What is the recommended treatment for malaria in Ethiopia?

Recommended Treatment for Malaria in Ethiopia

Artemether-lumefantrine (AL) is the first-line treatment for uncomplicated Plasmodium falciparum malaria in Ethiopia, with cure rates exceeding 95% and an excellent safety profile. 1, 2, 3, 4

Diagnosis

• Microscopy: Gold standard for diagnosis, allowing calculation of parasitemia percentage and monitoring treatment response
• Rapid Diagnostic Tests (RDTs): Use when qualified microscopists are unavailable
• Clinical diagnosis: When laboratory facilities are not available, clinical symptoms (paroxysmal fever, chills, sweats, headache) and signs (measured fever) can guide diagnosis 5, 1

Treatment Algorithm for Malaria in Ethiopia

1. Uncomplicated P. falciparum Malaria

First-line treatment: Artemether-lumefantrine (AL)

• Dosing: Total of 24 tablets for adults >35kg, taken with fatty meals 1
• Administration schedule: 4 tablets at 0,8,24,36,48, and 60 hours
• Efficacy: 97.2-99.1% cure rate in Ethiopian studies 2, 3, 4

Alternative treatments (if AL is unavailable or contraindicated):

• Artesunate plus amodiaquine
• Artesunate plus sulfadoxine-pyrimethamine
• Dihydroartemisinin-piperaquine (superior to AL for preventing P. vivax recurrence) 1, 6

2. Severe P. falciparum Malaria

First-line treatment: Intravenous artesunate 1

• Administer until patient can tolerate oral medication, then complete treatment with full course of AL

If IV artesunate unavailable:

• IM quinine dihydrochloride (10 mg/kg) every 4 hours for two doses, then every 8 hours until oral therapy possible 5

3. P. vivax Malaria

Blood stage treatment:

• Chloroquine: Total dose of 25 mg base/kg over 3 days
  • Adults: 600 mg (base) initially, then 300 mg at 6,24, and 48 hours
  • Children: 10 mg/kg at 0 and 24 hours, then 5 mg/kg at 48 hours 5, 1

Radical cure (after G6PD testing):

• Primaquine: 15 mg (base) daily for 14 days
• Tafenoquine: Single 300 mg dose 1

Important: In populations with high prevalence of G6PD deficiency, primaquine should not be administered for more than 5 days without G6PD testing 5, 1

Special Considerations

Pregnancy

• AL is now endorsed for use in all trimesters of pregnancy
• Chloroquine is safe during pregnancy for P. vivax treatment
• Primaquine and tafenoquine are contraindicated during pregnancy; defer anti-relapse therapy until after delivery 1

Treatment Failure

• If symptoms persist after 48-72 hours of chloroquine treatment, treat with second-line drug
• For AL failure, consider alternative ACTs or quinine plus doxycycline/clindamycin 5, 1

Monitoring

• For uncomplicated malaria: Monitor parasitemia every 24 hours until negative
• For severe malaria: Monitor parasitemia every 12 hours until <1%, then every 24 hours until negative 1

Prevention

High-Risk Groups

Consider chemoprophylaxis during high transmission seasons for:

• Children under 5 years, especially those with malnutrition or anemia
• Pregnant women
• Individuals with compromised health status 5

Travelers to Endemic Areas

• Weekly chloroquine (300 mg base) during exposure and for 6 weeks after leaving
• In areas with chloroquine resistance, mefloquine (250 mg weekly) is recommended 5

Common Pitfalls to Avoid

1. Delayed treatment: Malaria should be treated as an emergency, especially severe cases
2. Inadequate dosing: Ensure full course of AL is completed with fatty meals to enhance absorption
3. Failure to consider P. vivax co-infection: In Ethiopia, patients may develop P. vivax infection during follow-up (observed in 6.7% of P. falciparum patients) 4
4. Not monitoring for treatment failure: Patients should be evaluated for persistent symptoms after 48-72 hours
5. Administering primaquine without G6PD testing: Can cause life-threatening hemolysis in G6PD-deficient individuals

The high efficacy of AL in Ethiopia (97.2-99.1%) supports its continued use as first-line therapy for uncomplicated P. falciparum malaria 2, 3, 4. Regular monitoring of antimalarial efficacy is essential to detect early signs of resistance.