Primary Level Care of Malaria

PRIMARY LEVEL
CARE OF MALARIA.
Evelyn Zachary- H31/53719/2012
Victor M.Mugambi- H31/53533/2012
OBJECTIVES
• Define malaria (Uncomplicated and Severe)
• Describe the distribution of malaria in Kenya
• Risk factors for malaria morbidity and mortality
• Magnitude of morbidity and mortality
• Strategies for malaria control and prevention (case management,
insecticide treated net, indoor residual spray)
Introduction
• Malaria- is a life threatening disease caused by plasmodium
parasites that are transmitted to people through the bites of
infected female anopheles mosquitoes. (WHO)
• The plasmodium species are:
 P. falciparum (Which accounts for 80-90% of cases in Kenya and
is mostly responsible for severe malaria)
 P. ovale
 P. vivax
 P. malariae
 P. knowlesi
DEFINITION FOR UNCOMPLICATED AND SEVERE MALARIA.
• Uncomplicated malaria- Symptomatic infection with malaria parasitemia

without signs of severity and evidence of vital organ dysfunction. Signs
and symptoms nonspecific.
• Severe malaria- Malaria parasitemia with clinical and/or laboratory

evidence of vital organ dysfunction.
2014 WHO TROPICAL MEDICINE AND INTERNATIONAL HEALTH

IN RED ARE SIGNS MOTHERS SHOULD BE EDUCATED TO IDENTIFY WITHIN THE COMMUNITY
Uncomplicated malaria Severe malaria
Fever >37.5C, chills, sweating, malaise Acute kidney injury

Hemoglobinuria (Black water fever)
Metabolic acidosis Hco3 <15mmol/l
Tachypnea, tachycardia Acute pulmonary edema
RDS( Deep Acidotic breathing)
Joint aches, muscle aches, fatigue Prostration i.e. Generalized weakness that the
patient is unable to sit, stand or walk without
assistance
Irritability and refusal to feed Impaired consciousness(unarousable coma)
Multiple convulsions(>2 within 24hrs)
Confusion
Nausea, vomiting, diarrhea, lack of appetite Hypoglycemia <2.2mmol/l
Hyperparasitemia
Anemia Hb<5g/dl, DIC
Jaundice
WORLD MAP DISTRIBUTION OF MALARIA DEATHS PER 1000
Kenya Malaria
Endemicity Zones
MOH: Kenya Malaria Indicator Survey 2015

MALARIA PREVALENCE IN KENYA
Di s trib uti on of ma lari a in Ke ny a
• There are four epidemiological zones :

• Endemic areas: Lake Victoria basin, Coastal region. Falciparum incidence>20%
• Highland and epidemic-prone areas: Malaria prevalence 5-20%
• Low malaria risk areas: Central highlands of Kenya, Nairobi. Incidence < 5%
• Seasonal malaria transmission areas: Arid and semi-arid areas of Northern and
central parts of the country which experience short periods of intense malaria
transmission during rainy seasons. Malaria prevalence between 1-5%
Risk factors for malaria morbidity and
•
mortality
There are some population groups that are at a considerable higher risk of
contracting malaria, and developing severe disease. These include:
• Young children: WHO reports 70% malaria death occurs in under 5s. In
the first 6 months of life they acquire immunity from the mothers
antibodies but thereafter they develop their own making them susceptible
since they do not yet have partial immunity to malaria.
• Pregnancy: Mothers in second and third trimester due to depressed
immunity.
• Lower immunity for malaria in low malaria transmission zones.
Continuation: Risk factors
• Non-immune immigrants
• Genetic factors
Sickle cell trait relatively protected against P. falciparum while Sickle cell
diseased are at high risk of developing severe malaria.
Negative for the Duffy blood group relatively protected against P. vivax
• Behavioral factors:
Human activities such as stagnant water pools in quarries or irrigation
schemes, being outdoor at night.
• Immunosuppression
People living with HIV, or those who have undergone splenectomy.
MAGNITUDE OF MORBIDITY AND
MORTALITY.
• There were 216 million cases of malaria in 2016 up from 211 million
cases in 2015 (World malaria report, 2017)
• Estimated number of deaths 445 000 in 2016 almost similar to previous
year(446 000)
• Africa accounts for 90% of malaria cases and 91% of malaria deaths.
• In areas of high transmission of malaria disease, children under 5
accounted for more than two thirds (70%) of malaria deaths.
Continuation to magnitude of morbidity and mortality
• In Kenya 25 million out of 44 million are at risk.

• More than 4 million cases reported annually in Kenya.
• There is a 5.1% mortality rate among patients admitted with severe
malaria.
• Malaria accounts for 30-50% of outpatients visits and 20% of inpatient
admissions.
• Malaria is estimated to cause 20% of all deaths in under 5s (MOH. 2016)
2015 KENYA MALARIA INDICATOR SURVEY.
Strategies for malaria control and prevention
• Interventions to control and eliminate malaria governed by the Kenya
malaria strategic plan 2009-2018
• Key objectives are;
- By 2013 to have at least 80% of people living in malaria risk areas
using appropriate malaria preventive interventions.
- To have 80% of all self managed fevers receive prompt and effective
treatment and 1005 fever cases
- By 2010 ensure capacity to detect and respond appropriately to
malaria epidemics especially in malaria endemic areas.
- By 2011 to strengthen surveillance, monitoring and evaluation systems
so that key malaria indicators are routinely evaluated.
Malaria control and prevention
• Three main strategies:

Vector control with Insecticide treated nets(ITNs), Indoor residual
spraying(IRS) and larval source management.
Management of malaria in pregnant mother by making sure they receive
and use ITNs ad also undergo intermittent preventive treatment.
Case management using ACT and improving early diagnosis and effective
treatment.
Others:
Epidemic preparedness and response (EPR)
Advocacy, communication and mobilizing the society
Cross cutting strategies include programme management, resource
Capacity building among counties.
Personal protection measures such as mosquito repellants, long protective
clothing, wire screens on windows, mosquito coils
Vector control
• Most effective control measure.
• There are two kinds:
-Against adult stages e.g. IRS, ITNs and ultra-low volume space
spraying(fogging)
- Against aquatic stages e.g. draining stagnant water, clearing bushes
Indoor residual spraying
This is the application of insectide to the inside of houses, on walls and
surfaces that serve as resting places for mosquitoes. When they come into
contact with such treated surfaces, they get killed. Remains effective for 3 to
6 months.
Status and concerns with IRS
• The IRS business plan targets spraying in the lake endemic counties of
Western Kenya, reaching 7 counties with an estimated population of 8.7
million
• In 2017 PMI supported IRS in Migori county using a long acting
organophosphate and covered 906,388 people (212,029 structures)
Presidents Malaria Initiative 2017

• Conditions successful for IRS
1. The population has to live in houses or hut with spray-able walls
2. The vector has to be susceptible to the insecticide used.
3. The vector enters and rests inside the dwellings long enough to absorb the insecticide
4. Applying the insecticide safely targeting local environmental factors including seasons and topography
5. Ensuring high enough proportion(>80%) of the house and rooms spraying to ensure more exposure of
the insecticide to the mosquitoes.
• Challenges.
1. Vector resistance to pyrethroid insecticide
2. High cost of non-pyrethroid insecticide and environmental effects linked to DDT. Some studies links it
with breast cancer in women, neurodevelopmental delays in neonates though there is limited evidence
or study. (https://www.ncbi.nlm.nih.gov/books/NBK1724/)
3. Inadequate entomological data that profiles resistance monitoring, vector density and behavior and
insecticide residual life.
Insecticide treated nets (ITNS)
• These are factory treated mosquito nets that retain their insecticidal activity without need
for retreatment even with repeated washing.
• Lasts 3-5 years then replaced
• There is routine distribution through ANC and child welfare clinics; commercial outlets
selling IRS, social marketing at designated locations in poor areas.
ITN UTILIZATION IN KENYA (Kenya Malaria Indicator Survey 2015)
• 59% of households in Kenya own at least one ITN and 63% at least LLIN
• 40% of households have at least one net for every 2 people
• 48% of households slept under an ITN prior the survey
• 56% of under fives slept under an ITN
• 55% of pregnant women slept under an ITN
Challenges of ITN
• ITNs need to be retreated with insecticides every six months to retain their
effects hence the introduction of Long lasting insecticide treated nets
(LLIN)
• Inaccessibility to those who really need the nets.(Low socio-economic
status)
• Insecticide resistance- mosquitoes are able to survive for longer than
before when they died rapidly.
http://kemri-wellcome.org/blog-post/bed-nets-and-the-fight-against-malaria/
INTERMITTENT PREVENTIVE TREATMENT OF
PREGNANT WOMEN. (IPTp)
• There is considerable morbidity and mortality in pregnant women and infants.

• For women residing in malaria endemic zones, providing intermittent treatment during ANC is
vital.
• At least two doses of sulfadoxine pyrimethamine (Fansidar)should be given during the 2nd and
3rd trimester every 4 weeks.
UTILIZATION IN KENYA
• ANC services widespread at 94% of pregnant women.
• Of these 75% received one dose of SP, 56% received at least two doses, 37% received the
recommended 37%
Case Management
• Objectives-:
 Provision of good quality, safe and effective treatment for malaria patients as
outlined in the Kenya Malaria Strategy 2014-2018
 Prompt parasitological diagnosis(malaria RDT which can be done at home) and
(microscopy available at a health facility) and treatment within 24 hours of
symptoms onset with appropriate and effective medicine.
 First line treatment with artemether-lumefantrine for uncomplicated malaria (can be
given at home by the CHW) and parenteral artesunate for severe malaria (health
facility)
KDHS 2014
Kenya Malaria Indicator Survey 2015
REFERENCES
• Kenya malaria indicator survey 2015
• 2014 WHO, Tropical medicine and international health
• Malaria diagnosis new perspectives WHO
• WHO Malaria Control Today 2005
• WHO Pocket handbook of hospital care for children Second Edition (2013)pages 156-
157. 163

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PRIMARY LEVEL

• Uncomplicated malaria- Symptomatic infection with malaria parasitemia

• Severe malaria- Malaria parasitemia with clinical and/or laboratory

2014 WHO TROPICAL MEDICINE AND INTERNATIONAL HEALTH

Uncomplicated malaria Severe malaria

Fever >37.5C, chills, sweating, malaise Acute kidney injury

MOH: Kenya Malaria Indicator Survey 2015

• There are four epidemiological zones :

• In Kenya 25 million out of 44 million are at risk.

• Three main strategies:

Presidents Malaria Initiative 2017

• There is considerable morbidity and mortality in pregnant women and infants.

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