Summarized GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF MALARIA IN THE SOMALI CONTEXT 2016 GUI

Guidelines for the Diagnosis and Treatment of Malaria in the Somali Context (2016)

This document provides a comprehensive framework for managing malaria in Somalia, focusing on early diagnosis, appropriate treatment, and continuous monitoring to combat malaria effectively.

1. Introduction

• Malaria is a significant public health problem in Somalia.

• Plasmodium falciparum is the dominant species, but P. vivax cases are increasing in Somaliland and Puntland.

• Challenges include limited data, overdiagnosis, and inadequate health infrastructure.

• The first guidelines were developed in 2005 and updated in 2011 and 2016.

2. Malaria Classification & Treatment

Uncomplicated Malaria

• Symptoms: Fever, chills, headache, joint pain, nausea, and vomiting.

• First-line treatment: Artemether + Lumefantrine (AL).

• Second-line treatment: Dihydroartemisinin + Piperaquine (DHA-PPQ).

• Pregnant women:

• 1st trimester: Quinine.

• 2nd & 3rd trimesters: Artemether + Lumefantrine (AL).

Severe Malaria

• Life-threatening; requires hospitalization.

• Common signs: Unconsciousness, convulsions, respiratory distress, severe anemia, and jaundice.

• First-line treatment: Injectable Artesunate.

• Alternative treatments: Injectable Artemether or Quinine if Artesunate is unavailable.

3. Malaria Treatment Dosages

1. Uncomplicated Malaria Treatment

First-line Treatment: Artemether + Lumefantrine (AL)

• Dosage: Twice daily for 3 days.

• Weight-based dosing:

• 5–14 kg: 1 tablet per dose.

• 15–24 kg: 2 tablets per dose.

• 25–34 kg: 3 tablets per dose.

• ≥35 kg: 4 tablets per dose.

• Administration:

• Take with food, preferably a fatty meal to enhance absorption.

Second-line Treatment: Dihydroartemisinin + Piperaquine (DHA-PPQ)

• Used when AL treatment fails.

• Dosage: Once daily for 3 days.

• Weight-based dosing:

• 5–8 kg: ½ tablet.

• 9–16 kg: 1 tablet.

• 17–24 kg: 1½ tablets.

• 25–36 kg: 2 tablets.

• ≥37 kg: 3 tablets.

• Administration:

• Take on an empty stomach with water.

2. Severe Malaria Treatment

First-line Treatment: Injectable Artesunate

• Dosage:

• 2.4 mg/kg IV or IM at 0, 12, and 24 hours, then once daily until the patient can take oral AL.

• For children <20 kg: 3 mg/kg per dose instead of 2.4 mg/kg.

• Switch to oral Artemether + Lumefantrine after at least 24 hours of injectable treatment.

Alternative Treatments (If Artesunate is Unavailable)

Injectable Artemether

• Dosage:

• 3.2 mg/kg IM on day 1.

• Followed by 1.6 mg/kg daily until the patient can take oral medication.

Injectable Quinine (Only if Artesunate & Artemether are unavailable)

• Dosage:

• Loading dose: 20 mg/kg IV over 4 hours.

• Maintenance dose: 10 mg/kg IV every 8 hours (infused over 4 hours).

• IM alternative: Same doses, split into two injections in anterior thigh.

• Monitor for hypoglycemia (common side effect of quinine).

4. Malaria in Pregnant Women

Uncomplicated Malaria

• First trimester: Quinine tablets (10 mg/kg) every 8 hours for 7 days.

• Second & third trimester: Artemether + Lumefantrine (AL) as standard treatment.

Severe Malaria in Pregnancy

• First-line: IV Artesunate as per severe malaria protocol.

• Alternative: IV Quinine if Artesunate is unavailable.

5. Malaria Prevention in Pregnancy (Intermittent Preventive Treatment - IPT)

Sulfadoxine-Pyrimethamine (SP)

• Dosage: 3 tablets (500 mg sulfadoxine + 25 mg pyrimethamine each) once per month starting from 2nd trimester until delivery.

• Minimum interval: 1 month between doses.

• Take under direct observation with clean water and food.

6. Special Considerations

Gametocyte Clearance in Falciparum Malaria

• Primaquine (Single-dose for P. falciparum only)

• 0.25 mg/kg once added to AL treatment except in:

• Infants <6 months.

• Pregnant women.

• Breastfeeding women (if infant <6 months).

• Individuals with G6PD deficiency.

Anti-Relapse Treatment for P. vivax

• Primaquine (14-day course)

• 0.25 mg/kg daily for 14 days except in:

• Infants <6 months.

• Pregnant women.

• Breastfeeding women (if infant <6 months).

• Individuals with G6PD deficiency.

• G6PD testing is required before treatment.

7. Malaria Diagnosis

• Preferred method: Microscopy or Rapid Diagnostic Tests (RDTs).

• If laboratory facilities are unavailable, clinical diagnosis is used.

8. Implementation Challenges

• Lack of reliable diagnostic facilities.

• Unregulated drug markets and self-medication.

• Limited awareness and inadequate health facility coverage.

9. Monitoring & Evaluation

• Treatment efficacy and resistance must be monitored every two years.

• Health workers should be trained, and the public educated.

Key Notes:

✔ Early diagnosis and complete treatment are crucial to prevent complications and resistance.

✔ Monitoring of severe malaria cases is essential, especially for hypoglycemia and anemia.

✔ Adherence to full-course treatment ensures parasite clearance and reduces transmission.

These guidelines ensure the safe and effective treatment of malaria in Somalia, considering drug resistance patterns and patient-specific risks.

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