|MISSION HOSPITAL SECTION
|Year : 2014 | Volume
| Issue : 4 | Page : 286-290
Approach to malaria in rural hospitals
Jency Maria Koshy1, Jacob Koshy2, Vineeth Jaison3, Preethi Paul4
1 Department of Medicine, Christian Medical College, Ludhiana, Punjab, India
2 Department of Ophthalmology, Christian Medical College, Ludhiana, Punjab, India
3 Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
4 Department of Pathology, Christian Medical College, Ludhiana, Punjab, India
|Date of Web Publication||16-Oct-2014|
Dr. Jency Maria Koshy
Department of Medicine, Christian Medical College, Ludhiana - 141 008, Punjab
Source of Support: None, Conflict of Interest: None
Malaria is one of the most common parasitic infections in the developing countries. In Rural India, most patients would be treated by primary and secondary care physicians. This article is aimed at providing a feasible approach to the cases of malaria in mission hospitals and other rural hospitals taking into account all the resource limitations. A study done over one year on patients detected to have malaria at Jiwan Jyoti Christian Hospital in Sonbhadra district has helped the authors to identify the various challenges faced by doctors working in the rural hospitals. The article has looked at the various complications associated with malaria and their management. It has also stressed upon the increasing incidence of chloroquine resistance.
Keywords: Malaria, rural hospital, severe malaria
|How to cite this article:|
Koshy JM, Koshy J, Jaison V, Paul P. Approach to malaria in rural hospitals. CHRISMED J Health Res 2014;1:286-90
| Introduction|| |
Malaria is one of the most common parasitic infections in the developing countries and cerebral malaria (CM) is one of the most common causes for non-traumatic encephalopathy in the world. Malaria is endemic in India. According to the latest WHO estimates, there were about 219 million cases of malaria in 2010 and an estimated 660,000 deaths. 
In rural India, most patients would be treated by primary and secondary-care physicians. It is a challenge to treat these patients with limited resources amongst various other concerns like prevailing endemic infections, malnutrition, poverty and illiteracy. This article is aimed at providing a feasible approach to the cases of malaria in mission hospitals and other rural hospitals taking into account all the resource limitations. Studying the cases of malaria over 1 year at a mission hospital in North India has helped us with this.
| Background|| |
Jiwan Jyoti Christian Hospital is a 75-bed mission hospital in eastern Uttar Pradesh in India. This is a secondary care hospital catering to an area of 200 km radius in the Sonbhadra district. Majority of the patients belong to the poor economic strata and struggle to meet their basic needs [Figure 1]. Burden of an illness or the hospitalization of a family member would distraught the entire family's hand to mouth existence. Mission hospitals like this have an unwavering focus to reach out to these patients. The doctors working in this area are committed to treat these patients without compromising on the standard of care.
|Figure 1: Relatives of patients cooking with basic aminities in the hospital premises|
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This hospital is situated in an endemic area for Malaria. On an average two to three patients of malaria present to the department of medicine everyday [Figure 2] and [Figure 3]. In view of the high prevalence of malaria in the region the authors decided to look at the challenges faced by the physicians while treating these patients. A study done over one year helped us in identifying the problems faced while treating these patients and solutions for the same. The patients above the age of 12 years detected to be having malaria on the basis of the blood smear were included in the study. Clinical profile including various complications, treatment and outcome of these patients were studied.
Resource limitations: Unavailability of antigen testing for malaria, acid blood gas testing, ventilators and hemodialysis facility.
| Etiology and Clinical Presentation|| |
Malaria is caused by five species of Plasmodium namely Plasmodium vivax, Plasmodium falciparum, Plasmodium malariae, Plasmodium ovale and Plasmodium knowlesii. The species commonly encountered in India are vivax and falciparum. Among the 186 cases identified, 150 (80.65%) were vivax malaria, 23 (12.37%) were falciparum malaria and 13 (6.99%) were mixed infection [Figure 4]. However, according to WHO report of 2013, almost half the infections in India are attributed to falciparum.  Among them 76.34% patients were less than 40 years of age. This is always a concern as these are the young productive population and usually the earning member of the family.
Clinical presentation of malaria varies from uncomplicated acute febrile illness to a severe form of malaria when infections are complicated by serious organ failures or abnormalities in the patient's blood or metabolism. The symptoms could be nonspecific like, fatigue, myalgia, headache, abdominal discomfort and fever. 
The 2010 revised criteria for severe malaria are the presence of one or more of the following: Prostration, impaired consciousness, failure to feed, respiratory distress ("air hunger"), multiple seizures (more than two episodes in 24 hours), circulatory collapse, pulmonary edema (on radiological imaging), abnormal spontaneous bleeding, jaundice, hemoglobinuria, severe anemia, hypoglycemia, acidosis, renal impairment, hyperlactataemia, and hyperparasitemia. 
| Cerebral Malaria|| |
Cerebral malaria (CM) is a diffuse encephalopathy in which focal neurological signs are relatively unusual. It is often accompanied by multisystem dysfunction. CM is defined as severe P. falciparum malaria with cerebral manifestations, usually coma (Glasgow coma scale <11, Blantyre coma scale <3). Malaria with coma persisting for >30 minutes after a seizure is also considered as CM.  Most of the cases of CM are caused by P. falciparum as in this cohort, where 82.6% of the patients with falciparum had CM. There were a total of 32 (17.2%) cases of cerebral malaria. Among those, 18 were attributed to falciparum malaria, nine were due to mixed infection and five were due to vivax malaria.
The causes for anemia in malaria patients are obligatory destruction of red blood cell (RBCs) at parasite schizogony, accelerated destruction of non-parasitized RBCs by spleen, and ineffective erythropoiesis.  In rural India anemia is a commonly encountered problem due to worm infestation and malnutrition. Malaria superimposed on an underlying anemia is a major cause for morbidity. The incidence of anemia was as high as 54.84% with 34.78% of severe anemia among the falciparum cases in this cohort. The incidence of anemia in various studies varied from 46 to 66%. ,, Patients with severe anemia would need blood transfusion. It is not uncommon to have thrombocytopenia with various species of malaria.
Hypoglycemia in malaria patients are due to peripheral requirement of glucose consequent upon anaerobic glycolysis, increased metabolic demands of febrile illness, obligatory demand of parasites, failure of hepatic gluconeogenesis and glycogenolysis (parasites consume up to 70 times as much glucose as uninfected cells). It is compounded by the stimulation of insulin secretion from pancreatic beta cells by quinine. Patil noted an incidence of 6.38%. 
It is advisable to do frequent blood sugar monitoring and to administer dextrose infusion.
Adult respiratory distress syndrome
Adults with severe falciparum infection can present with noncardiogenic pulmonary edema. It is often a manifestation of overenthusiastic hydration in patients with leaky alveolar capillaries. These patients should be positioned with head elevation and should be given oxygen and intravenous diuretics.  Most of the patients could be salvaged by this. However, some patients may need invasive or noninvasive ventilation. They may have to be shifted to a higher centre if ventilatory facilities are not available.
Jaundice is a common manifestation and is caused by a combination of red blood cells hemolysis, hepatic dysfunction due to parasite vascular sequestration in the liver and cholestasis. 
Renal impairment is more common among adults than children with severe falciparum malaria. It may be due to erythrocyte sequestration interfering with renal microcirculatory flow and metabolism. Clinically and pathologically this syndrome manifests as acute tubular necrosis.  Renal dysfunction was noted in 11.8% of the patients. Hydration of patients with malaria is like walking on a tight rope, balancing between ARDS and renal dysfunction.
Renal dysfunction could be transient, responding to fluids and diuretics or would need dialysis. Peritoneal dialysis is a feasible option in rural areas where facilities for hemodialysis are not available.
Metabolic acidosis is a known complication of malaria. Hyperventilation (Kussmaul breathing) with a clear chest on auscultation suggests metabolic acidosis. Center's where there are no facilities for estimation of acid blood gases, a clinical diagnosis can be made based on this.  Clinical improvement with treatment as indicated by normal respiratory rate guided us in our management.
Severe P. vivax malaria
They are increasing reports of complicated malaria by vivax species as well. , In the patients we studied, 10% of the P. vivax malaria cases had severe malaria with cerebral malaria in five of them [Figure 5]. Other complications noted were severe anemia, renal dysfunction and jaundice. This is supported by evidence from literature. , All the patients with severe vivax malaria should be treated like falciparum infection.
Treatment of malaria
Antimalarial drugs are the only interventions that unequivocally reduce mortality in patients with malaria. The guidelines for treatment of malaria are revised periodically with the pattern of resistance noted in various areas. National vector-borne disease control programme has given guidelines for the Indian scenario. 
Treatment of confirmed cases of vivax malaria
Chloroquine is the treatment of choice. It should be given at 10 mg/kg on day 1, 10 mg/kg on day 2 and 5 mg/kg on day 3. This should be combined with primaquine 0.25 mg/kg for 14 days. Primaquine is contraindicated in infants, pregnant women and individuals with G6PD deficiency. 
Treatment of uncomplicated falciparum malaria
The recommendations are different for the Northeastern states and the other states in India.
In Northeastern states the recommendation is four tablets of Artemether (20 mg) and Lumefantrine(120 mg) for 3 days. On the second day 0.75 mg/kg of primaquine is advised. Whereas in the other states in India, Artesunate 4 mg/kg body weight daily for 3 days Plus Sulfadoxine (25 mg/kg body weight) - Pyrimethamine (1.25 mg/kg body weight) on first day is advised. Primaquine has to be given on the second day. In pregnancy quinine should be used in the first trimester. 
Treatment of severe malaria
Severe malaria irrespective of the species should be treated with parenteral drugs atleast for 24 hours. Treatment options are quinine, artesunate, artemether or arteether. Later patients can be switched over to oral drugs. When oral drugs are initiated quinine is combined with either doxycycline or clindamycin. Artesunate should be combined with either lumifantrine or sulfadoxine- pyrimethamine. 
Choroquine resistance among vivax malaria
As per WHO protocol, resistance was defined as the presentation of signs of severe malaria within the first 2 days after supervised treatment or the presence of parasitaemia and axillary temperature >37.5°C between days 3 and 28 or presence of parasitemia on any day between days 7 and 28, irrespective of clinical conditions.  We noted choloroquine resistance in 16.67% patients. These patients were switched over to either artimisinin components, quinine or mefloquine with complete clinical resolution. Even though chloroquine is still the drug of choice for uncomplicated vivax malaria, one should be cautious about the possible resistance.
We noted a mortality of 1.08% among them and 4.15% among severe malaria cases. Case fatality rates in the other studies from Africa have shown a high mortality rate of 13-21%. , Lon C et al. noted a mortality rate of 35% among CM cases.  This cohort reassures that even at a secondary care mission hospital the outcome of these patients are commendable.
| Conclusions|| |
Managing malaria in a rural hospital is challenging at times. Physicians caring for them should be aware of all the complications associated with it. Most of the complications can be dealt with at such a hospital. Renal failure needing dialysis can be managed with peritoneal dialysis. Patients needing ventilator care has to be shifted to a higher center if the hospital does not have facility for the same. This study has further strengthened the evidence of severe malaria with P. vivax including cerebral malaria. Irrespective of the species identified on the blood film, severe malaria should be treated with artesunin components or quinine as per the WHO recommendation.  Chloroquine is still the drug of choice for uncomplicated vivax malaria. However, practitioners should be vigilant about the local prevalence of resistance.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]