Uncomplicated Malaria

Uncomplicated malaria is symptomatic infection with Plasmodium (mainly P. falciparum in Kenya) without signs of severity or vital organ dysfunction. Prompt parasitological diagnosis and effective treatment prevent progression to severe disease.

• Transmission by Anopheles mosquitoes; endemic zones are the lake region and coast, with epidemic risk in western highlands and seasonal transmission in arid north.
• Young children, pregnant women, people with HIV, travellers and non immune visitors are most vulnerable.

Fever (often irregular), chills, rigors, sweats, headache, myalgia, nausea, vomiting, diarrhoea, malaise, mild jaundice and splenomegaly.

• Children may present with fever, vomiting, cough or poor feeding, without classic paroxysms.
• Differential diagnosis: viral infections, typhoid, bacterial sepsis, pneumonia, urinary tract infection, dengue, leptospirosis, brucellosis, meningitis, acute HIV infection, tuberculosis, influenza, hepatitis.
• Complications: progression to severe malaria within hours, anaemia, hypoglycaemia, malaria in pregnancy outcomes (miscarriage, stillbirth, low birth weight), relapse (P. vivax and P. ovale), recrudescence from drug failure.

Confirm before treatment.

• Rapid diagnostic test (pfHRP2 or pLDH based) or thick and thin blood film microscopy, with species and parasite density.
• Haemoglobin, glucose in children and sick patients, HIV test as indicated; malaria PCR for reference.
• Treat for malaria and a second cause when RDT is positive but another cause is likely; investigate other causes when tests are negative.

Give an effective artemisinin based combination therapy and a full course of the drug.

• Supportive: paracetamol 15 mg/kg (adults 1 g) every 6 hours for fever, tepid sponging, oral fluids, continued feeding, rest, insecticide treated nets, advise return if worsening or vomiting within 1 hour of dose.
• Pharmacological: artemether lumefantrine (20 mg/120 mg tablets) twice daily for 3 days with fatty food or milk: 5 to under 15 kg 1 tablet per dose; 15 to under 25 kg 2 tablets; 25 to under 35 kg 3 tablets; 35 kg and over 4 tablets; doses at 0, 8, 24, 36, 48 and 60 hours. Alternative: dihydroartemisinin piperaquine (40 mg/320 mg tablets) once daily for 3 days: 36 to under 60 kg 2 tablets; 60 to under 80 kg 3 tablets; 80 kg and over 4 tablets (children by weight band: 5 to under 8 kg half a paediatric tablet, 8 to under 11 kg 1, 11 to under 17 kg 1 adult tablet, 17 to under 25 kg 1.5, 25 to under 36 kg 2). Another alternative: artesunate amodiaquine once daily for 3 days (artesunate 4 mg/kg plus amodiaquine 10 mg/kg). First trimester pregnancy: quinine 10 mg/kg (maximum 600 mg) orally three times daily with clindamycin 10 mg/kg twice daily for 7 days, or artemether lumefantrine when quinine is unavailable. Second and third trimester: artemether lumefantrine. If vomiting twice within 30 minutes, repeat the dose.
• Procedures: none; if unable to take oral therapy, give parenteral artesunate 2.4 mg/kg IV at 0, 12 and 24 hours (3 mg/kg for children under 20 kg).
• Special groups: infants under 5 kg, artemether lumefantrine used with specialist advice; HIV, avoid artemether lumefantrine with efavirenz or nevirapine interactions when possible (use dihydroartemisinin piperaquine or monitor), cotrimoxazole prophylaxis; sickle cell disease, prompt treatment; non immune travellers, treat in hospital.
• Red flags: drowsiness, convulsions, inability to drink, persistent vomiting, severe pallor, jaundice, dark urine, difficulty breathing, hypoglycaemia, hyperparasitaemia.
• Follow-up: review at day 3 and day 28 with repeat smear if symptomatic; retreat with a different artemisinin combination if recrudescence; prevention advice (nets, intermittent preventive treatment in pregnancy with sulfadoxine 500 mg plus pyrimethamine 25 mg, 3 tablets monthly from 13 weeks).