Overview Of Malaria In Nigeria

Overview of Malaria Illness in Nigeria BY Prof. C.T. JOHN Department of Obstetrics & Gynaecology U.P.T.H. Port Harcourt.

Major Causes of Maternal Mortality in Nigeria Haemorrhage

Other Causes

Obstructed Labour

Malaria Anaemia HIV/AIDS TB

Hypertensive Disorders

Sepsis

Unsafe Abortion

Overview of Malaria Illness in Nigeria Malaria is:    

Responsible for 63% of all clinic attendances in Nigeria Affects mainly children under the age of 5 years and pregnant women Causes 25% of infant mortality and 30% of all childhood deaths Associated with 11% of all maternal deaths and 70.5% of morbidity in pregnant women

The Good News! Malaria can be prevented and/or detected and treated during antenatal care

Where do you stand? The old traditional approach, OR The refocused “evidencebased” approach

Facts about Malaria and Pregnancy About 6 million Nigerian women are pregnant yearly Malaria is more frequent and serious during pregnancy Malaria during pregnancy may account for: – Up to 15% of maternal anaemia – 5–14% of low birth weight – 30% of “preventable” low birth weight

Overview of Malaria Illness in Nigeria Malaria is:    

Responsible for 63% of all clinic attendances in Nigeria Affects mainly children under the age of 5 years and pregnant women Causes 25% of infant mortality and 30% of all childhood deaths Is associated with 11% of all maternal deaths and 70.5% of morbidity in pregnant women

Effects of Malaria on Pregnant Women All pregnant women in malaria-endemic areas are at risk Parasites attack and destroy red blood cells Malaria causes up to 15% of anaemia (low blood Haemoglobin) in pregnancy Can cause severe anaemia In Africa, anaemia due to malaria causes up to 10,000 maternal deaths per year

The Old Practice of malaria chemoprophylaxis in pregnancy First ANC visit: – Stat. dose of Chloroquine (4 tablets)

Subsequent ANC visits: – Weekly (SundaySunday medicine) Pyrimethamine tablets during pregnancy up to 6 weeks postpartum

Problems with the Old Practice….. Poor medication compliance due to: – – – – –

Fear of drug-induced miscarriage Experience of generalized itching with chloroquine Bitter taste of chloroquine Need to swallow too many tablets Poor knowledge of health care providers about correct dosages – Inability to buy antimalarial drugs due to poverty – Inadequate health care infrastructures – Forgetfulness

Problems with the Old Practice….. Reduced Efficacy due to: – Malaria parasites’ resistance to drugs – Fake and adulterated drugs

New Policy for Malaria in Pregnancy (MIP) Focused antenatal care (ANC) with health education about malaria Constant use of insecticide-treated nets (ITNs) Intermittent preventive treatment (IPT) with sulfadoxine-pyrimethamine Early detection & prompt appropriate case management of women with symptoms and signs of malaria

Intermittent Preventive Treatment

Although a pregnant woman with malaria may have no symptoms, malaria can still affect her and her unborn child.

Intermittent Preventive Treatment: WHO Recommendation All pregnant women should receive two doses of IPT after quickening, during routinely scheduled ANC visits, but no more frequently than monthly (as DOT) WHO recommends a schedule of four visits, three after quickening Presently, the most effective drug for IPT is sulfadoxine-pyrimethamine (SP) HIV positive pregnant women should receive at least three doses of IPT with SP at ANC visits after quickening, but no more frequently than monthly.

IPT: Special target groups Women in their first or second pregnancies HIV infected women Adolescents (10-19 years of age) Women with sickle cell disease All pregnant women with unexplained anaemia

Intermittent Preventive Treatment: Dose of SP A single dose is three tablets of SP each containing sulfadoxine (500 mg) + pyrimethamine (25 mg) Healthcare providers should dispense the dose and directly observe the client taking the tablets (DOT strategy)

Chemoprophylaxis with Chloroquine: For Women Allergic to Sulfa Drugs* Dose 1

Chloroquine Timing 150 mg 4 tablets First ANC visit after 16 weeks

2

4 tablets

Second day after first dose

3

2 tablets

Third day after first dose

Weekly

2 tablets

Every week during pregnancy till delivery

*Where chloroquine resistance rates are high, use ITNs

Types of Malaria Uncomplicated – Most common

Complicated

Decerebrate rigidity in complicated (cerebral) malaria

– Life threatening, can affect brain – Pregnant women more likely to get complicated malaria than non-pregnant women

Current First Line Drug Policy on Case Management of Uncomplicated Malaria

*Each tablet contains 150 mg. of Chloroquine base Antimalarial drug policy for uncomplicated malaria is currently under review due to increasing chloroquine resistance in some parts of the country

Current Second Line Drug Policy on Case Management of Uncomplicated Malaria

*Consists of Sulfadoxine(500 mg.) + Pyrimethamine, (25 mg) and Paracetamol (500 mg./tablet) Antimalarial drug policy for uncomplicated malaria is currently under review due to increasing chloroquine resistance in some parts of the country

Treatment of Severe Malaria with Quinine in ADULTS Woman diagnosed with severe malaria First (Loading) dose of IV Quinine: 20 mg/kg in ½ liter of fluid (e.g. 5% dextrose) given over 4 hours (Max. dose 1,200mg)

Maintenance dose: 8 hours after commencing the initial dose give 10 mg/kg in ½ liter of fluid over 4 hours (max 600mg) Repeat 10mg/kg 8 hourly until the patient can take orally

No

Is patient taking oral drugs?

Yes

Change to SP STAT OR Give oral quinine (10 mg./kg) to complete 7 days therapy

Precautions for use of Quinine Loading dose of quinine should not be used if the patient has received any quinine in the last 24 hrs or received mefloquine in the last 7 days. Maintenance dose of quinine should be halved in patients with renal failure after 2 days. After switching to oral SP, stop quinine Hypoglycemia should be looked for and corrected with 50% dextrose (1ml/kg)