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Severe Malaria

Overview:

Of the 1-3 million annual deaths caused by falciparum malaria, 90% are in children under the age of 5 years, mainly in Africa.  In Asia older age groups account for a greater proportion of deaths because of low malaria immunity and greater occupational exposure. Severe malaria occurs in patients who are not treated promptly and can arise quickly in children. Death can occur within 24 hours of a child being hospitalised with severe falciparum malaria. Clinical signs vary by geographical distribution and with age. In Africa, and particularly in children, symptoms include severe anaemia, fever and convulsions, problems with breathing, cerebral malaria, extreme weakness/prostration, and also hypoglycaemia, circulatory collapse, oedema, septicaemia and occasionally renal failure. Case Fatality Rates (CFR) are higher in children who do not receive treatment until they reach hospital. CFR is also higher in children with severe hypoglycaemia, alongside severe anaemia or cerebral malaria, so hypertonic glucose should be administered routinely. Children who recover can develop neuro-cognitive sequelae. Because of the intensive care required in children with severe malaria, high costs are involved in treatment, for both administration of appropriate antimalarial drugs and hospital days, so pre-treatment either at home or at the primary health centre is a priority.

Prevalence of anaemia is high in malaria-endemic regions (up to 80%) and severe anaemia causes many thousands of deaths annually in under-five year olds. Some clinical signs of severe malaria can be mistaken for other infections, such as meningitis and respiratory tract infections, and it is preferable to either use microscopy to detect parasites in blood films, or use a Rapid Diagnostic Test.

For treatment of severe malaria antimalarial drugs are administered parenterally, with quinine or artemesinin derivatives being the drugs of choice. Suppositories of artemesinin derivatives can be given, where injectable treatment is not possible.  It is essential to make a quick diagnosis, and start parenteral drug treatment as quickly as possible. Because the time taken to get a patient to hospital for intensive care may be long, home care and treatment at a primary health care facility, before the disease has progressed, are vital. The Malaria Consortium is strongly committed to raising awareness of these issues in communities. See entries on Home Based Management of Fever [Linkl] and Rapid Diagnostic Tests [Link].

Key Points:

  • 90% of deaths from severe malaria are in children under five years.
  • Death can occur within 24 hours.
  • Signs and symptoms vary according to geographic area and age/sex of patient, but often include loss of consciousnees, severe anaemia, fever, convulsions and problems breathing.
  • Hospitalisation is required, which is costly, as are the drugs required to treat, so improving recognition and treatment  at home and in primary health care facilities prior to deterioration has enormous benefits.

Operational Programmes:

The Malaria Consortium has recently completed a baseline assessment on the case management of severe malaria in 4 districts in the west of Uganda, serving a population of 1.5 million people. We are now introducing interventions shown to improve the quality of care of severe malaria at all levels of the health system, and continuing to support the home-based management of fever in these districts.  [Link to "Communications & Severe Malaria"]

 

References:

  2. * Marsh K, Forster D, Waruiru C et al (1995); Indicators of Life Threatening Malaria in African Children New England Journal of Medicine Vol 332 No. 21
  3. * Berkely J A, Ross A, Osier FHA et al (2003) Prognostic Indicators for Early and Late Death in Children Admitted to District Hospital in Kenya; Cohort Study. BMJ Vol 326:361
  4. * Njuguna P, Newton C (2004): Management of Severe Falciparum Malaria. Journal of Postgraduate Medicine 50(1): 45-50
  5. * McIntosh HM, Olliaro P.(2000) Artemisinin derivatives for treating severe malaria. The Cochrane Database of Systematic Reviews Issue 2. Art. No.: CD000527. DOI: 10.1002/14651858.CD000527
  6. South East Asian Quinine Artesunate Malaria Trial (SEAQUAMAT) group (2005) Artesunate versus quinine for treatment of severe falciparum malaria: a randomised trial. The Lancet 366: 717-725 (Free with registration)
  8. * Pagnoni, F. and Delacollette Lebrun, C. (2002). Clinical, behavioural and socio-economic factors related to severe malaria; a multi-centre study in the African Region. World Health Organization Report - Regional Office for Africa
  9. * Crawley J (2001) Reducing deaths from malaria among children; the pivotal role of prompt effective treatment. Africa Health Supplement. September 2001; 25-28
  10. Nolan T, Angos P, Cunha AJL, Muhe L, Qazi S, Simoes EAF, Tamburlini G, Weber M, Pierce NF. (2001) Quality of hospital care for seriously ill children in less-developed countries. Lancet 357: 106-10. (Free with registration)
  11. * Planche T. et al Assessment of Volume Depletion in Children with Malaria PLOS Medicine October 2004, Vol. 1, Issue 1
  12. Mishra SK, Mohanty S, Mohanty A, Das BS. (2006) Management of severe and complicated malaria. J Postgrad Med [serial online] 52:281-287.Free access with registration to site.