MLERIA TREATMENT IN ALLOPATHIC
In recent years, significant progress has been made reducing child deaths from diarrhoea. But diarrhoea remains a leading killer of young children, particularly in humanitarian settings.
Uncomplicated malaria is defined as symptomatic malaria without signs of severity or evidence of vital organ dysfunction. Uncomplicated P. falciparum infection should be treated according to the sensitivity of the parasite at the area of acquiring the infection. To counter the threat of resistance of P. falciparum to monotherapies, and to improve treatment outcome,
combinations of antimalarials are now recommended by WHO for the treatment of falciparum malaria. Two or more blood schizontocidal drugs with independent modes of action and thus unrelated biochemical targets in the parasite are used and at present Artemisinin Combinations (ACTs) are the recommended treatments for uncomplicated falciparum malaria.
LAMP of parasite-specific DNA is a more recent technology more suited to ACD in endemic settings.
The technique does not require expensive thermocyclers or gel electrophoresis,
the readout being a visual color change in a small test tube. Recent evaluation of a commercially available kit (with P. falciparum and pan-genus-specific reagents) showed the technique to be comparable to standard nested PCR technique and superior to expert microscopy.17,18 The procedure can be completed in about 1 hour at the site of collection. A modified LAMP procedure, as well as standard nested PCR, was performed in the diagnosis of P.
vivax in large field surveys in China.19
Chloroquine phosphate is used occasionally to decrease the symptoms of rheumatoid arthritis and to treat systemic and discoid lupus erythematosus, sarcoidosis, and porphyria cutanea tarda. Talk to your doctor about the possible risks of using this drug for your condition.
Referral forms were generally filled out well by traditional healers, accuracy appeared to improve over time. Only 19 (5%) of forms were missing the name of the traditional healer, 38 (11%) were missing the date of referral, and 351 (100%) referral forms included data about the nature of the patient symptoms (either by circling pictures depicting symptoms or writing additional information on the forms). Clinical data were included with less regularity, with 22% of the forms lacking a diagnosis.
Additional informationCompeting interestsThe authors declare that they have no competing interests.Authors' contributionsSMA conceptualized and designed the study, analysed data, drafted the manuscript and made final revisions. RH did sample calculations and designed the study, analysed data and made critical revision of the manuscript. UH organized the field activities, analysed data and helped in the revision of the manuscript. AH analysed data, made the tables and helped in drafting the manuscript. All authors read the final manuscript and approved.
Artesunate: 2.4 mg/kg body weight, intravenously or intramuscularly given on admission (time = 0), then at 12 and 24 hours, and then once a day. This is the treatment of choice.
Children are especially sensitive to an overdose, so keep the medication out of the reach of children.Keep all appointments with your doctor and the laboratory. Your doctor may order certain lab tests and electrocardiograms (EKG, a test to monitor your heart rate and rhythm) to check your response to chloroquine phosphate.
Your doctor will also test your reflexes to see if you have muscle weakness that may be caused by the drug.If you are taking chloroquine phosphate for a long period of time, your doctor will recommend frequent eye exams. It is very important that you keep these appointments. Chloroquine phosphate can cause serious vision problems. If you experience any changes in vision, stop taking chloroquine phosphate and call your doctor immediately.Do not let anyone else take your medication. Ask your pharmacist any questions you have about refilling your prescription.It is important for you to keep a written list of all of the prescription and nonprescription (over-the-counter) medicines you are taking, as well as any products such as vitamins, minerals, or other dietary supplements. You should bring this list with you each time you visit a doctor or if you are admitted to a hospital. It is also important information to carry with you in case of emergencies.
Diagnosis of P. vivax and G6PDd for hypnozoitocidal efficacy. The methodology of anti-relapse efficacy trials is challenging, but broadening enrollment criteria may be warranted to include those with subpatent infections.
In this context, the use of highly sensitive diagnostic techniques such as LAMP may help to discriminate patient risk groups at enrollment. It is important to identify patients with G6PD variants known to be at high risk of severe hemolysis. Historically, the NADPH spot test (which identifies patients with < 30–40% of normal activity) has been used for this purpose, including a series of trials of PQ as primary prophylaxis in the past decade where subjects received large cumulative doses of this drug over prolonged periods.36 Although valid concerns may be raised regarding insensitivity to milder variants and female heterozygotes, there are no documented cases of acute severe hemolytic anemia following PQ therapy and a classification as normal by the NADPH spot test. At least in the specific instance of PQ, this record of safe use with NADPH spot test screening argues in favor of good safety of this technique or those of similar diagnostic performance. Nonetheless, direct evidence of safety in this practice is lacking.
A detailed clinical examination should be conducted, with particular note of the level of consciousness (the Glasgow coma scale is suitable for adults, and the simple Blantyre modification or children’s Glasgow coma scale for children). The airway should be secured in unconscious patients and breathing and circulation assessed.
Body weight of the patient should be measured or estimated so as to calculate the dose of antimalarial drugs and fluids. An intravenous cannula should be inserted and blood should be taken for cross-match, full blood count, platelet count, clotting studies, blood culture and full biochemistry; immediate measurements of blood glucose (stick test), haematocrit/haemoglobin, parasitaemia and, in adults, renal function should also be done. Unconscious patients should have a lumbar puncture for cerebrospinal fluid analysis to exclude bacterial meningitis.
The degree of acidosis is an important determinant of outcome; the plasma bicarbonate or venous lactate level should therefore be measured if possible. If facilities are available, arterial or capillary blood pH and gases should be measured in patients who are unconscious, hyperventilating or in shock. The assessment of fluid balance is critical in severe malaria.
Respiratory distress, in particular with acidotic breathing in severely anaemic children, often indicates hypovolaemia and requires prompt rehydration and, where indicated, blood transfusion.
ConclusionTreatment for febrile illness was sought from allopathic health centres and traditional practitioners, depending upon the severity of symptoms, availability of cash, distance to health centre, road conditions, and the availability of transport. In spite of these barriers, health centres were the preferred choice for treatment.
Improvements in local infrastructure would probably help to overcome some of these issues but are likely to take time and considerable investment. In light of redoubled efforts to eliminate malaria, however, at least in the short-term, less costly options include strengthening the network of village health volunteers and involving traditional healers. These groups are easily accessible to community members and their roles in malaria control strategies could be strengthened through training and by formalizing their links with these programmes.
Treatment of P. falciparum malaria depends on the severity of infection, status of the host and drug sensitivity pattern in the locality. In view of the potential seriousness of the infection and synergistic toxicity of antimalarial drugs, the drugs should be properly chosen right at the start of the treatment; changing the drugs or adding the drugs half-way through the treatment only complicates the issue and adds to the adverse effects of treatment.
The intrarectal dose used in treatment trials in Africa was either 12 mg/kg bw quinine base every 12 h without a loading dose, or 8 mg/kg bw every 8 h, also without a loading dose. The retention and absorption of quinine is dependent on pH.
Results with gluconate salts (pH 4.5) cannot be extrapolated to more acidic solutions (such as the dihydrochloride salt, pH 2).
Evaluation of the safety and efficacy of therapies for acute vivax malaria, which necessarily includes both blood schizontocidal and hypnozoitocidal therapies, employs diagnostics for both the infection and G6PDd. Clinical trials of experimental therapies often demand higher standards of diagnosis than may be applied in routine clinical care, to provide greater assurance of subject safety and the precision of efficacy estimates.
Drug interactions. Primaquine is metabolized by monoamine oxidase to the biologically inert, but slowly eliminated, carboxyprimaquine, and via CYP450 (predominantly 2D6) to reactive intermediates that mediate both the antimalarial effects and hemolytic toxicity. Theoretically, inhibitors such as quinidine, ketoconazole, paroxetine, and fluoxetine may reduce toxicity, but these predictions require further study. Historic examples of likely drug–drug interactions have occurred between pamaquine (a PQ precursor) and mepacrine (structurally similar to CQ) impacting safety, and between quinine and CQ impacting efficacy against relapse.126
These children could have been saved by simple effective interventions, such as oral rehydration salt and zinc: Approximately 70 to 90 per cent of deaths caused by acute watery diarrhoea can be prevented by oral rehydration salt, while zinc is estimated to decrease diarrhoea mortality by 11.5 per cent. Appropriate fluids, breastfeeding, continued feeding and selective use of antibiotics are also critical.
