GUIDELINES FOR THE

MANAGEMENT
OF MALARIA IN CAMEROUN
INTENDED FOR HEALTH
PERSONNEL
12
 CAMEROON &
GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON

5 CALCULATE THE DOSE 6 ADMINISTER WHO INTENDED FOR HEALTH PERSONNEL

RECOMMENDATED
TREATMENT2
Calculate and withdraw the required dose
in ml according to route of administration: PREFACE
Case management is an essential strategy in malaria
control and effectively contributes to the reduction of morbidity
and mortality of this disease.
Example: Example:
Dose needed(ml) for de 6kg child: Dose needed(ml) for de 6kg child:
These guidelines are intended for the health care
2.4 x 6 2.4 x 6
providers who receive malaria patients on a daily basis. This
DOSING SCHEDULE
10
= 1.44 ml
20
= 0.72 ml
7 tool should be used to ease the diagnosis, treatment and
1.44 rounded up to 2 ml 0.72 rounded up to 1 ml
Give 3 parenteral doses for a minimun of 24
follow-up of a patient with either uncomplicated or severe
* IMPORTANT hours once started, irrespective of the patient’s malaria.
ability to tolerate oral medications earlier:
Total doses less than 0,5 ml should be .Day 1:
rounded up to 0,5 ml (not 1ml). Dose 1: on admission (0 Hours) The previous edition of these guidelines took into
For example, if the dose is 0,3 ml,round Dose 2: 12 hours later account the recommendations of the World Health
up to 0,5 ml. .Day 2: Organization concerning countries with resistance to
Dose 3: 24 hours after first dose
monotherapy. This edition describes malaria case
- If the patient can take oral medication, prescribe management protocols using artemisinin based combination
a full 3-day course of recommended first line oral
Artemisinin Conbination Therapy (ACT).
therapy (ACT).
- If the patient cannot take oral medication, continue
with parenteral treatment (one dose a day), for a
maximun of 7 days, until oral medication can be
The current guidelines highlight the recommendations of
given. the World Health Organization and the adoption of systematic
- A course of injectable artesunate should always be
followed by a 3-day course of ACT.
biological diagnosis of all suspected cases of malaria before
treatment. Rapid Diagnostic Tests (RDTs) are now available to
. Evaluate the patient’s progress regularly. all (Healthcare providers and Community Health Workers),
IMPORTANT although microscopy remain the test of reference performed in
. Prepare a fresh solution for each
health facilities.
administration.
. Discard any unused solution after The Ministry of Public Health has since 2006 retained
use.
two ACTs for the treatment of uncomplicated malaria. For first
This document is intended to demonstrate to health workers
how to prepare and administer injectable artesunate, a
line treatment, artesunate-amodiaquine is used. This is free of
treatment for severe malaria. It is not intended to provide
personal medical advice. The responsability for the
charge for children under five years and subsidized for the rest
interpretation and use of this material lies with the reader.
In no event shall MMV be liable for damages arising from
of the population since 2011. Artemether-lumefantrine is
its use. recommended for the second line treatment.
© 2014 Medicines for Malaria Venture (MMV). All rights
reserved. A copy of this document can only be made upon
MMV’s written authorization.
Remark: the upper limit for each weight band is 0,9 kg e.g. 13-16 kg
covers 13 -16.9kg.
74 3
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON THE USE OF INJECTABLE ARTESUNATE
INTENDED FOR HEALTH PERSONNEL APPENDIX 12 TO TREAT SEVERE MALARIA
1
For severe malaria, injectable artesunate is the PRODUCT DESCRIPTION
Dose: 2.4mg/kg
recommended first line treatment; injectable artemether and + + can be given by intravenous route (IV) or intramuscular route (IM).
quinine are use for second line treatment. Pregnant women in IV is the preferred route of administration.
the first trimester are treated with quinine for severe malaria. Artésunate
powder 60mg
bicarbonate
ampoule
Saline Please refer to the patient information leaflet for more information.
solution

Since July 2014, the treatment of severe malaria with

artesunate or artemether is free of charge for children under 5 1 WEIGH THE PATIENT
years and subsidized for people aged 5 years and above,
including pregnant women.
2 DETERMINE THE NUMBER OF VIALS NEEDED
Weight 5kg-25kg 26kg-50kg 51kg-75kg 76kg-100kg
60mg vial 1 2 3 5
I urge all healthcare providers to make good use of
these guidelines in order to significantly improve malaria case 3 RECONSTITUTE
Activate the drug: artésunate pwoder + bicarbonate ampoule (immediately before use)
management.
A B C D

4 DILUTE
Reconstituted artesunate + saline solution (or dextrose 5%)
Volume for dilution
IV IM IMPORTANT
Bicarbonate solution volume 1 ml 1 ml
saline solution volume 5 ml 2 ml Water for injection
is not an appropriate
Total volume 6 ml 3 ml dilutant
Artésunate 60mg solution concentration 10mg/ml 20mg/ml

A B C D

1. Word Health Organization (WHO) List of Prequalified Medicinal Products (http://apps.who.int/prequal/query/ProductRegistry.

aspx?list=ma): artesunate injectable, reference N°MA051,prequalified on 05-Nov-2010.

2. World Health Organization, Management of severe Malaria - A practical handbook - Third edition - April 2013 - (http://www.who.
int/malaria/publications/atoz/9789241548526/en/index.html)

4 73
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON INTENDED FOR HEALTH PERSONNEL
INTENDED FOR HEALTH PERSONNEL

b) 1 vial of 600mg/2ml at 82.6% of quinine base + 4 ml of

sterilized water, that is 600mg/6ml or 82.6 mg of quinine
base per ml.
ACKNOWLEDGEMENTS
Calculation of dose to be administered

82 mg/ml = Weight x Dose (mg/kg)/Quantity to be taken per The present guidelines are the result of extensive work
dose between malaria experts and partners involved in malaria
control.
Appendix 11: SALT / BASE EQUIVALENCE
OF THE MAIN ANTI MALARIAL DRUGS I take this opportunity to thank you for your contributions
in the development of this reference document and do hereby
QUININE Salt Base express all the gratitude of the National Malaria Control
Quinine Sulfate tablets 362 mg 300 mg Program.
Quinine Disulfate tablets 508 mg 300 mg
Quinine dihydrochloride tablets 500 mg 408,5 mg (81,7 %)
(Quinine Lafran*, …) 300 mg (74 %)
Quinine dihydrochloride tablets 405 mg 82% i.e. 492 mg/2ml
Quinine dihydrochloride inj. 600 mg/2 ml 82% i.e. 492mg/2ml
Quinine dihydrochloride inj. 600 mg/2ml 8 2, 6% i . e. 4 9 5, 6
Quinine sulfate inj. 600 mg/2ml m g/2m l
Quinune Gluconate inj amp 100 mg 100 mg (100 %)
(Quinimax*)

ARTEMISININE BASED
COMBINATION THERAPY
HOMOLOGATED AND
RECOMMENDED

Artésunate + amodiaquine 25mg/67.5mg 25mg/67.5mg

(Coarsucam*, Asaq*,etc) 50mg/135mg 50mg/135mg
100mg/270mg 100mg/270mg

Artémether + Lumefantrine 20mg/ 120mg 20mg/ 120mg

(Coartem*,Artefan*)

INJECTABLE ARTEMETHER (20mg,40mg, (20mg, 40mg,

80mg)/ml 80mg)/ml

INJECTABLE ARTESUNATE 60mg/ml 60mg/ml

5
72
GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL

Appendix 10: NUMBER OF DROPS PER MINUTE

TO BE RUN IN A DRIP DEPENDING ON THE
QUANTITY OF FLUIDS

5 to 10 ml./Kg/4heures
(Max quantity: 500ml per quinine infusion)

QUANTITY OF FLUIDS TO BE NUMBER OF DROPS PER

RUN IN 4 HOURS MINUTE
50 ml. 4

75 ml. 7

100 ml 9

150 ml 13

200 ml 17

250 ml 21

500 ml 42

Calculation of dose to be administered

82 mg/ml= body weight x Dose (mg/kg) / Quantity to
be obtained in ampoule or vial per dose.

Dilution of quinine
a) 1 vial of 600mg/2ml at 82% of quinine base + 4 ml of
sterilized water, that is 600mg/6ml representing 100mg
of salt per ml or 82 mg of quinine base per ml.
6
71
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL
GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL

TABLE OF CONTENTS
Q = 1.5 ml ; Q=0;
21 – 25 6 – 8 years
G = 250 ml G = 250 ml SUMARY ………………………………………….………………......…………………………….………9
Q = 1.8 ml ; Q=0; 1. INTRODUCTION………………………..........……….................……………………………13
26 – 30 8 – 10 years
G = 250 ml G = 300 ml
1.1. Epidemiology of malaria……………………...……………….………….…………..……13
Q = 2.1 ml ; Q=0;
31 – 35 10 – 11 years 2. OBJECTIVES OF THESE GUIDELINES………………...........................……….....…14
G = 300 ml G = 300 ml
Q = 2.1 ml ; Q=0; 3. HOW IS MALARIA DIAGNOSED? ........................................................................15
36 – 40 11 – 13 years
G = 300 ml G = 325 ml 4. HOW TO RECOGNIZE SEVERE MALARIA ………………………………….….........18
Q = 2.75 ml ; Q=0;
41 – 45 13 – 14 years 5. ALGORITHM FOR MALARIA CASE MANAGEMENT IN A HEALTH FACILITY
G = 300 ml G = 350 ml
Q = 3.1 ml ; Q=0; FROM A “FEVER” SYMPTOM……….........................…….....................…....20
46 – 50 14 – 15 years
G = 350 ml G = 375 ml 6. ALGORITHM FOR MALARIA CASE MANAGEMENT.........................……..22,23
Q = 3.4 ml ; Q=0; 6.1. First visit………………………………………...........................................……………….22
51 – 55 15 – 16 years
G = 400 ml G = 400 ml
6.2. Next visit………………………………………...............................……..….........………..23
Q = 3.7 ml ; Q=0;
56 – 60 ≥ 16 years 7. HOW TO TREAT UNCOMPLICATED MALARIA………….....…………..…………24
G = 400 ml G = 450 ml
Q = 3.9 ml ; Q=0; 7.1. Treatment of uncomplicated malaria in the general population.........24
> 60 ≥ 16 years
G = 450 ml G = 450 ml 7.1.1 Antimalaria medicines……………………………………………..………………….….24
7.1.2 Antipyretics / analgesics………………………………………………………..……….25
12.5 mg of quinine base = 0.1 ml of quinimax new 7.2. Treatment of Malaria in particular populations……………..…......……..….32
presentation. G = Glucose or Dextrose.
7.2.1. Pregnancy………………………………………..……………………………………..………32
*If there is a weighing machine available, it is preferable to
7.2.2 Persons living with HIV…………………………………..……….…....……….………..33
use the body weight which is more specific, and not the
7.2.3. Over weight persons…………………………………………..……………...……...……33
age.
If on the 3rd day, the patient is still comatose, reduce the 7.2.4. History of serious side effets from ASAQ…………………………….…......…...33
total quantity of infusions and tube-feed the patient to 7.2.5 Malnourish children…………………..………………………………...……..….……….33
provide the latter with calories. 8. How to treat severe malaria……………………………..……........................………35
8.1. Treatment of severe malaria in the general population…..……........…...35
8.1.1 First line treatment : Injectable artesunate…………………….........…..…….35
THE QUANTITIES OF SOLUTION PROVIDED HERE ARE
8.1.2 Second line: Treeatment with quinine……….……………………..…........…….36
ONLY INDICATIVE.
8.1.3 Third line : treatment with injectable artemether……………........……….37
IT IS UP TO THE PRESCRIBING PHYSICIAN TO MODIFY THESE
8.2 Treatment of malaria in pregnancy (severe malaria)………….…......……37
QUANTITIES OR TO PRESCRIBE OTHER SOLUTIONS DEPENDING
8.2.1 Treatment during the first trimester…………….…….……..……..….........……38
ON THE CLINICAL OUTLOOK OF THE PATIENT.
8.2.2 Treatment during the second and third trimester…..………………........…38

70
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL INTENDED FOR HEALTH PERSONNEL

8.2.3 Associated treatment…………………………………….………………………......……40

Appendix 9: 24 -HOUR TREATMENT OF SEVERE
9. HINTS ON CURATIVE TREATMENT OF MALARIA……………...……………..…43
MALARIA WITH QUINIMAX ®
10. PREVENTION OF MALARIA………….………………………………...………………....44
10.1 Chemoprevention……………………………………………….……….....…….………....44
Q = Quinimax; G = glucose (or Dextrose) 5% or
10.1.1 Intermittent preventive treatment(IPT) of Malaria in pregnancy….44
10% (+ electrolytes)
10.1.2 Chemoprophylaxis in Children age 03 to 59 month and new 0
subjects…………………..……………………………………………………….....................……....50
Weight of HOURS
10.2. Selective vector control…………..……………………………………….….........…….51 patient AGE of patient*
H0-H4 H8-H12 H4-H8 H12-H16
APPENDIX 0 (Kg)
H16-H20 H20-H24
Appendix 1 How to test for malaria with a rapid diagnostic test.….............54 Q = 0.2 ml ; Q=0;
3 ≤ 1 month
Appendix 2 Classification of the main antimalarials ............................……....54 G = 50 ml G = 50 ml
Q = 0.26 ml ; Q=0;
Appendix 3 Arthemeter 80mg/ml ..........................................................……….....54 4 1 – 2 months
G = 75 ml G = 50 ml
Appendix 4 Arthemeter 40mg/ml....……………...…....……………….………….....….60 Q = 0.32 ml ; Q=0;
5 2 – 3 months
Appendix 5 Arthemeter 20mg/ml.....…………………………………….……………......61 G = 100 ml G = 75 ml
Q = 0.4 ml ; Q=0;
Appendix 6 Detailed quinine administration regimen.…….……………......62 6 3 – 4 months
G = 100 ml G = 100 ml
Appendix 7 24-hours treatment of severe malaria with quinine 0 Q = 0.45 ml ; Q=0;
7 4 – 6 months
hydrochloride without a loading dose ....................................................................65 G = 100 ml G = 150 ml
Q = 0.5 ml ; Q=0;
Appendix 8 24-hours treatment of severe malaria with quinine 0 8 7 – 9 months
G = 150 ml G = 125 ml
hydrochloride with a loading dose............................................................................67 Q = 0.6 ml ; Q=0;
9 10 – 12 months
Appendix 9 24-hours treatment of severe malaria with quinimax..............69 G = 200 ml G = 100 ml
Q = 0.65 ml ; Q=0;
Appendix 10 Number of drops per minute to be run in a drip depending on 10 13 – 15 months
G = 200 ml G = 150 ml
quantity of fluids .........................................................…….……………...........................71 Q = 0.75 ml ; Q=0;
11 – 12 16 – 24 months
Appendix 11 Salt /base equivalence of the mind antimalarial drugs ..........72 G = 200 ml G = 150 ml
Q = 0.8 ml ; Q=0;
Appendix 12The use of injectable artesunate to treat severe malaria .72,74 13 – 14 2 – 3 years
G = 200 ml G = 200 ml
Q = 1.0 ml ; Q=0;
15 – 16 3 – 4 years
G = 200 ml G = 225 ml
Q = 1.1 ml ; Q=0;
17 – 18 4 – 5 years
G = 200 ml G = 225 ml
Q = 1.25 ml ; Q=0;
19 – 20 5 – 6 years
G = 250 ml G = 225 ml

69
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON INTENDED FOR HEALTH PERSONNEL
INTENDED FOR HEALTH PERSONNEL

7–9 Q = 0,52 ml ; Q = 0,26 ml ; G Q=0;

8 SUMMARY
months G = 150 ml = 150 ml G = 125 ml
Proper management of malaria requires early
10 – 12 Q = 0,60 ml ; Q = 0,30 ml ; G Q=0;
9
months G = 200 ml = 200 ml G = 100 ml diagnosis and prompt and effective treatment with
13 – 15 Q = 0,64 ml ; Q = 0,32 ml ; G Q=0;
antimalarial medications. Guidelines on the
10 diagnosis and appropriate treatment of malaria are
months G = 200 ml = 200 ml G = 150 ml
16 – 24 Q = 0,74 ml ; Q = 0,37 ml ; G Q=0; summarized in the table below:
11 – 12
months G = 200 ml = 200 ml G = 150 ml
2–3 Q = 0,88 ml ; Q = 0,44 ml ; G Q=0; Malaria Diagnosis
13 – 14
years G = 200 ml = 200 ml G = 200 ml • Systematic confirmatory diagnosis of all suspected cases
3–4 Q = 1 ml ; Q = 50 ml ; G = Q=0; of malaria should be done by a rapid diagnostic test (RDT)
15 – 16
years G = 200 ml 200 ml G = 225 ml
or good quality microscopy.
4–5 Q = 1,12 ml ; Q = 1,56 ml ; G Q=0;
17 – 18
years G = 200 ml = 200 ml G = 225 ml • RDTs are free of charge to children under five years and
5–6 Q = 1,26 ml ; Q = 1,63 ml ; G = Q=0; subsidized for the rest of the population.
19 – 20
years G = 250 ml 250 ml G = 225 ml Treatment of uncomplicated malaria
6–8 Q = 1,48 ml ; Q = 1,74 ml ; G = Q=0; • 1st line: Artesunate-amodiaquine (ASAQ).
21 – 25
years G = 250 ml 250 ml G = 250 ml
• 2nd line: Artemether-Lumefantrine (AL).
8 – 10 Q = 1,8ml ; Q = 1,9 ml ; G = Q=0;
26 – 30
years G = 250 ml 250 ml G = 300 ml
• Only solid or dispersible forms are recommended.
10 – 11 Q = 2,2 ml ; Q = 1,1 ml ; G = Q=0; • The artesunate-amodiaquine (ASAQ) is free for children
31 – 35
years G = 300 ml 300 ml G = 300 ml under five years and subsidized for the rest of the population.
11 – 13 Q = 2,4 ml ; Q = 1,2ml ; G = Q=0; • Antipyretic treatment is recommended for children under 5
36 – 40
years G = 300 ml 300 ml G = 325 ml
years.
13 – 14 Q = 2,8 ml ; Q = 1,4 ml ; G = Q=0;
41 – 45
years G = 300 ml 300 ml G = 350 ml Treatment of cases of clinical failure
14 – 15 Q = 3,2 ml ; Q = 1,6 ml ; G = Q=0;
In case of clinical failure, repeat the microscopy of
46 – 50
years G = 350 ml 350 ml G = 375 ml an RDT (pLDH).
51 – 55
15 – 16 Q = 3,4 ml ; Q = 1,7 ml ; G = Q=0; W hen positive:
years G = 400 ml 400 ml G = 400 ml - If ACT administration was poor, repeat ACT
≥ 16 Q = 3,8 ml ; Q = 1,9 ml ; G = Q=0;
56 – 60 administration.
years G = 400 ml 400 ml G = 450 ml
≥ 16 Q = 3,9 ml ; Q = 1,95 ml ; G Q=0;
- If ACT administration was good, repeat treatment
> 60 with another ACT.
years G = 450 ml = 450 ml G = 450 ml
- If negative: Look for another cause of fever and
treat appropriately.

9
68
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL

Treatment of severe malaria - pre-referral

If on the 3rd day, the patient is still comatose, reduce the total
treatment.
quantity of infusions and tube-feed the patient to provide the latter
• First line: First dose of artesunate injection with calories.
preferably intravenously.
T H E Q U AN T I T I E S O F S O L U T I O N P R O V I D E D H E R E A R E O N L Y
• Second line: quinine drips or intramuscular
I N D I C AT I V E .
artemether.
IT IS UP TO THE PRESCRIBING PHYSICIAN TO MODIFY THESE
Treatment of severe malaria QUANTITIES OR TO PRESCRIBE OTHER SOLUTIONS DEPENDING ON
Parenteral treatment for at 24 hours, followed by an THE CLINICAL OUTLOOK OF THE PATIENT.
oral treatment when the patient is able to eat and
drink.
Three types of treatment are available:
Appendix 8: 24 -HOUR-TRE ATMENT OF SEVERE
• First line: Artesunate injection, otherwise MALARI A WITH QUININE HYDROCHLORIDE WITH
A LO ADING DOSE.
• Second line: Injectable quinine or injectable
artemether Q = Quinine hydrochloride; G = glucose (OR
dextrose) 5% OR 10%
W hatever the option, continue with oral treatment as
HOURS
soon as patient can swallow, for seven days with WEIGHT AGE OF
OF Maintenance Keep vein
quinine (when treating with quinine) or for 3 days PATIENT
PATIEN
Loading Dose Dose open
with artemisinine based combination therapy (ACT) (Kg) T*
H 0-H4 H12-H16, H0-H4 H4-H12-H16
(artesunate-amodiaquine or artemether- H16-H24
≤1 Q = 0,2 ml ; Q = 0,1 ml ; G Q=0;
lumefantrine). 3
month G = 50 ml = 50 ml G = 50 ml
Treatment of malaria in pregnanc y 1–2 Q = 0,26 ml ; Q = 0,13 ml ; G Q=0;
Malaria in pregnancy is considered as severe 4
months G = 75 ml = 75 ml G = 50 ml
malaria and treated as such. 2–3 Q = 0,32ml ; Q = 0,16ml ; G Q=0;
5
First trimester: months G = 100 ml = 100 ml G = 70 ml
Quinine infusion for at least 24 hours followed by 3–4 Q = 0,40 ml ; Q = 0,2 ml ; G = Q=0;
6
months G = 100 ml 100 ml G = 100 ml
oral quinine for up to the 7th day. 4–6 Q = 0,46 ml ; Q = 0,23 ml ; G Q=0;
From the second trimester: 7
months G = 100 ml = 100 ml G = 150 ml
Refer to the treatment of severe malaria above.

10
67
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON INTENDED FOR HEALTH PERSONNEL
INTENDED FOR HEALTH PERSONNEL

W hen uterine contractions develop during treatment

Q = 0.37 ml ; Q=0;
11 – 12 16 – 24 months with quinine, it is recommended that tocolytics
G = 200 ml G = 150 ml
Q = 0.44 ml ; Q=0; (salbutamol) be associated.
13 – 14 2 – 3 years
G = 200 ml G = 200 ml Treatment of particular populations and in
15 – 16 3 – 4 years
Q = 0.50 ml ; Q=0; particular situations
G = 200 ml G = 225 ml • People living with HIV on ARV treatment (Efavirenz,
Q = 0.56 ml ; Q=0; Zidovudine): Avoid taking ASAQ to avoid hepatotoxicity.
17 – 18 4 – 5 years
G = 200 ml G = 225 ml
Instead take AL;
Q = 0.63 ml ; Q=0;
19 – 20 5 – 6 years • History of serious side effects with ASAQ (severe asthenia,
G = 250 ml G = 225 ml
Q = 0.74 ml ; Q=0; extrapyramidal syndrome, skin eruption, etc. take AL;
21 – 25 6 – 8 years
G = 250 ml G = 250 ml • Overweight persons: For fear of under-dosing there should
Q = 0.9 ml ; Q=0; be follow up of treatment outcome (clinical
26 – 30 8 – 10 years
G = 250 ml G = 300 ml
Q = 1.1 ml ; Q=0;
evaluation and eventually microscopy);
31 – 35 10 – 11 years • Malnourished Children: Preferably take AL.
G = 300 ml G = 300 ml
36 – 40 11 – 13 years
Q = 1.2 ml ; Q=0; Intermittent Preventive Treatment in Pregnanc y
G = 300 ml G = 325 ml (IPT)
Q = 1.4 ml ; Q=0;
41 – 45 13 – 14 years
G = 300 ml G = 350 ml • The pregnant woman must take four doses of Sulfadoxine-
Q = 1.6 ml ; Q=0;
46 – 50 14 – 15 years pyrimethamine as from the second trimester of pregnancy.
G = 350 ml G = 375 ml
Q = 1.7 ml ; Q=0; • The interval between two doses should be at least one
51 – 55 15 – 16 years month.
G = 400 ml G = 400 ml
Q = 1.9 ml ; G = Q=0; • The last dose of IPT can be taken even during childbirth.
56 – 60 ≥ 16 years
400 ml G = 450 ml • It is not recommended to administer SP together with folic
Q = 1.95 ml ; Q=0;
> 60 ≥ 16 years
G = 450 ml G = 450 ml
acid at doses > 5mg per day. This is because folic acid
decreases the effectiveness of the SP in malaria
12.5mg of quinine base = 0.45 ml of quinine prevention.
hydrochloride/chlorhydrate of quinine. G = Glucose or Dextrose • Pregnant women on cotrimoxazole should not take
*If there is a weighing machine available, it is preferable to use the SP.
body weight which is more specific, and not the age.

11
66
GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL

Appendix 7: 24–HOUR TREATMENT OF SEVERE

MALARIA WITH QUININE HYDROCHLORIDE WITHOUT A
LOADING DOSE

Q = Quinine hydrochloride; G = glucose (OR

dextrose) 5% OR 10%

12.5mg of quinine base = 0.45 ml of quinine

hydrochloride/chlorhydrate of quinine. G = Glucose or Dextrose

HOURS
WEIGHT
OF AGE OF
PATIENT PATIENT* Loading dose Keep vein open
(Kg) H0-H4 H8-H12 H4-H8 H12-H16
H16-H20 H20-H24
Q = 0.1 ml ; Q=0;
3 ≤ 1 month
G = 50 ml G = 50 ml
Q = 0.13 ml ; Q=0;
4 1 – 2 months
G = 75 ml G = 50 ml
Q = 0.16 ml ; Q=0;
5 2 – 3 months
G = 100 ml G = 70 ml
Q = 0.20 ml ; Q=0;
6 3 – 4 months
G = 100 ml G = 100 ml
Q = 0.23 ml ; Q=0;
7 4 – 6 months
G = 100 ml G = 150 ml
Q = 0.26 ml ; Q=0;
8 7 – 9 months
G = 150 ml G = 125 ml
Q = 0.30 ml ; Q=0;
9 10 – 12 months
G = 200 ml G = 100 ml
Q = 0.32 ml ; Q=0;
10 13 – 15 months
G = 200 ml G = 150 ml

12
65
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON INTENDED FOR HEALTH PERSONNEL
INTENDED FOR HEALTH PERSONNEL

Day 2 to day 7: Same regimen if the patient cannot take 1. INTRODUCTION

orally.
1.1. Epidemiology of malaria
Use 10% glucose in case of hypoglycaemia. Add
electrolytes to the drip. Watch out for any case of Malar ia remains a major public health problem in
diabetes. Cameroon. The country has three main epidemiological
If the quinine cannot be administered by infusion, zones, linked to geo-climatic variations: The sudano-
give it intramuscularly according to the regimen below sahelian zone (areas of the Far North and North
and refer the patient to the appropriate level of care. regions), the large savanna area of interior plateau
(Adamawa region) and the large equatorial forest of
INTRAMUSCULAR ROUTE the south (the remaining 7 regions of the southern
part of the country). The existing climatic conditions
are favorable for the development of the malaria
For intramuscular injections, it is recommended that the vectors and the parasites. Plasmodium falciparum is
chlorhydrate should be diluted in 0.9% normal saline at the the most common species plasmodium (95%),
concentration of 60mg/ml and half of the quantity injected in followed by P. malariae and P. oval.
the anterior surface of each lap.
To avoid abscesses, tetanus, hepatitis and HIV, use only In 2012, malaria was responsible for 31% of all
disposable injection material. cases of consultations and 46% of all
hospitalizations and is responsible for 19% of all
deaths occurring within the health facilities in the
SWITCH TO ORAL TREATMENT AS SOON AS POSSIBLE
country. Approximately, 40% of deaths in children
AND CONTINUE AT THE SAME DOSE TO THE SEVENTH
less than 5 years old are due to malaria (Rapport
DAY.
2012 du PNLP).
ORAL TREATMENT The management of uncomplicated malaria in
Start oral treatment as soon as the patient feels better: health facilities has improved in recent years thanks
8mg/kg Quinine base or 10mg/kg Quinine salt every 8hours for to the increased accessibility of ACTs. However,
7 days or with an artémisinine based combination therapy ACT diagnosis and treatment of severe malaria still
(artesunate-amodiaquine or artemether-lumefantrine) for three requires improvement.
days.
All forms of quinine, injectable or oral
Should be used taking into consideration the
quantity of quinine base in the tablet or vial.

13
64
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL

2. OBJECTIVES OF THESE GUIDELINES H 4 to H 12: Glucose 5 % or 10% only (+ electrolytes);

H 12 to H 16: 8.3 mg/kg of quinine base in 5 % or 10%
• This document seeks to review the following six (6) glucose (+ electrolytes);
questions: H 16 to H 24: Glucose 5 % or 10% only (+ electrolytes).
• How is malaria diagnosed?
Maintenance treatment: From day 2 right to the day that the
• How is uncomplicated malaria differentiated from patient can take oral treatment.
severe malaria?
• How is uncomplicated malaria treated? H 0 to H 4: 10 mg / kg of quinine in 5 % or 10% glucose (+
electrolytes) without exceeding 600mg of quinine;
• How is severe malaria treated?
H 4 to H 12: Glucose 5 % or 10% only (+ electrolytes);
• What are the different drugs to be administered and in H 12 to H 16: 10 mg / kg of quinine salt in 5 % or 10% glucose
what doses? (+ electrolytes) without exceeding 600mg of quinine;
H 16 to H 24: Glucose (+ electrolytes).
• What preventive measures should be recommended?
Fever is the most common symptom of malaria and Regimen 2
the most reliable criterion in the diagnosis,
treatment, and follow-up of malaria. About 80% of No loading dose
fever cases are first treated as malaria within the
communities. Day 1:
Parasitological diagnosis of malaria is based on the
identification of plasmodium using a rapid diagnostic H 0 to H 4: 8 mg/kg of quinine base in 5% or 10% glucose +
test (RDT) or a microscope either on a blood film electrolytes;
and/or a thick blood smear. H 4 to H 8: glucose 5% or 10 % only (+ electrolytes);
H 8 to H 12: 8 mg/kg of quinine base in 5% or 10% glucose +
Malaria RDTs detect specific antigens electrolytes;
(proteins) produced by malaria parasites. These H 12 to H 16: glucose 5% or 10 % only (+ electrolytes);
antigens are thus present in blood of infected H 16 to H 20: 8 mg/kg of quinine base in 5% or 10% glucose +
persons, whether the person is symptomatic or not. electrolytes;
Good quality microscopy is the diagnostic test of H 20 to H 24: glucose 5% or 10 % only (+ electrolytes);
reference for malaria, when a well-trained laboratory
technician and well equipped laboratory are
available. RDTs are another acceptable diagnostic
test and are easier and much quicker to perform and
have good sensitivity and specificity.

14
63
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON INTENDED FOR HEALTH PERSONNEL
INTENDED FOR HEALTH PERSONNEL

RDTs are available in all health facilities

31 to 35 10 to 11 5.3 ml 2.65 ml through the regional drug supply units (CAPRs).
years
Only in the absence of an RDT or a laboratory
36 to 40 11 to 13 6 ml 3 ml
should treatment be initiated without diagnosis first,
years
however, this must be predicated by a systematic
41 to 45 13 to 14 7 ml 3.5 ml
years
exploration for other causes of fever.
46 to 50 14 to 15 8 ml 4 ml Healthcare personnel are confronted with
years cases of malaria at different stages of severity. It is
51 to 55 15 to 16 8.5 ml 4.25 ml up to them to order an urgent treatment procedure if
years the malaria case is considered severe and to refer
56 and above ≥ 16 10 ml 5 ml complicated cases to an appropriate level of care as
soon as possible and under the best possible
conditions.
*If there is a weighing machine available, it is preferable to use the
body weight which is more specific, and not the age. Prevention is an indispensable stage in the
**The small doses of the artemether should be measured with a 1 ml management of malaria.
syringe (vaccination or insulin syringe).

3. HOW IS MALARIA DIAGNOSED?

Fever or a history of fever is the most common

Appendix 6: DETAILED QUININE symptom of malaria. It can be reported by the patient or the
ADMINISTRATION REGIMEN parents/caregivers of a child (even if the temperature is normal
at the time of examination) or ascertained by taking the
temperature (higher or equal to 37°C under the armpit or
INTRAVENOUS ROUTE (INFUSION)
37.5°C rectally).
Intravenous (infusion) administration of quinine has to
It should be noted that the cause of fever should be
follow the following regimens:
sought thorough clinical examination, followed by a
parasitological test for malaria. All fever cases should be
Regimen 1:
tested parasitologically for malaria, even if the fever is thought
to be from another cause.
Loading Dose:

H 0 to H 4: 16.6mg/ kg of quinine base in 5% or 10% glucose

(+ electrolytes) without exceeding 1G of quinine base.

15
62
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL

Table 1 presents the most frequent causes of fever that

should be ascertained during collection of the patient history 51 to 55 15 to 16 4.25 ml 2.12 ml
with the patient or his/her family and by a simple test: years
56 and above ≥ 16 5 ml 2.5 ml
Table I: Signs and symptoms of the causes of fever to be
sought at first contact with a febrile patient
SIGNS AND SYMPTOMS THINK OF : *If there is a weighing machine available, it is preferable to use the
body weight which is more specific, and not the age.
Stiff neck **The artemether should be measured with a 1 ml syringe
MENINGITIS*
Bulging fontanel (young infant) (vaccination or insulin syringe).
Runny nostrils COMMON
Cough COLD*
Cough,
Fast breathing PNEUMONIA* Appendix 5: ARTEMETHER 20MG/ml
Chest in-drawing (sub-costal, intercostal…) 1 vial of 1ml = 20 mg
Spontaneous pain in the ear
Pain with pressure on the tragus OTITIS*
Discharging ear
Weight of
Pain in the throat 1ST DAY: IN 2ND TO 7TH DAY: IN
TONSILLITIS patient AGE *
Red inflamed throat with or without whitish spots TWO DOSES ONE DOSE
(sore throat)* (Kg)
Painful cervical lymph nodes
Colicky pains, Diarrhoea (bloody or not) 3 to 4 1 – 2 months 0.64 ml 0.28ml
GASTRO-
Vomiting ENTERITIS
5 to 7 3 – 6 months 1 ml 0.5 ml
Prolonged fever not responding to appropriate
antimalarial treatment. TYPHOID
8 to 10 7 – 11 1.5 ml 0.72 ml
Dissociation between the pulse rate and FEVER‡
months
temperature
11 to 15 1 to 3 years 2 ml 1 ml
Abdominal pains URINARY
Pains (burns) on micturition, Turbid urine INFECTION* 16 to 20 4 – 6 years 3 ml 1.5 ml
Many cases in the neighbourhood
n pox) etc.…
Characteristic skin rash 21 to 25 7 to 8 years 4 ml 2 ml

Bilateral or unilateral swelling behind the jaw MUMPS 26 to 30 9 to 10 years 4.5 ml 2.25 ml

Functional impotence, local inflammation of a OSTEO-

ARTHRITIS
16
61
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON INTENDED FOR HEALTH PERSONNEL
INTENDED FOR HEALTH PERSONNEL

limp
**The artemether should be measured with a 1 ml syringe
(vaccination or insulin syringe). Fever resistant to appropriate treatment
SEPTICAEMIA
Altered general physical state
Icterus (jaundice), Enlarged spleen
HEPATITIS
Right hypochochondrial pain
Appendix 4: ARTEMETHER 40mg/ml * Refer to the appropriate algorithms
1 vial of 1ml = 40 mg If any of the above diseases is diagnosed, it should be treated
appropriately while keeping in mind that the patient could
ST ND TH
Weight of 1 DAY: 2 TO 7 DAY: always still be coninfected with malaria.
AGE *
patient (Kg) IN TWO DOSES IN ONE DOSE
Therefore in all cases of fever, malaria should be
3 to 4 1 – 2 months 0.28ml 0.14 ml suspected and a confirmatory test (rdt or microscopy)
performed.
5 to 7 3 – 6 months 0.5 ml 0.24 ml
If the test is negative, look for another cause of the fever
8 to 10 7 – 11 0.72 ml 0.36 ml and if found treat it appropriately.
months
If the test is positive, grade the case as either
11 to 15 1 to 3 years 1 ml 0.5 ml uncomplicated or severe malaria
16 to 20 4 – 6 years 1.5 ml 0.72 ml For management of fever, see algorithms on pages 13
and 14.
21 to 25 7 to 8 years 2 ml 1 ml

26 to 30 9 to 10 years 2.25 ml 1.12 ml WHAT IS UNCOMPLICATED MALARIA?

31 to 35 10 to 11 2.65 ml 1.32 ml In uncomplicated malaria, the patient does not present any
years signs of severity. In addition to fever, the uncomplicated
36 to 40 11 to 13 3 ml 1.52 ml malaria may present with the following main symptoms:
years - Chills / shivering
41 to 45 13 to 14 3.5 ml 1.72 ml - Headache
years - Body aches
46 to 50 14 to 15 4 ml 2 ml - Joint pain
years
- Abdominal pain in the child

17
60
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL

- Digestive disorders (loss of appetite, diarrhea, nausea,

vomiting). APPENDIX 3: ARTEMETHER 80mg/ml
1 vial of 1ml = 80 mg
WHAT IS SEVERE MALARIA?
In severe malaria, the patient presents with one or more signs
Weight of 2ND TO 7TH DAY:
of severity (table 2, page 11). 1ST DAY: IN TWO
patient AGE * IN ONE DOSE (1.6
DOSES (3.2MG/KG)
4. HOW TO RECOGNIZE SEVERE MALARIA (Kg) MG/KG)
3 to 4 1 – 2 months 0.14ml 0.07 ml
Once malaria has been diagnosed, the presence of one or
more of the following symptoms indicates a severe case. 5 to 7 3 – 6 months 0.24 ml 0.12 ml

8 to 10 7 – 11 months 0.36 ml 0.18 ml

Table II: Signs of severe malaria
11 to 15 1 to 3 years 0.5 ml 0.25 ml
CO NS C IOU S N E S S D I S O RD E RS ( Irr i ta b il it y , c o nf u si o n,
d el ir iu m, o bn ub i la t i on , d r o ws i nes s, c o ma ). 16 to 20 4 – 6 years 0.72 ml 0.36 ml
CO NV U L S IO N CR IS E S
21 to 25 7 to 8 years 1 ml 0.5 ml
A CU TE RE S P I RA T OR Y D IS TR E S S ( s upe rf i cia l br ea t h in g,
ra pi d br ea t h in g, c he st in d ra w in g …) . 26 to 30 9 to 10 years 1.12 ml 0.55 ml
RE P E A T E D V O M I T IN G ( Hi nd eri n g ora l trea tm e nt).
31 to 35 10 to 11 years 1.32 ml 0.65 ml
DE H YD RA T I ON ( T h i rst y, d r y li ps, s u nk en eye s,
d epre s sed f o n ta nel , pe rsi s te nt a bd o mi na l sk i n p i nc h, 36 to 40 11 to 13 years 1.52 ml 0.75 ml
a bse n ce of tea r s i n c hi ld re n) .
41 to 45 13 to 14 years 1.72 ml 0.85 ml
S E V E R E A NA E M IA ( p a ll or of t he pa l m s, pla nta r a nd
co n ju n ct iva , ha em o g lo bi n lev el < 5 g /d l or 46 to 50 14 to 15 ears 2 ml 1 ml
Ha e ma t o cri t <1 5 % ) .
H YP OG L YCA E M IA < 4 0 mg/ d l or 2 .2 m mo l / l . 51 to 55 15 to 16 years 2.12 ml 1.06 ml
IC TE RU S ( J a un d i ce) .
56 and ≥ 16 2.5 ml 1.2 ml
A B N OR MA L B L E E D I N G ( a t i n j e ct i on si t e , n ose b l e e d i n g above
or b l e e d i n g o f t h e gu m, e t c.) . *If there is a weighing machine available, it is preferable to use the
body weight which is more specific, and not the age.

18
59
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON INTENDED FOR HEALTH PERSONNEL
INTENDED FOR HEALTH PERSONNEL

BL A CK U R IN E o r « C OCA - C OL A U R I NE » ( ma ss iv e
Appendix 2: CLASSIFICATION OF THE MAIN Ha e m og l ob i nur ia ) ,
ANTIMALARIALS
E X T RE ME FA TI GU E ( Th e pa ti en t is u na b le to s it up o r
sta nd up ) ,
A BS E N T O R R A RE U RI NE ( A c ute k id ne y f a il ure) ,
SCHIZONTICIDES
CL IN I CA L A C ID OS IS ( De ep a nd a m pl e re sp ira t i o n) ,

H IG H TE MP E RA TU R E > 4 0 º C ( r ec ta l) or 3 9 . 5 °C ( a xi lla ry ) ,
NATURAL ANTIMALARIALS
S H OCK ( l o w bl o od p res su re, ra p id a nd t hr ea d y pu l se a nd
co ld e xt re mi ti es) ,
Cinchona alkaloids: Quinine, Quinidine, Cinchonine
Bi ol o gi ca l si gn s o f se ve re ma l a ri a
Qinghaosu (Artemisia) derivatives : Artemether, Artesunate
- Hy p o cl y ca e mi a ( Gl yca em ia <4 0 mg /d l or g ly ca em ia
<2 .2 m m ol / l) ;
SYNTHETIC ANTIMALARIALS - Me t a b ol i c a ci d osi s ( S eru m bi ca rb o na t es <1 5 m m ol / l) ;
- S e ve re a n a e mi a ( Hb <5 g /d l o r H e ma t oc ri te < 1 5 % ) ;
Amino-4-quinolines: Chloroquine, Amodiaquine,
- Ha e m o gl u b i n u r i a ;
Amopyroquine
- Hy p e r p a ra si t a e mi a ( p a ra s ita e m ia >5 % of r ed bl o od
Aryl-Amino-alcohols : Mefloquine, Halofantrin
cel ls o r >2 5 0 ,0 0 0 /μ l) ;
Antifolics and Antifolinics : Sulfonamides, Sulfones,
- S e ru m l a ct a t e ( la cta te >5 m mo l /l ) ;
Pyrimethamine, Proguanil and Chlorproguanil, Atovaquone
- K i d n e y fa i l u re ( s er um crea ti n in e >2 6 5 μ m ol / l) .
Antibiotics and others : Cyclines, Macrolides,
Fluoroquinolones, Hydroxynaphtoquinones
Any patient with any of the symptoms of
severe malaria should be immediately
GAMETOCIDES administered an initial dose of injectable
artesunate. Alternatively, injectable quinine or
injectable artemether can be administered and if
Amino-8-quinolines : Primaquine, tafenoquine necessary the patient should be referred to a
higher level of care as soon as possible.

IN PREGNANCY: All confirmed cases of malaria (with RDT

or microscopy) in a pregnant woman should be
considered as severe malaria.

19
58
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL

NEW SUBJECTS COMING INTO A MALARIA ENDEMIC

ZONE: All new subjects coming into a malaria endemic Step 7 Take a sample pipette
zone with confirmed malaria and symptoms of sever provided, and while
malaria should be treated as such, otherwise treat as gently squeezing the
uncomplicated malaria. tube, immerse the open
end in the blood drop
and then gently release
5. ALGORITHM FOR MALARIA CASE the pressure to draw
MANAGEMENT IN A HEALTH FACILITY FROM blood into the sample
A “FEVER” SYMPTOM pipette up to the black
line.
1. Fever may be present (temperature equal to or above
37.5°C rectally or 37°C axillary) when the patient is NB: Never set the
examined or revealed during the patient history. Fever can lancet down before
also be ascertained by a warm body to touch. discarding it.
Never discard the
2. Look for signs of severe malaria. lancet in a non-sharps
container.
2.1. In case of one or more signs of severe malaria Never use a lancet on
more than one
- At the Health Centre: Perform an RDT or microscopy. person.
- If test is positive, administer first dose of injectable
artesunate, preferably intravenously, otherwise Step 8 Hold the RDT flat on the table top with one
intramuscularly. Alternatively, administer injectable Test hand. With your other hand, carefully add (5µl)
quinine or injectable artemether then refer procedure of whole blood from the pipette into the Sample
immediately.
well (small well).
- If test is negative, observe algorithm of IMCI –
PCIME or refer immediately. Discard the pipette in the sharps container.
- In the Hospital: Perform an RDT or microscopy Add two drops of assay buffer into the buffer
- In case the test is positive, administer injectable well. Hold buffer vertically.
artesunate, preferably intravenously, otherwise Check the time or begin a stop watch. Read the
intramuscularly. Alternatively, administer injectable test result in 20 min. Do not read the test before
quinine or injectable artemether. or after the 20 minutes. You may get false
- If both tests are negative, look for another cause of results.
the fever and treat accordingly. In case of doubt,
repeat test, preferably during a fever peak.
20
57
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON INTENDED FOR HEALTH PERSONNEL
INTENDED FOR HEALTH PERSONNEL

2.2. If there is no sign of severe malaria, do an RDT or

For infants < 5 kg prick microscopy.
the heel
For infants 5-10 kg - If test is positive, treat as uncomplicated malaria with
prick the big toe ASAQ or AL, and look for any other cause of fever
For children > 10 kg and treat accordingly.
prick the finger. - If test is negative, look for other causes of fever and
treat accordingly. When in doubt or with temperature
Squeeze the tip of the spikes, repeat the test.
finger with your own
fingers and prick the NB: Never treat for malaria when the malaria test is
outside of the fleshy negative.
part. This is less painful 3. Re-evaluate patient at least 48 hours later, or if patient’s
Step 6 (a) than pricking in the condition worsens.
middle or at the tip.
4. In case of improvement, continue treatment to
Prick once hard enough
completion.
so that a drop of blood
quickly appears on the 5. In case of persistence of fever or recurrence 48 hours
skin. after initial treatment,
- Re-evaluate the patient and look for signs of severe
Discard the lancet in
the sharps box malaria;
immediately after - Hospitalize or refer to a higher facility if necessary;
pricking finger. - Re-perform RDT (pLDH) or microscopy.
Wipe away the first
Step 6 (b) drop of blood with 5.1. - If test is positive, inquire about current treatment (how
sterile gauze or cotton. effective is current treatment; dose, quality of
Apply gentle pressure medication, duration of treatment etc?),
to the finger until a new - If treatment is poorly administered, re-administer in
blood drop appears. correct dosage (ACT for uncomplicated malaria and injectable
artesunate / quinine / artemether for severe malaria),
- If treatment is correctly administered, re-perform the
test using microscopy. For patients that have initiated
antimalarial treatment, an RDT can appear as a false positive.
These patients should only be diagnosed using microscopy.

21
56
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL INTENDED FOR HEALTH PERSONNEL

5.2. If test is negative, look for cause of fever and treat the RDT may give a false result).
accordingly, otherwise refer patient if necessary. W rite the patient’s name and or OPD
6. ALGORITHM FOR MALARIA CASE MANAGEMENT number on the cassette. (Pencil works
6.1. First visit best for writing on the RDT)
Open the alcohol

Positive
swab.
then refer
treatment
malaria

microscopy
Start
Ask if the patient is

RDT or

Center
Health
right-handed or
Négative left-handed (W hat
is this result?
Refer

If right-handed,

YES
Step 5 use the left hand).
Négative
malaria febrile

Hospitalization
a) Specimen W ith the palm
Severe non -
management

appropriately
illness. treat
of childhood

(see IMCI-
Antibiotics
Integrated
illnesses)

microscopy

HOSPITAL
collection upwards; select the
RDT or

using a fourth finger (ring)

Positive

preferably, or the
lancet
for severe
malaria

fifth finger,

Fever or history
Treat

Clean with an
of fever
Danger
Signs

alcohol swab and

allow it to dry.
Positive
uncomplicated

NB: The thumb or

Treat for

index finger
should not be
in case danger signs occur.

microscopy
Do RDT or

All Health
facilities
Review after two days

Ask patient to return

used. The fourth

NO
if fever persists

finger is chosen
because it is the
and treat accordingly

Négative
causes of fever
look for others

least used finger

Not malaria

and will cause the

least
inconvenience to
the patient).

55
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL INTENDED FOR HEALTH PERSONNEL

6.2. NEXT VISIT

Appendix 1: HOW TO TEST FOR MALARIA WITH A RAPID
DIAGNOSTIC TEST

NO
Immédiate
referral
Step 1 Preferably this should be a designated, well lit

microscopy
Do RDT or
Organize space, with a washable surface (can be

Center
Health
your plastic table cloth) with sufficient space to

malaria treatment
place all test kit components, sharps box and

Administer first
- Look for others causes
- Change treatment (ACT)

dose then refer

workspace.

appropriately
of fever & treat

YES
non-sharps waste bin and registry book.

Treatment failure
Step 2

YES
NEW unopened cassette test packet
Ensure you NEW pipette

visit to health facility

Positive

Procede as in first
have the

Hospitalization
NEW unopened alcohol swab
following

Hospital
NEW unopened lancet
materials

Do RDT or microscopy
before you NEW pair of disposable gloves

YES
Buffer

- Look for others causes for fever &

- Do not administer antimalarials
- Malaria cured
- Another febrile illness
begin the

treat appropriately

Danger Signs
test: Timer or clock

YES
Sharps container

Négative

Received malaria treatment

whitin last two weeks
Non-sharps waste container

Positive

facility after malaria treatment

Step 3 Prior to performing the test to ensure

Review visit to the health

Persitence or recurence
Review the you are familiar with the instructions.

during first visit to health facility

initial résult of malaria test
instructions Explain to the patient what the test is

- add any others needed treatment

- Look for others causes of fever &
- Treat appropriately for malaria

of fever
in the box, for and the procedure.

All health
facilities
or national Check expiration date on the packet.

NO
uncomplicated malaria

NO
RDT SOP An expired RDT may give a false
result.

Look for others causes of fever &

Put on a pair of gloves (Use a new

No malaria treatment.
treat appropriately

treatment with ACT

pair for each patient).

Complete malaria

any malaria test

Do not perform
Négative
Open the packet and remove the test

NO
cassette. (Note: Do not open an RDT
Step 4 packet until you are ready to use it for
Puton a patient. If a packet has been open
gloves for some time before the RDT is used,

54
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL INTENDED FOR HEALTH PERSONNEL

7. HOW TO TREAT UNCOMPLICATED MALARIA

7.1. Treatment of uncomplicated malaria in the general ‛

population

The treatment of uncomplicated malaria consists of the use of

a combination of two antimalarial medicines one of which is -
always an artemisinine derivative. In Cameroon, the two
combinations retained are: amodiaquine + artesunate (AS-
AQ) and artemether + lumefantrine (AL). These combinations
are known by the name ACT (Artemisinine-based Combination
Therapy). They are administered by the oral route with an
antipyretic.

7.1.1. Antimalarial medicines:

7.1.1.1. The Amodiaquine + Artesunate Combination
The fixed dose combination is the only recommended
formulation in Cameroon. It should be administered as a daily In Cameroon, the insecticide treated bed nets are distributed
single dose for 3 consecutive days. It should be taken with free of charge to the entire population during mass distribution
food to encourage tolerance. The paediatric formulations are campaigns and to pregnant women during antenatal
breakable or dispersible. consultations (ANC)
There are four presentations of the fixed combination:

A blister of 3 tablets, each containing 25mg of artesunate + 67,

5mg of amodiaquine
A blister of 3 tablets, each containing 50mg of artesunate +
135mg of amodiaquine
A blister of 3 tablets, each containing 100mg of artesunate +
270mg of amodiaquine,
A blister of 6 tablets, each containing 100mg of artesunate +
270mg of amodiaquine.

24 53
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL INTENDED FOR HEALTH PERSONNEL

against the vectors of disease. It aims at reducing malaria- Table III: Dosage of fixed dose combination AS-AQ according
related morbidity and mortality by preventing transmission. to age and body weight
Vector control involves individual and collective protective Weight
measures. of
AGE
patient PRESENTATION Day 1 Day 2 Day 3
(Kg)
1. Individual protective measures
Artesunate +
There are many individual protective measures but that ≥4,5 2 – 11 amodiaquine
which has a high cost-effective ratio is the long lasting à <9 months 25mg/67,5mg
insecticide treated bed net (LLIN). An LLIN is a special blister of 3 tablets
net that is treated with an insecticide that kills and Artesunate +
repels mosquitoes without danger to man. ≥9 à 1–5 amodiaquine
For the bed net to give optimal protection, it must follow <18 years 50mg/135mg
blister of 3 tablets
certain conditions:
• It should not be perforated; Artesunate +
• It should be properly tucked around the bed at ≥18 à < 6 – 13 amodiaquine
36 years 100mg/270mg
bedtime. blister of 3 tablets
• It should withstand washing with simple laundry
Artesunate +
soap for a maximum of 20 times without losing its 14 years
amodiaquine
insecticidal properties. ≥ 36 and
100mg/270mg
above
• It should be slept under every night. blister of 6 tablets

7.1.1.2. The Artemether + Lumefantrine (AL)

2. Collective protective measures Combination
Among these measures which include environmental
management, using wire screens on windows and The tablet form is the only form recommended for use and
doors, treatment of curtains, in-door residual spraying, distributed in Cameroon.
larviciding…), in-door residual spraying (IRS) is the This is a fixed combination with each tablet containing 20mg of
method that has a direct impact on the reduction of the artemether and 120mg of lumefantrine. The maximum daily
transmission of malaria. The insecticides used during dose must not exceed 8 tablets per day in an adult.
IRS and the spraying cycle vary in function of the The paediatric tablets are breakable and dispersible.
epidemiological facies. AL should be taken with a lipid rich diet.

52 25
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL INTENDED FOR HEALTH PERSONNEL

Dosage: during the stay and for 4 weeks after returning from
Artemether: 4mg/kg per day in 2 administrations for 3 days. a malaria endemic area.
Lumefantrine: 24 mg/kg per day in 2 administrations for 3
days. NOTE: This medicine is contraindicated in infants less than one
year and weighing less than 11Kg.
Table IV: Dosage AL fixed dose combination according to age and
Due to the unavailability of the syrup or contraindication of
body weight.
certain medications in infants, erythromycin (50 mg / kg / day)
► DOSE OF ARTEMETHER – LUMEFANTRINE 20MG/120MG
could be used. This should be taken throughout during the
Weight of
stay in a malaria endemic area and for 4 weeks after return.
Day 2 : two
Patient AGE Day 1 : two doses Day 3 : two doses
doses
(Kg)
H0 H8
(Immedi (8 hours
Morni
Evening Morning Evening
In adults
ng
ately) later) - Atovaquone - proguanil 250 mg (Malarone)
Less than ¾
5 Kg
¾ tablet ¾ tablet
table
¾ tablet ¾ tablet ¾ tablet - 1 tablet per day,
1 month Started the day before or the day of departure.
5 to < 15 –2 Taken throughout during the whole stay and
years
continued for 4 weeks after return.
15 to < 3–8
25 years - Doxycycline (doxycycline monohydrate) 100mg daily in
patients over 40Kg and 50mg per day for patients less than
40Kg body weight, starting the day before departure. It
should be taken during the whole stay and for 4 weeks after
25 to < 9 – 11
35 years return from a malaria endemic area.
Doxycycline is contraindicated in children less than 8 years.

N.B : Malarone and doxycycline are contraindicated in

pregnancy.
35 and >11
above years
10.2. SELECTIVE VECTOR CONTROL

Definition: Selective vector control is the application of

targeted and efficient control methods, adapted to each site

26 51
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL INTENDED FOR HEALTH PERSONNEL

• Elements of pharmacovigilance should be introduced in 7.1.2. Antipyretics / analgesics

the monitoring and evaluation process at all levels.
Indication: - Temperature ≥ 38.5ºC or pain
10.1.2. CHEMOPROPHYLAXIS IN CHILDREN The f ollowing medications are recom mended f or the
symptomat ic treatment of f ever and pain, particularly in
AGED 03 TO 59 MONTHS AND NEW SUBJECTS
children less than 5 years.
10.1.2.1. Chemoprevention in children aged 03
7.1.2.1. Paracetamol (oral or rectal)
to 59 months 60 mg/kg in 4 divided doses (6 hourly), maximum dose
of 3g/day in adults.
For children aged 03 to 12 months 7.1.2.2. Acetyl-salicylic acid (oral)
• Sulfadoxine-pyrimethamine + Amodiaquine 50 mg/kg /day in 4 divided doses (six hourly), maximum
(SP+ AQ 250/12,5mg + 75 mg) dose of 3g/day in adults.
Day 1 : 1 tablet of SP and 1 tablet of AQ,
Day 2 : 1 tablet of AQ, 7.1.2.3. Ibuprofene (Oral)
Day 3 : 1 tablet of AQ. 25 g/kg per day in 4 doses (6 hourly); maximum dose of
1.5g/day in adults.
For children aged 13 to 59 months
• Sulfadoxine-pyrimethamine + Amodiaquine Dosage of Paracetamol
(SP+ AQ 500/25mg + 153 mg)
Day 1 : 1 tablet of SP and 1 tablet of AQ, a. Tablets of 100mg
Day 2 : 1 tablet of AQ,
Day 3 : 1 tablet of AQ. The recommended dose for children is the 100mg tablet.

Dosage is according to age and body weight.

10.1.2.2. Chemoprophylaxis in new subjects If a scale balance is available, it is preferable to use body
weight in dose calculation than age.
In children
- Atovaquone - proguanil 250 mg (Malarone)
- 1 to 4 years: 1/4 tablet per day,
- 5 to 10 years: ½ tablet per day,
- 10 years and above: 1 tablet per day.
Start treatment the day before or the travelling day.
Prophylactic treatment should be taken throughout

50 27
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL INTENDED FOR HEALTH PERSONNEL

Table V: Dosage of 100mg paracetamol Follow up and implementation committees need to establish a
team whose role will be to develop a proper communication
DOSE OF PARACETAMOL 100MG strategy based on findings of a situation analysis. The most
Weight
of appropriate tools and techniques of communication should be
AGE used.
Patient Day 1 : in Day 2 : in 4 Day 3 : in 4
(Kg) 4 doses doses doses
Target groups are pregnant women, health workers,
1–2 administrative, religious, political and traditional leaders,
3-4 members of dialogue structures, traditional birth attendants,
months
traditional healers etc.
3–6
5-7
months x. Supervision, monitoring and evaluation

a. Data Collection
7 – 11 Routine data collection registers for antenatal clinics and
8 - 10 laboratories will be adapted to allow the monitoring and
months
evaluation of these guidelines. Implementation of guidelines
will be supervised, monitored, and evaluated by the monitoring
committees at various levels of the health pyramid.
1–3 Coordination will be primarily by the Central technical group /
11 - 15
years National Roll Back Malaria Committee and Family Health Unit
of the Ministry of Health. .
Timely evaluation surveys will be conducted to give an
overview of the situation.
b. Institution of a pharmacovigilance system
4–6
16 - 20 • Forms for data collection of adverse reactions to SP
years
should be provided to managers of ANC clinics.
• These health care providers should be trained to fill
these reporting forms.

28 49
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL INTENDED FOR HEALTH PERSONNEL

vi. What to do in case of contraindication to SP b. Tablets of 500mg

In cases of contraindications to SP, the alternative is the
association chloroquine-proguanil (Savarine ®) at a daily dose The 500mg tablets is primarily indicated for adults. However in
the absence of the 100mg tablets, the 500mg tablets can be
of one tablet from the second trimester to term. The cost of this
used for children.
medication is however an important limitation, the risk of an
allergy should also be considered. In extreme cases, we may
use the amodiaquine curative dose (35mg/kg spread over 03 Table VI: Dosage of 500mg paracetamol
days) once every trimester as from the second trimester.
Remember that this molecule is poorly tolerated. Weight
of
AGE Day 1 : in 4 Day 2 : in 4 Day 3 : in 4
Patient
vii. Advice to the pregnant woman doses doses doses
(Kg)
This should focus on the following:
1–2
• The benefits of effective IPT; 3-4
months
• Possible side effects of treatment;
• The need for the use of insecticide-treated nets; 3–6
• The importance of antenatal consultations. 5-7
months

viii. Procurement and stock management of SP 7 – 11

Management of SP stocks is integrated into the existing 8 - 10
months
essential medicines distribution system of CENAME. Stock
supplies to health facilities are made by CENAME through the 1–3
11 - 15
regional essential drug units, under the coordination of Central years
technical group / National Roll Back Malaria Committee. The
SP is free of charge. 4–6
16 - 20
Pregnant women receive their dose of SP free of charge in years
the presence of the health personnel, irrespective of whether
7–8
they have eaten or not. 21 - 25
years
ix. Behaviour Change Communication (BCC)
The role of the community health workers is crucial for home 9 – 10
26 - 30
years
visits because they guide pregnant women to health facilities
for ANC.

48 29
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL INTENDED FOR HEALTH PERSONNEL

iii. Place and mode of utilization of IPT

10 – 11
31 - 35 • It is recommended to administer the IPT under
years
direct observation of the nursing staff (Directly
11 – 13 Observed Therapy (DOT)).
36 - 40
years
• SP can be administered to a pregnant woman on
an empty stomach or after meals.
13 – 14 iv. Periodicity of treatment
41 - 45
years
• To improve the coverage of IPT in pregnant
women we need to ensure that every ANC
opportunity is used to administer the IPT in the
second trimester (ie, from the 16th week of
14 – 15 pregnancy or from perception of the 1st fetal
46 - 50 active movements). Note that in general, the first
years
dose of IPT should be administered as soon as
possible during the second trimester of
pregnancy.
• A pregnant woman should take four IPT
15 – 16
51 - 55 treatments.
years
• The interval between doses should be at least
one month.
• The last dose of IPT can be administered even at
56 and ≥ 16
over years the time of delivery.

v. Precautions for use of IPT

Dosage of Acetyl Salicylic Acid Administration of SP together with folic acid at doses greater
than 5mg per day is not recommended. This is because folic
a. Tablets of 500mg
Dosage is according to age and body weight. If a scale acid reduces the effectiveness of the SP in the prevention of
balance is available, it is preferable to use body weight in dose malaria. SP should not be administered to pregnant women
calculation than age. receiving cotrimoxazole prophylaxis.

30 47
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL INTENDED FOR HEALTH PERSONNEL

iv. Contraindications Table VII: Dosage of 500mg Acetyl Salicylic Acid

• First trimester pregnancy,
• Known allergy to sulphonamides, Weight
• Severe liver disease, of
AGE
Patient Day 1 : in 4 Day 2 : in Day 3 : in
• Renal failure,
(Kg) doses 4 doses 4 doses
• History allergic skin disease.
1–2
C- How to administer IPT in health facilities 3-4
months
3–6
i. Prerequisites 5-7
months
• Staff trained in IPT with SP,
7 – 11
• Constant availability of SP, 8 - 10
months
• Availability and need for drinking water (glass /
cup),
• Pregnant woman informed and aware of the IPT 11 - 15 1 – 3 years
with SP.

ii. Effective commencement of IPT 16 - 20 4 – 6 years

• As from the second trimester of pregnancy or at
the first perception of fetal movement by
21 - 25 7 – 8 years
pregnant women.
• It is recommended that every pregnant woman
9 – 10
completes 4 ANC consultations. 26 - 30
years
• IPT is not given in the first trimester.
10 – 11
• From the 16th week of pregnancy (second 31 - 35
years
trimester) or from the perception of the first fetal
active movements by the pregnant woman, IPT 11 – 13
36 - 40
should be administered at each ANC visit. In all years
cases, the interval between doses should be at 13 – 14
least 1 month. 41 - 45
years

46 31
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL INTENDED FOR HEALTH PERSONNEL

retained as the drug for IPT of malaria in pregnancy. In the

absence of any contraindications and for better efficiency, four
14 – 15 doses of SP are recommended in all areas where HIV
46 - 50
years
seroprevalence is greater than 10%. Administration of IPT
should respect gestational age and the minimum interval
between doses.

15 – 16 WHO recommends increasing access to IPT in all areas with

51 - 55
years moderate and high malaria transmission in Africa, as part of
prenatal care and is composed of four ANC sessions for each
pregnancy. To improve IPT coverage for pregnant women we
will ensure that any opportunity for ANC is used to administer
56 and IPT to pregnant women as from the second trimester (i.e. from
≥ 16 years
over perception of 1st fetal movements).

B- Sulfadoxine-Pyriméthamine
i. Active principle
7.2. Treatment of malaria in particular
This is a fixed combination tablet containing 500 mg of
populations
sulfadoxine and 25 mg of pyrimethamine.
7.2.1. Pregnancy
ii. Dosage
• Fever in pregnancy should always be considered an 03 tablets administered as a single dose
emergency, and its management should always be
done in a health facility. iii. Side effects
• Malaria treatment: Treat as severe malaria if signs • Gastrointestinal Disorders,
and symptoms of malaria are present.
• In case severe uterine contractions occur, administer • Allergic skin reactions,
tocolytics, according to stage of pregnancy. (1st • Blood Disorder,
trimester: Papaverine, diazepam. 2nd and 3rd • Lyell Syndrome (burn like skin rash),
trimester: Spasfon, Salbutamol or diazepam). • Kidney affection with rare and unusual elevation of
• Use paracetamol as anti-pyrexia. transaminases.

32 45
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL INTENDED FOR HEALTH PERSONNEL

10. PREVENTION OF MALARIA 7.2.2. Persons living with HIV

• Persons living HIV and diagnosed with malaria
Malaria prevention has two components: chemoprevention and should immediately receive an effective antimalarial
vector control. medicine following the recommendations of the new
malaria diagnosis and treatment guidelines.
10.1. CHEMOPREVENTION • HIV positive pregnant women on antiretroviral (ARV)
treatment (Efavirenz, Zidovudine) should not take
Chemoprevention is the use of drugs as prophylaxis against
ASAQ as this may worsen hepatotoxicity. In this
malaria. case preferably use AL for treatment of malaria.
There are two aspects of chemoprevention:
7.2.3. Over weight persons
• Intermittent Preventive Treatment (IPT) of pregnant • In order to avoid the risk of taking under dose,
women with with sulphadoxine-pyrimethamine. monitor treatment with microscopy.

• Chemoprevention for children aged 03 to 59 months 7.2.4. History of serious side effects from ASAQ
(Seasonal Malaria Chemoprevention – SMC) and In case of severe asthenia and other severe side
effects, evaluate and eventually stop treatment and
chemo prophylaxis for new subjects or travelers from
prefer AL.
non-endemic countries.
7.2.5. Malnourish children
10.1.1. Intermittent preventive treatment of Prefer AL. In case of severe malaria, prefer
malaria in pregnancy (IPT) injectable artesunate.
Generalities on Intermittent Preventive Treatment (IPT) of PRACTICAL NOTES
Malaria in Pregnancy
• To ease taking the tablets orally, the tablet can be
A- Definition ground and mixed with sugar and a little bit of water;
Intermittent preventive treatment (IPT) of malaria in pregnancy • In addition to the antipyretics, it is advised to:
involves the pregnant woman taking a periodic curative dose
of an antimalarial from the second trimester of pregnancy, in - undress the child,
order to prevent malaria infection. - give him/her ample water to drink,
- if the fever persists, bath the child with lukewarm
After the withdrawal of chloroquine from the list of antimalarial water or do tepid sponging.
drugs in Cameroon, sulfadoxine-pyrimethamine (SP) was

44 33
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL INTENDED FOR HEALTH PERSONNEL

Ask that the patient be brought back if any signs of severity 5mg/kg body weight IVD. In case of fever, undress patient
occur or if he/she does not improve after 48 hours. and tepid sponge and administer antipyretics. Clear airways
• The malaria treatment algorithm, with the dosing and avoid feeding.
instructions in accord with the national guidelines
should be made available to all prescribers. b. Look for and treat the cause of convulsion
• Prescribers should follow the treatment and dosage
guidelines validated in the national guidelines. Any o Correct glycaemia,
exceptions should be justified and documented.
Directors of hospitals, regional delegates of public o Correct fluid-electrolytic imbalance,
health, as well as district medical officers are each
expected to ensure health care providers adhere to the o Nursing care of coma…
national guidelines.
9. HINTS ON CURATIVE TREATMENT OF
Quality Assurance MALARIA
Quality assurance should ensure that medications are properly
• Malaria is a costly disease to the household and to
managed. Expiry dates and good transport conditions should
always adhered to. society. The importance of an appropriate treatment
cannot be overemphasized.
• The supervision checklist includes quality control
checks of stocks. • The doses and treatment duration must be respected.
• Ensure that drug stock management tools exist and are
well kept, medications are neatly arranged, and drugs • Drugs must be procured from the health facility
are stored in temperatures according to manufacturer pharmacy or from the commercial pharmacy.
guidelines. FEFO (First Expiry First Out) should be used
to avoid expiries.
• Drugs must be kept away from sunlight, heat, and out of
• Health care providers should be wary of reach of children.
pharmacovigilance. Pharmacovigilance forms should • If fever persists or any sign of severity appears, the
be available to all health facilities.
patient must report back to the health facility as soon as
• Pharmacovigilance should be integrated into national possible.
health information management system.

34 43
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL INTENDED FOR HEALTH PERSONNEL

of an increase in the heartbeat; the respiratory rate in 8. HOW TO TREAT SEVERE MALARIA
search of dyspnoea; the colour and volume of urine in
search of dark coloured (coca-cola) urine or diminished 8.1. Treatment of severe malaria in the
urine output; the state of consciousness in search of general population
agitation, coma or convulsion);
After parasitological diagnosis, sever malaria should be
- Blood transfusion should be immediately stopped on
diagnosed through one of the following ways:
occurrence of skin eruptions, pruritus of chills. Redo blood § Existence of one or several signs of severe malaria;
grouping and cross match and replace the blood bag with § Worsening of condition of patient being treated for
an appropriate one; uncomplicated malaria.
- Check the level of haematocrit or haemoglobin at the end
Severe malaria should be managed at an appropriate level
of transfusion. of care. Refer the patient IF NECESSARY after the
After blood transfusion, it is recommended that the patient be parenteral administration of an initial parenteral dose of
given iron and folic acid supplements for at least 2 to 3 artesunate, quinine, or artemether.
months.
Initial treatment should always be parenteral for at least 24
2. Other anaemic patients not needing blood transfusion hours relayed by oral treatment as soon as the patient is able
to eat and drink.
They can be given iron and folic acid supplements (6 to
10mg/kg in two daily doses). Three types of treatment regimens exist:
- Injectable artesunate as first line treatment,
8.2.3.3. Other treatments
- Injectable quinine,
- Injectable artemether.
8.2.3.3.1. Management of convulsions
Start with symptomatic treatment of convulsions, and then 8.1.1. First line treatment: Injectable artesunate
proceed by looking for the cause of convulsions.
Dosage: 2.4mg/kg at 0.12 and 24 hours, followed by
a. Symptomatic treatment of convulsion administration every 24 hours until the patient is able to take
oral treatment (timing can then become less stringent for
Injectable diazepam 0.5mg/kg intrarectally in a single dose to practical reasons).
be repeated just once 10 min after if convulsion persists, after
Route of administration: Injectable artesunate is preferably
which aqueous phenobarbital injection 10mg/kg in a single administered intravenously (IV) otherwise it should be
dose. This can be administered again 24 hours later at administered intramuscularly (IM).

42 35
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL INTENDED FOR HEALTH PERSONNEL

8.1.2. Second line: Treatment w ith Quinine 8.2.3.2. Treatment of anaemia

Regimen 1: (see details in appendices 6, 7, 8 and 9) When faced with malaria-related anaemia, it is necessary to
distinguish patients who need transfusion from the others.
This regimen entails a loading dose of quinine and is
administered in two daily infusions: 1. Patients who need transfusion

Loading Dose: 16.6 mg/kg of quinine base (see Indications for transfusion:
appendix 8 for equivalents in quinine salts) in 5 % or 10% - Haematocrit < 15% in children or <20% in adults of pregnant
glucose with electrolytes (NaCl, KCl, Calcium gluconate), women
without exceeding 1 gram of quinine base, to be run in 4 - Haemoglobin < 5 g/dl in children or < 7 g/dl in adults or
hours.
pregnant women
Maintenance Dose: 12 hours after the onset of the - Symptoms of poor clinical tolerance (severe intensive
loading dose, give 8.3 mg/kg of quinine base in 5 % or 10% polypnoea, tachycardia, gallop rhythm).
glucose to be run in 4 hours every 12 hours without exceeding
500mg of quinine per dose. Even in the absence of haematocrit and haemoglobin, a
patient presenting with extreme pallor and symptoms of poor
If the patient is pregnant, if he/she had taken quinine
clinical tolerance should be transfused.
within the previous 24 hours, Mefloquine within the 7
previous days, or is a cardiac patient do not administer
the loading dose. Quinine will be given at the dose of 8.3 Transfusion conditions:
mg/kg of quinine base every 12 hours. - Packed cells 10cc/kg in 3 hours;
- In the absence of packed cells, transfuse 20 cc of whole
Regimen 2 : blood/kg in 3 hours and then administer furosemide 1mg/kg
intravenously at the beginning or during transfusion, except
This regimen has no loading dose. Treatment is given in three
for patients who are dehydrated or exhibiting signs or
infusions per day:
symptoms of shock;
Quinine base: 8.3 mg /kg/ of quinine base in four-hour - The blood should be compatible within the ABO/ Rhesus
infusions, every 8 hours grouping system and screened for the following diseases:
♦ maximum Dose: 1,5 g/day of quinine base HIV, hepatitis B and C, syphilis) During transfusion monitor
In case the patient has received quinine in the preceding clinical vital signs (the colour of mucosae in search for
24 hours, mefloquine in the preceding 7 days or if the jaundice or submucosal bleeding; the heart rate in search
patient has a cardiac disease, no loading dose should be

36 41
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL INTENDED FOR HEALTH PERSONNEL

8.2.2.3. Third line: Injectable Artemether administered. Only the regimen without a loading dose
should be used.
Injectable artemether is used in the absence of injectable
artesunate or when quinine is contra indicated. Whatever the chosen regimen, switch to Oral treatment as
soon as the patient is able to swallow: 8.3 mg/ kg of quinine
Dosage in adults: base every 8 hours for a total of 7 days from the beginning of
160mg per day: 80mg in two doses (with an interval of 12 treatment, or an artemisinine based combined therapy (ACT)
hours), administered by IM injections the first day. This is then (ASAQ of AL), for three days.
followed by 80mg once a day IM for the next 6 days.
8.1.3. Third line: Treatment w ith injectable
artemether
Dosage in children:
3.2mg per day in two doses: 1.6mg in two doses (with a 12 Injectable artemether is used in the absence of injectable
hour interval), administered by IM injections the first day. This artesunate and when quinine is contraindicated.
is followed by 1.6mg once a day by IM injections for the next 6
days. The injection is administered on the superior external Dosage in adults:
quadrant of the buttock or on the anterior surface of the lap.
160mg per day: 80mg in two doses (with an interval of 12
8.2.3. Associated treatment hours), administered by IM injections the first day. This is then
followed by 80mg once a day IM for the next 6 days.
8.2.3.1. Antipyretics (oral,rectal or parenteral)

First line treatment: Injectable paracetamol - 60 mg/kg/day Dosage in children:

divided into 4 doses in children IV. 3.2 mg per day, in two doses (with a 12 hour interval);
administered by IM injections the first day. This is followed by
Second line treatment: Injectable Lysine acetylsalicylate acid - 1.6mg once a day by IM injections for the next 6 days. The
50mg/ kg per day in 4 doses, I.V. (or I.M.). injection is administered on the superior external quadrant of
Paracetamol suppositories: 60mg/kg/day in 4 doses in children the buttock or on the anterior surface of the lap.
without diarrhoea.
Oral paracetamol, Acetyl salicylic acid or ibuprofen: like in 8.2. Treatment of malaria in pregnanc y (Severe
malaria)
treatment of uncomplicated malaria.
Never administer non-steroidal anti inflamatories (acetyl During pregnancy, the severity of malaria is linked to foetal
complications. Hence all cases malaria during pregnancy
salicylic acid, ibuprofen etc.) during the 3rd trimester of
should be considered as severe malaria and treated as such.
pregnancy.

40 37
 GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON GUIDELINES FOR THE MANAGEMENT OF MALARIA IN CAMEROON
INTENDED FOR HEALTH PERSONNEL INTENDED FOR HEALTH PERSONNEL

8.2.1. Treatment during the first trimester Dosage of tocolytics

Treatment with quinine without a loading dose (Regimen 2 Initial treatment: Salbutamol (ventoline) infusion:
above). Add 10 ampoules of 0.5mg/ml of ventoline (i.e. 5mg of
This regimen uses 3 perfusions per day: salbutamol) in 250ml of normal saline or 5% dextrose solution.
Quinine bases: 8.3 mg/kg of quinine bases in 4 hours infusion,
every 8 hours. Start with 10 drops/minute, increasing by 10 drops every 10
Relay is made with oral treatment as soon as patient can minutes until contractions cease. Do not exceed 60
swallow. The oral dose is 8.3 mg/kg of quinine bases every 8 drops/minute.
hours until the 7th day of treatment, starting from the beginning
of the treatment. Relay with salbutamol tablets 2mg: 1 tablet every 12 hours.
Maximum dose 1.5g of quinine base per day.
Salbutamol can cause the following side effects: palpitations,
8.2.2. Treatment during the second & third tachycardia, arythmia and trembling. Consequently treatment
trimesters requires strict monitoring. This consists of:
• Monitoring the pulse – should not exceed 100 per
8.2.2.1. First line: Treatment with injectable minute,
artesunate
• Monitoring of blood pressure – Should neither fall below
Dosage: 2.4mg/kg at 0.12 and 24 hours, followed by one 90/60mmHg or rise above 140/90mmHg.
administration every 24 hours until the patient is able to take
In case the pulse rate exceeds 110 beats per minute or blood
oral treatment (timing can then become less stringent for
pressure falls below 90/60mmHg or rises above 140/90mmHg,
practical reasons).
stop administration of tocolytics but continue malaria
Route of administration: Injectable artesunate is preferably
treatment.
administered intravenously (IV) otherwise it should be
Whatever regimen used, continue with oral quinine as
administered intramuscularly (IM).
soon as the patient is able to swallow. This should be at a
dose of 8.3mg/kg of quinine base every 8 hours for a total
8.2.2.2. Second line: Treatment with Quinine
without a loading dose (Regimen 2 above) of 7 days from onset of treatment, otherwise administer
ACTs (ASAQ of AL) for 3 days, as from the second
If uterine contractions occur during treatment with quinine, trimester of pregnancy.
administer tocolytics.

38 39