Sudan Malaria Diagnosis and Treatment Protocol 2017

Manual and Guideline
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Malaria in Sudan:

Malaria constitutes a major public health problem in Sudan. Almost, 75% of population is at risk of developing malaria. Malaria transmission is unstable putting the whole country under the risk of malaria epidemic. The possibility of epidemic increased with heavy rains, floods and in case of interruption of control activities.
In 2015, 586,827 confirmed cases were reported from public health facilities out of the estimated 1,400,000 cases (970,000; 1,900,000). As well, 868 deaths were reported out of the estimated 3,500 deaths (130; 6800). The reported malaria cases represent 8.7% and 12.2% of the total outpatient attendance and of hospital admissions respectively. The disease proportional mortality was 4.3% in 2015 putting malaria as one of the main causes of death in Sudan.
Results of the Sudan Malaria Indicators Survey in 2016 (Sudan MIS 2016), showed an overall parasite prevalence of 5.9%. The prevalence is range between<1 in Red Sea, Northern, River Nile and Khartoum States to >20% in Central Darfur State. In South and West Darfur, Blue Nile and South Kordofan states the prevalence approached or exceeded 10% (Table 1). The prevalence correlates with age, as children are 3 times more likely to get malaria than adults. Apparently there was no difference between male and female. Similarly, the lowest economic class is at higher risk. Internally displaced people and refugee camps reported prevalence doubled that in rural areas and 3 times higher than that in urban areas. The main species is the P. falciparum (pf) representing 87.6% of cases. However, the P. vivax (pv) unexpectedly reaches 8.1% and mixed infection (pf & pv) approached 5%. P. vivax alone plus mixed infection exceeded 15% in North Darfur, West Darfur, South Darfur, River Nile and Khartoum states. The main vector species is An.arabiensis besides An. Gambia and An. funestus.

Epidemiological strata:

Malaria transmission in Sudan is highly linked with climatic conditions. There are two peaks of transmissions; one during the rainy season and the other during winter season. Malaria during the rainy season involves most of the areas in Sudan. In urban areas and in irrigated schemes the transmission is throughout the year with a noticeable peak during the winter time. Six malaria epidemiological strata could be identified: irrigated schemes, seasonal, man-made urban, desert-fringe, riverine and emergency and complex situation malaria.

Main strategies for malaria control in Sudan:

The Communicable and Non-communicable Disease Control Directorate (CNCDCD) lead the response to malaria toll in Sudan. Sudan is still in the control phase but efforts to move towards elimination in Red Sea, Northern, River Nile and Khartoum States are under way. In line with the malaria global strategy, 2016 -2030, the CNCDCD together with partners emphasize the importance of ensuring:

  • Early diagnosis and prompt treatment of malaria,

  • Vector control response (including insecticide treated nets, indoor residual spraying and larval source management etc.),

  • Forecasting, early detection and containment of the epidemics,

  • Capacity building and strengthening of malaria control activities through improvement of the information system, operational research and partnership

  • Raising the public awareness and knowledge on malaria prevention and control .

Early diagnosis and prompt treatment of malaria:

Since 2004, the treatment of uncomplicated malaria in Sudan has changed from monotherapy to artemisinin-based combination therapies (ACTs). Combination therapy “is the simultaneous use of two or more schizonticidal drugs with independent mode of action and different biochemical targets in the parasite”. Combination therapy is more effective than monotherapy as it delays the emergence of resistance.
The treatment outcome of malaria depends on appropriate management with the recommended ACTs. However, delay in providing adequate care will eventually lead to poor outcome. Adherence of health care providers to treatment policy is necessary to ensure good treatment outcome and to delay the emergence of resistance. The presence of quality assured laboratory diagnosis as well as the availability of adequate, quality assured, safe, and affordable antimalarial medicines at all levels of health service delivery are critical for provision of effective malaria case management. Efforts also should be directed to raise the awareness of patients and communities about the importance of early diagnosis and safety of antimalarial drugs as well as compliance to treatment.

Sudan Malaria Treatment Protocol, 2017:

Many efficacy studies were carried out during the past few years in different regions of the Sudan. Findings showed a decreasing efficacy to artesunate + sulphadoxinepyremethamine (AS+SP), particularly in Gedarif State (>10%). Findings also showed high efficacy (>95%) of artemether-lumefantrine (AL) and dihydroartemisinin-piperaquine (DHAP). Moreover, the Sudan MIS 2016 showed irrational use of artemether intramuscular for treatment of uncomplicated malaria. Some published studies showed higher rate of non-adherence of health care providers to the treatment guidelines and self-treatment.
In response to this situation, the malaria technical advisory committee (formed from national experts and partners) recommended the use of AL as a first-line and DHAP as a second-line treatment for malaria in Sudan. The committee also recommended the use of quinine or intravenous artesunate for treatment of severe malaria at hospital level. Artesunate suppository and intramuscular quinine are recommended for prereferral treatment. The committee recommended banning the use of intramuscular artemether in Sudan. The recommendations of the committee were endorsed by the “Council of Undersecretary in Federal Ministry of Health” and were issued by the “Ministerial Decree no. 17/2017”. Necessary implementation arrangements are taking place at all levels following this decree.
The CNCDCD established a technical committee to update the malaria national treatment protocol and the training materials. This document “Sudan Malaria Diagnosis and Treatment Protocol, 2017” was written and revised by the committee members taking into consideration the “National Technical Committee Recommendations”, the “Ministerial Decree” and the best practice in malaria treatment as reflected in the “WHO Guidelines for Malaria Treatment, 2015”.
Following this introduction the “Sudan Malaria Diagnosis and Treatment Protocol, 2017” is arranged in 6 units as follow:
Unit 1: Diagnosis of uncomplicated malaria Unit 2: Treatment of uncomplicated malaria Unit 3: Management of severe malaria Unit 4: Malaria in pregnancy Unit 5: Malaria in children Unit 6: Malaria in special situations The diagram below summarizes the general plan for malaria diagnosis and treatment with more details in the following secessions.