1. 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 Services

2. 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 with
Children
Pregnant women

3. Three Essential Components of Malaria Case Management
1. Parasitologicaldiagnosis by lab/slide or RDT 3.
Counseling to ensure adherence 2.
Treatment with recommended drug (e.g., ACT)
In the graphic above:
RDT = rapid diagnostic test
ACT = artemisinin-based combination therapy

4. 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)

5. Diagnosis Malaria classification includes:
Taking the patient’s brief history
Checking for fever
Checking for anemia (check the eyes and palms)
Checking for other signs of non-malarial illness with fever
Performing 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

6. Decerebrate rigidity in complicated (cerebral) malaria
Types of Malaria
Uncomplicated
Most common
Severe
Life threatening, can affect brain
Decerebrate rigidity in complicated (cerebral) malaria

7. Treating Malaria in Children

8. Recognizing Malaria How do you recognize malaria?
A child with malaria will have fever—fever simply means hotness of the body
You 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

9. Other Symptoms
In addition to fever, other manifestations of malaria may include:
Refusal to feed
Generalized body weakness
Not playing actively as usual/feeling unwell
Excessive sweating
Shivering and cold
Vomiting
Aches and body pains
Bitterness in the mouth
NOTE: In the absence of an RDT or a lab test, a child who has fever—but none of the other symptoms—has malaria

10. Steps to Take When a Child Comes with Fever
Assess fever
A patient has fever if he or she has:
History of fever
Feels hot or
Has axillary temperature of 37.5° C and above
Then ask how long he or she has had fever

11. 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

12. Danger Signs The following are the general danger signs: Convulsions
Loss of consciousness/coma
Vomiting everything/severe vomiting
Child not able to drink or breastfeed
Very sick child (unable to sit or stand)
Difficulty in breathing or fast breathing

13. Steps to Take When a Child Comes with Fever (continued)
Check for general danger signs
Ask:
Has the patient had convulsions?
Is the patient able to drink or eat—or breastfeed (if a child)?

14. What Can We Observe? Look to see if the patient:
Is lethargic or unconscious
Is convulsing now
Has severe paleness/pallor (e.g., very pale palms)
Has difficulty in breathing (fast breathing)
Is passing dark or little urine
Has jaundice (yellowing of eyes)
Has abnormal bleeding

15. 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

16. Other Signs and Other Diseases
Look and feel for other signs that may indicate another disease that needs different treatment:
Stiff neck
Running nose
Signs of measles

17. Steps to Take When a Child Comes with Fever (continued)
Classify fever
The 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

18. 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 immediately
If the patient has only fever without general danger signs, classify as:
Mild malaria—please treat

19. 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 slide
Always read medicine packet for exact dosing

20. Treatment Chart Dosage for Most ACTs (see packet for details) Weight
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
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)

21. Treating Malaria in Children— Dosing Caution
Note: 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

22. 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 tablet
Mix banana or honey with the crushed medicine to sweeten it (discuss)
Make sure the child eats some food before taking medicine
Fatty foods help the body absorb medicine
If the child vomits within 30 minutes of swallowing the medicine, please repeat that vomited dose

23. More Tips
If the child begins to react to the medicine, take him/her to the health facility immediately
Reactions may include:
Rashes and itching
Difficulty breathing/cough
Restlessness
Other behavior or manifestation the caregiver considers unusual

24. 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/her
Bathing the child with lukewarm or tepid water
Giving the appropriate dose of paracetamol
Giving the child enough fluid
If the child is not responding to treatment, take him/her to a health center immediately

25. 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 temperature
What to do?
See next slide

26. What to Do If Convulsion Occurs
Loosen all tight clothing, and leave only light clothing on the child
Disperse the crowd
Keep the child isolated
Lay the child flat on the floor
Remove any dangerous objects around the child
Take the child to a health center as soon as possible

27. Treatment Challenges— What 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 illnesses
If 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

28. Treating Malaria in Pregnancy

29. Benefits of Treatment
Treat malaria in pregnancy (MIP) quickly and correctly to prevent:
Anemia in pregnancy
Miscarriage
Fetal growth retardation
Low birth weight
Stillbirth
Greater likelihood of death in the neonatal period

30. Recognizing Malaria in Pregnant Women
Uncomplicated Malaria
Fever (hot body)
Shivering/chills/rigors
Weakness
Headaches
Muscle and/or joint pains
Nausea with or without vomiting
False labor pains
Mild anemia
Loss of appetite

31. Common Signs of Malaria
Some common signs of malaria are:
Axillary temperature of 37.5° C or higher
Anemia (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 considered
Use RDT and follow the results

32. 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

33. 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:
Dizziness
Breathlessness/difficulty breathing
Sleepiness/drowsiness
Confusion
Coma
Sometimes fits, jaundice, severe dehydration
Severe anemia
Pulmonary edema
Again, always verify with an RDT

34. 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 malaria
Facilitators will provide a handout for MIP treatment in your own country

35. Managing MIP
Provide the drug of choice for malaria according to national guidelines
Quinine in the first trimester
ACT in the second or third trimesters
If the pregnant woman is in her first trimester, refer her to the health center in your community
Manage fever with analgesics, tepid sponging

36. 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 drugs
Return if there is no improvement in 48 hours
Consume iron-rich food (e.g., plantain, beans)
Use long-lasting insecticide-treated nets (LLINs)/insecticide-treated nets (ITNs) and other preventive measures

37. As Part of Treating MIP …
Arrange follow-up within 48 hours of DOT
Advise to return if condition worsens
Educate on danger signs
Reinforce use of LLINs/ITNs
Most 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

38. 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
In summary, malaria in pregnancy (MIP) has been shown to have adverse consequences for mothers and their babies. However, a malaria preventive package—that includes intermittent preventive treatment (IPT) with monthly doses of sulfadoxine-pyrimethamine (SP) during antenatal visits, and the use of insecticide-treated nets (ITNs) throughout pregnancy and during the postnatal period—has been shown to minimize these adverse events. Preventive efforts must be complemented by case management of malaria illness with effective anti-malarial medication for all women of reproductive age. Preventive efforts should emphasize screening and prompt treatment for anemia. Successful programs can only emerge from partnerships between malaria control and reproductive health units.

39. 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?