letter should be as comprehensive as possible and a health
worker should accompany the referred patient.

6.5.1. Administration of parenteral artemisinins

● Artesunate is dispensed as a powder of artesunic acid. This must be dissolved in
5% sodium bicarbonate (diluent) to form sodium artesunate. (Refer to 6.3.1.2
for administration instructions).

6.5.2. Administration of rectal artesunate

● In the event that a suppository is expelled from the rectum within 30 minutes
of insertion, a second suppository should be inserted. In young children the
buttocks should be held together for 10 minutes to ensure retention of the
rectal dose of artesunate. Patients should be transported immediately to a
higher level facility where IM or IV treatment is possible. In the event that
referral is not possible a single daily dose of Artesunate should be administered
until parenteral treatment or oral AL is instituted.

● A single dose of 10 mg/Kg body weight should be given to children < 6 years and
only when Intramuscular Artesunate is not available.

6.5.3. Administration of intramuscular quinine

● Quinine MUST be diluted (maximum concentration is 100 mg/ml for adults, and
50mg/ml for children) before intramuscular injection.
● A loading dose of 20 mg/kg of quinine (diluted to a maximum 100 mg/ml for
adults and 50mg/ml for children) is given by intramuscular injection (preferably

30 FIFTH EDITION
 the anterior thigh). A maximum of 3ml should be injected into one site. If the
amount to be injected exceeds 3ml, multiple sites should be used.
● An example of body weights and dose (ml) of injection is given in Annex 3,
Table 19).
● Administer a stat dose of 3.2 mg/kg of artemether solution by the intramuscular
route to the anterior thigh.

6.5.4. Referral of the patient

● Send a clear letter or referral form about the clinical picture, including
dosages, times, and route of administration for any medications given.
● Carry all blood film examination or slides (if these have been taken) to be sent
along with the patient to the referral centre.
● Send potential blood donors.
● Ask the guardian to keep the child lying down on their side during the journey.
● Accompany or ask a fellow health worker to accompany the patient to the
referral centre.

6.6. FOLLOW-UP OF ALL PATIENTS WITH SEVERE MALARIA

● Monitor for possible complications and manage accordingly.
● Monitor Hb levels and give haematinics as appropriate.
● Monitor and rehabilitate patients with neurological sequelae.

FIFTH EDITION 31
7. Malaria in pregnancy
Pregnancy increases the risk of malaria infection in all women. Malaria during pregnancy
causes febrile illness, anaemia and increases the risk of maternal illness and death,
miscarriage, stillbirth, low birth weight and neonatal death. All pregnant women living
in malaria risk areas should be advised on malaria prevention measures and clinical cases
of malaria treated promptly with effective antimalarials. Women in their first and second
pregnancies, and all HIV infected women are at greatest risk of the effects of malaria.

7.1. MANAGEMENT OF UNCOMPLICATED MALARIA

7.1.1. Diagnosis
Table 7: Symptoms and signs of uncomplicated malaria in pregnant women
TYPE OF MALARIA SIGNS AND SYMPTOMS USUALLY SIGNS AND SYMPTOMS
PRESENT SOMETIMES PRESENT
Uncomplicated malaria Fever Enlarged spleen
Shivering/chills/rigors
Headache
Muscle/joint pain
nausea and vomiting
False labor pain(uterine contractions)

● In all pregnant women with fever or history of fever the use of parasitological
diagnosis is recommended.

● At health facilities where malaria diagnostics (microscopy or RDT) are not

available, patients suspected to have malaria should be treated for malaria.

Pregnant women at most risk of malaria infection

• First or second pregnancy in malaria endemic areas.
• Immigrants or visitors from areas of low or no malaria transmission.
• HIV infected.

7.1.2. Treatment

7.1.2.1. First trimester

The recommended treatment for uncomplicated malaria in the first trimester is a 7­-
day therapy of oral quinine. Do not withhold artemether-lumefantrine or any other
treatment in 1st trimester if quinine is not available. Malaria if untreated can be fatal to
the pregnant woman.

7.1.2.2. Second and third trimesters

Artemether-lumefantrine is the recommended treatment in the 2nd and 3rd trimesters.
Oral quinine may also be used but compliance must be ensured. Dose regimens for
quinine and AL are as given in the uncomplicated malaria section.

32 FIFTH EDITION
7.1.3. Supportive care
● Prevent hypoglycaemia (particularly if taking quinine).
● Foetal monitoring.
● Treatment of anaemia5.
● Antipyretics.

7.1.4. Follow-up management

Antenatal Care6

7.2. MANAGEMENT OF SEVERE MALARIA IN PREGNANCY

Severe malaria in pregnancy is a medical emergency that puts both the lives of the
mother and unborn baby at high risk. Aggressive management is essential.

7.2.1. Diagnosis
Features of severe malaria in pregnant women are similar to non-pregnant women.
These are detailed in Section 6.1.1. Pregnant women have an increased risk of quinine
induced hypoglycaemia and also complications from severe anaemia.

Table 8: Symptoms and signs of severe malaria in pregnant women

TYPE OF SIGNS AND SYMPTOMS SIGNS AND SYMPTOMS USUALLY

MALARIA SOMETIMES PRESENT PRESENT

Severe Symptoms and signs of · Convulsions

uncomplicated malaria plus one · Severe jaundice
or more of the following: · Signs of severe dehydration,
· Confusion, drowsiness, coma especially if woman has been
· Fast breathing/ vomiting repeatedly
breathlessness/difficulty in · Sudden weight loss
breathing · Sunken eyes
· Vomiting at every feed or · Reduced skin turgor
unable to feed · Dry mouth
· Pale conjuctivae, mucous · Reduced amount of urine or no
membranes, tongue and urine at all
palms · Spontaneous bleeding from the
· Jaundice gums, skin and vein puncture sites

Table 9: Convulsions in pregnancy

Eclampsia is a differential diagnosis in pregnant women presenting with convulsions or
alteration in level of consciousness. In which case the table below should be used to
differentiate the two.

5
All pregnant women should receive an iron supplementation during ANC as part of the prevention of anaemia.
6
IPTp with SP should be prescribed in high transmission areas and LLINs given during the ANC visit to all pregnant women.

FIFTH EDITION 33
 SIGNS/SYMPTOMS SEVERE MALARIA ECLAMPSIA
Recent history of fever, chills Yes No
(from patient or family)
Temperature >38◦C <38◦C
Blood pressure Diastolic < 90mm hg Diastolic often > 90mm hg
Enlarged spleen yes No
Jaundice Yes No

Additionally, check for protein in urine which commonly occurs in Eclampsia

In all suspected cases of severe malaria in pregnancy, it is recommended to confirm a

diagnosis of malaria parasitologically. In the absence of or delay in obtaining a parasitological
diagnosis, it is most important to initiate treatment for severe malaria without delay.

7.2.2. Treatment
The recommended medicine for severe malaria in pregnancy is parenteral artesunate.
In the absence of artesunate, artemether or quinine can be given. The preferred route
of administration is intravenous for artesunate. However the intramuscular route can be
used as an alternative where intravenous route is not feasible. Due to the increased risk
of hypoglycaemia in pregnant women, a dextrose containing solution must be used for
quinine administration.

NOTE
Pregnancy is not a contraindication for the use of a loading dose of quinine

7.2.3. Pre-referral treatment for severe malaria in pregnancy

● Treatment of a patient with severe malaria should begin in the primary health
facility (while waiting for referral) so that life-saving therapy is not delayed.
● Management of severe malaria in pregnancy should follow the adult dosing forArtesunate.
Where Artesunate is not available, Artemether can be administered. Management of
severe malaria in pregnancy should follow the adult dosing for Artesunate. A loading
dose of Artesunate at 2.4 mg/Kg body weight should be administered.
● All efforts should be made to move the patient to a centre where the expertise
and infrastructure exist for the adequate management of severe malaria.
● In patients with alteration in the levels of consciousness, parenteral antibiotics
(ceftriaxone) should also be administered along with the antimalarial.
● It is not enough to give a referral letter and assume that the patient has been
referred. A health worker should accompany the referred patient to the next
level of health care.

7.3. PREVENTION OF MALARIA IN PREGNANCY

The goal of prevention of malaria in pregnancy is to reduce maternal and perinatal
morbidity and mortality associated with malaria. The strategies in prevention of malaria
in pregnancy are integrated in the overall antenatal care (ANC) package for maternal
health. They include the provision of:

34 FIFTH EDITION
 ● Intermittent preventive treatment for malaria in pregnancy (IPTp).
● Long lasting Insecticidal Nets.
● Provision of prompt diagnosis and treatment of fever due to malaria.
● Health education.

7.3.1. Intermittent preventive treatment of malaria in pregnancy (IPTp)

IPTp is the presumptive (regardless of whether the woman is infected or not) provision of a full
treatment course of the recommended antimalarial at specific intervals during pregnancy. IPTp
has been shown to reduce the risk of placental infection and the associated risk of maternal
anaemia, miscarriage, premature deliveries and low birthweight. The current recommended
medicine for IPTp of Sulphadoxine 500mg and Pyrimethamine 25mg (SP).
● IPTp is recommended in areas of high malaria transmission.
● Administer IPTp with each scheduled visit after quickening to ensure women
receive a minimum of 3 doses.
● IPTp should be given at an interval of at least 4 weeks (1 month).
● IPTp should be given under directly observed therapy (DOT) in the antenatal
clinic and can be given on an empty stomach.
● SP as IPTp is safe up to 40 weeks pregnancy and even one dose is beneficial for
women presenting late in pregnancy.
● High dose Folic acid (5mg) tablets should NOT be administered with SP given for
IPTp and if need be, may be taken 14 days following administration of IPTp.

Always ask the mother if she is allergic to sulpha drugs or has experienced side
effects to sulpha drugs before giving SP

7.3.1.1. IPTp and HIV+ pregnant women

HIV infection during pregnancy increases the risk of the complications of malaria in
pregnancy while malaria infection during pregnancy particularly placental malaria
increases the risk of mother to child transmission of HIV.
● Pregnant women who are HIV positive and are on daily Cotrimoxazole
Chemoprophylaxis should not be given SP for IPTp.

7.3.2. Long Lasting Insecticidal Nets (LLINs)

● LLINs are key in the prevention of malaria in pregnancy.
● Each pregnant woman living in a malaria risk area should receive a LLIN at
the first contact visit to the ANC.
● Each pregnant woman should be shown how to hang the LLIN and encouraged
to use the net each and every night during her pregnancy and thereafter
● LLIN are not a substitute for IPTp and vice versa. Both must be used in
order to achieve maximal benefits in the reduction of both maternal and
perinatal morbidity and mortality.

7.3.3. Health education

● Continuous maternal health education should be provided at the ANC
encouraging use of all interventions and services and encouraging the
pregnant woman to attend all ANC visits as scheduled.

FIFTH EDITION 35
8. Basic techniques in managing malaria medicines
8.1. CONCEPT OF ESSENTIAL DRUGS
The WHO defines essential drugs as those that are indispensable and necessary for the
health needs of the population. They should be available at all times, in the proper
dosages forms to all segments of society. Antimalarials are “essential medicines”.

8.1.1. Pharmaceutical management

Pharmaceutical management is a set of practices aimed at ensuring the timely availability
and appropriate use of safe, effective, quality medicines and related products and
services in any health-care setting.

8.1.2. The Pharmaceutical Management Cycle7

The Pharmaceutical Management Cycle is a systematic approach to ensure that medicines
at all levels of health care delivery are consistently available and appropriately used.
It emphasizes the connections between four drug management activities - selection,
procurement, distribution and use. The cycle is depicted below:

Figure 2: The Pharmaceutical Management Cycle

Policy and Legal Framework

7
The cycle was developed by the Management Sciences for Health Centre for Pharmaceutical Management in collaboration
with the World Health Organization’s Action Program on Essential Drugs.

36 FIFTH EDITION
8.2. QUANTIFICATION OF ANTIMALARIAL MEDICINES
Quantification is the process of estimating the quantities of antimalarials needed for a
specific period of time in order to ensure an uninterrupted supply. Quantification is an
important step in procurement and ordering for re-supply. Good quantification ensures
the appropriate allocation of funds to enable purchase of the right medicine in the right
quantity at the right time.

8.2.1. The rationale for quantification of antimalarials

● To ensure that there are sufficient quantities to meet clients’ / patients’
needs and avoid shortages/stock-outs.
● To avoid surpluses that may lead to over-stocking, expiries and/or wastage of
commodities.
● To make informed adjustments to procurement when faced with budgetary
constraints.
8.2.2. Quantification methods
This guideline focuses attention on the two most commonly used methods— consumption
and morbidity. The particular method used depends on the type of data available.
8.2.2.1. Consumption method
This is the preferred quantification method for antimalarials. The consumption based
method uses historical data on the actual medicines dispensed to patients to calculate
the quantity of medicines that will be needed in the future. When using the consumption
method for quantification, out of stock periods must be adjusted in the calculation.
8.2.2.2. Morbidity method
The morbidity-based method uses data about diseases and the frequency of their
occurrence in the population (incidence or prevalence) or the frequency of their
presentation for treatment. It forecasts the quantity of drugs needed for the treatment
of specific diseases, based on projections of the incidence of those diseases.

8.2.3. Good inventory management

An inventory management system is a cycle of activities comprising ordering, receiving,
storage and issuing of commodities.

8.2.4. Definitions of inventory terms

● Average monthly consumption: This refers to the average quantity of
commodities consumed per month.
● Months of stock: The quantity on hand expressed as the number of months
that quantity should last. It is calculated based on the commodity’s average
monthly consumption.
● Lead time: The time interval between when a new stock is ordered and when
it is received and available for use.
● Review period: The routine interval of time between assessments of stock
levels to determine if an order should be placed. It is also known as order
interval or re supply interval.
● Maximum stock level: The amount of stock above which a facility should not
exceed under normal circumstances, a Maximum of 6 months of stock.

FIFTH EDITION 37
 ● Minimum stock level: The amount of stock below which a facility should not
fall under normal circumstances, a minimum of three months of stock.
● Shelf life: The length of time a product may be stored without compromising
its usability, safety, purity or potency.
● Pipeline: The entire chain of storage facilities and transportation links
through which supplies are moved from manufacturers to clients
● Stock out days: Is the number of days that the commodity is not in stock.

8.2.4.1. Ordering
The facility should order supplies periodically from the central medical store using a
standard order form. The formula below is used to derive the amount of medicines to
order:

Quantity to Order = (Average Monthly Consumption X review period in months)

less stock on hand

8.2.4.2. Receiving
The facility should counter check commodities received against the standard order form
and delivery note, and record the receipts on a stock/bin card.

8.2.4.3. Storage
Malaria medicines and commodities such as RDTs should be stored in optimal conditions
to ensure their safety and efficacy in accordance with the principles of good storage
practices:
● Good arrangement.
● Quality maintenance (appropriate temperature, light and humidity).
● Assured security.
● Good inventory control and stock rotation (First in First Out/First Expiry First out).
● Good record keeping.

8.2.4.4. Issuing
The facility should issue supplies to various points of use, using an issue/requisition
voucher (S11/S12) and must record the issue on the bin card.

8.2.4.5. Disposal
Disposal of unusable stock should be carried out according to the guidelines for disposal
of pharmaceuticals and Biosafety guidelines for medical waste.

8.2.5. Types of inventory records

Various forms are used for requisitioning and issuing medicines, financial accounting, and
preparing consumption and stock balance reports.

38 FIFTH EDITION
Table 10: Types of inventory records
Record type Source document Information
Stock keeping Bin cards, stock ledger card Stock at hand
records Receipts, losses and
adjustments
Transaction Issue and receipt voucher –(S12 , S11), Orders, issues and receipts
records KEMSA delivery notes, Standard order form
Consumption Daily activity Register, Health facility Consumption data
records monthly summary Stock out days
Patient numbers

Figure 3: Flow of logistic management information

8.2.6. M & E LMIS Indicators

● National reporting rate.
● Proportion of health facilities having no stock-out of all ACTs in a month.
● Number of patients treated with ACTs.
● Proportion of health facilities having no stock-out of RDTs in a month.

FIFTH EDITION 39
8.3. RATIONAL USE OF ANTI-MALARIAL MEDICINES

8.3.1. Definition of rational use

The rational use of medicines requires that patients receive medicines appropriate
to their clinical needs, in doses that meet their own individual requirements, for an
adequate period of time, and at the lowest cost to them and the community8

8.3.2. Factors affecting rational use of medicines

● Diagnosis – correct diagnosis based on parasitologically confirmed diagnosis.
● Prescribing – prescribing /administering the recommended medicine based
on the correct diagnosis.
● Dispensing – correct dispensing (quantity, packaging and labelling) of the
prescribed medicine.
● Patient compliance - patients’ adherence to health worker and label
instructions.

Figure 4: The medicine use cycle

8
World Health Organization, 1988

40 FIFTH EDITION
8.3.3. Implications of irrational use of medicines
● Irrational medicine use can destroy the benefits of a good pharmaceutical
management system and also reduce the therapeutic useful life of an
effective medicine.
● Resources spent on procurement are lost if the correct drugs are not
prescribed and dispensed to the right patient.

8.3.4. Minimum dispensing information

● Directly observed treatment for first dose of AL and SP.
● Instructions on how long to take the medicine.
● Instruction on what to do in the event the patient vomits within 30 minutes
of taking the medication.
● The common adverse drug reactions and instructions to report any suspected
adverse drug reactions (ADR).
● Clear label with appropriate patient and medicine information.

8.3.5. M & E Indicators

i. Proportion of patients with fever presenting to health facility who are
managed in accordance with national malaria guidelines.
ii. Proportion of patients presenting to health facility with fever and ACT
prescribed, to whom counselling and ACT dispensing tasks are performed
according to national guidelines.

8.4. PHARMACOVIGILANCE

8.4.1. Pharmacovigilance
WHO defines pharmacovigilance as the science of collecting, monitoring, researching,
assessing and evaluating information from healthcare providers and patients on the
adverse effects of medicines, biological products, herbals and traditional medicines, with
the view to identifying new information about hazards, and preventing harm to patients.

Ultimate goals of Pharmacovigilance

● The rational and safe use of medicines.
● The evaluation of and communication of the risks and benefits of drugs on
the market.
● Education and information of patients.

8.4.2. Adverse drug reaction (ADR) is a response to a drug which is noxious and
unintended, and which occurs at doses normally used in humans for the prophylaxis,
diagnosis or therapy of disease. Adverse drug reactions are also called side effects.

FIFTH EDITION 41
Report ALL suspected side effects with medications, especially those where the patient
outcome is:
● Death.
● Life-threatening (patient would have died if no intervention was
undertaken to treat adverse reaction or event).
● Hospitalization (initial or prolonged).
● Disability (significant, persistent or permanent).
● Congenital anomaly.
● Required intervention to prevent permanent impairment or damage.

Report even if:

● You are not certain if the drug caused the side effect.
● You do not have all the details.

8.4.3. Counterfeit
WHO defines a counterfeit pharmaceutical product as a product that is deliberately and
fraudulently mislabelled with respect to identity and or source.

8.4.4. Tools for reporting side effects, adverse drug reactions and poor quality medicines
Reporting of side effects is done using the forms below: (These forms are also available
online at the Pharmacy and Poisons Board website www.pharmacyboardkenya.org
● Yellow form (PV 1) - form to capture all suspected adverse drug reactions.
● White card (PV 4) - alert card to report life threatening drug reactions.
● Pink form (PV 6) - form for reporting poor quality medicinal products.

42 FIFTH EDITION
Figure 5: Flow of information on adverse drug reactions

● Feedback to all levels of the system is the responsibility of the Pharmacy and Poisons
Board (PPB).
● All forms should be collected and sent to PPB pharmacovigilance department using
the address provided on the forms.

8.4.5. M & E Indicator

Number of adverse drug reactions reports received.

FIFTH EDITION 43
9. Malaria prevention
9.1. CHEMOPROPHYLAXIS FOR NON-IMMUNE POPULATIONS
Chemoprophylaxis is recommended for the following high-risk groups:

9.1.1. Non-immune visitors (tourists)

The recommended medicines for chemoprophylaxis for non-immune persons visiting a
malarious area are mefloquine, atovaquone-proguanil or doxycycline.

Note
● Chemoprophylaxis and other preventive measures are not 100% effective.
Early medical care should be sought if they develop fever within 3 months of
travel to an endemic area, even if adequate prophylaxis has been taken.

● Travellers are encouraged to use other barrier methods (LLINs, insecticide

treated materials and repellents) to prevent or reduce bites from mosquitoes.

● Travellers should carry a full course of Artemether-Lumefantrine (as standby

treatment) for use in the event they develop a fever and have no immediate
access to health services.

9.1.2. Patients with sickle cell disease

The currently recommended prophylactic medicine for those with sickle cell disease is
still proguanil. Although there is increasing documented resistance to anti-folate drugs,
no studies on the effectiveness of proguanil in sickle cell disease have been conducted to
recommend otherwise. It is important for patients with sickle-cell disease to consistently
use other malaria prevention methods and to promptly seek treatment for any febrile
illness.

9.1.3. Patients with Tropical Splenomegaly Syndrome (TSS)

The currently recommended malaria prophylactic medicine for those with TSS is
proguanil. Although there is increasing documented resistance to anti-folate drugs,
no studies on the effectiveness of proguanil in this group have been conducted to
recommend otherwise.

9.1.4. Medicines for malaria chemoprophylaxis

9.1.4.1. Mefloquine
Mefloquine is available as tablets of 274mg mefloquine hydrochloride containing 250mg
base or tablets of 250mg mefloquine hydrochloride containing 228mg base (United States
only). Mefloquine is administered as a weekly dose of 250mg for adults or 5mg base/kg
body weight for persons below 36 kg.

It is recommended that Mefloquine prophylaxis is started 2 – 3 weeks before arrival in

a malaria risk area, taken throughout the stay and continued for 4 weeks after leaving
the area.

44 FIFTH EDITION
Table 11: Dosing schedule for mefloquine
Weight Age Number of tablets per day
< 5 kg < 8 Months Not recommended
5 – 12 kg 8 months – 3 years ¼
13 – 24 kg 4 – 7 yrs ½
25 – 35 kg 8 – 10 yrs ¾
36 and above 11 yrs and above 1

Side effects
Nausea, vomiting abdominal pain and diarrhoea these are most common but are dose
related and self-limiting. Other CNS related ones include dysphoria, dizziness, ataxia,
headache some visual and auditory disturbances, sleep disturbances and nightmares,
convulsions.

Contraindications
● The first trimester of pregnancy.
● Do not administer to patients less than 5 kg.
● Avoid use in history of seizures and in severe neuro-psychiatric disturbance.
● Do not administer concomitantly with quinine and avoid quinine use after
administration of mefloquine.
Caution
● Mefloquine can compromise adequate immunisation with the live typhoid
vaccine.
● Mefloquine should only be taken 12 hours after administration of the last
quinine dose.
● Care should be taken when administering concomitant medications that
interfere with cardiac function.

9.1.4.2. Proguanil
Proguanil is available as tablets of 100mg of proguanil hydrochloride containing 87mg of
proguanil base.
Dose
Proguanil is administered at a daily dose of 3mg/kg daily. Often, the average daily dose
is 200mg/day for adults and 100mg/day for children for the duration recommended by
the physician.

Table 12: Dosing schedule for proguanil

Weight Age Number of tablets per day
5 – 8 kg < 8 Months ¼
9 – 16 kg 8 months – 3 years ½
17 – 24 kg 4 – 7 yrs ¾
25 – 35 kg 8 – 10 yrs 1
36 – 50 kg 11 – 13 yrs 1½
50 + kg 14+ yrs 2

FIFTH EDITION 45
Side effects
Low doses – nausea, diarrhoea, rarely, hair loss and mouth ulcers. High doses - vomiting,
haematuria and diarrhoea. Symptoms are treated as they appear. There is no specific
antidote for proguanil overdose.
Contraindications
The use of Proguanil is contraindicated in persons with liver or kidney dysfunction.

Caution
Antacids like magnesium trisilicate decrease absorption of Proguanil.

9.1.4.3. Atovaquone – Proguanil (Malarone®/Malanil®)

Atovaquone–proguanil is available as film coated adult tablets containing 250 mg
atovaquone and 100mg proguanil hydrochloride or paediatric tablets containing 62.5 mg
atovaquone and 25 mg proguanil hydrochloride.

Dose
It is administered as a daily dose of 1 tablet commencing 1 day before departure to a
malaria endemic area, throughout the stay and continuing 7 days after leaving. Adults
and children > 40kg should take 1 adult tablet daily. The drug should be taken with food
or milk at the same time each day.

Table 13: Dosing schedule for atovaquone-proguanil for children

Weight Number of paediatric tablets
<11 kg Not recommended
11 – 20 kg 1
21 – 30 kg 2
31 – 40 kg 3

Side effects
Abdominal pain, nausea, vomiting, diarrhoea, headache, anorexia and coughing.

Contraindications
● Persons with hypersensitivity to atovaquone and/ or Proguanil.
● Pregnancy because of lack of data.
● Caution is indicated in persons with severe renal failure (creatinine clearance)

9.1.4.4. Doxycycline
Doxycycline is commonly available as capsules containing 100mg doxycycline
hydrochloride. Tablets containing 100mg doxycycline hydrochloride may be available.

Dose
Doxycycline is administered as a daily dose of 100 mg salt or 1.5mg salt per kg daily. It is
taken 1 day before departure to a malaria endemic area and continued daily throughout
the stay and for 4 weeks after departure.

46 FIFTH EDITION
Table 14: If tablets are available, fractions can be administered for patients aged 8 to 13 years.

Weight Age in years No of tablets

<25 kg <8 Contraindicated
25 – 35 kg 8 – 10 ½
36 – 50 kg 11 - 13 ¾
>50 kg 14+ 1

Side effects
GIT irritation, increased vulnerability to sun-burn (phototoxic reaction), transient
depression of bone growth and discoloration of teeth, vaginal candidiasis.

Contraindications
Doxycycline shouldn’t be used in:
● Children under 8 years of age.
● Pregnant and lactating mothers.
● Persons with hepatic insufficiency.
● Persons with known hypersensitivity to tetracyclines.
Caution
Doxycycline should not be used for prophylaxis for periods exceeding 4 months. Antacids
and milk impair absorption of tetracycline and concurrent administration should be avoided.

9.2. VECTOR CONTROL

Integrated vector management is one of the recommended methods to augment other
malaria control interventions to reduce transmission of malaria. Vector control must
be selective, targeted, site specific and cost effective. The selection of vector control
methods should be based on intensity of the disease transmission, vector, human
behaviours, the environment and resources available. The community should actively
participate in the implementation of these vector control measures especially measures
to reduce mosquito breeding within their environments. Inter-sectoral collaboration
involving line ministries, NGOs and the private sector is encouraged in this respect.
The following vector control strategies are available:
● Use of long lasting insecticidal nets: The use of LLINs is encouraged for all
persons living in malaria endemic areas.
● Indoor residual spraying – both in endemic and epidemic prone areas.
● Larviciding - in focalized breeding sites.
● Screening of house inlets with wire mesh to reduce entry of mosquitoes.
● Environmental management for source reduction of vector density e.g.
drainage of breeding sites.
● Biological control measures where feasible – larvivorous fish, growth
regulators, BTI (Bacillus thuringiensis var israeliensis).
● Repellents and fumigants.

9.2.1. M & E Indicators

i. Proportion of households who own at least 2 LLIN.

FIFTH EDITION 47
 ii. Proportion of households in targeted areas sprayed in the last 12 months.
iii. Proportion of household members who use LLIN.

9.3. EPIDEMIC PREPAREDNESS AND RESPONSE

Malaria interventions are reducing malaria prevalence in many areas, converting them
into areas at risk of malaria epidemics; therefore there is need to:
● Strengthen routine surveillance of:
- Epidemiological & entomological indicators i.e. parasite rates
(sentinel facilities, community), vectors.
- Meteorological data.
● Ensure availability of buffer stocks for all medicines for uncomplicated
and severe malaria, chemicals, spray pumps and LLINs.
● Plan for logistics support.
In case of an epidemic threat; conduct:
● Advocacy and social mobilization.
● Mobilize health workers to provide active surveillance and prompt
treatment of cases.
● Warn referral facilities about potential patient influx and strengthen
referral systems.
● Indoor residual spraying and net hanging campaigns.

9.3.1. M & E Indicator

Proportion of targeted subcounties with functional Epidemic Preparedness and
Response (EPR) teams and logistics.

9.4. PREVENTION OF MALARIA INFECTION THROUGH BLOOD TRANSFUSION

All donated blood should be screened before transfusion using a sensitive diagnostic
method. Ministry of Health is developing guidelines on blood transfusion transmisible
infections for further guidance.

9.5. ADVOCACY COMMUNICATION AND SOCIAL MOBILIZATION

Advocacy communication and social mobilization is a critical intervention for behavioural
change towards improved health practices. The following important information should be
provided to patients, caretakers/guardians of young children and community members to:
● Seek prompt diagnosis and correct treatment of all fevers within 24 hours
of onset of symptoms.
● Recognize symptoms and signs of malaria and severe malaria.
● Test before treating.
● Adhere to dosing instructions and complete all prescribed medicines.
● Use appropriate prevention measures especially to sleep under LLIN every night.
● Pregnant women in endemic areas to get a minimum of 2 doses of IPTp.

9.4.1. M & E Indicator

Proportion of people reached by ACSM messages on malaria prevention and treatment.

48 FIFTH EDITION
10. Annexes
ANNEX 1: OUTPATIENT ALGORITHM FOR DIAGANOSIS AND MANAGEMENT OF
MALARIA FOR CHILDREN AND ADULTS

FIFTH EDITION 49
ANNEX 2: THE PHARMACOLOGY OF ANTIMALARIALS
Antimalarials can be classified according to their chemical composition and mode of
action. In this guideline, classification based on the mode of action is used.

Table 15: Common antimalarials classified by mode of action

Class Definition Examples
Blood schizonticidal Act on (erythrocytic) stage of the Quinine, artemisinins,
drugs parasite thereby terminating clinical amodiaquine, chloroquine,
illness lumefantrine, tetracyclinea,
atovaquone, sulphadoxine,
clindamycina, proguanila
Tissue schizonticidal Act on primary tissue forms of Primaquine, pyrimethamine,
drugs plasmodia which initiate the proguanil, tetracycline
erythrocytic stage. They block further
development of the infection
Gametocytocidal Destroy sexual forms of the parasite Primaquine, artemisinins,
drugs thereby preventing transmission of quinineb
infection to mosquitoes
Hypnozoitocidal These act on persistent liver stages Primaquine, tafenoquine
drugs of P.ovale and P.vivax which cause
recurrent illness
Sporozontocidal These act by affecting further Primaquine,proguanil,
drugs development of gametocytes into chlorguanil
oocytes within the mosquito thus
abating transmission
a
Slow acting, cannot be used alone to avert clinical symptoms
b
Weakly gametocytocidal

50 FIFTH EDITION
ANNEX 3: ADDITIONAL INFORMATION ON ANTIMALARIALS

Only fixed dose ACTs should be used for the treatment of uncomplicated malaria. Not all
the medicines in this reference section are recommended for use in Kenya.

Artemether-Lumefantrine (AL)
For information on regular tablets and child friendly dispersible tablets, see Section
5.2.1. AL may also be presented as a powder for suspension. Once reconstituted, the
suspension must be used as directed and discarded after 3 days.

Table 16: Dosing Schedule for AL powder for reconstitution

Body weight in kg Dosage (in ml) to be administered once a day for three days
3 4.5
4 6
5 7
6 8
7-8 10
9-10 13
11-12 15
13-14 18
15-17 22
18-20 25
21-23 29
24-26 33
27-29 37
30 40

Side effects
Dizziness and fatigue, lack of appetite, nausea, vomiting, abdominal pain, palpitations,
muscle pain, joint pain, headache and rash.

Contraindications
● There is limited data on the safety of use in the first trimester pregnancy.
● Persons with known hypersensitivity to either of the components.

Dihydroartemisinin-piperaquine
DHA-PPQ is available as both adult and paediatric tablets administered once a day for
three days. See section 5.3.2 for dosing information.
Side effects
Nausea, diarrhoea, loss of appetite, rash, pruritus.
Contraindications
● Hypersensitivity to any of the components of the combination.
● There is limited data on the safety of use in the first trimester pregnancy.

FIFTH EDITION 51
Amodiaquine-artesunate
Dose
Available as fixed dose combination tablets containing amodiaquine 10 mg /kg daily for
three days plus artesunate 4 mg/kg given daily for 3 days.

Side effects
Pruritus, rash, and with higher doses, syncope, spasticity, convulsions and involuntary
movements.

Contraindications
● Hypersensitivity to any of the component medicines.
● Not recommended during the first trimester of pregnancy.

Primaquine
Dose
Primaquine is available as tablets containing 5.0, 7.5 or 15 mg Primaquine Diphosphate.
Dose 0.25 - 0.5 mg / kg once daily for 14 days.

Side effects
The most important adverse effects are haemolytic anaemia in patients with G6PD
deficiency. Therapeutic doses may also cause abdominal pain if administered on an
empty stomach. Larger doses can cause nausea and vomiting. Methaemoglobinaemia
may occur. Other uncommon effects include mild anaemia and leukocytosis. Overdosage
may result in leukopaenia, agranulocytosis, gastrointestinal symptoms, haemolytic
anaemia and methaemoglobinaemia with cyanosis.

Quinine
Quinine is presented as the following tablet strengths:
• 300 mg quinine dihydrochloride
• 300 mg quinine hydrochloride
• 300 mg quinine bisulphate
• 300 mg quinine sulphate
• 200 mg quinine sulphate

Table 17: Quinine tablets equivalence table

Quinine salt Number of tablets
300 mg Quinine Dihydrochloride 1
300 mg Quinine Hydrochloride 1
300 mg Quinine Bisulphate 1.5
300 mg Quinine Sulphate 1.5

Dose
Quinine is administered as a seven-day dose of 10 mg /kg salt three times a day every 8
hours; in severe malaria.

52 FIFTH EDITION
Table 18: Dosing schedule for quinine 200mg tablets
Weight in kg No of 200mg tablets
4–7 ¼
8 – 11 ½
12 – 15 ¾
16 – 23 1
24 – 31 1½
32 – 39 2

Table 19: Dosing schedule for quinine 300mg tablets

Weight in kg No of 300mg tablets
6 – 11 ¼
12 – 17 ½
18 – 23 ¾
24 – 35 1
36 – 47 1½
48+ 2

For children below the lowest weight category, the dosage of quinine is 10mg/kg and the
tablets should thus be reconstituted into a suspension and given based on the weight of
the patient. It is important to note that this is not an accurate method for quinine dosing
and the reconstitution must be done prior to each dose as the stability of quinine in the
liquid used is not known.
Injectable quinine
● Quinine hydrochloride (82% quinine base).
● Quinine dihydrochloride (82% quinine base).
● Quinine sulphate (82.6% quinine base) respectively.
The ampoules contain 300mg/ml and come as 2 ml or 1 ml ampoules.

Quinine for intramuscular injection

The dosage of IM quinine injection for pre referral treatment is a loading dose of 20mg/
kg up to a maximum of 1200 mg.
How to give the intramuscular injection
● Weigh the patient (if he/she cannot be weighed the following formula can be
used to estimate the weight of children under 5 years: (age (in years) x 2) + 8
= wt in kg)
● Use a 10 ml sterile syringe. Draw up 5 ml of sterile water for injection. Then
into the same syringe, draw up 300 mg (1 ml) from an ampoule of quinine. The
syringe now contains 50 mg quinine per ml. Mix the drug by shaking the syringe
before injection. *For the formulation of 600mg/2ml, only one ml is drawn
out into the syringe. For the 300mg / ml the whole vial is drawn out while
for the 150mg/ml, two vials will be required to make 300 mg.

FIFTH EDITION 53
 ● In all situations a maximum of 3ml should be injected into one injection site.
If the amount to be injected exceeds 3 ml, half the amount should be injected
into each injection site (refer to table below for number of sites).

Table 20: Dosing schedule for IM Injections of quinine

Dilute quinine to 50 mg/ml – and give based on 10 mg/kg doses.
Body weight Volumes of diluted quinine injection Number of injection
(ml) to be administered sites
Less than 5 kg 1.0ml one
5.1 - 7.5 kg 1.5ml one
7.6 –10kg 2.0ml one
10.1 - 12.5 kg 2.5ml one
12.6 - 15 kg 3.0ml one
15.1 - 17.5 kg 3.5ml two
17.6 – 20 kg 4.0ml two
20.1 - 22.5kg 4.5ml two
22.6 – 25 kg 5.0ml two
25.1 - 27.5 kg 5.5ml two
27.6 –30 kg 6.0ml two
30.1 - 32.5 kg 6.5ml three
32.6 – 35 kg 7.0ml three

Quinine intravenous infusion

Intravenous quinine is administered in isotonic fluid; either 5% dextrose or dextrose -
saline as follows. See section on treatment of severe malaria.

Adults
● The first dose 20 mg/kg in 500mls of isotonic fluid given over 4 hours (maximum
1200 mg).
● Then 8 hours after commencing the initial dose give l0mg/kg in 500mls of
isotonic fluid over 4 hours (maximum 600mg).
● Repeat l0mg/kg 8 hourly until the patient can take orally.
● Then preferably, give a full treatment course of Artemether-Lumefantrine or
Quinine may be continued orally at 10mg/kg three times a day to complete a
total of 7 days treatment of Quinine.
● Assessment of fluid status should be monitored regularly including urine output.
● If patient cannot be weighed – IV quinine loading dose should be 900mg.
Followed by 600 mg 8 hourly.
Children
● Put up IV quinine drip (20mg/kg body weight loading dose in 15ml/kg of isotonic
fluid) to run over 4 hours.
● Fluid intake should be calculated according to weight, bolus 20 ml/kg (minimum
10mls/kg) and maintenance 4-6 ml/kg/hr.

54 FIFTH EDITION
 ● 8 hours after commencing the initial dose of quinine, give 10mg/Kg in 10mls/
kg of isotonic fluid.
● Repeat l0mg/kg 8 hourly until the patient can take medication orally.
● Then preferably, give a full treatment course of Artemether-Lumefantrine or
quinine may be continued orally at l0mg/kg three times a day to complete a
total of 7 days treatment of quinine.

Side effects
The triads of quinine toxicities comprise cinchonism, hypoglycaemia and hypotension.
Careful attention should be paid to these and adequate measures taken to correct them.
Cinchonism is characterized by tinnitus, high tone deafness, visual disturbances,
headache, dysphoria, nausea and vomiting and postural hypotension all of which
disappear on withdrawal of the drug. It is usually mild.
Hypotension is often associated with excessively rapid IV infusion or bolus injection.
Hypoglycaemia is due to the stimulative effect of quinine on the β cells of the pancreas
which produce insulin. It is common in pregnancy and very prolonged and severe
infection.
Other side effects include nausea, vomiting, diarrhoea, blurred vision, distorted colour
perception, photophobia, diplopia and night blindness, cutaneous flushing, pruritus,
rashes, fever and dyspnoea.
Black water fever is seen in patients with G6PD enzyme deficiency and malaria treated
with quinine. It is characterized by haemolysis, Haemoglobinuria and in severe forms
renal failure.

Pharmacology of Artesunate injection:

Desription: Artesunate is a white crystalline powder. It is a rapidly acting blood
schizontocide active against all plasmodium species. It is active against asexual
parasites killing all stages from young rings to schizonts. In P. falciparum malaria, it
also kills the gametocytes including stage 4 gametocytes.

Administration
● Artesunate can be administered IV or IM after reconstitution with sodium
bicarbonate and dilution with normal saline or 5% dextrose.

Intravenous
● Intravenous route is preffered.
● Weigh the patient to determine the dosage needed and therefore the number
of vials required.
● Dissolve each vial of Artesunic powder with all the 5% sodium bicarbonate
solution provided with each vial. Shake gently until the resultant solution is
clear.
● Dilute resultant solution with 5 ml normal saline or 5% dextrose*.
● The resultant solution has a strength of 10 mg/ml.
● Administer by slow IV over 3-5 minutes.

FIFTH EDITION 55
 Intramuscular
● Weigh the patient to determine the dosage needed and therefore the number
of vials required.
● Dissolve each vial of Artesunic powder with all the 5% sodium bicarbonate
solution provided with each vial. Shake gently until the resultant solution is
clear.
● Dilute resultant solution with 2 ml normal saline or 5% dextrose*.
● The resultant solution has a strength of 20 mg/ml.
● Administer by IM route.
● Spread the doses of more than 2 ml over different sites for babies and 5 ml for
adults.

* This refers to 60 mg Artesunate. For all other strengths refer to product insert for
diluent volume.

Precautions
● Inject immediately after reconstitution and discard if not used within 1 hour.
● Discard if the solution isn’t clear.
● Do no use in an intravenous drip.
● Water for injection isn’t suitable for dilution of Artesunate injection.
● Sodium Artesunate MUST be reconstituted with Sodium Bicarbonate solution to
activate it.

Side effects
Common S/E: Dizziness, vomitting, headache, insomnia, cough, altered taste, abdominal
pain, diarrhea, rash, pain at injection site.
Uncommon: Anaemia.

Contraindications
Oral Artesunate should not be used during the 1st trimester of pregnancy.

56 FIFTH EDITION
Table 21: Dosing schedule for Parenteral Artesunate

Dosing schedule
Artesunate is administered at 0hrs, 12hrs, 24hrs then daily until the patient can take
orally. If patient cannot take orally, continue the Artesunate injection for a maximum
of 7 days. **All attempts should be made to allow patients who can take orally to take
a full course of AL.**
● Include discard after 1 hour of reconstitution.

FIFTH EDITION 57
ANNEX 4: COMA MONITORING SCALES
The Glasgow coma scale
Table 22: The Glasgow coma scale (for adults and children over 5 yrs).
Spontaneous: open with blinking at baseline 4 points
Eye Opening Response Opens to verbal command, speech, or shout 3 points
Opens to pain, not applied to face 2 points
None 1 point
Oriented 5 points
Confused conversation, but able to answer questions 4 points
Verbal Response Inappropriate responses, words discernible 3 points
Incomprehensible speech 2 points
None 1 point
Obeys commands for movement 6 points
Purposeful movement to painful stimulus 5 points
Motor Response Withdraws from pain 4 points
Abnormal (spastic) flexion, decorticate posture 3 points
Extensor (rigid) response, decerebrate posture 2 points
None 1 point

It is recommended to use the simpler Blantyre coma score for children. However, if the GCS
is used for children under 5, adjust the verbal response according to the Table 23 below.

Table 23: Adjusted verbal response for children <5yrs.

Score 2 to 5 years 0 to 23 months
5 Appropriate words or phrases Smiles or coos appropriately
4 Inappropriate words Cries and consolable
3 Persistent cries and/or screams Persistent inappropriate crying and/or screaming
2 Grunts Grunts or is agitated or restless
1 No response No response

To obtain the Glasgow coma score obtain the score for each section add the three figures
to obtain a total out of 15.

Interpretation of symptoms: (Severe: 8 or less; Moderate: 9-12; Mild: 13 or more)

The Blantyre coma scale

The Blantyre coma scale9 is a modification of the Glasgow coma scale suitable to use
in children not yet able to speak. The scale uses motor and crying responses to pain
and includes the ability to watch. It can be used to assess young children with cerebral
malaria.

9
Molyneux ME Taylor TE et al. Clinical features and prognostic indicators in paediatric cerebral malaria: A study of 131
comatose Malawian children. Q J Med. 1989; 71: 441-459.

58 FIFTH EDITION
Table 24: The Blantyre coma scale for children <5 years
Response Findings Score
Eye opening Directed (e.g. towards mother’s face) 1
Not directed 0
Best verbal response Appropriate cry 2
Inappropriate cry 1
None 0
Best motor response Localizes painful stimuli 2
Withdraws limb from pain 1
Non-specific or absent response 0

Blantyre coma scale = (best motor response score) + (best verbal response score) + (eye
movement score).
The score can range from 0-5. Any score < 4 is abnormal while 2 or less indicates unrousable
coma. The score can be used repeatedly to assess improvement or deterioration.

FIFTH EDITION 59
ANNEX 5: UPDATED IMCI ALGORITHM
The integrated management of childhood illnesses (IMCI) algorithm has been updated
to reflect the recommendation for confirmation of malaria diagnosis before treatment.

60 FIFTH EDITION
ANNEX 6: FIFTH EDITION GUIDELINE REVIEW TEAM

FIFTH EDITION 61
62 FIFTH EDITION