Uncomplicated malaria is a parasitic infection caused by Plasmodium species, primarily transmitted by Anopheles mosquitoes. Prompt diagnosis and treatment with artemisinin-based combination therapies (ACTs) are essential to prevent progression to severe disease, reduce transmission, and combat drug resistance in endemic areas like Ghana.
🦟 Overview and Pathophysiology
Malaria is caused by Plasmodium parasites, with P. falciparum being the most common and severe species in Ghana:
Common Species
- P. falciparum: Most prevalent, responsible for severe cases
- P. vivax: Less common, can cause relapses
- P. malariae: Chronic infections possible
- P. ovale: Rare, similar to P. vivax
Transmission and Risk
- Vector: Female Anopheles mosquitoes
- Risk Groups: Children <5 years, pregnant women, non-immune travelers
- Prevention: Insecticide-treated nets (ITNs), intermittent preventive treatment (IPT)
- Key Point: Early treatment prevents complications
🔍 Clinical Presentation
Typical features of uncomplicated malaria:
Symptoms
Paroxysmal Attacks: Fever, chills, rigors, sweating (every 48-72 hours)
Systemic: Headache, generalized body/joint pain, nausea/vomiting
Gastrointestinal: Loss of appetite, abdominal pain (especially children)
Behavioral: Irritability, refusal to feed (infants)
Signs
Vital: Fever (axillary >37.5°C)
Hematologic: Mild pallor (anemia)
Hepatic: Mild jaundice
Abdominal: Splenomegaly (tender or non-tender)
- Altered consciousness, repeated convulsions
- Respiratory distress, severe anemia (Hb <5 g/dL)
- Oliguria, dark urine, hypoglycemia
- Prostration, shock
🧪 Diagnosis
Confirmatory testing is crucial to avoid overuse of antimalarials:
Investigations
First-Line: Rapid Diagnostic Test (RDT) for HRP-2/pLDH antigens
Confirmatory: Microscopy (thick/thin blood films) for species identification and parasitemia
Supportive: Full Blood Count (FBC) for anemia/thrombocytopenia
Others: Blood glucose, renal/hepatic function if indicated
💊 Treatment
Objectives: Prevent severe malaria, shorten illness duration, reduce resistance. Use ACTs as first-line.
Non-Pharmacological
Tepid sponging for fever in children; ensure hydration and nutrition.
Artesunate + Amodiaquine (AS+AQ)
- Dose: See dosing tables below
- Regimen: Once or twice daily for 3 days
- Administration: After meals to reduce GI upset
- Evidence: [A] - First-line in Ghana
Artemether + Lumefantrine (AL)
- Dose: See Table 18-8
- Regimen: 6 doses over 3 days (0, 8, 24, 36, 48, 60 hours)
- Administration: With fatty food for better absorption
- Contraindications: <5 kg body weight
Dihydroartemisinin + Piperaquine (DHA+PPQ)
- Dose: See Table 18-9
- Regimen: Once daily for 3 days
- Evidence: [A] - Alternative ACT
- Key Point: Avoid in patients with cardiac conduction abnormalities
| Weight | Age | AS (50 mg tabs) Day 1-3 | AQ (150 mg tabs) Day 1-3 |
|---|---|---|---|
| 5-10 kg | <1 yr | ½ | ½ |
| 11-24 kg | 1-6 yr | 1 | 1 |
| 24-50 kg | 7-13 yr | 2 | 2 |
| 50-70 kg | 14-18 yr | 3 | 3 |
| >70 kg | >18 yr | 4 | 4 |
AS+AQ Once Daily (4 mg/kg AS + 10 mg/kg AQ daily x 3 days)
| Weight | Age | Dose 1 | Dose 2 (8h) | Doses 3-6 (12h apart) |
|---|---|---|---|---|
| 5-15 kg | 6 mo-3 yr | 1 | 1 | 1 |
| 15-25 kg | 3-8 yr | 2 | 2 | 2 |
| 25-35 kg | 8-12 yr | 3 | 3 | 3 |
| >35 kg | >12 yr | 4 | 4 | 4 |
AL (20/120 mg tabs); Not for <5 kg
| Weight | Age | Day 1-3 Tabs |
|---|---|---|
| 5-10 kg | <1 yr | ¼ |
| 11-15 kg | 1-3 yr | ½ |
| 16-24 kg | 4-6 yr | 1 |
| 24-35 kg | 7-10 yr | 1¼ |
| 36-50 kg | 11-13 yr | 1½ |
| 50-70 kg | 14-18 yr | 2 |
| >70 kg | >18 yr | 3 (Day 1-2), 2 (Day 3) |
DHA+PPQ (40/320 mg tabs)
- Do not use monotherapy with artemisinin derivatives
- Follow-up: Repeat RDT/parasitology on Day 3 and Day 7 if no response
- Resistance: Report failures to surveillance
🤰 Special Populations: Malaria in Pregnancy
Pregnancy increases severity; prioritize prevention (ITNs, IPTp-SP).
First Trimester (Uncomplicated)
Quinine: 10 mg/kg (max 600 mg) oral 8-hourly x 7 days
Plus Clindamycin: 10 mg/kg oral twice daily x 7 days (if available)
Second/Third Trimester (Uncomplicated)
Preferred: ACTs (AS+AQ, AL, or DHA+PPQ) as above
Alternative: Quinine + Clindamycin (first trimester regimen)
IPTp
Sulphadoxine-Pyrimethamine (SP): 500/25 mg oral at each ANC visit after quickening (≥3 doses recommended)
Key Point: SP for prevention only, not treatment
🚨 Referral Criteria
- Suspected severe malaria (e.g., coma, convulsions, severe anemia)
- Treatment failure after 3 days
- Pregnant women or children <5 years with complications
- Non-response or worsening symptoms
Initiate ACT before transfer if possible.
🧠 Key Takeaways
- ✅ Diagnose First: Use RDT or microscopy; treat confirmed cases only
- ✅ ACTs First-Line: AS+AQ, AL, or DHA+PPQ for 3 days
- ✅ Pregnancy: Quinine in 1st trimester; ACTs in 2nd/3rd
- ✅ Prevent: ITNs, IPTp-SP for pregnant women
- ✅ Monitor: Follow-up on Days 3 & 7; refer failures
- ✅ Avoid: Monotherapy to prevent resistance