THE PATTERN OF MALARIA
TREATMENT IN KUALA LIPIS
HOSPITAL, PAHANG
Norsyazana Ab Hashim
Sean Kwong Kien Seang
Phuan Ke Shin
Department of Pharmacy
Hospital Kuala Lipis
INTRODUCTION
Malaria is one of the serious diseases causedby parasitic protozoan, plasmodium spp. thatis spread to people through infectedAnopheles mosquito.
Common features and symptoms of malariaare nonspecific and there include fever,fatigue, headache, muscle and joint painwhich severe case it can lead to coma ordeath.
Malaysia is one of the countries with highrisk of malaria transmission(Rahman et al,1997)
PROBLEM STATEMENT
Among Peninsular Malaysia, Pahang had beenreported as having the highest cases of malaria since1985 (Mak et al, 1992).
In recent years, there are reports of increase in theincidence of malaria cases in Lipis Hospital (UnitRekod,Lipis Hospital) which cause burden in term oftreatment cost to the hospital.
The studies of malaria are scarce in Pahang state,specifically in Lipis district where malaria is known toexist. Information such as knowledge of the commonspecies of malaria in Lipis area is important foreffectiveness treatment of malaria.
RESEARCH QUESTIONS/ OBJECTIVES
General objective:
To identify the relationship between treatment received for
various malaria species and the patients’ clinical outcome
Specific objective:
To determine the demographic features of malaria cases in
Hospital Kuala Lipis, Pahang for past 3 years from 2011 to
2013
To identify the relationship between treatment received for
plasmodium knowlesi and the patients’ clinical outcome.
DEFINITION
Treatment received:
artemisinin-based:
Artemether plus lumefantrine combination
(riamet®) and artesunate are classified as
artemisinin-based regime
non-artemisinin-based:
Combination oral quinine with primaquine
or sulfadoxine-pyrimethamine (fansidar®)
represent as non-artemisinin-based
LITERATURE REVIEW
Malaria category:
Malaria can be divided into complicated and uncomplicatedmalaria(WHO, 2010)
Plasmadium knowlesi:
Previously malaria refers to four strains of plasmodium spp. Fifthmalaria cases caused by plasmodium knowlesi is being recognizedmore and more commonly in Southeast Asia including Malaysia.(Singh B et al, 2004)
There is limited information on treatment guideline forp.knowlesi(Timothy W et al,2011)
Most of uncomplicated p.knowlesi cases responded well towardscholoquine plus primaquine(Daneshvar et al,2009)
LITERATURE REVIEW Treatment option for various malaria species:
Rajahram et al (2012) had highlighted the issue of
standardising the treatment for severe malaria regardless of
the species due to the complications including death
SEAQUAMAT study had also suggested that parenteral
artesunate is preferred over quinine for patients with severe
P. falciparum malaria. (Prof M Abul Faiz et al.,2005)
Artemisinin-based combination therapy such as artemether
and lumefantrine (riamet®) was the treatment of choice for
uncomplicated P. falciparum malaria and P. vivax (Barber et
al.,2013).
P. ovale and P. malariae malaria can be treated adequately
with chloroquine since there was rarely resistance towards
chloroquine( non artemisinin based)(WHO,2010).
RESEARCH METHOD
Study design
cross sectional, retrospective study.
Study Period
Jan 2011 to Decemeber 2013.
Study area
Hospital Lipis
RESEARCH METHOD Study population
Inclusion criteria:
Patients aged 13 years and above with malaria cases
Exclusion criteria:
patients were discharge at their own risk
pregnant or lactating mother
patient with known allergy to any of the anti-malarial
medications.
Sampling
non random purposive sampling based on the name list
recorded in ‘Unit Rekod’ Hospital Lipis
RESEARCH METHOD
Data Collection
Patient case note from ‘Unit Rekod’ Hospital KualaLipis.
The indicator used to determine the clinical outcomes ofmalaria patient
Time taken to achieve afebrile (days)
Length of hospital stay (days)
Time to achieve BFMP clearance (days)
Effectiveness of different type of treatment was measuredby classifying the patients into two groups depending onthe treatment received:
artemisinin-based therapy
non-artemisinin-based therapy
RESEARCH METHOD
Data Analysis
statistical package for social sciences (SPSS) program version19 and Microsoft excel.
Kruskal Wallis test was used to test for an association betweenvarious malaria species against the study variable which aretime to achieve afebrile, BFMP clearance and length ofhospital stay (clinical outcome).
Independent t-tests were used to observe the associationbetween artemisinin based therapies against non- artemisininbased therapy for uncomplicated plamodium knowlesi.
A p-value of <0.05 was defined as significant associationbetween the dependent and independent variables.
FINDINGS/ RESULT
Patients Demographic Data
Variable Number (%)
Gender
Male 102
Female 24
Locality
Felda 20
Rural area 96
Urban area 10
FINDINGS/ RESULT
0
20
40
60
2011 2012 2013
Plasmodium falciparum
Plasmodium malariae
Plasmodim knowlesi
Plasmodium vivax
TOTAL
Trend of Malaria Cases from 2011 to 2013 in Kuala Lipis Hospital
FINDINGS/ RESULT Treatment option among all species of malaria in Kuala
Lipis Hospital
0102030405060
Nu
mb
er o
f P
ati
en
t
Species of Malaria
Treatment option among all malaria
species
artemisinin base
non artemisinin
base
FINDINGS/ RESULT
Type of treatment P-value a
Artemisinin
bases(N=16)
Non artemisinin
bases (N=88)
mean time to
achieve afebrile
(days)
3.13± 0.957 3.31±1.216 P = 0.573
mean time to
achieve BFMP
clearance (days)
4.06± 1.181 4.49± 1.061 P = 0.150
mean length of
hospital
stay(days)
5.94± 1.289 6.26±1.160 P = 0.315
Table: Association between mean time to achieve afebrile, time toachieve BFMP clearance and length of hospital stay with type oftreatment in all species
a independent t-test
FINDINGS/ RESULT
Type of treatment P-value
artemisinin base
(N=15)
Non artemisinin
base (N=16)
mean time to
achieve afebrile
(days)
3.13± 0.957 3.00± 0.926 P = 0.715
mean time to
achieve BFMP
clearance (days)
3.13± 0.957 3.00± 0.926 P = 0.715
mean length of
hospital
stay(days)
5.94± 1.289 5.53± 0.640 P = 0.283
Table: Association between mean time to achieve afebrile, time to
achieve BFMP clearance and length of hospital stay with type of
treatment for plasmodium knowlesi
DISCUSSION
Demographic data:
Majority malaria infected patients (76.2%) were come
from rural area. This could be explained by the
geographical that rural area was near to the forest
and felda was involving in plantation of rubber or
palm oil.
A study done by Barber and his colleague found that
almost all malarial infected patients were reported
forest or plantation exposure.(Barber et al., 2013).
DISCUSSION
Demographic data:
Male was the main contributor for the malaria cases
in Kuala Lipis Hospital. This may be due to the
occupation of the patients. Majority of the infected
male patients were working in plantation such as
rubber tapper or palm oil collector. There was higher
chance for them to expose to the vector (mosquitoes).
DISCUSSION
Species of malaria:
In West Malaysia the vectors for P. knowlesi have
been identified as An. hackeri in Selangor and An.
cracens in Kuala Lipis, Pahang. (Singh & Daneshvar,
2010)
Both of these mosquito species prefer to feed on
monkeys rather than humans, which may explain the
plasmodium knowlesi was one of the highest number
of infected malaria species in Hospital Kuala Lipis.
(Singh & Daneshvar, 2010)
DISCUSSION
Treatment option:
The prescribing pattern of antimalarial in Kuala Lipis Hospital
was the combination of more than 1 antimalarial agent. This
strategy was to prevent the resistance of single antimalarial drug
and to be more efficient to kill parasite in the blood stream.
Before 2013, chloroquine was the core antimalarial in the
treatment of all kind of malaria species.
After national drug surveillance on antimalarial was carried out
in whole Malaysia, only riamet or artequine was prescribed to
patient with the species of falciparum, malariae and
knowlesi.(uncomplicated cases)
Since then¸ the spectrum of antimalarial agents used in Kuala
Lipis Hospital has changed. Chloroquine only reserved for
Plasmodium vivax. For complicated malaria, IV artesunate was
using to treat all kind of malaria regardless of species.
DISCUSSION
Clinical outcome vs different types of treatment
regime in all malaria species:
From previous studies concluded that artemisinin
base drug was more effective compare to chloroquine(
non artemisinin) and antifolate agent (Luxemburger,
Nosten, Raimond, Chongsuphajaisiddhi, & White,
1995)
We compared artemisinin base and non artemisinin
base in uncomplicated malaria and we found that
there was no statistical significant different between
these 2 groups in patients’ clinical outcome.
DISCUSSION
Effect on different type of treatment in Plasmodium
knowlesi:
Chloroquine was shown to be effective for uncomplicated
knowlesi malaria in Kapit (Daneshvar et.al,2010),
The retrospective study at QEH found faster parasite
clearance with oral artemisinin combination therapy
(ACT), artemether-lumefantrine (William et.al, 2011)
In the study, we compared the use of chloroquine and
riamet and we could conclude that 2 groups of treatment
were equally effective in treatment of uncomplicated
plasmodium knowlesi.
LIMITATIONS
Case note for malaria cases from record storage
unit Kuala Lipis Hospital were used as one of the
source of data throughout the study. In few, case
note records were not properly filled, therefore
the information obtained was incomplete and no
follow up could be done on all the malaria cases.
CONCLUSION
The main malaria species isolated from the
patients were plasmodium malariae and
plasmodium knowlesi.
All malaria cases regardless of species were
treated with more than 2 antimalarial agent to
prevent resistance of single antimalarial agent
Use of artemisinin derivative in management of
non-complicated malaria did not show superior
effect in all clinical parameter. Frequently, exert
drug pressure in certain drug will promote the
résistance of that agent.
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