CDI Module 6: Applying CDI to Home Management of Malaria - PowerPoint Presentation

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CDI Module 6: Applying CDI to Home Management of Malaria

©Jhpiego Corporation

The Johns Hopkins University

A Training Program on

Community-

Directed

Intervention

(CDI) to Improve Access to Essential Health ServicesSlide2

Module 6 Objectives

By the end of this module, learners will:

Outline the three components of malaria case management

Describe the processes of case management withChildrenPregnant women

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Three Essential Components of Malaria Case Management

1. Parasitologicaldiagnosis by lab/

s

lide or RDT

2.

Treatment with recommended

drug (e.g., ACT)

3.

Counseling to ensure adherence

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Benefits of Early Diagnosis and Treatment of Malaria Illness

Enabling sufferers of malaria to have access to efficacious and appropriate drugs within 24 hours of onset of illness can reduce the:

Duration of the illness (morbidity)

Chances of progressing to severe malaria (death)Probability of developing gametocytes (the form in which transmission takes place)

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Diagnosis

Malaria classification includes:

Taking the patient’s brief history

Checking for feverChecking for anemia (check the eyes and palms)Checking for other signs of non-malarial illness with feverPerforming a rapid diagnostic test (RDT)

Taking the patient’s body weight (to determine the amount of medicine to give)Recording and documenting, on paper, all you have observed

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Types of Malaria

Uncomplicated

Most common

Severe

Life threatening, can affect brain

Decerebrate rigidity in complicated (cerebral) malaria

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Treating Malaria

in Children

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Recognizing Malaria

How do you recognize malaria?

A child with malaria will have

fever—fever simply means hotness of the bodyYou can recognize a child with fever:By touching the chest/body with the back of your hand

If the child’s caregiver says the child had fever before coming, or If the axillary (armpit) body temperature is 37.5° C or higher

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Other Symptoms

In addition to fever, other manifestations of malaria may include:

Refusal to feed

Generalized body weaknessNot playing actively as usual/feeling unwellExcessive sweatingShivering and cold

VomitingAches and body painsBitterness in the mouthNOTE: In the absence of an RDT or a lab test, a child who has

fever

—but none of the other symptoms—has malaria

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Steps to Take When

a

Child

Comes with FeverStep 1

Assess feverA patient has fever if he or she has: History of feverFeels hot or

Has axillary temperature of 37.5°

C

and above

Then ask how long he or she has had fever10Slide11

Recognizing Severe Malaria

Malaria can be serious—severe malaria can lead to disability or even death

A patient with severe malaria presents with

general danger signs, in addition to fever

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Danger Signs

The following are the

general danger signs

:ConvulsionsLoss of consciousness/comaVomiting everything/severe vomitingChild not able to drink or breastfeedVery sick child (unable to sit or stand)

Difficulty in breathing or fast breathing

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Steps to Take When a

Child

Comes

with Fever (continued)Step 2

Check for general danger signsAsk:Has the patient had convulsions?Is the patient able to drink or eat—or breastfeed (if a child)?

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What Can We Observe?

Look to see if the patient:

Is lethargic or unconscious

Is convulsing nowHas severe paleness/pallor (e.g., very pale palms)Has difficulty in breathing (fast breathing) Is passing dark or little urineHas jaundice (yellowing of eyes)

Has abnormal bleeding

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How Can We Be Sure?

Microscopy and RDTs

Unless we test for actual malaria parasites, we cannot be sure the person has malaria

We will address how to perform RDTs in a later module

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Other Signs and Other Diseases

Look and feel for other signs that may indicate another disease that needs different treatment:

Stiff neck

Running noseSigns of measles

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Steps to Take When a

Child

Comes

with Fever (continued)Step 3

Classify feverThe two possible classifications for fever in a malarious area are:

Very severe febrile disease (febrile = with fever)

Malaria

Please give examples of other non-malarial febrile diseases

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Classifying Malaria

Look at the table in your job aid and classify the following case:

If a patient has a

general danger sign, stiff neck, or symptoms or signs of severe malaria (passing dark or little urine, jaundice, severe dehydration or difficulty in breathing, abnormal bleeding), then the patient has:

Severe malaria—please refer immediatelyIf the patient has only fever without general danger signs, classify as:

Mild malaria—please treat

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Treating Malaria in Children

Artemisinin-based combination therapies (ACTs) are recommended medicine for uncomplicated malaria

For dosage of artemether/lumefantrine (Coartem), see the picture on the right and the chart on the next slide

For dosage of paracetamol as supportive treatment, see the next slideAlways read medicine packet for exact dosing

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Treatment Chart

Dosage for Most ACTs (see packet for details)

Weight

Age

Number of

tablets/dose

5–14kg

6 months to 3 years

1 tab twice daily X 3 days

15–24kg

4–8 years

2 tabs twice daily X 3 days

25–34kg

9–14 years

3 tabs twice daily X 3 days

≥ 35kg

> 14 years

4 tabs twice daily X 3 days

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Supportive Therapy: Dosage

for Paracetamol

Age Group

Amount

2‒24

months

(125mg) give

(1/4 tab)

2‒6

years

(250mg) give

(1/2 tab)

>

6‒12

years

(500mg) give

(1 tab)

>12 years

(500mg) give

(2 tabs)Slide21

Treating Malaria in Children—

Dosing

C

autionNote: These drugs stay in the body for a long time

So, to avoid overdosing:A child—who had a complete course of appropriate ACT in the same month, and is now presenting again with fever,

should be referred

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TIPS on Counseling for Malaria Medicines

New Coartem will dissolve in water

If using artesunate-amodiaquine (AA) for children less than one year of age, you may need to crush the tabletMix banana or honey with the crushed medicine to sweeten it (discuss)

Make sure the child eats some food before taking medicineFatty foods help the body absorb medicine

If the child vomits within 30 minutes of swallowing the medicine, please repeat that vomited dose

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More Tips

If the child begins to react to the medicine, take him/her to the health facility immediately

Reactions may include:

Rashes and itchingDifficulty breathing/coughRestlessnessOther behavior or manifestation the caregiver considers unusual

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How to Prevent Onset

of Danger Signs at Home

Give the child correct treatment immediately when you notice illness and ensure that the child completes the full dose

Bring down fever immediately by:Undressing the child and fanning him/herBathing the child with lukewarm or tepid water

Giving the appropriate dose of paracetamolGiving the child enough fluidIf the child is not responding to treatment, take him/her to a health center immediately

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Convulsions

What is convulsion?

When the whole or part of the child’s body begins to make repeated jerky movements In small children, convulsion is usually caused by a sudden rise in body temperatureWhat to do?See next slide

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What to

Do If Convulsion Occurs

Loosen all tight clothing, and leave only light clothing on the child

Disperse the crowdKeep the child isolatedLay the child flat on the floor

Remove any dangerous objects around the childTake the child to a health center as soon as possible

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Treatment Challenges—

W

hat If It Is Not Malaria?

When we involve the community in delivering integrated community case management (iCCM), we are creating expectations that

community-directed distributors (CDDs) and other volunteers will be able to address common illnessesIf our diagnosis using signs, symptoms and RDTs does not find that a fever is caused by malaria:We have (it is hoped) included treatment of pneumonia in our iCCM package

Fever could be caused by something other than malaria, and our CDDs will need to refer people when the cause of their fever is not clear

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Treating Malaria

in

Pregnancy

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Benefits of Treatment

Anemia in pregnancy

Miscarriage

Fetal growth retardationLow birth weightStillbirthGreater likelihood of death in the neonatal period

Treat

malaria

in

pregnancy (MIP) quickly

and

correctly to prevent:

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Recognizing Malaria in Pregnant Women

Uncomplicated Malaria

Fever (hot body)

Shivering/chills/rigorsWeaknessHeadachesMuscle and/or joint pains

Nausea with or without vomitingFalse labor painsMild anemiaLoss of appetite

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Common Signs of Malaria

Some common signs of malaria are

:

Axillary temperature of 37.5° C or higherAnemia (pallor of the mucus membrane or palms)Enlarged spleen and/or liver

If any one or more of these symptoms and signs are found:Malaria should be consideredUse RDT and follow the results

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Malaria in Different Transmission Settings

In highly endemic, stable, year-round malaria transmission areas, a pregnant woman may not always exhibit the typical clinical signs due to some acquired immunity

RDTs are very helpful in this situation

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Recognizing Severe Malaria

Pregnant women are more likely to get severe malaria than non-pregnant women

Signs of uncomplicated malaria

plus one or more of the following indicate severe malaria:DizzinessBreathlessness/difficulty breathing

Sleepiness/drowsinessConfusionComaSometimes fits, jaundice, severe dehydration

Severe anemia

Pulmonary edema

Again, always verify with an RDT

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Treating Malaria: Uncomplicated or Severe

ACTs are the drug of choice for uncomplicated malaria

The most common ACTs are artemether-lumefantrine and artesunate-amodiaquine

ACTs are also recommended for the treatment of MIP in most countries, but guidelines vary

Quinine is also recommended for MIP and is usually the drug of choice for severe malariaFacilitators will provide a handout for MIP treatment in your own country

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Managing MIP

Provide

the drug

of choice for malaria according to national guidelinesQuinine in the first trimester

ACT in the second or third trimestersIf the pregnant woman is in her first trimester, refer her to the health center in your

community

Manage fever

with analgesics

, tepid sponging35Slide36

Treating MIP

Observe the client taking the first dose of anti-malarial drugs

Direct observation of treatment (DOT) strategy ensures that medicines are not wasted

Advise the client to:Complete the course of drugsReturn if there is no improvement in 48 hoursConsume iron-rich food (e.g., plantain, beans)

Use long-lasting insecticide-treated nets (LLINs)/insecticide-treated nets (ITNs) and other preventive measures

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As Part of Treating MIP …

Arrange follow-up within 48 hours of DOT

Advise to return if condition worsens

Educate on danger signsReinforce use of LLINs/ITNsMost clients will respond to malaria treatment and begin to feel better within 48 hours; however:

If the woman’s condition does not improve—or worsens—within 48 hours of starting treatment, and/or other symptoms appear, refer immediately

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Summary

Malaria case management has three essential components—diagnosis, treatment and counseling

We should differentiate malaria from other febrile illnesses and treat all illnesses correctly

Look for danger signs to prevent cerebral malaria (e.g., convulsions)Treat malaria in pregnant women to prevent stillbirth, miscarriage and low birth weight

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In Conclusion

If the person who is ill does not have malaria, treat for appropriate illness or refer

We will address two other illnesses, pneumonia and diarrhea, in subsequent modules

Any comments or questions please?

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